Jan 15

Q&A: The Principles and Practices of Sexual Offender Rehabilitation

I was recently invited to address, as a guest speaker, a graduate seminar on clinical issues in forensic psychology. The aim of my lecture, I was informed by the inviting professor, would be to familiarize her students with the principles and practices underlying sexual offender rehabilitation. I agreed with a mix of excitement and reluctance. Excitement at the prospect of sharing with students my passion for my area of practice. Reluctance because reactions often tend to be disapproving: typical responses have ranged from, “All sexual offenders deserve is a bullet to the head,” to the comparatively more moderate (but only comparatively), “How about we just throw away the keys?” A particularly memorable response by a student of social work (a field typically attuned, much more so than psychology at least, to the needs of social outcasts) was: “Fine. Go ahead and be the Robin Hood of sexual offenders if you want to. They’re not worth my time.” (To this day, I still struggle to grasp what exactly this student meant by “Robin Hood of sexual offenders.” I understand the sentiment: in choosing to offer psychotherapy to sexual offenders, I am upholding their right to such services. But what exactly am I stealing from the law-abiding community and giving to sexual offenders?)

Students from the seminar I would be addressing were asked to provide me, in writing and in advance, with some of their questions regarding sexual offender rehabilitation. This would mainly help me gage where in their reflection students were at, but also give me time to come up with replies to any “out-of-left-field” comments. It would, additionally, provide a springboard for discussion during class. In case there would not be enough time, over the course of my lecture, to address all the questions sent to me, I prepared a document, which I handed to students at the end of class, providing answers to each of their questions. Following are the questions—in the end, all of them thoughtful—students posed to me, along with my answers. I reproduce them here as a resource for anyone curious to learn more about the “whys” and “hows” of providing psychotherapeutic services to sexual offender clients.

Q1: It seems that many sexual offenders deny any responsibility for their actions, or confidently justify them. How does a clinician work with that kind of person?

Sexual offenders display varying degrees of resistance* to change and to attempts from others to bring about change in them. In my experience, many individuals convicted of a sexual offense understand they have committed a destructive act and are motivated to behave in such a way as to reduce their risk of re-offending. When resistance is present, however, it can manifest itself in different forms: for instance, a) individuals can altogether deny** they committed a sexual offense, b) individuals can acknowledge some aspects of the allegations made against them, yet contest others, c) individuals can fully accept their guilt, but still hesitate or refuse to find ways to reduce their risk of re-offense.

In working with sexual offenders (or any type of client, really), it is important to remember that resistance is an expected part of the change process, which can be divided into five general stages: precontemplation, contemplation, preparation, action, and maintenance (Miller & Rollnick, 2013; Mitchell, 2012). Individuals in earlier stages of change are more likely to demonstrate resistance (in the form, for example, of denial), and with greater intensity, than individuals in later stages. Since resistance is as much a relational matter as it is an internal one, it is important, in order to avoid sparking or compounding resistance in clients, to tailor one’s interventions to the stage of change they currently are at: namely, individuals at earlier stages of change will benefit from interventions that seek to instigate change (by, namely, shifting their focus from stated problems to possible solutions), whereas individuals at later stages of change will benefit from interventions that help them maintain their commitment to change.

Regarding, specifically, denial in sexual offenders, it is important to remember that this cognitive stance does not generally increase risk of sexual recidivism (Hanson & Bussière, 1998; Hanson & Morton-Bourgon, 2004). (Note, however, that this finding does not apply to individuals who committed intra-familial offenses; Nunes, Hanson, Firestone, & Moulden, 2007.) As such, it is not necessary to target denial in the context of sexual offender therapy. (Even when denial is associated with an increased risk of recidivism, it could prove counterproductive to work toward getting a client to admit to his crimes, especially at the onset of therapy. This will likely serve to increase initial resistance and effectively limit any possibility of progress, not only in regards to taking responsibility, but also to other possibly worthwhile targets.) To put it another way, even though denial may spring from an inner resistance to the idea of pro-social change, it does not necessarily need to be eliminated for actual pro-social change to come about.

