Empathy in Sex Offender Treatment: What it is, how it develops, and when it doesn’t

1. Empathy in Sex Offender Treatment: What it is, how it develops, and when it doesn’t David X. Swenson PhD LP Gerald Henkel-Johnson PsyD LP MNATSA 2012 Full powerpoint available at: http://faculty.css.edu/dswenson/web/sitemap.html

2. Agenda • Function & types of empathy • Development of empathy • Hereditary & neurological basis of empathy deficits • Empathy deficits of offenders (callous-unemotional traits, brain injury) • Treatment considerations

3. Function & Types of Empathy Walk in another’s shoes…

4. Yawning • Extreme Skiing • Laughing baby

5. The Functions of Empathy • Establish relationships & bonding • Supplements objective knowledge • Helps make predictions about others • See other sides of arguments; facilitates negotiation • Enables cooperation • Tool for persuasion & manipulation • Creates common social grouping & cohesion • Enables trust

6. The structure of empathy Supportive empathy Emotional enmeshment Psychopathic callousness Professional distancing Generalized empathy for nonvictims; defensive nonempathy for victims Autistic offenders

7. Moderators of Automatic Empathy Emotional Cue Context “automatic” response Empathic Response Appraisal Processes modulation • Low familiarity, identification, or similarity with the subject • Lack of previous similar experience • Knowledge of deceptive, deviant motivation • Self-implication (e.g., jealousy, anger) • Preoccupation with personal goal focus (psychopath) • Professional perspective taking • Generality vs specificity de Vignemont, F., & Singer, T. (2006). The empathic brain: How when and why? Trends in Cognitive Sciences, 10(10), 435-441.

8. Perspective Taking (Theory of Mind, Mind-Reading, Mentalizing) (Baron-Cohen, 1995) “I think she thinks I think…” “I think …” “I think he thinks…”

9. If I can’t see them, they can’t see me”: Theory of Mind • ToM is the ability to infer the full range of mental states (e.g., beliefs, desires, intentions, emotions) • Autistic thinking does not recognize what others do and do not know • Low ToM people may not be able to identify or empathize with others • They have limited ability to consider how behavior affects others • Antisocials may be able to accurately infer, but this becomes irrelevant when goal-focused Sally-Ann Test Perspective Taking (Theory of Mind, Mind-Reading, Mentalizing) (Baron-Cohen, 1995)

10. Emotional empathy involves the limbic and paralimbic structures that develop early. • somato-sensory areas for touch • insular and anterior cingulate cortex (ACC) for pain & disgust • amygdala for fear • Cognitive perspective taking involves the pre-frontal and temporal cortices that develop later (not until age 25): • medial pre-frontal lobe (mPFC) • posterior superior temporal sulcus (STS) the anterior insula and anterior cingulate cortex are activated when viewing disgust expressions, while the amygdala is activated when observing faces displaying fear or distress (Decety & Jackson 2006).

11. Development of Empathy A P M T E

12. Heredity: 1/3-1/2 of empathy is hereditary (Knafo et al. 2008). Early Empathy Development Newborns: reactive crying or emotional contagion; self comforting to reduce personal stress from other’s negative emotions; facial expression imitation 2 years: verbal comfort and advice, sharing, and distracting the person in distress; beginning of self recognition 3 years: expressing verbal and facial concern and interest in another’s distress, and continued to engage in a variety of helping behaviors 4-5 years: initial perspective taking; false belief task; attach empathic feeling to conception of others’ experience more effective helping Late Childhood: Awareness beyond immediate situation; awareness of groups of people, and chronicity of distress Adolescence: stages of moral reasoning Late Adolescence-Early Adulthood: Maturity of perspective taking Roth-Hanania, Busch-Rossnagel, & Higgins-D’Allesandro, (2000)

