Given the rising concern about the problem of sexual violence, increased attention has been given to the evaluation of existing treatment interventions and the exploration of new treatment models that aim to prevent or reduce future sexual violence. Because the rehabilitation of sex offenders might curb future sex offending and thus enhance overall public safety, the importance of research that examines the efficacy of sex offender treatment interventions cannot be overstated. To date, the majority of research has been directed at examining whether suitable treatment interventions exist, whether sex offenders are amenable to such treatment, and most important, whether such treatments “work.”
Numerous treatment models have been used to rehabilitate sex offenders. While some forms of treatment were developed specifically for use with sex offender populations, most have been adopted from the larger class of treatment techniques developed for use with wide-ranging clinical populations. Moreover, while some of these sex-offender-specific treatment approaches have received at least modest empirical support, others have only limited support or have not yet been subject to any form of systematic evaluation. Indeed, because of the many difficulties in evaluating treatment outcome with this population, considerable work remains with regard to understanding what works for whom and whether this treatment success actually translates into reductions in recidivism.
Sex Offender Treatment Models
The cognitive-behavioral therapy (CBT) approach, which involves an integration of both cognitive and behavioral therapy techniques, has been adapted for use with sexual offenders. The central tenet of CBT is essentially that our thoughts, behaviors, and emotions interact with one another in a cyclical manner, such that changing thoughts about a situation or event might change subsequent behaviors that ultimately change our emotions. Purely cognitive interventions used with sex offenders include cognitive restructuring, which is aimed at challenging rationalizations, minimizations, or other offense-supportive beliefs involved in the initiation or maintenance of sexual offending behavior. For example, a therapist using a cognitive restructuring technique might challenge an offender’s minimization that “no one was hurt,” by having the offender examine the veracity of such belief.
Behavioral approaches have also been used in the treatment of aberrant sexual behaviors. Behavioral therapies are premised on the idea that deviancy is a learned behavior that can be unlearned. Thus, inappropriate (or deviant) sexual desire might be reduced if associated with negative consequences, while appropriate sexual desire might be enhanced if paired with rewards or other positive consequences. Masturbatory satiation, for example, involves having an offender masturbate to deviant fantasies for an extended amount of time through the sexual refractory (i.e., postorgasm) period, with the idea that this unrewarded and perhaps aversive masturbatory experience will reduce or eliminate deviant arousal. Although procedures might vary, verbal satiation similarly aims to reduce deviant interest by having an offender repeat aloud deviant sexual fantasies during the postorgasm period. Aversion tech-niques similarly aim to reduce the deviant sexual response by pairing aversive stimuli (such as mild electric shock or foul odors) with deviant arousal. When the arousal is followed by a shock or other aversive stimuli, the resulting behavior (deviant arousal) is, again, expected to decrease. Just as behavioral strategies might be used to reduce deviant arousal, they are also used to reinforce or enhance “normal” sexual arousal. While there is some limited support for the use of these pure behavioral techniques, these approaches have generally fallen out of favor in preference of more integrative and comprehensive treatment interventions.
Cognitive-behavioral interventions thus combine elements of the pure cognitive and pure behavioral camps. Covert sensitization, for example, relies on the behavioral technique of pairing negative stimuli with deviant arousal, but instead of a physical stimulus uses an imaginal (or cognitive) negative stimulus. In a typical use of the technique, an offender might be asked to masturbate to a deviant fantasy, pairing with that fantasized act an imagined unpleasant negative consequence. For example, the offender might fantasize about committing a deviant offense but then interrupt that fantasy with a vivid and highly personalized negative consequence, such as the offender’s wife discovering the act and reporting it to the police.
Relapse prevention (RP), a model adopted from the substance abuse literature, aims to help sex offenders identify the emotional and situational precursors to sex offending. In emphasizing the importance of cognitive states and decisional processes, RP often employs a CBT framework. RP operates under the assumption that by identifying the emotional or contextual states that precede offending, an offender can intervene in the cycle and prevent a recidivistic sexual offense from occurring. RP might typically incorporate a wide range of treatment components, such as anger management, social skills training, empathy enhancement, or the aforementioned CBT techniques. Indeed, the general focus is on giving offenders the skills to manage their offending behavior once they return to the community. Thus, offenders learn their “offense cycles” and are taught how to use this knowledge to recognize high-risk situations, with the aim of preventing relapse (or re-offense). Although RP is one of the most widely used models for treating sexual offenders, there have been mixed findings with regard to its utility in reducing sexual recidivism. More research is needed to examine whether there is sufficient empirical support for the continued use of this model.
