THE THERAPIST RATING SCALE-2. Liam E. Marshall, Ph.D. W. L. Marshall, O.C, F.R.S.C., Ph.D. (C.PSYCH)

Transcription

1 1 THE THERAPIST RATING SCALE-2 By Liam E. Marshall, Ph.D. & W. L. Marshall, O.C, F.R.S.C., Ph.D. (C.PSYCH) Address for correspondence: TRS-2 c/o ROCKWOOD PSYCHOLOGICAL SERVICES 303 BAGOT STREET, SUITE 304, KINGSTON, ON., CANADA, K7K 5W7 PHONE: ; FAX:

2 2 Table of Contents TRS-2 - RATING FORM... 3 RATINGS... 4 HOW TO DO IT:... 4 WHEN TO DO IT... 5 INTERPRETATION... 5 WHO CAN I APPLY THE TRS-2 TO?... 5 WHO CAN USE THE TRS REFERENCE FOR THE SCALE... 6 RESULTS OF RESEARCH USING THE TRS CASE EXAMPLE... 8 Initial TRS Post-treatment TRS TWO EXAMPLES OF REPORTS BASED ON THE TRS Discharge Summary Example Discharge Summary Example

3 1 SENSE OF AGENCY Topics Believes in and demonstrates ability to control own life Takes responsibility for making life changes Can identify and take steps to achieve goals 2 GENERAL EMPATHY TRS-2 - RATING FORM Can perceive the emotions of others Is able to put self in other s shoes Responds with appropriate emotion to other s emotions Attempts to comfort others - when possible and appropriate 3 PROSOCIAL ATTITUDES Espouses, and behaves in accordance with, pro-social attitudes Challenges anti-social attitudes expressed by other group members Cooperates with supervisor/supervision or case management staff 4 ADEQUATE COPING SKILLS/STYLES Responds to stressors with appropriate emotionality Understands how emotions can impact ability to cope Faces problematic issues Is able to problem solve 5 ADEQUATE INTIMACY SKILLS Values others Appropriately self-discloses Able to make friends, establish relationships, with others Has realistic beliefs about relationships 6 POSITIVE SELF-ESTEEM Has a realistic belief in own abilities Sees value and engages in positive self-talk Does not use either self-deprecating or derogatory humour 7 GOOD GENERAL SELF-REGULATION Can adapt to changing circumstances Not impulsive or overly negative Is neither overly emotional nor suppresses emotions Sees value of, and has the capacity for some degree of stability in life 8 GOOD SEXUAL SELF-REGULATION Doesn t use sex to cope Is not preoccupied with sex Has normative sexual interests Has a healthy approach to sexuality 9 UNDERSTANDS RISK FACTORS Has an awareness of actual and possible risk factors and situations Able to take feedback from others 10 QUALITY OF FUTURE PLANS Has realistic plans and goals for the future Has adequate community supports Engages in and recognizes the value of leisure activities Has employable skills or is financially independent SubTotals Plus TOTAL SCORE (Range: 20-80) Intellectual Understanding Categories Acceptance/ Demonstration 3

