Culture, Norms, and Process
in Adult Sex Offender Groups
Getting Reacquainted
with the Therapeutic Factors of Groups
James...
 (1) To provide a review of the
therapeutic factors and
change mechanisms
available in group psychotherapy.
 (2) To port...
 (3) To provide mental health clinicians who
conduct sexual offender-specific treatment
with a summary of the strategies ...
 (4) To sensitize treatment professionals to
the ways in which the following dynamic risk
factors (amenable to change) cl...
 Intimacy deficits
 Deviant sexual attitudes, beliefs and
interests
 Distorted attitudes/cognitions
 Poor social funct...
 Section 1: Sex-offender Specific Treatment
and Group Therapy: Two Worlds Divided
 Section 2: Ten Basic Concepts of Grou...
 Section 5: Mechanisms and Processes of
Change
 Section 6: Patient Preparation and the
Group Agreements
 Section 7: The...
 Section 9: Using the Group Modality to
Maximize the Efficacy of SO Treatment: A
Synthesis of Two Worlds
 Section 10: Em...
Participants will be able to:
 Access a core foundational knowledge
base in group theory, process, and
technique.
 Ident...
Participants will be able to:
 Articulate how the group therapy modality
can be capitalized on to maximize the
efficacy o...
Participants will be able to:
 Apply clinical techniques and strategies to
their current SO groups.
11
Sex-Offender Specific Treatment
and Group Therapy: Two Worlds
Divided
12
 Sex-offender specific treatment and group
therapy: two words divided!
 How I came to this work ...
13
 The goal of sex offender-specific treatment
is community protection.
 The effective treatment of SOs in order to
reduce...
 Group therapy is the most common
treatment modality for this population.
 Yet, to me it was (and is) a paradox that
wha...
 There are, potentially, many reasons for
this:
 the specific qualities and challenges of SOs
 certification demands th...
 Involuntary clients
 Forensic setting
 Risk assessment and standard treatment goals
 Containment model/limited confid...
 The primary focus of treatment is not the
well-being of the client, but the protection
of the community.
 The emergence...
 Yet I think this duality is somehow related to
why specialization in working with sexual
offenders seems to overshadow a...
 Understanding what the group therapy
modality has to offer in terms of creating
opportunities for key moments of insight...
 Lack of standardized certification and other
credentialing requirements in most
jurisdictions presents a major difficult...
 There is a wide variance re: group content,
process, and cultures
 A wide variance re: knowledge of group
therapy theor...
 Lack of basic training in group therapy
 One-to-one treatment in the context of
group
 Merely an extension of parole/p...
 Psychoeducational
 Interpersonal/
process-oriented
 Supportive
 Relapse prevention/recovery-based
 CBT
 Case manage...
 CBT
 R/N/R
 Social Learning Theory
 Relapse Prevention Model
 Behavioral Techniques (thought-stopping, etc.)
 Motiv...
 Desistance (risk reduction; the R/N/R Model):
will not do it again
 Transformation (characterological): will be a
diffe...
 This training will attempt to address these
issues by providing a foundational
knowledge of group psychotherapy,
specifi...
 Groups are excellent for the mandated
(involuntary) and difficult/resistant client.
 My prediction is that most SO grou...
 For example, full disclosure rarely occurs at
the beginning of treatment nor via the
pressure of the therapist.
 If the...
 Giving and receiving feedback (here-and-
now engagement) is pivotal in SO groups,
but often clinicians lack a knowledge ...
 (1) Given the unique characteristics of SOs
and the knowledge base required to
conduct sex offender-specific treatment,
...
 (3) The group therapy perspective I will
present in this talk addresses offenders’ life
problems related to recidivism r...
 Dynamic risk factors (risk-relevant and
potentially changeable) are directly
addressed by the group therapy modality,
es...
 (4) The varied orientations used when
conducting SO group therapy (CBT,
relapse-prevention, etc.) can be enhanced
with t...
 (5) A major underlying goal of all groups is
to assist members in gaining insight into their
thoughts, emotions, and beh...
Ten Basic Concepts of Group
Psychotherapy
36
 https://www.youtube.com/watch?v=NI7K_
ojMUoo
 https://www.youtube.com/watch?v=Y7xaC
bMqpJI
37
 If all of the group members
are “ill” or share the same
problems, they are unable
to help each other.
 Groups (and the ...
 Groups are artificial, unreal and sterile – not
emotionally charged.
 Groups are suited for everyone.
 The main goal o...
“If it is true that personality is formed in,
through, and by relationships, then a
therapeutic modality that uses the
int...
 It can be argued that most forms of
psychopathology involve problems with
“the ability to effect, experience, and enjoy
...
 The group itself is your “client” and holds
within it the curative factors necessary to
promote change in each member.
...
 The leader is mainly focused on creating a
group culture (norms)that promote the
group’s optimal level of development (a...
 The efficacy of any group is primarily
determined by the group leader.
 The attitude of the leader is more important
th...
 The leader must model acceptance of
others, a high level of frustration-tolerance,
the capacity to be observed/critiqued...
 Groups provide commonality (e.g. “I’m not
the only one with this problem”) and the
feeling of being a part of
something/...
 The group is a social microcosm of the real
world – allows group members to become
more aware of (1) their feelings and
...
 Groups offer a natural laboratory in which
members can experiment with new ways of
being with themselves and others;
reg...
 Members confront each other, increasing
accountability and the motivation for
change and avoiding the issue of getting
i...
 Powerful forces at work in groups make
them quite vibrant and dynamic –
members experience their interpersonal
difficult...
 Here-and-now processing
(“freeze-frame”) moments
advances the members’
capacity to reflect upon
affective states and def...
 The group leader represents a composite of
all authority figures.
 Members’ attachment to the leader is
highly informat...
 Family-of-origin dynamics are always
replicated in group.
 Given this, group members will take on
“roles” in the group ...
 Altering these roles/experimenting with new
roles can make it possible for
developmental issues to be considered and
ref...
 A group provides an oral history/legacy –
group programs have a narrative legacy to
which clients repeatedly refer.
 Th...
 Group Theory
 Group Process
 Group Technique
See Rutan, Stone, and Shay (2007) and
Vannicelli (1992)
56
 The mechanisms of change and
therapeutic factors associated with the
group environment.
57
 The unfolding of a group from beginning to
end including group norms, generating
trust, how conflict emerges in a group,...
 Leader interventions aimed at facilitating
the progression of the group-as-a-whole
and creating social learning opportun...
Group Dynamics and Group
Development
60
 Groups evolve and change over time.
 The term “group dynamics” implies the view
of the group as a whole, not as a sum o...
 The attractiveness and sense of
belonging to a particular group (and its
culture).
62
 Members opt for particular roles based
on skills, tendencies, and personal history.
 Members are assigned and maintaine...
 Refers to the evolution of the group that is
more or less predictable.
 Not linear; subject to movement forward
and bac...
 Fears and anxieties often emerge at
transitional junctures and typically involve
concerns re: being judged, being too
em...
 The ability to identity the developmental
stage of a group allows the leader to
predict members’ behavior and use
interv...
Three Primary Models of Group
Development in the Literature
67
Initial or Orientation Phase
 The leader refers to the group agreements
and begins to establish norms.
 The leader begin...
Middle or Working Phase
 Productive work toward goals is
undertaken.
 The leader’s role diminishes and morphs into
that ...
Final or Termination Phase
 A sense of loss may be experienced by
group members.
 The leader encourages the members to
d...
The Formative Stage
 The joining stage of the group; group
members find what is common between
each other (“we-ness”).
 ...
The Reactive/Rebellious Stage
 Members struggle with concerns about
belonging to the group (“I-ness”).
 Members try to e...
The Mature Stage
 Members work maturely toward goals, the
apex of group development.
 Members interact spontaneously; th...
 Members are open to exploring problems
they did not identity when they joined the
group.
 There is an emerging oral his...
The Termination Stage
 Separating/terminating.
 The oral history of the group continues to be
referred to and there is a...
Stage One (Orientation/Forming)
 Group members orient to group and each
other.
Stage Two (Transition/Storming)
 Anxiety,...
Stage Three (Cohesiveness/Norming)
 A therapeutic alliance forms between
members.
Stage Four (Working/Performing)
 Membe...
Commonalities: An Amalgamation
78
 Members focus on others rather than
themselves.
 Conflicts are ignored or avoided (sterile tone);
communication is uncl...
 Members have internalized the ground rules and
begin following them; members begin to test the
group and seek power and ...
 Members feel attached to the group; show care and
empathy toward each other, but appropriately confront and
challenge.
...
 Feelings of ambivalence about the group ending
(and/or members leaving) are verbalized.
 Regression and disengagement c...
 Self-disclosure moves from being centered
on impersonal events or feelings (of the
past or outside of group) to more per...
 The support for norms shifts from the leader
to the more experienced members of the
group.
 Members begin to offer and ...
Phase of Development Meaning Intervention
Initial phase: Forming
Group
Reality-based Acceptance/normalizing,
advice, norm-...
Group Therapeutic Factors
and Yalom’s Curative Factors
86
 Members re-create their social situations in
group, through the interactions they form
with other members and the leader...
 The leader directs attention not necessarily
to the elimination of defenses, but to the
utility of these defensive proce...
(#1) Group environmental factors
(#2) Belonging
(#3) Self-revelation factors
(#4) Learning factors
(#5) Self-understanding...
 Empathy, acceptance, support and safety
of group members generated by each
other and by the leader.
 A supportive clima...
 Involves ordinary courtesies, and verbal and
nonverbal communications by the leader.
 A “holding environment.”
 The gr...
 Not being isolated.
 The feeling of being a part of something
outside of oneself, in which one is valued.
 Close socia...
