BEST PRACTICE & EVIDENCE-BASED TREATMENT

Transcription

1 Rob Butters PhD LCSW 1 BEST PRACTICE & EVIDENCE-BASED TREATMENT SEXUAL ASSAULT

2 About Me 2 Assistant Professor, College of Social Work, University of Utah. Chair of Forensic Social Work at CSW, U of U Director, Utah Criminal Justice Center Primary Investigator on over 20 funded research projects. Clinical Director at LifeMatters Counseling & Health Center. Worked with offenders and victims of crime for 20 years. Specialties include forensic social work, evidence-based practice, restorative justice, domestic violence, sexual abuse & assault, empathy. Rob Butters PhD LCSW

3 3 Guiding questions for today: 1. What do typical sexual assault survivor and offender treatment programs look like? 2. What does the research on treatment programs and are these programs effective in improving outcomes? 3. What are the characteristics of effective treatment programs? 4. How can I use the principles of effective programs to improve treatment and outcomes for victims and offenders? Rob Butters PhD LCSW

4 Effective Treatment Modalities? 4 Effective: Prolonged Exposure Therapy (Foa 1991, Resick 2002, Rothbalm 2005) EMDR (Rosenbaum1997 & 2005) Cognitive Processing Therapy (Resick & Schnicke 1992, Resick 2002) Not-effective: (Regehr et al 2013) Supportive Counseling & Psychotherapy Assertiveness training Rob Butters PhD LCSW

5 Effectiveness of sexual assault Survivor 5 Interventions (Regehr et al 2013) 6 studies total, including 405 participants Overall effect Reduction is PTSD symptoms Self Report ES = 1.9 Clinician report = 1.8 Depression ES = 1.1 Anxiety ES = 1.1 Dissociation ES = 0.94 Rob Butters PhD LCSW

6 Sexual assault survivor interventions 6 Research on effectiveness is lacking despite the widespread recognition of sexual violence and its aftermath for almost four decades, there continues to be a surprising and discouraging paucity of rigorous evaluations of interventions aimed at reducing distress experienced by victims. (Regehr et al, 2013 p. 263) There are promising practices but many practitioners focus on supportive therapies or on the modality of the week Effective interventions are TRAUMA FOCUSD! Rob Butters PhD LCSW

7 Adult vs. Juvenile Sex Offenders 7 o Pedophiles/Sex Offenders Youth with Sexual Behavior problems o Deviant Arousal Sexual Mis-Education o Lengthy History of Sexual Offending Few hands-on offenses o Criminal behaviors generally limited to sex focused behaviors Often have diverse criminal behaviors, ATOD Rob Butters PhD, LCSW

8 Recidivism Rates for Juveniles Rob Butters PhD, LCSW ing.com 8

9 Adult Sexual Offender recidivism (Hanson et.al 2009) 9 Sexual reoffense Treated 10.9% Untreated 19.2% General Reoffense Treated 31.8% Untreated 48.3% Rob Butters PhD, LCSW

10 10 Meta-analysis of Juvenile SO (Sarver, Molloy, Butters 2012) Average reduction in sexual recidivism g = 0.28 Rob Butters PhD LCSW

11 Meta-analysis of Adult SO (Sarver, Molloy, Butters 2012) 11 Adult SO reduction in sexual recidivism g = 0.67 Rob Butters PhD LCSW

12 Overview of SO Treatment 12 Treatment is targeted to address risk factors identified in the risk assessment. Sex Specific Treatment is highly effective <10% recidivism Treatment is highly specialized and utilizes proven, evidence-based interventions Cognitive-Behavioral Therapy techniques Targets thought, feelings, and actions Reduce dysfunctional thoughts and behaviors, increase healthy thoughts and behaviors CBT has consistently been found to be the most effective treatment modality Cornerstone of treatment is to take personal responsibility, not just for abuse but in all aspects of life. Treatment providers are careful about contamination effects Rob Butters PhD, LCSW

13 Examples of Therapy Assignments 13 Autobiography Full Disclosure of Offense Letter(s) of Apology Relapse Prevention Plan Risky Situations Consent Abuse Cycles Healthy vs. Unhealthy Arousal Fantasy Pornography Empathy Social Skills Impulsivity Aversive Conditioning Journaling Rob Butters PhD, LCSW

