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Compendium 2000 on Effective Correctional Programming

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CHAPTER 17

The Assessment and Treatment of Sexual Offenders

WILLIAM L. MARSHALL1 and SHARON WILLIAMS2


PREVALENCE OF SEXUAL OFFENDING

The true prevalence of sexual offending can only be estimated. It is clear, for example, that many victims of sexual offending do not report the crime to the police or, all too often, to anyone at all (Koss & Harvey, 1991; Russell, 1984, 1986). The Committee on Sexual Offences Against Children and Youth (1984) reported the results of Canadian national surveys. They found that one-half of women and one-third of men reported being subjected to some form of sexual abuse during their lives, with 70% of the men and 62% of the women indicating that it occurred prior to pubescence. There is, therefore, a pressing need to develop a comprehensive social response to this very serious social problem.

One aspect to this response should include not only the treatment of identified offenders, but also the development of an understanding of these offenders; what features need to be addressed in treatment; how these features should be assessed; and the generation of an actuarial basis for estimating risk to reoffend and response to treatment. Of course, if treatment is implemented, we must also evaluate its effectiveness. This chapter will attempt to address these issues.

For the past 26 years, the Correctional Service of Canada (CSC) has been at the forefront of the development of assessment and treatment for incarcerated sexual offenders. Over the last 10 years, CSC has expanded and refined its programs for sexual offenders so that it now funds numerous institutional programs and community-based follow-up treatment for released sexual offenders. While much of what follows in this chapter is derived from research and treatment conducted within CSC, we also draw on data, observations and theories generated by various researchers and clinicians around the world. For the most part, programs that have proliferated in all Western societies over the past 10 years have adopted the “cognitive behavioural/relapse prevention” approach developed in North America (for examples of such pro-grams, see Marshall, Fernandez, Hudson, & Ward, 1998). This is also the approach adopted by CSC from the first systematic application of sexual offender treatment in 1973. We will, therefore, primarily focus on that approach, although we will also acknowledge the value, as adjunctive features of treatment, of various medications in assisting in the rehabilitation of sexual offenders.

In considering treatment, cognitive behaviourists who adhere to the early form of relapse prevention take the view that sexual offending cannot be “cured” and claim the offender can be taught to “control” his propensity to abuse. To some extent, this is more a semantic issue than is suggested by the claim. For example, if a sexual offender completes treatment and does not ever again offend, is it reasonable to say he has simply been controlling his deviant urges, particularly when there is no evidence he still has such urges and he denies they are present. The language of “cure” and “control” is a mixture of medical and correctional perspectives. The language of research into learning processes, upon which cognitive behavioural/relapse prevention approaches are said to be founded, would, on the other hand, simply suggest that in the hypothetical client described above, the deviant urges have extinguished and been replaced by prosocial urges. A learning analysis would indicate that care should be exercised both by the offender and his supervisors upon his release back into the community, since spontaneous resumption of well-practised behaviours is to be expected. However, it would also indicate that once a competing set of behaviours (i.e., prosocial courtship and adult consenting sexual and relationship behaviours) is established, vigilance by both the client and supervisor could be reduced. While this is the approach CSC has been using effectively in the community management of released sexual offenders, the advocates of relapse prevention (e.g., Marques, 1984; Pithers, 1990), and those who consider treatment to be ineffective (Quinsey, 1996) encourage far more intensive post-release supervision, extending for up to 10 years. There is, however, no evidence that such supervision reduces the risk of reoffending; indeed, there are reasons to suppose that such extensive super-vision may counteract treatment benefits (Marshall, Anderson, & Fernandez, 1999).

MEASUREMENT

Measurement is a critical feature of any program. Assessments are done for various reasons, and the types of measures chosen should be guided both by what is known about the problem in question (in the present case, sexual offending), and why testing is being done. In prison settings, assessments of sexual offenders may be used to determine the treatment needs of sexual offenders; their security needs; the effects of treatment; and the offenders' risk to reoffend upon release. Such comprehensive evaluations can provide a basis for all the above decisions except, of course, that it would be necessary to repeat the assessment pack-age after treatment was complete to determine the degree to which treatment targets have been met. In community settings, the same issues might be relevant, although hopefully the within-prison evaluations, if they are recent enough, should provide most of this information. In addition, community programs may be asked to provide an evaluation to assist in determining whether or not an offender is ready to return to his family or to some other setting where access to victims may occur.

Certainly over the past 30 years there has been a shift in assessment and treatment away from the strictly sexual aspects of sexual offending to more social and cognitive elements. These changes in focus have not always been driven by research findings, but quite often by clinical intuition that is subsequently empirically evaluated, or by developments in other fields. An example of the latter was the decision to examine the relevance for sexual offenders of intimacy deficits after these problems had been incorporated into the treatment of various other disorders. Approaches to the assessment and treatment of sexual offenders over the past several years attempted to maintain an empirical basis so that, as new information emerges, programs can be adjusted accordingly.

