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Sex Offender Specific Treatment. Howard Levine Ph.D., LCP Coles County Mental Health Center Mattoon, IL Grateful Acknowledgements. Center for Sex Offender Management ( ) For their expertise and excellent training curricula used here.

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sex offender specific treatment

Sex Offender Specific Treatment

Howard Levine Ph.D., LCP

Coles County Mental Health Center Mattoon, IL

grateful acknowledgements
Grateful Acknowledgements
  • Center for Sex Offender Management ( For their expertise and excellent training curricula used here.
  • Kurt Bumby, Center for Effective Public Policy ( Work on shame/guilt and other excellent slides used in this presentation.
  • Donya Adkerson, Alternatives Counseling, Glen Carbon, IL, 62034, (618) 288-8085 ( For dedication to the field and her slides on PGE use in treatment.
the goal of sex offender specific treatment
The Goal of Sex Offender –Specific Treatment
  • Community protection through effective treatment and management of sex offenders in order to REDUCE THE LIKILIHOOD OF FURTURE VICTIMIZATION
not all sex offenders are the same
Not All Sex Offenders Are The Same
  • Majority, but not all, offenses are committed by males
  • Sex offenders can be adolescents or adults, male or female, rich or not, white or not, straight or not, bright or not
  • Offenders differ in preference of victim and offense, risk to offend, supervision and treatment needed
  • Odds are the offender is family, friend or acquaintance to the victim; but not always
  • This presentation will focus on adult male sex offenders; however, “special populations’ will be discussed
why do most sex offenders sexually abuse
Why do most sex offenders sexually abuse?
  • They want to (deliberate,no accident)
  • They are interested (suspend empathy and fear of consequences)
  • The option is unappealing
  • Victimization is not a self esteem issue
sexual abuse is the last step in a long effort to manipulate
Sexual abuse is the last step in a long effort to manipulate
  • Victim, wife, partner and other adults
  • Environment and family

The purpose of all this is to

Feed his imagination, strengthen justifications

Co-opt other adults, and victim(s)

Create reliable source for ongoing victimization

Decrease chances of being caught or stopped

Without external intervention most offenders behavior escalates and continues

why would a sex offender change
Why would a sex offender change?
  • When dire consequences are about to ensue
  • Severe consequences have already been experienced
  • He is reliably and credibly managed by a system (natural and official) that can intervene with personally relevant consequences before reoffense
  • The offender has become disgusted with himself (herself) AND views his deviance as a liability, intolerable and ‘too expensive’
the problem of motivation
The Problem of Motivation
  • It takes a different set of motivation (internal and external) to make initial change and to sustain that change
  • Offenders are asked to change NOT to a previously more healthy state BUT to a never known/unfamiliar responsible state
  • Big difference between compliance and change
  • Natural and official systems can assist in compliance. Change is up to the offender
two facets of sex offender management addressing both external and internal controls
Two Facets of Sex Offender Management: Addressing both External and Internal Controls
  • External Controls:
  • Probation/Parole
  • Supervision
  • Polygraph
  • Testing
  • Registration/
  • Notification
  • Use of
  • Community
  • Networks
  • Internal Controls—The Four Domains of Treatment:
  • Sexual Interests
  • Distorted
  • Attitudes
  • Interpersonal
  • Functioning
  • Behavior
  • Management

External Controls

Internal Controls

differences from other forms of mental health treatment
Differences From Other Forms of Mental Health Treatment
  • Involuntary clients (need leverage)
  • Victim and community focus
  • Limited confidentiality
  • Treatment goals set by provider
  • Collaboration with others essential
  • Length of treatment
characteristics of sex offender specific treatment
Characteristics of Sex Offender Specific Treatment
  • Published standards
  • Containment approach
  • Specialized providers
  • Specialized assessments
  • Group treatment is treatment of choice
  • Individual treatment alone is rare exception
  • Cognitive behavioral therapy
  • Judicious use of medicines
characteristics of sex offender specific treatment cont
Characteristics of Sex Offender-Specific Treatment (cont)
  • Explicit, empirically-based model of change
  • Expected to reduce, never eliminate, recidivism
  • Social learning theory-based
  • Addresses criminogenic needs
  • Targets factors closely linked to sex offending (criminogenic needs)
what methods are effective
What Methods are Effective?
  • Cognitive-behavioral techniques
  • Adult learning theory methods
  • Positive reinforcement rather than punishment
  • Respectful confrontation
treatment is skills oriented
Treatment is Skills Oriented
  • Skills to avoid sex offending
  • Skills to engage in legitimate activities
  • “Skills oriented treatment” includes:
    • Defining the skill
    • Identifying the usefulness of the skill
    • Modeling the skill
    • Practicing the skill
    • Giving feedback
    • Practicing the skill again
how long should sex offender treatment last
How Long Should Sex Offender Treatment Last?
  • Until recently, answers to this question were based only on opinion—there is now research that addresses this question
  • Different offenders require different lengths of treatment
  • Higher levels of denial, sexual deviancy, and risk require longer, more intense treatment
how long should supervision of sex offenders last
How Long Should Supervision of Sex Offenders Last?
  • Different offenders require different lengths of supervision based on risk determined through specialized SOS evaluations
  • Typically, active supervision should continue long after active treatment
  • Offenders should have the burden to establish that they no longer require official supervision
  • Longer is usually better
monitoring and quality control of treatment are a must
Monitoring and Quality Control of Treatment are a Must
  • Monitoring of:
    • Program activities
    • Clients
    • Containment team members
    • Containment team protocol
    • Natural supervisors
treatment of the denying sex offender
Treatment of the Denying Sex Offender
  • Denial is common among sex offenders
  • But, admitting is vital to treatment
  • Sex offenders who do not admit at some point can’t be treated
  • Therefore, treatment of denial is usually necessary to make a client ready for sex offender treatment
various forms of denial
Various Forms of Denial
  • Complete denial
  • Victim or other blaming
  • Denial of personal intent
  • Minimize extent or impact
  • Denial of planning
  • Denial of risk to reoffend
  • Family, community, system denial
tools for addressing denial
Tools for Addressing Denial
  • The polygraph—aimed at specific deceptions
    • Physiological indications of deception
    • Offenders often abandon denial
  • Group treatment—targets four issues
    • Eliminating cognitive distortions
    • Facilitating engagement in treatment
    • Challenge offenders need to protect himself
    • Developing victim awareness
treating denial focuses on its complexity
Treating Denial Focuses on its Complexity
  • Many purposes—why offenders are often in denial
  • Multiple pressures to deny
  • Denial in various phases of the offense (before, during, and after)
methods to address cognitive distortions
Methods to Address Cognitive Distortions
  • Role play explaining to a victim all the information he would need to give “informed consent” to sexual activity
methods to address cognitive distortions cont
Methods to Address Cognitive Distortions(cont.)
  • Articulating the thinking errors and cognitive distortions offenders use to excuse their behavior
increasing victimization awareness
Increasing Victimization Awareness

