Treatment Of The Repetitive Sex Offenders Research Paper

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Designation of a specific subclass of sex offenders as ‘repetitive’ derives from sexual psychopath legislation that has sought, over the past half of the twentieth century, to confine sex offenders for indeterminate periods under civil commitment. In response to horrendous crimes committed by a few sex offenders recently released from prison, states passed a series of laws providing for the involuntary, civil commitment of individuals identified as ‘sexually dangerous persons,’ ‘sexual psychopaths,’ or ‘mentally disordered sex offenders.’ Thirty states passed such laws, but over time they fell into disuse or were successfully challenged in court and most were legislatively repealed. In 1990, however, a sex offender recently released from a prison in Washington state abducted, raped, and castrated a 7 year old boy. An outraged public demanded a response, and involuntary commitment was resurrected. The legality of the Washington statute, as well as other similar laws, were immediately challenged, and a Kansas statute, identical to Washington’s statute, reached the United States Supreme Court.

1. The Hendricks Era

The single most influential court decision in the decade of the 1990s has been Kansas vs. Hendricks, -U.S.-, 117 S. Ct. 2072 (1997). The Kansas statute established procedures for civil commitment of persons who, due to a ‘mental abnormality’ or a ‘personality disorder’ are likely to engage in ‘predatory acts of sexual violence.’ Kan. Stat. Ann. Sec. 59-29a01 1994; Kansas . Hendricks). The state invoked the Act for the first time to commit Leroy Hendricks, a 60 year old man with a long history of taking ‘indecent liberties’ with children, and who was scheduled for release from prison shortly after the Act became law.

Hendricks had a ‘serious mental disorder’ (pedophilia) that rendered him dangerous because of a ‘specific, serious, and highly unusual inability to control his actions’ (from Justice Breyer’s dissenting opinion) (Cornwell 1998, p. 397). The clear implication is that pedophiles are incapable of controlling their impulses to molest children. Indeed, in those instances where diagnostic criteria may be inferred, the predominant behavioral criterion for the old sexual psychopath statutes and the new sexual predator statutes involves some form of volitional impairment (i.e., an inability to control impulses to engage in acts of sexual aggression). Impaired impulse control is, at least in principle if not in reality, associated with ‘repetitive’ offenses. Thus, the ‘modal’ individual committed under these statutes is a repetitive or habitual sex offender. Importantly, the use of the word ‘repetitive’ in statutory lexicon tells us relatively little about the individual, clinically or dynamically. All offenders with multiple known sexual crimes may be classified as ‘repetitive,’ resulting in a highly heterogeneous group.

2. Treatment Of The Institutionalized Sex Offender

To improve the constitutional viability of civil commitment for ‘sexual predators,’ treatment had to be offered. The model for treating these ‘repetitive’ sex offenders is no different, however, from the model used to treat sex offenders not classified as predators or as repetitive. The cognitive-behavioral model is an adaptation of relapse prevention, and the many elaborations and revisions of this model have been the subject of considerable commentary (cf., Laws 1989, Schwartz and Cellini 1995, 1997; see Sex Offenders, Clinical Psychology of ). The rationale for the modification of any unwanted behavior stems from the informed consideration of those factors that are most importantly associated with the emergence and the sustenance of the behavior. From the ample research on addictive disorders, particularly alcoholism, smoking, and obesity, there has emerged a substantial literature on preventing relapse (Brownell et al. 1986). Relapse prevention, as a model, has been revised and adapted for use with sex offenders (cf. Laws 1989, Laws et al. 2000). Although sexual aggression derives from a substantially more complex amalgam of factors than most addictive disorders and typically reflects a chronic pattern of maladaptive behaviors, the underlying principles remain the same. That is, before designing strategies for modifying sexually aggressive behavior, we first must identify those factors that are most importantly related to the behavior (i.e., determinants of relapse). Although the factors discussed here are, by no means, inclusive, they do represent the core components of most contemporary treatment programs.

3. Core Elements Of Most Treatment Programs For Sex Offenders

3.1 Impaired Adult Relationships

Impaired relationships with adults reflect a broad dimension of social competence that is temporally stable and multiply determined. Although social skills training is one of the most frequently included components of treatment for sex offenders, its role in relation to sexual aggression remains unclear. Because there are many facets to social competence, specifying what aspect one is assessing is critical. For instance, although there is reasonable support for the conclusion that rapists have assertiveness problems, differences in other areas of social competence are less evident. Likewise some child molesters, such as ‘pedophiles,’ have a variety of social and interpersonal inadequacies.

Although the question of the etiologic importance of social competence remains uncertain, the inclusion of techniques to address social skills deficits is still clinically appropriate. In addition to social skills training, the modalities that are most often used to improve relationships with adults include assertiveness training, relaxation training, systematic desensitization, sex education, and self-esteem enhancement.

