September 18th WATSA

Presentation

Presenters: Lisa Dandescu, Jeff Landon, Corey McNally,

Renee Schuiteman, Christine Gomes Psy.D. and Tim

Whetstine-Richel PhD

Lisa Dandescu, MA

Correctional Mental Health

Unit SupervisorProgram Initiatives:

• Prioritization of higher risk offenders

• Engaging higher risk offenders

• SOTP Staff Trained in Motivational Interviewing and participating in ongoing coaching and coding towards achieving a minimum level of competency.

• SOTP Staff Trained and Certified in STABLE 2007, Static 99R and Acute.

Prioritization of higher risk offenders

• This has been longstanding policy however client selection criteria made it difficult to provide services to this population.

• For the past two years we have a renewed focus to provide and prioritize as many

of our resources as possible to higher risk offenders, as the waitlist for SOTP becomes larger

• Policy, practice and efforts to increase the higher risk clientele is well established in

research. Providing the majority of scarce resources to the population which is the highest risk benefits the community in terms of overall recidivism reduction.

Engaging higher risk offenders

• Face to Face screening and assessment of all sex offenders who enter prisons through reception for risk and treatment amenability.

• Emphasis on engagement and enhancing motivation at the time of screening using Motivational Interviewing skills.

• Setting realistic expectations in regards to treatment amenability and understanding the role of SOTP towards enhancing motivation to change.

• Prioritize high risk offenders for available SOTP resources

• Higher risk offenders have tended to be more challenging to engage in the institution based SOTP with higher levels of denial, anti-social personality traits and treatment interfering behaviors.

• Results demonstrate a high rate of offenders willing to participate in treatment subsequent to a face to face screening. The program has observed a commensurate increase in Moderate to High risk offenders participating in treatment.

SOTP Staff Trained in Motivational Interviewing

• All staff are finishing up in-depth training on conducting Motivational

Interviewing in order to most effectively engage clients presenting with

ambivalence or treatment resistance.

• The goal of using MI is to increase positive changes while in treatment and

engaging more offenders (who might otherwise refuse) in treatment

through the pre-treatment screening process.

SOTP Staff Trained and Certified on STABLE 2007, Static 99R and Acute

• Static 99R utilized for SOTP treatment prioritization decisions

• Stable 2007 utilized to identify a clear, focused and individualized SOTP

treatment plan, as well as responsivity needs during treatment

• Acute used in Community Based DOC SOTP

• Currently in the contract development stage to certify SOTP staff as trainers

in the Static, Stable and Acute.

Jeff Landon, Director –

Sex Offender Treatment

Programs• Prison participation / completion

• All Sex Offender Recidivism Crime

• Community SOTP Participation as of June 30, 2015 *New Data and Opportunity

• Shift from Community Corrections to Offender Change Division and implications.

Funded Future Opportunities

� Community SOTP Expansion 2016-2017

�Quality Assurance and comprehensive training program.

�ATSA, WATSA and various therapist development opportunities.

� Static, Stable and Acute Training Certification.

�Development of a structured case management and documentation program to increase ease of use and reduce

administrative redundancy.

Prison participation / completion

396

461

540

611591

498

588

FY2009 FY2010 FY2011 FY2012 FY2013 FY2014 FY2015

Prison SOTP Participation Counts

154145

224243

288269 272

FY2009 FY2010 FY2011 FY2012 FY2013 FY2014 FY2015

Prison SOTP

Completion Counts

All Sex Offender Recidivism Crime

Violent Crime*

6%

Property

16%

Drug Violation

6%

Other Offense

13%

Failure to Register

51%

Other Sex Offense

5%

Violent Sex Offense **

3%

FY2012 Recidivism statistics

Offenders Released

from Prison in FY2012

All Sex Offenders Sex Offenders who did not

Enter/Complete Prison

SOTP

Sex Offenders who Complete

Prison SOTP

Count % Count % Count %

Total Offenders 708 554 78.3% 154 21.7%

Recidivated 129 18.2% 119 21.5% 10 6.5%

Community SOTP Participation as of June 30, 2015

Current Participation 262

Average Age 41

Youngest 21

Oldest 80

Gender:

Male 98%

Female 2%

Race:

White 89%

Black 5.7%

Amer. Indian/ Native Alaskan 2.3%

Other 1.1%

unknown 0.4%

Hispanic: 3.0%

Sex Offender Level

Level 1 54%

Level 2 30%

Level 3 12%

Unknown 4%

Developing and

Implementing Quality

Assurance within SOTP

Corey McNally, MS., LMHC

SOTP Quality Assurance Supervisor

Quality Assurance in SOTP

Department level and down

• The Department of Corrections is committed to implementing and maintaining Evidence Based Practices in order to reduce recidivism.