It is possible to work on many criminogenic needs (i.e., experiences that can change over time and that are, unlike “non-criminogenic needs,” related to re-offending) without getting clients to admit to their crimes (Marshall, Marshall, Serran, & Fernandez, 2006). With deniers, it is recommended practice for therapists to help clients find which (cognitive, emotional, behavioral, situational) experiences led to their alleged false accusations, with the intention of avoiding these experiences (and any false accusations these may lead to) in the future. Generally, clients will, in the midst of such an exploration, identify experiences that happen to be (if they truly are guilty) criminogenic: for example, “We agreed on a safe word. She says we didn’t, but we did. I wasn’t raping her for real. I’m no sicko. Whatever she says, that’s the God’s honest truth.” In this example, working on diversifying the client’s sexual interests (or, in instances where preferred sexual stimuli are problematic and exclusive, on mourning one’s sexuality) will be worthwhile for the client, whether his innocence is factual or not. Should the client really be innocent, avoiding situations where misunderstandings about consent are more likely to occur (e.g., S&M play) will help him reduce his risk of once again falling victim to false allegations. Should he really be guilty, avoiding situations where another person willingly hands power over to him (thinking he is worthy of his or her trust) will help him reduce the risk of once again mishandling that power over the course of such a situation.

Q2: Does sexual offending have a strong biological component similar to other forms of psychopathology such as bipolar disorder or schizophrenia? For example, if someone is a sexual offender, are their children more likely to engage in the same behavior when they get older? If so, what is the treatment prognosis?

This is an interesting question, one I believe will be best answered by acknowledging and addressing the different assumptions that seem to underlie the question.

Assumption #1: Sexual offending is a form of psychopathology.

Assuming that psychological processes can be pathological (see Assumption #5), sexual offending may or may not involve mental illness. The tendency to commit sexual offences is not, in and of itself, considered a mental illness. In this sense, sexual offending cannot be considered (again, in and of itself) a form of psychopathology. One could say, however, that the tendency to commit sexual offences involves psychopathological processes, in the form, namely, of deviant sexual interests (e.g., pedophilia). It is important to keep in mind, however, that not all sexual offenses are motivated by unusual sexual interests (Langevin, Lang, & Curnoe, 1998).*** (Likewise, not all individuals who exhibit unusual sexual interests commit sexual offenses; Hall, Hirschman, & Oliver, 1995; Williams, Cooper, Howell, Yuille, & Paulhus, 2009.)

Assumption #2: Sexual offending and other behaviors generally considered to be inappropriate (e.g., bipolar and schizophrenic modes of behavior) are more biologically determined than behaviors generally considered to be appropriate (e.g., prosocial, “unipolar,” and “uni-phrenic” modes of behavior).

It is important to keep in mind that all modes of behaving, whether considered appropriate or inappropriate by society, are founded in biology. While there is a tendency in the literature to only summon biological explanations when discussing inappropriate behavior, and to assume that appropriate behaviors come about spontaneously, as if materializing out of God’s breath itself, there is no reason to believe that appropriate behaviors are not similarly governed by biological rules and processes. For this reason, I find the following question equally fascinating: “Does non-criminal behavior have a strong biological component similar to other forms of psychological functioning, such as bipolar or schizophrenic behavior?” It is also important to remind ourselves that the exact role of biology (to say nothing of whether the processes involved can best be described as “disordered” or “pathological”) in behaviors commonly referred to as mental illness has been greatly overstated. The American Psychiatric Association itself, in its research agenda for the fifth and latest edition of the Diagnostic and Statistical Manual of Mental Disorders, rather candidly admitted that “the field of psychiatry has thus far failed to identify a single neurobiological phenotypic marker or gene that is useful in making a diagnosis of a major psychiatric disorder” (Kupfer, First, & Regier, 2002, p. 33). So premature are, namely, neuropsychologists’ conclusions regarding the neurological underpinnings of behaviors referred to as mental illness, that certain critics of psychology (e.g., Bentall, 2004; Greenberg, 2010) have likened modern neuropsychology to phrenology.

