A small but growing niche of clinical practice involves services provided to sexual offenders, typically within the criminal justice system. This is an emotionally, and ethically, challenging area of practice that has, for all practical purposes, been unregulated, with the sole exception of the efforts of one professional organization (Association for Treatment of Sexual Abusers). Given the unusual demands placed on the clinicians working with sex offenders, and the high stakes nature of their work (providing effective treatment for clients disposed to committing sexual offenses, and offering evaluative judgments about the risk posed by these clients), it would seem reasonable to expect that this area of practice would be well regulated. As noted, this appears not to be the case. In this chapter we provide a framework for establishing guidelines for professional competence at two levels of practice – basic and expert. Our mission is not to provide an end product, but rather a blueprint to initiate dialogue and, in so doing, a process that will eventuate in a uniformly adopted standard for professional competence in this area.
38.1 16.1 Overview
The past several decades have witnessed an unprecedented number of state and federal laws intended to curb sexual violence. Federal legislation has included the Violence Against Women Act of 1994 (VAWA), the expanded VAWA legislation in 2000 (P. L.106–386, 18 U.S.C. 2261), The Wetterling Act, passed in 1994 as part of the Violent Crime Control and Law Enforcement Act (42 U.S.C. 14071), the amended Wetterling Act of 1996, known as “Megan’s Law” (P. L. 104–145), the amended Federal Rules of Evidence in 1995 to include prior sex crimes, the Pam Lynchner Sexual Offender Tracking and Identification Act (42 U.S.C. 14072) in 1996, The Wetterling Improvements Act of 1997 (P.L. 105–119), the Victim’s of Trafficking and Violence Prevention Act of 2000, and the Adam Walsh Child Protection and Safety Act of 2006 (P. L. No. 109–248, 42 U.S.C. 16901). The Adam Walsh Act established a comprehensive national system for the registration of all sex offenders (Title I, §301). The 2005 Florida law, referred to as “Jessica’s Law,” was introduced at the federal level during the 109th Congress. The federal bill (H.R. 1505), known as The Jessica Lunsford Act, mandates more stringent tracking of sex offenders. The most impactful legislation at the state level has taken the form of civil commitment laws targeting sex offenders.
This form of legislation first appeared in its current incarnation in 1990 in the State of Washington (WA Laws of 1990, chap. 3). Twenty states now have such laws (cf. Gookin, 2007). In addition, as of 1997, every state has had some variant of a sexual offender public notification law pursuant to the federal Wetterling Act of 1996.
All sex offenders, upon returning to society, are evaluated for risk by a state registry board and most end up in some form of outpatient treatment. All 20 states with civil commitment laws have prison-based treatment programs for those who are committed. In addition, many states provide prison-based treatment for noncivilly committed sex offenders (i.e., those serving their criminal sentence). As noted above, most sex offenders returned to society are mandated or volunteer to enter treatment. Treatment for sex offenders, whether in prison or in the community, has evolved into a niche of clinical practice that employs a sizeable and growing number of practitioners. The largest professional organization, Association fo r Treatment of Sexual Abusers (ATSA), has 2,049 clinical members (as of 04/2009), and that number does not reflect the numerous therapists who treat sex offenders and do not belong to ATSA. Roughly 50–60% of those attending ATSA conferences each year, for instance, do not belong to the organization. Given the increasing demand for therapists to treat sex offenders, the emotionally – and ethically – challenging nature of the practice, and the unregulated nature of the “industry,” it would seem prudent to establish, at minimum, guidelines for professional competence. It does not appear that this has ever been done, at least not in any formal sense. Our mission is not to provide an end product, but rather a blueprint to initiate dialogue and, in so doing, a process that will eventuate in a uniformly adopted standard for professional competency in this area.
38.1.1 16.1.1 Recognition of Symptoms and Their Assessment
Symptom recognition is complicated by the nature of the population being served. Sex offenders do not constitute a diagnostically or clinically homogeneous group possessing a discrete set of symptoms. If anything, “sex offender” is a legal term and refers to a person who has committed a sexual offense according to the legal standards of the jurisdiction in which the offense took place. This term is differentiated from “sexually deviant behavior,” which does not necessarily imply illegal behavior and typically refers to a paraphilia.
Although some sex offenders can be diagnosed with a paraphilia called pedophilia, most sex offenders do not undergo any formal DSM-IV-TR (American Psychiatric Association [APA], 2000) diagnosis specific to being a sex offender. Simply stated, sex offenders are markedly heterogeneous with regard to their backgrounds, emotional problems, personality traits, treatment needs, and the nature of offenses they commit (Knight & Prentky, 1990; Knight, Rosenberg, & Schneider, 1985). As such, there is no discrete set of symptoms associated with being a sex offender. The best thing that we can do is to note what the clinical literature reports as being most frequently observed among child molesters and among rapists.
Although relatively little is known about the etiology of child molestation, there has been considerable speculation about the dimensions that are hypothesized to differentiate among different types of child molesters (Knight et al., 1985). Such dimensions include (a) sexual preference for children, (b) psychosocial and psychosexual immaturity; poor social skills, low social competence, poor self-esteem, and (c) impulsive, antisocial behavior. They define three core subtypes that appear to have clinical utility: (1) a child molester with an exclusive, long-standing sexual and social preference for preadolescents (i.e., a pedophile), (2) a child molester whose sexual offenses represent a “regression” or downward drift from an adult level of psychosocial adaptation in response to chronic stressors and perceived rejection (i.e., an incest offender), and (3) an exploitative, predatory child molester with a track record of impulsive, antisocial behavior and very poor social skills who turned to children because they were easy prey (Knight & Prentky, 1990; Knight et al., 1985; Prentky & Burgess, 2000).
In sum, etiologic factors gleaned from the empirical literature on child molesters include: (a) deviant sexual arousal to children, (b) other paraphilias (i.e., other deviant sexual interests), (c) developmental immaturity, poor social skills, and “stunted” relationships with adults, (d) antisocial behavior, and (e) the presence of highly intrusive sexual abuse, typically lasting for a protracted period and beginning at an early age. These factors do not, however, constitute symptoms. Psychiatric symptoms, usually in some combination, point towards the presence of a specific disorder or abnormality. There is no single disorder that captures all child molesters. As noted, the closest that we can come to is pedophilia, which is appropriate for a subset of child molesters.
Since the Diagnostic and Statistical Manual (DSM) was first published in 1952 (APA, 1952), there has always been a category for pedophilia. The current Manual (DSM-IV-TR) requires evidence of (1) recurrent, intense sexual behaviors, urges or fantasies involving sexual activity with a prepubescent child (generally age 13 or younger) for at least 6 months, (2) the individual has acted on these urges or is markedly distressed by them, (3) the individual is at least 16 years old and at least 5 years older than the victim, and (4) late adolescents who are involved in ongoing relationships with 12 or 13 year olds are excluded. Although there are multiple criteria noted above for diagnosing a pedophile, there essentially is only one symptom – recurrent, intense sexual behaviors, urges or fantasies involving sexual activity with a prepubescent child. All child molesters who have acted on their urges over a time period of 6 months or longer can be diagnosed as pedophiles. Hence, the DSM provides a single diagnostic category with a single symptom that can subsume most child molesters. Taxonomic models that differentiate among child molesters (e.g., Knight & Prentky, 1990), however, clearly reflect diversity of deficits, emotional and psychological problems, and motives.
Several investigators have developed and tested useful path models for explaining sexual aggression against women (e.g., Knight & Sims-Knight, 2003; Malamuth, 2003; Malamuth, Sackloskie, Koss, & Tanaka, 1991; Malamuth, Heavey, & Linz, 1993; Malamuth, Linz, Heavey, Barnes, & Acker, 1995). In Malamuth’s earliest version of his confluence model (Malamuth et al., 1991), two major paths were identified, each with three factors. The first path consisted of (1) an abusive home environment, (2) delinquent behavior in adolescence, and (3) impersonal sexuality in adolescence and adulthood (e.g., early onset of sex, numerous brief partners, high frequency of sexual activity). The second path consisted of (1) cognitive distortions (irrational attitudes) that supported rape, (2) personality traits that included narcissism, entitlement, and hostility toward women, and (3) low empathy. A subsequent hierarchical-mediational version of the confluence model (Malamuth et al., 1995) added proneness to hostility (general anger) as a precursor of cognitive distortions on the second path. This additional hostility factor, along with low empathy and hostile masculinity (personality traits on the second path) are a theoretical match to Factor 1 of Hare’s Psychopathy Checklist (PCL-R) (Harpur, Hakstian, & Hare, 1988), while impersonal sex on path one is a theoretical match to some of the items on Factor 2 of the PCL-R (Malamuth, 2003). Knight and Sims-Knight (2003) revised the Malamuth model, noting that the important dimension of hostile masculinity was not univocal. Knight and Sims-Knight (2003) tested a three path model on adult sex offenders and a sample of community controls (non-offenders). Path one begins with an abusive home environment, leads to callousness and lack of emotion (flat affect), which disinhibits sexual fantasy and sexual urges. Path two begins with sexual abuse, which disinhibits sexual fantasy and sexual urges. Path three begins with early onset antisocial behavior, which leads directly to sexual aggression. The principal difference between these path models is the single dimension of hostile masculinity in the confluence model or a bifurcation into separate dimensions of antisocial behavior and callousness/unemotionality in the Knight model. This research, and the models issuing from it, has been pivotal in providing sound evidence for a unified, theoretical explanation of sexual aggression against women. Distilling the essence of this research, multiple major etiologic factors (dimensions) have been identified: (a) an abusive home environment, (b) a stable record of antisocial behavior, generally beginning in adolescence, (c) classic PCL-R Factor 1 traits, including narcissism, grandiosity, arrogance, and entitlement, callousness indifference to others, and lack of empathy, and (d) misogynistic attitudes. Unique to Malamuth’s confluence model is the additional factor of impersonal sex, including promiscuity, high sexual drive, and numerous brief sexual encounters.