4 RATINGS 4 NOTE: Average is compared to non-offenders; normal, average, non-offending, everyday people on the street of a comparable socio-economic status. Level 4 = Optimal Functioning o Significantly better than average o Most group participants will not achieve this level on any topic or category Level 3 = Normative (Is the target of treatment) o Average functioning o Mostly achieves target of treatment o Might still have a little work to do, but no worse than non-offenders Level 2 = Approaching Normative o Approaching average functioning o Starting to understand and see value in topic/category o May achieve level 3 post-treatment Level 1 = Unsatisfactory o Needs to redo treatment component Information on Ratings Levels should vary across topics (Sense of Agency, Empathy, Prosocial Attitudes, etc.) Levels should vary between categories (, ) Avoid halo and opposite ( pitchfork ) effect When learning to use, have therapists complete separately and independently, and then discuss differences aiming for inter-rater agreement 8-9 times out of 10 (i.e., does not have to be perfect agreement on all items) HOW TO DO IT: Using the descriptors (e.g., Believes in own ability to control life ) below each topic HEADING (e.g., SENSE OF AGENCY ), rate your impressions of where the offender is at this moment in terms of his of the issue and how much he has taken it on board (i.e., ) using the described 4-point rating scale. is often reflected by the offender being able to say the right things in group but not always do so outside of the group setting. Intellectual understanding usually, but not always, occurs prior to actually doing the right things as a habit. For example, an offender may espouse appropriate attitudes in the program and elsewhere, but may not totally behave in a way reflective of these better attitudes. is when an offender is not just saying the right things, but also putting them into practice. For example, being empathic toward others, espousing appropriate attitudes to people outside the group, contacting supports in the community, establishing relationships with pro-social peers. As an example of QUALITY OF FUTURE PLANS, an offender might report seeing the importance of establishing good community supports and thus receive a 3 or 4 on his intellectual understanding of the topic, but not have actually contacted, or established, any good community supports yet and therefore receive a 1 or 2 on acceptance/demonstration of the issue. When struggling with a particular topic, it may be useful, until comfortable with that topic, to rate the offender on each of the descriptors of the topic and average them out.

5 5 WHEN TO DO IT It is suggested to use the TRS-2 approximately halfway through an offender s time in treatment and then again at the end of treatment. Using the TRS-2 halfway through treatment helps therapists to have a sense of where the offender is well before the end of the program in order to direct the remaining time in treatment to the most pressing issues. Using the TRS-2 at the end of treatment will give a sense of how close the offender is to normal functioning and inform report writing. Reports based on the TRS-2 can inform on whether subsequent treatment is necessary and what the focus of subsequent treatment should be. We recommend using the Topics of the TRS-2 as headings in treatment reports and including the ratings both within the body of reports, and attaching a copy of the complete TRS-2 to the report; parole boards and supervisors report this to be helpful. Redacted examples of reports are given below. INTERPRETATION Although the TRS-2 has not yet received extensive empirical validation, it is based on the original TRS (17-item version), which has received some examination (e.g., good inter-rater reliability), and what is known about dynamic risk in sexual offenders. At the current moment the TRS-2 is intended as a guide for therapists and others making post-treatment decisions about sexual offenders. Offenders are considered to have reached the target of treatment when they achieve a score of 3 on an item. Ideally, group members will achieve a 3 on both and for each of the 10 topics. However, this is unlikely to occur and consequently therapists will have to use good judgement about the overall impact of treatment. In a recent study, the total score of sexual recidivists (M= 44.57, SD= 6.85) was statistically significantly lower than non-sexual and non-recidivist offenders (M= 51.07, SD= 5.07; possible range of the TRS-2 total score is 20-80), t = 4.78, p <.001, suggesting total scores above 50 may be indicative of treatment success. Total scores less than 45 likely indicate a need for further treatment. This pattern of higher scores indicating lower risk for sexual recidivism was also found for the and categories, both p <.001. However, more research is needed to better define cutoffs for treatment success and this example is provided as a possible guideline. The TRS-2 can be a helpful guide to writing treatment reports and redacted exemplars are included at the end of this package. We include the TRS-2 at the beginning of the report, and then subsequent paragraphs explain and give rationale for the scoring, finally, a Conclusions and Recommendations section can comment on treatment induced risk reduction, if appropriate. Parole boards and supervisors also report the information from the TRS-2 to be helpful. WHO CAN I APPLY THE TRS-2 TO? The TRS-2 was developed for use with sexual offenders however the issues in the TRS-2 apply to many forms of group treatment for offending behaviour and has been used with anger management, domestically violent, and mentally disordered offenders. The TRS-2 reflects all of those dynamic risk factors for offending in general commonly referred to as the Big Eight, such as antisocial attitudes, antisocial associates, general self-regulation problems, and relationship issues. WHO CAN USE THE TRS-2 The TRS-2 is a license free measure; that is, there is no cost associated with its use. However, please use the reference below to cite the measure in any publications or presentations. Using the TRS-2 does not require any particular educational level (e.g., Bachelor, Masters, PhD degrees) in any particular discipline (e.g., Psychology, Psychiatry, Social Work). However, knowledge of dynamic risk factors in offenders is recommended and training programs designed to enhance knowledge of these issues in offenders are available (e.g.,

