Treatment and The Sex Offender
Treatment and The Sex OffenderTreatment and The Sex Offender
by Brent M. Pergram, Masters of Arts in Sociology
The Martinson Report of the early 1970�s, said that rehabilitative efforts or treatment programs in general had failed to reduce recidivism. The Report led those in control of government and the criminal justice system to say that rehabilitation does not work, and therefore
focus on deterrence and punishment of offenders. Martinson�s study of 231 treatment studies measured offender improvement in various areas, but recidivism is the issue here. Martinson
says �With few and isolated exceptions, the rehabilitative efforts that have been reported so far have had no appreciable effect on recidivism� (p.292).
Martinson says that education and vocational training in the studies he reviewed had no influence on reducing recidivism. But he admits that a correctional facility running a truly rehabilitative program that gets inmates ready for life on the outside by way of education and vocational training will have more successful persons than prisons that have no such
programs (Martinson, p.292).
Martinson says that individual counseling also fails to reduce recidivism. In terms of group counseling he admits that a study of adult offenders did show improvement in attitudes of offenders, but since it did not include information on recidivism it was discounted.
Martinson is criticized because the counseling programs may not seem to work because of the institutional environment outside the program. Martinson says that even in institutional environments that control every part of the offenders environment and treatment, did show a reduction in recidivism for one year. But he says the effects of such treatment did not reduce recidivism any more than no treatment after two years. And it had no influence on reducing the recidivism rates of young offenders (Martinson, p.296).
Prisoners with less sentences were found to have a higher parole success rate than those with longer sentences, but did not deal with the issue of offender degree of risk (Martinson, p.299).
Martinson says that since these treatment programs in prison did not work, maybe rehabilitating offenders outside an institutional setting may work. But the studies he reviewed showed no effect in treating the client. But he says that individual psychotherapy may work in a community setting.
Martinson said that their was no evidence to believe that intensive supervision of adults would reduce recidivism. But he said that a smaller case load did improve a person�s chances of parole success (p.305). But he says that intensive supervision works not because of the mechanisms of treatment or rehabilitation, but due to the mechanism of deterrence (Ibid).
Martinson says that community treatment may not reduce recidivism, but it does insure that the client will not become worse. Also community treatment is cheaper than treatment in prisons.
Martinson admits that the reason why treatment has not worked is due to these reasons:
�the education we provide to inmates is still poor education, that the therapy we administer is not administered skillfully enough, that our intensive supervision and counseling do not yet provide enough personal support for the offenders who are subjected to them� (p.307).
Sundt et al. (1998) article says that past research has shown that the public supports rehabilitation as a core goal of corrections. They say that over the past decade, the conservative campaign to get tough on crime has grown in strength and influence. Stundt et al (1998) article replicates a 1986 study by Cullen et al that explored attitudes toward correctional treatment. They found that public support for rehabilitation has declined , but that the public continues to view treatment as a legitimate correctional objective. A majority of the public now believes that the main emphasis of prisons should be to punish offenders or protect society. But the majority of the public still favors expanding rehabilitation programs. In terms of early release from prison for good behavior and participation in educational and work programs, half of the public opposes early release. Also 40% of the public oppose expanding treatment programs (p.426).
Sundt et al (1998) found that two thirds of the public perceived correctional rehabilitation to be very helpful or helpful. They found that only with regard to sex offenders and violent offenders did a majority of the public perceive that treatment would be ineffective, but 40% believed that treatment would be slightly helpful for these offenders.
The Sundy et al (1998) article shows that the belief in the efficacy of rehabilitation is somewhat stable. Even if the public is less confident that specific treatment programs work, most still perceive rehabilitation as being an effective way to treat offenders. They say that the decline in support from 1986 is not due to the belief that nothing works. They say that many studies from the past decade (the late 1980�s through the early 1990�s) shows the effectiveness of treatment interventions is now extensive and stronger that it was in 1986. For example Palmer 1995 article shows that treatment programs do work to reduce recidivism and are effective ways to treat offenders in prison. The change in support for rehabilitation is due to the penal harm movement that wants to punish offenders, and opposing any treatment or rehabilitation due to cost and perception that criminals cannot change.
Gendreau et al (1996) article discusses effective assessment, believing that good risk measures can predict recidivism in the .30 - .45 range. In terms of the methods of assessment, Gendreau et al (1996) says their is two models of assessing and predicting human behavior, which are clinical and actuarial. They say that the clinical model dominates, and in the case of corrections clinical assessment consists of an expert, such as probation officer interviewing an offender for the purpose of determining their risk to reoffend. The expert bases their decision on intuition, experience, and file information on the client to make the correct decision. The actuarial method is based on empirically established correlation\\\'s between a standardized objective risk measure and recidivism, and therefore limits the experts subjective opinion in the decision making process.
Gendreau et al. (1996) article says the actuarial approach is the best, since the clinical method only predicted recidivism 8% of the time (r=.08). The actuarial method was r=.22, and produced higher correlation\\\'s with outcome 76% of the time. The results apply to corrections, such as that sex offenders (Hanson & Bussiere, 1996) and violent offenders (Mossman, 1994) clearly demonstrated the superiority of the actuarial model. The Hanson & Bussiere, 1996 study of sex offenders found the actuarial model to be about three times more powerful. Gendreau et al (1996) say that �there is simply no justification whatsoever for the continued use of the clinical model of assessment considering what is at stake (i.e., protecting the public) in our line of work.�
The static risk factors that are criminal behavior predictors are age, gender, past criminal history, early family factors, and criminal associates that predict recidivism. But their is also dynamic risk predictors, such as criminogenic needs. Simourd (1996) defined criminogenic needs as attitudes, values, beliefs, and behaviors held by an offender that support negative attitudes toward all forms of official authority and conventional non deviant pursuits (e.g., education, work, stable pro social relationships); deviant values that are used to justify aggression, and substance abuse; and rationalizations for antisocial behavior that free one from any moral constraints. Gendreau et al. (1996) tested the static risk predictors by a meta-analysis of 131 studies from 1970-94 that produced 1,14f1 correlation\\\'s with recidivism. They confirmed that age, gender, early family factors, adult criminal history and history of antisocial behavior as a teen, and criminal associates are reliable predictors of recidivism. They found that dynamic predictors, especially criminogenic needs predicted recidivism (r=.17) as well as static predictors including past criminal history (r=.16).