The first concern clinicians should have when planning assessment is to determine the domains that need to be assessed. Once the targets of assessment have been identified, a search can be made for the best measures of each target.

Measures relevant to treatment

Several instruments have been developed to measure the principal issues in the treatment of sexual offenders. Table 17.1 presents a list of the principal issues and some of the measures used to assess them.

..

TABLE 17.1 Measures relevant to treatment

.
Issues Measures Authors
.
Cognitive Distortions Abel's Child Molester Cognitions Scale Abel et al., 1989
Molest Scale Bumby, 1996
Rape Scale Bumby, 1996
Rape Myth Acceptance Scale Burt, 1980
Hostility Toward Women Scale Check, 1984
.
Empathy Empathy for Children Hanson & Scott, 1995
Empathy for Women Hanson & Scott, 1995
Child Molester Empathy Measure Fernandez et al., 1999
Rapist Empathy Measure Fernandez & Marshall, 1999
Interpersonal Reactivity Test Davis, 1983
.
Social Functioning Social Self-esteem Inventory Lawson et al., 1979
Problem solving D'Zurilla & Goldfried, 1971
Social Support Inventory Flannery & Wieman, 1989
. Assertiveness Social Response Inventory Keltner et al., 1981
Rathus Assertiveness Scale Rathus, 1973
. Anger Buss-Durkee Hostility Inventory Buss & Durkee, 1957
State-Trait Anger Expression Inventory Spielberger, 1988
. Anxiety State-Trait Anxiety Inventory Spielberger et al., 1970
Fear of Negative Evaluations Scale Watson & Friend, 1969
Social Avoidance and Distress Scale Watson & Friend, 1969
. Relationships UCLA Loneliness Scale Russell et al., 1980
Miller's Social Intimacy Scale Miller & Lefcourt, 1982
.
Sexual Interest Clarke Sexual History Questionnaire Langevin, 1983
Multiphasic Sexual Inventory Nichols & Molinder, 1984
Laws Card Sort Laws, 1986
Wilson Sex Fantasy Questionnaire Wilson, 1978
.
Psychopathy Psychopathy Checklist-Revised Hare, 1991
.
Relapse Prevention Self-monitoring Procedure McDonald & Pithers, 1989
STEP Measures of Offence Chain Beckett et al., 1994
Situational Competency Test Miner et al., 1989
Coping Inventory for Stressful Situations Endler & Parker, 1990
Sex as a Coping Strategy Cortoni & Marshall, 1996
.
Recidivism Level of Service Inventory-Revised Andrews & Bonta, 1995
Violence Risk Assessment Guide Harris et al., 1993
Minnesota Sex Offender Screening Tool Epperson et al., 1995
Rapid Risk Assessment for Sexual Offence Recidivism Hanson, 1997
.
Social Desirability Marlow-Crowne Social Desirability Scale Crowne & Marlow, 1960
Paulhaus Balanced Inventory of Desirable Responding Paulhaus, 1991
.

 

TREATMENT

Conceptual model

The first thing to note about treatment for sexual offenders is that group therapy is the chosen approach (Hall, 1995). Borduin, Henggeler, Blaske, and Stein (1990) have shown that group treatment is far more effective than individual one-on-one therapy for sexual offenders. However, the recidivism rate for the individual therapy in this study was high (75%), and consequently, we should treat the findings with some scepticism. Nevertheless, there can be no doubt about the superior efficiency of group therapy, allowing, as it does, the possibility of treating far more clients in the same amount of time.

Responsivity

Setting

Although some writers suggest that treating an offender in the community is superior to treating him in prison, there seems no reason to force a choice between settings. The National Strategy described by Williams, Marcoux-Galarneau, Malcolm, Motiuk, Deurloo, Holden, and Smiley (1996) involves a continuum of services that are initiated during the incarceration phase at an intensity level commensurate with risk and needs, and continues into the community as less intensive, but equally important, maintenance. It seems reasonable to provide the most intensive phase of treatment while the offender is incarcerated, and rein-force what he has already learned once he is reintegrated into the larger community. This strategy also provides more structured maintenance treatment for sexual offenders at higher risk on release, and may involve placement in a supervised halfway house.

A relatively small number of sexual offenders are considered intellectually challenged, while others have identifiable psychiatric disorders such as schizophrenia and depression. Some have also been diagnosed as learning disabled. Among the lower risk sexual offenders, the aging process may be accompanied by memory deficits, language problems related to stroke, and an over-all decrement in the ability to learn and retain new information. These deficits require a slower, more concrete, and simpler approach to the material covered in treatment. Boer et al. (1995) describe a program that presents information and role-plays in a manner consistent with these responsivity-based difficulties. In Canada's Atlantic Region, the Challenge Program allows sexual offenders with similar learning difficulties to assimilate information at a more comfortable pace.

Contraindications

Most programs exclude offenders who are suffering from an acute psychiatric disorder because they are unlikely to gain from treatment and are a disruptive influence. However, as soon as the illness can be managed effectively (e.g., via medication), such sexual offenders should be permitted to join a suitable treatment program. Their offence chain should incorporate those idiosyncratic internal or external stimuli which may be part of the relapse process.

