Create an 8- to 10-slide Microsoft® PowerPoint® presentation on treating special populations in the correctional setting. Include the following:Describe characteristics of special populations that a

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an 8- to 10-slide Microsoft® PowerPoint® presentation on treating special populations in the correctional setting. Include the following:

  • Describe characteristics of special populations that are necessary for consideration when choosing a counseling model.
  • Compare the models used for treatment of the special populations within the correctional system.
  • Describe the methods unique to each model, and explain how they reduce relapse.


a minimum of three sources.


any citations in your presentation consistent with APA guidelines.

Do NOT repeat information from slides and speaker notes.

  • Keena, L. (2012). Female offenders and special needs.

    Encyclopedia of Community Corrections

    , n/a.

  • Morgan, R. D. (2013). Vocational psychology in corrections: It is about time. The Counseling Psychologist, 41(7), 1061-1071.
  • von Dresner, K. S., Underwood, L. A., Suarez, E., & Franklin, T. (2013). Providing counseling for transgendered inmates: A survey of correctional services. International Journal of Behavioral Consultation and Therapy, 7(4), 38-44.

Create an 8- to 10-slide Microsoft® PowerPoint® presentation on treating special populations in the correctional setting. Include the following:Describe characteristics of special populations that a
8 Substance Abuse Counseling and Co-occurring Disorders CHAPTER OBJECTIVES After reading this chapter, you will be able to: 1. Recognize substance dependence and substance abuse. 2. Know key diagnoses and definitions from the DSM-IV-TR. 3. Be aware of the various co-occurring disorders that are common to substance abusers. 4. Understand the various screening and assessment tools that are used in the treatment of substance abuse disorders. 5. Know the 12 core functions associated with substance abuse treatment. 6. Be aware of the impact that denial has on the addicted population’s prognosis. 7. Understand the dynamics of relapse prevention. INTRODUCTION The prevalence of offenders suffering from substance use and abuse problems currently in the American Criminal Justice System is staggering. The massive increase in the number of convicted offenders suffering from substance abuse began in the 1980s and continues through the present. As Hanser (2006) points out, any informed discussion of drug offenders in the United States must begin with the war declared on drugs by the U.S. Government. As crack cocaine began to sweep through the nation in the early to mid-1980s an outcry shivered through the fabric of our society. Not only was the drug trade burgeoning and access to illegal substances becoming easier than ever, the violent crime rate was also increasing. A connection was quickly made between the expanding drug culture and the often violent incidents that occurred within its realm. This connection, along with societal upheaval, forced the government to take action in an attempt to rid ourselves from the evils and perils commonly associated with substance abuse and criminal behavior. The resulting action taken by federal and state lawmakers has been to draft laws aimed at corralling illegal substance–using offenders. And, law enforcement efforts have been somewhat successful—successful at least in its ability to arrest a sufficient amount of drug-related offenders so that nearly every correctional agency in America is at or beyond capacity. Once drafted these laws are enforced. In order to be enforced assets must be well equipped and mobilized. What is the primary ingredient for equipping and mobilizing assets? Money. As a country we have spent enormous amounts of money in attempt to halt the flow and usage of illegal substances. The money has primarily gone to two components of the criminal justice system: enforcement and corrections. Enforcement efforts are usually aimed at stopping the flow of illegal substances from entering our country; arresting those transporting and distributing illegal substances after they have entered the country; as well as, arresting those found to be using illegal substances. Enforcement efforts are carried out by a multitude of law enforcement agencies ranging from federal to state and local jurisdictions. Once arrested these offenders then become the responsibility of correctional agencies, also operating at local, state, and federal levels. In essence, we have filled every space available within the correctional component of criminal justice with a human inmate. Closely related to substance use and abuse problems are co-occurring disorders. Co-occurring disorder is a phenomenon whereby individuals are not only suffering from substance abuse issues but they are also afflicted with psychological or emotional impairments that affect their overall health and well-being. For example, co-occurring disorder would be the appropriate concept used to describe an offender suffering from substance use or abuse in conjunction with some other ailment such as anxiety or depression. In fact, it is very rare to observe an offender with substance abuse issues but not also suffering from other psychological or emotional disorders. This is because, in general, substance use and abuse is a method of relieving or adapting to life circumstances that are experienced as unpleasant and troublesome. Psychologically and emotionally healthy human beings are generally not involved with the abuse of illegal substances because of their limiting effects. Humans function best in natural states of existence free of foreign substances. The ingestion of illegal substances by mostly psychologically and emotionally healthy individuals has a tendency to “gum things up” keeping them from functioning at their highest levels. What we do know is that our correctional system is at full capacity. We also know that our correctional system is filled mostly with offenders suffering from co-occurring disorders. It would be difficult at best to refute these facts. The question then becomes, What do we do? How do we deal with our inmate population that is largely made up of offenders suffering from a multitude of psychological and emotional disorders coupled with the use and abuse of illegal substances? First, it is important to point out that there are no simple answers or solutions. Our democratic style of government ensures checks and balances that work to limit one ideology from completely dominating policy and procedure. Conservatives may argue that the answer lies in building more prisons. The problems with this approach, however, are robust. How many more prisons would we need to build? Who would assume responsibility for the massive costs? On the other hand, liberals may argue that we need to decriminalize all forms of substance use. In relation to this postulate, the reality is that our society is not yet ready to seriously consider this approach as viable. Therefore, we are left to function somewhere between these two extremes. Our contention is that we need a strong presence on different fronts. We need law enforcement to work diligently because many offenses, often violent, occur in conjunction with substance use and abuse. In addition, we need to create innovative approaches to address both the substance abuse issue among offenders as well as mental health issues that confront them. Among the innovations that have been incorporated, it is the use of both drug courts and mental health courts that has received widespread support and popularity within the criminal justice system. Students may recall the mention of these types of interventions from Chapter 1, noting again that drug courts synthesize therapeutic treatment and judicial processes to optimize outcomes with the drug-addicted offender population (Watson, Hanrahan, Luchins, & Lurigio, 2001), while mental health courts consist of specialized dockets for defendants with mental illnesses (Bureau of Justice Assistance, 2004). Over the past two decades, there has been fervent support for drug courts and, upon the common realization that substances induce and correlate with other disorders, mental health course as well. As can be seen, the trend is, and should be, to bear public resources on treating offenders who suffer from co-occurring disorders while in custody. Recidivism rates speak loudly and aggressively to this last postulate. As Hanser (2006) points out, recidivism rates are closely related to substance abuse. When considering co-occurring disorders recidivism rates are even higher. However, the complexities in providing the actual intervention for offenders who present with these multiple challenges are great. Therefore, the remaining portions of this chapter are aimed at identifying, describing, and treating those offenders suffering from substance use and abuse as well as co-occurring disorders. To begin, it is useful to define some of the concepts commonly used within the parameters of treating offenders suffering from substance abuse and co-occurring disorders. Many of these terms are commonly used interchangeably but as will be pointed out there are subtle differences that need to be illuminated. PART ONE: RECOGNIZING SUBSTANCE DEPENDENCE AND SUBSTANCE ABUSE Important Concepts Defined The document most relied on to provide official definitions for most psychological and emotional concepts is the Diagnostic Statistical Manual (DSM-IV-TR) published by the American Psychological Association (APA). The latest version being the fourth edition published in 2000. First, substance-related disorders are divided into substance use disorders and substance-induced disorders (CSAT, 2006). Substance use disorders are further divided into substance abuse and substance dependence. Substance use disorders are characterized by 11 categories provided by the APA (2000, p. 191): 1. Alcohol 2. Amphetamine or similarly acting sympathomimetics 3. Caffeine 4. Cannabis 5. Cocaine 6. Hallucinogens 7. Inhalants 8. Nicotine 9. Opioids 10. Phencyclidine (PCP) or similarly acting arylcyclohexylamines 11. Sedatives, hypnotics, or anxiolytics. These 11 categories are separated by criteria into abuse and dependence. Substance abuse is often used to refer to both abuse and dependence. Also, substance dependence and addiction are often used interchangeably although there is strong debate as to whether this is appropriate (CSAT, 2006). Finally, the system of care responsible for treating substance-related disorders is commonly referred to as the substance abuse treatment system. Substance Abuse—the DSM-IV-TR defines substance abuse as a “maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances” (APA, 2000, p. 198). Individuals who abuse substances are likely to experience harmful consequences such as, but not limited to, the following: 1. Repeated failure to fulfill roles for which they are responsible 2. Use in situations that are physically hazardous 3. Legal difficulties 4. Social and interpersonal problems. Substance Dependence—is defined by the APA (2000) as “a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems” (p. 192). This harmful pattern of behavior includes all of the features of substance abuse as well as such features as: 1. “Increased tolerance for the drug, resulting in the need for ever-greater amounts of the substance to achieve the intended effect 2. An obsession with securing the drug and with its use 3. Persistence in using the drug in the face of serious physical or psychological problems” (CSAT, 2006, p. 1). Substance-Induced Disorders—are characterized by three main facets which include substance intoxication, substance withdrawal, and group of symptoms that are “in excess of those usually associated with the intoxication or withdrawal that is characteristic of the particular substance and are sufficiently severe to warrant independent clinical attention” (APA, 2000, p. 210). Further exacerbating the problem of substance-induced disorders is the fact that individuals suffering from this ailment often present with a wide variety of symptoms characteristic of various mental disorders including delirium, dementia, amnesia, psychosis, mood disturbance, anxiety, sleep disorders, and sexual dysfunction (CSAT, 2006). Co-occurring Disorders—a condition where individuals suffer from substance-related and mental disorders. Offenders suffering from co-occurring disorders will likely have one or more substance-related disorders operating in conjunction with one or more mental disorders (CSAT, 2006). The Center for Substance Abuse Treatment (CSAT) further defines co-occurring disorders, at the individual level, as a phenomenon where “at least one disorder of each type can be established independent of the other and is not simply a cluster of symptoms resulting from a single disorder” (CSAT, 2006, p. 3). An important distinction noted by CSAT (2006) is that some offenders at particular points in time may present with symptoms that do not neatly fit the criteria for diagnoses found in the DSMIV-TR categories. From a practical standpoint, however, these offenders are suffering from symptoms that are best addressed from a framework which assumes the presence of a co-occurring disorder. To address this distinction CSAT (2006) created a “service definition of co-occurring disorder.” The definition consists of three postulates: 1. “Individuals who are ‘prediagnosis’ in that an established diagnosis in one domain is matched with signs or symptoms of an evolving disorder in the other 2. Individuals who are ‘postdiagnosis’ in that either one or both of their substance-related or mental disorders may have resolved for a substantial period of time 3. Individuals with a ‘unitary disorder and acute signs and/or symptoms of a co-occurring condition’ who present for services. Suicidal ideation in the context of a diagnosed substance use disorder is an excellent example of a mental health symptom that creates a severity problem, but itself does not necessarily meet criteria for a formal DSM-IV-TR diagnosis. Substance-related suicidal ideation can produce catastrophic consequences. Consequently, some individuals may exhibit symptoms that suggest the existence of co-occurring disorder but could be transitory (e.g., substance-induced mood disorders). While the intoxicated person in the emergency room with a diagnosis of a serious mental illness will not necessarily meet abuse or dependence criteria, he or she will still require co-occurring disorder assessment and treatment services” (p. 3). How Substance Abuse Starts First, it is important to state clearly that it is impossible to articulate a clear path to substance abuse to capture the path taken by all people. The paths are as complex and varied as human beings themselves. In addition, there has been much debate that still continues to try and place substance abuse within a particular domain. For example, in past years it was believed that substance abuse was primarily a moral issue. Addicts were viewed as morally deficient and corrupt (Dimoff, 2001). More recently, debate has shifted to consider substance abuse as a disease. This ideology places the enigma into the medical profession. Today, it is mostly accepted that the issue of substance abuse is primarily grounded on at least two main components: heredity and environment, and/or a combination of the two. There is strong evidence that heredity is a major factor with powerful influence on the likelihood of some individuals engaging in substance abuse. Some reports claim individuals reared by parents who are substance users and abusers are four times more likely to be involved with substance abuse (Dimoff, 2001). Environmentally, the United States comprises of approximately 5–6 % of the world’s population. Americans consume, however, three-quarters of all illegal drugs produced in the world making us the leading consumers of alcohol and prescription drugs. Important to this discussion is one environmental factor that highlights current emphasis on “feeling good.” With medical advances we now have a variety of medications aimed at soothing almost any ailment. If we do not feel good we turn to substances as a solution. And, this ideology has become big business for drug makers and pharmaceutical companies. This fact is quickly observed by the constant flow of media outlets telling us there is medication for whatever adverse feelings we may experience. Closely related to this phenomenon is the media-advanced depiction of what we should physically look like in order to be accepted and successful. In essence, if you are not thin and attractive you are relegated to the outer fringes of society. This ideology creates enormous social and environmental pressures which are impossible to achieve. There is a constant drive toward perfection. The problem with perfection, however, is that it is a very elusive concept that is usually characterized by such statements as, “If I were only able to be a little more … then I would be perfect.” We mentally create scenarios that are impossible to achieve. And when we are unable to measure up to the impossible circumstances we create the result which is usually a feeling of shame or defectiveness. In order to alleviate the painful feelings of these emotions some turn to substances to dull the effects. A vicious circular cycle is created and rigidly adhered too and unfortunately this cycle is one that is incapable of producing the feelings we truly desire. An additional component that may be most salient in the origins of substance abuse is the role or influence of parents or guardians. A strong consensus now exists that indicates much of a child’s personality is formed by the age of eight. This includes values, morals, work ethic, and attitude. In most cases, parents will have the greatest influence on their children’s psychological and emotional well-being. Ideally, children need to be given sufficient freedom to explore and learn their ever-expanding world. This freedom needs to be balanced with guidance and support aimed at showing the child what is right and wrong and also what is safe and dangerous. If children are not given sufficient freedom to learn and grow it is likely that deep emotional problems will result such as stress, low self-worth, depression, anxiety, and nervousness. These psychological and emotional disorders often contain negative feelings that are powerful influences on behavior. As children grow to adolescence and early adulthood it becomes very difficult to function in a normal and healthy manner. Not surprisingly, many will turn to substances to relieve the powerful pangs of anxiety, depression, shame, anger, and fear. External pressures also contribute to the origins of substance use and abuse. External difficulties are commonly characterized by such issues as school problems, work difficulties, family problems, peer pressure, and relationship issues. All of these circumstances or environments are strong causal factors for individuals to experience feelings such as shame and defectiveness, which are described as being at the heart of addiction. As will be covered later in the chapter, substance abuse is really a symptom of psychological and emotional dysfunction. The issue is not so much treating substance abuse as it is treating repressed emotion and the psychological dys-function that accompanies it. Progressive Stages of Substance Abuse It is important to recognize the different stages that usually lead to substance abuse. Obviously, these stages may vary for some individuals depending on particular circumstances. However, there is usually observable behavior that would fit the following five categories: 1. Compulsion to acquire and use substances and a preoccupation with their acquisition and use 2. Loss of control over substance use or substance-induced behavior 3. Continued substance use despite adverse consequences 4. A tendency toward relapse following periods of abstinence 5. Tolerance and or withdrawal symptoms (LASACT, 2004). Compulsive behaviors usually result from users learning that good feelings can be produced by using substances. The individual may start out using substances at parties or on weekends to “take the edge off.” Initially, powerful feelings of euphoria are experienced because of a lack of tolerance. And, generally there are no adverse behavioral effects because the substance has not yet begun to interfere with the user’s lifestyle or obligations. In essence, there is a powerful feeling of euphoria with few consequences (Dimoff, 2001). Due to the euphoric effects and initial lack of consequences, compulsive behaviors become more pronounced as users begin to actively plan both attainment and use of the substance(s). At this point use may still be controlled. For example, the individual may use only at “appropriate” times and places such as, not at work, not before 5:00 P.M. and certainly not in the mornings. Nonetheless, a very important and powerful process is now underway; tolerance is beginning to be developed. Loss of control over substance use or substance-induced behavior usually becomes evident as the individual becomes more preoccupied with euphoric mood swings. There is generally an increase in the frequency of substance use and some of the self-imposed rules begin to be broken. The individual may engage in solitary use as opposed to only at parties or on the weekends with friends. In addition, more of the substance may be used than originally planned. At this point, the user is quickly approaching the realm of chemical dependency. This is where the individual’s lifestyle begins to change. In fact, individuals who have become chemically dependent on a substance will usually arrange their life so that the substance and its obtainment and use are paramount. Everything else becomes secondary to the substance. Once the individual has become dependent on a substance(s) a variety of destructive behaviors will usually become evident to the informed observer. Keep in mind that the dependent individual will likely be very clever in disguising his or her substance use and abuse. In fact, cognitive processes of these individuals may now be arranged in such fashion that their very survival is dependent on the substance. The individual begins to shift from using a substance to obtain euphoria to one of coping with negative emotions such as anger, guilt, fear, or anxiety. The individual’s actions may become sneaky and mysterious as more effort is allocated to keeping his or her use a secret. Appreciate, that at this point the concept of control has shifted. The individual is no longer in control; the substance is in control. Due to the shame that will accompany the loss of control, individuals will usually be irritable or angered easily. The individual will attempt to rationalize his or her behavior to avoid responsibility and become very adept at projecting one’s problems to others. Personal relationships will begin to deteriorate as the substance will command more importance than other people, and also, the individual begins to repeatedly violate his or her own value system. All of these factors contribute to emotional distress perpetuating the circular cycle of what is now chemical dependence/addiction. The concept of denial, which will be explored in greater detail later in the chapter, begins to take hold within the individual’s methods of coping. In fact, denial is a concept often described as a person’s way of coping with painful situations whereby the denial of the existence of a problem allows the individual not to deal with or assume responsibility for it. At this point, the person’s use of a substance or substances can be described as chronic chemical dependency. Chronic chemical dependency can be described by the following characteristics: 1. Individual uses substance to feel normal and avoid pain rather than for achieving euphoria. 2. Individual experiences blackouts which progressively become longer and more frequent. 3. The desire to use the substance is now the most important factor in the individual’s life. 4. The individual experiences complete loss of control. 5. The individual experiences paranoid thinking and may fear insanity. 6. Individual feels alone and isolated. 7. Individual is likely to experience a loss of desire to live. 8. Individual begins to experience physical problems (Dimoff, 2001). During this phase of the substance abuse process there is usually a strong tendency toward relapse following periods of abstinence. In fact, some users may begin experimenting with the idea of not using. This is an attempt to show themselves or others that they really are not dependent and that they could halt usage if desired. This period of abstinence, however, is usually short lived and usage quickly resumes, resulting in relapse. It is important to note that relapse is not an isolated event. Relapse is a condition of becoming unable to cope with life without the use of substances. Relapse prevention is a critical strategy that will be given specific attention later in the chapter. Finally, tolerance levels and withdrawal symptoms are such that the offender needs more of the substance and experiences noticeable difficulties during periods of abstinence. Tolerance is the “need for markedly increased amounts of the substance to achieve intoxication,” or a “markedly diminished effect when using the same amount” (DSM-IV). Withdrawal syndrome is the characteristic group of signs and symptoms that typically develop after a rapid, marked decrease or discontinuation of a substance upon which an individual is dependent. The severity and duration of the withdrawal syndrome depends on several factors including the nature of the substance used, the half-life and duration of action of the substance, the length of time the substance has been used, the amount used, the use of other substances, the presence of other medical and psychiatric conditions, and other individual biopsychosocial variables. Recognizing Substance Abuse As a counselor in a correctional setting it is important to be able to recognize certain signs indicative of substance abuse. The proper recognition allows for proper assessment which in turn enables the institution to better provide appropriate services. Many offenders will under-or overreport their substance use and abuse problems. Even if not an intentional attempt at deception, it is rare that offenders will accurately depict their current reality concerning substance use and abuse. The following characteristics, provided by Dimoff (2001), are meant to provide a guide or framework for some of the more common characteristics displayed by offenders suffering from substance abuse. They are certainly not meant to be all inclusive: Outward Physical and Mental Signs: • Rapid weight loss or gain • Discolored fingers • Injection marks along veins—due to increased scrutiny of arms and other common injection points many offenders are now injecting substances in more concealed areas of the body including thighs, and over tattoos • Wears long sleeve shirts on warm days. • Dilated pupils • Bloodshot or glassy eyes • Poor balance • Perspires excessively • Health complaints • Smells of alcohol or marijuana. • Displays droopy eyelids or sleepy appearance. • Frequently wears sunglasses at odd times. • Uses gum or mints to cover breath. Source: SACS, 2006. Mental Impairments: • Denial • Delusional • Paranoia • Preoccupation • Blackouts • Memory impairment • Poor judgment • Difficulty concentrating • Difficulty thinking Co-occurring Disorders Currently, there is strong movement on behalf of the federal government to address offenders suffering from co-occurring disorders. As previously stated, co-occurring disorder refers to any psychological or emotional disorder that is operating in conjunction with substance abuse. One such program being funded through SAMHSA is jail diversion. Jail diversion programs are aimed at identifying offenders who are suffering from substance abuse and/or co-occurring disorders. Once identified, those offenders meeting necessary criteria are diverted from jails and placed into comprehensive community service programs aimed at treating the offender’s disorders. The theoretical structure on which jail diversion rests is that if those offenders suffering from co-occurring disorders are not treated then the likelihood of them being released and further acting out in ways that bring them into contact with criminal justice system is enhanced. It is important to note that most offenders, once assessed, will meet necessary criteria for dual diagnosis. “Dual diagnosis” is a term used to describe a phenomenon whereby offenders are suffering from a substance abuse disorder in concert with a mood disorder, anxiety disorder, personality disorder, or a psychotic disorder. MOOD DISORDER Mood is a concept that describes a pervasive and sustained emotional state that may affect all aspects of an individual’s life and perceptions (LASACT, 2004). Mood disorder describes a pathologically elevated or depressed disturbance of mood and includes full or partial episodes of depression or mania (LASACT, 2004). It is important to note the term “pathological” because this denotes the presence of disease. Elevated or depressed mood states are normal adjustments to daily activities and circumstances. In some instances where we are engaged in pleasurable activities it is considered normal and healthy to experience elevated moods. The same is true for circumstances that are experienced as painful such as the loss of a loved one. Moods become pathological when there is a persistence and prolonged nature of being in either a depressed or elevated state. In essence, we are not free to traverse different states of mood based on current life circumstances. The disorder works to keep us trapped so that we experience either depressed or elevated states of being, independent of our surroundings. The term used to describe an elevated mood state is “manic episode.” A manic episode is a period of at least one week where an individual experiences a persistently elevated, euphoric, irritable, or expansive mood (LASACT, 2004). A manic episode is usually characterized by such symptoms as hyperactivity, grandiosity, flight of ideas, talkativeness, a decreased need for sleep, and distractibility (LASACT, 2004). A depressive episode, or major depressive episode, is used to describe a mood characterized by a depressed state. Major depressive episodes involve feelings of depression that are accompanied by loss of pleasure or indifference to most activities, most of the time for at least two weeks (LASACT, 2004). Some common examples of major depressive episodes include feelings of worthlessness and inappropriate guilt. In addition, some individuals may experience recurrent thoughts of death or suicide. According to the Louisiana Association of Substance Abuse Counselors and Training (LASACT) (2004), there are four major components that are able to capture a wide range of cognitive and behavioral patterns described by the broad term of “mood disorder.” These components consist of bipolar disorder, cyclothymia, dysthymia, and hypomanic episode and are listed below: • Bipolar disorder—is a condition that entails cycling mood changes from severe highs (mania) to severe lows (depression). In many cases, periods of normal mood levels will be mixed in-between. While clients are in the depression cycle, they will present with any or all of the symptoms of depression. While in the manic cycle, the client will likely be overactive, overtalkative, and will typically have an overabundance of energy. Further, manic states tend to affect thinking and judgment leading to impulsive and disproportionately exuberant social behaviors that can cause serious problems and/or embarrassment. For example, clients experiencing a manic phase may feel elated, engaging in anything from unwise business decisions to romantic sprees that are later regretted (National Institute of Mental Health, 2009). • Cyclothymia—is likened to a low-key form of bipolar disorder but, with cyclothymia, mood variability occurs with greater frequency and tends to be more chronic in nature (LASACT, 2004). Exhibited episodes of mania and depression are not severe enough to be diagnosed in the major category of severity but they are serious enough to disrupt the client’s ability to lead a balanced and adjusted life (APA, 2000; LASACT, 2004). • Dysthymia—is described as a chronic mood disturbance that usually entails a loss of interest or pleasure in most day-to-day activities. The mood disturbance, however, is not sufficient to meet the full criteria for a clinical diagnosis of major depressive episode. Dysthymia is a mood disturbance that, while not debilitating to the client’s day-to-day functioning, tends to diminish the client’s ability to enjoy life; these individuals often have pessimistic outlooks and attitudes, regardless of their circumstances. In other words, a person diagnosed with dysthymia is often able to carry out normal duties and functions but there is no “zest” to life. • Hypomanic episode—is a condition described as a period, usually weeks or months, “of pathologically elevated mood that is similar to but less severe than a manic episode” (LASACT, 2004, p. 41). Similar to dysthymia, hypomanic disorders are usually not severe enough to cause overt and clearly observable impairment in functioning within social or occupational settings (LASACT, 2004). SUBSTANCE-INDUCED MOOD DISORDER As mentioned, it is important to remember that many offenders will be suffering from more than one disorder. Substance abuse and mood disorder often exist in conjunction with the other. Any variation of mood disorders is sufficient to greatly diminish the joys of life. When people are unable to experience natural joy or pleasure their response will often be to turn to substances in order to change their mood. A substance-induced mood disorder is described in the DSM-IV-TR as meeting the following criteria: A. A prominent and persistent disturbance in mood characterized by either, or both, of the following: 1. Depressed mood or markedly diminished interest or pleasure in all, or almost all activities 2. Elevated, expansive, or irritable mood. B. There is evidence from the history, physical examination, or laboratory findings of substance intoxication or withdrawal, and the symptoms in Criterion A developed during, or within a month of, significant substance intoxication or withdrawal. C. The disturbance is not better accounted for by a mood disorder that is not substance induced. Evidence that the symptoms are better accounted for by a mood disorder that is not substance induced might include the following: The symptoms precede the onset of the substance abuse or dependence; they persist for a substantial period of time after the cessation of acute withdrawal or severe intoxication; they are substantially in excess of what would be expected given the character, duration, or amount of the substance used; or there is other evidence suggesting the existence of an independent non-substance-induced mood disorder. D. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. E. The disturbance does not occur exclusively during the course of delirium. In essence, a substance-induced mood disorder can be described as having manic features, depressive features, or mixed features that manifest during intoxication or withdrawal (LASACT, 2004). ANXIETY DISORDERS Anxiety disorders are commonly noted as being the most common group of psychiatric disorders (LASACT, 2004). Fosha (2000) describes anxiety as being the mother of all pathologies. Anxiety is a concept that describes the sensations of nervousness, tension, apprehension, and fear that are experienced in anticipation of some type of danger. The danger may manifest itself through internal or external mechanisms. It is important to note that anxiety is also described as a normal reaction to stress. Anxiety may function as a motivator to get things done such as studying for an exam, completing necessary assignments in the office, and preparing for a speech. Anxiety becomes a disabling disorder when it grows to an excessive and irrational dread of everyday life and circumstances. Anxiety disorder refers to different clusters of signs and symptoms that may manifest themselves in a variety of ways including anxiety, panic, and phobias (LASACT, 2004). A panic attack is described as a period of intense fear or discomfort that usually develops abruptly and reaches a peak within a few minutes. There is usually a manifestation of both physical and psychological symptoms. Physical symptoms may include hyperventilation, heart palpitations, trembling of body limbs, sweating, dizziness, hot flashes or chills, sensations of numbness or tingling, as well as nausea or choking. Psychological symptoms are mainly rooted in the emotion of fear. Common symptoms include the fear of fainting, dying, losing control, or losing one’s mind. Individuals who suffer from panic attacks often describe the episodes as being extremely frightening. The fear of losing complete control can be so overwhelming that once the attack subsides a persistent fear reemerges with the thought of the recurrence of more panic attacks. In essence, those who experience panic attacks live in a constant state of fear and arousal that reaches climax during the attack and then subsides until the next (LASACT, 2004). A phobia is a type of anxiety disorder where the focus of the anxiety is on an activity, person, or situation that is dreaded, feared, and avoided if at all possible. Phobia can be so powerful that one’s life becomes restricted. For example, someone with a fear driving may only feel comfortable in their own home or places within walking distance. Some of the more common phobias include agoraphobia, social phobia, and simple or specific phobia (LASACT, 2004). Agoraphobia is the fear of being caught in a situation or environment from which an exit would be impossible, difficult, or embarrassing. Embarrassment in this sense is usually in relation to the idea of being seen losing control in public. Typical situations in which agoraphobia may present include driving, standing in line, being in an auditorium, or just simply being outside of one’s home. Agoraphobia will usually result in a pattern of avoidant behaviors, particularly avoidance of places or situations where an attack was experienced (LASACT, 2004). Social phobia refers to persistent and irrational fear of embarrassment and humiliation in social situations. Often the fear is recognized as being irrational; however, the feelings are so powerful that one’s cognitions are completely consumed. Individuals suffering from social phobia often view others as being much more competent and greatly exaggerate the effects of small or common mistakes. The most common social phobia is public speaking. However, symptoms of social phobias may also present when being around anyone other than those closest to the individual (LASACT, 2004). Specific phobias are sometimes called single or simple phobias. Specific phobia is an intense, excessive, or unreasonable fear triggered by the presence or anticipation of a specific object or situation. Naturally occurring specific phobias may consist of rain, lightening, or spiders, whereas situational specific phobias have been known to manifest when one is faced with heights or riding in elevators (LASACT, 2004). Another form of anxiety disorder is obsessive compulsive disorder (OCD). Obsessions are described as repetitive and intrusive thoughts, impulses, or images that trigger feelings of anxiety. Compulsions are described as repetitive rituals and acts that people are driven to perform, often reluctantly, in order to prevent or reduce stress. Oftentimes the obsessions or compulsions or both consist of thoughts and actions that are contrary to social norms. Some examples of OCD include harming others, becoming contaminated, excessive hand-washing, and silently counting and repeating words. Manifestations of OCD are extremely time consuming and significantly interfere with daily functioning (LASACT, 2004). Post-traumatic stress disorder (PTSD) is a disorder where an individual experiences a psychologically traumatic stressor. In most cases PTSD is thought of in relation to severely traumatic events such as war, witnessing a death, experiencing a near-death situation, as well as sexual abuse. And, though these instances are more than sufficient to provide the necessary framework for PTSD, it is important to note that PTSD may result from situations and circumstances that are much less severe. Whether a person experiences the effects of PTSD depends on how they process the effects of certain circumstances. For example, the witnessing of a deadly automobile accident may leave permanent psychological scars for one individual thus inhibiting this individual from ever driving again. The same accident, however, witnessed by another person operating from a different cognitive structure may experience the wreck as tragic but is able to effectively move on and experiences little residual effects (LASACT, 2004). PTSD consists of a persistent reexperiencing of a traumatic event through recurrent and intrusive images and thoughts (LASACT, 2004). These recurrent images may also manifest themselves in the form of dreams where the trauma is relived. Some of the symptoms experienced by people suffering from PTSD include insomnia, irritability, hypervigilance, and exaggerated startle responses. In addition, sufferers from PTSD will often avoid stimuli associated with the trauma including certain activities, feelings, and thoughts (LASACT, 2004). PERSONALITY DISORDERS Personality refers to deeply ingrained patterns of thought and behavior that affect the way individuals perceive, relate to, and think about themselves and their world (LASACT, 2004). A personality disorder is generally described as a cluster of behaviors that are considered rigid, inflexible, and maladaptive. These behaviors are usually of sufficient severity to cause significant impairment in functioning or significant internal stress (LASACT, 2004). Additionally, personality disorders are enduring and persistent styles of behavior and thought; they are not atypical episodes that are uncommon behavior in certain circumstances. Four personality disorders that present some of the greatest challenges to treatment providers include: • Antisocial personality disorder • Borderline personality disorder • Narcissistic personality disorder • Passive-aggressive personality disorder. For an individual to be diagnosed with antisocial personality disorder there is usually a history of chronic antisocial behavior that begins before the age of 15 and continues into adulthood. Certain behaviors common to antisocial disorder include academic failure, poor job performance, illegal activities, recklessness, and impulsive behavior. Some of the symptoms common to antisocial personality disorder include dysphoria or an inability to tolerate boredom, feeling victimized, and a diminished capacity for experiencing intimacy (LASACT, 2004). Oftentimes offenders will describe their feelings just prior to committing an offense for which they were caught as being bored. They will make such statements as “there was nothing else to do,” or “I was looking for some excitement and wanted to see if I could get away with it.” Borderline personality disorder is usually characterized by unstable moods and self images. These individuals will sometimes display extreme mannerisms of overidealization and devaluation along with drastic shifts from baseline to extreme moods or anxiety states. In addition, they are usually very impulsive. Offenders suffering from borderline personality disorder will usually be involved in very intense and unstable interpersonal relationships (LASACT, 2004). These relationships are often volatile and include periods of euphoria followed by extreme disruption that will often culminate in violence. Narcissistic personality disorder is a concept that describes a pattern of grandiosity, lack of empathy, and hypersensitivity to evaluation of others. The pattern is pervasive and rigid (LASACT, 2004). Offenders suffering from narcissistic personality disorder will usually blame everyone but themselves for their circumstances. They lack empathy and are usually unable to experience compassion for others. In essence, a narcissistic individual will usually conclude that they are more intelligent than others and that their problems are due to the faults of those around them. In addition, they become extremely rigid when receiving feedback that is not positive. The concept of passive-aggressive personality disorder describes a behavior that reflects hostility and aggression in passive ways. Offenders suffering from passive-aggressive personality disorder usually lack adaptive or assertive social skills, especially in relation to authority figures. These individuals likely endured strict control during formative years and have adapted by learning to substitute passive resistance for active resistance. This is because active resistance in the presence of a controlling authority figure was perceived as dangerous. Some common symptoms of passive-aggressive behavior include purposefully being late with social or job tasks, failing to do one’s share of the work, criticizing authority figures in subtle ways, and having a constant negative attitude. PSYCHOTIC DISORDERS Psychosis refers to a disintegration of the thinking process, involving the inability to distinguish external reality from internal fantasy (LASACT, 2004). A psychotic disorder is described as a mental disorder in which a person’s personality is seriously disorganized and contact with reality is impaired. Some of the characteristics commonly associated with psychotic disorders include, but are not limited too, delusions, hallucinations, bizarre behavior, incoherent or disorganized speech, and disorganized behavior (LASACT, 2004). One of the most salient characteristics in the identification of psychosis will be the offender’s inability to differentiate between information that originates from the external world and information that originates from the inner world of the mind (LASACT, 2004). In the following, some of the more common psychotic disorders are discussed along with attendant characteristics. Schizophrenia is a formidable psychotic disorder where symptoms usually persist for at least six months resulting in deterioration of occupational and social functioning. Schizophrenia is best understood as a group of disorders with similar clinical profiles. Common characteristic symptoms include hallucinations, delusions, bizarre behaviors, and deterioration in general levels of functioning. In addition, one may experience severe disturbances in relation to language and communication, content of the thought processes, as well as perceptions, affect, and relationship to the external world. Schizophrenia can also be divided into subtypes that generally consist of the following: • Paranoid type—usually characterized by delusions or hallucinations • Disorganized type—usually characterized by speech and behavior problems • Catatonic type—usually characterized by catalepsy or stupor, meaning a trance-like state with loss of sensation or consciousness, as well as extreme agitation or extreme negativism. • Undifferentiated type—here there is no single clinical presentation that predominates. Usually consists of a cluster of characteristics with no one characteristic that is diagnosable within a particular subgroup. • Residual type—at this point there are no predominant characteristics or psychotic symptoms. The disorder may have been successfully treated or the symptoms dormant. Additional psychotic disorders that offenders may present with include brief reactive psychosis. “Brief reactive psychosis” is a term used to describe psychotic symptoms that result from being confronted by overwhelming stress. Delusional disorders describe prominent and often well-organized delusions but generally absent of hallucinations. Additional symptoms may include disorganized thought and behavior as well as abnormal affect. Induced psychotic disorder is a disorder in which psychotic behaviors or thoughts result from the acceptance of one person of the delusional beliefs of another. In essence, a dominant partner suffers from delusional psychosis and these delusions are believed and accepted by a more passive partner. Finally, alcohol and other drug-induced psychotic disorder (AOD) is a condition where individuals suffer conditions characterized by delusions or hallucinations as a result of psychoactive drug use. SECTION SUMMARY It is important to recognize that a large portion of offenders will be suffering from substance abuse problems. In addition, the literature is clear regarding the fact that most offenders suffering from substance abuse will also be suffering from various other psychological and emotional disorders. Therefore correctional counselors should anticipate the likelihood of having to address multiple issues stemming from a variety of sources. In fact, it is important that counselors understand that oftentimes substance abuse is a symptom of repressed emotion. In essence, the real task is to help guide offenders through the process of reconnecting with their repressed emotion and fully identify and express what they are feeling. LEARNING CHECK 1. What does Fosha describe as the “mother of all pathology”? a. Depression b. Bipolar disorder c. Fear d. Anxiety 2. Common characteristics of schizophrenia include which of the following. a. Delusions b. Bizarre behaviors c. Hallucinations d. All of the above 3. Psychosis describes the process of being unable to distinguish between external reality and internal fantasy. a. True b. False 4. Common signs of substance abuse include which of the following. a. Rapid weight loss or gain b. Poor hygiene c. Blood shot or glassy eyes d. All of the above 5. Personality disorders generally describe behaviors that are inflexible, rigid, and maladaptive. a. True b. False PART TWO: SCREENING, DIAGNOSIS, AND ASSESSMENT Screening, diagnosis, and assessment are critical components in the process of deciding the depth and nature of services appropriate for offenders suffering from substance abuse and co-occurring disorders. In criminal justice settings, substance use and mental health disorders are often under-diagnosed which ultimately leads to misdiagnosis (Peters, 1992). When offenders are misdiagnosed it becomes difficult at best to employ proper interventions aimed at treating substance abuse and mental health disorders. It is for this reason that the proper assessment of substance abusers is critical to the ultimate prognosis. However, as noted before, it can be difficult to accurately assess the substance-abusing correctional client. Several reasons for nondetection of substance abuse and mental health disorders are commonplace. First, there is often a negative consequence associated with disclosure of symptoms; second, there is usually a lack of training on behalf of the staff concerning the diagnosis and management of substance abuse and co-occurring disorders (Peters & Bartoi, 1997). Further adding to the enigma is the fact that mental health, substance abuse, and criminal justice systems often operate independently and do not adequately share critical information. In essence, each entity has a different, or at least slightly different, mission. This inadequate sharing of information often results in the nondetection of substance abuse and mental health disorders thereby stymieing the offender’s opportunity to access integrated services (Peters & Bartoi, 1997). Kofoed, Dania, Walsh, and Atkinson (1986) suggest that integrated screening and assessment approaches are commonly found to produce more favorable outcomes. This is because there are very few, if any, validated single instruments capable of assessing co-occurring disorders inside or outside the criminal justice system (Peters & Bartoi, 1997). Therefore, for the purposes of screening and assessment the combination of specialized substance abuse and mental health instruments used in conjunction is most desired. Definitions of Screening, Diagnosis, and Assessment Screening is a concept used to describe the process of detecting mental health and substance abuse disorders along with indicators that reflect the need for treatment (Peters & Bartoi, 1997). Drake and Mercer-McFadden (1995) point out that screening is usually conducted early in the process of gathering information and usually precedes diagnosis and assessment. Common goals of the screening usually include the following: • Detect current mental health and substance use disorders • Identify individuals with a history of violence and/or severe medical problems • Identify individuals suffering from severe cognitive deficits • Identify individuals who would not be suitable for treatment of co-occurring disorders (Peters & Bartoi, 1997). Diagnosis describes the process of reviewing symptoms related to DSM-IV-TR mental health and substance use disorders. Diagnosis is usually a more detailed description of the types of disorders detected in an offender. Diagnosis usually involves an interview, psychological assessment, review of archival records, as well as other types of testing (Peters & Bartoi, 1997). Diagnosis usually helps determine the primary focus of treatment and whether the focus will be substance abuse disorders, mental health disorders, or both. Some of the common goals of diagnosis include the following: • Identify the presence of specific DSM-IV-TR mental health and substance use disorders. • Develop hypotheses for psychosocial assessment (Peters & Bartoi, 1997). Assessment is a concept describing a comprehensive examination of psychosocial needs and problems including the severity of disorders, the conditions associated with the occurrence and maintenance of the disorders, problems related to the disorders that may affect treatment, the offender’s motivation for treatment, and specific areas for treatment interventions (Peters & Bartoi, 1997). Assessments are commonly conducted through interviews and/or specialized instruments and consist of the following goals: • Examine the scope of mental health and substance abuse problems • Assess the full spectrum of psychosocial problems that need to be addressed in treatment • Provide a comprehensive foundation for treatment planning (Peters & Bartoi, 1997). Selection of Screening, Diagnosis, and Assessment Instruments In the following sections detailed information is provided concerning different instruments used to screen, diagnose, and assess offenders. Appreciate that the concepts of screening, diagnosing, and assessing offenders represent different stages in the process of identifying disorders in need of treatment, and to some degree represent different goals. It should also be noted that the following instruments presented in this discussion are not meant to be all inclusive. A cursory glance at the literature will yield hundreds of psychometric instruments designed to measure a wide range of psychiatric, psychological, emotional, and substance abuse disorders. Therefore, when reviewing the different instruments and deciding which to include in this discussion three important concepts were considered: 1. Reliability—a concept used to describe the accuracy of a measure. In other words, is the instrument accurately measuring a variable regardless of what the variable may be? 2. Validity—a concept used to describe whether an instrument is actually measuring what it is intended to measure. In other words, if the intended variable to be measured is depression, is the instrument truly measuring depression and not anxiety? 