Forensic Psychology Exam 3

Violence definition

actual, attempted, or threatened infliction of bodily harm [including serious psychological harm] on another person”

Bodily harm definition

substantially interferes with the health or well being of an individual

Examples of acts causing serious psychological harm

stalking, unlawful confinement, kidnapping, extortion

Violence then requires the following:

1. Person engages in some act (including threats)

2. There is at least some degree of intention or willfulness (in contrast to something purely accidental) - Note Mens Rea (“Guilty Mind”)

3. The act has caused or had the potential to cause…

4. Physical or serious psychological harm (generally acts serious enough to bring criminal or civil charges count)

5. Another person or persons are impacted

When/why does the criminal justice system or others ask for violence risk assessments?

• Criminal justice system often asks when needing to determine level of supervision required upon release to community

• Schools actively engage in violence risk assessments

Important legal case associated with violence risk assessment:

Barefoot v. Estelle (1983)

Barefoot v. Estelle Context

• Expert witness testified that defendant (convicted of murder) should receive death penalty as he would continue to be at risk for violence 

• Ironically, case led to psychologists and psychiatrists being allowed to testify about someone’s risk for future violence

• Prior to Bigfoot case, research indicated future dangerousness could not be accurately predicted

• Since then violence risk assessment is much more precise (not perfect)

Violence risk assessment has implications for prevention and intervention which may take several forms:

1. Monitoring – e.g., ongoing/repeated assessment

2. Supervision – e.g., restricting freedom via incarceration, civil commitment, removing weapons

3. Treatment – e.g., rehabilitation, psychotherapy, medication, education/vocational training

4. Victim Safety Planning – e.g., victim education, increased security

Violence Risk Assessment (post Barefoot)

• “... gathering information about people in a way that is consistent with and guided by the best available scientific and professional knowledge to understand their potential for engaging in violence in the future and to determine what should be done to prevent them from doing so” (Hart & Logan, 2011)

• Note that before the 1990’s the focus was on determining “dangerousness” and this term is still used in legal settings

• More recently the focus has been on “risk assessment”

What does violence risk assessment address?

• Risk for what specific outcome?; How high is the risk?; and What variables/influences contribute to the risk?

• Field has moved away from binary (yes/no) predictions of violence or dangerousness to risk assessment and management

What is some uncertainty that still remains concerning violence risk assessments?

• Important to be clear about how we define terms like dangerousness in the settings where these assessments are conducted

• Potential for judgment error and bias, e.g., thinking about dangerousness only as a personality trait vs. considering importance of environment, social factors, context in determining potential for violent behavior

• Must be mindful that such assessments often occur outside person’s usual environment, making it easy to miss social/context factors

• Caution needed to avoid illusory correlations (concluding relationship exists between variables despite lack of empirical evidence)

• Clinician’s opinions might be impacted by concerns about outcome (e.g., judgment leading to person being returned to community and then re-offending). Maybe “safer” to find in direction of dangerousness?

Unstructured Professional/Clinical Judgment (VRA)

• Not considered evidence-based; allows for use of intuition, clinical impressions, subjectivity

• Inconsistency across clinicians with this

• Lack of solid evidence regarding reliability and validity in VRA

• Method used for >100 years

• Evaluator decides which information to obtain and manner of weighing & organizing it

• Can result in low inter-rater reliability; high amounts of variability in methods used

Why is unstructured professional/clinical judgment still frequently used despite its inconsistency and low reliability?

• Courts generally accept this approach

• Clinicians typically focused on assessment of the individual case and factors unique to each case

• Often less time consuming than other approaches

• Allows for flexibility, can be used in many settings & with many populations; Structured RA method may not be available for all cases.

