Psychological Treatment of Incarcerated Sex

Psychological Treatment of Incarcerated Sex Offenders
The Spanish case
Óscar Herrero
Secretaría General de Instituciones Penitenciarias (Spain)
Sexual offences are a problem of growing public concern. Last February, 2991 men
were serving a sentence for a sexual offence in a Spanish prison. This means a great social
expense in terms of incarceration costs. And, what is more important, behind this figure
hide hundreds of victims and an unimaginable amount of human suffering.
The answer to this problem is not an easy one. Correctional systems around the
world have to deal with a great number of sex offenders, whose management is a major
question of public safety. Being a bit simplistic, there are two options: punishment or
rehabilitation. Even though there is a strong social tendency toward harsher punishment
and incarceration, there is also a growing interest in preventing sexual reoffending through
correctional treatment (Schmucker & Lösel, 2008).
Punishment by itself doesn’t seem to be an effective way of managing offenders, at
least in order to reduce recidivism rates. In fact, punishment hast little or no effect on
recidivism (Aker & Sellers 2004, Andrews & Bonta, 2006). Limpsey and Cullen (2007) have
reviewed the existing meta-analytic literature about the effectiveness of punishment and
supervision in recidivism. In general, the results do not provide consistent support for the
view that correctional supervision is effective in reducing recidivism. In fact, some studies
found that longer sentences were associated with higher likelihood of recidivism. Of
course, dangerous violent offenders must be supervised and controlled. The major issue is
that if correctional systems aim to reduce recidivism, something else has to be done.
Is there and effective alternative to punishment? Current scientific literature aims to
psychological correctional treatment as a good candidate. In the following pages I will
review some of the existing evidence about the efficacy of sex offender treatment, and
explain which are the basic goals and assumptions of these programs. Then I will turn
specifically to the Spanish sex offender treatment program and some of the available
outcome data will be presented.
Why should sex offenders be treated?
This question is not a naive one. If sex offenders have to be therapeutically treated,
the first question to be asked is what do we have to change in this population? First intervention
approaches were heavily behavioural and understood sexual aggressiveness as the result of
a deviant learning process that began in childhood. The appropriate respond was the use of
classical and operant behavioural procedures in order to extinct old deviant responses and
create new appropriate behaviours (Marshall et al 1999). This over-simplified view was
soon overturned as treatment providers began to expand the issues addressed in treatment
(Marshall & Laws, 2003). However these techniques are still present in many treatment
programmes (Marshall, O´Brien & Marshall, 2009).
Currently most theories don’t consider sexual assault as a problem specifically
restricted to sexual behaviour, but as a broader array of vulnerabilities. The most common
risk factors are:
1. During their childhood and adolescence, is common to find early sexual interest, a
positive attitude toward impersonal sex life (Merrill, Thomsen, Gold y Milner,
2001; Abbey, McAuslan, y Ross, 1998), a history of child abuse experiences and an
insecure attachment (Covell y Scalora, 2002; Ward, Keeman y Hudson, 2000;
Craissati, 2009), antisocial behaviour and peer’s group pressure toward sexual
coercion (Abbey, Parkhill, Beshears, Clinton y Zawacki, 2006).
2. Low empathy. Jolliffe & Farrington (2004) conducted a meta-analysis on the
relation between empathy and offending. The authors found a moderate size effect
that indicated that sex offenders tend to be less empathic than general population.
Other studies have found inconsistent results (Smallbone, Wheaton y Hourigan
,2007). Mann & Marshall (2009) suggest that empathy deficits in sex offenders
could be restricted to their victims.
3. Cognitive distortions. The first authors who suggested the presence of beliefs that
supported sexually aggressive behaviours were Abel, Becker & Cuningham-Rathner
(1984). These thoughts were labelled as cognitive distortions. Even though this seminal
work was focused on child abusers, there is currently wide evidence that supports
the presence of this kind of cognition in the general sexual offender population.
Cognitive distortions are thoughts that justify, minimize or deny the sexually
abusive behaviour. Ideas about lack of control (I couldn’t avoid it), hostility against
the others, need of empowerment, child sexual intentionality, denial of damage, or
female sexual needs (Polaschek & Ward, 2002; Polasched & Gannon, 2004; Beech,
Ward & Fisher, 2006; Burn & Brown, 2006; Ward, Keenan & Hudson, 2000).