3. Has the instrument been used in a criminal justice setting (Peters & Bartoi, 1997)? In addition, we include positive features as well as concerns for each of the instruments listed in order to assist practitioners and students in the selection of instruments most suitable for a particular agency. Screening Instruments A possible combination of screening instruments suggested by Peters and Bartoi (1997) include the following: 1. The Brief Symptoms Inventory (BSI) (Derogatis & Melisaratos, 1983) or the Referral Decision Scale (RDS) (Teplin & Schwartz, 1989) to measure mental health symptoms; and 2. Either the TCU Drug Dependence Screen (DDS) (Simpson, 1993), Simple Screening Instrument (SSI) (CSAT, 1994), or the combination of the Alcohol Dependence Scale (ADS) (Skinner & Horn, 1984) and the Addiction Survey Index (ASI) (McLellan et al., 1992) to measure substance abuse symptoms. These instruments have been found to be the most effective in identifying inmates with substance dependence problems (Peters & Greenbaum, 1996). The BSI is comprised of 53 items and consists of three global indices of psychopathology and nine primary psychiatric dimensions. Positive Features • Brief to administer and requires no significant training. • Only a sixth-grade reading level is required. • Has adequate internal consistency and test-retest reliability. • Adequate convergent validity with the Minnesota Multiphasic Personality Inventory (MMPI) (Hathaway & McKinley, 1989). Concerns • The BSI has poor discriminant validity. • Has low construct validity and may be most useful as a general indicator of psychopathology (Boulet & Boss, 1991). The RDS is a 14-item measure of mental health symptoms that was designed to identify individuals entering jails with significant mental health problems requiring treatment while in jail. Positive Features • Developed and validated in a criminal justice setting. • Requires no training to administer. • Can be self-administered. Concerns • Its validity has not been examined among offenders with co-occurring disorders. • Examines only a few mental health disorders (depression, bipolar disorder, schizophrenia), however, in criminal justice settings these disorders are commonly the most problematic. The DDS is a 19-item screen that examines diagnostic symptoms of drug use developed at the Texas Christian University, Institute of Behavioral Research. Positive Features • One of three screening instruments found to be most effective in identifying substance dependant inmates (Peters & Greenbaum, 1996). • One of two screening instruments found to be most effective in identifying substance using inmates who were nondependent (Peters & Greenbaum, 1996). • DDS is brief to administer. • Because the DDS is a public domain instrument it is available at no cost. Concerns • The validity of the DDS has not been examined among offenders suffering from co-occurring disorders. • The DDS does not examine quantity or frequency of recent or past substance use. The SSI is a 16-item screening instrument that examines symptoms of alcohol and drug dependence. The SSI examines five different domains related to substance dependence including: (1) alcohol and/or drug consumption, (2) preoccupation and loss of control, (3) adverse consequences, (4) problem recognition, and (5) tolerance and withdrawal. Positive Features • The SSI was one of three screening instruments found to be most effective in identifying inmates considered to be substance dependent. • The SSI had the highest sensitivity of all screening instruments in a study conducted by Peters and Greenbaum (1996). • The SSI is brief to administer. • The SSI is a public domain instrument available at no cost. Concerns • Validity has not been examined among offenders with co-occurring disorders. • The SSI does not examine quantity or frequency of recent or past substance use. The ADS is a 25-item instrument developed to screen for alcohol dependence symptoms. The instrument was developed and published by the Addiction Research Foundation in Toronto, Canada. Positive Features • The ADS, when used in conjunction with the ASI, was found to be one of three instruments most effective in substance dependent inmates (Peters & Greenbaum, 1996). • The ADS, when used in conjunction with the ASI, was found to be very effective in identifying nondependent inmates. • The ADS is brief to administer and easy to score. Concerns • The ADS is limited to screening for alcohol abuse. • Although the cost is modest, the ADS is a commercial product and would need to be purchased. The ASI is described as the most widely used substance abuse instrument and is commonly used for screening, assessment, and treatment planning (Peters & Bartoi, 1997). In addition, the ASI is commonly used in criminal justice settings. Seven areas of functioning commonly related to substance abuse are measured. These areas include drug or alcohol use, family or social relationships, employment or support status, and mental health status (Peters & Bartoi, 1997). Positive Features • In combination with the ADS, the ASI was found to be very effective in identifying substance dependent inmates. • In combination with the ADS, the ASI was found to be very effective in identifying nondependent inmates. • The ASI measures different psychosocial components related to substance abuse. • The ASI is capable of capturing the history of substance abuse as well as recent and current use. • Normative data are available for criminal justice populations (McLellan et al., 1992). • The ASI is a public domain instrument and available at no cost. Concerns • The ASI requires significant training to administer and score. • Administration of the entire ASI requires up to 75 minutes. Aside from the suggestions of Peters and Bartoi (1997), we strongly recommend the Substance Abuse Subtle Screening Inventory (SASSI) as an alternate instrument for drug abuse screening. This instrument utilizes several criteria to detect personality profiles and/or characteristics that have a strong likelihood for substance abuse problems. In fact, the SASSI is designed to detect likely substance abuse among persons who are either in denial or who deliberately attempt to deceive the clinician. Because of this and because of the SASSI’s effectiveness (substance abuse detection at 93% accuracy), it is a premier assessment tool. The SASSI is a brief and easily administered screening measure that helps identify individuals who probably suffer from a substance use disorder. The SASSI Institute notes that “interpretations of SASSI profiles also produce hypotheses that clinicians may find useful in understanding clients and their treatment planning” (SASSI Institute presentation). The SASSI has enjoyed widespread popularity and is used in both criminal justice and mental health settings. This means that the SASSI is ideal for correctional counseling objectives, and, as the student may recall from Chapter 1, the continual generation of hypotheses augments the scientific method of inquiry and also aids in the refinement of treatment plans (see Chapter 2). The SASSI consists of face valid items and subtle items that do not directly address substance abuse in a detectable manner. The questions are oblique in nature and instead ask about other lifecourse issues that often are commonplace with the substance-abusing lifestyle. The profiles generated provide several clinical inferences, and among these are the following: (1) indication of defensive responding, (2) level of insight and awareness of the effects of substance misuse, (3) evidence of emotional pain, and (4) likely future risk of involvement with the criminal justice system. It is clear from these other inferences that the SASSI is ideal for correctional treatment programs and that it appeals to both treatment and custodial-related concerns. In addition, the SASSI can be administered by traditional pencil and paper format, computer and compact disc, or even online. Further, clinicians are given extensive support and guidance by the SASSI Institute, making its use “counselor friendly” and all the more easier to competently implement within the facility setting. Addictions professionals who are trained in a one-day SASSI workshop can effectively implement this screening tool. The SASSI Institute produces newsletters semiannually and provides phone and online support. The reason that we note these positive aspects of SASSI products is not to necessarily solicit our readers (we have no actual profit motive in recommending the SASSI) but to instead demonstrate that clinicians will find this tool both effective and easy to administer. We speak from experience when we note the effectiveness of the SASSI and when we note that the SASSI Institute provides ongoing and effective support to its consumers. It is with this in mind that correctional counselors may find this instrument to be a prudent choice in there drug abuse screening and assessment. Lastly, one additional component of a comprehensive screening process includes measuring offenders’ motivation and readiness for treatment. Motivational screening instruments are primarily designed to identify those offenders not suitable for treatment (Peters & Bartoi, 1997) and are able to predict dropout, as well as treatment outcome. In addition, those offenders who are not found to be ready for treatment can be diverted to other programs aimed at educating the offender regarding the effects of substance abuse and co-occurring disorders. One motivational screening instrument commonly used in correctional settings is the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES). The SOCRATES consists of a personal drinking questionnaire and a personal drug use questionnaire. Both instruments consist of 19 items and capture data in relation to three scales: ambivalence, recognition, and taking action. These scales reflect stages of offenders’ motivation and readiness for treatment (Peters & Bartoi, 1997). Positive Features • According to Peters and Greenbaum (1996), the SOCRATES has been found to be highly reliable among correctional settings. • The instrument is brief to administer and easily scored. • It is a public domain document and free of charge. Concerns • Validity has not been determined among populations suffering from co-occurring disorders. • The SOCRATES has not been validated for use in treatment matching in criminal justice settings. Diagnostic Instruments Diagnostic instruments are useful in identifying key questions or issues that will need to be addressed in the assessment stage as well as in the development of individual treatment plans (Drake & Mercer-McFadden, 1995). Diagnostic instruments are primarily used to examine symptoms of substance abuse and mental health disorders within the framework of the DSM-IV-TR. In essence, diagnostic instruments build on the information obtained during the initial assessment and provide a more in-depth look into the offender’s psychosocial characteristics. The Diagnostic Interview Schedule (DIS) (Robins, Helzer, Croughan, & Ratcliff, 1981) is a f y structured diagnostic instrument. The DIS measures such constructs as mood, anxiety, schizophrenia, eating, somatization, psychoactive substance abuse, and antisocial personality disorder (Peters & Bartoi, 1997). Positive Features • The DIS is able to measure antisocial personality disorder which is often associated with substance abuse. • The DIS requires little training and can be administered by nonclinicians. Concerns • Structured instruments sometimes fail to detect up to 25% of those individuals abusing alcohol and it is possible that even a larger percentage of substance abusers go undetected (Drake et al., 1990; Stone, Greenstein, Gamble, & McLellan, 1993). • According to Hasin and Grant (1987) the DIS may not be best suited to detect depression among offenders suffering from co-occurring disorders. A second diagnostic instrument that may be useful is the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) (First, Spitzer, Gibbon, & Williams, 1996). The SCID examines 32 different Axis I diagnoses and includes major mental health and substance use disorders. Positive Features • Interrater reliability of the SCID is mostly good (0.64–0.72) among individuals suffering from co-occurring disorders (Corty, Lehman, & Myers, 1993). • Peters and Greenbaum (1996) note the SCID has good test-retest reliability (77–100%) among male, prison inmates. Concerns • Similar to the DIS, the SCID also suffers from an inability to detect up to 25% of alcohol abusers and possibly even a higher number of substance abusers (Drake et al., 1990; Stone et al., 1993). • The SCID requires clinical expertise to determine if symptoms meet the criteria of a particular disorder (Corty et al., 1993). • Significant training is required for administration and scoring. Assessment Instruments The assessment of an offender usually entails a detailed and personalized gathering of information that is relied upon to develop a specific treatment plan. The assessment usually takes place after screening and diagnosis and once the offender has been referred to treatment services. One note important to the concept of assessment is that sufficient time should be given prior to an assessment to ensure the offender has been detoxified, is sober, and that any mental health symptoms are not the result of withdrawal (Weiss & Mirin, 1989). Some of the key components of a thorough assessment include examining skill deficits, the need for psychotropic medication, as well as the types of treatment and support services that will be needed to properly attend to the various disorders of a particular offender (Peters & Bartoi, 1997). In addition, Peters and Bartoi (1997) suggest the following types of information should be included in the assessment of co-occurring disorders: • Criminal justice history and status • Mental health history, current symptoms, and level of functioning • Substance abuse history, current symptoms, and level of functioning • History of interaction between mental health and substance use disorders • Family history of mental health and substance use disorders • Medical and health status • Social/family relationships • Interpersonal coping strategies, problem-solving abilities, and communication skills • Employment/vocational status • Educational history and status • Literacy, IQ, and developmental disabilities • Treatment history and response to treatment • Prior experience with peer support groups • Cognitive appraisal of treatment and recovery • Motivation and readiness for treatment • Self-efficacy in adopting lifestyle changes • Expectancies related to substance use • Participant conceptualization of treatment needs • Resources and limitations affecting the ability to participate in treatment. When deciding on which instruments are most appropriate for assessment it is important to understand that an integrated approach is critical to success. There should be a comprehensive assessment of mental health and substance use disorders as well as an in-depth examination of criminal justice history and current status. Based on information provided by Peters and Bartoi (1997) the following combination of instruments may be best suited for assessing offenders’ suffering from substance abuse and/or co-occurring disorders: 1. Either the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) (Hathaway & McKinley, 1989), the Millon Clinical Multiaxial Inventory-III (MCMI-III) (Millon, 1992), or the Personality Assessment Inventory (PAI) (Morey, 1991). 2. The Addiction Severity Index (ASI) to examine substance abuse–related areas. All three personality inventories (MMPI-2, MCMI-III, and PAI) are self-report measures that have undergone intense research and proven to be mostly reliable and valid instruments. The MMPI is a very robust instrument that is now used in a multitude of correctional settings. Students may recall that the MMPI-2 was discussed extensively in Chapter 2. The MCMI-III is useful in assessing personality disorders that may affect involvement in treatment. The MCMI-III also includes a drug abuse scale aimed at measuring personality characteristics associated with drug abuse. In addition to personality constructs, the PAI also includes measures of alcohol and drug problems (Peters & Bartoi, 1997). When used in conjunction with the ASI, previously described, this combination should yield mostly accurate depictions of offenders’ current state regarding substance abuse and co-occurring disorders. Threats to Accurate Screening, Diagnosis, and Assessment It can be very difficult to obtain reliable and valid information from offenders suffering from substance abuse and co-occurring disorders. Many offenders vested in a criminal lifestyle will be hesitant to provide accurate and truthful information. There is often a lack of trust on behalf of offenders for anyone working in the various components of the justice and mental health system. As a result, screening, diagnosing, and assessing should be conducted on an ongoing basis throughout the duration of the offender’s involvement with the justice system. It is important to note that in addition to the various psychometric instruments it is also important to engage offenders in interpersonal conversation aimed at assessing their overall mental and physical status. Some of the more common threats include the following: • Inadequate staff training and poor familiarity with mental health and/or substance use disorders • Inadequate amounts of time for proper screening and assessment • Previous clinicians who may have avoided, or neglected, to provide screening for co-occurring disorders • Incomplete or misleading records • Extreme variation in the expression of co-occurring disorders • An offender may be in temporary remission at the time of screening • Considerable symptom interaction between co-occurring disorders • Individuals suffering from co-occurring disorders may have difficulty providing accurate histories due to cognitive impairment, mental health symptoms, and confusion • Individuals in the criminal justice system may anticipate negative consequences related to disclosure • Symptoms may be feigned or exaggerated if an individual believes that this will lead to more favorable placement or disposition. SECTION SUMMARY Screening, diagnosing, and properly assessing offenders is a critical component of being able to effectively render appropriate services. The essence of each of these steps is to ascertain what types of services an offender needs. There are a variety of instruments available to help counselors properly screen, diagnose, and assess offenders. It is important that the counselor carefully identify certain instruments based on their reliability and validity. Also, it is important that counselors identify instruments that are capable of assessing both psychological and emotional disorders as well as substance abuse. This process usually consists of using several instruments because of the lack of single instruments able to capture the necessary components salient to the criminal justice system. Finally, it is important that counselors thoroughly familiarize themselves with the types of information produced by the instruments they use in order to maximize their utility. LEARNING CHECK 1. Diagnosing describes the process of detecting mental health and substance abuse disorders that need to be treated. a. True b. False 2. Assessments are commonly conducted through interviews and/or specialized instruments. a. True b. False 3. A common threat to accurate screening, diagnosis, and assessment is the fact that many offenders distrust the criminal justice system and are hesitant to provide truthful information. a. True b. False 4. Motivational screening instruments are primarily used to identify offenders who are a. most suitable for treatment b. highly motivated c. not sure if they need treatment d. not suited for treatment 5. When choosing a particular instrument, it is not important to consider whether the instrument has been used in a criminal justice setting a. True b. False PART THREE: TREATING ALCOHOL/SUBSTANCE ABUSE AND CO-OCCURRING DISORDERS Treating offenders suffering from alcohol and/or substance abuse requires an informed and comprehensive approach that targets each area of the offender’s life circumstance that may be contributing to the continued use. An informed treatment approach must be able to identify psychological and emotional characteristics, dynamics of interpersonal relationships, as well as the offender’s physical surroundings that may be contributing to or causing the use of alcohol and/or other drugs. It is important to note that there are many different treatment paradigms that can be effective in treating alcohol and substance abuse as well as co-occurring disorders. The specifics of a particular treatment modality usually depend on the emphasis of a particular service provider as well as the training undergone by a particular counselor or mental health professional. The 12 core functions that are presented below have been widely adopted by service providers throughout the world in treating alcohol and substance abuse. Each function is critical to the success of treating offenders. For the purposes of this text, we suggest these functions as a guide to be implemented according to the specific protocols of individual mental health and substance abuse providers. 1. Screening—as mentioned above, this is usually the point at which the offender is determined to be eligible for admission to a particular program. During the screening an initial evaluation is conducted aimed at gathering information regarding psychological, social, and physiological signs and symptoms of substance abuse and co-occurring disorders. 2. Intake—consists of administrative and initial diagnosis procedures for admission to a program. Clients are usually expected to fill out and complete necessary forms and documents including informed consents. 3. Orientation—generally consists of describing to the client the general nature and goals of the program as well as rules governing client conduct and infractions that could lead to disciplinary actions or discharge from the program. 4. Assessment—procedures consisting of an in-depth evaluation of a client’s strengths, weaknesses, problems, and needs in order to develop a particular treatment plan. The assessment should consist of gathering relevant history including, but not limited to, alcohol and drug use; identifying methods and procedures for corroborating the client’s history from significant secondary sources; identifying appropriate assessment tools; explaining to the client the rationale for using the assessment techniques; and finally, developing a comprehensive diagnostic evaluation of the client’s substance abuse and/or co-occurring disorders in order to provide an integrated approach to treatment based on the client’s strengths, weaknesses, and identified problems and needs. The results of the assessment should suggest the focus of the treatment. 5. Treatment planning—the process by which the counselor and client, through collaboration, identify and rank problems needing resolution. In addition, the counselor and client establish immediate and long-term goals and decide on the appropriate treatment process and the resources to be utilized. 6. Counseling—the process of using special skills to assist individuals, families, or groups in achieving objectives through exploring problems and their ramifications; examining attitudes and feelings; and consideration of alternative solutions and decision-making skills. In essence, counseling is the relationship whereby the counselor helps mobilize the client’s resources to resolve problems and/or modify attitudes and values. Counselors need to have a working knowledge of various counseling theories. These theories may include reality therapy, transactional analysis, strategic family therapy, client-centered therapy, existential therapy, and so on. 7. Case management—the process of bringing services, agencies, resources, and/or people together within a planned and coordinated framework with the goal of achieving identified goals. Case managers may perform counseling, however, the bulk of their responsibilities usually entail the coordination of multiple services needed to address specific needs of the offender. In addition, it is very important that case managers assume an active role in the treatment process where they are able to closely monitor the offender’s progress or lack thereof. 8. Crisis intervention—describes the process of delivering services that respond to an offend-er’s needs during acute emotional and/or physical distress. A crisis is a decisive event in the course of treatment that threatens to compromise or destroy the rehabilitation effort. A crisis may consist of overdose or relapse as well as indirect circumstances such as the death of a loved one or divorce. It is critical that the counselor identify the crisis as quickly as possible and take immediate action to begin mitigating or resolving the salient problems. 9. Client education—educating offenders is an important part of the overall treatment process. Education can be provided in a variety of ways including relevant psychosocial concepts, dangers and risks associate with certain behaviors, as well as describing self-help groups and other resources that may be available. 10. Referral—the process of identifying the needs of an offender that cannot be met by the counselor and then following up by assisting the client in obtaining support and resources from other professionals that are able to provide appropriate services. It is important that counselors be aware of the referral process as well as the different community resources and their deliverables. 11. Report and record keeping—the process of accurately recording the results of the assessment and treatment plan usually through writing reports, progress notes, discharge summaries, and other offender-related data. If performed properly, the process of reporting and record keeping will enhance the offender’s entire treatment experience. Accurate reporting facilitates communication, timely feedback from supervisors, assists other programs that may provide services, and enhances the accountability of the program that may be necessary for licensing and funding. 12. Consultation with other professionals—usually consists of communicating with in-house staff or outside professionals to ensure the best care possible for the offender. Consultations provide a good opportunity for professionals to gather in order to generate and share ideas regarding the treatment process of an offender. In addition to the 12 core functions in treating alcohol and substance abuse, the Center for Substance Abuse Treatment (2006) provides 12 principles to address the needs of persons with co-occurring disorders. These principles were generated from the accumulated experience of mental health professionals over many decades of practice. Some of the information provided in the following principles may overlap with information already provided. We go forward, however, based on the belief that these areas of overlap cannot be emphasized enough. • Principle 1—Co-occurring disorders are to be expected in all behavioral health settings. In other words, it should be assumed that many offenders will be suffering from a multitude of disorders. Based on this assumption, all policies, regulations, funding mechanisms, and programming should reflect the need to serve people with co-occurring disorders. • Principle 2—An integrated system of mental health and addiction services that emphasizes continuity and quality is in the best interest of consumers, providers, programs, funders, and systems. This principle cannot be emphasized enough. A variety of services must be available and need to be matched with the specific needs of offenders. • Principle 3—The integrated system of care must be accessible from multiple points of entry and be perceived by the offender as caring and accepting. Many offenders suffering from substance abuse and co-occurring disorders lack the capacity to traverse complicated service systems and their attendant bureaucracy. In addition, a variety of barriers such as financial limitations, inadequate transportation, and so on may prevent some offenders from accessing or even seeking treatment. These barriers need to be removed whenever possible to avoid discouraging offenders from seeking treatment and continuing down the path of the untreated waiting for the next crisis. • Principle 4—The system of care for co-occurring disorders should not be limited to a single “correct” model or approach. Every individual is different, and what works for one may not work for the other. Systems of care need to be diversified and able to adapt to the specific needs and learning styles of particular offenders. • Principle 5—The system of care must reflect the importance of the partnership between science and service, and support both the application of evidence- and consensus-based practices for persons with co-occurring disorders and evaluation of the efforts of existing programs and services. In essence, there needs to be a constant effort aimed at enhancing services based on scientifically grounded evidence. • Principle 6—Behavioral health systems must collaborate with professionals in primary care, human services, housing, criminal justice, and education and related fields in order to meet the complex needs of persons with co-occurring disorders. This breadth of need is based on the fact that offenders suffering from co-occurring disorders are often among the most disadvantaged and impoverished members of society. • Principle 7—Co-occurring disorders must be expected when evaluating any offender, and clinical services should incorporate this assumption into all screening, diagnostic, assessment, and treatment planning. • Principle 8—Within the treatment context, both co-occurring disorders are considered primary. For offenders with co-occurring disorders, symptoms of either disorder may vary over time. One set of symptoms may be managed at a particular time while the other set causes impairment. This interactive nature requires each disorder to be continually assessed. This principle is based on the assumption that there is always a relationship between the disorders. • Principle 9—Empathy, respect, and belief in the individual’s capacity for recovery are fundamental provider attitudes. Many offenders suffering from co-occurring disorders have experienced significant let-downs and disappointment throughout the course of their life. They are often very keen to any form of judgmentalism on behalf of the counselor and will likely feel demoralized, rejected, or disappointed once again. When faced with judgmentalism, whether real or perceived, many offenders will instinctively employ the defense mechanism of shutting down, which is an attempt at reducing emotional pain. Once cognitively and emotionally shut down real therapeutic progress is all but impossible. • Principle 10—Treatment should be individualized to accommodate the specific needs, personal goals, and cultural perspectives of unique individuals in different states of change. The concept of cultural competency on behalf of the service provider must be adhered to. Cultural differences must be learned, respected, and incorporated into all aspects of the treatment plan. • Principle 11—The special needs of children and adolescents must be explicitly recognized and addressed in all phases of assessment, treatment planning, and service delivery. • Principle 12—The contribution of the community to the course of recovery for consumers with co-occurring disorders and the contribution of consumers with co-occurring disorders to the community must be explicitly recognized in program policy, treatment planning, and consumer advocacy. Denial as Clinical Treatment Issue Counseling criminal justice offenders with substance abuse and/or co-occurring disorders is challenging work for a myriad of reasons. Often offenders will be resistant due to a lack of trust in the system; their only motivation for attending counseling sessions will be because they have been ordered to do so by the court; and the thought of getting in touch with emotion may be considered a weakness to be taken advantage of by others. In essence, many offenders will be unable to express and feel emotion. Their emotional landscape is barren due to past experiences that have left them feeling hurt and rejected. As a result, the thought of trying to reconnect with emotion and feeling, a critical part of the recovery process, will often provoke powerful feelings of anxiety. One defense mechanism often employed to reduce the unpleasant feelings of anxiety, and particularly salient to offenders suffering from substance abuse and/or co-occurring disorders, is the concept of denial. Often offenders will deny the fact that they have a problem with the use of substances. This denial serves as an internal mechanism aimed at staving off powerful pangs of anxiety induced by the thought of living one’s life without alcohol and/or drugs. Offenders seriously addicted to substances may be unable or unwilling to imagine their existence sober. The paradox, however, is that denial as a defense is only effective in the short term. As long as an offender is using denial as a coping mechanism he or she will be unable to experience or truly participate in lasting therapeutic change. Therefore, the goal is to assist and accompany offenders through the frightening process of rejecting the concept of denial as a defense mechanism and replacing it with acceptance and a true desire to recover their natural self. There are a variety of strategies that can be effective in helping the offender move from denial to acceptance. The following strategies are meant to serve as guide that may be useful in assisting some offenders dismantle the concept of denial as a viable defense mechanism. • Confront—At some point the offender’s use of denial as a defense mechanism will have to be confronted. In other words, it will have to be clearly articulated, in a manner in which the offender is able to comprehend, that the continued use of denial is counterproductive to the healing process. Even though the client may not be ready to accept the alternative, the counselor may be well served by further articulating that what needs to replace denial is acceptance of self; accepting the fact that he or she is a flawed but worthy human being deserving of love and freedom. • Empathy/Compassion—When offenders are using denial as a coping mechanism, they will often be resistant to much of the information being provided by a counselor. This resistance can trigger the counselors own negative emotions. For example, when an offender resists or rejects what the counselor is saying many counselors will begin to feel confused, panic, hurt, and even rejected (Egan, 2007). Based on these negative feelings counselors may react in ways that are counterproductive such as: becoming impatient and hostile; blaming the client and entering into a power struggle; or simply giving up (Egan, 2007). It is critical that counselors be aware of their own issues related to denial, resistance, and reluctance. In other words, how would you, the counselor, feel if you were being coerced or encouraged to do something that involved significant change? Or, as Egan (2007) points out, how do you avoid personal growth and development? By exploring these issues, counselors are better equipped to appreciate the fear and anxiety being experienced by the offender. The ability to understand the offender’s plight allows the counselor to genuinely express empathy and compassion free of judgmentalism. • Understand that some reluctance on the part of the offender is normal—Appreciate that many offenders will be heavily vested in the use of substances as a coping mechanism. Denial may be the only construct available that is strong enough to keep them from having to immediately face the realities of their destructive behaviors. • Educate the offender as to why the concept of denial is so powerful—Help the offender understand the underlying structure that is supporting the continued use of denial as a coping mechanism. For example, a counselor may suggest that the offender talk to his or her denial. The counselor may prompt the offender to complete this statement, “Denial, I am so glad I have you in my life. If it were not for you, denial, I would have to …” The likely completion of the aforementioned sentence would probably be something like, “Denial, if it were not for you I would have to admit that I have a drug or alcohol problem and it is destroying my life.” • Be realistic, it is ultimately up to the offender—Try to remember that there are limits to what a counselor can do (Egan, 2007). Unrealistic expectations can lead to a power struggle that is counterproductive. Some clients may choose to reject help and continue on with their current lifestyle. As unfortunate as this may sound it is a reality that must accepted by the counselor. • Strategies to remember: • Show deep respect. • Relate with empathy and compassion. • Be genuine. • Maintain a sense of humor. • Be honest—admit when you are confused or do not understand. • Always try to relate to an offender in a nonjudgmental fashion. Judgmentalism will quickly erode any connection between the counselor and offender (Egan, 2007). Alcoholics Anonymous (AA) and 12 Step Groups Alcoholics Anonymous (AA) is a process carried out by self-help groups whose members suffer from alcoholism. AA was founded in the 1930s by Dr. Robert Smith and William Wilson (Alexander, 2000) and has been very successful in helping scores of individuals recover from alcoholism. AA is predicated on 12 steps that are to be followed by members in chronological order. A complete breakdown of the 12 steps can be found at Because AA and its 12 steps have been so successful it has served as a prototype for the treatment of other problems including Narcotics Anonymous, Al-Anon Family Groups, Gamblers Anonymous, Alateen, Adult Children of Alcoholics, Co-Dependents Anonymous, and others (Alexander, 2000). There are several components of self-help groups that make them extremely effective for many people. First, usually everyone in the group is suffering from similar circumstances ranging from addiction, co-dependency, or living with family members who are drug addicts or alcoholics. This is an extremely powerful component and lets the individual know that they are not alone. Oftentimes people suffering from addiction or emotional/psychological disorders come to believe that they are the only ones suffering from these ailments. In addition, because they feel alone in their suffering they begin to feel as though they are defective which usually results in powerful feelings of shame. The group works to alleviate these negative emotions by providing an atmosphere of caring individuals suffering the same afflictions. Second, by working the 12 steps individuals are able to share their stories and circumstances and be heard. For some addicts, they may not have ever had the experience of truly being heard by others. They may not have had the opportunity to receive empathy and compassion unconditionally. In addition, the group may provide their first experience at being able to share their feelings and not be judged. These are powerful therapeutic forces that greatly enhance recovery efforts. Third, because members are addicts themselves they are able to provide practical guidance and support that has worked for them. Members are able to provide advice to others in regard to how they have traversed each of the steps. SECTION SUMMARY When attempting to treat offenders suffering from co-occurring disorders, it is important to recognize that an integrated system of care is necessary. Treatment should be individualized based on a specific offender’s needs. It is important to avoid a “one-size–fits-all” mentality when working with offenders due to the myriad of factors that will be contributing to their problems. These factors are likely to be very specific to the individual and though some may appear to be common to most offenders the underlying characteristics are likely to be different. The primary reason for the differences is the fact that individuals have different cognitive processes for interpreting and responding to their environments. Counselors should always provide services with empathy and respect. Finally, it is important to recognize different cultural values and how they impact the offender’s methods of reasoning. LEARNING CHECK 1. A counselor should never admit to being confused or not understanding. This would reduce the counselor’s credibility and hinder the ability to provide services. a. True b. False 2. In most circumstances where an offender is suffering from co-occurring disorders, the substance abuse problem should be considered primary. a. True b. False 3. Denial is a powerful defense mechanism primarily because of which of the following. a. Its ability to stave off powerful feelings of shame. b. Its ability to allow the offender to justify his or her actions. c. Its ability to allow the offender to pretend as though he or she does not have a problem. d. All of the above. 