• The Offender Change Division (OCD) is tasked with the legislative mandate, which directs the Department to implement programming following the Risk Needs Responsivity Model.

• In practice, OCD and SOTP utilizes the Principals of Effective Intervention (National Institute of Corrections)as a guide for programming.

• Assessment, Motivate, Target Interventions (RNR), CBT, Positive Reinforcement, On-going support in natural communities, Measure Processes/Practices, Provide Measurement Feedback.

Quality Assurance in SOTP

• Goals of QA

• Maintain the Integrity of a Quality Program

• Program is based in best practices, and ensuring it continues to operate on best practices to provide consistent results.

• Develop and retain skilled clinicians

• Provide Best Possible Outcomes

• Data Driven Practices

• Measure and Communicate Outcomes

• Accountability

• Ensure program practices are following established standards and achieving Department goals.

• Stages in the development and implementation of QA in SOTP

• Program Evaluation (internal and external)

• Report on findings

• Make Recommendations on changes

• Concurrence process with SOTP leadership and stakeholders prioritizing gaps to be addressed

• Training and Implementation Plan

• Maintenance

Quality Assurance in SOTP

• Vision of QA structure

• Standardized training for new staff, and regular in-service training

• Group Observations/clinician assessments

• Research strongly indicates that therapist characteristics, the therapeutic alliance and group cohesion produce the greatest effect on positive treatment variance over adherence to a highly manualized program.

• QA will ensure a manual is guiding treatment to address dynamic risk through a CBT approach. However, much of its efforts will be on training therapists to enhance clinical skills directly related to positive treatment outcomes.

• Guide clinical supervision to develop clinical skill that enhances treatment outcomes

• Clinician characteristics: Warmth, empathy, Rewardingness, directive, flexibility…, adherence to CBT model and addressing dynamic risk.

• Measurement of group cohesiveness and therapeutic alliance with feedback on group facilitation skills

Quality Assurance in SOTP

• Use data to tell the story of SOTP outside of recidivism

• Treatment effects (intermediate outcomes and tx progress)

• Clinician development

• Accountability

• Population

• Risk and Needs Assessments

• Utilizing the RNR model, measuring change, targeting dynamic risk.

• SOTP Risk Assessment Unit

• Completes STATIC 99R assessments on all sex offenders coming in through receiving for prioritization of tx. and population characteristics.

• Working to complete risk assessments on current population

• Completing risk assessments on offenders in community to set supervision levels and warrant service areas

Quality Assurance in SOTP

• SOTP Risk Assessment Unit- Static 99r Data

Low

112

24%

Low/Mod

139

29%

Mod/High

126

27%

High

97

20%

Year to Date-2015

Low

Low/Mo

d

Mod/Hig

h

High

Renee Schuiteman, MSW

Correctional Mental Health

Unit Supervisor

• Program Data

• Lean Process Improvement Efforts

Airway Heights Data Information

Airway Height Corrections Center:

• 1 psychologist, 3 supervisors, 15 clinicians and 2 administrative staff

• Originally AHCC was slated as a low risk treatment program and treating lower needs MH clients (81) S-1, (22) S-2, (4) S-3

• Since November 2014-Observable movement towards treating moderate to high risk clients, screening, completing stables and staffing for non-prioritization before entering them into tx.

Static 99R and Static/Stable combined

Risk level without Spanish speaking

20152014

LEAN Process Improvement Group

• Originally 34 steps in the process

• Future State process has 11 steps

• Stakeholders involved: ISRB, Classification, SOTP, Transportation

• Goal: Streamline our process and ensure the right clients are getting into treatment in the right order at the right time.

• We are developing a state wide waitlist, we are currently piloting a mock process

• We are addressing: paperless options, prioritization matrix, screening consistency, policy consistency for information uploading.

The beginning of the lean process

Current Process

Christine Gomes, Psy.D.

