Worling, 2016 Texas CSOT 1

Texas Council on Sex Offender Treatment, March 2016 Moving Forward: How Lessons learned from research and practice are improving our ability to help adolescents who have offended sexually Dr. James R. Worling, Ph.D., C.Psych. jworling@ican.net Since the offending act is an exercise in power and control perpetrated by an anti-social, conduct-disordered, manipulative, deviant person, descriptors of the treatment of choice include confrontation, insistence on accountability for the offending behavior, a punitive rather than therapeutic orientation, and a focus on self-disclosure and the acquisition of strategies to prevent relapse. (Goocher, 1994, p. 244) That was then Final Results from California s Sex Offender Treatment and Evaluation Project (SOTEP) Marques, Wiederanders, Day, Nelson, & van Ommeren, 2005 Sexual Abuse: A Journal of Research & Treatment, 17, 79-107 Group Sexual Recidivism (8 years) Relapse prevention 22% Volunteer controls 20% Nonvolunteer controls 19% Don t they ALL have deviant sexual arousal? PPG Data Seto, Lalumière, & Blanchard (2000) 25% - maximal sexual interest in prepubescent children Seto, Murphy, Page, & Ennis (2003) 30% - responded equally or more to child stimuli Therapist Ratings Worling (2004) 36% - rated as having deviant sexual interests Worling, Bookalam, & Litteljohn (2012) 39% - rated has having deviant sexual interests 1. Aren t they all deviant? Worling, 2016 Texas CSOT 1

Seto & Lalumière, 2010, Psychological Bulletin, 136 Nonsexual offences only Sexual offences Depression Antisocial personality Antisocial beliefs/attitudes Intelligence Neurological anomalies General psychopathology Social skills deficits Family relationship problems Sexual experiences 2. Aren t they just delinquent? Seto & Lalumière, 2010, Psychological Bulletin, 136 Nonsexual offences only Sexual offences Criminal history Sexual abuse Antisocial peers Physical abuse Substance abuse Emotional abuse/neglect Anxiety Low self-esteem Social isolation Learning disabilities Exposure to sex/pornography Atypical sexual interests 3. Aren t they all disordered? Most adolescents who have offended sexually have the following clinical disorder: None Worling, 2016 Texas CSOT 2

Strength-Based Approaches Protective factors Capacities Skills Positive gains Hope 4. Don t they just have deficits? Seto (2000) Validity of Self-Report? Most adolescents who acknowledged sexual interest in children showed deviance in PPG Worling (2006) Adolescents who reported sexual interest in children more likely to have child victims 5. Aren t they all deceitful? Why do adolescents offend sexually? Theory Assessment Treatment It Depends Worling, 2016 Texas CSOT 3

Why Assess Adolescents Who Have Offended Sexually? Specific treatment recommendations Placement considerations/reunification Measure treatment progress/outstanding goals Reoffense risk estimation 30 25 20 15 10 5 0 from Worling & Långström (2006) 0 1 2 3 4 5 6 7 8 9 10 Years of follow-up Meta-Analysis of Treatment Effectiveness Reitzel & Carbonell, 2006 9 studies (4 published; 5 unpublished) n = 2,986 (121 females) All studies had treatment vs. a comparison group Average follow-up = 58.6 months Sexual Abuse: A Journal of Research & Treatment, 18, 401-421 Worling, 2016 Texas CSOT 4

Meta-Analysis of Treatment Effectiveness Reitzel & Carbonell, 2006 Overall Recidivism (%) Sexual Nonsexual (violent) Nonviolent other 12.5 24.7 29 20.4 Sexual Recidivism (%) Treatment 7.4 Comparison 18.9 Never reported Potential perils of risk assessment 1. Potential for irreversible damage to adolescent 2. Lack of empirical evidence to make precise or definitive risk statements 3. May keep the focus on risks and deficits (rather than on strengths and protective factors) Worling, 2016 Texas CSOT 5

Potential benefits of risk assessment 1. Matching client need and risk to treatment intensity/duration 2. Proper allocation of valuable treatment resources 3. Identification of specific risk factors to alter in treatment Risk, Need, & Responsivity (Andrews & Bonta, 1998) Effective Correctional Treatment Risk Principle: Intensity of treatment should vary according to risk to reoffend Need Principle: Treatment should target criminogenic needs dynamic risk factors Responsivity Principle: Treatment should be tailored to the individual s learning style and abilities 100% Risk Instruments U. S. Programs for Adolescent Males McGrath, Cumming, Burchard, Zeoli & Ellerby (2010). Safer Society Survey. www.safersociety.org www.safersociety.org 80% 60% 40% 20% 0% ERASOR JSORRAT-II J-SOAP-II Multiple 2003 (n=664) 2009 (n=373) Worling, 2016 Texas CSOT 6