As with child molesters, these etiologic factors are not, in the conventional sense, psychiatric symptoms. Although rape is a specific behavioral (and criminal) outcome, it is not a specific psychiatric disorder. There has never been a category for “rape” in the DSM. As illustrated above, there are different paths that lead to an outcome of rape and each of those paths will comprise of a different set of symptoms. Although the extant literature described numerous dimensions associated with rape (cf. Prentky & Knight, 1991), it is reasonable, based on more recent literature, to reduce those dimensions to roughly five: (a) impulsive, antisocial behavior, (b) anger, (c) attitudes associated with hostile or negative masculinity, (d) traits common to Factor 1 on the PCL-R, such as lack of empathy, entitlement, narcissism, grandiosity, and callousness, and (e) impersonal and promiscuous sexual behavior.
38.1.2 16.1.2 Maintenance Factors of the Disorder
The basic mechanism underlying the continuation of sexual offending behavior is, at least theoretically, the offense cycle, described originally by Pithers, Marques, Gibat, and Marlatt in 1983. The basic process is as follows: life stressors lead offenders to experience intense affect that is distressing or disturbing. This negative affect is coupled with a sense of subjective deprivation, prompting the individual to seek relief or diversion from negative affect and noxious life experience. These individuals begin to make a series of superficially trivial decisions that undermine self-restraint, placing themselves in high-risk situations in which there is an increased likelihood of both unstable emotions and contact with potential victims, clearly a maladaptive response to aversive affect. By placing themselves in such situations, offenders lose their sense of self-control over refraining from offending (i.e., they have “lapsed”). This stage can include fantasies about offending, arousal to such fantasies, and distorted thinking that will allow acting on those fantasies. At this juncture, the short-term benefits of offending become more powerful than the long-term consequences, allowing offenders to slide from lapse into relapse: sexual contact with a victim. Post-relapse, offenders evaluate themselves, their victims, and the offense. Negative self-evaluation is common but temporary, giving way to cognitive distortions that rationalize the offense. Thoughts occurring during this stage provide justification for the offense that is essential to maintain offending behavior. In order to break the cycle of offending, it is crucial to intervene before a lapse develops into a relapse; doing so is the only way to prevent the justificatory thought processes that encourage future relapses. The offense cycle and its treatment will be described in more detail later in this chapter in the context of the relapse prevention treatment modality.
Another possible maintenance factor is mental illness. Anywhere from 15% to 24% of inmates in the USA have a severe mental illness (Teplin, Abram, & McClelland, 1996), and half of inmates have at least one mental health condition (James & Glaze, 2006). Inmates with major psychiatric disorders such as bipolar, schizophrenia, and nonschizophrenia psychotic disorders are more likely to have been previously incarcerated than those without psychiatric disorders (Baillargeon et al., 2009), suggesting that mental illness may play a role in recidivism. Although relatively few sex offenders are known to have major mental illness, a much larger proportion of sex offenders are thought to have some affective disorder necessitating antidepressant medication. As noted above, aversive affect is thought to underlie much sexually deviant and sexually criminal behavior. In the case of general dysphoria or clinical depression, sexual gratification may be a learned response that temporarily brings relief from depression. Clearly, this is not the case for all sex offenders, but it may well be a contributing factor in many cases. Substance abuse falls in the same category as a maintenance factor. Alcohol and drugs may serve the same purpose as sexual gratification – temporarily relieving the individual of chronic, noxious thoughts and feelings.
Lastly, the most obvious maintenance factor for some, by no means all, sex offenders is sexually deviant thoughts, fantasies, and urges. As a maintenance factor, sexual deviance is noted primarily among those child molesters who have an exclusive sexual preference for children and underage adolescents. Although sexual deviance may also be noted among child molesters with nonexclusive preferences (i.e., they have relationships with adults), there is a greater likelihood that other maintenance factors play a critical role as well. Sexual deviance may be observed among rapists as well (e.g., sadism), but it is rare.
38.1.3 16.1.3 Evidence-Based Treatment Approaches
Effectiveness of treatment can be measured by one question: does treatment reduce sexual reoffending, and if so, by how much? The management and treatment of sex offenders is often uninformed by research and is more often driven by personal feelings, moral convictions and political agendas. However, several meta-analyses have shown the treatment of sex offenders to be effective.
A 1995 study conducted by Hall brought together 12 studies of treated sexual offenders for a total of 1,313 men. Hall found a small but significant decrease in rates of reoffending as a result of treatment: sexual recidivism for non-treated offenders was 27%, while recidivism for treated offenders was 19%, an overall decrease of 8%. For studies that employed cognitive behavioral methods or anti-androgen medication, the decrease in recidivism was even larger. Hanson et al.’s Collaborative Outcome Data Project on the Effectiveness of Psychological Treatment for Sex Offenders (2002) examined 43 studies for a total of 9,454 offenders, approximately 54% of whom had received treatment. Across studies, sexual recidivism was about 12% for treated and 17% for untreated offenders. When examining only the most recent studies using the most current methods (e.g., CBT), they found sexual recidivism to be around 10% for treated and 17% for untreated offenders. The largest meta-analysis conducted to date, with69 studies and 22,181 offenders, demonstrated a 6% reduction in sexual recidivism with treatment (Losel & Schmucker, 2005).
A 2000 study by Nicholaichuk, Gordon, Gu, and Wong compared 296 treated to 283 untreated offenders, finding the conviction rate for sexual reoffending to be 15% for treated and 33% for untreated offenders. This sizable discrepancy may not be as encouraging as it appears on first glance; Nicholaichuk et al. (2000) acknowledge that this difference is likely due to the high rate of reoffending for the untreated offenders rather than a reduction in recidivism for untreated offenders. Zgoba and Simon (2005) investigated offenders from New Jersey’s state prison for sexual offenders, which provides treatment to sexual offenders from the general prison population. Fourteen percent committed a new sexual offense within the 7-year follow-up period, with no statistically significant differences between treated and untreated offenders.
To date, only one randomized clinical trial has been conducted to investigate effects of treatment for sexual offenders: California’s Sex Offender Treatment and Evaluation Project (SOTEP) (Marques, Day, Nelson, & West, 1993; Marques, Nelson, Alarcon, & Day, 2000). Volunteers were randomly assigned either to treatment or no-treatment conditions; guided by the possibility that willingness to participate might predict better treatment outcome, a randomly selected group of offenders who did not volunteer were also included as a control group. Participants who completed a course of treatment were found to have a higher rate of recidivism (22%) than did the volunteer control group (20%) or the non-volunteer control group (19%) (Marques, Wiederanders, Day, Nelson, & van Ommeren, 2005).
There is a clear discrepancy between results of the meta-analyses and those of the individual studies, the former indicating that treatment for sexual offenders is effective and the latter demonstrating that it is not. All three meta-analyses yielded similar results. However, due to the large sample sizes, minor differences in the rates of recidivism across the studies could reach statistical significance without achieving practical significance; Zgoba and Simon’s (2005) considerably smaller sample, for example, was unable to achieve significance. According to Barbaree (1997), recidivism studies often do not pick up on the effects of treatment. Base rates for recidivism are fairly low to begin with (10–40%); when the sample size is also small, the treatment effect must be very large (e.g., 50%) to achieve significance between treated and untreated offenders. This sets the bar for significance very high and is a criterion that many researchers struggle to achieve.
Considering the difficulty in achieving significance, it may be tempting to rely on the findings of the meta-analyses and conclude that treatment works. Such a conclusion, however, ignores the findings of the most methodologically sound study conducted to date (SOTEP). How to interpret these findings has become a matter of controversy in itself (Marshall & Marshall, 2007, 2008; Seto et al., 2008), since it is risky to override what it widely regarded as the gold standard of research design. Due to the current lack of certainty regarding effectiveness of treatment for sexual offenders, treatment should be regarded as one potentially effective method for managing the risk of recidivism. It should neither be viewed as a panacea for offenders, nor be utilized in isolation. Rather, it should be included as an element of a rehabilitation plan that may include medication, probation, GPS monitoring, and other interventions.
38.1.4 16.1.4 Mechanisms of Change Underlying the Intervention
As we have pointed out in this chapter, the leading treatment utilized with sex offenders is Cognitive Behavioral Therapy (CBT). Through CBT, sex offenders achieve a sense of accountability for their behavior and an understanding of the impact of thinking on behavior. By learning to identify problem thoughts (cognitive distortions), how to self-monitor these thoughts, and eventually replace these distorted thinking patterns with adaptive thinking, offenders undergo the changes necessary to reduce the risk of recidivism (Lipsey, Landenberger, & Wilson, 2007). Generally, CBT involves changing cognitions and thinking patterns, but specific skills such as anger management may be highlighted to initiate change. In their analysis of the effect of different cognitive behavioral programs on recidivism, Lipsey et al. (2007) found that cognitive behavioral therapy in general and not any CBT program specifically was responsible for change.
CBT with a sex offender population usually incorporates a Relapse Prevention model. Polaschek (2003) points out that Relapse Prevention is now part of nearly all sex offender treatment programs in the USA and is widely used in other countries as well. As discussed elsewhere is this chapter in greater detail, Relapse Prevention attempts to eliminate the possibility of a relapse by identifying triggers. By taking steps to deal with triggers in an adaptive way, the subsequent lapse or relapse can be avoided. Essentially, the process of identifying triggers for relapse and engaging in new behaviors following triggers interrupts the offense cycle. This is the mechanism of change that is sought in employing Relapse Prevention with sex offenders. In order for this to work and change to occur, the requirement at the outset of Relapse Prevention treatment is the desire to change. Offenders must be able to identify their behavior as problematic and be willing to make the changes necessary to stop engaging in the behavior. Without this first step it is understood that Relapse Prevention Treatment cannot take place.
In addition to the aforementioned methods through which change is achieved, Serran, Fernandez, Marshall, and Mann (2003) have pointed out the importance of the therapeutic alliance in effecting change in clients. Serran et al. (2003) highlight the importance of empathy, warmth, flexibility, support, and encouragement in effectively engaging clients in change through therapy. Additionally, the authors discuss the importance of boosting self-esteem when working with sex offenders. These elements should not be overlooked, as they are linked to the effectiveness of therapy through the client’s willingness to participate in treatment, remain in treatment, and ultimately undergo change through the treatment process and the therapeutic relationship.
