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Efficacy of a psychological treatment for sex offenders
Santiago Redondo Illescas and Vicente Garrido Genovés* Universidad de Barcelona and * Universidad de Valencia The aims of the present paper are the following: firstly, to describe the psychological treatment ad- ministered to sexual offenders in Spain; secondly, to assess the effectiveness of the application of this psychological treatment in the prison of Brians (Barcelona). For this purpose, two equivalent groups were selected: a treatment group of 49 subjects who received the whole treatment program, and an un- treated control group of 74 subjects. These groups were selected taking into account various risk fac- tors in order to guarantee group comparability. The main results not only show the efficacy of the cog- nitive-behavioural program for sexual offenders but also that the effectiveness of this program exceeds the average of similar programs in the meta-analytic reviews performed to date.
Eficacia de un tratamiento psicológico para delincuentes sexuales. Los objetivos de este artículo son dos. En primer lugar, describir el tratamiento psicológico que se aplica con los delincuentes sexuales en España. En segundo término, evaluar la efectividad de dicho tratamiento en la prisión Brians de Barcelona. Con este propósito se seleccionaron dos grupos: un grupo de tratamiento integrado por 49 sujetos que habían recibido el programa de tratamiento completo, y un grupo de control constituido por 74 sujetos que no habían recibido dicho tratamiento. Ambos grupos se crearon teniendo en cuenta di- versos factores de riesgo con la finalidad de asegurar la equivalencia de los grupos. Los principales re- sultados obtenidos no sólo muestran una buena eficacia del tratamiento cognitivo-conductual aplicado con los delincuentes sexuales, sino también que dicho tratamiento supera, en esta evaluación, la efec- tividad promedio de programas similares en las evaluaciones que se han realizado con anterioridad.
The field of psychological intervention on sex offenders’ From the seventies onwards, there arose the need to not merely antisocial behavior is specially complex and problematic. This is due reduce sex offenders’ unacceptable behaviors, but, especially, to to the fact that, from a clinical point of view, sex offenders present train them in all skills required in agreed sexual relationships with three different -though interrelated- kinds of deficit: in their behavior adults (Marshall, 1971; Wood et al., 2000). Later, programs have and sexual preferences (as is obvious), in their cognitions («cognitive been extended to also include the eradication of sex offenders’ distortions») and in their social behavior in a wider sense (Berlin, «cognitive distortions»; that is to say, to eliminate their trends to 2000; Brown, 2005; Echeburúa & Guerricaechevarría, 2000; misunderstand social signs, to deny that they hurt victims, to Marshall, 2001; Redondo, 2002). All these deficits should be taken minimize the importance of their attacks and to blame other into account, consequently, to design and to implement any persons or factors out of their own control. Finally, «cognitive- rehabilitation program (see Schmucker & Lösel, 2008, to learn about behavioral» treatment programs for sex offenders have also the state of the art of the evaluation of sex offender treatment).
incorporated prevention strategies to avoid recidivism (Laws, The first behaviorally orientated programs for sex offenders 1989, 2000; see also: Becker & Bradley, 2001; Beech & Mann, understood that the etiology of sex offending was essentially the 2002; Brown, 2005), previously introduced in the field of individual’s deviant interest. In accordance with this, the treatment addictions by Marlatt and colleagues (Marlatt & Gordon, 1985).
