Briefly describe each of the three treatment outcome models: recidivism, relapse, and harm-reduction. Compare (similarities and differences) the three treatment outcome models in t

10.1177/0093854804267093 ARTICLE CRIMINAL JUSTICE AND BEHAVIOR Stalans / RECENT DEVELOPMENTS

ADULT SEX OFFENDERS ON COMMUNITY SUPERVISION

A Review of Recent Assessment Strategies and Treatment

LORETTA J. STALANS Loyola University Chicago

Sex offenders present challenges to treatment providers and probation officers. This article reviews recent developments in assessing risk and gauging their treatment progress. Probation departments in many jurisdictions have recently created specialized sex offender programs that provide intensive supervision and treatment. This article also reviews studies that have carefully evaluated these new probation strategies. In addition, it surveys the literature on treatment effec- tiveness and the predictors of treatment failure. Finally, the current article discusses directions for future research and implications for professional practice.

Keywords: sex offenders; specialized probation; sex offender treatment; risk assessment

Sex offenders are one of the most difficult groups of offenders to treat and supervise in the community. Estimates indicate that

about 234,000 convicted sex offenders are under the care, custody, or control of corrections agencies in the United States on any average day. Of these offenders, almost 60% are under conditional supervision in the community (Greenfeld, 1997). Given that many sex offenders are sentenced to probation and reside in the community, it is important to determine which supervision and treatment strategies are effective

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AUTHOR NOTE: The author would like to thank Arthur Lurigio and Amie Gates for their constructive comments on an earlier draft. Correspondence concerning this article should be addressed to Loretta J. Stalans, Department of Criminal Justice, Loyola University, 820 N. Michigan Avenue, Chicago, Illinois 60611.

CRIMINAL JUSTICE AND BEHAVIOR, Vol. 31 No. 5, October 2004 564-608 DOI: 10.1177/0093854804267093 © 2004 American Association for Correctional Psychology

at reducing sexual, violent, and general recidivism. This article pro- vides a comprehensive review of probation and treatment strategies and the effectiveness of such efforts at reducing recidivism. It is divided into five major sections. The first section is a review of the dif- ferent treatments for sex offenders. The second section reviews the lit- erature on the effectiveness of treatment, including predictors of which sex offenders are most likely to be noncompliant with treat- ment. The third section is a discussion of critical concepts that should be carefully assessed to determine risk of sexual recidivism and stan- dardized instruments to measure sexual recidivism and treatment progress. The fourth section reviews studies that have used compari- son groups to evaluate specialized probation programs for sex offend- ers. The final section summarizes the major conclusions from the lit- erature and describes areas that need further research as well as possible probation strategies that should be evaluated in the future.

SEX OFFENDER TREATMENT

A description of sex offender treatment is available in many coun- tries, including Belgium (Cosyns, 1999), Czech Republic (Weiss, 1999), England (D. Fischer & Beech, 1999; Grubin & Thornton, 1994), Germany (Pfafflin, 1999), the Netherlands (Frenken, Gijs, & Beek, 1999), and North America (Marshall, 1999). A nationwide sur- vey of sex offender treatment providers in the United States found that more than 75% identified the cognitive-behavioral or relapse preven- tion treatment model as their primary approach (Freeman-Longo, Bird, Stevenson, & Fiske, 1995). However, there is much heterogene- ity in what constitutes cognitive-behavioral or relapse prevention treatment. Almost all of the cognitive-behavioral treatment approaches attempt to treat lack of victim empathy, cognitive distor- tions, denial or minimization of responsibility, and deviant sexual preferences (Marshall, 1999). Generally, cognitive-behavioral treat- ment is delivered through group therapy, which is recognized as an appropriate and effective way of delivering sex offender treatment. Sex offenders may more easily manipulate treatment providers to see their point of view in individual treatment (D. Fischer & Beech, 1999).

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RELAPSE PREVENTION

Relapse prevention was initially used as a maintenance strategy to keep treated drug addicts, alcoholics, and smokers from returning to their initial substance use (Laws, 1999). Pithers, Marques, Gibat, and Marlatt (1983) adapted the relapse prevention model to address sexual offending. The model begins with sex offenders being committed to abstinence from sexual offending. Sex offenders are then taught about “seemingly unimportant decisions” that can place them in high-risk situations that might provide the opportunity to commit a new sex offense. Seemingly unimportant decisions can include going to res- taurants or recreation centers where children gather, keeping catalogs that display children in bathing suits or underwear advertisements, having a fantasy of exposing private parts to women in a public set- ting, buying pornographic adult magazines, buying a six pack of beer, and so forth.

