The first question to come to mind when picking up this title is exactly what wouldn't be controversial in the field of sex offender treatment. Whether it's prime‐time television or the halls of academe, nothing stirs the pot like the question of what to do with people convicted of sex offenses. The general public's response, or at least that of the politicians contending to represent the public, has been generally either to lock up sex offenders for as long as possible or to restrict where registered sex offenders may reside to the areas as far away from schools and child care facilities as possible (whether or not they have ever committed an offense against a child). While emotionally (and politically) satisfying, questions remain as to how actually successful such measures are in protecting the public, and some have even had unintended consequences. Restricting where registered sex offenders may reside has in some localities blocked off so much real estate as to raise questions about the constitutionality of the laws and has also drawn comment from experts about the importance of adequate housing in reducing recidivism: making housing that hard to find may actually increase recidivism among released offenders.
The editors of Sexual Offender Treatment: Controversial Issues intended this collection of chapters written by experts in the field to challenge conventional thinking and provoke new ways of looking at relevant issues, in hopes of promoting scientific advances. Many of the chapters succeed in this endeavor, but some also make a useful contribution in the opposite direction, by injecting a little common sense into some existing controversies that have derailed scientific inquiry. The editors all practice at, or have practiced at (or are the directors of) sexual offender services in Canadian federal penitentiaries (primarily the Millhaven Institution and Rockwood Psychological Services in Kingston, Ontario) and are widely published experts in the field. Their contributing authors are drawn primarily from correctional and forensic mental health settings in Canada, England, Wales, Australia, and New Zealand (with the exception of Dennis Doran of Wisconsin's Sand Ridge Secure Treatment Center and Anita Schlank of the Human Development Center in Minnesota).
Part I of the book (Chapters 1 through 9) covers general topics, beginning with Dennis Doran's chapter, “Recidivism Risk Assessment: Making Sense of Controversies,” which describes a common‐sense approach to deciding which actuarial risk assessment instrument to use and when to use one. He even points out when some apparent controversies aren't really controversies at all. R. Karl Hanson's chapter, “Stability and Change: Dynamic Risk Factors for Sexual Offenders,” introduces a little more controversy into the risk‐assessment topic with his position that dynamic, changeable factors are not only useful in understanding sexual offending but improve prediction over static factors alone, a position stoutly opposed by others in the field (e.g., see discussion of the positions of Marnie Rice, Grant Harris, and colleagues later in the review). Hanson's discussion of acute and stable risk factors and their role in risk assessment and treatment is one of the best chapters in the book and the one pointing most clearly to what's next for research in the field.
Anita Schlank provides an excellent overview of the questions regarding the various programs for the civil commitment of sex offenders who have served a sentence of incarceration (“The Civil Commitment of Sexual Offenders: Lessons Learned”). The primary lesson appears to be that various potential solutions to the release, treatment, and/or confinement of sex offenders have their own problems (e.g., Are they constitutional? Who gets selected for commitment? Does anyone ever get out? What happens to staff working in these programs?). This chapter comments on the political and clinical controversies of civil commitment programs and identifies some promising innovations and future directions.
There are very good chapters about the process of sex offender treatment (Geris Serran and Liam Marshall's “Coping and Mood in Sexual Offending,” and Michael Proeve and Kevin Howells' “Shame and Guilt in Child Molesters”) which are thought provoking, if not exactly controversial. Other chapters in this first section are also devoted to areas of great research and treatment potential, none newer than the chapter on “Online Sexuality and Online Sexual Problems: Skating on Thin Ice” (Al Cooper, Gale Golden, and William Marshall) which covers the full scope of deviant sexual activity on the internet (or at least more than most pre‐internet era clinicians would even imagine). A chapter on “Sadistic Sexual Aggressors” (Jean Proulx, Etienne Blais, and Eric Beaurgard) is controversial, in that a review of the actual empirical research suggests that we may not understand sadistic offenders as well as we think we do. William Marshall does a fine job of describing the disconnection between most taxonomies of sexual offending and DSM diagnostic categories (“Diagnostic Problems with Sexual Offenders”). His droll, humorous style is fun to read, but there's probably more controversy over the idea about whether sexual offending should be a diagnosed condition at all than over problems with the DSM.