Gendreau et al (1996) article found that the prediction of recidivism is best accomplished by using measures that assesses static and dynamic risk factors. They recommend the Level of Service Inventory (LSI-R) (Andrews & Bonta, 1995), due to the studies that confirm its predictive validity in predicting recidivism and prison adjustment for a variety of offender populations, such as sex offenders.
The sex offender literature is complex, such as Marshal (1996) belief that assessment of the sex offender with phallometric procedures is ethically questionable, and that it is much easier to predict violent recidivism than sexual recidivism.
However, Hanson and Bussiere�s (1996) meta-analysis of 61 sex offender studies found 970 correlation\\\'s with recidivism concluding the following: a) the largest single predictor of sexual offending were sexual preference for children and deviant sexual preference as measured by phallometric methods. The respective r values were high (.32 and .22); b) measures of personal distress, be they anxiety, depression, or self-esteem, were not significant predictors of sexual, non-sexual, or violent recidivism; c) combinations of variables identified in their research should be able to predict recidivism in the .30-.40 range, that is similar to what has been found in studies of general recidivism (Gendreau et al., 1996).
Gendreau et al. (1996) says that assessments of general criminal deviance, such as antisocial personality attitudes, and non-sex offending criminal history have been under used in the sex offender area. This is especially true of the rapist who appears to have a good deal in common with the high risk non-sex offender (Quinsey, Lalumiere, Rice, and Harris, 1995).
Researchers in the area of sex offending have identified a list of other factors that should be assess in the future, such as the lack of empathy toward the victim, denial and minimization, deviant sexual fantasies, unfulfilled intimacy needs, association with other sex offenders, access to victims, and the interaction of psychopathy and deviant sexual arousal (Hanson & Bussiere, 1996; Marshall, 1996; Quinsey et al, 1995). Gendreau et al. (1996) says that well-galidated measures designed specifically for use with sex offenders are rare (e.g., Epperson, Kaul, & Huot, 1995).
Gendreau concludes that the most effective model of assessing offender characteristics predictive of recidivism is the actuarial technique, and that �the realization that dynamic predictors (i.e., criminogenic need) are crucial for the accurate assessment of offender risk�.
Male sex offenders in prison represent a major problem for correctional administrators in the United States, due to the public, legislative, and legal pressures to do something about these most reviled offenders. Most correctional systems in the United States and Canada offer some form of treatment for sex offenders, ranging from individual to group counseling to highly intensive therapeutic communities that use the most recent treatment techniques (US Dept. of Justice).
The responsibility for treating and supervising sex offenders has increasingly shifted from mental health institutions to corrections, as the Mentally dangerous Sexual Psychopath laws adopted by many states in the 1940�s have been phased out. In general treatment professionals have concluded that most sex offenders are not mentally ill and have not benefited from traditional psychiatric treatment. Fortunately for society, promising new approaches in corrections have been developed to help treat sex offenders that hopefully will reduce recidivism.
The Association for the Treatment of sexual Abusers supports the position that treatment of sex offenders should not replace a criminal justice response, but should be one of several tools used by society to meet the needs of the offender and protect and insure public safety. The fact is that treatment can be combined with other criminal justice responses, such as jail, incarceration in prison, probation, and community monitoring and supervision (ATSA).
The U.S. Department of Justice, National Institute of Corrections article, �An Administrator�s Overview-Questions and Answers on Issues Related to the Incarcerated Male Sex Offender,� hereafter cited as (US Dept. of Justice) adapted by Barbara Krauth and Roger smith from A Practitioner�s Guide to Treating the Incarcerated Male Sex Offender summarizes the new treatment approach used to meet the needs of this offender population. The Administrator�s Overview highlights material contained in the Practitioner�s Guide used by those expected to treat sex offenders and is focused at correctional administrators, who must make critical decisions with limited resources. The NIC training seminars, and the Practitioner�s Guide produced as a result of these seminars that began in 1986, stress the importance of a systems approach to program planning, design, and management. The approach requires the active participation and support of legislators, prosecutors, judges, mental health professionals, advocacy groups, and all segments of the correctional system. It grew out of the belief that supportive administrators play an important role in the developing and operating effective treatment programs for sex offenders who are incarcerated to help end the vicious cycle of abuse, in which victims frequently become offenders.
There is more than one type of sex offender. Sex offenders are a diverse group that cannot be characterized by any single motivation or causal factor. Typologies have been created to account for the different forms of sexual deviance. The categories developed by the FBI, based on other typologies, are currently most frequently used in criminal investigations. The FBI categories of sex offenders are as follow:
Child molesters who turn to prepubescent youths for sexual gratification. The two main types of child molester are the situational and preferential (often called the pedophile).
The situational child molester is made up of persons that do not have a defined sexual preference for children. They include the following subtypes: Regressed, who is an immature, socially inept person that relates to children as peers. This person usually experienced a brief period of low self-esteem and turned to his own kids or others for sexual satisfaction. He is morally indiscriminate, with an antisocial attitude that uses and abuses everyone. He chooses his victims based on vulnerability and opportunity and only coincidentally because they are kids. He is sexually indiscriminate, who may be developmentally disabled, psychotic, senile, or organically dysfunctional (US Dept. of Justice, pp.2-3).
The preferential (pedophile) child molesters are fixated, in that they are attracted to children throughout their lives and have been unable to attain any degree of psycho-sexual maturity. The subtypes of this type of child molester is as follows: Seductive, having an exclusive sexual interest in children and trying to court and seduce them. He is introverted, having a fixated interest in children but does not have the social skills to seduce them. He typically molests strangers or very young children or marries women with children the age of his preference. He may be sadistic, having a sexual preference for children, coupled with a need to inflict pain in order to obtain sexual gratification (US Dept. of Justice, p.3).
The adult sex offender is the rapist, who are usually motivated by a fusion of anger and power needs and sexuality. They are classified according to the characteristics of the assault as well as of the assailant. There is three main types of rapists, the anger rapist, the power rapist, and the sadistic rapist.
The anger rape is associated with gratuitous violence and the intention to hurt, devalue, and express contempt for the victim. This type of assault is typically opportunistic and is usually committed in response to a precipitating stress.
The power rape is typically used as a way of exercising dominance, mastery, strength, authority, and control over the victim. The power rapist has little need for excessive physical force beyond what is needed to gain the victim�s submission. They are less physically dangerous that the anger rapist, but may be more compulsive and often engage in elaborate fantasies and plans.
