Clinical assessment of adult sexual offenders with learning disabilities

Abstract

Assessment and treatment of adults with learning disabilities who commit sexual offences presents a number of challenges. Much of the professional forensic and psychiatric literature on work with this group concentrates on the development of interventions based on theoretical models of sexual offending originating from the mainstream criminal justice system and have often been adapted and applied to people with learning disabilities. Currently, there is very little evidence to demonstrate the effectiveness or validity of the adaptation and application of mainstream models to this population. The efficacy of such adapted models used to describe sexual offending in people with learning disabilities clearly has an impact of any intervention informed by them. In particular, some researchers suggest that key factors such as cognitive distortions are evident in sexual offenders with learning disabilities; there is, however, no research relating to the prevalence of these or other key factors within the general population of people with learning disabilities. The present literature review highlights some of the clinical issues with a particular focus on the assessment of deviant sexual interest. Specifically, the literature is confused with inconsistencies relating to the definition of the group, the extent and nature of offending and a lack of standardized methodology for assessment and comparison. Consideration is given to the particular needs of this group and the implications for research and treatment.     

Sexual offenders with learning disabilities: risk,recidivism and treatment

Abstract

While the literature on the assessment, treatment and management of non-learning disabled sexual offenders is well established, it is only in recent years that researchers and clinicians have focused on sexual offenders with learning disabilities. In contrast to mainstream sex offender treatment programmes, there are few evaluated community-based treatment programmes for sexual offenders with learning disabilities, and of the small number of published studies that describe treatment programmes, most are based on small samples and few have been validated empirically. Sexual offenders with learning disabilities differ from their non-disabled counterparts in several important ways, having implications for management and treatment. Due to methodological differences between studies, the prevalence of sexual offending by men with learning disabilities is not clear. However, in some studies, the sexual recidivism rate of offenders with learning disabilities is 6.8 times and 3.5 times that of non-disabled sexual offenders at 2- and 4-years’ follow-up, respectively. Sexual offenders with learning disabilities are also at greater risk of re-offending in a shorter time period. There remains an urgent need for further research into the assessment of risk and whether components from mainstream treatment programmes can be adapted to meet the needs of learning disabled sexual offenders. Approaches to working with sexual offenders with learning disabilities and programme development are discussed.     

An assessment for attitudes consistent with sexual offending for use with offenders with intellectual disabilities

Background . Over the past 10 years, the focus of assessment and treatment for sex offenders has changed from the assessment of skills and deviant sexual preferences to the assessment and treatment of cognitions that might be considered to encourage or justify inappropriate sexual behaviour. There have been a few assessment measures of deviant sexual cognitions developed for adults in mainstream sex offender populations but none in less able populations. The present study describes an assessment questionnaire consisting of 7 scales for cognitions associated with rape, voyeurism, exhibitionism, dating abuse, stalking, homosexual assault and offences against children, designed to be used by sex offenders with intellectual disabilities. Method . Four groups of subjects were employed in this study – sex offenders, non‐sexual offenders, non‐offenders all with mild intellectual disabilities or borderline intelligence and a further group of normal men. All subjects completed the questionnaire and 86 subjects provided reliability data. Results . Each item was subjected to 3 tests of reliability. Retained items were required to achieve an item‐to‐total correlation of at least 0.4. Of the 7 scales, 5 achieved an internal consistency coefficient of 0.8 or greater. All scales successfully discriminated between groups even when the normal controls were eliminated because their scores were so low. Conclusions . It is possible to develop scales to assess cognitions related to types of offences which discriminate between sex offenders and other groups with intellectual disabilities. The final scales have robust statistical properties and can be used for clinical and research purposes. Some caution was noted in the use of attitudinal assessments for sex offenders.     

Treating offenders with mental illness: a research synthesis

The purpose of this research synthesis was to examine treatment effects across studies of the service providers to offenders with mental illness. Meta-analytic techniques were applied to 26 empirical studies obtained from a review of 12,154 research documents. Outcomes of interest in this review included measures of both psychiatric and criminal functioning. Although meta-analytic results are based on a small sample of available studies, results suggest interventions with offenders with mental illness effectively reduced symptoms of distress, improving offender's ability to cope with their problems, and resulted in improved behavioral markers including institutional adjustment and behavioral functioning. Furthermore, interventions specifically designed to meet the psychiatric and criminal justice needs of offenders with mental illness have shown to produce significant reductions in psychiatric and criminal recidivism. Finally, this review highlighted admission policies and treatment strategies (e.g., use of homework), which produced the most positive benefits. Results of this research synthesis are directly relevant for service providers in both criminal justice and mental health systems (e.g., psychiatric hospitals) as well as community settings by informing treatment strategies for the first time, which are based on empirical evidence. In addition, the implications of these results to policy makers tasked with the responsibility of designating services for this special needs population are highlighted.     

