Working positively with sexual offenders: maximizing the effectiveness of treatment

Transformative Learning Theory and Its Application to the Delivery of Community Maintenance Programs for Men Who Have Sexually Offended

Given public perceptions about those who have sexually offended, there tends to be a focus on offence-specific intervention programs in a bid to address re-offending risk. With a significant portion of the literature on sexual offending focused on the development and evaluation of interventions targeting this behavior, there is little that considers community maintenance programs (CMPs) or those programs in the community where those who are released from prison are attempting to reintegrate. Further, there is no known research considering the theoretical underpinnings of or a framework for delivering CMPs. This paper offers Transformative Learning Theory as a potential framework for the delivery of CMPs and offers that adult learning theory needs to be considered in the delivery of offending interventions.

Child sexual exploitation material offenders, one-size-fits-all for? Exploring tailored clinical dimensions based on cognitive and behavioural criminogenic factors

BACKGROUND

Interventions for individuals involved in sexual offending behaviours are likely to be more effective if adapted to focus on their specific characteristics, suggesting that men who engage in sexual offences against children over the Internet should be treated differently from those who have actual physical contact against children.

AIMS

The goal of this study is to explore possible associations between the criminogenic cognitions and behaviours of men using online child sexual exploitation material (CSEM) and variables relevant to intervention. We hypothesised that antisocial tendencies, sexual, emotional and relational problems and self-regulation problems, as well as cognitive distortions would be associated with CSEM use.

METHOD

Ninety-eight men who had been convicted of at least one online CSEM-related offence, but no child contact sexual offences, at any time between 2001 and 2020 were recruited in the province of Quebec (Canada). Cases were reviewed to identify cognitive and behavioural criminogenic factors according to a coding sheet developed after reference to prior literature. Variables were extracted from official criminal records, sexological and psychological reports, as well as investigative and forensic reports and interviews. Exploratory factor analysis was carried out to identify potentially relevant dimensions.

RESULTS

Analysis confirmed five distinct factors which, together, accounted for 60% of the variance: dissocial traits, dysfunctional intimacy, passive alienation (internalised sense of alienation), normless alienation (social norms experienced as alien) and coping with threat.

CONCLUSION

Because online CSEM-related offenders present heterogeneous risks and needs, a 'one-size-fits-all' intervention is unlikely to be optimal for most of them. Our findings suggest a way of classifying risks and needs to facilitate more focused interventions. Future research should evaluate the relative effectiveness of general interventions compared to those tailored towards the dimensions of risks and needs identified in this study.

The World Federation of Societies of Biological Psychiatry (WFSBP) 2020 guidelines for the pharmacological treatment of paraphilic disorders

Objectives: The primary aim of these guidelines is to evaluate the role of pharmacological agents in the treatment and management of patients with paraphilic disorders, with a focus on the treatment of adult males. Because such treatments are not delivered in isolation, the role of specific psychotherapeutic interventions is also briefly covered. These guidelines are intended for use in clinical practice by clinicians who diagnose and treat patients, including sexual offenders, with paraphilic disorders. The aim of these guidelines is to bring together different views on the appropriate treatment of paraphilic disorders from experts representing different countries in order to aid physicians in clinical decisions and to improve the quality of care.Methods: An extensive literature search was conducted using the English-language-literature indexed on MEDLINE/PubMed (1990-2018 for SSRIs) (1969-2018 for hormonal treatments), supplemented by other sources, including published reviews.Results: Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for its efficacy, safety, tolerability, and feasibility. The type of medication used depends on the severity of the paraphilic disorder and the respective risk of behaviour endangering others. GnRH analogue treatment constitutes the most relevant treatment for patients with severe paraphilic disorders.Conclusions: An algorithm is proposed with different levels of treatment for different categories of paraphilic disorders accompanied by different risk levels.