4. The primary concept that needs to replace the offender’s denial is the acceptance of a. the situation b. oneself c. the fact that they will never change d. none of the above e. all of the above 5. One of the most powerful components of self-help groups is the fact that all of the members are suffering from similar circumstances. a. True b. False PART FOUR: RELAPSE PREVENTION Unfortunately, many offenders who undergo treatment while in the criminal justice system will go back to old environments and return to using alcohol and/or drugs. The recidivism statistics clearly show this to be a fact. For some, there is nothing really that can be done. In order to stay sober the offender must be fully committed to maintaining a substance-free life and willing to work diligently at maintaining an environment that is conducive to this success. The final segment of this chapter is aimed at those offenders who have successfully gotten clean and are committed to maintaining a life free of drugs and/or alcohol. Much of the information presented is drawn from the Counselor’s Manual for Relapse Prevention with Chemically Dependent Criminal Offenders. The manual is part of the Technical Assistance Publication Series funded by SAMHSA. Relapse prevention is the process of helping recovering addicts recognize and manage internal and external life circumstances that may lead to relapse. Relapse, in this context, is the process of becoming dysfunctional in recovery, which leads to a chemical use, physical or emotional collapse, or suicide. There are typically observable warning signs that precede episodes of relapse. Relapse usually progresses from bio/psycho/social stability through a period of distress that culminates with physical and/or emotional collapse. The symptoms intensify and the offender turns to substances for relief. Understanding and identifying the warning signs is a critical component in helping offenders stay clean. In essence, relapse occurs when offenders reverse the basic components of the recovery process. Therefore, it is possible to articulate a relapse process by first identifying the recovery process. Process of Recovery: 1. Abstaining from alcohol and other drugs 2. Separating from people, places, and things that promote the use of alcohol or drugs, and establishing a social network that supports recovery 3. Stopping self-defeating behaviors that prevent awareness of painful feelings and irrational thoughts 4. Learning how to manage feelings and emotions responsibly without resorting to compulsive behavior or the use of alcohol or drugs 5. Learning to change addictive thinking patterns that create painful feelings and self-defeating behaviors 6. Identifying and changing the mistaken core beliefs about oneself, others, and the world that promote dysfunctional thinking. Relapse Process: 1. Have a mistaken belief that causes dysfunctional thoughts 2. Begin to return to addictive thinking patterns that cause painful feelings 3. Engage in compulsive, self-defeating behaviors as a way to avoid the feelings 4. Seek out situation involving people who use alcohol and drugs 5. Find themselves in more pain, thinking less rationally, and behaving less responsibly 6. Find themselves in a situation where drug or alcohol use seems like a logical escape from their pain and as a result they use alcohol or drugs. Based on the idea of being able to identify the relapse process a number of principles have been constructed specifically geared toward relapse prevention therapy. These principles are geared toward helping relapse-prone offenders maintain abstinence. Principle 1: Self-Regulation The risk of relapse decreases as the offender’s capacity to self-regulate thinking, feeling, memory, judgment, and behavior increases. In essence, when the offender experiences disruptive stress he or she needs to be stabilized. The stabilization process often involves: • Solving the immediate crises that threaten continued abstinence • Learning skills to identify and manage withdrawal • Establishing a daily structure that includes proper diet, exercise, stress management, and regular contact with treatment personnel and self-help groups. Principle 2: Integration The risk of relapse will decrease as the level of conscious understanding and acceptance of situations and events that have led to past relapses increase. The offender needs to become aware of critical issues that are capable of triggering relapse through a critical self-assessment. Identifying these critical issues allows the counselor to develop intervention plans, in conjunction with the offender, that enable the offender to work through crises before relapse occurs. Principle 3: Understanding The risk of relapse will decrease as the offender’s awareness of the general factors that cause relapse increases. Oftentimes this process is carried out in structured education sessions and reading assignments. In addition, it is important to test offenders to ensure adequate comprehension and retention of the material. Principle 4: Self-Knowledge The risk of relapse will decrease as the offender’s ability to recognize personal relapse warning signs increases. The offender should create a personalized warning sign list which includes circumstances and feelings that have led to past relapses. It is important that the list be developed and constantly revised as new problems arise. Principle 5: Coping Skills The risk of relapse will decrease as the ability to manage relapse warning signs increases. Once warning signs have been identified coping skills must be in place to help offenders deal with the problems that arise in a manner that fosters their ability to stay in recovery. First, offenders are taught to modify their behavioral responses in situations or circumstances that trigger warning signs. Second, through a cognitive behavioral approach offenders are taught to challenge dysfunctional thoughts. Third, offenders are taught to identify the core addictive and psychological issues that initially create the warning signs. Principle 6: Change The risk of relapse will decrease as the relationship between relapse warning signs and recovery program recommendations increases. The primary task is to identify a recovery activity for each warning sign on the offender’s personalized list. Principle 7: Awareness The risk of relapse will decrease as the use of daily inventory techniques designed to identify relapse warning signs increases. The offender is taught to identify primary goals for each day, create a to-do list, and then carry out the necessary tasks for achieving the goals. At the end of the day the offender should review his or her warning sign list and recovery plan and determine whether any warning signs were present while carrying out the tasks. Principle 8: Significant Others The risk of relapse will decrease as the responsible involvement of significant others in recovery and in relapse prevention planning increases. Relapse-prone individuals are not likely to recover alone. They need help. A counselor should encourage significant others to be involved in the recovery process whenever possible. Principle 9: Maintenance The risk of relapse decreases if the relapse prevention is regularly updated during the first three years of sobriety. It is important to note that nearly two-thirds of all relapses occur within the first six months of recovery. In addition, less than one quarter of the variables that actually cause relapse can be predicted during the initial treatment phase. In essence, ongoing outpatient treatment is necessary for effective relapse prevention. CONCLUSION A lot of information has been presented in this chapter. We began by discussing substance abuse issues and some of the common issues concerning this disorder. As a counselor working with offenders it is important to be able to identify the common signs and symptoms that will usually be present among substance abusers. This is particularly salient when considering that many offenders will not freely admit their substance abuse problems. Oftentimes, this is because they are untrusting of the criminal justice system and will not want to get into further trouble. A detailed discussion was provided concerning common occurring mood, anxiety, personality, and psychiatric disorders. Appreciate that many offenders, once assessed, will be determined to be suffering from co-occurring disorders. If an offender is suffering from substance abuse problems it is extremely likely that they will also have another co-occurring disorder. Both disorders must be treated and both should be considered primary when attempting to devise a treatment plan. The process of screening, diagnosing, and assessing offenders is the process whereby counselors and other professionals determine what disorders are present as well as the severity of each. Each step in the process builds upon the previous. Several psychometric instruments were presented in order to assist counselors with accurately identifying the various disorders from which offenders may be suffering. It is through each of these three components that we ultimately create an individualized treatment plan for each offender. The treatment plan serves as a roadmap for providing offenders with necessary counseling and information aimed at treating their disorders. Many offenders suffering from co-occurring disorders require substantial counseling to modify or completely change old patterns of thinking and behaving. Counseling offenders is sometimes difficult due to their lack of trust as well as being heavily vested in ways and patterns of living. In addition, those offenders suffering from substance abuse issues will often be in denial regarding the seriousness of the disorder. Denial is a very common concept among populations of substance abusers. It will be critical to work with these offenders in a manner in which they are able to be guided through and out of the process of denial and begin to take ownership of their circumstances. This takes skill and vigilance on the part of the counselor. It is also important for the counselor to be intimately aware of his or her own emotions and vulnerabilities so as to avoid getting into power struggles and psychological games with offenders. The importance and value of self-help groups cannot be overstated. One combination that may be particular beneficial is the use of self-groups in conjunction with counseling. Self-help groups provide support for many offenders and consist of others who are suffering the same symptoms and problems. Through sharing and support, offenders are able to learn that they are not alone and are also able to receive valuable feedback and guidance from their peers. Finally, relapse prevention must be considered a critical component to any mental health service provider attempting to treat offenders suffering from substance abuse and co-occurring disorders. Through relapse prevention techniques offenders are taught skills aimed at identifying situations in which they may be vulnerable and the ability to exercise new and better behaviors rather than drug use. Essay Questions 1. Is there a difference between substance dependence and substance abuse? Is one more difficult to treat than other? Why or why not? 2. Define the concept of co-occurring disorders. Among the offender population, identify two of the most common co-occurring disorders. Why is it so important that counselors be familiar with and able to treat co-occurring disorders? 3. Discuss some of the key factors usually associated with how substance abuse starts. If you had to choose one, which factor would you identify as most important? Why? 4. What is the difference between a psychotic disorder and a personality disorder? Provide at least one example of each. 5. What is the primary purpose of denial? How does this concept affect the counselor’s ability to effectively work with an offender? Discuss two methods of reducing or eliminating an offender’s use of denial in relation to co-occurring disorders. Treatment Planning Exercise The case vignette presented below addresses substance abuse issues but also adds a twist for students; the client has co-occurring disorders. This makes the clinical case much more complicated but this is precisely the issue that confronts correctional counselors on a daily basis. It is seldom that counselors have clients with a singular issue. Rather, in many cases, the problems are multivariate and one clinical issue tends to compound the other. It is with this in mind that we present this case for students to address. Providing challenging treatment cases ensures that students understand the complexities with the treatment process and also ensures that material is not presented in an elementary or topical fashion. Further, co-occurring disorders tend to require the implementation of information from various chapters, thereby integrating the information that students acquire throughout the text and providing interlocking learning process where information is applied rather than being memorized. With this in mind, the student must do the following: 1. Refer back to Chapter 4 and explain how you would go about developing an effective therapeutic alliance with Mike? What challenges are you likely to encounter? How would you work to overcome these challenges? 2. What defense mechanisms and/or behaviors does Mike exhibit that is common to substance abusers? How can you determine if this is a dimension of Mike’s addiction or more a dimension of his potential for Narcissistic personality disorder? 3. What would you treat first, the drug abuse or the potential personality disorder? Would you treat them simultaneously? 4. How likely do you think it is that Mike will refrain from further drug use? How likely do you think it is that Mike will refrain from engaging in further criminal activity? 5. How would you motivate Mike to address his substance abuse issues? Explain some of the first initial processes that you might use when implementing the treatment planning process with Mike (some suggestions might come from Chapters 2 and 4). The Case of Mike Mike is a 20-year-old male who has just recently been released from jail. Mike is technically on probation for car theft, though he has been involved in crime to a much greater extent. Mike has been identified as a cocaine user and has been suspected, though not convicted, for dealing cocaine. Mike has been tested for drugs by his probation department and was found positive for cocaine. The county has mandated that Mike receive drug counseling, but as you continue counseling with Mike, you notice that he is very resistant to treatment. In fact, he denies issues with the severity of his drug use and blames either environmental circumstances or the behaviors of other people. When looking through his case file, you notice that at one time Mike was diagnosed by a psychologist to have Narcissistic personality disorder. This would then mean that he has comorbid issues that would need to be addressed. Mike seems to have little regard for the feelings of others. Coupled with this is his extreme sensitivity to the comments of others. In fact, his prior fiancée has broken off her relationship with him due to what she calls his “constant need for admiration and attention. He is completely self-centered.” After talking with Mike, you quickly find that he has no close friends. As he talks about people who have been close to him, he discounts them for one imperfection or another. These imperfections are all considered severe enough to warrant dismissing the person entirely. Mike makes a point of noting how many have betrayed their loyalty to him or have otherwise failed to give him the credit that he deserves. When asked about getting caught in the auto theft, he remarks that “well my dumb partner got me out of a hot situation by driving me out in a stolen get-a-way car, we got nabbed only because the cop recognized the vehicle.” (Word on the street has it that Mike was involved in a sour drug deal and was unlikely to have made it out alive if not for his partner.) Mike adds, “You know, I plan everything out perfectly, but you just cannot rely on anybody … if you want it done right, do it yourself.” During this crime, Mike was high on a variety of stimulant drugs, including methamphetamine. In one group counseling session, he noted that his clarity is better with stimulants even though other members pointed out that his use of stimulants may actually be the reason that he finds himself in continual “bad luck” situations. Mike recently has been involved with another woman (unknown to his prior fiancée) who has become pregnant. When she told Mike he said “Tough, you can go get an abortion or something, it isn’t like we were in love or something.” Then he laughed at her and told her to go find some other guy who would shack up with her. Incidentally, Mike is a very attractive man and he likes to point that out on occasion. “Yeah, I was going to be a male model in L.A., but my agent did not know what he was doing … could never get things settled out right … so I had to fire him.” Mike is very popular with women and has had a constant string of failed relationships due to what he calls “their inability to keep things exciting.” As Mike puts it “hey, I am too smart for this stuff. These people around me, they don’t deserve the good life cause they’re a bunch of dummies. But me, well I know how to run things and get over on people. And I am not about to let these dummies get in my way. 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TCU Forms Manual: Drug abuse treatment for AIDS-risk reduction (DATAR). Fort Worth, TX: Texas Christian University Institute of Behavioral Research. Skinner, H. A., & Horn, J. L. (1984). Alcohol dependence scale: User’s guide. Toronto: Addiction Research Foundation. Stone, A., Greenstein, R., Gamble, G., & McLellan, A. T. (1993). Cocaine use in chronic schizophrenia outpatients receiving depot neuroleptic medications. Hospital and Community Psychiatry, 44, 176–177. Teplin, L. A., & Schwartz, J. (1989). Screening for severe mental disorder in jails. Law and Human Behavior, 13(1), 1–18. Watson, A., Hanrahan, P., Luchins, D., & Lurigio, A. (2001). Mental health courts and the complex issue of mentally ill offenders. Psychiatric Services, 52(4), 477–481. Weiss, R. D., & Mirin, S. M. (1989). The dual diagnosis alcoholic: Evaluation and treatment. Psychiatric Annals, 19(5), 261–265. CH9 Youth Counseling and Juvenile Offenders CHAPTER OBJECTIVES After reading this chapter, you will be able to: 1. Identify and discuss the various mental health issues that compound the difficulties in treating juvenile offenders. 2. Explain how family-of-origin issues may be an important consideration for juvenile offenders. 3. Explain why sex counseling is particularly important for juvenile offender population. 4. Describe some of the topics that should be covered when delivering culturally competent interventions to juvenile offenders. 5. Identify and discuss the various reasons for youth obtaining gang affiliation. PART ONE: BACKGROUND ISSUES Introduction Treatment of youth who are found to be delinquent is one of the most common types of work that exists within the correctional counseling arena. Though most youth are not kept in detention centers there is still a high demand for therapists who work with youth. Even if juveniles are required to stay in a detention facility, their stay is likely to be short term when compared to jail and prison sentences for adults. Thus, correctional counselors working with youth are likely to do so in community-based settings as much as they are likely to do so in structured facility settings. For chronic youthful offenders, there are a number of risk factors that will be discussed later in this chapter. Further, there are differences in the type of offending and the type of resources that each youth may have. Most youthful offenders engage in minor delinquent activities. While this may consist of the majority of delinquent youth, this chapter will focus primarily on those youth who have committed more serious crimes or ones that are violent in nature. Thus, students should understand that this chapter is not one that deals with the run-of-the-mill youngster who engages in low-key delinquent and/or status offenses but instead those youth who commit serious forms of burglary, gang-related activity, sexual assault, substance abuse, physical assaults, arson, and/or other more serious behaviors. Family Issues Within the families of origin of many serious juvenile offenders, there is some sort of family violence that may have occurred. While this is not to say that all households with a youth who is processed through the justice system is automatically an abusive home, it is to say that in many cases serious delinquency also correlates with a tumultuous home life that tends to have some level of conflict and domestic abuse. In this section, we will not yet address the issue of child abuse and neglect, but will simply make note of the fact that domestic abuse and family strife is common within the backgrounds of seriously delinquent youth. For male juveniles who are institutionalized due to some form of assault, it is not uncommon for them to have committed their crime against a male stepparent who was abusive to the youth’s mother. This is a common observation among juvenile workers who work with male teens who are transferred to adult court for crimes against a family member. In such cases, the young male is acting in defense of his mother. In other cases, particularly with female delinquents, there may be a tendency to leave the home or to use substances as a means of escape. Though in both of these examples the youth have not been specifically abused, the effects of domestic abuse within the home generate their reactions and behaviors that become problematic within the juvenile justice system. SUBSTANCE ABUSE IN THE FAMILY Another common observation among homes with seriously delinquent youth is the existence of substance abuse. Substance abuse problems in the home can exist among the parents and/or adult caretakers as well as among other siblings. When substance abuse habits exist among the parents, this can naturally have a negative impact on the youth. Even when substances are relatively soft drugs this can leave the youth with negative social messages. However, even when substance abuse consists of the use of legal drugs, the youth is not likely spared of the negative influence. For example, the use of alcohol is legal for adults but, if the youth’s home is domestically violent, alcohol tends to exacerbate the violence and the frequency of that violence. Further, alcoholic families have a wide range of issues that must be addressed, such as the ability of the alcoholic to maintain employment and even caring for the alcoholic. In many alcoholic homes, the child is “parentified” and actually serves in a capacity that is similar to the parent of the alcoholic. These youth will tend to be fairly responsible in taking care of the house but they may have problems with the school system due to their sense of extended autonomy. In other words, these youth may fail to follow up with their school work due to the roles that they fill at home. Homes where substance abuse problems are a chronic and routine issue seldom have any true stability. Indeed, when one or both parents are in and out of treatment over a number of years, this often tends to impair the relationship that is maintained with the child. As we will see in Chapter 11, female offenders tend to be the primary caretakers of their children. Thus, from one point in time to another, these women are likely to be in jail, residential treatment, or prison and will not likely have much contact with their children. Likewise, fathers in the home may also be absent on a routine basis if they are addicts. Just like female offenders, these men will tend to have intermittent stints in jail, residential treatment, or prison, with returns back into the community that tend to be short-lived. The main point is that youth who grow up in family systems that are afflicted by drug or alcohol abuse tend to be fairly chaotic and unstable. Unstable homes tend to breed delinquency and more serious forms of criminality among youth. Therefore, youth who come from homes with substance abuse problems should be given specific group interventions to address this issue. This is even true if the drug or alcohol abuse was at the hands of a sibling rather than a parent or adult. Indeed, siblings can have a strong impact on one another and younger siblings are likely to emulate the actions of their older siblings, especially if the parents are absent due to their own chaotic drug-using lifestyle. Child Abuse and Neglect: Correlates with Delinquency When delinquent behavior occurs, it may bring about further abuse, resulting in a vicious cycle that generates behavior that continues to get worse and worse. Children and adolescents who exhibit patterns of delinquency that emanate from the home often imitate the behaviors of parents or other family members. In some extremely dysfunctional homes, children may even be instructed on how to commit crimes. Though this may sound unusual, it is not unheard of, and there have been court cases where such occurrences have specifically been noted. Consider also that the crime of contributing to the delinquency of a minor is a form of neglect where an adult specifically facilitates the ability of youth to commit delinquent or criminal acts and encourages these youth to engage in such acts. Aside from circumstances where adults deliberately teach youth to commit crimes, it would seem that the trauma experienced because of abuse and neglect also fosters delinquency in children. For instance, Ireland, Smith, and Thornberry (2002) examined official records and utilized longitudinal survey data and found a strong relationship between maltreatment and delinquent behaviors. This was especially true with drug use among youth. Interestingly, Ireland et al. (2002) found that early childhood maltreatment that did not extend into later years of childhood had little impact on negative behaviors in adolescence. Contrasting with this, they found that maltreatment in adolescence, as well as persistent maltreatment from childhood through adolescence, was consistently related to various types of delinquency. This same pattern was known when drug use among youth was separately examined, without the effects of other delinquent behaviors. The research by Ireland et al. (2002) is important because this aids in demonstrating where much of the more serious offending among youth and young adults may come from. Though this does not explain all juvenile misbehavior, it does tend to be consistent in explaining etiology within a substantial portion of the more serious youthful offending as well as later adult offending. Consider the research by English, Widom, Spatz, and Brandford (2002) who note that there is strong relationship between child abuse, neglect, delinquency, adult criminality, and future violent criminal behavior. The research by English et al. (2002) clearly underscores our contention that, for the majority of hard-core youthful offenders, the prior homelife circumstances are interlaced with the youth’s offending behavior. English et al. (2002) further note that abused and neglected children were 4.8 times more likely to be arrested as juveniles, 2 times more likely to be arrested as an adult, and they were 3.1 times more likely to be arrested for a violent crime than were subjects who were members of a matched control group. From the research just presented, it should be clear that youth who come from abusive homes do indeed have an increased likelihood of engaging in serious delinquency, drug abuse, and later adult criminality. The authors of this text believe that this is an important point to emphasize because the focus of this text is on the offender population. While we recognize that a large number of youth engage in minor forms of delinquency, we contend that much of the minor delinquency (i.e., teen age sex, use of alcohol at an occasional outing, speeding and minor traffic violations, violating minor ordinances) is actually part and parcel to the development of many teens. Indeed, these activities are often simply considered the process by which youth experience their newly budding sense of adolescent autonomy. However, when delinquency goes beyond the minor types of activity, such as with full-fledged burglaries (as opposed to petty shoplifting), drug use that goes beyond alcohol and marijuana, assaultive behavior, and other actions such as teen rape, we contend that in many cases prior childhood socialization and exposure to noxious family and peer influences are a common thread in etiology. Other researchers share similar views on minor delinquent behavior among adolescents, going so far as to say that it is statistically normal among young boys growing up in the United States (Moffitt, 1993). According to Terrie Moffitt (1993), youthful antisocial and risk-prone acts are personal statements of independence. For example, these youth may engage in underage drinking or cigarette smoking, particularly with their peers, as a means of displaying “adult-like” behaviors. Another common form of delinquency for this group might be minor vandalism that is often perceived more as a “gag” rather than an act of victimization (actions such as the defacing of road signs, the destruction of residential mailboxes, and other petty forms of destruction). Shoplifting in various stores may also be encouraged among some members of this group for the occasional “five finger discount” in chosen music and/or clothing stores that are frequented by the adolescent peer group—displaying bravado among one’s peers and, incidentally, obtaining an item that is valued by the individual and the peer group in the process. Lastly, some of these individuals may engage in occasional truancy from school, particularly if they are able to hide their absence. These adolescents typically commit acts of defiance or nonconformity simply as a means of expressing their developing sense of autonomy. However, these adolescents are not likely to continue their activities into late adulthood. Moffitt (1993) referred to these youth as adolescent-only offenders. While youth who might be classified as adolescent-only offenders may occasionally be in need of some sort of counseling for any number of life-course issues, they seldom will need to see a treatment provider who specializes in the offender population. In more instances than not, these youth will age out of their behavior and will have no need for a correctional counselor. Rather, general counseling that addresses teen development, social pressure, peer groups, and other common aspects of development are likely to be more effective for this group. On the other hand, some adolescents continue their delinquent behavior into and throughout adulthood; these are what Moffitt (1993) referred to as the life-course-persistent juvenile delinquents. Unlike the adolescent-limited delinquent, these adolescents lack many of the necessary social skills and opportunities possessed by the adolescent-limited delinquent. The reason for this difference in development is quite startling but nonetheless a common phenomenon to this group. For these offenders, the clue to their difference in conformative ability lies less in their adolescent years as much as it does with their early childhood development; many of these youth will have suffered from some sort of trauma and/or child abuse. Indeed, it has been found that many life-course-persistent delinquents are children with inherited or acquired physiological deficiencies that develop either prenatally or in early childhood. To compound this problem, many of these same children often come from abusive social environments as well, reflecting the parental deficiencies that are transmitted intergenerationally from parent to child (Moffitt, 1993). This combination of the difficult child with an adverse child-rearing context (i.e., an abusive home) serves to place the child at risk for future delinquent behavior, setting the initial groundwork for a life-course-persistent pattern of antisocial behavior during years when the child is usually most impressionable (Moffit, 1993). Moffitt also found that early aggressive behavior is an important predictor of later delinquency and could possibly be a marker for the life-course-persistent offender. TYPES OF CHILD ABUSE AND DETECTION OF ABUSE In many cases, juvenile youth are victims of various forms of neglect or abuse. This is a very important aspect of juvenile offending, particularly in community corrections. In many cases, community supervision officers will find themselves networking with child protection agencies and will likewise tend to have offenders on their caseloads who are in need of parenting assistance, whether the offender realizes it or not. Further, one must consider that over 70% of female offenders on community supervision are also the primary caretakers of their children. This is an important observation, especially when one considers that the proportion of female offenders on community supervision is much higher than those that are incarcerated. This means that community supervision officers are likely to come across issues related to the welfare of children on a fairly frequent basis. Further still, among a high number of delinquent youth, disproportionate rates of abuse and neglect occur. In discussing these issues, we first turn our focus to child neglect since such maltreatment is often a precursor to later forms of abuse and also occurs in conjunction with abusive treatment. Child neglect occurs when a parent or caretaker of the child does not provide the proper or necessary support, education, medical, or other remedial care that is required by a given state’s law, including food, shelter, and clothing. Child neglect also occurs when adult caretakers abandon a child that they are legally obligated to support (Cox, Allen, Hanser, & Conrad, 2008). Neglect is typically divided into three types: physical, emotional, and educational (Cox et al., 2008). Physical neglect includes abandonment; the expulsion of the child from the home (being kicked out of the house); excessive delay in or not seeking medical care for the child; inadequate supervision; and inadequate food, clothing, and shelter (Cox et al., 2008). Emotional neglect includes inadequate nurturing or affection, allowing the child to engage in inappropriate or illegal behavior such as drug or alcohol use, as well as ignoring a child’s basic emotional needs (Cox et al., 2008). Lastly, educational neglect occurs when a parent or even a teacher permits chronic truancy or simply ignores the educational and/or special needs of a child (Cox et al., 2008). The impact of neglect is not as readily observable as is abuse. Over time, however, the long-term effects to the child can be just as damaging as they are when a child is overtly abused. Among the offender population, child neglect is not at all uncommon. In cases where either the male or female parent is a serious drug abuser, it may be common for the child to be neglected. In fact, there are some circumstances where the oldest child may be parentified and delegated responsibility of caring for younger siblings while also taking care of the parent as well. As noted in the previous section of this text, child parentification occurs when he or she is placed in a position within a family system whereby they must assume the primary caretaker role for that family, often taking care of both children and adults within that family system. This is common in single head-of-household families where the adult caretaker is an alcoholic or drug abuser, and even in some dual adult household families, particularly those that are criminogenic in nature. Interestingly, children that are neglected, including those that are parentified, often do not realize that they are necessarily being mistreated. Even if they do, many have no recourse and when coupled with the emotional bonds that they may have with their siblings, they are unlikely to leave or report such maltreatment on their own. These inappropriate family circumstances lead to very poor socialization in many cases, with children observing negative behaviors and developing criminogenic mindsets. Thus, these toxic family systems help to breed a new generation of persons who are susceptible to further perpetuation of the criminal lifestyle. It is because of this that community supervision officers overseeing juvenile offenders must take into account the family situation, encouraging family involvement when the family is functional and recommending family interventions when the family is not functional. Beyond child neglect, acts of abuse are even more serious forms of maltreatment and include both physical and psychological forms of harm. Child abuse occurs when a child (under the age of 18 in most states) is maltreated by a parent, an immediate family member, or any person responsible for the child’s welfare (Cox et al., 2008). Child maltreatment can include physical, sexual, and emotional abuse as well as physical, emotional, and even educational neglect from the caretaker (Cox et al., 2008). There are varying degrees of abuse and, in many cases, multiple forms of abuse may have been inflicted against the child. Further, these youth may also come from homes where there is domestic abuse between spouses or significant others. Research has shown that among juvenile sex offenders, the existence of child abuse is a common characteristic among such offenders in the United States as well as other countries (Hanser & Mire, 2008). The existence of abuse in a youth’s background is an important observation to attend to, since aberrant behaviors are likely to have been learned from other dysfunctional family members. In some cases, the youth’s behavior may be a form of acting-out against the stress and frustration of their toxic family environment. According to Cox et al. (2008), physical abuse “can be defined as any physical acts that cause or can cause physical injury to a child” (p. 266). These authors go on to describe child abuse as a vicious cycle that involves parents who have unrealistic expectations of their children, thereby getting easily frustrated with the shortcomings that they perceive their children to have. It is not uncommon for such parents to have themselves been abused as children, resulting in an intergenerational transmission of violence through their abusive behavior. The extent of the harsh discipline tends to depend on the level of frustration that the parent feels, their ability to regulate their own emotions, and their views on appropriate parenting and discipline practices. The level of parenting skills and the age of the child often affect the type of abuse and frequency of abuse that is inflicted, since younger children are less able to defend themselves and/or perhaps run away. Further, this type of treatment can greatly exacerbate any potential diagnoses that the young person might have (such as those just discussed in prior subsections) and this further complicates potential treatment approaches for that child. In fact, it may well be that the adult family members themselves have a number of mental health issues and this adds further difficulty to the family situation. Within such family environments, it is unlikely that the youth will be able to ever achieve any sense of normalcy or positive support. The parent’s own challenges will tend to aggravate those problems facing the youth, and the youth’s behavior will in turn serve as a further aggravating factor for their own maladaptive parenting. The two then will tend to continually fuel the dysfunction within the family system, thereby ensuring that the maladaptive system continues. In such cases, it is not likely that the juvenile should remain within the family system and it should be considered that the youth’s behavior is perhaps a symptom of what is an unhealthy family grouping. Psychological abuse is the third most frequently reported form of child abuse, with physical abuse and child neglect being the first and second most common types of abuse. Psychological abuse is somewhat vague and hard to define. Definitions that are too narrow are not likely to capture the various aspects of psychological abuse that might exist within an adult–child relationship that is abusive. On the other hand, definitions that are too broad may be nearly impossible to clearly identify in quantitative terms for research and/or in a legally substantive manner that could aid law enforcement and prosecutors. Because of these difficulties, this is the most difficult form of abuse to prosecute, being somewhat elusive when put to rigorous examination. Further, the difficulty in proving this abuse makes it likely that much of it goes unreported since it is so difficult to detect, prove, and document. Psychological abuse is also sometimes referred to as emotional abuse and includes actions or the omission of actions by parents and other caregivers that could cause the child to have serious behavioral, emotional, or mental impairments. In some instances of psychological abuse, there is no clear or evident behavior of the adult caregiver that provides indication of the abuse. Rather, the child displays behavior that is impaired and/or has emotional disturbances that result from profound forms of emotional abuse, trauma, distance, or neglect. This is an issue that should be seriously considered when children present with diagnosable disorders, particularly those that are obsessive/compulsive, dissociative, anxiety-based, and/or oppositional/defiant in nature. When considering children with disorders such as those just previously indicated, it should be taken to mean that the caregiver is necessarily the cause of the disorder, though that likelihood can certainly exist as well. Rather, it may well be that the child presents with these disorders and, due to frustration, the parent resorts to punishments that are bizarre or unorthodox in nature. For example, parents of a strongly oppositional child may resort to locking the child in a dark closet as a means of containing the child and also depriving him or her of stimuli that may heighten the child’s emotionality. While this may have a basis of logic to it, this type of punishment is not appropriate yet may occur for long periods of time. In the process, the child’s short-term behavior may be adjusted, but his or her sense of long-term maladjustment is further aggravated; in short, the parents contribute to the emotional disturbances that the child exhibits. On the other hand, parents who are psychologically abusive may also actually be a causal factor in a child developing any variety of emotional or adjustment disorders. Children who are psychologically abused may present with depression, anxiety, dissociative, and so forth. In such cases, the treatment from the caregiver negatively impacts that child’s ability to thrive, resulting in an emotionally impaired child. When neglect or abuse is detected within the home of a juvenile on a community supervision officer’s caseload and/or when an adult offender is thought to be neglecting or abusing his or her children, correctional counselors must remember that they are under a legal obligation to report these actions to child protection services within that state. In reality, most all citizens are required to report this activity anytime they observe it occurring, but correctional counselors are especially liable and are required to make these reports. Further, the correctional counselor must make these reports even if he or she believes that others have already filed a report about the abuse. In short, the correctional counselor cannot simply rely on the good word of others that a report was filed. Once the abuse is reported, child protection officials typically then generate a risk assessment and make a decision regarding the best type of action to be taken that meets the best interests of the child. Sexual abuse of youth consists of any sexual contact or attempted sexual contact that occurs between an adult or designated caretaker and a child. It should be noted that it is rare that physical indicators of sexual abuse are found. This means that most sexual abuse is detected due to behavioral indicators and/or when the youth discloses such acts. Possible behavioral indicators might include observations such as an unwillingness to change clothes or to participate in physical education classes; withdrawal, fantasy, or infantile behavior not typical of a teen; bizarre sexual behavior; sexual sophistication that is beyond the child’s age (a bit hard to gauge with teens); delinquent runaway behavior; and reports of being sexually assaulted. The behavior of parents also may provide indicators of sexual abuse. Such behaviors may include jealousy and being overprotective of a child. A parent may hesitate to report a spouse who is sexually abusing their child for fear of destroying the marriage or fear of retaliation. In some cases, intrafamilial sex may be considered a better option than extramarital sex. Lastly, sexual abuse of children can have numerous side effects, including guilt, shame, anxiety, fear, depression, anger, low self-esteem, concerns about secrecy, feelings of helplessness, and a strong need for others. In addition, victims of sexual abuse have higher level of school absenteeism, less participation in extracurricular activities, and lower grades. Emotional Storm and Stress During adolescence, there are substantial changes that take place within the development of youth. While this is common knowledge among parents, school teachers, and child development experts, this does not necessarily seem to be sufficiently touched upon by most texts on correctional counseling. We believe that it is important that the emotional aspects of the youth’s development are covered, along with other issues that seem to be specifically relevant to adolescent youth. Erik Erikson developed a theory of psychosocial development in 1975 that has continued to shape how modern day mental health and counseling experts view human development throughout the life span. According to Erik Erikson’s (1975) theory of psychosocial development, youth who are in adolescence must contend with a developmental period where identity versus identity confusion becomes a primary hurdle in the youth’s psychological formation. For the teen who is experiencing rapid growth and making a transition to adulthood, the search of one’s place in society can be unpredictable, stressful, and frustrating. Indeed, the roles open to teens are influenced by ethnic and racial background, geographic location, values within the family of origin, and their own peer-group social values. Correctional counselors who work with youthful offenders much keep these variables in mind when working with youth. Because of these vast differences in background, youth will have varying perceptions on what they should strive for and/or what is important. According to Davis and Palladino (2002), teens in the United States who have explored the alternatives and adopted a well-chosen set of values, goals, and sense of self will have reached identity achievement. In such cases, these youth will have a good sense of psychological well-being. But in other instances, the frustrations involved with meeting the challenges of this stage of development may prove so unpleasant as to result in a rejection of typical pro-social expectations. In such cases, the teen may adopt behaviors that are opposite to those that would be expected. This results in a negative identity and can affect the youth’s sense of self and their view of their own place in the world. In addition, youth who are not given support and guidance may experience identity diffusion (Erikson, 1975). This occurs when the teen has few goals and little motivation. These youth will often be indifferent to their schoolwork, the desire for friends, and/or planning for the future. These youth often have a sick sense of genuine self-identity. Youth who develop a negative identity and/or experience identity diffusion are at risk of engaging in delinquent behaviors. This is particularly true if their peer group is involved in delinquent activity. ANGER AND AGGRESSION Anger is a normal response to frustration and interference (Morris, 1991). In some cases, anger can be appropriate and can even lead to a constructive outcome. For example, a youngster upset about unfair treatment in school may channel his or her anger to work constructively within a student organization or through some civic group to voice his or her desire for change. Others may channel their frustrations into other pursuits resulting in what is referred to as sublimation. Sublimation occurs when a person has pent up frustration, stress, and/or aggressive feelings and they channel those feelings toward some activity or pursuit that allows them to act on those feelings in a manner that is considered socially acceptable. For example, some youth who have feelings of aggression may find themselves drawn to heavy-contact sports such as football, wrestling, or boxing. These types of activities relieve tension through physical exercise and they provide a sense of mastery in defeating persons in competition. Others may find gratification from competitive activities that, while not physically grueling, provide a sense of mastery over circumstance and/or over persons in competition, such as with debate teams and/or even art competitions. This is not to imply that all competitive activities are simply ruses under which masked anger is allowed to manifest. Rather, this is just to demonstrate that some people who experience anger, stress, and frustration may utilize various mechanisms to exert that energy in a manner that does not lead to delinquency. However, it is more often that anger leads to destructive forms of aggression. Aggression is any hostile action that is intended to harm, humiliate, or scare another person and it can be caused through physical or psychological means. Naturally, the use of overt violence is an act of aggression and when youth behave in such a manner they are engaged in an act of delinquent conduct. However aggression also occurs when we say or do something in anger to intentionally hurt someone’s feelings and/or cause them psychological discomfort. Thus, when youth make sarcastic comments about another person, particularly in the presence of a peer group, and the comment is intended to embarrass the person (especially in front of one’s peers), this is an act of psychological aggression. On the other extreme, if a group of youth decide to collectively refuse to speak to a member of the group and refuse to allow that youth to associate with the group, this is also an act of aggression. Relational aggression is any behavior that is intended to harm someone by damaging or manipulating relationships with someone. This type of aggression can include gossip or rumors that are spread to humiliate or embarrass another youth. Teasing, taunting, and exclusion from a peer group are all psychological means of victimizing a person. This type of aggression is more often used by females than males, but even though this aggression is not physical and even though it may seem to be associated with feminine social cunning, it should not be discounted or taken lightly. Indeed, such activities can be quite mean spirited and even extend into the world of cyberspace where forms of cyberbullying can produce lethal outcomes for some youth. Cyberbullying may be direct communications with the victim or the simple posting of derogatory information online for other youth in the peer group to view. While the purpose of this subsection is not to discuss specific acts of aggression in detail, it is hoped that the reader will understand that aggression comes in many forms and that it can take a serious toll on the development of a young person’s sense of self. Further, the youth that correctional counselors are likely to see will have problems with anger and aggression in many cases. Later, in Chapter 10, we present specific information on anger management programs. These types of programs and the use of anger management group interventions are frequently required among many adjudicated youth. An understanding of how these groups are implemented as well as the underlying dynamics related to anger problems among youth is important for correctional counselors. Thus, students are encouraged to read the anger management section in Chapter 10 and, while doing so, to consider its application to both adult and juvenile clients. UNHEALTHY SELF-EFFICACY Self-efficacy is an individual’s own belief about his or her ability to successfully accomplish certain desired goals and/or behaviors. The greater a person’s sense of self-efficacy, the more able he or she is to meet the challenges that exist in life. Self-efficacy is an important characteristic for juveniles and for adults. In the case of teens, self-efficacy is forming and is impacted by the experiences that are first encountered within the family and later within broader society. When children are encouraged and provided support, their sense of self-efficacy is likely to be high, or at least suitable for life’s challenges. However, when children are subject to emotional or psychological abuse, their sense of self-efficacy will likely be low. This often results in the child (and later the teen) reacting in some manner that is problematic. Children who do not think well of themselves are likely to internalize negative emotions. This is even more likely if the household itself is host to numerous negative relationships among family members and/or caretakers. When youth are raised in negative surroundings and if these youth are not involved with pro-social activities and are within the vicinity of delinquent peers, the likelihood that negative behaviors will occur is increased. In fact, there is a large body of criminological research that demonstrates the influence of delinquent peers upon a youth’s involvement in delinquent activity. However, when youth have a healthy sense of self-efficacy, the pull of delinquency will not tend to be as great. While this is not to say that youth with high self-efficacy will not engage in delinquent acts, it is to say that such youth will be unlikely to engage in serious acts of delinquency and criminal activity, particularly on a long-term basis. GRIEF Grief is commonly associated with a sense of loss. The grief response may include a flat affect and a lack of interest in positive activities. With grief some form of depression is common and this is a common reaction to the death of someone valued by a given person. Among today’s youth, death and bereavement are not entirely uncommon, particularly among juveniles who grow up in impoverished areas of the United States where crime rates are high. Indeed, among youth who are members of gangs or who have grown up in domestically violent homes, a sense of grief may be a common emotion. Later, in Chapter 13, we will discuss the stages of grief and the treatment of grief. It should be pointed out that grief can be experienced from any type of loss. For instance, divorce within the family may lead to a sense of grief among children over the loss of having both parents in the home. Children and adolescents may need time to process their emotional response to such developments where anxiety and depression are likely to emerge. Also, youth who have a parent incarcerated may feel a sense of grief since that parent will essentially be lost to the child while in the criminal justice system. Thus, grief manifests itself through a variety of means that commonly impact juvenile offenders. DEPRESSION Depression is the feeling of being dejected