Week 2 - Motivating change, Dealing with violent and sexual offenders

Question 1

How likely is it that trauma is never recalled?

Answer 1

l

Question 2

How likely is it that trauma is forgotten and recalled later?

Answer 2

l

Question 3

How likely is it that trauma not happened and is recalled?

Answer 3

l

Question 4

remembering

Answer 4

reconstructive process

Question 5

source confusion

Answer 5

elements not necessarily from one and the same external experience

• -> other possible sources:
• imagination
• dreams
• other external source

Question 6

retrieval

Answer 6

–> importance of plausibility

–> first question at retrieval: Is it possible? If yes, continue search

• -> it takes a series of decisions
• -> thus, it can become more and more plausible

Question 7

factors influencing false retrieval

Answer 7

• interpreted “body memories” by the therapist (fists etc.)
• addressed parts (“little girl”, “angry teenager”
• reinforced desired behavior (memories, holding postcards)
• punished undisered behavior (ignoring, scolding)
• group pressure (if your mother is not a bitch you do not belong here)

Consequences:

• -> socially isolated; no contact with parents, lost job, lost friends
• -> at home –> searching for confirmation
• -> more and more intense symptoms

Question 8

Underlying beliefs: Repression

Answer 8

Functional account
Banishing of threatening memories to the subconscious – out
of self-protection and without awareness of doing so

Three characteristics:

1. Selective forgetting to avoid psychological pain
2. Is not under voluntary control
3. Repressed material stays intact

Assumption
Repressed memories cause other symptoms (“it’s got to get
out one way or the other”) and behavior

Dissociation
Assumptions resemble repression

Question 9

Body memories

Answer 9

Memories are stored somewhere else in the body
than in the brain

• -> body stores unprocessed sensations in the muscles, bones, fascia, and other tissues
• -> stored trauma energy can be released by processing sensory memories in a safe enough setting

Question 10

Triune Brain Theory (MacLean)

Answer 10

Assume that 
reptilian brain stores 
traumatic memories 
and / or is involved 
in storage in body

Rational Brain
Neocortex: What can I learn?

Mammalian Brain
Limbic System:
Am I loved?

Reptilian Brain
Brain stem:
Am I safe?

Brain function
modular rather than
anatomical

Question 11

Preverbal trauma

Answer 11

Assumptions/beliefs
› No memories of early childhood indicative of 
early trauma
 Infantile amnesia
› Trauma in infants is stored in preverbal fashion
 Forgetting is the norm in infancy
 Meaning is important for later recall
› Preverbal trauma can influence adult 
functioning
 No evidence

–> early memories might be remembered/recalled by the Age of 3 the earliest

Question 12

Infantile / childhood amnesia

Answer 12

Young children form memories
• But forget relatively fast
 Brain structures need to mature 
 Cognitive self: late in 2nd year
 Use of language (18- 24 mo)
• Continuous development
 Parent – child interaction
 Language
 Understanding of time
 Encoding specificity less important

Question 13

The role of cue specificity

Encoding Specificity principle

Answer 13

Associative retrieval:
Automatic,
“Proustian” memory

–> memory performance depends directly on the similarity
between the information in memory and the information
available at retrieval.
(a cue is effective to the extent that it is encoded)
› Not only context/ stimulus configuration, also
interpretation

Question 14

Interpretation of indirect signs is risky

Answer 14

Risk: Reversed reasoning 
(Infer the cause from a 
result)
› Problem: multiple causes
› That a painkiller helps, 
does not mean that 
headache is caused by a 
painkiller-deficit

Confirmation bias 
(tunnelvision)
› Consequences: 
 Trauma Diagnosis 
 Trauma therapy

More indirect signs does
NOT mean more convincing

Question 15

Satanic Ritual Abuse

Answer 15

› Extreme and organized violence in the context of
devil worship.
› Recollections of e.g. pregnancy with children who
were later sacrificed.
› Brainwashing by network (the cult) / “mind-control”
because the abuse and the cult itself must remain
secret.
› Until now, forensic investigation (mostly 1990s) has
failed to find any objective evidence
› Now: increased call for investigation

Question 16

What is motivational interviewing and when should it be used (by whom and for whom)?