4. Drug and alcohol abuse. The study of wide community samples of victims and
offenders, suggest that alcohol abuse is present in near 50% of the sexual assaults
(Abbey, Zawacki, Back, Clinton & McAuslan, 2004). The amount of alcohol
ingested, seems to be positively related to the degree of violence employed by the
offender during the assault (Abbey, Clinton-Sherrod, McAuslan, Zawacki & Buck,
5. Low IQ scores (Cantor, Blanchard, Robichaud & Christensen, 2005) and in some
cases intellectual disabilities (Holland, 2004; Lindsay, 2002, Lindsaw, Elliot, &
Astell, 2004).
6. Personality disorders, (Chesire, 2004; Madsen, Parsons & Grubin, 2006; Knight &
Quay, 2006).
7. Self-control difficulties and low executive functioning (Joyal, Black & Dassylva
,2007; Herrero, Escorial & Colom, 2010, 2011).
8. Effective problem solving difficulties (Wakeling, 2007).
9. Intimacy deficits. Several studies have found that low intimacy and high emotional
loneliness are features commonly found in sexual offenders (Cortoni & Marshall,
2001; Cortoni, 2009).
Therefore, violent sexual behavior is a problem with many underlying causes (or at least
correlates) apart of a mere deviant sexual arousal. Treatment seeks to change these risk
factors through the use of appropriate psychological techniques. For example, cognitive
distortions are challenged through cognitive restructuration techniques, deviant sexual
arousal through covert aversive conditioning, and intimacy deficits through social skills
training (Redondo & Garrido, 2008). Most of the existing programs are delivered in group
sessions in a prison context (Marshall et al, 1999), and in some cases in community settings
(McGrath, Cumming, Hoke & Bonn-Miller, 2007).
During the whole process, the therapeutic style held by the therapist plays a key role.
Therapist who tend to be empathic, rewarding, directive, and who tend to create a positive
group atmosphere, seem to be the most effective. Those with a hard confrontational style
show the worst performance in therapy (Serran, Fernandez, Marshall & Mann, 2003;
Drapeau, 2005).
There are different models of treatment for sex offenders, namely the Risk-NeedResponsivity model (RNR; Andrews & Bonta, 2006) and the Good Lives Model (GLM;
Ward, Vess, Collie & Gannon, 2006). Even though the RNR model is the most prominent
rehabilitation approach for offenders, some theorist and researches have questioned this
perspective. RNR proposes that correctional interventions should be structured according
to three core rehabilitation principles: risk, need and responsivity. Treatment should target
dynamic risk factors that are causally related to criminal behavior and that are changeable in
nature. This is the need principle. The risk principle specifies that treatment of offenders
ought to be organized according to the level of risk they pose to society. High risk
offenders should receive more intense treatment than low risk offenders. Finally, the
responsivity principle states that correctional interventions should match certain
characteristics of the offenders (motivation, learning style). The features that are associated
with offending come from a range of variables including biological, psychological, social,
personal and situational. In the field of sex offender treatment, these principles have
several implications. High risk offenders should receive the higher amount of intervention.
And this intervention should focus on changing features associated with high risk of
reoffending. These include pro-offending attitudes, antisocial traits, substance abuse or
deviant sexual interest. Finally, the mode of intervention should match with the client
interest, cognitive ability and learning style.
The second approach to sex offender rehabilitation, the GLM, adopts a humanistic
perspective. Offenders, like general population, attempt to secure positive outcomes such
as good relationships, sense of mastery and recognition from significant others. Offenders
and non offenders seek these primary goods. Examples of primary human goods are:
relatedness, mastery, autonomy, creativity, or health. The GLM is a strength based
approach that seeks to train individuals in the capabilities to reach positive outcomes
(intimate relationships, for example) taking into account their values, strengths and
preferences (Ward, Mann & Gannon, 2006; Ward & Gannon, 2006; Ward, Collie &
Bourke, 2009).
The effectiveness of the intervention
There is an alternative to an exclusively punitive management of the sex offenders.