The first and foremost controversy in sex offender treatment—namely, whether it works at all—is addressed in the last chapter in the book (William Marshall's “Appraising Treatment Outcomes with Sexual Offenders”), which is also one of the best. Marshall takes on the camp that has argued most strenuously against there being any reliable evidence that sex offender treatment works, most notably represented by Marnie Rice and Grant Harris. Rice and Harris, along with colleagues Vernon Quinsey and Catherine Cormier, are perhaps best known for describing “actuarial” approaches to risk assessment with the Violence Risk Appraisal Guide (VRAG) and Sex Offender Risk Appraisal Guide (SORAG) in their book Violent Offenders: Appraising and Managing Risk (2nd ed. Washington, DC: APA Press, 2005), in which they advocate a quite rigorous (some would say purist) scientific/statistical approach. The complete absence of these fellow Canadians as contributors to Sexual Offender Treatment (while their positions on the ineffectiveness of treatments for sexual and psychopathic offenders are criticized) is at least a mild controversy in itself.
Rice and Harris, for example, argued (Ann NY Acad Sci 989:198–210, 2003) that randomized controlled trials (RCTs) are the gold standard for evaluating the efficacy and effectiveness of treatment and that, without such methodology, no valid conclusions should be drawn from either individual studies or meta‐analyses that include studies with other methodologies. The RCT model requires randomized assignment to treatment and nontreatment groups and strict adherence to the implementation of the treatment (usually detailed in a standardized manual) so that the purity of the treatment delivered can be assured across all subjects, and any noted effect may be attributed to the treatment. William Marshall contrasts this with the more realistic, and reality‐based, method of “incidental designs” of matched samples of treated and untreated subjects, and he cites a host of authors who have commented on how poorly RCT studies translate to the real world of treatment regardless of the type of therapy being employed. In fact, the rigidity of RCT protocols even violates some principles of clinical practice, such as attempting to adjust treatment to match the learning style and particular needs of each client, and may therefore even be the wrong method for validating treatment, rather than the gold standard. The argument effectively undermines the position that therapy that has not been demonstrated to be effective with an RCT model should not be considered effective.
Marshall cogently points out the weaknesses of the arguments that no acceptable study has ever shown a treatment effect, and he demonstrates how the effect sizes of studies on treatments using cognitive‐behavioral techniques in a relapse‐prevention approach should be considered reliably significant. He makes interesting comparisons between the effect sizes associated with common medical treatments (e.g., aortocoronary bypass surgery and dipyridamole for angina pectoris), which are much smaller than either those for general mental health treatments (the largest) or sex offender treatment (in the middle). He makes useful recommendations about focusing research on treatments with a social learning approach using cognitive behavioral techniques on specific relapse‐prevention elements. He concludes that we can accept with “reasonable confidence” that sex offenders may be effectively treated to reduce (but not eliminate) the number of future victims. This comes across as the reasonable alternative to more extreme views, falling like a well‐executed drop shot that wins the game and set, if not the match.
Howard Barbaree, Calvin Langton, and Edward Peacock tackle a similar controversy in their chapter “Sexual Offender Treatment for Psychopaths: Is It Harmful?” It seems that for years, one or two early studies in which dubious treatment approaches were used have been cited as evidence that psychopaths receiving treatment re‐offend at a higher rate and sooner than psychopaths left untreated. A more recent study (Seto MC, Barbaree HE: J Interpers Violence 15:1235–1248, 1999) appeared to show that psychopaths rated as having active and appropriate treatment behavior reoffended sooner and more often than psychopaths with poor treatment behavior, adding weight to the concept that treatment makes psychopaths worse. This is a comforting thought, frankly, to clinicians who are acquainted with how difficult it is to work with psychopaths and how disruptive and destructive psychopaths can be to programs attempting to provide treatment for other offenders. It is powerfully tempting to conclude that psychopaths should be identified and eliminated from treatment and instead managed with confinement or other external limitations (see Harris and Rice, in Handbook of Psychopathy. Edited by Patrick C. New York: The Guilford Press, 2006, reviewed in this space in J Am Acad Psychiatry Law, 34:428–30, 2006).
