Cognitional Impairment: Is There a Role for Cognitive Assessment in the Treatment of Individuals Civilly Committed Pursuant to the Sexually Violent Predator Act?

Sexually Violent Predator statutes allow the involuntary treatment of individuals who are found to pose a threat to public safety. Most sex offender treatment programs rely on cognitive interventions to reduce the risk of recidivism. The purpose of this study was to examine (a) whether individuals with paraphilia diagnoses have cognitive deficits compared with the general population; (b) whether individuals diagnosed with pedophilia differed on cognitive performance when compared with individuals diagnosed with paraphilia not otherwise specified (NOS), nonconsent; and (c) whether individuals with paraphilia plus antisocial personality disorder (ASPD) differed in cognitive performance when compared with individuals with a paraphilia diagnosis only. The sample consisted of 170 males (M age = 50.21; SD = 10.22) diagnosed with pedophilia or paraphilia NOS, nonconsent, who were detained or civilly committed to a forensic psychiatric hospital. Assessments included Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), Wechsler Abbreviated Scale of Intelligence (WASI), and Wide Range Achievement Test 4 (WRAT4). Individuals diagnosed with pedophilia and paraphilia NOS, nonconsent, obtained lower scores than matched controls based on the RBANS Immediate Memory, Visuospatial/Constructional, Delayed Memory indices and Total Score. In comparison with individuals with paraphilia NOS, nonconsent, those with pedophilia diagnosis had lower scores on the RBANS Delayed Memory. Individuals diagnosed with a paraphilia disorder combined with ASPD demonstrated trends toward lower IQ scores than those with a paraphilia diagnosis only. Treatment programs can improve their chance of success by assessment of cognitive processes, and offer therapy in a style that is consistent with the cognitive abilities of their clients.

The Use of Phallometric Evidence in Canadian Criminal Law.

The use of phallometric evidence by Canadian criminal courts has steadily increased since the early 1980s. Phallometry was initially considered by courts to be a potentially useful tool in the determination of accused persons' culpability; however, its contemporary use is limited to the postconviction contexts of sentencing and dangerous and long-term offender applications, as one of several means of diagnosing offenders, determining recidivism risk, and assessing treatment prospects. We provide an overview and assessment of the use of phallometric evidence by Canadian criminal courts and conclude that its contemporary application appears to be consistent with the expert psychiatric consensus on its proper role and function in the forensic context. We further identify potential difficulties associated with the adequacy of offenders' consent and the occasional divergence of expert opinion about the reliability and validity of phallometry for diagnosis and risk assessment.

Commentary: Phallometry in Court­Problems Outweigh Benefits.

Phallometry evaluations are of great value in sex offender treatment programs, in assessing for a deviant drive related to criminal offenses and in monitoring treatment results, especially in connection with cognitive behavioral techniques that teach skills for reducing deviant sexual interests. The research on phallometry, however, is fraught with methodological problems that limit its utility in settings such as court procedures where there is a strong self-interest in producing results that suggest the absence of deviant sexual drives. The lack of consensus in methodology and scoring, the difficulty encountered in "nonadmitters," the ability to dissimulate ("fake good") on the assessments, and the lack of good specificity and sensitivity data limit the use of such procedures in any setting that could affect length of sentence or determination of civil commitment.

[Treatment management of sexual offenders]. / Prise en charge thérapeutique des auteurs d'agressions sexuelles.

In France, the Court can issue a medical treatment order only for criminally responsible persons. The nature of the treatment to be administered is at the discretion of the physician in charge of the sexual offender's care. Treatment management of sexual offenders relies essentially on psychotherapy, and preferentially cognitive behavioral therapy. For most severe sexual offenders, drug treatments, including hormonal treatment and selective serotonin reuptake inhibitors, are used to complement psychotherapy. This literature review aims at synthesizing practice changes in the treatment management of sexual offenders.

Visual Reaction Time™ as a predictor of sexual offense recidivism.

In this study, we investigated the use of Visual Reaction Time™ (VRT™) for sexual interest in children to predict recidivism of sexual offenses among men who sexually abused children and men with other sexually deviant behaviors. The authors hypothesized that study participants with a higher VRT™ to stimuli of children would be more likely to sexually reoffend compared with those with a lower VRT™ to stimuli of children. Participants included 621 adult males on parole or probation for acting on a range of sexual paraphilias who sought outpatient treatment or evaluation at two separate therapists' practices. Sample 1 consisted of 284 adult males followed up (by the lead author) during a 15-year period, while Sample 2 consisted of 337 adult males followed up (by the second author) during a 7-year period. A discrete-time hazard model found VRT™ to children to be significantly related to sexual recidivism. The researchers found that VRT™ to children measured at intake held up in its predictive ability over a 15-year period. When the participants were divided into three groups based on their VRT™, of the 97 participants who measured at least one standard deviation lower than the mean VRT™, 0% reoffended. The 432 participants in the medium-VRT™ group had an estimated recidivism rate of 7% after 15 years and the 92 participants who measured at least one standard deviation higher than the mean had an estimated recidivism rate of 27%.