38.1.5 16.1.5 Basic Competencies of the Clinician
The APA (1992) defines competence as consisting of (a) education, training, and experience; (b) knowledge of scientific and professional information on services being rendered, including related fields of knowledge; (c) ongoing efforts to maintain competence; (d) efforts to protect the welfare of clients; and (e) the ability to recognize when effectiveness is compromised. The APA (1992) has outlined additional standards of competence for forensic psychologists, indicating that their activities should be based on suitable and sufficient data and that there should be a clear understanding of the limitations that constrain generalization in that field. It is important for psychologists training in all fields to understand that competence is not an endpoint, but rather an ongoing process of change and renewal that is measured by education, training, supervision, consultation, and other appropriate professional experiences (Nagy, 2005). Experience gained over time is essential for developing high-quality skills, as both experience and time are essential ingredients in developing sophisticated internal models (Ericsson & Smith, 1991), as well as learning to link information and to distinguish between relevant and irrelevant information in problem solving (Patel & Groen, 1991).
Although more refined gradations in level of competence may be useful, for purposes of this chapter, we focus on a simple distinction between a “basic” level of competence that may be expected of most practitioners in the field and a more advanced level of competence that may be expected of “experts” in the field. Since we are focusing on the question of competencies for clinicians that assess, evaluate, and treat sexual offenders, we are always assuming some forensic context to the provision of services; hence, when we refer to clinicians, we are speaking about “forensic clinicians.” In the broadest sense, basic competencies are those that a forensic clinician would require to develop and implement treatment plans, whereas expert competencies are more likely those that would be required to supervise and manage programs and to serve the courts. Each level encompasses three areas of competence: legal knowledge, assessment, and treatment. Basic legal knowledge is required to be able to work with offenders, and includes such topics as civil commitment, community notification, and registration laws, as well as the regulations governing the local sex offender registry board that oversees the clinician’s clients. Expert legal knowledge requires a more extensive familiarity with legislation applying to sexual offenders. Basic assessment skills primarily focus on the task of developing an informed plan for provision of treatment services, including the assessment of individualized treatment goals. Assessment typically centers on the gathering of history at intake, both through self-report, psychological testing, and review of archival documents. The task of an expert that has been retained to evaluate an offender for a court proceeding may include a range of forensic assessments, such as competency, risk, civil commitment, malingering, and diminished capacity. Basic therapy skills consist of familiarity with the most commonly used treatments with sex offenders, an awareness of the role of medication in treatment, and an understanding of how and why medications are used to complement certain types of treatment. Expert therapy skills include a wider range of less frequently employed treatment interventions, more advanced knowledge of the use of medication, sophisticated supervisory skills, and an in depth knowledge of the treatment literature. We will now explore each of these areas of competence in detail, following a simple structure for this chapter: Three major areas of competence, each delineated for two levels of competence. We begin with basic competence, discuss each area, followed by expert competence, with a discussion of each area.
38.1.6 16.1.6 Education
Before embarking on an exploration of the legal, assessment and therapeutic knowledge a competent clinician must possess, we should address the question of what, if any, course of formal study provides a foundation for acquiring the skill to work with sex offenders. To begin with, there is no course of undergraduate study that trains one to work with sex offenders, other than basic education in core areas of psychology (e.g., abnormal psychology, developmental psychology, personality theory, and social psychology) and criminology (e.g., delinquency, violent crime, psychology of criminal behavior, and victimology). Some undergraduate majors in psychology include a concentration in forensic psychology. When a concentration in forensic psychology is absent, a minor in criminology is a good complement to psychology. Some institutions now offer graduate programs leading to a Master’s degree in forensic psychology, with more targeted courses applicable to work with sex offenders, including electives on sex offenders or field placements working with that population. At present, the optimal course of formal education for basic competence would be a Bachelor’s Degree in Psychology or Criminal Justice, followed by a Master’s degree in Forensic Psychology. A doctoral degree is required for expert competence. Since, with minor exceptions (e.g., John Jay College of the City University of New York), there are no doctoral-level degrees in Forensic Psychology, the conventional route is a Ph.D. or Psy.D. in clinical psychology, followed by postdoctoral forensic training.
In addition, and perhaps even more importantly, are the numerous opportunities for workshops and training offered by professional organizations, such as ATSA. These workshops provide focused training on sex offender-specific topics (e.g., the latest revisions to the RP model; new assessment techniques; techniques for working with special populations of sex offenders, such as females, juveniles, the developmentally disabled, and those with major mental illness; coping with burnout; new adaptations of covert sensitization or aversion therapy; the latest uses of anti-androgen and antidepressant medication; motivational interviewing; etc.). Since there is no formal educational program that prepares for work with sex offenders, such workshops, in conjunction with hands-on training, intensive supervision, and awareness of the literature, provide the primary education for this work.
38.1.7 16.1.7 Legal Knowledge
Clinicians working with sexual offenders must be aware of the legislation governing both incarceration and release conditions, specifically civil commitment, registration, and community notification. As noted, the country’s first Sexually Violent Predator law was Washington’s Community Protection Act of 1990. The Community Protection Act, providing for the civil commitment of sexual offenders, sought to protect the public by keeping the “most dangerous” offenders off the streets through indefinite incarceration. The decision to civilly commit is based on an assessment that an offender suffers from a “mental abnormality” that increases the likelihood that he will reoffend if released into the community (Kansas v. Hendricks, 1997). The US Supreme Court has given the states a great deal of flexibility in determining who is at risk of reoffending, and clinicians must be familiar with the prescribed procedures in their state.
Sex offender registration was introduced in 1994 with the passage of the Jacob Wetterling Act, a component of the Violent Crime Control and Law Enforcement Act (42 U.S.C. 14071), which required states to implement a sex offender registry wherein all offenders released into the community must provide the state with the location of their residence. In 1996, the Wetterling Act was amended by “Megan’s Law,” which required states to establish a community notification system making state registry information available to the public (P. L. 104–145). Megan’s Law requires that every sex offender must be evaluated by the state’s sex offender registry board (SORB) upon release from prison. Depending on the individual’s level of risk for reoffending, as determined by the SORB, presumptive risk-mitigating procedures will be instituted, including notifying the public of the offender’s identity and location. Since 1997, every state in the USA has adopted a public notification law.
In 2006, the Adam Walsh Child Protection and Safety Act (P. L. No. 109–248, 42 U.S.C. 16901) was passed, which organizes offenders into three tiers based on the severity of their offense histories. The Walsh Act mandates that Tier 3 offenders (the most serious) be subject to lifetime registration and update their whereabouts with the state registry board every 3 months. Tier 2 offenders are to remain registered for 25 years and update their whereabouts every6 months, and Tier 1 offenders must remain registered for 15 years and update their whereabouts annually. Failure to register or to update is considered a felony. Clinicians must possess rudimentary knowledge about such management strategies and the known or anticipated impact of those strategies on their clients.
Basic competency includes general knowledge about how sex offenders are civilly committed, the elements that must be satisfied for commitment, acquaintance with the diagnostic issues related to the determination of mental abnormality, a rudimentary understanding of the legal concept of risk, the local laws governing registration and community notification, and the tier system used by the local sex offender registry board for classifying risk.
38.1.8 16.1.8 Assessment
As with any client, assessment of sex offenders should be preceded by a thorough review of all available documents and file records. Document review is followed by a comprehensive interview, the purpose of which is to corroborate or cross-check history, facilitate defensible diagnoses, and inform treatment plans, goals, and objectives. A comprehensive history includes such basic information as demographic, developmental, family, social, educational, work, and medical history, past and present substance use, psychiatric history, including treatment and inpatient hospitalization, psychological testing, and medication history. In addition, information must be gathered on psychosocial, psychosexual, cognitive development, history of trauma and maltreatment, history of conduct disordered, delinquent, and antisocial behavior, and lastly a complete history of all sexually deviant, coercive, and criminal behavior.
A mental status exam is typically included, covering the offender’s appearance, attitude, behavior, speech, mood and affect, thought process and content, perception, cognition (including orientation, memory and concentration), insight and judgment. Both indirect means, such as observation, and direct means, including brief psychological tests (e.g., counting backwards by sevens from 100 or spelling the word “world” backwards), should be employed.
Supervision around the interview and treatment sessions is essential, as those who receive no supervision can be expected to make slower progress in developing population-specific clinical skills than trainees who receive feedback from seasoned supervisors (Lambert & Arnold, 1987). Arguably, ongoing supervision should be mandated for all clinicians treating sex offenders, regardless of how seasoned the clinicians are. The most “expert” clinicians can be fooled by the most wily, manipulative offenders. Supervision should address, among other things, boundary violations; cognitive distortions; minimization; superficial, flat, or inappropriate affect; feigned empathy; and factual distortions, as well as emotional impact on the clinician.
38.1.9 16.1.9 Treatment
Basic competence is generally the skill level required for providing conventional clinical and treatment services for sex offenders. Of all the basic services provided by clinicians, treatment is overwhelmingly the most common. Consequently, our major focus, when discussing basic competence, is on treatment.
38.1.10 16.1.10 Nonspecific Factors
When working with sexual offenders, clinicians should become familiar not only with treatment protocols to be utilized, but also with the nontreatment-specific factors associated with working with this population.
Emotional Preparedness and Burnout. Maslach (1976) defined burnout as therapists’ loss of all concern and emotional feelings for the clients they work with, leading therapists to treat clients “in detached or even de-humanized ways.” Therapists may become cynical towards their clients, blaming them for their own psychological distress and labeling them in derogatory terms (Farber & Heifetz, 1982). Burnout can result from a variety of experiences; according to a survey conducted by Farber and Heifetz (1982), 57.4% of therapists attributed their burnout to nonreciprocated attentiveness, giving, and responsibility demanded by the therapeutic relationship, and 73.7% cited “lack of success” as the single most stressful aspect of therapeutic work.
