Effects of a relapse prevention program on sexual recidivism: final results from California's sex offender treatment and evaluation project (SOTEP)

Transformative Learning Theory and Its Application to the Delivery of Community Maintenance Programs for Men Who Have Sexually Offended

Given public perceptions about those who have sexually offended, there tends to be a focus on offence-specific intervention programs in a bid to address re-offending risk. With a significant portion of the literature on sexual offending focused on the development and evaluation of interventions targeting this behavior, there is little that considers community maintenance programs (CMPs) or those programs in the community where those who are released from prison are attempting to reintegrate. Further, there is no known research considering the theoretical underpinnings of or a framework for delivering CMPs. This paper offers Transformative Learning Theory as a potential framework for the delivery of CMPs and offers that adult learning theory needs to be considered in the delivery of offending interventions.

Moderators of Sexual Recidivism as Indicator of Treatment Effectiveness in Persons With Sexual Offense Histories: An Updated Meta-analysis

The present meta-analysis is an update of the meta-analysis by Schmucker and Lösel [Campbell Syst. Rev. 2017; 13: 1-75], which synthesized evidence on sexual recidivism as an indicator of treatment effectiveness in persons with sexual offense histories. The updated meta-analysis includes 37 samples comprising a total of 30,394 individuals with sexual offense histories, which is nearly three times the sample size reported by Schmucker and Lösel (2017: 28 samples, N = 9781). In line with Schmucker and Lösel (2017), the mean treatment effect was small with an odds ratio of 1.54 [95% CI 1.22, 1.95] (p < .001). A moderator analysis suggested three predictors of importance, i.e., risk level, treatment specialization, and author confounding. Greater treatment effectiveness was suggested in high- and medium-compared to low-risk individuals and in specialized compared to non-specialized treatments. Authors affiliated with treatment programs reported larger effectiveness than independent authors. These findings were overall in line with Schmucker and Lösel (2017), though the effects of risk level and treatment specialization were stronger in the current meta-analysis. The findings of the updated meta-analysis reinforce the evidence for the first and second principle of the Risk-Need-Responsivity model. The results may support researchers and decision-makers in interpreting the current evidence on sexual recidivism as an indicator of treatment effectiveness, and, based on that, implement and carry out informative, methodologically sound evaluations of ongoing treatment programs in persons with sexual offense histories.

Learning From Consumers of Mandated Sex-Offending Programs: "It's Not Treatment, I Wish It Was."

The purpose of this qualitative study was to explore clients' perceptions of sex-offending treatment. The sample included 291 people required to register as sex offenders in the U.S. who answered an open-ended question in an online survey asking them to describe their positive and negative experiences in mandated treatment. Using qualitative analysis, three overarching themes (with several subthemes) were identified: (1) positive and (2) negative treatment experiences and (3) the affiliation between the criminal justice system and clinical services. Experiences in sex offending treatment were viewed as positive when clients had opportunities to learn about themselves, experience group cohesion, build a positive alliance with a caring therapist, learn tools and skills for emotional health, explore the roots of offense behavior, and create healthy life plans to reduce risk for re-offending. Negative themes emerged when treatments were viewed as coercive, confrontational, or demeaning; when therapists seemed inexperienced or unqualified; and when seemingly outdated or unscientific methods were emphasized without explanation or dialogue. The entanglement between court-mandated treatment providers and the criminal justice system led to concerns about confidentiality, conflicts of interest, and role ambiguity. Drawing upon literature related to therapeutic alliance, trauma-informed care, and Risk-Need-Responsivity models, we offer suggestions for integrating client feedback to improve treatment responsivity and prevent re-offending.

The Effectiveness of Psychological Treatment in Adult Male Convicted for Sexual Offenses Against Children: A Systematic Review

Child sexual abuse is a public health problem of global magnitude with profound and negative consequences for the victims and society. Thus, psychological intervention with individuals who sexually offended against children is crucial for reducing recidivism. Numerous reviews and meta-analyses have shown the effectiveness of psychological interventions in individuals who sexually offended, but few reviews have been done on this subtype of offenders. This article reviews evaluation studies of intervention programs designed to treat individuals who sexually offended against children, providing a more detailed account of treatment procedures. Articles were identified from peer-reviewed databases, bibliographies, and experts. Following full-text review, 12 studies were selected for inclusion by meeting the following criteria: quantitative or qualitative research studies published in English from 2000 to 2020 with titles or abstracts that indicated a focus on treatment effectiveness, detailing the psychological treatment procedures on adult, male individuals convicted for child sexual abuse. Cognitive-behavioral therapy with a relapse prevention approach was the most frequent modality found in child sexual offending treatment. Besides, different criminogenic and non-criminogenic factors emerge as targets for intervention. Study design, study quality, and intervention procedures shortened the accumulation of evidence in treatment effectiveness.

Maladaptive Beliefs of Young Adults in Interpersonal Relationships: A Systematic Literature Review

Beliefs that are too rigid and misadjusted may legitimize interpersonal relationships marked by verbal, physical, or sexual violence. A systematic literature review was performed to identify the existence of maladaptive beliefs (MBs) in interpersonal relationships of young adults and their association with problematic behaviors. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, studies were obtained through a search in multiple databases: EBSCOhost, PubMed, and Web of Science. Of the 1,280 articles retrieved, 42 were retained for further analysis and 15 were considered eligible for inclusion. In addition, seven studies were added through manual search, leading to a final sample of 15 articles, published between 1964 and 2021. Only empirical studies with quantitative methodologies were included. Objectives, sample (age in years), sample type, country of origin of studies, instruments, control group, and results and main conclusions were extracted from each study. Results suggest the existence of MBs that may legitimize antisocial behavior and violence, whether physical, sexual, gender, domestic, or in intimate relationships. Some intervention programs were also identified, with different approaches with a reasonable degree of efficacy in changing these beliefs or in reducing the rates of recidivism by the aggressors.