1 2 2003 1995 1992 1988 1991 1989 3 Police Records Retrospective 1 2 3 2001 2002 Police Records 2002 Prospective Worling, 2016 Texas CSOT 7

High Score on the Recidivism TEST Recidivists Non-recidivists How to interpret an AUC value Area Under the receiver operating characteristic (ROC) Curve: The probability that a randomly selected person with the condition (e.g., recidivist) will have a higher score than a randomly selected person without the condition (e.g., nonrecidivist). ranges from 0 (100% incorrect) through 0.5 (50%, or chance) to 1.0 (100% perfect) AUC of.56-.63 small effect size AUC of.64-.71 moderate effect size AUC of >.71 large effect size Hanson & Morton-Bourgon, 2009 Psychological Assessment, 21, 1-21 Meta-analysis of risk assessment accuracy All actuarial tests 81 studies 24,089 males (primarily ADULT) average AUC=.68 (d =.67) Static-99 63 studies 20,010 males (primarily ADULT) average AUC=.68 (d =.67) Accuracy of instruments for adults Worling, 2016 Texas CSOT 8

Meta-analysis of validity of risk assessment instruments for juvenile justice Craig S. Schwalbe Law & Human Behavior (2007), 31: 449-462 28 studies (53,405 juveniles; 28% female 55% white) 28 risk different assessment instruments Follow-up from 6-60 months (12 months typical) 45% reoffended Weighted average effect size AUC=.64 (SD=.042) Accuracy of instruments for general delinquency Predictive Validity (AUC) Retrospective Studies Study The ERASOR AUC Judgment Score 1. Morton (2003).54.59 2. Skowron (2004).71 3. Worling (2004).66.72 4. McCoy (2007).50 5. Viljoen et al. (2009).64.60 6. Rajlic & Gretton (2010).67.71 7. Chu et al. (2012).83.74 Predictive Validity (AUC) PROspective Studies The ERASOR Study AUC Judgment Score 1. Worling et al. (2012) M=3.7 year follow-up.61.73 M=1.4 year follow-up.82.90 Worling, 2016 Texas CSOT 9

Other Popular Risk Assessment Tools: Adolescent Sexual Re-Offense Risk J-SOAP-II (Juvenile Sex Offender Assessment Protocol) Robert Prentky & Sue Righthand www.csom.org/pubs/jsoap.pdf JSORAT-II (Juvenile Sexual Offender Recidivism Risk Assessment Tool) dleppers@calpoly.edu J-SOAP-II Validity Sexual recidivism Published retrospective studies / Total score Total score AUC Martinez et al. (2007).78 Viljoen et al. (2008).53 Rajlic & Gretton (2010).69 Aebi et al., (2011).64 Chu et al., (2012).51 Fanniff & Letourneau (2012).58 J-SORRAT-II Validity Sexual recidivism Published studies AUC (Total score) Viljoen et al. (2008).53 Epperson & Ralston (2015).65 Worling, 2016 Texas CSOT 10

Viljoen, Mordell, & Beneteau (2012) Law and Human Behavior Meta-analysis Risk Measure (# of studies) AUC (sexual recidivism) Judgment Total Score (95% CI) (95% CI) J-SOAP-II (9) n/a.67 (.59-.75) J-SORRAT-II (7) n/a.64 (.54-.74) ERASOR (10).66 (.60-.71).66 (.61-.72) To predict sexual and nonsexual recidivism 16 static (historical) factors 12 dynamic factors (7 if in residential care) numeric scores; designed to be actuarial multiple sources of data ideal significant training requirements To predict sexual recidivism 12 static factors based only on charged offences based only on file review numeric score; actuarial To predict sexual recidivism 9 static and 16 dynamic factors based on comprehensive assessment structured professional judgment significant training requirements Can you answer all questions regarding risk? Is the youth at No Risk? Does the youth fit the profile of a sex offender? What is the risk of a youth reoffending sexually through his/her adult years? What is your estimate of the risk that a youth poses of reoffending sexually over the next year? 1. Yes No 2. Yes No 3. Yes No 4. Yes No Worling, 2016 Texas CSOT 11