What Works in Israeli Prison-Based Sex Offender Rehabilitation Programs: Program Participants' Perspective

This study invited 10 of the 22 sex offenders enrolled in a prison-based rehabilitation program in one of the prisons in Israel to engage in the two first of the 4-D ( Discover, Dream, Design, and Deliver) stages of the Appreciative Inquiry . Consistent with the responsivity principle, and the IA tenets, program participants were interviewed to Discover components to which they were responsive and Dream/envision additional ones that would increase engagement and progress. Content analysis of the interviews indicated that despite the initial decision to enrol based on external incentives, participants eventually engaged in group therapy and expressed the desire to understand and regulate their sexual behaviour. While the the modules of Cognitive Behabioral Group Therapy (CBT) were viewed as assets, the lack of sufficient recruitment criteria, the large therapy group size, and its open-ended structure were mentioned as impediments reaching therapeutic goals. Social workers/therapists were criticized for their request that they be informers, and for their accusative therapeutic style whenever sexual issues were broached. Recommendations derived from the offenders' narrative were to increase staff professionalism to create a therapeutic alliance that promotes trust and open communication. Criminal justice practitioners may then take up the challenge of the never-ending process of Appreciative Inquiry to Design and Deliver program components envisioned by the participants to increase participants' responsivity to the program and thus its effectiveness.

An Etiological Approach to Sexual Offender Assessment: CAse Formulation Incorporating Risk Assessment (CAFIRA)

PURPOSE OF REVIEW

Case formulations (CF) have been the cornerstone of effective practice in clinical psychology since the 1950s and now form one of the core competencies in clinical and forensic assessment. The use of CFs within forensic settings is becoming more relevant when working with offenders who have experienced significant trauma, suffered from personality disorder, and have displayed sexually abusive behavior. Furthermore, most North American and European jurisdictions insist that expert witnesses adopt an idiosyncratic approach to risk assessment and consider the characteristics of the individual as part of a wider formulation of the problem behavior. This article focuses specifically on CF incorporating risk assessment procedures of sexual offenders.

RECENT FINDINGS

While empirical support for the use of risk analysis and formulation in managing offending behavior generally, and sexual offending behavior in particular, is limited, there is mounting evidence to suggest that CF can improve understanding of an individual's problem sexual behaviors. We argue that by integrating risk formulations into the CF provides a conceptually robust link between the etiologically development of the problem sexual behavior and effective assessment and risk management of sexual offenders. As forensic treatment programs increasingly moved toward strength-based approaches, in keeping with the Risk-Need-Responsivity principles Andrews and Bonta (2004), and the Good Lives Model Ward and Stewart (Prof Psychol Res Pract 34:353-60, 2003) of offender rehabilitation, the use of CFs in the assessment, treatment, and management of sexual offenders is indispensable. We present an etiological framework for understanding risk in an individual sexual offender by integrating a case formulation model to include the use of (static, stable, and acute) actuarial and clinical risk assessment measures as well as protective risk factors, referred to as the CAse Formulation Incorporating Risk Assessment (CAFIRA) model.

Cognitive-Behavioral Therapy Efficacy for Reducing Recidivism Rates of Moderate- and High-Risk Sexual Offenders: A Scoping Systematic Literature Review

This literature scoping review compared recidivism rates of moderate- and high-risk sexual offenders who received cognitive-behavioral therapy (CBT) oriented treatments. Ten empirical studies from 2001 to 2014 were selected for review that met the following criteria: (a) Treatment program included a CBT-based intervention with a comparative intervention; (b) participants included adult, male, moderate- and high-risk sexual offenders only; and (c) follow-up data for up to 12 months. Data were analyzed using a summative metric for recidivism rate comparisons ( N = 3,073 for CBT and N = 3,588, for comparison approaches). Sexual offense recidivism rates varied from 0.6% to 21.8% (with CBT) and from 4.5% to 32.3% (with comparison intervention). The within-sample median rate of violent recidivism with a history of sexual offense was 21.1% (with CBT) versus 32.6% (comparison). Sexual offenders had a general felonies (within-sample) median recidivism rate of 27.05% (with CBT) versus 51.05% (comparison). The evidence supports the conclusion that CBT in its various forms is an efficacious treatment modality to prevent offense recidivism by sexual offenders. Suggestions for future research are considered.