Improving professional practice in the investigation and management of intrafamilial child sexual abuse: Qualitative analysis of serious child protection reviews

BACKGROUND

Local multi-agency case reviews are regularly held in England when children have suffered significant harm from abuse or neglect, including from child sexual abuse (CSA). Most CSA takes place within families, is common but under-reported and can cause long-term harm.

OBJECTIVE

The aim was to analyse English child protection reviews relating to intrafamilial CSA to identify improvements for professional practice.

PARTICIPANTS AND SETTING

Local Child Safeguarding Practice Reviews (LCSPRs) and Serious Case Reviews (SCRs) relating to serious incidents of intrafamilial CSA occurring between 01 April 2017 and 31 March 2020.

METHODS

LCSPRs and SCRs were obtained from the National Case Review Repository and thematically analysed.

RESULTS

There were 243 reviews, of which 25 featured intrafamilial CSA. The main themes related to perpetrators, vulnerable families, and professional practice. Half of perpetrators were known by services to have previously abused children, but issues with professional practice enabled them to continue. Most children did not disclose CSA verbally showing challenging or sexualised behaviour; but professionals lacked knowledge and confidence on how to intervene without verbal disclosure, which limited safeguarding actions. Non-engagement by families with services was common, with some non-abusing parents complicit in abuse and deception. Significant neglect occurred in half the families, which diverted professional attention away from CSA.

CONCLUSION

CSA is deliberate abuse of children involving considerable deception by perpetrators in contrast to some other types of child abuse. This difference in abuser behaviour makes child protection more difficult, particularly when professionals do not recognise and respond to children's non-verbal disclosures.

Changes in the Risk of Sexual Reoffending: The Role and Relevance of Perceived Self-Efficacy and Adult Attachment Styles in Correctional Treatment

According to the Risk-Need-Responsivity (RNR) model, treatment effectiveness increases when treatment addresses all three associated core principles. While researchers have focused on the risk and need principles, responsivity remains under-investigated. The theoretical foundation of the RNR model and former research indicates low perceived self-efficacy and inadequate adult attachment styles as potential responsivity factors that can impede treatment of the underlying risk factors. This study assesses firstly whether these factors predict treatment attrition, and secondly changes in the assessed risk of sexual reoffending. Participants were N = 146 men sentenced for sexual offenses in a German social-therapeutic correctional facility. Younger age, higher number of previous convictions, and higher scores on the interpersonal facet of the Psychopathy Checklist-Revised are associated with a higher risk of treatment attrition. Unemployment prior to incarceration was found to be an aggravating factor, whereas substance abuse emerged as a mitigating factor, according reducing the risk of reoffending. Neither pre-treatment self-efficacy nor attachment styles revealed as responsivity factors in this study. Future studies should examine if the consideration of these factors during treatment might impact treatment outcomes.

"I've Got the Energy to Change, But I Haven't Got the Energy for This Kinda Therapy": A Qualitative Analysis of the Motivations Behind Democratic Therapeutic Community Drop-Out for Men With Sexual Convictions

Prison-based democratic therapeutic communities (TCs) provide an alternative to mainstream prison, where prisoners can work on psychological difficulties and address offending behavior. Research demonstrates TCs are effective at reducing reoffending rates for residents who stay in therapy 18+ months, and those who drop out of TCs offend at a significantly higher rate than those who complete therapy. Thus, it is important to reduce attrition in TCs. No research has yet explored the explanations for TC drop out offered by those with sexual convictions. The present study uses Interpretive Phenomenological Analysis to qualitatively explore the accounts of men with sexual convictions (n = 7) who dropped out of a TC in a UK prison. Results highlight that issues surrounding external responsivity, therapeutic relationships, and treatment readiness were salient in the participants' accounts of drop out. This research has implications for TCs seeking to better understand and address attrition of people with sexual convictions.

A Preliminary Analysis of Sexual Recidivism and Predictive Validity of the Static-99R in Men Discharged From State Hospitals Pursuant to California's Sexually Violent Predator Act

We examined the recidivism rates and the predictive validity of the Static-99R in 335 men who were detained or civilly committed and released from California State Hospitals pursuant to the Sexually Violent Predator (SVP) Act, and followed up for approximately 21 years from date of hospital admission. In all, 8.7% were arrested or convicted for a new sexual offense during the total follow-up (N = 335) and 7.8% over a fixed 5-year follow-up (n = 205). The Static-99R demonstrated small in magnitude discrimination for sexual, violent, and general recidivism (area under the curve [AUC]/C = .56 to .63). Calibration analyses, conducted through expected/observed (E/O) index, demonstrated that the Static-99R overpredicted sexual recidivism, irrespective of whether the Routine or High Risk/Need norms were used. Observed recidivism rates were lower than predicted by Static-99R scores and may be the result of the sample's older age at release, lengthy hospitalization, or other factors.

Mandated or Voluntary Treatment of Men Who Committed Child Sexual Abuse: Is There a Difference?

Child sexual abuse is associated with multiple and often severe consequences for people who are affected by it. From the perspective of indicative prevention, the treatment of people who have sexually abused children represents one important strategy, with the assumption that there is often a risk for sexual recidivism. However, there is still very limited knowledge about how men who have not been convicted of child sexual abuse but participate in voluntary treatment (here called non-forensic clients) differ from those who have been convicted and undergo mandated treatment (here called forensic clients). This study compared 22 forensic and 22 non-forensic clients regarding pedophilic interests, static and dynamic risk factors, responsivity features, and treatment progress during an individualized treatment based on the principles of risk, need, and responsivity. We found neither differences in the rates in the DSM-5 diagnosis of pedophilic disorder, nor in risk and responsivity associated scores at the beginning of treatment. In both groups, a low to moderate risk for sexual re-offending was estimated. Both groups improved their functioning on dynamic risk and responsivity factors under treatment, while age at the beginning of therapy also had a positive effect on all outcomes. Non-forensic clients had a higher amount of responsivity associated resources than forensic clients during treatment. The limitations of these results and their implications for further research and prevention approaches are discussed.

