Managing difficult reactions to difficult clients

Many legal professionals will be used to managing clients with challenging behaviour, developing professional relationships, and de-escalating the situation when needed in order to do the best by their client. It is also important, however, to take the time to prepare and reflect on the impact that challenging behaviour has on us as professionals.

Clients encountered in the forensic and especially the forensic mental health space can present with unique challenges. They may be suffering from mental health issues, which may not be adequately treated. They may present with personality vulnerabilities, making communication and collaboration difficult. They may lack motivation to obtain a good outcome and to compromise. At the severe end of the spectrum, forensic clients may present as dominating and aggressive.

Clients in this space may present with a great deal of mistrust towards legal and medical professionals. It may be challenging to establish positive therapeutic rapport, particularly in the context of providing constructive feedback or challenging their perspective of past or current events. A helpful strategy may be agreeing with the client from the outset with him that any concerns or disagreements could be openly discussed, and regular check-ins conducted at the outset and conclusion of any interactions to check for any misunderstandings or grievances. Another strategy is to maintain a light-hearted and friendly tone when appropriate and use humour. Giving clients agency and a sense of control may also help them to feel more comfortable in a situation where agency is limited.

More specifically, clients with narcissistic traits may present as distrustful and defensive, inflating their own worth by denigrating the value of other people, particularly when triggered by feelings of loss of autonomy and power. Naturally, it can be difficult to develop a good professional alliance when dealing with this challenging behaviour. In such cases, it may be beneficial to return to the client’s goals in terms of legal proceedings. Again, it is important to maintain openness and consistency in every interaction.

Lastly, it is vital for professionals interacting with clients with challenging presentations to maintain their own professional boundaries, proactively address any negative reactions they feel towards their clients, and practice a non-judgemental stance towards themselves and colleagues who may react negatively to challenging clients. It is inevitable that as human beings working with challenging populations, we will experience our own reactions. These can be addressed with regular debriefs, reflective practice and clinical supervision.

 ©Sydney Forensic Clinic 2023

Assessment and treatment of adolescents with harmful sexual behaviours.

Although the term “harmful sexual behaviour” refers to a broad spectrum of sexual behavioural problems, including those that are considered non-criminal, this article will focus on adolescents who have engaged in sexual behaviour that has led to adjudication by the youth justice system.

Any contact with adolescents with harmful sexual behaviour should consider the reluctance they are likely to feel about disclosing the behaviour to others and the social, personal and legal consequences they are likely to experience as a result of disclosure. Establishing a therapeutic alliance through respect, credibility and transparency, minimising embarrassment and shame and instilling hope throughout the process is a key challenge of working with this group. 

The assessment of adolescents who have sexually offended can have different purposes at different stages of the legal process. A pre-sentence assessment, for instance, may focus on risk of reoffending, treatment targets and prognosis, whereas a pre-release assessment may focus on community safety, and long-term treatment needs. Psychological assessment of adolescents who have sexually offended should include information from multiple sources, including official documentation, interviews with the adolescent and collateral sources such as family, school and other mental health professionals, and relevant psychometric measures, and aim to establish the functions of the harmful sexual behaviours and how these have occurred in the context of the adolescent’s family and other systems.

Structured professional judgement (SPJ) tools can be used to inform assessment of adolescents’ risk of sexual reoffending. SPJ tools allow for risk assessments to be conducted in a systematic manner with consideration of empirically-validated static (historical and unchangeable) and dynamic (changeable through intervention or treatment) risk factors, while remaining flexible to consider the unique needs and strengths of the individual. Some of the dynamic risk factors relevant to adolescents’ risk of sexual reoffending include sexual preoccupation and obsessive sexual interests, poor interpersonal functioning, poor self-regulation, high-stress or unstable family environments, internal motivation for change and insight into one’s own risk factors.

It is important to note that SPJ tools should not be used to address long-term risk of adolescents’ sexual re-offending, and that scores from SPJ tools should not be used in isolation when assessing risk. Adolescence is a time of rapid neurological, social, sexual, physical and moral development, which any formulation of adolescent risk should consider.