The sadistic rape is the most severe pathology of rape on the part of the offender as well as the most dangerous type of assault. This type of rape has the ritual of torturing the victim and the perception of her suffering and degradation gives the offender erotic pleasure. As the rapists arousal builds, so may his sadistic acts of violence, progressing in some cases to the point of lust murder (US Dept. of Justice, p.3).
The Administrator�s Overview, says that just about every incarcerated sex offender in treatment is a rapists or child molesters. Therefore I will not discuss voyeurs, exhibitionists, or obscene phone callers in jail, except to say that this misdemeanor sex behavior may be about to commit a rape, or is engaged in an escalating pattern of deviant behavior that may lead to rape. Also the sex offender may not specialize in one type of sex abuse, but be engaged in voyeurism, rape, and child molestation.
The vast majority of offenders are males, with about 80% of sex offenses against children being committed by males and about 20% by females (ATSA-reducing sex abuse...). The offender is usually know by the victim or family eighty to ninety-five percent of the time. The sex offender is a family member in less than 50% of cases, and are identified as acquaintances, such as neighbors, coaches, teachers, religious leaders in the remaining cases (Ibid.).
Clearly intervention and treatment is very important to treat the sex offender. Sex crimes are viewed with horror by the public. Those that fear this offender population would prefer to lock them up forever. This negative public attitude has caused some corrections officials to not spend scarce resources on creating treatment opportunities for this group of offenders, thinking that punishment and deterrence are more appropriate (US Dept. of Justice, p.4).
The typical atmosphere in the usual prison tends to aggravate the problem of most sex offenders. The secrecy, negative social interactions, poor self-esteem, denigrating attitudes toward women, and deviant sexual arousal are usually reinforced in prison.
Despite the criticism, without treatment, sex offenders are highly likely to re-offend. The statistical data suggests that the recidivism rate of untreated offenders is about 60 percent, while recidivism among those who have been treated is about 15 to 20 percent. Therefore, it is in the interest of society to protect potential victims by treating sex offenders.
Treatment is not a cure for sex offenders, but successful treatment does reduce the likelihood of recidivism. It does not permanently eliminate the attraction of deviant sexual acts for sex offenders, who are always at risk of repeating their deviant behavior. But, only through treatment can the offender learn to control their behavior. The sex offender must use what they learn in treatment to maintain self-control over their behavior. It can help them to recognize the situations that increase their likelihood of re-offending, and teach them techniques to control their behavior in these situations.
Kaufman, et al. (1998) discusses factors that influence sexual offender�s modus operandi, including an examination of victim-offender relatedness and age. They say that the majority of research literature in this area has focused mainly on adult offenders, and offers only preliminary understanding of sexual- offending process. The general findings indicate that it may be useful to describe offense patterns based on specific variables, such as relationship of the victim to the offender. For example, Faller (1989) found that intrafamilial offenders with close relationships to victims, such as biological and stepfathers abuse their victims more often and for a longer duration of time than do intrafamilial offenders of more distant relations, such as noncustodial fathers, or other relatives.
The purpose of the Kaufman et al. (1998) study was to investigate and contrast the modus operandi (MO) of key subgroups of sexual offenders in an effort to increase the understanding of the behavioral process associated with sex offending. Their findings support the assertion that offender age group (i.e.
adolescent vs. adult) as well as victim / offender relatedness maintain victim silence following the onset of sex abuse. The study found that adolescent offenders consistently reported using MO strategies with greater frequency than did their adult counterparts. Adults larger physical size as well as their inherent power, social or parental may reduce their need to engage in MO strategies. The impact of offender / victim relatedness was found to have a major impact on some MO dimensions. The intrafamilial offender reported the use of gifts to gain victim compliance in sexual activities more than did extrafamilial offenders. They may use gifts to maintain their relationships with victims as well as to obtain compliance in sexual activities. Extrafamilial offenders said they gave victims alcohol and drugs more than did their intrafamilial counterparts to gain compliance in sexual activities. The study suggests some prevention programs conveying simple messages (e.g., �Say no, run, and tell�) are unlikely to lead to a reduction in sex offenses. Prevention must look at the subtle nature of the grooming process (i.e., including the involvement of prosocial behaviors), the reality that most offenders are known to the victim, and the impact of key subgroup factors (e.g., offender age and relationship to the victim) on the offenders modus operandi.
Some sex offenders cannot be treated successfully, such as those with lifelong histories of antisocial acts are not likely to benefit from treatment. Also very violent and sadistic offenders, sociopathic offenders with no empathy, and those not motivated for treatment are typically impossible to treat. Offenders with the best prognosis for treatment have committed few sex crimes, having little history of Alcohol and other Drug dependence, are not mentally ill, and are of normal intelligence can benefit from treatment. Clearly those with a mental illness, or who are under the influence of mind altering drugs or who have less that a seventh grade education cannot possible benefit from a cognitive behavioral treatment program that requires the ability to comprehend and think on a level to overcome thinking errors, cognitive distortions, and other problems.
The Administrator�s Overview, says that it is difficult to determine if sex offender treatment programs in correctional institutions have been successful by reducing recidivism because experimentally based data is rare, and different treatment programs collected data in different ways and tracked divergent groups of sex offenders without the use of classical experimental design (US Dept. of Justice, p.5). Also they say that recidivism data may vary because different definitions of recidivism exist. They do say that these problems should be resolved over the years to come, due to the improvements in keeping reliable outcome data for programs.
The approaches to assessment and treatment of sex offenders must include the following techniques to identify sex offender treatment needs. Techniques used to assess sex offenders include clinical interviews, self-reporting, psychological tests, questionnaires, and physiological methods, such as use of the plethysmograph to measure deviant sexual arousal.
The following are important types of information that is used to assess candidates for sex offender treatment programs:
1) Nature of the offense - level of violence; 2) Characteristics of the victim - age, gender.
3) Circumstances of the offense - AOD use, presence of stress, or psychological state such as depression; 4) Criminal history - career criminals and those with antisocial personalities usually do not respond to sex offender treatment; 5) Development history - nature of the offenders relationship with his parents and siblings, especially information on abuse, neglect, parental death or abandonment, methods of discipline, family sexual behavior, and the adequacy of parental role models. 6) Educational, social, and sexual history; 7) Inhibiting beliefs - sex offenders are sometimes from backgrounds that have instilled repressive sexual attitudes and a fear of adult sexuality; 8) Level of anger - anger serves as the main motivation for many sex crimes, especially rapists; 9) Acceptance of responsibility - offenders who accept responsibility for their actions are more likely to be successfully treated; 10) Ability to empathize - sex offenders who can empathize with their victims are better candidates for treatment; 11) Awareness of emotions - sex offenders are often not aware of their emotions, or unable to express, their feelings; 12) Cognitive distortions - sex offenders usually blame their victims or have distorted notions about sex.