might aim to eliminate such deviant behavior and to establish It can be stated that good psychological strategies for the more appropriate activation patterns towards suitable sexual acts treatment of sex offenders are currently available, which have a and partners (Marshall & Fernández, 1997). Some decades ago the technical development level comparable with methods used in most used treatment techniques were the aversion therapies, the other psychological intervention fields (Budrionis & Jongsma, masturbatory reconditioning and the covert sensitization, as well 2003). Nevertheless, from a practical point of view, the application as the systematic desensitization for the individuals’ social anxiety of rehabilitation programs for sex offenders is an activity limited (Marshall & Redondo, 2002; Wood, Grossman, & Fichtner, 2000). to a few developed countries and, among them, to a few programs in prison, and only sporadically are they implemented in the community. This means that the proportion of sex offenders Fecha recepción: 18-6-07 • Fecha aceptación: 11-9-07 receiving treatment is very small in relation to the number of Correspondencia: Santiago Redondo Illescas identified sex offenders —who are, normally, imprisoned. In spite of this, the public powers are increasingly conscious of the need to apply specialized treatments for sex offenders and, for this reason, in North American and European countries gradually new EFFICACY OF A PSYCHOLOGICAL TREATMENT FOR SEX OFFENDERS programs are being introduced. Such programs have the following DiClemente on the stages of change (Prochaska & DiClemente, 1992; Prochaska & Prochaska, 1993). According to this model, which has been explored in multiple addictive and • They use intensive long lasting programs.
psychopathologycal problems, to make the change of behavior • They include techniques specifically aimed to act in the viable (and, consequently, to make the treatment more effective) three mentioned problematic areas: sexually deviant the subject must, at least, be in a stage of problem contemplation, behavior, cognitive distortions, and the subject’s social that is to say, he must become aware of it (admit having a problem) and demonstrate interest to solve it soon.
• Sometimes, in the global context of the program, chemical In the case of sex offenders, so that the individual has agents are used to inhibit the sexual impulse. Three «displeasure about own actions and wish for change», as a starting medications have been used to reduce the male sexual point it is necessary that the offender admits the offense, this is, impulse: cyproterone acetate, medroxyprogesterone acetate that he gives up the habitual denial processes which are associated and, more recently, analogous agonist of the gonadotropin- with such a strongly rejected and socially shaming behavior as sex releasing hormone (GnRH) (Greenberg & Bradford, 1997; Marshall & Redondo, 2002; Rösler & Witztum, 2000).
Often sex offenders are prone to perceive themselves as • When implementing them, diverse therapists (often a man current, even good persons, for which they use a chain of thoughts and a woman) train sex offenders in socially specific skills to minimize and to make external the facts (Navarro, 2004): with a double goal: 1) to teach them to inhibit their criminal behaviors and, 2) to teach them the communication skills 1. Overoptimism, i.e.: «I will be able to solve it by myself, it needed to establish adult and agreed sexual relations.
was just something circumstantial».
• In general, this treatment has a voluntary character, although 2. Resistance to be treated, i.e.: «I don’t need any treatment, the subject’s eventual participation in it is rewarded by it’s been a long time since that happened; moreover, anyone penal and penitentiary benefits (permits to temporally leave can make a mistake; I’ve already paid for it».
prison, improvements in the ordinary regime of life in 3. Denial, i.e.: «I don’t need any treatment, so, why must I go prison, or future releases under parole).
through such a rough patch explaining what happened?».
4. Justification, i.e.: «My life it’s nobody else’s business; if I As a result of the mentioned evaluations and according to the explain it, be sure that they will tell it to people that matter international prescriptions on cognitive behavioral treatment of to me most, and I will be ashamed».
offenders (Beech & Mann, 2002; Brown, 2005; Budrionis & 5. Conclusion, i.e.: «Explaining it will be no use at all; it‘s not Jongsma, 2003; Garrido, 2005; Lipsey & Landerberger, 2006; Marshall & Serran, 2004; McGuire, 2001; Redondo, Sánchez- Meca, & Garrido, 2002a, 2002b), first specific program for sex This program asks its participants, initially or after a prudential offenders was created for the spanish context, named The Program time of implementation, to admit having committed the attack.