Answer 16

It focuses on strengthening personal motivation for a commitment to a specific goal by eliciting and exploring the person’s own reasons for change, while the therapist is working from acceptance and compassion.

Some specific characteristics of MI:

• Partnership; the therapist and client work together, collaborative, people are the experts of their own lives.
• Evocation; person’s priorities, values and wisdom to explore reasons for change
• Compassion
• Acceptance

4 fundamental processes

• Engaging > establish a productive working relationship through careful listening and reflect the person’s experience and perspective, while supporting autonomy.
• Focusing > move into a directional conversation about change
• Evoking > help the client to build their own why; why they want to change
• Planning > explores how to change, develop a plan based on the person’s own insights and expertise.

Question 17

What is the Parole Board and what are their responsibilities?

Answer 17

Parole = the temporary or permanent release that enables the offender to serve the remainder of their sentence in the community as long as the terms of conditions set by the parole board are met.

The parole board thus is the body that considers and determines parole eligibility, sets conditions of release, and revokes parole when the conditions are violated. Members may be social workers, judges, psychiatrists, criminologists, or members of the general public, depending on the jurisdiction. Responsibilities are generally the same, just the organization of the body is different across countries/states/jurisdictions.

The Netherlands: “Openbaar Ministerie” (OM) decides whether or not the offender is eligible for parole. The probation service (= reclassering in Dutch) checks if the offender complies to the conditions and advises the OM/the judge in court about the offender

UK: The Parole Board (246 members) is an independent body that carries out risk assessments on prisoners to determine whether they can be safely released into the community. Their primary role is to determine whether prisoners continue to represent a significant risk to the public

Germany: Not a lot of information on parole, rather on probation.
Probation officers are social workers (Bewährungshelfer) who mainly have to assist, to guide and to supervise offenders in the case of a suspended sentence (Strafaussetzung zur Bewährung) or a conditional release.

Question 18

What is a therapist allowed to share and what can he himself decide to share?

Answer 18

You can only tell the parole board about the progress of the patient, but you can’t tell them about the things you talk about with the patient. Even if the patient confesses something, you can’t break the confidentiality rule. Only if you think that the community, other people or the patient himself will be in danger, you can share information with the parole board (or other parties).

–> is allowed to share if there is progress or not

Question 19

Differences in legislation over what you are allowed to share (country differences, The Netherlands, Germany and England/USA)

Answer 19

In Germany you should disclose past crimes, while in the Netherlands this is strictly prohibited.
· For Germany, it is more likely that a judge can tell a psychologist that they do not need to stick to confidentiality, while in the Netherlands confidentiality is more important.
- In the UK, the counsellor must break confidentiality when disclosing crimes such as terrorirsm, drug trafficking, and money laundering. In other countries it is considered when society is at risk.

Question 20

What should a therapist do when parole is violated and what are cultural differences?

Answer 20

In the Netherlands a psychologist is not allowed to share anything that the client says, unless the therapist believes the patient will do harm to himself, the therapist, or someone else (NIP, 2015). A therapist is obliged to tell the parole board about the progress of the client, if the client shows up to the sessions, and if the client walked out during the sessions. However, the therapist is not allowed to speak about the content of the sessions (Eric Blaauw, said in his lecture).

• In Germany the same principle applies. Psychologist is bound to confidentiality unless they believe the client poses a risk to themselves, the therapist, or someone else. It is also specified in the German ethics code that confidentiality is ensured “except in those exceptional instances defined by law or in the event that other higher-ranking legal interests are in jeopardy” (DGP & BDP, 1999). It is reasonable to assume that this can be the case for parole violations.
• In the United States it depends from state to state in how is dealt with confidentiality. It is possible that the court decides to waive confidentiality as a condition of probation. The therapist has to share all the information of the patient with the court if asked. If such thing is not ordered, the therapist is not allowed to share personal information of the client with other parties without the permission of the client

Question 21

On what grounds can you refuse to treat a client and are there cultural differences?

Answer 21

In the Beroepscode of the NIP it says that a professional relationship between a client and a psychologist can only start when it is professionally and ethically responsible. So, when this is not the case, a psychologist can refuse to start treatment.