13) Degree of sexual arousal to deviant stimuli - must be considered in relation to degree of arousal to appropriate stimuli to non-deviant sexual behavior.
All of the above information can not only identify those persons most likely to benefit from treatment, but also help to identify specific areas that need to be targeted for intervention and treatment ( US Dept. of Justice, p.7-8).
Howard E. Barbaree�s article, discusses the assessment and treatment outcomes of sex offenders that use denial and minimization to not accept responsibility. Denial is usually seen as a main impediment to successful therapy and as a consequence, most treatment programs exclude offenders who deny their offense. The offender use denial to conclude that he has no problems and that there is no reason for him to be treated, even if he admits to the offense, he may history the truth by minimizing the frequency severity and variety of his criminal sexual behavior. He found that in a nonrandom survey, 114 incarcerated rapists were divided into those that admitted to the offense for which they had been convicted (41% and those who denied it (59%). Also both groups presented justifications that were used to support their denial or to minimize responsibility for the offense. They blamed the victim, by saying she had a bad sexual reputation, an by saying they it was alcohol an drugs that caused them to do it. Also some blamed a bad childhood. Denials and distortions weakens both the accurate assessment and the effective treatment of sex offenders. Therapists depend on offenders to provide truthful descriptions of the events that lead of to their offenses to help determine what behaviors need to be targeted in therapy. Denial and minimization is the results of a psychological process involving distortions, mistaken attributions, rationalization, and selective attention and memory, which helps the offender avoid blame and responsibility for their actions. They recommend that offenders not be excluded from treatment due to denial and minimization, because such cognition�s can be amenable through treatment and should be the first stage of treatment, to increase motivation for treatment and set the stage for further assessment and treatment (Barbaree).
Nancy Howard and Rick Caslin (1999) says that cognitive training and not excuses is what sex offenders need to avoid recidivism. Sex offenders often show thinking errors and rationalizations to justify their actions and avoid accepting responsibility for their actions. Sex offenders used several defensive mechanisms, such as rationalization, minimization, intellectualization, and denial to avoid the truth and reality. They may feel guilty or ashamed of their actions, but want to hide it instead of accepting responsibility. An essential element of any sex offender that works, must be to challenge an offender�s thinking errors to help the offender learn responsible, non-criminal behavior. The use of thinking journals or logs of their daily thinking can be used to help them and the treatment provider identify thinking errors and become aware of how often they make them. Offenders should assist one another in recognizing thinking errors. This will help the offender to have a better decision making process, and reduce their risk of recidivism (Howard & Caslin).
Sex offender treatment can be treated by professionals from various disciplines, such as rehabilitation counselors, social workers, psychologists, criminologists, and educators. Also correctional officers, counselors, and caseworkers can be trained to facilitate group therapy and teach modules to sex offenders. Also inmates are expected to be active participants in the group process, and can assist in providing certain treatment techniques under the supervision of the treatment provider.
The kind of personality of the treatment provider that works best has the ability to work in a group setting. They are confrontative in a non-defensive proactive way and have an empathetic and caring attitude. They are comfortable with their sexuality. They must maintain a professional relationship with the offender. They must not be influenced by their personal bias, and be objective with sex offenders whose behavior may be viewed as personally repugnant. Also if the counselor has been sexually victimized themselves, must successfully resolve their own personal issues before they can best interact effectively with sex offenders.
Gerber (1995) article discusses counter-transference in working with sex offenders to help treatment providers recognize their reactions to the male sex offender. Professional working with male sex offenders in treatment programs must work to enhance self-knowledge in order to protect their clients from personal bias. Polson & McCullom (1995) article examined therapists feelings toward sexual abuse offenders and the offenders� perceptions of caring on the part of the therapist. Therapists working with offenders should periodically assess the family member caring for the offender as well.
If it is possible, male-female teams should be used to conduct group sessions. The advantages to this approach is as follows: 1) A positive male role model can demonstrate correct non-deviant social skills and attitudes toward women; 2) A positive female role model can help the offender practice social skills, as well as work through anger, power, and other issues;
3) The male-female team can model appropriate interactions, conflict resolution, and non-sexual relationships (US Dept. of Justice, p.8-9).
Gordon et al. (1990) article dealing with Canada, shows that there is a need the match risk and needs of sex offenders to give them treatment, since only one quarter of sex offenders in Canada received any treatment. They say that even if treatment is shown to reduce recidivism, some sex offenders may have less a need for specialized and intensive treatment. Also that some can be provided treatment after their incarceration ends. They say that the ones that need treatment most of all is those with previous sex offenses, since they are the most high risk offenders. Treatment for such offenders reduced the rate of sexual reconviction by 37%, than those with no treatment.
They recommend the triage approach to classifying risk and need according to level of priority to more efficiently use limited resources. They say that pedophiles and more violent rapists will be prime candidates for treatment in the Regional Psychiatric Center, while other rapists will be treated at Bowden, and most incest offenders in community treatment programs. They say that each type of sex offender should be treated with the same type of offender in a treatment setting that has the specific assessment and treatment procedures to meet their particular needs (Ibid).
Since, sexual deviance is a complex behavior, several treatment approaches are usually needed to meet provide the best treatment possible. The following is a summary of treatment techniques used by most correctional sex offender treatment programs. Some use all these techniques, while others use only a few. All of these approaches are described in greater detail in A Practitioner�s Guide to Treating the Incarcerated Male Sex Offender.
Most treatment programs include both group and individual therapy. But individual therapy is not seen as effective as group therapy because of the denial and secrecy that are characteristic of many sex offenders. Group therapy lets the offender realize that his behavior is not unique, and promotes honest non-defensive feedback from other offenders, and can help motivate a person to change. It is also more cost effective than individual treatment. Group therapy teaches the offender to develop empathy for the victim. It helps the offender deal with feelings about their own past abuse or problems. It encourages the offender to work with his family members that can also help him upon his release from prison. It teaches him about the individuals cycle of sexual assault by recognizing the situations, emotional, cognitive, and behavioral patterns that lead to deviant behavior, as well as techniques to intervene in this cycle.