14 Ineffective Approaches Psychoeducation Shaming offenders Non-directive, client centered approaches Gestalt Bibliotherapy Freudian approaches Self-Help programs Vague unstructured rehabilitation programs Medical model Fostering self-regard (self-esteem) (Lowencamp et al, 2006; Lilienfeild 2007)

15 Lillienfeid (2007) and the Dodo Bird 15 Effect Everyone has won, and all must have prizes. Rob Butters PhD LCSW

16 Effective treatment programs Rob Butters PhD, LCSW ing.com Any treatment program is only as good as its weakest component: Assessment Treatment/programming Supervision (offenders) Re-assessment Transition Aftercare 16

17 Length of SO Treatment 17 Varies according to presenting offense, risk to re-offend, and level of treatment 2 months-18 months Shorter is better Goals are to help the client function successfully in the community, not to function well in an artificial clinical, residential, or institutional setting. But, treatment is complex and holistic The immediate, external risk factors are addressed quickly Internal factors that may contribute to long-term health and safety may require more intensive and longer treatment Therapy is more that just a collection of assignments and termination should be guided by clinical judgment and a review of risk factors. Families and support system play a large role Especially when considering returning home Rob Butters PhD, LCSW

18 Predictors of treatment success? 22 Common factors: Humanistic (Wampold, 2012) Making sense of the world Influencing through social means Connectedness Expectation mastery Treatment engagement, retention, & completion Treatment adheres to RNR Model (Bonta & Andrews, 2010) Risk: Placed at appropriate level of treatment for risk level (offenders) safety and need (for survivors) Need: Target specific factors that are correlated with positive outcomes Responsivity: treatment is individualized Skillful clinical staff (and line staff) Remediation of mental health issues Engagement with outside support system 18

19 Characteristics of Effective Offender 19 treatment Programs Lowencamp, Latessa, & Smith (2006), Andrews & Bonta (2010) The term what works means that evidence exists that the program or intervention is effective in reducing recidivism. Effectiveness is demonstrated through empirical research not stories, anecdotes, common sense, or personal beliefs about effectiveness. Evidence strongly indicates that TREATMENT is more effective in reducing recidivism than PUNSIHMENT. But Not All Treatment Programs Are Equally Effective Absent rigorous outcome research on a given program we can evaluate a program using the principles of effective interventions. Rob Butters PhD LCSW

20 Characteristics of Evidence-Based Programs Risk Principle (WHO) Primary Focus on HIGH Risk Need Principle (WHAT) Target Criminogenic Needs Treatment Principle (HOW) Use Behavior Approaches Responsivity (HOW) Ability and Capacity to Match Behavior Treatment to offender Needs Program Integrity (HOW WELL) - Ensure quality Implementation and Improvement Gendreau, P., French, S. A., & Gionet, A. (2004). What works (what doesn t work): The principles of effective correctional treatment. Journal of Community Corrections, 13, 4-6,

21 Overview of the Correctional Program Checklist (CPC) Developed at University of Cincinnati Based on the what works literature- based on evidence (i.e., the results of meta-analytic reviews) - based on the collective experience of authors and associates Based on the results of over 400 evaluations and three large outcome studies conducted by the University of Cincinnati Criminal Justice Center (40,000 Offenders) 77 items for a possible score of 0-83 HIGHLY EFFECTIVE (65% to 100%); EFFECTIVE (55% to 64%); NEEDS IMPROVEMENT (46% to 54%); or INEFFECTIVE (45% or less).

22 CPC Areas of Assessment Content Offender Assessment Risk and Needs Treatment Characteristics CBT, Social Learning Capacity Program Leadership - Responsivity Staff Characteristics - Responsivity Quality Assurance and Improvement

23 Components of the CPC Evaluation Staff survey of experience, education, and training Structured interviews with program director and staff using evaluation questionnaire Program file review Program participant interviews Group observation assessment Family interviews Review of assessment instruments and scoring guide

24 Average CPC Scoring The University of Cincinnati developed averages and norms for the CPC based on an evaluation of over 400 programs (Shaffer 2007)

25 Reduction in Recidivism Community Based versus Institutional Programs: Results from Meta-Analyses of Programs Based on Principles of Effective Treatment Community Based Institutional Source: Gendreau, P., French, S.A., and A. Taylor (2002). What Works (What Doesn t Work) Revised Invited Submission to the International Community Corrections Association Monograph Series Project.