 The exposure (affect, history, self-disclosure,
etc.) of the offender to other members is
vital.
 Both tests the safety...
 Many different types of learning including
education, suggestions/advice, vicarious
learning, and practicing/trying out ...
 The integration of cognitive understanding
with emotional experience (insight).
 The group process evokes events in the...
96
Nonfiction
 1970 The Theory and Practice of Group
Psychotherapy (5th edition 2005)
 1980 Existential Psychotherapy
 198...
Novels and Stories
 1974 Every Day Gets a Little Closer
 1989 Love´s Executioner and Other Tales of
Psychotherapy
 1999...
99
 Major therapeutic benefit for Yalom: the
group interaction as it takes place in the
here-and-now (allows members to lear...
 Focus on the here-and-now involves:
(1) the present moment in the group; and
(2) the illumination of the process (adding...
 Involves freeze-framing an interpersonal
experience in the group to assist members
to reflect upon communication blocks,...
 https://www.youtube.com/watch?v=R9k
TWTzRqe8
103
 Eleven curative factors – often called
healing factors or factors responsible for
therapeutic change.
 Reflect differen...
 (1) Universality: the feeling of having
problems similar to others, not being alone.
 (2) Altruism: helping and support...
 (3) Instillation of hope: faith that the
treatment will be effective.
 (4) Imparting of information: sharing
knowledge;...
 (5) Development of social skills: social learning
and the development of interpersonal skills;
learning new ways to talk...
 (7) Imitative behavior: members expand
their personal knowledge and skills through
the observation of others; model the
...
 (9) Existential factors: recognizing that even
with guidance and support, everyone is
ultimately solely responsible for ...
 (11) Corrective recapitulation of family-of-
origin issues/Self-understanding: identifying
and changing the dysfunctiona...
Mechanisms and Processes
of Change
111
 Refer to the ways group members use the
therapeutic factors available in group.
 Individuals repeat cognitive, emotiona...
Patient Processes
113
 Especially relevant early in the group.
 Observe others (veterans), see how they
do it, may help reduce fears and
anxie...
 A deeper, more unconscious type of
“imitation.”
 Increases the pride, self-esteem, and
altruistic value of the member w...
 The group member behaves differently: he
has integrated something that was learned
in the group and the learning alters ...
 A group member has transference to the
leader, the other members, and the group
as a whole.
 This creates an endless ar...
Therapeutic Processes
118
 Motivated by the group agreement: “You
are obligated to verbalize your thoughts
and feelings and to communicate them in
...
 It is always better to advise members to
make observations/confrontations that are
largely non-judgmental, rather than t...
 Clarification often is used following a
confrontation.
 It involves the collection of data around a
specific behavior o...
 Often provided by the leader and best
communicated with an empathic
hypothesis.
 Contains 3 components: (1) a here-and-...
 I also routinely attempt to include in the
interpretive remark some speculation as
to the causality of the original offe...
 Interpretations are typically thought as
directed toward the individual, as in
individual therapy.
 Yet there is also t...
 Most evident during transitions between
developmental phases, during crises, and
when a group member is added to, or
dep...
 When the group is unable to process
something and move forward, is
ambivalent about moving forward, or is
attempting to ...
 John hasn’t done his homework assignment
(yet again).
 “John, how does it feel that the group is
allowing this to happe...
 These interpretations can be suggestive in
tone, or certain in tone, and often the latter
is better.
 Whenever you say ...
 Resistance to all interpretations and
feedback is common and invaluable in
groups for SOs.
 Each member sees an offende...
 An individual’s use of the group process is
often viewed from the perspective of:
relatedness: primitive: hiding, lying,...
Patient Preparation
and the Group Agreements
131
 Nature of the group
 Goals of the group
 Structure of the group sessions
 Expectations of the offender (work on
perso...
 Gain a detailed understanding of the
offender’s sexual crime; risk-assessment
tools; psychological testing.
 Attempt to...
 Offer information about your curriculum,
group psychotherapy, and how the
offender will be evaluated across
treatment.
...
 The group is a social microcosm of one’s
world (repetition of roles, interpersonal
tendencies, and the possibility for
i...
 The offender will be expected to give and
receive feedback, explore roles (e.g.,
compliance, acceptance, anxiety,
rebell...
 Attend every group, on time, and stay for the
entire duration.
 Agree to work on the problems that brought
you to the g...
 SOs typically tend to want to bypass the
entire therapeutic element of the group; see
it as a “class” and something mere...
 Demonstrate your interest in the offender’s
life and general well-being (how to help
him not get violated; how to work o...
 Anxiety over being accepted
or rejected
 Concern about the judgment
of others
 Afraid of appearing stupid
 Concerns a...
 The group agreements establish safety and
structure.
 It is inevitable that the group agreements
will be broken; these ...
The Role of the Group Therapist
142
 Because it is a system, a therapy group
requires the leader to work on numerous
dimensions, be capable of working on
eac...
 The leader must create a ritualistic structure.
 The ritual we use at La Paz:
identity/envelope, fee payment, receipts,...
 Active commentary re: expectation of
promptness, regular attendance, and on
time payment of fees.
 Putting thoughts and...
 Members using personal disclosure,
advice/empathy, inquiry, and
confrontation whenever possible
146
 Empathizing/supporting as much as
possible
 Joining offenders together (subgrouping is
advised)
 Sharing of the leader...
 The leader gradually begins to lower his or
her activity as the established norms
promote a member-centered context and
...
 Other members will emerge as mini-
therapists and leaders (veterans help the
rookies).
 From time to time, the leader i...
 There are frequent references to the legacy
of the group, other offenders and situations,
and vicarious and social learn...
 Most leaders are typically too active, and
shoulder the burden of the group.
151
 It is generally prudent to be active in the
early phase of a group, then gradually
become less active and observe.
 Mov...
 A balance must be achieved between
self-disclosure and an odd withdrawal
and lack of personalization. Mistakes on
both e...
 Personal information is always being
revealed.
 When you are confronted, don’t assume
it’s merely “transference” – ask ...
 I am always transparent about certain
issues: my role in containment team
meetings, my contact with POs and PGs,
hearing...
 I will also mention issues in my life that I want
to model (time management, affect
regulation, social skills, etc.).
156
 Group members tend to stay at a content
level, i.e., what is said and the concrete
meaning of things.
 Process is often...
 The members will naturally want to talk
about out-of-group events and situations,
their POs, legal cases, etc.
 The lea...
 It is sometimes helpful to evaluate out-of-
group content as a metaphor for
(displacement of) in-group phenomena.
 Even...
 The leader is always attending to, and
shifting between, observations of the group
as a whole and individual’s particula...
 Group-as-a-whole interventions help to
promote a sense of cohesion between
group members and the sense that one is
not a...
 Even when focusing on an individual
member, it is often useful to attempt to
inquire if his personal issues may be share...
 In SO groups, the past is frequently avoided
by the members who instead prefer to
focus on the present (the leader must
...
 Links between the present (inside the
group) and past (prior to offense/at time of
offense) are ideal and, over time, be...
 A natural rhythm emerges between subject
matter content.
 Deviant sexual interests, distorted attitudes,
interpersonal ...
 I generally attempt to inquire about how
what emerges in group may have been
part of a member’s life experience for a
lo...
Special Group Leadership Issues
and Techniques
167
 Communication is often expressed through
metaphors and symbolic meaning (often
seen as a compromise between direct
expre...
Most SOs may be viewed, at
least in part, as suffering from
a poor or limited capacity to
be intimate with others.
 Gestu...
 “Dan, you are really showing us all what it
might mean for you if you didn’t have to be
closely monitored.”
 Indicate t...
 From the work of Peter Fonagy
and his colleagues (2002, 2006)
in London.
 You are recognized by another and the
other h...
 The leader must actively observe group
members’ nonverbals; norm-setting: putting
thoughts and feelings into words, not
...
 There is often a pull in groups to be highly
directive, gratify, teach, and relieve
tension/anxiety.
 The leader must t...
 One way to think about process is that the
members of the group, and the group as a
whole, are always operating at an
un...
 Hesitation to express oneself, an
unwillingness or inability to initiate personal
work in group, the denial of problems ...
 Resistance is commonly dealt with
punitively, and should not be!
 Merely mentioning resistance (fears) in your
groups w...
 Group leadership skills cannot be
separated from the leader’s own
personhood and conscious and
unconscious feelings abou...
 Consider your genuineness/self-
disclosure/respect for members vs.
critical/demeaning tendencies.
 Consider content vs....
Using the Group Modality
to Maximize the Efficacy
of SO Treatment: A Synthesis of Two
Worlds
179
 In all systems, there is a tendency for role
reversals in which the abuser/perpetrator
becomes the abused.
 This can ha...
 Overt and subtle forms of aggression
toward offenders must be avoided
(sarcasm, shaming, etc.).
 Encourage members to e...
 Avoid “objectifying” the offender: state
your observations and hunches in a
tentative way, never convey a clinical
arrog...
 The leader is consistently observed by SOs,
for a variety of reasons and motives.
 Your observations, statements, and i...
 Your credibility is enhanced if you call it as
you see it, and consistently demonstrate a
concern for your group members...
 You also demonstrate consistent efforts at
clarifying to POs the offender’s mental
status and psychological make-up (you...
 There is a big difference between
treatment compliance and the conversion
of the offender into an offender who is also
a...
 One element of this conversion process is
creating a space for the member to be
seen accurately (the treatment becomes
“...
 Many offenders never get to this place, and
their mere compliance needs to be
tolerated (to model to other group
members...
 The adage that full disclosure is a pre-
condition for SO treatment is problematic,
in my opinion.
 Compliance is typic...
 The overcoming of denial is a gradual,
therapeutic process that marks the
conversion of the offender into an actual
grou...