Some sex offenders can have momentarily “lapses,” such as mas- turbating to deviant fantasies, grooming children, or purchasing por- nography; as these examples indicate, lapses involve voluntarily risky sex-related behaviors that can lead to a relapse. A relapse is defined as the commission of a new sex offense. After a “lapse,” sex offenders may often experience a feeling of failure and guilt for breaking their abstinence pledge (called an abstinence violation effect [AVE]). If they attribute the lapse to a personal inability to deal with their prob- lems, they have a higher probability of committing a new sex offense. In the relapse prevention model, sex offenders are taught coping skills to deal with high-risk situations and with momentary lapses. The pri- mary goal of these coping skills is to decrease the chances of the commission of a new sex offense.

Several advancements in the relapse prevention model have been made in recent years (see Hudson & Ward, 1996; Johnston & Ward, 1996; Ward & Hudson, 1996, 1998; Ward, Hudson, & Keenan, 1998). For example, it has been expanded to include prevention teams that consist of supportive neighbors, family members, and friends who are informed of a sex offender’s high-risk indicators of relapse so that they can help keep the sex offender on track (Pithers, 1999).

Ward and Hudson (1996) have critiqued the relapse prevention model and have noted that the model has three major weaknesses.

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First, it fails to address the interactions between high-risk situations, lapses, apparently irrelevant decisions, AVEs, and relapse. Second, it overemphasizes the role of skill deficits compared to explicit decision making in the commission of new offenses. Finally, it does not distin- guish between high-risk situations that refer to external situations and those that refer to emotional states. The self-regulation model of relapse prevention has attempted to address these weaknesses (see Hudson & Ward, 1996).

According to the self-regulation model, sexual offending behaviors can occur through the following three distinct pathways: (a) dis- inhibition, (b) misregulation, and (c) purposeful (Ward et al., 1998). The disinhibition pathway involves sexually deviant urges and acts that result from situational or emotional triggers, such as anxiety, loneliness, low self-esteem, and chance contact with potential vic- tims. Child molesters reported that anxiety, anger, depression, and having actual contact with children triggered sexual fantasies about children (Swaffer, Hollin, Beech, Beckett, & Fisher, 2000). The misregulation pathway involves efforts to control deviant sexual urges through counterproductive strategies, such as masturbating to deviant fantasies, often resulting in offenders having less control and eventu- ally committing sex crimes. Supporting the misregulation or disinhibition pathways, 25% of child molesters in one study reported using drugs, alcohol, or pornography during the 12 hours preceding their last criminal offense (Proulx, Perreault, & Ouimet, 1999). The purposeful pathway involves carefully planning the sex crimes and believing that sexual assaults are appropriate because of apparent atti- tudes, such as women want to be raped. In the purposeful pathway, sex offenders are likely to experience positive affect or to be frustrated that their goals of deviant sexual contact are thwarted.

BEHAVIORAL TREATMENTS

Several behavioral treatments apply operant and classical condi- tioning principles to reduce deviant sexual urges, preferences, and fantasies (Heilbrun, Nezu, Keeney, Chung, & Wasserman, 1998; Marshall & Barbaree, 1978). These treatments assume that deviant sexual arousal or fantasies have been formed through experiential learning and reinforcement. Typically, behavioral treatments are

Stalans / RECENT DEVELOPMENTS 567

adjunct treatments reserved for sex offenders who express deviant sexual arousal patterns, fantasies, or preferences. For example, covert sensitization involves patients imagining performing behaviors that have led to prior sex offenses and then interrupting this imagery before the offense occurs through imagining an averse consequence such as getting caught. Most of the treatments have been evaluated using single-case designs or studies without control groups (Heilbrun et al., 1998); given these methodological limitations, the effectiveness of behavioral treatment is unknown.

