Forensic Psychology
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It is equally important when planning treatment to consider how to prepare and motivate the violent offender. Howells and Day (2002) discussed this in terms of the offender’s readiness for treatment (see section below on this). Violent offenders are typically ambivalent at best regarding the need for treatment, or are simply not ready to benefit from it. Violent offender treatment is further complicated by the difficulties therapists may face in working with violent offenders.
As described in Chapter 16 , Andrews and Bonta (2006) initially coined the term criminogenic needs to describe the attributes of offenders that are directly linked to criminal behaviour and that should therefore be the focus of treatment. Polaschek (2006) reviewed the evidence base for criminogenic needs for violent offender treatment. She noted that there was “a need for more research on serious violent offenders” as there were “still too few studies that have investigated their criminogenic needs”. (p. 145). However, most multi-modal treatment violent offender programmes target a number of issues – many of which appear to have at least some relationship to risk of recidivism, and therefore are likely to be criminogenic needs (Polaschek, 2006). As an example, negative/antisocial attitudes may reflect generally antisocial attitudes or they may reflect attitudes specifically condoning the use of violence.
Polaschek, Collie, and Walkey (2004) have demonstrated that both a general criminal attitude measure and a measure of violent attitudes, predicted recidivism risk. A number of studies have shown impulsivity to be higher in violent than non-violent offenders (e.g. Nussbaum et al., 2002). We have listed a number of criminogenic needs identified as being relevant to violent offenders in Table 3.1.
19.3.2 Frameworks for Treating Sexual Offenders
Although sex offenders are commonly studied and discussed according to offence type, treatment for sexual offenders in general is primarily targeted to address the treatment needs of child molesters. Rapists are generally treated alongside child molesters, although there is little evidence to support this practice (Gannon, Collie, Ward, & Thakker, 2008). It would also appear that of the men who attend treatment, only 15% of them are rapists, despite rapists making up roughly half of all of the incarcerated sexual offenders in the UK (Beech et al., 2005). We will now examine current treatment approaches for sexual offenders.
Table 19.1 Treatment needs of violent offenders
Anger
Negative/antisocial attitudes
Hostility
Substance abuse
Impulsivity
Active symptoms of major mental illness
Interpersonal and problem-solving skill deficits
Antisocial personality
Social information-processing deficits
Relationship instability
Empathy deficits
Education/employment
Antisocial companions
CASE STUDY 19.1 TREATING A VIOLENT OFFENDER
Ron was 28 years old when he was incarcerated for his third time. All of his prison sentences were for violent and drug related offences but he also has a long list of theft, fraud, and driving convictions. He has been unemployed for most of his life. His most recent violent offences all occurred on the same evening. The initial offence involved a serious assault on an unknown 18-year-old male, which happened outside a busy pub. Police witnesses described it as a totally unprovoked attack. The second offence occurred within two hours of the first. It involved an assault on a 55-year-old patrol station attendant during the commission of an armed robbery. Ron and two friends were armed with meat cleavers. Both of the victims suffered injuries that required hospitalisation.
When asked about the offences during an assessment Ron described the night in question as “a little fun with me mates”. He was not concerned over either victim’s injuries and stated that the 18-year-old pushed him when he was buying a drink (insulting him) and that the robbery was simply a way of “getting more money for drugs”. He also stated that “everyone needs a little bashing now and again – it toughens you up”. Ron reported consuming a large quantity of alcohol and drugs over a 24-hour period prior to being in the pub. He reported being “a little bit” angry at his girlfriend whilst at the pub and then also added that he thought that the victim was a “good looking little jerk”. Later, Ron acknowledged that he had seen the victim talk to his girlfriend. Ron’s description of the robbery indicated that it was not very well planned. Ron and his friends simply needed more money to pay for drugs and had previously discussed maybe “doing over” the petrol station.
