Managing complex sex offenders in the community

1. Managing complex sex offenders in the community Jackie Craissati Oxleas Foundation NHS Trust

2. ….or….. • ….The road to desistance is a long and bumpy one, necessitating a collaboration with the offender which stretches way into the distance….

3. What does “complex” mean • Recidivism versus failure • Developmental variables and personality disorder • Variable definitions • A psychological approach to management • Psychodynamic & CBT • Anticipating problems • Adjusting treatment approaches • Clinical vignettes & discussion

4. My credentials • Specialising in failure • Specifically, sex offenders who have • Failed to participate in treatment • Failed to complete treatment • Failed to stay in the community • Failed to refrain from sexual re-offending

5. The Challenge Project • A community assessment and treatment programme for sex offenders in S.E.London • a partnership between Oxleas NHS Foundation Trust (forensic mental health) and the London Probation Area • running 13 years (CM), and 10 years (R)

6. METHOD • All convicted sex offenders (at sentencing and/ release from prison) • Living in S.E. London • Probation files for all • Psychological assessment for 66% • Psychometrics pre and post treatment

7. ‘Key developmental variables’ definition • Sexual victimisation • Physical victimisation • Emotional abuse/neglect • 2+ childhood difficulties • That is, significant developmental trauma associated with impaired attachment experiences leading to enduring psychological difficulties

8. Sexual victimisation • Sexual contact with another person that was either unwanted or perpetrated by an adult at least 5 years older than the subject • tell me about your first sexual experience • did you ever get involved in sex play with other boys? • have you ever been touched by someone in a sexual way when you were a child, which made you feel uncomfortable?

9. Physical victimisation • Physical contact, perpetrated by an adult on a number of occasions, which was unprovoked or excessive in relation to any misdemeanour committed by the participant.

10. Emotional abuse or neglect • Persistent and marked failures on behalf of the caring adult(s) to provide adequate and consistent care.

11. 2 + Childhood Difficulties • Before the age of 16, problems with two or more of the following: • truanting • bullying/ being bullied • miserable a lot • no friends • aggression/expulsion • bed wetting/ soiling

12. Failures – 4 police/home office databases • Formal failure at follow-up • sexual, violent & other reconvictions • breach/recall for other behaviours • Treatment failure • attrition (failing to complete for any reason) • non-compliance (2+sessions missed or formal failure during treatment)

13. Failures - sexually risky behaviours • SRB 1 (general) • Any intelligence which could be suspicious (kids in car, minicab driver); includes SRB 2 and SRB3. • SRB 2 (serious) • Any intelligence/allegations which suggest that an offence was about to happen, or may have happened (unsubstantiated allegations, ‘sex talk’); includes SRB 3. • SRB 3 (offence) • Any offence with sexual element, charges/acquittals with strong supporting evidence

14. Challenge data – total subjects 301

15. Risk Matrix 2000 base rates

16. Risk Matrix 2000 and Failure

17. Failure - enhanced prediction model (AUC)

19. Probation research: personality disordered sex offenders • 162 CM and 79 R, contact, community • Any one childhood trauma (emotional abuse or 2+ childhood difficulties) significantly associated with: • Adult contact with MH services • Elevated OASys mental health score • PD diagnosis (MCMI) • 2 or more PD clusters • PCL-R score

20. Why worry about PD and failure?

21. PD definition : the 3 P’s • Pathological • Significantly deviating from the social norms • Persistent • From 20’s onwards • Pervasive • Social, employment, personal contexts • Across domains • Cognitive • Affective • Interpersonal • NB • causing distress to self or others • Not exclusively related to sexual offence

23. How to get rid of PD • Natural resolution over time (2-10 years) with 10-80% no longer meeting the diagnostic criteria • Two components: • Immutable core personality traits (callousness, egocentricity, emotional sensitivity) • Responsivity to the emotional/behavioural expression of such traits

24. Personality disordered offenders: problem domains Offending behaviour Social functioning & care Mental health & psychological need

25. Management – integrated structures

26. When MAPPA encounters high risk, personality disordered sex offenders…?

28. A psychoanalytic perspective • “The view is taken that professionals who deal with offenders are not free agents but potential actors who have been assigned roles in the individual offender’s own re-enactment of their internal world drama. The professionals have the choice not to perform but they can only make this choice when they have a good idea of what the role is they are trying to avoid. Until they can work this out they are likely to be drawn into the plan..” (Davies)

29. The cognitive perspective: activation of core beliefs

30. What to expect from PDSO’s • Rule breaking for the sake of it • Excessive confiding or secretiveness • Emotional instability – needy then oppositional • Impulsive behaviour • Inability to disentangle care from control • Thinking one thing, doing another • Role of fantasy as compensatory rather than rehearsal • Forming alliances with other sex offenders • Inflexible cognitive style and poor perspective-taking

31. What to expect from MAPPA in response to PDSOs • Arguments between agencies • Mistaking co-operation for reduced risk • Assuming unco-operativeness equals higher risk • Taking their eye off the ball • Persecutory intrusion & control • “Common sense” but “irrational” controls • Betraying the offender’s honesty/trust

