Foundation: Empirically Driven Practices

Research indicates significant diversity among youth who have caused sexual harm (Hunter & Chaffin, 2005). Additionally, youth and families receive services from a variety of systems with an interest in the youth’s success but with potentially conflicting agendas. A collaborative, multidisciplinary approach meets the complex and myriad needs of the youth and family (Hunter & Chaffin, 2005). A youth’s support by, and connection to, the community are critical to successful treatment outcomes.

Successful treatment outcomes require understanding of the complex nature of sexual harm by youth (Longo, 2002; Longo, 2004; Longo & Prescott, 2006; Morrison, 2006). Trajectories leading to problematic sexual behavior are multi-determined (Becker, 1998) and recidivism risk includes non-sexually harmful behavior (Borduin, 1990; Becker, 1990; Kahn & Chambers, 1991; Schram, Milloy & Rowe, 1991; Chaffin, Bonner & Pierce 2003). Successful treatment is not limited to behavioral modification of sexually harmful behavior. Approaching youth as multifaceted individuals addresses relevant needs that contribute to a youth’s overall long-term success.

We recognize that the behavior of a youth receiving services may reflect the pain of an over-stressed family system.  Family sensitive services that embrace strength, competency and resilience provide the most direct and effective route to therapeutic solutions. Treatment begins at the time an initial referral for services is received and is provided in the least restrictive manner. 

All service provision is holistic in nature, addressing a youth’s full ecological context relating to physical, social, psychological, and spiritual life domains. Since some youth who have caused sexual harm have experienced trauma and abuse (Creeden, 2004; Creeden, 2006; Burton, Rasmussen, Bradshaw, Christopherson, & Huke, 1998; Ryan & Lane, 1997), holistic treatment includes addressing childhood trauma. Best practices for child abuse treatment include trauma-focused and abuse-focused cognitive behavior therapy, and parent-child interaction therapy (Kauffman Foundation Best Practices Project, 2004).

Since recidivism rates of youth who have caused sexual harm indicate a higher risk of non-sexual delinquent behavior (Hunter, Gilbertson, Vedros, & Morton, 2004; Langstrom & Grann, 2000; Schram, Milloy, & Rowe, 1991; Worling & Curwen, 2000), programs should make a concerted effort to adhere to the developing body of literature on youth violence prevention. Program structure should be consistent with evidence from resources such as Youth Violence: A Report of the Surgeon General (Office of the Surgeon General, 2001); Blueprints for Violence Prevention (Center for the Study and Prevention of Violence, 2006); and Best Practices of Youth Violence Prevention: A Sourcebook for Community Action (Thornton, et al., [Center for Disease Control], 2002). These sources indicate a need for multi-modal treatment utilizing parent- and family-based, home-visiting, social-cognitive, and mentoring strategies.

Current evidence indicates that the most effective treatment is based upon a foundation of non-judgmental attitude, empathy, genuineness, and warmth (Hubble, Duncan, & Miller, 1999; Hunter & Chaffin, 2005). Additionally, recent studies indicate that successful outcomes in psychotherapy are based upon four factors (Miller, Hubble & Duncan, 1999).  They are: therapeutic technique (15%); creation of hope and expectation for change (15%); the therapeutic relationship between service providers and clients  (30%); and client characteristics (40%) including strengths, resources, social support, living environment.

Treatment is based upon these concerns in order to reduce harm; enhance the lives of the children and families we serve; and create safer communities for everyone. 

 

Initial Assessment

In addition to specialized evaluation for each youth, all families receive a thorough assessment in order to best meet their goals for treatment. Addressing individual and environmental protective factors and core competencies create a foundation for competency development vital to harm reduction.  This information guides safety and treatment planning throughout the therapeutic process.

The following conceptual framework provides the foundation for healing through a full continuum of care.

 

Services for Youth and Families

Therapeutic change occurs in the context of relationship.  While progress is measured through competency development (Torbert & Thomas, 2005), the treatment process is not based on linear progression.  Services may be more accurately described as analogous to a weaving.  Therapeutic issues are introduced into the treatment process and are interwoven in ways that integrate themes and connections to each family member's life experiences.  Many threads are similar and repetitive throughout the fabric of treatment.  The entire process and content of a healing experience creates a unique pattern that illuminates the changing tapestry of a youth’s life story.