Clinicians working with sexual offenders, either in prisons or in the community, must be emotionally prepared for burnout. Working with sex offenders places greater than usual demands for self-protection from high-stress working conditions and high-voltage clinical issues. Clinicians vary in their sensitivity to stress, and certain job conditions may be more problematic for some than for others. Therefore, those aspiring to work with this population should carefully consider their own histories and motivations before entering the field (e.g., those with histories of personal and/or family victimization). Providing therapy for others as a vehicle for resolving one’s own issues is likely to undermine treatment efficacy and possibly take a personal toll. Conducting therapy even under “normal” conditions can lead to burnout, but clinicians must consider the added personal and professional stress of working with this population, including uncooperative, unmotivated, and potentially malingering offenders; presenting behaviors that include violence toward children and women; and presenting childhood histories that may include severe trauma, as well as the added stress of working ina prison setting. Students considering this line of work should consult with those already in the field for first hand feedback about what to expect, keeping in mind that such feedback will be unique to the individual providing it and may not be a “good fit.”
Awareness of, and Sensitivity to, Individual Differences. According to the APA’s Multicultural Guidelines (2003), psychologists are encouraged to recognize that they may hold attitudes and beliefs that can negatively influence their perceptions of, and interactions with, clients who are different from themselves. Though this was intended as a reference to ethnic and racial prejudices, it can also be considered in the context of biases against sexual offenders due to the nature of their crimes.
Historically, cultural sensitivity training has been utilized to prepare clinicians for working with diverse populations, as it provides knowledge of politically correct terminology, mannerisms, and identifying characteristics of various groups (Back, 1973). However, this approach has not proven successful, as cultural generalizations are not always applicable to individuals (Myers, 2000). For example, referring to a Black client as African-American may not be politically correct (or sensitive), if the client does not identify as such. A human relations approach may be more useful. Instead of attempting to learn obscure facts about innumerable ethnic and cultural groups, psychologists should instead operate on the understanding that there are no rules about groups, that everyone is different, and that no one should be categorized culturally, racially, or ethnically. Categorization may lead to generalizations that foster bias and judgment error (cf. Monahan, 1981). A human relations approach advocates a style of communication that can bridge cultural gaps. It is intended, moreover, to motivate the clinician to learn about each individual client, rather than the group in which they are believed to be a member (Myers, 2000). Social and cultural norms cannot be disregarded completely, however, as they can be useful in differentiating between normal and deviant behavior and in implementing appropriate interventions. What is out of the ordinary in one culture may be acceptable in another, and the application of one’s own norms to an individual of differing background is equivalent to a failure to assess for individual differences. The result can be a false assumption of pathology or a failure to recognize pathology.
Despite an awareness of individual differences and the ways in which one might endeavor to be sensitive to them, it can still be difficult for clinicians to see past the heinous nature of the crimes committed by some sexual offenders and to make neutral and dispassionate assessments of people whose behavior they find reprehensible. We should acknowledge, however, the natural process of self-selection. Clinicians with a low tolerance threshold for sexually aggressive behavior are unlikely to be attracted to working with sex offenders. Having said that, there are many clinicians who, from time to time, are caught off guard and find that their objectivity is taxed by an offender’s behavior. In the therapeutic realm, one solution lies in the treatment alliance. A strong alliance can control, contain, and place in perspective one’s negative attitudes and adverse emotional reactions to the offender’s behavior. A great deal of research has demonstrated a significant positive relationship between therapeutic alliance and outcome (e.g., Horvath & Symonds, 1991; Martin, Garske, & Davis, 2000). Yalom (1980) asserted that it is the therapeutic relationship itself that generates healing and makes a collaborative working relationship with clients essential. This is particularly true of clients who may be viewed as lacking motivation for participating in treatment, such as men who have sexually offended (Serran et al., 2003).
Cultivating an alliance with offenders can go a long way towards improving the quality of the treatment. Offenders need to feel accepted by their therapist, regardless of their previous behavior. Therapists working with sexual offenders will maximize their influence and increase the chances that the offenders will overcome their criminal propensities if they display empathy and warmth in a context where they provide encouragement and some degree of directiveness (Marshall, 2005). Such techniques, in conjunction with being rewarding, speaking the right amount and in an appropriate tone of voice, and asking open-ended questions have been shown to correlate with an increase in offenders’ coping skills, while being confrontational correlates with a decrease in coping skills (Marshall et al., 2003a). Being respectful of offenders is also important, as it reflects acceptance and valuing of the offender and leads to more positive outcomes (Rabavilas, Boulougouris, & Perissaki, 1979; Strupp, 1980). Respect is demonstrated through an acceptance of personal strengths and interests, and is especially important when working with offenders, whose behavior is frequently the object of public condemnation. Therapists should make it clear to offenders that they distinguish between the individual and the crime, that disapproval is directed towards the offending behavior rather than the enactor of such behavior. As a rule, feeling bad about oneself leads to shame, which stifles change, whereas feeling bad about one’s behavior leads to guilt, which facilitates change (Tangney & Dearing, 2002). When utilized properly, these techniques can have a positive effect, leading to the positive changes observed in sexual offenders as a result of treatment (Marshall et al., 2003b).
Forensic Ethics. Not every clinician working with sex offenders will be doing so in a prison setting; much of the work is conducted in the community. Regardless of where the work is conducted, clinicians must become familiar with their ethical obligations, both as psychologists in general and as practitioners providing services to a forensic population in particular. The APA (2002) has stated that forensic practitioners have an ethical obligation to understand the laws and rules governing their roles. However, equally as important is an understanding of what is ethical and appropriate practice. Practitioners must make every effort to define their role at the outset of their involvement, as different roles suggest responsibility to different parties (Heltzel, 2007): a treating clinician may report directly to a supervisor who works for the prison or is in the employ of a vendor hired by the prison. By contrast, a forensic clinician assigned to evaluate an offender will report directly to the attorney that hired her/him or directly to the court. Failure to define roles may have serious implications and may result in a breach of confidentiality if a clinician reports or discloses to an improper authority. Furthermore, clinicians involved in ambiguous relationships with offenders run the risk of engagingin dual or even multiple relationships as the distinctions between roles blur. In the code of ethics, the APA (2002) explicitly warns against engaging in multiple relationships with clients due to the considerable potential for impairment of the clinician’s objectivity, and hence effectiveness, as well as the possible exploitation of the client. Because sex offenders in prison are a “captive” audience, they may solicit seemingly small “special favors” (e.g., Can you call my lawyer for me? Can you mail this for me? Can you make a copy of this for me?). A bright line must be maintained between the appropriate duties and responsibilities of the clinician and the slippery slope that crosses that bright line into inappropriate and unethical acts. The offender may be asking for a letter to be mailed, for instance, to circumvent the normal prison surveillance of outgoing inmate mail, or the offender may be requesting a copy of a document that is not supposed to be copied.
The Committee on Ethical Guidelines for Forensic Psychologists (1991) has published additional standards of practice. Practitioners must: (a) be prepared to present to the court the knowledge, skills, experience, training, and education that qualify them as experts, as well as the boundaries to their competence; (b) possess a “fundamental and reasonable” level of knowledge and understanding of the legal standards that apply to them; (c) be aware of the civil rights due to offenders and act in a manner that in no way diminishes or threatens those rights; (d) recognize that their own values and beliefs may interfere with their ability to practice competently, and under such circumstances must decline to participate or must limit their assistance in a way that is consistent with professional obligations; and (e) when testifying, present all findings and conclusions in a fair manner, without engaging in distortion or misrepresentation, nor avoiding, denying, or subverting the presentation of any evidence that may be contrary to their position. Every effort must be made to remain current with changing legal and ethical standards.
38.1.11 16.1.11 The Treatment Protocol: Relapse Prevention
The core model for treating sexual offenders is cognitive behavioral therapy (CBT) with an emphasis on relapse prevention (RP). Developed by Beck (1997) in the 1960s, CBT is a goal-oriented psychotherapeutic approach that attempts to influence problematic and dysfunctional cognitions, behaviors and emotions. The objective is to identify and monitor thoughts, assumptions, beliefs, and behaviors that are related and often accompanied by debilitating negative emotions and to ascertain those which are dysfunctional, inaccurate, or simply unhelpful. This is done in an effort to replace such damaging thoughts with more realistic and useful ones. CBT has been used to treat a wide variety of disorders, ranging from disruptive behaviors in childhood to depression, anxiety, phobias, pain management, smoking, substance dependence, and even positive symptoms associated with schizophrenia.
RP was developed by Marlatt in the early 1980s (Marlatt & Gordon, 1985) and was designed to strengthen self-control by providing alcohol-abusing clients with methods for identifying problematic situations and analyzing decisions that lead to relapse. Its goal is to develop strategies to avoid or cope more effectively with “risky” situations. During the 1980s, the potential utility of RP for sex offender treatment was explored by Marques and Pithers and a model developed that was an adaptation of RP (Laws, 1989; Pithers et al., 1983). In the context of alcohol abuse, RP was originally intended to be used during the maintenance phase of treatment, following a phase during which abstinence was first achieved. However, this progression was not applicable to the treatment of sex offenders, for whom the behavior in question has often ceased prior to entering treatment. In practice, RP is used as an organizing principle for sex offender treatment. Since the early 1990s, numerous articles, chapters and books have been written about the application of RP to sex offenders (cf. Laws, Hudson, & Ward, 2000) and almost every sex offender treatment program in North America has reported the use of RP in their treatment in some way (e.g., Freeman-Longo, Bird, Stevenson, & Fiske, 1994). RP has been adopted by treatment programs in many other countries as well, including Canada, England, Australia, and New Zealand (Hudson, Wales, & Ward, 1998).