Assumption #3: The level to which a behavior is biologically determined will determine the likelihood at which it can be altered.

This is an interesting assumption that I am not certain science, in its current state, can corroborate. There is, however, a variation that can be addressed: biologically determined behaviors are necessarily resistant to intervention. This assumption starts crumbling to pieces if we conceptualize all human behavior as being (at least in part) biologically determined. Yes, behaviors like heterosexuality and religious belief, both of which presumably involve some biological processes, are very resistant to change. Yet, other behaviors, like vocational interests and emotional infatuations, both of which also presumably involve some biological processes, are known to be amenable to change (often without intervention).

Practically speaking, clinical psychologists working with sexual offenders do not ask, “How much is my client’s behavior due to biology?” when attempting to assess their amenability to change. Rather, they ask, “How likely is my client to re-offend in the future?” Indeed, amenability to change appears related to sexual offenders’ risk of sexual recidivism. (That is not to say, of course, that one’s level of risk is not, to some extent, rooted in biology.) More precisely, higher-risk offenders will benefit from rehabilitation more so than lower risk offenders; for low-risk offenders, rehabilitation may even increase risk of recidivism. (Although these findings are generally discussed in regards to “general” offenders [Andrews & Bonta, 2010], they seem to extend to sexual offenders as well [Lovins, Lowenkamp, & Latessa, 2009].) Regarding those sexual offenders who express inappropriate sexual interests, some behavioral methods exist (e.g., covert association, directed masturbation, masturbatory reconditioning, verbal satiation) to extinguish such interests and to reinforce more appropriate ones. These methods, however, possess varying degrees of empirical support (Marshall, Anderson, & Fernandez, 1999).

Assumption #4: Sexual offending behavior can be passed down from one generation to the next via genetic transmission.

In actuality, many dispositional and environmental factors (not to mention social norms) combine to create a moment between two individuals that comes to be described as sexual offending. While certain traits or tendencies involved in sexual offending (e.g., sexual interest in children) can be believed to be passed down from generation to generation, it is hard to conceptualize how sexual offending as a whole could be transmitted from one generation to the next, as if constituting some unique physical entity singly represented in one’s biology by a specific set of genes. Regarding inadequate sexual interest specifically, research suggests that sexual interest in children is mainly determined by one’s environment (Alanko, Salo, Mokros, & Santtila, 2013), a finding similar to that for adequate sexual interest (e.g., homosexuality; Santtila, Sandnabba, Harlaar, Varjonen, Alanko, & von der Pahlen, 2007). That is not to say, of course, that biology (simply in a form other than genetics) is not involved somehow, or that sexual offenders with pedophilic interests experience any sense of choice in their desire to engage in sexual activity with children (similarly to individuals with teleiophilic interests).

Assumption #5: Behavior can be “pathological.”

The idea that mental illness is real represents the most commonly made assumption in the entire field of clinical psychology, not to mention psychiatry. While it may appear to be self-evident, there are a number of philosophical and scientific objections to the notion that mental illness exists. (That is not to say, of course, that the behaviors referred to as mental illness do not exist [although the means via which these behaviors are categorized may be flawed] or that they are necessarily the product of human volition.) Interestingly, most of these objections, leveled by psychologists and psychiatrists alike, have and continue to come from within our field. (Arguments range from “mental illness is a metaphor” to “unlike physical illness categories, mental illness categories circularly mistake description for explanation.”) Entire books have been filled with these objections, and so I cannot hope to do justice to any of them in the space of a few short paragraphs. For those interested in finding out more on the subject, I have taken care to list a few seminal titles in the “Suggested Readings” section of this document, books that have greatly influenced my philosophy as a professional helper. Mainly, my philosophy manifests itself linguistically: I make special efforts to avoid using medical language when describing and explaining human misbehavior, preferring instead to use humanistic language, which possesses the dual advantages of a) being more parsimonious than its alternatives (i.e., not only medical, but also religious and romantic language) and of b) acknowledging the human experiences that exist behind many of the behaviors psychiatry dismisses as symptoms.