If sex offenders come to understand the harm they cause, they will be more reluctant to commit future sex offenses because they will find it more difficult to disregard the consequences of their actions to their victims and others

methods to address victimization awareness
Methods to Address Victimization Awareness
  • Videotaped programs of sexual assault victims
  • Visits by victims to the treatment group
involving sex offenders formerly in denial
Involving Sex Offenders Formerly in Denial
  • Often graduates of the “deniers’ group”
  • Emphasis on the positive benefits of abandoning denial
  • “If I can do it, so can you”
the culmination of denier s treatment
The Culmination of Denier’s Treatment
  • The denier is at last permitted to discuss his own offense—many are now quite willing to do so
  • Some therapists report that 80% of deniers admit to the offense when this approach is used
bottom line for denial
Bottom Line for Denial
  • Admitting to a sex crime is a necessary condition for successful treatment
  • Offenders are to be given a specified period of time to resolve their denial or risk removal from treatment
  • Denial is inversely related to treatment progress and engagement in treatment
sex offender treatment goals and plans
Sex Offender Treatment Goals and Plans
  • Accepting personal responsibility for a complete sexual assault history
  • Improving social, relationship, and assertiveness skills
  • Appropriately managing anger
  • Learning about the traumatic effects of victimization and developing empathy
  • Learning to separate anger and power from sexual behavior
  • Developing pro-social support networks
sex offender treatment goals and plans cont
Sex Offender Treatment Goals and Plans(cont.)
  • Recognizing and changing cognitive distortions
  • Identifying and modifying sexual arousal patterns as appropriate via
    • Behavioral interventions and/or
    • Medication
  • Developing and using interventions to interrupt the offense cycle
  • Adopting non-exploitative, responsible lifestyle
conditions for community supervision
Conditions for Community Supervision
  • NO CONTACT WITH CHILDREN UNDER 18, unless approved in advance and in writing by supervising officer and provider
  • No contact with victim(s)
  • Not to date or befriend anyone who has children or lives with children
  • No access or loitering near places used primarily by children
conditions for community supervision continued
Conditions for Community Supervision, continued
  • No employment or volunteering that includes contact with children
  • Not possess or use any pornographic, sexually oriented or stimulating material
  • No internet use
  • No alcohol or illegal drug use
  • Residence pre-approved
  • ‘Successfully complete’ all conditions of TX
why no contact orders
Why No Contact Orders?
  • Sex offenders are not purists, ‘victim profile’ is a myth. Anyone weaker than an offender is a potential victim.
  • It is more a matter of opportunity than preference.
  • The “official record” is always wrong.
  • Realigns incentive to cooperate in treatment.
  • NO MORE VICTIMS. Community safety first.
crossover effect
‘Crossover effect’

Gene Abel et. al, (1983) landmark study on the frequency and variety of sexual offending behavior offenders commit. The 411 offenders in the study on average over a 12 year period had attempted 581 crimes, completed 533 crimes, had 366 victims and completed an average of 44 crimes a year. These crimes included ‘hands off’ offenses. 73%+ had two or more types of deviant sexual interest.

more on crossover
More on crossover

Freeman-Longo, 1985

23 ‘rapists’

5090 incidents of sex offending

319 child molestations

178 rapes

30 ‘child molesters’

20667 offenses

5891 assaults on children

213 rapes on women

more still this time with polygraph
More still; this time with polygraph

Colorado DOC, 1998

36 sex offenders on average

2 victims by official records

165 victims after first polygraph

185 victims after second polygraph

more yet
More yet

Ahlmeyer et. al., (2000)

Incarcerated sex offenders (average)

Official records

2 victims 5 offenses

After second polygraph

110 victims 318 offenses

crossover gender age and relationship
Crossover; gender, age and relationship
  • Emerich and Dutton (1993, JSO) 55% assaulted both boys and girls, 47% acknowledged multiple victim relationships
  • O’Connell (1998, community based ASO) 64% of ‘rapists’ had assaulted a child, 59% of ‘incest fathers’ admitted to victims outside of home.
ahlmeyer 1999 143 aso inmates polygraph and tx
Ahlmeyer, 1999. 143 ASO Inmates, Polygraph and TX
  • 89% crossover by relationship, gender or age
  • 82% child molesters and 50% of rapists crossover by age
  • 58% ‘male victim ASO’ and 22% ‘female victim ASO’ crossover by gender
  • 86% of sample had victims in 2+ relationship classes
contact with children high risk behavior increased
Contact with children: high risk behavior increased
  • Davis et al, (1993) Of 143 incarcerated child molesters studied only 3% of those not allowed contact masturbated about a known child as compared to 60% offenders permitted contact.
  • 66-99% of incarcerated ASO with permission to visit kids in DOC waiting room masturbated about those kids. (Colorado DOC, 1999).
sex offenders even in treatment are dangerous
Sex offenders, even in treatment, are dangerous

