Creating Balance 2017 ATSA Conference Friday October 27 3:30 PM 5:00 PM

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1 F-40 ID Clients Treatment and Ethical Considerations Ethical Challenges and Considerations When Supporting Persons with ID Who Have Sexually Abused and Are Supported in Community Settings Christa Outhwaite-Salmon, B.A. (Hons) Tiffany Charbonneau, B.A. Sophia King, M.ADS Mackenzie Health Ethical challenges are often encountered when providing assessment and treatment for persons who have sexually abused in community based settings. These ethical challenges become more prevalent when working with individuals who also have an intellectual disability. For over 30 years, The Program for the Assessment and Treatment for Healthy Sexuality (PATHS) has been supporting persons with intellectual disabilities (ID) who sexually abuse. To guide our practice, PATHS abides by the code of ethics outlined by the Association for the Treatment of Sexual Abusers and the Applied Behaviour Analyst Association, and the Principles of Biomedical Ethics (1994). For the purpose of this presentation, the latter will be the main focus. Biomedical Ethics outline four principle standards which practitioners should adhere when resolving ethical issues (Beauchamp & Childress, 1994). These principles include autonomy, beneficence, nonmaleficence, and justice. Autonomy is based on the right of individuals to make their own choices and develop their own life plans (Erlanger Medical Ethics Orientation Manual, 2000). Within the treatment provisions for persons with ID who have sexually abused, concepts such as informed consent are of high priority. However, ensuring that clients are fully informed and capable of understanding the potential risks and benefits of assessment and treatment can be challenging. Beneficence guides clinicians to maximize the possible benefits of treatment (Paola et al., 2010). Although this principle sounds straightforward, it can become complicated when considered alongside Autonomy. Since it is not ethically sound to act without the client s consent, challenges arise when the definition of doing good differs between clinician and client (Lawrence, 2007). In the course of treatment of persons with ID who have sexually abused, clinicians must ensure that they are doing good for the community and the client concomitantly. Therefore, managing the risks to the community can at times outweigh possible benefits to the client. Nonmaleficence refers to a clinician s obligation to do no harm (Lawrence, 2007). This principle is closely related to the principle of Beneficence, in that these two principles

2 guide clinicians in making choices that best fit their clients goals in treatment. With this in mind, clinicians must ensure that clients fully understand any potential risks associated with participating in treatment such as restrictions impacting on community access and/or increased supervision. Clinicians have a responsibility to create a balanced treatment program that addresses both a good lives approach for the client and maintains public safety through risk reduction. The final principle, Justice, requires the distribution of services to be fair, and that comparable cases be treated equally (Paola et al., 2000). Agencies providing treatment to persons with ID who have sexually abused are faced with high demand and limited resources. Therefore, agencies are required to determine priorities for both those waiting for treatment as well as the level of intensity for those involved in treatment. The Risk, Needs, Responsivity model (Andrews & Bonta, 2010), helps to guide clinicians to effectively support clients and endorse community safety while adhering to the Justice principle. This workshop will closely examine each or these four principles and how they relate to treatment for persons with ID who have sexually offended. Specifically, case study examples will illustrate ethical issues and challenges which our clinicians have encountered. These examples will be used to further illustrate how to effectively and ethically support those who sexually abuse in community settings. Participants will engage in an interactive exercise of applying the four principles to a fictional case that challenge the ethical principles. Learning Goals and Objectives: Provide an overview of Biomedical Ethics principles. Identify ethical challenges that may arise when supporting persons with ID who sexually abuse. Identify solutions which can be applied to ethical dilemmas Review case studies to illustrate the application of the four principles. To gain a functional understanding of the four principles and how they can be used when supporting persons who have engaged in sexual abuse and reside in community settings. To engage participants in an effort to better understand concrete strategies when formulating and applying these four principles within practice. Christa Outhwaite-Salmon has worked as a the Central East Educator/ Behaviour Therapist with the Program for the Assessment and Treatment for Healthy Sexuality (PATHS) for over ten years specializing in the assessment and treatment of sexually abusive behaviours and intellectual disabilities. Christa s position of educator was designed to build capacity and skill in the area of the assessment and treatment for persons with ID who sexually abuse to fellow Behavioural Therapists and community organizations across the Region. This is attained through providing clinical consultation, socio-sexual and risk assessments, public education, and conducting research. Christa has presented at a number of local, national and international conferences, including The Association for the