6 DATA COLLECTION: 6 We are currently collecting data on inter-rater reliability. If you have more than one therapist in a treatment group and are willing to be part of our data collection, please have therapists complete the forms separately and independently and identify which forms belong to which therapists and which group member (there are many ways to do this, such as by a number or alphabet system), then therapists are encouraged to compare answers and complete a final combined TRS-2 form which can be kept for your records and reports. Please send the inter-rater data to the address for correspondence on the cover page REFERENCE FOR THE SCALE Marshall, L. E., & Marshall, W. L. (2009). The Therapist Rating Scale-2. Unpublished Manuscript available from the first author: liam@rockwoodpsyc.com. RESULTS OF RESEARCH USING THE TRS-2 Psychometrics The internal consistency of the TRS-2 has been found to be high with alphas of.97 for the total score,.96 for, and.95 for. REFERENCE: Marshall, L. E., Marshall, W. L., Humphries, S., Serran, G. A., O Brien, M. D. (September, 2010). A Therapist Rating Scale for Determining Treatment-Induced Change. Paper presented at the 11th annual conference of the International Association for the Treatment of Sexual Offenders (IATSO). Oslo, Norway. Inter-rater reliability of the scale has been demonstrated to be excellent with intraclass correlation coefficients of.90 for,.96 for, and.95 for the total scale score. REFERENCE: Marshall, L. E., Marshall, W. L., Gates, M., Alguire, T., & Humphries, S. (October, 2010). A Therapist Rating Scale for Determining Treatment-Induced Change. Paper presented at the 29th annual conference of the Association for the Treatment of Sexual Abusers (ATSA). Phoenix, AZ. In a preliminary retrospective study the TRS-2 demonstrated encouraging predictive ability for sexual recidivism (see Table below). A sample of ninety-six of the offenders in our most recent outcome study were scored on the TRS-2 from therapist reports on those offenders by a rater blind to the results of the outcome study. Under these less than ideal conditions scores on the TRS-2 and categories, and the total scores demonstrated a statistically significant ability to predict sexual reoffending (AUC =.75, 78, &.77, respectively, all p <.001) see table below. REFERENCE: Marshall, L. E., Marshall, W. L., Humphries, S. (February, 2012). A Therapist Rating Scale for Determining Treatment-Induced Change. Paper presented at the annual conference of the Partner Assault Response program of Eastern Ontario (P.A.R.E.O.). Gananoque, Canada.

7 7 Intellectual Understanding Acceptance / Demonstration Total No Failure.65*.66**.65* Revocation Non-sexual non-violent Violent Sexual.75**.78***.77*** * p <.05, ** p <.01, *** p <.001 NOTE: Except for No Failure, all scales are reverse scored so that higher scores indicate greater probability of recidivism. For No Failure, higher scores indicate greater probability of no failures. Prospective studies using the TRS-2 are currently underway examining recidivism in treatment groups for sexual offending, anger management, and domestic violence with completion expected to be in late 2013.

