Sharon Kelley, Psy.D . Sand Ridge Evaluation Unit Madison,WI

1. Can Current Assessment Tools Accurately Predict Risk Among Sex Offenders with Major Mental Illness? Sharon Kelley, Psy.D. Sand Ridge Evaluation Unit Madison,WI

2. Dual Stigma • Sexual offenders with Major Mental Illness (SOMMI) are often underserved • Traditional mental health system lacks expertise in the management of sexual deviance • Traditional sex offense-specific treatment programs often do not consider unique psychiatric issues • “Best practices” is based on research samples that do not include SOMMI • Tension between what is known/available for this population and risk/treatment needs of population

3. Prevalence Rates of MMI Among SOs

4. Prevalence Rates of Sex Offenses Among MMI Population

5. Recidivism Rates • Very few studies • Hanson & Bussiere (1998) meta-analysis • “The large correlation for our ‘severely disordered’ variable could be almost completely attributed to Hackett’s (1971) report that all of his exhibitionists with psychotic symptoms eventually recidivated” (p. 353). • Association not found in follow-up meta-analysis (Hanson & Morton-Bourgon, 2004) • Hanson et al. (2007; DSP) • Twice as many MMI subjects re-offended (18%) as compared to the total sample (9%)

6. What we have learned from the general violence research: • Inconsistent findings regarding the relationship between MMI and risk for violence in the general pop • Bonta et al. (1998) found that the average association between psychosis and violence was small and negative (r=.04) across the 11 studies in their meta-analysis reporting on psychosis (results limited to MDOs released from a correctional setting) • Douglas et al. (2009) meta-analysis involving 204 studies: psychosis associated with a 49%-68% increased likelihood for violence. • Effect size depends on presence of moderators but MMI found to be a strong risk factor for violence compared to persons without MMI

7. What we have learned from the general violence research: • The relationship b/n violence and MMI is strengthened by the presence of other risk factors: psychopathy, ASPD, substance use (Douglas et al., 2009; Fisher et al., 2006; Monahan et al., 2001) • Positive symptoms of psychosis more strongly related to violence (Douglas et al., 2009) • Swanson et al. (2006) reported on 1,410 patients with schizophrenia drawn from 57 mental health sites across 24 states. They found that positive symptoms of schizophrenia were associated with both minor and serious violence, even after controlling for numerous possible confounds and covariates.

8. Relationship Between SO and MMI • No comprehensive study like MacArthur Risk Assessment Study for SOMMI • Very broadband definitions used in SO studies, such as “any mental disorder,” are apt to blur important distinctions between specific psychotic syndromes (Douglas et al., 2009) • Most articles are descriptive with small sample sizes • Still provide a good start…

9. Relationship Between SO and MMI • Phillips et al. (1999) 17 pts with Schizophrenia • Sex offending usually postdated onset of psychosis • Majority were psychotic at the time of the offense • Psychosis was not a direct causal factor but contributed to disinhibited sexual behavior. • Craissaiti & Hodes (1992) 11 pts with psychosis • Sex offenses generally non-violent and impulsive • No evidence the pts attempted to evade capture • Victims mostly adults and known to offender • Only 1 pt taken admitted to a hosp following arrest • 4 pts had engaged in mast fantasy prior to offending

10. Relationship Between SO and MMI • Phillips et al. (1999) 15 SOs with Schiz • None had a hx of sexual promiscuity • Little to no hx of long-term intimate partners • Compared to MMI without hx of SO, this group was twice as likely to report an unimpaired sexual interest • Sahota & Chesterman (1998) 20 SOMMI pts • None had a stable intimate relationship lasting longer than 12 weeks • Psychotic break usually occurs at a crucial age period when many pts are dev a sexual identity and establishing intimate sexual relationships

11. Relationship Between SO and MMI • Greenall & Jellicoe-Jones (2007) 11 cases • 3 subjects were psychotic at the time and offenses driven by anger that was exacerbated by psychosis • 4 cases primarily driven by psychosis • 2 cases were sexually inhibited • 2 cases had underlying paraphilias • Concluded: the presence of MMI may exacerbate risk factors by reducing effective self-regulation

12. Relationship Between SO and MMI • Smith & Taylor (1999)  84 pts with Schiz hosp after conviction for a sex offense • 80 pts committed offenses when actively psychotic • 4 pts had onset of psychosis following offense

13. Factors to Consider: Onset of MI sxs in relation to onset of PSBs How do PSBs manifest or change when psychiatrically decompensated? Are PSBs present when psychiatrically stable? How is PSB manifested in this MI individual? Relationship Between SO and MMI

