Elliott, H

Faulkner, J

Grubin, D

Lievesley, R

Norman, C

Winder, B

Nottingham Trent Institutional Repository (IRep)

Evaluation of the use of medication to manage sexual arousal (MMSA) with individuals convicted of a sexual offence (and some other stuff)Belinda Winder & Don Grubinand lots of other people….Who are we?• Me – Prof. of Forensic Psychology, Set up and head RU, Vice Chair of SLF charity and responsible for managing research and evaluation plus charity givernance• All of us - forensic psychologists (researchers, clinicians, combination)• Sexual Offences, Crime and Misconduct Research Unit • Set up in 2007, based at Nottingham Trent University & HMP Whatton• Take up space at various prisons• 30ish researchers plus MSc Forensic Psychology students and Doctorate in Forensic Psychologists (e.g. stalking)• Strong service user involvement• Linked to SLF charitySOCAMRU projects• Evaluation of interventions (e.g. MMSA, Good Vibrations, Man Up)• Prison-driven research e.g. denial, dementia, ASC, education, therapeutic climate of prisons, personality disorder• Measures e.g. SARN for ID, creating a measure of adaptive functioning for use in the UK prison system• Projects requested by externals (such as Muslim community, police) or to contribute to national reviews or inquiries (F&F, Care home perps)• Qualitative research on ‘specialist’ groups e.g. collecting behaviour, offending against elderly victims, sextortion via internet• Studying protective factors and purposeful activity (e.g. exercise, CoSA, religion / spirituality, work, education, peer support schemes)• SLF projects – prevention, release, accommodation, transitions, CoSA, Drop In CentreWhere we live (most of the time)HMP Whatton, a treatment prison in the UK, holds approximately 840 adult males convicted of a sexual offence. Category C prison, not a TC but has rehabilitative culture (people choose to come here for treatment).42% have a sentence of more than four years56% are serving an indeterminate sentence including life sentenceMix of child, adult and non contact offendersRM 2000 scores - 40 % medium - 37 % high / very highAge: 18-80+; average age in 40sOther prisons and establishments• HMP Stafford (750+) – active citizenship• HMP Nottingham (1050+) - local• Secure hospitals (e.g. Rampton)• Probation & Police• Work with other organisations including charities, other universitiesSafer Living Foundation• www.saferlivingfoundation.org• http://saferlivingfoundation.org/trustees-2/• Registered UK charity 13 Feb 2014SLF: Projects• Prison-based Circles of Support and Accountability• Community-based Circles of Support and Accountability project• Young People’s Circles project• Prevention project• Transitions and Release project e.g. Drop In Centre, Employability• Three-quarters House project• Peer buddy groups?SOCAMRU Service User Research & Evaluation group• Prison-based (2 years +)• Community-based (new)• Group meets every month to discuss research and evaluation plans• Specialist groups e.g. ASC, dementia, understanding licence recall• Prisoners help develop, and critique research protocols, suggest research ideas and mechanisms for evaluation eg time lag for prevention, lack of support out there, prison rumour mill, not understanding licence conditions• Help to publicise projects (also through posters, prison radio and prison newsletters)• Results fed back through posters, individuals leaflets, prison newsletters, radio, 121 meetingsSOCAMRU qualitative research• Prisoner as ‘expert’ e.g. IICSA study• Use hand in hand with quantitative research to triangulate and understand quant. data.• Consider what is normal, non-pathological and what others’ ‘normal’ is• Not anecdotal evidence, systematically gathered, coded and analysed then linked to theory and current evidence base• Thematic analysis / IPA ‘tell your story’• Repertory grids ‘What’s normal? Who are you? Who are you similar to? What do you think of yourself?’• Q sort ‘understanding different perspectives’• Narrative analysis (e.g. transgender sex offenders)MMSA Evaluation Location: Governor’s office at HMP WhattonGovernor (Lynn Saunders): Does the medication ‘work’? Can you evaluate it? We need to know.Me: SureMMSA Evaluation How effective is anti-libidinal medication in reducing these Clinical Measures: sexual preoccupation, hypersexuality, strength of sexual urges, deviant fantasies?What impact does the anti-libidinal medication have on a range of Psychometric Measures e.g. anxiety & depression, sexual compulsivity, personality traits including maladaptive ones?Clinical MeasuresPsychometric MeasuresOffenders’ ExperiencesStaff Perspectives and ExperiencesCase Study to further understand journeys on anti-libidinalsClinicalOffenders ExperienceCase StudiesOffender Managers