The key question is if this alternative leads to a reduced rate of reoffending, which is the
major goal that correctional systems seek.
Meta-analyses have supposed a relevant source of information about the
effectiveness of correctional treatment. In the field of sex offender treatment, several meta-
analytic studies have been conducted. The following table summarizes the results of some
of them.
Table 1. Meta-analytic studies of sex offender treatment (adapted from Lipsey & Cullen,
Meta-analysis report
Reitzel & Carbonell
Gallagher et al. 1999
Hanson et al. 2002
Lösel & Schmucker
Hall 1995
Aos et al. 2001
Aos et al. 2001
Schmucker & Lösel,
Juvenile sex offenders
Juvenile and adult sex
Juvenile and adult sex
Juvenile and adult sex
Juvenile and adult sex
Juvenile sex offenders
Adult sex offenders
Juvenile and adult sex
Mean effect size
-0.24 (9)
Change in
-0.18 (26)
-.14 (31)
-0.13 (49)
-0.12 (12)
-0.06 (5)
-0.05 (7)
1.7 (80)**
*Number of comparisons. **effect size reported in Odds Ratio. The rest of the effect sizes are Phi scores.
The summarized studies yield significant reductions in recidivism rates when
treated and non treated groups are compared. This intervention seems to be effective both
with adult and young sex offenders. Even though some authors have put into question
these results (Rice & Harris, 2003), and obviously more research is needed, there is a
promising empirical evidence that supports the effort of treating sex offenders.
The Spanish sex offender’s program
During the last years, the Spanish correctional system has experienced an increasing
interest and effort in implementing treatment initiatives. Specific interventions for
populations like domestic batterers, mentally disordered offenders, juveniles, and sex
offenders have been designed, manualized and implemented.
The Program of Sexual Aggression Control (SAC; Ministerio del Interior, 2006) is
an updating of the original program designed by Garrido & Beneyto (1996). This revision
and updating was conducted by a group of prison psychologist with a wide experience in
the field of sex offender treatment.
The current form of the SAC has the following characteristics:
1. It’s a psychoeducational intervention, based in cognitive-behavioral principles.
2. It’s delivered in a group format.
3. It’s organized in modules that address different psychological aspects involved in
sexual assault.
4. It’s a long and intensive program, with weekly sessions, and with a duration of 1824 months.
5. Inmates participate in the program voluntarily, even though prison staff tries to
motivate them. Specific treatment for sex offenders is priorized during the time
they spend in prison.
6. The program is conducted by a multi-professional team. The professionals must
complete a specific training program in sex offender treatment.
7. The program has a relapse prevention orientation. This means that participants are
trained in specific techniques to prevent future reoffending. The program seeks to
increase the self-control skills of the participants.
8. Even though the program is delivered in a prison setting, the intervention is
oriented to the community.
9. The major goal is reducing the likelihood of future reoffending.
This goal is reached through intermediate therapeutic goals. The assumption that
underlies the intervention is that if the psychological well being of the offenders is
increased, the likelihood of future reoffending will decrease. Therefore, the therapy will
seek to:
1. Increase the empathy levels.
2. Increase self-knowledge and induce a critical view of their biography.
3. Reduce cognitive distortions that support sexual assault.
4. Help the offender to understand his own process of offending.
5. Train the participants in coping strategies for their specific risk factors.
6. Reduce deviant sexual drive.
7. Increase their sexual education.
Which is the profile of the inmates included in this program? They have to meet the
following criteria:
1. To be sentenced for a sexual offence.
2. He has to be about two years away from his release date, or from his access to a
less restrictive modality of life with regular contact with the community.
3. He has to be free of major mental disorders of intellectual disabilities. These
inmates are motivated to participate in the specific programs designed for these
4. Literate in Spanish. If this is not the case, the inmate has to complete his education
before participating in therapy.
The modules of the program are the following:
1. Biographical analysis.
2. Emotional management.
3. Introduction to cognitive distortions.
4. Aggressive behaviour.
5. Denial.
6. Empathy training.
7. Cognitive distortions.
8. Positive lifestyle.
9. Sexual education.
10. Deviant sexual arousal.
11. Relapse prevention.
In the following pages, the most relevant modules will be described.