13. Normal attachment Normative Healthy Attachment • eye contact • cooing • crying • smiling • reaching • grasping • approaching • following • discomfort • hot/cold • hungry • happy • afraid • angry • tired • wet Availability Sensitivity Responsiveness Consistency • prolonged gazing • kissing • cuddling • fondling • high voicing • rocking • rhythmic contact • seek closeness & reciprocity • frustration tolerant • high intimacy • long lasting relationships • high levels of commitment • high relationship satisfaction • stress resilient • fewer physical & psychological problems • less aggressive, more cooperative • high belonging • Secure attachment • trust • safe/secure • regularity • easier to comfort • more affectionate

14. Poor attachment • mental illness • postpartum depression • attachment disordered • chemical abuse • physical illness • multiple caretakers • frequent moves • criminal behavior • preoccupation • separation/divorce • death • PDD Attachment Problems • Unresponsive to Comforting • severe illness • premature birth • surgeries/pain • hyperactive • hospitalizations • colicky • autistic • FAS/FAE • Insecure Attachment • untrusting • fearful • angry • physical abuse • domestic violence • absence • neglect • inconsistency • over/under stimulate • over/under attentive • rejecting • Early indicators • poor clinging & stiffness • poor sucking response • weak crying, rage, constant whining • poor eye contact, tracking • indifference to others • not recognize parent • delayed motor skills • flaccid

15. r=.53* r=.74* r=.27* Consistent, sensitive and appropriate care-giver response to distress Positive emotionality: ability to monitor or adjust the duration or intensity of emotional reaction to cope constructively with a distressing situation or achieve a goal Empathy Internal Working Model Empathic modeling Stress Negative emotionality: the frequency, speed, and ease of onset, intensity, and duration of negative affective states, such as sadness, anger, and fear Inconsistent, insensitive, or dismissive responses Empathic overarousal becomes overwhelmed with negative affect and refocuses efforts on reducing their own distress Panfile, T. M., & Laible, D. J. (2012). Attachment Security and Child’s Empathy: The Mediating Role of Emotion Regulation. Merrill-Palmer Quarterly, 58(1), 1-21.

16. Wei, M., Liao, K. Y-H, Ku, T. Y., & Shaffer, P. A. (2011). Attachment, self-compassion, and subjective well-being among college students and community adults. Journal of Personality, 79, 191-221.

17. Unempathic response to victim Unempathic response to victim Unempathic response to victim (Un)Empathic Process in Offenders Blocks recognition of harm Low self esteem Shame Unempathic response to victim Recognizes harm Overwhelmed by personal distress Shame Self focus on reducing own distress Low self esteem Unempathic response to victim Uncaring/hostile toward victim or sadistically disposed Adequate self esteem Unempathic response to victim Able to take perspective of victim Compassionate emotional response Adequate self esteem Recognizes harm Guilt Reparative action Empathic accuracy Sympathy Empathy Empathy (Marshall, Marshall, Serran, & Obrien, 2009)

18. Neurological Basis of Empathy deficits

19. Empathy– The “mirroring” of emotions

20. Our brains react as if we are the athlete

21. What are these people feeling?

22. Mirror neurons: Monkey see, monkey do • Newborns as young as 72 hours old can imitate some facial expressions • A mirror neuron is a neuron which fires both when an animal performs an action and when the animal observes the same action performed by another • mirror neurons have been found in the premotor cortex (motor behavior) and the inferior parietal cortex (distinguishing self/other) • These appear to be involved in understanding intentions of others, empathy, predicting actions of others, and social bonding • Such empathy usually prevents us from causing discomfort to others (Blair’s theory of Violence Inhibition Mechanism)

24. Faulty Facial Processing by adult psychopaths • fMRI tested 9 normal and 6 criminals in their response to joyful & neutral, and fearful & neutral facial expressions • Normals showed reaction to distressed sad and fearful faces, while psychopaths showed even less activity than when they viewed neutral faces • Antisocials misinterpret social cues & attribute hostile intentions • Impairment in deep emotional relationships that come from reading emotion cues • Less communication between amygdala and ventromedial prefrontal cortex impairs processing of fear and moral reasoning • Conclusion: the neural pathways that are supposed to process human emotion are either non-functional or are processed differently– psychopaths don’t identify with the emotional stress of their victims Deeley Q, Daly E, Surguladze S, Tunstall N, Mezey G, Beer D, Ambikapathy A, Robertson D, Giampietro V, Brammer MJ, Clarke A, Dowsett J, Fahy T, Phillips M and Murphy DG (2006). Facial emotion processing in criminal psychopathy. Preliminary functional magnetic resonance imaging study. British Journal of Psychiatry, 189, 533-539.