26 Risk Principle 1. Target those offenders with higher probability of recidivism 2. Provide most intensive treatment to higher risk offenders 3. Intensive treatment for lower risk offender can increase recidivism

27 Change In Recidivism Rates The Risk Principle & Correctional Intervention Results from Meta Analysis High Risk Low Risk Dowden & Andrews, 1999

28 Change in Recidivism Rates Risk Principle Ohio Study of Low Risk Offenders Lowenkamp, C. T., Latessa, E. J., & Smith, P. (2006). Does correctional program quality really matter? The impact of adhering to the principles of effective intervention. Criminology and Public Policy, 5 (3),

29 Change in Recidivism Rates Risk Principle Ohio Study of High Risk Offenders Lowenkamp, C. T., Latessa, E. J., & Smith, P. (2006). Does correctional program quality really matter? The impact of adhering to the principles of effective intervention. Criminology and Public Policy, 5 (3),

30 Goals of Assessment 1. To identify risk of recidivism 2. To identify appropriate offenders for programs 3. To identify criminogenic needs 4. To identify factors that can affect program success 5. To provide risk & need levels that will facilitate development of case plan 6. To facilitate reassessment of offender to determine which risk & need factors have changed

31 JSORRAT-II score x Recidivism risk 31 Rob Butters PhD LCSW

32 Best Practices in Assessment 1. Assessment process is systematic, objective, and standardized 2. Use Instruments that are normed and validated 3. Best predictors of criminal behavior: a. Static factors past criminal behavior (best) b. Dynamic factors crime producing needs c. Latest generation of instruments allow for measurement of change in offender 4. Programs need screening criteria-to be good, you can t take everyone. a. Screen out low risk offenders! 5. Offenders should be assessed on all major risk, need & responsivity factors. 6. Levels of risk, need & responsivity are determined by assessment process 7. Offenders should be reassessed regularly 8. Discharge criteria should be tied to a re-assessment of risk and need (an objective reduction of risk and need)

33 Criminogenic Needs (Big 4) 1. Antisocial Behavior: Exploitive, aggressive, or harmful behavior toward others 2. Antisocial Personality Pattern: Impulsive, sensation seeking, risk-taking, aggressive, manipulative and exploitive. 3. Antisocial Cognition: Values, beliefs, and cognitions that contribute to personal identity that favors criminal behavior. 4. Antisocial Peers

34 Criminogenic Needs (moderate 4) 5. Family: Chaotic and poor-quality family relationships that have minimal or no pro-social expectations. 6. School/Work: Poor performance and limited engagement with school or work 7. Leisure & Recreation: Limited involvement in anticriminal leisure activities. 8. Substance Abuse: Use and abuse of alcohol, tobacco, or other drugs (ATOD).

35 Change In Recidivism Rates Need Principle and Correctional Intervention Lowenkamp, C.T., Pealer, J., Smith, P., & Latessa, E.J. (2006). Adhering to the risk and need principles: Does it matter for supervisionbased programs? Federal Probation, 70 (3), Target 1-3 more criminogenic needs Target at least 4-6 more criminogenic needs

36 Criminogenic Need Antisocial Behavior Exploitive, aggressive, or harmful behavior toward others Treatment Targets Increase pro-social behaviors by reinforcing prosocial beliefs supporting a crime-free lifestyle. Develop clear, consistent, and proximate reward and consequence system for addressing behaviors. Teach, model, and reinforce pro-social alternative behaviors, especially in high-risk situations. Antisocial Personality Pattern Impulsive, sensation seeking, risk-taking, aggressive, manipulative and exploitive. Antisocial Cognition Values, beliefs, feelings, and cognitions that contribute to personal identity that favors and reinforces criminal behavior. Treatment target: increase self-control and delayed gratification skills, anger and conflict management, problem solving and reinforce prosocial, reciprocal interpersonal interactions. Address cognitive distortions and rationalizations that maintain a criminal identity. Build, practice, and reinforce new cognitions and attributions that lead to positive outcomes through cognitive restructuring and cognitive-behaviors therapies. Antisocial Peers Preferring to associate with pro-criminal peers and isolation from anti-criminal peers and social contexts. Reduce and eliminate association with delinquent peers and increase opportunities for regular association with anti-criminal peers and institutions (school, church, clubs, sports teams, and other structured and supervised activities). Family Chaotic and poor-quality family relationships that have minimal or no pro-social expectations regarding crime and substance abuse. Increase pro-social communication, nurturance, structure, supervision, and monitoring in the family. Address dysfunctional boundaries and role confusion. Implement behavioral management system that provides for consistent rewards for pro-social family interactions. School/Work Poor performance and limited engagement with school or work resulting in dissatisfaction and avoidance of these institutions. Increase school engagement and performance in work and school though remediation of barriers to satisfaction i.e. Individualized Education Plan, additional job training or alternate job placement. Implement monitoring and behavioral reinforcement program to increase consistent attendance at school and work. Leisure & Recreation Limited involvement in anti-criminal leisure activities. Substance Abuse Use and abuse of alcohol, tobacco, or other drugs (ATOD). Expose youth to a variety of pro-social leisure and recreational activities. Increase opportunities for regular involvement in preferred activities and reward milestones in achievement. Reduce substance use through targeted treatment, increase supervision and reduce access to ATOD, and reduce exposure to ATOD using peers. Increase capacity to cope with stressors though lifestyle changes like regular exercise, sleep, and nutrition. 36 Butters, R. P. (2014) Community Based Treatment Interventions. In W. Church & D. Springer (Eds.), Juvenile Justice Sourcebook. New York, NY: Oxford University Press.