8 The following is a case example of the use of the TRS-2 with a sexual offender who participated in one of our treatment programs. CASE EXAMPLE Background/Assessment Information: Independent Assessment Results Medium-low static risk Moderate dynamic treatment needs Offender and Offence Information 28 year old recidivist offender 2 year sentence for Sexual Interference & Sexual Exploitation Victim was his 5 year-old step-son Pled guilty & admitted to offences at assessment Entered the victim's bedroom while he was asleep Fondled the victim's penis, waking him up, and then directed victim to fondle himself Living with the victim's mother for 5 years Extensive criminal history, including sexually motivated Assault With a Weapon Previously received a short sentence (< 2 years) Previously attended treatment but did not complete Disclosed own sexual abuse at assessment Involved in fire-setting Prostitute from ages 15 to 18 years (hundreds of clients) Many consensual partners (most one-night-stands) Participated in group sex with various combinations of both genders on many occasions Masturbated a lot to adult pornography magazines Experimental sexual relationship with his partner involving sado-masochistic activities (and had affairs) Phallometric assessment - sexual interest in adult males and passive prepubescent children First TRS-2 Scoring TRS-2 completed after 12 sessions (including Disclosure & Autobiography) Initially anxious to share his offence details Later discussed his offending in reasonable detail, omitting a prior conviction Reported that disclosing felt like a "big weight lifting" Did well to focus on certain issues, including his possible sexual preoccupation Was more accepting of his sexual interests (homosexuality with adults) Group helped him acknowledge stress as a risk factor Reported that as a result of stress he was masturbating five or six times a day Acknowledged substituting coping with drugs to coping with sex He said that doing this provided him with a sense of escape and release Indicated that he now wanted to focus on celibacy and a lifetime of bible study Talked of getting a dog as a primary companion Became more open in general group discussions Disclosed increasing personal information Reported asking for a longer sentence in order to get treatment but had been getting cold feet Increasingly able to develop key realizations about himself and his past Increasingly enthusiastic about treatment Now I would happily pay money from my inmate account to come to this group!!!! 8

9 Initial TRS-2 Topics 1 SENSE OF AGENCY Believes in and demonstrates ability to control own life Takes responsibility for making life changes Can identify and take steps to achieve goals 2 GENERAL EMPATHY Can perceive the emotions of others Is able to put self in other s shoes Responds with appropriate emotion to other s emotions Attempts to comfort others - when possible and appropriate 3 PROSOCIAL ATTITUDES Espouses, and behaves in accordance with, pro-social attitudes Challenges anti-social attitudes expressed by other group members Cooperates with supervisor/supervision or case management staff 4 ADEQUATE COPING SKILLS/STYLES Responds to stressors with appropriate emotionality Understands how emotions can impact ability to cope Faces problematic issues Is able to problem solve 5 ADEQUATE INTIMACY SKILLS Values others Appropriately self-discloses Able to make friends, establish relationships, with others Has realistic beliefs about relationships 6 POSITIVE SELF-ESTEEM Has a realistic belief in own abilities Sees value and engages in positive self-talk Does not use either self-deprecating or derogatory humour 7 GOOD GENERAL SELF-REGULATION Can adapt to changing circumstances Not impulsive or overly negative Is neither overly emotional nor suppresses emotions Sees value of, and has the capacity for some degree of stability in life 8 GOOD SEXUAL SELF-REGULATION Doesn t use sex to cope Is not preoccupied with sex Has normative sexual interests Has a healthy approach to sexuality 9 UNDERSTANDS RISK FACTORS Has an awareness of actual and possible risk factors and situations Able to take feedback from others 10 QUALITY OF FUTURE PLANS Has realistic plans and goals for the future Has adequate community supports Engages in and recognizes the value of leisure activities Has employable skills or is financially independent Intellectual Understanding Categories Acceptance/ Demonstration

10 POST-TREATMENT Treatment Gains Improved self-esteem Reduced shame Increased coping ability Improved knowledge about relationships Greater focus on achieving intimacy Learning about healthy sexuality Improved goal-setting Better able to deal with loneliness Improved problem-solving ability Improved emotion management strategies RECOMMENDATIONS Post-treatment risk considered to be LOW HOWEVER IF... o Resumes sexually-centred lifestyle o Uses sex to cope o Had access to potential victims RISK WOULD INCREASE Avoid unsupervised contact with children Further community treatment to focus on healthy relationships and sexuality 10