Assumption #6: Inappropriate behaviors can be “cured” with “treatment,” and have different “prognoses.”

This assumption flows from the previous one. If misbehaviors can be diseases, then they can also be “cured” with “treatment,” and have different “prognoses.” If misbehaviors are simply misbehaviors, however, medical terminology like “cured,” “treatment, and “prognosis” is inappropriate to describe the actions of those who seek to alter the misbehaviors in question, as well as to describe the course these misbehaviors adopt across time (with or without the influence of the actions of those who seek to alter them). Let me elaborate: Much in the same way what we refer to as mental illness has very little to do with physical illness, what we refer to as psychological treatment has very little to do with medical treatment (rendering the usage of the term “illness” or “treatment” in both instances misleading). What we describe as treatment in psychology is, in actuality, a relational enterprise (Szasz, 1988) that shares more in common with conventional forms of communication than it does with medical intervention: words and other symbols, combined with our ability to reason and reflect, are harnessed in the service of deciphering life challenges and developing the skills needed to overcome them.

How effective are psychological interventions at getting individuals to stop committing sexual offenses? Research has shown that psychological interventions are able to effectively reduce risk of sexual recidivism. To be effective, however, interventions must be based on what is known as the Risk-Need-Responsivity (R-N-R; Andrews & Bonta, 2010) model of offender rehabilitation: in other words, level of risk, criminogenic needs, and level of receptivity to intervention must all be taken into account when attempting to help sexual offender clients commit to a pro-social lifestyle (Hanson, Bourgon, Helmus, & Hodgson, 2009). Interventions should also abide by contemporary, empirically supported (e.g. cognitive-behavioral) principles (Andrews & Bonta, 2010; Hanson, Gordon, Harris, Marques, Murphy, Quinsey, & Seto, 2002).

Q3: Based on your experience, what do you feel are the greatest barriers to successful treatment for sexual offenders? Are the barriers related more so to external factors such as stigma and lack of access to adequate resources or are they related more so to factors involving the offender’s personality/mental health?

There are many forces, internal and external, that conspire to thwart a sexual offender’s efforts to lead a pro-social life, even when the person in question is highly motivated to do so. Fear and anger from the community (e.g., strangers, family, policy-makers, case management team members), compounded by poor knowledge of the literature on sexual offending (embodied in the form of the uniquely American notion of the mythical sexual predator), often lead to measures being taken that poorly balance a) the community’s legitimate needs for protection from harm and for revenge with b) the offender’s need to live a pro-social life (and, thus, become less of a danger to the community). In fact, while many of these measures successfully satisfy our needs as a community, they do so at the expense of offenders’ rehabilitative process, by self-defeatingly limiting these individuals’ ability to access pro-social experiences and even exacerbating particular risk factors (e.g., social rejection). In sum, we owe it to ourselves and to the sexual offenders in our communities to find a middle ground, one that takes into account our needs for protection from harm and for revenge, without producing the very circumstances we wish to avoid (i.e., by thwarting sexual offenders’ efforts to become pro-social).

Permit me a brief tangent. Certainly, fear and anger are legitimate responses to sexual offending. It is essential to our humanity, however, that we do not debase ourselves in moments of despair by acquiescing to our basest instincts and by letting these animalistic drives guide our behavior as we attempt to regain control over the situation. To summon compassion for sexual offenders is a challenging endeavor, I concede. If we are to pride ourselves as compassionate beings, however, we owe it to ourselves to attempt to offer compassion to those who ignite our ire. To put it bluntly, if we are only able to feel compassionate toward starving orphans or three-legged dogs, then the very concept of compassion becomes rather hollow and meaningless, to say nothing of our impression of ourselves as benevolent individuals.****

To those who can never see themselves mustering any compassion whatsoever for rapists or child molesters, it is important to remember that, even if we harden our hearts to the personal challenges of sexual offenders, the cost of overly restrictive offender management initiatives to the rest of us “law-abiding folks” remains potentially damaging (as mentioned previously) and should still be opposed, if only for our own sake.