Therapeutic issues, or threads, that create the weaving, provide a pattern design for treatment.  The following treatment components identify therapeutic tasks for harm reduction and healing.  While they are presented in a sequential format, actual intervention does not assume such a step-wise progression.

 

 

Competency Development

Competency development is the process by which juvenile offenders acquire the knowledge and skills that make it possible for them to become productive, connected, and law abiding members of their communities (Torbet & Thomas, 2005, p.3.).  Competency development is not treatment. Youth do not become competent just because they complete a treatment program (Torbet & Thomas, 2005, p.5.).

Some youth receiving services are involved with the juvenile justice system. According to The Juvenile Justice and Delinquency Prevention Committee of the Pennsylvania Commission on Crime and Delinquency the purpose of juvenile justice is “to provide for children committing delinquent acts programs of supervision, care and rehabilitation which provide balanced attention to the protection of the community, the imposition of accountability for offenses committed and the development of competencies to enable children to become responsible and productive members of the community” (Torbet & Thomas, 2005, p.1.).

The role of the juveniles justice system is to facilitate efforts that advance youths’ competencies so that offenders are less likely to take part in anti-social, delinquent behaviors and better able to become responsible and productive members of their communities (Torbet & Thomas, 2005, p.12.). Whether, or not, youth receiving services are court mandated, developing pro-social competencies is critical for life-long success.

It is critical to acknowledge that education does not equal change.  Research indicates five core competency domains.  They are: social skills (interaction, cognition and self-control); moral reasoning; academic skills; work force development skills; and independent living skills.   All youth must be able to integrate knowledge into consistent practice in order to demonstrate measurable progress. They can do so throughout the following process of treatment.

I. Therapeutic Engagement

This is the opportunity to establish a relationship with each client using empirically driven treatment approaches. Development of a therapeutic alliance allows individuals to find courage and the capacity to make successful changes in their lives. It employs Motivational Interviewing (Miller & Rollnick, 2002). The first priority is to engage all participants in such a way that they are motivated to consider change.

1. Participate in a welcoming ritual and introductory process.
2. Complete all logistical procedures for intake services.
3. Introduction to the treatment process by primary staff.
4. Review rules, policies, procedures and expectations with primary staff.
5. Participate in a clearly defined, structured, individual and family systems assessment with clinical staff if not previously completed.
6. Join with the treatment team in the creation of a treatment plan.            
7. Identify people who can potentially be trusted to make up a social support network and participate in the therapeutic process.
8. Discuss viable options with primary staff about the role that each social support network member will play throughout treatment and aftercare.
9. Initiate contact with social support network members as identified in 1. G.
10. Clarify and define the specific role that each social support network member will play.
11. Participate in therapeutic activities.
12. Learn self-soothing activities to enhance stress reduction and affect regulation.

1. Begin to demonstrate respectful behavior.
2. Actively give and receives feedback.
3. Begin Sexual Health curriculum.
4. Begin Social Skills Curriculum that includes anger management when indicated.
5. Begin participation in Substance Abuse Curriculum when indicated.
6. Begin monitoring competency development.

II.  Facing Up to Harmful Behavior

Acknowledgment of sexually abusive behavior that has brought a youth into treatment provides the first opportunity for participants to begin taking responsibility for their actions.  This requires a willingness to talk about the reasons for needing services.  It does not require details of the behavior or acknowledgment of complete responsibility for their actions.  This process introduces cognitive behavioral interventions in an effort to reduce antisocial behavior and change social learning.

1. Identify behavior that brought them into treatment
2. Adjust the treatment plan, if necessary to include a comprehensive response for taming violence and sexual aggression.
3. Acknowledge harmful behavior in therapy.
4. Begin integrating behavior congruent with treatment plan and therapeutic goals.
5. Begin participation in Dynamics of Abuse curriculum.
6. Continue participation in psycho educational curricula.
7. Demonstrate reduction of harmful behaviors.
8. Continue to monitor and document competency development.