 Denial is often erroneously referred to as a
global construct; it actually has many
distinct components: complete denial...
 Some offenders externalize,
minimize, and deny not to
intentionally offend again,
but to avoid intolerable
self-recognit...
 If the victim is empathized with, so too will
the offender empathize with the parts of
himself that perpetrated and abus...
 The emotional manipulation of others and
tendency to exploit are outcomes of a
fractured identity and a profound sense o...
 It is beneficial for SOs to realize that without
external intervention and treatment, their
offending behavior would mos...
Level of Personality
Development
Primary Issues Group
Interventions/Priorities
Organizational/Psychotic Breakdown of relat...
Level of Personality
Development
Primary Issues Group
Interventions/Priorities
Narcissistic Abandonment of
reliance on oth...
Empirical Assessment of Group
Process and Therapeutic Factors
198
 Lack of research in this area.
 Easy to do and informative to the group
leader.
 Need to use process measures from the...
 Do treatment programs assess dynamic risk
factors (and other domains of functioning)
pre- vs. post-treatment? [OUTCOME]
...
 Are those SOs who demonstrate the greatest
magnitude of improved outcomes (or
achievement of “normal” categorizations)
a...
 The Group Climate Questionnaire—Short Form
(GCQ-S; MacKenzie, 1983), the most common
measure of group process, is a self...
 Developed by Piper et al. (1983), the
Cohesion Questionnaire (CQ) consists of 8
items in which members evaluate each
oth...
 The Curative Climate Instrument (CCI)
was developed by Fuhriman et al. (1986)
to assess group members’ ratings of the
th...
Item Factor
Being able to say what was bothering me instead of holding it in. Catharsis
Belonging to and being valued by a...
Item Factor
Expressing my feelings even though I am uncertain. Catharsis
Learning why I think and feel the way I do (i.e.,...
 Therapeutic Factors Inventory (TFI) is an
empirically-derived comprehensive
assessment of the presence or absence
of the...
 The Yalom Q-sort (Lese & MacNair-Semands,
2000) was developed to measure patients’
perceptions of Yalom's (1995) 11 ther...
 Developed by Gold, Kivlighan, and Patton
(2013), this measure consists of three
questions focusing on an event that
occu...
 Developed by Burns and Auerbach (1996),
The Empathy Scale (ES) is a 10-item self-
report questionnaire that reflects cli...
 The Working Alliance Inventory-Short Version
(WAI-S; Horvath, & Greenberg, 1989) is a 12-
item measure that assesses bot...
Summary and Conclusion
212
 https://www.youtube.com/watch?v=eJY
RBc3_JaI
213
 Those who have committed sexual crime
vary in terms of static and dynamic risk
factors, and offending circumstances.
 T...
 I believe that the sexual offender can be
converted from “criminal” to “therapy
client” if the leader successfully mines...
 I have emphasized the development of
prosocial skills (interpersonal learning) and
the capacity to relate to others.
 Y...
 By increasing the offender’s level of self-
relatedness, he is better able to ascertain
when he may be at risk for actin...
 Alonso, A., & Rutan, J.S. (1996). Activity/nonactivity and the group
therapist: ‘Don’t just do something, sit there.’ Gr...
 Burns, D.D., & Auerbach, A. (1996). Therapeutic empathy in
cognitive-behavioral therapy: Does it really make a differenc...
 Kroner, D.G., & Yessine, A.K. (2013). Changing risk factors that
impact recidivism: In search of mechanisms of change. L...
 Purvis, M., Ward, T., & Shaw, S. (2013). Applying the good lives
model to the case management of sexual offenders. A pra...
222
James Tobin, Ph.D.
Licensed Psychologist PSY 22074
220 Newport Center Drive, Suite 1
Newport Beach, CA 92660
La Paz Psycho...
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Culture, Norms, and Process in Adult Sex Offender Groups: Getting Reacquainted with the Therapeutic Factors of Groups

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Most clinicians who treat adult sex offenders utilize group therapy. However, facilitation of groups for sex offenders is often highly idiosyncratic, with great variance in the content and process of groups, clinicians’ views of intervention goals, strategies, and technique, and how the cultural fabric of the group is established. Moreover, clinicians who treat sex offenders typically have expertise in the assessment of risk, relapse prevention, and individual factors that impact the nature and magnitude of aberrant sexual beliefs and tendencies, yet have never had or don’t readily recall advanced training in group psychotherapy. To address this issue, this presentation will describe and delineate transtheoretical factors of group psychotherapy, including here-and-now processing, vicarious learning, group-as-a-whole phenomena, and developmental dynamics across the evolution of the group. Attention will be devoted to the relevance of these factors for adult male sex offender groups, with clinical case material used to illustrate significant themes. Additionally, empirically-based measures that assess group process factors showcased in this talk will be introduced. Attendees will leave this presentation with a greater repertoire of intervention strategies from which to draw, and a theoretical framework for understanding the common events and dynamics that emerge in groups for adult male sex offenders.

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Culture, Norms, and Process in Adult Sex Offender Groups: Getting Reacquainted with the Therapeutic Factors of Groups

  1. 1. Culture, Norms, and Process in Adult Sex Offender Groups Getting Reacquainted with the Therapeutic Factors of Groups James Tobin, Ph.D. Director, La Paz Psychological Group Laguna Hills, CA Presentation at the Annual Conference of CCOSO May 9, 2014 | San Diego, CA 1
  2. 2.  (1) To provide a review of the therapeutic factors and change mechanisms available in group psychotherapy.  (2) To portray the shifting role of the group leader throughout the developmental phases of groups. 2
  3. 3.  (3) To provide mental health clinicians who conduct sexual offender-specific treatment with a summary of the strategies and techniques of successful group therapy as applied to offenders. 3
  4. 4.  (4) To sensitize treatment professionals to the ways in which the following dynamic risk factors (amenable to change) closely linked to sexual offending can be addressed in groups: 4
  5. 5.  Intimacy deficits  Deviant sexual attitudes, beliefs and interests  Distorted attitudes/cognitions  Poor social functioning/interpersonal competency  Impaired self-regulation/poor behavior management 5
  6. 6.  Section 1: Sex-offender Specific Treatment and Group Therapy: Two Worlds Divided  Section 2: Ten Basic Concepts of Group Psychotherapy  Section 3: Group Dynamics and Group Development  Section 4: Group Therapeutic Factors and Yalom’s Curative Factors 6
  7. 7.  Section 5: Mechanisms and Processes of Change  Section 6: Patient Preparation and the Group Agreements  Section 7: The Role of the Group Therapist  Section 8: Special Group Leadership Issues and Techniques 7
  8. 8.  Section 9: Using the Group Modality to Maximize the Efficacy of SO Treatment: A Synthesis of Two Worlds  Section 10: Empirical Assessment of Group Process and Therapeutic Factors  Section 11: Summary and Conclusion 8
  9. 9. Participants will be able to:  Access a core foundational knowledge base in group theory, process, and technique.  Identify the therapeutic factors of group psychotherapy.  Identity group developmental phases and change mechanisms. 9
  10. 10. Participants will be able to:  Articulate how the group therapy modality can be capitalized on to maximize the efficacy of SO groups by affecting numerous dynamic risk factors and criminogenic and non-criminogenic needs. 10
  11. 11. Participants will be able to:  Apply clinical techniques and strategies to their current SO groups. 11
  12. 12. Sex-Offender Specific Treatment and Group Therapy: Two Worlds Divided 12
  13. 13.  Sex-offender specific treatment and group therapy: two words divided!  How I came to this work ... 13
  14. 14.  The goal of sex offender-specific treatment is community protection.  The effective treatment of SOs in order to reduce the likelihood of future victimization through the safe release of offenders into the community.  And, also ... 14
  15. 15.  Group therapy is the most common treatment modality for this population.  Yet, to me it was (and is) a paradox that what the group therapy modality has to offer seems to be lost/muddled in the context of sex offender-specific treatment. 15
  16. 16.  There are, potentially, many reasons for this:  the specific qualities and challenges of SOs  certification demands that emphasize knowledge of SOs and treatment vs. group therapy  group treatment approaches that devalue or avoid a focus on group process 16
  17. 17.  Involuntary clients  Forensic setting  Risk assessment and standard treatment goals  Containment model/limited confidentiality  Treatment goals set by provider  Client motivation is largely self-serving  A consistent atmosphere of distrust (polygraphs, etc.)  A consistent atmosphere of shame  Victim and community safety focus 17
  18. 18.  The primary focus of treatment is not the well-being of the client, but the protection of the community.  The emergence of the Good Lives Model implies movement toward an integration of this duality. 18
  19. 19.  Yet I think this duality is somehow related to why specialization in working with sexual offenders seems to overshadow a knowledge base in and appreciation of group psychotherapy process and technique. 19
  20. 20.  Understanding what the group therapy modality has to offer in terms of creating opportunities for key moments of insight, new behaviors, and change, and how therapists (with a specialized knowledge of sex offender-specific treatment) can capitalize on the full potential of this modality and will go far in uniting the divide. 20
  21. 21.  Lack of standardized certification and other credentialing requirements in most jurisdictions presents a major difficulty in promoting common standards of group psychotherapy practice.  Re: sex offender-specific practice, we seem to emphasize knowledge competencies over skill competencies (i.e., how to facilitate a group effectively). 21
  22. 22.  There is a wide variance re: group content, process, and cultures  A wide variance re: knowledge of group therapy theory and technique  “Groups” vs. “classes” 22
  23. 23.  Lack of basic training in group therapy  One-to-one treatment in the context of group  Merely an extension of parole/probation 23
  24. 24.  Psychoeducational  Interpersonal/ process-oriented  Supportive  Relapse prevention/recovery-based  CBT  Case management 24
  25. 25.  CBT  R/N/R  Social Learning Theory  Relapse Prevention Model  Behavioral Techniques (thought-stopping, etc.)  Motivational Interviewing/Cycle of Change  Attachment Theory  The Good Lives Model  Desistance Theory  Positive Psychology (Strengths-based Work) 25
  26. 26.  Desistance (risk reduction; the R/N/R Model): will not do it again  Transformation (characterological): will be a different person  Return to previous level of functioning (prior to offending): will be who he was before he became vulnerable to offending  New level of functioning (the Good Lives Model): will be a more effective and fulfilled person  Victim empathy, accountability, reunification, assimilation back into the community, etc. 26