MAIN TREATMENT TARGETS/CRIMINOGENIC NEEDS
Offence supportive attitudes towards the use of violence (e.g. “It was a little fun and “everyone needs a bashing”)
Probable antisocial personality (three previous violent offences and other convictions)
Antisocial companions (would he have committed these offences if not with his friends?)
Substance abuse (noting that the violence appears to be used as a means to get money for alcohol and drugs)
Anger (the treatment question was whether the important emotional state to target was anger or in fact jealousy/fear of rejection)
Relationship instability
Interpersonal and problem-solving skill deficits
Impulsivity (it is probable that he decided to assault the victim very quickly without necessarily planning to do so)
Employment/education
TREATMENT APPROACH
Given the multiple treatment targets Ron is unlikely to benefit from only a cognitive skills or anger management programme. In fact he had completed an anger management programme whilst incarcerated previously. In his case the violence appears to have been caused by multiple issues and therefore all of these should be targeted within a multi-modal treatment programme (or through the use of a number of specific programmes such as alcohol and drug programmes, cognitive skills, programmes).
A multi-modal treatment approach would involve the development of an overarching relapse prevention/self-management plan that would determine the multiple situations in which Ron is likely to use violence and plan strategies to assist Ron not to have to resort to violence. Treatment would also need to target all of the criminogenic needs, particularly given that Ron’s use of violence was both reactive and instrumental.
19.3.2.1 Cognitive-Behavioural Treatment
The most common method of treatment of sexual offenders is cognitive-behavioural therapy (CBT). The cognitive component addresses the pro-offending beliefs that individuals have, as well as cognitions that affect mood state and behaviours in ways that increase the likelihood of offending. Cognitive therapy therefore aims to encourage an individual to think differently about events, specifically, enabling insight into how cognitions influence their sexual behaviours; trains them to identify their own thinking patterns related to sexual offending; and uses various tools to help them re-evaluate these thinking patterns.
The behavioural aspect of CBT addresses the overt and covert behaviour of an individual. Originally this was confined to the use of procedures to alter behaviour, based on the principles of learning theory (i.e. rewarding desired behaviours and punishing unwanted behaviours), but has since broadened out to include modelling (demonstrating a desired behaviour) and skills training (teaching specific skills through behavioural rehearsal). CBT, therefore, provides a comprehensive approach to treating sex offenders, which now has research evidence to support its efficacy (see the section on treatment efficacy below).
19.3.2.2 Relapse Prevention Approaches
A significant addition to the CBT approach was the adaptation of the relapse prevention (RP) approach from the addictions field (Marshall & Laws, 2003; Pithers, Marques, Gibat, & Marlatt, 1983). RP is a self-management approach designed to teach individuals who are trying to change their behaviour, how to anticipate and cope with the problem of relapse. As applied to sex offenders, a relapse is a return to sexually deviant fantasies or reoffence. RP is intended to help clients maintain control of thei
r sexual deviance over time and across various high-risk situations they may encounter in the community. However, more recently issues regarding the overall usefulness of RP as a one-size fits all approach, has been questioned in that:
It presumes that all offenders follow the same pathway to offending (Laws & Ward, 2006). However, evidence suggests that there are multiple potential pathways that sex offenders may take in the lead up to an offence (Bickley & Beech, 2002; Ward & Hudson, 1998; Ward & Siegert, 2002).
RP also has a rather negative focus in treatment, in that it presumes offenders must avoid multiple situations to minimise their risk of reoffending, which makes it less appealing to the offenders than approaches that have a more positive focus. There is clearly evidence that using approach rather than avoidance goals in treatment results in greater engagement (Mann, Webster, Schofield, & Marshall, 2004).
However, in spite of the issues that have been raised with RP, it is still a component in many current CBT programmes.