Most treatment programs include psycho-educational modules are effective at addressing social and interpersonal deficits in offenders. It should include introductory modules that discuss how men become sex offenders and what they must do to change. The psycho-educational modules can be a cost effective way of teaching sex offenders basic information, and to test their motivation to change. In the early part of treatment the authority and credibility of the staff that teaches these modules are established. They should also learn about the following: 1) Drug and Alcohol abuse; 2) Criminal thinking errors; 3) Victim empathy and awareness; 4) Deviant sexual acting out cycle; 4) Assertiveness training; 5) Social skills training; 6) Stress management;
7) Human sexuality.
The Behavioral Techniques / Penile Plethysmograph is used to treat sex offenders, who have deviant sexual arousal. It is believed that for any long term success for sex offenders, there must be a reduction of deviant sexual arousal, along with indications of adequate levels of correct sexual arousal. The Penile Plethysmograph is the most common device used to assess both deviant and appropriate sexual arousal by directly measuring penile erection in response to the presentation of audio tapes or picture slides depicting sexually explicit scenes. It consists of a gauge or transducer that the offender attaches to their penis, and measures changes in the circumference of the penis, in response to different sexual stimuli presented. These changes are recorded on a strip chart, giving the clinician a record of the persons response to each sexual stimulus. It lets the counselor and other authorities know the sexual interests of sex offenders, such as if they are interested in deviant sexual acts. This information can be used by the treatment provider to provide behavioral treatment to help the sex offender change his sexual interests from deviant to appropriate consenting acts (US Dept. of Justice, p.10-11).
Miner, et al. (1995) article discusses a voluntary inpatient sex offender treatment program in which, 154 subjects were tested using penile plethysmography. Their research showed child molesters (male victims) showed a more offense related arousal profile than either child molesters (female victims) or rapists.
The behavioral techniques listed below are used to alter deviant sexual arousal patterns in an attempt to reduce the potential for future sexual victimization. There is two main types of techniques, those used to decrease deviant arousal and those used to increase appropriate sexual arousal. Some of the behavioral changing techniques listed bellow are controversial to some, but trained professionals are expected to use these techniques ethically and legally. Also it is ethical and legal as long as the sex offender gives informed consent for such techniques. The offender may be expected to audio tape exercises that will be randomly reviewed by the proper authorities.
The techniques for reducing deviant arousal are as follows:
The covert sensitization techniques has been used for a couple of decades in the treating of those with various disorders, such as obesity, alcoholism, and smoking. The sex offender is expected to fantasize about a highly arousing deviant sexual scene and then imagine a highly negative scene, which over time is expected to reduce the strength of the deviant sexual fantasy. The scenes are designed by the sex offender to be the most arousing to that particular person, such as a pedophile having a deviant fantasy about a child. The deviant fantasy details the types of situations and victims that are most sexually arousing to the offender. The negative scenes would include images that are frightening, nauseating, sickening, and stress-producing.
The assisted covert sensitization method is about the same as covert sensitization, but is used when the offender was not able to generate negative scenes capable of reducing sexual arousal. The offender must therefore pair a noxious odor with a arousing deviant sexual fantasy.
The olfactory conditioning method includes the presentation of slides, audio tapes, or videos of sexually deviant scenes, followed by the presentation of a noxious odor by the clinician.
The satiation therapy technique has two approaches: masturbatory and verbal. The masturbation therapy approach involves the offender masturbating to ejaculation in response to appropriate sexual fantasies, and then immediately continuing to masturbate even after it becomes discomforting to deviant fantasies. The verbal satiation method involves the sex offender repeatedly verbalizing deviant fantasies for at least 30 minutes on at least three occasions per week. These two approaches have been found to reduce deviant sexual arousal.
The aversive behavioral rehearsal is a strong technique involving the offender acting out his sexual offense in the presence of the therapy group. They use act their sex crime out on a mannequin. The session is videotaped and later viewed by the offender. This lets the sex offender see what he looks like and sounds like while sexually abusing a victim. Since it is deeply intrusive and has potentially negative side effects, it is not in common use in correction programs.
The techniques used to increase appropriate sexual arousal in an institutional program is basically limited to only one recognized method. The method used to increase appropriate, non deviant sexual arousal is through mastubatory exercises. It encourages masturbation to appropriate sexual fantasies. Early on the offender will probably indicate little or no arousal to appropriate sexual stimuli. This will require the technique of masturbating to deviant stimuli and shifting to appropriate sexual stimuli at the high point of sexual arousal. It is expected that the sex offender will eventual not be sexually aroused by deviant stimuli, and be sexually aroused by a fantasy with socially accepted sexual acts and partners (US Dept. of Justice, p.12-13).
Cognitive restructuring treatment is need by sex offenders, who use distorted patterns of thinking, or cognition, that all them to start and then rationalize deviant behavior. Treatment programs that work must require the offender to participate in psycho-educational modules on thinking errors or to keep daily journals, which are examined by the counselor or members of the group. The goal is to recognize irresponsible and deviant patterns of thinking and help the sex offender to learn and practice alternative thinking patterns that will reduce the likelihood of re-offending.
The reasons why sex offenders should be treated is to protect public safety, help victims, and is more cost effective than incarceration, and additional victims. The majority of sex offenders will eventually return to the community. Therefore, it is important that community correctional programs use treatment as a way to supervise offenders and increase public safety. Also by treating offenders they may be more likely to make restitution efforts and help in the victim treatment process. Treatment is cost effective, for example a 1% reduction in recidivism pays for the treatment of all treated sex offenders by reducing investigations, trials, incarceration, victims, and supervision (CSOT- Management of Sex Offenders).
The treatment approach to sex offenders is different from traditional psychotherapy because it is more confrontive, directive, structured and focused. Also unlike some treatment programs, information is hared with other treatment team members, including justice officials. Public safety must always come before counselor / client confidentiality. The sex offender must learn to accept accountability for their behavior and face the consequences of their actions on their innocent victims and society as a whole. The sex offender treatment promotes specialized community supervision for paroled and probated sex offenders by monitoring high risk behavior (Ibid).
Treatment is a powerful way to help prevent future sexual offenses. Prevention can be better addressed by using what is learned in treatment about the offenders risk level to potentially re-offend.