and uninterested in committing to any particular action. A deflated sense of self, listlessness, low initiative, and other signs of unhappiness and a lack of caring characterize depression. Depression is often referred to as a type of mood disorder that includes major depressive disorder, bipolar disorder, and dystymic disorder. For purposes of this section and this chapter, we will restrict our discussion to major depressive disorders since these are the most problematic and most common among teens. Major depressive disorder is characterized by one or more major depressive episodes (i.e., at least two weeks of depressed mood or loss of interest accompanied by at least four additional symptoms of depression). Major depressive disorder is the most common mood disorder associated with the offender population (both adult and juvenile). According to the DSM-IV-TR, the degree of impairment associated with major depressive disorder varies, but even in mild cases, there must be either clinically significant distress or some interference in social, occupational, or other important areas of functioning (p. 351). The afflicted youth will likely have decreased energy, tiredness, and fatigue without physical exertion. Even the smallest tasks may seem to require substantial effort. Further, these individuals often have a sense of worthlessness or guilt that may include unrealistic negative evaluations of one’s worth or guilty preoccupations or ruminations over minor past failings. Such individuals often misinterpret neutral or trivial day-to-day events as evidence of personal defects and have an exaggerated sense of responsibility for untoward events (DSM-IV-TR, p. 350). There are multiple designations for depression within the DSM-IV and these various subcategories of diagnosis can be confusion and somewhat overly complicated for the layperson. Much of the differences in these categories have to do with the factors that led to the onset of depression such as life-course events, the use of toxic substances, or even physiological factors. To provide a complete overview of each of these types of depression would go well beyond the scope of this chapter. However, the following symptoms are included since they are the most frequently encountered among the gamut of depression categories of diagnosis. Specifically, the National Institute of Mental Health (2002) notes that a person experiencing major depression is likely to present with: • Persistent sad, anxious, or “empty” mood • Feelings of hopelessness, pessimism • Feelings of guilt, worthlessness, helplessness • Loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex • Decreased energy, fatigue, being “slowed down” • Difficulty concentrating, remembering, making decisions • Insomnia, early-morning awakening, or oversleeping • Appetite and/or weight loss or overeating and weight gain • Thoughts of death or suicide; suicide attempts • Restlessness, irritability • Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain. The symptoms cited by the National Institute of Mental Health (NIMH) are common symptoms cited by most anyone presenting with depression. These symptoms were provided due to their compatibility with clinical symptoms in the DSM-IV-TR and to provide a general clinical overview of depression symptoms. However, there are some specific symptoms that are related to teens and that are not typically noted among adults. These symptoms should be seen as indicators of depression and might include attempts to run away from the family and/or home, problems with school performance (truancy or not paying attention in class), a lack of concern with appearance, persistent physical ailments that are not common to that age group (i.e., constant headaches, fatigue, or stomachaches), a reduction in contact with one’s peer group and/or a sudden change in peer groups, a tendency to gravitate toward dark or somber topics, and/or self mutilation (Family First Aid, 2009). Research on teen depression shows that youth are most vulnerable between the ages of 12 and 17, with older age ranges having more frequency of depression. One study, the National Survey on Drug Use and Health, provided specific percentages for youth ages 12 through 17 (Figure 9.1). It is important to point out that these percentages only include youth who have had major forms of depression but not youth with other less severe categories. If all categories had been considered, the percentages would likely be higher. Students should also keep in mind that Figure 9.1 refers only to depression in the past year among youth and does not include depression throughout the lifetime; if it did, the percentages would most assuredly be higher. Thus, Figure 9.1 illustrates a conservative presentation of the percentages of youth who present with depression. It is unfortunate that so many teens suffer from depression but it is even more unfortunate that only roughly one in four youth receive treatment for this disorder (National Institute of Mental Health, 2009). Further, it has been found that depression in teens is quite treatable. Indeed, the Treatment for Adolescents with Depression (TADS) series of studies, sponsored and directed by the NIMH, found that combination treatment is a safe and very effective means of providing treatment for adolescents with depression (2004). By combination treatment, the NIMH is referring to treatments that use both medications as well as psychotherapy. The TADS study found that the combination of antidepressants (particularly SSRI inhibitors) and the use of cognitive behavioral therapy (CBT) were particularly effective. The use of CBT has been mentioned throughout this text as a premiere treatment modality. This type of therapy has consistently received empirical support throughout a variety of domains and with a diverse array of clients and client issues. Exhibit 9.1 provides additional insight on the effectiveness of this treatment modality. FIGURE 9.1 Percentage of Youths Aged 12–17 Who Experienced a Past-Year Major Depressive Episode (MDE), by Age (2004–2006) Source: Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (2008). The NSDUH report: Major depressive episode among youths aged 12 to 17 in the United States: 2004 to 2006. Rockville, MD. Retrieved from: FEAR, ANXIETY, AND POST-TRAUMATIC STRESS DISORDER It is important to first distinguish between fear and anxiety. Fear is typically used to describe a response to a specific and known threat. Anxiety, on the other hand, is more general in nature and is not always targeted at a specific source of concern or stress. Often, fear and anxiety may seem to be one and the same. But, fear is a response to the clearly perceived and understood aspects of a dangerous situation and anxiety is related to the less predictable aspects of a situation. A primary reason that anxiety is presented is because it tends to occur among children who are in dysfunctional homes and it is also a common symptom among substance abusers and persons with depression. Further, the existence of post-traumatic stress disorder is common among victims of abuse and it is also included in this section since many juveniles (especially those suffering from serious physical and/or sexual abuse) may have symptoms of this disorder. EXHIBIT 9.1 Cognitive Behavioral Therapy (CBT) and Teen Depression While research from numerous sources have confirmed the efficacy of cognitive behavioral therapy (CBT), it is perhaps the Treatment for Adolescents with Depression (TADS) series of studies, sponsored and directed by the National Institute of Mental Health, that have proven to be the most comprehensive and multifaceted examination of depression among children and teens. The TADS research has consistently found that CBT is highly effective with depression among teens, just as it is with adults. In particular, one study in 2004 found that while medication and CBT combined was more effective than CBT alone, this same study did conclude that, over time, the effects of CBT alone tend to “catch up” with outcomes observed from the combination treatment (National Institute of Mental Health, 2004). Further, other research has found that, when stacked up against other modalities of treatment, CBT has consistently produced superior outcome effects with depression among adolescents (National Institute of Mental Health, 2009). Specifically, the NIMH 2009 study sought to compare treatment outcomes between those using cognitive behavioral program and those using other types of affective-based therapeutic care. It was found that, over a nine-month follow-up period, the rate of depression in teens in the CBT program was 11 percent lower than those in the usual care condition—21.4% versus 32.7%. Adolescents in the prevention program also self-reported lower levels of depression symptoms than those in usual care. Among teens whose parents were not depressed at the beginning of the study, the program was more effective in preventing onset of depression than usual care—11.7% versus 40.5%. However, this advantage did not hold for youth in the CBT if they had a parent who was depressed at the start of the study. Such teens had significantly higher rates of depression than those without a currently depressed parent. This study is just one of many that have consistently found that CBT interventions are superior to other types of interventions when sound and rigorous methodological research principles are utilized. Further, this government-funded research, as part of the TADS project, has utilized numerous clinics and facilities throughout the United States. Results are consistent with diverse populations and in different geographical locations throughout the nation. All of this lends to the generalizable nature of the research and demonstrates that CBT is perhaps the treatment of choice for youth with depression. This type of intervention has been shown to be more effective than those based on other orientations and, over time, it is even as effective as combined treatments. Though combined treatments may provide a quick positive outcome (useful in client circumstances that are crisis oriented) it is the CBT component, not the medication, that would appear to provide the long-term benefit for teens who face depression. Sources: National Institute of Mental Health. (2004). Combination treatment most effective in adolescents with depression. Bethesda, MD: National Institute of Mental Health. Retrieved from:; National Institute of Mental Health (2009). Re-shaping negative thoughts shields at-risk teens from depression. Bethesda, MD: National Institute of Mental Health. Retrieved from: Post-traumatic stress disorder (PTSD) is a reaction that can occur when a person has been exposed to a traumatic event in which both of the following were present: 1. The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. 2. The person’s response involved intense fear, helplessness, or horror. Further, the individual must present with the following symptoms for a period that is longer than one month. The individual will have PTSD if the traumatic event is persistently reexperienced in one (or more) of the following ways: 1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions 2. Recurrent distressing dreams of the event 3. Acting or feeling as if the traumatic event were recurring 4. Intense psychological distress at exposure to internal or external cues that resemble the traumatic event 5. Physiological reactivity to the exposure to the internal or external cues that resemble the event. Other factors that may indicate PTSD are persistent avoidance of stimuli that are associated with the trauma and numbing of general responsiveness, as indicated by three (or more) of the following: 1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma 2. Efforts to avoid activities, places, or people that arouse recollections of the trauma 3. Inability to recall an important aspect of the trauma 4. Markedly diminished interest or participation in significant activities 5. Feeling of detachment or estrangement from others 6. Restricted range of affect 7. Sense of a foreshortened future. Persistent symptoms of increased arousal (not present before the traumatic event), as indicated by two (or more) of the following: 1. Difficulty falling or staying asleep 2. Irritability or outbursts of anger 3. Difficulty concentrating 4. Hypervigilance 5. Exaggerated startle responses. This disorder is commonly found among juvenile girls and among adult female offenders due to prior childhood sexual abuse. Quite often, the female offender (particularly those involved in the sex trade and/or having addiction problems) will have at least mild levels of this disorder. Likewise, as odd as it may seem, many juvenile sex offenders may present with this disorder due to similar childhood sexual abuse that has been inflicted against them. As it turns out, many juvenile sex offenders learn their means of acting out from having been victimized themselves. This is also consistent with the research that indicates that many sex offenders are themselves victims of prior childhood sexual abuse. The connection between the prior childhood sexual trauma and future sex offending by perpetrators is discussed in Chapter 12 on sex offender etiology and treatment. SUICIDAL THOUGHTS Perhaps one of the most difficult and worrisome areas of dealing with juveniles would be the onset of suicidal ideation. Suicide is the third leading cause of death among teens in the United States. Aside from the fact that suicide happens to be a leading cause of death among teens, suicidal thoughts also intertwine with feelings of depression and, in some instances, a sense of grief. One researcher has found that in many cases, youth who feel incompetent in areas that are important to them (self-efficacy), as well as when they feel a lack of support from persons important in their lives such as parents or peers, feelings of hopelessness emerge (Harter, 1990). Hopelessness then tends to lead to a depression composite, which includes low self-efficacy, general hopelessness, and a depressive affect. Harter (1990) contends that there are powerful implications for both prevention and intervention. Harter (1990) notes that intervening at the front end, by influencing self-efficacy and social support, will have the greatest impact, since it is here that Harter has found that the chain of causal influences seem to begin. Thus, therapists should intervene to improve self-efficacy, by helping the individual to become more competent in areas in which he or she has aspirations or by aiding the individual to discount the importance of domains in which high levels of success are unlikely. Self-efficacy can also be improved by interventions that provide more opportunities for support and approval from significant others. Such interventions should not only enhance the youth’s sense of self-efficacy, but it should also prevent further reinforcement of the insidious cycle that involves hopelessness, depression, and associated suicidal thoughts. Thus, the various points regarding juvenile development that have been discussed up until this point (i.e., self-efficacy, depression, grief, and anxiety) are ultimately relevant to ensuring the welfare of youth who may see no true purpose in continuing forward. CONDUCT DISORDER It is the first five years of life that behavior related to child delinquency are established. This early years are closely dependent upon a child’s individual characteristics and the family dynamics that exist. Risk factors at home include antisocial parents, mother suffering from depression, family poverty, marital strife, large family, history of family violence, and parents who abuse drugs or alcohol, discipline harshly and erratically, and rely on poor parenting practices. In these cases, children that have persistent adjustment problems may present with a childhood disorder that is known as “conduct disorder.” This term is the name of a diagnosis that is used by mental health practitioners and the criteria for this diagnosis is found in the Diagnostic and Statistical Manual of Mental Disorders IV (or the DSM-IV-TR). Certain characteristics of a child, such as a difficult temperament as an infant and depressed moods as a child, are risk factors for conduct disorder and/or future delinquency. If the child has been a victim of violence or if the child has been exposed to a steady dose of violence on television, in movies, and/or in video games, the child may be at increased risk of developing conduct disorder. Some factors stand out more than others but aggression seems to be the best predictor of conduct disorder. Thus, many factors can contribute to a child developing conduct disorder, including brain damage or trauma, child abuse, genetic vulnerability, school failure, or other traumatic life experiences. Essentially, conduct disorder is a complex group of behavioral and emotional problems that are experienced by some children. The children and adolescents with this disorder have great difficulty following rules and behaving in a socially acceptable way. They are often viewed by other children, adults, and social agencies as “bad” or delinquent rather than disordered. According to the DSM-IV-TR, children with conduct disorder may exhibit a repetitive and persistent pattern of behavior in which the basic rights of others are violated. This is often manifested by the presence of three (or more) of the following criteria (all taken from the DSM-IV-TR) in the past 12 months, with at least one criterion present in the past six months: Aggression to People and Animals • bullies, threatens, or intimidates others • often initiates physical fights • has used a weapon that could cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, or gun) • is physically cruel to people or animals • steals from a victim while confronting them (e.g., assault) • forces someone into sexual activity Destruction of Property • deliberately engaged in fire setting with the intention to cause damage • deliberately destroys other’s property Deceitfulness, Lying, or Stealing • has broken into someone else’s building, house, or car • lies to obtain goods or favors, or to avoid obligations • steals items without confronting a victim (e.g., shoplifting, but without breaking and entering) Serious Violations of Rules • often stays out at night despite parental objections • runs away from home • often truant from school Children that exhibit these behaviors should receive a comprehensive assessment. Many children with conduct disorder may have coexisting conditions as well, such as ADHD, learning disorders, or PSTD. Research shows that children with conduct disorder are more likely to have ongoing problems if they and their families do not receive early comprehensive treatment. Many children with conduct disorder are unable to adapt to the demands of adulthood and thus have repetitive problems with relationships, job performance, and legal issues. These children are at high risk of becoming a future adult offender. SUBSTANCE ABUSE From the research, it is clear that youth are experimenting with drugs, alcohol, and tobacco at young ages. Typically, significant change in drug awareness and corresponding usage starts to take place around 12–13 years of ages. Indeed, youth around 13 years of age are three times more likely to know how to obtain marijuana or to know someone who uses illegal substances than are their 12-year-old counterparts (Ericson, 2001). Further, by the time youth enter eighth grade, roughly half will have tried alcohol, and about 1 in 5 will have smoked marijuana (Ericson, 2001). The use of drugs tends to increase mostly between eighth and ninth grade. Hess and Drowns make it clear, however, that although no single theory can explain the cause of juvenile delinquency, one fact is clear, “there is a direct connection between substance abuse and other forms of delinquency” (p. 86). SECTION SUMMARY In this section, it becomes clear that there is a multiplicity of issues to consider when providing interventions for juvenile offenders. When discussing interventions for juveniles, this chapter is largely focused on those offenders who are adjudicated for actions that are more seriously delinquent and/or criminal in nature. Many youth who present with serious offenses have a host of issues that negatively impact them. They may come from tumultuous family systems where abuse is common or their families may be plagued with substance abuse issues. These family-of-origin issues have a strong influence on the socialization of the youth and seem to exacerbate the likelihood that the youth will engage in serious forms of offending. Likewise, adolescence is a period of storm and stress for most teens, and this is no different for youth who commit acts of delinquency. In fact, this is likely to be all the more true. Many youth who are adjudicated in the juvenile justice system tend to have a number of emotional and/or mental health challenges. For instance, anger problems and tendencies toward the use of aggression are common with these youth. Interventions that help youth identify their aggression and anger problems while teaching them to effectively utilize their assertiveness skills are important components of juvenile treatment. Further, many youth suffer from difficulties with their sense of self-efficacy. This impacts their overall self-identity, sense of confidence, and overall mental well-being. This is further exacerbated by the onset of substance abuse, depression, anxiety, and suicidal ideation, all of which are common and serious concerns with this population. LEARNING CHECK 1. The use of aggression can be both physical and psychological. a. True b. False 2. The experience of child abuse is more common among the delinquent population than the non-delinquent juvenile population. a. True b. False 3. For the most part, fear and anxiety are the same concept. a. True b. False 4. Suicide is the number one cause of death among teens. a. True b. False 5. Many juveniles who have an adult substance abuser in the house are parentified and fulfill a family role of responsibility that exceeds what would normally be considered age appropriate. a. True b. False PART TWO: SPECIAL ISSUES WITH YOUNG OFFENDERS Counseling Offending Youth on Sex When addressing youth on sex-related issues, it is important to keep in mind that many will already have a good idea about sex and sex-related topics. In fact, many will have been sexually active and even on a routine basis. However, many will not be conversant on specific anatomical issues associated with sexual activity and with the transmission of sexually transmitted diseases. In many cases, juvenile males will be much less informed than juvenile females. When conducting this type of counseling, it is recommended that correctional counselors use a youth-centered approach to counseling. This is similar to person-centered techniques discussed in Chapter 5; however, these techniques are geared toward reflection and listening to the youth’s perspective. Importantly, youth-centered correctional counselors should provide pertinent and accurate information regarding sexuality, sexual health, and reproduction. Counselors in this role should work to demystify sexual myths, provide accurate and precise science-based information on sexuality, and provide practical strategies for the young person to act on the new information and skills learned. Among the typical counseling techniques and strategies, correctional counselors should use active listening to identify the youth’s needs, and the counselor should express a sense of empathy. Keen observation of nonverbal behavior should be maintained with prompts from the counselor for relevant sexual health questions. Likewise, the correctional counselor using a youth-centered approach should provide reflection and summarization skills of the young client’s personal situation and should develop a safe therapeutic relationship or alliance. The counselor is required to develop rapport and trust through appropriate self-disclosure while maintaining confidentiality. Lastly, it is very important that the counselor use age-appropriate language that the juvenile population will understand. The use of jargon and clinical terminology is to be avoided. Confidentiality and consent issues are more complicated when working with adolescents. For adults, the choice to be tested is their own, and the process and results are confidential. For young people, guidelines vary on the age at which they can decide for themselves to be tested, as well as on when, or if, their parents or guardians must be notified of the test and the results. Naturally, this will be more relevant to youth who are on community supervision, but it may also be an important consideration when youth are in short-term detention. Correctional counselors should keep the following points in mind when working with juveniles: • Youth often have different terminology for, and understanding of, sexual terms. In many cases there may be terms and slang that are used. It is recommended that the correctional counselor be well versed on this terminology. Though the counselor may know the terminology, it is not necessarily recommended that they incorporate the terminology in their own feedback and/or questions. If such use sounds artificial and/or if the youth seem uncomfortable with such informality from the counselor, then this technique should be avoided. On the other hand, if youth in therapy respond with additional dialogue and do not give indication that the use of common verbiage is not respected, then this can be a good means of joining and rapport building. • Unlike many adults who seek counseling and testing for STDs and/or HIV, juveniles may actually be more interested in counseling and receiving information than in being tested. Youth who may not have initiated sex might be seeking support in making informed decisions about their sexual and reproductive health. • Youth may not always be candid about their sexual experiences out of fear of stigma and labels. For instance, some youth may have engaged in sexual activity with the same sex, but due to number of reasons, these youth may not wish to divulge their experiences. Another example might be a youngster who had consensual sex with a sibling and/or another family member who due to self-consciousness of the taboo about incest may not wish to admit to the activity. Further, if the experience was with an adult, the youngster may avoid mentioning the encounter to protect the adult. • Counseling adolescents often takes more time than working with adults, because young people often know less about their sexual health than adults do. Also, keep in mind that from some youth, particularly young males, some of the issues discussed may elicit humor and jokes, particularly jokes that are macho or male-dominated in nature. The correctional counselor should never join in such humor and should ensure that all topics are addressed in a serious and respectful manner. Teenage Mothers and Unwanted Pregnancies The United States has the highest rates of teen pregnancy and births in the Western industrialized world. Teen pregnancy costs the United States at least $7 billion annually. Indeed, 34% of young women become pregnant at least once before they reach the age of 20, which amounts to roughly 820,000 pregnancies a year by girls or young women. Roughly 80% of these teen pregnancies are unintended and 79% are to unmarried teens. Furth the younger an adolescent girl is when she first has sex, the more likely it is that her first sexual experience was actually unwanted or non-voluntary in nature. Lastly, almost 40% of girls who first had intercourse at the age of 13 or 14 report that the sexual activity was not wanted. In addressing teen sex, young girls, and potential pregnancy, consider the following: • Approximately one in five adolescents has had sexual intercourse before his or her 15th birthday. • Approximately one in seven sexually experienced 14-year-old girls report having been pregnant. That translates into about 20,000 pregnancies each year and 8,000 births. (For those aged 15–19, the numbers are about 850,000 pregnancies and 450,000 births.) • Teens who are 15 years and older who use drugs are more likely to be sexually experienced than are those teens who do not use drugs—72% of teens who use drugs have had sex, compared to 36% who have never used drugs. • Teens who have used marijuana are four times more likely to have been pregnant or to have gotten someone pregnant than teens who have never used marijuana. From the above information, it is clear that adolescents’ early life-course sexual activity leads to pregnancy and it is also clear that much of the sexual activity occurs in tandem with drug use. Indeed, it would seem that some drug use further facilitates that likelihood of a future pregnancy. Given this, it is important to consider that in many families in which a daughter acts out sexually, the parents tend to be noncommunicative or they may be in constant conflict and turmoil with one another. In such cases, these teens do not feel comfortable talking with their parents due to the added strain and burden that the pregnancy is likely to add to the family household. In trying to limit the amount of teen pregnancy, abstinence should be presented as one choice. Indeed, the primary reason that teenage girls who have never had intercourse give for abstaining from sex is that having sex would be against their religious or moral values. Other reasons cited include desire to avoid pregnancy, fear of contracting a sexually transmitted disease (STD), and not having met the appropriate partner. When educating juvenile girls on peer pressure and sexual activity, the correctional counselor should provide these youth with suggestions on how they can be assertive in resisting sexual advances from young men. Making facts clearer to girls, three-fourths of all girls at 14 who report having had sex state that they indulged mainly because their boyfriends wanted them to. Correctional counselors should ensure that young girls are aware of these facts and that they are aware of their own right to refuse such advances. When attempting to prevent undesired pregnancies among juvenile girls, it may be useful to note that teens who have strong emotional attachments to their parents are much less likely to become sexually active at an early age and are therefore at a lower risk for teen pregnancy. In addition, contraceptive use among sexually active teens has consistently increased. This is a good trend since it has been found that sexually active teen who does not use contraception has a 90% chance of teen pregnancy within one year. While it may be the view of the correctional counselor that these youth should simply abstain, the fact of the matter is that many will not. With this in mind, alternative safeguards against pregnancy should be discussed with juvenile girls, particularly if the young girl notes her intent to be sexually active. When correctional counselors work with juvenile girls, the discussions on use of contraceptives and decisions to engage in sexual activity can be very emotional for a young girl. Moreover, male counselors may also have some degree of discomfort discussing these issues. In cases where a female counselor is available, it may be useful to have same-gendered counselors discuss sex and pregnancy issues—but this should not at all be considered mandatory. If the juvenile girls are not uncomfortable with the male counselor’s input and if the male correctional counselor is professionally adept with such topics, then there is an opportunity for the male counselor to provide some very effective and pro-social modeling. In fact, male counselors can demonstrate genuine care and consideration for the young girl’s future and health. On the other hand, male counselors working with juvenile girls should be careful to not seem “fatherly” or as if they are “lecturing” the youth. This is important because this is common among many father–daughter relationships and this can have an opposite effect than what is intended. Instead, the male counselor should ensure that he utilizes the youth-centered approach that was discussed earlier. This is important because the use of cross-gendered therapeutic interventions can have very positive effects if implemented correctly; and they can have very negative effects if they are not implemented correctly. Lastly, when and where the opportunity exists, the use of both a male and a female cotherapist team might be most effective. The use of group interventions with young juvenile girls can allow the youth to discuss issues of sexual activity and pregnancy. The inclusion of peers can help to facilitate the intervention and also to create a stronger set of reinforcements for the young girl. The use of a cotherapist team can allow for effective modeling and even role-playing between the male and female therapist. These techniques can be very effective. As with most groupwork, the young girls can and should be encouraged to use techniques such as role-playing and assertiveness training within the group. Further, the feedback that juvenile girls gain from supportive peers can be very useful in providing the support and encouragement needed so that the girl can make her own independent choices regarding her own sexual behavior. Parenting Classes and Parenting Issues Though counseling regarding juvenile sex and teen pregnancy may be useful with many youth, some young girls will inevitably choose to engage in sexual activity that will conclude with a pregnancy. Further, the correctional counselor is likely to have juvenile girls in treatment who already have children when they are in the correctional system. In such cases, these youth may not be ready for parenthood and may need guidance and assistance on effective parenting techniques. Further, some of these juvenile girls will still be in contact with their male partners who are the biological fathers of the teen’s child. In such cases, these juvenile fathers should also be encouraged to attend parenting classes. An example of a well-established curriculum for training on parenting would be the Systematic Training for Effective Parenting, which is published by STEP publishers. Systematic Training for Effective Parenting (STEP) is a comprehensive program to train parents on effective child-rearing techniques. The program emphasizes the use of “I” statements for personal responsibility, the use of reflective listening common to youth-centered counseling, and the use of appropriate consequences for desired and undesired behavior. We advocate the use of the STEP program because it is based on extensive research that demonstrates the viability of this program. Indeed, the program has been tested on roughly 60 different occasions. From the evaluative research, it has been found that the program has also been used successfully with drug-addicted parents, abusive parents, foster parents, disadvantaged single mothers, and middle-class parents. In addition, STEP program research has looked at parents of antisocial children, low-GPA students, “problem” children, children with low self-concept, special needs children, and parents of adolescents who were hospitalized for emotional and behavioral problems. Lastly, this program has also been found effective within a multicultural context, having been studied with Chicana parents, Mexican-American parents, and parents from Appalachia, Canada, Puerto Rico, and Australia. Lastly, an author of this text has had training in the use of this program and has even taught numerous families on effective parenting using this system. By all accounts, the author found this curriculum to be quite workable, both from a teaching standpoint and in regard to implementation. The curriculum is written in a clear and effective manner that is trainer friendly and parent friendly. For additional information regarding the STEP program, see Exhibit 9.2, which provides information on the STEP program for adolescents. The STEP/Teen curriculum is ideal for parents who are contending with a juvenile youth at home. The other STEP products can be used by teen mothers when raising their newborns. EXHIBIT 9.2 Systematic Training for Effective Parenting The STEP/Teen’s handbook is a useful tool for parents and for teenagers who are faced with accepting the responsibility of parenthood. This curriculum emphasizes positive approaches to parenting. The use of encouragement, teaching of consequences, and an understanding of the underlying goals of behavior are primary topics that parents will learn. However, recent additions to this classic parent training curriculum have included special and comprehensive suggestions for single parents and stepfamilies. In addition, this curriculum addresses specific and challenging topics such as drug use among youth, violence, and gang membership. Techniques for dealing with these issues are specifically provided. This makes the STEP process unique from other parenting guides. Further, the material designed for parents of teens is written in easy-to-understand language. This section also provides at-home activities to apply STEP/Teen techniques. The curriculum covers the following topics: 1. Understanding teens 2. Communication with teens 3. The use of encouragement 4. Healthy problem solving 5. Responsibility built through experiencing consequences. This curriculum includes videos that are designed to be used with the curriculum. These videos are current and up-to-date, allowing parents and teens to view and discuss the scenarios. The primary key to this curriculum is the emphasis on effective communication and rapport building. Emphasizing accountability among youth and the need to consider consequences of one’s behavior provides an effective approach to handling undesired behavior that provides parents with an alternative to punitive approaches. Lastly, this type of parenting curriculum is grounded in a balanced and realistic orientation toward parenting with today’s youth. In other words, the realities and challenges of parenting youth in today’s society are not side-stepped or ignored. Rather, the STEP process makes a point to address difficult and hard-to-answer problems that parents may face when raising teens. Source: STEP Publishers. (2008). Step into parenting: About STEP. Retrieved from: In addition to providing parenting classes, it may be useful to include couple and/or family counseling as an intervention. In such cases, it may be that the juvenile girl and her partner are still in touch and/or involved with one another. In fact, it may even be the case that they intend to cohabitate or get married. This is especially true among the Latino-American culture where earlier pregnancies are not uncommon and where, due to culture (particularly based on religious orientation), young males will be expected to marry the young girl who is expecting to give birth. In such cases, family therapy can be even more productive if other family members (i.e., the parents of the juvenile female and/or the juvenile male) are also included in these interventions. Indeed, in many cases, the parents of the juvenile female, and sometimes the juvenile male, will offer assistance in raising the newborn. Such family systems should be provided services to prepare them for the challenges that will undoubtedly emerge in the future. Peer Groups, Subculture, Minority Issues, and Socialization Peer groups are important for youth and, when seeing youth, the correctional counselor should keep this in mind. The peer group will likely be the primary source of socialization aside from the youth’s family. Indeed, if the family was seriously dysfunctional, it is likely that the youth only identifies with his or her peer group. Among youth who are processed in the juvenile justice system and/or the criminal justice system, there exist a number of subcultural groupings that will be important reference points for youth seen by the counselor. In particular, it should be noted that the “gangsta” movement has had a particularly strong impact on youth culture, particularly among delinquent youth. The “thug” look and/or genre of music is fairly common among youth who are processed throughout the juvenile system. While other subcultural groups exist (i.e., Goths, alternative, etc.) they are not as well represented among the hard-core juvenile offender population. This is not to say that knowledge of such groups is not relevant to correctional counseling, but it is to say that these groups will not be as prevalent, largely due to the fact that they are simply not as widespread in popularity among today’s youth and the public media. Further, there are a disproportionate amount of minority youth who are processed through the justice system. Thus, in many juvenile systems, youth will tend to congregate along racial lines just as they might along subcultural lines. African-American and Latino-American youth are particularly represented, and these youth will likely affiliate with their own racial categories. In many cases, the youth from these minority groups will also come from families that are not affluent, with economic challenges being common to their background. These factors will tend to impact the socialization process that has been experienced by these youth and this is likely to be quite different from the backgrounds of many counselors. Because of this, the correctional counselor who works with the youth must also understand the cultural backgrounds common to the youth in their intervention programs. Knowledge of the locale from which the youth may have been raised can also be helpful for the correctional counselor. Culturally Relevant Considerations The cultural identity will be important for many youth that the correctional counselor may encounter within the juvenile and/or criminal justice system. This then requires that the correctional counselor be culturally competent in providing therapeutic services. With this in mind, there are several points that should be made about the content of culturally competent intervention services for juveniles. Certain key themes and issues should be included in these interventions when dealing with minority clients. Among these issues are those of acculturation, assimilation, migration history, race and institutional racism, and socioeconomic classism. These issues are likely to be directly relevant to most juvenile minorities who are processed within the formal system. Further, Caucasian youth in treatment should likewise be encouraged to explore their cultural roots, particularly with family-of-origin issues, for all the same reasons that minority youth would do so. In fact, there should be no distinction, as cultural beliefs are transmitted through all families and all youth can benefit from drawing on their cultural strengths and from learning about how issues such as racism and classism affect us all. Correctional counselors should likewise discuss the importance of acculturation and assimilation—the former referring to the abilities and actions of the individual in adapting to the host culture and the latter referring to the permeability of the host culture (Smart & Smart, 1997). With respect to acculturation, minority youth should be encouraged to discuss how maintaining their own original culture and language can place them at cross purposes with the criminal justice system and American ideal of appropriate functioning. This should be compared with issues pertaining to assimilation, in which the minority juvenile is coerced to become more like the mainstream culture. The benefits and drawbacks to both options should be discussed openly in the group and youth should be given homework that causes them to reflect on these issues. In addition, some juvenile youth may come from families that have only lived in the United States for a handful of years. Migration issues should be discussed as well, with difficulties in the adaptation process being discussed openly. Issues pertaining to first generation immigrants and the generations that follow should be discussed. Clients should be required through homework assignments to discuss immigration issues and cultural belief systems that were maintained or discarded by their families. In covering these topics, the self-efficacy of the youth is improved through the strengthening of their self-identity and understanding of the development of their family of origin in the broader society. Also, issues of classism should be brought squarely into focus for the battering client. The effects of poverty on family relationships should not be overlooked. Economic levels affect the type and amount of service delivery that different populations receive in educational, medical, and political arenas. The effects of poverty can likewise affect feelings of power over one’s environment, feelings of self-worth, and perceptions of victimization. Minority youth should be made aware of this and be provided with an environment where these issues can be openly discussed. Explorations into how social class can shape a youth’s reactions to his or her sense of powerlessness should be made so that juveniles can readily identify with the social structures that put them at heightened “risk” of turning delinquent. Gangs and Youth When working with juveniles in the correctional setting, gang membership will be encountered on a fairly frequent basis. This is particularly true if the community supervision agency referring the youth is in a larger or mid-sized metropolitan area or if the correctional counselor works with youth who are in a state-operated facility. For correctional counselors who work with juveniles, it is advisable that they develop a working knowledge of the different gang groups in their area and among their juvenile population. An understanding of the tenets of a particular gang, how leadership structures operate, and gang alliances can be important in rapport building and can also provide the counselor with an understanding of the youth’s world which will, undoubtedly, be influenced by the activities of their gang. This basic knowledge—and the correctional counselor should strive to learn more the basic information—will provide the counselor with the bare basics to competently provide services to these youth. It is advisable that the correctional counselor have sufficient training with gangs and gang offenders if they plan to work with the offender population (both juvenile and adult) on a long-term basis. An excellent source of training and information for correctional counselors would be the National Gang Crime Research Center (NGCRC). The NGCRC is a nationally based nonprofit organization of recognized gang experts from around the nation. This organization hosts an annual training conference where information regarding juvenile and adult gang issues are covered in a comprehensive manner. Organizations such as NGCRC should be consulted by correctional counselors if they have little or no experience with gang offending because a wealth of information may be available to enhance one’s effectiveness when dealing with gang offenders. There has been considerable debate as to why youth join gangs. It is our contention that many youth join gangs for a number of reasons, but, among all others, the primary reason is to have some sort of need met. There has been considerable research that has demonstrated that gangs provide many youth with basic human needs related to belonging. Some of these needs might include security, acceptance, friendship, food, shelter, discipline, belonging, status, respect, power, and money (Hess & Drowns, 2004; Valdez, 2000). Thus, gangs and gang membership likely results from any variety of personal, social, or economic factors. In some cases, youth may be pressured into gangs. This is particularly true where rivalries are rampant and the need to recruit members exists. Peer pressure and intimidation may be the causal factor for some youth. Likewise, protection from victimization at the hands of other gang groups in the community might be another motivator. In addition, there may be expectations from older siblings and/or family members who have also joined a given gang. This is an important consideration because gangs in some areas of Chicago, Los Angeles, and New York have family memberships that may span three or more generations. Indeed, some neighborhoods in these metropolitan areas may have members throughout who are current members or, now well into adulthood, were once members before settling down. In such cases, it is not uncommon for that neighborhood to sympathize with the gang and to provide it with support. These types of neighborhood dynamics can result in community-wide socialization that promotes gang membership. Hess and Drowns (2004) note that it is common among many underprivileged youth to experience frustration and feelings of deprivation from the predominantly middle-class values that pervade throughout broader society (Hess & Drowns, 2004). These youth are not afforded the same opportunities and privileges that more affluent families may have. Underprivileged youth eventually become aware of this and feel the stings of poverty that other middle-class youth avoid. To youth socialized in poor communities that are rampant with vice, crime, and violence, delinquency may not see to be anything abnormal or undesired (Hess & Drowns, 2004). Amidst these neighborhood social conditions, the internal influences of the gang membership also work on the youth’s development. The youngster may grow up knowing older gang members prior to himself becoming a member. He may learn to admire these members. Over time, an informal familiarization with the gang may develop. Eventually, the gang psyche is taught via the gang formal indoctrination process. This transformation of a youth into a gang member involves a slow process of assimilation (Hess & Drowns, 2004). Once the youth reaches an age at which he is able to prove his worth to the gang leadership, he is required to engage in some sort of ritual. In most cases this may consist of getting “jumped in,” which is when the gang members beat the youth and the youth is expected to fight until they cannot continue to do so, or it may consist of getting “sexed in,” in which some females may be required to have sex with male members to obtain affiliate status. Other cases may not require such ceremonies, particularly when the recruit is highly desired by the gang. Also, these forms of initiation are typical of male juvenile gangs but female gangs may not use the same types of initiation rites. Among Latino and Asian juvenile gang members, the structure of their family of origin may consist of numerous immigrant members. In such cases, the parents may not speak English. Youth in these families learn the language and due to school influences become quickly comfortable with American society. In the process, some may lose respect for their parents and/or may seek to divest themselves of their cultural roots. In