Tanner (1998) 128 ASO in first year of community based treatment and supervision

31% had sexual contact with child

25% had unauthorized contact with a child

12% had forced someone to have sex

86% was participating in new high risk behavior and/or new crimes

when to increase intensity of supervision
When to Increase Intensity of Supervision
  • Offender in stress or crisis
  • Offender in high risk situation
  • Offender will have contact with potential victims
  • Offender shows high or increased denial
  • Offender works with internet
  • Active treatment or probation ending soon
the four domains of treatment
The Four Domains of Treatment
  • Sexual Interests
  • Distorted Attitudes
  • Interpersonal Functioning
  • Behavior Management
sexual interests the first domain of treatment
Sexual Interests—The First Domain of Treatment
  • Deviant sexual arousal is sexual arousal to:
    • Non-consenting partners
    • Non-age-appropriate partners
    • Acts that are abusive in nature
  • For many sex offenders, a strong motivation to commit sexual assaults is deviant sexual arousal
  • Not all offenders have deviant sexual arousal
for offenders with deviant sexual arousal
For Offenders with Deviant Sexual Arousal

If such arousal can be decreased, the likelihood of future sex offending will be decreased

Treatment goals include:

  • Reduce deviant sexual arousal while increasing non-deviant sexual arousal
  • Increase reactions to the offender’s deviant behavior as non-offenders react—with disinterest or revulsion
behavioral intervention to reduce deviant sexual arousal
Behavioral Intervention to Reduce Deviant Sexual Arousal
  • Based on the idea that deviant sexual arousal is “learned” behavior and can be unlearned
  • Substitutes non-deviant thoughts for deviant thoughts
  • Connects deviant thoughts with non-arousal
types of behavioral interventions
Types of Behavioral Interventions
  • Covert Sensitization
  • Ammonia (aversive) conditioning
  • Masturbatory reconditioning
common questions about behavioral interventions
Can offenders sabotage this?

Who is this best suited for?

Is this technique essential?

Can this technique be used exclusive of others?

Yes—but they’re only hurting themselves

Offenders with significant deviant sexual arousal

No—but some intervention must address deviant sexual arousal


Common Questions about Behavioral Interventions
goals of covert sensitization
Goals of Covert Sensitization
  • To reduce the attractiveness of sexual assault by having the offender focus on the negative social consequences he faces
  • To have offenders explore all of the consequences of their actions—in particular the negative consequences which offenders so often refuse to recognize
methods of covert sensitization
Methods of Covert Sensitization
  • Offenders identify the chain of thoughts that lead them to offense behavior
  • Offenders are taught to deliberately interject vivid scenes of the negative consequences they will face during that chain of thoughts
  • Audiotape homework provides structured practice sessions for this technique that can be reviewed by the treatment provider
goals of ammonia aversive conditioning
Goals of Ammonia (aversive) Conditioning
  • To reduce the strength of a deviant sexual fantasy by association with unpleasant stimuli
  • To reduce the strength of sexual response to the deviant fantasy
  • To facilitate offenders likelihood to escape/terminate deviant sexual fantasy
methods of ammonia aversive conditioning
Methods of Ammonia (aversive) Conditioning
  • Offenders identify and audiotape a powerful deviant sexual fantasy.
  • Offenders listen to their deviant fantasy and deeply inhale ammonia at the first sign of sexual stimulation.
  • Last step is repeated frequently across days until offender has eliminated arousal to fantasy.
more methods of ammonia aversive conditioning
More Methods of Ammonia (aversive) Conditioning
  • Homework sessions are reviewed by treatment provider
  • Offender eventually may carry small vial of ammonia, or smelling salts, to use in real life situations to escape/terminate deviant sexual fantasy
  • After inhaling the ammonia the offender is to focus on non sexual thoughts and/or coping skills
goals of masturbatory reconditioning
Goals of Masturbatory Reconditioning
  • Increase sexual arousal to appropriate sexual fantasies with consensual adults
  • Weaken arousal to deviant sexual fantasies by association with boredom/non-arousal
methods of masturbatory reconditioning
Methods of Masturbatory Reconditioning
  • Offender verbalizes appropriate sexual fantasy while masturbating to orgasm
  • Immediately after orgasm to appropriate fantasy, the offender continues to masturbate to verbalized deviant sexual fantasy for 45 or more minutes
  • Audiotape homework is reviewed with treatment provider
pharmacological interventions to address deviant sexual arousal
Pharmacological Interventions to Address Deviant Sexual Arousal

There are two primary types of medications used in the treatment of sex offenders:

  • Selective Serotonin Reuptake Inhibitors (SSRIs)
  • Antiandrogens—used for what some call “chemical castration”
selective serotonin reuptake inhibitors
Selective Serotonin Reuptake Inhibitors
  • Commonly prescribed for depression
  • Reduce libido (sexual interest)
  • They can also reduce aggression, decrease deviant fantasies, empower people to better manage their behavior, and reduce the intensity of compulsive aspects of sexual offending
  • Many physicians are knowledgeable of and comfortable with prescribing such medications
antiandrogen medications
Antiandrogen Medications
  • Drastically reduce testosterone
  • Reduce sex drive and the ability to have an erection
  • “Sexual appetite suppressants”
  • Examples include Provera and Lupron
  • Doctors reluctant to prescribe
incidence of side effects of antiandrogen medications
Incidence of Side Effects of Antiandrogen Medications
  • Decreased sperm count—100%
  • Increased body temperature—100%
  • Decreased sex drive—95%
  • Erectile dysfunction—95%
  • Decreased amount of ejaculate—95%
  • Weight gain—58%
  • Increased blood pressure—50%
  • Fatigue—30%
side effects of antiandrogen medications cont
Side Effects of Antiandrogen Medications(cont.)
  • Nervousness and/or depression—30%
  • Hot/cold flashes—29%
  • Headaches—20%
  • Nausea—14%
  • Gall bladder disease (sometimes necessitating surgery)—13%
  • Diabetes—4%
  • Phlebitis (can lead to life-threatening pulmonary emboli)—2%
some physicians are reluctant to prescribe antiandrogens
Some Physicians are Reluctant to Prescribe Antiandrogens
  • They are not approved by the FDA for the treatment of sex offenders
  • It is outside of normal, clinical practice to prescribe to men for reduction in sexual arousal
methods of administration and costs antiandrogens
Methods of Administration and Costs: Antiandrogens
  • Depo-Provera
    • Injected weekly
    • $40 per week
  • Provera
    • Administered orally
  • Depo-Lupron
    • Injected monthly
    • $400 per month
is medication alone an effective treatment method
Is Medication Alone an Effective Treatment Method?
  • Medication that complements the cognitive-behavioral center of treatment can be very helpful in facilitating treatment—5 to 30% can benefit
  • If our goal is to reduce recidivism, and medication will help maintain an individual long enough to help him assimilate the cognitive-behavioral response, it is irresponsible not to use it
  • Conversely, given the current body of evidence, it would be irresponsible to only medicate and not include a cognitive-behavioral treatment component
distorted attitudes the second domain of treatment
Distorted Attitudes—The Second Domain of Treatment
  • Purpose—to identify and alter offenders’ justifications for sex offending
  • One approach is through cognitive restructuring
  • By examining and exposing these thoughts, justifications, rationalizations, and excuses, the offender is challenged to understand his faulty thinking and recognize its distorted, self-serving nature
cognitive restructuring
Cognitive Restructuring

Assists offenders to:

  • Examine rationalizations, excuses, and cognitive distortions
  • Obtain candid feedback on these distortions from others
  • Heighten awareness of victimization issues
  • Recognize the faultiness of his thinking
  • Confound his ability to justify future offending
thinking errors of sex offenders sobs
Thinking Errors of Sex Offenders: SOBS

Offenders, in order to sexually abuse another person, have changed their way of thinking so that molesting another is not the same as others believe. Offenders think in ways that have made their sexual assault harmless, ‘OK’ or deserved. SOBS is also used to justify the behavior after the fact and support the offenders self-centered approach to meeting his needs. Offenders fight hard to justify and maintain their SOBS.

some examples of sobs
Some Examples of SOBS
  • Excuses; anything to avoid accepting personal responsibility
  • Blaming; excuses with a bad attitude
  • Seeking sympathy; feel sorry for me
  • Justifying; Yes, but…..
  • Re-defining; shifting the focus of an issue to avoid solving a problem
  • Pet Me; notice me, cuddle me, applaud me
more examples of sobs
More Examples of SOBS
  • Lying; complete, partial, phoniness
  • Uniqueness; I am not like the others, this can’t apply to me
  • Minimizing; At least I didn’t…..
  • Anger; to manipulate or distract others
  • Victim stance; so others will rescue or forgive him
  • Helpless; I can’t … so don’t ask
  • Arrogance and what is in it for me; bottom line
methods of cognitive restructuring
Methods of Cognitive Restructuring
  • Examine role of distortions in non-sexual situations
  • Offenders anonymously relate the distortions they have used in the past
  • Role playing of victim, victim’s parent, long-time friend of offender, probation/parole agent
  • Debrief role plays
  • The power of the group
rationale for victimization awareness empathy training
Rationale for Victimization Awareness/Empathy Training
  • Most offenders victimize for selfish gratification
  • If sex offenders learn about the true consequences of their actions for victims, this confounds their ability to discount the trauma that their actions create and maintain their SOBS
  • Many offenders do not have a generalized empathy deficit
  • However, most sex offenders have little empathy for their victims
  • If they learn, they will be less able to ignore/discount the trauma their victims suffer
goals of victimization awareness empathy training
Goals of Victimization Awareness/Empathy Training
  • To understand the pervasive negative effects of sexual assault on victims and others
  • To know the consequences of his assaults (past and future) on his victims and others
  • To learn empathy skills, especially the ability to empathize with his victims
  • To make re-offending more complicated, less enjoyable
practice implications
Practice Implications
  • SOS treatment programs should assess and target the specific empathy deficits of each offender
  • Important to ensure that the offender does not harbor hostility toward their victim before providing training in victim awareness. Such awareness is valuable only in a caring or benign relationship
  • Contraindicated for sociopath/psychopaths
practice implications cont
Practice Implications (cont)
  • Providers should carefully consider the value of their existing empathy training program.
  • Misdirected interventions would be expected to have no effects, or detrimental effects, on the offenders sympathetic, compassionate, responses to victims.
methods of victimization awareness empathy training
Methods of Victimization Awareness/Empathy Training
  • Presentation of information on the typical trauma to sexual assault victims
  • Use of audiovisual materials
  • Written assignments
  • Group education and confrontation by adult sexual assault survivors
  • Role play
methods of victimization awareness empathy training cont
Methods of Victimization Awareness/Empathy Training(cont.)
  • Each offender describes his worst offense from the victim’s perspective
  • Introduces his victim by first name and age
  • Describes how he accessed and groomed the victim
  • Describes what he did to influence the victim not to report
  • Discusses how the victim is doing now
  • Postulates what the victim would like to say to him or ask him now
interpersonal functioning the third domain of treatment
Interpersonal Functioning—The Third Domain of Treatment
  • Why is this important?
  • Persons with poor social skills may, out of frustration:
    • Overpower victims, or
    • Retreat to the lower stress environment of children
  • Improved social skills and success can reduce the need to resort to abusive behavior to interact with others or meet emotional needs
the goals of increasing interpersonal functioning
The Goals of Increasing Interpersonal Functioning