Psychologist 4• Role of Psychologists at SOTP

• SOTP and SARU Combined Pilot Group

SOTP Psychologists

• SOTP recently hired two licensed psychologists:

• Christine Gomes, Psy.D.

• Timothy Whetstine-Richel, Ph.D.

• SOTP is currently updating policy in order to clarify roles of psychologists,

limitations of liability and ensure that testing data is treated as Protected

Health Information (PHI).

Role of Psychologists at SOTP

• Provide consultation and support for SOTP staff members.

• Will at times involve psychological testing when policy is finalized.

• Staff training and development.

• Examples: Stable-2007 interrater reliability exercises; understanding the change process (precursors model); working with offenders with prominent personality disorders.

• Work closely with Quality Assurance Supervisor to ensure SOTP is using evidence-based practices and providing the highest quality of treatment possible.

• Collaborate with Mental Health Department regarding offenders’ admission into SOTP, particularly offenders living in Residential Treatment Units.

• Work with mental health units at each facility coordinating care for those with serious mental illness transitioning into or out of treatment.

SOTP and SARU Combined Pilot Group

• Group designed to address both substance abuse issues and sex offending behavior simultaneously.

• Enhancing the overall treatment experience by providing co-occurring treatment to a residential population with high needs in both areas (as identified by the Static-99R and Offender Needs Assessment).

• Reduce treatment overlap/service redundancy, improve collaboration between experts in both fields and capitalize on opportunities to most effectively treat problematic sexual behaviors related to substance abuse.

• Development Team:

• Corey McNally, SOTP Quality Assurance Supervisor

• Lisa Dandescu, CMHUS SOTP

• Brian Smith, Substance Abuse Recovery Unit Clinical Supervisor

• Joint Project – HQ Substance Abuse Recovery Unit and SOTP

SOTP and SARU Combined Pilot Group

• Goals:

• Determine feasibility of running parallel curricula with combined days being co-facilitated by both a CDP and SOTP clinician.

• The goal of the combined days is to emphasize related treatment components and assist the offender to learn to mitigate risk from a united treatment perspective rather than categorical, generalizing skills learned in both programs.

• Timeline:

• Development team has one more meeting to finalize curriculum, then the plan will go to the SOTP and CD leadership teams for final approval.

• Offenders with high needs in both areas then need to be identified.

• The goal is to have the group start by November, 2015.

• Participants:

• 10 Offenders identified as higher risk to sexually reoffend and having high needs in chemical dependency with an ERD that allows for the 12 month SOTP program to be completed.

SOTP and SARU Combined Pilot Group• Schedule:

• Quarters 1 and 2: SOTP Only

• Focus will be on assignments aimed at helping participants increase their level of disclosure with the group and begin to identify offending patterns.

• Assignments: Autobiography, Disclosure, Sexual History Timeline, BCA for sex offense, BCA for substance relapse

• Quarter 3: Combined SOTP and CD-IOP

• Focus will primarily be on Offense Cycles, with combined elements of SOTP and CD-IOP.

• The Offense Cycle assignment will include common triggers, thoughts and feelings for both committing a crime and relapse into substance use. Focus should be on the identification of the maladaptive pattern of thoughts and feelings leading to behaviors that have an outcome that is not desired.

• During this quarter, participants will be in group 5 days a week (2 days of CD-IOP, 2 days of SOTP, and 1 combined day)

• Quarter 4: Primarily SOTP with one SOTP/CD-IOP group per week

• Focus will be on Relapse Prevention Plans for both substance abuse and sexual offense behavior.

• Outpatient CD treatment is recommended if feasible.

MOVING FORWARD:A 14 WEEK PILOT PROGRAM FOR SEX OFFENDERS WHO

CATEGORICALLY DENY THEIR GUILT

Timothy Whetstine-Richel, Ph.D.

Psychologist 4

Airway Heights Correction Center

Washington State Department of Corrections

THE WHY?

• To mitigate risk for recidivism for those who categorically deny their offending

behavior and have refused or been found non-amenable for standard treatment.

• Risk for recidivism can be addressed without direct discussion of offending behavior.

• Comfort discussing themes may facilitate greater willingness to engage in standard

treatment.

• Address criminogenic risk factors (CRF) by three core processes:

1. Foster sense of necessity to address CRFs

2. Awareness of protective and risk factors

3. Development of skills to strengthen protective factors and mitigate propensity for CRFs

as they pertain to sexual recidivism.

