Assessing and treating sexual offenders with mental disorders
| Published date | 06 May 2014 |
| DOI | https://doi.org/10.1108/JFP-02-2013-0012 |
| Date | 06 May 2014 |
| Pages | 94-109 |
| Author | Alex Lord,Derek Perkins |
| Subject Matter | Health & social care,Criminology & forensic psychology,Forensic practice |
Invited paper
Assessing and treating sexual offenders
with mental disorders
Alex Lord and Derek Perkins
Professor Derek Perkins is
based at Broadmoor Hospital,
Crowthorne, UK, where Dr Alex
Lord is a Principal Forensic
Psychologist.
Abstract
Purpose – The purpose of this paper is to increase our understanding of the role of mental disorder in
sexual offending as well as identifying innovations in assessment and treatment with offenders who present
with these typically complex risks and needs.
Design/methodology/approach – The converging literatures on “good lives”and other developments in
sexual offender treatment are compared with recovery from mental disorder and what is known about the
particular needs and characteristics of sexual offenders with mental illness and severe personality di sorder( PD).
Findings – A key outcome of this review is that many mentally disordered sexual offenders have similar
needs to those in prison and the community but there are particular challenges posed by severe PD,
paraphilias and the relatively rare individuals whose offending is functionally linked to psychotic symptoms.
Practical implications – Practical implications include the need for case formulation of complex needs
related to mental disorder using direct and indirect measures of attitudes and interests. Treatment needs
to be responsive to very different personality and mental health presentations as well as problems
with offending and cognitive schemas. Direct functional links between mental health symptoms such as
delusions and hallucinations are very rare in practice and are usually secondary to PD and sexual offending
issues. In practice, treatment promoting recovery from mental disorder is highly compatible with the
“good lives”approach to sexual offender treatment. Staff development, supervision and support are
particularly important for staff treating mentally disordered sexual offenders.
Originality/value – It is argued that mentally disordered sexual offenders are an under-researched
sub-group within the wider sexual offender population. This paper brings together the relatively limited
literature on treatment with examples of recent treatment innovations, multi-modal assessment approaches
and reviews of research on the needs of this relatively uncommon but highly risky group.
Keywords Recovery, Mental disorder, Paraphilias, Psycho-physiological assessment, Schemas,
Sexual offending
Paper type General review
Introduction
Mentally disordered sexual offenders present with issues including schizophrenia,
psychoses, delusional disorder, mood disorders, autistic spectrum disorder, personality
disorder (PD) and often high levels of psychopathy (Perkins, 2010). This paper contends from
a review of relevant literature that, while treating these symptoms is necessary for an
individual’s recovery, it is not sufficient to reduce sexual offending risk (Lockmuller et al.,
2008). Sexual offenders are challenging to treat due to the compulsive element of deviant
sexual interests, limited impulse control, entrenched offence-related beliefs and problems
maintaining desistance from offending (Beech, 2010). Advances in the treatment of sexual
offenders primarily based on prison research are described in reviews by Mann and Marshall
(2009) and Serran and Marshall (2010). Less is known about treating sexual offenders with
a mental illness (Garrett and Thomas-Peter, 2009) although those with PD have received
recent research interest (Jones, 2009). The implications are considered for treating mentally
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disordered sexual offenders regarding cognitive and offending schemas, delusional beliefs
linked to offending and specific offence-related paraphilias.
This paper first examines the challenge of a formulation-based (Ward et al., 2000) approach to
treatment, particularly establishing functional links between sexual offending, criminogenic needs
(e.g. sexual interests and offending schemas) and mental disorders (e.g. PD, mental illness,
mood and developmental disorders). Methods of obtaining reliable assessments of deviant
sexual interests including sexual violence, homicide, paraphilias and sadism are reviewed.
Regardless of diagnosis, there is now more attention paid to therapeutic process including
motivation and treatment style. Treatment programmes that emphasise therapeutic engagement
within a therapeutic milieu rather than strict adherence to manualised exercises are showing
promising treatment effects (Ware and Bright, 2008). This paper explores how the treatment
process issues of readiness, responsivity and interpersonal style (illustrated by anxious/avoidant
and narcissistic individuals in therapy) are particularly relevant to mentally disordered sexual
offenders (Clarke et al., 2013) and PD offenders with learning disabilities (Taylorand Morrissey, 2012).
In contrast to avoidance-based relapse prevention, there is a growing emphasis on equipping
offenders to meet primary needs through non-offending “good lives” approach goals and
post-release follow-up (Willis et al., 2012). Such approaches encourage self-management of
sexual interests and acquisition of coping skills such as mindfulness and emotional regulation
through role play practice that “frees up” thinking in individuals who may be less responsive to
purely cognitive learning methods (Mann et al., 2003; Mann and Carter, 2012). It will be shown in
this paper that the “good lives” approach and the need for developing and practicing pro-social
skills are highly congruent with the model of “recovery” advocated for mentally disordered
offenders (Doyle et al., 2012).
Research on mentally disordered sexual offenders
Compared to the thousands of sexual offenders detained in UK prisons, there are far fewer in
secure psychiatric hospitals. Smith and Taylor (1999) noted that the total number of male
psychiatric in-patients with a history of contact sexual offences whose cases were overseen by
UK Home Office restriction orders was 84. Of these, 95 per cent had been psychotic at the time
of the index offence and most had committed their first sexual offence after the onset of
schizophrenia. In only 21 per cent of cases could a direct link be established between the
content of hallucinations or delusions and the index offence. While this is still a significant
minority and merits further research, it lends credence to the view that solely treating mental
illness is not usually sufficient to reduce offending risk (Lockmuller et al., 2008).
Alden et al. (2007) found in a Danish birth cohort that 8.4 per cent of the “physically aggressive”
sexual offences were men withpsychotic disorders.Fazel et al. (2007) found that sexual offenders
were 6.3 times more likely to have been in-patientsand 20.1 per cent of the totalsexual offending
was committed by those who had required psychiatric hospitalisation. Craissati and Hodes (1992)
studied 11 mentally ill (MI) sex offenders in a regional secure unit: 27 per cent had committed sexual
offences prior to their index offence and 63 per cent had been supervised by psychiatric services.
The majority, 86 per cent, of these had ceased contact and medication before the index offence.
The offences were generally impulsive with little attempt to evade capture. The authors attributed
most of the offending to “sexual disinhibition” as a symptom of mental deterioration and they
concluded that the men in their sample were not markedly “sociopathic”.
In contrast, Chesterman and Sahota (1998) described treatment needs of 20 MI sex offenders
admitted to a regional secure unit showing a very different profile: 45 per cent had committed
previous sexual offences and 78 per cent of the offences were against strangers. During the
offence, 50 per cent had paranoid ideation, 35 per cent had delusions and 5 per cent command
hallucinations while 45 per cent met the criteria for anti-social PD and 40 per cent misused
substances. Baker and White (2002) studied 53 sexual offenders in the Scottish State Hospital
finding that 51 per cent had anti-social PD and 58 per cent had some form of mental illness.
Out of the MI patients, 77 per cent were psychotic at the time of the index offence with a majority
of offences against strangers. The patients with co-morbid PD had more prior sexual offences
and were more likely to have violent or paedophilic fantasies.
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