The World Federation of Societies of Biological Psychiatry (WFSBP) 2020 guidelines for the pharmacological treatment of paraphilic disorders

Objectives: The primary aim of these guidelines is to evaluate the role of pharmacological agents in the treatment and management of patients with paraphilic disorders, with a focus on the treatment of adult males. Because such treatments are not delivered in isolation, the role of specific psychotherapeutic interventions is also briefly covered. These guidelines are intended for use in clinical practice by clinicians who diagnose and treat patients, including sexual offenders, with paraphilic disorders. The aim of these guidelines is to bring together different views on the appropriate treatment of paraphilic disorders from experts representing different countries in order to aid physicians in clinical decisions and to improve the quality of care.Methods: An extensive literature search was conducted using the English-language-literature indexed on MEDLINE/PubMed (1990-2018 for SSRIs) (1969-2018 for hormonal treatments), supplemented by other sources, including published reviews.Results: Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for its efficacy, safety, tolerability, and feasibility. The type of medication used depends on the severity of the paraphilic disorder and the respective risk of behaviour endangering others. GnRH analogue treatment constitutes the most relevant treatment for patients with severe paraphilic disorders.Conclusions: An algorithm is proposed with different levels of treatment for different categories of paraphilic disorders accompanied by different risk levels.

Cognitive-behavioural therapy (CBT) interventions for young people aged 10 to 18 with harmful sexual behaviour

BACKGROUND

Around 1 in 1000 adolescents aged 12 to 17 years old display problematic or harmful sexual behaviour (HSB). Examples include behaviours occurring more frequently than would be considered developmentally appropriate; accompanied by coercion; involving children of different ages or stages of development; or associated with emotional distress. Some, but not all, young people engaging in HSB come to the attention of authorities for investigation, prosecution or treatment. Depending on policy context, young people with HSB are those whose behaviour has resulted in a formal reprimand or warning, conviction for a sexual offence, or civil measures. Cognitive-behavioural therapy (CBT) interventions are based on the idea that by changing the way a person thinks, and helping them to develop new coping skills, it is possible to change behaviour.

OBJECTIVES

To evaluate the effects of CBT for young people aged 10 to 18 years who have exhibited HSB.

SEARCH METHODS

In June 2019, we searched CENTRAL, MEDLINE, Embase, 12 other databases and three trials registers. We also examined relevant websites, checked reference lists and contacted authors of relevant articles.

SELECTION CRITERIA

We included all relevant randomised controlled trials (RCTs) using parallel groups. We evaluated CBT treatments compared with no treatment, waiting list or standard care, irrespective of mode of delivery or setting, given to young people aged 10 to 18 years, who had been convicted of a sexual offence or who exhibited HSB.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We found four eligible RCTs (115 participants). Participants in two studies were adolescent males aged 12 to 18 years old. In two studies participants were males simply described as "adolescents." Three studies took place in the USA and one in South Africa. The four studies were of short duration: one lasted two months; two lasted three months; and one lasted six months. No information was available on funding sources. Two studies compared group-based CBT respectively to no treatment (18 participants) or treatment as usual (21 participants). The third compared CBT with sexual education (16 participants). The fourth compared CBT (19 participants) with mode-deactivation therapy (21 participants) and social skills training (20 participants). Three interventions delivered treatment in a residential setting by someone working there, and one in a community setting by licensed therapist undertaking a PhD. CBT compared with no treatment or treatment as usual Primary outcomes No study in this comparison reported the impact of CBT on any measure of primary outcomes (recidivism, and adverse events such as self-harm or suicidal behaviour). Secondary outcomes There was little to no difference between CBT and treatment as usual on cognitive distortions in general (mean difference (MD) 1.56, 95% confidence interval (CI) -11.54 to 14.66, 1 study, 18 participants; very low-certainty evidence), assessed with Abel and Becker Cognition Scale (higher scores indicate more problematic distortions); and specific cognitive distortions about rape (MD 8.75, 95% CI 2.83 to 14.67, 1 study, 21 participants; very low-certainty evidence), measured with the Bumby Cardsort Rape Scale (higher scores indicate more justifications, minimisations, rationalisations and excuses for HSB). One study (18 participants) reported very low-certainty evidence that CBT may result in greater improvements in victim empathy (MD 5.56, 95% CI 0.94 to 10.18), measured with the Attitudes Towards Women Scale, compared with no treatment. One additional study also measured this, but provided no usable data. CBT compared with alternative interventions Primary outcomes One study (59 participants) found little to no difference between CBT and alternative treatments on post-treatment sexual aggression scores (MD 0.09, 95% CI -0.18 to 0.37, very low-certainty evidence), assessed using Daily Behaviour Reports and Behaviour Incidence Report Forms. No study in this comparison reported the impact of CBT on any measure of our remaining primary outcomes. Secondary outcomes One study (16 participants) provided very low-certainty evidence that, compared to sexual education, mean cognitive distortions pertaining to justification or taking responsibility for actions (MD 3.27, 95% CI -4.77 to -1.77) and apprehension confidence (MD 2.47 95% CI -3.85 to -1.09) may be lower in the CBT group. The same study indicated that mean cognitive distortions pertaining to social-sexual desirability may be lower in the CBT group, and there may be little to no difference between the groups for cognitive distortions pertaining to inappropriate sexual fantasies measured with the Multiphasic Sex Inventory.

