Trending research demonstrates
low rates of sexual recidivism for nearly all juveniles and most adult sexual offenders. Many studies have been aimed at trying to determine
whether ‘sex offender’ treatment is effective at reducing recidivism. But there is growing evidence that most
sexual offenders will not reoffend, regardless of treatment, and moreover, that
treatment has only a small or moderate effect on recidivism. If treatment isn’t as effective as we want it
to be, what do we do with such ‘inconvenient’ data? We can consider elements of an effective intervention, and uniquely tailor
individual pathways for clients to recover.
When indicated, it should include sex-specific treatment.
A recent, large
meta-analysis by Schmucker and Lösel (2015) reports sexual recidivism of 13.7%
for untreated offenders, and 10.1% for clients who completed treatment - an
absolute reduction in recidivism of 3.6%, and a relative reduction of 26.3%. Previous studies by Lösel and Schmucker (2005),
(2008) showed a slightly stronger, but still low-moderate treatment
effect. Duwe and Goldman (2009) found a
13.4% sexual reoffense rate for treated clients versus 19.5% sexual recidivism
for offenders who did not participate in treatment. Many other studies have found similar results.
Karl Hanson and
colleagues (2014)
confirmed a low rate of reoffending (1%-5%) for low risk sexual offenders, and
a 22% rate of reoffending for high-risk offenders after five years, but then
discovered that after ten years offense-free in the community, high-risk
offenders effectively became low recidivism offenders. Michael Caldwell (2016)
completed the largest meta-analysis to date, which revealed current sexual
recidivism rates for juveniles is likely to be less than 3%. In both studies, if clients reoffended, it
was likely to occur within the first few years after intervention. Authors in both studies were unable to
determine WHY recidivism was low and desistance was stronger over time; yet it seems
that effective treatment might enhance outcomes.
Risk for reoffending,
as part of a psychosexual assessment, seems to have become overly simplified
into essentially three categories: low, medium, and high risk, which then often
determines outcomes: everything from plea agreements, to incarceration,
treatment, and perhaps conditions of supervision or imposition of civil regulations.
So how can we analyze the cost-benefit of interventions to clients, and to
public interests?
Gregory DeClue has
suggested an empirical process from the world of medical treatment might be
helpful to determine the cost-benefit of treatment. Dr. DeClue points to statistical concepts
known as “Number Needed to
Treat” (NNT), and “Number
Needed to Harm” (NNH). Together, NNT and NNH provide an empirical
way to consider, in an aggregate manner, the cost-benefit to “treat” or “not to
treat.” According to DeClue, using data
from Schmucker and Lösel (2015), NNT reveals that only about one person in 28
is likely to not reoffend as the direct result of treatment. That seems like a weak return on the
investment, but more troubling is the counterbalance: to what extent is treatment actually
unwarranted, counterproductive, or indeed harmful to individuals and their
families – known as iatrogenic
consequences?
A meta-analysis by Kim,
Benekos, & Merlo (2016) found “that sex offender treatments can be
considered proven or at least promising.” They also determined that ages of
clients and types of interventions influence the success of treatment. This study also suggests that outpatient
treatment may be more effective than treatment in prison, “If community
treatment is more effective than institutional treatment, then a review of
existing sentencing statutes and policies might be appropriate.” So if treatment
is not the primary change agent, what is?
It might be, broadly, the intervention.
Most individuals
arrested for sexual offending do
not sexually reoffend, and treatment effect alone doesn’t account for low
recidivism rates; so what else might broadly mitigate reoffending? Research indicates that civil regulations
(the registry, residency restrictions, etc.) are not only ineffective,
they might be counterproductive.
More and more, civil regulations are
being challenged
by the judiciary in state and federal courts as not only being ineffective,
but unconstitutional. Caldwell
wrote, “The bulk of available evidence indicates that
the decline in adult and juvenile sexual recidivism rates has occurred,
unrelated to, and perhaps despite, these recent policy trends.” The sex offender registry is especially harmful to juveniles. Birgden and Cucolo (2011)
argue that treatment as management, rather than treatment as rehabilitation,
panders to public policy and puts unwarranted concerns about public safety
ahead of effective treatment. CSOM
promotes a systems
approach to interventions, including effective supervision, and that
recovery is not all about ‘treatment.’
We should be mindful
that reducing risk is not the only aim of treatment, and only tells part of the
story about an effective intervention. And how do we determine what kind of
treatment experiences we should offer? For
example, Levenson and Prescott (2013), discuss many benefits that may be
derived from treatment, resulting in improved outcomes for clients, victims, and
their families - better lives AND safer communities. Indeed, the same authors have published three
studies indicating that people who have sexually abused typically believe their
treatment experiences to be worthwhile (e.g., Levenson & Prescott, 2009). Perhaps one avenue for professionals to
consider is moving beyond treatment interventions that focus on reducing risk
and help people remain at low risk. Another treatment target might be helping clients
adjust to the social consequences of being publically labeled a “sex offender.”
Still another focus of treatment might be “cognitive transformation” –
promoting desistance by helping clients view themselves as having become a
different (better) person.
When recidivism rates
are low, and treatment effect is weak, it raises questions about when sex
offender ‘treatment’ is indicated – effectively begging the question: “to
treat” or “not to treat.” The answers
are only partially informed by risk/recidivism studies. Many questions abound,
including the influence of treatment on the nature, severity, imminence, and
frequency of re-offense, if it does occur. Further, while it makes sense to ask
whether treatment works, we are still in need of research into the effective
components of both treatment and treatment providers. In addition to
psychological factors, we should consider situational factors that might contribute
to re-offending after treatment completion.