Treatment is sufficient to reduce a sex offenders risk to the community. Risk reduction can be objectively measured by longitudinal studies of sex offenders and identifying their rates of re-offending. An effective treatment program should be able to reduce the recidivism of its clients, compared to similar offenders with no treatment. As discussed at the start of this paper, Martinson�s review of treatment programs in the 1970�s raised questions about the effectiveness of treatment. But studies conducted since that time have examined programs using more state of the art treatment techniques and results are indicative of some reduction in recidivism for the groups of offenders receiving treatment (ATSA, p.3).
In Canada, the Nova Scotia Sexual Behavior Clinic offered group and individual cognitive behavioral treatment for sex offenders. Program participants undergone extensive psychological testing before and after treatment in this community based program. Test results showed major improvements in those behaviors, attitudes and cognitive distortions targeted for change, and no significant difference in untargeted behavior. Also contacts with enforcement agencies, the courts and the Correctional Service of Canada indicated no new offenses at the end of the seven month contract period among 16 treated offenders. Three offenders who had been assessed as high risk but who were not treated in the program did re-offend. The clinic also provided intensive training and education to parole officers and Correctional Service of Canada administrators who worked with sexual offenders. The key elements of the clinic that appear to be successful is their careful assessment of offenders, the linking of assessment and treatment, the interaction of professional staff and other agencies in the delivery of service, the ongoing evaluation of change, and intervention strategies such as referrals to other health professionals (Konopasky, et al., 1991).
Kevin Graham�s details a program for sex offenders offered at a minimum security Westmorland Institution in Canada, that developed from the sexual addiction model. It is a program that is eclectic, borrowing form cognitive behavioral, psycho-dynamic and spiritual domains to treat the sex offender. It began as a pilot program in February 1988 for male sex offenders, and as of January 1991 had approximately 100 sex offenders who had received treatment in the program. It consisted of 15 modules delivered over 15 weeks, with the offender participation in 3 hours of group therapy and one hour of individual treatment per week. They are often made up of mixed offenders, both rapists and child molesters, and are led by a female-male co-therapist team. At the end of the program, the offender has access to follow-up care offered at the institution at six-week intervals, and often are open to family members. Graham discuss the issue of offender abuse as a child. The Westmorland program found a high level of abuse, with 51% of the offenders reporting having been physically abused, and 60% reporting sexual abuse as a child. In about three of cases (74%), the abuser was male, usually a father or father substitute, and the remaining 26% were abused by females, either the mother, older female relatives or baby-sitters. Graham raises this issue because he believes that the way the offender deals with their own abuse is related to their subsequent offending. He says sex offenders use repression or dissociation as a defense and as a means to cope with their traumatic sex abuse. They tend to be more withdrawn and alienated in their relationships with others and themselves. They tend to remove the sex offender from the experience of both other and self. Looking at the offenders own victimization can help him began to recover the repressed emotions associated with the abuse. Also one they are able to relate to their own experiences, the sex offender may be more able to relate to the experiences of their victims.
Eisenmen (1991) article said that their is not only the need to have treatment of sex offenders in prison, but also in the real world environment, where their is an urgent need for monitoring the sex offender after release from incarceration and post-confinement treatment similar to that provided by Alcoholics Anonymous.
In Texas high risk sex offenders that are paroled, have contact requirements to meet face to face every month at least three times with their probation officer. The sex offender continues to receive therapy after prison, such as to attend therapy once a week and pay for it if they can afford it. Studies indicate that sex offenders placed on specialized caseloads have lower rates of recidivism. The caseload in Texas is part of a Therapeutic Intervention Model, that emphasizes the treatment of disorders that cause criminal behavior. Sex offender caseload officers receive training in identification, assessment, and supervision of sex offenders as well as the development of therapeutic resources (NIC- High Risk Offenders in the Community).
William L. Marshall & A. Eccles article says that their is a great value for community treatment programs for released sex offenders. The say that sex offenders require both reassessment and treatment once they are released from institutions. The data shows that support for the idea that adding these post-release components- reassessment and treatment in the community - to the overall treatment approach for incarcerated sex offenders reduces their subsequent risk of recidivism. Relapse prevention helps the offender avoid risks and cope effectively when some degree of risk is unavoidable.
The National Institute of Corrections Prison division done a national survey of correctional agencies on the issue of Sexually Violent Offender Legislation. The goal was to find out the number of states who had statutes that provided for the civil commitment of convicted sex offenders upon their release from incarceration. The US Supreme Court decision in State of Kansas vs. Leroy Hendricks upheld the right of a state to engage in a civil commitment proceeding based on a �mental abnormality� or �personality disorder� when the person is �likely to engage in predatory acts of sexual violence.� The significance of the decision was that the facts that there is no requirement to show mental illness, nor a finding of double jeopardy when the civil commitment occurs upon the release from incarceration. The NIC faxed the survey instructions to departments of corrections nationwide on September 3 and 4, 1997. The completed surveys were returned by 49 states and the District of Columbia. The results show a great legislative interest in the issue. The results find that 19 states indicated that there were no current statutes and no statutes were pending or introduced. Of the remaining survey respondents, 17 indicated that legislation had been previously introduced or was pending and 12 states had current statutes. Iowa and Maine had laws that were repealed, but both had new bills introduced. The Ohio statute provides for a �modified life sentence� rather than civil commitment. Most survey respondents that have statutes said that the Departments of Mental Health or Departments of Human Services were the agencies to which offenders got
committed. Their are 395 offenders now under civil commitment and at least an additional 521 currently in process of being committed as of September 1997 (NIC).
The Council of Sex Offender Treatment, Texas Department of Health, makes the following recommendations regarding the issue of civil commitment of sex offenders. They say that the concern over recidivism of sex offenders, the Council recommends the state of Texas set up a system that is an overall revamping of how sex offenders are managed within the system from conviction to release. They say that civil commitment is the answer that many states are making to the issue of short sentences and no guarantees of sex offender rehabilitation. They say that most of the states do not provide sex offender treatment to incarcerated sex offenders. They say that in order to protect the public from a sexual predator, civil commitment has been developed. The propose a definition for sexually violent predator, as follows: Is the person who has been convicted or charged with a sexually violent offense and who suffers from a mental impairment or personality disorder which makes it substantially probable the person will engage in further acts of sexual violence if not civilly committed to undergo comprehensive treatment? They say that the definition should include any person who has been convicted of or charged with a sexually violent offense, and who suffers from a mental impairment, or personality disorder, which makes it substantially probable (51% or more chance of re-offending) in further acts of sexual violence if not civilly committed to undergo comprehensive treatment (CSOT- Proposed Definition).
