July 13, 2010

"Treatment": Backwards and upside down?

Don't focus on "denial" or "lack of empathy," warn sex offender treatment experts

Social scientists have long known about the human tendency to divide into in-groups and out-groups. Current popular fascination with so-called psychopaths illustrates this us-versus-them bent. If psychopaths represent evil, that makes the rest of us good. The non-criminal breathes a sigh of relief to discover a distinct "criminal brain" (unless, as neuroscientist Jim Fallon found, we share the abnormality).

Nowhere is this infrahumanisation more extreme than in regards to sex offenders, who are seen as a species apart. Infrahumanisation prevails not just among the general public, but among treatment providers as well. Sex offenders, the popular therapeutic wisdom holds, are likely to lie, distort, and manipulate. Thus, sex offender programs target these attributes in treatment. If a sex offender accepts responsibility and learns empathy, the theory goes, he will be less likely to reoffend.

Not so fast, say three highly experienced scholars and clinicians of sex offending: "As it turns out excuse-making is healthful and results in a reduction in reoffending. It may, therefore, not only be counter to accepted principles of offender treatment to attempt to change noncriminogenic distortions, it may result in increased rates of reoffending."

In their article in the most recent issue of Sexual Abuse in Australia and New Zealand, the researchers argue that many of the entrenched assumptions underlying sex offender treatment are not empirically supported and may actually impede therapeutic progress. Lead author Bill Marshall, an award-winning professor emeritus at Queen's University and Director of a sex offender treatment program in Kingston, Ontario, is one of the world's preeminent scholars of sex offending, with more than 300 publications (including 16 books) dating from long before the fad took hold. Liam Marshall is the primary therapist at the Sexual Offender Treatment Program at Millhaven Assessment Unit, a high-security federal penitentiary in Canada. Jayson Ware, a graduate student at the University of New South Wales who works in the Australian prison system, also specializes in the treatment of sex offenders.

Accepting responsibility. That has a nice moral ring to it. But what does it really mean? And does it translate into a reduction in crime? Most definitely not, the authors state:
[T]aking responsibility, as this is commonly understood in offender treatment, requires the offender to indicate that the behavior has an internal stable cause; that is the client offended because he is a "deviant" or a "bad person." Such attributions are not conducive to change but rather are likely to persuade the offender that his behavior is intractable…. Perhaps it is those sexual offenders who blithely, and readily, admit to all aspects of their offenses, that are the ones who should be given the most therapeutic attention and yet in most programs the full admitters are seen as ideal participants.
In practice, the authors point out, "taking responsibility" often means agreeing with the victim's version of events, which is automatically assumed to be Truth. Treatment manuals instruct clinicians to aggressively challenge any rejection of the victim's account. It is this therapeutic aggression, in turn, rather than the offender's initial minimization or excuse-making, that blocks effective treatment:
Sometimes these challenges are quite harsh and clearly imply that the offender is lying. This type of confrontational challenging has been shown to prevent progress toward the goals of treatment.... Whatever style of challenging is employed, the underlying assumption is that the official record of the offense is a veridical account which the offender must come to agree with if he is to progress further in treatment....

Overall it is hard to see the value in having sexual offenders provide offense details that match the victim's account.... [D]oing so may produce all manner of problems both for the target client and for the other group members. These potential problems might be tolerable if, indeed, overcoming denial and minimizations did result in an enhanced acceptance of responsibility but there is no evidence that it does. Most importantly, there is no evidence that an increase in acceptance of responsibility leads to a reduction in reoffending.…

Therapists may be better advised to change their views on this issue and alter their treatment approach. What we want sexual offenders to do is not blame themselves for their past but rather accept responsibility for their future....

Excuses are attempts to preserve the person's reputation, to prevent the erosion of self-esteem, and to avoid feelings of shame. Stigmatizing shame, where the person concludes they did something wrong because they are bad, leads to an increase in criminal behavior…. While therapists see excuses as examples of criminogenic thinking, extensive research shows that those offenders who offer excuses for their crimes are at lower risk to reoffend than those who accept full responsibility.
The authors similarly tackle the thorny issue of "empathy." Empathy training is a primary component of 94 percent of sex offender treatment programs in North America, according to one survey. Yet a supposed empathy deficit does not predict reoffending, and should not be a focus of treatment, the authors contend.

Finally, the authors address the widespread assumption that sex offenders elaborately plan their crimes. When sex offenders claim an offense "just happened," clinicians accuse them of lying or minimizing. But what if they are telling the truth, and "some, or even most, sexual offenses are not planned?" Again, therapists' insistence that clients adopt their version of reality is an adversarial stance that prevents therapy from succeeding. Offenders learn to keep their true thoughts to themselves and parrot the therapist's opinions, promoting cynicism rather than healing.

So what is left, if therapists ignore excuses, denials, or deficient empathy? Research has established two stable sets of distortions as highly predictive of reoffending, the authors remind us: attitudes tolerant of rape or of child sexual abuse, and emotional identification with children. It is these distorted attitudes, as well as many individual-specific factors -- such as depression, substance abuse, and/or trauma histories -- that put offenders at risk. These empirically established factors, then, should be the foci of treatment aimed at reducing risk.

I highly recommend the full article, "Cognitive Distortions in Sexual Offenders: Should They All Be Treatment Targets?" It is available upon request from the authors. Jayson Ware, one of the authors, will be presenting at the upcoming conference of the Association for the Treatment of Sexual Abusers in Phoenix, Arizona. His Oct. 21 presentation is in the session, "Re-Examining Sexual Offender Treatment Targets," chaired by Ruth E. Mann, PhD of Her Majesty’s Prison Service (UK).