It could also be that there is no connection between the psychologist and the client so then a treatment can also be refused because the connection between the psychologist and the client is very important. But it should be phrased in a clear way.

A client is also able to refuse treatment by a psychologist except when the client has been sent to the psychologist commissioned by a third party like the Parole Board.

In every country, a psychologist is allowed to refuse a patient.

–> Aren’t benefiting from therapy.
May be harmed by the treatment.
No longer need therapy.
Threaten the therapist, themselves or others

Question 22

How can one motivate behavioral change in different types of offenders?

Answer 22

In Ward (2002) they stated that it is important to use the Good Live Model in every rehabilitation program (so for all types of offenders), so that they can learn how to reach their primary good in an appropriate way.

no confrontation because of cognitive dissonance
gentle way of motivating someone
GLM, intrinsic motivation (make change arise from within)
don’t try to convince him with your words

In light of sex offenders
confrontation is gentle rather than aggressive
increase client’s intrinsic motivation so that change arises from within rather than being imposed from without

Question 23

How does motivational interviewing with sex offenders work?

How can shame influence motivational techniques?

Answer 23

• Shame/guilt
• shame and guilt can be reduced by expressing empathy (first of the 5 principles in MI)
• therapist stay nonjudgmental and makes sure that he does not make the offender feel stigmatized → Monster stigmatization
• only when the offender takes responsibility of their offense, treatment might succeed
  → if shame or guilt is still present, offender might deny their offense (risk factor)
• support self-efficacy (3rd principle of MI), because a lot of violent offenders see their efficacy only in their criminal conduct
  → This conveys understanding, acceptance and interest in the person—conditions that have been found to be necessary for change to occur
  → It is an acceptance without judgement of the person (does not mean a s a therapist that you have to accept the offense or be fine with it)
  → This does not mean that every situation is acceptable, but every person is
  → Only when patient perceives acceptance can they experiment with alternate ways of behaving
• Sex offender might display primary and/or secondary cognitive distortions
  → Primary cognitive distortions:
• belief in one’s own views, needs, and expectations to the extent that the views of others are inconsequential or totally disregarded
• The associated behaviors are related to the belief that the offender can do whatever he/she wants — in effect, they are above the law
• can seriously impede rehabilitation readiness, because the offender believes that he/she already ‘knows it all’ and as such is unlikely to see the need for personal change
  → Secondary cognitive distortions:
• blaming others, minimizing/mislabeling and assuming the worst of others
• support the primary distortions by rationalizing and justifying the offending behavior
• It has been suggested that such strategies serve to protect the offender’s self-image following their antisocial behavior → might help the sex offender to deny their offense
  Youtube video: Why do some convicted sex offenders claim they are innocent
  → like to think of us as good people
• Doing something bad but maintain that we are still good → deceiving ourselves
• Deny and minimize and distort their own behavior
• Integrity → challenge
• Facing up and working through your own deception
• Threat to self-concept
• Protecting their self-concept by denying their own guilt
• If we look at sex offenders as monsters, we help them to deny their offense
• That’s not me so I didn’t do anything bad → false hope of innocence or permanently labeled as a monster
• Challenge our own integrity as a kind society → As a society we need to make room for that change of sex offenders to prove their worth and that they are still good
• Otherwise, our behavior will not be much different than a sex offender who denies their guilt → we stagnate, blame victims and label offenders
  Youtube video: the trouble with juvenile sex offenders
  Stigma of monsters
• Cannot develop to healthy young men
• Leads us to advocate punishment rather than rehabilitation
• Perpetuates a stigma that keeps families of abusers silent
• Causes us to miss what is happening right in our own community or even our own home

Question 24

How does prioritizing treatments work with comorbidity?

Transtheoretical Model

Answer 24

recovery and the engagement with therapy is typically not a linear process but rather involves a cycling back and forth of the person’s perception of his or her problems and the level of behavior change

Question 25

MI and its differnet stages

Answer 25

MI has five basic principles:
1 express empathy
2 avoid argument
3 support self-efficacy
4 roll with resistance
5 develop discrepancy.