A more internal barrier to change in sexual offenders is shame. Most sexual offenders understand that they have committed a destructive act, a realization that naturally produces shameful feelings in them. Some individuals seek to protect themselves from this uncomfortable emotional experience by resorting to less-than-ideal strategies, like “cognitive distortions” or, more appropriately and less presumptuously, problem thoughts (e.g., minimization, victim-blaming). While it may be tempting (especially to the strict cognitive-behavioral therapist) to immediately seek to replace problem thoughts with less damaging alternatives, this can be a mistake. It is important to understand that problem thoughts often represent defenses, and that defenses are, by their nature, protective. As such, it will often prove quite fruitless to try to eliminate problem thoughts when the experiences clients are seeking to defend themselves against (via these thoughts) remain threatening to them. For this reason, when problem thoughts are defensive, it is best to focus on, say, emotion management, before attempting “cognitive restructuring.”

While some problem thoughts are meant to protect us from feelings stemming mainly from our past, others are meant to protect us from feelings stemming from our future (or, more accurately, what we imagine our future to be). “It is perfectly acceptable for adults to have sexual relationships with children” may represent one such thought. Given the inflammatory nature of such a statement, many therapists would be quick to attack it. Again, while it may be tempting to immediately argue with an offender about the legitimacy of his belief, such a conversation might be less than productive if the subjective purpose of his belief is to permit (in the face of doubts as to the feasibility of having a satisfactory relationship with an adult) for the possibility of having one’s needs for intimacy met in the future. In this instance, only once the offender becomes confident in his ability to meet his intimacy needs within the context of an adult relationship will he become open to replacing his problem thought with a more constructive one.

Even when an offender has learned how to “navigate” his shame without feeling threatened and defensive, shame can still weigh heavily on him and limit his ability to commit to a new, pro-social lifestyle: “Look at what I’ve done. I’m a piece of shit. Scum like me doesn’t deserve friends.” One way to render shame less incapacitating is to interpret such feelings as painful indicators of clients’ humanity, of the intactness of their moral compass. (After all, they wouldn’t be feeling shameful if they thought what they did was right.) This “re-framing” of shame can be transformative for clients, bringing into perspective a moral foundation upon which to build their new life. (Once a given client has made this realization, he would also be encouraged to think about what caused him to disregard his moral compass at the time of his offense, so as to help him prevent any further deviations from his moral center in the future.) In sum, even if shame is not, in and of itself, criminogenic, it is crucial that it be recognized and addressed in therapy with sexual offenders, in that it can give rise to and maintain behaviors that are criminogenic, not to mention keep pro-social behaviors at bay.

Q4: My question is in relation to the process of treatment. Is it particular personality traits that guide you to determine treatment? Do you begin treatment focusing on the urge/impulsivity issues and work your way from there? What factors determine your treatment method?

The first part of the rehabilitative process is to assess the sexual offender’s risk of re-offense. This process highlights a number of factors that serve to increase the individual’s risk of committing a new sexual offense over the course of several, pre-determined periods in the future. Some of these factors are considered static (or historical, and thus mostly unalterable through intervention; Hanson & Thornton, 2000), whereas others are considered dynamic (or changing in time, and thus alterable through intervention; Hanson, Harris, Scott, & Helmus, 2007). Rehabilitation targets those risk factors that are considered dynamic. (Since dynamic risk factors are synonymous with criminogenic needs, this approach at rehabilitation is known as the need model). There are two types of dynamic risk factors: acute dynamic factors change rapidly across time and risk bringing about a sexual re-offense in the immediate short term (e.g., access to potential victims), whereas stable dynamic factors change slowly across time and risk bringing about a sexual offense in the longer short term (e.g., hostility toward women). Unless acute dynamic risk factors are present, rehabilitation will focus on eliminating, or a the very least decreasing, the influence of stable dynamic risk factors.