RP proposes that a variety of factors influence whether or not an offender will commit an offense, and that the interaction of these factors affects the probability of relapse (Pithers, 1990). The basic pattern of relapse has been identified as follows (Pithers et al., 1983): the offender feels that the pleasant events in his life are outweighed by adverse life events, resulting in the experience of acute stress. This stress results in a subjective sense of deprivation (known as lifestyle imbalance) that leads the offender to desire indulgence. As a result, the offender makes a series of superficially trivial decisions that undermine self-restraint and lead to high-risk situations, which could be an emotional state (e.g., feeling sad) or an environmental situation (e.g., going to a park where children play). Finding oneself in the midst of a risky situation threatens the offender’s sense of control over abstinence from offending. This results in a lapse, such as fantasizing about offending behavior or viewing pornography. At this point, the short-term benefits of offending become salient, allowing the offender to slide from lapse into relapse and to experience a series of negative attributions and affects due to the failure to refrain from engaging in offending behavior. Some sex offenders relapse in situations that would have been difficult to anticipate, but many set themselves up for relapse by consciously or unconsciously placing themselves in high-risk situations. The probability of relapse further increases when offenders selectively remember the positive aspects of the offense (e.g., sexual gratification) rather than the negative aspects (e.g., getting arrested) (Pithers, 1990).
RP begins by dispelling the myth that treatment will “cure” the offender and continues with an assessment of the offender’s high-risk situations and coping skills. Pithers (1990) hasoutlined the assessment procedures to be used in RP. Prior to meeting with the offender, the therapist must analyze the offender’s case records to learn about predisposing factors and to develop hypotheses to test during the interview. During the interview, the clinician investigates affective, cognitive, and behavioral patterns associated with offending, as well as the offender’s pattern of sexual arousal; what the offender finds sexually stimulating may indicate something about the pattern of abuse and choice of victim. To identify the determinants of sexual aggression, the clinician should assess why the offender’s response to a stressful situation led to a sexual offense rather than any other type of response. Self-report measures may also be used to assess the offender’s history and behavioral patterns. To assess coping skills, the clinician presents the offender with hypothetical situations and asks the offender to indicate which coping skills he would utilize and to rate how much difficulty he would have enacting such a response and avoiding a lapse. Problems are considered to exist when the offender does not provide a response, elaborates on the risky elements of a situation, provides a strategy that is unlikely to be successful, or responds only after a long pause. The offender is then asked to provide a fantasized account of a future relapse, which allows the clinician to determine where adaptive and maladaptive coping responses are being used.
The treatment phase of RP has been conceptualized differently by different researchers. Pithers (1990) organized the treatment into two distinct groups of procedures: those for avoiding lapses and those for preventing lapses from becoming relapses. To avoid lapses, Pithers recommended that the clinician first identify offense precursors: many events preceding relapse can be avoided, and clinicians must teach offenders to recognize such events. Clinicians assist offenders in identifying behaviors and attitudes that were not previously recognized as being tied to offending; self-monitoring techniques can be useful at this stage. Once the relapse process has been delineated, treatment begins to focus on identifying the specific precursors for that offender, which could be emotions, thoughts, behaviors, or some combination of the three. The clinician should provide strategies to minimize lapse and to cope more effectively with momentary falters in self-management, assisting the offenders in viewing lapses not as signs of failure but as opportunities to enhance self-management. When a lapse is reported, the offender and clinician analyze it together with an emphasis on the circumstances that preceded the lapse; this helps to reduce the likelihood of recurrence under similar circumstances in the future.
Once offense precursors have been established, the treatment begins to focus on specific strategies the offender can use to avoid future lapses. When external stimuli lead to lapses, offenders can be taught to enhance their self-control through the use of stimulus control procedures that remove such stimuli from the environment or avoid such circumstances altogether. Since it is unlikely that offenders will be able to avoid every situation that may lead to relapse, escape strategies can aid offenders in removing themselves from a dangerous situation should one arise unexpectedly. The clinician should emphasize that escape strategies must be employed as early as possible when the offender finds himself in a situation he is unequipped to handle, and that the most important aspect of this strategy is the speed with which it is executed. As escape is not always a viable option, learning to cope with urges is a necessary skill. Offenders should be taught to deal with positive outcome expectancies through a reminder that initial gratification is typically followed by delayed negative effect; for example, though an abusive encounter might have been sexually gratifying, it may also have resulted in incarceration. Urges may dictate behavior; giving in to an urge is an active decision, and offenders must take responsibility for it. Treatment should help them see that if they refrain from acting on an urge, urges will eventually weaken and pass with time. If offenders find themselves unable to cope with their urges, programmed coping responses can be used to manage difficult situations: using a standard problem-solving process, offenders can be taught to describe problematic situations in detail, brainstorm potential responses, evaluate the likely outcome of each response, and rate their own ability to execute each response. The most adaptive response is then selected for practice. Lastly, skills building interventions can be used to remediate deficits in anger management, problem solving, stress tolerance, sexual knowledge, interpersonal empathy, and basic survival skills.
According to Pithers (1990), there are two major techniques used to prevent lapses: cognitive restructuring and contracting. The former is used to restructure the offenders’ interpretation of lapses. Instead of viewing lapses as an irreparable failing, clinicians should teach them to view lapses as mistakes that provide an opportunity to learn and the possibility to develop new coping skills, which can increase self-control. As treatment progresses, offenders should come to view lapses as slips in self-management rather than unchanging negative personality characteristics and as a single event rather than a predictor of catastrophe, provided that the event is dealt with in an appropriate and timely fashion. Clinicians should encourage offenders to summarize this material on a reminder card that can be carried with them at all times: when a lapse occurs, the offender should review the card and be reminded that this is a temporary lack of judgment that need not culminate in relapse. A complementary approach to preventing relapse is the use of contracting, in which the therapist and offender agree upon and commit in writing the specific limits to which the offender may permit himself to lapse. The offender is an active participant in determining the “lapse limit,” but it is the responsibility of the therapist to ensure that it is a reasonable limit from which the offender will be able to return without danger of relapse. In addition to specifying the limit to which lapses will be tolerated, the contract requires the offender to limit his exposure to stimuli that lead to offending and to view offending behavior as a choice that demands a penalty.
Polascheck (2003) has conceptualized RP with sex offenders somewhat differently, organizing the treatment in terms of the sequence of events that led to offending in the first place; since there are different motives for engaging in offending, there must also be varying methods for preventing relapse. In this model, offending behaviors are identified as being due either to approach or avoidance. According to Polascheck, it is unclear whether offenders with approach motives should even be accepted into RP programs: “RP’s core treatment philosophy is that the client is at least minimally motivated to refrain from the target behavior. …As such, RP is ill-matched to individuals who want to engage in the prohibited behavior” (p. 365). However, clinicians working within the prison system are often not authorized to decide who will and will not receive treatment, and must be prepared to work with offenders whose offense history is approach-based. Therefore, Polascheck provided guidelines for working with such individuals.
Approach goals are divided into two patterns, each with their own set of procedures: approach-automatic and approach-explicit. The approach-automatic pattern is a rapidly unfolding offense process that lacks planning, and such offenders often report that their behavior was spontaneous or reflexive. When working with such individuals, the goal of treatment is to disabuse them of the notion that their offenses simply “happened” (Hudson & Ward, 2000) and to lead them to acknowledge that their behavior had identifiable antecedents in which they knowingly and willingly engaged. Since offenses tend to occur rapidly once the offender begins to make contact with the victim, the key skill for approach-automatic offenders to learn is self-monitoring, which should be used to enhance self-control before behavior can escalate into offending. Contrary to the approach-automatic pattern, in which offenses occur without prior planning, approach-explicit offenses occur because the offender wants them to occur and arranges them. Such offenders typically feel no remorse following an offense. When working with this group, the major treatment task is to alter core beliefs associated with sexually or generally exploitative worldviews and hostile beliefs (Hudson & Ward, 2000). Cognitive restructuring techniques may be useful, but attempting to purge such offenders of their deeply entrenched, highly reinforced, offense-justifying distorted attitudes will likely prove daunting.
Avoidance goals are also divided into two categories: avoidant-passive and avoidant-active. Avoidant-passive offenses occur due to chronic under-regulation of moods and behavior coupled with a lack of awareness of one’s own agency in the offense. Such offenders seem genuinely oblivious to their own internal states and as such do not believe themselves responsible for their external behavior. These offenders must be taught to challenge this sense of helplessness. A main goal of the treatment is actively to engage in self-monitoring, so that offenders can identify emotional and behavioral antecedents such that situations do not appear to have arisen from nowhere. In contrast, avoidant-active offenses occur when offenders actively take steps to reduce offending, but the steps are poorly chosen and have the opposite effect (e.g., drinking alcohol and masturbating in an attempt to reduce sexual fantasies [Ward & Hudson, 1998]). Traditional RP works well with this group, as offenders are generally aware of their own contributions to the problem. However, treatment efficacy will be based on whether offenders can accept that these exacerbating strategies have a detrimental effect.
No matter what the approach to RP, clinicians should always be realistic and candid with offenders about the likelihood of relapsing. If an offender believes that the treatment program will cure him, he is more likely to see a momentary lapse as an irreversible trend and to give up on therapy. However, if an offender sees a momentary loss of control as an opportunity to benefit from lessons learned from the lapse and to gain greater self-control when similar situations arise in the future, lapses can become an instrumental part of therapy.
We have discussed some of the basic tenets of the RP model as originally formulated by Marques and Pithers. In reality, there is a considerable clinical literature on treatment of sex offenders (e.g., Laws, 1995; Laws et al., 2000; Schwartz & Cellini, 1995, 1997), as well as theoretical developments (Ward & Hudson, 1996, 1998; Ward, Louden, Hudson, & Marshall, 1995; Ward, Hudson, & Keenan, 1998), and recent applications of old treatment modalities (e.g., Hanson, Bourgon, Helmus, & Hodgson, 2009). Many of these developments, although refreshing, remain untested and have minimal practical utility for most therapists. We recommend for clinicians practicing with basic competence a thorough understanding of the theory and the application of RP. With training and supervision, basic competence might also include other behavioral modalities commonly used with sex offenders (e.g., systematic desensitization and aversion) and psychoeducational modules commonly used with sex offenders (e.g., anger management and social skills training).
38.1.12 16.1.12 Medication
As mentioned previously, the CBT platform upon which RP is built has been shown effective in treating a variety of psychological disorders. In some cases, however, psychotherapy, augmented by medication, may yield an improved response. Although nonmedically trained clinicians will not, as a rule, be responsible for prescribing medication, the treating clinician, as the individual primarily involved in the offenders’ care, may be the first to determine that medication may be helpful. With regard to basic competency, we would set the knowledge bar fairly low. We recommend that it is incumbent upon the clinician to be familiar with medications commonly used with sex offenders, principally the anti-androgens and the (SSRI) antidepressants, and to know all of the behavioral indicators or signs suggesting the need for these medications. As the potential “first-line responder,” the clinician must be vigilant to the need for medication and to know when to make a referral to a physician.
