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). 

Free, one-stop shopping: Bulletin showcases new violence articles

The first monthly bulletin from the Alliance for International Risk Research just hit my email box, collating August's journal offerings on violence risk assessment and management. A quick sampling from the 17 articles listed:

• Large MM, Ryan CJ, Callaghan S, Paton MB, and Singh SP (2013) Can violence risk assessment really assist in clinical decisionmaking? Australian & New Zealand Journal of Psychiatry (online first Aug 2013)

• Rettenberger M, Haubner-Maclean T, and Eher R (2013) The contribution of age to the Static-99 Risk Assessment in a population-based Prison sample of sexual offenders. Criminal Justice & Behavior (online first June 2013)

• Lund C, Hofvander B, Forsman A, Anckarsater H, and Nilsson T (2013) Violent criminal recidivism in mentally disordered offenders: a follow-up study of 13-20 years through different sanctions. International Journal of Law and Psychiatry, 36, 250-257

• Caldwell MF (2013) Accuracy of Sexually Violent Person Assessments of Juveniles Adjudicated for Sexual Offenses Sexual Abuse (online first March 2013).

AIRR's goal is to make information about the latest research on violence risk assessment available to researchers, practitioners, and policymakers for free. I you don't have access to an academic database you still have to find a way to access the articles themselves, but that can generally be done through a request of the author.) If you haven't already signed up to receive your monthly email, you can do so by clicking HERE. 

'Authorship bias' plays role in research on risk assessment tools, study finds

Reported predictive validity higher in studies by an instrument's designers than by independent researchers

The use of actuarial risk assessment instruments to predict violence is becoming more and more central to forensic psychology practice. And clinicians and courts rely on published data to establish that the tools live up to their claims of accurately separating high-risk from low-risk offenders.

But as it turns out, the predictive validity of risk assessment instruments such as the Static-99 and the VRAG depends in part on the researcher's connection to the instrument in question.

Publication bias in pharmaceutical research
has been well documented

Published studies authored by tool designers reported predictive validity findings around two times higher than investigations by independent researchers, according to a systematic meta-analysis that included 30,165 participants in 104 samples from 83 independent studies.

Conflicts of interest shrouded

Compounding the problem, in not a single case did instrument designers openly report this potential conflict of interest, even when a journal's policies mandated such disclosure.

As the study authors point out, an instrument’s designers have a vested interest in their procedure working well. Financial profits from manuals, coding sheets and training sessions depend in part on the perceived accuracy of a risk assessment tool. Indirectly, developers of successful instruments can be hired as expert witnesses, attract research funding, and achieve professional recognition and career advancement.

These potential rewards may make tool designers more reluctant to publish studies in which their instrument performs poorly. This "file drawer problem," well established in other scientific fields, has led to a call for researchers to publicly register intended studies in advance, before their outcomes are known.

The researchers found no evidence that the authorship effect was due to higher methodological rigor in studies carried out by instrument designers, such as better inter-rater reliability or more standardized training of instrument raters.

"The credibility of future research findings may be questioned in the absence of measures to tackle these issues," the authors warn. "To promote transparency in future research, tool authors and translators should routinely report their potential conflict of interest when publishing research investigating the predictive validity of their tool."

The meta-analysis examined all published and unpublished research on the nine most commonly used risk assessment tools over a 45-year period:

• Historical, Clinical, Risk Management-20 (HCR-20)
• Level of Service Inventory-Revised (LSI-R)
• Psychopathy Checklist-Revised (PCL-R)
• Spousal Assault Risk Assessment (SARA)
• Structured Assessment of Violence Risk in Youth (SAVRY)
• Sex Offender Risk Appraisal Guide (SORAG)
• Static-99
• Sexual Violence Risk-20 (SVR-20)
• Violence Risk Appraisal Guide (VRAG)

Although the researchers were not able to break down so-called "authorship bias" by instrument, the effect appeared more pronounced with actuarial instruments than with instruments that used structured professional judgment, such as the HCR-20. The majority of the samples in the study involved actuarial instruments. The three most common instruments studied were the Static-99 and VRAG, both actuarials, and the PCL-R, a structured professional judgment measure of psychopathy that has been criticized criticized for its vulnerability to partisan allegiance and other subjective examiner effects.

This is the latest important contribution by the hard-working team of Jay Singh of Molde University College in Norway and the Department of Justice in Switzerland, (the late) Martin Grann of the Centre for Violence Prevention at the Karolinska Institute, Stockholm, Sweden and Seena Fazel of Oxford University.

