To facilitate consistency, integrity, and effectiveness, sex offender treatment programs must have a clearly articulated model of change or theoretical approach that outlines both the underlying philosophy and method of intervention. At present, the cognitive–behavioral approach is the most widely employed model of treatment for both adult and juvenile sex offenders (see McGrath et al., 2003). Cognitive–behavioral treatment addresses the inter–relatedness of thoughts, emotions, and behaviors—specifically as they relate to sex offending and other problem behaviors. Through skill building, reinforcement, and practice, interventions center around replacing maladaptive thoughts and unhealthy coping methods with positive strategies. This approach is designed to assist clients with meeting several goals, including the following (see, e.g., ATSA, 2005; Longo & Prescott, 2006; Marshall et al., 2006a, 2006b):
- Modifying thinking errors, cognitive distortions, or dysfunctional schemas that support offending behaviors;
- Dealing with emotions and impulses in positive ways;
- Developing or enhancing healthy interpersonal and relationship skills, including communication, perspective–taking, and intimacy;
- Managing deviant sexual arousal or interest, while increasing appropriate sexual interests;
- Practicing healthy coping skills that address identified risk factors;
- Establishing or expanding positive support systems;
- Addressing one’s needs in positive ways and not at the expense of others; and
- Leading a productive, satisfying, and fulfilling life that is incompatible with sex offending.
Research demonstrates that cognitive–behavioral approaches designed for sex offenders result in significant reductions in recidivism with both adults and juveniles (Hanson et al., 2002; Lösel & Schmucker, 2005; MacKenzie, 2006; Reitzel & Carbonell, 2006; Walker et al., 2004).
Another treatment model that appears promising for juvenile sex offenders is Multisystemic Therapy (MST) (Borduin & Schaeffer, 2002; Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 1998; Letourneau, Borduin, & Schaeffer, in press; Saldana et al., 2006). MST is a community–based model that targets multiple key influences (e.g., individual, family, peer, school) with the goals of improving family functioning, enhancing parenting skills, increasing positive peer involvement, improving school performance, and building upon community supports (Henggeler et al., 1998). An extensive body of research demonstrates its efficacy with justice–involved youth, not only with respect to reducing recidivism, but also in terms of increasing other positive outcomes for youth and their families (see Henggeler et al., 1998). Research suggests that using MST as the framework for intervention with juvenile sex offenders can yield similarly positive outcomes (see, e.g., Borduin, Henggeler, Blaske, & Stein, 1990; Borduin & Schaeffer, 2002; Gallagher, Wilson, Hirschfield, Coggeshall, & MacKenzie, 1999; Letourneau et al., in press; Reitzel & Carbonell, 2006).
Given the current available research, jurisdictions that are invested in implementing research–supported models of treatment are well–advised to use a cognitive–behavioral approach with adult sex offenders. And with juveniles, the contemporary literature indicates that employing either Multisystemic Therapy or cognitive–behavioral treatment is a logical choice (see, e.g., Reitzel & Carbonell, 2006; Walker et al., 2004).
Most treatment programs for adult and juvenile sex offenders deliver interventions within a group setting (McGrath et al., 2003). Group treatment is advantageous for several reasons, not the least of which are resource and time efficiency. It also provides the opportunity for participants to embark on the change process with other individuals who can relate to them, increases their receptiveness to feedback because it comes from peers, allows for modeling and practicing positive skills with peers, and instills hope and self–efficacy through observing the progress and success of others (ATSA, 2005; Berenson & Underwood, 2000; Jennings & Sawyer, 2003; Marshall, Anderson, & Fernandez, 1999, Marshall et al., 2006b; NAPN, 1993; Sawyer, 2002; Schwartz, 1995). The following are key issues related to modes and methods of treatment.
- Co–Facilitation of Treatment Groups. When used as a mode of treatment, group therapy is ideally facilitated by two clinicians. Among other benefits, co–facilitation prevents important details from being overlooked from both a process and content perspective, promotes balance and objectivity because the information from the groups is filtered through different lenses, and ensures continuity of service delivery when one of the clinicians is unable to be present. It can also prevent therapist burnout (Marshall et al., 1999). In some jurisdictions, treatment providers and supervision officers co–facilitate treatment groups (see McGrath et al., 2003). There is controversy in the field over this practice. While some argue that it promotes multidisciplinary collaboration, enhances information–gathering, and demonstrates a unified partnership to the individuals on these common caseloads, others express concerns about the potential for blurring of roles, ethical questions regarding non–clinically qualified supervision officers providing treatment, and the impact on clients’ participation or willingness to disclose fully during the group (see, e.g., ATSA, 2005). As such, it may be less problematic for supervision officers to schedule occasional “observations” of treatment groups, ensuring that participants are informed in advance that the officer will be present and that the role of the officer is appropriately clarified (ATSA, 2005).
