In the late 1970s and early 1980s, "rehabilitation" programs in prisons across the country were dramatically curtailed when R. Martinson published two articles1,2 that became the foundation for the "nothing works" philosophy. State legislatures began shifting from indeterminate sentencing with its emphasis on program participation influencing parole to the "just deserts" model with felons serving set sentences not affected by participation in "rehabilitative" efforts. Unfortunately, the movement to dismantle these vocational, educational, and treatment programs of reoffenders went on despite the fact that Martinson's methodology was so questionable that eventually even he recanted his conclusions.3,4
Further studies and more careful analysis of previous studies have yielded positive outcomes in 47% to 86% of the programs studied.'''6 Andrews and associates7 performed a meta-ana!ysis on 45 studies of treatment effectiveness and found that across studies the same three criteria predicted a successful outcome:
1. delivery of service to higher risk cases;
2. targeting of criminogenic needs;
3. use of styles and modes of treatment (eg, cognitive and behavioral) that are matched with client need and learning style.7
Andrews and associates conclude, "The effectiveness of correctional treatment is dependent upon what is delivered to whom in particular settings. "7(p372) Paul Gendreau, former president of the Canadian Psychological Association, reiterated these sentiments when he stated that appropriate treatment programs reduce recidivism by 53%.6
According to Hester and Miner,8 the same "nothing works" philosophy characterized professional attitudes toward the treatment of alcoholism. However, a wide variety of treatment programs are now flourishing and developing what these authors call "informed eclecticism."8 Stanton Peele, referring to the 1990 report of the Institution of Medicines, Broadening the Base of Treatment for Alcohol Problems, states, "Perhaps the endorsement of this prestigious body indicates that a critical mass has finally been reached for the creation of a pluralistic system of alcoholism treatment."9(p71) There is a growing recognition that the question is not "Can you treat alcoholism?" but "What types of treatments are most effective with which types of alcoholics?"
The same "nothing works" philosophy lias plagued the treatment of sexual deviance. Two studies have been most frequently cited as the bases for pessimism in this field. In 1977, The Group for the Advancement of Psychiatry published Psychiatry and Sex Psychopathy Legislation: The 1930s to the 1980s.10 This report justly addressed the problem inherent in assuming that sex offenders are mentally ill and attempting treatment in mental hospitals, most of which offered no specialized treatment whatsoever.
A more recent article, widely quoted as evidence that "nothing works," was written by Furby, Weinrott, and Blackshaw." These researchers did a meta-analysis of 42 studies reporting treatment outcomes for sex offender programs. Most (747f) of these studies were published before 1980. As a control group, the authors used studies of recidivism rates of untreated sex offenders, with 98% of these studies conducted in Europe.
Marshall and associates12 have criticized this research on a number of counts, including the lack of studies using matched control groups and the design, which lumped all treatment programs together regardless of location, type of sex offender, or treatment methods, and then draws sweeping conclusions. This is exactly what Martinson1 had done in the previous decade.
FROM "NOTHING WORKS" TO "WHAT WORKS"
This past year, two articles reviewed treatment effectiveness and reported much more optimistic results.12,13 Additionally, other studies have reported positive outcomes fur programs located in the community,12,1,1,15 in hospitals,Ih and in prisons.1,"2" These studies represent a variety of treatment modalities, most being multimodal in approach. Programs may emphasize behavioral reconditioning, cognitive-behavioral techniques, family systems approaches, or the addictions model.
As diverse as they may be, successful programs do hold much in common. Today, successful programs recognize that they are part of an overall criminal justice system. Just as Hester and Miller8 point out that alcoholism treatment has moved toward a "public health" approach that addresses the problem on a number of different fronts, so sex offender treatment programs are recognizing that a systems approach that advocates cooperation between police, the courts, child protective services, public and private treatment, victims' services, and prison, parole, and probation, will provide a climate for more effective treatment and a safer community.
Treatment programs are most effective when they are available both in the community and in institutions. ? judge should not have to choose between public safety and treatment because treatment programs are not available in the local prison. Nor should the public have to pay for the high cost of imprisoning an individuai who could be treated in the community. The community treatment program in a state without institutional treatment may find itself pressured to take "high-risk" clients. The institutional program without community providers will find itself unable to provide vital aftercare services or filling up its treatment slots with "minimal-risk" clients.
Another area of potential controversy is the professional qualifications of those specializing in treating sex offenders. Currently there is no recognized speciali/ed academic training program for this field. Those active in this area come from all types of mental health and human service backgrounds. This field does require that the practitioner adopt a mindset somewhat difierent from the traditional therapist. Community safety must be the primary concern. Additionally, there must be a different approach to the therapist's traditional role of serving as the patient's advocate, refusing to impose one's values on tiie patient, allowing the patient to set the therapeutic agenda, and strictly adhering to confidentiality.