It can also be helpful, during the course of therapy, to identify, along with the client, the positive experiences (e.g., autonomy, intimacy, belonging) he was attempting to create for himself prior to and during his sexual offence. (This approach is known as the Good Lives model; Yates, Prescott, & Ward, 2010.) These valued experiences are known as “primary goods.” After validating the innate legitimacy of these experiences, the therapist should help the client (among other objectives regarding what is known as the “Good Lives plan”) find methods of achieving these same experiences in the future, this time without moving toward or engaging in sexual offending. These methods (whether constructive or not) are known as “secondary goods.” Because dynamic risk factors promote the use of inappropriate secondary goods (in the form of sexual offending), can themselves represent inappropriate secondary goods (by virtue of their risk properties), and can prevent clients from meeting primary goods not already embedded in their offense chain (up to and during their sexual offense), work on primary and secondary goods is complimentary to work on dynamic risk factors.

Finally, the therapist should help the client identify the goals, in regard to future offending, that he set for himself prior to actually committing his offense, as well as the manner in which he went about achieving these goals. (This approach is known as the self-regulation model; Yates, Prescott, & Ward, 2010.) There are several goal-manner combinations, also known as “pathways” to sexual offending. Prior to his offense, the client may have a) wished to avoid offending, but failed to implement any strategies to accomplish this (“avoidant-passive pathway”), b) wished to avoid offending, but implemented ineffective strategies to accomplish this (“avoidant-active pathway”), c) wished to offend and done so impulsively (“approach-automatic pathway”), or d) wished to offend and done so in an involved and strategic manner (“approach-explicit pathway”). Notice that, in each of these scenarios, the client either regulated improperly (by not at all attempting to control his behavior, or by attempting to do so, but ineffectively) or regulated properly (by attempting to control his behavior, and doing so effectively) toward his stated goal, which was either pro- or anti-social. Thus, the nature of the therapeutic conversation will vary depending on where exactly the problem lies: the problem may lie in the client’s goals or in his ability to regulate toward these (or in both). If the client’s stated goals are problematic, then the therapist will want to gear the therapeutic conversation toward replacing the client’s intentions with less problematic ones. Likewise, if the client’s ability to regulate toward his goals is problematic, then the therapist will want to gear the therapeutic conversation toward improving self-regulation (by curbing passive or automatic tendencies, and/or by developing goal-directed decision-making). Because dynamic risk factors and primary/secondary goods interact with sexual offenders’ goals regarding future offending and with the manner in which they accomplish these goals, work on goal-selection and self-regulation is complimentary to work on dynamic risk factors and primary/secondary goods.

Q5: How does building a strong therapeutic alliance with sexual offenders differ from the average non-sexual offender and from the general population?

Psychotherapy with sexual offenders poses particular challenges to therapeutic alliance that are generally absent or less intensely present in therapy with non-sexual offenders or the general population. Challenges to therapeutic alliance in the context of sexual offender therapy usually originate in the following order, first from within the therapist, then from within the context inside which the therapeutic relationship must unfold, and subsequently from within the client: (1) Sexual offenders have committed crimes that can sometimes elicit intense emotions like disgust or anger in the therapist, emotions that, while entirely appropriate, can easily thwart one’s ability to relate (both internally and externally) constructively with clients. (2) While some sexual offenders volunteer for psychotherapy, therapy is most often mandated. Also, the same level of confidentiality afforded to clients in non-correctional therapy cannot, for security purposes, be afforded to clients in correctional therapy. As such, sexual offenders’ motivation to invest in therapy (and any component thereof) can be very low. (3) Given the shameful nature of their crimes, sexual offenders are likely to erect various defenses within therapy, to protect themselves from the therapist’s judgment, and, ultimately, their own. This defensive tendency is compounded by sexual offenders’ common inability to interact with others in constructive ways. (Interestingly, some practitioners conceive of sexual offending as mainly a relational problem, as opposed to a sexual one.) Since all of the aforementioned experiences tend to materialize at the onset of therapy, it is important to intervene, from the very first session on, in such a way as to prevent these states of mind from crystallizing and impacting, in counterproductive fashion, the course of therapy.