3 Treatment for Sexual Abusers and is currently completing a Masters of Social Work at the University of Windsor. Tiffany Charbonneau has worked for the Center for Behaviour Health Sciences for 10 years. For the past 5 years, she has worked in The Program for the Assessment and Treatment for Healthy Sexuality specializing in assessment and treatment of sexually abusive behaviours and intellectual disability. Tiffany is supports adults, adolescents, and their supports in community based settings. Her focus is on assessment, risk management and treatment with individuals who sexually abuse. Tiffany has recently presented at previous ATSA conferences and Ontario Association for Behaviour Analysis conference. A Group Treatment for Sex Offenders with Intellectual Disability in Switzerland Andrea Hollomotz, Ph.D. University of Leeds, UK Monika Egli-Alge, lic. phil. I Psychology Forio Meinrad Rutschmann, Diplom Heilpädagogik Forio Since 2004 Forio has offered psychological interventions to men with intellectual disability who have sexually offended. This delict-oriented, psychodynamic group treatment draws on principles of cognitive behavioural therapy and Heilpädagogik. The latter is an approach to working with people with intellectual disability, which is best translated as a form of curative education that is free from religious values. Most groups run in an open, community based format, but Forio also run in-house groups within institutions for people with intellectual disability. This paper is the result of a collaboration between an academic researcher and key practitioners from Forio. It combines emerging findings from research with the practice experiences of therapists. For the researcher Forio constitutes a case study within an international, comparative evaluation project of group treatments for men with intellectual disability who have sexually offended. The academic project follows a realist evaluation methodology and seeks to understand what works in what ways, for whom and under what circumstances. So far, the researcher spent six weeks at Forio during three separate fieldwork visits and combined a number of research methods. These include a document analysis of program tools, overt participant observations of treatment sessions and risk cycle meetings, expert interviews with program designers, focus groups within risk cycles and individual patient interviews. The practitioners add to this paper their extensive expertise on the rational for establishing the program, its development over time, how things work in practice and in-depth knowledge of individual case studies.

4 The comparison of six programs in five international locations that was carried out by the first author exposed that Forio strives towards similar intended outcomes when compared to other group cognitive behavioural therapies, namely that participants will learn to better understand the consequences of their own actions, increase their risk management skills and strive towards a better quality of life to ensure they are meeting their needs by pro-social means. The more unique aspects of Forio therapy relate to how the men are expected to put the pro-social behaviour skills that are intended to emerge as a result of the therapy into practice in their daily life between meetings. Therapists have considerable flexibility in respect to the format and order in which different components of treatment are covered, as they are expected to be responsive and to work with the experiences the men report back to group. For instance, if a participant reports that he has met a new romantic partner this may prompt the therapists to bring forward or recap content on sexual relationships and boundaries. This format of treatment would not be possible without input from the risk-cycle, a participant s supervision and social care network. This may include the therapists, probation worker, parents or other family carers and key workers from the participant s living unit, educational setting or sheltered workshop. This network stays in close contact throughout treatment via regular progress meetings and ad hoc information exchange. They help to manage risk, personalise the intervention, monitor progress and reinforce new pro-social behaviours. Risk-cycle meetings usually continue for one year after completing treatment with the aim to use this time period to transfer the lead risk management responsibility from Forio therapists and probation to others within the supervision and social care network, but prolonged Forio engagement via risk cycles is also possible in more complex cases. Those would typically involve men who continue to require considerable impact to manage risks after completing treatment, possibly because they were unable to meet all of the stated treatment aims. Learning Goals and Objectives: This presentation will demonstrate how Forio works as a learning by doing program, which means that learning from group treatment is expected to be applied outside the treatment setting in participant s daily lives. It will be illustrated how the treatment group is then used to reflect on those new experiences. We will also introduce some of the other applied methods in use, which arise from Heilpädagogik, including the use of singing, visual objects, kinaesthetic tasks and linking taste to the therapeutic experience. The presentation will provide practice examples of the collaborative working of the risk-cycles, with a view to inspire others on ways in which they may emulate practices of individualised planning and inter-agency working. Dr. Andrea Hollomotz has come to academia from a social work background. She held her first lecturing post at Manchester Metropolitan University from In 2012 she joined the department of Sociology & Social Policy at the University of Leeds. Her PhD ( ) resulted in a number of academic outputs, including a monograph and five peer

5 reviewed journal articles. The study explored the social construction and creation of sexual vulnerability of adults with intellectual disability. This work inspired an interest in sex offending. Dr Hollomotz is currently working on a 3-year research project, which is an Economic and Social Research Council (UK) funded realist evaluation of sex offender treatment programs for men with intellectual disability ( Monika Egli-Alge, Lic. phil. I is a forensic psychologist and psychotherapist and the manager of Forio. She has a vast range of experience in outpatient psychiatric and psychotherapeutic treatment of children, young people and families, as well as inpatient care of adults with intellectual disability. From the early 1990s onwards Egli-Alge has been a key practitioner in the development of treatment for sex offenders. In 2002 she developed the first treatment for sex offenders with intellectual disabilities in the German speaking regions, in collaboration with Meinrad Rutschmann. Two years later they founded Forio together. Egli-Alge has published a number of academic outputs and has a track record of national and international conference presentations. She is a member of the Scientific Advisory Board for the Institute of Sexology and Sexual Medicine, Charité - Universitätsmedizin Berlin (Germany). Meinrad Rutschmann is a clinical Heilpädagoge, offender therapist and mediator. He is furthermore the deputy director of Forio AG. Heilpädagogik is an approach to working with people with intellectual disability which is, in its exact form, unique to the Germanspeaking regions. It may be translated as a form of curative education that is free from religious values. Rutschmann is a fully qualified group therapist with a vast range of experience in working with children, young people and adults with intellectual disabilities. From the early 1990s onwards he worked in public sector in-patient and semi-inpatient settings for children and young people with mental health problems. In 2002 Rutschmann and Egli-Alge developed the Forio treatment for sex offenders with intellectual disabilities. Rutschmann continues to be an active key practitioner who has lead on many successful treatment cohorts for over a decade.