Sexual Behavior Among Persons With Cognitive Impairments

Although the cognitively impaired are frequently included in heterogeneous studies of problematic sexual behavior, the epidemiology, etiology, and approach to assessment and treatment of persons with dementia and intellectual disability are distinct from those of the general population. The incidence of inappropriate sexual behavior among the intellectually disabled is 15-33%; however, the nature tends to be more socially inappropriate than with violative intent. Limited sociosexual education is a large contributor, and better addressing this area offers a target for prevention and treatment. A thorough clinical assessment of problematic sexual behaviors in the cognitively impaired requires understanding the patient's internal experience, which can be challenging. Assessment tools validated for the general population have not been validated for this population. Very few studies have assessed treatment approaches specifically among the cognitively impaired; however, research does suggest utility in habilitative, psychotherapeutic, and pharmacologic approaches which have been validated among the general population.

Pathways to Desistance Among Men Convicted of Sexual Offenses: Linking Post Hoc Accounts of Offending Behavior and Outcomes

Within many sexual offender-specific treatment programs, clients and their therapists devote considerable time to understanding "cycles" or "pathways" to sexual offending, and clients often need to fit their stories into existing offending paradigms. Although this post hoc processing of offending behaviors may assist clients in understanding their individual pathway toward crime, we know little about how they situate this information within their lives moving forward. Relying on in-depth interview data, the current study examined accounts of the sexually related crimes that brought 28 men to prison. Analyses suggest varied perspectives among the men regarding pathways to and from their sexual offenses; some aligning with existing models, but others merging around different theoretical frameworks. Implications are discussed as they relate to treatment models and the desistance process for men convicted of sexual offenses.

Treatment During Civil Commitment for Sexual Offending Behaviors

The first sex offender civil commitment legislation passed in Washington State in 1990. Since that time, 21 additional jurisdictions in the USA have passed similar statutes. Although considered controversial by some, the statutes have withstood legal scrutiny at the state and federal levels. These statutes have been found constitutional in large part because they offer treatment to those individuals detained under them. In the 25 years since sex offender civil commitment became a reality, significant advances in sex offender assessment and treatment have shaped the landscape of the associated treatment programs. This article reviews current practice in programs that treat individuals detained under these laws and provides a framework in which these programs are delivered.

Comprehending and Rehabilitating Roman Catholic Clergy Offenders of Child Sexual Abuse

Many have studied Roman Catholic clergy who have sexually abused children, but the range of investigations remains disconnected. This article brings together various disciplinary perspectives to form a comprehensive view. A review of the literature is first undertaken to comprehend how clergy offenders have been conceptualized in psychosocial, sociocultural, and moral-religious studies. These perspectives are then used as a foundation for examining how these clergy can be rehabilitated. Three rehabilitative modalities--psychological treatment, rehabilitation through restorative justice, and ritual healing--are explored. The article concludes with a discussion of the insights gained from the literature review and how the modalities can be advanced in an interdependent and considered approach.

Forensic psychiatric patients' narratives of their offense

This study aims to describe forensic psychiatric patients' experiences of their offense and its meaning for their lives, and to increase the understanding of the meaning of the offense in the eyes of the patient. The data analyzed was collected by interviews with forensic psychiatric patients and analyzed by narrative analysis. The findings suggest that forensic psychiatric patients have different types of stories describing the offense and its meaning in their lives. Illness narratives can be utilized therapeutically because they may construct patients' identity, experiences, and their situation as people with an illness seek explanations and meanings for their plight.

Ethics and the treatment of sexual offenders

Clinicians in sex offender treatment programs always encounter the need to balance the best interests of sex offenders and the safety needs of the community. The protection of the community often takes primacy, resulting in violation of traditional mental health codes of ethics. These ethical dilemmas have generated debates in the academic community. To minimize ethical dilemmas, clinicians in sex offender treatment programs need to acknowledge the conflicts, adhere to safeguards, and thoughtfully address the challenges with profession-specific ethical values and codes. This article reviews ethical principles in relation to conceptualization of sex offenders and their assessment and treatment and research involving sex offenders.