CONCLUSIONS FROM LITERATURE REVIEW

1. Treated deniers have been shown to have lower recidivism rates than untreated

deniers and admitters.

2. Approaches to denial that conceptualize it as a form of ambivalence rooted in a

contextual web of internal and external reinforcement appear to be the most

effective.

3. Resolving denial is not necessary before risk factors can be addressed.

4. Dynamic risk factors can be addressed without disclosure of specific offending

behavior.

5. Impersonal interventions, or interventions that require minimal disclosure are more

effective for deniers.

CORE ASSUMPTIONS

1. Dysfunction or dysregulated behavior is rooted in a lack of awareness and skills

about how to get needs met in more prosocial ways.

2. Ambivalence about treatment is normal, especially in a correctional environment.

3. Specific change is a byproduct of other factors that either are or are not present in

an individual’s life.

4. Change factors can be strengthened through targeted motivational interviewing

and precursor’s model techniques.

THE WHO?

• Adult male, incarcerated @ Medium Security Facility

• Convicted of Sex Offense or Crime with Sexual Component

• Categorically deny guilt in conviction

• Actuarially assessed Mod-High to High risk for re-offense using Static-99R

• For the pilot:

• 11 adult males

• Average age= 34.9

• Average Static 99R= 5.54, Highest 7

• ~50% of group have significant MH needs S2-S4

THE LENGTH

• 14 week total process

• 2 individual appointments

• 12 weeks of group

• 4 hours of group per week

CONTRASTS WITH THE STANDARD TX

Moving Forward • Program

• Psychoeducational Focus

• Harm Reduction Focus

• Cognitive Behavioral approach, with some skills

rehearsal

• Accountability for criminogenic risk factors encouraged

• Does not address deviancy outside of psychoeducational

context

• Goal is flexibility, workable behavioral solutions, and

value driven behavior.

Standard/Traditional

• Treatment

• Heavy group process component

• More focused on accountability for offending

behavior.

• Cognitive Behavioral focus on refuting offense

facilitating distortions, rehearsing skills

• Includes option for arousal reconditioning

• Includes treatment of deviancy

EPISTEMOLOGY OF CHANGE

Knowing Change within the Moving Forward Pilot

CHALLENGES

What are the behavioral markers of treatment if we can’t rely on

responsibility and accountability for offending behavior?

How will we know the program is impacting DRFs?

META-CHANGE MODEL

Community

Flourishing

Motivation

•MI

•Precursors Model

•Values Work

Awareness

•Harm Reduction

•Cognitive Interventions

•Dynamic Risk Factors

•Mindfulness

Action

•Comittment to Values Driven

Behavior

•Defusion Techniques

•Address Contingencies

•Sexual Self-Regulation Skills

Committment and Support

•Success Planning

•Cooperation with Supervision

PRECURSORS MODEL HANNA, (2002)

1. Sense of Necessity

2. Readiness for Anxiety

3. Awareness

4. Confronting the Problem

5. Effort or Will Toward Change

6. Hope for Change

7. Social Support for Change

• All items rated from 0 (None) to 4

(Abundant).

• 0-6 Change unlikely

• 7-14 Change limited or erratic

• 15-21 Change is steady and noticeable

• 22-28: Highly motivated to inspired client.

Change occurs easily. Standard

approaches work well.

• Hanna (2002) P. 117

BEHAVIORAL MARKERS OF CHANGE

Moving Forward

• Change is evidenced by:

• Increased strength & number of Precursors to change (Hanna,

2002).

• Acknowledgement of DRFs.

• Expressed desire to reduce impacts of DRFs

• Increased awareness of core values

• Increased ability & willingness to defuse from problematic

cognitive content.

• Increased ability & willingness to navigate difficult emotional

states.

• Increased ability to achieve valued behavior in a consistent,

committed way.

• Key Change Ingredients:

• Motivation: Approach: Valued directions.

• Awareness: Fusion with Cognitive Content & Avoidance of

Unpleasant Emotional States; Focused on Process & Function

• Behavior: Defusion, Commitment,

Standard/Traditional

Accountability Model

• Change is evidenced by:

• Correspondence of self-reported offending behavior

with official account of offending behavior.