AUTHORS' CONCLUSIONS

It is uncertain whether CBT reduces HSB in male adolescents compared to other treatments. All studies had insufficient detail in what they reported to allow for full assessment of risk of bias. 'Risk of bias' judgements were predominantly rated as unclear or high. Sample sizes were very small, and the imprecision of results was significant. There is very low-certainty evidence that group-based CBT may improve victim empathy when compared to no treatment, and may improve cognitive distortions when compared to sexual education, but not treatment as usual. Further research is likely to change the estimate. More robust evaluations of both individual and group-based CBT are required, particularly outside North America, and which look at the effects of CBT on diverse participants.

On the Effectiveness of Sexual Offender Treatment in Prisons: A Comparison of Two Different Evaluation Designs in Routine Practice

Although there is less continuity of sexual offending in the life course than stereotypes suggest, treatment should lead to a further reduction of reoffending. Contrary to this aim, a recent large British study using propensity score matching (PSM) showed some negative effects of the core sex offender treatment program (SOTP) in prisons. International meta-analyses on the effects of sex offender treatment revealed that there is considerable variety in the results, and methodological aspects and the context play a significant role. Therefore, this study compared different designs in the evaluation of sex offender treatment in German prisons. PSM was compared with an exact matching (EM) by the Static-99 in a sample of 693 sex offenders from Bavarian prisons. Most results were similar for both methods and not significant due to low base rates. There was a treatment effect at p < .05 on general recidivism in the EM and at p = .06 on serious reoffending in the PSM. For sexual recidivism, EM showed a negative trend, whereas PSM suggested the opposite. Overall, the study underlines the need for more replications of evaluations of routine practice, methodological comparisons, sensitive outcome criteria, and differentiated policy information.

Evaluating Change in Men Who Have Sexually Offended: Linkages to Risk Assessment and Management

PURPOSE OF REVIEW

We provide a review and synthesis of the sexual offense treatment change literature with implications for dynamic sexual violence risk assessment and management. An argument is presented for the need for a dynamic approach in research and practice, and that for change to be prognostic, such changes need to be risk relevant and to come from credible change agents.

RECENT FINDINGS

Extant research demonstrates that changes on psychologically meaningful dimensions of risk and need (e.g., sexual deviance; attitudes and cognitions; anger, aggression, and hostility) tend to be associated with reductions in sexual and other forms of recidivism; however, changes in domains less germane to risk and need tend not to be (e.g., empathy, mental health and well-being). Formalized dynamic sexual offense risk measures can be administered at multiple time points to reliably measure changes in sexual violence risk. Change information can then be used systematically to adjust risk appraisals. The extant literature supports the dynamic nature of sexual violence risk. Working toward the routine assessment of change with psychometrically sound measures, and integrating this information into risk management interventions, can not only improve lives and reduce sexual violence but is an ethical and human responsibility.

A Long-Term Outcome Assessment of the Effects on Subsequent Reoffense Rates of a Prison-Based CBT/RNR Sex Offender Treatment Program With Strength-Based Elements

This article describes an evaluation of the effects of an early version (1991-2001) of Rockwood's prison-based Cognitive Behavioral Therapy/Risk-Needs-Responsivity (CBT/RNR) sex offender program that had emerging elements of a strength-based approach. This program was implemented under contract to Correctional Service of Canada (CSC) and continued to evolve in response to emerging evidence until it closed in 2013. Thus, the program as evaluated here did not involve a fixed approach as did the comparison CSC program (hereafter referred to as SOTP). Long-term reoffense data, from Rockwood's program (n = 579), were compared with SOTP (n = 625) and with a group of untreated men (n = 107) sentenced for sex offenses. A modified brief actuarial risk scale (BARS-M) was used to control for baseline risk among the three groups, along with additional controls for age at release, victim type, and individual differences in the length of long-term follow-up period. Both treatment groups displayed lower rates of both sexual and violent reoffending when compared with the no-treatment offenders. Overall, the Rockwood program generated the lowest recidivism rates. The results demonstrate that prison-based sex offense-specific treatment can be effective. We discuss the strengths and limitations of the current design through the Collaborative Outcome Data Committee's guidelines.

State of the Art Treatment Options for Actual and Potential Sexual Offenders and New Prevention Strategies

Sexual violence is a significant and devastating issue for men and women throughout the world. Its consequences are not only disastrous for victims of sexual violence but are also extremely costly (estimated cost of $41,000 per rape) for society. Successful treatment of sexual offenders is therefore an important goal for society as well as for victims and offenders themselves. Over the years, multiple treatment approaches for sex offenders have been developed. Treatment programs range from the risk-need-responsivity (RNR) model, which focuses on providing tailored treatment for high-risk and low-risk offenders, to psychodynamic models. This article presents an overview for clinicians of state-of-the-art offender treatment, describing the most common treatment approaches, in particular the RNR model, cognitive-behavioral programs (relapse prevention programs, sexual offender treatment programs), psychodynamic approaches (transference-focused psychotherapy, mentalization-based therapy), the Good Lives Model, as well as pharmacological options. In addition, it provides an evaluation of the various treatment programs. However, given the fact that most acts of sexual violence will never be reported to the police, the question arises if treating convicted perpetrators is enough. Do we need rather-in terms of preventive work-a program for potential sexual offenders and men with delinquent sexual fantasies? Given the prevalence of sexual violence and its impact on victims, society, and the medical community, it would be remiss not to try to reach potential/unconvicted perpetrators. This article offers novel ideas and a project the goal of which is to prevent sexual offenses against women by introducing the "I CAN CHANGE" program from Hannover Medical School.