For all sexual offenders, management difficulties may arise in the course of treatment. These may include refusal to participate, breaking confidentiality, or disruptiveness during groups. All efforts should be made to engage the offender in the treatment process, but if individual counselling, peer confrontation, or, as a last resort, behavioural contracting, is ineffective, the group needs should take precedence over the individual. Removal from therapy may be necessary in persistently disruptive or otherwise problematic cases. Some programs adopt the tactic of removing clients from a group context and offering individual treatment to reduce the threat, or fear, of discussing issues before a large audience. However, there is no evidence that individual therapy is conducive to changes in sexual offenders, and providing the option of one-on-one treatment may discourage the offender from discussing critical issues in group sessions.

Denial, or lack of motivation, may be exclusionary criteria. However, the CSC's Standards and Guidelines for Provision of Services to Sex Offenders (Williams et al., 1996) states that denial should be considered a treatment target. Motivation can be enhanced and denial issues can be dealt with as part of the cognitive distortions component. Development of a therapeutic alliance can also reduce the degree of denial. In any case, there is evidence (Hanson & Bussière, 1998) that denial does not increase risk to reoffend sexually.

Program timing

There is some debate regarding the best time to provide sexual offender treatment programs. Some suggest treatment should occur just prior to release into the community. Others suggest that treatment should occur at the earliest opportunity in order to capitalize on motivation and on a more vivid recollection of the offence and its impact on all those affected by it. Often the timing of treatment is related to availability of treatment services. By matching risk and need to treatment intensity, resources can be directed to the programs serving the largest populations. Because high intensity programs are expensive, lengthy, and cover numerous modules, the waiting list tends to be long. Extreme care must be taken to identify those clients whose risk and needs best match high intensity treatment. However, some effort should be made to deal with the problem of offenders who have very long sentences and are unlikely to enter a fully-fledged program for several years.

Program sequencing

Programs which target thinking styles, impulsivity, educational upgrading, employment skills, alcohol and drug abuse, as well as family violence, could be provided while the higher risk sexual offender is awaiting specialized treatment. These programs could prepare the offender by addressing general therapeutic issues such as group processes, confidentiality, trust, openness, and by exposing offenders to specific strategies such as video-taping. Introduction to learning principles such as competing behaviours, immediacy of reinforcement, generalization, and cognitive mediators can be transferred from one treatment pro-gram to another, and should reduce the time required to address these issues early in the group process. However, for moderate and lower risk offenders, access to adjunct programs should not take priority over specialized sexual offender treatment.

Special applications

Women make up a very small percentage of the total population of sexual offenders under federal jurisdiction in Canada (0.3%), and they recidivate at a low rate (3.8% over 6 years). A recent study by Kleinknecht, Williams, and Nicholaichuk (1999) identified only 70 convicted women sexual offenders who had served federal sentences between 1972 and 1998. However, there has been an increase in this population over these three decades. Over the past decade, a broader definition of sexual assault (any form of non-consensual sexual contact) has resulted in increased prosecution of women.

Atkinson (1995) suggests that the assessment of women sexual offenders can utilize self-report, collateral sources, and psychological tests, as well as actuarial tools for predicting general recidivism and violence. However, the use of measures with women that have been standardized on men, is a questionable practice. Women sexual offenders are more likely than men offenders to be co-perpetrators, and are most likely to offend against young girls within their own family (Mathews, Mathews, & Speltz, 1993; McCarty, 1986; Syed & Williams, 1996), which typically describes motivational as opposed to offence-based characteristics.

Kleinknecht et al. (1999), surveying all women offenders incarcerated since 1972, found that their primary characteristics were consistent with those of women offenders in general. They had little education, minimal or no employment history, and patterns of alcohol or drug abuse. The majority described childhood and adult histories of being emotionally, physically, and sexually abused. Many had diminished self-esteem, assertiveness deficits, relationship problems, and mental health concerns, such as depression, post-traumatic stress disorder, and eating disorders. Of those who had a criminal history, most involved acquisitive, drug-related, or prostitution offences.

For repeat offenders whose assault history involved extra-familial children or adults, and who describe deviant fantasies, treatment with women offenders should focus on fantasy control and victim awareness, as well as enhancing self-esteem, social skills, and anger or impulse management. However, in many cases, the primary focus of intervention will be mental health issues, educational upgrading, employment skills, family violence and substance abuse. Determining the chain of behaviours culminating in sexual offending is essential since it allows the offender to intervene more adaptively prior to the occurrence of a relapse. At this time, the number of women sexual offenders in any single location is extremely low, and this makes it difficult to establish group therapy. As a result, when specific sexual offender treatment is provided for women, it is likely to be individualized.

