July 15, 2010

"Consumed With Sex": Sex offender treatment in risk society

Tuesday's post on sex offender treatment has been reposted on several discussion boards and listservs and is getting some hits from Alltop, a kind of cool online psychology news service. In doing research for an article I am writing about sex offense prevention, I just came across another one that may interest many of you. It's based on ethnographic research by Dany Lacombe, a professor of sociology and anthropology at Simon Fraser University, at a sex offender treatment program up in Canada.

Dr. Lacombe ended up dubbing the program Sex Offender School because of the way that it indoctrinated sex offenders into internalizing a high-risk identity as "a species entirely consumed by sex." Her observational analysis, "Consumed With Sex: The Treatment of Sex Offenders In Risk Society," published in the British Journal of Criminology, is fascinating. Here is the abstract:
This ethnography of a prison treatment programme for sex offenders examines the meaning of rehabilitation in the context of the 'new penology.' As it explores how cognitive-behaviourism structures treatment, it uncovers a therapeutics grounded in risk that actively constructs the identity of the sex offender. It shows how the management of risk relies on techniques of introspection and self-discipline—a patient's internalization of his crime cycle and relapse prevention plan—that target primarily sexual fantasies. These self-policing techniques radically transform the sex offender into a species entirely consumed by sex.
I recommend the entire article, which can be requested directly by emailing Dr. Lacombe.

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).

July 12, 2010

Heartbreaking video on elderly and dying prisoners

Readers appreciated the video documentary I posted last week on the mentally ill in U.S. prisons, so here's a newer video on the elderly in prison. Forget humanitarianism; the economic costs alone of incarcerating so many elderly and infirm should be cause for alarm.



Al Jazeera's investigative reporting continues to impress me. In this special investigation, "Fault Lines: Dying Inside," we see amazing footage that includes:
  • a prisoner with Huntington’s Chorea in the nation's first specialized unit for demented patients, a 30-bed facility in New York that has never before been filmed for TV
  • 100-year-old Sherman Parker, demented and missing one leg, being cared for by a prisoner earning $5 a month in an Oklahoma prison "operating in warehouse mode" due to severe budget cuts
  • 86-year-old Plutarcho Hill, imprisoned for 66 years for a 1947 murder, who has escaped and returned to prison 10 times
  • Larry White, a 72-year-old ex-convict released from prison three years ago who is "going back and helping those I left behind" by lobbying for compassionate release for elderly prisoners
  • a woman volunteer who is dedicating her life to providing hospice for dying prisoners in the Pennyslvania prisons

July 10, 2010

Normality endangered: "Psychiatric fads and overdiagnosis"

That's the title of this week's Psychiatric Times commentary by Dr. Allen Frances, chair of the DSM-IV Task Force and psychiatry professor emeritus at Duke University. The column begins:
Fads in psychiatric diagnosis come and go and have been with us as long as there has been psychiatry…. In recent years the pace has picked up and false "epidemics" have come in bunches involving an ever-increasing proportion of the population. We are now in the midst of at least 3 such epidemics -- of autism, attention deficit, and childhood bipolar disorder. And unless it comes to its senses, DSM5 threatens to provoke several more (hypersexuality, binge eating, mixed anxiety depression, minor neurocognitive, and others).

Fads punctuate what has become a basic background of overdiagnosis. Normality is an endangered species. The NIMH estimates that, in any given year, 25 percent of the population (that’s almost 60 million people) has a diagnosable mental disorder. A prospective study found that, by age thirty-two, 50 percent of the general population had qualified for an anxiety disorder, 40 percent for depression, and 30 percent for alcohol abuse or dependence. Imagine what the rates will be like by the time these people hit fifty, or sixty-five, or eighty. In this brave new world of psychiatric overdiagnosis, will anyone get through life without a mental disorder?
While focusing on the alarming spread of psychiatric diagnoses among children, as he has in the past Dr. Frances touches on the forensic implications of diagnostic freneticism:
Mental disorder labels can provide cover for societal problems. Criminal behavior has been medicalized (eg, rape as a psychiatric disorder) because prison sentences are too short and such labeling allows for indefinite psychiatric commitment.
Frances concludes:
The DSM-5 bias to thrust open the diagnostic floodgates is supported only by flimsy evidence that does not come close to warranting its great risks of harmful unintended consequences. It is too bad that there is no advocacy group for normality that could effectively push back against all the forces aligned to expand the reach of mental disorders.
The full essay is HERE.

July 9, 2010

Correctional ethics: New guidelines; licensing complaints

New correctional psychology standards published

As most of you know, the largest mental health institutions in the Land of the Free are not hospitals, but penal institutions: Riker's Island in New York, Cook County Jail in Chicago, and the Los Angeles County Jail. The USA incarcerates the largest proportion of its population of any country on the planet, and at least 15 percent of those 2 million or more people have serious mental illnesses. Unfortunately, many correctional systems lack resources to meet the constitutionally mandated needs of mentally ill individuals in their custody.

For you folks in correctional psychology, Criminal Justice and Behavior has just published a special issue containing the newly revised standards for psychologists working in jails, prisons, and other correctional facilities and agencies. This is only the second revision of the standards since their initial publication by the International Association for Forensic and Correctional Psychology (IACFP) in 1980. They are the result of more than a year's effort by a revision committee chaired by Richard Althouse, Ph.D., president of the IACFP.

Guantanamo psychologists face ethics charges

The timing of these new guidelines is serendipitous. Earlier this week, the San Francisco-based Center for Justice and Accountability and Harvard Law School's International Human Rights Clinic filed state licensing board complaints against two former Guantanamo psychologists. The aim of the complaints, filed in New York and Ohio, is to force investigations into the psychologists’ roles in the torture of prisoners.

The Ohio complaint alleges that Larry C. James, now dean of Wright State University's School of Professional Psychology, headed a special unit called the Behavioral Science Consultation Team, known as "Biscuit," that advised the military on how to break down prisoners and participated in the controversial interrogations at Guantánamo. The New York complaint is against psychologist John Leso, Dr. James's predecessor on the special team.

APA revises ethics standards

In the wake of the Guantanamo abuses, the American Psychological Association has revised its Ethics Standards to clarify that compliance with the law is no excuse for unethical behavior.

Specifically, language has been added to Standards 1.02 and 1.03 ("Conflicts Between Ethics and Law, Regulations, or Other Governing Legal Authority" and "Conflicts Between Ethics and Organizational Demands") stating that the standards may "under no circumstances … be used to justify or defend violating human rights." In addition, a clause allowing psychologists to behave unethically in order to "adhere to the requirements of the law, regulations, or other governing legal authority" has been struck out.

Related resources:
  • The new correctional standards are available HERE for free for a limited time.
  • Mother Jones and Democracy Now have in-depth coverage of the Guantanamo complaints, with links to additional background materials.
  • The Ohio complaint against psychologist Larry James is HERE. Local coverage of that case, in the Dayton Daily News, is HERE.

July 8, 2010

Video: Criminalization of mentally ill

I just stumbled across an outstanding educational video on the mentally ill in U.S. prisons. Focusing on Texas prisons, it touches on the problems of isolation, decreased funding, and telecare. Brought to you by Al Jazeera.