BIOCHEMICAL TREATMENT

California became the first state to enact a law requiring sex offend- ers convicted twice of molesting a child under 13 years old to take medication designed to lower their deviant sexual urges. Florida, Georgia, and Louisiana have passed similar “chemical castration” laws (Miller, 1998). Miller (1998) provided an overview of the ethical and legal issues surrounding laws mandating the use of drugs to reduce the sex drive of sex offenders. Miller (1998) also suggested that the phrase “‘chemical castration’ implies a medically inappropri- ate use of the medication” (p. 183). Prentky (1997) advocates that these laws are inconsistent with maximizing the effectiveness of antiandrogen medication, which requires individually tailored treatment regimens for sex offenders.

Treatment providers, in conjunction with cognitive-behavioral treatment, have used antiandrogen drugs to attempt to suppress sex offenders’ sexual urges and deviant sexual arousal. Medroxypro- gesterone acetate (MPA) is the most common prescribed drug (Prentky, 1997). MPA has shown some success at reducing symptoms of deviant sexual urges and arousal, but most of these evaluations have not included control groups, have used small samples, and/or have varied a great deal in methodology. Hence, generalization across stud- ies was impossible (Prentky, 1997). Moreover, sex offenders are more resistant to hormonal treatments compared to cognitive-behavioral group therapy. Across studies, 33% to 66% of sex offenders refused hormonal treatment, and 50% discontinued its use because of side effects after beginning treatment, compared with approximately one

568 CRIMINAL JUSTICE AND BEHAVIOR

third of sex offenders dropping out of cognitive-behavioral treatment (Hall, 1995).

An alternative to antiandrogen drugs is serotonin reuptake inhibi- tors (SRIs; see Greenberg & Bradford, 1997). Clinical studies have found that antidepressant agents, such as SRIs, cause delayed ejacula- tion, impotence, and reduced sexual drive in some patients (see Greenberg & Bradford, 1997). SRIs also have fewer side effects than antiandrogen or progesterone treatments. The antiandrogren treat- ments can be safely prescribed for only short periods of time and can interfere with conventional sexual drive, whereas the SRIs are rela- tively safe for prolonged use, and conventional sexual drive is pre- served in most patients (Greenberg & Bradford, 1997). Greenberg and Bradford (1997) reviewed studies using SRIs to treat nearly 200 sex offenders and concluded that SRIs “have shown favorable treatment responses in paraphilic disorders” (p. 356). These authors call for double-blind crossover studies to yield more definitive conclusions about the effectiveness of SRIs in the treatment of sex offenders.

TREATMENT FOR DENIERS

Treatment providers have much difficulty dealing with sex offend- ers who deny all involvement in their crimes. Studies do not indicate what percentage of sex offenders are total deniers; one study of 608 sex offenders on probation found that 16.3% completely denied the offense (Stalans, Seng, & Yarnold, 2002). Complete deniers create obstacles to conducting effective group therapy for sex offenders in that they often refuse to participate in the group discussions, are unable to imagine steps leading up to the offense, and refuse to do group assignments that require some admittance to involvement in a sex crime. Treatment providers have attempted to use several individ- ual counseling sessions to break complete denial before integrating these offenders into the group therapy. Other treatment providers allow complete deniers to attend group therapy and discuss their feel- ings, beliefs, and behaviors before the sex crime, and the other sex offenders in the group challenge the deniers’ accounts of the crimes until the deniers acknowledge responsibility for the crime (Marshall, 1994). If these procedures are unsuccessful, two studies have evalu-

Stalans / RECENT DEVELOPMENTS 569

ated group therapy modules for treating deniers (O’Donohue & Letourneau, 1993; Schlank & Shaw, 1996). These treatments for deniers may have promise, but the methodological problems in the current evaluations, such as lack of control groups, small sample sizes, and no short- or long-term assessment of sexual recidivism, pre- clude any conclusions about overall effectiveness of these therapies for complete deniers.

In summary, there are several treatment modalities that can be used to reduce sex offenders’ risk of reoffending. Cognitive-behavioral group therapy with a focus on relapse prevention is the most com- monly used and has been the focus of most evaluations. Biochemical and pharmacological treatments show promise, but additional research is needed. Behavioral therapies are often used as supplemen- tal therapies to reduce abnormal sexual urges or fantasies but have not been adequately evaluated. A significant proportion of convicted or accused sex offenders completely deny committing any sex crimes and are a particularly difficult group to treat. Several strategies and treatment modalities have been tried with complete deniers and await further systematic evaluation.