11 Post-treatment TRS-2 Topics 1 SENSE OF AGENCY Believes in and demonstrates ability to control own life Takes responsibility for making life changes Can identify and take steps to achieve goals 2 GENERAL EMPATHY Can perceive the emotions of others Is able to put self in other s shoes Responds with appropriate emotion to other s emotions Attempts to comfort others - when possible and appropriate 3 PROSOCIAL ATTITUDES Espouses, and behaves in accordance with, pro-social attitudes Challenges anti-social attitudes expressed by other group members Cooperates with supervisor/supervision or case management staff 4 ADEQUATE COPING SKILLS/STYLES Responds to stressors with appropriate emotionality Understands how emotions can impact ability to cope Faces problematic issues Is able to problem solve 5 ADEQUATE INTIMACY SKILLS Values others Appropriately self-discloses Able to make friends, establish relationships, with others Has realistic beliefs about relationships 6 POSITIVE SELF-ESTEEM Has a realistic belief in own abilities Sees value and engages in positive self-talk Does not use either self-deprecating or derogatory humour 7 GOOD GENERAL SELF-REGULATION Can adapt to changing circumstances Not impulsive or overly negative Is neither overly emotional nor suppresses emotions Sees value of, and has the capacity for some degree of stability in life 8 GOOD SEXUAL SELF-REGULATION Doesn t use sex to cope Is not preoccupied with sex Has normative sexual interests Has a healthy approach to sexuality 9 UNDERSTANDS RISK FACTORS Has an awareness of actual and possible risk factors and situations Able to take feedback from others 10 QUALITY OF FUTURE PLANS Has realistic plans and goals for the future Has adequate community supports Engages in and recognizes the value of leisure activities Has employable skills or is financially independent Intellectual Understanding Categories Acceptance/ Demonstration

12 TWO EXAMPLES OF REPORTS BASED ON THE TRS-2 12 Discharge Summary Example-1 Self-Regulation Program for Sexual Offending MONTH DAY, YEAR FINAL REPORT: ANONYMOUS, Jerry Jerry is a XX-year old male serving an XX-month sentence for one count of Possession of Child Pornography and one count of Failing to Appear. He is serving his first period of incarceration and has no prior criminal record. Jerry attended the Self-Regulation Program between MONTH DAY, YEAR, and MONTH DAY, YEAR, and is considered to have satisfactorily completed (other options = completed or not satisfactorily completed) the program on the basis of his attendance and completion of the required group assignments. (INSERT BRIEF PROGRAM DESCRIPTION HERE) Treatment Summary: Progress in this group is being evaluated according to the Therapist Rating Scale-2 (TRS-2) (L. E. Marshall & W. L. Marshall, 2009). The dynamic risk variables included in the TRS-2 are taken from the most current research in the field and have been empirically established to be the most strongly predictive of sexual recidivism. Each treatment target is evaluated twice: first on the basis of the group participant s intellectual understanding of the concept or target, and second, on the basis of his emotional acceptance and formal demonstration of the target. The targets are evaluated on the basis of the participant s presentation within the treatment group itself and on his demonstrated ability to generalize the group principles to his life overall. Ratings are based on estimates of what would be considered to be normal functioning among the general population. There are four levels of possible ratings for each target: LEVEL 4= OPTIMAL FUNCTIONING (SIGNIFICANTLY BETTER THAN AVERAGE) LEVEL 3= NORMATIVE (AVERAGE FUNCTIONING, MOSTLY ACHIEVES THE TARGET) LEVEL 2= APPROACHING NORMATIVE (APPROACHING AVERAGE FUNCTIONING) LEVEL 1= UNSATISFACTORY (NEEDS TO REDO TREATMENT COMPONENT) The following ratings reflect the participant s level of functioning at the time of his discharge from the program: Sense of Agency This target reflects an individuals belief in his ability to control his own life, to take responsibility for making life changes and the ability to identify the requisite steps in achieving these goals. 2 1

13 General Empathy 13 This target represents an individuals ability to perceive the emotions of others, to be able to put themselves in other s shoes, to respond with appropriate emotion to others emotions, and their attempts to comfort others when possible and appropriate. 2 2 Prosocial Attitudes This target assesses the degree to which an individual espouses and behaves in accordance with pro-social attitudes, challenges anti-social attitudes expressed by other group members and cooperates with supervisor/ supervision or case management staff. 2 1 Adequate Coping Skills/ Styles This target reflects an individuals response to stressors with appropriate emotionality, their ability to understand how emotions can impact their ability to cope, their ability and willingness to face problematic issues and problem solve. 2 2 Adequate Intimacy Skills This target assesses whether or not the individual values others, is able to appropriately selfdisclose, make friends and establish relationships with others and has realistic beliefs about relationships. 2 1 Positive Self-Esteem This target evaluates the extent to which an individual has a realistic belief in their own abilities, whether they see value in and engage in positive self-talk and their avoidance of self-deprecating or derogatory humour. 2 1

