September 22, 2013

Efficacy of sex offender treatment still up in the air

Sex offender group treatment, Larned State Hospital, Kansas
"Did he complete treatment?"

That is a front-burner question for judges and jurors in sexually violent predator trials. Understandably, before they decide to release someone who has been convicted of sexually molesting a child, they want reassurance that he is sincerely remorseful and has acquired the tools to turn his life around. In short, they want a certificate of rehabilitation attesting to his low risk.

But does formal sex offender treatment really lower risk?

A systematic review found no scientifically rigorous studies that establish a link between treatment completion and a reduced risk of reoffending among men who have sexually abused children.

This isn't altogether fresh news. We knew from earlier research reviews that:
  • Any effect of treatment was modest, at best
  • Treatment works best for the tiny minority of very high-risk offenders, while possibly aggravating risk for the broad majority of men at lower risk of recidivism 
  • Older offenders, due mainly to their very low risk, derive no tangible benefits from treatment
But considering both the prevalence and the harm of child sexual abuse, there is surprisingly little high-quality research on effective interventions. Partly, this is because of the lock-'em-up-and-throw-away-the-key mentality of policy makers. And partly it is because of the ethical difficulties in implementing random-design procedures, a hallmark of the scientific method, because men assigned to a control group would be denied treatment that could reduce their risk and in some cases shorten their prison terms.

Patient at "treatment program" in Minnesota
Scouring research databases, a six-member, international research team was able to locate only three well-designed experimental studies. These included one with adults, one with adolescents and one with children. In only the study with adolescents was treatment shown to reduce recidivism. That project used multisystemic therapy, a very promising approach that integrates the family and larger community in the treatment. 

Even broadening the search to include observational studies that lacked experimental designs, the research team found only five studies with a low enough risk of research bias to be deemed reliable. None of the five observational studies demonstrated that formal treatment -- primarily cognitive behavioral therapy with relapse prevention -- impacts sexual reoffending.

High-bias studies, in which the study design introduced a high probability of unreliable findings, were excluded. An example of such research bias would be a study in which treated and untreated offenders differed on a variable known to affect risk. When subjects are  not randomly assigned to treatment or control groups, any observed differences between groups may be due to factors outside of the treatment itself.

Treatment in most formal sex offender programs is cognitive behavioral, and relies primarily on manual-based group therapy. For example, group exercises challenge distorted thinking, denial and minimization.

The research team found no  minimally adequate studies whatsoever on the efficacy of pharmacological treatment with antiandrogen drugs, more popularly known as "chemical castration." They found this omission "particularly striking," in light of the prominence of this method in public debates. 

Can treatment cause harm?

Given "the overall unimpressive treatment effects" that were found, the researchers cautioned clinicians working with sex offenders to consider the potential negative effects of treatment:
"Journeymen" by Ricky Romain (reproduced with permission)
"Under certain circumstances, with some people and some interventions, treatment could increase the risk of sexual reoffending. For instance, prolonged or intense interventions for offenders at low risk of relapse, or grouping low risk offenders with those at high risk for reoffending, could result in adverse outcomes."

They especially cautioned against unnecessary treatment of children. With recidivism risk very low among untreated children, treatment may lead to "unjustified stigmatization and could negatively affect the child’s development…. If these children are subjected to excessively intense or inappropriate therapy, this could increase the risk for future antisocial behavior."

The team was headed up by prominent researcher and professor Niklas Långström and included Canadian researcher R. Karl Hanson, psychologist Pia Enebrink, forensic psychiatrist Eva-Marie Laurén and researchers Jonas Lindblom and Sophie Werkö. The research was commissioned and partially funded by the Swedish government.

The Convention on the Protection of Children against Sexual Exploitation and Sexual Abuse, ratified by 27 countries so far, mandates effective treatment to sexual abusers of children, individuals at higher risk of committing such offences, and children with sexual behavior problems.

This mandate is a bit of a problem, given the inconclusive evidence that the dominant treatment approach works.

Manualized, one-size-fits-all approach

My own belief is that the one-size-fits-all approach of manualized group therapy, driven in part by a shortage of highly qualified and talented clinicians in bureaucratic institutions, can never meet the needs of a heterogeneous population of offenders. Indeed, in the hands of poorly trained technicians, much of what passes for "treatment" is actually punishment in disguise. As anthropology professor Dany Lacombe noted in her insightful ethnographic study,  sex offender treatment can paradoxically cement deviance through its obsessional fixation on sex. As an 18-year-old patient told Lacombe:
"They want to hear that I always have fantasies and that I have more bad ones than good ones. But I don't have bad ones that often. I make up the bad ones. I make them really bad because they won’t leave me alone." 
"Contained" by Ricky Romain (with artist permission)
Genuine treatment, as we all should remember from our graduate school training, is all about the empathic relationship -- not the technique. Indeed, although more and more psychologists have internalized the insurance industry's mantra that cognitive-behavioral therapy (CBT) is the "evidence-based" treatment of choice for a variety of conditions, this is not actually true. For example, in a new randomized clinical trial published in the American Journal of Psychiatry, psychodynamic therapy performed just as well in the treatment of depression.