For those sex offenders that are released into the public, the federal government has beefed up action against sexual predators in May 1997, when President Clinton signed the Jacob Wetterling Crimes against Children and Sexually Violent Offender Registration Act, which links establishment of a sex offender warning system to federal anti-crime funding. The new law went into effect in September of 1997, and requires all states to notify communities of the presence of sex offenders. The federal effort is modeled on New Jersey�s Megan�s Law, spurred by the rape and murder of a 7 year old girl by a paroled sex offender in 1994. It was a more a symbolic act of the federal government, since similar Megan�s laws are in effect in 45 states, and all 50 states have some form of sex offender registration. By mid-1998 only New Mexico did not have a community notification law, but did have one pending. Federal law now requires all 50 states to register offenders with state law enforcement, maintain a data bank of all sex offenders, require annual re-registration continuing for at least 10 years, and release information as necessary to protect the public (Anonymous, The New Federal Law). States like California has the offenders names on CD-Rom so any person can find out about a sex offender based on certain characteristics, such as hair color, current county location, age, and so on. Washington state actually puts names of offenders determined as having the highest risk for recidivism in local newspapers.
The Association for the Treatment of Sexual Abusers (ATSA) does not support or oppose community notification. But they believe that treatment should be the focal issue. They support education efforts directed at prevention of sexual abuse. They want community notification to strengthen, and not replace the social policy for preventing sexual abuse. They also think that only those that have the highest risk of recidivism should be included in community notification, and need to protect the identity of sexual abuse victims.
Pallone (1995) says that citizen attacks against sex offenders due to New Jersey�s Megan�s Law has dampened the enthusiasm for parole, and even for active participation in the treatment process that is a necessary prelude to parole. Also people with the same or similar names to sex offenders may suffer abuse in their communities based on the release of such information, such as the case of Raymond c. Weeks, 37 year old, that was confused with the real sex offender Raymond L. Weeks, 57 year old sex offender living in a near by town. The paper that ran the list of offender names in San Diego, California decided to get another paper that ran every day to say that the one man was not a offender and should not be harmed by the public. Journalists must decide whether to publish names, addresses, and pictures of offenders, knowing that the information could provoke hostility or panic in communities.
The community notification laws are popular, with a 1994 Gallop poll showing that 89 percent of adults favored laws requiring police to notify residents about sex offenders released from prison and living in their community (Pollone, 1995).
Beatty (1997) article says that community notification is the right thing to do, since sex offenders represent one of the most virulent threats to the safety of our nations kids. He says that before community notification the sex offender that gone back to the community was anonymous, which let them run free to consort with kids without parents or others knowing of the threat posed by such offenders. Beatty says that courts have rejected the challenges to community notification dealing with issues like public embarrassment, or right to privacy. He says that most laws only apply to repeat violent offenders and not to lesser sex crimes, which avoid the laws destroying the lives of those not a threat to the community. Also he says that only one percent of sex offenders became victims of vigilance acts of violence, due to community notification. The public puts the interests of their families ahead of the rights, and security of sex offenders, which is why community notification laws are so popular. But they do nothing to threat offenders, and if offenders are not treated, some relapses will definitely occur.
In November 1996, the National Institute of Corrections (NIC) participated in �Promoting Public Safety through the effective Management of Sex Offenders in the Community,� which was a summit, that brought together practitioners, academicians, researchers, and other experts in the sex offender management field, that encouraged participants to discuss the needs and challenges of those working with sex offenders. The Office of Justice Programs, State Justice Institute, and NIC designed and funded a Center for Sex Offender Management (CSOM) to operate by the Center for effictive Public Policy (CEPP) in collaboration with the American Probation and Parole Association (APPA). CSOM is a national project with the goal to support local jurisdictions in the effective management of sex offenders under supervision of probation, parole, and other community based agencies. They will provide the development of knowledge and its dissemination, the training and technical assistance needed by those in the field, and public education and assistance. They will also provide training sessions to address the knowledge, skills, and resources at all levels of a supervisory agency to ensure effective management of sex offenders in the community. It will address specific areas of concern to the personnel, such as community notification. The training participants willl be encouraged to take responsible action that will have the greatest impact in communities. They will also help jurisdictions tailor a developmental strategy to best meet their specific community needs.
Relapse prevention is another vital component of any treatment program. Sex offender relapse prevention was developed to help offenders learn to control their behavior over time and in different situations. Having offenders write an autobiography is an important step in helping them identify their own relapse process.
Learning about thinking errors can help sex offenders to change their behavior, but it cannot predict when a sex offender might aggressively act out. Risk factors or predictors for sexual offending, or those most likely to re-offend have been found to be the following:
1) prior sex offenses; 2) age at time of release; 3) victim gender; and 4) relationship to
victim. Hanson�s research showed that offenders tend to be at higher risk to re-offend if they have more than one offense and are younger than age 25, if the victim and offender were both male, and if the victim was a stranger to the offender (Hanson & Bussiere, 1996).
The Research and Statistics Branch of the Correctional Service of Canada provides a comprehensive statistical profile of federal sex offenders in Canada found that the recidivism rate of sex offenders is less than that of offenders in the general prison population. But sex offenders are more likely than offenders in the general to return to prison or to recidivate with a sex
offense. Also compared to all sex offenders, repeat sex offenders (those with a previous federal term for a sex offense) are more than twice as likely to commit further sex offenses, much more likely to violate conditional release conditions, and more likely to re-offend with a non-sexual offense.
A core goal of sex offender treatment is relapse prevention. Anechiarico (1998) article says the goal is to address needs of the offender: internal, self-management dimension, and the external, supervisory dimension. The internal dimension wants to teach offender to identify high risk situations that lead to sexually abusive behavior, and develop strategies to avoid or cope with high risk situations. The external dimension involves the help of parole and probation officers as well as a community network to monitor specific precursors to the offending behavior, creating a network of collateral contacts to assist the court officers in monitoring offenders� behavior, and developing a collaborative relationship with the therapist to reduce recidivism (Anechiarico).