Theorising sexual media and sexual violence in a forensic setting: men's talk about pornography and offending

This article reports findings from a discourse analytic study which critically explored the language of mental health nurses, and detained sexual offenders, in relation to pornography in one high-security hospital. It recognised previous empirical investigation, and pro-feminist theorising, into mediated representations and male sexual violence, but situated the research process in a forensic nursing context. Decision-making about access to, or restriction of, commercial sexual literature, as a component of therapeutic intervention and offender management, reveals tensions between service-user rights and treatment goals. The aim was to access nurse and patient talk in a specific culture. Semi-structured interviews with eighteen nursing staff, and nine patients, were used to co-construct accounts of pornography, sexual offending, and treatment. Analysis and data collection were undertaken concurrently. Interviews were audio-taped and transcribed. Data was coded to identify theoretical/conceptual themes and sub-themes representing discursive repertoires. Attention was given to how textual variation positioned respondents in relation to each other and the institution. Findings suggested collective male talk textured the environment, promoted gendered inequality, marginalised female nurses, and undermined rehabilitation. Shared discourse enabled male staff and patients to relate to each other as men, while maintaining distance through constructions of otherness. Discussion focuses on discriminatory discursive-practices, where men's talk about pornography and sexual violence embodied gendered knowledge/experience and contributed to a toxic culture. Consideration is given to ways of resisting institutional impediments and promoting positive therapeutic relations.

As relações familiares do adolescente ofensor sexual

O texto trata de uma pesquisa qualitativa que enfoca o conhecimento das relações familiares do adolescente ofensor sexual, enfatizando as figuras da mãe e do pai, e se baseia nas entrevistas que antecedem o oferecimento de uma intervenção grupal, com os adolescentes e familiares. As entrevistas foram realizadas com sete adolescentes, entre 14 e 17 anos, e suas mães. Foram construídos três núcleos de resultados sobre: a interação familiar desse adolescente se organiza para garantir a sobrevivência da família; esse adolescente apresenta uma intensa e paradoxal relação com sua mãe; e há uma relação extremamente pobre de convivência e vinculação afetiva com a figura paterna. Concluímos que a violência sexual intrafamiliar, cometida pelos adolescentes, está ligada à dinâmica afetiva familiar de distanciamento e autoritarismo. Uma melhor compreensão da violência presente nas relações familiares desse adolescente é fundamental, porque uma característica desses sujeitos é a falta de habilidade social, e esse aspecto provém de um processo pobre de vinculação com seus pais.

The influence of risk and psychopathy on the therapeutic climate in sex offender treatment

The current study examines the relationship between therapeutic climate of sexual offender treatment groups, risk level, psychopathy and phase (i.e., early/later) of treatment. The participants were 137 sexual offenders detained indefinitely under Wisconsin's Sexually Violent Person's Law who attended a treatment group based on their level of psychopathy: higher levels of psychopathy (i.e., PCL-R scores of 25 or above) or lower levels of psychopathy (i.e., PCL-R scores of less than 25). Using MANOVA with aspects of the therapeutic climate as the dependent variables, the therapeutic climate did not differ as a function of the risk level of the participants. However, the overall therapeutic climate of the two treatment tracks (Lower vs. Higher PCL-R) differed significantly. The mean therapeutic climate scores for both treatment tracks were in the medium to high range (with exception of group cohesion, which was low in the Higher PCL-R track), indicating a fairly positive therapeutic climate in both treatment tracks overall. The therapeutic climate also differed as a function of phase of treatment for each of the treatment tracks, with some aspects being rated more positively early in treatment and others in more positively in later phases. In particular, group cohesion was viewed more positively for the Higher PCL-R group in later phases of treatment.

Evaluation of a community-based sex offender treatment program using a good lives model approach

In this study the authors assessed a Good Lives model (GLM) approach to sex offender treatment and compare it to a standard Relapse Prevention program. The comparisons examined (a) attrition rates, (b) treatment change in areas targeted in treatment and achievement of a posttreatment treated profile, and (c) views of offenders and facilitators. There were no differences in the attrition rates or the rates of treatment change between the two programs, indicating that they were equally effective at retaining participants and achieving change on areas targeted within treatment. Both facilitators and program participants reported the Good Lives approach module's impact in a positive, future-focused manner. In contrast, those who attended the Relapse Prevention module did not report their perceptions and motivations in a manner that was focused on the positives in their future as frequently as those who attended the module with the Good Lives model approach.