understandingPsy’cStaffs ExperienceOffender Supervisors understandingSARN writers perspectives –when needed/not & whyExploring individuals who drop out/are unsuitableClinicalOffenders ExperienceCase StudiesOffender Managers’ understandingPsy’cStaffs ExperienceOffender Supervisors’ understandingSARN writers’ perspectives –when needed/not & whyExploring individuals who drop out/are unsuitableIndividuals on medication released and are back in custodyIndividuals taking medication in communityKnowledge & attitudes of GPs in communityClinOff’sOffender ManagersPsy’cStaffOffender SupervisorSARN writersDrop out/ unsuitableIndividuals back in custodyIndividuals in communityGPsWhat are the demographics of the populationEstablish normative data for sexual compulsivityMatched Control Group to assess differences in clinical measures; problematic sexual behaviour; and reoffending rates Case StudyProportion of SOs scoring ‘strongly present’ on most frequently occurring SARN risk factorsMedicationTwo main types: − Fluoxetine (SSRI) − Cyproterone acetate (CPA, anti androgen)− GnRh agonist (Triptorelin)• Referral: can be made by anyone in the prison e.g. wing staff, offender supervisor, psychologist• Individuals have an initial appointment with myself to discuss the medication and consider whether they are suitable• Further appointments are made as necessary to answer questions• Individuals suitable for medication are typically started on 20mg Fluoxetine, taken daily as a tablet, with dosage increased to 40/60mg as necessary. • Where SSRIs do not appear to work, CPA is prescribed. Starting and typical dosage for CPA are 50mg daily by tablet, increased to 100mg where individuals are still reporting difficulties in managing deviant sexual fantasies, hypersexuality and/or sexual preoccupation.Medication & ParticipantsHMP Whatton started offering meds in November 2009• Drugs used o Fluoxetine, Paroxetine (SSRIs)o Cyproterone acetate (CPA, anti androgen)o Triptorelin (GnRH agonist)145 + men referred for medication at HMP Whatton; initial medication was:• 58% SSRIs • 13% Anti-androgens • 5% SSRIs & Anti-androgens– 1% GnRH• 5%  still under assessment• 18% No medication (declined / not suitable)55 CONTROLS  recruited on admission Now expanded throughout UK to 7+ prisonsClinical Measures•Captured at regular meetings between participants and Dr Kaul (prescribing psychiatrist)•Data collated during private therapeutic session; used clinically to discuss and tailor medicationPsychometric measuresDynamic measures (baseline pre-meds, then approximately every 3 months)• Sexual Compulsivity Scale (SCS)o 10 items; 1-4; used means i.e. between 1-4; ‘My desires to have sex have disrupted my daily life; I think about sex more than I would like to’• Hospital Anxiety and Depression Scale (HADS)o Scoring is 0-21 on each sub-scale; caseness 8/21• Severity Indices of Personality Problems (SIPP 118)Static measures (conducted once only)• PAI: Personality Assessment Inventoryo 22 scales measuring clinical, treatment and interpersonal factors related to personality• MPI: My Private Interests  (was MSI)o Short scale measuring offence related sexual interests with 4 subscales 1) an obsession with sex; 2) a sexual interest in children; 3) a sexual interest in violent sex; and 4) multiple paraphilia.MeasuresEvidence base in prison – HMP WhattonMean Sexual Compulsivity Scores for participants taking medication to reduce sexual preoccupation: pre-medication (T0), three months post-medication (T3) and six months post-medication (T6).Below the levels of ‘typical’ sex offendersLevels of Sexual Compulsivity                                  Anti-libidinal group have significantly higher Sexual CompulsivitySC of main sex offender population at WhattonYoung sexually active studentsCM: strength of sexual urges01234567T0 T1 T3 T6Strength of urges and fantasiesTime intervals in monthsSSRIAASSRI &AAHighLowCM: strength of sexual urges – all meds combined01234567T0 T1 T3 T6Strength of urges and fantasiesTime intervals in monthsMain effect of time F(3,150) = 54.54, p= 0.001; ηρ2 .522Baseline - T1, P = 0.001T1-T3 P = 0.066T3-T6 nsHighLowBASELINESIPP scores VS general population, in-patients, out patients SIPP-118 Subscale(Lower means more disordered) Participants (n=69)General population (Andrea, 2007) (n=555)In-patients (Andrea, 2007) (n=555)Out patients (Andrea, 2007)  (n=157)Mean (SD) Mean (SD) Mean (SD) Mean (SD)Emotional regulation 2.40 (0.67) 3.30 (0.61) p=.001 2.44 (0.69) ns 2.78 (0.63) p=.001Effortful control 2.21 (0.66) 3.16 (0.56)  p=.001 2.53 (0.70)  p=.001 2.80 (0.71) p=.001Frustration tolerance 2.38 (0.60) 2.96 (0.56)  p=.001 2.24 (0.56)  ns 2.36 (0.56)  nsResponsible industry 2.72 (0.69) 3.44 (0.50)  p=.001 2.87 (0.67)  ns 3.07 (0.69)  p=.001Aggression regulation 