Aboriginal sexual offenders comprise 12% of federal admissions, 19% of provincial admissions, but only 2.5% of the Canadian population. In 1996, the Offender Management System identified 17% of federal sexual offenders as Aboriginal, with the largest number in the Prairie Region.

From 1995 to 1997, the Aboriginal Advisory Committee, from CSC, and the National Committee on Sex Offender Strategy agreed that treatment should be Aboriginal-specific, as mandated by law (Correctional and Conditional Release Act, Section 81). Programs for these offenders attempt to provide a cognitive behavioural approach within a spiritually appropriate context. This involves the use of spiritual Elders and Aboriginal facilitators whenever possible. Specific issues, such as residential school experiences, parental abandonment, and alcohol abuse are given additional weight. In the programs described by Buller (1997), and Ellerby and Stonechild (1998), healing through the use of teachings, rituals, and ceremonies are given equal weight to modules which are an integral aspect of “Western” treatment: victim awareness, development of communication skills, anger/emotion management, control of deviant arousal and fantasy, and relapse prevention strategies. The acceptance and retention rates for these programs have been high and feedback has generally been positive. Preliminary data suggest that Aboriginal sexual offenders who complete this form of treatment have similar recidivism rates to non-Aboriginal sexual offenders.

TREATMENT FEATURES

Therapist requirements

The only evidence currently available on the influence of therapist features in the treatment of sexual offenders comes from two studies by Beech and his colleagues in England (Beech, 1999; Beech & Fordham, 1997). They found, in both community and prison programs, that therapists who treated clients with respect, challenged supportively, and displayed empathy toward clients, generated far greater behavioural change than did more authoritarian, confrontative, and unempathic therapists. The importance of therapist characteristics or style has been neglected, yet it is a seemingly important feature of sexual offender treatment that needs to be addressed. A joint project between the English Prison Service and Canadian researchers is underway to examine the influence of both therapists' behaviours and offenders' responsivity in the effectiveness of treatment with sexual offenders (Marshall et al. 1999). To date, this study has demonstrated that a number of therapist features can be reliably identified (Mulloy, Serran, & Marshall, 1999), and that these are related to beneficial changes in the clients' targeted behaviours, thoughts, and feelings (Fernandez et al., 1999).

It is important to note that the standard for treatment providers is necessarily linked to the manner in which treatment programs operate. Viewing treatment as a set of psycho-educational components, where the operation of each component is specified in detail and must be followed rigorously, lends itself more readily to the provision of treatment by personnel with limited qualifications rather better than does a more process-oriented way of delivering treatment. The latter requires more therapeutic skill and greater basic psychological knowledge, particularly about group processes, than can be expected of prison officers even with specialized training.

Mode of delivery

Most treatment programs for sexual offenders in North America, Great Britain, Australia, and New Zealand are based on a cognitive behavioural model incorporating relapse prevention strategies. These models lend themselves to the specification of treatment procedures. Indeed, the advent of behavioural therapy (which was the precursor of cognitive behavioural treatment) was characterized both by a rejection of all that was identified with traditional psychotherapy and a determination to be scientific. This latter feature led to an effort to specify procedures and a corresponding, although in retrospect an unfortunate, rejection of concern for process (i.e., the way in which treatment is delivered, including the skills of the therapist and the effective engagement of the clients). It is only in recent years that concerns about process variables and their influence has been given any attention in the cognitive behavioural literature (Schaap, Bennun, Schindler, & Hoogduin, 1993).

Decisions about how important process is to treatment effectiveness have direct effects on decisions about the mode of treatment delivery. Viewing treatment as psycho-educational is not necessarily identical with adopting a cognitive behavioural model, although it does all but exclude adopting a more process-oriented approach. Therapy can be cognitive behavioural and procedures can be broadly specified while still allowing for an emphasis on process. A psycho-educational component approach not only constrains the influence of therapist characteristics and group processes, it also limits the full and active participation of the clients and restricts the possibility of running open or rolling groups.

Open groups allow clients to complete the program at their own pace so that when one finishes, another replaces him. This means that these groups are composed, at any one point in time, of clients who may be at different stages of treatment. This essentially excludes the possibility of operating a program as a set of psycho-educational components, and requires the therapist to focus more on the process of treatment delivery and behaviour change in the clients. There are virtues to this way of providing treatment. For example, waiting lists are more flexible and accommodation can be made for clients who need to be immediately included in treatment. Also, the more senior participants in such an open group can assist the newer clients since they have already dealt with the earlier issues. This helps the therapists judge the degree to which these senior members have truly assimilated the earlier issues. Finally, open groups allow each client to continue in treatment until he has achieved all his treatment goals. However, not all therapists are comfortable with the looser structure of open groups and, at the moment, there is no evidence available on which to choose between open and closed groups. In addition, open groups do allow the possibility that clients will spend far too much time in treatment, thereby wasting resources. Some therapists find it hard to discharge clients from open groups until they feel certain the client has become almost perfect on each issue of importance. This, combined with a client's reluctance to leave the group, can easily lead to a very low turnover of clients that is, again, a waste of resources.