14 General Self-Regulation 14 This target reflects the idea that the individual can adapt to changing circumstances, not be overly impulsive or negative, is neither overly emotional nor suppressing of their emotions and the extent to which they see value of, and has the capacity for some degree of stability in their life. 2 1 Sexual Self-Regulation This target represents normative sexual interests and a healthy approach to sexuality, avoidance of sex as a coping strategy and the degree to which they do not over or undervalue sex in their life and relationships. 1 1 Understands Risk Factors This target evaluates the degree to which the individual has an awareness of actual and possible risk factors and situations and is able to take feedback from others. 1 1 Quality of Future Plans This target represents the degree to which the individual has realistic plans and goals for the future, has adequate community supports, engages in and recognizes the value of leisure activities, has employable skills and is financially independent. 2 1 Jerry demonstrated little interest or motivation to engage in treatment in a meaningful manner. He was consistently late for the group sessions and attended only after reminders from other group members or the group facilitator. Jerry s contributions to the group discussions, his written exercises and his feedback to the other group members were limited and superficial. He often appeared preoccupied, had difficulty following the conversations and demonstrated very limited insight into his own difficulties and those of others. Jerry continues to be resistant to the idea that he has control over his life, his decisions, and his future. He has often expressed hope that his life will be different in the future, but, has yet to take the steps to make the requisite changes.

15 15 Jerry continues to experience significant difficulties establishing meaningful peer connections an issue that was frequently observed during the course of his stay at the facility. Although this continued to be the case right up to the time of his release from custody, he did make an improved effort at the end of his incarceration to socialize with the other residents and not isolate himself as often as he had done in the beginning. These attempts were observed by staff as well as his co-peers. Jerry has acknowledged his attractions to children, but, suggests that he has overcome this issue in his life. He quite often spoke of his love for children, but, was quick to add that he loved them in the right way. In addition to direct observations of Jerry in the Self-Regulation Program, feedback from staff and residents suggested ongoing preoccupation (both emotional and sexual) with children throughout his stay. Despite these observations, Jerry often theorized about the phases of pedophilia and believed that he was almost through that stage in his life. He continues to express his belief that society has created pedophilia by sexualizing children and takes little responsibility for his own actions. Jerry will very likely have significant difficulty controlling his interests in the community. He is dismissive of the risk he may pose in the future, does not perceive the need to avoid contact with children, and has done little to develop a release plan that will assist him in managing his future risk. He was instructed on masturbatory satiation, a sexual reconditioning technique designed to address the issue of his deviant arousal, but, expressed little interest in applying it. In order to manage his risk for reoffending, Jerry will need to make a concerted effort to broaden his support network and commit to creating greater intimacy in his life and establishing and maintaining improved peer connections. As a result of his inability to successfully bond with peers, Jerry has led a very isolated life. On an emotional level, he identifies more strongly with children. These factors coupled with the degree of his attractions to children poses increased risk for sexual offending behaviour. Jerry is prone to depression, has few plans to stay busy and has identified few social and leisure activities that would enhance his likelihood of meeting other adults who share similar interests. Jerry is considering volunteer work, but, has yet to demonstrate any real commitment or motivation to the few activities or changes he has spoken of throughout his attendance in this treatment program. It will be very important that Jerry be followed in the community and has been recommended to attend a treatment program in the community to which he will be released. Recommendations: In light of issues raised during the course of his participation in the Self-Regulation Program, as well as concerns regarding ongoing risk management, the following are recommended; 1. Full treatment program for sexual offending in the community. 2. Never be alone with children A. Counselor, MA. Psychology D. Supervisor, Ph.D., C. Psych Psychometrist Psychologist

