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Remaking Relapse Prevention. “Determinants of Relapse” ( Marlatt & Gordon, 1980) New type of cognitive-behavioral intervention Relapse prevention. Relapse prevention. Maintaining change in addicts Ceased Through other interventions. Relapse Rates for Addictions.

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slide2

“Determinants of Relapse”

(Marlatt & Gordon, 1980)

New type of cognitive-behavioral intervention

Relapse prevention

relapse prevention
Relapse prevention

Maintaining change in addicts

Ceased

Through other interventions

relapse rates for addictions
Relapse Rates for Addictions

First 12 months after cessation

80%

First 3 months

66%

(Hunt et al., 1971)

slide5

Negative emotional states

Interpersonal conflict

Social pressure

71% of all relapses

(drinkers, smokers, heroin addicts, compulsive gamblers, and over eaters)

(Cummings et al, 1980)

deviant cycle
Deviant Cycle

Life Event

Negative Affect

Remorse,

Guilt, or Fear

Seemingly

Unimportant

Decisions (SUDS)

Offense

Thinking Errors

Grooming

or Force

High Risk

Situations

Planning

Passive/Active

Target Selection

developed for
Developed for

Offenders motivated to change

Already ceased offending

Offended through “seemingly unimportant decisions”

not developed for
Not Developed For

Psychopaths

Child molesters who want to continue

slide9

“An important precondition for applying RP interventions is that the offender be motivated to stop offending.”

(George & Marlatt, 1980, p. 16)

in the beginning
In the Beginning

“the confidence and optimism we feel . . . are quite strong . . .

“our confidence . . . is without empirical support”

(Gordon & Marlatt, p. 28)

why was rp adopted so readily
Why Was RP Adopted So Readily?

No other game in town

Northwest Treatment Associates

Seattle, WA

Gene Able & associates

NY/Atlanta

what is rp today
What is RP today?

“Relapse Prevention”

Has little meaning

“In the past 15 years, those words have served as an umbrella under which a huge variety of clinical interventions that had little or nothing to do with the original notions of RP could be found.”

(Laws, 2000, 0. 16)

nationwide survey
Nationwide Survey

RP Includes

Primary RP

  • Community 18% 97.9%
  • Residential 25% 93.4%

(McGrath et al., 2002)

cognitive behavioral treatment
Cognitive Behavioral Treatment
  • Empathy
  • Assertiveness
  • Social skills
  • Healthy sexuality
  • Intimacy training
  • Cognitive distortions
  • Cognitive skills
  • Relapse Prevention
slide15

“Relapse prevention “performed a deep alchemy through which clinicians could look at rapidly declining survival curves and see mission, not despair.”

(Hanson, 2000, p. 36)

instilling knowledge of rp
Instilling Knowledge of RP

Satisfactory offense chains

Initial testing

39%

3 repetitions

100%

(Marques et al., 1989)

test of basic rp concepts
Test of Basic RP Concepts

Initial testing

34%

3rd testing

100%

(Marques et al., 1989)

was sotep a test of rp
Was SOTEP a Test of RP?
  • Sex education
  • Human sexuality
  • Relaxation training
  • Stress & anger management
  • Social skills
  • Substance abuse
  • Deviant arousal
  • RP
sotep
SOTEP

Chronic offenders

Mastered RP model

Lower recidivism rates

All offenders

No relationship

Mastering RP & recidivism

rp low risk offenders
RP & Low Risk Offenders

SOTEP

Mastering RP

No lowered recidivism

No cycle?

why did sotep fail
Why Did SOTEP Fail?

Failure to motivate offenders

Lack of challenge of offenders

Too little focus on affective factors

Lack of practice in coping skills

Lack of a strong conditional release component

instilling knowledge of rp1
Instilling Knowledge of RP

Community based tx in England

27%

rp too complicated
RP Too Complicated
  • Abstinence violation effect
  • Success expectancy
  • Erroneous attributions
  • Apparently irrelevant decisions
  • Negative emotional state
  • Problem of immediate gratification
  • Adaptive coping response
  • Increased probability of relapse
rp can be taught
RP Can Be Taught
  • Awareness of high-risk thoughts
  • Willingness to admit planning
  • Recognition of high risk factors
  • Knowledge of motivation for offending
  • Ability to think of coping strategies
  • Ability to tell others when at risk

Exposure to RP greater skills

(Mann, 1996)

summary
Summary

RP dominant tx strategy for 15 years

Rarely as a solo program

Hard to teach

When mastered, ability to think of coping strategies and tell others risk level

negative results
Negative Results

Kenworthy, Adams, Brooks-Gordon & Fenton, 2004

Rice and Harris, 2003

does tx work long term
Does Tx Work Long Term?