In sum, under the umbrella of basic competencies, clinicians should be aware of the classes and names of drugs commonly used with sex offenders as well as the emotional and behavioral signs and symptoms that reflect a possible need for those drugs. We will discuss medication in somewhat greater detail under expert competencies.
38.2 16.2 Expert Competencies of the Clinician
Expert clinical work with sex offenders requires knowledge of specific techniques and interventions beyond the basic competencies. A general overview of the areas of basic competence for this niche of practice was presented earlier in this chapter, and will now be readdressed with respect to expert competence. According to the APA ethics code, adopted in August of 2002, “When assuming forensic roles, psychologists are to become reasonably familiar with the judicial or administrative rules governing their roles.” Clinicians must become familiar with the issues and problems that are specific to not only a forensic population in general, but to sexual offenders in particular. This section will discuss expert competencies for assessing and treating this population.
Legal Knowledge. The interface of the mental health system with the practices and procedures of the Sexually Violent Predator courtroom is fraught with problems that have been addressed extensively elsewhere (e.g., Janus & Prentky, 2003; Prentky, Janus, Barbaree, Schwartz, & Kafka, 2006). Experts practicing in this interstitial world are expected to have an in-depth understanding of the legal requirements of the prevailing statute, case law, if any, related to the statute, and the aforementioned problems commonly encountered with these cases. Although experts do not interpret laws, they must understand the language and the putative intent of the laws to provide opinion testimony that will be useful to the court. In particular, experts must be conversant with the relevant case law and social science literature that address two key topics: (1) mental abnormality (the full array of diagnostic issues related to a statutory finding of mental abnormality), and (2) risk assessment. With regard to risk assessment, the expert must be acquainted with (a) the literature addressing the comparative efficacy of clinical assessments of risk and mechanical (actuarial) assessments of risk, (b) the empirical literature supporting the variable strength of different risk factors in predicting reoffense, (c) the critical methodological concerns that compromise objectivity (and accuracy) in rendering opinions about risk (e.g., base rate estimates and illusory correlations between presumptive risk factors and reoffense), and (d) the admissibility issues related to mechanical risk assessment, including Daubert criteria and scale-specific issues (e.g., error rates), should they arise.
38.2.1 16.2.1 Assessment
Assessing sexual offenders presents unique challenges to the clinician. According to Clipson (2003), “all forensic assessments must address the possibility that the person being interviewed may minimize, deny, exaggerate, or feign a psychiatric disorder to obtain a desired outcome.” Beyond the potential for malingering, which will be addressed later on in this section, Clipson points out that sex offenders may be reluctant to honestly discuss their offending behavior due to the legal implications of doing so, as well as embarrassment (i.e., awareness that their behavior is not only legally but socially unacceptable). Consequently, a well-crafted interview is essential, the sophistication of which can be expected to improve over time with experience, training, and supervision. Although conducting an interview is clearly part of basic competence, a “basic” interview will most often be restricted to history gathering, mental status, and informing a treatment plan. An “expert” interview, by contrast, may delve into a range of much more difficult issues, including (a) criminal responsibility, (b) malingering, (c) assessing psychopathy, (d) assessing symptoms of ADD, PTSD, or affective disorders, (e) formulating and exploring evidence for hypotheses about etiology, (f) gathering evidence related to risk, and so forth.
Lanyon (2001) noted that forensic psychologists require a structure “that delineates the relevant issues and provides some basic knowledge about appropriate assessment procedures.” He proposed a six-step structure for assessing sex offenders. The six questions that can serve to guide the clinician in their initial assessment are as follows: (a) What kind of a person isthis – what are the person’s general psychological characteristics? (b) What kind of an offender is this – what are the person’s deviant sexual interests? (c) What is the risk of reoffense – how dangerous is the person? (d) What is the person’s amenability to treatment? (e) To what extent is the person engaging in self-serving misrepresentation during the evaluation? (f) In regard to forensic contexts, how well does the person fit specific formal criteria, either legal or other, such as “sexually violent person” or “pedophile?” The following sections will cover steps a through e presented above.
38.2.2 16.2.2 The Interview
Steps (a) and (b) described above are applicable to the initial interview with a sex offender. The first step, according to Lanyon, involves the assessment of personality and the gathering of background information to aid in an understanding of the individual to be treated. A detailed and extensive clinical interview should be used not only to gather pertinent information, but to establish rapport and provide a preliminary assessment of clinically significant behaviors that may aid in potential future diagnosis. In performing a preliminary assessment of a sex offender or an individual characterized as sexually deviant, there are areas that should be explored with greater detail than may be required in most initial assessments. Information pertaining to the psychosexual development and adaptation of the individual is pertinent and will aid in providing a comprehensive understanding of the specific manifestation of symptoms or behaviors in the sexually deviant individual. In addition, gathering a thorough history of childhood maltreatment and sexual history is necessary, and frequently critical. Areas, specific to the presenting problem, will be explored beyond that required of a general interview. This information will not only clarify potential sexually related disorders, but will serve to inform appropriate treatment and identify target behaviors.
38.2.3 16.2.3 Assessment of Sexual Attitudes, Sexual Fantasies, and Sexual Preference
Within step (b) Lanyon points out, in accordance with the diagnosis of a DSM-IV-TR Paraphilia, the importance of assessing the range of sexually deviant behaviors, the strength of interest in the behaviors, and the comparison with nonsexual interests. There are several assessment tools designed to aid in assessing sexually deviant behavior and acquaintance with these instruments is imperative. Clinicians should be aware that psychometric tests exist for specific ages (e.g., children, adolescents, and adults), types of offenses (e.g., rape, pedophilia), and types of sexually deviant behaviors. Due to the wide variety of assessment tools available, a complete and clear understanding of the individual should be determined through the initial interview and information gathering. A short, incomplete list of commonly used measures specific to assessment of sex offenders is presented below. Clinicians should be aware that assessment tools used with a general clinical population do not necessarily translate to use with sex offenders. Clinicians should therefore be cautious of the relevance and validity of using any measure within this specific forensic context. Although assessment can inform treatment and aid in diagnostic formulation, no measure is infallible and should be considered only part of the information gathering.
Although the following is not intended to be exhaustive, or even comprehensive, we will list a number of commonly used measures that experts should be familiar with. Familiarity includes not only acquaintance with the relevant literature but a working knowledge sufficient to supervise the use, scoring, and interpretation of the procedure.
Cognitive Distortions. Offenders frequently use cognitive distortions (irrational attitudes) to justify, minimize, and occasionally deny their behavior. Consequently, cognitive restructuring is a commonly used treatment modality, and the assessment of cognitive distortions is occasionally included in a clinical assessment battery. Two well-known measures are the Abel, Becker & Kaplan Cognitions Scales (specific to sexual behavior with children, this assessment measures distorted ideas and attitudes about sex) and the Bumby Cognitive Distortion Scales (includes the Molest Scale and the Rape Scale, used with adolescents and adults). Although the use of any one of these scales may be infrequent, expert competence clearly includes facility with them.
Sexual Fantasies and Behaviors. There are a variety of self-report measures that are well-known and commonly used to assess sexual and paraphilic fantasies and behaviors, including the (a) Clarke Sex History Questionnaire (Langevin, Handy, Paitich, & Russon, 1985), currently published by Multi-Health Systems, (b) the Multiphasic Sex Inventory, published by the authors, Nichols and Molinder, (c) the Sexual Experiences Scale (Koss & Gidycz, 1985), and (d) Attraction to Sexual Aggression Scale (Malamuth, 1989a, 1989b). A resource guide for practitioners provides a much more complete list (Prentky & Edmunds, 1997). As noted above, although the use of any one of these scales may be infrequent, expert competence clearly includes facility with them.
184.108.40.206 220.127.116.11 Sexual Preference
18.104.22.168.1 Penile Plethysmograph (PPG)
The penile plethysmograph is a medical device used to measure male sexual preference by quantifying erectile responses to auditory and visual stimuli depicting normative and deviant sexual themes. There are two methods: circumferential and volumetric. Circumferential, the method commonly used in the USA, measures changes in the circumference of the penis using a transducer, either a mercury strain gauge or an electromechanical gauge. Generally, PPG assessments are done only in clinical settings and only for clinical purposes (e.g., to monitor changes as a function of treatment). There seems to be general agreement, moreover, that the PPG should not be used for forensic purposes (McConaghy, 1989; Murphy & Barbaree, 1994). Travis, Cullin, and Melella (1988) went as far as to suggest that, “the only purpose that erectile measurements have in a forensic setting would be as one evaluative element contributing to an expert opinion offered to the court regarding potential treatment” (p. 248). Expert competence does not include ownership and routine use of the PPG. Expert competence does include, however, working knowledge of PPG, methodological issues, answers to frequently asked questions that may come up in court (cf., Lalumiere and Harris, 1998), and admissibility case law related to the PPG.
22.214.171.124.2 Abel Assessment for Sexual Interest-2 (AASI-2)
Abel developed a method for assessing sexual interest that is noninvasive (involves no measurement of erection), requires no stimuli depicting nudity, and always yields some response (i.e., there are no “flat liners” or “nonresponders” as are occasionally seen with the PPG) (Abel, Lawry, Karlstrom, Osborn, & Gillespie, 1994). The ASSI is a computerized assessment of self-reported sexual interest in images of children, teenagers, and adults. Because this visual reaction time procedure is easily transported and administered, noninvasive, and less expensive than the PPG, it has gained a considerable following and is widely used, especially when assessing sex offenders known to be, or suspected of being, pedophiles. As with the PPG, it is not assumed that an expert will own the ASSI. It is assumed, however, that expert competence includes working knowledge of the test and admissibility case law surrounding the test.