3.2 Lack Of Empathy

In all domains of interpersonal violence, a general lack of empathic relatedness for one’s victim can be regarded as a powerful disinhibitor. Alternatively, the presence of empathic concern may serve to inhibit aggression. There is a clear clinical rationale for assuming the presence of such deficits and targeting interventions to enhance empathy.

Hildebran and Pithers (1989) described the importance of developing empathy for all victims of sexual abuse as an essential first stage of treatment, followed by the development of empathy for one’s own victims. At this point most sex offender treatment programs include a separate component for increasing victim empathy. Indeed, Knopp et al. (1992) found in their survey of treatment programs in North America that 94 percent included victim empathy training. In addition to the standard exercises and tapes (video and audio) used in victim empathy training, expressive therapy may be used to increase the offender’s emotional or affective response to the distress of the victim. Some programs introduce victim advocates, victim counselors and occasionally victims to increase further the emotional impact. Moreover, increasing the offender’s affective appreciation of his own childhood experiences of victimisation can instill a greater awareness of his victim’s experience of abuse.

3.3 Degree And Nature Of Anger

The degree and nature of anger evidenced in the assault has long been assumed to differentiate between offenders who were—and those who were not—willing to use extreme force to gain victim compliance (cf. Prentky and Knight 1991). Sex offenders differ considerably in the nature and extent of their anger and the ways that anger manifests itself in their crimes. Sex offenders who intend only to force victim compliance are likely to vary widely in the amount of aggression evident in their offences. When the aggression clearly exceeds what was necessary to force victim compliance, the motivation and manifestation may also vary considerably. In some cases the anger may be undifferentiated with respect to victims (i.e., the offender may be globally angry and express his anger at any available target), and in other cases the offenders may be focally angry at women (i.e., misogynistic anger) and displace their anger at women in general or on specific groups of women (e.g., prostitutes or the elderly). Similarly, child molesters who intentionally inflict considerable physical injury on their victims may be focally angry at children.

The recognition of the critical importance of anger as a driving force in sexual offenses has resulted in the inclusion of treatment techniques to reduce and contain anger. The most commonly employed of these techniques is an anger management group which uses cognitive-behavioral strategies to increase self-control as well as the timely and appropriate expression of angry feelings. In addition, Relapse Prevention, which also focuses on increasing self-management skills, and Stress Management can assist the offender to gain control over chronic and situation ally-induced anger. Finally, early life experiences of victimization can fuel lifelong anger that is periodically triggered by real or imagined provocations. A group that focuses on childhood victimization can help the offender to master these traumatic events.

3.4 Cognitive Distortions

Cognitive distortions are ‘irrational’ ideas, thoughts, and attitudes that serve to: (a) perpetuate denial around sexually aggressive behavior, (b) foster the minimization and trivialization of the impact of sexually aggressive behavior on victims, and (c) justify and sustain further sexually aggressive behavior. Cognitive distortions are presumed to be learned attitudes that are instilled at an early age by caregivers, reinforced by peers during childhood and adolescence, and further strengthened in adulthood by the prevailing social climate.

The social and cultural forces that have been hypothesized to contribute to sexual violence include the permissive responses of a wide variety of social systems and institutions that function to perpetuate rape myths and misogynistic attitudes, the objectification and exploitation of children and women in pornography, and the often similar but more subtle messages conveyed in advertising that support, or at least condone, sexual harassment (cf. Stermac et al. 1990). The importance of cognitions in moderating sexual arousal has been repeatedly demonstrated. Moreover, clinical observations have suggested that many sexual offenders harbor offense-justifying attitudes and that these attitudes are importantly related to the maintenance of the ‘sexual assault cycle.’ Thus, the modification of irrational attitudes has been a major focus of treatment intervention. Although there are a variety of treatment modalities that may impact these distortions, the most commonly employed technique is cognitive restructuring. For cognitive restructuring to be most effective, it is critical that cognitive and affective components be addressed. That is, it is insufficient merely to confront the ‘distorted’ nature of the attitudes, to discuss the role that such distortions play for the individual, or to provide accurate information about sexual abuse (all cognitive components). It is equally important to create discomfort by focusing on the victim’s response (e.g., fright, pain, humiliation)—the affective component. This latter exercise is also integral to victim empathy training.

In addition to cognitive restructuring, a group that focuses on childhood victimization can also be very helpful. Since the origin of these distorted attitudes is often a primary caregiver who was an influential role model, as well as exposure to peer role models, often in institutional settings, a group that focuses on these early life experiences can help to trace the cognitions to their source, thereby challenging their generality and diminishing their ‘truth’ or their ‘reality.’