25. “I gotta feeling”…or not! • The amygdala is involved in aversive conditioning and instrumental learning (e.g., learn goodness & badness of actions), and passive avoidance learning (stopping actions when they will result in punishment) • Also involved in fearful and sad facial expressions • fMRI’s show reduced amygdala volume and psychopathic functioning • The ventromedial PFC & medial OFC gives and receives projections from the amygdala & is involved in instrumental learning and response reversal • Social convention, care-based morality, disgust-based morality and fairness/justice are impaired

26. Hypersensitive Brain Reward System • Heightened expectation of reward interferes with anticipation of consequences • Combined with reduced empathy this leads to more manipulative & aggressive behaviors • Amount of dopamine released was up to four times higher in people with high levels of these traits, compared to those who scored lower on the personality profile

27. The brain during empathy response fMRI scan shows normal brain activity with empathy on left; psychopathic low activity on right Participants were asked to view pictures of unpleasant scenes and people experiencing distress Department of Clinical and Cognitive Neuroscience, University of Heidelberg Laughing Baby

28. “That was funny!”— enjoying the pain of others • Aggressive youth were shown clips of a pianist having fingers pinched by closing the piano lid on them • Areas related to processing pain were activated, but… • So were the amygdala and ventral striatum (reward centers) • Unlike unaggressive youth, aggressives did not activate medial prefrontal or temporoparietal junction associated with self regulation (impulse control) • Youth without aggression problems did not show the same activation, but instead it evoked empathy • We tend to be more empathic with people we view as similar to ourselves http://huehueteotl.wordpress.com/category/science/neuroscience/

29. Lykken study startle The amygdala is 17% smaller in psychopaths Normal people show fear, startle, and avoidance reactions to painful stimuli– psychopaths don’t

30. Poor discrimination between emotional & non-emotional cues Screaming Laughter Persons with high affective-interpersonal psychopathic traits (e.g., superficiality, manipulative, charm, lack empathy) show reduced GSR to both pleasant & unpleasant sounds (Verona, et al., 2004)

31. Non-reactivity to Emotional Stimulation Antisocials react to horrific pictures the same as they do to neutral pictures

33. Vancouver child rapist, Clifford Olson: “If I gave a shit about the parents, I wouldn’t of killed the kid.” Empathy in Sexual Sadists • Sexuality and aggression appear to be linked early in experience • They often have high perspective taking in order to con their victims • Sadistic arousal is enhanced by victim perspective taking and empathy with their suffering (Ward, Polaschek, & Beech, 2006) • Some non-psychopathic sadists appear to compartmentalize their victims (e.g., Kenneth Bianchi), doubling (separate selves), and dehumanizing stereotyping • Suffering of others may elicit overwhelming empathy that switches to anger as they gain revenge or control over their own abuses • Empathy enhancement is not recommended with sadists, particularly when they have psychopathic features (Thornton, 2006)

34. Moral Reasoning or not…

35. The Brain and Ethical Reasoning: The lesser of two evils “You are standing next to a switch in a trolley track and you notice that a runaway trolley is about to hit a group of five people who are unaware of their danger. However, if you switch the track, the trolley will hit only one person. What do you do?”

36. “You are standing on a bridge over a trolley track beside a single person. Again you notice that the runaway trolley is headed toward five unaware people. Do you push the single person onto the track to stop the trolley?”

