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Cognitive behavioural therapies derived from relapse prevention therapy which had become popular following successes in areas such as self-esteem and substance use (McCulloch et al, 2007). Its use with sex offenders reflected some progression away from the previous methods as it recognised social and environmental influences upon sexual offending as opposed to simply deeming it a mental illness (Moster et al, 2008). Since the 1980's, the use of CBT has gained respect and usage from agencies making it the most common intervention used (Andrews & Bonta, 1998; 1998; Freeman-Longo & Knopp, 1992; Laws, 1989). Hanson (2002) found, after significant meta-analysis a recidivism rate of 9.9% compared to 17.4% for those who had not undergone CBT interventions. This evidence was reinforced by Lösel and Schmucker's (2005) whose meta-analytical study of sexual offender program espoused similar findings giving further kudos. The emergence of CBT as a means of sex offender treatment coincided with a new socio-political climate which sought to promote and publicise 'what works' with offenders. CBT is the most commonly used intervention with sex offenders, and widely considered to be the most effective (Andrews and Bonta, 1998; Becker and Murphy, 1998; Freeman-Longo & Knopp, 1992; Home Office, 2010), it does however still remain much less used than initially planned.Â
Authors such as Sparrow (2002) suggest that such a shortfall from initial expectations, is, at least in part, due to a prevailing negative media response, unhappy with anything seen than 'less than' the most draconian of interventions and punishments, alongside a centralized, managerialist government unwilling to work with agencies they felt to be 'untrustworthy' and preferring to focus on more punitive measures which sought to minimising risk rather than therapeutic intervention.
CBT with elements of Relapse Therapy (RT) are the most common interventions with sex offenders in both the UK, Canada and US and generally involve group and individual therapy, work on victim empathy, learning about abuse cycles, cognitive restructuring, anger management and assertiveness, interpersonal skills and changing deviant sexual arousal patterns (Moster et al, 2008).
4.2 Ethical conflicts within CBT
CBT is postulated on the idea that all our emotional responses and behaviours are determined by pre-existing attitudes and beliefs which we may have developed or 'picked up' along the way (Beck, 1995). Thus, if we are to change how we react to experiences and emotions then we must change both our thoughts and how we perceive the matter (Moster, 2008). Facilitating this requires the use a number of techniques and constructs to help the subject examine and understand their cognitive processes and the subsequent link between these thoughts and their behaviour. Beck (1995) suggests that some of the most effective techniques are cognitive restructure, reversal of behaviours and directive role play which aims to confront the individual with the consequences of their behaviour and engender a reflective stance to be developed. While motivational methods of treatment do exist, some practitioners prefer the well-established confrontative approach which can raise questions in relation of social work ethics (Sheath, 1990; Moster et al, 2008).Â
With some offender treatments for example, practitioners may be required to adopt a set of principles which may differ from the core values of their profession. This includes, but is not limited to mandatory participation in treatment which contradicts traditional mental health ethics and confrontative CBT intervention which has been criticised for its apparent manipulative nature (Sheath, 1990; Glaser, 2003). While this may present a dilemma for social work where values of empowerment and respect are fundamental; Holmes and Lindley (1991) contend that clinicians should feel 'no shame' and that even if some of the techniques used are perceived to be ethically dubious, if they result in individuals gaining better understanding and capacity to make rational and informed choices with the client group, then they should be encouraged. Indeed many writers share this notion and discuss the idea that the offender learning from their own 'internal management' rather than dependence of external control is key to the reduction of recidivism (Marshall et al, 1999).Â
While the main goal of CBT with sex offenders is recidivism there are other goals for social workers to be mindful of; essential to CBT is that offenders are able to retain (or perhaps regain) self-worth. This requires intervention which both serves to protect the public and, at the same time, helps nurture the offender (Moster et al, 2008). While areas of CBT do encourage the client to create 'false realities' and pasts, the client is actively encouraged to think positively about their lives post-therapy; be this in the near future or following release from custody (Marshall, Anderson and Fernandez, 1999).Â
Another potentially contentious issue arises from the fact that CBT with Sex Offenders has to date unapologetically focused on directly challenging and changing opinions, actions and attitudes focusing on reactionary intervention which aims to modify existing behaviours but also questions the underlying conflicts that facilitate. Sheath (1990) refers to this form of intensely confrontative treatment as being nothing short of a 'legitimate form of nonce bashing' and discusses his own feelings of prejudice and repulsion which no doubt blur the quality of intervention being delivered. This is one of the fundamental conflicts of intervention with sex offenders and an area which requires practitioners to be open, honest and reflective about their abilities to put their feelings aside. Whilst social work is built around the principles of non-discrimination, managers and teams must also be realistic about the expectations of their staff.
Sheath is not the only practitioner to recognise the shortcomings of CBT; Payne discusses some of the problems of the intervention from another ethical position, critiquing the process as simply a manipulation of offenders' behaviour rather than progress achieved as a result of the client rather than the professional retaining control (1997). Payne does not however clarify his position as to whether he feels the right maintain to self-determination can be incorporated within CBT, or indeed if it's incompatible, stating only that it is only achieved when the client's one aim is toÂ 'free themselves from behaviour'Â (1997: p. 123). Such tension might reasonably be held to present social workers, for whom issues of self-determination are central to the value base of the profession, with a very difficult 'circle to square' when attempting to justify the use of CBT in this manner.