Anenhiarico (1998) found that the offender needs to develop not only social skills, but also intimacy training. They must develop the capacity for intimacy to restore their self-esteem. They need to overcome their narcissism by experiencing an authentic mutual relationship. The experience in group therapy of being listened to and feeling understood is usually the beginning of an offender�s first intimate attachment. Two studies found that improvement in the low self-esteem of sex offenders was significantly correlated to a reduction in sexual deviant indices demonstrated in phallometric assessments (Marshall, 1996). The restoration of self-esteem through the experience of empathic connections with others reduces the need to restore self-esteem through narcissistic sexually exploitative behavior and can reduce recidivism in sex offenders (Anechiarico, 1998).
Pithers (1990) article says that mental health interventions are ineffective in changing sex offenders behavior, and that the treatment programs that work all address the following components: sexual arousal disorders, social competence, emotional management, victim empathy, and resolution of personal sexual victimization. He says that relapse prevention has gained increased recognition as one essential component to include in comprehensive treatment programs for sex offenders. He discuss the precursors to sexual aggression, such as emotions, fantasy, cognitive distortion, plan and act that leads to the sexual offense. Relapse prevention does reduce the likelihood of committing new offenses., with only 15% of rapists, and 3% of pedophiles having re-offending in a sex year follow up period, for those that were treated in the Vermont Treatment Program for Sexual Aggressors (Pithers, 1990).
The goal of relapse prevention is to help an offender recognize situations that increase the potential for relapse, and to help identify ways of controlling deviant behavior or avoiding high risk situations all together. For example, a pedophile, should not work with children, which would create a high risk situation that could increase the likelihood of recidivism. The sex offender must learn techniques to control his deviant behavior after he is released from a correctional or treatment institution. Bur various persons still have a responsibility to monitor the offender in the community, such as parole officers, mental health professionals, family members, and neighbors in his community to insure that the offender does not relapse. The offender must recognize his deviant cycle, or set of precursors that leads up to sex offenses. The offender must recognize their emotions, fantasies, cognitive distortions, plan, and act. The sex offender must avoid a high risk situation or risk lapse, such as buying pornography, having a fantasy about a child, that can lead to relapse. They must maintain control, and realize that they are responsible for their actions when they place themselves in high risk situations, and must used what they learned to intervene or avoid relapse. Also probation officers, counselors, and others must recognize an offenders pattern of relapse and intervene in a timely fashion to avoid relapse.
Community treatment and supervision is the main component of the essential final stage in an overall plan to reduce recidivism among convicted sex offenders. A graded and selective movement through the prison system is needed to optimize the offenders chance of
rehabilitation. Maximum and medium security institutions should provide treatment to sex offenders that are assessed as high risk. After they complete this treatment those offenders can be relocated to a less intense program in a minimum security setting along with those sex offenders designated as low risk. Lastly, those in minimum security programs that complete treatment, should be released into the community, either into a halfway house, or as part of a gradual release program that provides supervision and monitoring, depending on their risk to the community. If the offender has any problems at any one of these stages, they should quickly go back into a more secure setting to meet their specific needs. Several nations have already moved toward this approach, such as Canada, Britain, New Zealand, and some states in America, although implementation of this comprehensive response has not been fully achieved. The two main components to treating released sex offenders in the community is to correct those problems identified at community reassessment, and implementation and supervision of offenders relapse prevention program. Most relapse prevention training is best done in institutions, where risks factors and strategies for dealing with the offender can be made as part of the offenders post-release plan. The community treatment program can help the offender to effectively implement and if need, to modify the relapse prevention plan when confronted with problems in life (Marshall, & Eccles).
Marques et al. (1994) findings of a longitudinal outcome study of sex offender treatment found that those who received comprehensive relapse-prevention treatment were less likely to re-offend than those who received no treatment.
Pithers (1990) found that the advantages of relapse prevention over traditional treatment are as follows: 1) a more realistic therapeutic goal of control versus cure; 2) reliance on multiple rather than single sources of information about offender behavior; 3) integration of mental health and probation or parole professionals; and 4) definition of behavior maintenance as a continuum rather than an abstinence-relapse dichotomy. He says that relapse prevention holds considerable promise for reducing sex offender recidivism.
Marques (1999) article says the question of whether sex offender treatment works is the wrong question, since their is so many different kinds of sex offender treatment programs, with different approaches to the problem and different offenders with specific needs. The California�s Sex Offender Treatment and Evaluation Project (SOTEP), highlights several problems that are inherent in adequately determining if treatment works, because even its well designed study only offered a limited contribution to the empirical database on treatment effectiveness. It shows that the question �Does sex offender treatment work,� needs to be broken down into a number of more specific and useful questions. For example, a better question is what kinds of sex offenders benefit most from treatment. For example, if you exclude high risk sex offenders with a prior record of sex offenses, the data would show that treatment works. Also issues like if the offender is married must be considered, because those that are unmarried will be more likely to re-offend than married persons for certain crimes, such as female child molesters. Also data shows that rapists have a lower re-offense rate than those with no treatment. Marques (1999) says that the pattern for sex offenses is that offenders are at a fairly high risk for the first 3 years after release, then have a gradual decline in potential recidivism after that. Rapists that had treatment did not re-offend in the first year, while a majority of those with no treatment occurred during the first year. For the treated rapist the most highest risk for recidivism is during year three.
Marques (1999) says that treatment changes the offender in the following ways:
1. an increased sense of personal responsibility and decreased use of justifications for sexual deviance; 2. a decrease in deviant sexual interests; 3. an understanding of, and ability to apply, the basic concepts and techniques of relapse prevention; 4. an improved ability to identify their high risk situations; and 5. better skills in the areas of avoiding and coping with high-risk situations.
Marques (1999) found that those that benefited most from treatment were married, did not have a history of being physically abused as a child, and had been employed at the time of their offense.
The Alaska Department of Corrections article (1996) �Sex Offender Treatment Program: Initial Recidivism Executive Summary,� completed a study of sex offenders in treatment programs at Hiland MountainCenter during the period of 1987 to August of 1995. They found that treatment effect was clearly demonstrated that those receiving treatment had a lower recidivism rate than non-treated offenders. Also treatment at any level improved survival in the community without re-offense.
Clearly treatment is needed to reduce relapse, and to protect the public from future harm that is likely to result from those non-treated sex offenders that are a threat to society. Treatment can reduce recidivism, and make society a safer place for women and children. I believe that every sex offender should receive sex offender treatment to reduce their likelihood of recidivism, and to end the cycle of abuse that has destroyed to many families lives. Treatment is an obligation of the government to protect the public, and to ensure that those with disorders are treated to improve their quality of life, and to make society a better place.
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