The Way Forward in Sex Offender Treatment: A Brain-based Approach

1. The Way Forward in Sex Offender Treatment: A Brain-based Approach Anthony Beech Dawn Fisher (alternative approaches)

2. Overview The aim of the presentation is to suggest ideas in terms of what could be the way forward for sex offender treatment noting that we are all products of our brain development and brain function Incorporating ideas from the rapidly advancing field of neuroscience And what this says about other approaches to therapy, as adjuncts to current cognitive-behavioural treatment

3. Embodiment There may be no brain parts for cognition, not least separate from the brain mechanisms pertaining to bodily functions (Tucker, 2007) According to Tucker the neural structures of the mind exist to construct information, by constructing concepts that relate internal personal need to external environmental reality In its most basic form personal need is represented within the emotional and motivational networks within the limbic core cortical areas in the brain While data from the world is are interfaced by the sensory and motor areas in each cerebral hemisphere Between these boundaries the brain constructs the �information of mind� through linked patterns of meaning, woven across each cerebral hemipshere�s corticolimbic network

4. Is it important to think in a neurobiological way in terms of treatment for sex offenders? Some neurobiological markers in paedophilic sex offenders indicative of early trauma: Lower IQs (Cantor et al., 2004) Poorer visuospatial and verbal memory scores Higher rates of left handedness (Cantor et al., 2005, 2005) Higher reported rates of having reported childhood head injuries (Blanchard et al., 2002, 2003) More likely to have been placed in special education facilities

5. The neurobiology of trauma Advances in technology have enabled a much greater understanding of neurobiology in recent years Use of fMRI, PET, MRS, EEG, SPECT & Diffusion Tensor Imaging (fibre tracking) Studies have found differences in the brains of traumatised humans and animals compared to controls Trauma affects memory, learning, ability to regulate emotion, social and moral development Trauma causes both immediate and long-term endocrine changes that affect metabolism and neuropsychology Even high levels of cortisol (caused by stress) can have very real effects upon the brain

6. Adverse early experiences In fact we are programmed by adverse early experience to have: an enhanced cortisol norepinephrine/adrenaline vasopressin response and decreased oxytocin response to subsequent stressors.

7. The neurobiology of trauma 2 Traumatic events overwhelm the brain�s capacity to process information The memory may be dysfunctionally stored in the right limbic system indefinitely and may generate vivid images of the traumatic experience, terrifying thoughts, feelings, body sensations, sounds and smells Schore (1994, 1996,2003) reported that children who experience chronic traumatic stress have adversely affected right brain development due to neuronal damage and atrophy As a result they do not deal well with stress, have difficulty understanding emotion expressed by others and thus have problems with empathy

8. Exposure of the developing brain to stress hormones exerts consequences by: Affecting gene expression Myelination Neural morphology Neuroegenesis synpatogenesis

10. Areas of the brain said to be affected by early stress Corpus callosum Hippocampus Prefrontal cortex Visual cortex Auditory cortex

12. Later effects of early stress/trauma when recalling trauma the left frontal cortex shuts down (especially Broca�s area, the centre of speech and language) but the right hemisphere associated with emotional states and autonomic arousal, especially the amygdala (centre for detecting threat) increases activity the frontal lobes become impaired and so the individual has trouble thinking and speaking�

13. Need for alternative approaches in treatment �Traumatic experience is largely affective and somatic and so effective treatment must also address the body� (Solomon & Heide, 2005) As the effects of trauma are often stored in body memories that verbal therapies cannot release, we need therapies that depend on action rather than verbalisation� (van der Kolk, 2003)

14. �There is nothing more practical than a good theory� (attributed to Kurt Lewin) A neuroscientific account of human behaviour requires consideration of four levels of analysis (from Pennington, 2002) aetiology - concerned with the influence of genetic and environmental factors causing psychopathology brain mechanisms - concerned with the effects of aetiological factors on the development of the brain (how it is sculpted in its early formation) and its subsequent functioning neuropsychology - concerned with the brain-based mechanisms that generate human behaviour Symptom level analysis - concerned with the clinical phenomena thought to characterise psychopathology

15. Can we broadly apply this framework in sex offender work? Sexual abuse occurs as a consequence of a network of causal factors: biological (genetic variations, abuse history) core neuropsychological systems ecological (social and cultural environment, personal circumstances, physical environment) clinical factors All four of these levels should be mutually constraining, hence consistent with each other

16. Brain mechanisms: Recent scanning studies Cantor et al. (2007) compared 65 paedophilic sex offenders with 62 non-sex offenders The study found cerebral white matter deficiencies in the paedophilic sample White matter is composed of bundles of myelinated nerve cells which connect various gray matter areas (which primarily contains neural cell bodies) to each other

17. Brain mechanisms: Recent scanning studies These deficiencies were specifically related to two major fibre bundles The superior frontal-occipital fascuculus The right arcuate fascilus Cantor�s argument is that the these two bundles connect the cortical regions that respond to sexual cues Therefore the cortical regions act as a network for recognizing sexually relevant stimuli Paedophilia results from a partial disconnection from this network

