by Eileen Finnegan
‘I count him braver who overcomes his desires than him who conquers his enemies; for the hardest victory is the victory over self.’ (Aristotle,384-322 BC)
I began writing a series of articles in 2009 based on my experience of working on a treatment programme for perpetrators, beginning with ‘Moving beyond my prejudices’, to ‘How theory can support me when the internal world is so challenged by the work’. The final piece I am writing about is the efficacy of treatment based on my current working experience and the research carried out on this area.
As I begin to write this final piece the first issue that emerges for me is the impact on my-self as I complete the first year of this treatment programme. I will further discuss the changes to me personally, the changes that occurred to the individuals on the programme and the changes that I experienced within an organisation that works with perpetrators and victims. The treatment programme began in November 2008 and the final module was on relapse prevention. I will start with a review of what some of the research informs us regarding efficacy of treatment.
As recidivism rates are the most commonly employed method of evaluating treatment programme efficacy (Cooke and Philips, 2000), it has been suggested that for treatment to be considered effective, two questions need to be answered: firstly, does the treatment programme produce the expected changes and secondly, does it produce lower recidivism rates than for untreated offenders? (School of Psychology, Module 2. 2007). Although some forms of treatment for sex offenders appear promising, little is known definitively about which treatments are most effective, or for which offenders, over what time span, or in what combinations. What emerges from the literature is a strong suggestion that a comprehensive cognitive-behavioral program should involve components that reduce deviant arousal while increasing appropriate arousal and should include cognitive restructuring, social skills training, victim empathy awareness, and relapse prevention. In addition, individuals should be considered for antiandrogen medication if they are at high risk of reoffending.
Furby and colleagues (1995) amassed data from numerous studies of sex offenders that included at least ten subjects and used criminal justice records for outcome measures. The review covered almost 7,000 men. The authors concluded that their review failed to provide any convincing evidence that treatment is effective in reducing recidivism of sexual offenses. They further stated that their data did not permit evaluation of the relative effectiveness of treatment for different types of offenders. In fact, the authors reported difficulty discerning any patterns relating treatment to recidivism, including the expected pattern that longer follow-up periods would produce higher recidivism rates.
Hall (1996) although limited to only 12 studies—provided an overall estimate of the results of treatment for sex offenders. This analysis included all published studies since the Furby review that compared samples of more than ten offenders who had completed a treatment program with others who had completed a comparison program or no treatment program, and that used arrest records for sexual offenses as outcome data. The mean length of treatment in the studies was 18.5 months, and the mean follow-up period was 6.9 years. Overall, the analysis found that the recidivism rate for treated offenders was 19 percent, compared with 27 percent for nontreated offenders. Some such as Marshall (et al 1999) assert that when we consider recidivism rates, research consistently supports the view that the majority of treatment programmes that take a cognitively behavioral approach are effective in reducing recidivism.
So what is it about CBT that leads to such a significant impact on treatment efficacy? A lot of research into the effects and the delivery of CBT have focused on what is needed in the development of relapse prevention plans targeting treatment of low self-esteem, cognitive distortions, empathy deficits, problems in social functions, poor coping skills and aberrant sexual preferences (Fernandez, Shingler and Marshall (2006) and (Marshall, Anderson and Fernandez (1999). Other areas targeted include offence specific problems such as anger, violence, substance abuse, impulse control, inadequate problem-solving and deficient parenting skills (School of Psychology, Module 2, 2007).
Another important component affecting treatment efficacy is the climate in which treatment is delivered and the way in which the therapist behaves whilst delivering the therapy, including cognitive behavioural therapy. Another important factor, closely related to and often influenced by the therapist, is group atmosphere. Group atmosphere refers to the degree of engagement, avoidance, conflict, and the relationship between the group members and the group facilitators. (Yalom, 2005).
Changes in Treatment
In recent years, the move in the treatment of sexual offenders has been away from just attempting to change behaviour and distorted thinking patterns. In the past, society’s need to be protected from offender re-offending was the primary reason for treatment programmes. The needs of the offender was not generally considered when developing or delivering treatment. With research identifying the most effective therapist features and the significance that hope has on effectiveness, this led to this new and more humanistic approach, generally termed a “good lives approach” (Ward 2002) (Marshall et al 2005). Put very simply, the theory behind the good lives model is basically that if a human being, an offender or non-offender, can identify and achieve those goals then they will be happier and therefore less likely to engage in negative behaviour. The model recommends that the shift in treatment should be away from focusing on the negative, which currently is a large component of the relapse prevention model.
Programmes often take an approach that dictates to the offender all they must stop doing or can no longer have in their lives without offering an alternative. Whilst relapse prevention may be an important part of rehabilitation, to focus on this aspect can lead to the offender maintaining a very negative self-image. Whereas, the good lives model takes the view that, as all offenders are individuals with individual needs, there can be no one size fits all model. The good lives model encourages the offender to attempt to identify a positive alternative to negative formulation of goals. For example, offenders are often told that they must not allow themselves be alone with a child in case they might abuse them. With a good lives model he or she would be invited to reframe this negative or “avoidant goal” (Ward 2002) (Marshall et al 2005) into a positive or “approach goal” which would focus on how to not allowing themselves to be alone with a child and would have positive implications for his or her new good life. The good lives model of treatment has had a significant impact on treatment efficacy with research findings presented at ‘The Good Lives Conference’ in Dublin, 2006 reporting recidivism rates as low as 3% (Ward 2006).
Society may baulk at the idea of sexual offenders being treated as anything less than monsters, however, the vast majority of research indicates that the more you acknowledge offenders human aspects the better they do. The good lives model seems to embody the factors that are identified, as been of such importance when it comes to treatment efficacy.