these cases, they quickly become experts at manipulating their parents and the parents lose the ability to regulate the behavior of their child. In such cases, it is very difficult to obtain any genuine reform of these youth unless they are separated out from any of their old influences prior to adjudication. In these circumstances, the use of some type of family therapy is highly recommended. This is typically because the parents have little support and also because the structure of the family is being undermined. In such cases, the correctional counselor will find that the parents are more than willing to assist in regulating their youth, but they just are not able to because of linguistic and cultural limitations. It should be pointed out that these types of interventions require a correctional counselor who is either fluent in the client’s primary language or an interpreter will be needed. One of the authors of this textbook has conducted therapy concerning similar issues through the use of an interpreter and found the process to be quite productive. Consider further that many hard-core juvenile offenders come from abusive and/or neglectful homes. This is one key motivator for youth from these homes to join gangs. This motivation holds true for both male and female juvenile gang members. As was noted earlier in this chapter, the family of origin is the primary source for developing the youth’s sense of belonging and self-worth. If these youth do not get this support at home, they are likely to seek this support from some other source; gangs provide that source (Hess & Drowns, 2004). Certain commonalities exist with many families that have hard-core gang members. A family that has members who are also gang members is quite often a racial minority with underprivileged economic resources (Hess & Drowns, 2004). In many cases, the male role model may have a criminal history and/or may actually be incarcerated at the time that the youth obtains gang affiliation. Thus, the gang becomes a surrogate family, of a sort. Within the gang family, violence toward others is commonplace. Hess and Drowns (2004) note that “one reason for this is that gang members were often neglected or abused as children” (p. 194). Naturally, the previous point dovetails with points made earlier in this chapter regarding the backgrounds of many juvenile offenders. Further, the issues related to economic deprivation and the desensitization toward gang affiliation and gang violence that may occur illustrates one reason why it is important to discuss issues related to classism and poverty with these youth. Thus, it is clear that many points made throughout the earlier segments of this chapter may serve as genuine causal factors for gang membership and for the maintenance of that affiliation over the span of years. As noted earlier, this may even become an intergenerational affiliation as entire families become enmeshed within the gang and neighborhood identity. Here again is an opportunity for family systems techniques, when and where some adult members do not wish to support a criminogenic lifestyle for their children. In some cases, even older members of a family who were gang members may not wish the same for their own offspring or kin. In such cases, it may be worthwhile to engage multiple family members into the intervention process, so long as these members do not seek to encourage delinquent or criminal activity among family members. Gang Exit Strategies for Youth As is clear, there are numerous incentives for youth to maintain membership with their gang affiliation. However, this affiliation stands at cross-purposes with the youth’s ability to ultimately escape a life of crime. Thus, correctional counselors may find themselves in contact with programs that specialize in safely exiting juveniles from gang membership. In fact, some correctional counselors may work with gang offenders, leaving the door open for those youth who may decide to leave the gang life. Evans and Sawdon (2005) have provided a model process to facilitate the exit of youth from gang membership. This gang-exit program strategy has three components: (1) Assessment and intake, (2) intensive training and personal development, and (3) case management process. Gang member assessment and intake is the phase that identifies interest and motivation of the gang member, the amount of gang involvement, and the member’s family and social history (Evans & Sawdon, 2005). During this phase, members are provided an orientation to the program. The next phase is the gang member intensive training and personal development phase. This phase implements two separate curricula, one for the male gang member and another for female gang members. Each curriculum involves up to 60 hours of intensive training. Topics during this training include anger management, aggression, sexism, racism, homophobia, and bullying. Communication skills training is also given during this phase. The last phase is the gang member case management phase, which involves individual support for the member but also requires ongoing group meetings for the ex-gang member. The intent is to reinforce what was learned at intake and to provide a proactive intervention when life takes some unforeseen turn for the prior gang member. This program utilizes prior members who successfully complete the exit program as future facilitators with future members of the program. These prior gang members are tasked with being active in establishing community contacts and outreach. Participants visit local community centers and other youth services to provide information about the program. From this point, may prior members will engage in community presentations to help generate support (financial and otherwise) for the antigang program. This program trains these prior members who are “passing the word” with leadership skills training, empathy building, counseling, and the development of their own “personal stories,” which are stories that explain how they became involved in gangs and why they have chosen cease involvement with the gang. This “story” is told in schools and other areas where the ex-gang member tries to warn against joining the gang life. If it is possible to extract youth from the gang-oriented environment, then this option should be given priority. Indeed, the youth is much less likely to recidivate when away from the adverse peer group. In the absence of such an intervention, the next best strategy is to inoculate him or her from the effects of the gang world and to also replace the prior peer group with a new pro-social peer group. This is specifically what the gang-exit program attempts to do all the while working against the backdrop of the prior gang family’s pressure to return. This is what makes the task so difficult for the offender and the community supervision officer and it is the strong tug of a subculture that eschews any attempt at reform made by the prior member. SECTION SUMMARY In this section, the issues associated with teen sex and sexuality are discussed. The need for counseling youth on safe-sex practices to avoid STDs and HIV as well as contraception strategies to avoid unwanted pregnancies were discussed. Correctional counselors who work with youth should be prepared to talk with male and female juveniles about these issues. Effective strategies for providing counseling on these topics were presented and specific mention of the STEP was presented as a premier approach to teaching young mothers and fathers skills for effective parenting. Further, an understanding of peer-group subcultures is important for correctional counselors, as is the ability to provide culturally competent interventions. The various groupings and subgroupings by which juveniles gather are important since this will often be laced within their own sense of self-identity. In addition, the existence of juvenile gang offenders represents the most serious form of peer grouping. Juveniles join gangs for a number of reasons and the savvy correctional counselor will make a point to obtain knowledge and understanding of gang subculture. LEARNING CHECK 1. Many youth who join gangs do so to gain acceptance and to have a sense of belonging. a. True b. False 2. The younger an adolescent girl is when she first has sex, the more likely it is that this first sexual experience was actually unwanted or nonvoluntary in nature. a. True b. False 3. Acculturation refers to the permeability of the host culture and assimilation refers to the abilities and actions of the individual in adapting to the host culture. a. True b. False 4. Youth whose parents are recent immigrants may fall into delinquency due to the ease with which they can manipulate their parents who, in many cases, may not know English or understand the broader American culture. a. True b. False 5. Teens who have used marijuana are four times more likely to have been pregnant or to have gotten someone pregnant than teens who have never used marijuana. a. True b. False CONCLUSION Juvenile offenders present with a variety of specialized needs and considerations that can prove challenging for even the most seasoned of correctional counselors. The issues that impact youth in their earliest of years can impact the likelihood of future delinquency occurring among a given youngster. The home life is the initial point of socialization and the early caretakers have a substantial (but not total) influence on the youth’s future behavior. Many hard-core juvenile offenders come from homes that are substantially different from those where youth who commit minor acts of delinquency come from. Such homes more frequently have abusive or neglectful parental practices and substance abuse issues than do homes of less serious delinquents and non-delinquents. Juveniles tend to have higher rates of clinical disorders than the general population. Indeed, depression, anxiety, and suicidal ideation are serious concerns among the adolescent population. Further, these problems are even worse among the delinquent population due to their increased likelihood of being victimized and their increased likelihood of abusing illicit substances. Both the abusive home life and the use of drugs and alcohol tend to simply make matters worse, though they serve as a coping mechanism for many youth (albeit a dysfunctional coping mechanism). Juvenile offenders tend to have difficulty with anger issues and the prevalence of conduct disorder among these youth is higher than is observed with other groups. Teen sex and teen pregnancy is another important area that correctional counselors must attend to. Juvenile offenders are in particular need to have sex education that teaches them about safe-sex practices (in regard to STDs and HIV transmission) and they tend to be in need of information regarding fertility and birth control. Further, both male and female delinquents need this education and correctional counselors will need to be professional comfortable in addressing these issues with both male and female juvenile offenders. Similarly, some juvenile offenders have incurred parental responsibilities and are in need of parent training. The STEP is presented as a quality curriculum and training process of educating youth on this area of responsibility. Correctional counselors should be informed on different subcultural groups and their prevalence within the juvenile justice system. In addition, multicultural competence is important and correctional counselors will need to be familiar with specific issues associated with different cultural and racial groups. The marginalization of many minority youth in the juvenile system truly provides few options for these youth. Further, community influences can point toward the support of gang membership. The lure of gang membership can be powerful, particularly when such membership is respected and idealized. Getting youth out of the gang life can be difficult but, with the aid of effective gang-exit strategies, this can be done. Ideally, such exit from gang affiliation will be indicative of future reform for the youth in question. Essay Questions 1. Consider your readings from Chapter 5 regarding common theoretical counseling perspectives. In doing so, consider also the use of youth-centered counseling techniques that were mentioned within this chapter. Choose and discuss at least two theoretical approaches that you believe would be useful with juvenile clients. Be sure to explain your answer in some detail and provide specific examples. 2. Refer to your earlier readings in Chapter 7 on group therapy. Explain how and why group therapy might be an effective means of intervention with delinquent girls regarding safe-sex practices, birth control, and teen pregnancy. In which cases might this not be as effective an intervention? What are some variations in the group therapy process that you might employ? 3. Refer to your readings in Chapter 6 on family systems therapy. Explain how and why family systems therapy might be an effective means of intervention with delinquent youth. How might family systems be best in dealing with issues for immigrant families? What might be done in family systems therapy with homes that are abusive? Likewise, explain how family systems therapy might be beneficial for teen couples who will be contending with an unplanned pregnancy. 4. Consider a youth who is growing up in a ganginfested community. If you were counseling youth who were in such a location, what might you do to try to prevent youth from joining such an organization? How would you work with other youth who desired to leave the gang life? When might family systems therapy be effective and when might it not be? 5. Discuss some of the issues that impact many of the more serious juvenile offenders. Given these various issues that might emerge, explain what you might do if a youth disclosed that he or she were the victim of a prior childhood sexual assault. In addition, explain how you might intervene if the youth were presenting with signs of serious depression and if you suspected suicidal ideation. Treatment Planning Exercise For this treatment planning exercise, the student should consider their readings throughout this chapter as well as prior chapters. For this exercise, you should determine which, if any of the issues discussed in this chapter, apply to Danny’s case. Be sure to identify those issues and explain how you would address them. Be sure to include a discussion of any corollary services that you might have the client utilize. In addition, explain whether a youth-centered approach would be appropriate with this client. Provide details on this aspect of your response. The Case of Danny Danny is a 17-year-old-male who has had a number of legal problems. Danny is currently on juvenile probation and has been referred to you by his juvenile probation officer. Danny’s parents have also chosen to come to you for counseling because they feel that they have not done enough as parents. Danny has constantly been in trouble at school and has just recently been placed on temporary suspension from the school grounds due to acts of vandalism. Danny is also fond of taking risks, such as jumping in the street to force cars to veer aside …all the while he throws eggs at the windshield to blind the driver. When Danny was 10 years old he was diagnosed with oppositional defiance. He has continuously defied anything that is requested of him, unless there is a clear advantage for him when giving compliance. Danny’s parents are not naïve about his behavioral problems. In fact, they are very worried because he is now 17 and they feel as if they have completely failed as parents. They tell you that Danny will be made to attend treatment, and they will ensure it since they also plan to attend your clinic for couple’s counseling. The counseling you are giving is in addition to his anger management and substance abuse counseling that he already receives as a mandatory condition of his probation. His parents tell you that they do not expect miracles; they just ask you to help if you can. Bibliography American Psychological Association (2004). Mentally ill offender treatment and crime reduction act becomes law. Washington, DC: American Psychological Association. Retrieved from: Cox, S. M., Allen, J. M., Hanser, R. D., & Conrad, J. J. (2008). Juvenile justice: A guide to theory, policy, and practice (6th ed.). Thousand Oaks, CA: Sage Publications. Davis, S. F., & Palladino, J. J. (2002). Psychology (3rd ed.). Upper Saddle River, NJ: Prentice Hall. English, D. J., Widom, C. S., & Brandford, C. (2002). Childhood victimization and delinquency, adult criminality, and violent criminal behavior: A replication and extension. Washington, DC: National Institute of Justice. Ericson, N. (2001). Addressing the problem of juvenile bullying. OJJDP Factsheet #27. Washington, DC: U.S. Government Printing Office. Erikson, E. H. (1975). Life history and the historical movement. New York: Norton. Evans, D. G., & Sawdon, J. (2005). The development of a gang exit strategy. Corrections Today, 66, 76–81. Family First Aid: Help for Troubled Teens. (2009). Teen depression, statistics, and warning signs. Retrieved from: Hanser, R. D., & Mire, S. M. (2008). A comparison of juvenile sex offenders in the United States and Australia. International Review of Law and Technology, 22(1), 101–114. Harter, S. (1990). Visions of self beyond the me in the mirror. Denver, CO: University of Denver. Hess, K. M., & Drowns, R. W. (2004). Juvenile justice (4th ed.). Belmont, CA: Thompson/Wadsworth. Ireland, T. O., Smith, C. A., & Thornberry, T. P. (2002). Developmental issues in the impact of child maltreatment on later delinquency and drug use. Criminology, 40(2), 358–380. Moffitt, T. E. (1993). Adolescence-limited and life-course persistent antisocial behavior: A developmental taxonomy. Psychological Review, 100, 674–701. Morris, C. G. (1991). Contemporary psychology and effective behavior (7th ed.). Glenview, IL: Scott, Foresman/Little, Brown Higher Education. National Institute of Mental Health. (2002). Depression. Bethesda, MD: National Institute of Mental Health. Retrieved from: National Institute of Mental Health. (2004). Combination treatment most effective in adolescents with depression. Bethesda, MD: National Institute of Mental Health. Retrieved from: National Institute of Mental Health. (2009). Re-shaping negative thoughts shields at-risk teens from depression. Bethesda, MD: National Institute of Mental Health. Retrieved from: Smart, D. W., & Smart, J. F. (1997). DSM-IV and culturally sensitive diagnosis: Some observations for counselors. Journal of Counseling and Development, 75, 392–397. Valdez, Al. 2000. Gangs: A guide to understanding street gangs (3rd ed.). San Clemente, CA: LawTech Publishing. 11 Female Offenders and Correctional Counseling CHAPTER OBJECTIVES After reading this chapter, you will be able to: 1. Identify and discuss challenges that are more common for female offenders than for male offenders. 2. Explain how family-of-origin issues may be an important consideration for female offenders. 3. Explain why beliefs pertaining to sex and sexuality may be an important area of consideration for many female offenders. 4. Describe the underlying aspects of feminist therapy and how this may be applicable to female offenders. 5. Identify and discuss various issues related to females who come from minority groups that are more commonly represented in the criminal justice system of the United States. INTRODUCTION One specialized population that has gained quite a bit of attention since the mid-1990s is the female offender population. The rate of growth in the number of women in prison and on community supervision has continued to get higher, with the proportion of female offenders in treatment sharing a corresponding growth. It is not the focus of this chapter to determine the specific number of women nor the rate of growth of women in custody, but instead we simply wish to note that the female offender population has emerged as a substantive group within the correctional population. It is therefore important that correctional counselors be knowledgeable in providing interventions with this group of offenders. It is with this in mind that we now turn our attention to some of the common issues that are more specific to female offenders than male offenders. PART ONE: WOMEN IN THERAPY Parental Roles Undoubtedly, the role as a mother has proven important within the identity of many female offenders (Hanser, 2007). In fact, the prognosis for successful correctional treatment is often linked with the woman’s ability to maintain contact with her children (Hanser, 2007; Kassebaum, 1999). Further, it is important to consider that female offenders in the criminal justice system are mothers to approximately 1.3 million children. This then means that, at one point or another, issues related to parenting and childcare become important considerations for female offenders. This is particularly true since many women who are placed in treatment programs and/or put on community supervision may lose custody of their children. In some cases, the children may be kept by relatives of the female offender. In other cases, the children may be placed in foster care. When children are placed in foster care, caseworkers are expected to make concerted efforts to sustain family ties and to encourage family reunification (Bloom, Brown, & Chesney-Lind, 1996). Regardless of whether the offender is given incarceration or is kept on community supervision, the issue of child custody usually must be addressed for these offenders. However, once released from custody to community corrections, mothers face numerous obstacles in reunifying with their children. They must navigate through a number of complex governmental and social service agencies in order to regain custody of their children. In the process, they often have to demonstrate that they are “fit” to have custody of their children. During this time, female offenders may need instruction on everything from pregnancy issues to parenting to child placement. Thus, it is important that correctional counselors see to it that female offenders gain parenting instruction, since many female offenders themselves have come from dysfunctional homes. Substance Abuse Substance abuse is a major contributor to female criminality. Substance abuse is correlated with a number of female crimes such as prostitution and shoplifting. Often these other crimes are committed to support the female offender’s drug problem. Further, female offenders tend to use alcohol, cocaine, and heroin as drugs of choice. These are highly addictive drugs that require intensive treatment. Indeed, women are particularly in need of quality drug abuse interventions because female offenders are more likely than male offenders to use drugs, they use more serious drugs than male offenders, and they use them more frequently. Further, female offenders are more likely than male offenders to be under the influence of drugs at the time of their crimes (Kassebaum, 1999). Not only are female offenders likely to be in more need of drug treatment but the intervention should be specifically tailored to the female population. Indeed, treating women in all-female rather than coeducational settings—where the environment can be more nurturing, supporting, and comfortable for speaking about such issues as domestic violence, sexual abuse and incest, shame, and self-esteem—is helpful (Kassebaum, 1999). Recently, women’s treatment experts have been calling for new treatment models designed specifically for women. Adding special services to a male treatment model should not be considered sufficient. Rather, the female treatment program must be separate from the traditional male treatment models to ensure that it fits the psychological and social needs of women (Kassebaum, 1999). Lastly, substance abuse issues for women are often tied to the relationships that they have with others, particularly their significant other. In most cases, a woman with a drug problem has been intimately involved with a man who also has a drug problem. In addition, many women report that a man introduced them to drugs, while men tend to more often begin using drugs with male peers. One study found that roughly 33% of female heroin addicts indicated that a male friend, spouse, or partner influenced their decision to use narcotics. On the other hand, only 2% of male addicts in the study indicated that a woman influenced their decision to use drugs (CASA, 1996). Kassebaum (1999) notes that it is probably accurate to say that some of these women are addicted both to the substance and to a man who is addicted. A man introduces them to drugs, and they depend on the man for their supply. In many cases, the woman’s criminal behavior may simply result from dependent acquiescence in response to the desires of an addicted male partner. Depression and Anxiety Depression is perhaps the single most common DSM-IV-TR diagnosable disorder among female offenders. There are several reasons that contribute to this observation. First, within the general population of men and women, there is a slightly higher prevalence of depression and anxiety among women than men. In most cases, certain disorders in the DSM-IV-TR are represented more by one sex than the other: Women tend to present with depression more frequently than men. While this only accounts for cases that involve persons willing to report their symptoms, the general clinical landscape is one where depression and anxiety (anxiety tends to correlate with depression) are more commonly found among the female population. Second, women tend to gravitate toward drug use, and this exacerbates their likelihood of reporting levels of depression and anxiety. It may be recalled from Chapter 8 that depression and anxiety are frequently found to be co-occurring disorders for substance abusers. Naturally then, this would be the case for female offenders just as it would be for male offenders. However, it is not clear if the female offending population tends to initially present with depression and anxiety which is then aggravated by the drug use, or if the drug use initiates and leads to long-term problems with depression and anxiety. The true answer is probably that both means of onset occur frequently among women processed in the criminal justice system, but it is probably more likely that women initially experience depression and anxiety prior to and aside from their drug use, given that the life-course profile of most female offenders tends to consist of a history or prior abuse, trauma, and deprivation. This brings us to our last point regarding depression and anxiety among female offenders. Many women who are incarcerated and/or on community supervision often report some sort of abuse that has been experienced in their past. In childhood, it is not uncommon for sexual abuse and/or other forms of abuse to be reported. In adulthood, many female offenders report experiences with domestic abuse in their intimate relationships. These experiences often lead to some sort of trauma, including post-traumatic stress disorder (PTSD), which then also tends to correlate with anxiety (indeed, a traumatic event is anxiety producing) and depression. Thus, the life-course experiences of female offenders tend to add to the complications. Further still, experiences in the criminal justice system further aggravate the symptoms and severity of these disorders, particularly when long-term separation from their children tends to occur. Thus, issues related to these two disorders, depression and anxiety, are central to the effective treatment for female offenders. Domestic Abuse The research on the prevalence of domestic violence and its impact on women in the United States is so abundant and obvious that it goes beyond the scope of this chapter to discuss. However, when limiting the discussion to female offenders and their experiences with domestic violence, it appears that they are at greater risk for physical abuse than those in the general population. One survey of female offenders shows that incarcerated women are very likely to have histories of physical abuse (American Correctional Association, 1990). This study indicated that 53% of adult women and nearly 62% of juvenile girls had been victims of physical abuse. Nearly half of both these groups (49% of adults and 47% of juveniles) reported experiencing multiple episodes of physical abuse. Furthermore, this study found that this violence is most likely to have been perpetrated by a boyfriend or husband in the case of adult women offenders (50%) or by a parent in the case of juvenile girls (43%). For juvenile girls, most of the cases of domestic violence occur between the ages of 10 and 14 years (Bloom, Owen, & Covington, 2003). Adult incarcerated women report being subjected to violence most at ages 15 to 24 (Bloom et al., 2003). This means that this abuse tends to follow the female offender throughout their life span, indicating that these offenders return to a lifestyle that is self-damaging. Because the women on probation and parole are likely to be somewhat socially isolated from common social circles, her peer network is likely to be limited (Bloom et al., 2003). At best it will include other women in a similar situation or perhaps persons from employment (keep in mind the educational level, unemployment rate, and vocational skills of these women). More likely, these women are likely to continue to associate within the subculture of origin, meaning that many of the friends and family that they return to are likely to be, or have been, criminal offenders themselves. This may be much more common since many women who offend often tend to do so as secondary accomplices with a male primary offender. Thus, these women are not likely to have many resources to rely on and may find themselves quite dependent on a man, including an abusive man. Further, as was noted earlier in regard to the confluence of issues related to depression, anxiety, and past trauma issues (i.e., sexual assault and domestic violence), there has long been a noted relationship between substance abuse and domestic violence. For example, Miller et al. (1990) argue that female alcoholics are at significantly higher risk for becoming victims of domestic abuse. According to the same study, male parolees are at high risk for involvement as perpetrators of spousal abuse. Although Miller et al. (1990) do not address whether spouses or partners of male parolees are themselves former offenders, these findings clearly show that many women released on community supervision may be in abusive relationships. Further, since it is the case that many female offenders commit their crimes while acting in tandem with a primary male offender (i.e., transporting drugs for their drug smuggling boyfriends and husbands, having a pimp that they may associate with, or providing alibis and resources for the male offender during periods of crime commission), many of them simply return to these significant others (who are criminal offenders themselves) and therefore continue to be with men who are more likely to be abusive than otherwise noncriminal men. There is an added danger with this because these women already tend to be marginalized, and with the added stigma of being an offender on community supervision, along with worries of maintaining custody of any children that are likely to exist, the female offender may simply consign herself to such a dangerous and damaging lifestyle due to the lack of available options. Physical and Sexual Abuse A study on the self-reported prior abuse conducted by the Bureau of Justice Statistics in 1999 found that female offenders are abused more frequently than male offenders. State prison inmates reported both physical and sexual abuse experiences prior to their being sentenced. The results found that 57.2% of females had experienced abusive treatment compared to 16.1% of males. Of this same group, 36.7% of the female offenders and 14.4% of the male offenders reported that the abuse occurred during their childhood or teenage years. Other findings from this study are as follows: 1. Males tend to be mistreated as children, but females are mistreated as both children and adults. 2. Both genders reported much more abuse if they had lived in a foster home or other structured institution. 3. Higher levels of abuse were reported among offenders who had a family member who was incarcerated. 4. Offenders reporting prior abuse had higher levels of drug and alcohol abuse than those who did not report abuse. Further, female offenders abused drugs or alcohol more frequently than did male offenders. PTSD Related to Sexual Assault and Prior Child Abuse Post-traumatic stress disorder (PTSD) describes a series of symptoms where the victim’s response to the experienced traumatic event involves intense fear, helplessness, or horror. The victim is likely to psychologically reexperience the traumatic event, while exhibiting persistent symptoms of anxiety or increased arousal that were not present before the traumatic incident (American Psychiatric Association, 2000). Further, the victim will likely have difficulty falling asleep and may have persistent nightmares related to the victimization. Displays of hypervigilance and exaggerated startle responses are also common (American Psychiatric Association, 2000; Daane, 2005). Lastly, it is very common for victims to avoid stimuli that are connected with the source of trauma or that remind the victim of the traumatic experience (American Psychiatric Association, 2000; Daane, 2005). The symptoms of PTSD have been observed as being fairly common among victims of rape and sexual assault, domestic abuse, and various types of child abuse. When referring to the traumatic responses of victims to sexual assault and/or rape, the term rape trauma syndrome is sometimes used. Rape trauma syndrome consists of symptoms that include physical, emotional, and behavioral effects that result from an encounter with a life-threatening and psychologically damaging sexual victimization (Burgess & Holstrom, 1974; Daane, 2005). The trauma from rape tends to be comparable to any other life-threatening event regardless of the level of violence actually used during the attack (Daane, 2005). A great number of victims report fear of extreme bodily harm during their experience, such as mutilation or death. These victims also report the existence of symptoms such as nausea, startle responses, insomnia, and nightmares. According to Burgess and Holstrom (1974), rape trauma syndrome is divided into two phases. The first phase, known as the acute phase, can last anywhere from several days to weeks. During this phase, the victim experiences reactions to the realization of her experience, which tends to occur within a matter of hours. There are two common forms of reaction among victims of rape trauma syndrome. One reaction results in visible signs of trauma such as crying, restlessness, or tenseness. Conversely, some victims present with a controlled reaction that results in the masking of feelings, with the victim appearing calm or having no emotion. The reorganization phase is the second phase. This phase tends to last considerably longer, spanning anywhere from several months to several years (Burgess & Holstrom, 1974). During this phase, victims contend with the need to regain structure and order within their life and provide some of control (Burgess & Holstrom, 1974). Intermediate effects that often emerge during this phase may include a disruption and change in the victim’s lifestyle, such as moving houses or changing jobs, increased dependence on family or friends, and fear of going out or being alone. During this phase, the victim may feel anger especially toward the offender, sometimes toward family or friends, or toward the legal system if the victim does not feel that some sense of justice was meted out against the offender (Daane, 2005). It is important for correctional counselors to understand the symptoms to PTSD and rape trauma syndrome. Counselors may find that many of their clients suffer from residual elements of this syndrome, if not fully meeting the requirements of the syndrome. Thus, an understanding of the dynamics associated with rape victimization is important when working with female offenders because sexual abuse is very common in the history of female offenders. This may have occurred during childhood or during adulthood. Further still, many of these women may have been involved in the illicit sex industry, and, even though it may not be reported to police, these women are also likely to be the victims of rape. Indeed, the amount of rape that occurs among prostitutes and other sex workers tends to be vastly underreported due to apprehension of going to the police among this population. In addition, as was noted in the prior section, the experience of domestic abuse, both during adulthood and in the female’s prior childhood, can also lead to trauma that is PTSD inducing. In adulthood, this can even lead to a set of symptoms that have been dubbed the battered woman syndrome, and this will be discussed momentarily in the section that follows. The key point is that this, in addition to the increased sexual abuse among this population, tends to increase the likelihood of trauma among the female offending population. Lastly, the pain of domestic abuse may not necessarily be in the recent case history of the female offender. Rather, many offenders (both male and female) report prior child abuse and neglect. Indeed, many female offenders come from violent and/or abusive families of origin; and, it may be speculated that, to some extent, female offenders learn to normalize abusive patterns of communicating. This means that they are likely to remain in later adult relationships that are abusive, simply because these dynamics will be familiar to them from their childhood experiences. Naturally, these prior experiences shape their views of their own childhood and this, in turn, is likely to affect how the female offender may parent her own young. In some cases, this may increase the likelihood that the female herself ends up committing acts of abuse or neglect against her own children (Barnett, Miller-Perrin, & Perrin, 2004). In addition, this is further compounded if the female offender, who has herself grown up in an abusive home, becomes involved with an adult partner who is abusive. In such cases, it is more common for these women to repeat the abuse and/or to fail to intervene when her children are abused (Barnett et al., 2004). Thus, the prior childhood experiences of the female offender can significantly shape many of the later aspects of her future adult relationships, family dynamics, and sources of trauma. Just to further illustrate how these prior experiences can complicate an already muddled picture for female offenders, consider that one common experience among women who present with dissociative identity disorder (DID) is the experience of childhood abuse. The trauma from these experiences often lead to a “splitting off” of the personalities such that the “bad” personality will be the one associated with abusive treatment and the “good” personality is identified with positive treatment from parents and caretakers. While DID is a rare disorder, it is more common among the abused than nonabused population. Given that psychiatric “breaks” with reality (i.e., schizophrenia and other related disorders) have been noted to be higher among female inmates than male inmates in jails and prison throughout the United States, even this serious psychiatric disorder becomes an issue of specific concern when dealing with female offenders. In such cases, the placement of offenders in “lock down” or forms of isolation tends to exacerbate the vulnerability to the illness and magnify its symptoms. Thus, even serious psychiatric disorders can have their basis in the traumas of the female offender’s past, and, depending on the criminal justice reaction, these problems can be either aggravated or alleviated. From this and other sections in this chapter, it should become clear to the student that there are a number of co-occurring factors that impair women in treatment. Prior sexual abuse and domestic violence lead to experiences of trauma. This trauma induces fear, depression, anxiety, and other negative affective states. Further, substance abuse tends to be common among this population, quite possibly as a means of alleviating their negative affective states. The use of various stimulant and/or depressive drugs (including alcohol) may seemingly provide initial relief, but over time these drugs simply exacerbate their symptoms. This then means that ultimately the use of drugs as a coping mechanism ends up compounding the problem. This then leads to the further aggravation of disorders that are associated with drug use and, over time, the life-course experiences of these women and their involvement in-and-out of treatment becomes a vicious cycle. It is precisely this cycle that correctional counselors must interrupt if long-term recovery can be successful among these women. Battered Woman Syndrome Battered woman syndrome is, for our purposes, considered a form of PTSD. Essentially, this syndrome describes a set of psychological symptoms that are common to women who live in battering relationships, with the following four general characteristics of the syndrome: 1. The woman believes that the violence was her fault. 2. The woman has an inability to place the responsibility for the violence elsewhere. 3. The woman fears for her life and/or her children’s lives. 4. The woman has an irrational belief that the abuser is omnipresent and omniscient. As can be seen, these characteristics are grounded in a heightened and perhaps hyper state of fear of the batterer, to the point that the victim sees herself as powerless to prevent further abuse. The fear that grips such a person is based on psychological learning (reinforced over time) as well as real circumstances that are, in many instances, beyond her control to influence or mitigate. Regardless, the battered woman syndrome should not be equated to some form of mental disorder; rather it is the product of trauma. Lenore Walker, a preeminent pioneer within the domestic violence literature, has stated that “battered woman’s syndrome is best understood as a subgroup of what the American Psychological Association defines as Post-traumatic Stress Disorder, rather than as a form of mental illness” (1989, p. 48). When working with female offenders, it is important for the correctional counselor to understand that many of their clients will readily identify with this syndrome. While they may not have experienced the syndrome directly, they are highly likely to know someone (a friend or family member) who has suffered from this syndrome. Further, the female offender is, herself, at an increased likelihood of having experienced this syndrome. Even if not, many have experienced the ravages and trauma associated with domestic abuse and they will often still be able to readily sympathize and empathize with women who do experience this syndrome. Thus, the correctional counselor must be knowledgeable about the various dynamics associated with the domestic violence. For example, knowledge of the well-known cycle of violence, which has three specific phases—the tension-building phase, the explosion or acute battering phase, and the calm respite or “honey moon” phase (Walker, 1979)—should be commonplace among correctional counselors who routinely see female offenders. Knowledge regarding the symptoms and signs of sexual abuse, child abuse, and other forms of domestic violence should be readily understood by the counselor to the point that they are fully conversant on these issues. In addition, as was noted in the prior subsection, the correctional counselor should be knowledgeable in regard to the symptoms of PTSD and in treating those symptoms. STDs and HIV/AIDS Because female offenders engage in risky behaviors such as unprotected sex and the use of alcohol and drugs, they tend to enter correctional facilities with high rates of sexually transmitted disease (STD). Rich et al. (2001) found that of all the women in the state of Rhode Island who had been incarcerated at some point between 1992 and 1998, roughly half of them had infectious syphilis. Other research has shown higher rates of gonorrhea, chlamydia, and trichomoniasis among incarcerated women than among women with no history of incarceration (Hammett, Harmon, & Rhodes, 2000; Shuter, 2002). Clearly, this demonstrates that female offenders are at an increased risk of having sexually transmitted diseases. Because correctional counselors may not necessarily be well versed on the specific symptoms and medical effects of various STDs and because medical care is often a critical issue among the female offender population, we have decided to include some brief information on the more common STDs that are encountered among the female offending population. The information provided has been derived from the Epigee Foundation (2004). These diseases are among those most commonly encountered within the offender population and are among those that are most problematic for correctional agencies. These diseases and their symptoms are listed below: Human Papalloma Virus (HPV)—The most common STD with symptoms that include cauliflower-like warts developed on and inside the genitals, anus, and throat. It should be noted that condoms provide almost no protection against contracting the disease during sex and even more disturbing is the fact that there is no known cure. The warts can be suppressed by chemicals, freezing, laser therapy, and surgery. Syphilis—The most common way of contracting the disease is through vaginal, anal, or oral sex. However, it can be spread by nonsexual contact if the sores (chancres), rashes, or mucous patches caused by syphilis come in contact with the broken skin of a noninfected individual. If untreated, syphilis may cause serious damage to the heart, brain, eyes, nervous system, bones, and joints and can lead to death. A person with active syphilis has an increased risk that exposure to HIV will lead to infection because the sores (chancres) provide an entry point for the AIDS virus. The disease can be cured with penicillin; however, damage done to body organs cannot be reversed. Latex condoms can reduce but not eliminate the risk of contracting the disease during sex. However, it is still possible to contract syphilis, even after using a condom, via sores in the genital area. Chlamydia—This is a very dangerous STD as it usually has no symptoms; 75% of infected women and 25% of infected men have no symptoms at all. Infection can be cured with antibiotics. However, it cannot undo the damage done prior to treatment. Infected individuals are at greater risk of contracting HIV if exposed to the virus. Latex condoms can reduce but not eliminate the risk of contracting the disease during sex. Gonorrhea—This is one of the most frequently reported STD. Infection can be cured with antibiotics. However, it cannot undo the damage done prior to treatment. Latex condoms can reduce but not eliminate the risk of contracting the disease during sex. Untreated gonorrhea can infect the joints, heart valves, and/or the brain and can cause sterility in men. Herpes—This disease is painful and episodic; it can be treated but there’s no cure. Herpes is spread by direct sexual skin-to-skin contact with the infected site during vaginal, anal, or oral sex. Abstaining from vaginal, anal, and oral sex with an infected person is the only 100% effective means of preventing the sexual transmission of genital herpes. Latex condoms can reduce but not eliminate the risk of contracting the disease during sex. From the list above, it is clear that these diseases can easily be problematic to the correctional practitioner. Some of them (such as syphilis) do not even require sexual contact and can be transmitted by simply rubbing against the open sores. Thus, even though these diseases may not frequently be life-threatening, it is still prudent that interventions and educational efforts be provided to offenders for their own safety and for the safety of staff who must interact with them. A large body of research shows that female criminals often have some sort of history of prostitution although the causal factor(s) and the order of causal factors are not very clear. This, in addition to risky drug use, contributes to the inflated likelihood that female offenders will present with STDs in correctional settings. This is an issue that cannot be ignored by correctional counselors, and it should be specifically noted that both male and female counselors must be conversant on the symptoms and treatments of STDs. Once these diseases are contracted, they often impact the overall prognosis of the offender. Aside from the effects of sexually transmitted diseases, it is also important to note that the rate of HIV infection is higher for female offenders than for male offenders. According to the Bureau of Justice Statistics (Snell, 1994), among state prisoners tested for HIV, women were more likely to test positive. An estimated 3.3% of the women reported being HIV positive, compared to 2.1% of the men. Among prisoners who had shared needles to inject drugs, more women than men were likely to be HIV positive (10% vs. 6.7%). In the vast majority of cases, those who become infected with HIV will eventually develop AIDS and die of AIDS-related complications. As with STDs, the physical and psychological effects of having HIV can greatly impair treatment outcomes for female offenders. Body Image, Sexuality, and Sexual Image Body image is an often-cited issue of concern for women in the United States. Among female offenders the issue is just as relevant. Indeed, research has shown that substance abusers often suffer from a low sense of self-efficacy (Hanser, 2007). This is not necessarily surprising when one considers that depression is a common co-occurring disorder among substance abusers (a person who is depressed would likely have a poor sense of self-efficacy). This observation has been particularly noted among female drug offenders (Kassebaum, 1999). In many cases, female offenders report feelings of low self-esteem, self-confidence, and ability. Many come from low socioeconomic backgrounds and this also seems to impact the feelings that these women may have about themselves and their own value in society. Further, many of these women have had their identities tied to sex and sexuality throughout much of their life. In many cases, the association with sex and/or sexuality has been abusive (sexual abuse as a child and/or an adult) or utilitarian in purpose (i.e., making money through prostitution). These types of sexual identification are not healthy and contribute to the negative self-image that female offenders may have if they have had these past experiences. Given that many women in society often