A Project of the Office of Justice Programs, U.S. Department of Justice

Long Version
Section 1: An Overview of Sex Offender Treatment for a Non–Clinical Audience
The Basics of Sex Offender–Specific Treatment
2 Hours

(30 minutes)

Use SlideUse Slide #9: Characteristics of Current Sex Offender–Specific Treatment Methods

What are some characteristics of current sex offender–specific treatment methods? What might you expect to see in a sex offender treatment program that incorporates those practices that have been demonstrated to be effective in reducing sexual recidivism?

Group Treatment

First, most sex offender treatment takes place in a group treatment setting. 12 Although individual treatment sometimes accompanies group treatment (and, under certain limited circumstances, might replace group treatment altogether), there are a number of advantages to group treatment.

One is economic—treating offenders in groups consumes fewer resources than treating them individually.

A second reason to treat sex offenders in groups is that they learn and benefit significantly from teaching one another. As long as the treatment provider ensures a pro–social milieu, group treatment can provide a rich therapeutic environment in which offenders learn from hearing about the experiences of others. Such an environment provides offenders with opportunities to challenge and confront one another—in a constructive and helpful fashion—about the inappropriate and distorted thinking that is associated with the abuse they have perpetrated. Well–functioning treatment groups also serve as a support to individual offenders who are having problems with the treatment process.

Additionally, attending group treatment represents another level of acknowledgement by the offender of his behavior—it provides an opportunity for sex offenders to begin to practice talking openly about their issues. The group treatment setting helps address denial and confront distorted thinking far more effectively than the individual, one–on–one treatment provider–offender setting.

In a little while, we will talk about the specific criminogenic needs that are addressed in group treatment. Because sex offenders often share many of the same needs, an issue that is relevant to one offender is very often relevant to others in his group.

Later in this training, I will provide several practical examples that illustrate how—with the guidance and facilitation of trained treatment providers—individual sex offenders contribute to the treatment process in the group setting.

In addition, we will also talk in detail about what is known about the efficacy of sex offender treatment. That is, does it work? Does it reduce sexual recidivism in sex offenders and, thereby, help us to protect past and potential victims, and our communities? Many of the studies that have been undertaken on sex offender treatment have included group treatment approaches.13 As some of you probably know already, the data we have to date on these approaches are promising.

Cognitive–Behavioral Therapy

The most widely accepted mode of treatment in use today with sex offenders is cognitive–behavioral (applied in a group setting).14 Cognitive–behavioral treatment addresses both the cognitions—that is, the thoughts—and the behaviors of offenders.

People commit sex offenses for a variety of reasons. What they have in common, however, are thought patterns that are conducive to sex offending. For example, if an offender believes that children are not harmed by having sexual contact with adults, then this cognitive distortion (distorted thought) justifies, and indeed encourages, his sexual offending behavior. Of course our concern is not so much with thoughts as it is with behaviors, which are the ultimate targets of our treatment and the relevant measure of treatment effectiveness, but the fact that thoughts can both promote and discourage sex offending behavior requires that offenders’ cognitions (thoughts) be addressed in the therapeutic environment.15

The behavioral component in cognitive–behavioral treatment refers, of course, to offenders’ behaviors. But more than that, it speaks to particular treatment methods that are effective in changing behavior.

As I just mentioned, it’s often not enough to simply change people’s thinking to get them to change their behaviors. Let’s use an everyday example to think about it for a moment: Those of us who love ice cream or chocolate know that eating it in large quantities is not particularly good for us, especially if we are trying to be fit. Our thinking is not distorted in any way about this—we know for a fact that ice cream and chocolate are not healthy foods and that we should limit our intake of them.

However, how often do we all ignore our appropriate, non–distorted thinking and consume large quantities of ice cream or chocolate anyway? How often do our actions overpower our thinking? How often do we take the route home from work that just happens to go by an ice cream or candy store? It’s pretty easy to stop for a snack when you drive right by the place, isn’t it? And then after we indulge ourselves, we promise that we will never do it again.