19. An Integrated Theory of Sexual Offending

20. ITSO-Overview According to this theory, sexual offending occurs through the ongoing confluence of distal and proximal variables that interact in a dynamic way. Genetic predispositions and social learning have a significant impact upon brain development and the level of operation of three interlocking neuropsychological systems Social learning, and these neuropsychological systems work together to generate clinical problems evident in offenders deviant arousal offence related thoughts and fantasies etc Socio-affective functioning Dysregulation problems Each neuropsychological subsystem is associated with distinct functions and brain structures

21. From Pennington: Three interlocking neuropsychological functions Three interlocking neuropsychological systems. These systems are components of human agency as reflected in goal directed actions (practical reasoning) Motivation and emotional system perception and memory system action selection and control system

22. Motivational-Emotional systemAssociated with orbitofrontal, some limbic (amygdala), and brainstem (locus ceruleus, ventral tegmental areas, substantial nigra, raphe nuclues) brain structures

23. Motivation and Emotional System Allow goals and values to influence both perception and action selection rapidly and to adjust motivational [and emotional] states to fit changing environmental circumstances (Pennington, 2002) Problems in an individual�s genetic inheritance, or negative individual experiences, may lead to defects in the motivational/emotional system would include feelings of: Inadequacy Loneliness Lack of empathy Hostility Maps broadly onto the kinds of problems that have been described as stable dynamic risk factors Thornton (2002) Domain 3 - social and emotional functioning Intimacy deficits - Hanson & Harris� STABLE 2007

24. Action Selection and Control SystemAssociated with the frontal cortex, the basal ganglia, and parts of the thalamus 

25. Action Selection and Control System Help to plan, implement, and evaluate action plan and to control behaviour in service of higher-level goals Essential for evaluation of goals (and associated primary goods or values) Problems that might arise from malfunctions in action control and selection system essentially span self-regulation problems such as Impulsivity failure to inhibit negative emotions inability to adjust plans to changing circumstances and poor problem solving skills. Maps broadly onto the kinds of problems that have been described as stable dynamic risk factors Self-management problems (Domain 4) (Thornton, 2002) Sexual self-regulation and general self-regulation - STABLE 2007

26. Perception and Memory SystemAssociated primarily with the hippocampal formation and the posterior neocortex

27. Perception and Memory System Major functions of this system are to: Process incoming sensory information To construct representations of objects and events, and make them available to the Motivational/emotional and the Action selection and control systems Can be seen to contain representations or knowledge of world, others and self. Problems in perceptual and memory system can lead to: maladaptive beliefs attitudes dysfunctional interpretations of interpersonal encounters These problems can be seen as stable dynamic risk factors Attitudes supportive of sexual assault (STABLE 2000) Distorted attitudes (Thornton, 2002) (cognitive distortions)

28. Neurobiology of dynamic risk domains (recap) Domain 2 problems - Perception and Memory system difficulties Domain 3 problems � Motivation and Emotional system problems Domain 4 problems - Action Selection and Control system difficulties Negative interactions between all three systems thoughts, feelings, lack of impulse control/ emotional dysregulation leads to Domain 1: deviant sexual interest problems � as arousal per se. is a purely a mechanical function

29. Clinical Phenomena Deficits in neuropsychological functioning interact with individuals� current ecology or physical environment (proximal dimension) Cause the emergence of four groups of symptoms or clinical phenomena that are directly associated with sexual offending. These clinical phenomena can be usefully viewed as proper temporal acute risk factors Deviant arousal Cognitive distortions Social difficulties Emotional/behavioural dysregulation

30. Brain-based approaches to therapy Compassionate mind training/self-compassion Neuro Linguistic Programming (NLP) Sensorimotor psychotherapy Somatic/movement therapies EMDR Mindfulness Biofeedback

31. Self-compassion approaches to treatment Based on work of Kristin Neff (University of Texas) �the extending of compassion to the self for one�s failings and inadequacies and during experiences of suffering� Three components: Mindfulness � seeing things as they really are and in perspective, accepting what the situation is without minimising or exaggerating Kindness � treating the self with care and understanding rather than harsh self-judgment Common humanity � seeing one�s own experience as part of the larger human experience rather than separate and isolating

32. Self-compassion 2 �self-compassion is different to self-pity as it does not involve being self-centred or exaggerating personal suffering� �self-compassion provides self-clarity, seeing things as they really are, which can help to identify problem ways of behaving (seeing yourself as you are) �self-compassion creates a supportive emotional environment for change as it provides the safety to admit the truth about oneself and this can in turn provide the motivation for change�

33. Self-compassion contd. Studies have shown that self-compassion is strongly linked to well-being This includes: greater happiness optimism sense of connectedness (belonging) resilient coping Therefore links to the �Good Lives� approach to treatment

