Post?a brief description of the two types of sex offenders you selected and explain at least two similarities and two differences between these two types of sex offenders. Then explain one

Therapeutic Responses of Psychopathic Sexual Offenders: Treatment Attrition, Therapeutic Change, and Long-Term Recidivism

Mark E. Olver University of Saskatchewan

Stephen C. P. Wong University of Nottingham, University of London,

and University of Saskatchewan

The authors examined the therapeutic responses of psychopathic sex offenders (�25 Psychopathy Checklist—Revised; PCL–R) in terms of treatment dropout and therapeutic change, as well as sexual and violent recidivism over a 10-year follow-up among 156 federally incarcerated sex offenders treated in a high-intensity inpatient sex offender program. Psychopathy and sex offender risk/treatment change were assessed using the PCL–R and the Violence Risk Scale—Sexual Offender version (VRS–SO), respec- tively. Although psychopathic participants were more likely than their nonpsychopathic counterparts (�25 PCL–R) to drop out, almost 75% of the former completed treatment. Psychopathic offenders who failed to complete sex offender treatment were more likely to violently but not sexually recidivate than completers. Positive treatment changes were associated with reductions in sexual and violent recidivism after psychopathy and sexual recidivism risk were controlled. Overall, the results suggest that given appropriate treatment interventions, sex offenders with significant psychopathic traits can be retained in an institutional treatment program and those showing therapeutic improvement can reduce their risk for both sexual and violent recidivism.

Keywords: psychopathy, sexual and violent risk, sex offender treatment, treatment change

Sexual violence is a significant social and criminal justice problem worldwide. Of importance, recent meta-analytic reviews have suggested that providing appropriate treatment (i.e., broadly following the principles of effective correctional intervention)1 for sex offenders assessed as posing substantial sexual offense risk can reduce posttreatment sexual recidivism (Hanson et al., 2002).

To better inform treatment and evaluate therapeutic change, researchers have developed risk assessment tools with both static (i.e., unchangeable) and dynamic (i.e., potentially changeable) variables. Correctional treatment that produces positive changes in dynamic variables or criminogenic needs should lead to reductions in recidivism. However, there has been a dearth of empirical inves- tigations that attempt to establish linkages between changes in dy- namic variables through treatment, and subsequent reductions in re- cidivism, to support the changeable nature of putatively dynamic variables (see Douglas & Skeem, 2005).

Olver, Wong, Nicholaichuk, and Gordon (2007) examined dy- namic risk and therapeutic change in a sample of 321 treated sex

offenders. Therapeutic change scores computed from the Violence Risk Scale—Sexual Offender version (VRS–SO; Wong, Olver, Nicholaichuk, & Gordon, 2003) were significantly associated with reductions in sexual recidivism after the effect of static risk was controlled. Change was also significantly negatively correlated with sexual recidivism among higher risk, but not lower risk, offenders. The results, consistent with the risk and need principles, suggest that higher risk offenders stand to benefit more from treatment and that the changes higher risk offenders make (or the lack thereof) are likely more prognostic of their outcome following release than for lower risk offenders who are already less likely to reoffend, irrespective of any changes they make.

Psychopathy and Response to Treatment

While the clientele referred to sex offender treatment programs vary in risk and need, inevitably psychopathic offenders are also referred. Psychopathic offenders are a particularly high-risk, high- need group of individuals (Simourd & Hoge, 2000). While ele- vated scores on the rating scale most commonly used to assess psychopathy, the Psychopathy Checklist—Revised (PCL–R; Hare,

1 The risk principle posits that the intensity of treatment should be matched to the level of recidivism risk posed by the client (i.e., high-risk offenders receive high-intensity services, low-risk offenders receive min- imal or low-intensity services); the need principle asserts that dynamic characteristics associated with antisocial behavior (i.e., criminogenic needs) should be targeted in treatment; the responsivity principle holds that service delivery should be matched to the learning style, cognitive capa- bility, and other client characteristics (such as motivation, personality, or cultural background) that could impact treatment (see Andrews & Bonta, 2003).

Mark E. Olver, Department of Psychology, University of Saskatchewan; and Stephen C. P. Wong, Personality Disorder Institute, University of Nottingham, Nottingham, UK; Department of Forensic Mental Health Science, Institute of Psychiatry, University of London; and Department of Psychology, University of Saskatchewan.