37. Brain injury & moral choices: “Willingness to violate moral choices of any type” Ventromedial Cortex Koenigs, M., Young, L., Adolphs, R., Tranel, D., Cushman, F., Hauser, M., & Damasio, A. April 19, 2007). Damage to the prefrontal cortex increases utilitarian moral judgments. Nature. Glenn, A. L., Lyer, R., Graham, J., Koleva, S., & Haidt, J. (2009). Are all types of morality compromised in psychopathy? Journal of Personality Disorders, 23(4), 384-398.

38. Low oxytocin levels • Low feelings of trust, sharing & generosity • Narcissism Stress • Low skin conductance Prenatal retinoid toxicity? • High daring & stimulation seeking • Low anxiety & fear • Low cortisol (low stress response) • Low resting heart rate & arousal • Low harm avoidance • Not anticipate consequences • Low capacity for fear, aversive conditioning (or punishment insensitivity • High dopamine hunger • Colder more predatory violence 50-80% Genetic inheritance (5-HTTLPR gene, s-allele, MAOA genotypes, ?) • Low serotonin • High reactive & proactive aggression • Increased gray matter in the anterior cingulate cortex • Co-morbid ADHD (75%) • Impulsiveness • Fewer mirror cells • Lack conscience (don’t read distress, no empathy, poor response to punishment) • Underactive amygdala • Deficit in ethical & moral reasoning & social responsibility • Reduced reaction to emotional words & images • Diminished avoidance of aversive stimuli • Absent empathy, guilt, remorse • Underdeveloped ventro medial prefrontal and orbito frontal cortex • Limited facial recognition • Diminished emotional memory • Low perspective taking • Poor behavioral inhibition Bringing it all together…maybe

39. Treatment Implications & Considerations

40. Empathy has a central role in most therapies. For example, 94% of sex offender treatment programs include an empathy training component (Freeman-Longo, Bird, Stevenson & Fisk, 1995). Marshall, Marshall, & Serran, 2006)

41. Empathy in Sex Offender Treatment Programs • Highest risk offenders most often present deficits in victim empathy, emotional control, intimacy skills and problem-solving abilities (Perkins, Hammond, Coles, & Bishopp, 1998) • 94% of sex offender treatment programs include an empathy training component (Freeman-Longo, Bird, Stevenson & Fisk, 1995). • The belief is that feeling empathy in a potential offenders will deter the offender from carrying out the offense • Most often, indications of empathy development is from verbal expressions of insight and appreciation or test results • “Low remorse, denial, & low victim empathy was unrelated to sexual recidivism” (Hanson & Bussiere, 1998) • But– most programs teach cognitive empathy rather than affective empathy that would explain the low relationship with recidivism (Roys, 1997); emotional empathy is more critical for relapse prevention (Hilton, 1993) • People’s capacity to tolerate their own distressful emotions affects their capacity to empathize with distress in others (Lisak , 1997)

42. Empathy in Sex Offender Treatment Programs • General or non-victim empathy may not show deficits, victim empathy often does • Empathy enhancement for sexual sadists may paradoxically heighten their arousal (Perkins, Hammond, Coles, & Bishopp, 1998) • Highest risk offenders most often present deficits in victim empathy, emotional control, intimacy skills and problem-solving abilities (Perkins, Hammond, Coles, & Bishopp, 1998) • 94% of sex offender treatment programs include an empathy training component (Freeman-Longo, Bird, Stevenson & Fisk, 1995). • The belief is that feeling empathy in a potential offenders will deter the offender from carrying out the offense • Most often, indications of empathy development is from verbal expressions of insight and appreciation or test results • Hanson and Bussiere’s (1998, p. 357) found that “low remorse, denial, & low victim empathy was unrelated to sexual recidivism”

43. Empathy in Sex Offender Treatment Programs cont’d • But– most programs teach cognitive empathy rather than affective empathy that would explain the low relationship with recidivism (Roys, 1997); emotional empathy is more critical for relapse prevention (Hilton, 1993) • Lisak (1997) examined the relationship between empathy for the self and empathy for others: people’s capacity to tolerate their own distressful emotions affects their capacity to empathize with distress in others • While general or non-victim empathy may not show deficits, victim empathy often does • Empathy enhancement for sexual sadists may paradoxically heighten their arousal (Perkins, Hammond, Coles, & Bishopp, 1998)