of Sexual Aggression Control (SAC) (Garrido & Beneyto, 1996, Doing that, besides facilitating the treatment, has to have 1997). It was first implemented simultaneously in two prisons in beneficial emotional effects for the subject. In the framework of the province of Barcelona: Quatre Camins and Brians (Roca & the treatment, the group represents in a sense the society and it is Montero, 2000). The same program, with some adjustments, is healthy for the subject to be able to talk about his crime with currently applied in diverse spanish penitentiary centers. reduced anxiety and increased objectivity, learning to coexist with In this program the treatment is conceived under two what he did, and, in sum, experiencing therapist and group complementary axes (Navarro, 2004). First, an axis consisting of acceptance (Navarro, 2004). This process needs the therapist to the individual evaluation of every subject and in formulating stimulate, to direct and to value the subject’s efforts towards the functional hypotheses about the factors that probably feed every recognition of the crime. Every individual must cover this road at aggressive act. Secondly, another axis of grup intervention based on all the knowledge, skills, cognitive and emotional changes that sex offenders must assimilate and modify (Ward, 2000; Webster & Beech, 2000). Researches on offenders have emphasized a series of clinical correlations associated with the subjects’ motivation to take part in a treatment program (Andrews & Bonta, 2003; Garrido et al., 1995; Groth, 1979; Quinsey et al., 1995; Maletzky, To show displeasure about own actions and wish for change 1991; Marshall, 2001; Marshall & Barbaree, 1989, 1990). Table 1 To admit the existence of factors linked to his behaviors (fantasies, beliefs, anger, alcohol) As the previous table shows, some of the aforesaid correlations To be capable of opening affective relationships («to show displeasure about own actions and wish for change», «to admit the existence of factors linked to his behaviors», «to be To be capable of learning from his experiences capable of controlling his behavior in some extent») refer to an important background factor: the level of conscience that the individual has about his aggressive behaviors and, in consequence, To be capable of controlling his behavior to some extent the intensity with which he wants or tries to solve the problem. To To have some adjustment in his life with his partner, his labor situation and other areas sum up, it is about the will to change the behavior, and that connects us, in psychotherapy, with the approach of Prochaska and Not having neither psychosis nor serious neurological disabilities SANTIAGO REDONDO ILLESCAS AND VICENTE GARRIDO GENOVÉS penitentiary benefits (possible permits, conditional release and The fundamental goal of this research is to assess the effectiveness of the described rehabilitation programs for sex offenders, once a large number of individuals have been treated and enough time has passed to be able to carry out a reasonable This research is a retrospective study carried out by means of a follow-up of their behaviors in the community. Our main non equivalent control group design, that is to say, with groups not hypothesis is as follows: subjects who completed the treatment selected at random. Nevertheless, diverse measurements of (experimental group) will obtain significantly better results in the methodological control have been taken in order to eradicate the evaluated dependent variables (lower sexual, nonsexual and total most important biases that might threaten the homogeneity and recidivism, and lower seriousness of the crimes that they may equivalence of the groups. As result of it, the groups can be commit) than the untreated individuals (control group).
To gather data, a template to code variables was created, structured in four big categories: A) independent variable (treatment application vs. non-application); B) moderating variables The total population of sex offenders who have served (demographic, belonging to criminal career, victims, clinical, etc.); sentences in the Prison of Brians, since it was inaugurated in May, and C) criteria or dependent variables (different parameters of 1991, until December 31, 2002, is 346 subjects, who have recidivism). Altogether, 51 variables have been analyzed.
committed more than 770 sex offenses (with an average of 2.23 sex offenses per subject). Besides, they are responsible for more than 630 nonsexual crimes. The groups studied in this research have been extracted and selected from this whole population: one An initial evaluation is carried out using a semi-structured treated group (n= 49) and one untreated (control) group (n= 74). A interview and applying the Hare Psychopathy Checklist PCL-SV follow-up has been carried out for both of them (once inmates and a 10 item risk scale designed for this purpose. At the most, one were released and reintegrated to the community) for an average subject with a psychopathic profile is included per group (assessment measure by Hare PCL-SV, with a score between 18 The groups treated in this program consist of between 10 and and 24). The reason to adopt this measure lies in thus giving the 15 subjects, who were selected from those penitentiary inmates therapist a better control of the possible attempts at manipulation serving sentences for sex offending, and fulfilling both following that people with a high level of psychopathy may make, and, conditions (Navarro 2004): 1) being in the juridical and penal simultaneously, it enables the other members of the group to situation to obtain the conditional release in the next 3 or 4 years, and 2) having admitted (even in a tiny or partial way) his crime, and show a certain initial motivation to take part in the program.