  27. 27.  This training will attempt to address these issues by providing a foundational knowledge of group psychotherapy, specifically re: components of group process.  It is my hope that his knowledge base will promote an effective and useful synthesis of sex offender-specific treatment and group therapy. 27
  28. 28.  Groups are excellent for the mandated (involuntary) and difficult/resistant client.  My prediction is that most SO group facilitators work too hard and don’t capitalize on the group therapy modality (they lapse into 1-1 therapy and case management, and/or lose focus on the systemic elements of group). 28
  29. 29.  For example, full disclosure rarely occurs at the beginning of treatment nor via the pressure of the therapist.  If the group process is appropriately supported by the facilitator, the group members themselves will support the offender (shame, guilt, fear of going to jail, humiliation, etc.) to make an honest and helpful disclosure (what led to the offense, what were the consequences, etc.). 29
  30. 30.  Giving and receiving feedback (here-and- now engagement) is pivotal in SO groups, but often clinicians lack a knowledge of intervention techniques and strategies to promote here and now experience, especially in highly-resistant, uncooperative SO groups.  Here-and-now processing energizes the group and serves to initiate inquiry re: circumstances outside of the group. 30
  31. 31.  (1) Given the unique characteristics of SOs and the knowledge base required to conduct sex offender-specific treatment, clinicians must be equally knowledgeable of group therapy theory and technique.  (2) There are unique therapeutic benefits of group and unique ways the group promotes positive treatment outcomes, especially for SOs. 31
  32. 32.  (3) The group therapy perspective I will present in this talk addresses offenders’ life problems related to recidivism risk (criminogenic needs) and other life problems (non-criminogenic needs). 32
  33. 33.  Dynamic risk factors (risk-relevant and potentially changeable) are directly addressed by the group therapy modality, especially social problems, intimacy deficits, lifestyle instability, poor cognitive problem- solving, and sexual deviance.  Non-criminogenic needs (internal distress, lack of victim empathy, denial of sexual crime, and low sexual knowledge) are also addressed; necessary in treatment to encourage engagement (Hanson & Yates, 2013). 33
  34. 34.  (4) The varied orientations used when conducting SO group therapy (CBT, relapse-prevention, etc.) can be enhanced with the principles taught in this training.  This training is atheoretical and emphasizes key elements of interactional/interpersonal processes that can be modified to supplement any group therapy program operating from numerous theoretical orientations and treatment approaches. 34
  35. 35.  (5) A major underlying goal of all groups is to assist members in gaining insight into their thoughts, emotions, and behaviors, especially in social contexts, and achieving a greater degree of flexibility and freedom.  (6) The optimal use of the relational and process elements of groups will directly help the offender develop more positive ways of being with others, meet their communicative and emotional needs, and gain insight into problematic, hurtful and self-destructive behaviors. 35
  36. 36. Ten Basic Concepts of Group Psychotherapy 36
  37. 37.  https://www.youtube.com/watch?v=NI7K_ ojMUoo  https://www.youtube.com/watch?v=Y7xaC bMqpJI 37
  38. 38.  If all of the group members are “ill” or share the same problems, they are unable to help each other.  Groups (and the group leader) tell people how they should be.  Group pressure forces members to lose their sense of identity and conform to the group leader. 38
  39. 39.  Groups are artificial, unreal and sterile – not emotionally charged.  Groups are suited for everyone.  The main goal of a group is for everyone to achieve closeness and feel they are not alone.  Groups are a cost-effective, yet inferior, form of treatment. 39
  40. 40. “If it is true that personality is formed in, through, and by relationships, then a therapeutic modality that uses the interactions of networks of individuals should be capable of altering disturbed or disturbing personalities” (Rutan, Stone, & Shay, 2007, p. 5). 40
  41. 41.  It can be argued that most forms of psychopathology involve problems with “the ability to effect, experience, and enjoy intimate and sustaining relationships” (Rutan, Stone, & Shay, 2007, p. 6). 41
  42. 42.  The group itself is your “client” and holds within it the curative factors necessary to promote change in each member.  The group leader treats the group, not its individual members (may be counter- intuitive). 42
  43. 43.  The leader is mainly focused on creating a group culture (norms)that promote the group’s optimal level of development (a less mature state to a more sophisticated and mature “working group”). 43
  44. 44.  The efficacy of any group is primarily determined by the group leader.  The attitude of the leader is more important than any specific therapeutic technique.  The leader should be open, warm, direct, curious, generally non-authoritative, stable/not take group events personally, and tolerant of conflict and uncertainty (and willing to create it). 44
  45. 45.  The leader must model acceptance of others, a high level of frustration-tolerance, the capacity to be observed/critiqued and attacked, and a tolerance of members’ ambivalence to grow. 45
  46. 46.  Groups provide commonality (e.g. “I’m not the only one with this problem”) and the feeling of being a part of something/needed/valued.  Relieves some degree of shame and feeling stigmatized.  Having a role in the group/providing feedback creates opportunities to give to others (altruism) and is an antidote to self- absorption. 46
  47. 47.  The group is a social microcosm of the real world – allows group members to become more aware of (1) their feelings and behaviors toward others and (2) how they are perceived and experienced by others (social learning).  Members more easily learn interpersonal skills in a safe social setting: can observe others and and mimic them or apply others’ experiences to their own (vicarious learning). 47
  48. 48.  Groups offer a natural laboratory in which members can experiment with new ways of being with themselves and others; regulating their emotions; and empathizing with themselves and others. 48
  49. 49.  Members confront each other, increasing accountability and the motivation for change and avoiding the issue of getting into tangles with the therapist; members exert pressure on each other to comply with treatment and confront denial and minimization.  The offender receives ongoing feedback from the group. 49
  50. 50.  Powerful forces at work in groups make them quite vibrant and dynamic – members experience their interpersonal difficulties being played out right in front of everyone (not there-then, but here- now). 50
  51. 51.  Here-and-now processing (“freeze-frame”) moments advances the members’ capacity to reflect upon affective states and defensive tendencies.  Here-and-now processing increases the potential for greater degrees of empathy toward others and stimulates curiosity about long-term patterns. 51
  52. 52.  The group leader represents a composite of all authority figures.  Members’ attachment to the leader is highly informative and a mediator of therapeutic change. 52
  53. 53.  Family-of-origin dynamics are always replicated in group.  Given this, group members will take on “roles” in the group (partly volunteered for, partly assigned by the group) that are familiar to them. 53
  54. 54.  Altering these roles/experimenting with new roles can make it possible for developmental issues to be considered and refined.  Problematic (“rigid” roles) common in SO groups include silence, rebellion, storytelling, complainer/whiner, do-gooder, monopolizer. 54
  55. 55.  A group provides an oral history/legacy – group programs have a narrative legacy to which clients repeatedly refer.  This instills hope and the belief that the group is worthwhile and meaningful (buy-in to treatment).  There is ongoing access to role models and the opportunity for “rookie” members to advance and ultimately become “veterans” (mini-therapists) to new offenders entering treatment. 55
  56. 56.  Group Theory  Group Process  Group Technique See Rutan, Stone, and Shay (2007) and Vannicelli (1992) 56
  57. 57.  The mechanisms of change and therapeutic factors associated with the group environment. 57
  58. 58.  The unfolding of a group from beginning to end including group norms, generating trust, how conflict emerges in a group, patterns of resistance and defensive posturings (“personas”), and inter-member feedback. 58
  59. 59.  Leader interventions aimed at facilitating the progression of the group-as-a-whole and creating social learning opportunities. 59
  60. 60. Group Dynamics and Group Development 60
  61. 61.  Groups evolve and change over time.  The term “group dynamics” implies the view of the group as a whole, not as a sum of its parts; also refers to the group norms and culture linked with these norms, the leader’s attitude and behavior, and the way the members act toward each other. 61
  62. 62.  The attractiveness and sense of belonging to a particular group (and its culture). 62
  63. 63.  Members opt for particular roles based on skills, tendencies, and personal history.  Members are assigned and maintained in roles so that the group is stabilized (status quo). 63
  64. 64.  Refers to the evolution of the group that is more or less predictable.  Not linear; subject to movement forward and backward.  The addition or departure of a member always leads to regression back to an earlier stage.  The leader must acknowledge the optimal level of group development attainable based on its members. 64
  65. 65.  Fears and anxieties often emerge at transitional junctures and typically involve concerns re: being judged, being too emotional, taking too much of the group’s time, emptiness, depression and losing one’s control. 65
  66. 66.  The ability to identity the developmental stage of a group allows the leader to predict members’ behavior and use interventions to promote readiness for transition. 66
  67. 67. Three Primary Models of Group Development in the Literature 67
  68. 68. Initial or Orientation Phase  The leader refers to the group agreements and begins to establish norms.  The leader begins to promote trust.  Members are superficial and overly polite; trust has not yet been established. 68
  69. 69. Middle or Working Phase  Productive work toward goals is undertaken.  The leader’s role diminishes and morphs into that of a conductor.  Trust begins to be established between the members, and cohesion emerges.  Conflict is managed by the group members themselves. 69
  70. 70. Final or Termination Phase  A sense of loss may be experienced by group members.  The leader encourages the members to discuss these feelings of loss and reminisce about the accomplishments of the group and individual members.  Grief for previous losses may be triggered. 70
  71. 71. The Formative Stage  The joining stage of the group; group members find what is common between each other (“we-ness”).  Each member establishes a way of relating to others that is comfortable and safe.  Anxiety and apprehension about how to be, and what is expected and acceptable, emerge.  The group leader sets the norms. 71