• Acknowledgement of responsibility

• Acknowledgement of harm/ Victim empathy

• Expressed remorse

• Commitment to non-offending future

• Restructuring of offense facilitating cognitive

distortions

• Behavioral management skills

• Key change ingredients:

• Motivation: Avoidance: Remorse, prevention of future

harm.

• Awareness: Permission giving cognitive distortions:

Focused on content

• Behavior: Skills to stop criminogenic behavior, mostly

avoidance oriented.

ACCEPTANCE AND COMMITMENT THERAPY

• Grew out of Cognitive-Behavioral Therapy tradition.

• Innovative in addressing limitations of traditional CBT

• Recognized by American Psychological Association as Evidence-Based across a

wide array of disorders.

• Superior to CBT for co-occurring disorders.

• Clinical effects more persistent than CBT.

SELF-REGULATION: TARGETED PSYCHOLOGICAL PROCESSESHexaflex Model: Hayes, Strosahl, & Wilson, 2012

Flexible Attention to the Present

Moment

Acceptance

Defusion

Values

Committed

Action

Self-as-context

Psychological

Flexibility

Willingness and

ability to redirect

attention from

problematic sexually

deviant fantasies,

thoughts, emotions

Awareness of core

sustaining values,

and uses values as a

means to evaluate

workability of

behavior

Routinely makes

movement in

direction of values.

Redirects after

upsets.

Able to skillfully utilize

observer self to

experience thoughts,

emotions, and self-

referent ideas

Able to shift attention,

identify repertoire of

responses. Recognizes

attentional narrowing.

Willingness to accept

life on life’s terms.

Willing to be present

with unpleasant

circumstances.

SELF-DYSREGULATION: EXAMPLE DEVIANT SEXUAL INTERESTS

Hexaflex Model: Hayes, Strosahl, & Wilson, 2012

Inflexible Attention

Experiential

Avoidance

Cognitive

Fusion

Disruption

of Values

Inaction,

Impulsivity

Attachment to Conceptualized Self

Psychological

Inflexibility

Unwillingness to accept

experience without

enhancement of sexual

gratification

Mindless absorption in

deviant sexual scripts

Preoccupation with

sexually deviant themes,

mental rehearsal,

anticipation of reward

Foregoing pursuit of

core values for

immediate gratification.

Lack of clarity about

core values.

Rationalization.

Impulsively seeking

pleasure, low

commitment to valued

action.

I’m a dirt bag anyway,

so what does it matter if

I get in trouble.

EXAMPLES OF ACTIVITIES

Module 1:

Motivational Enhancement &

Fostering Awareness

• Values Sort

• Brick Wall Exercise

• Male Attachment & Destructive

Interpersonal Behavior

• Problematic Sexual Behavior

• Victim Awareness

• High risk attitudes

Module 2:

Self-Regulation Skills

• Managing Urges

• Reframing Skills

• Shifting the Script

• Mindfulness

• Behavioral Chain Analysis

• Asking for help

• Communicating Consent &

Boundaries

• Self-Talk

Module 3:

Committing to Success

• Disclosure of High Risks

• Success Plan

• Recommendations

RISK FACTORS & MOTIVATIONAL

ENHANCEMENT

CURRENT STATUS ??? Observations:

• High degree of mistrust of authorities

• Sincere belief in innocence for about half.

• Other half, seems more related to impression management.

• Majority have history of addiction, particularly to alcohol & methamphetamine ~ 90%

• High level of complex trauma rooted in exposure to severe domestic violence

• Normalization of domestic violence

• Bimodal, offense patterns: domestic violence with adults/ sexual relations with adolescent females.

• Tend to have a preoccupied attachment style

• Compared with standard tx group, more explicit distrustful attitudes towards women.

• In values sort, tend to rank family as most important

• High degree of hopelessness about living within registration system. High number of FTRs.

Sexual PreoccupationAntisocial Attitudes

Attitudes Supportive of Sexual

AssaultDeviant Sexual Interests

Antisocial Activities

Static Factors: HISTORY OF OFFENDING

Stable Risk

Factors

Off

en

se

Tre

e

Acute Risk

Factors

Anything immediate

factor that facilitates

an offense. • Active Deviant

Arousal

• Active Substance

Use

• Rejection of

Supervision

Ris

k M

ap

ROC 1