To develop therapeutic alliance with sexual offenders, it can be helpful to: a) trigger one’s ability to empathize by focusing not on the client’s crime, but on the person who committed the crime, their regrets, their fears and their hopes (however suppressed or otherwise protected these may be), all of which can be rallied in service of rehabilitation, b) earn the client’s collaboration by recognizing the fact that they must attend therapy, by being forthright about the limits imposed on confidentiality, by acknowledging their (possible) reluctance to attend therapy as a function of these contextual issues, and by together finding ways to make the therapeutic hour, despite its mandatory nature and its limited confidentiality, helpful to the client, c) validate the positive experiences (e.g., connection) the client was attempting to create for himself when he engaged toward a sexual offence, and explain that, while the manner in which he sought to achieve these experiences was less than ideal, the desired experiences themselves were wholly legitimate, d) adapt one’s interventions to the stage of change the client is currently at (i.e., precontemplation, contemplation, preparation, action, or maintenance). By instilling a humane climate endowed with patience, understanding, and non-judgment, most often these methods will help to strengthen the therapeutic alliance, and to increase clients’ motivation to commit toward change through therapy.

Q6: According to Conroy (2003), “females who perpetrate against children constitute a very small percentage of sex offender population” (p. 475). What types of sexual offenses are women most likely to commit? Has research identified why women sexually offend less, especially against children? What makes them different than men? How do their special needs that differ from the needs of male sexual offenders impact treatment?

My clinical experience is limited to working with male sexual offenders, and so I am not very familiar with the literature on female sexual offending. What I do know, however, is that there is very little research available, at present, on the subject of women who perpetrate sexual crimes. For this reason, there are very few guidelines regarding how to properly assess and reduce the risk of re-offense in female sexual offenders. Regarding differences between female and male sexual offenders, it appears that female sexual offenders re-offend less often (Cortoni, Hanson, & Coache, 2010), and that the factors involved in their re-offending are different (Sandler & Freeman, 2007). On a practical note, until more is known on the causes (or, at the very least, the correlates) of sexual offending in women, I would suggest using what is currently known about male sexual offending as a template when working with female sexual offenders, while, of course, carefully keeping in mind the empirical limitations of this template.


* I use the term “resistance” not in a psychoanalytically dismissive way, but to describe that aspect of consciousness that is opposed to change—an aspect that may exist on its own, or that may be counterbalanced with openness to change. (The experiential blend of opposition and openness to change is typically referred to as “ambivalence.”)

** For the purposes of this answer, I am using the term “denial” (or any derivative of the term, e.g., deny, denier) in its categorical, all-or-nothing sense. (Certain definitions of the term will accommodate partial acknowledgement of the subject of denial.)

*** This is also implied by the possibility of assigning a given sexual offender a score of “0” on the “Deviant Sexual Preference” row of the STABLE-2007, a measure of sex-offender specific criminogenic needs (see Fernandez, Harris, Hanson, & Sparks, 2012, for coding rules).

**** This tangent was brought to you by the philosophies of Viktor Frankl, psychiatrist and author of Man’s Search for Meaning (1946), and of Paul Gilbert, psychologist and founder of Compassion Focused Therapy (see Gilbert, 2009, for an outline of the approach).


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Marshall, W. L., Marshall, L. E., Serran, G. A., & Fernandez, Y. M (2006). Treating sexual offenders: An integrated approach. New York, NY: Routledge.