14. Increased MI Sxs = Increased Impulsivity Increased Hypersexuality Decreased Behavioral Controls Decreased Ability to Consider Consequences Decreased Ability to Make Rational Decisions Decreased Ability to Engage in Treatment in a Meaningful Way Decreased Ability to Plan and Influence Others Complicated relationship b/n PI and Grievance Thinking Impaired social and intimacy skills How Relationship Impacts Risk

15. MI/PSB Case Examples

16. MI/PSB Case #1: PSBs Due to Psychosis • 27-year-old male • Paranoid Schizophrenic Disorder • Risperdal, Benadryl, Ativan, and Aterax • Charged with 3 counts Indecent A&B < 14 but found NGI • Had not been med compliant for several months prior to his offenses • Offenses related to a fixed delusion that people were actually robots, that he had magical powers, and that he could have “eye sex” with children

17. MI/PSB Case #2:Hypomanic with Underlying Paraphilia • 47-year-old male released from prison out of state after serving 15 years for 3 counts of Criminal Sexual Conduct, 1 count Gross Indecency, and 1 count Assault with Intent to Commit Criminal Sexual Conduct • Victims were all under-aged boys • Self-reported approximately 100 victims for which he did not get caught • Recently re-arrested for possession of child porn • Dx: Bipolar Disorder and Pedophilic Disorder • Although mania increases hypersexuality, evidence suggests it didn’t play a significant role

18. MI/PSB Case #3:Risk Increases When Psychiatrically Stable • Paranoid Schizophrenic Disorder • Prolixin, and Cogentin • Convicted of Rape and 2 counts Indecent A&B • When non compliant with meds has engaged in more primitive type of offenses (i.e., leering at women, following women, exposing self). When compliant with meds has engaged in more well organized offenses such as grooming behaviors, getting victim incapacitated (i.e., alcohol), kidnapping, and rape.

19. MI/PSB Case #3: Risk Decreases When Psychiatrically Decompensated • Same case • Less meds = more disinhibited, impulsive, disorganized sexual behavior • As he gets more psychotic, though, the problematic sexual behaviors decrease • When acutely psychotic, he is catatonic = Absence of Risk.

20. Could MMI Symptoms Increase Risk? • Langstrom et al. (2004) N=1,215 sex offenders • 4% had a psych hosp in within the year preceding the index offense • Sexual recidivism was found to be associated with psychosis, any psychiatric disorder, and any inpatient care. • However, a prior diagnosis of etoh abuse/dep more than doubled the odds of a sexual reconviction • A personality disorder diagnosis increased the odds by a magnitude of ten times

21. Could MMI Symptoms Increase Risk? • Olver, Stockdale, & Wormith, 2011 Meta-analysis of attrition (included sex offender, domestic violence, general correctional, and violent nonsexual offender programs) • Major mental illness was a mediating variable for recidivism • MMI pop (psychotic disorders and BPDs) less likely to complete treatment across all programs. Those who were less likely to complete treatment were more likely to recidivate. • However, MMI was not the strongest correlate. • Young, single, unemployed, ethnic minority, male, limited formal ed, low SES, hx of prev offenses, high static risk

22. Could MMI Symptoms Increase Risk? • Abracen & Looman (2012 ATSA Conference): • Examined 348 high risk sex offenders. Found that after controlling for risk scores on the Static-99R, only those with a history of psychiatric impairment was found to add incrementally to predict recidivism.

23. Dynamic Supervision Project (Hanson et al., 2007) • Only study to date to specifically examine the predictive validity of a dynamic risk measure in the SOMMI population • Problems: • Small N = 61 • Coded by probation officers • Major mental illness defined as: at least one night in a hospital • Unknown whether this was due to depression, bereavement, adjustment disorder, personality disorder, malingering, etc…..?

24. Sexual Recidivism

25. Relationship Between SO and MMI • Are there risk factors that are unique to the SOMMI population? • Do criminogenic needs operate independently of symptoms of a major mental illness? • Does the presence of a major mental illness exacerbate pre-existing criminogenic needs? • Does the presence of a major mental illness act as a protective factor and serves to moderate the effect of pre-existing criminogenic needs?

26. SOMMI Study • Specific Aims: • Determine whether the SRA-FV can be scored reliably on the SOMMI population. • Develop supplementary scoring guidance and training to facilitate the reliable application of the SRA-FV to the SOMMI population. • Develop SOMMI norms for the SRA-FV. • Identify groupings of criminogenic needs within the SOMMI population (and whether they have needs that are unique to this population). • Explore whether acute symptoms have a moderating or worsening effect on existing criminogenic needs.