Structured Professional Judgment (SPJ) for VRA

• Decisions regarding violence risk are “guided” by scientific evidence and best professional standards

• Developed for use in clinical practice, in variety of settings for both assessment and management (prevention)

• Evidence based with scientific support for reliability and validity

• All relevant scientific, clinical, & legal literature reviewed incorporated

• HCR-20 – Perhaps most frequently used VRA instrument worldwide

SPJ Methods

• Developed for use in clinical practice, in variety of settings for both assessment and management (prevention)

• Evidence Based: All relevant scientific, clinical, & legal literature reviewed incorporated

• Emphasize role of professional judgement rather than just combining risk factors mathematically 

• Each item/variable often “scored”: Absent, Possibly Present; Present

• Emphasis not on getting “score” to estimate violence risk; Scoring used to focus clinician’s attention on factors known to be related to violence risk

HCR-20v3

• “Historical, Clinical, Risk Management” (Version 3)

• 20 risk factors/variables considered

• Focuses on past (Historical Scale); present (Clinical Scale); and future (Risk Management Scale)

Historical Scale of the HCR-20v3

• 10 Historical Variables (e.g., violence, other antisocial behavior; substance use, major mental disorder, personality disorder, violent attitudes)

• Manual provides definitions for each

• Examiner rates each variable along 2 dimensions: Presence & Relevance

• Presence: Yes, Possible/Partial, No, Omit

• Relevance: (to risk for violence & to development of risk management strategies): High, Moderate, Low, Omit

• Examiner ratings should be based upon integration of multiple sources of data: Interview, observations, record reviews, collateral input, psychological testing (where appropriate). 

Clinical Scale of HCR-20v3

• 5 (recent timeframe) Clinical Factors (also rated for Presence and Relevance)

• Insight, violent ideation or intent, symptoms of major mental disorder, instability, treatment or supervision response

Risk Management Scale for HCR-20v3

• 5 (future focused) Risk Management factors (also rated for Presence and Relevance)

• Professional services & plans, living situation, personal support, treatment or supervision response, stress or coping

Next steps after VRA

• Violence risk formulation developed

• Several “future violence scenarios” are developed

• Several “case management plans” are developed

• “Final Opinions” are developed regarding violence risk

• The assumption with SPJ is that as the number of risk factors present (and relevant to the case) increase, so does violence risk.

• As the amount of intervention needed to manage this risk increases, violence risk also increases.

• Two people may be positive for the same risk factor(s) but the importance or relevance of these factors may be judged to be different given the circumstances of the cases

• Result is not a mathematical risk estimate

So what does SPJ do…

1. Identifies which risk factors (determined by research on violence in larger populations) are present and most relevant in the case, and, 

2. Uses these findings to develop appropriate management and treatment strategies 

Advantages to SPJ approach

• Increased reliability and validity; greater consistency in evaluation process as same variables are considered

• Accuracy rates equal to or better than actuarial methods

• Allows dynamic factors to be considered which may be relevant to treatment and management

Dynamic risk factors

• factors which are changeable over time. Ex: alcohol use or current addiction (may be treated and controlled), depression, anxiety, psychosis

Actuarial Risk Assessment

• Clinician judgment is removed from process

• Groups of violent and nonviolent person’s might be compared to ID variables/factors which discriminate between the 2

• Best discriminators are combined to generate violence risk measure that produces violence risk probability estimate

• variables are weighted and combined using an algorithm to generate prediction of violence risk

• often a probability estimate for a particular time period is given

• information is processed by actuarial formula instead of human judgment

• higher inter-rater reliability

• Only limited number of risk factors are considered thus there is question about whether approach uses full range of scientific & professional literature

• VRAG-R (for violence risk); STATIC-99 (for sexual offending)

violence risk probability estimate

likelihood person will engage in future violent behavior within specific time frame

How are variables tested in actuarial risk assessment?

• ONLY variables included in the instrument are considered

• Variables are tested out empirically: How do they work in the prediction of “known outcomes” (combining factors/variables to determine how well they “predict” violent outcomes which have already occurred)

• These “validated” risk factors are combined mechanically

• Usually variables are static (e.g., # of past violent offenses)

VRAG

• Assessment of risk for violent reoffending (to assist courts, clinicians & parole officers make predictions as part of decision making/planning/asset allocation/management/intervention…)

most effective variables correlated with violence risk for VRAG

• the combination of variables that worked best to predict violence in this sample of violent individuals

Goal of VRAG

• Actuarial instrument will predict which offenders will commit at least 1 additional act of criminal violence given the opportunity (i.e., upon release to the community, a minimum security psychiatric facility, or half way house)