  72. 72. The Reactive/Rebellious Stage  Members struggle with concerns about belonging to the group (“I-ness”).  Members try to exert their particular mark on the group.  There is an uneven commitment to the group.  Group agreements and norms are tested; the leader’s competence is often attacked. 72
  73. 73. The Mature Stage  Members work maturely toward goals, the apex of group development.  Members interact spontaneously; there is trust for, and appreciation of, each other.  Members support group norms and emulate the activity of the leader.  Members experiment with different roles. 73
  74. 74.  Members are open to exploring problems they did not identity when they joined the group.  There is an emerging oral history of the group.  The therapist is demystified – seen more collegially, as an expert but more or less an equal. 74
  75. 75. The Termination Stage  Separating/terminating.  The oral history of the group continues to be referred to and there is a sense of faith and hope in the group (if the termination of an individual member is good).  New members signify the continuity and ongoing life of the group. 75
  76. 76. Stage One (Orientation/Forming)  Group members orient to group and each other. Stage Two (Transition/Storming)  Anxiety, ambiguity, and conflict prevalent as group members struggle to define themselves and adjust to group norms. See Rutan, Stone, and Shay (2007) 76
  77. 77. Stage Three (Cohesiveness/Norming)  A therapeutic alliance forms between members. Stage Four (Working/Performing)  Members experiment with new ideas, behaviors or ways of thinking. Stage Five (Adjourning/Terminating)  The group disbands or a member leaves. 77
  78. 78. Commonalities: An Amalgamation 78
  79. 79.  Members focus on others rather than themselves.  Conflicts are ignored or avoided (sterile tone); communication is unclear and indirect.  The leader is active to help establish a therapeutic group environment (e.g., attention to goals of each member, group norms to promote safety and a sense of what is expected, a curiosity in group interactions, and modeling communication). 79
  80. 80.  Members have internalized the ground rules and begin following them; members begin to test the group and seek power and greater self-disclosure.  Other members may attempt to block increased self- disclosure due to feelings of threat, discomfort, or fear of losing one’s identity.  The leader accepts and normalizes the ambivalence of the evolving group; encourages direct communication and the expression of feedback as it pertains to here-and-now events in the group; identifies common themes that bond the group members together, then uses group-as-a-whole interventions; avoids scapegoating by drawing negative affect to one’s self; does not get defensive when personhood is attacked, but demonstrates security, competence, and a non-retaliatory stance. 80
  81. 81.  Members feel attached to the group; show care and empathy toward each other, but appropriately confront and challenge.  Social learning is maximized; changes occur and are acknowledged; risk-taking occurs/new roles are explored.  A mixture of similarity and difference (uniqueness) emerges.  The leader can be more self-disclosing and candid in this phase, and uses direct observations and inquiries to specific members; attends to how members can apply what is learned inside of the group to outside of the group (“real life”); there is an underlying theme of offenders’ capacity to tolerate others’ weaknesses and limitations and modify their own behaviors and reactions (changing oneself, not others). 81
  82. 82.  Feelings of ambivalence about the group ending (and/or members leaving) are verbalized.  Regression and disengagement commonly occur.  Issues of grief and loss in members’ lives enter the discourse.  There is often anger and rage expressed at the leader for not preventing the loss of group members.  Growth is acknowledged in the context of humility and acceptance of one’s own (and others’) limitations. 82
  83. 83.  Self-disclosure moves from being centered on impersonal events or feelings (of the past or outside of group) to more personal and present-centered events within the group.  Conflicts are handled less by avoidance and withdrawal, and more by acknowledgment; the group begins to feel less sterile and more animated. 83
  84. 84.  The support for norms shifts from the leader to the more experienced members of the group.  Members begin to offer and accept feedback from each other, and begin to make connections between inside of the group phenomena and what has occurred (or is occurring) in their lives. 84
  85. 85. Phase of Development Meaning Intervention Initial phase: Forming Group Reality-based Acceptance/normalizing, advice, norm-setting Second phase: Transition Ambivalence; self- preservation; fear; rebellion Group-as-a-whole affirmation of the lateness Third phase: Working Group A symbolic gesture (a communication) toward other group members, the leader, or self (self- destruction); to be pursued as a pathway for knowledge and understanding Curiosity about the behavior; engagement of other members to voice their reactions (here-and- now processing) Final phase: Termination Powerful communication Observed as an individual and group event 85
  86. 86. Group Therapeutic Factors and Yalom’s Curative Factors 86
  87. 87.  Members re-create their social situations in group, through the interactions they form with other members and the leader.  The group is a social microcosm of “real life.”  Change is made possible when members’ defensive postures are identified and explored through observation and feedback. 87
  88. 88.  The leader directs attention not necessarily to the elimination of defenses, but to the utility of these defensive processes and the underlying problems which caused them to arise in the first place. 88
  89. 89. (#1) Group environmental factors (#2) Belonging (#3) Self-revelation factors (#4) Learning factors (#5) Self-understanding See Rutan, Stone, and Shay (2007) 89
  90. 90.  Empathy, acceptance, support and safety of group members generated by each other and by the leader.  A supportive climate where the group is attentive, listens, respects, and attempts to understand and respond.  This is often called “cohesion”: a group atmosphere of respect where there is room to explore and be heard; a sense of safety. 90
  91. 91.  Involves ordinary courtesies, and verbal and nonverbal communications by the leader.  A “holding environment.”  The group culture promotes the idea of being useful to each other (altruism); sometimes this can be framed in terms of a group member who may be called “a gift” to another group member. 91
  92. 92.  Not being isolated.  The feeling of being a part of something outside of oneself, in which one is valued.  Close social contact.  Relied on; of worth to other group members.  Being accepted and understood by others. 92
  93. 93.  The exposure (affect, history, self-disclosure, etc.) of the offender to other members is vital.  Both tests the safety of the group and marks that the group is safe. 93
  94. 94.  Many different types of learning including education, suggestions/advice, vicarious learning, and practicing/trying out new behaviors.  Vicarious learning: group therapy is a hall of mirrors, i.e., each group member sees himself in the others. 94
  95. 95.  The integration of cognitive understanding with emotional experience (insight).  The group process evokes events in the members’ outside worlds and early developmental experiences, which lead to exploration and learning.  The gaining of insight involves linking here- and-now events, external contemporary events, and events from the past. 95
  96. 96. 96
  97. 97. Nonfiction  1970 The Theory and Practice of Group Psychotherapy (5th edition 2005)  1980 Existential Psychotherapy  1983 Inpatient Group Psychotherapy  2001 The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients  2008 Staring at the Sun: Overcoming the Terror of Death 97
  98. 98. Novels and Stories  1974 Every Day Gets a Little Closer  1989 Love´s Executioner and Other Tales of Psychotherapy  1999 Momma and the Meaning of Life  1992 When Nietzsche Wept  1996 Lying on the Couch  1996 Yalom Reader  2005 The Schopenhauer Cure  2005 I´m calling the police! A Tale of Regression and Recovery  2012 The Spinoza Problem 98
  99. 99. 99
  100. 100.  Major therapeutic benefit for Yalom: the group interaction as it takes place in the here-and-now (allows members to learn about themselves from inside the group). 100
  101. 101.  Focus on the here-and-now involves: (1) the present moment in the group; and (2) the illumination of the process (adding perspective to what has been observed in the here-and-now in order to develop cognitive understanding). 101
  102. 102.  Involves freeze-framing an interpersonal experience in the group to assist members to reflect upon communication blocks, distortions, characteristic ways of being and not being (including emotional defenses), and historical issues.  The processing of the here-and-now is, unfortunately, left out of many groups. 102
  103. 103.  https://www.youtube.com/watch?v=R9k TWTzRqe8 103
  104. 104.  Eleven curative factors – often called healing factors or factors responsible for therapeutic change.  Reflect different parts of the change process; some refer to actual mechanisms of change, whereas others are really conditions for change. 104
  105. 105.  (1) Universality: the feeling of having problems similar to others, not being alone.  (2) Altruism: helping and supporting others; an opportunity to rise out of oneself; the feeling of usefulness. 105
  106. 106.  (3) Instillation of hope: faith that the treatment will be effective.  (4) Imparting of information: sharing knowledge; empowering patients through education; receiving and giving suggestions for strategies for handling problems; providing nurturing support and assistance. 106
  107. 107.  (5) Development of social skills: social learning and the development of interpersonal skills; learning new ways to talk about feelings, observe others and express concerns.  (6) Interpersonal learning (modeling; vicarious learning): receiving feedback from others and experimenting with new ways of relating; finding out about oneself in two ways: (a) input: gain personal insight about one’s interpersonal impact through feedback provided from other group members; and (b) output: a safe group environment allows members to interact in a more adaptive manner. 107
  108. 108.  (7) Imitative behavior: members expand their personal knowledge and skills through the observation of others; model the behavior of others’ who function more adaptively.  (8) Cohesion: feeling of belonging to the group and valuing the group; feeling the comfort, support, and safety of the group; feeling more at home in the group than anywhere else. 108
  109. 109.  (9) Existential factors: recognizing that even with guidance and support, everyone is ultimately solely responsible for the way he or she lives; regardless of close relationships, people still face life alone; assumption that life can be unfair and unjust; people should cherish life by living honestly and letting go of trivialities.  (10) Catharsis: expressing strong affect about the past or the present; release of emotional tension that allows members to gain relief; ventilation. 109