In a sense, the same analogy can be applied to sex offenders. Just because offenders have assimilated non–distorted or appropriate thoughts doesn’t necessarily mean that their behavior will always reflect their thinking. In a later section of this training, we will spend significant time talking about relapse prevention, an intervention strategy that is designed to assist offenders to implement new behaviors and to recognize—and take specific actions—to avoid high–risk situations that increase the likelihood that they will reoffend.

Let’s go back to the ice cream and chocolate analogy for a moment. What is a new behavior that one might use to reduce the risk of eating ice cream or chocolate? If you always stop at that ice cream or candy store on your way home from work, taking a new route home from work that does not go past such a store might reduce your risk of stopping for ice cream. In a similar fashion, relapse prevention helps sex offenders to identify specific behaviors, actions, and strategies that they can use in their own lives to reduce their risk of abusing again.

To sum up, then, when both cognitions (thoughts) and behaviors are addressed, offenders are able to make greater and more long–lasting changes. The research—which we will review shortly—reflects that it is this combination that is most impactful in lessening the likelihood of reoffense.

Psychopharmacology: Treating Sex Offenders with Medication

As was already mentioned, people commit sex offenses for a wide variety of reasons. These might include expressions of anger or power, inadequate skills in initiating or maintaining social and sexual relationships, having erotic attraction to persons or activities that, if acted on, constitute criminal sexual behavior, and so on. Treatment must be geared to addressing those specific issues.

The individual whose sexual arousal involves, for example, children or forcing sex on adults, has a problem that is deeper than simply poor judgment or poor impulse control. In part, what motivates him to commit sexual assaults is that to do so is sexually arousing. For some of these individuals, the only way they can become aroused is to fantasize about or act on these deviant interests. Not all sex offenders have deviant interests, but many do. This is especially true of sex offenders who sexually assault pre–pubescent children; that is, kids under the age of 13, as well as some sex offenders who use extreme violence in the commission of their offenses. For these individuals, medications can be helpful in reducing the intensity of their sexual urges and can serve as an effective adjunct to standard cognitive–behavioral treatments.16

These medications tend to fall into two categories. The first, and perhaps most well–known, are the class of medications that reduce sex drive and sometimes are referred to in the popular media as “chemical castration.” They are properly referred to as anti–androgen medications, and they are effective because they reduce the male sex hormone testosterone, which contributes to sex drive and aggression.17 Trade names for these medications include Provera and Lupron. The other class of medications that can be effective as an adjunct to other forms of sex offender treatment and supervision are anti–depressants. The class of anti–depressants most often used is Selective Serotonin Reuptake Inhibitors (SSRIs).18 These very common medications include such drugs as Prozac and Zoloft. The reason they are effective with sex offenders is that they typically reduce sex drive as well as reducing the compulsive aspect of sex offending that exists for some sex offenders.

Because not all sex offenders have deviant sexual arousal, nor are they all compulsive, these medications aren’t useful for all sex offenders. However, for those who do have these characteristics, medication can be a very important tool in the “tool bag” of treatment options. It is important to know, however, that pharmacological treatment alone—without other interventions such as cognitive–behavioral treatment and community supervision—is not sufficient.19 In other words, although medication can be an appropriate adjunct to treatment for some sex offenders, it is not a stand–alone remedy to the problem of sexual offending.

Note: Section 3 contains additional information about the use of medication in the treatment process.

We will talk in great detail later in this training about the use of medication in the sex offender–specific treatment process.

Specialized Sex Offender Assessment

Because of the complex and varying nature of sexual abuse and the offenders who perpetrate it, treatment providers, supervision officers, and others must assess sex offenders and their behavior effectively and in an ongoing, collaborative fashion. This enables them to respond appropriately to offender risks and needs as they change over time.

Note: Inform participants that CSOM is developing a training curriculum and a policy and practice brief on specialized sex offender assessment.