Miller and Rollnick outline the eight steps of MI that allow
the therapeutic process to work. These are outlined below:
1 establishing rapport
2 setting the agenda
3 assessing readiness to change
4 sharpening the focus
5 identifying ambivalence
6 eliciting self-motivating statements
7 handling resistance
8 shifting the focus.

Miller and Rollnick (2002) defined what they called the “spirit” of MI, describing a way of being with and talking with patients founded on collaboration, evocation, and autonomy.

Collaboration: The patient should be approached as a partner in a consulta­tive manner. The emphasis is on working together with the patient to arrive at decisions as to what to do and how to proceed

Evocation: The clinician should ask the patient about what is important to him or her, what he or she values, and then listen carefully and formulate further questions mainly to further draw out the patient’s point of view. Thus, the emphasis is on open-ended questions and active, “reflective” listening.

Autonomy: The patient is ultimately in charge of his or her care, and the clinician should respect the patient’s decisions and freedom to choose.

Miller and Rollnick (2013) refined and expanded the dimensions of the spirit of MI to include partnership, accep­tance, compassion, and evocation.

Partnership:
Similar to the notion of collaboration, patient approached as a partner in a consultative manner. Emphasis is on working together to arrive at decisions as to what to do and how to proceed.
–> “dancing rather than wrestling” with the patient.
recognize that the clinician has agenda for the patient (to stop using drugs or alcohol typically), but the patient’s agenda must be respected as well, and it is ultimately the patient who must decide to implement change.

Acceptance:
Acceptance (from Carl Rogers), is further divided into four concepts:
· absolute worth, involving valuing, accepting the patient for who they are as opposed to passing judgment;
· accurate empathy, the effort to deeply understand the patient’s point of view without allowing the clinician’s perspective to interfere;
· autonomy support, respecting that the patient is in charge and needs to decide for himself or herself the course of action, as opposed to any attempt by the clinician to impose on or coerce the patient toward particular goals;
· and affirmation, identifying and recognizing a patient’s strengths, abilities, and efforts, rather than focusing on weaknesses or failures.

Compassion: fundamental commitment to understand and pursue the best interests of the patient. Emphasized to ensure that MI support the goals and values of the patient, not those of the clinician or anyone else.

Evocation:
fundamental assumption of MI: patient has strengths and capabilities à goal is to draw these out. = in contrast to a deficit model; the patient lacks something or has weaknesses, which the therapy will seek to build or strengthen.

Question 26

Stages of change model (SCM)

Answer 26

has been used to assess readiness to change and guide interventions with adolescent offenders, anger management programs, sex offenders, and drug rehabilitation. The SCM focuses on the process of change which it breaks down into a series of stages from the time before change is considered through to the maintenance of change. Stages:
1. Precontemplation stage: during this stage the individual has no intention to change his or her behavior in the foreseeable future.
2. Contemplation stage: individual is seriously thinking about changing but not made commitment to take action.
3. Preparation stage: individual intends to take action within the next month.
4. Action stage: individual actively modifies his or her behavior.
5. Maintenance stage at which point the individual works to consolidate the gains they have made during the action stage and prevent relapse.
The authors of the model illustrate the stages in a cycle and suggest that individuals may spiral around the model several times until successful change is achieved.

Question 27

Barriers to change model (BCM)

Answer 27

arises from the Readiness to Change Framework (RCF). The BCM includes 10 different barriers that act as obstacles that can lie between an individual and behavior change:

1. Perceived importance of change in comparison to conflicting goals
2. Perceived need for change
3. Perceived level of personal responsibility to change
4. Perceived cost of benefit analysis of change
5. Perceived sense of urgency to change now
6. Perceived personal ability to change
7. Perceived personal ability to maintain the change
8. Perceived costs associated with the means to change
9. Perceived suitability and efficacy of the means to change
10. The realities of change

Cognitive distortions that can make patients resistant

• self-centered attitudes and beliefs.
• Beliefs in one’s own views and expectations and that the needs of others are not important
• Secondary cognitive distortions like blaming others and expecting the worst of others. Assuming the worst, relating to implicit theories, they think they have to stay aggressive in order to avoid being victimized, and therefore show high hostility. This validates their crimes, because they think they had to do it. These cognitions are points to target in therapy.
• Minimization, mislabeling of criminal behavior.