  110. 110.  (11) Corrective recapitulation of family-of- origin issues/Self-understanding: identifying and changing the dysfunctional patterns or roles one played in his family; experiencing transference relationships in the group that provide the opportunity to re-learn and clarify distortions; gaining insight into underlying behaviors and emotional reactions. 110
  111. 111. Mechanisms and Processes of Change 111
  112. 112.  Refer to the ways group members use the therapeutic factors available in group.  Individuals repeat cognitive, emotional, and relational patterns that worked for them in the past.  Mechanisms of change are often organized into 2 categories: patient processes and therapeutic processes (Rutan, Stone, & Shay, 2007). 112
  113. 113. Patient Processes 113
  114. 114.  Especially relevant early in the group.  Observe others (veterans), see how they do it, may help reduce fears and anxieties. 114
  115. 115.  A deeper, more unconscious type of “imitation.”  Increases the pride, self-esteem, and altruistic value of the member with whom one has identified.  There is also identification with the group norms. 115
  116. 116.  The group member behaves differently: he has integrated something that was learned in the group and the learning alters some aspect of his attitude or characterological tendency. 116
  117. 117.  A group member has transference to the leader, the other members, and the group as a whole.  This creates an endless array of perceptions and behaviors to explore, especially in terms of who each group member represents to the other (often, transference reactions are fueled by the projection of disavowed parts of the self into others). 117
  118. 118. Therapeutic Processes 118
  119. 119.  Motivated by the group agreement: “You are obligated to verbalize your thoughts and feelings and to communicate them in words, not actions.”  Creates the expectation of giving feedback to and confronting others.  Can always be used to promote the hall of mirrors idea and activate self- confrontations. 119
  120. 120.  It is always better to advise members to make observations/confrontations that are largely non-judgmental, rather than to use “interpretations” which are usually resisted or denied.  “You always talk about your PO and nothing else.” 120
  121. 121.  Clarification often is used following a confrontation.  It involves the collection of data around a specific behavior or event that has been observed; multiple group members contribute to further specification of what has been confronted (who, what, where, when ... with tentative why’s).  This allows for the identification of patterns and a greater degree of exploration and understanding. 121
  122. 122.  Often provided by the leader and best communicated with an empathic hypothesis.  Contains 3 components: (1) a here-and- now event is used, (2) unbearable affect is speculated, and (3) a defensive process is inferred: “So it seems like when you get stressed, you feel alone and paralyzed; and then you need to feel alive somehow, often in destructive ways.” 122
  123. 123.  I also routinely attempt to include in the interpretive remark some speculation as to the causality of the original offense.  Debate re: “strike when the iron is cold” or “strike when the iron is hot.”  Interpretation becomes mimicked, then ultimately internalized, by other group members. 123
  124. 124.  Interpretations are typically thought as directed toward the individual, as in individual therapy.  Yet there is also the group-as-a-whole interpretation (as group-as-a-whole dynamics are always involved in the group process, also known as whole-group phenomena). 124
  125. 125.  Most evident during transitions between developmental phases, during crises, and when a group member is added to, or departs from, the group.  Boundary-breaking of any kind (late arrivals, failure to pay the fee, therapist vacations, change of schedule, violating a group agreement, etc.) is often more effectively approached (at least initially) as a whole-group action, not an individual action. 125
  126. 126.  When the group is unable to process something and move forward, is ambivalent about moving forward, or is attempting to defend or protect.  The group-as-whole interpretation observes what is occurring and speculates as to the cause; it may be offered somewhat facetiously and dramatically. 126
  127. 127.  John hasn’t done his homework assignment (yet again).  “John, how does it feel that the group is allowing this to happen to you?” or “It must be that the group cannot tolerate people’s responses to these assignments and is using John to demonstrate this to me.” 127
  128. 128.  These interpretations can be suggestive in tone, or certain in tone, and often the latter is better.  Whenever you say “the group is ....,” some members will be narcissistically injured, which is not a problem but merely grist for the mill. 128
  129. 129.  Resistance to all interpretations and feedback is common and invaluable in groups for SOs.  Each member sees an offender deny or disagree with an obvious truth.... and this helps him understand and gain insight into his own refusal to acknowledge the veracity of members’ comments. 129
  130. 130.  An individual’s use of the group process is often viewed from the perspective of: relatedness: primitive: hiding, lying, denying, refusing help and assistance, being overly-bounded in shame and guilt .... vs. usage: more advanced: using the group and its members to learn and grow. 130
  131. 131. Patient Preparation and the Group Agreements 131
  132. 132.  Nature of the group  Goals of the group  Structure of the group sessions  Expectations of the offender (work on personal goals and the group agreements)  Activities of the group leader  Confidentiality will be broken (containment model) 132
  133. 133.  Gain a detailed understanding of the offender’s sexual crime; risk-assessment tools; psychological testing.  Attempt to establish a preliminary alliance (have a positive, invitational and motivational style that supports the offender’s situation).  Offer information about your role, the containment team, and how you communicate to parole/probation. 133
  134. 134.  Offer information about your curriculum, group psychotherapy, and how the offender will be evaluated across treatment.  Deal with anxiety about joining a group.  Collaborate in the formulation of individualized treatment goals as well as specific offender-related treatment goals: clear goals about how to use the group to achieve a lower risk of recidivism.  Review and sign the group agreements. 134
  135. 135.  The group is a social microcosm of one’s world (repetition of roles, interpersonal tendencies, and the possibility for interactive learning through here-and- now processing [freeze-framing]).  An element of all offending is a social/relational problem. 135
  136. 136.  The offender will be expected to give and receive feedback, explore roles (e.g., compliance, acceptance, anxiety, rebellion, etc.) people play in group, express thoughts and feelings, be helpful toward each other (mutual aid), model for others, and tolerate frustrations. 136
  137. 137.  Attend every group, on time, and stay for the entire duration.  Agree to work on the problems that brought you to the group.  Agree to put all thoughts and feelings into words, not actions.  Agree to use the group therapeutically, not socially.  Agree to be responsible for group fees and pay on time.  Agree to protect the confidentiality of others in the group (relevant for court testimony re: needing to claim the privilege of all group members). 137
  138. 138.  SOs typically tend to want to bypass the entire therapeutic element of the group; see it as a “class” and something merely to get through.  Combat this; avoid the belief that involuntary members will not want to change; the challenge is to demonstrate the value of the group to the offender and promote his engagement. 138
  139. 139.  Demonstrate your interest in the offender’s life and general well-being (how to help him not get violated; how to work on the issues that made him vulnerable to offending in the first place).  I always tentatively hypothesize some relational issue or dynamic as important in the offending cycle. 139
  140. 140.  Anxiety over being accepted or rejected  Concern about the judgment of others  Afraid of appearing stupid  Concerns about not fitting into the group  Not knowing what is expected  Concern over being revealed or “found out” 140
  141. 141.  The group agreements establish safety and structure.  It is inevitable that the group agreements will be broken; these boundary violations are meaningful and should be addressed in the group (not avoided or treated in a 1:1 way).  This creates the group culture and the norm that everything that occurs in group is meaningful and shall be explored. 141
  142. 142. The Role of the Group Therapist 142
  143. 143.  Because it is a system, a therapy group requires the leader to work on numerous dimensions, be capable of working on each dimension, and be able to accurately judge what opportunities are present in the group at any given time. 143
  144. 144.  The leader must create a ritualistic structure.  The ritual we use at La Paz: identity/envelope, fee payment, receipts, accountability, manners, house-keeping, agenda items, open group process, pragmatic reminders at the end of group (you may call this the group “frame”). 144
  145. 145.  Active commentary re: expectation of promptness, regular attendance, and on time payment of fees.  Putting thoughts and feelings into words, not actions.  Expectation of giving meaningful feedback to each other and to the leader (feelings toward the leader must be actively invited and considered to model the safety of feedback). 145
  146. 146.  Members using personal disclosure, advice/empathy, inquiry, and confrontation whenever possible 146
  147. 147.  Empathizing/supporting as much as possible  Joining offenders together (subgrouping is advised)  Sharing of the leader’s experience/gaining credibility  Tolerating extensive discussion of POs, outside of the group experiences, complaining, and denial/minimization 147
  148. 148.  The leader gradually begins to lower his or her activity as the established norms promote a member-centered context and here-and-now situations (become more common than discussion of outside of the group experiences). 148
  149. 149.  Other members will emerge as mini- therapists and leaders (veterans help the rookies).  From time to time, the leader invites here- and-now considerations, and makes references to individual members (helpful if positive commentary can be made -- noting development). 149
  150. 150.  There are frequent references to the legacy of the group, other offenders and situations, and vicarious and social learning memories.  If possible, the uniqueness of each group member is addressed (they are similar to others, but ultimately different from others). 150
  151. 151.  Most leaders are typically too active, and shoulder the burden of the group. 151
  152. 152.  It is generally prudent to be active in the early phase of a group, then gradually become less active and observe.  Move the dialogue to in-group phenomena and affective experience (e.g., “The group is very reactive about my being late today”; “You know, we talk so much in here about PGs that I wonder if you want to know if I think you’re all lying, or if I can even tell if you are”). 152