From parallel to intersecting narratives in cases of sexual assault

Restorative justice alternatives to criminal justice are designed to balance the needs of victims, offenders, families, friends, and the community at large to achieve social justice, repair of victims, and deterrence of crime. In the model we evaluated from RESTORE (Responsibility and Equity for Sexual Transgressions Offering a Restorative Experience), each offender and victim received individual services and met in guided conferencing to mutually determine reparative actions for the offender. At the exit meeting, the offender, as the responsible person, read a written apology to the survivor/victim. In this article, we analyze the expression of empathy in the apology, in which the initial mitigation of responsibility in early documents was replaced by acknowledgment of harm to the survivor/victim and acceptance of responsibility for the assault. Those accused of felony rape and those targeting a visible person in cases of misdemeanor indecent exposure expressed greater regret and remorse than offenders of indecent exposure with an indeterminate victim.

Current concepts in the pharmacotherapy of paraphilias

Concerns about paraphilia and its treatment have grown in the past few years. Although the aetiology of paraphilia disorder is still not completely understood, pharmacological treatments have been proposed for this disorder. Paraphilias are a major burden for patients and society; nevertheless, only a few individuals with paraphilias voluntarily seek treatment. Antidepressants have been used in the treatment of certain types of mild (e.g. exhibitionism) and juvenile paraphilias. Antilibidinal hormonal treatments, such as steroidal antiandrogens and gonadotrophin-releasing hormone (GnRH) analogues, have also been studied and they seem to be effective in paraphilic disorders, although caution should be taken in the prescription of these treatments in order to avoid or minimize adverse effects and the risk of victimization. The combination of psychotherapy and pharmacological therapy is associated with better efficacy compared with either treatment as monotherapy. Paraphilia is a chronic disorder and a minimal duration of treatment of 3-5 years is highly recommended for severe paraphilia with a high risk of sexual violence. In conclusion, this review of the literature provides suggestive evidence that paraphilias are well characterized disorders marked by pathological dimensions. Although further research is necessary to confirm treatment efficacy and to improve our knowledge of long-term tolerance, available data on the use of selective serotonin reuptake inhibitors, steroidal antiandrogens and GnRH analogues strongly suggest the efficacy of these treatments for paraphilic disorders.

A different perspective: introducing positive criminology

Positive criminology is a new conceptual perspective of criminology, encompassing several theories and models. Positive criminology refers to a focus on individuals' encounters with forces and influences that are experienced as positive, which distance them from deviance and crime, whether by means of formal and informal therapy programs and interventions, such as self-help groups; through emphasis of positive social elements, such as exposure to goodness, social acceptance, and reintegrative shaming; or based on positive personal traits, such as resilience and coherence. The perspective of positive criminology broadens that of traditional criminology, which focuses mainly on understanding the factors and processes that lead individuals and groups to what is defined as deviant and criminal behavior. Positive criminology is implemented in treatment and rehabilitation of individuals and groups that have demonstrated deviant and criminal behavior, by emphasizing positive experiences that may potentially prevent or discourage continued criminal behavior. Positive criminology is also expressed in prevention based on a positive approach.

A review of the use of therapeutic communities with sexual offenders

Sexual offender treatment programmes are often facilitated in secure settings such as prisons or psychiatric hospitals, which are not ideal environments for such treatment. Arguably, however, when these environments are structured as therapeutic communities (TCs), opportunities are created to enhance the effectiveness of treatment. This article describes the concept of a TC, its operating principles and rationale, as well as the benefits and rationale for establishing TCs in conjunction with cognitive-behavioural treatment with sexual offenders. This is discussed in terms of the potential of TCs to improve targeting of treatment content, to enhance treatment process, to provide optimal environments for therapeutic gain, and to provide a broad therapeutic framework for treating sexual offenders. The article reviews and summarizes what evidence exists for the use of TCs with both non-sexual offenders and sexual offenders. Finally, it highlights the gaps in our knowledge of the use of TCs to inspire further empirical and conceptual consideration of these issues.

The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of paraphilias

OBJECTIVES

The primary aim of these guidelines was to evaluate the role of pharmacological agents in the treatment and management of paraphilia, with a focus on the treatment of adults males. Because such treatments are not delivered in isolation, the role of specific psychosocial and psychotherapeutic interventions was also briefly covered. These guidelines are intended for use in clinical practice by clinicians who diagnose and treat patients with paraphilia. The aim of these guidelines is to improve the quality of care and to aid physicians in clinical decisions.