Washington is the first state tu recognize the unique role of the sex offender treatment provider and has established a special certification tor all mental health providers including psychiatrists who treat sex offenders in the community. These individuals must be licensed or certified health /mental health care providers with 2,000 hours of specialized treatment experience with sex offenders and must pass a written examination (Washington Administrative Code 246-930-330, 1991).
The treatment of sex offenders originally consisted of traditional individual psychoanalysis for those few individuals who received private treatment, and confinement in a generic mental hospital for those who were identified under the sexual psychopath laws. Others were imprisoned with no treatment at all. In the 1960s, a few specialized programs concentrating largely on group therapy began developing. In the 1970s and early 1980s, behavioral techniques designed to recondition deviant sexual arousal were developed and added to the group therapies model. The developing school of cognitive-behavioral therapy contributed the techniques of psychoeducation classes and relapse prevention. Family systems theory and the addictions model have recently been adapted for use in the treatment of sexual deviance.
The contribution of a wide variety of techniques was recently acknowledged when the national professional organization for those treating sex offenders changed its name from the Association for the Behavioral Treatment of Sexual Abusers to the Association for the Treatment of Sexual Abusers.
The state of Washington has written into its legal code a set of standards for treatment. Professionals from various theoretical approaches have agreed that treatment goals for sex offenders should:
* address client's deviant sexual urges and recurrent deviant sexual fantasies as necessary to prevent sexual reoffense;
* attempt to educate clients and the individuals who are part of their support systems about the objective risk of reoffense;
* attempt to teach clients to utilize self-control methods to avoid sexual reof fending where applicable;
* consider the effects of trauma and past victimization as factors in reoffense potential where applicable;
* address client's thought processes that facilitate sexual offense and other victimizing or assaultive behaviors;
* attempt to modify client's thinking errors and cognitive distortions where possible;
* attempt to enhance client's appropriate adaptive /legal sexual functioning;
* attempt to ensure that clients have accurate knowledge about the effect of sexual offense upon victims, their families, and the aimmunity;
* assist clients to develop a sensitivity to the effects of sexual abuse upon victims;
* address client's personality traits and personality deficits that are related to reoffense potential;
* address client's deficit coping skills in present life situations where applicable;
* include and integrate the client's family into the therapy process where appropriate;
* attempt to maintain communication with client's spouse and family where appropriate to assist in meeting treatment goals (Washington Administrative Code 246-930220, 1991).
This set of treatment goals goes far beyond the behavioral and cognitive-behavioral models of treatment in acknowledging the complexity and dynamic nature of the problem.
Most specialized programs focus on a number of specific goals in dealing with this population, including:
* helping the offender overcome denial and take responsibility for his behavior;
* develop empathy for others;
* identify and treat deviant sexual arousal;
* identify social deficits and inadequate coping skills;
* challenge cognitive distortions that may perpetuate sexual actingout;
* develop a comprehensive relapse prevention plan.
Additionally, in addressing these issues the therapist will be challenged by the peripheral issues that begin to emerge, most commonly including substance abuse, family dynamics, and the offender's own victimization.
A popular model currently operating in a number of states combines group therapy, behavioral reconditioning techniques, relapse prevention, and cognitive-behavioral approaches including psychoeducational classes.21
Usually the first task of sex offender treatment is to begin to break down denial.21 In some institutional programs and almost all community-based ones, admission of guilt is a prerequisite to program entry. However, even those offenders who admit the deed itself will often deny personal responsibility, impact on the victim, planning of the assault, and a variety of other aspects of the crime. It is the task of the therapist and the group to confront that denial, point out the cognitive distortions that have justified that behavior, and encourage full acceptance of culpability.
Along with acceptance of responsibility must come an appreciation of the damage caused by sexual assault. The impact on the victim is addressed in a variety of ways including literature, films, letters, role-play, and face-to-face discussions with victims.21,22 Many programs explore the offender's own victimization in an attempt to understand his inordinate need for power and control over others. Other programs shy away from that approach, feeling that it allows the offender to use rationalization and blame. The choice to deal with the offender's developmental traumas may frequently be a function of length and intensity of treatment. In any case, ii should never be allowed to become an excuse lor victimizing others.
Furthermore, initial assessment of the sex offender should identify specific deficits that contribute to the deviance or complicate the treatment process. Is the individual lacking in social skills or unable to control his anger? Is his knowledge of human sexuality adequate? Does he have a concomitant substance abuse problem, a major mental illness, or a developmental disorder? Programs may address these needs and numerous others through psycho-educational classes, specialized groups, or referral to other agencies or therapists who cooperate in an integrated treatment plan.