Behavioral discriminators of sexual sadism and paraphilia nonconsent in a sample of civilly committed sexual offenders.

Sexual sadism continues to be a diagnosis fraught with controversy concerning its reliability and validity. The current study examined the offense behavior of 39 civilly committed sexual offenders diagnosed with sexual sadism compared to a group of similarly committed individual diagnoses with Paraphilia Not Otherwise Specified (NOS)- Nonconsent. In addition, offense elements common across studies of sadism were identified. Specifically, offense behaviors including victim abduction and confinement, beating the victim during a sexual assault, and using restraints were indicative of sexual sadism across studies. In addition, this study found the use of noncontingent threats as well as gestures of mutuality to be more common among sadists. Results overall suggest that sadistic acts may be more characterized by humiliation of the victim through the exercise of power and control than by the use of violence. Differential diagnosis between Sexual Sadism and Paraphilia NOS-Nonconsent, may be aided by close inspection of offense behavior.

The management of sex offenders: perspectives for psychiatry.

In the effort to identify and manage sex offenders, the differences between legal and medical/psychiatric terminology and approaches are readily apparent. This article discusses the different definitions and approaches of the two fields and considers both the behaviors that create risk to others and the strategies for reducing that risk. Particular attention is paid to the subcategory of paraphilic sex offenders. Treatment goals, modalities, and efficacies are discussed, as are evolving legal strategies for risk control and the need for interaction between law and medicine/psychiatry in order to accomplish common goals of risk management.

Comparing indicators of sexual sadism as predictors of recidivism among adult male sexual offenders.

OBJECTIVE: In this longitudinal study, the predictive validity of a psychiatric diagnosis of sexual sadism was compared with three behavioral indicators of sadism: index sexual offense violence, sexual intrusiveness, and phallometrically assessed sexual arousal to depictions of sexual or nonsexual violence. METHOD: Five hundred and eighty six adult male sexual offenders were assessed between 1982 and 1992, and these offenders were followed for up to 20-years postrelease via official criminal records. Assessment information included the Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis, offense characteristics, phallometric assessment results, and an actuarial risk measure (the Sex Offender Risk Appraisal Guide). RESULTS: Predictive validity was demonstrated in univariate analyses for the behavioral indicators of sexual sadism (area under the curve [AUCs] from .58 to .62) but not psychiatric diagnosis (AUC = .54). Cox regression analyses revealed that phallometrically assessed sexual arousal to violence was still significantly associated with violent (including sexual) recidivism after actuarially estimated risk to reoffend was controlled. A psychiatric diagnosis of sexual sadism, in contrast, was unrelated to recidivism. CONCLUSIONS: The results support the use of more behaviorally operationalized indicators of sexual sadism, especially phallometric assessment of sexual arousal, and suggest the DSM criteria for sexual sadism require further work.

[Assessment of sexual deviance by forensic psychiatrists]. / Begutachtung bei Sexualstörungen in der Forensischen Psychiatrie.

The article reviews the legal changes in dealing with sexual offenders in Germany during the last ten years. The developments described are in many respects comparable to other countries of Northern and Western Europe and to Austria. The laws, which regulate the penal aspects for sexual deviance, have been drastically tightened up. Publicist, political and public pressure against perpetrators and their advocates has massively grown; the number of committals in special institutions has dramatically increased. On the other hand the handling of these individuals by forensic psychiatrists has become much more professional. Standards for the assessment of culpability have been established, the treatment facilities have been largely extended, instruments for risk assessment and the prediction of recidivism have been developed and validated for German speaking countries. With respect to the political consideration to coercive treatment and for tightened and prolonged security measures for all sexual perpetrators professionals have to emphasize that sexual deviant individuals have to be differentiated, not only regarding their crimes and their personality but also regarding their potential to profit from treatment and their probability for recidivism

Exploring consensus in practice with youth who are sexually abusive: findings from a Delphi study of practitioner views in the United Kingdom and the Republic of Ireland.

This article presents the findings of a study exploring current levels of consensus among practitioners in the United Kingdom (UK) and the Republic of Ireland (ROI) about good practice in relation to youth who are sexually abusive. A three-stage Delphi procedure was used to survey the views of 78 practitioners, experienced in this field, on a range of matters relating to preferred responses to this population. The exercise indicated high levels of agreement that youth who are sexually abusive should be seen as a group clinically distinct from adult sex offenders and that all of their developmental needs, and their problematic behavior, should be targeted in intervention. A strong level of consensus was found among respondents about the goals and content of ideal practice with this user group, although there was less consensus about the theoretical models that should underpin practice.

Subspecialization in psychiatry: third-generation programs.

Psychiatry, unlike internal medicine, was slow to develop subspecialty certification. For many years, child and adolescent psychiatry was the only major subspecialty recognized by the American Board of Psychiatry and Neurology (ABPN). The situation changed in the early 1990s with the recognition by the ABPN of additional subspecialties of psychiatry including forensic psychiatry. Using the experience of the American Board of Internal Medicine as a guide, this commentary asks what comes next? What are our options as it becomes clear that there is a deepening of knowledge in the field of forensic psychiatry? Are we ready for, or interested in, the development of so-called third-generation certification programs?