METHODS

The aim of these guidelines was to bring together different views on the appropriate treatment of paraphilias from experts representing different continents. To achieve this aim, an extensive literature search was conducted using the English language literature indexed on MEDLINE/PubMed (1990-2009 for SSRIs) (1969-2009 for antiandrogen treatments), supplemented by other sources, including published reviews.

RESULTS

Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for its efficacy, safety, tolerability and feasibility.

CONCLUSIONS

An algorithm was proposed with six levels of treatment for different categories of paraphilias.

Child sexual abusers' views on treatment: a study of convicted and imprisoned adult male offenders

In spite of an increasing focus on the assessment and treatment of sexual offenders over the past two decades, much debate persists as to the effectiveness of treatment in reducing recidivism. Given the dearth of research on offenders' perspectives in this area and the potential for offenders' views to inform the development of effective treatment, we consider the views of 35 adult male child sexual abusers on the prison treatment program. Focusing on a number of key themes, namely victim empathy, strategies for desistence, group or individual treatment, motivation, and postprogram support. In doing so, the extent to which this work furthers knowledge in this area and future research directions was considered.

Sexual offender treatment: a positive approach

This article describes a treatment program for sexual offenders that is a modification of cognitive-behavioral therapy (CBT) and that emphasizes a positive approach. Several issues that characterize most CBT programs for sexual offenders are challenged and alternatives are offered. The overall features of the positive approach are then described. Finally outcome evaluations of the effects of CBT programs are described and compared with the long-term outcome of the current positive program. This comparison suggested that the positive program is more effective than the traditional CBT approach.

The Rockwood Preparatory Program for sexual offenders: description and preliminary appraisal

This article describes the Rockwood Preparatory Program for sexual offenders. This program operates in the Millhaven induction center of the Correctional Service of Canada. Clients remain in the program for 6 to 8 weeks, depending on when they are placed in their home prison, where they will receive a full treatment program. The preparatory program takes a motivational approach, integrating several theoretical views and employing the therapeutic approaches that have been shown to maximize effectiveness with sexual offenders. The content and approach of the program are described and the observed benefits are outlined.

Changes in coping following treatment for child molesters

Relapse prevention theory assumes that specific coping skills deficits contribute to sexual reoffending. Recent research suggests that the general coping style of sexual offenders is also ineffective. In this study changes were examined in specific and general coping deficits following a treatment program that incorporated specific skills training as well as modifying general styles. Treated incarcerated child molesters were compared to a group of incarcerated child molesters on a waiting list for treatment. Groups completed various measures aimed at identifying coping strategies used in specific high-risk situations and general coping styles. Compared to the waiting list group, treated child molesters identified more effective coping strategies in specific high-risk situations. Changes are noted in their general coping styles with an increase in the endorsement of task-focused strategies and social diversion strategies. No changes in their endorsement of ineffective strategies such as emotion-focused or distraction strategies occurred. Implications for treatment are discussed.

The utility of the random controlled trial for evaluating sexual offender treatment: the gold standard or an inappropriate strategy?

This paper examines the scientific, practical, and ethical issues surrounding the employment of the Random Controlled Trial (RCT) in the evaluation of sexual offender treatment. Consideration of these issues leads us to conclude that the RCT design is not suitable for determining the effectiveness of sexual offender treatment. We also examine the RCT study by Marques et al. (Sexual Abuse: A Journal of Research and Treatment and Evaluation 17:79-107, 2005) that is often held up as the model for the evaluation of sexual offender treatment. We found several problems with this study that, in our opinion, reduce its relevance for deciding whether treatment is effective with these clients. Finally, we examine two alternative strategies for evaluating treatment that may allow treatment providers to more readily examine, and report, the results of their programs.

Narrative identity and offender rehabilitation

The rehabilitation of offenders is an evaluative and capability-building process and is concerned with promoting primary goods and managing risk. At the heart of this process is the construction of a more adaptive narrative identity and the acquisition of capabilities to enable offenders to secure important values in their postrelease environments. In this article, the authors examine the idea of narrative identity and its relationship to values and to assessment and treatment.