The research team cautioned that their failure to find significant effects of treatment should not be interpreted to mean that treatment as currently implemented is ineffective. The low base rates of recidivism among sex offenders make it difficult to find treatment effects without very large sample sizes and long follow-up periods, they point out.

Additionally, an early study out of California provided some evidence that it was not the formal completion of treatment per se that reduced risk but, rather, the internalization of treatment messages and a desire to change -- something that is harder to measure. 

The research team issued a call for large-scale, multinational randomized controlled trials. In the meantime, in the absence of solid proof that manualized cognitive-behavioral group therapy works as intended, they recommend a shift to more individualized assessment and treatment.

That's a solid, and very welcome, recommendation.

The study is: "Preventing sexual abusers of children from reoffending: Systematic review of medical and psychological interventions" by Niklas Långström, Pia Enebrink, Eva-Marie Laurén, Jonas Lindblom, Sophie Werkö and R Karl Hanson. It is freely available online from the British Medical Journal (HERE). 

Subscribers: View the conversation and add your comment by scrolling to the bottom of the original blog post (HERE). 


Anonymous said...

I realize that men commit most of the sexual crimes, but women commit them as well, and this article appears to be geared toward men when, IMO, it should be gender neutral.

fl9826024 said...

A friend of mine picked up a prostitute at a bar. When they were caught in his car, it turned out that she was only 16. She had a fake ID. He would never harm nor is attracted to children yet suffers the stigma of being a pedophile. He has been forced out of his home of 30 years and has been floating around in motels despite owning a home. While doing four years in prison for rape, he was forced to take the treatment program and if he didn't pass, he was threatened with losing his good time. In order to pass the treatment program, he was forced to lie and admit to things he didn't do nor had the propensity to do. It seems the program turned him into a liar and made him a very angry and withdrawn person. Before, he would have given anyone the shirt off his back. Today, if there was a burning building with kids screaming inside, he'd drive right by. Yup, he was corrected.

willB said...

this information has been available since 1989 is just that nobody wanted to look at. Research studies evaluating the effectiveness of current politically and socially acceptable treatment programs have resulted in the classification of three types of programs they can best be described as forced failure, possible, and none. Studies researching Behavior Modification programs that are approved and mandated by the courts the board of post prison supervision and probation officers and implemented by State Hospital’s verified recidivism rates across the country. The (1989) Furby, Weinrott, and Blackshaw study of these studies being the most extensive and meticulously analytical. The studies found that offenders placed on probation with NO therapy are the least likely to re-offend. Offenders sent to jail or Prison also WITHOUT THERAPY are rated second least likely to re-offend. But those who are mandated, volunteer (under threat of prison or jail time) or are sentenced to Behavior Modification therapy are at least twice and as much as ten times as likely to re-offend in the committing of a new sex crime, and will commit other types of violent crimes at unreasonable rates as well. In the George Dix (1976) study, those who had been imprisoned and not treated, only 7.3% (That is about 1.1% per year) were convicted of subsequent sex offense and none of a subsequent non-sex offense. Those who had treatment were convicted at a rate of 16.7% for a subsequent sex offense and 12.5% of a subsequent non-sex related offense. That is a total conviction rate of 7.3% without treatment and 29.2% with treatment.

In the state funded study for the legislator " Sex offenders in Oregon", by Marcia Morgan M.S., The Furby study was quoted as stating "there is as yet no evidence that clinical treatment reduces the rate of sex offense." Furby and her colleagues statement was omitted from the state report, Where they stated: "The recidivism rate of treated offenders is not lower than that for untreated offenders; if anything, it tends to be higher.

Why is it then when Furby looked at 24 exceptional North American study's with 9957 sex offenders, 5292 with treatment and 4665 with out. The treated ones committed a new sex offense at 20.3% while only 5.6% of the ones without treatment committed another sex offense. The reconviction rate for any other types of crimes was 12.3% for untreated and 30.8% for those with treatment. That is a total reoffence rate for all crimes of 51.1% for those treated and 17.9% for those without treatment. From the Furby studys

The widely recognized researcher on psychological evaluation Robyn M. Dawes in his book House of Cards "Psychology and Psychotherapy Built on Myth", stated "A person who claims that a treatment is effective must demonstrate that it has an effect in comparison to a hypothetical counterfactual, obtained through construction of a randomly constituted control group." Such randomized experiments are very necessary in evaluating treatments for emotional disorders and one of the best is what is called a "Wait List Control". This was used in the Florida Department of Health and Rehabilitative study from 1984 the people who had completed treatment re-offended in a sex crime at 13.6% and other crimes at 18.6%. Those who did not complete treatment at 6.5% for sex offense and 12.9% for other crimes and those that were on the list, but did not get into treatment re-offended in sex crimes at 5% and other crimes at 0%. The more the treatment, the more the criminal activity! The jacks study in 1962 looked into non-treated offenders showed the re-offense rate of 3.7% over 15 years that’s 2/10 of 1% per year , this must be used as the base line set as laid out by Robyn Dawes any treatment program with a reoffence rate higher then 3.7% for a 15 year period must be consider a failure of the program not the individuals in it.

dHarbour60 said...