We thank the Correctional Service of Canada for providing access to data and resources for the current study and Brenda Maire and Linda Flahr for their assistance in data collection. The views expressed in this article are those of the authors and do not necessarily represent the views of the Correctional Service of Canada or the University of Saskatchewan.

Correspondence concerning this article should be addressed to Mark E. Olver, Department of Psychology, University of Saskatchewan, 9 Campus Drive, Arts Building, Room 154, Saskatoon, Saskatchewan S7N 5A5, Canada. E-mail: [email protected]

Journal of Consulting and Clinical Psychology © 2009 American Psychological Association 2009, Vol. 77, No. 2, 328–336 0022-006X/09/$12.00 DOI: 10.1037/a0015001

328

2003), have been found to predict various forms of recidivism, the PCL–R scores tend to be a stronger predictor of violent and general recidivism than sexual recidivism (Hanson & Morton- Bourgon, 2004; Olver & Wong, 2006). Therefore, not all psycho- pathic offenders are necessarily high risk for sexual offense recid- ivism, although this does not appear to be the case for general crime and violence.

The small body of literature on psychopathy treatment has found psychopathic offenders frequently respond poorly to treatment, display poor motivation, show little improvement, and have high rates of attrition (Hobson, Shine, & Roberts, 2000; Ogloff, Wong, & Greenwood, 1990). Hobson et al. (2000) further found the interpersonal and affective features of psychopathy (i.e., Factor 1) to be particularly associated with treatment-interfering behaviors. Some research has even suggested that inappropriate treatment approaches may make psychopathic offenders worse (Rice, Harris, & Cormier, 1992). In recent years, however, there have since been significant advances in designing psychopathy treatment programs (e.g., Wong & Hare, 2005), in which psychopathic offenders are not only construed as high-risk individuals with myriad treatment needs but also understood to be individuals with a responsivity issue. In other words, psychopaths make difficult treatment clients owing to their interpersonal and emotional style. An important challenge for service providers is to develop effective working alliances with this offender group and to retain them in treatment despite the challenges they bring.

The recent research literature on sex offender treatment has investigated psychopathic offenders, their treatment responses, and recidivism. In the first of a series of studies, Seto and Barbaree (1999) first found, among a sample of 224 sex offenders who participated in an institutional sex offender treatment program, that positive treatment behavior was paradoxically associated with increases in violent recidivism, while psychopathic offenders with negative treatment behavior were less likely to recidivate. How- ever, in two subsequent reports (Barbaree, 2005; Langton, Barba- ree, Harkins, & Peacock, 2006), one with a larger sample (N � 418; Langton et al., 2006) and each with longer follow-ups, no such paradoxical findings were observed. In Langton et al. (2006), as expected, psychopathic offenders who exhibited negative treat- ment behavior had significantly higher sexually violent failure rates.

In a sample of 154 treated sex offenders, Looman, Abracen, Serin, and Marquis (2005) examined the relation of psychopathy, treatment progress/behavior, and risk reduction to violent recidi- vism. Treatment progress/behavior was coded on the basis of the quality of homework assignments on therapeutic tasks, and risk reduction was assessed on the basis of global appraisals of psy- chologists at posttreatment using varied and comprehensive treat- ment information. While they found that, paradoxically, psycho- pathic offenders with good treatment progress/behavior ratings had somewhat higher but nonsignificant violent recidivism rates than those with poor treatment ratings, they also found that psycho- pathic offenders who showed some risk reduction had lower rates of violent recidivism than those with no risk reduction. The results, however, fell short of significance perhaps in part due to small cell sizes and thus poor statistical power.

To build on earlier findings, we investigated in the present study the therapeutic responses of psychopathic sexual offenders to institution-based sex offender treatment. We investigated the rela-

tion of psychopathy to treatment dropout and for sexual and violent recidivism. We then examined the relation of therapeutic change, measured by the Violence Risk Scale—Sexual Offender version, to reductions in violent and sexual recidivism to determine whether psychopathic offenders could potentially derive benefits (i.e., risk reduction) from sex offender treatment.