Autobiographical analysis.
This is the first unit of the program. Group atmosphere is not created, and the
participants tend to feel cautious about the therapist and the rest of the group. In these first
steps, therapeutic style is of the highest relevance.
Through this unit, the inmates will begin to review their own biography. They will
have to write short texts where the main aspects of their lives (family, friends, sexual
experiences, antisocial behaviour) are explained. Distortions of the reality and social
desirability are common, but the therapist won’t confront the participants. The most
important goals in this first moment is collecting information about the inmate that will be
useful in future steps of the therapy (biographical risk factors), and create a positive group
Emotional management
Sex offenders are usually described in the literature as individuals with poor
emotional lives. The goal of this module is to increase the self awareness of their emotional
life. They will also be educated in the relation between thought, emotion and behaviour.
Introduction to cognitive distortions
In this unit the concept of cognitive distortion will be outlined. Later in the
program this concept will be analyzed deeply. In this first contact, the therapist aim to
introduce the idea that sometimes thought is distorted and leads to a distorted view of
reality. Beck et al’s. (1979) thinking mistakes are explained and the participants look for
examples in their own lives.
Aggressive Behaviour
This is a short unit where the dynamics of human aggression are explained and analysed.
The relevance of the relation between thought, emotion and behaviour is stressed. The
basic assumptions are that we create our own aggressive behaviour through a distorted
interpretation of the reality, and that if we learn how to do it, aggression can be controlled.
Denial is a cognitive distortion, but the SAC treats denial separately from other forms of
thinking that exonerate the offender of his responsibility. In this phase, the participants will
begin to accept full responsibility of their abusive behaviour. Successive descriptions of the
offence will be analyzed and the therapist will help the participants to identify the defence
mechanism that they are using. A hard confrontative style will be avoided. Instead, the
therapist will show a firm but warm and supportive attitude to cope with denial. The first
steps of cognitive reconstruction techniques will be trained, in order to help the
participants to identify and question their own thoughts. The therapist will also avoid
labelling the inmates as “sex offenders”, as long as this term is a menace to their selfesteem that could make them go ahead with their denial as a self protective shield.
This phase of the program is one of the most important. The focus is no longer on the
inmates but on their victims. The concepts learned in the “emotional management” unit
will be useful. The participants are educated in the emotional sequels of the sexual assault.
Documentaries with victim’s testimonies are used. Finally, the inmates have to write a letter
adopting the role of their victim. In this letter they explain the offence and how it made
them feel.
Cognitive distortions
In this module inmates are thoroughly trained in cognitive reconstruction techniques. The
automatic thoughts, fantasies and schemas that underlie aggressive behaviour are identified,
questioned and restructured through rational emotive therapy.
Positive lifestyle
This unit is of educational nature. The relevance of a structured lifestyle and its
influence in psychological well being is highlighted. It is common to find that in the time of
the offence, participants had highly unstructured lives, without basic healthy habits (sleep,
alimentation, sport, social relationships, work, leisure). Participants imagine how they want
their daily lives to be when they return to the community, and what goals do they want to
Sexual education
In this unit special attention is devoted to the false beliefs that inmates may held
about female and child sexuality. This unit is especially relevant for child molesters, who
usually have false beliefs about child sexual development.
Deviant sexual arousal
Even though all inmates must complete the whole program, this unit will be of special
relevance for those who display a stable deviant sexual interest toward stimulus like
children or violent behaviours. In this unit behavioural techniques are used to reduce
deviant fantasies and sexual arousal. Basically the inmates are trained in covert aversive
Relapse prevention
In the final steps of the program, the classical relapse prevention scheme adapted to sexual
violence is used to help the offenders to understand the risk factors that could lead them to
a new offence. The basic steps range from abstinence, to a high risk situation which is
reached through “seemly irrelevant decisions”. This high risk situation could end with a
failure, which is cognitive in nature. Basically, a failure occurs when an offender considers
sexually assaulting a new victim as something desirable. If the offender doesn’t cope
effectively with this thought, a new offence could take place.
Since the beginning of the SAC, outcome evaluation has been a priority. The
evaluation was designed in cooperation with the University of Barcelona. It is a complex
design that includes a treatment group and a control group of untreated offenders. Figure 1
is a schematic representation of the whole design.