  153. 153.  A balance must be achieved between self-disclosure and an odd withdrawal and lack of personalization. Mistakes on both ends are problematic. 153
  154. 154.  Personal information is always being revealed.  When you are confronted, don’t assume it’s merely “transference” – ask what the member noted about your verbal or nonverbal behavior, tone of voice, etc. 154
  155. 155.  I am always transparent about certain issues: my role in containment team meetings, my contact with POs and PGs, hearing from current or former group members, and when I am concerned – particularly about risk for violation. 155
  156. 156.  I will also mention issues in my life that I want to model (time management, affect regulation, social skills, etc.). 156
  157. 157.  Group members tend to stay at a content level, i.e., what is said and the concrete meaning of things.  Process is often more useful in group: how members are relating to each other and to the therapist, how the context feels, and nonverbal behaviors.  Often, but not always, overt content unconsciously refers to process issues (displacement). 157
  158. 158.  The members will naturally want to talk about out-of-group events and situations, their POs, legal cases, etc.  The leader must tolerate this for a while, and communicate an acceptance of and empathy for these issues.  Eventually, the leader must begin to maneuver the members to talk about in- group phenomena (often by using group- as-a-whole interventions). 158
  159. 159.  It is sometimes helpful to evaluate out-of- group content as a metaphor for (displacement of) in-group phenomena.  Even if you’re wrong, this will help the members think at a deeper level. 159
  160. 160.  The leader is always attending to, and shifting between, observations of the group as a whole and individual’s particular circumstances and issues. Too much focus on one at the expense of the other is problematic. 160
  161. 161.  Group-as-a-whole interventions help to promote a sense of cohesion between group members and the sense that one is not alone; best used to promote the members’ transition into a working group and re: any issue that affects the entire group. 161
  162. 162.  Even when focusing on an individual member, it is often useful to attempt to inquire if his personal issues may be shared by others. 162
  163. 163.  In SO groups, the past is frequently avoided by the members who instead prefer to focus on the present (the leader must empathize with present issues, but always attempt to revisit over and over again the past).  The past is also segmented: prior to addictive/illegal behaviors, and after the offense. 163
  164. 164.  Links between the present (inside the group) and past (prior to offense/at time of offense) are ideal and, over time, become fairly routine.  The future is always present and may be referred to by the leader, especially when these present-past links are achieved. 164
  165. 165.  A natural rhythm emerges between subject matter content.  Deviant sexual interests, distorted attitudes, interpersonal functioning, affective experience, and behavioral management are issues that commonly emerge, especially through assignments, the review of PG results, and discussion of recent PO interactions. 165
  166. 166.  I generally attempt to inquire about how what emerges in group may have been part of a member’s life experience for a long time and likely played a role in his offense.  If the group discussion becomes too abstract, unfocused, or limited to external issues, I actively redirect to members’ specific goals and the group-as-a-whole. 166
  167. 167. Special Group Leadership Issues and Techniques 167
  168. 168.  Communication is often expressed through metaphors and symbolic meaning (often seen as a compromise between direct expression of feelings and complete concealment).  Authority-figure references may be explored as potentially representing feelings about the leader. 168
  169. 169. Most SOs may be viewed, at least in part, as suffering from a poor or limited capacity to be intimate with others.  Gestures/defensive postures/personas may be considered a means of protecting oneself vs. the fears and dangers associated with intimacy (thus, it is always beneficial to challenge/confront with empathy rather than a punitive tone). 169
  170. 170.  “Dan, you are really showing us all what it might mean for you if you didn’t have to be closely monitored.”  Indicate that the offender’s fears are in place for a very good reason, but that you would someday want him to be able to experience what it would be like to move forward without being stymied by the persistent fear. 170
  171. 171.  From the work of Peter Fonagy and his colleagues (2002, 2006) in London.  You are recognized by another and the other has attempted to understand you (“theory of mind”) -- crucial for the promotion of psychological growth and development.  Vital in SO groups. 171
  172. 172.  The leader must actively observe group members’ nonverbals; norm-setting: putting thoughts and feelings into words, not actions.  Interventions should lead with an acknowledgment of the fear of voicing what one is thinking and feeling, rather than with a tone that can be construed as criticizing. 172
  173. 173.  There is often a pull in groups to be highly directive, gratify, teach, and relieve tension/anxiety.  The leader must tolerate this environment, and always seek to use interventions that allow group members to connect with their feelings, self-observe, and reflect first (self- recognition is a significant competency I try to develop). 173
  174. 174.  One way to think about process is that the members of the group, and the group as a whole, are always operating at an unconscious level to protect vs. self- revelation, interpersonal intimacy, and, finally, self-relatedness.  Yet the need for healthy relationships is innate and largely thwarted in one way or another among SOs. 174
  175. 175.  Hesitation to express oneself, an unwillingness or inability to initiate personal work in group, the denial of problems or concerns, role rigidity, and opting for either conflict or non-conflict in group are standard elements of group process (serve a function) that will need to be repetitively addressed by the leader (more so than any other content). 175
  176. 176.  Resistance is commonly dealt with punitively, and should not be!  Merely mentioning resistance (fears) in your groups will help promote safety and trust. 176
  177. 177.  Group leadership skills cannot be separated from the leader’s own personhood and conscious and unconscious feelings about SOs.  Most leaders have a preferred style (authoritative, empathic, case- management, etc.) that does not capitalize on numerous therapeutic factors and change mechanisms groups offer. 177
  178. 178.  Consider your genuineness/self- disclosure/respect for members vs. critical/demeaning tendencies.  Consider content vs. process tendencies.  Consider case management vs. therapeutic tendencies.  Consider your capacity for and comfort with serving as an object of transference (i.e., you are consistently lied to, deceived, and the focus of attempted manipulations). 178
  179. 179. Using the Group Modality to Maximize the Efficacy of SO Treatment: A Synthesis of Two Worlds 179
  180. 180.  In all systems, there is a tendency for role reversals in which the abuser/perpetrator becomes the abused.  This can happen in therapy groups for SOs.  The leader must demonstrate and actually possess empathy for and acceptance of the offender, even if the offender will attempt to manipulate, lie, and not engage in treatment. 180
  181. 181.  Overt and subtle forms of aggression toward offenders must be avoided (sarcasm, shaming, etc.).  Encourage members to explore their resistances.  Avoid taking member’s behavior in an overly personal way, especially being lied to or avoided by the offender or triangulated within the containment model. 181
  182. 182.  Avoid “objectifying” the offender: state your observations and hunches in a tentative way, never convey a clinical arrogance or rigidity re: theoretical or experiential assumptions. 182
  183. 183.  The leader is consistently observed by SOs, for a variety of reasons and motives.  Your observations, statements, and inquiries of agreement/disagreement by group members evidences a direct, candid, straightforward, non-biased, and attentive demeanor – you cannot model your own avoidance (in any way) of anything about the group process or content because that will be exploited and the group will be perceived as unsafe. 183
  184. 184.  Your credibility is enhanced if you call it as you see it, and consistently demonstrate a concern for your group members and investment that they do well. 184
  185. 185.  You also demonstrate consistent efforts at clarifying to POs the offender’s mental status and psychological make-up (you provide a theory of the mind of the offender, to refine his assumption that he is and/or is seen as merely being a “predator” or “monster”). 185
  186. 186.  There is a big difference between treatment compliance and the conversion of the offender into an offender who is also a group therapy patient.  The system assists re: compliance; conversion is really the art of the group therapy leader. 186
  187. 187.  One element of this conversion process is creating a space for the member to be seen accurately (the treatment becomes “real,” not just something to get through).  I say, “Even beyond not offending again, I want you to grow as a man/become a man/have a more fulfilling life as a man.” 187
  188. 188.  Many offenders never get to this place, and their mere compliance needs to be tolerated (to model to other group members the acceptance of people’s personal limitations, including their own). 188
  189. 189.  The adage that full disclosure is a pre- condition for SO treatment is problematic, in my opinion.  Compliance is typically linked with denial/minimization, so we must assume that a portion of offenders “graduate” from treatment in denial, to a greater or lesser degree. 189
  190. 190.  The overcoming of denial is a gradual, therapeutic process that marks the conversion of the offender into an actual group therapy patient; often occurs through the vicarious learning that the group affords. 190
  191. 191.  Denial is often erroneously referred to as a global construct; it actually has many distinct components: complete denial, victim or other blaming, denial of personal intent, minimization of extent or impact, denial of planning, denial of risk to reoffend, denial of impact on family and community, etc.).  In my view, denial to others is associated with self-denial (and profound limitations re: self-relatedness). 191
  192. 192.  Some offenders externalize, minimize, and deny not to intentionally offend again, but to avoid intolerable self-recognitions that ultimately will affirm shame and a damaged sense of self. 192
  193. 193.  If the victim is empathized with, so too will the offender empathize with the parts of himself that perpetrated and abused (this is highly-feared and anxiety provoking). 193
  194. 194.  The emotional manipulation of others and tendency to exploit are outcomes of a fractured identity and a profound sense of one’s limited repertoire of resources to solve problems and get one’s needs met appropriately. 194