A goal was to settle once and for all a dispute over whether the authorship bias effect is real. The effect was first reported in 2008 by the team of Blair, Marcus and Boccaccini, in regard to the Static-99, VRAG and SORAG instruments. Two years later, the co-authors of two of those instruments, the VRAG and SORAG, fired back a rebuttal, disputing the allegiance effect finding. However, Singh and colleagues say the statistic they used, the receiver operating characteristic curve (AUC), may not have been up to the task, and they "provided no statistical tests to support their conclusions."

Prominent researcher Martin Grann dead at 44

Sadly, this will be the last contribution to the violence risk field by team member Martin Grann, who has just passed away at the young age of 44. His death is a tragedy for the field. Writing in the legal publication Das Juridik, editor Stefan Wahlberg noted Grann's "brilliant intellect" and "genuine humanism and curiosity":

Martin Grann came in the last decade to be one of the most influential voices in both academic circles and in the public debate on matters of forensic psychiatry, risk and hazard assessments of criminals and ... treatment within the prison system. His very broad knowledge in these areas ranged from the law on one hand to clinical therapies at the individual level on the other -- and everything in between. This week, he would also debut as a novelist with the book "The Nightingale."

The article, Authorship Bias in Violence Risk Assessment? A Systematic Review and Meta-Analysis, is freely available online via PloS ONE (HERE).

Related blog reports:

• Violence risk instruments overpredicting danger (Aug. 2, 2012) 
• Violence risk in schizophrenics: Are forensic tools reliable predictors? (Sept. 14, 2011) 
• Violence risk meta-meta: Instrument choice does matter (June 19, 2011)
• Psychology rife with inaccurate research findings (Nov. 20, 2011)
• International violence risk researchers launch free news service (June 13, 2013) 

Violence prevention: DC to host major collaborative venture

From U.S. Attorney General Eric Holder to legal scholar Barbara Bennett Woodhouse, the speakers at next month's APA-ABA collaborative conference read like a who's who in the field of violence prevention.

To give a flavor:

• Carl Hart, the neuroscientist whose memoir I recently featured, will speak on the contribution of U.S. drug policy to violence
• James Garbarino, author of the terrific book Lost Boys: Why Our Sons Turn Violent and How We Can Save Them, will address the developmental effects of violence -- a topic that forensic psychologists confront daily in our practices
• Mary Ann Dutton, a leading researcher on domestic violence, will discuss preventing intimate partner violence
• Patrick Tolan and Dewey Cornell will address youth violence in the schools 
• Judge Jay Blitzman and colleagues will talk about disrupting the 'cradle to prison pipeline' by implementing alternatives to school suspension and exclusion 
• Charlotte Patterson, a pioneer in LGBT research, will focus on reducing violence against sexual minorities 
• Mark Soler, an attorney who taught my media law class way back in journalism school, will speak on alternatives to incarceration in juvenile justice 
• Edward Mulvey will address mental illness and substance abuse in violence 

And that's just for starters. With more than 40 plenary and invited sessions, the lineup goes on and on, with a wide array of programming that should appeal to psychologists, attorneys, judges, legal and social science scholars, and anyone else interested in the roles of law and psychology in addressing the effects of violence:

• Intergenerational transmission of violence
• Violence in Native American communities
• Offender reentry
• Risk assessment and threat assessment
• Hate crimes
• Poverty and race in violence
• Sexually violent offenders
• Violence among military veterans
• Elder abuse
• and much more

A major goal of the conference, entitled "Addressing the Unspeakable: Confronting Family and Community Violence, The Intersection of Law and Psychology," is to build on the momentum of Eric Holder's Defending Childhood initiative, which aims to address the effects of violence on children, youth and families.

The conference is co-sponsored by the American Psychological Association and the American Bar Association, and continuation education credits will be provided for both legal and mental health professionals. Early registration ends this week, so register now if you're planning to attend.

The preliminary program is HERE; an overview of the event and its logistics is HERE; the online registration form is HERE. 

8-year prison term in long-running Ayres saga

The up-and-down case of a child psychiatrist who sexually molested boys sent to him by the courts for counseling has finally concluded -- at least for now. William Ayres, 81, pleaded no contest to molesting five boys and was sentenced this week to eight years in prison.

