Treating offenders with mental retardation and developmental disabilities.
Second, the offender with MR/DD often has committed a sex offense, and laws have become more stringent in identifying and prosecuting sex offenses. What at one time might have been excused due to a disability is now legally challenged. Also, court personnel are becoming more educated about offenders with MR/DD and better understand when offenders are manipulating the system and using their disability as an excuse. Better questions are asked by prosecutors that highlight the offenders' intent. As a result of the growing population of offenders with MR/DD, there is now a burden of looking for viable treatment options other than prison as the primary sanction. This population typically has done poorly in prison, and nationally, effective treatment while incarcerated has been lacking. Keeping these offenders in the community gives more treatment options to the courts. Treatment can be effective, but takes a knowledge of how the systems of MR/DD, mental health and corrections work. Historically, there has been very little collaboration among the three systems.
Characteristics That Influence Treatment
The population of individuals with MR/DD is characterized as having multiple needs, but with many contradictions. For example, these offenders can be extremely charming, yet very shallow; extremely endearing, yet very domineering; very charismatic, yet actively and passively control people in a variety of situations; very friendly, yet also very ruthless; very cooperative, yet very stubborn and manipulative; and extremely hardworking, yet noncompliant. These contradictions often make treatment a challenge for staff and providers.
According to the American Association of Mental Retardation, mental retardation is defined as a disability characterized by significant limitations both in intellectual functioning and in adaptive behavior as expressed in conceptual, social and practical adaptive skills originating before age 18. Offenders with retardation are often higher functioning and know they have gross impairments and do not fit in. This often contributes to low self-esteem, depression, poor self-concept, poor body image, insecurity and general feelings of inferiority. With these types of psychological deficits often come personality disorders and mental health problems. These problems can often be severe and require medications. These medications, however, pose a problem because many of the offenders with mental retardation also have some type of substance abuse problem, which further complicates the situation.
Treatment is at times very difficult because gross deficiencies in adaptive behavior occur. These deficiencies make it very hard for these offenders to use community resources and handle such tasks as banking, using public transportation or handling shopping needs. Community deficits typically accompany social skills deficits, where these offenders have difficulty solving problems and dealing with problem situations such as handling a complaint constructively. These social deficits often get this population noticed and often contribute to a variety of crimes. This population has a higher proportion of social crimes such as sexual offending, arson, property damage and burglary compared to the general population of offenders. (1) These crimes against others often occur because the offender with MR/DD does not have the social skills to know how to handle or resolve certain social situations. As an example, one offender with MR/DD detailed as a teenager how he was always being rejected by girls because he did not fit in, wear the right clothes or say the right things. His frustration led him to the only age group that would pay attention to him--underaged girls. This made it very easy, when he was going through puberty, to look to the young girls as the only ones he could relate to in getting his sexual needs met.
Often, the thought process of this population can be compared with Swiss cheese. These offenders are adept in certain areas where they appear very normal, but in other areas they have gaping holes that show up as gross deficits of learning and responding. They often have an extreme difficulty generalizing from one situation to another. What is learned in one environment needs to be retaught in another. For example, knowing how to sort items at work would not necessarily transfer to sorting clothes at home. Along with the lack of generalization comes the inability to discriminate important cues. In treating this population, providers often forget that the offender may not know what to target in any given situation. For example, going to a church setting means the offender needs to know to be quiet, sit appropriately in the pew and follow the service program.
This population has many thinking errors (as do many offenders). However, given their limitations, they often need concrete, repetitious, simple terms to understand the error in their thoughts. They also have a hard time following how thoughts and feelings connect, often just understanding basic feelings such as anger, sadness, tiredness and happiness. They have a need to learn to identify basic feelings and then process how feelings and thoughts can influence one another.
Treating an Offender With MR/DD
Treatment approaches that work with this population are borrowed from literature and experience working in a community corrections environment with this population for the past 12 years. One program that has used such treatment approaches is o.k. Alvis House in Columbus, Ohio, which is a 15-bed intermediate-care facility for the mentally retarded. It houses offenders from potentially all counties in Ohio and provides long-term care to address their mental retardation, mental health and corrections needs. The team that works with these individuals comprises a program director, qualified mental retardation professional, recreation therapist, doctor, psychiatrist, psychologist, nurse, community service coordinator, as well as counselors, direct care workers, student interns and volunteers. This type of team approach is essential in working with this population since they have such diverse needs that extend to many areas.
In working with this population, a level system, especially in the form of a token economy, works very effectively. These offenders need concrete ways to see that their behaviors are influencing others, both in a pro-social manner and in an antisocial manner. Alvis House institutes a daily point system that allows consistent and immediate feedback for behaviors and gives staff an opportunity to model responsible behavior for the offenders. Pro-social alternatives are emphasized more than antisocial behaviors so that residents buy into the program and have motivation for change. Each level reached has more privileges but also more responsibilities. As offenders prepare to leave Alvis House, they are weaned off the points and given common social rein-forcers such as praise and positive feedback.
Since such a high percentage of MR/DD offenders have committed sexual crimes, there must be a strong counseling program to address breaking their pattern of offending and developing more healthy sexual outlets. Breaking the cycle of offending children, for example, demands that offenders admit their crimes, see how their crimes hurt an innocent child and figure out ways to prevent such violations in the future. Good sex offender treatment can take several years to take root in these offenders, as they do not seem to learn at the same rate and often go through significant initial resistance. An offender new to treatment will often say, "If that child had not approached me as he had, I would not be in this mess." Sex offender treatment must be repetitious, confrontational and concrete for this type of offender to realize the need to make changes.