Method

Participants

Participants were 156 male federal sex offenders who had received treatment services from the Clearwater Sex Offender Treatment Program at the Regional Psychiatric Centre (RPC), Saskatoon, Saskatchewan, Canada, between 1983 and 1997. The mean age of the sample was 32.8 years (SD � 9.2) at the time of admission. Approximately 64.3% of the offenders were White, while 35.7% were Aboriginal. Overall, 30.1% of the sample were single or had never been married, and the average education level attained was 9.8 years (SD � 3.5). The average sentence length was 5.8 years (SD � 3.9). When broken down by offender group, 76 (48.7%) individuals in the sample were rapists (i.e., victims at least age 14), 25 (16.0%) were child molesters (i.e., victims under age 14), 26 (16.7%) were mixed offenders (i.e., at least one child and one adult victim), and 29 (18.6%) were incest offenders (i.e., victims sufficiently close in relationship that marriage would be prohibited).

Materials

Violence Risk Scale—Sexual Offender version (VRS–SO). The VRS–SO (Wong, Olver, Nicholaichuk, & Gordon, 2003) is a sex offender risk assessment and treatment planning measure. The VRS–SO is composed of 7 static (generally unchangeable) and 17 dynamic (potentially changeable) items. Each item is rated on a 4-point (0, 1, 2, and 3) scale. A detailed scoring manual (Wong et al., 2003) has been developed with rating criteria for each static and dynamic item. Dynamic items given a 2 or 3 rating have close links to sexual offending (i.e., are criminogenic) and are considered treat- ment targets, whereas items with a 0 or 1 rating are not. Changes on the dynamic items are assessed and quantified using a modified transtheoretical model of change (Prochaska, DiClemente, & Norcross, 1992).

Each of the five stages of change (precontemplation, contempla- tion, preparation, action, and maintenance) has been operationalized for each of the 17 dynamic items. The progression in the stages of change shows the extent to which the offender has improved by developing positive coping skills and strategies that are stable, sus- tainable, and generalizable with respect to each dynamic item. Thus, the stages of change ratings indicate the extent to which knowledge and skills relevant to risk reduction have been acquired through treatment rather than merely demonstrating the degree of compliance with treatment providers. As such, progression in the stages of change would indicate risk reduction. All dynamic items rated 2 or 3 (treat- ment targets) are given as stages of change baseline rating at pretreat- ment to assess at which stage of change the individual was. Dynamic items that are not treatment targets (i.e., with 0 or 1 rating) generally require no stages of change rating. The stages of change are then rerated at posttreatment on all dynamic items identified as treatment

329PSYCHOPATHY AND RESPONSE TO TREATMENT

targets. Change is quantified by comparing the stages of change rating for each dynamic item at pretreatment to that at posttreatment. Mov- ing to a more advanced stage of change is an indication of positive change and, therefore, risk reduction. Progression from one stage to the next stage is scored as a 0.5-point reduction in the pretreatment rating of the item; progression in two stages, as a 1.0-point reduction; and so on. The total point deductions for each dynamic item at posttreatment are summed across all 17 dynamic items to arrive at a total change score reflecting the aggregated amount of change. The total change score is subtracted from the total pretreatment dynamic ratings to obtain the total posttreatment dynamic ratings.

Olver et al. (2007) conducted an exploratory factor analysis of the dynamic items, generating three oblique factors labeled Sexual Deviance (e.g., sexual preoccupations, compulsive sexual behav- ior), Criminality (e.g., substance abuse, impulsivity), and Treat- ment Responsivity (e.g., poor insight, treatment noncompliance, cognitive distortions). Psychometric research supports the reliabil- ity of the VRS–SO and its predictive validity for sexual violence (see Olver et al., 2007).

Psychopathy Checklist—Revised (PCL–R). The PCL–R is a 20-item symptom-construct rating scale with two oblique factors (Hare, 2003). Factor 1 assesses the interpersonal and affective characteristics of psychopathy while Factor 2 assesses chronic antisocial behavior. Recent factor analytic research (see Hare, 2003) has shown that the two factors can be further broken down into four facets. Factor 1 subsumes the interpersonal and affective facets, whereas Factor 2 subsumes the behavioral and antisocial facets. Total scores range from 0 to 40, with scores of 30 or higher traditionally used to indicate the presence of psychopathy (Hare, 2003), although for ratings made via file review, cutoff scores of 25 have been recommended given that the scores may be under- estimated (Wong, 1988). The 25-point cutoff has been frequently used and widely accepted for file-based assessment of psychopa- thy for research purposes (Langton et al., 2006; Looman et al., 2005; Rice et al., 1992) and is used as the cutoff for identifying those with psychopathy in the current study.