Figure 1. Evaluation design (Adapted from Redondo, Martínez & Pérez, 2006)
Criminal carreer
Follow up
(1-5 years)
Clinical measures
Psychological measures:
Reoffence measures
Two different sources of information were selected. First, the research group of the
University of Barcelona created a new self report measure designed to assess the core
psychological aspects of sexual aggressiveness, the Scale of Sexual Aggression (EPAS).
Participants complete this measure before they begin the program and after they have
finished it. This same measure is applied to a control group of untreated offenders in the
same moments than the treatment group. This process is conducted in every prison where
the program is being delivered. Treated offenders are expected to perform better in this
measure after they have completed the program. All the significant comparisons that could
be conducted are summarized in figure 2.
Figure 2. Mean comparisons between treated and control groups (Adapted from Redondo,
TG-Adult offenders
TG-Apre = CG-Apre
TG-Apost = TG-CHpost
TG-Apre = TG-CHpre
TG-Child molesters
CG-Adult offenders
TG-Adult offenders
TG-Apre ≠ TG-Apost
TG-CHpre ≠ TG-CHpo
CG-Apre = CG-Apost
TG-Child molesters
CG-Adult offenders
TG-CHpost ≠ CG-CHpost
TG-CHpre = CG-CHpre
CG-Child molesters
TG-Apost ≠ CG-Apost
CG-Child molesters
CG-CHpre = CG-CHpost
T-test were conducted in order to compare the EPAS scores of the different groups.
Results are shows in table 2.
Table 2. Mean comparisons between treated and untreated groups (T-tests).
Grupo de tto./control
Control group
Adult treatment and
control group PRE
Treatment group
Treatment group PRE
Adult treatment group
Treatment group
Control group
Adult control and
treatment group POST Treatment group
Control group
Child treatment and
control groups PRE
Treatment group
Treatment group PRE
Child treatment group
Treatment group
Control group
Child control and
treatment group POST Treatment group
Results indicate that control and treatment groups were equivalent before the
treatment was conducted. After treatment, significant differences were found for both
treated groups (adult offenders and child molesters). When treated and untreated groups
were compared after treatment, a significant difference was found for the adult offenders
group. The analyses didn’t show a significant difference between treated and untreated
groups of child molesters.
The second outcome variable is recidivism rates in both treated and untreated
groups. Once the inmates included in the study (treatment and control groups) are
excarcelated and return to the community, begins a follow up period. During this period
any new conviction, for a sexual or non sexual offence, will be registered. At the end of the
process, recidivism rates of both groups will be compared.
In this moment of evaluation process, reoffence data are only available for two
samples of treated offenders. All these date have been provided by the Program Evaluation
Unit of the Secretaría General de Instituciones Penitenciarias.
Sample 1 included 40 treated offenders who have been followed in the community
during a 5 years period. Reoffence rates were as follow. A 17.5% of the sample was
reconvicted for a non sexual offence (5 inmates), and 5% were involved in a new sexual
offence (2 inmates).
Sample 2 included 60 inmates, who are being currently followed up in the
community. The follow up period began two years ago. 8.4% of the sample were nonsexual recidivist (5 inmates), and 5% were convicted for a new sexual offence (3
Data from the control groups are not available yet. Therefore, currently it’s not
possible to compare the reoffence rates.
When these data are compared with the published longitudinal studies, we find that
the observed sexual recidivism rate is 5% to 10% after five years of follow up (Hanson &
Morton-Bourgon, 2005; Hanson & Bussiére, 1998). Even though these results are the
initial steps of the evaluation process, the considered samples seem to be in the lower
expected rate of recidivism. Future outcomes will indicate if the difference between treated
and untreated groups is a significant one.
Since 2006, 810 inmates have completed the program. Currently is being delivered
in 33 prisons.
The initial steps of the evaluation process are showing promising results, even
though more research is needed. Treated offenders seem to improve their psychological
adjustment when they are compared with untreated groups, or with themselves before
Recidivism rates of treated offenders once they return to the community are in the
lower end of the expected range. Future comparisons will show further evidence about the
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