Trends in Substance Abuse Treatment and Application for Sex Offender Treatment

Introduction

Interest in sex offenders and their treatment has been the subject of study since 1886 (Schwartz & Cellini, 1995). Since then, many changes have been made in the treatment of sex offenders. Current treatment for sex offenders includes: cognitive behavioral therapy, relapse prevention, behavior modification, harm-reduction, and self-regulation. Specifics in the type and time-frames of treatment are based on the program or clinicians approach, risk level, and community support available (Bumby, 2006). While there are many treatment options available, it is difficult to determine the success rates of these treatment methods. One study determined that out of 130 previously conducted studies on sex offender treatment, only 25 of these studies met the minimum quality control guidelines established for scientifically reliable research (Brockett, 2012).

While sex offender treatment has been compared to other methods of treating mental health issues, there is limited research available comparing sex offender treatment to the “lifelong” treatment model utilized in treatment for substance abuse. Treatment experts have identified a combination of group psychotherapy and a twelve-step program as the “gold standard” in substance use treatment (Korshak & Delboy, 2013). Currently, twelve-step programs provide fellowship, resources, and support. This model was developed by Alcoholics Anonymous (AA), which originated in 1935. AA currently has two million members’ worldwide and 200,000 weekly meetings (Galanter, 2014).

According to the rational model, policy makers seek to gather and examine all relative data, and after analyzing all the alternatives, construct a plan.  This model is sometimes called “means-end” thinking, and is built on the premise that problems can be solved by examining and choosing the best method to reach a goal. Often the solution that is deemed the “best” is based on cost effectiveness and maximum total welfare (Stone, 2011).

On the surface, this model appears to be the most logical. However, humans are not rational decision makers. This phenomenon can be described as the “human problem”, which asserts that humans are never truly rational because of personal bias, emotions, and world views we are never able to make purely rational decisions (Clemons & McBeth, 2009). An example of policy making that is not considered “rational” are policies surrounding sex offenders and their treatment.

In an effort to construct a more rational approach to treating sex offenders, I will be comparing and contrasting the models of treatment used for sex offenders and substance users and offering alternatives to current treatment models used for sex offenders.

 

Policy Implications

There are currently 747,408 registered sex offenders in the United States (National Center for Missing & Exploited Children, 2012). Since 1994, we have required that these offenders make their address, crime, photo, and physical description public record, and thus easily accessible to the general population.

The Jacob Wetterling Crimes Against Children and Sexually Violent Offender Registration Act of 1994 required that offenders of sex crimes against children be registered with law enforcement after release from confinement (Comartin, Kernsmith, & Miles, 2010). Subsequently, Megan’s Law of 1996 stipulated that this registry is made available to the public and included community notification policies. Other legislation, such as The Pam Lychner Sexual Offender Tracking and Identification Act (1996) and the Adam Walsh Child Protection and Safety Act (2006), increased registration periods for sex offenders and made community notification rules more stringent (Wagner, 2011). By invading the privacy of a sex offender, the general population feels safe. However, studies have shown that allowing public access to the sex offender registry discourages compliance with the registry (Murphy, Fedoroff, & Martineau, 2009).

The passage of these, and other pieces of legislation, has had a negative impact on registered sex offenders. Increasingly, research has shown that sex offenders have been plagued by problematic housing restrictions (Levenson & Cotter, 2005), harassment by the communities in which they live (Pogrebin, 2004), lack of accessibility to forms of public assistance (Travis, 2002), and employment (Wagner, 2011). Additionally, research has illustrated that perceptions and attitudes towards sex offenders are overwhelmingly negative (Olver & Barlow, 2010; Elbogen, Patry, & Scalora, 2003), with one study finding that participants thought it “acceptable” for sex offenders to be physically injured (Wagner, 2011, p. 267).

Some have suggested that the media has assisted in reinforcing myths and stereotypes about sex offenders by over-generalizing them as sexual predators (Katz-Schiavone, Levenson, & Ackerman, 2008). Morrison (2007) aptly summarized that much of the public thinks that registered sex offenders are “incurable, resistant to treatment, and all but certain to offend again” (p. 24). Perhaps not surprisingly, studies examining the public perceptions of sex offenders have found that stereotypes are often not congruent with accurate information related to this population (Church, Wakeman, Miller, Clements & Sun, 2008). In an ideal world, the media would portray objectivity, truth, balance, and accuracy. Unfortunately, there is little evidence to show that the media can live up to these expectations. Regardless of the apparent bias of the media, the general public continues to regard news stories as the “political watchdogs” or “guardians of the public interest” (Schnell, 2001, p. 186).