This population often needs sex education. Offenders with MR/DD may not understand basic terms such as sexual anatomy, consent and steps in a healthy dating relationship, so it is important to have a curriculum that is visual and to which they can relate. At Alvis House, staff use Life Horizons I and II to discuss these issues. (2) Offenders can learn over time that they can make healthy choices in social/sexual situations. One of the keys is for the offender to realize that intimacy involves sharing emotions and feelings rather than just a physical exchange. Most of the Alvis House offenders have never had a successful dating relationship, let alone a girlfriend. They need to be taught step by step how the process works.
Anger management is an essential area for these offenders to gain more control over their rage and their need to get even with others. Like an onion, layers of anger are peeled away to get to core issues. At Alvis House, individualized behavior programs are often written to give staff and clients ways to channel the offenders' anger and rage. Individual and group counseling reinforce these plans and help residents solve problems and accept constructive feedback. They learn they can control their anger appropriately. Homework assignments are essential so they can practice better ways to cope when in uncomfortable situations. When the offenders are handling tempers appropriately, staff give a lot of verbal praise and extra pro-social points. Residents learn that anger is not a wrong emotion, but one that needs to be channeled in careful ways. One offender stated, "I always used my anger to intimidate others, I did not know it could be used in positive ways."
Offenders with MR/DD can learn to positively identify thinking errors and replace them with healthier thoughts. However, the traditional common language found in cognitive-behavior programs should be simplified and defined for this population. At Alvis House, simple concepts from the EQUIP Program (3) are borrowed. Offenders in group sessions learn to identify their thinking errors through role play and group confrontation. The thinking errors are posted in the room and replacement thoughts go right alongside them to show that healthier thoughts are possible. The thinking error concept is incorporated into all the offender groups and therapies to show that thinking is never in isolation of any important life area or skill.
Vocational training is extremely important with this population because having something productive during the day cuts down on behavior issues and improves the offenders' feeling of self-worth. It also competes with a variety of other impulsive thoughts that can lead directly to behavioral issues. However, these offenders often are rejected from traditional jobs sites, and the sex offender often will be rejected from programs that traditionally serve the MR/DD population. Programs must be creative in setting up vocational training to serve this population. At Alvis House, an in-house vocational training program called Candlelites meets vocational needs. The offenders are taught the art and craft of making candles or soaps and accept donations from the community for their products. The residents then use the money they earn through the program to buy recreational equipment and other needed supplies for their use. Such creative thinking is essential to the development of effective vocational plans.
There are often tremendous medical issues that accompany working with this population. These medical issues are usually a product of homelessness and poor personal care for many years. Offenders who need major dental work and/or major surgeries may have been neglected for years. It is essential to have good nursing care 24 hours a day, seven days a week that could potentially intervene in a crisis situation. Fragile medical situations typically have to be resolved before mental health treatment can take place. It is important to have both a psychiatrist and a medical doctor at the disposal of the program. Medication must be monitored very closely due to the potential for seizures and other adverse drug interactions.
An often ignored area in programs for MR/DD offenders is substance abuse education and treatment. There have been providers in the fields that feel that those with MR/DD should be allowed to drink without any limits being placed on their usage. Also, many of these offenders have been homeless and using on the streets. It is essential to have both substance abuse education and counseling available to promote abstinence for those who are dependent. At Alvis House, the ways in which substances have negatively influenced most life skill areas are explored. One of the Alvis House offenders drank beer irresponsibly for 30 years prior to entering the program. Although he understood how alcohol had interfered with his life, he was not sure he could give it up. After several years of treatment, he was willing to admit that it might be possible to go through life without drinking. This offender was very scared because alcohol had always been the center of his life. He now had to learn to live in a new way.
Due to the multiple needs of this specialized population, it is essential that the burden of paying for these services is shared among the systems representing MR/DD, mental health and corrections. Not a single system can bear the brunt of what it takes to successfully treat this population. Networking and sharing resources are essential and a team effort is vital to promoting safety plans and coordinated treatment. There have been several models in Ohio that have had some success in training professionals to work with this population. One such model, Partners in Justice, has brought corrections professionals and MR/DD professionals together to learn from one another and to build teams. So far, there are 27 local teams from counties across Ohio that have committed to serving this population. This type of training at the state level is essential and should include department heads, MR/DD and mental health case managers, probation officers, judges, police personnel and others who officially intervene with this population. Cuyahoga County, in northern Ohio, has been very successful in bringing all these entities together and having the judges support this effort. They have learned to make better use of community resources, which has resulted in a decrease in recidivism.
Effective models of treatment should be relayed to all counties, especially rural counties. This growing population is both a drain on resources and a constant safety risk to the community. These risks need to be shared by all involved systems to identify early treatment needs and then find creative ways to fund and staff needed programs. Without treatment, offenses get repeated and continue to drain all involved systems.
(1) Simpson, M.K. and J. Hogg. 2001. Patterns of offending among people with intellectual disability: A systematic review. Part I. Journal of Intellectual Disability Research, 45(October):384-396.
(2) Kempton, W. 1991. Life Horizons I and II. Santa Monica, Calif.: Stanfield and Co. For more information, call 1-800-421-6534.
(3) Gibbs, J.C., G.B. Potter and A.P. Goldstein. 1995. The Equip Program: Teaching youth to think and act responsibly through a peer-helping approach. Champaign, III.: Research Press.
Randy Shively, Ph.D., is vice president of clinical services at Alvis House in Columbus, Ohio, and is also a licenced psychologist with a private practice where he specializes in the treatment of the mentally retarded and developmentally disabled. He has 20 years of experience working with offenders.