32. Aim – desistence To assist the PDO to integrate successfully into the community, enabling him to maintain an improved quality of life, with the appropriate level of support, the least possible restrictions and minimising potential harm to the public Aim – public protection To ensure the PDO’s risk of re-offending is minimised, thereby protecting the public and contributing to a safer community, with concern for the prevention of harm to future victims, and the successful rehabilitation of the offender into the community. Negotiating an integrative model

33. Role of treatment in maximising possibility of DESISTENCE • Criteria: at least 2 of the following • High or v.high on risk matrix • Prior failure to start or complete treatment • History of contact with mental health services • Persistent problems with interpersonal functioning

34. Preparation for treatment • Collaboration with client involves: • Scoring psychometrics together • Re-reading victim statements to identify areas of agreement • Agreeing treatment goals in line with client self-interest • Provisional written formulation of the meaning of the offending in relation to client’s life experiences • Treatment rules • Attend on time • Say something each week • NB. Slow open group format carries the culture

35. Group treatment • Process • Anticipate replication of family patterns • Explicit focus on group relationships • Behavioural conditioning of social interactions in group • Attending to the 2 rules in early weeks • Content • Less on offence/victim empathy, more on attachment/schemas • Individualised plan for prioritising dynamic factors/domains (eg, sexualisation of kids or reckless decision-making)

36. Relapse prevention goals: Avoid kids Avoid single mums Avoid parks Avoid low mood Avoid masturbation Avoid the beach Avoid other sex offenders Good life goals: Seek friendship & intimacy (obstacle=attraction to boys, not men) Seek value via competence/mastery (obstacle=social exclusion/lack of skills in team working) Spiritual fulfilment (obstacle=managing contact with kids at church) The future: good lives

37. Parallel interventions • Individual psychological work • Fantasies • Childhood trauma • Supportive psychotherapy • Psychiatric input • Occasional and ‘symptom’ specific • SSRI’s, anti-libidinal, beta-blockers, olanzapine • Structured work allied to project (First Step Trust)

38. Life after the group • Attachment fostered towards the project • Continuing psychological support • 3 day RP group turning into an annual maintenance group • ‘holding in mind’ • Letters (therapist and group) • Phone calls • Telling group about outcomes, modelling compassion • Role of secretarial staff • The Project-client relationship is central, failures are merely learning points along the way

39. 4 case vignettes • All high risk on RM 2000 • All with PD diagnosis • All spent more time in prison than in the community • All trying to change their behaviour • All managed competently

40. Graham – 30 (boys) • Paranoid & antisocial • Community for 6 wks in 16 years • Licence • Night work on motorways not possible with curfews • “unsuitable” partner 20 years older, interfering • Nightmares just before “confessing” to probation of a further sexual assault • False confession, 3 further yrs in prison

41. Graham - outcome • Released at end of sentence • Only sees therapist, controls frequency • Works hard • Married older girlfriend • “I don’t do anger any more” • 2.5 yrs in, ‘blip’ with threats from brother, replication of earlier ‘lapse’ but managed differently • Successfully and happily at liberty for 3 years

42. Paul – 50 (boys) • Borderline, dependent PD • Requests probation/police permission to visit seaside with another (incest) sex offender • Refused, friend warned off him • Refusal experienced as emotional withholding (like dad), increased isolation, increase in deviant fantasies • Followed, breached, chatting to 15 yr old re. porn @ bus stop

43. Paul - outcome • SOPO • Police assume forensic mental health is in control, little contact, then, repeated visits, disclosures, banned from all local public areas • Refused supported housing (risk) • Paul confides in his “support network” (police) re. contact with neighbour • Unlovable, lonely, ‘harmless’ chats to kids with their mums • breached on 3 occasions in 4 yrs • FMH create artificial family/world around him, shielding him from real world

44. Jack – 58 (sadistic sexual murder on woman 28 yrs previously) • Exemplary progress • PRES for 18m easy, with no rules • Released 12m in probation hostel • Disclosure letter to employers • Request to reduce risk status from high to moderate • Request to undertake counselling course • Refused (just prior to PO’s holiday)

45. Jack - outcome • Within 1 day, drinking, bondage porn • Within 2 days, planning an offence • Within 5 days, re-offended, no attempt to conceal it • “if they think I’m so high risk, I’ll f***ing show them what high risk is” • “shall I ring Jackie? It’s on my relapse prevention plan”

46. Conclusions • Approaches which work for mainstream sex offenders may have unexpected effects on high risk PD sex offenders • Childhood trauma & behaviour are good markers for PD in adulthood • PD differentiates between those sex offenders likely to succeed and those likely to fail (not necessarily sexually re-offend) • There is evidence for desistence with age in both the PD and the offending literature • There are few rights and wrongs to managment, only dilemmas • There is a fine line between control and persecution • Treatment is not a stand-alone approach, but may contribute to a desistence model • Social exclusion is an inevitable consequence of rigorous risk management • Enthusiastic recalls/breaches is resulting in a group of aggrieved, unmanaged offenders

47. ….or….. • ….The road to desistance is a long and bumpy one, necessitating a collaboration with the offender which stretches way into the distance….