16 Discharge Summary Example-2 Program for Sexual Offending 16 DATE Resident: OFFENDER, Daniel Relevant Information: Daniel is a XX-year old male serving a X-year sentence for Invitation to Sexual Touching and Luring a Child by Computer. Over a period of a number of months, Daniel was communicating online with what he believed to be a 13-year old girl, but who was in fact a police officer. After a series of sexual conversations over a period of a few months, he suggested they meet, and was subsequently arrested. He has two prior convictions, Possession of a Narcotic for the Purpose of Trafficking in 19XX and Dangerous Operation of a Motor Vehicle in 20XX. Daniel attended the Self-Regulation Program between DATE and DATE and is considered to have satisfactorily completed the program. INSERT PROGRAM DESCRIPTION Treatment Summary: Daniel s progress in the Self-Regulation Program is being evaluated according to the Therapist Rating Scale-II (TRS-II) (L. Marshall & W. L. Marshall, 2009). The dynamic risk variables included in the TRS-II are taken from the most current research in the field and have been empirically established to be the most strongly predictive of sexual recidivism. Each treatment target is evaluated twice; first on the basis of Daniel s intellectual understanding of the concept or target, and second on the basis of his emotional understanding and formal demonstration of the target. Not only are the targets evaluated on the basis of Daniel s presentation within the group treatment program itself, but, also on his demonstrated ability to generalize the group principles to his life overall. Ratings are based on estimates of what would be considered to be normal functioning among the general population. There are four levels of possible ratings for each target; Level 4= Optimal functioning (significantly better than average) Level 3= Normative (average functioning, mostly achieves the target) Level 2= Approaching normative (approaching average functioning, may achieve level 3 post-treatment) Level 1= Unsatisfactory (needs to redo treatment component) The following ratings reflect Daniel s level of functioning at the time of his release from the STU; Sense of Agency This target reflects an individuals belief in his ability to control his own life, to take responsibility for making life changes and the ability to identify the requisite steps in achieving these goals.

17 17 General Empathy This target represents an individuals ability to perceive the emotions of others, to be able to put themselves in other s shoes, to respond with appropriate emotion to others emotions, and their attempts to comfort others when possible and appropriate. Prosocial Attitudes This target assesses the degree to which an individual espouses and behaves in accordance with pro-social attitudes, challenges anti-social attitudes expressed by other group members and cooperates with supervisor/ supervision or case management staff. Adequate Coping Skills/ Styles This target reflects an individuals response to stressors with appropriate emotionality, their ability to understand how emotions can impact their ability to cope, their ability and willingness to face problematic issues and problem solve. 3 2 Adequate Intimacy Skills This target assesses whether or not the individual values others, is able to appropriately self-disclose, make friends and establish relationships with others and has realistic beliefs about relationships. 3 2 Positive Self-Esteem This target evaluates the extent to which an individual has a realistic belief in their own abilities, whether they see value in and engage in positive self-talk and their avoidance of self-deprecating or derogatory humour. 3 2

18 General Self-Regulation 18 This target reflects the idea that the individual can adapt to changing circumstances, not be overly impulsive or negative, is neither overly emotional nor suppressing of their emotions and the extent to which they see value of, and has the capacity for some degree of stability in their life. 3 2 Sexual Self-Regulation This target represents normative sexual interests and a healthy approach to sexuality, avoidance of sex as a coping strategy and the degree to which they do not over or undervalue sex in their life and relationships. 3 2 Understands Risk Factors This target evaluates the degree to which the individual has an awareness of actual and possible risk factors and situations and is able to take feedback from others. Quality of Future Plans This target represents the degree to which the individual has realistic plans and goals for the future, has adequate community supports, engages in and recognizes the value of leisure activities, has employable skills and is financially independent. Overall Summary: Daniel put forth considerable effort into the Self-Regulation Program. Not only was this evident in the group setting itself, but, he also demonstrated a good understanding of the group principles outside of this setting as he began to apply them to his life and behaviour overall. Daniel demonstrated a willingness to reflect upon his life as a means of identifying the factors that led to his current incarceration and made a number of important changes that should they be maintained, will serve to moderate his future risk. In particular, Daniel appears to be better able to monitor his moods and to regulate his negative mood states. Although he continues to be prone to depression and anxiety, and to rely on others to bring attention to changes in his mood and behaviour, he is much more receptive to feedback on these issues and seems increasingly open to discussing these difficulties with his supports in the community. As his incarceration progressed, Daniel chose to isolate himself less, he socialized more often with his peers, made greater use of the various activities available to him and