How should new data on
the weak effectiveness of ‘treatment’ guide interventions with individual
clients? How should public policies be
reviewed in light of new research? Collectively,
new data, and anecdotal evidence, provides strong evidence that the “sex offender
system” might be mired not just in ‘old research’ about what works in the treatment
and management of sexual offenders, but that public policies are straining
valid concerns for public safety. As a result,
systems are overreaching and over-treating individuals, in large numbers, from
juveniles to the civilly committed. The
consequences to individuals and families, and the costs to public interests, are
incalculable.
Why are so many people
ending up in the “sex offender system”?
Perhaps one reason is a tendency to conflate “seriousness” of a sexual
offense with “dangerousness.” This
results in catching too many individuals in the “sex offender net,” regardless
of “dangerousness” and, out of fear of any
risk of reoffending, the system is reluctant to let them go. In order to avoid any true positives
(predicted to reoffend and does), or false negatives (predicted to NOT reoffend
but does), the system is willing to tolerate a high percentage of false
positives (predicted to reoffend but doesn’t).
Or simply stated, “Better to lock up ten sex offenders than one might
reoffend.” The fallacy is that about nine
out of ten offenders are not likely to sexually reoffend, yet we commit vast,
unwarranted public resources to nine out of ten sexual offenders, as an
unwarranted hedge against possible recidivism.
In the UK, with the
introduction of the transforming
rehabilitation agenda, distinguishing between low and high risk offenders is
becoming more salient in community management.
It distinguishes between sex offenders and non sex offenders, by risk
categories and management. All sex
offenders are now managed by a streamlined probation services, while low/medium
risk non sex offenders are managed by private Community Rehabilitation
Companies (on a payment-by-results scheme).
All high/very high risk offenders are managed by traditional probation. This suggests that the UK government perceives
low risk sex offenders as generally more dangerous than low-risk non sex offenders.
Interestingly, in the
UK (and elsewhere outside the USA) not all sex offenders receive treatment – it is based
on their level of risk and whether or not clients deny their offence. In the UK, it is usually medium, high and
very high risk sex offenders that receive Sex Offender Treatment Programmes (SOTP);
with low risk offenders receiving a form of cognitive skills program. Putting low-risk sex offender in SOTP could
actually make
clients worse and increase their likelihood of offending. Practitioners and
policymakers suggest that we look at alternatives to traditional
SOTP, and Ruth Mann points to a wide-range of psycho-social
treatment interventions. With skepticism
about whether sex offender treatment
works, in the UK, treatment must be evidence-based.
So what are the
takeaways here? One is to avoid the tendency
to measure the success of ‘treatment’ in a dichotomous manner - whether or not
clients reoffend. There is much more to consider in decisions
about treatment, e.g. when is treatment indicated? Should treatment
be compulsory? If so, where should treatment take place (institution
or in the community)? What are the specific treatment targets
to measure progress and determine completion? What kind
of treatment is effective for a particular client? How much
treatment is enough? Principles of Risk-Need-Responsivity
and Good Lives are able to
empirically guide the application of aggregate data and other
research to individual clients.
Sometimes, when empirical evidence suggests treatment is not indicated,
we still need to intervene, but find
the courage to not put clients through unwarranted or lengthy ‘treatment.’
By all indications, a wide-range of interventions seems
to effectively mitigate recidivism, so perhaps rather than focusing on
“does treatment work,” what might be needed is to fine-tune characteristics
of interventions that are demonstrated to be effective with specific types of
clients, e.g. juveniles, low risk, non-contact, females, repeat offenders, etc.
Not all sexual offending is rooted in
sexual deviancy, sexual compulsion, or sexual violence. Sometimes people simply lose their sexual
boundaries, and it’s not likely to happen again. While it may be useful to trace pathways to
sexual offending, not every sexual offender has a sexual offense “cycle.” With half of all sexual assaults occurring
under the influence of alcohol, treatment for chemical abuse or addiction might
be primary.
Not everyone who sexually offends needs sex-specific treatment. A large percentage of adolescent offenders,
and their families, might be well-served by participation in a time-limited
psycho-sexual education program.
Because sexual offending is often more about relationship
violations than sexual violence, interventions might focus much more on managing
social damage, repairing relationships, and restoring families. When there is so much that can be accomplished
by creating a recovery plan that is unique to individuals and their families,
it’s unfortunate that there is so much emphasis placed on “relapse prevention,”
strict compliance with supervision, or criminal enforcement of civil
regulations. Effective interventions can build on the optimism of protective
factors, use positive psychology to build social skills, competency, and
resiliency, and embrace strength-based
principles of Good Lives.
When sexual misconduct occurs, intervention is almost always warranted – ‘treatment’ might not
be. Interventions can be empirically guided
by a client’s Risk-Need-Responsivity and principles of Good Lives, and perhaps by
uniquely tailoring interventions to individual clients, with consideration of
the five “W’s”: who, what, when, where, and why.
Jon Brandt, David Prescott, and Kieran
McCartan
Appreciation to Greg DeClue, Ph.D. and Michael D. Thompson, Psy.D. for contributions
to this blog.
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