III.  Mapping the Influence of Previous Trauma

Youth and families are supported in developing the ability to honestly address painful life experiences that played a part in the need for services.  Cognitive restructuring can enhance implementation of new skills for harm reduction.

1. Participate in Trauma Outcome Process curriculum.
2. Participate in Trauma-Focused Cognitive Behavioral Therapy when indicated.
3. Practice self-soothing activities to enhance affect regulation while healing trauma.
4. Create a family genogram and chronological time line with clinical staff.
5. In individual therapy, figure out how previous trauma influences current behavior.
6. During individual therapy, address specific traumas, triggers and choices.
7. Address grief and loss, and begin practicing self-expression that does not cause harm.
8. Teach the Trauma Outcome Process to social support network.
9. Continue participation in psycho educational curricula as indicated.
10. Demonstrate improved social skills, moral reasoning, and behavior:

            a.  No harmful language.
            b.  No harmful gestures.
            c.  No harmful physical contact.
            K. Monitor and document competency development.

IV.  Eliminating Patterns of Harmful Behavior

In order to tame harmful behavior, each youth and his, or her, social support network members learn to understand what events, thoughts, feelings and beliefs created and maintain a need for services.  Cognitive strategies are utilized to stop harmful behavior.

1. Explore and begin planning how to eliminate disturbances of arousal.
2. Learn pro-social affect regulation.
3. Practice pro-social affect regulation in all ecological contexts (home, school and community)
4. Begin practicing self-interventions to prevent harmful behavior.
5. Monitor and document competency development.

V.  Creating a Detailed Plan for Taming Violence And Sexual Aggression

Each youth can develop a detailed plan for self-intervention that decreases the likelihood of harmful behavior.  This becomes the framework for transition planning and aftercare services (when a youth has been placed out of home).

1. Create a plan for restitution and participate in restorative justice victim offender dialogues.
1. Identify all people who have been hurt by their harmful behavior.
2. Identify how they will go about making amends to each of those people.
3. Identify activities for community service as a component of restitution.
4. Publicly apologize to everyone who was in any way hurt by his or her harmful behavior.

1. Illustrate a detailed self-intervention plan for pro-social affect regulation.
2. Conduct social support network meetings to plan for transition and aftercare.
3. Create a formal document to serve as a map for success upon discharge, or termination of treatment.
4. Present plan to social support network.
5. Demonstrate understanding, empathy, compassion and moral reasoning.
6. Display developmentally appropriate pro-social interpersonal behavior.
7. When placed out of home, explore specific options for aftercare.
8. Monitor and document competency development.

VI.  Practicing the Plan

Termination of services, or discharge from residential treatment, is a challenging and vulnerable time.  Youth in residential treatment have experienced significant change in an artificial environment and return to the community represents a true test of adaptation and integration.  Each participant can enhance potential for success by practicing new ways of responding to difficult situations.

1. Begin process of transition out of intensive treatment.
2. Plan specific reintegration activities with primary staff and social support network.
3. For those in residential treatment, begin graduated lengths of stay in the community.
4. For those in residential treatment, meet with primary and clinical staff after each community visit in order to assess the experience and strategize for continued success.
5. Participate in family meetings to assess each member's preparation for reunification.
6. Formalize aftercare plan.
7. Monitor and document competency development.

VII.  Planning for Continued Success

Successful treatment outcomes are dependent upon each youth's commitment to living a respectful lifestyle.  This commitment can be punctuated and witnessed by those people who have supported this effort throughout the treatment process.  For youth in residential treatment discharge is a time of high risk when a youth returns to the environment where the sexually harmful behavior originated.  These tasks provide an opportunity for strengthening the plan for continued success.

1. Meet with primary staff to explore the creation of a ritual for symbolically completing treatment.
2. Create a ritual for symbolically completing the treatment process.
3. Facilitate the ritual with social support network members.
4. Schedule appointments for aftercare services.
5. Participate in closing celebration.
6. Discharge from residential treatment (when applicable).
7. Monitor and document competency development.

VIII. Aftercare Services

Aftercare services provide a transition from intensive focus on sexually harmful behavior towards successful application of newly acquired skills and abilities for life-longpro-social affect regulation.  Maintenance of therapeutic connections can enhance adjustment to change and influence successful outcomes.