19.3.2.3 Treatment Targeting Risk/Need/Responsivity
The principles of risk, need and responsivity (RNR) have been described in Chapter 16 as a key element of effective rehabilitation of offenders. But to briefly summarise here, this means prioritising high-risk cases, treating their identified psychological problems (their criminogenic needs) in a way that is appropriate to the person in question (responsivity issues). In relation to sex offenders in particular, risk level would most appropriately be determined using a specific sex offender risk assessment measure (see Chapter 16 ). Criminogenic need variables specific to sex offenders can be encompassed under four overarching domains proposed by Thornton (2002, 2013), that is their level of: (1) [deviant] sexual interests (i.e. are they sexually aroused to children, or coercive sex with adult victims); (2) distorted attitude (do they have thoughts that give them permission to have sex with children or coercive sex with adults); (3) [low levels of] socio- affective functioning (i.e. intimacy or hostility issues towards others); and (4) [problems in] self-management (i.e. poor control of their behaviours/emotions).
Problems in these four key areas have been shown to be related to recidivism (e.g. Craig, Thornton, Beech, & Browne, 2007; Hanson, Harris, Scott, & Helmus, 2007; Thornton, 2002; Wakeling, Beech, & Freemantle, 2013). When assessments are made of criminogenic needs before and after treatment, typically they are seen to improve as a result of treatment (e.g. Marques, Wiederanders, Day, Nelson, & van Ommeren, 2005; Olver, Wong, Nicholaichuk & Gordon, 2007). Therefore, crimonogenic needs are the most important variables to consider as treatment targets within sexual offender treatment (Mann, Hanson & Thornton, 2010; Thornton, 2013).
In terms of responsivity, some make the distinction between internal and external responsivity factors (Looman, Dickie, & Abracen, 2005). Internal responsivity factors include motivation. External responsivity factors are those that exist outside the individual but influence their ability to benefit from treatment, such as therapist characteristics and therapeutic climate (Looman et al., 2005). These will be discussed in more detail in the final section of this chapter.
In terms of evidence for the utility of the risk-need-responsivity principles, Hanson, Bourgon, Helmus and Hodgson (2009) identified 23 studies (n=6746) that met the basic criteria for quality of design. All studies were rated on the extent to which they adhered to the RNR principles. Hanson et al. found that the sexual recidivism rate in untreated samples was 19%, compared to 11% in treated samples. Studies that adhered to all three RNR principles were found to produce recidivism rates that were less than half of the recidivism rates of comparison groups. Studies that followed none of the RNR principles had little effect in reducing recidivism levels.
In spite of the evidence for the effectiveness of the RNR approach, a number of criticisms have been levelled at this approach. In particular it has been argued that the focus on criminogenic need in treatment means that other problems the individual has are neglected; the person is not treated as a whole, but as a collection of criminogenic needs. It is noted that if the focus is only on targeting criminogenic need, without also illustrating how this will improve the person’s life, this will likely hold little appeal to the client (Willis, Gannon, Yates, Collie, & Ward, 2010). As RNR is primarily focused on risk management, it does not maximise client engagement as much as approaches that consider the client’s values and priorities in life.
19.3.2.4 The “Good Lives” Model
Newer approaches have been suggested that address the criticisms of the RNR framework. In particular, the movement towards more positively oriented (as opposed to just risk management oriented) theoretical frameworks of offender rehabilitation have been received very positively by practitioners. The Good Lives Model (Ward & Stewart, 2003) is such a framework that is increasingly being used with sex offenders. Such positive rehabilitation theories recognise the utility of offering treatment in a manner that will likely hold more appeal to the individual and thus increase their likelihood of benefiting from treatment. According to this theory, all human beings, including sex offenders, seek a set of primary “goods” (Ward & Stewart, 2003; Ward, Vess, Collie, & Gannon, 2006; Willis, Yates, Gannon, & Ward, 2013). A set of 10 primary goods from Ward & Stewart (2003) are shown in Table 19.2.