Closed groups, where clients start at the same time, go through the same components together, and finish at the same time, lend themselves far better to a psycho-educational approach that is guided by a detailed treatment manual. This clearly reduces therapist uncertainty, guarantees uniformity across settings, and may make some clients feel more comfortable. Furthermore, all clients necessarily finish within a reasonable time frame, although any-one deemed to need more treatment must be recycled through the program. The disadvantages to closed groups are essentially the reciprocals of the advantages to open groups.

There are three dimensions on which group therapy for sexual offenders may vary: it may be psycho-educational or more psychotherapeutic in approach; it may involve discrete components that are procedurally specified in detail, or it may simply set targets and be more process-oriented; and groups may be open or closed. Presently we have no evidence that would allow us to decide between these alternatives, so it seems therapist preference should be the deciding factor.

Level of treatment

It would be both pointless and a waste of resources to provide the same level of treatment to all sexual offenders. Although this seems obvious, CSC is among the few systems that actually adjusts the intensity and extensiveness of treatment to the level of need among its clients. CSC quite sensibly attempts to match treatment needs with differing intensities of treatment. In order to meet the needs of a heterogeneous population of sexual offenders, Williams et al. (1996) developed a National Strategy for Canadian sexual offenders under the jurisdiction of the Correctional Service of Canada. This strategy uses a specialized sexual offender assessment in con-junction with the offender intake assessment to determine the risk, need, and responsivity factors for each sexual offender. Thorough evaluations permit the identification of three levels of need: high, moderate, and low.

High needs offenders need more time to reach acceptable levels of functioning for each of the targets of treatment, and they will almost certainly need programming additional to sexual offender specific treatment (e.g., cognitive skills, living without violence, substance abuse). Moderate needs offenders require somewhat less time in a less intensive sexual offender program, and may be accommodated in lower security level institutions. They should also need fewer additional programs. Low needs offenders require less intensive sexual offender treatment and minimal additional programs.

To prepare all incarcerated sexual offenders for treatment, and to facilitate placement in security levels optimal for their treatment, it is appropriate to provide preparatory treatment at the Induction Centre. Since January 1997, it is available in the Ontario Regional Induction Centre (Millhaven Institution), and has allowed most low needs offenders to be placed in minimum-security institutions; and offenders with high-moderate needs to be placed in a medium security prison where their needs can best be met.

Related to the issue of determining the intensity of treatment for the various offenders is the decision about what constitutes optimal weekly involvement in treatment. According to Williams et al., high need offenders should be in treatment for 6-8 months, and should attend five 3-hour sessions per week. It should be noted that there is no evidence to assist us here, but it would seem that such a schedule might be counterproductive. Involvement in treatment by offenders and therapists is an emotionally rigorous endeavour that would seem to suggest that by the fourth, and certainly by the fifth, session of the week, both might be at best emotionally tired, and at worst, exhausted. Indeed, if they are not, then treatment may not be initiating the emotional responses thought to be necessary to entrench, at a deeper than superficial level, the desired changes in attitudes, beliefs, perceptions, and behaviours. Treatment may, therefore, be more effective if limited to three 3-hour sessions per week. This, of course, may require more extended treatment, although it should be possible to reach acceptable levels of change within 6-8 months for the high needs offenders. For the moderate needs offenders, Williams et al. recommend 4-5 months at 10-hours per week. Again, there is no evidence to guide us, but experience at Bath Institution, in Ontario, suggests that two 3-hour sessions per week for four months should produce satisfactory gains. For the low needs offenders, William et al. suggest 8-12 weeks at 5 hours per week; this seems satisfactory. These suggested requirements refer only to the sexual offender-specific programs. Sexual offenders, as we noted, should be involved in other programs to address the other problematic features of their behaviour.

Timing of treatment

Many sexual offenders, upon completion of their required treatment programs, wait several months, and sometimes years, before they are deemed ready for release. This means that most high and moderate need offenders, at least, will remain in prison for some time after satisfactory completion of a treatment program. For some, this results in being recycled through the same, or a similar, program. For high needs offenders, this should involve them cascading to a moderate needs program at a lower security level, while the moderate needs offenders should move to minimum security. Maintenance programs (often falsely described as “relapse prevention programs”) can meet the needs of those offenders who have completed treatment, but who either can-not be transferred to the next level or who need just a maintenance program. These maintenance programs should aim at improving those areas that the previous program report indicated need enhancing, as well as refining relapse prevention plans and detailing release plans. Williams et al. indicate that biweekly 3-hour sessions should suffice, with offenders remaining in treatment until it is evident that there is no further gain.