1. Maintain telephone contact with primary staff on a graduated basis after service completion.
2. Monitor progress towards goals for maintaining continued success.
3. Notify appropriate staff immediately when success is threatened.
4. Return for treatment as necessary.
5. Document outcomes:

a. Intermediate Outcomes are those measured at termination or case closing.
b. Long-term Outcomes are those measured as some point after case closing, and indicate whether ultimate goals have been achieved

Measuring Competency Development
(Torbet & Thomas, 2005, p.17.)

Intermediate Outcomes are those measured at termination or case closing.

Long-term Outcomes are those measured as some point after case closing, and indicate whether the ultimate goals have been achieved

Competency Development Composite

References

Association for the Treatment of Sexual Abusers (ATSA). (March 11, 2000). The effective legal management of juveniles sex offenders. Retrieved from http://www.atsa.com/ppjuveniel.html.
Becker, J. (1990). Treating adolescent sexual offenders. Professional psychology: Research and practice, 21 (5): 362–365.
Becker, J. (1998). What we know about the characteristics and treatment of adolescents who have committed sexual offenses. Child Maltreatment: Journal of the American Professional Society on the Abuse of Children, 3, 317–329.
Borduin, C., Henggeler, S., Blaske, D., & Stein, R. (1990). Multisystemic treatment of adolescent sexual offenders. International Journal of Offender Therapy and Comparative Criminology, 34, 105–113.
Borduin, C., & Schaeffer, C. (2001). Multisystemic treatment of adolescent sexual offenders: A progress report. Journal of Psychology & Human Sexuality, 13:3/4, 25–42.
Brown, S., & Schwartz, C. (2006). Promoting healthy sexuality in sexually abusive youth. In
R. Longo, & D. Prescott (Eds.), Current perspective: Working with sexually aggressive youth and youth with sexual behavior problems. (pp. 193-214). Holyoke, MA: NEARI Press.
Burns B., & Hoagwood, K. (2002). Community treatment for youth: Evidence-based interventions for severe emotional and behavioral disorders (innovations in practice and service delivery with vulnerable populations). New York: Oxford University Press.
Burton, J., Rasmussen, L., Bradshaw, J., Christopherson, B., & Huke, S. (1998). Treating children with sexually abusive behavior problems. New York: Haworth Press.
Center for Sex Offender Management (CSOM) (December 1999). Understanding juvenile sexual offending behavior: Emerging approaches and management practices.Retrieved June 3, 2006, from www.csom.org.
Center for the Study and Prevention of Violence, Institute of Behavioral Science, University of Colorado at Boulder. Blueprints for violence prevention, Retrieved June 4, 2006, from http://www.colorado.edu/cspv/blueprints/.
Chaffin, M. (2006). Can we develop evidenced-based practice with adolescent sex offenders? In R. Longo & D. Prescott (Eds.), Current perspective: Working with sexually aggressive youth and youth with sexual behavior problems. (pp. 661-681). Holyoke, MA: NEARI Press.
Chaffin, M., Bonner, B., & Pierce, K. (2003). NCSBY Fact Sheet: What research shows about adolescent sex offenders. Oklahoma City, OK: Center on Child Abuse and Neglect, University of Oklahoma Health Sciences Center.
Creeden, K. (2004). Integrating trauma and attachment research in the treatment of sexually abusive youth. In M. C. Calder (Ed.), Children and young people who sexually abuse: New theory, research, and practice developments. Lyme Regis, Dorset, UK: Russell House Publishing.
Creeden, K. (2006). Neurological impact of trauma and implications. In R. Longo, & D. Prescott (Eds.) Current perspective: Working with sexually aggressive youth and youth with sexual behavior problems. (pp. 395-418). Holyoke, MA: NEARI Press.
Ferber, T., Pittman, K. with Marshall, T. (2002) Helping all youth to grow up fully prepared and fully engaged.Takoma Park, MD: The Forum for Youth Investment.
Henderson, N., Benard, B., & N. Sharp-Light (Eds.) (1996). Resiliency in action: Practical ideas for overcoming risks and building strength in youth, families and communities. Retrieved fromwww.resiliency.com.