Table 19.2 Ward’s primary goods from the GLM model
Life (including healthy living and functioning)
Knowledge acquisition
Excellence in play and work (being good at something)
Excellence in agency (being in control and the ability to be able to get things accomplished)
Inner peace (freedom from emotional turmoil and stress)
Relatedness (having intimate, romantic, and family relationships)
Community (being part of wider social networks)
Spirituality (finding meaning and purpose in life)
Happiness
Creativity
Sexual offending, according to this framework (e.g. Ward et al., 2006; Ward & Stewart, 2003; Willis et al., 2013) arises as a result of an attempt to obtain these goods in inappropriate ways. Treatment aims to instil in the individual the knowledge, skills and competence in order to lead successful lives, incompatible with offending, in the context to which they will be released (Ward et al., 2006).
The main criticism of the GLM to date is the lack of empirical evidence for its effectiveness. However, evidence is beginning to accumulate to support the use of this approach being at least as effective as RP approaches (e.g. Barnett, Mandeville-Norden, & Rakestow, 2014; Harkins, Flak, Beech, & Woodhams, 2012). In spite of the criticism of this framework, many are beginning to recognise the potential in combining the positive, motivational framework of the GLM approach with the empirically supported framework of RNR (Ward, Mann, & Gannon, 2007; Willis et al., 2010).
19.3.2.5 Integrated Frameworks
Modern theories of sexual offending integrate biological, social, and psychological causes (e.g. Marshall & Barbaree, 1999; Ward & Beech, 2005; Ward, Polachek & Beech, 2006). It could be argued that treatment frameworks have not yet quite caught up with this integrated approach, being mainly psychological, and focusing on issues such as offence-supportive attitudes, relationships, and self- regulation.
The majority of North American programmes described themselves as cognitive-behavioural in a recent survey (McGrath, Cumming, Burchard, Zeoli, & Ellerby, 2010), with about half describing themselves as following the RP model (respondents were able to select more than one option to describe their theoretical approach). Less than one third of programmes described themselves as adhering to the RNR model, despite the superiority of the evidence backing this approach (e.g. see Andrews, 2011). Even fewer programmes described themselves as following a sexual trauma model, or as multi-systemic therapy – an empirically supported approach for juvenile sexual offenders. Despite the evidence base for augmenting psychological treatment with medical treatment for those offenders who suffer from sexual preoccupation or compulsive sexual fantasies, less than 20% of
North American programmes reported the availability of a physician to prescribe anti-libidinal medication or selective serotonin reuptake inhibitors (SSRIs).
Obviously, some lead-in time is required for programme content to catch up with changes in the evidence base, particularly for large or multi-site manualised programmes such as the prison and probation programmes in England and Wales. The process of changing the design of a programme can take several years, especially if the changes have to be approved by an external body, as is the case in jurisdictions that operate a system of programme accreditation (McGuire, Grubin, Lösel, & Raynor, 2010).
The first decade of this millennium has seen some important developments in our knowledge about the causes of sexual offending as well as in evidence about effective treatment components, but there are still numerous unanswered questions about sexual offending and how it should be treated. For example, as Hanson (2010) concluded, the causes of paedophilia are still not known. Although some (e.g. Camilleri & Quinsey, 2008; Seto, 2008) have explicitly stated their support for neurodevelopmental explanations of paedophilia, this evidence base is still in its early days, and the translation of this knowledge into a treatment paradigm is yet to come.
At present, the best integrated treatment frameworks would aim to strengthen biological, social and psychological resources, would operate in line with the RNR principles, and would recognise that programme goals must be viewed as attractive and achievable by treatment participants. There are arguments for and against manualised treatments (e.g. Mann, 2009a; Marshall, 2009), although most people would agree that some pre-defined structure for a programme is necessary to maintain treatment fidelity and to permit evaluation studies. Most treatment programmes are group programmes, which are generally preferred not just for their efficiency but also because they offer the opportunity for participants to develop interpersonal skills in a way that would not occur in individual therapy, but there is no evidence to speak of that supports one modality over the other (Ware, Mann & Wakeling, 2009).