TREATMENT TARGETS

Williams et al. (1996), and Hanson and Harris (1998) have described a number of targets that should be addressed in a comprehensive sexual offender treatment program. These include: cognitive distortions, empathy and awareness of victim harm, social functioning and relationship issues, deviant sexual preferences, as well as knowledge of the chain of events culminating in offending behaviours and methods for effective prevention of risk. This latter component is referred to as “relapse prevention” (Laws, 1989). Marshall et al. (1999) have distinguished what they call “offence-specific” treatment targets from what are called “offence-related” targets. The latter include, but are not restricted to, anger management, substance abuse, cognitive skills, and conflict resolution. The offence-related targets are identified at initial assessment on an individual basis and offenders are referred to appropriate programs. These offence-related problems are important, but since programs provided by CSC are dealing with them, it is not necessary to include them in the sexual offender programs.

Cognitive distortions

Cognitive distortions involve attitudes, beliefs, and perceptions that are considered to be important underpinnings of deviant sexual behaviour and are, therefore, reasonable treatment targets (Ward et al. 1997). Hanson and Harris (1998) have reported that stable attitudes which justify sexual crimes are predictive of sexual recidivism (r = 0.37). Others have found that acceptance of interpersonal violence, sexual conservatism, and hostility toward women are related to the enactment of violence (Malamuth, Heavey, & Linz, 1993; Marshall & Hambley, 1996).

Initially each offender is required to provide a disclosure of his offence(s), detailing the chain of events, and his thoughts and feelings that led to the offence, as well as the actual offending behaviours. The therapist questions the offender to extract more details, and provides a model for the other group participants to challenge, in a firm but supportive manner, the evident distortions. Therapists should have in their possession official documentation of the crime so that they can effectively challenge the offender.

Empathy training

Marshall and Fernandez (2000), and Pithers (1994) have described the typical procedures used to enhance empathy in sexual offenders. The aim here is to sensitize offenders to the harm they have done. The evidence suggests that most sexual offenders are not generally unempathic, but rather, withhold empathy for their victim. Accordingly, treatment initially assists them to come to an understanding of the harm that typically befalls victims of sexual abuse, and then attempts to transfer this to their specific victim. Provision of didactic materials, such as films or videos of victims (real or enacted) recounting their distress and problems, or victim impact statements, encourages the acceptance of more accurate perceptions of harm. Having each offender either describe the harm his victim has suffered can follow this or by having him write a hypothetical letter from the victim to himself outlining how he/she feels. Rewriting this letter until the group is satisfied that it is a reasonably accurate reflection of the probable harm typically serves to sensitize the offender to the damage he has done. He may then be required to write a hypothetical response to the victim indicating that he is taking responsibility for the offence, apologizing for the abuse, and acknowledging the victim's pain.

Social functioning

Relationship skills, self-confidence, assertiveness, and empathy deficits are considered to be criminogenic factors because they influence the offender's ability to initiate and maintain the prosocial relationships necessary to overcome the isolation, loneliness, and maladaptive relationships that may impel a sexual offender to abuse a victim (Marshall, Anderson, & Fernandez, 1999).

Marshall, Bryce, Hudson, Ward, and Moth (1996) have described procedures for enhancing intimacy skills and reducing emotional loneliness. Issues such as assertiveness, communication, attitudes toward others, jealousy, human sexuality, and dealing with being alone, are targeted within a group discussion format and, where necessary, role-playing is employed. Marshall et al. (1996) demonstrated that these procedures were effective in achieving the goals of providing sexual offenders with the skills necessary to meet their intimacy needs in prosocial settings.

Similarly, various tactics are employed to increase self-confidence. The context within which therapy is conducted with sexual offenders appears to influence their self-esteem. Educational upgrading, increased social contacts, and scheduled pleasurable activities have been shown to increase self-esteem (Marshall, Anderson, & Champagne, 1996). However, specific procedures individually tailored for each offender are also important in enhancing a sense of self-worth. It is important to note that increasing self-esteem facilitates changes in all other targets of treatment (Marshall et al., 1997), including the reduction of deviant sexual preferences (Marshall, 1997).

Deviant sexual preferences

Deviant sexual preferences are generally associated with increased risk of recidivism (Hanson & Harris, 1998). Because of this association, deviant arousal is considered a criminogenic factor.

Electric aversive conditioning, although very popular in the 1970s and still utilized in some programs, has been abandoned by most clinicians. Quinsey and Earls (1990) expressed some puzzlement at this, since they considered there was no empirical reason for foregoing electric aversion. However, there are significant practical and ethical problems with its use, and this seems to have been the driving factor. Olfactory aversion, on the other hand, continues to be used, although not apparently by many practitioners. It involves pairing a noxious odour with the deviant fantasy. There is some controversy about how well these procedures generalize to the real world and how appropriate fantasies can be maintained. It should be stressed that these techniques are only one facet of a comprehensive treatment program focussing on cognitive restructuring, skills enhancement, and relapse prevention strategies. Covert sensitization associates erotic images or fantasies with aversive thoughts or consequences.

Masturbatory reconditioning requires the client to substitute appropriate sexual fantasies in place of deviant thoughts during masturbation to orgasm. Satiation involves repeated rehearsal of deviant images during the post-orgasmic refractory period until decreases are achieved in arousal to the sexually deviant stimuli.

