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

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

 (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) 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) 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

 Intimacy deficits
 Deviant sexual attitudes, beliefs and
interests
 Distorted attitudes/cognitions
 Poor social functioning/interpersonal
competency
 Impaired self-regulation/poor behavior
management
5

 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

 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

 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

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

 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

 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 the likelihood of future victimization
through the safe release of offenders into
the community.
 And, also ...
14

 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

 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

 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

 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

 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

 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

 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

 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

 Lack of basic training in group therapy
 One-to-one treatment in the context of
group
 Merely an extension of parole/probation
23

 Psychoeducational
 Interpersonal/
process-oriented
 Supportive
 Relapse prevention/recovery-based
 CBT
 Case management
24

 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

 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

 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

 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

 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

 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

 (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

 (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

 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

 (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

 (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

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 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

 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

“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

 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

 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

 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

 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

 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

 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

 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

 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

 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

 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

 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

 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

 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

 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

 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

 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,
patterns of resistance and defensive
posturings (“personas”), and inter-member
feedback.
58

 Leader interventions aimed at facilitating
the progression of the group-as-a-whole
and creating social learning opportunities.
59

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 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

 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 maintained
in roles so that the group is stabilized
(status quo).
63

 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

 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

 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

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 begins to promote trust.
 Members are superficial and overly polite;
trust has not yet been established.
68

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

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

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

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

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

 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

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

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

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

Commonalities: An Amalgamation
78

 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

 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

 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

 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

 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

 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

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

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 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

 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

(#1) Group environmental factors
(#2) Belonging
(#3) Self-revelation factors
(#4) Learning factors
(#5) Self-understanding
See Rutan, Stone, and Shay (2007)
89

 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

 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

 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

 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

 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

 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

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

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

 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

 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

 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

 https://www.youtube.com/watch?v=R9k
TWTzRqe8
103

 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

 (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

 (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

 (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

 (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

 (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

 (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

Mechanisms and Processes
of Change
111

 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

 Especially relevant early in the group.
 Observe others (veterans), see how they
do it, may help reduce fears and
anxieties.
114

 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

 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

 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

 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

 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

 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

 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

 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

 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

 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

 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

 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

 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

 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

 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

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
personal goals and the group agreements)
 Activities of the group leader
 Confidentiality will be broken (containment
model)
132

 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

 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

 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

 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

 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

 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

 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

 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

 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

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
each dimension, and be able to accurately
judge what opportunities are present in the
group at any given time.
143

 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

 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

 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’s experience/gaining
credibility
 Tolerating extensive discussion of POs,
outside of the group experiences,
complaining, and denial/minimization
147

 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

 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

 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

 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.
 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

 A balance must be achieved between
self-disclosure and an odd withdrawal
and lack of personalization. Mistakes on
both ends are problematic.
153

 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

 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

 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 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

 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

 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

 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

 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

 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

 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

 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

 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

 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

Special Group Leadership Issues
and Techniques
167

 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

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

 “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

 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

 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

 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

 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

 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

 Resistance is commonly dealt with
punitively, and should not be!
 Merely mentioning resistance (fears) in your
groups will help promote safety and trust.
176

 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

 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

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 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

 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

 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

 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

 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

 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

 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

 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

 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

 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

 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

 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

 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

 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

 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

 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

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

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

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
group therapy literature and adapt them to
SO treatment.
199

 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

 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

 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

 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

 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

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

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

 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

 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

 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

 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

 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

 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.
 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

 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

 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

 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

 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

 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

 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

 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

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

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

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