The pharmacologic treatment of problematic sexual interests, paraphilic disorders, and sexual preoccupation in adult men who have committed a sexual offence

This paper provides an international perspective on the use of medications to treat problematic sexual interests, paraphilic disorders, and sexual preoccupation in men who have committed a sexual offence. Experts from Canada, the Czech Republic (CR), Russia, the United Kingdom, and the United States met in Prague, CR in May 2017 to review and compare their treatment approaches. This report is a summary of their discussions, including empirical data from CR and Russia which have not previously been published in the English language. All participants agreed that continuing international collaboration would be very useful for the development of ethical international prescribing guidelines, as well as pooling data from studies on the efficacy and utility of pharmacological and other biological treatments for people who have committed sexual offences.

A Brief History of Psychological Theory, Research, and Treatment With Adult Male Sex Offenders

PURPOSE OF REVIEW

The goal of this paper is to provide a history of psychological theories, research, and treatment of male sex offenders from the onset of modern approaches that emerged in the 1960s up to the present time. The questions addressed in this paper primarily concern the reasons and justifications for the observed changes.

RECENT FINDINGS

Current conceptualizations of the motivations of sex offenders are quite comprehensive with a central focus on deficits in attachment and coping skills. Research now provides an empirical foundation for the issues to be addressed in treatment and for the manner in which treatment is delivered. Advances in theory and research have brought the field of sex offender treatment to the point where the empirical bases point to a structure that, if followed, seem likely to achieve the goal of reduced recidivism.

Behavioral Monitoring of Sexual Offenders Against Children in Virtual Risk Situations: A Feasibility Study

The decision about unsupervised privileges for sexual offenders against children (SOC) is one of the most difficult decisions for practitioners in forensic high-security hospitals. Facing the possible consequences of the decision for the society, a valid and reliable risk management of SOCs is essential. Some risk management approaches provide frameworks for the construction of relevant future risk situations. Due to ethical reasons, it is not possible to evaluate the validity of constructed risk situations in reality. The aim of the study was to test if behavioral monitoring of SOCs in high-immersive virtual risk situations provides additional information for risk management. Six SOCs and seven non-offender controls (NOC) walked through three virtual risk situations, confronting the participant with a virtual child character. The participant had to choose between predefined answers representing approach or avoidance behavior. Frequency of chosen answers were analyzed in regards to knowledge of the participants about coping skills and coping skills focused during therapy. SOCs and NOCs behavior differed only in one risk scenario. Furthermore, SOCs showed in 89% of all cases a behavior not corresponding to their own belief about adequate behavior in comparable risk situations. In 62% of all cases, SOCs behaved not corresponding to coping skills they stated that therapists focused on during therapy. In 50% of all cases, SOCs behaved in correspondence to coping skills therapists stated that they focused on during therapy. Therapists predicted the behavior of SOCs in virtual risk situations incorrect in 25% of all cases. Thus, virtual risk scenarios provide the possibility for practitioners to monitor the behavior of SOCs and to test their decisions on unsupervised privileges without endangering the community. This may provide additional information for therapy progress. Further studies are necessary to evaluate the predictive and ecological validity of behavioral monitoring in virtual risk situations for real life situations.

European Psychiatric Association (EPA) guidance on forensic psychiatry: Evidence based assessment and treatment of mentally disordered offenders

Forensic psychiatry in Europe is a specialty primarily concerned with individuals who have either offended or present a risk of doing so, and who also suffer from a psychiatric condition. These mentally disordered offenders (MDOs) are often cared for in secure psychiatric environments or prisons. In this guidance paper we first present an overview of the field of forensic psychiatry from a European perspective. We then present a review of the literature summarising the evidence on the assessment and treatment of MDOs under the following headings: The forensic psychiatrist as expert witness, risk, treatment settings for mentally disordered offenders, and what works for MDOs. We undertook a rapid review of the literature with search terms related to: forensic psychiatry, review articles, randomised controlled trials and best practice. We searched the Medline, Embase, PsycINFO, and Cochrane library databases from 2000 onwards for adult groups only. We scrutinised publications for additional relevant literature, and searched the websites of relevant professional organisations for policies, statements or guidance of interest. We present the findings of the scientific literature as well as recommendations for best practice drawing additionally from the guidance documents identified. We found that the evidence base for forensic-psychiatric practice is weak though there is some evidence to suggest that psychiatric care produces better outcomes than criminal justice detention only. Practitioners need to follow general psychiatric guidance as well as that for offenders, adapted for the complex needs of this patient group, paying particular attention to long-term detention and ethical issues.

Factors Predicting Desistance From Reoffending: A Validation Study of the SAPROF in Sexual Offenders

The present study aims at validating the German version of the Structured Assessment of PROtective Factors (SAPROF) for violence risk in a representative sample of incarcerated adult male sexual offenders. Sexual offenders ( n = 450) were rated retrospectively with the SAPROF using the database of the Federal Evaluation Centre for Violent and Sexual Offenders (FECVSO) in the Austrian Prison System. Interrater reliability and predictive validity of the SAPROF scores concerning desistance from recidivism were calculated. Concurrent and incremental validity were tested using the combination of the SAPROF and the Sexual Violence Risk-20 (SVR-20). Interrater reliability was moderate to excellent, and predictive accuracy for various types of recidivism was rather small to moderate. There was a clear negative relationship between the SAPROF and the SVR-20 risk factors. Whereas the SAPROF revealed itself as a significant predictor for various recidivism categories, it did not add any predictive value beyond the SVR-20. Although the SAPROF itself can predict desistance from recidivism, it seems to contribute to the risk assessment in convicted sexual offenders only to a limited extent, once customary risk assessment tools have been applied. Implications for clinical use and further studies are discussed.