Common risk-assessment questions? 1. What about adolescents who have noncontact offences (particularly child pornography possession)? 2. What about adolescents with impaired cognitive abilities? 3. What about female adolescents? Protective Factors? Borowsky, Hogan, & Ireland. (1997). Males Good emotional health (feel positive, hopeful, and worthwhile) Pediatrics, 100 e7 Males Feel that family cares, understands, respects, and enjoys Protective factors related to ever forcing sex 1,674 males 490 females Feel that school, friends, and community care Males Higher grades in school Females Worling, 2016 Texas CSOT 12

AIM2 (Assessment Intervention Moving On) Griffin, Beech, Print, Bradshaw, & Quayle (2008) Protective factors that differentiated sexual recidivists (n=7) from nonrecidivists (n=63) M=6 year follow up Positive leisure interests Individual Positive talents/interests Above average intelligence Positive evaluations from staff Positive emotional coping from significant adult Positive attitude from significant adult Positive relationships with staff At least one emotional confidant Relational A prospective investigation of factors that predict desistance from recidivism for adolescents who have sexually offended James R. Worling & Calvin M. Langton (2015) Sexual Abuse: A Journal of Research and Treatment, 27, 127 142 Behavioral and Emotional Rating Scale N=81 males aged 12 19 (M=15.1, SD=1.53) Ratings provided by parent/caregiver Worling, 2016 Texas CSOT 13

Variable AUC (95% CI) Sexual Recidivism ERASOR Total.77 (.61-.92) BERS Interpersonal Strength.52 (.36-.67) BERS Family Involvement.38 (.22-.54) BERS Intrapersonal Strength.50 (.32-.68) BERS School Functioning.51 (.28-.74) BERS Affective Strength.23 (.09-.37) Desistance from sexual reoffending Accept closenes s of others Express affection BERS Affective Strength Receive affection Show concern for feelings of others Acknowled ge painful feelings Factors that may well be related to desistance from sexual offending rewarding relationships with family, friends, and professionals active involvement in activities/community intimacy skills (compassion, affection, trust) Worling, 2016 Texas CSOT 14

Individual Systems Worling, 2013 Sexual Offending-Specific Factors Prosocial sexual interests Prosocial sexual attitudes Awareness of impact of sexual reoffense Hope in healthy, sexual-offence-free future Sexual offence-specific treatment completion Adequate environmental controls Prosocial sexual environment free to download at www.erasor.org Individual Systems Worling, 2013 General Factors Compassion for others Positive problem-solving skills Positive affect-regulation skills Emotional intimacy with peers Close relationships with positive & supportive adult Active involvement in prosocial peer activities Treatment for youth who have offended sexually Worling, 2016 Texas CSOT 15

We have learned the importance of. 1. Brain development 2. Therapeutic alliance 3. Parent/Caregiver involvement Implications of of Arre Arrested Development: Adolescent Behaviour Earlier development of the back of the brain and later development of the front of the brain Preference for physical activity Less than optimal planning and judgment More risky, impulsive behaviours Minimal consideration of negative consequences Earlier development of the back of the brain and later development of the front of the brain preference for physical activity less than optimal planning and judgment more risky, impulsive behaviours minimal consideration of negative consequences Emerging Adulthood (ages18-25) (Jeffrey Arnett, 2000) Average age of marriage Average age of having first child Average age of beginning career Worling, 2016 Texas CSOT 16

Emerging Adulthood Significant change and exploration Goals: Increase independence Find semi-permanent housing Obtain educational goals Develop career Maintain romantic relationships Importance of therapeutic alliance Conclusions from Meta-analytic Studies Common Factors associated with Psychotherapy Outcome Extra-therapeutic Factors (87%) Therapeutic Factors (13%) Therapeutic Alliance (8%) Therapeutic Allegiance (4%) Therapy model or technique (1%) Wampold, B.E. 2001. The Great Psychotherapy Debate: Models, Methods, and Findings. Erlbaum. 52 Therapist features that inhibit effectiveness Need to be liked Aggressive confrontation Sarcastic Nervous Angry Discomfort with silence Boundary problems Unable to wait for answers Marshall, W. L., Fernandez, Y. M., Serran, G. A., Mulloy, R., Thornton, D., Mann, R. E., & Anderson, D. (2003). Aggression and Violent Behavior, 8, 205-234. Worling, 2016 Texas CSOT 17

Therapist features that enhance effectiveness Empathic Directive Flexible Confident Warm Encourages participation Respectful Instills hope Marshall, W. L., Fernandez, Y. M., Serran, G. A., Mulloy, R., Thornton, D., Mann, R. E., & Anderson, D. (2003). Aggression and Violent Behavior, 8, 205-234. Importance of parent/caregiver involvement Treating youth in conflict with the law: A new meta-analysis 195 treatment-outcome studies published between 1964 and 2002 Treatment for adolescents who have engaged in criminal behaviour. www.justice.gc.ca/eng/pi/rs/rep-rap/2003/rr03_yj3-rr03_jj3/rr03_yj3.pdf Type of Treatment Effect on Reoffending Family-focused -.16 Multi-focused -.16 Group-focused -.05 Boot camps +.07 Wilderness programs +.09 Worling, 2016 Texas CSOT 18