feel that they have to meet some sort of ideal standard in regard to beauty and given that women still grapple with equality in our society, two things should be made clear. First, just as with all other women in our society, female offenders experience the biases and the standards that are placed on women, with physical beauty being emphasized in our society in a manner that negatively impacts women. Second, the specific forms of victimization that female offenders are likely to have also increases the risk that these women will make negative and self-depreciating associations with their own physical image. Indeed, many women with eating disorders such as anorexia and bulimia nervosa have serious negative images of their own bodies. Thus, the factors related to body image are important for women in general, and, given the case histories of many female offenders, it is even more important for female offenders. SECTION SUMMARY In this section, it becomes clear that there are a multiplicity of issues that confront female offenders. These issues are often intertwined with one another, with one problem aggravating the other. For example, substance abuse has been noted as a particular problem for female offenders, as has the occurrence of depression and anxiety. However, it is not always clear if the onset of depression and anxiety is due to the use of substances or if these offenders tend to gravitate toward these substances as a means of coping with their depression and anxiety. Female offenders tend to also suffer from the effects of abuse, both in childhood and in adulthood. Sexual abuse is experienced more often among the female offender population than among the remaining female population. Further, female offenders are frequently victims of domestic violence. Thus, rape trauma syndrome, battered woman syndrome, and other variants of PTSD are very common among this population. Correctional counselors must keep these background issues in mind when dealing with female offenders since these issues impact their prognosis for treatment. Lastly, female offenders tend to be the primary caretakers for their children. In addition, contact with their children tends to aid in their overall treatment and reform from criminal activity. The loss of contact between the mother and the child has negative effects for the youngster and also negatively impacts the mother’s likelihood of effective recovery. Thus, it is important that intervention programs provide mechanisms that foster and maintain the bond between the female offender and her children, for the welfare of the child and the mother. LEARNING CHECK 1. Criminal activity by female offenders is often committed due to the desires of a significant other with whom the female offender has an intimate relationship. a. True b. False 2. Substance abuse issues with female offenders are often related to problems with self-efficacy. a. True b. False 3. Given that female offenders tend to have substantial activity in the sex industry, they are more susceptible to developing STDs than are male offenders. a. True b. False 4. Among female offenders with children, most are the primary caretakers of those children. a. True b. False 5. Issues related to mental health disorders, prior trauma, and substance abuse seem to be interlinked among many female offenders. a. True b. False PART TWO: FEMINIST THERAPY, MARGINALIZATION, AND DIVERSITY Perhaps one of the best-suited paradigms for counseling female offenders would be a feminist approach. While there are numerous scholars and therapeutic professionals who have written on this approach, it should be stated that there is no “typical” or “traditional” feminist therapeutic intervention process. However, there are some commonalities in this approach despite the differences that may be encountered from one therapist to the other. First, “there is a belief that patriarchy is alive and sick in sociopolitical life and the life of the family” (Corey, 1996, p. 414). This means that men are given privilege and this power imbalance leads to an unbalanced and sick family and society. Second, there is the consensus that the traditional nuclear family, the stereotypical family of the 1950s, was one that was not constructive for women but instead better met the needs of men. Third, feminist therapeutic approaches emphasize a supportive attitude toward women and toward female independence, explicit examination of gender disparities, and connecting how imbalanced and sexist personal relationships lead to an imbalanced and sexist society. Incidentally, this same concept works in reverse order as well; an imbalanced and sexist society fosters and maintains imbalanced and sexist personal relationships between women and men. Emphasis on Gender Equality The feminist perspective of counseling tends to operate from the perspective that dominant culture groups will maintain themselves and will advance views that benefit the powerful, while disenfranchising those who do not have power. Further, feminists tend to see patriarchy as the oldest and most universal dominant cultural position to have existed worldwide. Simply put, women have been subordinate to men throughout history and across most cultures. The feminist perspective seeks to obtain an egalitarian form of balance between men and women. Thus, feminist perspectives do not contend that women are better than men or that men should be subservient to women. Rather, this type of therapeutic approach calls for quality and mutuality among both men and women. Empowerment of Women This aspect of feminist intervention is important with female offenders due to the already-noted tendency to have a lowered sense of self-efficacy as well as having higher rates of anxiety and depression. When using empowerment groups, women are encouraged to explore the definitions and the limitations that have been put upon them, and, above that, they are to provide positive support for one another. The sense of mutual acceptance and mutual understanding of the dynamics that shape the female experience is integral to this approach, as is the understanding that the only long-lasting empowerment will be that which occurs at the social level. In empowerment groups women are considered to be their own true experts on themselves and their own issues. In these groups, the correctional counselor will encourage the group to nurture clients, listen and respond empathetically, and identify those areas where the female client has made substantial or significant contributions to the community, their family, or some other cause. These groups also emphasize that communal qualities of interdependence, concern for others, emotional expression, and cooperation are valued and honored. Women are encouraged to identify their strengths, to value and nurture themselves, and to bond with other women. Language forms that devalue women are reframed from weakness to strengths (e.g., terms such as enmeshed and fused may be reframed as caring, concerned, and nurturing). The primary issue involved is countering the devaluation of women and identifying the inherent strengths that women have. Further, the group process is considered superior to most individual types of therapy because other members will be able to frequently identify with the female member and to provide her with support. According to Worell (1993), feminist empowerment strategies should include the following emphases: 1. Self-evaluation: Improved self-esteem, self-affirmation 2. Comfort-distress ratio: Less distress and more comfort 3. Gender- and culture-role awareness: Behaviors informed by gender role and culture role and power analysis of continuing life situations 4. Personal control/self-efficacy: Improved perception of personal control and self-efficacy 5. Self-nurturance: Increase in self-nurturing behaviors and avoidance of self-abusing behaviors 6. Problem-solving skills: Improved problem-solving skills 7. Assertiveness increased: Use of respectful assertiveness skills 8. Resource access: Increased access to social, economic, and community support 9. Gender and cultural flexibility: Flexibility and choice in beliefs and behaviors informed by gender and cultural identity 10. Social activism: Involvement in social activism, institutional change. Gender-Role Analysis, Power Analysis, and Intervention This aspect of feminist interventions examines traditional roles such as being the caretaker of the family and/or one’s significant other, particularly if that significant other is male. In many cases, women have been taught that it is their role to keep a family together and to keep the family functional. With belief system, family problems were thought to be the purview of the female member, and, if the family did not operate well, it was invariably considered due to the female’s own inadequacies. On the other hand, women have been stereotyped as being dependent on men (emotionally and economically) and being enmeshed in their family issues. According to Worell and Remer (2007) the changing of gender roles to be more egalitarian would include, among other things, the following components: 1. Inclusiveness: Acknowledges that the social impact of gender is experienced unequally and unfairly for women with diverse personal and social identities, including ethnicity and culture, sexual orientation, socioeconomic status, nationality, age, and physical characteristics. 2. Equality: Recognition that the politics of gender are reflected in lower social status and unequal access to valued resources for a majority of women in most societies. 3. Knowledge: Striving for increased understanding about the diversity of women’s experience as it is framed by multiple personal and social identities. 4. Attention to context: The realization that women’s lives are embedded in the social, economic, and political contexts of their lives and should not be studied in isolation. 5. Making change efforts: A commitment to action to accomplish social, economic, and political change toward establishing equal justice for all persons. By now, it should be clear to the reader that one of the primary issues regarding feminist therapy is the apparent power differential that has existed for women. This is fundamental to the social reality of female offenders, both in the micro and macro sense. In micro or personal terms, these offenders are likely to have suffered abuse at the hands of men, both in childhood and in adulthood. The high incidence of sexual abuse and other forms of abuse, most frequently at the hands of men, tends to create a landscape that is highly consistent with feminist thought. For female offenders, this is often a reality that they have lived with. On a macro level, these women are also likely to have suffered from various stereotypes and discrimination, as many women have. The loss of their children is, in itself, a taboo and source of shame for women in many parts of society, yet the same stigma is not as strong for male offenders. Further, as noted before, these women have a higher incidence of involvement in the sex industry. This industry is, in and of itself, driven by sex demands from men—men who are offenders. Yet, it is the female prostitute who bears the majority of the stigma, shame, and negative impact from this industry. Further, this industry simply confirms the notion that women are tools to meet the needs of men, adding further to the contextual framework from which female offenders are likely to identify. The primary point is that for women in general, and female offenders in particular, there are factors that impact both their personal and community-level relationships. These issues are often associated with male privilege and social circumstances that have created a state of oppression. For female offenders, this may have existed throughout their entire life span, starting from early childhood and continuing through adolescence and adulthood. For these women, operating in a “one-down” position in regard to men may be the only reality that they have ever known. Correctional counselors must understand this and be empathetic to these challenges that have faced the female offender. A failure to do so will simply ensure that interventions are ineffective and, even worse, may serve to further reinforce the already imbalanced system that exists within our society and the criminal justice system. Journal Writing The use of this technique is fairly common in group treatment processes. In this case, the use of journaling allows the client to track various occurrences throughout the week. When doing this, the client is able to extend the value of the group session throughout the duration of the week. The correctional counselor can provide specific issues or topics that female offenders can provide in their journal, such as difficulties with assertiveness. Journal entries can then be used in group settings among clients or can even provide the basis for additional discussions in individual settings. Another key use for journaling is to aid in the education process that is, to some extent, inherent in feminist therapy. Female offenders may not be attuned to the various means by which they themselves have been victimized. While this is not to necessarily create an excuse for their criminal offending, it is meant to point toward mitigating factors that exist for many female offenders. Further, this process can also allow these clients to identify those areas that have been sources of trauma. As the client makes observations in her journal, the idea is that they will see connections between the experiences in their own everyday life and those issues presented in a feminist-based treatment program. This then reinforces the client’s ability to participate in the intervention since this, in essence, provides a degree of psychoeducation on feminist perspectives and their impact on women’s needs in treatment. Assertiveness Training Ironically, this type of training is even recommended for clients who are at the other extreme of the spectrum from female offenders—domestic batterers. The reason for this is because many male domestic batterers do not exercise good impulse control and they are also unable to differentiate between aggression and assertiveness. For female offenders, this can also be the case where many may simply view conflicts as going from the point of little conflict or disagreement to dangerous form of conflict resolution that includes threats toward the person with whom they disagree. Thus, women in the criminal justice system often lack the skills necessary to effectively express their views and emotions in a manner that is clear, specific, and not subject to being dismissed or unheeded while also refraining from interaction patterns that aggravate the situation and/or lead to further conflict. It is imperative that female offenders are able to express their view in a direct and accurate manner and without guilt or apology. All too often, these women have not been given appropriate consideration, and in many cases they may not have promoted their own interests. Female offenders must be able to do this without using methods that either make matters worse or place them in jeopardy with the criminal justice system. Since these clients may have never been taught these skills within their own family system, it is important that correctional counselors ensure that assertiveness training is provided for female offenders so that they will be able to better cope with stressors in a manner where they address the stressor rather than allowing others to override their feelings and thoughts that they may harbor. Reframing and Cognitive Restructuring The use of reframing consists of generating new or alternate interpretations of a problem or situation in an effort to provide alternative solutions to that problem. In other words, if the interpretation of a social situation is changed, the options involved when reacting to that situation should also change. Reframes are effective means of reinterpreting negative situations or circumstances into experiences that are more tenable. For example, a female offender may be told by her women’s group that she is not a rape victim but that she is a rape survivor. The difference in the two terms is that one puts the client in a frail position while the other term is indicative of a person who has overcome and/or endured a serious injury. The use of the term “survivor” is meant to empower the client as she struggles to cope with the trauma associated with the experience of having been raped. One point should be made about reframing: This technique is not intended to “make light” of serious situations. Rather, this technique is intended to empower the client and to open additional avenues of approaching a problem so as to aid her meeting her therapeutic goals. The use of reframes to dismiss the impact of a client’s experience and/or to distract them from the key issue is a misuse of the technique. In some cases, clients and therapists may misuse this technique (accidentally) when this point is not kept in mind. The client should still face the problem that is before her, but effective reframes allow her to do so from a variety of angles. Lastly, cognitive restructuring refers to the deliberate attempt to change ones’ own dialogue that they have within themselves. In other words, we often consider a variety of options and circumstances and have an unspoken dialogue in which we make determinations about the world around us. This is the organizing aspect of thinking and our understanding of the world. A prerequisite to behavior change is that clients must notice how they think, feel, and behave and the impact that they have on others due to those thoughts, feelings, and behaviors. Accordingly, it is often the case that people have “scripts” within their thinking; these are predetermined means by which the world and our role in it are viewed. The use of cognitive restructuring helps to modify these scripts and the manner in which we interpret the world. Further, the use of journaling (discussed earlier) is a technique that can enhance the outcome of cognitive restructuring. In fact, the clients may see trends in their own cognitive interpretations when they read their own journal entries at later points in the weeks or months that progress. This tool can provide them with a record of their perceptions and, at the same time, provide documentation of their progress. Further, writing and elaborating on the cognitive restructuring process will further reinforce the impact and effectiveness of this approach. It should be pointed out that when using cognitive restructuring, the goal is not to create some sort of self-induced brainwashing to change our thoughts. Rather, we are challenged to interrupt the scripts that we use as a template to our thinking. For female offenders, this can be useful because they have often internalized scripts that include self-degrading views that are shaped by a system that has perpetuated this self-degrading means of interpreting one’s place in the world. Thus, cognitive restructuring allows the female to supplant old scripts based in victimization and/or mistreatment, with new ways of empowered thinking. Naturally, it is expected that this will provide women with the ability to provide a more healthy and self-confident dialogue within themselves. Role-Playing Role-playing is an important component of many groups where practice at a given set of behaviors is required of clients. The use of role-plays also allows the correctional counselor and other group members to provide feedback to members who are observed during the role-play. The use of role-playing can also allow the correctional counselor to model effective behaviors and responses to difficult situations. For instance, some women may have difficulty in establishing boundaries with people in their lives and/or acting in an assertive manner. The use of role-playing allows the person to view how assertive means of communication may be conducted and it helps them to practice this type of behavior with the feedback of others. This can be a strong therapeutic tool if done correctly. Autonomy Development In many respects, this is simply an extension of assertiveness training and/or empowerment of the female offender. However, there is one specific area of functioning that should be considered in the development of autonomy among women—vocational and/or career autonomy. In many cases, female offenders are economically dependent and do not possess the requisite skills to be viable and competitive in the world of work. Employment is a key factor in the reintegration of offenders in society, and this is true regardless of whether the offender is male or female. In fact, employment has been cited as one of the strongest predictors of whether an offender will successfully reform from a life of crime. With the difficulties of women in the job market coupled with the difficulties that most offenders may have in obtaining employment due to the stigma of a criminal record, the link between employment and the development of autonomy among female offenders is perhaps easy to understand. Further, the emphasis on employment also comports well with many advocates of feminist counseling approaches. For instance, Evans, Kincade, Marbley, and Seem (2005) note that one of the most significant messages of the feminist movement is that women should have the same opportunities for career choice as men. Throughout history, this has not been the case, particularly in homes where girls are taught to have roots and the boys are taught to have wings. The challenge to the old adage “a woman’s place is in the home” has changed social mores and has led to more women in the workforce. During the past two decades, there have been numerous advances in career counseling for women, and these benefits should be extended to female offenders as well. Naturally, this requires modification and/or differentiation from the traditional male-oriented theories. As career counselors have moved from perceiving the “career woman” as an anomaly in the 1960s and 1970s to assuming that all women work—including a redefinition of homemaker as one who works in the home—this same concept should be advocated by the correctional counselor. This aids in empowering the clients and also provides a new “script” from which they may generate thoughts and beliefs regarding their own identities. In the current era, it is common for career counselors to address issues of discrimination, underemployment, traditional and nontraditional career choices, role conflicts, and sexual harassment (Evans et al., 2005). Thus, these issues should be addressed with female offenders, particularly those who are about to be released from prison and/or those who are in community supervision. The ability to find workable employment is a very serious challenge for many female offenders, particularly if they intend to also retain custody of their children. Remember again that many female offenders are the primary caretakers of their children prior to their offending. Given that these women frequently face single parenthood, the need to maintain full-time employment, a treatment regimen for substance abuse and other mental health issues that warrant intervention, as well as the requirements of being on community supervision, these offenders have serious challenges that are not as common among the male offending population. When placed against the backdrop of heightened levels of prior abuse, the experience of domestically abusive relationships, and other noxious life experiences, it becomes clear that the female offenders have a unique set of challenges that the correctional counselor must be prepared to address. A failure to do so will result in an intervention that is inadequate and topical at best, sidestepping the important issues that confront the female offender. Female Offenders and Domestic Abuse As the women’s movement continued to gain momentum during the 1960s and 1970s an increased awareness of domestic violence issues emerged within the United States. As women continued to demand equality within the professional arena, equality became an issue within the personal realm as well. Eventually, these demands within the personal realm extended to expectations within the marital relationship between men and women. By extension, feminist theory has provided a guiding framework for understanding and addressing domestic violence. Feminist theory “… has provided explanations of how it has come about that men and women’s unequal status in society … and the differential socialization of male and female children perpetuated violence and abuse in the home” (Frances, 1995, p. 395). Feminist theory has been instrumental in raising the public consciousness about sex-role conditioning and how such conditioning can lead to belief systems that justify sexism, male privilege, and male socialization (Healey & Smith 1998). It is through the transmission of these belief systems that acts of domestic violence can reflect the patriarchal organization of society with the male partner exacting forced subservience from the female partner (Healey & Smith, 1998). These views on domestic violence are consistent with many schools of feminist thought (particularly radical feminism) that contend that it is the use of violence that keeps women subjugated in the home and in society as a whole. Crimes such as sexual assault, stalking, marital rape, and domestic violence have two key underlying similarities: the perpetrator is most often male and the victim is most often female. In addition, all of these crimes serve to exploit and/or control the sexual and social freedom of women to have a lifestyle of equality both inside and outside the home. Since these crimes target women and since these crimes are most often committed by male perpetrators, it is easy to see the connection to feminist theory. This theoretical perspective has been used in therapeutic interventions for women (providing a framework and rationale for empowering victims) as well as programs designed for perpetrators (providing psychoeducation on the rights of women and enforcing accountability in the recognition of those rights). Thus it is that with the women’s movement for equality in the broader society social changes simultaneously occurred that impacted the means and process of response to domestic violence issues during the decades that would follow. Feminism, Diversity, and the Female Offender Feminist scholars have bemoaned the fact that in addressing women’s issues, the feminist movement has traditionally failed to provide adequate analysis of the unique issues presented to women of minority status (Hanser, 2002, 2007). Feminism has been likened to a theory based on the historical and social experiences of Caucasian middle-class women. But these experiences were often quite different from those of African-American, Latino-American, and Asian-American women. Indeed, during the early years of the feminist movement, there were documented cases of racism and discrimination between Caucasian-American and African-American feminists (Baird, 1992). Issues of race, racism, and institutional oppression will likely be relevant to African-American women but are not likely to be similarly relevant to the experiences of most Caucasian-American women (Baird, 1992; Hanser, 2002, 2007). Further, the socialization for Asian-American women and Latino-American women is likely to emphasize even further subservience and other dynamics that are laced with traditional values from their own respective cultures. Even further, there may be issues of religion as well as racial and cultural differences that should be taken into consideration (Shaheen, 1998). This is particularly true for women who are of the Muslim faith and/or community (Shaheen, 1998). Because of the vast array of differences that can be encountered between women and since many mainstream Caucasian-American women are not necessarily likely to be well versed on these cultural differences, an awareness has developed for the need to have feminist schools of thought that can address these differences in an effective and supportive manner. As has been noted in previous sections of this chapter, feminism is personal and political. Nevertheless, the nuances of what this means for each individual woman will be different due to a variety of characteristics, such as race, culture, and class circumstances of individual women (Evans et al., 2005). Caucasian women have been benefactors of racial privilege. On the other hand, minority women have not experienced such privilege. Thus, there has been a movement to ensure that feminist therapists are sensitive to and knowledgeable about multiple issues important to women of color. Mental health practitioners have responded to criticism by feminists of color and have begun to be more inclusive of the issues of race, ethnicity, and social class (Evans et al., 2005). One current trend is the integration of race, gender, culture, and class in feminist writings and feminist-based therapy (Evans et al., 2005). Counseling African-American Women Though it may be appealing for correctional counselors to treat all clients the same, it would be a mistake to overlook the differences between cultural and racial groups that would likely result in a serious disservice to the client. Rather, it is important for the correctional counselor to be attuned to cultural differences that may be encountered since these aspects are part of the framework and perspective from which the client views and experiences the world. A correctional counselor who is not comfortable with making efforts to accommodate such difference will be ineffective with most minority clients, whether male or female. Further, the majority of professionals are Caucasian-American, and this makes it even more important that correctional counselors consider their values, beliefs, and expertise when working with minority groups. For African-American women, it is frequently the case that family and religion are key aspects of their identity. Kanel (2003) speaks to the African-American family in a very concise and effective manner by stating that: When one considers the history of African-American, much of their family structure and value systems make sense. Raised in slavery, the African American family learned to exist in settings where roles were flexible and families were usually extended to several generations. These aspects can be readily seen in modern-day African American families. Elderly people as well as young adults tend to be supported by collective efforts of family members both within and outside the nuclear family. (p. 117) The extended family plays a very important role in many African-American families. This is particularly true for female offenders who are African-American for two key reasons. First, there is a disproportionate rate of incarceration of African-American males throughout the United States. Specifically, the target age that would typically be most active in the workforce tends to be the age group among African-American males who are incarcerated. This means that the African-American community is affective economically and this affects African-American families as well. The ability to provide an income for children and other family members therefore tends to rest with the female and/or extended family when the male spouse or significant other is incarcerated, adding stress and strain to many women who are African-American. Second, when female offenders are incarcerated, issues with child custody tend to emerge, just as was noted in prior sections of this chapter. This naturally affects African-American female offenders and their children as well. In such cases, the extended family again becomes a vital resource since it is the extended family that is likely to raise children whose mother must serve a term of incarceration. Thus, correctional counselors must remember that extended kinship tends to be an important aspect of the African-American female offender. Likewise, religion is an important aspect of family life in many African-American households. The church is often a forum where African-American women can be active and also obtain belonging. Correctional counselors should remember that, from the client’s perspective, the church and figures associated with the church can be an important source of strength. Thus, correctional counselors should consider the role of prison clergy within facilities and/or the local church or affiliation if the offender is on community supervision. The integration of the church community can provide an effective therapeutic tool for many African-American women. Afrocentrism and Feminism According to Evans et al. (2005), the oppressive, brutal, and violent nature of slavery and racism over the span of four centuries has been considered a higher priority issue when compared to concerns about sexism among many African-Americans, both male and female. The prevailing sentiment has been that the survival of the African-American family and community is primary. Although African-American feminists were part of both the first and second wave of feminism, many found enough differences between their agenda and that of their white counterparts to found their own associations. African-American feminists have typically differentiated themselves from “mainstream” feminists because, for women of color, sexism was the only demon that needed to be addressed in U.S. society. In fact, the feminist movement received very little support or participation from women of color or the African-American community (Evans et al., 2005). This lack of participation of women of color in the first, second, and third waves of feminism can be attributed to the multiple oppressions of race, gender, and class and the dynamic interplay of these oppressions with politics (Evans et al., 2005). African-American feminism today is sometimes referred to as the “womanist” movement and perspective. This term tends to be more accepted among African-Americans and other women of color, perhaps because the term itself is different or perhaps because the term “womanist” includes man. The term “womanist,” was first coined by Alice Walker (1983) in her essay In Search of Our Mother’s Gardens: Womanist Prose. According to Walker (1983), a womanist is an African-American feminist or other feminist who is from a minority group who celebrates the feminine qualities and strengths of women while promoting the survival and wholeness of all humans, male and female (Evans et al., 2005). The womanist participates in combating racial, gender, heterosexual, and class oppression simultaneously so that the multiple oppressions that have been experienced by women from various minority groups can be addressed (Evans et al., 2005). As has been noted in our prior discussion on feminism, the belief that the “personal is political” is critical to the womanist (Evans et al., 2005). However, the womanist does not limit her focus on uplifting females to the exclusion of men when combating oppression. Instead, the womanist is mainly concerned with uplifting an entire culture and, in the process, uplifting women as well (Evans et al., 2005). Counseling Latino-American Women Latino-American women are perhaps the second most likely encountered minority group of female offenders that the correctional counselor will encounter. For the most part, this group of female offenders will have a perspective that is substantively different from Caucasian and African-American women due to their distinct sources of cultural backgrounds and the fact that most will be bilingual, speaking Spanish as well as English. In fact, depending on the length of time that a specific female offender may have resided in the United States, this diversity in language may be an impediment for the correctional counselor, because these women may, on occasion, speak little English. Unless the correctional counselor is also fluent in Spanish, the ability to communicate (and establish a rapport) may be severely hampered. Further, many Latino-Americans are Catholic in religious orientation and this tends to have a strong effect on the thought processes of female offenders. Religious affiliation will tend to be a strong source of support for most of these women, but some of the precepts that may be adhered to may also prevent the female offender’s ability to develop a sense of autonomy and independence that is akin to what most feminist therapists would suggest. Indeed, traditional values regarding the family, the mother’s role within the family, and the generally subservient nature afforded to women may work against attempts to develop autonomy. On the other hand, the various forms of fellowship and interconnectedness provided by the religious organization serve as a source of strength for many of these women. Machismo, Marianismo, and Acculturation Traditional and idealized Hispanic cultural expectations of appropriate male and female behavior are often referred to as machismo or marianismo. Machismo is described as being dominant, virile, and independent whereas marianismo emphasizes being submissive, chaste, and dependent (Raffaelli & Ontai, 2004). Although some research argues that these traditional gender roles are outdated and inapplicable, other studies show that they do influence behavior and interaction in Latino couples. The primary role emphasized for women in Latino-American families is that of mother instead of wife. This leads women to define themselves through their family and children instead of independently or as part of a couple. The role of martyr is also idealized, with women expected to be submissive and sacrifice themselves for their families. For marriage education providers, this stereotype provides both an opportunity and a challenge. It means that women will be extremely dedicated to their families and the good of their children, which can be a powerful motivator for participating in the counseling process. In addition, the emphasis on the wife’s quiet submission and the husband’s dominance and independence may make it more difficult for Latino-American women to communicate directly and assertively with their husbands. Although Latinas immigrating to the United States may acculturate away from traditional behaviors, it is important to recognize that these cultural expectations can still remain. Furthermore, the definition of a “good” woman can vary dramatically across culture, country of origin, and level of acculturation. For example, some families that are less acculturated may not view egalitarianism as an important part of a healthy relationship. It is also necessary to remember that different members of a family may acculturate at different rates, particularly with regards to these traditional gender roles. For example, men often tend to acculturate more quickly than their wives because they often arrive in the United States before the rest of the family and have more exposure to mainstream culture through the workplace. Lastly, a stereotype does exist that more conservative gender roles, such as those just previously described, can lead to increased domestic violence in the Latino-American community. In fact, traditional Latino gender roles can be both oppressive and protective when it comes to domestic violence. The woman’s role as sacrificing and subservient can lead to greater tolerance of domestic violence, as can the strong commitment to the family and the institution of marriage. The view of men as the dominant decision makers can also encourage controlling behaviors. Lastly, because of their role in the home, Latinas are often economically dependent on men, making it more difficult to leave the relationship. Counseling Asian-American Women Asian-Americans are not as frequently encountered within state and federal correctional systems throughout the United States. However, this group is perhaps the next more common group of minority offenders that correctional counselors may contend with. The exception may be in some areas of the United States (such as the Southwest) where Native Americans have a higher representation within the criminal justice system. However, female offenders are very infrequent among that population. Though Asian female offenders are not necessarily common, they are the more-often represented cultural racial group in the criminal justice system. It should be noted that there are a multitude of different ethnic Asian groups in the United States. Acculturation and Assimilation There has been a substantial amount of literature on the acculturation and assimilation of Asian-Americans in the United States. However, Shusta, Levine, Harris, and Wong (2005) provide one of the clearest yet pragmatic descriptions of this process by providing several categories or points of acculturation that Asian-Americans may fall within. These categories apply equally well to any Asian-American group, whether they be Chinese-American, Vietnamese-American, Asian Indian, or otherwise. These categories are adapted from Shusta et al. (2005) and are as follows: 1. Surviving—Includes individuals who have recently immigrated to the United States (within the last five years) and the majority of their socialization and experience will have been in their own nation of origin. 2. Preserving—This includes immigrants or refugees who have been in the United States for more than five years but who still had the majority of their socialization in their own nation of origin. 3. Adjusting—This includes the second-generation offspring of Asian-American immigrants. 4. Changing—This group includes immigrants, but these immigrants will have had the majority of their experiences within the United States. 5. Choosing—This category consists of third-generation (or later) Asian-Americans. When considering each of these categories, it is important to understand the individual perspective from which these individuals view the world. For instance, those in the “surviving” category are typically in a survival mode and may have come from areas where police and other authority figures were oppressive and abusive. This then will tend to shape their frame of reference when dealing with police in the United States. Likewise, individuals in the “preserving” category seek to preserve their home culture and identity. Their own values and customs are preserved and this can be the source of intergenerational conflict within their family as youth become more “Americanized” and lose contact with their culture of origin. Among the remaining categories (adjusting, changing, and choosing), there is value for the homeland but there is also a realistic understanding that changes will need to be made (Shusta et al., 2005). This is particularly true for those in the changing and choosing categories, where decisions to include aspects of the old culture or to integrate aspects of the new culture are made. These individuals tend to be truly bicultural and it may be that many will use English as their primary language, allowing their proficiency with their native language to lapse. For these individuals, contact with law enforcement may be no different than that occurring between other citizens of the United States. Proficiency with the English language is a particular hindrance that can cause serious misunderstandings between police officers and Asian-American citizens. This issue is somewhat tied to the generational status of the individual Asian-American since those groups that have immigrated most recently tend to be those with large percentages that do not speak English. This is particularly true among the Southeast Asian groups. Indeed, nearly 38% of all Vietnamese-Americans do not speak English (Shusta et al., 2005). In addition, it has been determined that an approximate 23% of Chinese-Americans also do not speak English (Shusta et al., 2005). Family Honor If norms are not followed in many Asian family systems, the family will experience a sense of shame, not only for their own actions but for the entire family (Kanel, 2003). This type of an honor system sometimes makes it necessary for a family to completely reject a certain member to avoid shaming or dishonoring the entire family. The differentiation between the family and the individual is not usually as distinct as is the case in European cultures. This is particularly true for Asian women in traditional family systems. In cases where a female continues to disobey the honor code of the family, it is likely that the other female members will ignore the violating family member and will, in many respects, use forms of social avoidance to either punish the female or to correct her for her prior act of disobedience. This means that there may be quite a few family secrets that are simply not addressed. For example, a female member who has a drug problem will be expected to hide this from the public. Likewise, some Asian women may be in domestically abusive relationships but may continue to remain with their significant other due to family expectations. This then means that, in many cases, Asian-American women may be in precarious position. Correctional counselors must be aware of these dynamics as this will complicate treatment with Asian-American female offenders. This group tends to be distrusting of mental health interventions and it is then likely that the counselor will have difficulty contending with resistance from these clients since their belief system is one that emphasizes privacy within the family and the maintenance of harmony and the status quo. Gender Roles As can be seen, gender roles can be fairly well defined in Asian-American families. Traditional views are giving way to mainstream American beliefs on the role of men and women, but this has caused serious friction in many Asian families. This is particularly true when youth become acculturated into mainstream views while the older family members do not. Many young Asian-American women find themselves at odds with the expectations of their families and the reality that exists throughout broader society. For female offenders who are of Asian descent, these expectations will likely have a strong impact on their own self-identity and their sense of self-efficacy. Asian women are thought to be submissive to males in the household, particularly their spouses and their fathers. When Asian-American women attempt to break out of this role, conflict typically emerges and, in many cases, differences in gender-role expectations serve as the underlying basis for domestic abuse that occurs. It would seem that, at least in some families, those women who seek egalitarian standing are more at risk for victimization at the hands of abusive family members. Lastly, among some Southeastern Asian-American girls and women, there may be a heightened risk for sexual victimization. As readers may be aware, Hmong and Vietnamese gangs exist in various areas of the United States and these gangs tend to victimize persons of their same cultural affiliation. In many cases, these gangs target young girls in their community who are also Hmong, Vietnamese, or some other Asian descent. This is important because for some Asian-American female offenders this type of victimization can be a source of trauma that lies at the base of other types of offending. SECTION SUMMARY This section addressed the use of feminist therapy as a paradigm for providing offender-specific intervention services. While women may have a number of individual needs for service, there are common experiences, due to being a woman, that tend to be constant among this group of offenders. The feminist perspective seeks to address these common issues since most other therapeutic orientations are not specifically tailored to meet the needs of women. Further, feminist perspectives target the victimization that has been common in the backgrounds of many female offenders and provides a paradigm that offers support, empathy, strength, and self-empowerment. Lastly, while feminist perspectives hold substantial promise for female offenders, this approach does not have equal appeal for all women. Even further, women who are from minority groups may have different views on feminism and its applicability to their own personal and public lives. The marginalization experienced by many minority women tends to be even greater than that experienced by Caucasian-American women, meaning that interventions will need to be more culture specific to meet the needs of these offenders. LEARNING CHECK 1. Feminist perspectives of counseling seek to give women identity and to empower them in society. a. True b. False 2. The experiences of African-American women may prevent traditional aspects of feminism from being optimally effective. a. True b. False 3. Assertiveness training is an important element of intervention with female offenders. a. True b. False 4. Feminist perspective of counseling teaches female offenders to blame men for the crimes that they commit. a. True b. False 5. Power differences between men and women add to the challenge of reform for many female offenders. a. True b. False CONCLUSION Female offenders have a host of therapeutic considerations that are distinct from those of their male counterparts. These differences go beyond simple physical differences between men and women in prison. Women throughout society experience a different socialization process than do men, and this must be included as a component within any treatment program for female offenders. Considerations for female offenders include social, psychological, and physiological aspects that must all be taken into account. The variety of challenges that confront female offenders tend to be complicated and interwoven with one another. Seldom are the challenges for female offenders mutually exclusive from one another. This means that treatment interventions must address numerous concerns in a simultaneous fashion, including psychological, sociological, and medical concerns. Many of the issues confronting female offenders extend beyond the personal realm and include family-of-origin issues and the impact that their criminal activity has had on their children. As has been noted, a large proportion of the female offending population are also mothers of children. A failure to address the mother–child bond in an intervention program will limit the effectiveness of that program and will therefore not be as likely to reduce future recidivism. Female offenders experience several co-occurring disorders that aggravate their challenges with substance abuse. The use of substances among the female offender population is common and has been found to be linked with a poor self-image and sense of self-efficacy. Female offenders tend to have poor self-image and this also correlates with the tendency to abuse substances. Sex, sexuality, and body image are all compounded issues where the media, society, and family expectations send contradictory messages that negatively affect the woman’s sense of self-value. Due to common problems of abuse in childhood and adulthood, female offenders tend to suffer from high levels of post-traumatic stress disorder. In addition, female offenders tend to be involved in high-risk relationships and to engage in risky behaviors. This is particularly true when it comes to sexual activity, and, due to their lifestyle choices, they tend to be at heightened risk of contracting STDs and/or HIV/AIDS. Drug use tends to aggravate their psychological coping and also impairs decision making when confronted with the opportunity to engage in high-risk behaviors. The use of feminist therapy as a basis for intervention with female offenders was presented. Feminist perspectives address the victimization that has been a common experience among female offenders and provides a message of empowerment throughout the therapeutic process. Nevertheless, this approach should not be used in a one-size-fits-all manner because many of these women are from minority groups that have different views on feminism and its applicability to their own circumstances. Correctional counselors will need to keep this diversity in mind when providing interventions for female offenders. Essay Questions 1. Consider your readings from Chapter 8 regarding substance abuse disorders and consider the discussion in this chapter regarding co-occurring disorders among the female offender population. What types of interventions will you recommend? Would you integrate this with a feminist perspective? If so, explain how you would do this. If not, explain why you would fail to do so. 2. Compare and contrast some of the differences that might exist when using feminist approaches with Caucasian-American women and those who come from minority groups such as African, Latino, or Asian-Americans. What are some of the issues you might consider to be similar? What issues might be different? Give reasons to your answers. 