Tuesday, April 1, 2014

Sex offender therapy: A battle on multiple fronts

TherapistOriginal Article

03/31/2014

By Michael Hubbard

Working with individuals with sex offense convictions is a specialized area of counseling. There are also “specialties within the specialty” when factoring in the different venues for treatment, including programs in prison, in private practice (often with those on postprison supervision or probation) and in mental institutions. The individuals within this population are generally quite different, and the dynamics are made even more complex when considering whether the offenders are adult males, adult females (yes, there are female sex offenders) or juveniles. The research on each population varies considerably. There is a paucity of research on female sex offenders, and research is still somewhat lacking (although growing) on the ever-complex juvenile offenders.

Sex offender therapy is challenging regardless of the nature of the clients, and other factors also come into play. There exists the constant issue of resistance to treatment, particularly when treatment is a condition of probation or parole. Criminogenic thinking pervades the scene, and counselors must be on guard for the often subtle signs of that mind-set. For instance, individuals convicted of sex offenses can be highly manipulative, not only with their therapist but also with others in their therapy groups. Power plays, deflection, grooming and lying are a few examples of the criminal thinking that may be evident. Many offenders will also present with a virtual encyclopedia of thinking errors. Often topping the cognitive distortion list are victim stance (“This label is unfair”), minimization (“All I did was grope her”), justification (“We’d had sex before and she didn’t complain”) and entitlement.

In addition to the cognitive distortions and potential for criminogenic behavior, counselors may also have to contend with other factors such as addictions, co-occurring disorders and, of course, shame, guilt and incredibly demeaning self-talk. The ultimate goal of sex offender therapy is relapse prevention, based first upon accountability and assumption of responsibility for offensive behavior. But when all of these factors are thrown into the mix, the counselor is often faced with denial on several levels: denial of facts (“It wasn’t me”); denial of intent (“I was drunk”); denial of impact (“She didn’t seem to mind”); and denial of the need for treatment.

Research supports the best practice of sex offender therapy being conducted in groups whenever possible. The peer support, which includes challenging denial and other thinking errors, is invaluable in treatment and also lends itself to generally better outcomes. Part of the reason for this is that so many sex offenses are based in secrecy. Bringing offenses out into the open is generally conducive to discussion and to the cognitive elements that are so important to reducing recidivism.

Of course, group therapy adds still other elements for the therapist to consider, including properly populating groups (for example, matching risk factors, genders and ages) and building and maintaining effective group dynamics. Sex offenders don’t want to talk about their “stuff” in front of others. Consequently, providing a safe environment and building trust are staples of effective sex offender therapy groups.

While this represents a formidable enough battlefront on its own, sex offender therapists are faced with another perhaps even more challenging front — that of our society, including our lawmakers.

Society’s perception
When will "tough" be tough enough?
In this discipline, we understand that risk mitigation is a primary concern. After all, society demands and deserves protection, and we all share the goal of ensuring that there will be no more victims of sex offenses. In fact, that is a primary directive.

Yet our society is also responsible for erecting many of the barriers that stand in the way of the recovery that sex offender therapists and our clients strive to achieve. Understandably, victim advocacy is far more palatable than the thought of treating a population that most would prefer to exile. However, the sad fact is that punitive barriers such as limited jobs, housing restrictions and sex offender registration raise significant risk factors for recidivism. These barriers often negate the efforts of sex offender therapists and those clients who possess legitimate desires to recover and return as productive members of society. In fact, our society may be contributing to future victimization — just the opposite of our primary goal.

As we all know, hopelessness is like a vampire to therapy. As our restrictive policies and biases feed that hopelessness, treatment and recovery are undermined, and relapse can become more likely. The short of it is that society’s efforts are based on a significant amount of misinformation and myths about sex offenders, and politicians and law enforcement officials often respond to the public’s demand for protection with tougher and more restrictive laws. Those laws and policies, even when couched as seemingly more sensible restrictions on living locations (as though all sex offenders are child molesters), send a clear message of “not on our block, in our neighborhood or in our town.”

In the meantime, the question of “Who is a sex offender?” is often overlooked. When I describe a 19-year-old who had consensual sex with his 16-year-old girlfriend of two years, some people will respond, “Well, he’s not a sex offender in that case.” Yet I have worked with a number of individuals convicted in similar situations who are now registered as sex offenders for life and required to complete treatment. In fact, there were so many such cases in Oregon that the state finally passed what is referred to as the “Romeo and Juliet law.” Under this law and similar laws in some other states, there is generally no charge of engaging in unlawful sex even if the “victim” is underage and the “offender” is an adult, as long as the age difference is no more than three years and the sexual act was consensual. My point here is that there is no set “profile” for all individuals labeled as sex offenders, yet society and the media frequently attempt to paint one.

Common myths
Fact or myth?
This particular battle is not restricted entirely to public sentiment. In the state institution in which our program operates, the public’s general misconceptions about sex offenders are often shared by some staff members. And I should point out that those in our counseling community are not immune. Some of the common myths about sex offenders are as follows.

Most sex offenders are predators. Reality: The most common sex offender is opportunistic, has one victim and is known to the victim.

