Cover Story

Controversial questions swirl around the correctional system's management of sex offenders: How long should they be incarcerated for their crimes of forcing sex acts on adults or children? How should they be monitored following release? Does psychological treatment in prison actually affect the risk of committing further offenses? And how can courts balance offenders' potential for rehabilitation with a community's need to protect its citizens?

Responses to these questions have varied over the years, and, accordingly, so has policy-making by the states and the federal government. Recent policies have been trending toward longer prison sentences and more restrictive after-release monitoring, stemming in part from a dismal view of treatment programs, treatment advocates say.

But many psychologists and policy advocates, including law professor John Q. LaFond, JD, of the University of Missouri-Kansas City, say that approach disregards key information on the nature of sex offenders--statistics show most are not likely to repeat their crimes--and on the increasing efficacy of offender treatment, largely due to a modern behavior modification model stressing relapse prevention through recognition and avoidance of criminal impulses.

"In the 1980s, American states made the decision that sex offenders were not sick; they were bad," LaFond says. "Some states decided to offer treatment, but there wasn't much hope that it would work. Now, however, there's an emerging optimism that psychologists can deal with these people and offer alternatives to continued incarceration."

Some of that optimism comes from a meta-analysis on the effectiveness of treatment for sex offenders published in Sexual Abuse: A Journal of Research and Treatment (Vol. 14, No. 2) in 2002. That analysis showed for the first time a significant difference between recidivism rates for sex offenders who were treated and those who were not, says psychologist R. Karl Hanson, PhD, lead author of the study and senior researcher for the Solicitor General Canada--the government agency that manages Canadian courts and corrections.

The study revealed, among the most recent research samples, sexual recidivism rates of 17.3 percent for untreated offenders, compared with 9.9 percent for treated offenders. Though that's not a large reduction, the large sample size and widely agreed-upon research methods make it statistically reliable and of practical significance, Hanson says.

Misperceptions

Even so, psychologists face challenges in convincing law enforcement authorities to take treatment seriously given the obvious public concern about sex offenses. One major obstacle is public misconceptions about recidivism, Hanson says. "Even when we're talking with law enforcement officials, they'll guess demonstrated rates to be in the 70s or 80s, so real rates of 10 to 20 percent surprise everybody," he notes.

That's why the recent meta-analysis finding is a breakthrough of sorts--low recidivism rates among untreated sex offenders make finding a statistically significant treatment effect difficult, says psychologist Robert Prentky, PhD, who is the director of research for Justice Resource Institute in Bridgewater, Mass.

"Through anecdotal evidence, we know that modern treatment lowers recidivism, and the meta-analysis backs that up now," Prentky says. "We are unlikely to find a large treatment effect as long as the re-offense rates for untreated sex offenders are relatively low, for example, around 15 percent."

Assessing dangerousness

Psychologists have gleaned a number of important treatment insights in their research--the most basic of which is one size does not fit all.

"A large part of the challenge to managing this group is educating the courts that sex offenders are a highly heterogeneous population and not all of them are at high-risk for re-offending," says psychologist Moss Aubrey, PhD, who does private assessment of male sex offenders in New Mexico.

People commit sexual crimes for different reasons, Aubrey says. "Some are highly predatory, highly psychopathic and have repeated offenses, making them more likely to re-offend," he explains.

In the last 10 years, psychologists have made substantial advances in clearly identifying factors that increase an offender's risk of committing an offense after release, Hanson says. These factors include the number of offenses, intimacy deficits, sexual preoccupations and age.

Actuarial scales for determining an offender's risk of committing more sex crimes after treatment are available, but not always trusted by judges and many clinicians, Prentky says. More often, courts base release decisions on progress reports from prison psychologists--relying heavily on their expertise.

"Psychologists are essentially being asked to determine what level of risk an individual poses to a community even though there is no definitive way to know for certain," LaFond says. "They're being asked to balance that risk with the individual liberty concerns of an offender. Science has come up with tools to help them, but it's still a huge responsibility and a terrible burden."

Challenges of treatment

Adding to that burden are clients who may not disclose all of their crimes or sexually deviant thoughts. Offenders who report crimes they have committed, other than those they were convicted of, face either additional prosecution or being held beyond their sentence under a civil commitment law.

"If you reveal in the course of treatment that you've done all sorts of things that the criminal justice system is unaware of, you place yourself at substantially increased risk of not being released or facing stricter regulation after release," Prentky says. "That is a serious roadblock to treatment."

This disclosure problem for the most part cannot be alleviated; it must be worked around. Providers have to spell out confidentiality rules both in writing and verbally during treatment, Prentky says. Therapists must tell their patients to do the best they can discussing their problems and tendencies without revealing information that would place them at greater risk, says Prentky, adding that, "It's unethical not to make clients aware of the limits to confidentiality."

Disclosure is most problematic in the early phases of treatment, in which offenders are expected to take full responsibility for all of their criminal behavior. But it is less of a problem in the subsequent phases, in which treatment focuses on developing and refining relapse prevention strategies, Prentky says.

Another key consideration for both psychologists and judges is timing. It's crucial to start therapy as soon after incarceration as possible, LaFond says. Offenders often fail to realize the severity of their crimes, and an antagonistic prison environment can exacerbate feelings of being wrongly accused and hamper treatment.

"Attitudes that led to offending can become stronger, more virulent in prison," says LaFond. "Offenders can develop explanations for themselves that become solidified over time. You want to confront those ideas right away and make it clear that sex offenses are very serious crimes."

If treatment methods are as effective as Hanson's meta-analysis indicates, they are likely to become more popular in U.S. prisons, LaFond says.

"Most sex offenders do eventually return to the community," LaFond says. "So we need to change them while they're in treatment."

APA will publish the book "Preventing Sexual Violence: How Society Should Cope with Sex Offenders" by John Q. LaFond in early 2004.