The case has been slogging through the courts for as long as this blog has been around, in large part due to disputes over Ayres's competency. Ayres is suspected of molesting dozens of boys over a period of several decades, but many cases were beyond the statute of limitations.

The case had all of the elements of high drama: A once-respected child psychiatrist accused of molesting vulnerable boys sent to him by the courts. Allegations that prosecutors turned a blind eye. Pressure from victim's rights lobbyists. And, of special interest to this blog's readers, a bevy of mental health experts presenting contradictory evidence.

After a jury trial on the issue of competency ended in a deadlock in 2011, both sides stipulated that Ayres was incompetent due to dementia. He spent about nine months at Napa State Hospital -- where defendants in Northern California are sent for competency restoration treatment -- before the hospital decided that he was faking dementia in an elaborate ruse to avoid trial. He was finally found competent to stand trial after a four-day court hearing late last year.

At his sentencing hearing, victims -- now adults, some with children of their own -- spoke of the traumatic effects of being victimized by someone in a position of trust. As evidence that the former head of the American Academy of Child and Adolescent Psychiatry knew the damage he was inflicting, one former victim even read an excerpt from a journal article Ayres co-authored entitled "Practice Parameters for the Forensic Evaluation of Children and Adolescents Who May Have Been Physically or Sexually Abused."

Victims and their family members burst into applause when Ayres was sentenced, hugging and rejoicing over their victory in a lengthy and uphill struggle for justice, according to a news report in the San Mateo County Times.

But the fight may not be quite over yet: Ayres' attorney warned in court that the wheelchair-bound octogenarian may seek to withdraw his no contest pleas.

My prior blog posts on this case include: 

• Ayres case: Final act in long-running competency drama? Notorious psychiatrist found fit for trial on molestation charges (Nov. 24, 2012)
• Psychiatrist accused of faking dementia to thwart retrial (Aug. 5, 2012)
• Professionals behaving badly: Mistrial in psychiatrist molestation case (July 27, 2009)
• Lesson to abusers: Target socially disempowered (April 23, 2007)

Forensnips aplenty, forensnips galore

Everybody knows that the war is over
Everybody knows the good guys lost
Everybody knows the fight was fixed
The poor stay poor, the rich get rich
That's how it goes, Everybody knows

I can't seem to get Leonard Cohen’s haunting Everybody Knows out of my mind.

Perhaps it's because I was just down in Alabama, the belly of the beast, working on a tragic case. With the highest per capita rate of executions in the United States, the Heart of Dixie State kills people for crimes that other nations punish with probation. No exaggeration. It was jarring to drive around  Montomery and see the close proximity of historic mansions to abandoned homes and decaying housing projects. The juxtaposition is fitting, as Montgomery claims the dual distinctions of being the "cradle of the Confederacy" and the "birthplace of the Civil Rights Movement."  

Montgomery, Alabama (c) Karen Franklin 2013

Or maybe it's a flashback to Elysium, in which the one percenters have left Earth’s teeming masses to rot away while they luxuriate on an idyllic orbiting satellite. The scene in the parole office, with a robot parole agent delivering a quick risk assessment and then pushing meds, is worth the price of admission, although the film is marred by interminable hand-to-hand combat scenes and a ridiculous Hollywood ending.

David Miranda, held hostage
by British security forces

Or, it could be because I’m still riled up over the British government's abuse of David Miranda. He is the Brazilian partner of journalist Glenn Greenwald (think Edward Snowden). In what can only be called an outrageous effort to intimidate journalists, the Brits detained Miranda at Heathrow Airport for nine solid hours -- the maximum allowed under the British Terrorism Act -- before finally releasing him sans his laptop, cell phone and camera. Under the Terrorism Act, he was not entitled to counsel, nor to decline to cooperate. I sure hope it backfires and incenses journalists; it certainly fired up USA Today columnist Rem Rieder (whose column I highly recommend).

* * * * *

I feel bad about the dearth of posts recently. It's been a hectic period. I'll try to make up for my lapse by packing this post with lots of links to forensic psychology and criminology news and views from the past few weeks:

Evidence-based justice: Corrupted memory

Nature magazine's profile of Elizabeth Loftus and her decades-long crusade to expose flaws in eyewitness testimony is worth a gander.

Psychopathic criminals have empathy switch

New research published in the journal Brain indicates that psychopaths do not lack empathy, as is often claimed. Rather, they can switch it on and off at will. The study, out of the Netherlands Institute for Neuroscience, is freely available online. BBC also has coverage.  