Treatment Program Information

The Clearwater program is a high-intensity inpatient treatment program designed to provide interventions to moderate- to high- risk sex offenders. The program is cognitive–behavioral in orien- tation with a relapse prevention component and was developed in accordance with the “what works” principles of effective correc- tional intervention. The program is comprehensive, addressing several criminogenic need domains, including treatment targets that would be considered offense specific (i.e., problem domains specific to sex offenders that warrant clinical attention, such as deviant fantasies or cognitive distortions) and those that are offense related (i.e., may be functionally related to sexual offending for some, but not necessarily for all sex offenders, such as anger management problems or substance abuse; Marshall, Marshall, Serran, & Fernandez, 2006). The treatment unit is staffed by a multidisciplinary treatment team including psychologists, psychi- atrists, psychiatric nurses, social workers, Tribal Elders, occupa- tional therapists, and parole officers. The Clearwater program length varied from 6 to 8 months, with patients occasionally remaining longer. Over many years of operation, the Clearwater program has been consistent in its focus on risk reduction, inter-

vention using cognitive–behavioral approaches, and the targeting of criminogenic factors in treatment (e.g., cognitive distortions, relationship problems, deviant interests). Detailed descriptions and outcome evaluations that support the treatment efficacy of the program are available elsewhere (Nicholaichuk, Gordon, Gu, & Wong, 2000; Olver, Wong, & Nicholaichuk, 2008).

A data collection protocol was drafted for the collection of several key variables. These included basic demographic informa- tion, index offense, criminal history, treatment program, admission and discharge information, psychiatric diagnosis, and recidivism. Treatment dropout was defined as any premature withdrawal or termination from the Clearwater program and consequent failure to successfully complete program requirements. The completion/ noncompletion status of the offender was usually clearly identified in file documents and was operationalized in a binary manner (0 � did not complete, 1 � completed).

Criminal History and Recidivism Information

Criminal offense data coded included criminal history, the index sexual offense, and recidivism. Criminal records from the Canadian Police Information Centre were updated and recorded between Au- gust 2001 and April 2002 to code these variables. Criminal history variables coded included prior sexual charges and convictions, non- sexual violent convictions, and all nonsexual convictions. The index offense was defined as the most recent sexual offense for which the offender was convicted prior to RPC admission. Two forms of recid- ivism were coded in binary format (0 � did not recidivate, 1 � recidivated). Sexual recidivism is defined as any new charge or conviction for an offense that was clearly sexual in nature or that was determined to be sexually motivated when such documentation was available. In the latter case, an individual may have been adjudicated for a violent nonsexual offense (e.g., second degree murder) and further examination revealed this to have been sexually motivated (e.g., sexual homicide). Violent recidivism is defined as any charge or conviction for a new violent offense (e.g., robbery, assault, murder) including sexual offenses.

Procedure

All offenders were rated on the VRS–SO on the basis of com- prehensive file information by two trained research assistants who were blind to recidivism outcome.2 VRS–SO dynamic items were rated at both pre- and posttreatment, and change scores were computed using the scoring rubric outlined earlier in the VRS–SO description in the Materials section. The interrater reliability pro- cedure and statistics for this sample are described in detail else- where (Olver et al., 2007). Briefly, 35 VRS–SO protocols were rated by Mark E. Olver for interrater reliability purposes and acceptable interrater agreement was obtained: VRS–SO pretreat- ment dynamic, intraclass correlation (ICC) � .74; VRS–SO post- treatment dynamic, ICC � .79. A subsample of participants were

2 Information contained in the files included nursing notes, psycholog- ical reports, treatment program summaries and performance evaluations, criminal records, social histories, community assessments, collateral re- ports, major homework assignments (e.g., crime cycles, relapse prevention plans), results of psychological testing and phallometric assessments, and a final input and appraisal by the program director/chief psychologist.