One of the most critical aspects of sex offender treatment is the assessment and identification of deviant sexual arousal. Current treatment has grown past the "either/ or" stage of attributing sexual deviance to an exaggerated sex drive, or discounting sex altogeiher and attributing deviance to other psychological dynamics such as anger or power needs. Sexual deviance is seen as combining physical arousal with distorted emotional needs. The penile plethysmograph is used to measure deviant arousal, and behavioral techniques are then used to lessen deviant arousal and strengthen appropriate arousal. Covert sensi tization, masrurbatory satiation, and olfactory aversion are three commonly used methods.
Another phase of treatment reported to be effective and used in a majority of programs is relapse prevention. This is a technique adapted from chemical dependency treatment, which focuses on identifying one's individual pattern of offense and relapse and developing appropriate interventions. This treatment modality is particularly useful when a wide range of support persons, including family, friends, employers, probation and parole officers, as well as the therapist and fellow group members, have a thorough knowledge oí the pattern and can reinforce appropriate interventions. This support system must also be willing to confront the offender or institute external controls if the offender is slipping into his deviant cycle and is unable or unwilling to intervene.
One of the less utilized techniques, but the one in which the psychiatrist becomes a vital part of the treatment team, is the use of drugs with this population. Of course, all sex offenders should be evaluated for concomitant mental problems ranging from major mental illnesses to depression to substance abuse. If the psychiatrist is not the primary treatment provider but is involved in prescribing and monitoring medication, she or he should nevertheless stay in close contact with the primary provider. The therapist should request a copy of the offender's relapse prevention plan and take particular note of how the use or misuse of medication might fit into an offender's relapse cycle.
The use of the antiandrogens has been the area of drug therapy most researched with sex offenders. The use of MPA (medroxyprogesterone acetate) is primarily recommended for patients plagued by intrusive deviant fantasies. This represents a minority of sex offenders. Issues involving side effects and high attrition rates have limited widespread li se of this medication. Marshall states, "Whether we can reasonably expect MPA Lo produce post-treatment benefits seems debatable, but if it serves to lower risk while changes induced by psychotherapy gradually take hold, then it will be an effective component in treatment. "'-1P47-1
More uniformly positive results have been reported with the use of cyproterone acetate in Canada and Europe.2" However, this medication is not available in the United States.
THE INTEGRATIVE MQQEL
The field of sex offender treatment is growing rapidly, and more and more treatm en t m od els a re being adapted for this population. The integrative model developed by the Washington Department of Corrections Sex Offender Treatment Program (but probably operating under other names in other programs) aims at responding to the individual complexity of the sex offender. It is recognized that the offender's deviance is a complex combination of physiological, cognitive, affective, social, cultural, and even spiritual issues. Not only is the problem multifaceted, but the type of technique that works best for a single individual varies widely.
For some, the social interaction of the group is the most curative; for others, gaining an intellectual understanding of their problem is a prerequisite to other work. For many, the behavioral reconditioning techniques can redirect their sexuality. Others may require medication to extinguish intrusive fantasies or assist coping with concomitant emotional problems. The emotional intensity of drama therapy reaches others, and still others may need help in refraining their spiritual orientation so that they do not flee into religiosity.
The sex offender is also a member of a family, a culture or subculture, an ethnic group, and a society. His relationship to his broader social context can either be destructive or curative and the treatment program for the sex offender needs to assist in rebuilding his relationship with his social network.
Fortunately, not all sex offenders exhibit all these problems to an equal degree. The key to an integrativo program is being able to devise a manageable treatment program based on comprehensive assessment of a wide range of potential problems. This then leads to the establishment of priorities and to careful tracking of progress in each area. The assessment should also identify particular learning styles or disabilities or personality factors that might enhance or preclude the use of certain treatment techniques. The program or therapist then has the flexibility to respond to those needs in an effective and creative manner.
Treatment of the sex offender is a highly controversial topic. The very issue is so inflammatory that it is difficult for even the professional to get past the initial emotional outrage and view the perpetrator as a human being whose behavior might possibly be changed. However, in the past decade, hundreds of individual therapists, mental health centers, and prisons have taken up this challenge so that there are now over T, 200 programs and treatment specialists around the country.-"^
While popular opinion may continue to be "nothing works/' thousands of professionals are exploring "what works." What works depends on where the treatment is tnking place, who is providing the treatment, and what types of issues that particular offender has. The popular model being taught to corrections professionals, which focuses on group therapy, behavioral reconditioning, cognitive refraining, and relapse prevention, is quickly being expanded and modified to include new techniques too numerous to outline in this brief article21,22
The reductionist view that sexual deviance is no more than a simple disorder of sexual arousal or a set of thinking errors, a set of past traumas, or a group of aberrant sexual fantasies is shifting to J more dynamic view of the condition. This dynamic view currently embraces a variety of approaches, some of which will prove helpful while others will be abandoned. Thus the treatment plan will become increasingly tailored to the needs of the individual and the question will shift from "Does anything work?" to "What works for whom?"
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