EFFECTIVENESS OF RELAPSE PREVENTION GROUP TREATMENT

The following section reviews the effectiveness of cognitive- behavioral (relapse prevention) group therapy, and treatment in this section refers to this approach. Several studies have examined the effectiveness of treatment at reducing recidivism rates in populations of sex offenders (see Furby, Weinroll, & Blackshaw, 1989; Marshall & Pithers, 1994; Quinsey, Harris, Rice, & Lalumiere, 1993). The dif- ferences and shortcomings in the research designs of these studies have led to mixed conclusions about the effectiveness of sex offender treatment. Barbaree (1997) noted that most studies designed to assess treatment effects have used samples of 200 or fewer sex offenders and have had insufficient power to detect even moderate treatment effects. According to Barbaree (1997), nonsignificant findings in prior studies provide little information about whether treatment is effective.

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An earlier narrative review of 40 studies, which were primarily conducted before 1980, concluded that treatment tends to be ineffec- tive at reducing recidivism (Furby et al., 1989). More recent reviews indicate that treated sex offenders have lower recidivism rates than untreated matched control groups (Alexander, 1999; Hall, 1995; Polizzi, MacKenzie, & Hickman, 1999). Alexander (1999) reported that relapse prevention group therapy approaches yielded recidivism rates below 11% for juveniles, rapists, child molesters, and exhibitionists.

In a meta-analysis, Hall (1995) found that treatment effects were stronger in outpatient settings than in institutional settings. Thus, the effectiveness of prison-based sex offender treatment is less certain than that of outpatient treatment. In a more recent review that consid- ered the quality of the studies, only two of the eight studies on the effectiveness of prison-based sex offender treatment were method- ologically sophisticated enough to provide any conclusions (Polizzi et al., 1999). One of the studies found that the treated group had lower sexual recidivism rates than the untreated group (Nicholaichuk, Gordon, Gu, & Wong, 1999), whereas the other study found no differ- ence between the treated and untreated groups (Hanson, Steffy, & Gauthier, 1993).

Since these reviews, Quinsey, Khanna, and Malcolm (1998) com- pared 213 treated men with 183 men assessed as not needing treat- ment. The untreated sample was not a comparable control group, because it had a less serious prior criminal history than the treated sample. After attempting to statistically control for pretreatment dif- ferences, the treated group had significantly higher sexual and violent recidivism rates than did the untreated group. The authors concluded that this 6-month prison-based sex offender treatment might have a negative effect on recidivism.

To correct for the shortcomings in this design, a recent study com- pared a small sample of 89 treated sex offenders at the Regional Treat- ment Centre in Canada with a matched untreated group (Looman, Abracen, & Nicholaichuk, 2000). This study used a sample of the par- ticipants in the Quinsey et al. (1998) study but eliminated sex offend- ers with extensive and serious prior criminal histories who could not be matched with an untreated sex offender and those with unknown

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treatment type. The treated group had a significantly lower sexual recidivism rate than the matched untreated group (Looman et al., 2000). The additional 4-year follow-up time and the elimination of the highest risk sex offenders might account for the different findings. Supporting this interpretation, Hall (1995) found that there were greater treatment effects when studies followed participants for 5 or more years.

An evaluation of the Sex Offender Treatment Program in the Eng- lish and Welsh prisons was recently published (D. Fischer, Beech, & Browne, 2000). The study collected data from 49 incarcerated child molesters. Child molesters who had observed significant change in pro-offending attitudes through treatment maintained their relapse prevention skills at the 9-month follow-up, but child molesters who had not changed their attitudes and had learned relapse prevention skills at the end of treatment had lost their relapse prevention skills at the 9-month follow-up. The authors suggest that relapse prevention training must occur within a framework covering all areas of offending behavior.

Some research has begun to address the question For whom is treat- ment effective? In a study that randomly assigned sex offenders to treatment or no treatment in the California State Hospital cognitive- behavioral program for sex offenders, findings show treatment bene- fits on violent recidivism and on sexual recidivism for certain groups of sex offenders (Marques, 1999). This study found that three groups of sex offenders benefited from treatment: child molesters with male victims, child molesters with victims of both sexes, and child molest- ers who learned relapse prevention training and had five or more prior crimes against children (Marques, 1999).