Empathy in sexually sadistic offenders: an experimental comparison with non-sadistic sexual offenders

Previous studies suggest that severe sexual sadism and psychopathy are phenotypically different, although both are characterized by deficits in emotional processing. We assessed empathic capacity in a sample of 12 sexual sadists in comparison with 23 non-sadistic offenders using the Multifaceted Empathy Test (MET). All participants were forensic patients under mandatory treatment orders who had committed sexual offenses. The MET is a computerized rating task that differentiates and measures cognitive and emotional components of empathy, or perspective-taking versus compassionate components. To identify the effects of possible empathy deficits caused by psychopathic traits, we controlled both samples for psychopathy as a covariate, measured by the Psychopathy Checklist-Revised (PCL-R). According to our results, sexual sadists did not differ from non-sadistic sexual offenders with regard to emotional empathy for either positive or negative stimuli. The results suggest that severe sexual sadism is a distinct, pathological sexual arousal response, not a deficit in emotional processing.     

Sexual and nonsexual offenders with intellectual and learning disabilities: a comparison of characteristics, referral patterns, and outcome

This article reports an evaluation of a community intellectual disability offender service over the period from 1990 to 2001. Men who committed sex offenses or sexually abusive incidents (n = 106) and men who committed other types of offenses and serious incidents (n = 78) are compared on personal characteristics, referral sources, forensic details, and outcome up to 7 years after referral. The cohorts are older than one would expect from the criminology literature, and, at about 33%, the incidence of mental illness is consistent with some previous studies. A greater proportion of sex offenders had criminal justice involvement and a formal disposal from court. Fire raising was not overly represented as an offense. There was a higher rate of reoffending in the nonsexual cohort, which persisted up to 7 years. Investigating only reoffenders, there was a considerable amount of harm reduction recorded up to 7 years, statistically significant up to 5 years following initial referral.     

Up the slippery slope: Groupwork with sex offenders with a learning disability

Abstract

Techniques developed for work with sex offenders are not always applicable to or appropriate for sex offenders with a learning disability due to the cognitive and social difficulties which such individuals may have. This paper describes an attempt to adapt and combine a number of psychological and art therapy techniques in group work with sex offenders with a learning disability. The aim was to identify areas relevant in sexual offending behaviour and to adapt treatment approaches for the above client group.     

A modified Stroop task with sexual offenders: Replication of a study

Abstract

Cognitive–behavioural treatment of sexual offenders assumes that sexual offenders are motivated by deviant attitudes, perceptions and values. Although aspects of deviant schema can be assessed by questionnaires, self-report measures are limited by the respondent's willingness to be forthright and by the fact that, typically, these cognitive processes occur quickly, revealing signs of automaticity. Recent research by Smith and Waterman has suggested that the deviant schema of sexual offenders could be assessed using a version of the Stroop colour-naming task. Long latency periods to sexual colour words imply a longer information-processing route and evidence of pre-established (deviant) sexual cognitive schema. Stroop techniques may offer the advantage of eliminating limitations that arise when using self-report techniques, such as fakeability and social desirability concerns. The current study replicates and extends Smith and Waterman's results using samples of sexual offenders, non-sexual violent offenders and non-violent offenders. The cumulative results of the two studies suggests that Stroop techniques have promise, but that further work is required before measures are available that have sufficient reliability and validity to be used in applied contexts.     

Assessing crossover in a sample of sexual offenders with multiple victims

Purpose . This study examined the proportion of sexual offenders in England and Wales who exhibited ‘crossover’ in their choice of victim, as defined by age, gender and relationship to the offender. It subsequently aimed to identify criminal and demographic variables predictive of crossover. Method . The sample comprised 1,345 adult male sexual offenders. All had offended against multiple victims and had been discharged from custody in England and Wales between 1992 and 1996. Offence summaries within police records were used to collect victim details for each sexual conviction for each offender, and criminal conviction histories were obtained from the Offenders Index for the sample. Results . A quarter of the sample (24.5%, n = 330) demonstrated crossover behaviour in regard to at least one of the victim dimensions examined (i.e. age, gender or relationship). Using the risk predictor Static‐99, these offenders were found to be significantly riskier than those who did not display crossover behaviour. Multinomial regression failed to identify reliable variables predictive of crossover. Conclusions . The findings from this study are likely to represent an underestimate of the prevalence of crossover within sexual offenders in England and Wales. Reasons for this are discussed, and the implications of crossover for offender risk assessment, treatment, community supervision and policing practices are explored.     