Because evidence suggests that the suppression of sexual drive will reduce sexual offending, there is general support for a combined psychological and pharmacological approach to treating sexual deviancy. Such pharmacological treatment (at times referred to as “chemical castration”) includes anti-androgens and hormonal agents that work to reduce sex drive, sexual arousal, and/or sexual fantasizing. These drug interventions, which diminish or alter testosterone levels, have been shown to be related to reduced rates of re-offending. Additionally, there has been support for the use of selective serotonin reuptake inhibitors (SSRIs) in reducing deviant sexual behavior. The class of SSRIs, which have generally been used in treating obsessive-compulsive tendencies, may have specific utility in reducing the intrusive or obsessive sexual thoughts often associated with sexual offending.
Finally, some mention of surgical castration deserves mention. Although rarely used, surgical castration involves the removal of the testes, which has the effect of reducing circulating levels of testosterone and thereby diminishing sexual drive. While some have expressed concern regarding the ethical merits of this form of intervention, surgical castration has been associated with reductions in sexual recidivism.
Risk, Need, and Responsivity
Some have maintained that treatment should be based on the principles of risk, need, and responsivity. Risk refers to the notion that treatment should be matched to the risk level (typically assessed through actuarially derived risk assessment tools such as the STATIC-99/STATIC-2002 or RRASOR) of the offender, with higher-intensity treatment services reserved for the highest risk offenders. The need principle distinguishes between criminogenic and noncriminogenic needs, with criminogenic needs referring to those factors that directly relate to recidivism, that is, those factors that have a direct relevance to reducing reoffending. Noncriminogenic factors include treatment needs that do not directly relate to re-offense risk but that may improve the overall adjustment or quality of life of the offender, which may thereby indirectly reduce sexual recidivism. Finally, the responsivity principle maintains that treatment interventions should be delivered in a way that is compatible with the ability, treatment readiness, or cognitive capacity of the offender. The strength of this risk, need, and responsivity model lies in its consideration of the heterogeneity of sexual offending. Indeed, this model advocates for the use of differential treatment strategies for offenders with varied criminogenic and noncriminogenic needs, thus renouncing a “one size fits all” approach to treatment.
Does Sex Offender Treatment Work?
Despite the early notion in the sex offender academic community that “nothing works,” recent research has been more optimistic with regard to the value of sex offender treatment. Indeed, recent evidence seems to suggest that there are small but important differences in the recidivism rates of offenders who do and do not receive sex-offender-specific treatment interventions. Indeed, researchers have found that sex offender treatment is effective in reducing both sexual and general recidivism.
A meta-analysis of sexual offender treatment outcome studies found that, on average, sex offenders who had completed treatment had a 12.3% sex offense recidivism rate compared with the 16.8% recidivism rate seen for offenders who did not complete treatment. In support of more recent (typically CBT) interventions, those who completed treatment demonstrated a sexual recidivism rate of 9.9%, while those who did not receive one of these newer interventions had a 17.4% recidivism rate. While more research may shed light on the particular strategies that work for particular types of offenders, one can reasonably conclude from the existing research that treatment does indeed reduce recidivism. Given this research evidence, some contend that effective treatment programs should target offenders who are deemed to be at highest risk to recidivate and, moreover, that best practices suggest that such programs must target the offender’s criminogenic needs and be based on a combined CBT and psychopharmacological model.
Critics charge, however, that the overwhelming majority of sex offender treatment studies use too weak a methodology to draw any firm conclusions. As a result of practical constraints and the many impediments to implementing sound research methodologies in criminal justice or treatment settings, treatment outcome studies typically fail to use rigorous research designs that use, for example, random assignment or lengthy follow-up periods. Sex offenders typically cannot be randomly assigned to treatment or no-treatment groups in these settings. Instead, researchers tend to examine differences between treated and untreated groups where assignment has been based on need, resulting in a selection bias. That is, offenders selected for treatment are typically different in important respects—either being viewed as amenable to treatment or more dangerous and, therefore, more in need of treatment. Thus, the groups being compared differ in risk level or motivation or other important respects that affect conclusions. Unfortunately, researchers are seldom able to use rigorous, tightly controlled designs, because they must do this research in real-world settings that allow for less sophisticated methodologies.
Moreover, there is often divergence with regard to what sort of outcome should be measured. While some studies might consider outcome very narrowly to include only sexual reconvictions, other studies consider outcome much more broadly, including for example, any arrests (even for nonsexual offenses), probation violations, and/or informal reports of re-offense. Some attention has also been given to the measurement of in-treatment change. Indeed, some research has examined pre- and posttreatment scores on dynamic variables related to sexual recidivism. Thus, treatment providers or researchers might focus on changes in attitudes tolerant of sexual offending or intimacy deficits as a function of treatment interventions. More research is needed to establish the direct relationship between these within-treatment gains and actual reductions in recidivism.
In sum, while meta-analytic research has generally supported the value of treatment for sex offenders, the research studies on which these meta-analyses were based have typically employed suboptimal methodological designs. Despite this, the weight of the research does show some support for cognitive-behavioral and psychopharmacological interventions. Thus, while there is room for optimism, especially with regard to certain techniques, firm conclusions about the utility of sex offender treatment await further research.
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