Most sex offenders are dirty old men, strangers and pedophiles who will grab children off playgrounds. Reality: First, pedophiles (those sexually attracted to children) are not necessarily child molesters, for most do not commit offenses regardless of their attraction. Most sex offenders and child molesters are relatives or otherwise known to the family; only 2-3 percent of such offenses are committed by strangers. An estimated half of all child molestations are committed by teenagers.

Once a sex offender, always a sex offender (most sex offenders will reoffend). Reality: Study results vary considerably depending on the nature of the crime, whether the offender was previously incarcerated, whether the offender received treatment, what kind of support exists and the time after release and/or treatment completion. Yet contrary to popular belief, studies and statistics (including those from the Bureau of Justice) indicate that recidivism rates for sex offenders are lower than those for the general criminal population. A five-year study from the New York State Division of Criminal Justice Services noted a rate of recidivism ranging from 6 to 23 percent, depending on the offense (incest had the lowest recidivism rate, while molestation of boy victims had the highest recidivism rate). The Center for Sex Offender Management cites a recidivism rate of 12-24 percent but adds that many such offenses are underreported.
- NOTE: It also depends on how they define recidivism.  If they define it as any new unrelated crime or violation then the statistics are higher, but if they only include new sexual crimes then the stats are a lot lower, below 5%.

Treatment for sex offenders does not work. Reality: This statement has been a source of debate for decades. The effectiveness of treatment depends on a number of factors, including the type of offender, the type of treatment and how much management, supervision and support the offender has. Although the risk of recidivism exists even in the best of cases, most offenders can and will lead productive and offense-free lives after treatment.

Most sex offenders were sexually abused when they were children. Reality: Although sex offenders are more likely to have been sexually abused than nonoffenders, the vast majority of individuals who were sexually abused will not go on to commit sex crimes. A 2001 study by Jan Hindman and James Peters found that 67 percent of sex offenders initially reported sexual abuse in their history. Yet, when subjected to a polygraph, that figure dropped to 29 percent, suggesting that reports of sexual abuse were initially exaggerated to justify or rationalize their offenses.

I recall my former graduate school classmates, and even some of my professors, asking me, “How can you do that kind of work?” Most often the question came from those working with victims of sexual and physical abuse. Others in law enforcement and victim advocacy programs often repeated the question. The implication from some is that a counselor who treats the instigators of sexual abuse cannot also identify with the victims of such abuse. That argument could not be more fallacious.

Other obstacles
Obstacles
In our sex offender treatment program at a state hospital, a primarily forensic mental institution, our first challenge is getting patients with sex offenses into our program. We run an evidence-based program, principally using cognitive behavior therapy (CBT), that serves all risk levels and populations that have regular and diminished cognition with a variety of biopsychosocial diagnoses. Most of the patients in our program are in the hospital under a “guilty except for insanity” adjudication and under the jurisdiction of Oregon’s Psychiatric Security Review Board (PSRB). No matter why they are here, any patient with a history of a sexual offense or who engages in inappropriate sexual activity is referred to our sex offender treatment program.

When referred, a sex offender risk assessment is conducted to evaluate risk and appropriateness for sex offender therapy and to provide recommendations. Participating in sex offender treatment at the hospital is not mandatory, although the PSRB — concerned with risk mitigation — may consider nonparticipation a risk factor when contemplating the patient’s release to a less restrictive facility.

The patients often balk at the thought of living with the “sex offender” designation, fearful they will be subjected to harassment and other abuse. Their fear is warranted; many are labeled with terms such as chimo (child molester), pedophile or predator and become targets for possible physical assault. Staff members are not immune to falling into the judgment trap, sometimes in the form of what we call the “ick factor.” Even if they try not to show it, the patients can read it. Many sex offender patients carry so much shame and guilt that any suggestion of judgment can keep them from engaging in treatment or create a setback. We use a considerable amount of motivational interviewing to facilitate patients’ decisions to engage in the treatment they sorely need to progress through this institution.

Because our team operates in a state institution, we face some challenges not seen as often in private practice or other counseling venues. Our patients have mental illness, with everything from schizophrenia spectrum disorders to various personality disorders. In addition, more than one-third of the members in the groups we facilitate have diminished cognition. This represents another barrier to effective treatment, especially when considering that CBT and adjunct approaches such as dialectical behavior therapy and acceptance and commitment therapy are the most foundational and evidence-based practices when working with sex offenders. Indeed, the dynamic risk factors between the populations vary considerably.

As stated before, therapists in this field often deal with criminogenic thinking. Although we may expect that with many clients on postprison supervision, it is easy to forget in this hospital, where we are working with those who have been diagnosed with some form of mental illness. But the guilty except for insanity plea and accompanying diagnoses do not preclude criminogenic thinking. We witness manipulation, victimization and other criminal activities all too frequently. Given all these factors, providing sex offender therapy in our program is sometimes like looking through a fractured lens and still trying to divine a clear image of each patient and how to work with that patient for engagement and progress.