Something not stated here was the idea that there are treatment providers who have no business treating sex offenders because of a personal bias that bleeds over into their work. I have, unfortunately suffered such a situation in the past.

Karen Franklin, Ph.D. said...

Mr. Sanders,

Thanks for your comment. While I appreciate your perspective, the extreme gender imbalance of sex crimes makes this an instance in which gender-neutral pronouns have the potential to be more obfuscating than enlightening. Males make up the overwhelming majority -- an estimated 96 percent to 99 percent -- of sex offenders who come to the attention of the legal system. Women's rates of recidivism -- on the order of 1 to 3 percent -- are also far lower than those of male sex offenders. This is in part because their motivations are distinct from those of male offenders. There are few pedophiles or preferential rapists among them. Their crimes are typically not predatory, and few use violence. Most of those few who do recidivate are motivated not by sexual deviance but by general criminality. Women's low base rate of recidivism would make it extremely difficult to get the statistical power needed to scientifically establish any treatment efficacy; a study would require very large samples in order to find any statistical effect of treatment. Thus, the methodological problems discussed in this article would be magnified. Like it or not, sexual offending is not a gender-neutral crime -- it is a crime overwhelmingly committed by men against women and children. But you have given me an idea for a follow-up blog post. ;-)

researcherone said...

@ fl9826024

I am aware that you were using the term in reference to the social stigma, but I will clarify it anyway: Being attracted to and having sexual relations with a 16-year-old does not make one a pedophile. The latter are drawn either exclusively or predominantly to PREPUBESCENT children. Sixteen-year-old youths are physically developed, on average, the same as 18-year-olds, which is attested by the fact that your friend erroneously thought the prostitute to be 18. That wouldn't necessarily have made him attracted to younger youths, although most m4en are so by nature, which isn't problematic. ACTING on that attraction is problematic as far as the law i9s concerned. That's why I find absolutely no reason to think he would undergo "treatment" (other than preventative), especially since he thought the girl 18 years old. What reasoning could the judge have had to sentence "treatment" other than preventative lock-up?

\I don't mean to be harsh, but I fail to see what kind of "treatment" would be used on SOs who have engaged with adolescents, especially older adolescents. True, some cases involve other issues, such as a history of sexual abuse or social ineptitude, but certainly not all cases are this way, like the other poster’s friend. Even you, Karen, and others like Green have stated that an age preference does exist. That was the reason for employing such terms in the first place. I remember when you mentioned "standard treatment". What kind of treatment is there for an attraction that is not deemed pathological?

That said, the low efficacy in "treatment" is no surprise to me, so I find it somewhat strange that such a result would be a mystery. Isn't it possible that such a condition is naturally innate? If so, how can it be treated? Is this a case of science trying to stifle or manipulate natural inclination? Could this be the basis of the reason behind the low efficacy outcome? I'm not saying, nor would I EVER say, this is absolute. Each case is different, yet, from what I recall, most of these cases involve adolescents.This would explain the lack of efficacy on the large part.

Why is such a natural attraction treated like a disease when the psychiatric community has adamantly affirmed it isn't?


researcherone said...

By the way, I wonder the personality change that came over the second poster's friend was due to his previous treatment or the social ostracism that followed. Or both?

I was going to say that seems like one good example of how such treatments serve a harmful rile in the rehabilitation process. If this treatment is the cause of psychological damage, who should be held accountable and what changes should be made and how?


researcherone said...

Can the non-predatory motivation of female offenders apply to the motivations of male offenders as well? If the women are, on average, non-deviant, couldn't the same status be applied to the male offender? What evidence exists to substantiate a male offender as deviant or more deviant than a female offenders simply because of head count? How can the number of one gender over the other serve as conclusive regarding motivation?

Karen Franklin, Ph.D. said...

Researcherone: Of course one cannot infer motivation from head count! And, equally obvious, some male sex offenders are not predatory. Motivation -- both on the individual and aggregate levels -- is adduced through in-depth research. Clinicians and researchers have been studying sexual deviance for decades, and have produced volumes and volumes of scholarly information and analysis. There are numerous books summarizing the research on the causes of sexually deviant behavior (and why there is a gender divide). A few I recommend: (1) Prentky, Janus and Seto's Sexually Coercive Behavior: Understanding and Management; (2) Laws and O'Donohue's Sexual Deviance (Second Edition); (3) Ward, Polaschek and Beech's Theories of Sexual Offending; (4) Brown and Walklate's Handbook on Sexual Violence; (5) O'Toole and Schiffman's Gender Violence: Interdisciplinary Perspectives; (6) Laws and Ward's Desistance from Sex Offending, and, specificially vis-a-vis pedophilia, (7) Seto's Pedophilia and Sexual Offending Against Children.

researcherone said...

@ Karen: Ah, okay. I read through the post, which explains some forms of treatment for SVPs, so that answers my question. Many of these are treatments, such as antiandrogen drugs, are among those of which I am aware.

If I'd just read first, I would have answered my own question. It was late last night and I was growing tired. My apologies.

Thank you for addressing my query. I appreciate the thoughtful response and the sources offered. I will certainly look into them.