19 demonstrated a generally improved affect and attitude overall. 19 With respect to the offence itself, Daniel acknowledges using the internet for sexual gratification, to having sexual communications with what he believed to be a young girl and has expressed significant remorse for his behaviour. Although he admits to having the sexual conversations online and going to the meeting place, he continues to deny any intent to engage in sexual contact with the minor and claims he only planned to see if she would show up. When challenged on the issue however, he was willing to explore how it came to be that he would place himself in such a high risk situation regardless of whether he would have followed through or not. Though he continued to deny his intention to follow through with the meeting, he appeared to be less convinced over time of his ability to resist the temptation to approach her had he had not been arrested. On a number of occasions during the group sessions, he expressed what appeared to be a sincere relief and gratitude for his arrest in light of his escalating pattern of risky behaviour. Prior to his incarceration, Daniel completed a Sexual Behaviours Assessment at the XXX. Results of phallometric testing demonstrated low levels of responding overall, but there was some evidence of both appropriate, adult consenting as well as deviant arousal (ie., physical coercion of a female child). In the current program, Daniel was introduced to masturbatory satiation, a technique designed to address deviant arousal and encouraged to implement the strategy to address his deviant interests. As part of Daniel s evaluation at the XXX, an actuarial risk assessment was also completed. His score on the Static-99 was consistent with a group of offenders deemed to be a medium-low risk who reoffended at a rate of 9% after five years and 13% over ten years (A. Nonymous, Psychiatrist, DATE). Daniel has acknowledged significant difficulties establishing and maintaining relationships with women his own age. Difficulties relating to same age peers in general and women in particular, feelings of inadequacy as well as fear of rejection have led him to settling for unfulfilling and unhealthy relationships with much younger women. At the time of the offence, Daniel was living in a common-law relationship with a much younger woman (21 at the time of the offence) and had so for a number of years, but, had been conversing with women online (sometimes sexual and sometimes not) over an extended period of time. He claims that the index offence was the first time he had communicated with a minor. Although he reports no significant concerns in his life at the time, there was seemingly little in his life that he identifies as truly pleasurable and fulfilling. His online communications appear to have been driven in part by sensation-seeking. The anonymity of the internet afforded him the opportunity to portray himself in any manner he wished and his behaviour further reinforced by the sense of power and control he experienced when someone was willing to comply with and cater to his needs and desires. This was particularly true when it came to contact with much younger women. In the past, Daniel has turned to sex, substances and online gambling as a means to cope with feelings of emotional loneliness and the internet provided an effortless way in which to do so. In light of the various factors that led to his sexual offence, a number of treatment targets were identified. Intimacy and healthy relationships, as well as improved emotional regulation and assisting him to identify more effective coping strategies were prioritized. Daniel seems to have gained an improved appreciation for increased intimacy in his life. He acknowledges the unhealthy nature of his past romantic relationships and has begun to address the factors that contribute to his pattern of relationships with much younger (mid to late teen) women and girls. Although he is not entirely closed to the possibility of reconciling with his girlfriend, he is currently reconsidering this as a wise decision for him at this time in his life. Daniel s self-management strategies and release plans appear to be both realistic and appropriate in terms of his managing his risk in the community. He has identified various strategies to regulate his emotions, cope more effectively with stress and conflicts in his life, to avoid boredom and emotional loneliness and also to increase his comfort level and success in relationships with women closer to his own age. He has identified a number of personal and professional supports he will have upon his release and states that he will be more inclined to ask

20 for help in the future in the event he should need it. 20 Recommendations: In light of issues raised during the course of his participation in the Self-Regulation Program, as well as concerns regarding ongoing risk management, the following are recommended; 1. Maintenance program for sexual offending. 2. Addictions counselling. 3. Follow-up with a psychiatrist to address ongoing mental health issues. A. Counselor, MA. Psychology D. Supervisor, Ph.D., C. Psych Psychometrist Psychologist