• For example, someone with a VRAG score of 10 (per norm tables) would be at the 74th percentile (scoring higher than 74% of offenders in the norm group), in VRAG Category 6 (of 9). Within the offender group, the proportion of individuals with this VRAG score meeting criteria for violent recidivism within 7 years was .44 and the 10 year rate was .58

• Note that because the violence risk predictions are based upon what is known for this particular offender group, risk estimates for a given examinee may change if a different comparison group is used. This would be important to explain to the court in an attempt to make clear what these violence risk estimates mean (and don’t mean)

Violence Risk Appraisal Guide-Revised (VRAG-R)

• 12 variables

• Estimates: Likelihood of violent recidivism after 5 year and 12 year periods (i.e., how likely is violent recidivism after 5 and 12 years for individuals with a particular VRAG-R score based upon normative information)

Examples of the variables in VRAG-R

1. Lived with Both Biological Parents to age 16 

2. Elementary School Maladjustment – up to 8th grade, or age 14

3. History of Alcohol or Drug Problems

4. Marital Status at the time of Index Offense

Some concerns about actuarial method

• They tend to produce “static” risk estimates (stays the same even if there are changes in person’s status on risk variables as might occur with treatment)

• Actuarial risk estimates may appear “precise” but may change when formula is used with different samples.

• May be difficulties explaining findings to judges/juries with limited backgrounds in statistics — juries tend to prefer clinical conclusions

• Tend not to incorporate dynamic risk factors (e.g., response to treatment) which may change a person’s risk level; situations or context not considered

• Less useful in assessing a person’s potential for change in violence risk

• Do not provide as much information about how to intervene to manage risk

SPJ and Actuarial Methods Similarities and Differences

•  both consider empirically supported risk variables

• Both require variables to be operationalized so they can be coded/rated

• They differ in way they integrate items/information

Juvenile Delinquency

• Forensic psychologists (and other mental health providers) are significantly involved in juvenile justice system

• Historical theme is that juvenile offenders differ from adult offenders and should be treated differently by legal system

• More focus on rehabilitation

• Views about this have varied over time - some question effectiveness of rehabilitation and some critical about “leniency” notion

Common Law of Infancy

• an absolute defense which prevented criminal charges until age 7 (or 10 in some places)

Juvenile crimes prior to the 1st juvenile code

•  juvenile crimes handled by general criminal law

• An assumption of immaturity did exist and could be used to decrease criminal responsibility in some cases

• For children/youth between 7-14, whether they could be found criminally responsible depended upon what evidence revealed about maturity level.

• Adolescence eventually came to be viewed as unique developmental period, supporting a distinction between adult vs. youth capacities

Juvenile Court history

• started around turn of 20th century

• Juvenile court (in contrast to criminal court) was to assume role of parens patriae & act on behalf of youth

• Goal: Make treatment available as way of improving adult outcomes

• Main focus thus on rehabilitation, not retribution

• J. court proceedings were closed & J. records sealed to prevent stigma and decrease likelihood of self-fulfilling prophecies

• Also involved attempt to shed positive light on J. Court

• JC’s would also use Civil (instead of Criminal) court procedures and language

Status Offenses

• Conduct that would not be a crime if committed by adult, i.e., legal violations due to offender being a minor

• Examples: “Incorrigibility”; “Unruliness”; “Truancy”

• These fall under CHINS (Children in need of supervision or services) or PINS

• Thus J. Court System involved less law & more MH intervention (creating large roles for MH professionals)

Problem with J.Courts in past

• Little science present in J. Courts

• Lots of MH work guided by assumptions about how best to deal with troubled youth, not by empirical evidence.

• Became clear that JC outcomes were not as expected

• Began to be looked at as ineffective and unjust

• 1967 Gault case very influential

Assumptions from the past views on J courts

• Youth were best viewed as less responsible

• It was best to use informal court proceedings

• That court had capacity to rehabilitate

Gault Case Established..