From my own personal experience I am left with more questions and curiosity than I began with. While there is some positive research about the efficacy of treatment the piece that stands out for me most is the therapist’s characteristics and how this can impact on the outcomes. For many weeks I questioned my motivation for working with offenders and tried my best to monitor the impacts on me personally. I have asked myself a question over and over since I began this work with this group of individuals; would I leave any of my children or indeed any children alone with these individuals? Indeed even as I write this down I wonder about having the right to make that call. Yet as part of my job I have to constantly assess the risk. I am not sure if I have the answer yet. What I am sure of is the commitment all group members made to the group, how they participated in group, and how they supported each other and indeed how they supported me. Do I personally feel those individuals who participated in the treatment programme will ever re-offend? I am not sure.
What I do feel is that all the individuals have an awareness of their offending behaviour, the motivations that led them into their offending behaviour and the knowledge of how to prevent their offending behaviour from re-occurring. However it is only the individual who can remain true to himself and support each other from re-offending. Asking myself the question as to whether I am more aware of why an individual offends in the first instance I am unsure. While many of the factors identified by research as to the motivations for individuals to sexually offend were evident in the group nothing concrete jumps out at me regarding their motivation. While low self esteem, intimacy deficits, poor social skills, isolation, denial, cognitive distortions and the lack of remorse or guilt became clearer to me, I was still not so sure why sexual offending needed to be the outcome of their emotions. I have worked for many years with individuals who had experienced a lot of trauma in their lives and who had not gone on and sexually offended so it was hard to understand why these particular individuals went on to offend.
What I did discover though was seeing the individuals behind the offending behaviour and for that I am truly grateful, as this has restored my faith in the therapeutic process. It reminds me that therapy does work and individuals can change their behaviour when they experience relating to others in a more positive way. In my experience of the treatment programme I feel I journeyed a very difficult path with individuals who had carried out horrendous acts of sexual abuse yet had begun to really understand the impact of their offending behaviour on their victims. For some the shame and disgust at their behaviour was evident and at these times I was concerned that they may take their own lives as living with what they had done was too much. Even as I write this I feel disloyal to some of the clients I work with who have experienced sexual abuse. I have also wondered how these offenders can live with themselves after what they have done. I am left with more hope than when I began this work, I have learnt that the value and necessity of peer support, supervision and the working environment all contribute to my psychological well being.
Changes to Individual Offenders
In the early stages of the programme most of the individuals were in a state of remorse and feelings of guilt, yet as I suggested to them on many occasions most of them were on the programme because they were caught and not because they realised the impact of their offending behaviour. It was at times hard for them to hear why society finds it so difficult to have anything to do with individuals who have offended because they do not see them taking responsibility for their offending behaviour. As the weeks went into months and the individuals began to look at traumas in their own lives and began to understand the impact of their own traumatic life experiences this slowly began to open their minds up to the impact on the victim. It was also a time of heightened cognitive distortions and a real challenge for me personally to stay in the room with them and hear the distortions. One of the things I did notice was how the men began to support each other in a way I imagine they had never experienced before. They were very challenging with each other and even disgusted with each other’s behaviour. As they began to see beyond the offending behaviour this brought about a shift. In fact some of them began to experience a lot of anger, which is a feeling they felt they had no right to feel. However as they began to look at relapse prevention most of the factors that led them to offend were still current in their lives. The only difference was they had been found out and were reminded every day of the impact of their offending behaviour on those close to them. They needed to be aware that issues of self-esteem, relationship difficulties and intimacy deficits were very alive for them and they needed to be alerted to this as it was a major factor in their motivation to sexually offend.
Changes in relation to the organisation which offers treatment to sex offenders and support to victims of sexual abuse
In relation to the organisation and my experience of the impacts of moving from working with individuals who have experienced sexual abuse to individuals who have perpetrated has positive and negative impacts. The positive impacts are having an understanding of the grooming process and how an individual may be at risk of being violated against especially in relation to intra familial abuse. This brought an awareness of the vulnerability of individuals and how these vulnerabilities may still be evident in adult life and supporting individuals to have more secure boundaries in their adult lives. In the negative pieces their were difficult times sitting with victims and listening to their distress as to how the organisation could work with offenders when they were so devastated in their lives by the abuse they had suffered. Staying focused on the bigger picture and the belief that in order to stop the cycle of offending behaviour all individuals including perpetrators had to be met and understood.
To conclude I want to sincerely thank all those who have been part of this programme from the very beginning and the insight it took to begin this work. I still feel we have a long way to go in this work, yet I feel we are moving in the right direction. What a wonderful world it would be if the cycle of offending behaviour ceased.
Eileen Finnegan IAHIP, is a psychotherapist and supervisor at One in Four.
Ennis, L., & Horne S., (2003) Predicting psychological distress in sex offender therapists sexual abuse: A Journal of Research and Treatments, 15,149-156‘. School of Psychology (2007). Module 3: Practice Assessment & Clinical Skills, Leicester: School of Psychology – Forensic Section, University of Leicester
Furby L, Weinrott MR, and Blackshaw L. (1995) Sex offender recidivism: a review. Psychological Bulletin 105:3-30,
Marshall, W.L. Anderson, D. Fernandez Y. (2005) Cognitive Behavioural Treatment of Sexual offenders. Sussex: Wiley Press,
School of Psychology (2007). Module 5 Research Methods Module, Leicester: School of Psychology – Forensic Section, University of Leicester
Ward, T., Polaschek, D. and Beech A. (2005). Theories of sexual offending. Sussex: Wiley.