3.05 (0.82) 3.66 (0.45)  p=.001 3.30 (0.73)  p=.013 3.34 (0.66) p=.004Intimacy 2.46 (0.56) 3.17 (0.60)  p=.001 2.68 (0.69)  p=.001 2.76 (0.63)  p=.001Enduring relationships 2.53 (0.58) 3.31 (0.58)  p=.001 2.47 (0.67) ns 2.54 (0.65) nsSelf-respect 2.59 (0.73) 3.30 (0.59)  p=.001 2.36 (0.67) p=.01 2.35 (0.74) p=.008CHANGES OVER TIMESIPP scores of participants VS general populationSIPP-118 Subscale(Lower means moredisordered)General pop’n(n=478)ParticipantsBaseline (n=69)Participants3 months (n=54)Participants6 months (n=41)Mean (SD) Mean (SD) T testp valueMean (SD) T testp valueMean (SD) T testp valueEmotional regulation 3.30 (0.61) 2.40 (0.67) p=.0012.78 (0.68)p=.0042.99 (0.65)p=.013Effortful control 3.16 (0.56) 2.21 (0.66) p=.0012.64 (0.65)p=.0012.77 (0.70)p=.001Frustration tolerance 2.96 (0.56) 2.38 (0.60) p=.0012.76 (0.64)ns2.86 (0.59)ns Responsible industry 3.44 (0.50) 2.72 (0.69) p=.0012.96 (0.60)p=.0013.13(0.56)p=.001Aggression regulation 3.66 (0.45) 3.05 (0.82) p=.0013.25 (0.69)p=.0073.38 (0.62)ns Intimacy 3.17 (0.60) 2.46 (0.56) p=.0012.67 (0.56)p=.0012.79 (0.54)p=.001Enduring relationships 3.31 (0.58) 2.53 (0.58) p=.0012.78 (0.64)p=.0012.86 (0.61)p=.001Self-respect 3.30 (0.59) 2.59 (0.73) p=.0012.87 (0.70)p=.0013.15 (0.63)nsStudy 1: Impact of SSRIs on sexual preoccupation: a service user experience• Aim: To explore the use of SSRIs to reduce sexual preoccupation• Participantso 13 convicted adult male sexual offenderso White British (12) or White Other (1) with a mean age of 51 (29-73) and an average IQ of 88 (63-108)o 20 – 60mg Fluoxetine per day• Data collectiono Semi-structured interviews, 1-2 hours eacho 1-3 interviews per participant, (total 23)o Thematic analysis of transcriptsResults• Five broad clinical themes emerged from deductive (T1, 2, 5) – inductive thematic analysis:1. Effects of medication: positive and negative2. Compliance and engagement3. Participant understanding4. Participant concerns5. Overall experience1: Effects of medication• Sexual preoccupation and associated  sexual behaviourso Decreased frequency & intensity of sexual thoughts, fantasies and urgeso Reduction in masturbatory frequencyo Increased control of sexual thoughts  & ability to distract o Physical effects• Obsessive compulsive disorder and depressive symptoms o Reduction in symptomso Increased ability to communicate with and to socialise• Impulse and emotional controlo Increased ability to recognise inappropriate sexual thoughtso Altered nature of fantasieso Improved management of emotions.• Side effectso Tiredness, drowsiness, nausea, constipation and headachesResearch & Clinical Team• Prof Belinda Winder belinda.winder@ntu.ac.uk• Dr Christine Norman• Helen Elliott• Jessica Faulkner• Rebecca Lievesley• Dr Kerensa Hocken• Dr Adarsh Kaul (prescribing psychiatrist at HMP Whatton)• Prof. Don Grubin• Next - CoSACircles of Support & AccountabilityBased on restorative justice principles Circles can help sex offenders, with little or no pro social support, to overcome these feelings and successfully reintegrate back into society.Started in Canada over 20 years ago, running in UK, in US (Minnesota, Vermont, Durham), Netherlands, Australia.What are Circles of Support and Accountability (CoSA)?• A Circle involves 4-6 volunteers who offer support to a high-risk sex offendero Screened, selected and trainedo Meet with a Core Member (sex offender) in the community once a week to offer social support• Volunteers are supervised by a professionally qualified Project Co-ordinatoro Provides advice and support through supervisiono Communicates and shares information with other risk management agencies through the MAPPA process09 January 2018 31Theory: The three key principles09 January 2018 32Reduce Isolation and Emotional LonelinessModel Appropriate RelationshipsDemonstrates Humanity and CarePublic ProtectionSupport Statutory Authorities-Police, Probation, MAPPASafer CommunitiesHold Offenders AccountableRelationship of TrustMaintain Treatment ObjectivesReduce ReoffendingSupport Monitor Maintain(Saunders & Wilson, 2003)Research and Evaluation09 January 2018 33Two strands of research form the evaluation:Strand OneDynamic Risk Review measures (every 3 months; fails vs succeeds)Questionnaires administered to the core members at different time points of the CircleHope Scale, Social and Emotional Loneliness Scale (Short), Personal Growth Initiative scale II, MOS Social Support, UCLA Loneliness Scale- Evaluate the impact and effect of the Circle on the CoreMember & compare core members against a matched control group End of Circle dataReconviction dataEvaluation 09 January 2018 34Stand TwoInterpretative Phenomenological Analysis of semi-structured interviews with core members at different time points during the Circle.o To explore