• Minors have constitutional rights (just as adults do) and deserve due process which creates fairness in legal system

• Included are Rights to Counsel; to Written & Timely Notice of Charges; & Right Not to Incriminate Oneself

• Per Court: Not appropriate for treatment to be substituted for fair legal proceedings/process

• In response – legal proceedings for juveniles became more similar to those seen in criminal courts

Public Opinion on J.Court system

• Supreme Court (several years after Gault) stated this system should not totally give up rehabilitation goals & that J. court system should not adjudicate as does adult criminal justice system

• need to protect public/desire to punish vs. developmental immaturity and rehabilitation

• many adults feel incarcerating juveniles with adults increases likelihood of continued offending

Should mental health and juvenile systems be interconnected?

• Both mental health & J. Justice systems often involved in cases of psych. hospitalization & J. Justice placements

• Courts often refer to mental health programs

• The legal system is often used as leverage to get youths & families into MH treatment (which they otherwise might not pursue).

Cons of Mental Health and juvenile justice systems being interconnected?

• J. courts not set up to intervene in psychiatric matters

• Perhaps taking on more than they can manage?

• Perhaps better to remain focused on legal matters?

• Some worry that if JJ system attempts oversight of mental health services for children & families, result will be people coerced into services and given “labels” which can stigmatize (e.g., Delinquent…)

• “Juvenile Mental Health Courts”; “Juvenile Drug Courts”; “Truancy Courts”

• Melton et al. (2018) argue for more separation between systems despite history of courts attempting to rehabilitate youth

• Suggest that such individuals & their families are more likely to benefit from MH services that are not mandated by JJ.

Voyeuristic Disorder

sexual arousal from observing an unsuspecting person who is naked, disrobing or engaged in sexual activity as manifested by fantasies (thought), urges (affective), or behaviors.

Paraphelia criteria

• Duration at least 6 months;

• urges acted upon with nonconsenting person OR urges, fantasies cause significant distress or functional impairment.

• Age 18 or older

• Note that person need not perform illegal act (or any act) to be diagnosed with paraphilia. Fantasies or urges which cause great distress or interfere with social, occupational or other functioning would satisfy criteria.

Exhibitionistic Disorder

• Recurrent & intense sexual arousal from exposing one’s genitals to unsuspecting person

Frotteuristic Disorder

• Sexual arousal from touching or rubbing against a nonconsenting person

Sexual Masochism Disorder

• Sexual arousal in response to being humiliated, beaten, bound or otherwise made to suffer

Sexual Sadism Disorder

Sexual arousal associated with the physical or psychological suffering of another person

Pedophilic Disorder

 Sexual arousal, urges, or behaviors involving sexual activity with prepubescent child (typically 13 y/o or younger)

Fetishistic Disorder

Sexual arousal from either using nonliving objects or a specific focus on non-genital body parts

Transvestic Disorder

• Sexual arousal associated with cross-dressing

Child molester

• Person who has committed a sexual crime against a child under the age needed to give sexual consent (usually 16-18)

Pedophile

•  Person who engages in sexual activity or has significant distress over urges to do so with pre-pubescent children (13 y/o or younger)

Pedophile and Child Molester

• So, a person may be a child molester but not a pedophile (if their actual preference is for sexual relations with an adult partner)

• One may be a pedophile but not a child molester

Sexual Assault

Broad descriptor covering range of sexual offense, not limited to rape.

Sexual Predator

• Legal term referring to mentally ill sexual offender likely to commit future sexual crime. Such an individual is often civilly committed after they serve criminal sentence to prevent future sexual assaults.

Rape

•  Typically defined as a type of sexual assault characterized by force or threat of force involving vaginal penetration

Hanson view of assessment of sexual offenders

• Both risk for sexual and non-sexual recidivism need to be assessed

• Evidence suggests sexual offenders (especially rapists) as likely to re-offend with non-sexual violent crime as with sexual offense

• But variables which predict sexual offending differ from those which predict non-sexual violent offending

• Thus, sexual offender risk assessments should include BOTH

Sexual Preoccupation

• Frequency of sexual activity, pornography use, strip clubs…(not just deviant interests)

Empirically Supported Risk Factors

• Sexual preoccupation

• Offense Related (Deviant) Sexual Interests

• Sexual interest in children

• sexual interest in violence

• paraphilia diagnosis

• offense supported attitudes

Relationship Factors for Sexual Offenders

• Emotional congruence with children – Unique to child molesters, emotionally connects with children better than with adults (usually not present with incest offenders)