Conversely, psychopathic deviant sex offenders are unsuitable can- didates for sex offender treatment. Research has shown that psycho- pathic deviants use their charm and manipulation skills in sex offender treatment to obtain good behavior ratings from therapists, but this good behavior and presumed “compliance” with treatment is unlikely to transfer to their conduct outside of treatment. Psychopathic devi- ants who behaved well in treatment were significantly more likely to commit new serious offenses (Seto & Barbaree, 1999). Hare (1996) also noted that group therapy and insight-oriented programs can actu- ally help psychopaths develop better ways of manipulating and

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deceiving people, but the therapies do little to change their lack of empathy or acceptance of responsibility or to reduce sexual or violent recidivism.

CHARACTERISTICS RELATED TO PREMATURE TERMINATION OF TREATMENT

Sex offenders have high rates of either dropping out or being expelled from treatment. Termination rates in the United States outpa- tient treatment programs have ranged from one quarter to more than one half of adult sex offenders (Geer, Becker, Gray, & Krauss, 2001; Moore, Bergman, & Knox, 1999), and two studies have found that about 50% of juvenile sex offenders failed to complete treatment (Hunter & Figueredo, 1999; Kraemer, Salisbury, & Speilman, 1998).

High termination rates indicate that many sex offenders do not receive the possible benefits of treatment and create other problems. For example, sex offenders who either drop out or are expelled from treatment have much higher rates of recidivism than do sex offenders who complete treatment (Hanson & Bussière, 1998; Marques, 1999; Stalans et al., 2002). Additionally, treatment slots are scarce in many jurisdictions. A national telephone survey of 732 probation and parole supervisors in the United States found that sex offender treatment ser- vices were in short supply in 26% of the jurisdictions (Jones et al., 1996). In England, there is only enough capacity in sex offender group treatment programs to handle 53% of the sex offenders supervised by probation services (D. Fischer & Beech, 1999). Research on the pre- dictors of premature termination can help treatment providers develop screening instruments to select individuals that are likely to complete treatment. Furthermore, treatment providers may be able to develop innovative treatment procedures for sex offenders who are likely to be expelled from treatment for noncompliance with attendance and rules. Sex offenders who are at high risk of dropping out may need more structure, guidance, or help with everyday living situations, such as employment and stress management. To determine how to create an effective treatment, it is important to know which offender and offense characteristics predict treatment failure.

Several findings suggest that sex offenders who have long-standing or more entrenched sexual deviance are more likely to withdraw from

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treatment. For example, 92% of the offenders who had multiple paraphilias, committed both hands-on and hands-off sex offenses, and molested both boys and girls dropped out of treatment (Abel, Mittleman, Becker, Rathner, & Rouleau, 1988). Other research using the Multiphasic Sex Inventory also has found that adult sex offenders who are defensive about their sexual preferences, have less knowl- edge about basic sexual anatomy, and have more obsessed sexual thought patterns were less likely to complete treatment (Simkins, Ward, Bowman, & Rinck, 1989). Two other studies have found that incarcerated sex offenders and community-based sex offenders who were sexually abused as children were less likely to complete a prison- based sex offender treatment program than were sex offenders with- out a history of victimization (Craissati & Beech, 2001; Geer et al., 2001).

Research has shown that psychopathic deviants are less likely to successfully complete outpatient or inpatient treatment programs (e.g., Chaffin, 1992; Moore et al., 1999; Ogloff, Wong, & Greenwood, 1990). One study, however, found no difference between incarcerated psychopathic deviants and incarcerated sex offenders who were not psychopathic deviants (Shaw, Herkov, & Greer, 1995).

Denial of the offense is also associated with premature termination of treatment. Three studies have found that incarcerated adult sex offenders (Geer et al., 2001), adult child molesters on probation (Stalans et al., 2002; Stalans, Seng, Yarnold, Lavery, & Swartz, 2001), and juvenile sex offenders (Hunter & Figueredo, 1999) with higher levels of denial were significantly more likely to drop out of or be expelled from treatment compared to sex offenders who acknowledge their involvement in the offense.