To increase social skills in:

  • Meeting strangers
  • Initiating and maintaining conversations
  • Correctly interpreting non-verbal communication
  • Developing appropriate non-verbal skills
  • Understanding appropriate methods of indicating interest and disinterest
  • Managing anxiety
the goals of increasing interpersonal functioning cont
The Goals of Increasing Interpersonal Functioning(cont.)
  • Appropriate personal disclosure
  • Transitioning from social to social-sexual interactions
  • Maintaining friendships
  • Respecting women and children
  • Understanding the importance of addressing attention to others beyond one’s self
methods of social skills training
Methods of Social Skills Training
  • Presentations on relevant topics
  • Role play various types of social settings/interactions
  • Behavioral assignments with reports back to the group
rationale for assertiveness training
Rationale for Assertiveness Training
  • Assertiveness increases self-esteem, reduces shame and anger, and increases satisfaction in interpersonal interactions
  • Sex offenders often suffer from shame and/or anger when they assert themselves
  • They often store up slights, humiliations, and react with inappropriate anger—sometimes contributing to violent sexual abuse
goals of assertiveness training
Goals of Assertiveness Training
  • Learn that the primary purpose of assertiveness is not to change others’ behavior but rather to increase self-respect
  • Reduce fear, shame and anger in interpersonal interactions
  • Increase appropriate self-respect and self-esteem
  • Improve effective interpersonal interactions
  • Teach specific assertiveness skills
methods of assertiveness training
Methods of Assertiveness Training
  • Presentation on relevant topics
  • Clarify differences between assertiveness, passivity and aggression
  • Role play various social situations or settings
  • Behavioral assignments with reports back to the group
shame vs guilt kurt bumby 2003

Focus on ‘bad self’

Self as unchangeable

Self-focus reduces empathy

Feel exposed and scrutinized

Defensive externalization

Hostility, low esteem, hopelessness

Cripples coping response

Leads to entitlement


Focus on ‘bad behavior”

Views behavior as changeable

Promotes sense of responsibility

Discomfort from impact of behavior on others

Optimism and self efficacy increases

Motivates commitment to make amends and personal change

Shame vs. Guilt (Kurt Bumby, 2003)
rationale for sexual values clarification training
Rationale for Sexual Values Clarification Training
  • Many sex offenders have deficits in sexual knowledge
  • They may commit offenses in part because they have unreasonable expectations of their sexual functioning, have high anxiety in sexual situations, or have had negative experiences with consenting sexual partners
goals of sexual values clarification training
Goals of Sexual Values Clarification Training
  • Increase knowledge about basic, healthy sexual functioning
  • Promote positive, respectful attitudes toward women and children
  • Educate about normal sexual attitudes, behavior, and performance
  • Reduce anxiety about sexual matters
  • Increase information about sexually transmitted diseases
behavior management the fourth domain of treatment
Behavior Management—The Fourth Domain of Treatment

Sex offending is a choice made by the offender. Relapse prevention is also a choice. Both require commitment, consistently reaffirmed, to the goal. Effective treatment and supervision can assist and encourage the offender to behave in responsible and non-victimizing ways.

relapse prevention
Relapse Prevention
  • First used in the treatment of alcohol and other drug abuse
  • If behavior could be managed to avoid certain situations, then relapse was less likely
  • Applied now in the treatment of sex offenders
rationale for relapse prevention
Rationale for Relapse Prevention
  • Sex offenders who believe that treatment will eliminate their risk for reoffense are more likely to recidivate
  • Offenders who understand that they are never “cured,” recognize offense precursors, and avoid high risk thoughts, feelings, and behaviors are more likely to remain offense free
  • Others must also accept this risk to reoffend
goals of relapse prevention
Goals of Relapse Prevention

The sex offender must learn:

  • That prevention of new offenses is a life-long process and daily choice
  • That certain situations, thoughts, or chains of events pose high risk for re-offense and must be avoided or managed
  • That seemingly unimportant decisions can lead to re-offense
  • That risk to re-offend is not static
  • To respect/fear his risk to reoffend
goals of relapse prevention cont
Goals of Relapse Prevention(cont.)

The sex offender must learn the typical sequence of events that lead to relapse:

  • Perception of control
  • Introduction of a negative mood state
  • Engaging in fantasies of reoffending
  • Development of a plan to commit the offense
  • (Often) use of disinhibiting substance
goals of relapse prevention cont92
Goals of Relapse Prevention(cont.)

The sex offender must learn that:

  • If he interrupts this sequence with positive coping, he can reduce the likelihood of reoffending
  • A lapse is the occurrence of any step in the sequence short of reoffending
  • Interrupting the pre-offense behavior cycle is easiest to do in its early stages
methods of relapse prevention
Methods of Relapse Prevention
  • Dispel offenders’ misconceptions about their reoffense risk—IT’S STILL THERE
  • Identify and share high risk factors and relapse indicators
  • Refine avoidance and coping skills and strategies
  • Design plan to avoid first lapse and how to prevent a lapse from becoming a relapse
  • Learn self-monitoring of moods and behaviors
  • Inform, motivate and empower supervisors
methods of relapse prevention cont
Methods of Relapse Prevention(cont.)
  • Write an autobiography to understand life patterns that result in offending
  • Teach problem-focused coping responses
  • Control stimuli that might promote relapse
  • Teach the relapse process
  • Teach that urges subside with time
  • Teach avoidance and escape strategies
methods of relapse prevention cont95
Methods of Relapse Prevention(cont.)
  • Teach relapse rehearsal
  • Promote lifestyle changes
  • Identify prosocial methods to express power
examples of high risk factors