Cognitive-Behavioral Therapy Efficacy for Reducing Recidivism Rates of Moderate- and High-Risk Sexual Offenders: A Scoping Systematic Literature Review

This literature scoping review compared recidivism rates of moderate- and high-risk sexual offenders who received cognitive-behavioral therapy (CBT) oriented treatments. Ten empirical studies from 2001 to 2014 were selected for review that met the following criteria: (a) Treatment program included a CBT-based intervention with a comparative intervention; (b) participants included adult, male, moderate- and high-risk sexual offenders only; and (c) follow-up data for up to 12 months. Data were analyzed using a summative metric for recidivism rate comparisons ( N = 3,073 for CBT and N = 3,588, for comparison approaches). Sexual offense recidivism rates varied from 0.6% to 21.8% (with CBT) and from 4.5% to 32.3% (with comparison intervention). The within-sample median rate of violent recidivism with a history of sexual offense was 21.1% (with CBT) versus 32.6% (comparison). Sexual offenders had a general felonies (within-sample) median recidivism rate of 27.05% (with CBT) versus 51.05% (comparison). The evidence supports the conclusion that CBT in its various forms is an efficacious treatment modality to prevent offense recidivism by sexual offenders. Suggestions for future research are considered.

Trauma and PTSD in the WHO World Mental Health Surveys

Background: Although post-traumatic stress disorder (PTSD) onset-persistence is thought to vary significantly by trauma type, most epidemiological surveys are incapable of assessing this because they evaluate lifetime PTSD only for traumas nominated by respondents as their 'worst.' Objective: To review research on associations of trauma type with PTSD in the WHO World Mental Health (WMH) surveys, a series of epidemiological surveys that obtained representative data on trauma-specific PTSD. Method: WMH Surveys in 24 countries (n = 68,894) assessed 29 lifetime traumas and evaluated PTSD twice for each respondent: once for the 'worst' lifetime trauma and separately for a randomly-selected trauma with weighting to adjust for individual differences in trauma exposures. PTSD onset-persistence was evaluated with the WHO Composite International Diagnostic Interview. Results: In total, 70.4% of respondents experienced lifetime traumas, with exposure averaging 3.2 traumas per capita. Substantial between-trauma differences were found in PTSD onset but less in persistence. Traumas involving interpersonal violence had highest risk. Burden of PTSD, determined by multiplying trauma prevalence by trauma-specific PTSD risk and persistence, was 77.7 person-years/100 respondents. The trauma types with highest proportions of this burden were rape (13.1%), other sexual assault (15.1%), being stalked (9.8%), and unexpected death of a loved one (11.6%). The first three of these four represent relatively uncommon traumas with high PTSD risk and the last a very common trauma with low PTSD risk. The broad category of intimate partner sexual violence accounted for nearly 42.7% of all person-years with PTSD. Prior trauma history predicted both future trauma exposure and future PTSD risk. Conclusions: Trauma exposure is common throughout the world, unequally distributed, and differential across trauma types with respect to PTSD risk. Although a substantial minority of PTSD cases remits within months after onset, mean symptom duration is considerably longer than previously recognized.

Has Psychiatric Medication Reduced Crime and Delinquency?

Several strands of research are consistent with the possibility that expansions in psychiatric medication usage have reduced crime and delinquency. Estimates suggest that medication usage has increased to as much as 9% of the youth population and up to 20% of the adult population in the United States and is high among populations associated with the criminal justice system. Studies show that four classes of commonly used psychiatric medication do reduce aggressive behavior, and crime rates are lower among diagnosed patients receiving such medications compared to those not. Prescriptions for medication increased fivefold for youth during the time that crime has declined in the United States and elsewhere, and two population-level analyses find some association between prescription rates and crime trends over time. However, true experimental studies are lacking, and one of the better trend studies does not show strong associations. This article proposes a research agenda for this issue.

A Longitudinal Outcome Evaluation of a Prison-Based Sex Offender Treatment Program

Sex offender outcome studies continue to produce mixed results. A common critique of these studies is their lack of methodological rigor. This study attempts to address this critique by adhering to the standards established by the Collaborative Outcome Data Committee (CODC) aimed at increasing the quality and confidence in outcome studies. We examined recidivism outcomes for a sample of formerly incarcerated sex offenders who participated in a state prison-based cognitive-behavioral-skills-based treatment program. We used propensity score analysis to compare treatment participants with a matched sample of non-participants. The final sample post-matching ( n = 512) was observed for a minimum of 4 years and a maximum of 14 years. Using survival analysis, findings indicate that there were no differences in recidivism rates between treatment participants and non-participants in sexual or violent crimes. However, participants demonstrated significantly lower rates of recidivism for non-violent crimes. We discuss strengths, limitations of the study, and implications of these findings.

The Development of In Vivo Measures to Assess the Impact of Sex-Drive Reducing Medications in an Offender with an Intellectual Disability

The ability to adequately evaluate medications in the treatment of paraphilias has been limited by reliance upon self-report as a measure of effectiveness over periods of time that may be too short to detect reoffending. One solution to this shortcoming is the development of valid, long-term, stable assessment measures. The purpose of this case study was to analyze the effects of Prozac and Provera on an array of behaviors germane to the successful treatment of paraphilias, including: (a) sexual arousal in the laboratory and natural environment, (b) sexual thoughts (deviant and nondeviant) accompanied by arousal in the natural environment, and (c) overt actions in the community associated with increased risk of reoffending over a 31-month period for an exhibitionist with an intellectual disability. Despite the ineffectiveness of the medications, the measures demonstrated long-term, differentiated significant clinical responding; further underscored the importance of assessing deviant sexual arousal and adherence to relapse-prevention procedures in the natural environment; and provided a new methodology to assess sexual preoccupations and sexual arousal. Use of these in vivo measures raises questions regarding their potential to improve the predictability of risk assessments, and serve as an aide in the analysis of whether a treatment procedure is effective for an individual.