Disorders of desire: addiction and problems of intimacy.

This essay investigates the tensions produced by the categorization of different forms of excessive desire under the singular model of addiction, and it challenges the increasing acceptance of addiction as an all-purpose explanation for unruly desires through a comparison of the different forms of disordered desire in sex addiction and alcoholism. Moreover, it argues for a broad understanding of addictive processes to undermine the normative and moralizing assumptions of addiction discourses. Refiguring addiction as a kind of intimacy is one way of making sense of the intense relationships people can develop with substances and with activities.

A 14- to 24-year longitudinal study of a comprehensive sexual health model treatment program for adolescent sex offenders: predictors of successful completion and subsequent criminal recidivism.

The study determines the effectiveness of a sexuality-positive adolescent sexual offender treatment program and examines subsequent criminal recidivism in the three outcome groups (completed, withdrawn, referred). The sample consists of 122 adolescent males and their families (491 individuals). Of the demographic variables, only living situation was significant, such that patients living with parents were more likely to graduate. None of the behavioral variables were found to be significant. Of the treatment variables, length of time in the program and participation in the Family Journey Seminar were included in the final model. When they were included in the model, no other treatment variable were significantly related to probability of graduation. There were no arrests or convictions for sex-related crimes in the population of participants that successfully completed the program. This group was also less likely than the other groups to be arrested (p = 0.014) or convicted (p = 0.004) across all crime categories.

The challenge of adolescents and adults with Asperger syndrome.

Despite the rapid growth of interest in Asperger disorder in children, there continues to be a lack of awareness of the diagnosis and its implications for adolescents and adults. The reasons for this lack of awareness lie in the history of the disorder and in the historical development of mental health services. Because, as Santayana wrote, "Those who cannot remember the past are condemned to repeat it," this article reprises some of the history given elsewhere in this issue, but in a highly partial way, to bring out what the author believes to be the historically grounded prejudices that are the first challenge to anyone wanting to help adolescents and adults with Asperger syndrome.

Treatment of non-incarcerated sexually compulsive/addictive offenders in an integrated, multimodal, and psychodynamic group therapy model.

Group therapy is a widely accepted model of care for sex offenders. However, most group therapy takes place in prison utilizing a cognitive-behavioral, psychoeducational model of care. Given that over 250,000 sex offenders are in ambulatory treatment, newer models of care may need to be employed to address their specific needs. I present a naturalistic outpatient study involving my private practice of 109 consecutive sex offenders treated over a 10-year period. A multimodal model of care informed by psychodynamic theory is presented with detailed case material from one group session. Preliminary results of recidivism are presented.

Trastornos múltiples de la inclinación sexual: presentación de un caso / Multiple Disorders of sexual inclination Case presentation

La actividad sexual es compleja y diversa en sus formas de manifestarse. Pero la mayoría de las personas saben diferenciar la conducta sexual normal de la anormal. La persona que sufre trastornos de la inclinación sexual o parafilia en dependencia del sistema de diagnóstico utilizado, se ve continuamente interferida en sus actividades y responsabilidades por las ideas de alcanzar la satisfacción sexual. Se realiza una revisión somera sobre los trastornos de la inclinación sexual y los conceptos actualizados sobre el tema según la clasificación Internacional de los trastornos mentales y del comportamiento (CIE-10) y el Manual de Estadísticas de Diagnóstico de los desórdenes mentales DSM-IV. Se presentó un caso en el que inciden varios trastornos y que se registra en la literatura como poco frecuente(AU)

Outcome of an institutional sexual offender treatment program: a comparison between treated and matched untreated offenders.

Data from a sexual offender treatment program operated by the Correctional Service of Canada at the Regional Psychiatric Center (Saskatoon) supported the conclusion that cognitive behavioral treatment can reduce sexual offense recidivism. The study compared 296 treated and 283 untreated offenders followed for a mean of 6 years after their release. An untreated comparison subject was located for each treated offender on three dimensions: (a) age at index offense, (b) date of index offense, and (c) prior criminal history. Data were analyzed using tests of proportion, survival analysis, and analysis of offender Criminal Career Profiles. Over a mean follow-up period of almost 6 years, convictions for new sexual offenses among treated offenders were 14.5% versus 33.2% for untreated offenders. During the follow-up period, 48% of treated offenders remained out of prison compared to 28.3% of untreated offenders. Time series comparisons of treated and comparison samples also showed that treated men reoffended at significantly lower rates after 10 years. A Criminal Career Profile (CCP) was constructed by taking the Age at First Conviction and plotting the offender's successive lengths of time free against time incarcerated. Pre- and posttreatment slopes of the CCP were lower for both groups posttreatment; however, the degree of change was significantly greater for the treated group, indicating a greater reduction in criminal activity among these offenders. Taken together, the results of all three analytic techniques supported the efficacy of appropriate correctional treatment for effective reduction of recidivism.