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Address social deviance vs Mental Disorder
Review outcome studies of sex offender treatment programs
Identify role and ethical conflicts and their management
Boundary between social/ legal deviance vs Mental Disorder
Paraphilia diagnosis criteria Assessment procedures Risk assessment and consequences Legal involvements: SVP, Sentencing Treatment vs Rehabilitation vs Management/
punishment
Heterogeneity of programs Variable goals and priorities Correctional: Custodial – Parole/probation Mental health: Forensic hospital – outpatient
programs – private practitioner
Min of Health, OPD based Multidiscipline Assessment including Psychiatric,
Psychological testing, Family assessment, Phallometry evaluation
Defined limits in communication/ relationship with Corrections
Helping patient will reduce recidivism Deviant sexual interests Social skills deficits Lack of empathy Lack of motivation for treatment Minimization and denial of responsibility CBT group/ individual delivery Relapse prevention
Correctional settings: institutions – parole Prime goal: Reduce recidivism Management focused Increased P.O. involvement Reduced confidentiality
Primary Duty: Protection of public Therapist seen as part of “management
team” Demand admission previous uncharged
assaults Use of Polygraph Mandatory physical or “chemical” castration
before release Values/ roles frequently in conflict
Social Deviance: Incidental offending Dissocial/ antisocial lifestyle Mental Disorder:
Paraphilia Personality Disorder Neuropsychiatric Disorder Comorbid Mood – Anxiety - SUD
Are Diagnoses based on facts or values? Values may outweigh facts Interpretation of facts based on our values Szasz: “ norms of mental disorders are
psychosocial, ethical and legal” vs structural or anatomical
Bodily Disorders: Values usually shared Cancer is ‘bad’ Disorder explained externally: ‘ have cancer’ Mental Disorders: Values often diverse/ in
conflict: sx’s defined by emotions, sexuality, desires
Disorder seen as internal: ‘you are a pedophile’ Social Stigma highest for Pedophilia
Moral Wrongfulness Test in Dx ( Franken 2005)
ASPD: ? What is left after removing value statements
Circular thinking critique ? Confounding legal and moral wrongfulness
with Mental Disorder ? Medicalization of deviance/ criminality
Are we treating the punished or is treatment punishment?
Should we ‘treat’ people with questionable Diagnosis of mental disorder?
Should psychiatrists be involved with reforming criminals?
Should psychiatrists contribute to system whose primary purpose is punishment / public protection?
Variable definitions Treatment: early intervention, evidence
based, reduction of relapse Rehabilitation: normalization of function Management: Reduce risk of offending
punishment, supervision, monitoring, SO registration, public notification
Research challenges: Definition/ measurement of recidivism Low base rates Need for long follow up to measure recidivism - lost data, lost subjects Treatment definitions/ integrity High treatment dropout Heterogeneity of populations Difficulty in random assignment
Guidelines for Collaborative Data Committee 25/130 studies accepted 5/25 ‘good’ or ‘strong’ Treatment outcome based on recidivism ? Adherence to RNR principles
Andrews, Bonta: Psychology of Criminal Conduct, 3rd Ed. 2003
Risk: Higher risk offenders warrant greater TX
Need: Focus on those criminogenic factors associated with recidivism, e.g.; SUD, Impulsivity
Vs Non-criminogenic factors e.g. Anxiety, low self esteem
Responsive: Apply interventions in manner that offender is able to understand / use
Professional discretion: Able to over-ride if necessary
80% of programs targeted Social Skills training, victim empathy, responsibility assumption
ODDS RATIO
0 Principles applies 1.17
1 .64
Any 2 .63
All 3 .21
General Offenders (Gourgon, Armstrong 2005 )
Low Risk No Treatment
Moderate Risk 100 hours
High Risk or High Needs
200 hours
High risk + High Needs
300 hours
Sexual deviance Lifestyle instability/ criminality Social intimacy deficits Response to supervision/ treatment Poor cognitive problem solving Age
NOT significant: - Lack of empathy - Denial of sexual crime - Minimization - Lack of motivation for Tx - Major Mental Illness - Psychological distress
Reviewed RCT’s + prospective studies 8/167 outcome studies deemed low to
medium bias Conclusions: Major weaknesses in scientific
support for treatment efficacy
Maryland Scientific Methods criteria III to V 29/3000 met criteria TG = 4,939