We’ll begin our discussion of sex offender assessment with an overview of empirically validated, actuarial–based risk assessment instruments. (These are often referred to simply as actuarial tools.) It is likely that many of you have heard of—or are already using—one or more of them in your work with sex offenders. Examples include the RRASOR and the Static–99.20

These instruments are noteworthy because they enhance our ability to identify sub–groups of sex offenders who pose a higher risk to reoffend than others (and who, therefore, require more intensive treatment and supervision responses than others). The tools are developed using historical or static (unchangeable) risk factors (such as the number of sex offense convictions) that are statistically correlated with sexual recidivism risk and they play a prominent role in the ongoing risk assessment process in which treatment providers and supervision officers are involved. Let’s talk briefly about this process.

Risk assessments that inform our sex offender management decisions (including those related to treatment and supervision) occur in both the clinical (or treatment) and criminal justice settings. We will quickly cover both, and highlight the importance of collaboration between treatment providers and supervision officers in the assessment process.

Criminal Justice Assessments

Criminal justice assessments are undertaken and used by supervision officers to inform their sentencing, case planning, and case management decisions; and are shared with treatment providers to inform their work with sex offenders.

The different types of criminal justice assessments include pre–sentence investigation assessments, assessments for supervision case planning, and assessments for ongoing case management.

Pre–Sentence Investigation Assessments

Those (usually supervision officers or staff) responsible for conducting pre–sentence investigations (PSIs) rely on many different kinds of information about sex offenders from a variety of sources to assess the risk that offenders pose. This information is critical to making sound disposition recommendations based on risk.21 The information considered in a PSI assessment includes an instant offense summary, the offender’s prior criminal record, offender statements, a victim impact statement, the offender’s social history, the offender’s substance/drug history, the offender’s level of admission of the instant sex offense, the offender’s willingness to enter sex offender–specific treatment, the risk posed by the offender as determined by one or more empirically validated risk assessment instruments (which we just discussed), and the results of a sex offender–specific (psychosexual) evaluation (which we will discuss in a moment).

Assessments for Supervision Case Planning

Assessments for supervision case planning are conducted by supervision officers and—like pre–sentence investigation assessments—rely on information from many different sources, including treatment providers. A primary purpose of these assessments is to identify the unique dynamic risk factors that are related to the risk that each offender poses to the community so that individualized case management plans can be designed that respond appropriately to these factors.22

Assessments for Ongoing Case Management

Supervision officers continually monitor and assess short–term (hourly, daily, or weekly) changes in sex offender–risk to inform their ongoing case management activities and decisions. They seek input from treatment providers and others involved in the case management process to assure that their case management plans are responsive to offenders’ current risk levels and specific needs.

Clinical (or Treatment) Assessments

Clinical assessments are undertaken by sex offender–specific treatment providers and are used to help guide the treatment process. Their results are also shared with supervision officers to inform their work with sex offenders. There are two types of clinical assessments: sex offender–specific (psychosexual) evaluations, and ongoing assessments of risk and criminogenic needs.

Sex Offender–Specific (Psychosexual) Evaluations

Ideally, sex offender–specific evaluations are conducted prior to community supervision and entrance into treatment. Their purposes are to:23

  • Assess the risk that sex offenders pose to the community;
  • Identify specific criminogenic needs that are related to the risk that each offender poses and that must be addressed in treatment—these become specific targets of treatment;
  • Determine the most appropriate method of treatment delivery (based upon each offender’s learning style); and
  • Determine the most appropriate treatment setting (i.e., institutional or community) and level of treatment intensity for each offender.

Ongoing Assessment of Risk and Criminogenic Needs

Like supervision officers, treatment providers continually monitor and assess short–term (hourly, daily, or weekly) changes in sex offenders’ risk and criminogenic needs to inform their treatment decisions and to update offender treatment plans. During this ongoing process, treatment providers seek input from supervision officers and other professionals to assure that treatment plans are responsive to current offender–risk levels and needs.