Every inmate must sign a behavioral contract with the therapist who directs the group, in order to maintain and to increase the This program is cognitive-behaviorally orientated and in its above mentioned motivation. Thus, the individual promises to grup phase is, on average, 10-12 months long, at a rate of 4 two- attend and to take part in the program daily sessions and the hour sessions every week. The fifth day of the week is spent therapist, on his part, commits himself to value as positive the following-up every subject through an individual interview, and above-mentioned participation and efforts for further proposals of solving unresolved questions (degree reviews, exit permits, etc.).
Therapeutic ingredients, basis and aims of the Program of Sexual Aggression Control (SAC) Modules or therapeutic ingredients
Theoretical basis
1. Cognitive distortions (cognitive restructuring) (44 ses- Beck’s cognitive therapy and other contributions on automat- To restructure the subject’s perception and distortions about
ic and erroneous thoughts and on restructuring the criminal fact, his own desires and his perception of 2. Defense mechanisms (15 sessions)
Matza’s neutralization techniques and Glasser’s reality therapy To eradicate the use of justifications and to promote the sub- ject’s responsibility for his own behavior 3. Emotional conscience (18 sessions)
To increase the subject’s emotional repertoire and conscience 4. Empathy towards the victim (27 sessions)
Marshall’s work on sensitization towards someone else’s pain To teach the individual to recognize other people’s (victims) and emotions; Platt et al.’s role taking technique emotions and feelings, and to increase his empathy abilities 5. Recidivism prevention (17 sessions)
Pithers and Laws, from Marlat and Gordon (for alcoholic peo- To improve the subject’s abilities to anticipate and to break the chains of his crimes precursors (cognitive, physiological, 6. Positive lifestyle (17 sessions)
Psychoeducative techniques and Goldstein’s structured mod- To improve his skil s for life planning, and his daily habits and EFFICACY OF A PSYCHOLOGICAL TREATMENT FOR SEX OFFENDERS General therapeutic program goals are as follows (Garrido & These results essentially confirm the main hypothesis of this research, namely: the cognitive-behavioral treatment applied to sex offenders in the Prison of Brians is effective. The treatment 1. To help participants to complete a more realistic analysis of achieves a successful reduction in sexual recidivism of 14.1 points, which comes from the difference between the rate of the 2. To improve their abilities and skills for personal Control Group (which is 18.2%), and that of the Treated Group (which is 4.1 %). In other words, this psychological treatment 3. To improve their possibilities to rehabilitate and not avoids, for a follow-up of four years, more than the 3/4 parts of the sexual recidivism that would be expected without treatment.
Figure 2 shows the recidivism distribution in the general samples In a more specific way, the program is structured in modules or of untreated sex offenders: according to the international research ingredients that approach the sex offenders’ most common deficits about 80% of them do not officially reoffend, whereas around 20% or factors of «criminogenic need». It incorporates 6 ingredients, ends up reoffending (Lösel, 2002; Quinsey et al., 1995). What whose technical basis and therapeutic aims are succinctly resumed changes are there if a good cognitive program, like the one in table 2 (Garrido & Beneyto, 1996; Garrido et al., 1995): presented here, is applied? What happens is that in general the The treatment staff responsible for this program is made up of treatment can reduce to 5-10 points the expectable rate of recidivists psychologists, criminologists, social educators and social workers.