Treatment targets are generated by the assessment process and are tailored to the individual. Research indicates that treatment outcomes for adolescents who have sexually offended are influenced by the therapeutic relationship between the therapist and the client and the willingness of the adolescent and their caregivers to engage in treatment. Wherever possible, the therapist sees the adolescent together with their caregivers to ensure that any interventions initiated in session are reinforced and modelled in other settings. Given the prevalence of victimisation and trauma among adolescents who have sexually offended, a trauma-focused approach to treatment is supported by research. Multisystemic Therapy for youths with problem sexual behaviours, the current best-practice intervention for this population, aims to identify individual and family strengths, promote responsible behaviour and teaches behavioural skills in the context where the young person and their caregivers will eventually practise the behaviour. Other approaches may address treatment targets including the development of healthy sexual interests, increasing accountability and responsibility for past offending, and developing sexual offence prevention plans, which includes the adolescent’s unique needs, strengths and risk factors. Professionals working with adolescents with harmful sexual behaviour should ensure they receive adequate support such as clinical and peer supervision to maintain their ability to work empathically and effectively with this population. 

 ©Sydney Forensic Clinic 2019

Useful links

http://www.atsa.com/juvenilepractice

https://www.mstpsb.com/

Assessing risk of reoffending

The assessment of the risk of sexual and violent reoffending is one of the pillars of the Risk-Needs- Responsivity model of offender assessment and rehabilitation (Andrews, Bonta & Hoge, 1990). The principle of “risk” states that the level of service provided to an individual should match their risk of reoffending. In addition, as services are always limited, the offenders at the highest risk of reoffending should be prioritised for treatment.

A few points on risk:

• Although risk cannot be eliminated altogether, it can be assessed, predicted and managed.

• Risk is dynamic – even a “high risk” offender is not “high risk” all of the time. Their level of risk increases and decreases based on various internal and external factors.

• Risk assessment is one part of the picture – we must also consider the individual’s motivation and capacity for change.

Risk assessment researchers talk about the “four generations” of risk assessment. These can be summarised as follows:

• First generation- First generation risk assessment involved professionals - usually correctional staff or clinical practitioners - assessing the “dangerousness” of an offender based on their clinical or professional judgement. It was the “In my opinion” assessment. Although it was flexible and inexpensive, it did not predict risk of reoffending better than chance. It also lacked transparency and consistency and was highly subjective.

• Second generation – Second generation risk assessment developed out of data looking at factors that were associated with reoffending. The factors assessed were historical, for example, age and number of prior offences, and were therefore static, that is, not amenable to change. Nonetheless, the predictive accuracy of second generation risk assessment tools was superior to professional judgement assessments. This type of risk assessment is termed actuarial, as it gives us an estimate of likelihood that an individual with a given risk level will or will not be charged or convicted of a new offence. Arguably the best-known and most widely-validated actuarial risk assessment measure is the Static-99R (Hanson & Thornton, 2000,2012), used to predict the risk of sexual reoffending in adult males.

  As second generation risk assessment is limited to historical, unchangeable factors, it does not reflect changes to an individual’s risk due to treatment or environmental factors.

• Third generation – third generation risk assessment, referred to as “risk-needs” assessment, addresses the limitation of second generation assessment tools by incorporating empirically-validated “dynamic” factors- that is, factors related to an individual’s offending (for example, substance use), but amenable to change (an individual can address their substance use through treatment).

  Assessing risk of reoffending by taking into account both static and dynamic factors enables correctional and clinical professionals to target certain factors in an individual’s rehabilitation. This type of risk assessment therefore informs treatment needs.

  Some well-validated third generation tools include the HCR-20 and the VRS to assess risk of violent reoffending and the STABLE and RSVP to assess sexual reoffending.

• Fourth generation – fourth generation risk assessment tools integrate all of the available best-practice approaches by considering static and dynamic factors, reoffending scenarios to be used for case management purposes, and general and individual responsivity factors. Responsivity factors are factors that can enhance or detract from how an individual responds to treatment.

  For more information:

  https://www.publicsafety.gc.ca/cnt/rsrcs/pblctns/rsk-nd-rspnsvty/index-en.aspx#a4

  http://www.static99.org/

   ©Sydney Forensic Clinic 2018