CG = 5,448
TG CG
Sex Offending
10.1% 13.7%
Any Offending
32.6% 41.2%
CBT/ MST Medium to high risk offenders Individualized treatment with group tx Affirmed RNR principles No benefit for low risk offenders Unable to assess pharmacological treatments
as none met criteria for inclusion
Randomized clinical trial CBT- Relapse prevention model 167 SO’s treated 1985 – 1995 in custody 225 controls 220 comparison group Tx group included dropouts [ 18%] No difference in recidivism
Collaborative Outcome Data Committee standards
512 inmates completing CBT/ skills based treatment matched retrospectively
F/U: 4 – 14 years No difference in sex offender recidivism Significant difference in general offending
Khan (Cochrane Data Base 2015) 7 studies, N=123 total All published 20 years ago No controlled studies for SSRI, GnRH Limited studies do not allow conclusion to
support pharmacological treatment
WFSBP (Thibaut 2010)
6 Levels based on severity of Paraphilia: I CBT
II CBT + SSRI
III CBT + low dose TLM
IV CBT+ full dose TLM
V CBT + GnRH
VI CBT + GnRH + full TLM
Turner 2013 German forensic hospitals/ opd’s 611 SO’s
GnRh 10.6% CPA 5.1% SSRI 11.5% Antipsychotics 9.8%
Ethical Conflicts: 1. Dual agency 2. Communication issues 3. Accuracy of risk assessment 4. Treatment efficacy 5. Balancing beneficence vs. public
protection
Applebaum model: Role based Profession’s ethical code is justified by
society’s desire to promote Profession’s values
Determination of preeminence of moral rule is dependent on identification of value society wishes to promote
Treatment of symptoms will reduce risk Patient welfare given priority Minimize intrusion of legal demands to
address protection of public More consistent with traditional treatment
model e.g., National Commission on Correctional
Healthcare
Protection / management given priority Goal primarily to prevent violence to victims Justifies action not justified by traditional
ethics e.g., lie detector testing, shared
communication with non- treatment staff, urine screens, monitoring etc.
Potential for harm to ‘client / patient’ high
Roles/ responsibilities may be confounded Argues for broader view of roles Include common morality of Profession and
personal morals/ integrity Add narrative of parties to further
perspective Determine if professional role is compatible
with institution/ program role Recognizes may not be able to resolve
Recognize conflict between values is integral to nature of values
Process: 1. Premise of mutual respect 2. Work in framework of explicit shared
values 3. Use narrative to reach balanced decisions
within shared values
Good Lives model (Ward) Positive psychology Treat patients with respect Strength building approach Assist SO to meet personal needs/ goals
through prosocial manner Evidence of improved engagement and
motivation
Non-criminal justice program Recruit subjects via media Empathic; minimize shaming/ stigma/
discrimination CBT/ Good Lives Model
Recruit volunteers without criminal hx Preventell: “helpline for unwanted sexuality” RCT approved by regulators GnRH antagonist Degarelix vs placebo Crowd funding
SOTP’s have modest effect on sex offending recidivism but better outcome for general offending
RNR approach shows best outcome Pharmacological interventions are used
routinely but lack good quality scientific support due to methodological limitations
Prison based SOTP’s have little benefit Best approaches use CBT + individual tx
Role definition may be rationally based on risk / needs /protections applicable to specific group
Must be compatible with Institution policy / legal demands
Must achieve general agreement amongst treatment staff / administration
Weight given different ethical values must be consistent with role definition
Role definition must be explicit: Clear Institutional Policy Program based ? Patient based Staff in specific programs must agree with role
definition / expectations
‘Patients / clients’ must be given full disclosure re: extent therapy is focused on public protection:
What will be communicated / to whom Extent of monitoring What info will be collected for court
purposes
Inherent role and ethical conflicts are endemic to correctional based SOTP’s
Identification and avoidance of role conflicts is paramount
If unable avoid role conflict, careful ethical analysis is required
Antiandrogen treatment under duress or compulsory orders raise substantial ethical issues that require detailed analysis and preferably external consultation