Working positively with sexual offenders: maximizing the effectiveness of treatment

In this article, the authors draw on literatures outside sexual offending and make suggestions for working more positively and constructively with these offenders. Although the management of risk is a necessary feature of treatment, it needs to occur in conjunction with a strength-based approach. An exclusive focus on risk can lead to overly confrontational therapeutic encounters, a lack of rapport between offenders and clinicians, and fragmented and mechanistic treatment delivery. The authors suggest that the goals of sexual offender treatment should be the attainment of good lives, which is achieved by enhancing hope, increasing self-esteem, developing approach goals, and working collaboratively with the offenders. Examples are provided of how these targets may be met. When this is done within a therapeutic context where the treatment providers display empathy and warmth and are rewarding and directive, the authors suggest that treatment effects will be maximized.     

Substance abuse among sexual offenders: review of research and clinical implications*

Substance abuse, and in particular alcohol abuse, has been linked to the aetiology and maintenance of violent offending generally and sexual offending specifically. The current paper reviews the literature pertaining to substance abuse among sexual offenders and highlights theoretical developments in the area. An emphasis on issues associated with the therapeutic alliance is stressed when working with high-risk clients who present with multiple needs, including alcohol abuse. The discussion concludes with some practical suggestions regarding assessment and treatment of groups of moderate- to high-risk offenders.     

Executive functioning profiles of adult and juvenile male sexual offenders: A systematic review

Evidence regarding biological correlates of sexual offending, which might enhance the understanding, research, and treatment of these offenders, is rather emerging or in the embryonic stage. In this study, our main objective is to identify specific executive functioning (EF) processes that are commonly impaired in sexual offenders, and to further determine whether these differ as a function of offender subtypes. A search is conducted in ProQuest, Criminal Justice Abstract, EBSCOhost, and Social Science Citation Index electronic journal databases for studies published spanning the period 1990–2015. Google Scholar and Google search engines were also searched and the reference lists of the retrieved papers were searched for additional papers. A total of 1303 papers were retained for consideration. After removing duplicates, and subjecting the retrieved papers to inclusion and exclusion criteria, 24 papers (19 published and 5 unpublished) were deemed appropriate for the review. While several EF processes have been investigated, the available evidence implicates deficits in cognitive flexibility and inhibition of interference as commonly reported among adult male sexual offenders. This finding may be due to the sensitivity of tests of cognitive flexibility (e.g. the Wisconsin Card Sorting Test) and inhibition of interference (e.g. the Stroop Test) to frontal lobe lesions, and also because these tests are among the most frequently administered EF tests as revealed by this study. Juvenile sexual offenders, however, exhibit no distinct EF profiles. The findings of the study, implications for treatment, and recommendations for future studies are succinctly discussed.     

Optimizing risk mitigation in management of sexual offenders: a structural model

Sexual violence is an insidious and pervasive problem that insinuates itself into all aspects of contemporary society. It can neither be mitigated nor adequately controlled through current socio-legal practices. A more promising approach must embrace four integrated elements: (1) public policy, (2) primary prevention, (3) statutory management, and (3) secondary intervention. In the present paper we tackle the 3rd and 4th elements by proposing an integrated model for reducing and managing sexual violence among known sex offenders. Relying on the highly effective Risk-Need-Responsivity (RNR) model as the core of our Sex Offender Risk Mitigation and Management Model (SORM³), we draw together evidence based practices from clinical interventions and risk assessment strategies. Developed by Andrews & Bonta (2006), RNR has a strong empirical track record of efficacy when applied to diverse samples of offenders, including sex offenders (Hanson, Bourgon, Helmus, & Hodgson, 2009). We offer a detailed structural model that seeks to provide a more seamless integration of risk assessment with management and discretionary decisions, including a primary focus on RNR-based post-release aftercare. We end with the mantra that sex offender treatment alone will never effectively mitigate sexual violence in society, since the problem is not confined to the handful of offenders who spend time in prison and are offered some limited exposure to treatment. Any truly effective model must go well beyond the management of those known to be violent and embrace a comprehensive and integrated approach that begins by recognizing the seeds of sexual violence sown by society. Such a public health paradigm places victims - not offenders - at the center, forcing society to come to address the full gamut of hazards that fuel sexual violence.     

Effect sizes in the treatment of sexual offenders

This article considers the benefits of sexual offender treatment in terms of the magnitude of the effect size produced by these interventions. Comparisons are made of the effect sizes with those generated by treatment of other offenders, by treatment for mental health problems, and by treatment for physical health problems. In all cases, effect sizes with sexual offenders are comparable to (and in some cases better than) effect sizes for the treatment of the other groups. As a final note, it is suggested that using a harm reduction index to estimate effect sizes for treatment with sexual offenders would produce more meaningful results.     

Developments in the assessment and treatment of sexual offenders: looking backward with a view to the future

This article provides a brief review of a number of key developments within the area of sexual offending over the past two decades. In addition, several directions for future research are discussed. The review presents information concerning several well-validated risk assessment instruments that are available. As well, some of the accumulating evidence concerning the efficacy of contemporary approaches to treatment with sex offenders is mentioned, as are theoretical developments within the field.