3. How is sex, sexuality, body image, and self-efficacy interrelated for many female offenders? Why would feminists say that these interrelations have occurred at the behest of men in society? How does such a claim comport with the observation that much of the crime committed by female offenders is in tandem with a male accomplice to whom the female is emotionally connected? 4. How might one make the point that female offenders are, in many cases, victims who have been turned into offenders? Provide at least three specific examples of how this might be true. 5. With reference to question number 4, explain some treatment approaches that you might use to aid a female offender who has herself suffered from a past of victimization. What techniques would you use? Would you use a feminist-based perspective or any one of the perspectives provided from Chapter 5 that provides an overview of the more common theoretical counseling perspectives? Treatment Planning Exercise In this exercise, students should consider their readings throughout this chapter as well as prior chapters when addressing this treatment planning exercise. For this exercise, you should determine which, if any, of the issues discussed in this chapter apply to Mary’s case. Be sure to identify those issues and explain how you would address them. Be sure to include a discussion of any corollary services that you might have the client utilize. In addition, explain whether a feminist approach would be appropriate with this client. Provide details on this aspect of your response. The Case of Mary Mary appears in your office vibrant and full of energy. She is whirlwind of activity, straightening things in your office and talking at a vigorous and almost annoying pace. But as soon as you ask her to sit with you and focus on the reason she is here to see you, she begins to get irritated. “Look, I have a lot to do today and I really do not have time for this. I know I have to come here, but if I do not get started, then the whole day could be wasted.” When you ask her about the lethargic state that her boss had said she was in the week before, she tells you, “Well, we all have the dumps from time-to-time.” Then she begins to tell, “But you know, my supervisor really does not know what he is doing. See, if I were boss, I could get that place running perfect in just two days.” Mary has been convicted and is on probation for check fraud and check forgery. It appears that Mary enjoys going on expensive spending sprees for brief periods of time. This is then followed by a cyclical period where she does not have the energy to even go to work. During these times, Mary will often fail to pay her bills or even deposit her paycheck into her bank account. Thus, Mary has a long list of checks that have been returned for insufficient funds. Further, when she was on one of her spending sprees, she decided to use a few checks that belonged to her friend saying, “Well I am just like, well borrowing the money … I will tell her later.” As a result of financial difficulties and her prior husband’s out-of-control temper, she divorced him about four years ago. He was into gambling and also drank heavily. He would complain about the lack of money, Mary’s spending habits, and her radical mood swings. When aggravated and/or drunk, he would have screaming fits. Sometimes during the night when he was drunk he would also force Mary into sexual activity, even when she made it clear that she was not interested. Mary, on the other hand, tends to vacillate back and forth between the use of amphetamines and alcohol, often complicating her life and any chance for stability that she might have. Between her husband’s problems and her own personal challenges, it was not surprising that the marriage did not last. When Mary does have her periods of dark withdrawal, she completely neglects her medication. Further, she tends to neglect her two children, Tina (age 10) and Tony (age 8), letting them take care of themselves. Sometimes, Tina has to take care of mom as well. Both kids prepare themselves for school and walk to school on their own during these times. During these periods, Mary will simply mull over her thoughts and always seem tired and exhausted. She does not sleep well and claims that this impedes her ability to function throughout the day. Regardless, Mary does not exhibit the desire to accomplish her daily-life routines but instead simply allows things to fall apart. Currently, Mary is upbeat and lively and wants to talk about her new boyfriend. From her prior case notes with other therapists, you can tell that “new boyfriends” tend to have a pattern that coincides with her manic episodes. What is interesting is Mary tends to neglect her children during these times as well while she is focusing on getting things right with her new “beau” or fixing her finances from the prior spending spree. This is of course then followed by self-loathing over neglecting her kids (who are neglected during this period as well) and the fact that her new “beau” has found her to be annoying or “moody,” as many have put it. Mary hates taking medication and does not really see why she needs to have therapy. All she really needs is for things to calm down and then she can get a grasp on her life. And according to Mary, “Time is running out as we speak, so can I go or what?” Bibliography American Correctional Association. (1990). 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Dobash, R. P. Dobash, & L. Noaks (Eds.). Gender and crime (pp. 390–409). Cardiff, UK: University of Wales Press. Hammett, T. M., Harmon, M. P., & Rhodes, W. (2002). The burden of infectious disease among inmates of and releasees from correctional facilities. In The health status of soon-to-be-released inmates: A report to Congress: Vol. II. Chicago: National Commission on Correctional Health Care. Hanser, R. D. (2002). Multicultural aspects in batterer intervention programs. Published Dissertation (UMI). Huntsville, TX: Sam Houston State University. Hanser, R. D. (2007). Feminist theory. In N. A. Jackson (Ed.), Encyclopedia of domestic violence. New York: Routledge, Taylor, & Francis. Healey, K., & Smith, C. (1998). Batterer programs: What criminal justice agencies need to know (BJS Publication No. NCJ 171683). Washington, DC: Bureau of Justice Statistics. Jackson, N. A. (2007). Encyclopedia of domestic violence. New York: Routledge. Kanel, K. (2003). A guide to crisis intervention (2nd ed.). Pacific Grove, CA: Brooks/Cole. Kassebaum P. A. (1999). Substance abuse treatment for women offenders. Center for Substance Abuse Treatment, TAP 23; Rockville, MD. Miller, B. A., Nochajski, T. H., Leonard, K. E., Blane, H. T., Gondoii, D. M., & Bowers, P. M. (1990). Spousal violence and alcohol/drug problems among parolees and their spouses. Women and Criminal Justice, 2, 55–72. Raffaelli, M., & Ontai, L. L. (2004). Gender socialization in Latino/a families: Results from two retrospective studies. Sex Roles: A Journal of Research, 50, 287–299. Rich, J. D., Hou, J. C., Charuvastra, A., Towe, C. W., Lally, M., Spaulding, A., Bandy, U., et al. (2001). Risk factors for syphilis among incarcerated women in Rhode Island. AIDS Patient Care and STDS, 15(11), 581–585. Shaheen, A. (1998). American, Ambitious, and Muslim. WIN: Women’s International Net, 8b. Retrieved from: Shusta, M., Levine, D. R., Harris, P. R., & Wong, H. Z. (2005). Multicultural law enforcement: Strategies for peacekeeping in a diverse society (3rd ed.). Upper Saddle River, NJ: Prentice Hall. Shuter, J. (2002). Public health opportunities for the correctional intervention on inmates with communicable disease. In The health status of soon-to-be-released inmates: A report to Congress: Vol. II. Chicago: National Commission on Correctional Health Care. Snell, T. (1994). Women in prison. Washington, DC: Bureau of Justice Statistics. Walker, A. (1983). In search of our mother’s gardens: Womanist prose. Orlando, FL: Brace-Harcourt Publishers. Walker, L. (1979). The battered woman. New York: Harper and Row. Walker, L. (1989). Terrifying love: Why battered women kill and how society responds. New York: Harper and Row. Worell, J. (1993, November). What Do We Really Know about Feminist Therapies. Approaches to Research on Process and Outcome. Invited presentation to the Texas Psychological Association, Austin, TX. Worell, J., & Remer, P. (2007). Feminist perspectives in therapy: Empowering diverse women (2nd ed.). Hoboken, NJ: John Wiley & Sons, Inc. 12 Sex Offenders CHAPTER OBJECTIVES After reading this chapter, you will be able to: 1. Identify aspects of denial that are common to sex offenders. 2. Discuss the four domains of treatment used with sex offenders. 3. Identify the common cognitive-behavioral techniques used in sex offender interventions. 4. List and discuss the five Cs of treatment by William Prendergast. 5. Identify and discuss the two types of interrogation-based interventions used with sex offenders. 6. Explain how relapse prevention and consistency in treatment are necessary. 7. Explain why collaborative approaches between treatment providers and criminal justice personnel are so important. PART ONE: ADDRESSING DENIAL AND THE FOUR DOMAINS OF TREATMENT This section will provide the student with a detailed understanding of the common components associated with sex offender treatment programs. While each program may vary to some degree across the nation, the basic components noted in this section provide the more common aspects to such treatment interventions. Further, the information utilized in this section has been adapted from public domain information provided by the Center for Sex Offender Management (CSOM), which is a project of the Office of Justice Programs in affiliation with the U.S. Department of Justice. Students may have noticed that many of the sources and resources in this text are derived from federal government publications and training materials. This is obviously no accident and reflects the fact that numerous high quality resources exist from various federal government programs. Most often, these resources are subjected to a great deal of rigor and are also the product of research conducted at the national level. Because of this, we believe that these resources tend to be superior to many other potential reference sources available. Further still, these resources are public domain and this allows us to direct readers to those specific sources if they would like to further study a topic and/or have access to the specific resources available. We consider this a very useful benefit for students and also a pragmatic approach to effectively integrate research material into this text. Though the information released by the Center for Sex Offender Management (CSOM) is written primarily for nonclinical audiences, we believe that it is highly appropriate to be referred to in this text as this text is primarily geared toward criminal justice students who are interested in treatment programs common to most correctional agencies. Further, the information contained in this section is quite thorough when compared to many other correctional counseling texts, making this base source of information more than suitable for our purposes. Thus, we follow an organization of presentation similar to the curriculum advocated by CSOM, which is developed to assist probation and parole staff, treatment providers, victim advocates, law enforcement personnel, judges, prosecutors, and justice system educators to plan and develop their own live training events on a variety of specific issues related to sex offender management. Thus, this curriculum is ideal for purposes of familiarizing students to the means by which sex offender treatment programs operate. Addressing Denial First and foremost, it is important to note that just as is common with substance abusers, sex offenders tend to deny the commission of their offense and also tend to deny the seriousness of their offense. It is with this in mind that the correctional counselor must consider how he or she will treat an offender who is adamant and convincing with his or her denial. Though denial is a pervasive issue when working with sex offenders, the presence of denial does not, in and of itself, preclude effective treatment. Nevertheless, denial is a primary concern because most treatment programs hinge upon an offender’s admission and willingness to agree that his or her behaviors are a problem. Among those offenders who refuse to admit to their offense, issues discussed in treatment group meetings, such as cognitive distortions, deviant arousal, and offense cycles, will simply indicate that such problems are not applicable to their own situation. Naturally, this would make treatment nearly impossible and would undermine the therapeutic process for the other sex offenders in the group who admit their sex offense histories. Thus, before sex offender treatment can be effective, the offender must admit his offense history, at least in part. In this regard, the treatment of denial is an essential characteristic before genuine treatment can be pursued. Accordingly, there are two primary approaches for breaking through denial with sex offenders—the polygraph and the use of group treatment. The use of polygraph examinations provides additional data that the correctional counselor can use, similar to information included in a police report. In these instances, counselors can refer to the results of the polygraph as a means of challenging the denial that some sex offenders will present. While it is not the intent of treatment to promote a sense of conflict within the therapeutic relationship, the level of manipulation that is common among these offenders warrants more concrete means of addressing offender denial. This is similar to earlier discussions in Chapter 10 regarding domestic batterers, who deny their actions as abuse, minimize damage from those actions, and blame other people or circumstances for their behavior. Sex offenders use these same tactics to avoid responsibility for these actions and the correctional counselor must be vigilant for these tactics. Another technique of challenging denial is to invite offenders who are in an advanced treatment group to challenge offenders who deny their actions in the less experienced group. The idea is that more experienced offenders in treatment will be adept at challenging offenders in denial than others. In other circumstances, correctional counselors may find it more effective to simply create a group of offenders who all exhibit levels of denial. This technique is called the “deniers group,” consisting of sex offenders who are all in denial. Essentially, this is a “pregroup” session that lasts from 12 to 16 weeks as a means of getting the offender in denial primed for the actual group therapy process. According to CSOM, treatment providers who employ this method report that the great majority of offenders are able to come out of their denial. This approach targets two major issues: • Eliminating cognitive distortions—which, left intact, allow offenders to continue denying or minimizing; and • Developing victimization awareness—which can allow offenders to understand the physical and psychological harm they inflict and, thus, render them more reluctant to commit future assaults. This approach involves a number of techniques geared toward reaching these major issues. They may include: Forming a treatment group composed exclusively of individuals who have been convicted of a sex offense and who are in substantial denial (either of committing the offense at all or of having actually harmed the victim as a result of the offense). Articulating the assumption that denial is a normal reaction for those involved in sexual offending behavior and the reasons for that denial. Allowing the group itself to identify the cognitive distortions often employed by sex offenders in order to access and assault their victims through role-plays and discussions of what “other” offenders tell themselves in order to convince themselves that their behavior is okay. Utilizing videotaped or live statements of sexual assault victims to communicate to offenders the nature and extent of the trauma suffered by victims. Inviting sex offenders who were formerly deniers to visit the group and describe the reasons for their initial denial, the reasons they decided to admit, and a description of their sexual offenses. Allowing group members—as the culmination of this 12–16 week process—to describe their offense history. One primary concern of group members is often related to confidentiality, particularly regarding information divulged by other group. One way to address this concern is to ask the group participants to come to an agreement about their own confidentiality, and in virtually every instance, the agreement they make among themselves is that what is discussed in the group does not get discussed outside of the group, as it pertains to anyone besides the person talking. Typically, it is best to have the group members come to this agreement among themselves rather than imposing such rules on them for two reasons. First, it is a simple way to begin their involvement in a discussion they are likely to understand and be interested in, without discussing any threatening content such as sex offending. This provides practice for what will be occurring in the group. Second, it requires that the group build cohesiveness and trust among its members, at least about this issue. Building trust among themselves can be a useful exercise because it leads to group members sensing that they can be helpful to each other. Most of what occurs during group sessions is discussion among the participants. The facilitators’ (or treatment providers’) primary function is to introduce ideas, suggest discussion topics and activities, praise progress, and, most importantly, ensure that the therapeutic milieu remains pro-social. By this we mean that it is essential that as the group progresses, group members feel they will be rewarded—principally by other group members—for admitting their sexual assaults, which often is different from most others. Facilitators begin the “denier group” treatment by talking about definitions of and the continuum of denial, asking group members to define what is meant by denial, followed by a discussion of the degrees of denial that range from complete denial, such as “I wasn’t even in the house at that time,” to minimization. Next, the correctional counselor would initiate a more comprehensive discussion of denial by asking the group to consider and suggest examples of denial in three phases of sex offending: before the offense, during the offense, and after the offense. A major component of many sex offenders’ denial is not simply that they say they did not have sexual contact with their victims, but that their victims were in fact “partners” because they gave consent. This is a common facet of denial for many offenders, both those who commit acquaintance rape and those who sexually assault minors. Therefore, the concept of informed consent should be discussed at length both in sex offender denial treatment as well as in conventional sex offender treatment. Once this has been discussed, the correctional counselor will then conduct a role-play demonstration to illustrate this point. This role-play is illustrated in Exhibit 12.1. EXHIBIT 12.1 An Example Role-Play for Denial Regarding Consent among Sex Offenders in Group Therapy As the role-play begins, selva the facilitator stands next to an empty chair and asks the group to imagine that in the chair is an 11-year-old boy. The facilitator tells the group that he will be playing the role of a sex offender who believes what the group just concluded, namely that in order for children to give consent to sex, they must have a great deal of information. As a child molester who believes in children’s right to consent, he will be telling the child what he needs to know about having sex with him, and then ask him if he wants to have sex. Standing next to the empty chair, the facilitator speaks loudly enough for the group to hear as he looks at the imaginary child in the chair and says, Johnny, I want to talk with you about something. I want to have sex with you. You look puzzled. Let me tell you what I mean, and what I hope we’ll be doing. I know that you like to be with me, to come over to my house, and for us to do stuff together. You’ve been coming over here after school now since October, right? You like to play my video games, drink the Mountain Dew I always keep in the refrigerator for you, stuff like that, don’t you? I know that you really like me, and I’ve acted like I really like you. I don’t actually like you that much, but I’ve pretended that I do, and I think that’s made you feel really good. It’s not that I don’t like you, but it’s that if I get you thinking I like you really a lot, then you might be more willing to do what I want you to do. Anyway, let me tell you about what I’m hoping will be happening between us. The correctional counselor then proceeds to explain to the mythical child exactly what having sex with him means, graphically describing the physical act, describing the consequences he (the offender) will suffer if anyone finds out about it, and the great lengths he will go to in order to avoid being discovered and punished. This, of course, involves making the child out to be a liar if he ever were to disclose the behavior. He also goes into great detail about what the child will have to face should he have to go to court and from all the different people who will know about what has happened. He also describes in detail how the child will feel—including physical pain, feelings of guilt and isolation—immediately after the abuse and later, as an adult. He goes on to indicate that, when the child grows to the age of puberty, this experience may have longer-term consequences on his comfort with his adult sexuality. He concludes … So, Johnny, now that you know about all this stuff, would you like to have sex with me? Source: Center for Sex Offender Management (2008). An overview of sex offender treatment for a non-clinical audience. Washington, DC: Office of Justice Programs, U.S. Department of Justice. Once the role-play demonstration has been enacted, the therapist will invite group reactions. In most cases, clients discuss the fact that no child would voluntarily have sex with an adult if he or she knew all of the information pointed out in the role-play. The therapist will usually then point out that the information given to the child in the role-play is the information that most adults would be aware of. In other words, by the time people become adults, much of the information used in the role-play must have become common knowledge. Generally, by adulthood people would have learned about sex, about how people get other people to have sex with them, and so forth. However, children do not usually know this information, and, even if they did, they would not necessarily understand the information. Therefore, they are not able to give informed consent. Despite this, sex offenders will often offer counter claims to justify inappropriate actions. Some common examples include the notion that the child wanted the sex, that the child should be considered old enough to have sex, that women like to be forced sexually, and/or that the sex is okay because the offender loves the child. Nevertheless, the seasoned group members tend to quickly challenge these various justifications, especially those of others, because they recognize these rationalizations as well or better because they themselves might have used similar tactics. In most cases, sex offenders do not gain satisfaction from causing physical harm to their victims; rather they may pursue their behavior due to self-centered desires for gratification. Regardless, these offenders cause trauma because they selfishly use their victims as objects and they disregard the harmful effects they cause. The exceptions to this are sexual sadists, who derive erotic arousal from causing victims to suffer, and psychopaths, who are indifferent to the pain that they cause others. From this point, most treatment programs will seek to increase awareness of the victim and the impact that sexual abuse trauma has upon that person. It is generally believed that by increasing victimization awareness and empathy sex offenders will come to understand the harm they cause and, in the process, will be less likely to commit future sex offenses. Victimization awareness is a component of sex offender treatment for offenders in denial for the above reasons and because many sex offenders deny that their victims were truly victims, that is, they fail to see the harm done. Victimization awareness can be addressed in treatment groups in a variety of ways. First, by showing videotaped programs of sexual assault victims describing how they have been traumatized by sex offenders; second, by a live discussion whereby adult survivors of sexual assault visit the group to describe their experiences of trauma. The obvious advantage of using videotaped material is its accessibility and control—group facilitators choose the audiovisual materials carefully and they know exactly what the content will be. On the other hand, the advantage of live sexual assault survivors is that this approach is much more powerful than videotape, and there can be interaction in the form of questions and answers between the offenders and the sexual assault survivors. It should be pointed out that the purpose of having group meetings with sexual assault survivors is not to instigate aggressive confrontation or anger. Rather, the point is to provide a forum for important education and thoughtful discussion that builds a sense of empathy on the part of the sex offender. This process takes considerable skill on the part of the correctional counselor who must regulate various dynamics of the group process. Among these dynamics would be the need for mutual respect and appropriate boundaries, clearly stating expectations, and ensuring that underlying agendas are not allowed to dominate the group process. Though this is a challenging process, it can be very rewarding since sex offenders and sexual assault survivors both tend to indicate that the experience was powerful, insightful, and instructive. After this point in the denial group process, the next point in treatment includes a visit from sex offenders who were formerly in denial but now admit to their own offense histories and who are also vigilant in working on their treatment. It should be pointed out that the offenders who visit the group should be carefully selected by the correctional counselor from among his or her agency. These visiting offenders must have usually completed their own sex offender denial group session. Since the denial group sessions tend to last from 12 to 16 weeks in duration, they will have had three to four months of experience, at a minimum, with the group process. The final point in the treatment for sex offenders who deny their crimes requires each participant to provide a sexual offense history. In this stage of treatment, each participant takes a turn at describing his or her offense history. Typically, correctional counselors conducting this type of group therapy find that 70 to 80% of the group members will admit to the offenses that they have committed. This allows the offender to then continue through further aspects of treatment. Treatment providers take different approaches to those offenders who persist in denial even after they have received significant therapy to assist them to break through denial. Some may proceed to use the polygraph, whereas others may provide the offender with another opportunity to participate in deniers treatment. Some therapists may decide that these offenders are simply no longer eligible for treatment. In such cases, the offender will most assuredly be incarcerated and will remain so until the expiration of their sentence. The Four Domains of Treatment For those offenders who either never express denial and/or those who successfully complete the deniers group, the genuine treatment process will begin. This will consist of additional group therapy that addresses a variety of issues related to sex offending and the manner by which offenders perceive their offending. Generally speaking, treatment programs address four broad domains, which are listed below: • Deviant sexual interest, arousals, and preferences; • Distorted attitudes; • Interpersonal functioning; and • Behavior management. Although not all sex offenders have difficulties or deficits in each of the four domains listed above, the majority do. Therefore, it is important that treatment programs address all four of these domains. It is at this point that we discuss each of these domains of sex offender treatment. The student is again reminded that, up to this point, the sex offender treatment has simply been focused on the offender’s denial. Challenging the offender’s denial was a “pre-group” phase just to ensure that group members all had at least a common baseline of acceptance of their crime and how it impacted the victim/survivor of the sexual assault. Deviant Sexual Interest, Arousal, and Preferences The CSOM notes that offenders typically commit sex crimes for a wide variety of reasons. In fact, we contend (as does CSOM) that a large number of sex offenses are not committed due to a desire for power or control. In a large number of sex offenses, the offender genuinely seeks gratification rather than dominance over the victim. In other words, the exploitation by the offender is utilitarian to gaining access to sexual gratification. This does not comport with much of the traditional belief regarding sexual offending, which is that all sexual offending is grounded in the desire to exploit, dominate, and denigrate the victim. For instance, consider an offender who engages in sex with his 14- or 15-year-old step-daughter; this is likely to be more grounded in the desire for sexual gratification rather than an intent to humiliate the victim. As another example, consider an offender who uses rohypnol to subdue his victim, has sex with her, and then leaves the area. Being that the victim was unconscious there is little likelihood that denigration or exploitation was the primary intent. Also, considering that the offender left upon completion of the act, it is all the more likely that sexual gratification was the basis for the criminal offense. This is not to say that many sex offenses are not grounded in the desire to have power and control over the victim—in fact, many are grounded in such a desire. Further, there are rapists who are misogynists in nature and others who are sadists. In both of these cases, the desire to humiliate and cause pain is certainly a strong motivation to their crimes. Still, it is our stance that this motivation does not account for the majority of the sex offender population. Going back to our example of the offender who encourages sex with his teenage stepdaughter, consider that, assuming he had no other criminal sexual history, if we were to measure his sexual arousal patterns in a laboratory, we likely would find that he is most erotically attracted to adult women, followed in intensity by adolescent girls, which is a normal sexual arousal pattern for a heterosexual adult male (CSOM, 2008). Thus, it might be concluded that his principal problem is likely to have more to do with his having used extremely poor judgment, having difficulties of impulse control, poor self-management, problems in his personal relationships, and other problems. On the other hand, the person who is motivated to commit sexual assaults on children to satisfy his sexual arousal, or to force people to have sex with him, or to expose his genitals to strangers has problems in the area of sexual interests. Although it may seem surprising, some sex offender treatment programs do not directly and effectively address sexual interests in treatment. This is a serious oversight since the reinforcing sensation of gratification serves as a powerful motivator for many sex offenders. Thus, techniques designed to address the pairing between gratification and the action taken must be included in any type of comprehensive treatment regimen. One technique that is often used is masturbatory satiation (Hanser, 2007). This technique is based on behavioral learning principles, with the treatment being based on the presumption that sexual arousal is, to some extent, a learned behavior that can likewise be unlearned and/or modified through a relearning process. This technique involves having the client masturbate to an appropriate fantasy, until he has an ejaculation (Hanser, 2007; Knopp, 1989). When the correctional counselor provides instruction on this technique, an explanation should be provided to the offender that he will be involved in a treatment approach that is intended to reduce his deviant sexual arousal while simultaneously increasing his arousal to nondeviant sexual stimuli. The offender will naturally complete this assigned technique in private. Prior to doing so, it is very important that the correctional counselor ensure that the offender understands the purpose to the assigned technique and that he conduct the exercise properly. Throughout the exercise, the offender is to record one’s experience on an audiotape which the correctional counselor will later listen to. Over time, this technique is intended to pair the intense pleasure associated with orgasm with healthy sexual fantasies. Likewise, it is expected that disinterest and/or even psychological discomfort will develop with deviant fantasies. Further, offenders may be requested to masturbate during their refractory period (the time right after they have achieved orgasm) because this typically induces boredom and some sense of physical discomfort. The purpose of this second aspect of the exercise is to have the offender experience negative reactions to deviant fantasies. Ideally, the attractiveness of the previously erotic (and deviant) stimuli is substantially diminished. By focusing on one aspect of his deviant arousal pattern, the offender will pair physical discomfort and extreme boredom with what typically would be arousing and pleasurable. Taken together, the pairing of healthy fantasies with the intense and positive experience of an orgasm is designed to strengthen healthy sexual interest and arousal patterns, while the pairing of discomfort, boredom with deviant fantasy can aid in reducing deviant fantasies and interests. In most treatment programs, the sex offender is required to make three audiotapes a week. Each of these audiotaped sessions is intended to be approximately an hour in duration. The purpose for making the audiotapes is so that the correctional counselor can monitor compliance and ensure that the offender is conducting the exercise properly. This aspect of the treatment process typically lasts for approximately seven weeks with roughly 20 hours of homework being assigned throughout the entire period. Distorted Attitudes One of the key commonalities among sex offenders is the distorted attitudes that they tend to have (Prendergast, 2004). It is common for people to have various distortions in their perceptions. Often, such distortions serve as psychological defenses to justify what a person has done and/or to normalize his experiences. Sex offenders use distortions in perception as a means of rationalizing their offenses to make their offenses not seem as serious as they actually are. This protects the esteem of the offender and also distances them from any sense of guilt that they might otherwise experience. COGNITIVE RESTRUCTURING Because sex offenders are aware that their behavior is illegal and/or harmful to the victim, they justify their behavior by creating rationalizations that minimize the negative impact of their actions. This is also intended to reduce dissonance that they might encounter, which leads to thinking errors or cognitive distortions. The purpose of cognitive restructuring with sex offenders is to have them identify and examine their cognitive distortions and to receive feedback that exposes the errors in their thinking. It is intended that the offender will develop an awareness of victim issues. The main goal is to circumvent the rationalizations that offenders use to justify their offending. In most cases, this intervention begins with a discussion on how these distortions are used to justify aberrant behaviors. Through the use of group counseling processes, offenders eventually acknowledge that, regardless of the reasons, some behaviors are simply wrong and inappropriate. Group members are then asked to complete a sentence that essentially makes them confront the nature of their act. For example, an offender may be required to complete the following statement: “Even though I knew my sex offenses were wrong, or at least illegal, what I said to myself to make it seem okay was ___________.” During these groups, offenders may be required to anonymously write down on paper a list of cognitive distortions that they have used. These lists of thinking distortions are later used as part of future group discussions, in which case the correctional counselor will read the various distortions one at a time and the group then discusses these distortions. Another common technique used in these groups is the use of role-play exercises. One such role-play method involves group members playing the role of someone related to the victims, such as the father, with another offender playing a role that supports the offender to take responsibility for the offense, and yet another offender playing a pro-social role such as that of a community supervision officer. In this exercise, the correctional counselor would play the role of a sex offender who uses various cognitive distortions, defending these distortions to the three offenders playing their respective roles. It becomes the task of the offender role-players to explain to the correctional counselor (playing the role of offender) the faults and distortions that exist in his thinking. This is often a fairly easy task for offenders to do, because although they might have trouble challenging their own cognitive distortions, they tend to be adept at noting the distorted thinking that occurs among other offenders. This is especially true when different types of sex offenders, such as rapists and child molesters, are mixed in the same group. VICTIM AWARENESS/EMPATHY TRAINING As was noted in the previous section on offenders in denial, another point in addressing distorted attitudes with sex offenders is the desire to increase their awareness of the victim’s experience and to increase empathy, when this is possible. However, these techniques are not intended for offenders who are diagnosed as sexual sadists (see the DSM-IV-TR) and those persons who qualify as genuine psychopaths. Indeed, attempts to increase victimization awareness in offenders who have no capacity for empathy for others can actually make these offenders more likely, rather than less likely, to commit subsequent offenses. In regard to sexual sadists in particular, these individuals gain erotic gratification through the infliction of pain, suffering, and humiliation of their victims. Thus, teaching these offenders about the victim’s pain and anguish is likely to excite and reinforce their crimes rather than extinguish them. For those sex offenders who do not find gratification in the infliction of physical harm or psychological torment, the intent of victim awareness techniques is to simply increase the offender’s understanding of the victim’s trauma. The general logic is that, with such awareness acquired, the offender will be less likely to commit similar offenses in the future. Generally, sex offenders are capable of empathy but they tend to be less receptive to issues related to sex and sex offending. Because of this, the goals of this component of treatment require offenders to do the following: • Understand the pervasive negative effects of sexual assault on victims and others; • Know the likely consequences of their assaults on their victims and their families; and • Learn empathy skills, especially the ability to empathize with their victims. Other methods that are often utilized to enhance this component of treatment include requirements that offenders complete written assignments describing the offenses they have committed. However, with these exercises, the offender does not write this from their own perspective. Rather, these offenders are instructed to write the narrative from the perspectives of their victims. This is a direct attempt to build feelings of empathy. This kind of homework is read and critiqued by the correctional counselor. When needed, the correctional counselor will often require the offender to rewrite sections of their report, particularly when the use of minimization has been detected. Interpersonal Functioning In many cases, the criminal acts committed by sex offenders are manifestations of their poor interpersonal functioning. Examples include a man who is inadequate in meeting his responsibilities as an adult, and, a man who because of friction between himself and his wife sexually assaults his daughter to meet his sex needs. Another case might be a man who uses coercion, manipulation, or deceit to gain sex with women whom he dates. Yet another example might be a man who is unable to effectively develop adult peer relationships and therefore turns to children to meet his emotional and sexual intimacy needs. These are examples that commonly occur among sex offenders and these point to the need for interventions that train sex offenders to be more socially effective as adults. These poor interpersonal skills, when combined with deviant sexual arousal, distorted attitudes, and poor impulse control, create an offender who is difficult to treat due to personality and cognitive challenges. Thus, the general idea among therapists is that if an offender can learn to live more functionally in the world of adults, they will find life more satisfying without the need to disregard the rights of others. However, it should be made clear that we do not mean to imply that a lack of social skills is the primary causal factor for sex offending; such is not the case. Rather, we simply mean to imply that it is much more difficult to treat a sex offender who has poor social skills and their risk of recidivism is greater since they are not as capable of developing appropriate adult sexual relationships as are persons who have effective social skills. Adding to this point, it is often the case among sex offenders that intimacy deficits and conflicts in intimate relationships have been found to correlate with sexual offending. The need for social skills training is less clearly specific than the rationale for reduction of deviant sexual arousal, but possession of effective social skills tend to improve the treatment prognosis. Put in another manner, if it is true that self-esteem and loneliness influence an offender’s ability to function, then addressing social skills of the offender would seem to enhance the treatment process. APPROPRIATE INTERACTIONS IN SOCIAL SITUATIONS The point to this aspect of treatment is to demonstrate that satisfying sexual interactions are extensions of social relationships. Because many sex offenders tend to see sexual activity as being an end unto itself within a relationship, this area of treatment emphasizes the role of friendship and intimate bonding with others. This treatment approach, like many others, utilizes participant role-playing exercises. In addition, offenders will likely be given homework assignments that require the offender to establish communication and relationship building. An example of such a homework assignment might be one in which the offender is required to talk with a given number of complete strangers and make a report about their experience when initiating such conversation. The types of strangers that the sex offender will seek to communicate with will usually be identified by the correctional counselor. Obviously, some degree of discretion would need to be maintained. Thus, the offender may be asked to strike up conversation with a salesperson at a store or perhaps a person who attends a religious institution with the offender. Though the setting is not important, it is important that the offender be required to develop some sort of conversation and that they become adept at engaging in appropriate dialogue. ASSERTIVENESS AS A TOOL TO AVOID FRUSTRATION AND POOR ANGER MANAGEMENT Another aspect of social skills that should be addressed with most sex offenders is the use of appropriate assertiveness. This area is relevant in the treatment of sex offenders for a variety of reasons. Sex offenders often mismanage anger, and assertiveness plays a significant role in anger reduction. In many cases, sex offenders suffer from insecurity in fearful attachment difficulties when establishing intimate relationships with adults. Some of this is due to fears of rejection and some due to a lack self-confidence and assertiveness skills. As a result, they may seek out contacts with people who are less likely to be rejecting, such as children. Other problematic attachment styles have been found to be due to mistrustful and hostile approaches to interacting with others. Rather than dealing effectively and assertively with others, these offenders may harbor resentment and experience pervasive anger, which may lead them to act out aggressively. Assertiveness training promotes more effective means of managing anger and teaches individuals how to interact with others more effectively, and as a result, it can promote self-confidence, enhance self-esteem, and promote intimacy. This is considered important because deficits in intimacy conflicts in intimate relationships have been found to be correlated with sex offending (CSOM, 2008). ADULT SEX EDUCATION On a cursory level, it may seem that the best message to give sex offenders is that they should not engage in any sexual thoughts, fantasies, or behaviors of any kind. Naturally, it is unrealistic to hope for this, thus the goal of treatment is to assist sex offenders in learning to be sexual beings without harming others. Thus, sex education is provided so that sex offenders develop a respect for the rights of others. This aspect of the treatment process is primarily psychoeducational in approach, with basic issues regarding safe sex, consensual sex, and other aspects of sexuality being covered. Throughout the educational component of sex offender treatment, considerable emphasis should be placed on the importance of verbal communication to promote clarity and ensure consent (because of their histories of having violated others). Correctional counselors should promote open, respectful, and clear communication related to sexual matters, teaching that sex is an important area for people to talk about (CSOM, 2008). Behavior Management Although deviant sexual arousal can motivate sex offending, distorted attitudes can promote it, and problems of interpersonal functioning can contribute to it, hence, ultimately sex offenders need to learn to manage their behavior. Deviant sexual arousal, distorted attitudes, and poor interpersonal functioning do not cause sexual offending, though they are correlated. Typically, the focus of this stage of treatment is on both the underlying issues and the behavioral acting out. One key component of sex offender treatment is teaching sex offenders very specifically how to manage their behavior. Behavior management is particularly important in situations where an offender easily could commit a sexual assault, such as being in the presence of someone who would be easy to victimize. One of the key points to remember when monitoring behavior management of sex offenders is the ability of treatment and criminal justice agencies to work collaboratively to reinforce responsible behavior management among sex offenders. Community supervision agencies have the authority and ability to utilize a set of external controls, such as surveillance, the restriction of access to victims, and reducing opportunities to engage in high-risk behavior, which most treatment professionals lack. On the other hand, sex offender treatment providers have a set of therapeutic tools that are aimed at assisting the offender to develop his or her own internal controls over one’s behavior. In some areas, these functions overlap and support one another. When taken together, both of these types of offender monitoring can contribute to successful offender management. Thus, it is important for correctional counselors to make routine contact with supervision personnel. COVERT SENSITIZATION: VISUALIZING THE CONSEQUENCES OF SEXUAL ASSAULT One common behavior management technique is called covert sensitization. In many cases, sex offenders do not truly consider the long-range consequences of their behavior, but instead tend to focus on the immediate pleasure that they expect to achieve when committing their crime (Prendergast, 2004). This failure to