- Heterogeneity versus Homogeneity of Groups. One question that
often arises when conducting groups is whether they should be heterogeneous
(composed of different types of sex offenders) or homogeneous (made up of
very similar offenders). Heterogeneity takes multiple forms when considering
the composition of sex offender treatment groups: type of victim or sex crime,
age, gender, functional status, and risk level. In many treatment programs,
treatment groups tend to be comprised of a heterogeneous “mix” of
sex offenders (e.g., individuals who have victimized adults and those who
have targeted children). This is often a function of convenience, supply
and demand, and the availability and capacity of treatment resources. And
because no clear evidence indicates that this type of heterogeneity in the
group context has a detrimental impact on treatment outcomes, it remains
It is, however, important to note that not all subpopulations of sex offenders should be placed in treatment groups together. For example, it is inadvisable to combine female offenders with male offenders, lower functioning clients with highly sophisticated individuals, or juveniles with adults. Distinct populations have unique intervention needs, and placing them together in treatment can create dynamics that may undermine treatment.
Other types of heterogeneity in treatment groups (i.e., mixing offenders who have varied levels of risk) can actually decrease the effectiveness of treatment, whereas homogeneous treatment groups (i.e., comprised of offenders with similar risk levels) may lead to better outcomes. This has been best illustrated through the application of the risk principle, which reveals that when interventions are delivered in accordance with assessed level of risk, they have a greater impact of reducing recidivism (see, e.g., Andrews & Bonta, 2007; Gordon & Nicholaichuk, 1996; Mailloux et al., 2003; Nicholaichuk, 1996). Stated differently, intensive services delivered to a treatment group comprised of high risk sex offenders (i.e., a homogenous group) will be more effective than providing the same intensive interventions to a treatment group comprised of sex offenders whose risk levels vary from low to high.
While commonly used, group therapy also presents disadvantages. For example, even when groups are limited to an ideal size of 8–10 members, they offer only a limited amount of time for participants to address multiple needs and issues during each treatment encounter. Groups may also be suboptimal for participants with specific responsivity considerations such as cognitive impairments, varied learning styles, low motivation, or denial. The group setting is also not conducive to discussing sensitive issues or addressing family or marital difficulties. Finally, with juvenile sex offenders specifically, treatment providers must remain cognizant of the research on aggregating juveniles for intervention (see, e.g., Chaffin, 2006; Dodge et al., 2006; Hunter, 2006; Hunter et al., 2004b). In some instances, the strong negative peer influences that exist when juveniles are treated in group settings may mitigate or even nullify the potential benefits of intervention (Dodge et al., 2006).
Although most empirical examinations that demonstrate treatment effectiveness include programs with group therapy as a primary mode of treatment, the research does not suggest that group treatment alone is superior to other modes of specialized treatment for sex offenders (Lösel & Schmucker, 2005; Reitzel & Carbonell, 2006). Indeed, the success of MST and other family– and community–based interventions with juvenile sex offenders clearly indicates that the use of group therapy is not the only means of achieving positive outcomes.
For these and other reasons, treatment for adult and juvenile sex offenders should not be limited to a group modality. Rather, depending upon the needs and circumstances of each client, programs should also employ the following treatment modalities:
- Individual therapy;
- Couples or marital therapy; and
- Family therapy.
Indeed, in sex offender treatment programs throughout the country, the overwhelming majority of programs report using individual, couples, and family therapy (McGrath et al., 2003).
Within the context of the principles of effective correctional intervention, the need principle states that recidivism is most likely to be reduced when interventions primarily target crime–producing or criminogenic needs (see, e.g., Andrews & Bonta, 2007). In order to maximize the likelihood that interventions will be effective for adult and juvenile sex offenders, therefore, treatment providers should focus their efforts on the changeable factors that are known to be associated with sexual recidivism (i.e., criminogenic needs). These dynamic factors are often identified through extensive research designed to identify the characteristics and factors that differentiate sexual recidivists from non–recidivists. This provides clinicians with insight into the kinds of factors that, if targeted in treatment, will significantly reduce reoffense potential. It also allows treatment providers to be aware of the types of factors that may not require a considerable investment of time and energy during the course of treatment, as they may not yield significant dividends in the long term.
Current research indicates that the following clusters of dynamic risk factors are linked to sexual recidivism, and, therefore, are important targets of treatment for sex offenders (see, e.g., Hanson & Bussiere, 1998; Hanson & Harris, 2000, 2001; Hanson & Morton–Bourgon, 2005; Worling & Langstrom, 2006):
- Sexual deviance variables. Included among these factors are deviant sexual interests, arousal, or preferences (e.g., sexual interest in young children) as well as sexual preoccupations. Although many individuals who commit sex offenses do not display deviant interests, for those offenders who do, treatment interventions (i.e., behavioral techniques) are designed to enhance behavioral control and reduce the likelihood of acting on such interests.
- Antisocial orientation. Variables within this category include antisocial personality and traits, psychopathy, negative social supports, and a history of rule violations. Also included are pervasive hostility, impulsivity, and employment instability.