Potential victims

Alcohol and/or drugs

Some TV or movies


Alone, unsupervised

Money problems

Relationship problems

New freedom

Pain or poor health

Examples of High Risk Factors
examples of relapse indicators
Examples of Relapse Indicators
  • Absence of appropriate sexual activity
  • Denial of risk to reoffend
  • Distance from supervisors, associating with those who don’t know or don’t care
  • Using alcohol or drugs
  • SOBS
  • Testing oneself
  • Unstructured or unmonitored time
  • Change in routine, appearance or demeanor
  • Access to potential victims
ethical practice standards
Ethical Practice Standards
  • Balancing the safety of the community with the offender’s privacy
  • Informed consent
  • Association for the Treatment of Sexual Abusers (ATSA) is the major professional organization that speaks to ethical practice standards in this field
  • ATSA has issued a “Code of Ethics” as well as practice standards and guidelines
a major ethical issue informed consent
A Major Ethical Issue: Informed Consent

At a minimum, sex offenders entering treatment should have spelled out to them—preferably in writing:

  • The purpose and nature of treatment
  • Its expected duration
  • Its anticipated benefits, costs, and risks
  • Limitations of confidentiality
adjunctive therapies
Adjunctive Therapies
  • Marital and family therapy
  • Family education seminars and couples’ groups
  • ‘Non-offending spouse’ groups
  • ‘Approved supervisor’ groups
  • Substance abuse treatment
  • Educational/vocational supports
  • Individual therapy (usually for other issues)
mental illness and sex offenders
Mental Illness and Sex Offenders
  • Most sex offenders are not mentally ill
  • Some sex offenders are mentally ill
  • Most persons with a mental illness never offend
  • Persons with a mental illness are more likely to be victims than offenders
  • Mental illness does not cause or explain sex offending
  • Category of mental illness sometimes diagnosed in sex offenders
  • Essential feature is a ‘recurrent, intense sexually arousing fantasies, sexual urges, or behaviors (at least 6 months) generally involving:
    • Nonhuman objects
    • Suffering or humiliation of self or other
    • Children or nonconsenting adults’
paraphilias cont
Paraphilias (cont)
  • ‘The behavior, sexual urges, or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.’
  • For some individuals, these paraphiliac fantasizes or stimuli are essential for sexual arousal.
  • For others, paraphiliac preference is episodic only.
types of paraphilias
Types of Paraphilias
  • Exhibitionism; exposure of genitals
  • Fetishism; use of non living objects
  • Frotteurism; touching/rubbing against nonconsenting person
  • Pedophilia; focus on prepubescent children
  • Sexual Masochism or Sadism; receiving or inflicting humiliation or suffering
  • Transvestic Fetishism; cross-dressing
  • Voyeurism; observing sexual activity
paraphilias and sex offending
Paraphilias and Sex Offending
  • Exhibitionism, voyeurism and pedophilia are the most frequent paraphiliac diagnosis among identified sex offenders
  • These behaviors are by their nature unlawful
  • With or without public masturbation,
  • Usually not physically assaultive,
  • Often begins in adolescence,
  • Frequency of arrests decrease after 40
  • Usually not physically assualtive
  • Often begins before 15
  • Often chronic in nature
  • Prepubescent children, 13 y/o and younger
  • Offender 16 y/o or older, 5 year plus age difference between offender and victim
  • Specify
    • Exclusive vs. Non exclusive
    • Males, Females, Both
    • Limited to incest
sexual dysfunctions
Sexual Dysfunctions
  • Premature Ejaculation
  • Male Erectile Dysfunction
  • Hypoactive Sexual Desire Disorder
  • Male Orgasmic Disorder
  • Dyspareunia
  • Subtypes
    • Lifelong vs. acquired
    • Generalized vs. situational
    • Psychological vs. combined factors
personality disorders
Personality Disorders
  • Enduring pattern of inner experience and behavior that markedly deviates from cultural expectations. Two or more; cognition, emotions, interpersonal functioning, impulse control
  • Inflexible and pervasive across situations
  • Clinically significant distress or impairment
  • Stable, long duration (adolescence)
  • NOT another MI, substance abuse, medical
antisocial personality disorder
Antisocial Personality Disorder
  • Pervasive pattern of disregard for and violation of rights of others. Since 15 y/o, 3 or more of
    • Repeated criminal acts
    • Deceitfulness, lying, aliases, conning
    • Impulsivity, failure to plan ahead
    • Irritability/aggressiveness, fights/assaults
    • Reckless disregard for safety (self/other)
    • Consistent irresponsibility, work history
    • Lack of remorse or indifference to harm caused
antisocial personality disorder cont
Antisocial Personality Disorder (cont)
  • Over 18 y/o
  • Conduct Disorder by 15 y/o
  • Sociopathic/psychopathic as extreme version
other mental illness
Other Mental Illness
  • Major Depressive Disorder
  • Bipolar Disorder
  • Posttraumatic Stress Disorder
  • Psychotic or Delusional Disorders
  • Other Anxiety Disorders
    • Social Phobia
    • Generalized Anxiety
    • Agoraphobia
mental illness and offending
Mental Illness and Offending
  • Mental Illness is often used as excuse, justification, or a description of criminal acts
  • Many MI complaints follow or increase after arrest
  • Most MI complaints decrease dramatically with SOS treatment
mental illness and insanity
Mental Illness and Insanity
  • Insanity is a legal concept regards culpability or diminished capacity
  • All criminally insane individuals are MI, very few individuals with a MI are insane
  • Criminally insane individuals are not able appreciate their behavior as unlawful or conform their behavior to the law
substance abuse and sex offending
Substance Abuse and Sex Offending
  • Some addicts/alcoholics are sex offenders, most are not
  • Alcohol/drug use can increase risk
  • Sobriety increases safety
  • Most offenders are sober at time of abuse
  • Some recovering addicts/alcoholics continue to sexually abuse
  • Successfully drug/alcohol treatment is essential but not sufficient
treatment progress and provider characteristics
Treatment Progress and Provider Characteristics
  • Treatment has been found to reduce recidivism (Hanson et al 2002)
  • Treatment failure increases recidivism (Hanson & Bussiere 1998)
  • High risk offenders are less compliant with treatment and supervision (Hanson & Harris 1998)
treatment progress and provider characteristics cont
Treatment Progress and Provider Characteristics (cont)
  • Denial and engagement together significantly correlated with treatment progress
  • In combination, engagement and denial explained close to 60% of the variance in treatment progress
  • Engagement was a stronger predictor then denial (Beta .52 & -.37, respectively)