330 OLVER AND WONG

also rated on the PCL–R (n � 113) from file information by the principal investigator who was also blind to recidivism status while making the ratings. Twenty five PCL–R protocols had been rated on the same individuals by the research assistants mentioned earlier, and these ratings demonstrated strong interrater reliability with the PCL–R ratings from the current sample, ICC � .84. An additional 43 PCL–R protocols (total scores only) were also available from a previous study, resulting in 156 PCL–Rs available for analysis. The PCL–R and VRS–SO ratings were completed by different raters, and thus they made the ratings on one tool while blind to the ratings made on the other tool with no cross-contamination. Recidivism and treatment dropout/completion status were coded by Mark E. Olver after PCL–R ratings had been made.

Results

Psychopathy, Treatment Dropout, and Recidivism

Applying the 25-point cutoff, we found that 45 (28.8%) offend- ers in the sample met the criteria for psychopathy. In total, 23 (14.9%) offenders dropped out of treatment, while 131 (85.1%) completed; dropout information was missing for 2 offenders. Al- though 13 (56%) of the dropouts met the criteria for psychopathy versus 33 (25.1%) of completers, the majority of psychopathic offenders (33/45 or 73.3%) completed treatment. Both psychopa- thy designation (�25 on PCL–R) and dimensional PCL–R total score were significant predictors of dropout (rs � .31 and .21, respectively; p � .01). While about half of those in the dropout group were psychopathic, and hence a measure of psychopathy can predict dropout, contrary to previous findings, the large majority or almost 3 of 4 psychopathic sex offenders completed treatment.

The sample was followed up an average of 9.9 years (SD � 3.5) postrelease, with follow-up times ranging from 2.1 years to 18.0 years. Fifty one (32.7%) offenders were charged with or convicted of a new sexual offense, and 85 (54.5%) were charged with or convicted of a new violent (including sexual) offense. We then examined the relation of psychopathy and treatment dropout to sexual and violent recidivism through comparing recidivism rates of four groups: nonpsychopathic completers (n � 98), nonpsycho- pathic dropouts (n � 11), psychopathic completers (n � 33), and psychopathic dropouts (n � 12). Sexual and violent recidivism rates are presented in Figure 1. Chi-square analyses did not show a significant overall effect for sexual recidivism, �2 (3, N � 154) � 4.26, ns, but did so for violence, �2 (3, N � 154) � 8.38, p � .05. When dropouts and completers in the psychopathic cohort were compared, group differences were not significant with re- spect to sexual recidivism, �2 (1, N � 45) � 0.65, ns, but remained so for violence, �2 (1, N � 45) � 3.96, p � .05.

The results suggest psychopathic offenders who did not complete treatment were more likely to violently reoffend than those who completed treatment, but this was not the case for sexual recidivism. Completing treatment, however, does not necessarily mean that the offender had done well and made substantial progress although drop- ping out obviously indicates a lack of progress. Data presented later in the article speak to the relation of treatment progress, or change, to recidivism as a function of psychopathy.

Psychopathy, Sex Offending Risk, and Recidivism

The PCL–R factors were correlated with certain VRS–SO dy- namic factors in conceptually meaningful ways (see Table 1).

Specifically, Treatment Responsivity, (which assesses poor in- sight, attitudes and cognitions supportive of sex offending, and treatment noncompliance) was significantly correlated with Factor 1 and less so for Factor 2, while Criminality (which assesses attributes consistent with general criminality or an antisocial life- style) showed an opposite trend. Of interest, none of the PCL–R factors were significantly correlated with the Sexual Deviance factor. Overall, PCL–R total scores were moderately correlated with VRS–SO static, dynamic, and total scores (rs � .33 to .48).

Given the moderate convergence, it would seem that not all psychopathic sex offenders are necessarily high risk for sexual recidivism. That is, it stands to reason that some psychopathic offenders may score lower on sex offender risk measures, while some will score high. To examine this proposition, we created four groups as a function of VRS–SO static score (lower risk, score �10 on VRS–SO static items; higher risk, score 11–21) and PCL–R total score (low psychopathy, �25; high psychopathy, �25) as follows: low psychopathy/low risk (LP/LR, n � 68), low psychopathy/high risk (NP/HR, n � 43), high psychopathy/low risk (HP/LR, n � 19), high psychopathy/high risk (HP/HR, n � 26).