3.5 Sexual Fantasy And Deviant Sexual Arousal

Sexual fantasy refers to cognitive activity that focuses on thoughts and images having sexual content, and deviant sexual arousal refers to an arousal response that is prompted by thoughts, stimuli (visual or auditory), or behaviors that are defined as unconventional or antisocial by society. Studies investigating the relation of sexual fantasy to sexual aggression have typically employed plethysmography to assess sexual arousal to auditory and visual stimuli that purportedly tap specific sexual preferences. The guiding premise of these studies has been that deviant sexual fantasy is highly correlated with deviant sexual arousal and that both deviant fantasy and deviant arousal patterns are important precursors of deviant sexual behavior (cf. Prentky and Knight 1991).

The frequent targeting of such fantasies for therapeutic intervention reflects the widely held belief that the modification of deviant sexual fantasies and deviant sexual arousal patterns is critical for the successful treatment of sex offenders. Indeed, the presence of deviant sexual fantasies does appear to increase the likelihood of subsequent deviant sexual behavior. Moreover, the moderate success at increasing nondeviant arousal and behavior by applying techniques aimed solely at modifying arousal to deviant sexual fantasies supports the hypothesis that deviant fantasies not only lead to and maintain deviant sexual behavior but also impede normal sexual adaptation.

Behavioral techniques for modifying sexual arousal patterns are grouped into two categories, those that decrease deviant arousal (e.g., covert sensitization, aversion, masturbatory satiation) and those that increase appropriate arousal (systematic desensitization, fantasy modification and orgasmic reconditioning). Although numerous behavioral techniques have been reported in the literature, the most widely used method has involved some variant of aversive therapy.

In addition to the repertoire of behavioral interventions, somatic treatment has become increasingly popular as a complement to psychological treatment. These organic or drug treatments consist primarily of antiandrogens (e.g., Bradford 1989) and antidepressants (e.g., Kafka 1991). The antiandrogens (e.g., medroxyprogesterone acetate and cyproterone acetate) reduce sexual drive by reducing the level of testosterone. The antidepressants that are used are primarily the selective serotonin reuptake inhibitors, such as fluoxetine. Although the neuroregulation of sexual drive remains unclear, there is some evidence that enhanced central serotonin neurotransmission inhibits sexual arousal. In addition, there is clinical evidence that uncontrollable sexual urges and compulsive sexual behaviors are associated with dysthymia and major depression.

3.6 Antisocial Personality Lifestyle Impulsivity

In research on sexual offenders, impulsive, antisocial behavior has proven to be a critical risk factor for recidivism (e.g., Hall 1988, Prentky and Knight 1986). There is increasing evidence even within noncriminal samples (e.g., college students) that the likelihood of engaging in sexually aggressive behavior is greater among those who are more impulsive (Prentky and Knight 1991).

Clinicians have long recognised the importance of impulsivity for relapse and have introduced self-control and impulsivity management modules into treatment. In addition to groups that focus specifically on impulse control, most treatment programs include components of Relapse Prevention. Relapse Prevention begins by identifying the chain of events and emotions that lead to sexually aggressive behavior. Once this ‘assault cycle’ is described, two interventions are employed: (a) strategies that help the offender avoid high risk situations, and (b) strategies that minimize the likelihood that high risk situations, once encountered, will lead to relapse. This is an ‘internal self-management’ system (cf. Pithers 1990) that is designed to interrupt the seemingly inexorable chain of events that lead to an offense. Relapse Prevention is potentially helpful for interrupting patterns of behavior that eventuate in specific outcomes, such as sexual assault, as well as patterns of behavior that are more global, such as impulsive, antisocial behavior.

4. Conclusion

Given the failure of more traditional correctional remedies, such as deterrence and incapacitation, for reducing the level of sexual violence in society, other interventions must be actively sought. One potentially effective intervention for known offenders is treatment. The verdict as to the efficacy of treatment for sexual offenders will inevitably be a complex one that addresses: (a) optimal treatment modalities for specific subtypes of offenders, (b) optimal conditions under which treatment and follow-up should occur, and (c) selection (or exclusion) criteria for treatment candidates. At the present time, the most informed and dispassionate conclusion must be that the jury is still out. The evidence submitted thus far, however, is encouraging.

The essential point, of course, is the legislative intent of laws that commit sexual offenders for indefinite periods of treatment. If the primary intent of the law is preventive detention, as Pacht (1976) argued 25 years ago, and treatment is merely thrown in so that the law will pass constitutional muster, then it is very unlikely that the law will promote a marked diminution in recidivism among released offenders. The task of effecting behavior change in seriously characterologically disordered individuals is, in itself, considerable. When these individuals have not chosen treatment but are placed in treatment by the court (as is often the case), and when the treatment occurs in the context of a dangerous prison environment where the goal is survival not therapy (as is often the case), then the task becomes immeasurably more difficult. When the treatment provided is suboptimal, the conditions (i.e., prison) are highly problematic and the therapists are inadequately trained and supervised, the task may well be impossible. Under these onerous conditions it would be an egregious error to draw any conclusions about the presumptive inefficacy of treatment with sex offenders.


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