37 Treatment Principle The most effective interventions to change behaviors are Grounded in Behavioral therapy (and enhanced by cognitive interventions) 1. Focus on current factors that influence behavior 2. Action oriented-role plays, experiential, practice 3. Offender behavior is appropriately reinforced a. Effective use of rewards and punishers

38 Most Effective Models Structured social learning where new skills and behavioral are modeled Cognitive behavioral approaches that target criminogenic risk factors Family based approaches that train family on appropriate techniques

39 Behavioral vs. NonBehavioral Reduced Recidivism Increased Recidivism Nonbehavioral (N=83) Behavioral (N=41) Andrews, D.A An Overview of Treatment Effectiveness. Research and Clinical Principles, Department of Psychology, Carleton University. The N refers to the number of studies.

40 The Four Principles of Cognitive Intervention 1. Thinking affects behavior 2. Antisocial, distorted, unproductive irrational thinking causes antisocial and unproductive behavior 3. Thinking can be influenced 4. We can change how we feel and behave by changing what we think

41 Social Learning Refers to several processes through which individuals acquire attitudes, behavior, or knowledge from the persons around them. Both modeling and instrumental conditioning appear to play a role in such learning

42 Evidence-based Group Treatment Facilitator provides a brief background on target behavior(s), i.e. violence, substance use, family discord (this could be place to use an engaging video clip, other media, or current event). 2. Identify the underlying thoughts, feelings, cognitions that are associated with the dysfunctional behavior. 3. Identify thoughts are dysfunctional, cognitive distortions, or misattributions. 4. Explore alternative thoughts/attributions and explore feeling associated with those options 5. Identify healthy thinking and behavioral alternatives 6. Facilitator models prosocial thinking and resulting behaviors for group 7. Participants role play real scenario while being directly observed by facilitator 8. Facilitator provides positive reinforcement for successes, provides feedback for improvement. 9. Participants continue to practice until skill, in increasingly challenging scenarios, until mastered. 10. Participants are provided homework to practice skill at home or school and report back to group on successes and challenges. Butters, R. P. (2014) Community Based Treatment Interventions. In W. Church & D. Springer (Eds.), Rob Butters PhD LCSW Juvenile Justice Sourcebook. New York, NY: Oxford University Press.

43 Responsivity: Interventions should match the uniqueness of the offender Culture Gender Trauma Learning/cognitive disability Motivation Reading ability Personality characteristics Mental Health

44 Last slide but most important! 44 There are effective modalities to treat both survivors and offenders of sexual assault But not all interventions are equal It is a social justice-and ethical-that we provide clients with the highest likelihood of success That means adding some Evidence-based practice to you mad clinical skills. Cognitive and behavioral approaches tend to yield the fastest and most durable results. Making that extra effort to collaborate yields big dividends most of the time we don t because us advocates & clinicians are uncomfortable or unsure. We re all (offender and victim specialists) really on the same team- right? We all speak a similar language about treatment-especially principles of EFFECTIVE treatments Rob Butters PhD LCSW

45 Thank you! 45 Office: Rob Butters PhD LCSW