A survival analysis of the four groups (see Figure 2) shows that HP/HR offenders had the highest sexual recidivism failure rate (61.5%), followed by LP/HR sex offenders (41.9), and the low-risk sex offenders, with the LP/LR (19.1%) and the HP/LR (21.1%) groups having very similar sexual recidivism failure rates. Signif- icant differences in sexual recidivism were found between the two higher recidivism rate groups compared with the two lower recid- ivism rates groups. No significant difference was found between the two groups with the higher recidivism rates and the two groups with the lower recidivism rates.3

The relative contributions of psychopathy and sex offender risk in predicting sexual and violent recidivism were also examined through logistic regression analysis. In each model, continuous PCL–R total scores were entered in the first step, followed by a scale component of the VRS–SO in the second step (see Table 2). Two primary themes appeared. First, the scale components of the VRS–SO made significant unique contributions to predicting sex- ual recidivism, while the PCL–R did not. The PCL–R, on the other hand, was clearly a significantly better and more consistent pre- dictor of violent recidivism, while the VRS–SO, with the excep- tion of the static items, was not.

Psychopathy, Therapeutic Change, and Recidivism

The relationship of psychopathy and therapeutic change (as measured by VRS–SO dynamic change score) to sexual and vio- lent recidivism was further examined. We conducted these analy- ses to examine whether therapeutic change was associated with reductions in recidivism after controlling for the PCL–R, a per- sonality disorder and therefore a relatively persistent attribute of the individual, and the VRS–SO static items, a measure of sexual recidivism risk based on historical or static information. It could be argued that controlling for static variance via the PCL–R and

3 The HP/HR had significantly higher failure rates for sexual recidivism than the HP/LR group, Wilcoxon (1) � 12.08, p � .001, and the LP/LR group, Wilcoxon (1) � 15.56, p � .001. The LP/HR offenders had significantly higher failure rates for sexual recidivism than the HP/LR group, Wilcoxon (1) � 5.97, p � .05, and the LP/LR group, Wilcoxon (1) � 6.67, p � .01.

331PSYCHOPATHY AND RESPONSE TO TREATMENT

VRS–SO static items would serve to highlight criminogenic fac- tors with variance that is dynamic, as measured by the VRS–SO dynamic items. These dynamic items are potentially changeable and their positive changes, as suggested by the sex offender treatment literature, should be inversely related to sexual and violent recidivism.

The results of these analyses are presented in the bottom two rows of Table 3. When PCL–R alone was controlled, change scores were not significantly associated with reductions in sexual recidivism but were associated with reductions in violent recidi- vism. The PCL–R also significantly predicted both outcomes. When the VRS–SO static items were used to control for sex offense risk in the second set of logistic regression analyses, the PCL–R no longer predicted sexual recidivism; however, the static items were significantly associated with increases in sexual recid- ivism, and the change score was significantly associated with decreased sexual recidivism. All three measures significantly pre- dicted violent recidivism in their expected directions, with the PCL–R and static items predicting increased violence while change was associated with decreased violence.4

According to the risk principle, treatment should produce larger changes in high-risk, as opposed to low-risk, offenders (Andrews & Bonta, 2003). Therefore, the relationship of therapeutic change to sexual and violent recidivism was further examined as a func- tion of psychopathy (high vs. low PCL–R scores, or HP and LP) as well as risk level based on VRS–SO static scores (high risk vs. low risk). Specifically, change scores were correlated with violent recidivism outcome among HP offenders (n � 45) and LP offend- ers (n � 111), the result of which allowed us to examine whether change predicted reductions in violent recidivism among HP and LP offenders. As shown in Table 4, change scores were signifi- cantly negatively correlated with violent recidivism among HP offenders but were not significantly associated with violence

among LP offenders or with sexual recidivism in either broad offender group.

The relationship of change to sexual and violent recidivism was further examined in the four psychopathy–sex offender risk groups created for the survival analyses. As shown in the lower half of Table 4, change was negatively correlated with sexual recidivism among the high-risk LP offender group and fell outside the level of significance in the high-risk HP group, most likely owing to limited power due to small sample sizes, although the correlation attained significance when change was examined across both actuarially high-risk groups as a whole (n � 69; r � �.29, p � .05). Such effects, however, were not observed with the low-risk HP and low-risk LP offenders or in the low-risk group as a whole (n � 87; r � .00, ns). Change was also negatively correlated with violence across each offender group; however, only among the HP offenders was the effect significant.

Discussion

The present study examined the therapeutic responses of psy- chopathic sex offenders to treatment, including dropout, therapeu-

4 Offenders varie

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