12 Year Follow-Up

Treated Untreated

(403) (321)

Sexual 21.1% 21.8

Violent 42.9% 44.5%

General 56.6% 60.4%

(Hanson et al., 2004)

deviant cycle1
Deviant Cycle

Life Event

Negative Affect

Remorse,

Guilt, or Fear

Seemingly

Unimportant

Decisions (SUDS)

Offense

Thinking Errors

Grooming

or Force

High Risk

Situations

Planning

Passive/Active

Target Selection

slide32

Self Regulation Model of Relapse Prevention

Life Event

Sometimes

Desire for

Offensive Sex

(Ward & Hudson, 1998)

slide33

Self Regulation Model of Relapse Prevention

Desire for

Offensive Sex

Avoidance

Goals

Approach

Goals

(Ward & Hudson, 1998)

slide34

Self Regulation Model of Relapse Prevention

Avoidant

Approach

Passive

Active

Automatic

Explicit

(Ward & Hudson, 1998)

type of offense pathway roger
Type of Offense Pathway: Roger
  • Unemployed
  • Bar from 12 to 3 pm
  • Left drunk
  • Boarded a train as “knew girls would be there”
  • Goals: get one to perform oral sex
type of offense pathway roger1
Type of Offense Pathway: Roger

Sat behind two 13-year-olds

Touched their hair and masturbated

Tapped one on shoulder

They got up and left

Got off train, saw a 13-year-old

Began masturbating

type of offense pathway roger2
Type of Offense Pathway: Roger
  • Walked up to her with penis out of pants
  • Wanted her to perform oral sex
  • She called out and other girls joined her
  • Bus arrived and they left
  • They reported to bus driver
type of offense pathway roger3
Type of Offense Pathway: Roger

“I just do things for no reason.”

“I wish I could put into words how I feel, and understand what it is all about.”

type of offense pathway roger4
Type of Offense Pathway: Roger
  • Knew by heart the routes home of children from local schools and holidays and breaks
  • It was “familiar territory” so never had to plan
  • Says “thousands” of victims
  • Convicted 13 times
type of offense pathway roger5
Type of Offense Pathway: Roger
  • Says he felt children enjoyed the experience
  • “I don’t hurt anyone and people quite like what I do. I never carry out my fantasies about rape and hurting people in real life.”
type of offense pathway dave
Type of Offense Pathway: Dave
  • 40 year-old
  • Confident and outgoing
  • Worked abroad in a program to help teen prostitutes
  • Talked to pimps
  • They made a “powerful case”
  • Felt his values had “become contaminated”
type of offense pathway dave1
Type of Offense Pathway: Dave

“Some of the younger girls I was trying to help said that things about the life were good. Intellectually I knew that that was about comparisons with the life they had before, extreme poverty and so on, but at another level I got interested – although I never did anything wrong to them.”

what type of offender dave
What Type of Offender: Dave
  • In past had baby-sat for 11-year-old
  • Went in bedroom aroused and watched child sleep
  • Told wife
  • Agreed never to babysit again
type of offense pathway dave2
Type of Offense Pathway: Dave
  • I talked to my wife about the babysitting experience before we had the children. That was good, but then I sort of laid the responsibility for stopping it happening again on her. I did that again after our daughter told her what I’d been doing.”
type of offense pathway dave3
Type of Offense Pathway: Dave
  • Family living in an open-plan home in hot climate
  • Kids often undressed
  • Felt 10-year-old daughter was seductive
  • Knew his arousal was wrong
  • Tried to avoid situations where he might abuse her
type of offense pathway dave4
Type of Offense Pathway: Dave
  • Refused to share a tent with her on camping trip
  • Other times he fondled her genitals
  • Once persuaded her to straddle him
  • Told himself knew what was happening and agreed
type of offense pathway dave5
Type of Offense Pathway: Dave
  • When wife gone, got into daughter’s bed to have intercourse
  • Realized what he was doing and stopped
  • Shaken that he almost raped her
type of offense pathway dave6
Type of Offense Pathway: Dave
  • “I thought that carrying on with my work would help me get my head straight – instead it was just making it worse.”
type of offense pathway dave7
Type of Offense Pathway: Dave

“I kept away from my daughter – wouldn’t take any interest in her. She wondered what was wrong with me – my wife says that made her more likely to want affection from me. Then when she came to me I misread what she wanted, because my thinking was getting so messed up.”