their experiences of being in a prison-based circle and compare them to core members on community only circlesThematic analysis of semi-structured interviews with the volunteers o To understand their experiences of working on a prison-based circle and compare them to volunteers on community only circlesRepertory grids administered to the core members at the same time as the interviews above.o To examine the constructs used by the core members to        make sense of their worldProject, Research & Clinical Team• Dr Nicholas Blagden• Michelle Dwerryhouse• Rosie Kitson-Boyce• Helen Elliott• Coordinators• Core Members• Volunteers• Service User group• Prof Belinda Winder • Rebecca Lievesley• Dr Kerensa Hocken• -) preventionResist not desist: The need for a prevention project Preventative initiatives• Stop it Now - free, anonymous helpline providing information, advice, and guidance to anyone concerned about child sexual abuse.• Currently no free community treatment available• Prevention Project Dunkelfeld: Nearly half of the 358 participants interviewed had never had sexual contact with a minor (Beier et al., 2009)• Research estimates a time frame of almost a decade betweenonset of sexual fantasies and the time of the first arrest (Piché, et al., 2016)Reactive not proactive• Criminal Justice System offer treatment only after an offence has occurred.• Only for those known to the authorities / CJSMethodologyParticipants• N = 17 convicted adult male sexual offenders• Mean age 48 (SD = 7.72; 31 - 57), all White BritishIndex Offence• 10 convicted for sexual offences; 6 violent & sexual; 1 violent• 10 had committed offences against children; 7 against adultsData collection & Analysis• Semi-structured interviews, with 1-2 interviews per participant• Thematic analysis – 5 themes emerged; we are focusing on ‘inadequate help’ today1. Inadequate HelpThis theme summarises the outcome for participants who actively sought help and the restrictive factors for those that did not seek help for their sexual thoughts prior to coming to prison.• Participants sought help in different ways – police; drop in centre; parents; doctor (GP); psychologist; Hospital; Counsellor; Spouse.• Offered either inadequate or no support • Fed into helplessness and lack of trust.• Number of barriers to seeking help: fear, shame, denial, uncertainty, regret1. Inadequate Help“so we sat down, started explaining what these fantasies were like the impact that was having on me life and the fact that I’d get more stressed. Anxiety. Debt. You know those were all triggers. And again she says I’m sorry Mr Nathan, but until you commit an offence there’s nothing we can do”“All that happened was it was an assessment [by psychiatrist]. There was no treatment…More time went by, still events were happening, I was still having these thoughts.’’“to have people basically, especially the experts not take it any further I thought then, they can’t believe me. You know, and do I actually have to do something to prove that I need, I need help. And it wasn’t long after that, that the attack on the [victim] happened.”NathanThe End• Attracting funding for e.g. drop in centre then evaluating potential impact• SLF - seeking to employ people with sexual convictions (practice what we preach)• Focus on understanding purpose, meaning and identity• Helping to improve the experience (and utility) of the prison environment• Consent and humanity• Consider non-pathological and what is ‘normal’• Understand what Sus normal is• Involving service users (e.g. see next slide) Service User MH:Physical & Mental Health• Registered with a GP in TOWN very quickly, however there was an issue with having enough medication on my release and getting a repeat prescription. This happened again when I moved back to TOWN.• Some difficulty finding a NHS Dentist that is taking new patients but this is an issue for everyone due to the lack of NHS Registered Dentists.• Remain motivated to sourcing appropriate employment/purposeful activity although I can’t say the same about my partner. He is finding my lack of job/purposeful activity prospects very difficult.• A feeling of loneliness has reared it’s ugly head. Due to my offending history I have lost all of my family and friends. The only person I have is my partner. Once I identified this I have started to deal with it through my Offender Manager & COUNTYshire Action Trust.

Evaluation of the use of medication to manage sexual arousal (MMSA) with individuals convicted of a sexual offence (and some other stuff)

http://irep.ntu.ac.uk/id/eprint/32510/1/9966_Winder.pdf

Evaluation of the use of medication to manage sexual arousal (MMSA) with individuals convicted of a sexual offence (and some other stuff)

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