In addition to the behavioural methods outlined above, various medications have been effectively employed to increase control over deviant tendencies. However, this should not be seen as effective treatment on their own, but rather as adjunctive treatments to comprehensive cognitive behavioural programs.

Relapse prevention

Relapse prevention is the overarching framework for most sexual offender treatment programs. It not only places responsibility for offending behaviour squarely on the offender's shoulders, it also situates offending behaviour as the last link in a chain of behaviours, some of which may appear to be innocuous (Pithers, 1990). This chain may involve poor choices as well as some behaviour that Ward (1999) has described as “automatic”. Helping the offender to identify the choices that lead to offending behaviour can produce a set of more adaptive and prosocial methods of coping with what are described as high-risk situations.

In addition, a variety of risk factors (e.g., depressive mood, relationship problems, use of intoxicants) and risky situations that might facilitate a return to offending are identified. For each of these risk factors, the offender is required to list plans to avoid them or deal with them should they arise. Offenders are warned that they must be vigilant upon release back into the community if they are to avoid reoffending. These relapse prevention plans are meant to assist this process, as are a set of warning signs generated by the offenders that include both internal and external features of his behaviour that suggest he is moving back to patterns of behaviour that precede offending.

TREATMENT EFFECTIVENESS

There are several aspects to determining the value of treatment, although the typical approach with sexual offenders has been to look at reductions in post-discharge recidivism. While this latter index is critical, even if recidivism is significantly reduced, a treatment program would be of little value if either few candidates entered treatment, or most withdrew or remained but were non-compliant. Thus, treatment refusals, dropouts, or failure to effectively comply are relevant indices of the utility of a treatment program. These variables can all be considered to be features of treatment participation.

Participation

Abel, Mittleman, Becker, Rathner, and Rouleau (1988) reported that 34.9% of their clients had dropped out by the third week of treatment. One of the primary reasons for this high rate of dropouts was the lack of any leverage to pressure them to remain in treatment. The leverage CSC clients' experience (i.e., less likelihood of parole for failure to effectively participate) may therefore account for the relatively low dropout rate in CSC programs. They also noted that the majority of those who dropped out of treatment were at greater risk to reoffend. California's evaluation program (Marques, 19984) has high refusal rates. Oddly enough, the outcome evaluations revealed that refusers are only marginally, if at all, more likely to recidivate than those who volunteer for treatment.

Sexual offenders in Canadian penitentiaries are well aware that refusal to enter, or withdrawal, from treatment are both likely to result in parole denial. Not surprisingly, a relatively small number of sexual offenders within the Correctional Service of Canada institutions refuse an offer of treatment, withdraw from a program, or fail to meet reasonable level of treatment compliance.

TREATMENT OUTCOME

There are two aspects to outcome evaluations. The first concerns an evaluation of whether or not participants meet the goals of treatment. This is assessed by evaluating changes from pre- to post-treatment on measures that assess functioning on each of the targets (or components) of treatment. If a treatment pro-gram aims at increasing self-esteem, correcting cognitive distortions, enhancing empathy, improving social and relationship skills, eliminating deviant sexual preferences, and generating clear offence chains and relapse prevention plans, then measures of these targets must demonstrate change. While this is obviously true for individual participants, it must also be shown that the overall program reaches its goals.

Treatment providers must first demonstrate that the procedures and processes they use typically generate the anticipated changes, otherwise it is unfair to hold any individual offender responsible for not having reached the expected goals. A series of studies have demonstrated that the procedures outlined above pro-duce the desired changes in self-esteem, empathy, denial, minimization, loneliness and intimacy. On the other hand, several reviews have come to rather gloomy conclusions about the general effectiveness of procedures aimed at reducing deviant sexual preferences. However, there are tentative reports suggesting that deviant preferences may be changed as a result of other features of an overall program without actually targeting the preferences themselves (Marshall, 1997). These reports, however, need replication before any firm conclusions can be made.

Recidivism studies

One of the problems that beset those who attempt to evaluate treatment effectiveness is the low base rate of reoffending among untreated sexual offenders. As Barbaree (1997) points out, this low base rate increases the probability that we may falsely reject the hypothesis that treatment has beneficial effects, simply because we do not have the statistical power to discern real effects. Quinsey and his colleagues (1993), on the other hand, have expressed concern that we may too hastily conclude that treatment is effective when in fact properly designed studies may subsequently reveal no effects for treatment. To date, no resolution has been reached on the best way to deal with these problems.

One possible solution to the low base rate problem, might be to count the number of victims resulting from reoffences rather than just recidivism. Marshall and Barbaree (1988), for example, found that on average sexual reoffenders abuse two victims each. Counting victims as the index of failure, then, would double the base rate over simple recidivism thereby giving more room to demonstrate reductions due to treatment. The number of victims is also a more socially meaningful index since reducing the number of innocent people victimized by sexual offenders is presumably the real goal of treatment.