(20%), that is to say, the rate can be in general reduced to half Psychologists are the main therapists in the program for sex (Beech & Mann, 2002; Hall, 1995). (These reductions are similar to offenders, and they carry out both the central part of the initial the general benefits of the best cognitive treatments for other evaluation and the implementation of the treatment techniques typologies of offenders: see Welsh & Farrington, 2006.) In spite of this, a residual percentage of 10%-15% of high risk subjects still The program develops at three intervention levels and formats: remains, who probably will end up reoffending even after having taken part in the treatment program. These subjects correspond with 1. Individual level (1 day per week): to carry out the initial evaluation of the subjects and, through the program development, to follow-up and to motivate every individual, Control G.
to solve possible eventualities, and to apply psychological Treatment G.
2. Group level (4 days per week): it is the core of the intervention, where the work is done by means of the psycho-social modules of the program.
3. External intervention and follow-up: carried out once the individual retourn to the community again. It happens first in a supervised way (through group or individual exits in the company of a therapist), a restricted way (exit permits of a few days, open regime) or an autonomous way (conditional and definitive release). In these follow-ups, program social workers and therapists take part themselves to carry out a monthly follow-up session outside the prison, in which participate both conditional released individuals and Nonsexual
inmates allowed to leave prison in a supervised way.
recidivism
recidivism
recidivism
In short, all the mentioned interventions (which form part of Figure 1. Treatment group and control group recidivisms: sexual, non se-
the Program of Sexual Aggression Control) are expected to result in behavioral, cognitive and emotional improvements which are conform to the mentioned goals and, in the end, to reduce the risk, Offending reduction
the frequency or the seriousness of new crimes to be committed. as a result
of the treatment
programs
Residual
Regarding its main goal, the most important results of this recidivism in high
risk subjects
research are the following (see Figure 1): during a 4 year follow- up period, of 49 subjects who entered the treatment group, 2 subjects (4.1%) reoffended officially in sex crimes, and 1 subject (2.0%) in nonsexual crimes. That adds up to a total recidivism of 3 subjects (6.1%). During a 3.5 year follow-up period, of 74 members of the control group, 13 subjects (18.2%) reoffended in Untreated no recidivists
Untreated recidivists
sex crimes and 10 more in nonsexual crimes (13.6%), which Figure 2. Model of the size of sexual non-recidivism/recidivism in samples
makes a total of 23 recidivist subjects (31.8%). All these of untreated sex offenders, and possible treatment program effects to redu- differences between the groups were statistically significant. SANTIAGO REDONDO ILLESCAS AND VICENTE GARRIDO GENOVÉS those who show the worst forecast according to static risk factors, had molested children and had committed 116 crimes. A third such as youth and early beginning in delinquency.
study (Garrido, Gil, Forcadell, Martínez, & Vinuesa, 1998) investigated a sample of sex offenders who were under-age with the purpose of adapting a specific program for young men. This study is the logical continuation of that efforts and, in The model shown in figure 2 is theoretical, and represents conclusion, the obtained results suggest a considerable therapeutic what the assessment studies find, without treatment and when power of the cognitive-behavioral treatment designed by Garrido treatment is applied. The data from our study are, in principle, a & Beneyto (1996, 1997) and applied in the Prison of Brians little more optimistic, since the reduction in sexual recidivism, as (Barcelona, Spain). Nevertheless, these initial results only result of the SAC treatment, is 14.1% (from a base rate of represent a first assessment approach that should be completed by recidivism of 18.2 % in the control group). Thus, a residual means of a more extended follow-up of the subjects to allow recidivism of 4.1% still remains (treated individuals who, in spite evaluate their recidivism in the longer term.
In Spain, the specific analysis of sex offenders and the application of rehabilitation programs for them began in Catalonia in 1996, from diverse previous researches on the topic. The first of This work has been developed as a part of a Coordinated these studies (Garrido et al., 1995) analyzed a sample of 29 rapists, Research Project (SEJ2005-09170-C04-01) on «Violent crime: authors of 226 diverse typology crimes. The second project programmes of prevention, treatment and prediction» (2005-2008) (Garrido, Beneyto, & Gil, 1996) analyzed 33 sex offenders who founded by the Spanish Ministry of Education.
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