The demographics of sexting

Sexting is becoming increasingly commonplace. But practices and meanings differ by gender, relationship and sexual identity, according to a new article, also available online, in the journal Cyberpsychology, Behavior, and Social Networking.

Brainwashed video discussion

New York Times columnist David Brooks just interviewed psychiatrist Sally Satel and psychologist Scott Lilenfield about their new book, Brainwashed, which is getting quite a bit of media buzz. The book is a workmanlike, if a bit superficial, exploration of the allure of "mindless neuroscience." If you’ve got 65 minutes, I recommend watching the video discussion.

Prison news: Hunger strike, juveniles, the elderly, women

On the prison front, a lot has been going on. California prisoners are into Day 50 or so of their hunger strike over solitary housing (a condition that the Department of Corrections denies, despite many men being kept in segregation units for years and even decades) and other cruel conditions. With prisoners' health deteriorating, a court order has been issued allowing force feeding if necessary to forestall deaths. Mainstream media reporting has been minimal, but at least Al Jazeera's got you covered.  

Even more local to me, a lawsuit has been filed over solitary confinement of juveniles in Contra Costa County. The lawsuit, filed in U.S. District Court, accuses county officials of flouting state laws mandating that juvenile detention facilities be supportive environments designed for rehabilitation.

Meanwhile, NBC news is sounding an alarm over the increasing number of elderly people in U.S. prisons. NBC sounds mostly worried about the cost to taxpayers of prisons teeming with upwards of 400,000 elderly prisoners by the year 2030. Read ithttp://usnews.nbcnews.com/_news/2013/06/29/.UeV62HppQL8.twitter, and weep. 

Piper Kerman, author of the memoir Orange Is the New Black that's become a trendy Netflix series, is also sounding an alarm. In a New York Times op-ed, she writes about a federal plan to ease overcrowding in men's prisons by shipping about 1,000 women from Connecticut down to Alabama and points beyond, where they will be even more estranged from their families. As Kerman notes: "For many families these new locations might as well be the moon." I recommend her thoughtful essay on alternatives for low-risk women prisoners. 

In a more promising development, the U.S. Justice Department has announced efforts to curtail the stiff drug sentences that have caused much of this overcrowding in the first place. The U.S. prison system is so bloated, so costly, and so irrational, that even conservatives are calling for reform. Better late than never, I suppose.

By the way, Florida has executed John Errol Ferguson, the prisoner whose controversial case I blogged about earlier this year, whose competency was contested in part because of his insistence that he was the "Prince of God." The American Bar Association had filed an amicus brief asking the U.S. Supreme Court to clarify the standard for competency for execution being applied in the case. 

Sex offender news

In yet another in a series of registry-facilitated vigilante attacks, a South Carolina man has been arrested for killing a sex offender and his wife in the mistaken belief that the man was a child molester. At the same time, there are signs that overzealous laws that contribute to such stigmatization are being scrutinized more closely. For example, a federal judge has struck down a Colorado city's ordinance restricting where registered sex offenders can live, ruling that it conflicts with a state law requiring parolees to be reintegrated into society. An appellate panel in North Carolina has also struck down a law that banned registered sex offenders from using social media sites. The state Court of Appeals agreed with the challenger that the law violated his Constitutional rights to free speech and freedom of association. 

Dispute over expert witness credentials

Finally, there's a big brouhaha in South Dakota over the credentials of a psychologist who frequently testifies as an expert witness in child custody cases. The credentials of the widely respected psychologist, Thomas Price, became an issue during a child custody dispute. It was ascertained that he had earned his PhD in behavioral medicine from an online degree mill called Greenwich University on Norfolk Island, Australia, that was subsequently shuttered by the Australian government. According to an expert on diploma mills quoted by the Sioux Falls Argus Leader, degree mills often adopt the names of respected English universities. Price's resumé says he earned a Ph.D. in behavioral medicine from Greenwich University, without noting the Norfolk Island location. "Typically," notes the article, "people don’t get caught using an unaccredited degree until they assume a high-profile position ... or they do something that causes another person to research their backgrounds…. If you stay under the radar, you can get by."

Science blogger

Finally (this time I really mean it), for those of you who are into offbeat science, I've just added a new blog, Mike the Mad Biologist, to my blog roll (which can be found a little ways down the right column of my blog site). Mike is prolific and wide-ranging in his news links, with a creative spin. 

Hat tips to Jane, Terry, Kirk and others