Hackett (2008) suggests that the predominance of CBT in this area has also contributed to the homogenisation of sex offenders, as many of the key interventions, such as the cycle of abuse (Ryan et al, 1987) and Finkelhor's four preconditions model, have a tendency to focus on the offence, rather than the offender.Â Â Thus a fundamental flaw in the approach would seem to be that a series of highly contentious and questionable assumptions are required about offenders as a group and how they operate, which fundamentally fail to recognise that every single sexual offender is a different person with their own issues, but also an offender with their own issues, agenda, perception of their offence and perception of their victims (Sheath, 1990). Indeed, it might plausibly be argued that a reactive, 'one size fits all', application of CBT side-steps what is often the crux of the client's problems; sexual orientation, self-perception, sexually deviant and unfulfilled fantasy. Attempting to 'decode' a sexual offender while they are still in a state of defensiveness may as a result be, as Sheath puts it, a 'nihilistic exercise and at worst counter-productive' (p. 161).Â
Given the ethical issues raised above, whose overall implication would appear to be that the 'ends justify the means', with regard to the use of CBT, it would seem reasonable to question the extent to which such a positive duality of outcome can in reality ever be more than 'wishful thinking', as it would seem that public protection will inevitably be given higher priority.
4.3 Beyond CBT
Research by Marshall (2002) and Craissati et al (2002) adds to discourse that suggests that it is an inability to form adult relationships which sometimes results in the pursuit of intimacy in maladaptive ways. Marshall (1989; 1993; 1996; 2002) uses the insights offered through the application of attachment theory to explain how sexual offenders are frequently emotionally distant and 'superficial' in intimate relationships. Going on to suggest a link between early attachment experiences and the development of internal working models which support the forming and maintenance of relationships in adolescence and adulthood (Bowlby, 1969). Such working models contribute not only to our own attitudes and beliefs, but also to how we recognise and respect the roles of others. Popular attachment debate discusses three main 'styles' of attachment; the secure which is thought to stem from warm and consistent parenting and then two types of insecure attachments, namely anxious which is thought to be rooted in inconsistent parenting and the avoidant which is linked to unresponsively in parenting (Ainsworth, 1979; Alexander, 1992).
Insecure attachments are considered to be a vulnerability factor with offending in general (Alexander, 1992) and Marshall suggests this can pose challenges in adolescence and can make children ill-equipped for the challenges of puberty, and thus less likely to achieve a satisfactory level of understanding of relationships and intimacy amongst peers and other relationships. He suggest that can result in confusing sex with intimacy which, combined with pre-existing loneliness, frustration and natural sexual urges may lead to inappropriate sexual promiscuity and violence (Marshall, 1989). Indeed, the pioneering practitioner on attachment, Bowlby (1944) published research based on a cohort of 47 young offenders, proposing that the absence of a secure attachment figure can ostensibly result in an 'affectionless psychopathy'. A condition characterised by a lack of empathy and an inability to form relationships.
Considering sexual offenders within a frame of attachment may enable practitioners who struggle to separate the offence and the offender to work more effectively with them. Indeed, there significant evidence which links insecure and disorganised attachment anti-social behaviour and aggression in adulthood. Using Attachment Theory in which a way with sex offenders does not serve to justify their actions or behaviour, however when considered amongst the myriad of other social and psychological factors, some understanding of cognition and behaviour may be observed which is something that practitioners struggle with (Sheath, 1990; Hudson, 2005). As such, attachment theory does not give us a set of rules for dealing with sex offenders but is does support better understanding as well as support a better understanding on their own behaviour.
5.1Â Working with sex offenders in custody
Whether it be increased awareness, less tolerance, changes in attitudes or the rise of DNA testing - there has been a gradual increase since the 1980's of incarcerated sex offenders, putting increased pressure on prison structures, agencies who work with the client group and the need to find suitable, sustainable and effective treatment for sexual offenders (Greenfield, 1997). We also live in a world where public opinion wishes sexual offenders to be as socially excluded as possible and therefore prison presents as the perfect place for them to remain. Though seemingly straightforward, this does however present with an increasing number of issues; there is of course the spiralling cost of custody and remand places, the likelihood of meeting 'like-minded' and collusive people but also the fact that social exclusion has a tendency to increase risk, rather than reduce it (Sommerville, 2000).Â
Over the past 30 years the focus of treatment in relation to sex offending has been almost exclusively around the management of risk and protection of the public demonstrated by highly reactive and confrontatitive interventions (Sheath, 1990). While there is a clear rationale for this approach, given the media and political pressures as well as the public fear of victimization; it has left a fundamental gap in relation to rehabilitation and led to an overuse of custody (Garland, 2001). This sort of 'out of sight' punishment further exacerbates the idea of sex-offenders as sub-human beings and provides justification to treat them less favourably. While it can be understood that this view is held by the public, it is sadly often replicated by prison staff and other male in-mates who revel in 'giving them a hard time' by ritual beatings, ostracization and often rape (Sheath, 1990).