38.2.4 16.2.4 Assessment of Risk
Perhaps the single most challenging and demanding area of sex offender assessment is the assessment of risk. As stated in step (c), assessment of risk is an area common to sex offender evaluation. Expert competence requires practitioners working with sex offenders to be well acquainted with the myriad issues – legal, theoretical, empirical – that arise with risk assessment (cf. Janus & Prentky, 2003; Prentky et al., 2006). Although risk assessments may be called upon for a variety of reasons, including preparedness for community-based treatment, tier classification by the registration board, and other discretionary and management decisions, the most frequent use of risk assessment is in the adjudication of offenders petitioned for civil commitment as “sexual predators.” Experts must be conversant with the different methods for assessing risk and the empirical literature that compares those methods (cf. Janus & Prentky, 2003). Experts must be conversant with the commonly used actuarial risk assessment scales, including the Violence Risk Appraisal Guide (VRAG), the Sex Offender Risk Appraisal Guide (SORAG), the Rapid Risk Assessment for Sexual Offense Recidivism (RRASOR), the Static-99, Static-2002, and the Minnesota Sex Offender Screening Tool-Revised (MnSOST-R) (Janus & Prentky, 2003; Seto, 2005), the rationale for using a particular scale, and the literature addressing the validity of that scale. Experts must be familiar with the empirical literature on risk predictors and relative effect sizes of each. Experts must strive to “avoid parochialism by embracing models and methods that are used by more ‘mature’ disciplines, far more seasoned in the ways of assessing risk” (Prentky, 2003, p. 22). Experts must be aware of the different types of risk predictors (e.g., static, dynamic, protective, etc.) and how each functions in an assessment. Experts must be conversant with, and make use of, the growing literature on acute and stable dynamic risk predictors. Experts must be cognizant of important potential risk mitigators, such as age, as well as risk aggravators, such as unruly institutional behavior. Experts must be aware of the impact of base rate estimates on their assessments. Overall, experts must, “in the scientific vernacular, strive to reduce uncertainty” by paying acute attention to the sources and nature of uncertainty in risk assessment with sexual offenders (Prentky, 2003, p. 22).
126.96.36.199 Psychopathy Checklist-Revised (PCL-R)
The current procedure for assessing psychopathy is the well-known semi-structured interview (PCL-R) developed by Hare almost 30 years ago (Hare, 1980). Extensive research over the past decade has examined the factor structure, reliability, and validity of the scale. Use of the PCL-R is a complex undertaking, requiring formal training, or, at the least, informed supervision. We do not assume that those possessing expert competence with sex offenders will include being trained to use the PCL-R, in part, because assessing psychopathy is a relatively unusual demand when working with sex offenders. If the PCL-R is called for, however, the expert must acquire adequate training or turn the psychopathy assessment over to someone that is properly trained.
188.8.131.52 184.108.40.206 Assessment of Deception
Evaluating misrepresentation in called for in step (e). When discussing deception, clinicians commonly focus on malingering. According to the American Psychiatric Association (2000), malingering is the intentional production or exaggeration of symptoms for secondary gain.We feel it is necessary to point out that while deception within any clinical population includes the possibility of malingering, deception is far more complex and includes a variety of formsof deception and dissimulation. Additionally, manifestation of deception within a general clinical population differs from that of a forensic population, such as sex offenders.
Rogers (1997) has delineated the basic types of dissimulation that may occur and of which clinicians should be aware. When performing psychological assessment, an individual’s response style can be indicative of the type of dissimulation in which they are engaging.By understanding the different response styles a respondent may employ, a clinician will be provided with clues as to the respondent’s level of motivation to tell the truth or to deceive, as well as the sophistication of their attempt at dissimulation. Rogers has broken down response styles into six types: (a) Malingering, the intentional falsification or overreporting of symptoms; (b) Defensiveness, the minimization of symptoms; (c) Irrelevant responding, disengaging from the assessment in an attempt to produce results that do not provide an accurate picture of the respondent; (d) Random responding, failure to attend to the task in order to provide meaningless results; (e) Honest responding, which leaves it to the clinician to determine the reason behind inaccuracies in the results; and (f) Hybrid responding, any combination of the above response styles.
Dissimulation is common among sex offenders and can occur for various reasons. Sewell and Salekin (1997) explore deception among sex offenders. The authors cite a 1992 study by Kennedy and Grubin that described four patterns of denial based on a study of 102 male sex offenders. Pattern 1, consisting of 18% of the sample, was comprised of offenders who admitted their offense but denied any harm to their victims. They typically offended against young boys and claimed to have helped rather than hurt their victims. Pattern 2, consisting of 20% of the sample, was characterized by externalizing responsibility. They typically offended against young girls and were likely to blame their victim or another person for their behavior. Pattern 3, consisting of 35% of the sample, completely denied their offense. The offenders in this group typically offended against adult females and were characterized by a lack of insight into the benefits of psychological treatment. Pattern 4, consisting of 27% of the sample, exhibited a dissociative style and attributed their behavior to “a temporary aberration of behavior or altered mental state.” This group included heterosexual incest perpetrators.
It is clear that deception among sex offenders is more complex than a mere understanding of the concept of malingering. Not only can deception take place for a variety of reasons, but it can take many forms. Clinicians should be aware of the ways in which offenders deceive and why they do so. Detection of deception is indispensable to producing a valid diagnostic and clinical understanding of the individual. Beyond a solid definitional and theoretical understanding of the manifestations of deception, clinicians should become familiar with the assessments of deception. The most well-known method for assessing malingering and deception is Rogers’ Structured interview of Reported Symptoms (SIRS). In addition, the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) is occasionally administered and validity scales for detecting deceptive responding reported. The Multiphasic Sexual Inventory-II (MSI-II), which is occasionally paired with the MMPI-2 when assessing sex offenders, also includes scales that assess deceptive responding.
38.2.5 16.2.5 Treatment
Elsewhere we have discussed efficacy of treatment with sex offenders. Treatment efficacy with sexual offenders is measured by whether or not it reduces the targeted behavior. Lanyon indicated in his steps that amenability for treatment should be considered. We argue that this is in fact a moot point, as often treatment is required of sex offenders whether incarcerated or in the community. At present, there is no definitive way of determining an individual’s amenability to treatment, however, the individual’s motivation to participate in treatment seems to play a key role in whether or not treatment will be effective for a particular individual. In forensic settings, treatment is largely forced upon offenders, it is understandable that those who voluntarily participate in treatment and seek out therapy are more likely to benefit from treatment.
For the expert clinician, treatment extends beyond relapse prevention. Though that is the primary modality used with sexual offenders, it is often insufficient to meet their needs or to address additional pathology that may be contributing to or perpetuating their offense cycles. Therefore, it is imperative that the expert clinician become familiar with, and proficient in, a variety of treatment approaches that may be useful in working with this population.
38.2.6 16.2.6 Beyond Relapse Prevention
Beyond relapse prevention, many other treatment interventions have been adopted from other areas of clinical practice that have utility for target problems observed among some sex offenders. For example, if depression is a significant factor in an offender’s offense cycle, it must be addressed, and the most effective interventions may be medication or medication combined with CBT. If trauma is a significant factor in an offender’s offense cycle, trauma therapy or EMDR might be called for as a compliment to RP. In this section, we discuss treatment interventions commonly used in sex offender treatment programs that clinicians must be acquainted with. It is important to note that, with the noteworthy exception of medication and some modes of behavior therapy (covert sensitization and aversion), there is a dearth of research investigating the efficacy of these treatments for sexual offenders. It is incumbent on sex offender treatment providers to know what interventions have been empirically validated with sex offenders and which have not. Empirical support for procedures and interventions developed for other client populations cannot be taken as empirical support for the application of those procedures to sex offenders. As with our discussion of RP, this section is not intended to instruct novice clinicians in the provision of the treatments detailed therein, but rather to familiarize clinicians with the treatments most commonly used with this population.
Posttraumatic Stress Disorder (PTSD). Four types of therapy are commonly used in treating posttraumatic stress disorder (Resick, Monson, & Rizvi, 2008): (a) Coping- or skills-focused treatment. The most commonly used coping/skills-based treatment is stress inoculation, which imparts coping skills in an effort to provide clients with a sense of mastery over fear. This is achieved through deriving an explanatory framework through which clients can understand the origin and nature of their fear and anxiety, thereby making sense of their trauma and its aftermath. Clients are also taught skills for dealing with physical, behavioral, and cognitive reactions, including relaxation and breathing control, covert modeling, role-playing, and guided self-dialogue. (b) Exposure techniques. Exposure involves reexperiencing the traumatic event in some way; techniques typically include imagining oneself in fear-producing situations, recalling traumas for extended periods of time, and confronting feared situations in vivo. A hierarchy of feared and avoided stimuli is generated, and clients are instructed to confront the feared cues daily for a prespecified amount of time, beginning with the least anxiety-provoking items on the hierarchy and eventually working up to the more distressing items. The therapist guides clients in reliving their trauma in the imagination, asking them to describe it aloud. As therapy progresses, clients are asked to describe the trauma in increasingly more detail, including thoughts, physiological responses, and feared consequences, with the goal of achieving habituation. (c) Cognitive therapy. Daily diaries and monitoring forms are often used to elicit dysfunctional and disturbing thoughts the client has experienced during the week. Therapy focuses on the meanings the traumatic event has for the client, and how those meanings confirm or contradict previously held beliefs about self and others. The therapist guides clients in discovering how they may have distorted the event in an effort to maintain prior beliefs about self and others, or how they may have changed their beliefs too much to cope with their trauma. Clients are taught to identify and dispute unrealistic thoughts about themselves, the world, and their futures through reasoning and evidence-based arguments. (d) Combination treatments. Such treatments typically combine exposure and cognitive elements, but may also include relaxation or coping elements.
Cognitive, exposure, and combined treatments have been found equally effective and more effective than relaxation exercises (Marks, Lovell, Noshirvani, Livanou, & Thrasher, 1998). Furthermore, prolonged exposure and prolonged exposure plus cognitive therapy have been found to work equally well (Foa et al., 2005), suggesting that exposure is the active ingredient in the treatment for PTSD. Whatever approach is selected, the therapist should be aware that clients with PTSD can be ambivalent about therapy and therefore somewhat difficult to work with; therapists should therefore expect some avoidance in the context of treatment (Resick et al., 2008).