Miller, W. R., & Rollnick, S. (2013). Motivational Interviewing: Helping people change (3rd edition). New York, NY: The Guilford Press.

Mitchell, C. W. (2012). Effective techniques for dealing with highly resistant clients (2nd edition). Publisher: Author.

Nunes, K. L., Hanson, R. K., Firestone, P., Moulden, H. M., Greenberg, D. M., & Bradford, J. M. (2007). Denial predicts recidivism for some sexual offenders. Sexual Abuse: A Journal of Research and Treatment, 19, 91–105.

Sandler, J. C., & Freeman, N. J. (2009). Female sex offender recidivism: A large-scale empirical analysis. Sexual Abuse: A Journal of Research and Treatment, 21, 455–473.

Santtila, P., Sandnabba, N. K., Harlaar, N., Varjonen, M., Alanko, K., & von der Pahlen, B (2007). Potential for homosexual response is prevalent and genetic. Biological Psychology, 77, 102–105.

Szasz, T. (1988). The myth of psychotherapy: Mental healing as religion, rhetoric, and repression. Garden City, NY: Syracuse University Press.

Williams, K. M., Cooper, B. S., Howell, T. M., Yuille, J. C., & Paulhus, D. L. (2009). Inferring sexually deviant behavior from corresponding fantasies: The role of personality and pornography consumption. Criminal Justice and Behavior, 36, 198–222.

Yates, P. M., Prescott, D., & Ward, T. (2010). Applying the Good Lives and Self-Regulation models to sex offender treatment: A practical guide for clinicians. Brandon, VT: The Safer Society Press.

Suggested Readings

Note: This section appeared as an appendix to the Q&A handout.

i) General readings in offender psychology

Making Good: How Ex-Convicts Reform and Rebuild Their Lives (Maruna, 2000)
The Psychology of Criminal Conduct (Andrews & Bonta, 2010)
Rehabilitation (Ward & Maruna, 2007)
The Criminal Recidivism Process (Zamble & Quinsey, 2001)

ii) Sexual offender assessment and rehabilitation

Applying the Good Lives and Self-Regulation Models to Sex Offender Treatment: A
Practical Guide for Clinicians (Yates, Prescott, & Ward, 2010)
Cognitive-Behavioral Treatment of Sex Offenders (Marshall, Anderson, & Fernandez, 2006)
Desistance from Sexual Offending: Alternatives to Throwing Away the Keys (Laws & Ward, 2011)
Rehabilitating Sexual Offenders: A Strength-Based Approach (Marshall, Marshall, & Serran, 2011)
Sexual Deviance: Issues and Controversies (Ward, Laws, & Hudson, 2002)
Sexual Deviance: Theory, Assessment, and Treatment (Laws & O’Donohue, 2008)
Treating Sex Offenders: An Integrated Approach (Marshall, Marshall, Serran, & Fernandez, 2006)

iii) Issues in clinical psychology

This is only a sample of titles from a wide and varied body of literature critically evaluating some of psychology and psychiatry’s most popular assumptions:

The Cult of Personality Testing: How Personality Tests Are Leading Us to Miseducate Our Children, Mismanage Our Companies, and Misunderstand Ourselves (Paul, 2004)
Doctoring the Mind: Why Psychiatric Treatments Fail (Bentall, 2010)
House of Cards: Psychology and Psychotherapy Built on Myth (Dawes, 1996)
Madness Explained: Psychosis and Human Nature (Bentall, 2004)
Manufacturing Depression: The Secret History of a Modern Disease (Greenberg, 2010)
The Myth of Mental Illness: Foundations of a Theory of Personal Conduct (Szasz, 1974)
The Myth of Psychotherapy: Mental Healing as Religion, Rhetoric, and Repression (Szasz, 1988)

iv) General readings in clinical psychology

Effective Techniques for Dealing with Highly Resistant Clients (Mitchell, 2012)
Motivational Interviewing: Helping People Change (Miller & Rollnick, 2013)

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