5.2Â Ethical conflicts
Sex offenders in custody occupy very low status, and in many UK prisons are routinely segregated on separate wings often referred to as the vulnerable prisoner's wing or, more commonly the 'nonce' wing. Separation from the main populous can lead to offenders denying their offence in order to maintain safety from retribution seeking inmates. Â The upshot of this is sex-offenders are immediately disadvantaged, socialising less and with less opportunity to show that they have 'changed'. In essence, this equals to a situation where, before prisons have even had the opportunity for rehabilitation or treatment, they are excluded, dehumanized, victimized and subject to more discrimination and oppression that offenders who may be serving back to back life sentences. Â
Glaser (1969) found that a positive attitude by custodial officers critical to facilitating change in sexual offenders prior to their release. Hogue (1995), for example, found that prison officers who were not involved in the treatment of sexual offenders were significantly more negative in their attitudes towards sexual offenders than prison officers involved in treatment. Weekes, Pelletier, and Beaudette (1995) further found that only 20.7% of custodial officers viewed sex offenders as even treatable, rating them as more unchangeable, dangerous, irrational, mysterious, than non-sexual offenders. Of particular note, 68% of this sample of custodial officers indicated that they wanted more training in how to deal with sexual offenders and only 12.3% reported that their training had prepared them adequately enough.
While prison exists to restrict the liberty of offenders, it also has a fundamental function to observe basic human rights of its inmates as per the Human Rights Act. The Howard League for Penal Reform found that sex offenders (and indeed many other prisoners) were routinely having basic rights abused or unmet, specifically with relevance to sex offenders is including Article 3: - the right to freedom from torture or inhuman and degrading treatment and Article 14: freedom from discrimination. The status quo is therefore damaging; as Ward and Brigden discuss, when the sex-offender has their dignity and rights observed they are more likely to comply with treatment and to behave. Indeed, further deprivation of human rights simply perpetuates stigmas and breeds resentment (Matravers, 2000). In fact, by continuing to oppress the basic needs and rights of a sex-offender, one could argue that you are simply reinforcing their existing attitude which vindicates their offending and compliments and confirms cognitive distortions (Hudson, 1998; Thomas and Tuddenham, 2002; McAlinden, 2005; Ward et al, 2007).
Hudson (2005) looks at sex offenders' perspectives of their treatment and management and concludes that the majority of sex offenders do indeed see themselves as victims; both in relation to how they are treated by fellow inmates and prison staff alike. Following the prison riots across England and Wales in 1990, Lord Justice Woolf conducted an inquiry which found that; the abuse that sex offenders suffer, together with the restricted regimes that they endure, produce, in sex offenders a sense that they are somehow victims themselves, rather than perpetrators of crime. Therefore if a reduction in re-offending is the aim, attention needs to be focused on what they themselves have done, rather than what they are having to suffer (Sampson, 1994).
5.3 Sexual Offender Treatment Programme (SOTP)
Whilst in custody is perhaps the best place to rehabilitate sexual offenders given that there is opportunity offend, however the attitude of the main prison populous and custodial officers meant that meaningful engagement with the client group was uncommon, resulting in engagement in intervention which was often incentive based, mandatory or coercive. SOTP is however regarded as the most ethical way of rehabilitating sexual offenders and is offered on a voluntary basis to male prisoners convicted of a sexual offence or a violent offence with a sexual element (HMPrison). Introduced in 1991, SOTP is based on the apparent 'effectiveness of cognitive behavioural therapy'Â (Beech, et al, 2003: 2), compromising Finkehorn's thinking that sex offenders lack social skills, empathy and awareness and a problem solving focus including socialisation and moral reasoning elements (Falshaw et al, 2003). Â
The programme can be lengthy and will only be offered to offenders who have both the capability and indeed the time to complete it (Cobley, 2005). This presents another ethical dilemma around the motivation as some sex offenders in custody may perceive inclusion in treatment as a vehicle to early release as opposed to an intervention to effect personal change (Ellerby, 1997). Consequently, many participants appear resistant, deceptive and unwilling to fully participate (Clarke, 2011).
While public opinion will favour custodial measures, the eventual goal for any prisoner must be re-ablement and release. Â While a punishment first, engagement in therapeutic process whilst in custody is fundamental to ensuring that sexual offenders receive the treatment they both require to better understand why they offend and help them desist and allay society's unrelenting distain towards them. This is by no means an easy process, and from the literature observed, practitioners must themselves be mindful about their health and well-being, but also the attitudes they hold towards this client group. It goes without saying that it is hard to be effective when working with difficult service users, however this can understandably become significantly more challenging when colleagues are unsympathetic and undertaken in physical surroundings which are themselves' unlikely to be relaxing or restorative. Although not studied directly in the context of sex offender treatment provision, the importance of physical surroundings on psychological health (e.g. lighting, noise, indoor air quality) is an important area for consideration and has a recognised impact on mental health and well-being (Evans, 2003).