type of offense pathway joe
Type of Offense Pathway: Joe
  • 40-year-old
  • 6 cts against one boy, now 19
  • Over 8 years
  • Fondling, oral sex, anal intercourse
  • Working as handyman at boy’s house
  • Boy began to hang around him
type of offense pathway joe1
Type of Offense Pathway: Joe
  • Urinated in bushes and boy saw it
  • Boy watching excited him
  • Asked boy to touch his penis
  • Boy compliant
  • Escalated to anal intercourse
  • Boy told him he didn’t want to do these things
type of offense pathway joe2
Type of Offense Pathway: Joe
  • Told boy it was normal
  • Told him no one would believe him
  • Told boy, why had he done it if didn’t want to
  • Told boy if reported, they would blame him
  • Told boy that he (the boy) was gay

“You’re just a little queer! Why don’t you accept that?” a

type of offense pathway joe3
Type of Offense Pathway: Joe
  • 2 previous convictions
type of offense pathway joe4
Type of Offense Pathway: Joe

Previous Treatment

“You’re got to go along to get along. If I was ever going to get out of there, I realized that I was going to have to learn to say what they wanted to hear.”

Psychologist: Did well and was able to “freely share his experiences and mistakes with other group members and to take responsibility for his actions.”

type of offense pathway joe5
Type of Offense Pathway: Joe

“showing them what real life was like”

“You need to know how to get that feeling of being in charge – the world is a frightening place”

“Of course, I took my ‘fee’”

type of offense pathway ben
Type of Offense Pathway: Ben
  • 25-year-old
  • Police called to residence – found father of a 5-year-old holding Ben in custody
  • Ben was babysitting
  • Returned to find him in bed with son
  • Boy crying; told parents Ben had “touched my thing and sucked on it.”
type of offense pathway ben1
Type of Offense Pathway: Ben
  • 3 arrests at ages 15, 22 and 23: all victims boys under 10
  • No other criminal history
type of offense pathway ben2
Type of Offense Pathway: Ben
  • 1st offense: met 6-year-old when he was coming home from school. Bought him ice cream, took him to a park, pulled down his pants and fellated him
  • After graduating from university, picked up a boy, took him for a ride, drove to a park, fondled him and fellated him
type of offense pathway ben3
Type of Offense Pathway: Ben
  • Uncomfortable around adults his age

“They seemed so much more grown up than I was.” “I felt awkward, like I couldn’t get one foot in front of the other.”

Children: “They weren’t trying to live up to some social standard.” “I envied them because they seemed so free, so at ease in their world.”

type of offense pathway ben4
Type of Offense Pathway: Ben

“I will admit that I especially liked looking at the boys. They were so cute, bright eyed, smooth skin. It sounds silly, but I wished that I could look like that, rather than a hulky, almost adult male.”

“It must have been then that I began to think about them sexually.”

type of offense pathway ben5
Type of Offense Pathway: Ben

“When I jerked off, I tried to fantasize about girls my age in my classes, but it didn’t work. When I thought about kids, I felt guilty, but I got really aroused and I could ejaculate. Although I didn’t really want them to be, the fantasies were about feeling these kids up and sucking their dicks. The more I did it, the easier it got.”

type of offense pathway ben6
Type of Offense Pathway: Ben

“When I saw that kid in 1989, I don’t know, I guess I just felt that I had to do it. I conned him and I took him to the park and went down on him. I felt like shit after that.”

type of offense pathway ben7
Type of Offense Pathway: Ben
  • Cruised while at university, but didn’t pick up any kids. Afraid of getting kicked out.
  • “After I graduated from university and couldn’t find a job, I felt worthless. So I started cruising again.” “This time I was afraid something would happen, and it did.”
type of offense pathway ben8
Type of Offense Pathway: Ben
  • Felt guilty. Boy couldn’t identify him.
  • “I should have said, ‘Hey! I did it!’ but I didn’t.”
type of offense pathway ben9
Type of Offense Pathway: Ben

Last offense, asked boy, “Do you want to learn about sex?”

“It seemed to me that he was fine with it until his old man burst into the room.”

type of offense pathway ben10
Type of Offense Pathway: Ben
  • Still masturbating to fantasies. “I can’t seem to stop it.”
  • Response to first arrest: “I just wanted to forget about it.”
factors in offending
Factors in Offending

Avoidant Passive

  • Lack of skills
  • Under-regulated
  • Deviant Arousal Patterns
  • Problems with Intimacy, Etc.
  • Cognitive Distortions
  • Dysfunctional Schemas
factors in offending1
Factors in Offending

Avoidant Active

  • Misinformation
  • Misguided strategies
  • Lack of effective skills
  • Deviant arousal
  • Problems with intimacy
  • Cognitive Distortions
  • Dysfunctional Schemas
factors in offending2
Factors in Offending