Die Wirksamkeit psychotherapeutischer Behandlung von Sexualstraftätern nach Entlassung aus dem Strafvollzug

Zusammenfassung. Hintergrund: Das zentrale Wirkkriterium forensischer Psychotherapie besteht in der Verringerung des Rückfallrisikos hinsichtlich neuerlicher Straftaten. In der vorliegenden Studie wurde die in Hessen dezentral organisierte psychotherapeutische Versorgung von Personen, die aufgrund sexuell motivierter Straftaten verurteilt wurden, evaluiert. Methoden: Hierfür wurden psychotherapeutisch behandelte Probanden (n = 134) mit psychotherapeutisch nicht behandelten Probanden (n = 134) hinsichtlich der Rückfälligkeit verglichen, wobei die Vergleichbarkeit beider Gruppen mittels eines Matching-Verfahrens bezüglich rückfallrisikorelevanter Merkmale sichergestellt wurde. Der Behandlungserfolg wurde mit Hilfe zweier Rückfalldatenquellen überprüft: Erneut eingegangene Anzeigen bei der Staatsanwaltschaft sowie Wiederverurteilung und erneute Eintragung im Bundeszentralregister (BZR). Ergebnisse: Behandelte Probanden wiesen hinsichtlich allgemein gewalttätiger und sexuell motivierter Rückfälle signifikant niedrigere Anzeigeraten auf (14.2 % bzw. 9.7 %) als die unbehandelten Vergleichsprobanden (26.9 % bzw. 19.4 %), wobei bei den übrigen Rückfallkriterien die Signifikanzgrenze nicht erreicht wurde. Diskussion: Die Ergebnisse der vorliegenden Studie verdeutlichen, dass auch eine dezentral organisierte Versorgungsstruktur grundsätzlich geeignet ist, zur Verhinderung von Rückfällen von entlassenen Sexualstraftätern beizutragen.

Sex Offender Risk Assessment and Management

Sexual violence is common and can have profound effects on victims compared with other forms of violence. This violence includes unwelcome and forced sexual contact on adults or children. Assessment of individuals who perpetrate sexual violence starts with a comprehensive biopsychosocial evaluation after a finding of guilt. Clinicians should then evaluate risk. Based on this assessment, a risk management plan should be developed, directed at the specific risk of the offender. Management options include external control (eg, incarceration, probation), psychotherapeutic interventions, pharmacologic interventions, and treatment of comorbidity. This organized approach aids in reducing the risk of future sexual violence.

Treatment Gain in Violent Offenders: The Relationship Between Proximal Outcomes, Risk Reduction and Violent Recidivism

This study examines whether change in dynamic risk factors and other treatment targets over the course of violent offender treatment is associated with a reduction in violent recidivism. Data from 82 adult male violent offenders who attended a prison-based violence treatment programme were collected via retrospective file review. Therapeutic change was assessed by comparing pre- and post-treatment Violence Risk Scale (VRS) scores, ratings of denial and minimisation of violence, level of victim awareness, and motivation to change. Completion of offender treatment is found to be associated with significant change on all proximal outcome measures (i.e. reduction in dynamic risk and minimisation of violence, and increased victim empathy). However, these changes do not translate into reductions in reoffending; only one measure of within-treatment change - enhancement of victim awareness - is (negatively) associated with recidivism. These results suggest that caution is required when considering the impact of change in a restricted range of treatment targets on violent recidivism. Future research should focus on identifying reliable indicators of within-treatment change to aid idiographic assessments of violence risk and to elucidate mechanism of change.

Social Policies Designed to Prevent Sexual Violence

Sex crimes provoke fear and anger among citizens, leading to the development of social policies designed to prevent sexual violence. The most common policies passed in recent years have included sex offender registration, community notification (Megan's Law), residence restrictions, civil commitment, and electronic monitoring. This article reviews the history of current sexual offender policies, their development, and their implementation. These policies do not appear to be evidence based in their development and implementation because they are founded largely on myths rather than on facts. Little empirical investigation has been conducted to evaluate sex offender policies, but extant research does not suggest that these policies achieve their goals of preventing sex crimes, protecting children, or increasing public safety. The authors make recommendations for more effective legislative solutions, including enlisting media in the promulgation of evidence-based information, creating policies that use risk assessment strategies to identify high risk offenders, and facilitating a more efficient distribution of resources that reserves the most intensive restrictions and interventions for the most dangerous offenders.

Exploring Client and Therapist Experiences of Sexual Offender Intervention: Developing a Model of "Significant Events"

This research explored the therapeutic events both clients and therapists from community-based treatment interventions for perpetrators of sexual abuse identify as significant in their experience of psychological therapy. A qualitative design was utilized to address this research objective. The sample for the present research is comprised of three different treatment programs for sexual offending. Twenty-five clients and nine therapists participated in the study. Two qualitative measures were used to elicit client and therapist responses. Significant Aspects of Therapy Form was administered every second treatment session during each intervention program. The Significant Aspects Follow-Up Interview was conducted with a sub-sample of participants at the conclusion of each treatment module. Thematic analysis was used to identify significant themes noted by clients and therapists from forms and interviews. Thematic analysis resulted in a model of significant events in therapy. In this model, significant events were categorized into six domains. The six domains were as follows: (a) the process of therapy, (b) making changes and progress in therapy, (c) content and structure of therapy, (d) therapist contributions, (e) negative contributions to therapy, and (f) other factors Each domain further contained between 6 and 18 themes, which are also reported. This study found much overlap and similarity in the experiences of therapy between clients of sexual offender therapy and general psychotherapy. Furthermore, there is overlap between therapists and clients in the aspects of therapy they identify as significant. The implications of these findings on effective service development and comprehensive service evaluations are discussed.