Three basic demographic characteristics—(a) marital status, (b) educational achievement, and (c) employment status—are signifi- cantly related to premature termination of treatment. In five studies, sex offenders who were never married had lower rates of successful completion (Abel et al., 1988; Craissati & Beech, 2001; Miner & Dwyer, 1995; Moore et al., 1999; Stalans et al., 2002). Other research also has found that unemployed or part-time employed sex offenders on probation were significantly more likely to be seriously noncompliant with treatment (Maletsky, 1990; Stalans et al., 2002; Stalans et al., 2001). Sex offenders with less educational achievement

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were more likely to terminate treatment prematurely than were sex offenders with higher educational achievement (Geer et al., 2001; Stalans et al., 2002; Stalans et al., 2001). It makes intuitive sense that educational achievement predicts success or failure in treatment. Cognitive-behavioral therapy requires clients to be able to reflect back on their behavior, to assess the circumstances surrounding their behavior, and to arrive at conclusions about their sexual assault cycle with the help of a therapist. Offenders without a high school education are often lacking these cognitive skills and often have problems with reading, which makes it difficult to complete homework assignments. Offenders without a high school education also often have poor com- munication skills and may have difficulty expressing their thoughts and feelings in therapy because they have had less experience with group discussions.

Conversely, two studies found that age, race, educational attain- ment, socioeconomic class of the offender, and prior number of crimi- nal offenses did not predict success or failure of cognitive behavioral therapy for outpatient sex offenders (see Marshall & Barbaree, 1990; Moore et al., 1999). Social status may have different effects on treat- ment failure depending on mental health, denial, and substance abuse of sex offenders. Recent research has begun to examine how demo- graphic characteristics combine with other characteristics to predict treatment failure (Stalans et al., 2002). In Stalans et al.’s (2002) study, child molesters who mostly blamed the victim for the offense, lived in poverty, and were 37.5 years of age or younger had a 75% chance of being seriously noncompliant with treatment. In contrast, child molesters who placed most of the blame on the victim but had an annual income higher than $13,500 had only a 24% chance of being seriously noncompliant with treatment. Thus, annual income deter- mined the effect of blaming the victim on sex offenders’ treatment noncompliance. Sex offenders living in poverty are at higher risk of failure because they have a difficult time paying for treatment and have less reputation to lose if they are noncompliant with treatment.

Child molesters who accepted all the blame or only partially blamed the victim also were at a very high risk of serious noncompli- ance with treatment if they used both illicit drugs and alcohol, victim- ized a stranger or acquaintance, had no prior arrests for sex crimes, and lived in poverty (Stalans et al., 2002). Conversely, sex offenders

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that did not or only partially blamed victims, used no substances or only alcohol, had no prior arrests for violent crimes, and had no his- tory of problems with impulsive behavior had a 94% chance of being compliant with treatment. Thus, sex offenders are less likely to be seriously noncompliant with treatment if they have no other mental health problems, such as impulsive behavior, substance abuse, and aggression. Juvenile sex offenders who had problems with impulsive behavior were more likely to be prematurely terminated from inpatient treatment (Kraemer et al., 1998).

In summary, outpatient cognitive-behavioral group therapy has been shown to be effective; however, there are too few studies to draw conclusions about prison-based treatment. Furthermore, several inter- mediate goals of therapy are achievable. Research has found that treat- ment can reduce sexual arousal to deviant stimuli or deviant sexual fantasies, increase acceptance of responsibility for the offense, increase empathy for the victim, and increase self-esteem of sex offenders (Dwyer, 1997; Earls & Castonguay, 1989; Marques, Day, Nelson, & West, 1994; Marshall, Champagne, Sturgeon, & Bryce, 1997).1 However, treatment effects can differ for low- and high-risk sex offenders (Stirpe, Wilson, & Long, 2001), and it appears that sex offenders must grasp an understanding of the relapse prevention tech- niques for sex offender treatment to generalize to their behavior (D. Fischer et al., 2000). Although treatment can be effective at reducing recidivism for sex offenders that complete treatment (Alexander, 1999; Hall, 1995), a significant percentage of sex offenders are pre- maturely expelled from or drop out of treatment. Single status, psy- chopathic deviancy, failure to achieve a high school education, and lower social status are related to being seriously noncompliant with treatment. Research has just begun to address how to combine signifi- cant predic

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