• Poor adult attachments-lack of intimate connections with adults (never married)

• Conflicts with lovers – has relationships but unhealthy

• Note following factors also seen in general recidivism offenders

Lifestyle Impulsivity affect on sexual offender

• Poor Self Regulation

• Impulsivity

• social problem-solving deficits

• limited self control

• recklessness (which continues after age 25)

• unstable work history

• lacks interest in stable life in community

Cognitive Problem Solving Deficits

• Problems logically reasoning through problems

• Grievance/Hostility: Belief world is against them, poor me syndrome justifying offending behavior (“sexual offending is wrong but in my case…”)

• Negative Social Influences: Involvement with antisocial peers but also with others who could be prosocial influences (e.g., family members who make excuses, overlook problematic behavior like drinking, providing access to children)

Resistance to Rules - Sexual Offenders

• Childhood behavior problems

• Non-compliance with supervision

• Violation of conditional release (e.g., not compliant if released on bail)

Promising Factors of Sexual Offending (more research needed)

• Hostility toward women (e.g., with rapists, child molesters) can’t trust women

• Machiavellianism – willingness to manipulate and use others to their benefit

• Callousness/Lack of Concern for others

• Sexualized coping – using sex to manage emotional states

Generally unsupported factors for sexual offending

• Denial or Minimization not reliably correlated with likelihood of reoffending

• Low Self Esteem

• Major Mental Illness

Definitely Not Risk Factors for Sexual Offending

• Depression

• Poor Social Skills

• Poor Victim Empathy

• Low Motivation for Treatment

Overall Strong Risk Domains for Sexual Offending

• Age (inversely related to risk)

• Sexual Preoccupation and Deviant Interests (especially sexual interest in children)

• Antisocial Orientation, e.g., impulsivity, hostility, psychopathy, antisocial PD

• For the most part risk factors relevant for general criminal offenders are also relevant for sex offenders in addition to sexual factors noted here

Stable Dynamic Risk Factors (treatment targets) for sexual offending

• Intimacy Deficits & Emotional Loneliness – Problems establishing relationships with depth & breath, resolving IP conflicts, hostility toward women

• Significant Social Influences – Criminal associates, important others that interfere with risk management

• Cognitions Supporting Sexual Offending (in self or others) – e.g., “I was drunk”, “rejecting wife”...

• Sense of entitlement to sex – beliefs regarding relationships, gender roles, sexuality

• Sexual Self Regulation – Problems managing sexual life & impulses, sexual preoccupation, sexual coping (vs. most people have less sexual desire when stressed), deviant sexual interests (e.g., paraphilias, interest in children, violence associated with sex).

• General Self-Regulation: Impulsivity, poor self control, pro-criminal attitudes, identification with criminal models

• Lack of Cooperation with Supervision – missing appointments, opposing supervision or treatment, testing limits e.g., “1 beer won’t hurt”, contact with children

Acute Dynamic Risk Factors for sexual offending

• Substance Abuse – Intoxication, Not a cause of offending but can lower inhibition to act on thoughts, Acute return to substance use can increase risk

• Emotional Collapse – Acute decrease in ability to cope with negative emotional stressors, reverting to old strategies, “quick fixes”

• Collapse of Social Support – Acute decrease in support from those not paid to be with offender, withdrawal from healthy relationships, “life happens to offenders as well”

• Hostility – (not baseline hostility) – Reckless, self-defeating defiance, “I’ll show you”, excessive, unwarranted hostility

• Sexual Preoccupation – (acute version of a stable factor) – Greater than baseline level of SP and activity, may be associated with increased stress

• Victim Access – Presence of other risk factors together with opportunity increases offending risk

• Rejection of Supervision (acute version of stable dynamic factor) – Acute increase in no-shows, not following treatment… may lead to quickly increasing risk

Assessment Approaches to Sexual Offending

• Risk Assessment via Actuarial Method

• STATIC-99R: 10 item instrument for assessing risk of sexual recidivism

• Most commonly used sexual re-offending risk assessment in USA

• Does NOT include all possible risk related factors (so must be supplemented)

• Used with incarcerated male sex offenders

• Evaluates empirically established risk factors; specifies rules for combining them; generates a total risk score 

STATIC-99R

• “... An actuarial risk prediction instrument designed to estimate the probability of sexual and violent reconviction for adult males who have already been charged with or convicted of at least one sexual offense against a child or a non-consenting adult”.