Levenson, 2003

treatment provider characteristics
Treatment Provider Characteristics
  • In the past, sex offender treatment has often involved a punitive treatment style characterized by aggressive verbal confrontation between offender and therapist (therapeutic reaming)

Studies have examined how therapist styles affect the success of treatment:

    • Marshall et al., Clinical Psychology and Psychotherapy (In Press)
    • Marshall et al., Journal of Sexual Aggression (In Press)
    • Jill Levenson, ATSA 2003
treatment provider characteristics cont
Treatment Provider Characteristics(cont.)

Some treatment targets seem to be better achieved with the use of treatment delivered with a motivational approach based on empathic understanding, mutual trust and acceptance.

  • Reduction in sense of entitlement to sexual gratification
  • Reduction of mistrust of women
    • Reduction in impulsivity
    • Client engagement
practice implications121
Practice Implications
  • Providers should consider a positive, invitational and motivational style that supports offender engagement in group
  • Setting expectations for mutual aid and modeling effective communication and helpfulness will foster engagement
  • Group members can take a major role in confrontation which may reduce shame and fears of judgment or rejection.
  • This approach may reduce the salience of the protective function of SOBS and denial
choosing sos evaluators and treatment providers
Choosing SOS Evaluators and Treatment Providers
  • Lack of standardized certification or other credentialing in most jurisdictions presents a major difficulty in promoting common standards of practice
however in illinois
However, in Illinois…
  • The Illinois Sex Offender Management Board ( has published standards for the evaluation, treatment and supervision of adult sex offenders.
  • Also, there is an interim list of individuals that have met SOMB qualifications for SOS evaluators and/or providers
somb interim qualifications for sos providers
SOMB Interim Qualifications for SOS Providers
  • Bachelor’s degree or higher in relevant field
  • 400+ hours of supervised experience in last 4 years, at least 200 face-to-face
  • Completed 10+ SOS evaluations in last 4 years
  • 40+ hours documented training in the specialty of sex offender specific assessment, treatment or management
  • Provide SOS evaluations and/or treatment in accordance with SOMB standards of practice
sos providers as collaborative partners
SOS Providers as Collaborative Partners
  • A willingness to collaborate and cooperate work with other professionals, including:
    • Probation and parole officers
    • Victim Advocates
    • Polygraph examiners
    • Other evaluators and treatment providers
    • Attorneys, prosecutors, and other criminal justice representatives
special populations
Special Populations
  • Juvenile sex offenders
  • Female sex offenders
  • MR/DD sex offenders
juvenile sex offenders
Juvenile Sex Offenders
  • Similarities to Adult Offenders
    • Victimize others
    • SOBS
    • Empathy deficits
    • Impaired interpersonal functioning
    • Not all alike, don’t all need the same thing
juvenile sex offenders128
Juvenile Sex Offenders
  • Differences from Adult Sex Offenders
    • Don’t belong in ASO treatment program
    • Psychopathy less common
    • Deviant arousal less common
    • Interpersonal competency and esteem problems more significant
    • Juveniles may be more amenable to and benefit more from appropriate SOS treatment
from juvenile to adult sex offender
From Juvenile to Adult Sex Offender
  • Not all juvenile sex offenders will become adult sex offenders
  • Long term risk for competently treated juvenile sex offenders is encouraging
  • High value on identifying and properly managing juvenile sex offenders
  • Not all adult sex offenders were juvenile sex offenders
what about children
What about children?
  • Children can and do behave in sexually aggressive ways that hurt others
  • However, it is not usually appropriate or helpful to label them as Sex Offenders
  • Specialized assessment, intervention and management is indicated
  • Sexually aggressive/reactive children should not be placed or treated with Juvenile Sex Offenders
female sex offenders
Adult females