How might this apply to you?
How does this affect me?
Those of us currently in this field, as well as those counselors who may one day work with sex offenders, must realize that our approach to treatment will be negatively affected should we hold on to the same misconceptions and biases that are so prevalent in society. We are already familiar with the more general bias toward mental illness. Consider how much more that can play out in a charged atmosphere of offenses with the prefix sex. If you are a counselor and saying to yourself, “I have no intention of working with sex offenders,” here’s news for you: Most counselors will work with sex offenders, although perhaps without even knowing it.

Consider that a U.S. Department of Justice report from 2005 said studies suggest that sexual assault is one of the most underreported crimes. That same report estimated that 60 percent of rapes go unreported. As a counselor, you may be just as likely to work with a client who has committed a sexual offense, even though the client comes to you for another unrelated reason, as you are to work with a client who eventually discloses that he or she was sexually molested. Given the underreporting of sexual crimes, it is not unthinkable that you may have a client who has offended and is coming to you due in part to the guilt that he or she is experiencing. Or you may have someone well into therapy for a different reason (for example, depression), only to finally have that client confess to sexual offending.

So, how should you prepare? As with any area in counseling, seek out information, research and guidance. There are a number of excellent resources in the field of sex offender therapy, including the Center for Sex Offender Management, the Association for the Treatment of Sexual Abusers (ATSA) and the New England Adolescent Research Institute. All provide forums for research and to improve the work we do, both in treatment and in support for recovery. ATSA has many organizations under its umbrella on a state level that offer workshops on sex offender therapy and related topics. It also hosts an annual conference with a plethora of research and presentations.

For those inclined to explore or promote advocacy, these organizations (as well as others) produce important educational information. Speaking of which, another misconception exists that if a therapist advocates for a recovery-minded approach in treating sex offenders, that person is precluded from advocating for victims. Some people even view us as “offender defenders.” But most of us have treated, and continue to treat, victims of sexual and other abuse. In doing so, we often treat individuals who are both victims and offenders.

Current research indicates that the most evidence-based therapy for sex offenders, with the best outcomes, is CBT. In addition, a person-centered approach has been demonstrated to be most effective. This is understandable given the shame and suspicion felt by many offenders. An interdisciplinary team that communicates well is another key factor for optimal treatment and supervision. When working with clients on postprison supervision in private practice, this team would include the therapist, the parole officer and other professionals such as polygraphers. In our hospital setting, the communication and cooperation between our sex offender treatment program personnel and the unit psychiatrists, psychologists, nurses and other staff such as treatment care plan specialists are essential to crafting and implementing treatment plans, considering and managing outings and other privileges, and working toward the patients’ recovery and eventual transition to other settings such as group homes.

Other programs, such as one begun in Canada called the Circle of Support and Accountability (COSA), have recognized the need to provide ongoing support and guidance as sex offenders leave treatment and attempt to make their way back into society as productive members. Studies involving the original COSA and those established in states such as Minnesota have demonstrated a significant reduction in recidivism — in some cases, in excess of 70 percent. In turn, this has had a positive fiscal impact by reducing prison time due to relapse and reconviction. Most important, that translates to fewer victims.

As stated earlier, group treatment is best practice in the field of sex offender treatment. Of course, many counselors in private practice may not have enough clients to establish a group. When there are enough members, setting up and running sex offender groups presents another level of challenge. First, groups should be set up with homogeneity in risk level, age and gender. In other words, low-risk clients should not be mixed with high-risk clients, genders should not be mixed and juveniles should not be included in groups with adults.

Once established, group dynamics become a focal point. Even though all group members will have committed some form of sex offense, some members will not be above judging others. For instance, a person convicted of raping an adult female may object to being in the same room with someone who molested a child, a relative or a male adult. Although society may not make distinctions between sex offenders, the offenders themselves sometimes have their own hierarchy.

Another challenge, yet to be sorted out by sufficient research, is treatment of offenders who are developmentally delayed. Some therapists have raised valid questions about using CBT with those who have diminished cognition. In addition, there are some risk factor differences between those with regular cognition and those with diminished cognition. Many treatment programs that handle both populations simply modify their regular program for clients who are developmentally delayed. Others have more distinct programs, with the one for developmentally delayed clients focused more on addressing emotional dysregulation and other dynamic risk factors.

Closing thoughts
Final thoughts
Sex offender therapy is a controversial topic. No matter your involvement (or lack of involvement) in working with or advocating for the treatment of this population, you may still experience the battlefront I have outlined. The research and dissemination of findings will be limited as long as there is polarization around sex offender issues and as long as those perceived “sides” are not willing to listen to each other.

As counselors, we all know that listening, and especially reflective listening, involves a number of skills, not the least of which is seeing through the issues without allowing our own emotions to get involved. The public needs to receive an education on these issues. In addition, politicians, government agencies and policymakers must be urged to listen rather than simply striving to establish more “tough on offender” laws that sometimes make little sense and may, in fact, ultimately contribute to additional victims.

As counselors, however, we first focus on caring and applying our skills as best we can. We know that we cannot cure, but we can do our best to prevent future victims. In the process, it’s very likely that you will be faced with the task and frequent frustration of educating others who will not care. In fact, many will suggest that you simply throw away the key rather than provide treatment.


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