• Provides estimate of recidivism risk as of day person is released from index sex offense (i.e., when they again have opportunity to offend)

• An index sex offense is typically the most recent conviction

To score STATIC-99R, must have

• Demographic Information

• Official Criminal Record

• Victim Information

To be considered a sexual offense, the behavior must have resulted in some form of criminal justice intervention or official sanctions

Child Pornography Offender Risk Tool (CPORT)

• Used to predict any sexual reoffending (contact or non-contact sexual offenses as well as child pornography recidivism) in adult males with a conviction for a child pornography offense.

Child Pornography Offense

• Accessing, possessing, distributing, and/or producing CP, which involves either children engaged in sexual acts or material in which the dominant characteristics include sexual organs. 

• May take the form of photos, drawings, paintings, video, cartoon animation, audio material, and text stories describing sex with children or advocating sex with children.

Recidivism rate for child pornography offenders

• Recidivism rate for child pornography offenders between 5%-12% for new sexual offense of some kind within time periods ranging from 1.5 to 6 years.

• Rate of new contact sexual offense as low as 2%; and 3% for a new CP offense

CPORT Items (7 total; Yes/No)

1. Offender age at time of index investigation: 35 or younger

2. Any prior criminal history

3. Any failure on conditional release

4. Any contact sexual offending

5. Indication of pedophilic and hebephilic interest (Hebephilia – persistent sexual interest in pubescent children – ages 11-14)

6. More boy than girl content in the CP material

7. More boy than girl content in the nude/other child material

Rates of Sexual Re-Offending

Difficult to determine as estimates often based upon legal data and many such acts may not be detected or result in criminal charges

Phallometric Assessment

• Penile Plethysmograph (PPG):

• Used to assess sexual preferences with male sexual offenders

• E is exposed to some type of sexual stimuli (visual, auditory, or combination) 

• Content consists of some neutral, some sexually appropriate, and some unusual or deviant material

• Prior to exposure, monitoring equipment is set up measuring heart rate; perspiration (skin conductance); and blood flow in penis

• Responses to various stimuli are recorded

• Provides information about urges and behavior in real world

• Research shows strategy can differentiate between child molesters and non-offenders

• Some evidence also shows that rapists and non-rapists can be distinguished by this approach.

• Appears less effective with other offender groups

• Penile plethysmograph often produces useful research results but caution needed when using for clinical work (i.e., clinical forensic assessment of the individual case)

• Note that polygraph exams are also used in some cases

Hypothesis for Phallometric Assessment

• Hypothesis is that sexual offenders will show deviant sexual preferences which will be detected in response to some sexual stimuli

• Approach may be useful given denial often seen on self report measures of sexual offending

Psychological Assessment for Child Porn Offenders

• Other psychopathology present?

• Characteristics which may have implications for sexual offending (e.g., self regulation; cognitive distortion; relationship patterns)

• Cognitive limitations?

• Types of deviant sexual interest(s); strength of such interests; presence of non-deviant sexual interests; level of dangerousness present

• Likely no specific “sex offender profile”

Other issues assessed for child porn offenders

• receptiveness to treatment

• degree to self serving distortion present

receptiveness to treatment assessed for child porn offenders

• Positive indicators might include adult heterosexual interests & skills; presence of stable personal and emotional support; presence of appropriate sexual partners; willingness to admit offense & accept responsibility; desire to discontinue offending

Degree of Self Serving Distortion Present Assessment for Child Porn Offenders

• Essential to evaluate response validity to r/o defensiveness (as well as exaggeration)

Sex offender treatment considerations

• Treatment Selection/Intensity Should be Based Upon Risk Level & Identified Needs

• Note importance of matching intervention to risk/needs

  Mandating intensive treatment for low risk offenders can actually increase risk for offending (“school of crime” concept).