Account for 10-20% of sexual abuse of children

Care-giving context

Socially isolated

Attachment issues

History of PTSD, addiction and MI

Victimized 2X male ASO

Adolescent females

Much more likely victimized sexually

Emotional abuse and neglect victims

Physical and domestic abuse

Use less force or coercion

Abuse in care-giving context

Female Sex Offenders
female sex offenders132
Female Sex Offenders
  • Don’t typically belong in male sex offender programs
  • Not all alike, don’t all need the same treatment program
  • More research and programs needed
  • Hurt people
  • Often overlooked by community,courts and providers
mr dd sex offenders
MR/DD Sex Offenders
  • Offenders with significant functioning deficits need specialized treatment from specialized providers
  • Inappropriate to place in program that doesn’t fit their needs or to forego treatment all together
  • Environmental management important
  • Increase premium on the commitment and dedication of supervisors, natural and official
use of polygraph examination in sos treatment why
Use of Polygraph Examination in SOS Treatment; Why?
  • Very few people (therapists, judges/lawyers or probation officers included) are much better than chance at telling when they are being lied to
  • Most people think they are an exception to this rule
  • Sex Offenders lie
  • Polygraph Examination (PGE) is better than chance and we don’t have anything better
utility of pge in treatment
Utility of PGE in Treatment
  • Encourages offenders to disclose earlier and more completely
  • Improves detail and accuracy of risk assessment
  • Improves safety planning and decision making
  • Motivates offenders to avoid high risk behavior
  • Improves safety for community and victim
  • PGE improves community safety and enhances treatment efficacy by increasing amount of accurate and timely information
concerns about pge in sos treatment
Concerns About PGE in SOS Treatment
  • PGE is not 100% accurate
  • PGE accuracy is affected by skill of examiner
  • PGE cost money
  • Not appropriate to base important decisions on PGE results alone. All information available must be considered
response to concerns about pge use
Response to Concerns About PGE Use
  • NO test is 100% accurate, most test are more easily faked, accuracy is much higher than human detection of deception
  • SOMB standards demand specialized training and experience for examiners
  • Costs are offset by faster movement in treatment and better success rates for programs using PGE
  • It is not responsible practice to ignore any reliable source of information in making important decisions
accuracy of pge
Accuracy of PGE
  • Computerized equipment and scoring have improved accuracy
  • Strength of motivation in the offender examined improves accuracy (If the offender believes the results of the exam matter the results are more accurate)
  • 52 lab studies; median accuracy of .86, range of .70 to .95
  • Field studies, although more difficult, show higher accuracy, median of .89
factors affecting pge accuracy
Factors Affecting PGE Accuracy
  • No significant differences in accuracy found in exam subjects based on;
    • Personality disorder
    • Intelligence (assuming at least 12 y/o level)
    • Ethnicity
    • Number of PGE taken already
    • History of anxiety disorder or high levels of anxiety at time of test
who should be excluded from pge
Who Should Be Excluded From PGE?
  • Actively psychotic or out of contact with reality
  • Physically illness or medication that renders PGE unreadable
  • Presence of acute pain or illness
  • Presence of acute, severe, distress
  • Adjusting to recent (last 2-3 weeks) medication change
types of pge used in treatment
Types of PGE Used in Treatment
  • History disclosure
  • Maintenance/monitoring
  • Specific issue

All include pre and post exam interviews

All PGE are limited to only a few (3-5) specific questions, chosen in consultation between provider and examiner. Offenders are informed of these questions prior to the exam.

history disclosure pge
History Disclosure PGE
  • Purpose is to obtain complete history of offending. Essential for risk assessment, safety planning, treatment planning.
  • Offender, with provider, completes a history booklet before PGE
  • PGE tests the accuracy and completeness of previous disclosures
  • Sometime additional exams are required
maintenance and monitoring pge
Maintenance and Monitoring PGE
  • Purpose is to improve compliance with supervision and safety planning, and to identify any problems (non-compliance) with same
  • PGE covers specific behaviors of the offender within a specific time frame
  • Important for identifying current risk behaviors before new offense occurs
  • Serves to motivate offenders to avoid high risk as they fear detection of the behavior
specific issue pge
Specific Issue PGE
  • Purpose is to detect deception/truthfulness regarding a specific incident
  • This narrow focus allows for the highest level of accuracy among the types of PGE discussed
assessing treatment progress
Assessing Treatment Progress
  • Accurate information and consistent observation across time are essential in assessing an offenders progress in treatment
  • Since offenders lie it makes no sense to use their report as the sole source of information in assessing progress
  • Rather, the offenders behavioral change across time and situations, confirmed by PGE, is the standard
tools for assessing progress
Tools for Assessing Progress
  • Critical and cynical observation across time
  • Consultation with containment team and others
  • PGE
  • Various instruments may be of use
    • Sex Offender Treatment Needs and Progress Scale (McGrath & Cumming, 2003)
    • Facets of Sex Offender Denial (Schneider & Wright, 2001)
    • Group Engagement Measure (Macgowan, 1997)
    • Sex Offender Rating Scale (Anderson et al, 1995)
change in behavioral restrictions
Change in Behavioral Restrictions
  • Only after sufficient progress in treatment
  • Only with collaboration with team
  • Only with specific safety plan
  • Only with increased supervision
  • Only with monitoring PGE
completion of treatment
Completion of Treatment
  • Completion of treatment does not imply the end of supervision or elimination of risk to the community
  • Treatment should be viewed as ranging from intensive to aftercare
  • If risk increases, treatment should be re-instated
completion of treatment cont
Completion of Treatment (cont)
  • The containment team should consult about the completion of treatment
  • The decision should come after the evaluation, treatment plan, course of treatment sequence, and a minimum of a non-deceptive disclosure PGE and two or more non-deceptive maintenance PGE regarding compliance with probation/parole orders, treatment contract and avoidance of high risk situations
unsuccessful termination from treatment
Unsuccessful Termination from Treatment
  • Increase in risk such that continued placement in the community is not safe
  • Reoffense
  • Repeated refusal to comply or engage in treatment process despite sanctions
  • Refusal to accept identity as sex offender
personally relevant circumstances
Personally Relevant Circumstances
  • Strict adherence to letter and spirit of probation order and SOS treatment contract
  • Initiate consequences early and hard
  • Range of consequences
  • Keep court/judge informed of progress or lack of
  • Consider PTR with jail time plus new term of probation for significant violations that no not necessitate termination
contact with children or family reunification
Contact with Children or Family Reunification
  • Only after sufficient progress in treatment
  • Only with “approved supervision”
  • Only with increased monitoring and PGE
  • Only with strict and specific rules and restrictions
  • Only with regular and ongoing coordination with victim advocate or family therapist