Sex Offender Recidivism Revisited: Review of Recent Meta-analyses on the Effects of Sex Offender Treatment

The effectiveness of sex offender treatment programs continues to generate misinformation and disagreement. Some literature reviews conclude that treatment does not reduce recidivism while others suggest that specific types of treatment may warrant optimism. The principal purpose of this study is to update the most recent meta-analyses of sex offender treatments and to compare the findings with an earlier study that reviewed the meta-analytic studies published from 1995 to 2002. More importantly, this study examines effect sizes across different age populations and effect sizes across various sex offender treatments. Results of this review of meta-analyses suggest that sex offender treatments can be considered as "proven" or at least "promising," while age of participants and intervention type may influence the success of treatment for sex offenders. The implications of these findings include achieving a broader understanding of intervention moderators, applying such interventions to juvenile and adult offenders, and outlining future areas of research.

The Effectiveness of Psychological Treatment for Reducing Recidivism in Child Molesters: A Systematic Review of Randomized and Nonrandomized Studies

In this systematic review, the effectiveness of psychological treatment interventions for child molesters was examined. Studies were restricted to randomized control trials (RCTs), controlled trials, and cohort designs where recidivism had been used as the outcome variable. ASSIA, NCJRS, Medline, PsychINFO, EMBASE, Pro-requests Dissertations and Theses A&I, and the Cochrane Library were searched. Ten experts were contacted and the reference lists of 12 systematic reviews and 40 primary studies were observed. The number of hits was 3,019, of which 564 duplicates, 2,388 irrelevant references, and 38 that did not meet the inclusion criteria were removed. Fourteen studies using mixed samples had to be omitted because it was not possible to determine the recidivism rates of child molesters in the samples described. One RCT and 9 cohort studies were included in the data synthesis, providing 2,119 participants. In all, 52.1% received the intervention under investigation and 47.9% did not. The reported recidivism rates were 13.9% for the treated child molesters compared to 18.6% for the untreated child molesters. Three studies reported statistically significant lower recidivism rates for treated child molesters. Eight studies were assessed as weak. Four studies were assessed as having bias which increased the chance of finding a treatment effect and four studies were assessed as having bias which reduced the chance of finding a treatment effect. It was not possible to determine the direction of bias for two studies.

Psychological Treatment of the Paraphilias: a Review and an Appraisal of Effectiveness

Initially, this paper notes that treatment for the paraphilias has been most thoroughly described and evaluated within the context of treating sex offenders (i.e., child molesters, rapists, and exhibitionists). We note that the literature does not always carefully distinguish "pedophiles" from other child molesters and that rapists are often identified as having a "Not Otherwise Specified" paraphilia. Both these practices appear problematic. We then outline current approaches to the treatment of sex offenders which have typically been seen as relevant to dealing with all types of paraphilias. The historical emergence of sex offender treatment is noted, leading to an outline of current approaches that address known problematic issues by employing established procedures and by delivering treatment in an empirically based manner. We conclude with a description of evaluations of the effectiveness of these treatment approaches which indicate overall positive outcomes.

Sex offender modus operandi stability and relationship with actuarial risk assessment

Three studies conducted in Vermont yielded data on 82 sexual recidivists' index offenses (Time 1) and sexual reoffenses (Time 2) across 16 modus operandi (MO) characteristics. The current study examines the stability of these 16 characteristics between Time 1 and Time 2 offenses. Probabilities of Time 1-Time 2 characteristic combinations are reported, including when controlling for static risk as measured by the Static-99R and Vermont Assessment of Sex Offender Risk-2 (VASOR-2). Overall, considerable stability of offenders' MO was evident between Time 1 and Time 2 offenses. Victim characteristics and offense behaviors were the most stable MO characteristics, and degree of force used and victim injury were less stable and trended toward less forceful and less injurious reoffenses. Controlling for static risk had little impact on the patterns of MO stability.

Using information from the violence risk scale to understand different patterns of change: an exploratory investigation of intensively treated life-sentenced prisoners

Research rarely has shown that in-program change in correctional rehabilitation is related to long-term outcome (i.e., recidivism), and surprisingly little is known about what happens to progress after treatment, especially for "lifers" whose release may not be imminent. This study investigated patterns of treatment response for 35 life-sentenced treatment completers of an intensive cognitive-behavioral program for high-risk male violent prisoners. Using Violence Risk Scale (VRS) ratings at pre-treatment, post-treatment, and 6 to 12 months following the program, we found that prisoners' mean treatment response was positive both at program end and follow-up. However, a fine-grained analysis identified five distinct change patterns within the sample. Importantly, the direction and volume of in-program change did not necessarily predict post-program change, and the highest risk prisoners did not benefit as much as those at medium-high risk. The findings suggest that (a) a better understanding of the effects of treatment may be gained by examining change beyond the end of interventions, including a focus on the individual and contextual factors that promote and inhibit generalization and (b) more therapeutic attention may be warranted for monitoring treatment change to maximize conditions for continued gain beyond the end of the program.

Psychological treatment of sex offenders: recent innovations

This article describes recent innovations in the psychological treatment of sex offenders. These recent innovations include the incorporation of Andrews and Bonta's RNR Principles, Ward's "Good Lives Model," and Miller and Rollnick's Motivational Interviewing into a strength-based approach. An example of a strength-based treatment program is described and treatment outcome evaluations are summarized.