However, Barbaree, Langton, and Peacock's thoughtful review of the literature shows that this is a premature conclusion. They report a follow‐up of the Seto and Barbaree 1999 study (Barbaree HE: J Interpers Violence, in press) with better measures of recidivism and longer follow‐up times, and the results showed no differences in the effect of good versus poor treatment behavior on recidivism for the high‐psychopathy groups. Other recent studies cited in this chapter also failed to show any evidence that treatment causes harm in psychopaths, leading to the conclusion that treating psychopaths is not harmful, just difficult.
Both of those chapters are in Part II of the book (Chapters 10 through 19), which is strictly about treatment—the other treatment chapters focusing on the elements of and approaches to sex offender treatment. D. Richard Laws' and Tony Ward's chapter, “When One Size Doesn't Fit All: the Reformulation of Relapse Prevention,” briefly recaps the history of the Relapse Prevention (RP) approach as having been adopted from substance abuse programs for people who were already in recovery (clean and sober) and actively trying to avoid relapse, making the initial model a rather shaky fit for sex offenders, only some of whom would be considered “in recovery” and actively trying to avoid relapse. Many sex offenders in treatment are not committing more offenses primarily because they have been incarcerated, hospitalized, or closely monitored by probation/parole authorities. Laws and Ward present the reformulated model allowing for four different paths in RP: those who are avoiding relapse versus those who are approaching relapse, and each of those groups broken down into those who take an active approach versus those taking a passive approach. The authors discuss how the cycle of offense differs for the different subgroups, recommend that RP be conducted with cognitive‐behavioral techniques (as it almost always is), and, for future directions, that RP be conducted as part of a more comprehensive treatment approach as described by the “good lives” concept.
The good lives approach is not described in detail in this book (see Ward T, Stewart CA: Profess Psychol Res Pract 34:353–60, 2003), but is discussed in Ward and Dawn Fisher's chapter on “New Ideas in the Treatment of Sexual Offenders,” which begins the section on treatment, as one of the more promising developments in the approach to sex offender treatment. Most of the chapter discusses concepts from gene/culture coevolutionary theory as applied to sex offending, which is very theoretical, very broad, and a conceptual challenge to those of us used to thinking of sexual offending strictly as criminal behavior. The authors point out that therapists' attitudes toward offenders should have some basis in their broader attitude toward the nature and value of human beings, and the good lives concept introduces a broader concern with the whole individual rather than the pathological, offense‐prone tendencies in isolation.
This leaning toward a more holistic and frankly positive attitude is discussed in more detail in “Focusing on the Positive and Avoiding Negativity in Sexual Offender Treatment” by Yolanda Fernandez. She cites evidence that confrontational approaches increase resistance among sex offenders and reduces treatment gains. The chapter describes specific techniques that may be more useful and effective, with an underlying (but unspoken) theme that therapy should be therapy and not punishment and that the therapist is just as obligated to avoid acting out the wish to punish sex offenders as with any other therapy client. This theme is echoed in Jo Shingler and Ruth E. Mann's chapter, “Collaboration in Clinical Work with Sex Offenders: Treatment and Risk Assessment.”
Less controversial but perhaps more educational are chapters on “Schema‐Driven Cognition in Sexual Offenders” (Mann and Shingler, again), “Putting ′Behavior' Back into the Cognitive‐Behavioral Treatment of Sex Offenders” (Fernandez, Shingler, and William Marshall) and “Preparatory Programs for Sexual Offenders” (Liam Marshall and Heather Moulden), the latter of which describes the Rockwood Psychological Services Sexual Offender Preparatory Program operated in the Canadian federal correctional system.
Overall, this book is not a comprehensive textbook of sexual offender treatment with a systematic review of the research and practice, but is instead a collection of reviews of particularly “hot topics” in the field. It is the high quality of most of the chapters that makes Sexual Offender Treatment: Controversial Issues a valuable and stimulating contribution.
- American Academy of Psychiatry and the Law