44. Implications for treatment: The balancing act • Assess the potential for empathy and other psychological assets and mechanisms that enable it to be learned, experienced, and expressed • Determine whether empathy will be used as a deterrent or prosocial choices, or sadistic appreciation. • Therapists should model empathy, warmth, directness, encouragement, and rewardingness, and accounts for 40-60% of variance in outcome (Marshall et al., 2003, 2003) • Remind offender of strengths and pointing out that offending behavior is only a small part of past behavior (reward positive behaviors) • Aggressive confrontation seems to elicit either withdrawal or passive compliance; consider motivational interviewing • Shift from experiencing shame to feeling guilt

45. Assessment of Empathy • Interpersonal Reactivity Index: 28 questions in four subscales: perspective taking, empathic concern, personal distress, fantasy identifi- cation with fictional characters • Victim Empathy Distortions Scale: Measures offender’s understanding of the effect of abuse on victim (Beckett & Fisher, 1994) • Test of Self Conscious Affect: 50 items in four scales measuring proneness to guilt, shame, externalization, and unconcern (Tangney, Wagner, & Gramzow, 1989) • Cognitive Empathy Scale: 64 questions from MMPI & CPI (Hogan) • Questionnaire Measure of Emotional Empathy: 33 items in 7 scales (Mehrabian and Epstein) • Empathy Quotient: 60 items on unifactor (but may be 3 factors) (Baron-Cohen & Wheelwright ) • Balanced Emotional Empathy Scale: 30 items in 9-point Likert format that measure vicarious experience of other’s feelings and interpersonal positiveness • Diagnostic Analysis of Nonverbal Accuracy-2: 24 photographs of four facial expressions (happy, angry, sad, fearful), and other stimuli such as voice and posture scales for assessing perception of emotions.

46. Parental contribution to empathy Care-Giver contribution to empathy • Secure attachment & nurturing: responsiveness to infant, available, sensitivity, consistency • Take children seriously: respect feelings, preferences, questions • Practice cooperating: demonstrating collaboration rather than competition • Guiding & explaining: value sharing, caring, helping, explain why prosocial behaviors are important and appreciated, how aggressive and selfish behaviors harms others, intervening when child is selfish or cruel, explain how others feel • Modeling: generosity, charitable to others, practice what preached, small acts of kindness • Promoting and praising prosocial self image: encourage opportunities to experience caring & helping, view self as caring and helping, volunteering, internal rather than external locus of control for altruism Socialization

47. Intervention Programs for CU Youth • Early assessment & intervention; Facial recognition training, especially distress and fear • Families and Schools Together (FAST): early childhood family support groups; Emotion talk with attachment figures • Multisystemic Therapy & Case management home visits to support family functioning • Parent training is effective is CD/ASP but less so with CU/PPD: Low-fear children don’t respond to the type of socialization (gentle, non-power, assertive discipline) that leads to conscience development in more fearful children (Dolan, 2004) (e.g., style has less influence than heredity) http://www.promoteprevent.org/Publications/EBI-factsheets/FAST.pdf

48. Developing a Feeling Vocabulary

49. Empathy Map: How can you tell what others feel?

50. Components of Empathy Enhancement for non-CU Juvenile Offenders • Ability to identify and express emotions • Development of good listening skills in order to be able to identify feelings of others • Address lack of awareness of the devastating short and long term emotional impact that the behavior had on the victim(s); Constructing a series of apologies to his victims • Identification of feelings prior to, during and after offenses; address lack of remorse • Comprehension of how anger, stress and values influence their reactions to others • Modification of behavior out of concern for others’ feelings • Dealing with own victimization • Reinforcement of prosocial behaviors (4:1 ratio) Questionable if client is older teen, repeat offender, psychopathic & sadistic indicators, poor response to treatment