Because the information from the different types of assessments informs the responses of treatment providers and supervision officers to sex offenders, it is critically important that treatment providers and supervision officers communicate clearly and consistently about the assessment process.

Psycho–Physiological Assessments

Before we proceed, let’s spend a few minutes discussing three adjunct assessment tools that are very helpful in informing the sex offender–specific treatment process and that are not typically used in the treatment of other kinds of offender populations. They include the polygraph, the penile plethysmograph, and the Abel Assessment of Sexual Interest. These are known as psycho–physiological assessments.

Let’s talk briefly about the polygraph first.

The polygraph is used to assess whether sex offenders are being deceptive. Polygraph examinations are increasingly regarded as a valuable tool in sex offender management.24 Determining whether an offender is being deceptive can be critically important in the treatment process.

Here’s an example of why: if an individual is convicted of a sex offense but claims that he did not commit the crime, a deceptive result on a polygraph examination can be very helpful in confronting and breaking down his denial and promoting an admission. We will discuss in a later section why offender denial—and confronting and breaking it down—is a critical target of the treatment process. Here’s another example: as many of you may know, sex offenders are often required to complete sexual history questionnaires in which they include their entire sexual histories, both criminal and non–criminal. The ability to verify the full extent and variety of sex offenders’ sexual histories enables treatment providers to: assess more effectively the kinds and levels of risk that offenders pose to past and potential victims and the community; identify the specific issues and needs that are related to their sexual abuse; and develop treatment plans that address those issues and needs.

The polygraph is often used to assess whether or not sex offenders have knowingly withheld any information from their sexual history questionnaires. This can result in significantly increased disclosures of sexual misconduct, even prior to the actual administration of the polygraph examination.25 That is, prior to the polygraph exam, the polygraph examiner shares the questions with the offender that will be asked during the polygraph exam and gives him an opportunity to divulge more information about those questions.

Now let’s spend a few minutes on two other psycho–physiological assessment tools: the penile plethysmograph and the Abel Assessment of Sexual Interests. The purpose of these assessment instruments is to ascertain offenders’ sexual interest and arousal patterns without having to rely on their self–report, which might be inaccurate.

The penile plethysmograph is a laboratory device that measures increments of erection of the penis. The evaluation involves the offender sitting alone in a small room. He places a small device on his penis, either an elastic band or a C–shaped metal device. Neither of these is in any way painful. The device is attached to a computer operated by the evaluator in the next room. The offender listens to audiotape descriptions of various kinds of sexual behavior, or views slides that depict males and females of various ages, typically photographs of individual nudes. The plethysmograph detects blood flow to his penis, a measure of his erotic arousal to these various stimuli.

The plethysmograph is an intrusive procedure that requires cooperation from the offender. It is also an expensive test, typically costing $300 to $750 per administration. Furthermore, it is not completely accurate because some offenders can distract themselves sufficiently so that they do not exhibit arousal in the laboratory when, in fact, they do have arousal in ordinary circumstances.26 For these reasons, the penile plethysmograph is not widely used in sex offender treatment. Nonetheless, it is noteworthy that of all of the characteristics that are associated with child molesters’ risk for sexual recidivism, Hanson and Bussiere (1998) found that having a deviant sexual interest in children as measured by the penile plethysmograph is the most powerful. (It should be noted that none of the characteristics in the research are extremely strong predictors of sexual recidivism, although the plethysmograph is accurately described as the strongest among only moderately predictive factors.) We will talk more about the treatment approaches used to address deviant sexual interest later.

The Abel Assessment of sexual interest is a less intrusive test because it evaluates erotic interest without requiring penile measures, and it avoids the problems associated with nude photographs of children.27 The Abel Assessment involves offenders’ viewing slides of clothed males and females (adults and children) and measuring offenders’ level of attraction to each. The device measures small differences in the visual reaction time of the person being evaluated; that is, how long they look at each slide, with longer reaction time being associated with increased sexual interest.

Although these assessments each have disadvantages, they can offer treatment providers and others important information about sex offenders that they otherwise might not have.