Approach Automatic

  • Automatic Scripts
  • Lack of Monitoring
  • Under Regulated
  • Deviant Arousal
  • Loneliness, etc.
  • Cognitive Distortions
  • Dysfunctional Schemas
  • Psychopathy
factors in offending3
Factors in Offending

Approach Explicit

  • Cognitive Distortions
  • Dysfunctional Schemas
  • Deviant Arousal
  • Psychopathy
  • Loneliness, etc.
  • NOT a Regulation Problem
slide81

RP Avoidant

Good lives model Approach

primary goods
Primary Goods

People seek primary goods

primary goods1
Primary Goods

Experiences, states of mind, activities

Sought for their own sake

Increase psychological well-being

sexual offending
Sexual Offending

Attempts to pursue primary human goods

Socially unacceptable

Personally frustrating

what are primary goods
What Are Primary Goods
  • Relatedness
  • Health
  • Autonomy
  • Creativity
  • Knowledge
tender minded theory
Tender Minded Theory

People are good

Bad acts are an attempt to meet same needs as everybody else

theoretical position
Theoretical Position

“It is true that we did not cite any study applying the ideas of Deci and Ryan [human needs and self-determination] to an offender population – to our knowledge there are no such studies yet.”

(Ward & Stewart, 2003, p. 222)

theoretical position1
Theoretical Position

“. . .there is little or no evidence for the assessment and treatment aspects of the theory other than the rationally based reasons outlined above. This weakness reveals that the theory lacks empirical adequacy.”

(Ward et al., 2006, p. 311)

deci ryan 2000
Deci & Ryan (2000)

Nonoffenders

Autonomy, competence & relatedness

Correlated with

Indices of well-being

(Negatively correlated with anxiety and depression; positively correlated with self-esteem)

slide90

Innate needs

Correlated with

Noncriminogenic needs

( Bonta and Andrews, 2003)

slide91
“I plain and simple needed to get some good, hot, kinky sex but resented having to rely on the generosity of women to hit on their pussies. . . My days of begging . . . Were over.”

(Athens, 1997, p. 10)

applying the good lives model
Applying the Good Lives Model

What goods are associated with offending?

Pursuit of emotional equilibrium

Intimacy

Personal control

Grievance

Sexual pleasure (goods of health & body)

Play (to get a thrill)

what prevents meeting these appropriately
What Prevents Meeting These Appropriately?

Socially isolated

Lack skills for relationships

Overly aggressive when mood low

identifying overarching primary goods
Identifying Overarching Primary Goods

Mechanically Inclined

“In this example, he might enroll in a night course on practical mechanics (knowledge), join a car club (relatedness), and eventually train as a car mechanic (mastery at work).”

(Ward et al., 2006, p. 308)

identify environment needed
Identify Environment Needed
  • Info about opportunities for work
  • Social supports
  • Living arrangements
  • Culture of the community
people are what they do
People are What They Do

To forge a more adaptive personal identity

Must live a better life

rehabilitation involves
Rehabilitation Involves

Looking at past life

Developing a new good lives plan

must take into account
Must Take into Account
  • Offenders’ strengths
  • Primary Goods
  • Relevant Environments
  • What competencies & resources?
slide99

“The problem does not reside in the primary human goods that underlie offending, but in the way individuals seek these goods.”

(Ward et. Al, 2006, p. 307)

secondary goods
Secondary Goods

Ways primary goods are translated into action

Primary goods: work

Secondary goods: Training in computers

at its best
At Its Best

Loneliness: Risk factor

How to build a life with social connection

at its worse
At Its Worse

Takes sex out of sexual offending

Exercise, eat well, get a job – you’ll be fine

assumptions
Assumptions

Lost Souls or Predators

Lost Souls Only Need Apply

is all offending from frustration
Is All Offending from Frustration?

Psychopathic

Predators

Sadists

slide105

“I like to live on the edge. I like being wanted by the police. I like being chased by the police. When you live that kind of life you really can’t stop to think. You never think. You just do, do, do. If you stop you won’t do it. I never stop to analyze it.”

slide106

“I’d have to say I did get a high out of violent behavior. I got – I got a high out of any controlling and dominating situation. Any, any situation that I was able to control – right? – I got a high out of. I had like an adrenaline rush. I felt powerful, in charge, where in a consensual sexual relationship, sure orgasm was achieved, ejaculation was achieved, and then it’s over. But the feeling of power and control lasts, it would last a lot longer. And it’s something I knew that I could achieve at any given point in time. All I, I knew what I had to do. All I had to do was control somebody or dominate, and that high was there.”