Quinsey et al.'s declaration that it is only a random-design study that can demonstrate the effectiveness or otherwise of treatment for sexual offenders fits with his concern that we do not overestimate the value of treatment. However, this design requires that we randomly allocate those sexual offenders who wish to enter treatment to either a treatment or a no-treatment condition. As Marshall (1993), and Marshall and Pithers (1994) point out, when parole is contingent upon satisfactory treatment completion (as is the case for sexual offenders in CSC institutions), no sensible sexual offender would volunteer for such a study. This is not to deny the value of the ideal treatment study; it is simply to note the practical restrictions on implementing such a study within CSC.

On the other hand, Canada is one of the few places in the world where outcome studies with sexual offenders can be con-ducted, because our national database (Canadian Police Information Centre) identifies all persons who have been charged or convicted of criminal offences. There are few other countries in the world where researchers can access such accurate and comprehensive recidivism data (England and New Zealand appear to have similar databases). Because of the difficulties in the United States in accessing information on recidivism that occurs outside the state boundaries of each treatment program, most, if not all, treatment outcome studies are flawed. In all studies from the United States reported to date, the recidivism data are almost certainly incomplete. For example, in Marques' (1998, personal communication) most recent report of her outcome evaluation of the treatment of sexual offenders selected from California prisons, only 6% of those rapists who refused treatment were identified as recidivating. In light of recidivism data from other countries, including Canada, this seems to be an absurdly low base rate. Accordingly, we cannot know whether the resultant data reported for the treated and untreated volunteer groups are accurate reflections of the true differences between these groups.

As a result of these various problems with treatment outcome studies, we have chosen to report data from studies in Canada plus one from New Zealand. Table 17.2 describes the comparative recidivism from these studies. We have chosen only the studies that report a reasonably well-matched comparison group of untreated sexual offenders where differences between treated and untreated subjects have been statistically evaluated. Those reports listed as having negative outcomes found no significant benefits for treatment, while those listed as having positive outcomes reported statistically significant benefits for treatment. In all cases, it should be noted, the comparison untreated groups are simply convenience groups. For example, in the Kingston Sexual Behaviour Clinic's (KSBC) outpatient program study, the untreated offenders were those who admitted their offences and sought treatment, but live too far away from KSBC to regularly attend treatment. For the prison-based programs, the convenience samples are untreated sexual offenders extracted from archival records and then matched to the treated sample on offence history and demographic variables. This use of convenience samples does detract from the methodological elegance of the studies but, given the practical limitations previously noted in doing ideal studies, we think they provide the best basis for deciding whether or not treatment is effective. In this respect, we leave it to the reader to come to his/her own conclusions about whether treatment for sexual offenders is effective by studying the data in Table 17.2 or by reading the reports in their original form.

TABLE 17.2 Treatment outcome studies
.
 
Treated*
Untreated
.
A. Studies with negative findings
. Rice et al., 1991
38
31
. Hanson et al., 1993
44
38
. Marques (personal communication, March 1998)
. Rapists (volunteers)
11
18
. Rapists (non volunteers)
6
. Child molesters (volunteers)
11
13
. Child molesters (non volunteers)
15
.
B. Studies with positive findings
. Marshall & Barbaree, 1988**
. Child molesters
. women victims
18
43
. men victims
13
43
. incest offenders
8
22
. Looman et al. 1998
.. Pre-1989 (most serious offenders)
28
52
. Post-1989 (least serious offenders)
7
25
. Nicholaichuk et al., 1998
. Rapists
14
42
. Child molesters
18
62
. Bakker et al., 1998
. Child molesters
8
21
. Proulx et al., 1998
. Child molesters
6
33
. Rapists
39
71
.
*
All figures are sexual offence recidivism rates rounded to the nearest whole number.
** All data for the Marshall studies are derived from unofficial and official records combined.
. . . . .
.
..

As the reader will note from Table 17.2, there are reports of treatment failure, although they are outnumbered by reports of treatment success. Marshall, Anderson, and Fernandez (1999) offer detailed analyses of what they view as serious limitations in those programs that failed to produce treatment benefits. It is worth noting that, to date, most reviewers have concerned themselves primarily with considerations about features of the client population as well as treatment content, duration and intensity when trying to explain why some programs are effective and others are not. Therapist characteristics or style, therapist-client relationships, and the client's participation in the treatment process, have all but been ignored as potential influences on the effectiveness of treatment with sexual offenders. These are, however, potentially important issues that urgently need research attention.

It is somewhat incomplete to determine the benefits of treatment solely in terms of reducing future victimization. This, of course, ought to be our main concern, but we also have to be fiscally responsible; that is, it may be possible to provide effective treatment, but the cost may be beyond society's willingness to pay for such benefits. This may be particularly so if reductions in recidivism are statistically significant but not remarkable.

While overall the presently available data may not convincingly demonstrate to all readers the benefits of treating sexual offenders, we are inclined to believe that, at the very least, they encourage optimism about the value of treatment.


1 Queen's University, Department of Psychology

2 Correctional Service of Canada


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