Hubble, M., Duncan, B., & Miller, S. (1999). The heart and soul of change. Washington, DC: American Psychological Association.
Hunter, J., Gilbertson, S., Vedros, D., & Morton, M. (2004). Strengthening community-based programming for juvenile sexual offenders: Key concepts and paradigm shifts. Child Maltreatment, 9: 2.
Hunter, J., & Chaffin, M. (2005). NCSBY Bulletin: Ethical issues in the assessment and treatment of adolescent sex offenders. Oklahoma City, OK: Center on Child Abuse and Neglect, University of Oklahoma Health Sciences Center.
Kahn, T. J., and Chambers, H. J. (1991). Assessing reoffense risk with juvenile sexual offenders. Child Welfare LXX (3), 333–345.
Kauffman Foundation Best Practices Project (2004). Closing the quality chasm in child abuse treatment: Identifying and disseminating best practices. Retrieved January 28, 2007 from www.capacitybuilding.net.
Langstrom, N., & Grann, M. (2000). Risk for criminal recidivism among young sex offenders. Journal of Interpersonal Violence, 15, 855–871.
Longo, R. (2002). A holistic approach to treating juvenile sexual abusers. In M. C. Calder (Ed.), Children and young people who sexually abuse: New theory, research, and practice developments. Lyme Regis, Dorset, UK: Russell House Publishing.
Longo, R. (2004). An integrated experiential approach to treating young people who sexually abuse. In R. Geffner & K. Raney (Eds.), Sex offenders: Assessment and treatment. New York, NY: Haworth Press.
Longo, R., & Prescott, D. (Eds.) (2006). Current perspective: Working with sexually aggressive youth and youth with sexual behavior problems. Holyoke, MA: NEARI Press.
Miller, W., & Rollnick, W. (2002). Motivational Interviewing. New York: The Guilford Press.
National Research Council and Institute of Medicine (2001, November 1). Community programs to promote youth development. Committee on Community-Level Programs for Youth. Washington, DC: National Academy Press.
Office of the Surgeon General (2001). Youth violence: A report of the surgeon general. Retrieved January 27, 2007 from www.surgeongeneral.gov.
Prescott, D. (2006). Risk assessment of youth who have sexually abused. Oklahoma City, OK: Wood’N’Barnes Publishing and Distribution.
Ryan, G., & Lane, S. (1991, 1997). Juvenile Sexual Offending. San Francisco: Jossey-Bass.
Schladale, J. (2002). The T.O.P.* workbook for taming violence and sexual aggression. Freeport, ME: Resources for Resolving Violence.
Schladale, J. (2006). Family matters: The importance of engaging families in treatment with youth who have caused sexual harm. In R. Longo & D. Prescott (Eds.), Current perspective: Working with sexually aggressive youth and youth with sexual behavior problems. Holyoke, MA: NEARI Press.
Schladale, J. (in press). Family reconciliation and reunification with youth who have caused sexual harm. In D. Prescott (Ed.), Applying knowledge to practice: Challenges in the treatment and supervision of sexual abusers.
Schore, A. (2003). Affect regulation and the repair of the self. New York: W.W. Norton & Company.
Schram, D., Milloy, C., & Rowe, W. (1991). Juvenile sex offenders: A follow-up study of reoffense behavior. Olympia, WA: Washington State Institute for Public Policy.
Stien, P., & Kendall, J. (2004). Psychological trauma and the developing brain. New York: The Haworth Press.
Thornton, T., Craft, C., Dahlberg, L., Lynch, B., & Baer, K. (rev. ed., 2002). Best practices of youth violence prevention: A sourcebook for community action. Atlanta: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.
Torbet, P. & Thomas, D. (2005). Advancing Competency Development: A White Paper for Pennsylvania. Pittsburgh, PA: National Center for Juvenile Justice.
Worling, J., & Curwen, T. (2000). Adolescent sexual offender recidivism: Success of specialized treatment and implications for risk prediction. Child Abuse and Neglect, 24, 965–982.
Zehr. H. (2002). The little book of restorative justice. Intercourse, PA: Good Books.