34. How might self-compassion be helpful for sex offenders? Can help them face up to what they have done and take responsibility for their behaviour � denial, shame, guilt Can help them tolerate difficulties and problems Can motivate them to change � by making them feel worthwhile Can increase their sense of self-worth - which can help lessen any urge to sabotage progress as a form of self-punishment � �I don�t deserve anything good � I need to be punished�

35. Helping overcoming treatment barriers Many offenders do not feel positive about themselves They may feel they do not deserve anything positive and so reject or sabotage progress Until they can feel compassion towards themselves they may be unable to fully face up to what they have done Until they can empathise with themselves they are unable to empathise with others, i.e., if you don�t care about yourself you are unlikely to care about others

36. Why self-compassion as opposed to working on self-esteem Self-compassion is associated with greater emotional resilience in stressful or negative situations, taking more personal responsibility for one�s role in negative life events, greater stability in feelings of self-worth and fewer downward social comparisons, being less self-centred and less angry Self-esteem involves needing to see yourself as better than others i.e. you put others down in order to feel better about yourself The pursuit of high self-esteem may also be linked to downward social comparisons and prejudice, defensive anger, self-centredness and distorted ideas about oneself

37. Compassionate Mind Training Developed by Paul Gilbert (Uni. of Derby) Client uses a series of meditations and is helped to develop a �compassionate image� which s/he then imagines focused on the self This helps to self-soothe, calm arousal and provide the client with feelings of support and nurturing � something they probably did not receive as a child Works at a neurobiological level to stimulate key areas of the brain Specifically the Motivational-Emotional system

38. Eye Movement Desensitisaton and Reprocessing (EMDR) Controversial method developed by Francine Shapiro in 1989 Use of alternating, rhythmic stimuli whilst client focuses on traumatic image Strong anectdotal evidence but controlled studies variable Critics believe it is a form of exposure and that there is more evidence for the use of exposure � however not all clients can cope with exposure treatment Despite this, now included in NICE guidelines regarding effective treatments for PTSD

39. EMDR contd. Levin, Lazrove & van der Kolk (1999) Used SPECT scans before and after EMDR sessions with 6 subjects over 3 sessions Reported an increase in bilateral activity in the anterior cingulate cortex (modulates the limbic system and helps distinguish real from perceived threat) Increased ACC indicates decreased hypervigilance Also increased pre-frontal lobe metabolism which suggests greater ability to make sense of incoming sensory stimulation

40. Mindfulness Defined as "a kind of nonelaborative, nonjudgmental, present-centered awareness in which each thought, feeling, or sensation that arises in the attentional field is acknowledged and accepted as it is". (Bishopp et al., 2004) Two-component operational definition self-regulation of attention so that it is maintained on immediate experience, thereby allowing for increased recognition of mental events in the present moment adopting a particular orientation toward one�s experiences in the present moment, an orientation that is characterized by curiosity, openness, and acceptance. Recent research supports promising mindfulness-based therapies for a number of medical and psychiatric conditions, chronic pain, depression and substance abuse, and recurrent suicidal behavior

42. Conclusions regarding other approaches to therapy �Top-down processing i.e. CBT � use cognitive strategies to manage or inhibit problematic thoughts, feelings and behaviours � uses the neocortex and does not process episodic memories or resolve physiological hyperarousal Even with years of therapy, immediate responses to triggering stimuli tend to be physiological rather than logical Biologically informed therapy uses �bottom-up� processing which focuses on what is going on in the body This helps clients connect with their bodies and feelings, facilitates learning to tolerate intense feelings and to release emotion appropriately (Solomon & Heide, 2005)

43. References Pennington, B. F. (2002). The development of psychopathology: nature and nurture. New York: Guilford Press. Siegel, D.J. �The Mindful Brain. London: Norton Solomon, E.P. & Heide, K.M. (2005). The biology of trauma: Implications for treatment. Journal of Interpersonal Violence, 20, 51-60. Teicher, M.H. (2007). Childhood abuse, brain development and impulsivity. Paper presented at the MASOC/MATSA Joint Conference, Marlborough, MA, available from: www.mclean.harvard.edu/pdf/research/clinicalunit/dbrp/mteicher-talks/MASOC_MATSA_meeting.pdf Tucker, D.M. (2007). Mind from body: Experience from neural structure. Oxford: OUP. Van der Kolk, B. (2003). The neurobiology of childhood trauma and abuse. Child and Adolescent Psychiatric Clinics of North America, 12, 293-317.

44. Other generally useful references Cozolino. L. (2006). The neuroscience of human relationships: Attachment and the social brain.�London: Norton. Hodgins, S., Viding, E., & Plodowski, A.. (2009), The neurobiological basis of violence: Science and rehabilitation. Oxford: OUP Romer, D. & Walker, E.F. (Eds.) (2007). Adolescent psychopathology and the developing brain.�Oxford: OUP