- Intimacy deficits. These include an overall absence of intimate relationships, conflicts in intimate relationships, emotional identification with children, attachment difficulties, and distorted schemas and perceptions about individuals and relationships.
- Pro–offending attitudes and schemas. This category includes beliefs and attitudes that support sexually abusive and other problem behaviors, and can include cognitive distortions such as minimizations and justifications, as well as implicit theories or world views that may support sex offending behaviors (Mann & Beech, 2003; Ward, Hudson, Johnston, & Marshall, 1997; Ward & Keenan, 1999).
It should be noted that although these broader categories of dynamic risk factors are associated with sexual recidivism, not all of the individual variables that are or can be included in these categories are independently correlated with recidivism.
Even though some dynamic factors do not predict long term recidivism, they may predispose an individual to begin sex offending (persistence factors versus initiation factors). Understandably then, many treatment programs address those variables. In addition, treatment programs focus on elements that can equip adult and juvenile sex offenders with the skills and competencies that will allow them to lead “good lives” (Mann, Webster, Schofield, & Marshall, 2004; Thakker, Ward, & Tidmarsh, 2006; Ward & Fischer, 2006; Ward & Stewart, 2003). These factors may not be directly linked to recidivism but will lead to improved quality of life, which is arguably an important goal of treatment.
Put simply, the emphasis on criminogenic needs provides the major thrust of intervention for sex offender treatment, but many current treatment programs also target non–criminogenic needs, including the following (Marshall et al., 2006b; McGrath et al., 2003; Rich, 2003; Worling, 2004):
- Self esteem;
- Social skills;
- Stress management;
- Sex education;
- Trauma resolution;
- Offense responsibility; and
- Victim awareness.
Providers must keep in mind the research on the need principle, which reveals that when non–criminogenic needs outweigh criminogenic needs in treatment, the overall impact of the interventions is undermined significantly (Andrews & Bonta, 2007; Dowden & Andrews, 2000).
When treatment programs for juvenile sex offenders rapidly developed approximately two decades ago, they mirrored programs for adult sex offenders. This occurred primarily because the differences between adult and juvenile sex offenders were not fully understood and the assumption was made that adults and juveniles were alike in most ways (see, e.g., Bumby & Talbot, 2007; Chaffin, Letourneau, & Silovsky, 2002; Longo & Prescott, 2006). But because the period of adolescence is characterized by cognitive, emotional, social, moral, and biological processes that are qualitatively different from those in adulthood, the treatment approaches and other management strategies designed for adults cannot simply be applied to juvenile sex offenders (see, e.g., ATSA, 2000; Chaffin, et al., 2002; Fanniff & Becker, 2006; Letourneau & Miner, 2005). Over the past several years, researchers have begun to further illuminate characteristics and features that differentiate juvenile from adult sex offenders (Barbaree & Marshall, 2006; Caldwell, 2002; Fanniff & Becker, 2006; Hunter et al., 2003, 2004a; Knight, 2004; Miranda & Corcoran, 2000; Worling & Langstrom, 2006). More specifically, this research suggests that juveniles:
- Have greater fluidity in sexual arousal, rather than having “fixed” patterns;
- Tend to have more social competency difficulties;
- Experience more family difficulties;
- Have been exposed to more violence, maltreatment, or other trauma;
- Are more likely to commit offenses within the family;
- Have fewer victims;
- Commit less intrusive sex offenses; and
- Have lower sexual recidivism rates.
Moreover, the available evidence indicates that juvenile sex offenders may be more similar to other justice–involved juveniles than to adult sex offenders, which means that treatment for juvenile sex offenders should take into account the broader juvenile delinquency research (Fanniff & Becker, 2006; Letourneau & Miner, 2005; Nisbet, Wilson, & Smallbone, 2004; Seto & Lalumiere, 2006; Smallbone, 2006). This has resulted in greater emphasis on and sensitivity to socio–ecological theories that recognize the multiple determinants of delinquent behavior (e.g., individual, family, peer, school, community) when approaching treatment for juvenile sex offenders (see, e.g., Borduin & Schaeffer, 2002; Longo & Prescott, 2006; Hunter et al., 2004b; Letourneau & Miner, 2005; Saldana et al., 2006).
To some extent, however, intervention targets addressed in “traditional” juvenile sex offender treatment programs will likely still resemble targets for adult sex offenders, because some of the risk factors believed to be associated with initiation and persistence for juveniles are similar to those for adult sex offenders (see, e.g., Bumby & Talbot, 2007; Prescott, 2006; Worling & Langstrom, 2006). The following are common targets of treatment currently employed in juvenile sex offender treatment programs throughout the country (McGrath et al., 2003):
- Offense acknowledgement and responsibility;
- Cognitive distortions;
- Awareness of victim impact;
- Healthy sexuality and sex education;
- Social skills and assertiveness;
- Antisocial attitudes, values, and associates;
- Emotional management;
- History of trauma;
- Impulse control;
- Family functioning; and
- Deviant sexual arousal, for those youth who evidence these patterns.
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