Phobias. When treating phobias, the main goal is to decrease fear and phobic avoidance to a level that no longer causes distress or impairment. Both CBT and medication have been found effective in doing so, and both appear to work equally well when treating social phobia (First & Tasman, 2004). Exposure-based treatments have been shown to be useful in treating a range of specific phobias (e.g., Foa, Blau, Prout, & Latimer, 1977; Muris, Mayer, & Merckelbach, 1998), and they work best when sessions are spaced close together, exposure is prolonged, and avoidance is discouraged; in addition, real life exposure is more effective than imaginal, and exposure is more effective when the therapist is involved than when a client is alone (Antony & Barlow, 1998, 2002).
As social phobia can be a factor in sexual offending, we focus on the treatment of that particular disorder. There are four main types of treatment for social phobia, and there is often overlap among these treatments (First & Tasman, 2004). In exposure-based treatment, clients list anxiety-provoking situations in a ranked hierarchy. The therapist then assists clients in repeatedly approaching feared situations, working from least to most anxiety-provoking, until the situations no longer elicit fear. Repeated exposure demonstrates to clients that feared consequences do not emerge despite having confronted the situation. In cognitive treatment, the therapist helps clients to identify and change their anxious thoughts by considering other ways of interpreting situations and by examining the evidence for their anxious beliefs. Social skills training is used to help clients become more socially competent in their interactions with others. The training includes modeling, behavioral reversal, corrective feedback, and social reinforcement. Lastly, applied relaxation is used to teach clients to relax their muscles during rest, during movement, and eventually in anxiety-provoking social situations (Ost, Lindahl, Sterner, & Jerremalm, 1984).
Inappropriate (Deviant) arousal. Sexual offending may be motivated by sexual arousal to inappropriate stimuli, inappropriate object choices (i.e., children), or inappropriate situations. Therefore, a primary therapeutic goal is to decrease deviant or inappropriate sexual arousal. The two principle behavioral modalities are olfactory aversion and covert sensitization. Covert sensitization has been used to treat sexual disturbance (Barlow, Leitenberg, & Agras, 1969; Callahan & Leitenberg, 1973; Segal & Sims, 1972) as well as a variety of other problems, such as alcoholism (Ashem & Donner, 1968; Cautela, 1970) and obesity (Cautela, 1967). The treatment is based on classical conditioning: deviant arousal is paired with an unpleasant stimulus, causing the deviant arousal to become aversive and therefore avoided. Nausea and vomiting have been used as aversive stimuli, and verbal descriptions of repulsive scenes in conjunction with imagined sexual behavior have been reported successful in controlling deviant sexual behavior in controlled studies and have been identified as the effective therapeutic ingredient in covert sensitization (Barlow et al., 1969). In covert sensitization, clients are asked to imagine a situation that would lead to arousal; however, it is important to note that they are not asked to imagine engaging in intercourse or anything else that might lead to a culmination of the arousal. Immediately after the imagined arousal, the aversive stimulus is introduced. When the aversive stimulus is removed, feelings of relief are emphasized; during this period of relief, offenders are asked to imagine a normative sexual experience (Levin, Barry, Gambaro, Wolfinsohn, & Smith, 1977), with the goal that offenders will develop an association between normative sexual experience and relief. This method has been shown to be effective for sex offenders as part of a behavioral modification program (Marshall, Jones, Ward, Johnston, & Barbaree, 1991).
38.2.7 16.2.7 Old Interventions Newly Applied to Sex Offenders
It is incumbent on all clinicians providing treatment for sex offenders to be aware of new developments, and one interesting new development is the application of the Risk-Need-Responsivity (R-N-R) model developed by Andrews and Bonta (Andrews & Bonta, 1998; Bonta & Andrews, 2007) for general offenders to sex offenders (Hanson et al., 2009). Hanson et al. reported that programs that adhered to R-N-R evidenced the largest reductions in both sexual and general recidivism. Program effectiveness increased as the total number of R-N-R principles adhered to increased. The R-N-R model proposes that the most intense treatment services be reserved for those at greatest risk (the Risk part), that treatment programs target those “criminogenic needs” with empirical support (the Need part), and that programs use only techniques with demonstrated responsivity (i.e., techniques that sex offenders are known to respond to) (the Responsivity part). It may be empirically defensible to argue that modern RP-based treatment programs adhere to the Responsivity component. We would further argue, however, that, by and large, the Risk and the Needs components are neglected. This is a good example of a newly developing application of an old offender treatment model that all clinicians, irrespective of competence level, should be aware of.
38.2.8 16.2.8 Medication
Drugs have been used in the USA to reduce sexual drive for over 60 years. Female sex hormones (i.e., estrogen) were the most commonly used substances in the late 1940s and early 1950s and major tranquilizers were used in the 1960s. Until recently, the principal alternative to the major tranquilizers has been the anti-androgens. The anti-androgen drug of choice in the USA has been medroxyprogesterone acetate (Provera, Upjohn). Since reduction of sexual drive in sex offenders is not an indicated use for Provera, it is used in the USA only on an experimental basis with sexual offenders (i.e., “off-label”).
The first systematic use of Provera for the treatment of sexual offenders was initiated in 1966 at Johns Hopkins University. The early research at Johns Hopkins during the 1960s and 1970s was conducted by Money (1970), and followed in the 1980s by Berlin (e.g., 1989). Research on another anti-androgen, cyproterone acetate, has been conducted by Bradford (e.g., 1998). In general, these anti-androgen drugs reduce overall sexual drive by reducing libido, sexual fantasies, nocturnal emissions, spontaneous erections and masturbation. To use the expression coined by Berlin, these drugs reduce “sexual appetite.”
Berlin (1983) described another approach to reducing testosterone, the use of a gonadotropin releasing hormone agonist (GnRH). The drug that has been most often used in the USA with sex offenders is leuprolide (Lupron). The advantages of Lupron over the more commonly used anti-androgen (Provera) include fewer side effects and greater potency when it comes to decreasing testosterone. The major disadvantage is that Lupron, at least at the present time, is much more expensive than Provera.
A major addition to the anti-androgens for treating sexual offenders is the group of antidepressants classified as selective serotonin reuptake inhibitors (SSRIs). Reduced serotonin has been associated with a wide variety of psychiatric problems, including most impulse control disorders, suicide, major affective disorders, anxiety disorders, panic disorder, consummatory disorders (such as alcoholism), obsessive-compulsive disorder and aggressive behavior. The SSRIs increase serotonin, and the biological basis for the use of these drugs with sex offenders was provided in a series of papers by Kafka (e.g., 1995, 1997a, 1997b, 2003) and others during the 1990s.
In summary, drugs used to treat sex offenders fall into two categories: (1) the anti-androgens, such as Provera and Lupron, and (2) the SSRIs, such as Prozac, Zoloft, and Paxil. These drugs are most helpful in treating sex offenders who are highly preoccupied with sexual thoughts and fantasies and those who report a high sexual drive or high total sexual outlet. In addition to their high sexual drive and often atypical or paraphilic expression of sexual urges, these individuals may also have low self-esteem, social anxiety, social skills deficits, low grade anxiety, and depressive symptoms. For these reasons, a combination of an SSRI with an anti-androgen may be most effective for those sex offenders that present with high sexual drive coupled with an affective disorder.
Expert competency must include a working knowledge of those drugs commonly used with sex offenders. Working knowledge includes awareness of (1) the principle on-label indications for these drugs, (2) side effects associated with these drugs, (3) the pharmacodynamic properties of these drugs, and (4) to a much lesser extent the pharmacokinetics of these drugs. Comorbid diagnoses may produce complex poly-pharmacy. Awareness of potential interactions between the anti-androgens and frequently observed medications used to treat other disorders (e.g., major affective disorders) is part of expert competency. In addition, familiarity with the recent literature on the efficacy of both the anti-androgens and the SSRI antidepressants is critical. There is a substantial empirical and theoretical literature on drug use with sex offenders. A rudimentary knowledge of this literature is essential. In addition, there are significant ethical issues that expert competency embraces. As noted above, for example, the principle anti-androgen used in the USA is prescribed off-label, requiring a detailed statement of informed consent. In addition, compulsory (mandated) use of drugs, occasionally referred to as “chemical castration,” may raise possible Eighth Amendment issues. Acquaintance with these ethical issues is part of expert competence.
38.3 16.3 Transition from Basic Competence to Expert
Since most practitioners working with sex offenders have a Master Degree, transition from basic to expert competence typically begins with education – acquiring a doctoral degree. Beyond the acquisition of a doctoral degree and licensure, transition to expert competence requires hands-on work experience with parallel supervision, extensive reading, and attendance at professional workshops.
38.4 16.4 Summary
Establishing benchmarks for levels of competence in the relatively small niche of specialized practice with sex offenders is difficult given the apparent absence of prior efforts in this regard. We have attempted, nonetheless, to provide a preliminary set of recommendations, subject to the scrutiny and critical appraisal of our colleagues. This area of clinical practice is unique in at least two major respects. First, a substantial proportion of practitioners are Master’s-level. Among ATSA’s 2,049 clinical members, for instance, only 455 (22.2%) have doctoral degrees. Thus, over three quarters of ATSA’s clinical members are MA-level practitioners. Thus, unlike most specialty areas of clinical practice wherein transition from basic to expert competence translates to training and supervision around new tasks or procedures, transition to expert competence for those providing basic clinical services to sex offenders usually means returning to school to acquire a doctoral degree. Second, since the “clients” are typically current or former offenders, there is increased sensitivity to ethical issues, as well as occasional demand for services that are uniquely forensic, such as assessment of risk for recidivism and court testimony.
We hope our contribution prompts further discussion around appropriate guidelines for levels of competence for those working with sex offenders. Given the increasing number of clinicians entering this field, working with forensic clients under heightened conditions of ethical and legal scrutiny, it would seem prudent that this area of professional practice be legitimized with accepted standards of training and practice, delineated standards for competence, and some form of certification process that insures competent practice.