Targets of Treatment Effect on Reoffending Family communication -.20 Leisure/recreation -.07 Non-specific employment goals -.01 The Primary Factors that Characterize Effective Interventions with Juvenile Offenders: A Meta-Analytic Overview 2009, 4, 124 147 Lipsey, M. W. 548 studies Effect on reoffending Deterrence +2% Discipline +8% Counseling -13% Individual counseling -4% Family involvement -13% The Safer Society 2010 North American Survey Changes in theoretical approaches: 2002-2009? Cognitive behavioral, family systems, strength-based, trauma Relapse prevention, psychoeducational $ Worling, 2016 Texas CSOT 19

Common Treatment Goals Healing from childhood trauma Enhancing accountability for sexual offending Worling, 2016 Texas CSOT 20

Shame vs. Guilt Enhancing social relationships/intimacy Enhancing healthy sexual interests/arousal Worling, 2016 Texas CSOT 21

Sexual Arousal Control Treatments Programs for Male Adolescents Safer Society Survey (McGrath, et al., 2010) Covert sensitization Minimal arousal conditioning Odor aversion Verbal satiation Masturbatory satiation Aversive behavioral rehearsal Orgasmic conditioning Community Programs (n=275) 0% 10% 20% 30% 40% 50% Residential Programs (n=98) Behavioral Interventions To Reduce Deviant Sexual Arousal? 1. Ethical concerns (punishment, consent, masturbation, sexual media, etc.) 2. Lack of empirical support with adolescents 3. Potential iatrogenic harm 4. Questions regarding long-term change Thought Stopping Johnston, Ward, & Hudson, 1997 Shingler, 2009 ironic rebound effect Worling, 2016 Texas CSOT 22

Thought Stopping To maximize effectiveness: 1. Teach WHY it s important to stop the thoughts 2. Utilize specific and relevant distractors 3. Inform client of inevitable recurrence 4. Use well-rehearsed strategies 5. Use only as a temporary emergency measure Promise of mindfulness-based approaches Use of mindfulness-based procedures to control deviant sexual arousal for men with intellectual disabilities Singh, Lancioni, Winton, Singh, Adkins, & Singh, 2011 Psychology, Crime & Law, 17, 165-179 Constructing Healthy Sexuality Prosocial relationships Intimacy Sexual Knowledge and attitudes Communication/Negotiation Problem-solving Healing from prior trauma Self-esteem Hope Worling, 2016 Texas CSOT 23

Sexual attitudes shaped by peers, family, and media Healthy Sexuality Geary, Lambie, & Seymour (2010), Journal of Sexual Aggression Consumer perspectives of effective treatment Treatment Therapist characteristics (caring, supportive, challenging, respectful) Cultural sensitivity Family involvement Strengths-based model of treatment Creative and physical treatment activities for youth Parent groups (reduced isolation) Kimonis, Fanniff, Borum, & Elliott (2011) Clinician's perceptions of amenability to sexual offencespecific treatment Sexual Abuse: A Journal of Research and Treatment, 23, 193-211 158 ATSA members surveyed 80 potential factors Worling, 2016 Texas CSOT 24

Parent willing to participate in youth s treatment Parental belief in efficacy of treatment Strong social support Strong bond to at least one prosocial adult Ability to form trusting relationship Good amenability Youth has motivation to change Youth believes in efficacy of treatment Youth has hope that offencefree future is possible Good amenability 2010 Behavioral Sciences & The Law, 28 20-year prospective follow-up study of specialized treatment for adolescents who offended sexually Worling, Litteljohn, & Bookalam SAFE-T Program, Thistletown Regional Centre Worling, 2016 Texas CSOT 25

Follow-Up Data Canadian Police Information Centre (CPIC) Minimum of 12 years post initial contact Maximum of 20 years Mean = 16.23 years (SD = 2 years) Average age of participants at follow up: 31 Percent recidivism: 20 year follow-up 60 50 40 30 20 10 Treatment Comparison all ps <.05 0 Sexual Nonsexual violent Nonviolent Any Age 25 Treatment Comparison 10 years Thank you so much for your time and attention, and all the best in your work! Jim Worling, 2016 Texas CSOT 26