High intensity SO Program

• High risk and moderate to high needs

• Minimum 6-8 months; 15 hours + group therapy per week; weekly individual therapy

• Usually conducted in residential settings (not community)

Moderate Intensity SO Program

• Moderate risk and Moderate to high needs

• Minimum 4 months (up to 8 months)

• 8-12 hours therapy per week (may or may not include individual therapy)

Low Intensity SO Program

• Low risk and low/moderate needs

• 2-3 months; 2-4 hours group therapy weekly; no individual therapy

• Primary target may be psychoeducation, improving relationships

Cognitive Behavior Therapy

• Based upon the assumption that cognitive, emotional, and behavioral variables are functionally interrelated. Treatment is aimed at identifying and modifying the client’s maladaptive thought processes and problematic behaviors through cognitive restructuring and behavioral techniques to achieve change 

• Focus more on offender behavior than character

• Supportive but firmly challenging therapeutic stance (note “non-specific” treatment factors)

• Increase frequency of appropriate social behavior and awareness of its effectiveness

Cognitive Distortions

• Distorted views toward self and others; patterns of rationalization; externalization; denial; justification associated with offending are challenged using CBT strategies

• Goal is to increase reality-based thinking related to offending

Social skills training

• Frequently targeted here are capacities for empathy and intimacy (Note however, victim empathy NOT empirically supported risk factor)

• Offenders are made increasingly aware of harm resulting from sexual assault

• Care must be taken with sadistic offenders who might better be seen individually

• Goal is to sensitize offender to problems victim experience and encourage remorse

• Above may require education in emotion recognition (and regulation)

Examples of CBT for sex offending

• Having offender review victim impact information, read accounts of sexual abuse (out loud); watch video of victims describing their trauma; offender role playing both self and victim roles; writing from victim’s viewpoint

• Abuse survivor may speak with group and facilitate discussion

Intimacy work for sex offenders

may need to address issues such as loneliness, jealousy, effective communication skills, conflict resolution and sexuality, including sexual myths

• Goal is to identify, learn, and practice interpersonal and intimacy related skills

Pharmacological strategies used for deviant sexual urges

• Pharmacological strategies may be useful in reducing deviant sexual urges in combination with CBT

• Antidepressants (SSRI’s) and Antiandrogens have been utilized (former likely impact co-morbid psychiatric problems)

• SSRI’s including Fluoxetine and Sertraline have been used in treatment of exhibitionists, compulsive masturbation, pedophilia (non-acting), and paraphilias in adolescents

• These not technically forms of “chemical castration”

• Cyproterone Acetate (CPA) is a synthetic steroid which reduces testosterone levels. This is used to decrease sexual urges in men (chemical castration)

• Long term studies needed to determine effectiveness of both drug classes over extended periods of time

• Used most in Canada, Europe, and Middle East

• Decreases sex drive & sexual arousal

Sorrentino (2022)

• Small number of states have court mandated chemical castration for problematic sexual behavior (CA the 1st)

• Castration = Removal or inhibiting functioning of tastes (chemical and surgical approaches)

• Recidivism with castration 2.2% vs. 13-17% for untreated sex offenders

Chemical castration

• Drugs used to decrease testosterone (brings down to level of person who has not gone through puberty)

• Chemical castration reversible unlike surgical castration

• Results in decreased sex drive and sexual behaviors

• Testosterone can be lowered without full chemical castratio

Main chemicals used in chemical castration

Progesterone, Antiandrogens, Gonadotropin-Releasing Hormones

Chemical castration as treatment for sex offenders

• Testosterone can be lowered without full chemical castration

• Interestingly sexual offenders do not necessarily have higher testosterone levels than non-offenders

• Not used with juvenile offenders because process arrests development

• More controlled research needed

• Treatment lasts 2-5 years depending on severity of impairment

• Candidates must be 21 y/o and must meet with psychiatrist and psychologist at start (GA requires psych counseling)

• Cost may be an issue, e.g., $1,500/month for some drugs

• Sorrentino states “My patients don’t want to stop [this treatment]”