  195. 195.  It is beneficial for SOs to realize that without external intervention and treatment, their offending behavior would most likely escalate and continue – this self-realization promotes usage (vs. mere relatedness) and the conversion to actually becoming a psychotherapy patient. 195
  196. 196. Level of Personality Development Primary Issues Group Interventions/Priorities Organizational/Psychotic Breakdown of relational bonding; self- vs. other- confusion; lack of reality testing; delusions; paranoia; absence of an observing ego. Group cohesion; being bonded to other group members; being attended to carefully and with empathy. Borderline Engulfment vs. abandonment; splitting; projection; affective dysregulation. Integration of others: see positive and negative qualities and attributes; self-monitoring/self- control – see impact one has on others; increased communication skills; more effective coping capacities. 196
  197. 197. Level of Personality Development Primary Issues Group Interventions/Priorities Narcissistic Abandonment of reliance on others for need fulfillment; turning inward; counter- dependency (refusal to be vulnerable); being manipulative and coercive; shaming so as not to be shamed. Victim and self-empathy; acknowledging the importance of others and his importance to others; ability to “use” others; capacity to understand others and engage them effectively. Neurotic Distortion of interpersonal experience; self-punitive belief systems; tendency to sway between compliance and rebellion; jealousy. Using the feedback of others, and identifications, to alter one’s sense of self; role flexibility. 197
  198. 198. Empirical Assessment of Group Process and Therapeutic Factors 198
  199. 199.  Lack of research in this area.  Easy to do and informative to the group leader.  Need to use process measures from the group therapy literature and adapt them to SO treatment. 199
  200. 200.  Do treatment programs assess dynamic risk factors (and other domains of functioning) pre- vs. post-treatment? [OUTCOME]  Are group climate/process (therapeutic) factors assessed? [PROCESS]  Are positive outcomes demonstrated and, if so, are these outcomes related to process factors? [OUTCOME X PROCESS] 200
  201. 201.  Are those SOs who demonstrate the greatest magnitude of improved outcomes (or achievement of “normal” categorizations) and/or favorable process less likely to re-offend than other SOs? Based on Beggs and Grace (2011) See Kroner and Yessine’s (2013) “Changing Risk Factors That Impact Recidivism: In Search of Mechanisms of Change” for a thoughtful discussion of the empirical criteria necessary to identify true mechanisms of change among forensic populations. 201
  202. 202.  The Group Climate Questionnaire—Short Form (GCQ-S; MacKenzie, 1983), the most common measure of group process, is a self-report instrument that contains 12 items assessing perceptions of a group’s therapeutic environment on three dimensions: Engagement (degree of self-disclosure, cohesion and work orientation in the group), Avoiding (degree of withdrawal; reliance on group leader or other group members to create and manage change) and Conflict (degree of interpersonal hostility, rejection, and distrust in the group – but not confrontation). 202
  203. 203.  Developed by Piper et al. (1983), the Cohesion Questionnaire (CQ) consists of 8 items in which members evaluate each other separately (e.g., “If she left, I would miss him”). 203
  204. 204.  The Curative Climate Instrument (CCI) was developed by Fuhriman et al. (1986) to assess group members’ ratings of the therapeutic factors present in group therapy. Derived from Yalom’s factors. 204
  205. 205. Item Factor Being able to say what was bothering me instead of holding it in. Catharsis Belonging to and being valued by a group. Cohesion Learning that I react to some people or situations unrealistically with feelings that somehow belong to earlier periods in my life. Insight Learning how to express my feelings. Catharsis Continued close contact with other people. Cohesion Learning how I block off my feelings towards others in the present. Insight Belonging to a group of people who understood and accepted me. Cohesion Expressing negative and or positive feelings toward other persons in the group. Catharsis Discovering and accepting previously unknown or unacceptable part of myself. Insight 205
  206. 206. Item Factor Expressing my feelings even though I am uncertain. Catharsis Learning why I think and feel the way I do (i.e., learning some of the causes and sources of my problems). Insight Learning how to share, in an honest and responsible way, how group members are coming across to me. Catharsis 206
  207. 207.  Therapeutic Factors Inventory (TFI) is an empirically-derived comprehensive assessment of the presence or absence of the 11 therapeutic factors in a group (Lese & MacNair-Semands, 2000) based on Yalom’s (1995) work.  A similar measure was developed by Bloch et al. (1979). 207
  208. 208.  The Yalom Q-sort (Lese & MacNair-Semands, 2000) was developed to measure patients’ perceptions of Yalom's (1995) 11 therapeutic factors in group therapy.  The Q-sort takes approximately one hour to administer.  Group members are given cards with the statements printed on them that reflect the therapeutic factors, and are asked to place these in piles under seven headings, ranging from “most helpful to me in the group” to “least helpful to me in the group.” Then, participants rank order the cards from “most helpful” to “least helpful.” 208
  209. 209.  Developed by Gold, Kivlighan, and Patton (2013), this measure consists of three questions focusing on an event that occurred in the group session that the rater perceived as most important; the measure is given after each group session. 209
  210. 210.  Developed by Burns and Auerbach (1996), The Empathy Scale (ES) is a 10-item self- report questionnaire that reflects clients’ perceptions of the warmth, genuineness, and empathy reflected by the therapist during the most recent session. 210
  211. 211.  The Working Alliance Inventory-Short Version (WAI-S; Horvath, & Greenberg, 1989) is a 12- item measure that assesses both the therapist’s and patient’s perception of the working alliance.  The measure is based on Bordin’s (1979, 1994) notion of the alliance construct as consisting of the affective bond between patient and therapist, agreement on the goals of treatment, and agreement on treatment tasks/means of achieving these goals. In accordance with Bordin’s view, the WAI-S yields Bond, Goal, and Task subscale scores. 211
  212. 212. Summary and Conclusion 212
  213. 213.  https://www.youtube.com/watch?v=eJY RBc3_JaI 213
  214. 214.  Those who have committed sexual crime vary in terms of static and dynamic risk factors, and offending circumstances.  The interpersonal/relational components of the group therapy modality afford the clinician the means to approach numerous criminogenic and non-criminogenic needs, thus linking the focus of mental health treatment and the criminal justice system’s mandate to protect the community. 214
  215. 215.  I believe that the sexual offender can be converted from “criminal” to “therapy client” if the leader successfully mines the multitude of resources available in group to promote change and transformation. 215
  216. 216.  I have emphasized the development of prosocial skills (interpersonal learning) and the capacity to relate to others.  Yet interpersonal development is associated with intrapersonal change: the ability to understand and empathize with others corresponds to oneself and one’s self-observation and –regulation skills. 216
  217. 217.  By increasing the offender’s level of self- relatedness, he is better able to ascertain when he may be at risk for acting-out behaviors, sexual deviance, and re- offending, and is more likely to adopt a way of being that more positively impacts his own life and the lives of others. 217
  218. 218.  Alonso, A., & Rutan, J.S. (1996). Activity/nonactivity and the group therapist: ‘Don’t just do something, sit there.’ Group, 20, 43-55.  Beggs, S.M., & Grace, R.C. (2011). Treatment gain for sexual offenders against children predicts reduced recidivism: A comparative validity study. Journal of Consulting and Clinical Psychology, 79, 182-192.  Bloch, S., Reibstein, J., Crouch, E., Holroyd, P., & Themen, J. (1979). A method for the study of therapeutic factors in group psychotherapy. The British Journal of Psychiatry, 134, 257-263.  Bordin, E.S. (1979). The generalizability of the psychoanalytic concept of working alliance. Psychotherapy: Theory, Research, and Practice, 16, 252-260.  Bordin, E.S. (1994). Theory and research on the therapeutic working alliance: New directions. In A.O. Horvath & L.S. Greenberg (Eds.), The working alliance: Theory, research, and practice (pp. 13-37). New York, NY: Wiley. 218
  219. 219.  Burns, D.D., & Auerbach, A. (1996). Therapeutic empathy in cognitive-behavioral therapy: Does it really make a difference? In P.M. Salkovski (Ed.), Frontiers of cognitive therapy (pp. 135-164). New York, NY: Guilford Press.  Fonagy, P., Gergely, G., Jurist, E., & Target, M. (2002). Affect regulation, mentalization, and the development of self. London: Karnac.  Fuhriman, A., Drescher, S., Hanson, E., Henrie, R., & Rybicki, W. (1986). Refining the measurement of curativeness: An empirical approach. Small Group Behavior, 17, 186-201.  Gold, P.B., Kivlighan, Jr., D.M., & Patton, M.J. (2013). Accounting for session-level dependencies in longitudinal associations of group climate and therapeutic factors in interpersonally focused counselor training groups. Group Dynamics: Theory, Research, and Practice, 17, 81-94.  Horvath, A.O., & Greenberg, L.S. (1989). Development and validation of the working alliance inventory. Journal of Counseling Psychology, 36, 223-233. 219
  220. 220.  Kroner, D.G., & Yessine, A.K. (2013). Changing risk factors that impact recidivism: In search of mechanisms of change. Law and Human Behavior, 37, 321-336.  Lee, K.P., & MacNair-Semands, R.R. (2000). The therapeutic factors inventory: Development of a scale. Group, 24, 303-317.  McKenzie, K. R. (1983). The clinical application of a group climate measure. In R.R. Dies & K.R. MacKenzie (Eds.), Advances in group psychotherapy: Integrating research and practice (pp. 159-170). Madison, CT: International Universities Press.  Piper, W.E., Marrache, M., Lacroix, R., Richardsen, A.M., & Jones, B.D. (1983). Cohesion as a basic bond in groups. Human Relations, 36, 93-108. 220
  221. 221.  Purvis, M., Ward, T., & Shaw, S. (2013). Applying the good lives model to the case management of sexual offenders. A practical guide for probation officers, parole officers, and case managers. Burlington, VT: Safer Society Press.  Rutan, J.S., Stone, W.N., & Shay, J.J. (2007). Psychodynamic group psychotherapy (4th ed.). New York, NY: The Guilford Press.  Vannicelli, M. (1992). Removing the roadblocks. Group psychotherapy with substance abusers and family members. New York, NY: Guilford Press.  Yalom, I. (1995). The theory and practice of group psychotherapy (4th ed.). New York, NY: Basic Books.  Yalom, I. , & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York, NY: Basic Books. 221
  222. 222. 222
  223. 223. James Tobin, Ph.D. Licensed Psychologist PSY 22074 220 Newport Center Drive, Suite 1 Newport Beach, CA 92660 La Paz Psychological Group 23461 South Pointe Drive, Suite 190 Laguna Hills, CA 92653 FOR COPIES/QUESTIONS: Email: jt@jamestobinphd.com Website: www.jamestobinphd.com Phone: 949-338-4388

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