consider the consequences of their actions is, in part, an outcome of the distortions and fallacies that exist within their thinking and perceptions. Therefore, if offenders learn to anticipate the consequences of their actions, it is then likely that this might prove to be some bit of a deterrent to their behavior. This is the underlying assumption to covert sensitization. With this in mind, the goal of covert sensitization is to teach offenders to have offenders substitute thinking about what is appealing about sex offending with considering instead possible negative consequences of committing sex offenses. This means that the correctional counselor will direct the sex offender toward taking a broader, more long-range view of their behaviors. The specific process involved begins with the correctional counselor describing the reasons for the intervention. From that point, the group members are then required to identify and discuss their antecedent thoughts, their behaviors, and their cognitive distortions that occur prior to their offending. It has been found that sex offenders typically traverse a number of steps (that create circumstances where they can commit sexual assaults), both internally in their thinking and externally in their behavior (CSOM, 2008). Group members help one another to identify the thinking patterns prior to the offense as well as the patterns and strategies that they use to justify their actions. Once the antecedent thoughts are identified, the offender is then asked to identify and describe imaginary neutral scenes where the offender is free to feel calm and relaxed, such as relaxing by the pool or engaging in a discussion with a good friend. After this, the offender is asked to identify some aversive scenarios. This must be reality based and serious enough so that, if they had actually occurred, the offender would have found them to be very unpleasant. The offender is then instructed to create several audiotapes as homework. When completing this homework, the offender starts by describing one of his neutral scenes which is then followed by a description of his antecedent behaviors that might likely lead to sexual offending. Included in this homework would be the need for offenders to discuss the early stages of the commission of their crime, such as when they arrange to isolate their victim, to gain the victim’s trust, and so on. Then, the offender is instructed to describe in detail an aversive scene, such as when he is arrested at his place of work by the police and is observed by those who are at his place of employment. The offender is required to spend at least two to five minutes focused on the aversive scene. The purpose of this exercise (particularly the aversive component) is to pair the experience of committing the sex offense with the aversive experiences. In addition, the correctional counselor might add an element to this technique by requiring the offender to imagine another scene where a consensual adult agrees to have sex with the offender. Though this aspect should only be interspersed between the precriminal scene and the aversive scene, it can help to pair the offender’s interest with the appropriate behavior. This third scene is sometimes referred to as the escape scene (CSOM, 2008; Prendergast, 2004), because it provides an option beyond the aversive scene. The use of this escape scene is to highlight the fact that if sex offending is avoided, the offender can have a more pleasurable and satisfying life, including his sex life. When conducting covert sensitization, offenders are typically required to complete about 10- to 15-minute covert sensitization audiotapes (CSOM, 2008). Correctional counselors are then required to review the covert sensitization audiotape homework and provide feedback to the offender, upon which time they erase the information and return the tapes to the offender. Naturally, if it does not seem that the offender is sincere in attempting this technique, the correctional counselor will need to challenge the offender’s lack of effort and commitment. RELAPSE PREVENTION Another treatment component related to sex offender behavior and self-management is relapse prevention (CSOM, 2008). The use of relapse prevention has its roots in the treatment of alcohol and other drug abuse, where it was found that getting people to stop drinking and using drugs was not nearly as difficult as was getting them to continue their abstinence (CSOM, 2008). Many of the notions and ideas regarding relapse prevention with drugs and alcohol have been borrowed and adapted to aid in sex offender treatment. When conducting relapse prevention with sex offenders, much of the focus is on the offender being required to asses his own offense patterns, his particular high-risk situations, and his coping strategies. From this point, offenders learn how they can avoid lapses and relapses and how to monitor themselves for mood states and behaviors that might place them at increased risk of recidivism. The correctional counselor will assist offenders by providing feedback and homework assignments. Offenders are required to engage in this self-examination exercises, such as the task of writing an autobiography to gain a greater understanding of life patterns that result in offending, learning more effective problem-focused rather than emotion-focused coping strategies, avoiding high-risk situations, learning that urges that are not acted upon diminish with time, and practicing (such as with role-playing) how best to manage risky situations (CSOM, 2008). In completing these exercises, problem-focused coping strategies involve examining alternative methods to address the problem, deciding on the most effective strategies, and implementing the plan utilizing those strategies. On the other hand, emotion-focused coping strategies involve actions derived primarily from immediate emotions rather than considering various alternatives and the efficacy of each. Each of these approaches—problem based and emotion based—are important since they both address necessary aspects of relapse prevention. Thus, each should be given due attention among offenders to maximize the relapse prevention training. SECTION SUMMARY It is clear that sex offenders provide serious challenges for the correctional counselor. Chief among these challenges is the denial that will be encountered among most members of this population. In cases where mandated offenders refuse to assume accountability, placement in deniers pregroup may be necessary. During this time, the offender will engage in group interventions that address denial and the need for personal accountability for one’s crime. If this phase of treatment is not successful in case of an offender, the offender will either be tested with interventions that are interrogation based or he will need to be incarcerated to ensure the public’s safety. Once issues regarding denial have been appropriately addressed, treatment will continue along four general domains of intervention. The first domain seeks to address deviant sexual interests and arousal that tend to be common among sex offenders. These deviant forms of arousal are typically learned (whether from prior sexual abuse or through other means), and the general consensus within the treatment literature is that aberrant forms of sexual arousal can also be unlearned. The next domain addresses distorted attitudes that sex offenders tend to have. In many cases, sex offenders have perceptions and beliefs that are not grounded in reality and they are subject to misread cues from their victims. Next, interpersonal functioning tends to be underdeveloped among many sex offenders, particularly among pedophiles. The inability to engage in relationships (both sexual and nonsexual) with adults and/or persons of equal stature and autonomy belies the insecurities that are common with many sex offenders. Lastly, behavior management is addressed in sex offender treatment. Regardless of the offender’s psychological distortions, aberrant forms of arousal, and poor interpersonal functioning, the offender must be self-disciplined and capable of controlling his own actions. Behavior management techniques train sex offenders to effectively moderate their own behavior. LEARNING CHECK 1. Before anything else in treatment can be accomplished, sex offenders must be willing to assume responsibility for their crimes. a. True b. False 2. Victim awareness technique is part of the domain of treatment that addresses deviant arousal. a. True b. False 3. Sex education is part of the interpersonal functioning domain of treatment. a. True b. False 4. Relapse prevention with sex offenders has its roots in relapse prevention programs used with drug offenders. a. True b. False 5. One aspect of social skills that should be addressed with most sex offenders is the use of appropriate assertiveness. a. True b. False PART TWO: COMMON TREATMENT TECHNIQUES While most students (particularly students of criminal justice) are aware that a variety of offenders may be given treatment, they are not typically aware of how these treatment techniques are utilized. In this section, we seek to clarify the various interventions by providing a brief overview of some of the techniques used in sex offender treatment. While some of these techniques may have been mentioned in the previous section, the presentation in this section should better organize their placement within the entire scheme of sex offender treatment. For purposes of this chapter, we consider the primary type of treatments to fall under one of two categories. These categories are cognitive-behavioral therapy and the interrogation-oriented approaches. Neither of the approaches just mentioned emphasize affective-oriented styles of counseling and we think that this is noteworthy. Indeed, both perspectives are geared more toward the sex offender identifying with others, rather than being understood by others. We think that this is an important observation and refer to the work of Prendergast (2004) in clarifying this approach. Insight by Prendergast (2004) has provided several clear and easy-to-follow guidelines when providing therapeutic services to sex offenders. In short, the correctional counselor should not be duped by the manipulative nature of the sex offender but, at the same time, he or she must maintain a rapport with the offender. Lastly, in this section we will provide much more extensive information regarding interrogation techniques. The use of criminal justice resources will be highlighted to demonstrate how collaboration between criminal justice personnel and the correctional counselor can optimize the prognosis for sex offenders. While this is true for all offenders who receive therapeutic services, this is particularly true for sex offenders due to their manipulative and convincing nature. The level of denial that is exhibited by sex offenders makes necessary the use of more invasive procedures when providing treatment interventions. Thus, we highlight the confrontational nature of sex offender treatment in this section of the chapter. Cognitive-Behavioral Techniques Revisited As noted earlier, cognitive-behavioral techniques are geared toward reducing and/or eliminating the deviant sexual arousal. There are many techniques commonly used by clinicians, each with a different rationale to their use. The first group of interventions teach impulse control, the second group of interventions teach arousal reduction, and the last group teach empathy to the offender. While each of these categories may overlap with information provided in the prior section, the current discussion seeks to simply clarify between the multiple techniques that are used with sex offenders. The impulse-control categories of cognitive-behavioral techniques include the following: Thought stopping: This is used to disrupt a deviant thinking pattern. The offender is given pictures of arousing images and is forced to stop his thoughts when the image is seen. The use of group confrontation, observation, and journaling assist in ensuring that this is accomplished (Knopp, 1989). Thought shifting: This requires that the offender shift his thoughts to aversive imagery. The sex offender may be allowed to view or think about some arousing image but then is trained to think about something aversive, like an approaching police officer. Again, the use of group confrontation, observation, and journaling assist in ensuring that this is accomplished (Knopp, 1989). Impulse charting: This is a method used to track points and times when certain thoughts and or desires seem more intense. The time of day, location, and number of times per week are to be noted. The offender will usually also be required to report the level of intensity of the impulse (i.e., 1–10 scale) and this will be tracked through a journaling process with the therapist (Knopp, 1989). The arousal-reduction forms of cognitive-behavioral techniques include the following: Scheduled overmasturbation: This intervention requires that the client routinely masturbate on a progressively more frequent schedule throughout the week. This is intended to reduce sexual drive and to make control easier for the offender. This exercise also teaches that the client does have some measure of control over his sexual arousal and use of sexual energy (Knopp, 1989). Masturbatory reconditioning: This technique involves having the client masturbate to an appropriate fantasy, until he has an ejaculation (Knopp, 1989). Aversion Therapy: This behavioral technique is often used in varying degrees within several sex offender programs. The aim of aversive techniques is to teach offenders to associate unpleasant stimuli with presently desirable yet unacceptable behaviors (Lester & Hurst, 2000). A wide range of physical or overt aversive stimuli have been used to treat sex offenders. Most notable ones are electric shock, foul odors and tastes, drugs that temporarily paralyze, and drugs that induce vomiting. Because of ethical and constitutional considerations, some of the more extreme forms of aversive stimuli are not used as frequently as they were some 20 to 30 years in the past. Spouse monitoring: This involves supervision on the part of the spouse (if and when available, though other family members may be able to assist) or significant other to complete a daily checklist on the offender’s compliance with the treatment and to ensure that any therapeutic homework given to the client is being completed at the prescribed times in the week. This increases the overall supervision that the offender has (Knopp, 1989). Environmental manipulation: This helps to get the offender out of situations that are high risk for him and his potential victims. The offender should train himself to move out of the house, not to the victim (Knopp, 1989). Cognitive-behavioral techniques that provide empathy training include the following: Victim counselors: Victims are invited to attend the group meeting. In fact, the victim may colead the group. Offenders may be required to visit a victim advocate center, and, at their own expense, ask a victim counselor to explain his or her feelings on sex crimes. Cognitive restructuring: The offender constructs scenes that cast him or significant others in the role of the victim. The client then focuses on typical rationalizations he uses to justify the assault (Knopp, 1989). Scenes are constructed where he utilizes and internalizes the rationalization. These scenes are then paired with aversive imagery. Lastly, alternate scenes are constructed where the offender catches himself in the distortion and counters with a reality-grounded message in which it is acknowledged that these actions do not end in the way that the offender hopes (Knopp, 1989). Role-playing: The offender reenacts his own crime scene(s) with another offender and they take turns playing the role of victim. The remaining group offenders observe and later critique the role-play and allow for group processing of the effects on the victim. The Five “Cs” in Sex Offender Treatment This section introduces the work of Doctor William Prendergast (2004), an experienced therapist for sex offenders. We have chosen his work because he provides numerous points of no-nonsense insight into the treatment of sex offenders. He has extensive clinical experience and provides very clear and concrete guidance on the various dynamics that may occur between the correctional counselor and the sex offender client. While much of the previous information of this chapter has dealt with the process and techniques associated with sex offender treatment, Prendergast’s (2004) work goes beyond this and highlights the interpersonal issues that are likely to impact therapy. In doing so, he points toward what he refers to as the “five Cs in sex offender treatment,” which are confrontation, caution, confirmation, control, and consistency. We now provide an overview of each of these aspects of treatment. CONFRONTATION Prendergast (2004) notes that due to the passivity, dependency, and seductiveness of many sex offenders, there can sometimes be a desire on the part of correctional counselors to be supportive, gentle, and parental in their approach. Prendergast (2004) notes that person-centered, Gestalt, and other affect-based approaches to therapy tend to be ineffective with this population. Rather, he contends that confrontation is the best method to reach the core of the sex offender’s problems. Whatever the sex offender says, it should be heeded with a strong dose of skepticism, and, though this may be contrary to traditional counseling approaches, these offenders should be ready to validate statements or claims that they make in therapy. One of the key observations regarding many sex offenders is that they are clever and tend to be adept at using vague generalities and/or utilizing psychological jargon as a means of mitigating or minimizing the impact of their offense (Prendergast, 2004). Thus, these offenders tend to become therapy-wise and begin to use the various technical terms to sanitize their actions and to place them within a clinical and sterile form of discussion. This tends to diminish the seriousness of their offense and, at the same time, creates the appearance of someone who is dedicated to the treatment regimen. When using confrontation, Prendergast (2004) notes that long-winded statements and/or questions are ineffective because they interrupt the thought processes of the offender without steering them toward specific acceptance of responsibility. Prendergast recommends the use of “cue phrases” to prevent therapist interruptions and confrontation from turning to a means of avoidance or manipulation (2004, p. 148). The principle behind this is that the less said by the therapist, the better the challenge will be. Some suggested cue phrases are as follows: • Because? I do not understand the motive or reasons for your actions/conclusions. • Picture? You are being vague, and I don’t get a clear understanding of the situation. • Tilt! You’re off the subject. Get back to what we were discussing. • And? Not enough. Whatever you are telling me is incomplete. Something is missing. • Pzzzzt! I don’t believe you, or I don’t buy that explanation/reason. As can be seen, these forms of confrontation are direct and they do not operate on the presumption that the offender is being genuine or that the correctional counselor should be concerned about rapport building. Prendergast notes that most therapists have been trained in the use of “passive” treatment modalities and insist that these approaches, given time, will work (2004, p. 149). Invariably, these therapists find that traditional approaches seldom work with the sex offender. Until a group is trained in the process and can function somewhat independently, the correctional counselor must direct, control, and keep the group on course (Prendergast, 2004). Since avoidance of any painful topic is to be expected, the correctional counselor must pay close attention not only to what is said but to what is not said in the session. Further, though offenders may challenge one another, there is a danger that the group may harm rather than help certain members. Indeed, Prendergast makes the insightful observation that sex offenders can become quite judgmental of one another, since this allows offenders to feel better about themselves in relation to other members. To mitigate this, the correctional counselor should always allow sufficient time at the end of each group meeting for (1) recovery from an emotional session; (2) a summary of what occurred in the session; and (3) each member to give feedback to other offenders who spoke of their problems. After each member gives his feedback, the correctional counselor should provide summary feedback. Lastly, it is critical that the correctional counselor show no favoritism or partiality when providing his or her feedback. CAUTIONS Prendergast notes that in most cases, sex offenders both in the institution and in community treatment settings, tend to be well-mannered, polite, and behaved individuals. This is important because this can, in some cases, lead to a lax attitude toward the offender; this is to be avoided. This is particularly true since many sex offenders will attempt to make themselves likable to the correctional counselor and they will also then attempt to form some sort of personal connection with the therapist. Through this process, there is a tendency to normalize themselves into feeling equal to the correctional counselor. Once this is started, the offender will tend to distance himself from his peers in the group and begin to picture himself as being somehow superior and/or in a position that is similar to staff rather than the client population. Once this delusion starts, the denial mechanisms are entrenched and they fail to identify with their criminal behaviors, evading accountability. Naturally, the therapist should safeguard against this. Prendergast also notes that female correctional counselors are at greater risk than are male treatment providers. Indeed, sex offenders often delude themselves into believing that the female treatment provider desires him for romantic purposes, and he will tend to misperceive even the most innocent of kind acts as indication of amorous feelings. In many cases, the correctional counselor is the last person to be aware of this. Once the offender’s perception becomes known, it has usually worked itself deeply into his internal thoughts and will prove resistant to countering. According to Prendergast (2004), even if the correctional counselor makes it quite clear that she has no desires for the sex offender and even if she sets firm professional boundaries, the offender’s delusional misperceptions will often result in the following forms of rationalization (p. 152): • The authorities have made her act that way. • She is worried about her job; but when I get out, we will be lovers. • She really loves me but has to be fair to the rest of the group. • She does not know that she loves me, but I will convince her. The dangers to these rationalizations are apparent. It is also important to note that this in no way is the fault of the female correctional counselor. Rather, it is the intent of this section to note that female treatment providers are likely to encounter reactions that are fairly unique from most male treatment providers. Further, this is meant to simply educate students, both male and female, of the realities encountered when working with sex offenders. CONFIRMATION Prendergast (2004) puts it simply by noting that treatment providers should simply “believe nothing” when working with sex offenders (p. 155). As was noted earlier in this chapter, truthfulness associated with sex offenders has less to do with what they do say and more to do with what they fail to mention. In essence, these offenders tell only part of the story. They are concerned with fear and rejection and have a difficult time coming to grips with their label as a sex offender. Further, most offenders will want to get the entire process of therapy over as quickly as possible, with minimal exposure or pain. Thus, these offenders will be very convincing and will seem sincere. It is in their best interest to not be honest in regard to their need for treatment. Thus, once the offender has passed through the denial phase of treatment, the correctional counselor will gain quick confirmation from the individual offender, who in many cases will seek to quickly claim that he sees the error of his ways. However, this should not be believed. Rather, the correctional counselor should rely on the group therapy participants to provide an additional gauge on where the offender stands therapeutically. This is especially true in an institutional setting where the offenders will live, eat, and sleep within proximity of one another. Thus, it is likely that the group will be much better at evaluating the change or lack of change at has occurred among one of the members. While we are not suggesting that the therapist should make decisions based solely on the input from group members, we are noting that in cases where the counselor’s assessment of the offender’s progress is divergent from the feedback that other group members tend to provide, the correctional counselor should be doubly careful in making any determination. Lastly, whenever possible, the correctional counselor is urged to seek input from family and/or other staff regarding an offender’s progress. The confirmation process by group participants can be further improved by these other outside sources of information. Naturally, the counselor will need to ensure that family, friends, or other individuals are willing to provide such input and the counselor must remain receptive to the trauma of the victim, especially if they are a family member whom the counselor will ask for input. Prendergast (2004) notes that, when possible and if feasible, wives, parents, siblings, children (especially in cases of incest), neighbors, employers, and anyone else may be excellent sources of information regarding the offender’s progress. The key is to go beyond the confines of the therapy session and to ask persons who might not be presented with impression management techniques. In this case, impression management is when the offender presents an impression that is most favorable, in the process failing to allow defects or genuine characteristics to be observed. Thus, it is likely that the offender’s supervision officer will see a side of the offender that is also more positive than actually exists. While correctional counselors should work in tandem with community supervision officers, it is the input from others who are close to the sex offender during their day-to-day routine that will provide the most reliable information. CONTROL Because therapy is typically built on a therapeutic alliance, there can be a tendency among novice correctional counselors to dwell more on relationship building in the group setting rather than boundary placement and maintenance of the group process. With sex offender group therapy, this is a mistake. This is particularly true given that sex offenders are most often skilled at manipulation and since many will try to ingratiate themselves to the counselor. Indeed, one of the major threats involved when a correctional counselor is too mild is that of a potential therapeutic conspiracy (Prendergast, 2004). In such cases, it is not uncommon for offenders to get together outside of the group sessions so that they can plan and stage reactions within the group setting. Indeed, some offenders may work together to rehearse reactions and/or feedback to present the impression that members are working together to make progress. This is an especially problematic issue when groups use peer review. Peer review is a constructive component of group therapy, but it should be used only by seasoned counselors who understand the challenges when dealing with sex offenders. As was noted earlier, the correctional counselor can augment the group input with other persons outside of therapy, such as family members, employers, and other persons who know the offender. In addition, it is recommended that the counselor should maintain healthy psychological and professional distance from himself or herself and the group members. This prevents the impression that the counselor has favorites. Once the habit of distancing is established, none of the group participants will feel isolated or left out. Ultimately, this will have the effect of an increased and balanced sense of involvement among group members. Further, the correctional counselor must provide this distance while maintaining control of the group in a subtle manner. Prendergast (2004) recommends using noncondemning questions rather than pointed statements. For example, when the group begins to deviate off the topic, the correctional counselor might ask of the group, “Are we getting lost? I am losing the original thought of what was being said” or “Where are we going with this discussion? Does it apply to what was being said?” These types of questions aid in directing the group while providing some degree of subtlety when doing so. CONSISTENCY In order for sex offenders to avoid recidivating, it is important that aftercare be provided once the treatment program has been completed. Access to follow-up assistance should be available on a 24-hour basis. In fact, private counselors and those working within agencies should have some sort of on-call system in place. It is important that therapeutic assistance be available to the offender even when the correctional counselor is gone on a vacation or for some other reason. Further, the additional therapeutic assistance should come from someone who is familiar with the offender’s past history and treatment progress. When offenders are released from being incarcerated, it is often the case that community agencies will attempt to start therapy all over again, doing it according to their own preferences. While this is understandable, to some extent, every effort should be made between institutional treatment personnel to develop effective relationships with community-based treatment personnel who will provide services after incarceration. In doing so, it is hoped that treatment groups will devise means of treatment that enhance one another rather than working against each other. Lastly, Prendergast (2004) notes that some sex offenders may never be completely cured, and they are then likely to experience recurrences. We completely concur with this point and would note that this means that sex offenders should have follow-up nearly indefinitely. Naturally, this can depend on the exact nature of the sex offense. In cases of statutory sex offenses without violence, particularly between persons close in age, this issue may not be relevant at all. But for pedophiles and rapists (particularly those who have used violence), it is important to have a long-term relapse prevention program in place. This notion is validated all the more by the criminal justice system where, in many states, certain categories of sex offenders are required to register with local law enforcement throughout the duration of their natural life. Such requirements are indication of the fact that sex offenders present a danger to society in the long run and are difficult to change. Interrogation-Oriented Techniques The next group of techniques used are designed to ensure that the offender is being honest in their feedback that they provide to program treatment staff. This is important and necessary since sex offenders are notorious for lying and manipulating. These tools assist the therapist and community supervision staff in determining whether progress is earnestly being made in the program. The two techniques presented require the use of mechanical instruments to ensure compliance with the program; the two instruments are the polygraph and the plethysmograph. The polygraph is a standard lie detector used to measure biological responses to deception. It is used in sex offender supervision to break through offender denial of the offense, assess the offender’s honesty in reporting their sexual history, and to monitor the offender’s compliance with probation conditions (Texas Council on Sex Offender Treatment, 2005). The penile plethysmograph uses a cup or band that is placed around the penis while the offender is in a private room. Once worn, the sex offender is presented with a variety of visual and auditory stimuli. While the offender is shown pictures and exposed to sounds, a computer program records the degree of sexual arousal that is experienced by the offender (Texas Council on Sex Offender Treatment, 2005). THE POLYGRAPH AND SEX OFFENDERS According to the Texas Council on Sex Offender Treatment (TCSOT), polygraph testing, when combined with intensive treatment approaches, provides the most comprehensive means of accessing the offender’s past deviant sexual history (2005). Further, it has been determined that the rate of “crossover” between adult and child victims among sex offenders is much higher when polygraph testing is used, as opposed to a reliance on standard interrogation techniques and/or disclosures to correctional counselors (Heil, Ahlmeyer, & Simons, 2003; TCSOT, 2005). This means that, without the use of the polygraph, it is very likely that criminal investigators and therapists alike are unable to gain an accurate picture of the criminal history of the offender. This is clear support for the use of polygraph testing and intensive sex offender treatment programming when seeking sexual offense history information (Heil et al., 2003). Further, a research demonstrates that the use of polygraph interrogations of sex offenders is highly accurate—with 98%—in detecting falsifications (TCSOT, 2005). During the past 25 years, there has been an increased use of the polygraph to test the truthfulness of adult sex offenders, to break through denial, and to ensure compliance with their supervision conditions (TCSOT, 2005). Accordingly, it would seem that the polygraph is an effective tool for intervention and for eliciting admissions. This again demonstrates the therapeutic value of this instrument as well as the value to public safety and security. The admissions made by sex offenders are crucial to break down denial and to facilitate offender accountability (TCSOT, 2005). This then aids in the change process. It is expected that the appropriate mix of sanctions (for dishonesty) and privileges (for honest compliance with supervision and treatment requirements) will encourage sex offenders to disclose and address their criminal behaviors. THE PENILE PLETHYSMOGRAPH AND SEX OFFENDERS In the past two decades, the plethysmograph has evolved into a sophisticated, computerized instrument that is capable of measuring slight changes in the circumference of the penis. The use of this instrument develops a diagnostic method used to assess sexual arousal by measuring the blood flow (tumescence) to the penis during the presentation of sexual stimuli (audio/visual) in a laboratory setting. It is interesting that the plethysmograph provides the identification of clients’ arousal in response to sexual stimuli and, in the process, provides an indicator of the effectiveness of a given therapeutic intervention. Indeed, if the offender internalizes the methods taught to control his deviant arousal, there should be a corresponding decrease in deviant arousal. Further still, there should also be an increase to positive appropriate arousal. This means that the plethysmograph provides a nearly full-proof means of measuring the effectiveness of covert sensitization exercises. As the student may recall, these exercises are designed to elicit aversive reactions to inappropriate sexual arousal and, in other cases, reinforce appropriate sexual arousal. The effectiveness of these techniques (and the genuine effort of the offender) can be validated through the use of the penile plethysmograph. Because sex offenders (especially highly compulsive offenders) have been found to ruminate over sexual fantasies involving the offense pattern, the phallometric assessments have been among the most successful at detecting the likelihood for relapse among these offenders. This is particularly true when, as noted in the prior section, one considers that these offenders will avoid disclosure of their fantasies at all costs. Thus, this process allows clinicians to identify those offenders who have deviant phallometry patterns; and the more deviant they are, the more likely that recidivism will occur (Lane Council, 2003; TCSOT, 2005). One of the strengths of phallometric testing is that it provides an objective means of assessing offender progress in treatment. This can be much superior to the subjective impressions of the correctional counselor and/or community supervision personnel. This is an important point because sex offenders can be so convincing, even to people who are trained to detect their deceptions. The use of phallometric testing further refines the treatment process as it allows the correctional counselor to identify key aspects of the offender’s challenges in treatment and provides guidance to the treatment professional when modifying and/or intensifying treatment approaches. Though phallometric assessments are considered valid and reliable, these test results are nonetheless interpreted in tandem with other relevant data to determine risk levels and revisions to the treatment regimen. Because so many sex offenders either deny their culpability or minimize the extent of their interest in and involvement with sexual offending behavior, this instrument can augment the group process during the denial stage of treatment or it can provide a clear indicator of the progress that an offender has made. It is well established that the self-report of sex offenders cannot be assumed to be valid or to capable of indicating the scope of the offender’s deviant fantasies, arousal patterns, or behaviors. Hence, psychophysiological assessment of sexual arousal patterns, which is one of the most effective means of breaking through the offender’s denial, can be used. Many offenders reveal their deviant sexual interests when they are shown their positive physiologic responses to sexually inappropriate stimuli (Kercher, 1993). This instrument then serves to improve the treatment prognosis since the correctional counselor can then utilize probative techniques and assignments that target the thoughts and feelings of the offender that are otherwise undetected and therefore resistant to treatment. SECTION SUMMARY The use of cognitive-behavioral techniques has been widely accepted as the primary approach in sex offender treatment. There are many reasons for this, but most important among them is the fact that sex offender treatment must be designed in a manner that provides demonstrated evidence of the offender’s progress. Given the public safety concerns involved with sex offenders, it is critical that interventions be grounded with clear indicators of progress. This then precludes many other modalities that are more affective based and/or person centered in orientation. Indeed, given that sex offenders tend to be clever and manipulative, the typical approaches utilized by many treatment professionals may prove to be ineffective and may result in the therapist being misled. Prendergast provides several excellent guidelines related to issues specific to sex offenders and their interpersonal dynamics with treatment providers. In this chapter, his five “Cs” of treatment are presented. The five “Cs” are confrontation, caution, confirmation, control, and consistency. All of these concepts provide a general approach to sex offender treatment that thwarts manipulation on the part of many sex offenders and also optimizes intervention techniques. The use of interrogation techniques demonstrates the importance of ensuring compliance among sex offenders. This also provides further evidence that, in general, sex offender treatment is not built on the same type of trust-building relationship that might be used with other offenders. Indeed, the use of such invasive techniques does not exist with most all other types of offenders. Due to their manipulative nature, their resistance to treatment, and their danger to public safety, the sex offender tends to be set apart from most other offender typologies in the treatment and criminal justice literature. LEARNING CHECK 1. In general, person-centered approaches should not be used within most sex offender group counseling interventions. a. True b. False 2. Masturbatory reconditioning involves having the client masturbate to an appropriate fantasy, until he has an ejaculation. a. True b. False 3. Aversion therapy is a cognitive-behavioral technique used to target impulse control deficits. a. True b. False 4. The phase known as “completion” is among Prendergast’s five Cs of sex offender treatment. a. True b. False 5. The polygraph has been found to be roughly 98% accurate when used as an interrogation device with sex offenders. a. True b. False CONCLUSION The sex offending population is perhaps the most difficult and controversial group of offenders whom correctional counselors will treat. Indeed, it is sex offenders in general, and the pedophiles in particular, who bring to bear serious public concern and anger. Against that backdrop, the correctional counselor is tasked with providing treatment to this group of offenders, who on the surface often appear compliant but in most cases are resistant to treatment. Thus, the first order of business when providing therapeutic interventions for sex offenders is to address their denial. If denial is particularly persistent, the use of a pregroup for deniers is warranted and/or the use of interrogation techniques that are administered by criminal justice personnel. When sex offenders are willing to assume some level of accountability for their criminal offense, the treatment process tends to follow along four different domains. The first domain addresses deviant sexual interests, arousal, and preferences that the sex offender may possess. Because sexual behavior is largely learned, this approach presumes that aberrant forms of arousal can be unlearned. The next domain is focused on the distorted attitudes that sex offenders tend to possess. For many sex offenders, perceptions and beliefs regarding sexual behavior are not based on what would seem to be realistic or common expectations. The delusions by which these offenders operate must be challenged and the sex offender must articulate his beliefs so that exposure to group participants and the correctional counselor can allow for feedback to be given to the offender. The next step in treatment addresses the interpersonal functioning of the offender due to the fact that many sex offenders are socially challenged. Learning more effective social skills are intended to supplant those that are dysfunctional, over time. The last domain of treatment addresses behavior management. Though this is the most direct form of intervention, it provides clear and specific guidance to the offender on how to moderate his reactions to environmental stimuli that might help generate relapse. From this chapter, it should be clear that cognitive-behavioral techniques are most often practiced in sex offender treatment programs. These techniques are a bit more direct than other techniques but they are also not as easily circumvented by sex offenders as are other techniques. This is a particular strength of the cognitive-behavioral approach to treatment. Likewise, Prendergast’s five “Cs” of treatment help to reinforce the implementation of cognitive-behavioral approaches. Prendergast’s directive style of therapy, replete with confrontational (but not aggressive) forms of implementation, help to maximize the likely effectiveness of cognitive-behavioral approaches. Lastly, the use of interrogation techniques underscores the need to ensure compliance among sex offenders, both for therapeutic purposes and for public safety needs. Regardless of a correctional counselor’s training, it is important to remember that the intervention with sex offenders is first and foremost an attempt to improve public safety. It is clear that sex offender treatment cannot be based on the same type of trusting relationship that exists with many other clients, including other types of offenders in the criminal justice system. Essay Questions 1. Provide an explanation of why the initial stage of denial is so important in sex offender treatment. Further, discuss some specific aspects of treatment for sex offenders in denial. In addition, explain how interrogation techniques such as the polygraph and the penile plethysmograph can assist treatment providers in countering denial among sex offenders. 2. Provide at least one example of a cognitive-behavioral approach used in group interventions with sex offenders. Further, explain the reason that most programs utilize group interventions with sex offenders? What are some techniques from your previous readings in Chapter 5 that would be effective with sex offenders, given what you now know about sex offenders and group interventions? 3. Discuss the various cognitive-behavioral techniques outlined in the second section of this chapter. What is unique about these types of techniques compared to other techniques used with most other offenders. Further, explain why cognitive-behavioral techniques have proven to be the preferred approach to implementing sex offender treatment. 4. Discuss Prendergasts “five Cs in sex offender treatment.” How does Prendergast’s suggestions enhance the information provided by the Center for Sex Offender Management presented in the first section of this chapter? In addition, explain how his suggestions enhance the various cognitive-behavioral interventions listed at the beginning of the second section of this chapter. 5. In your opinion, what might a new correctional counselor do to prepare himself or herself for working with the sex offender population? What are some particular challenges that might be encountered among some therapists? Lastly, how might professional collaboration be of use to correctional counselors who treat the sex offending population? Treatment Planning Exercise In this exercise, the student must consider the case of Nathan and determine whether Nathan is being manipulative or whether the reasons that he gives are sincere. You must explain how you would provide treatment for Nathan and you must consider how that may affect his final outcome. Further, you must identify specific techniques that you would use and discuss how you would determine those techniques did, in fact, work to reduce his likelihood of recidivism. The Case of Nathan Nathan is a 39-year-old Caucasian male. He lives alone in his rented home and is on intensive supervision probation. Nathan is a pedophile and the whole neighborhood knows it. Nathan is also divorced, and his previous wife left him after discovering that he had been molesting her seven-year-old son, Mark, for nearly two years. Prior to this, Nathan had been suspected of inappropriate relationships with other children when he was a substitute teacher at a local elementary school as well. Nathan’s prior wife did not know of the dropped allegations that had been made against him. Nor did she know that he had lived with another woman, Sherry, who had two kids and suspected that Nathan was not to be trusted around her children. Nathan is depressed because he really did care for Mark and really did not want to hurt Mark. Nathan really thought Mark was special, and Nathan was very attentive to Mark’s needs. And, Nathan explains to you that “Deep down inside, I know Mark cared about me, too. I just do not know why he would tell his mom otherwise. I feel so betrayed!” Nathan disclosed this during your last session with him. Instead of expressing remorse, he seems to be sorrowful over his loss of the “relationship” with Mark. Indeed, Nathan feigns commitment to treatment, but sometimes his comments indicate that he saw his molestation as consensual activity with Mark. When Nathan was ultimately arrested, he was found with excessive amounts of pornography, but none of it included children as subjects. Further, his two prior adult female partners both noted that Nathan was capable of normal sexual activity but would go through periods of seeming “distracted” and uninterested in a normal sexual routine. This might last for weeks. You can tell that Nathan genuinely does not desire to physically harm children, but his overpowering attraction to children is obvious. What is more, he acts as if he GENUINELY cared about these children as if they were some legitimate adult love interest. Further, he does not seem to have any deep-seated issues with adult women, and in fact he is capable of at least faking a relationship with women, though Sherry did note that Nathan always seemed a bit uninterested in their adult relationship and frequently found ways to involve the kids as a topic in their private discussions. Further, you can tell that Nathan is not really interested in treatment, but he goes along. Nathan currently has a night job stocking freight at a local warehouse. He has numerous restrictions on his movement. His prognosis does not seem great and he seems to be keeping to himself. He has no real friends and you notice that he seems to spend an exorbitant amount of time at home alon. Bibliography Center for Sex Offender Management. (2008). An overview of sex offender treatment for a non-clinical audience. Washington, DC: Office of Justice Programs, U.S. Department of Justice. Hanser, R. D. (2007). Special needs offenders. Upper Saddle River, NJ: Prentice Hall. Heil, P., Ahlmeyer, S., & Simons, D. (2003). Crossover sexual offenses. Sexual Abuse: A Journal of Research and Treatment, 15(4), 221–236. Kercher, G. (1993). Use of the plethysmograph in the assessment and treatment of sex offenders. Senate Interim Study Paper. Knopp, F. H. (1989). Northwest treatment associates: A comprehensive community-based evaluation and treatment program for adult sex offenders. In P. C. Kratcoski (Ed.), Correctional counseling and treatment (2nd ed., pp. 364–380). Prospect Heights, IL: Waveland Press, Inc. Lane Council of Governments. (2003). Managing sex offenders in the community: A national overview. U.S. Department of Justice, Office of Justice Programs. Lester, D., & Hurst, G. (2000). Treating Sex Offenders. In P. Van Voorhis, M. Braswell, & D. Lester (Eds.), Correctional counseling & rehabilitation (4th ed.). Cincinnati, OH: Anderson Publishing Company. Prendergast, W. E. (2004). Treating sex offenders: A guide to clinical practice with adults, clerics, children, and adolescents (2nd ed.). New York, NY: Haworth Press, Inc. Texas Council on Sex Offender Treatment. (2005). Use of the polygraph in the assessment and treatment of sex offenders. Retrieved from:

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