In the case of Jacob Wetterling and Megan Kanka, there was significant media attention which led to increased emotions surrounding these events. These news outlets play a vital role in drawing attention to political issues and deciding what is “news” and who is “newsworthy.” This attention is a powerful weapon in creating public interest in an issue and can be crucial in generating momentum behind policy issues. Altogether, “some scholars find that the media exert substantial influence in deciding what problems will be given attention and what problems will be ignored” (Oswald, 1994).

Media coverage is also an essential part of bringing the issues to the attention of policy makers. Some problems, no matter how large, are unable to generate enough attention, while other crises events generate enough focus and public support to be placed on the policy agenda. Robinson (1999) calls this phenomenon the “CNN effect”. The basis of the “CNN effect” is that news outlets and media can shape policy. Some argue that political elites influence the media to report stories in a way that is favorable to the political agenda. Alternatively, media reports weigh heavily on emotional response and this emotional response impacts voters and lobbyist (Robinson, 1999), and due to the irrational nature of humans, these emotions play a large part in irrational policymaking.

While the majority of citizens desire to be active political participants, studies show that the majority of the population is not consistent with political participation and is often uninformed. Additionally, even when individuals attempt to be more engaged in the democratic practices like attending political events, voting or researching legislation, they are often swayed by the media. The issue of sexual violence is clearly and easily understood by the general public, and requires no expertise on the subject. This issue is also one that is closely followed by the mass public and, like many political issues, is highly emotionally fueled and fear driven. Also, this issue has the potential to polarize interest groups, who play a dynamic role in effecting policy changes. These specialized groups attempt to influence policy changes in two major ways: insider strategies, and outsider strategies. Insider strategies appeal to our emotions by providing personal stories and expert testimony to influence legislation. Alternatively, outsider strategies attempt to enlarge the scope of conflict and political discourse. Often, this includes media coverage of the issue which may or may not be accurate and can be easily manipulated by the media outlets (Schnell, 2001).

To influence true change, it is vital for policy makers to strive towards a common goal, and work together to provide solutions to current issues. One of the ways to encourage alliances among policy makers is to merge disagreements into a more common goal (Stone, 2011). Reducing the prevalence of sexual violence is a goal I believe we can all agree on. However, the approach to achieving this goal is the subject of much debate. On one end of the spectrum is the punitive approach to managing this problem, and at the other end we have the treatment and preventative approach. While both methodologies have their merits, it is important to assess their individual feasibility.

 

Background of Sex Offender Treatment

Interest in sex offenders first peaked in 1886 with the release of Psychopathia Sexualis: eine Klinisch-Forensische Studie (Sexual Psychopathy: A Clinical-Forensic Study). This work by Richard von Krafft-Ebing proposed consideration of the mental state of sex criminals in legal judgments of their crimes. During its time, it became the leading textual authority on sexual pathology. Works by Krafft-Ebing depicted all sex offenders as pedophiles and demented strangers. After this work, Freud (1893) and Schrenck-Notzing (1895) published pioneer works in the area on sexual abnormalities (Schwartz, & Cellini, 1995).

In the 1930’s through the 1960’s, the view of sexually deviant behavior was thought to be a product of a mental disorder and that the offenders were too “sick” to be punished. As a result, the sexual psychopath laws were created as alternatives to the criminal justice system. Sex offenders were involuntarily committed to state hospitals for as long as the individual was deemed a threat to society. The purpose was to cure sex offenders in a shorter time than they would serve in prisons, and to protect society against the sex offender population (American Psychiatric Association, 1999).

In 1954, California’s Atascadero State Hospital became the leader in inpatient sex offender treatment, with the primary treatment method being assertion training. The thought that sexual offenders have difficulty relating appropriately to adults led to regression techniques which were believed to meet their sexual needs. This treatment was conducted by psychiatric technicians rather than professionally trained clinicians and did not have a consistent treatment philosophy or protocol.

In 1981, Theodore Frank was released from Atascadero State Hospital. Within three months of his release Fank kidnapped and murdered a two-year-old girl who was playing in her front yard. This crime unleashed a public outcry against the inpatient treatment model for sex offenders, state legislature quickly declared the inpatient treatment model a failure and repealed the sexual psychopath laws. The view that sexual deviance was connected to mental disorder was discredited, and by 1990, all but twelve states had repealed their sexual psychopath laws (California Coalition on Sexual Offending, 2009; Schwartz, & Cellini, 1995).

The 1990’s marked a turn in the management of sex offenders as treatment programs were transferred from hospitals to prisons. Washington became the first state to recognize sex offender treatment as a mental health profession and to begin the certification of sex offender treatment providers. The Association for the Behavioral Treatment of Sexual Abusers, now known as the Association for the Treatment of Sexual Abusers, was formed and became the national organization for sex offender treatment providers around the world (Schwartz, & Cellini, 1995).

Recently treatment for sex offenders has attempted to implement a more holistic approach. These methods utilize a multitude of approaches including; cognitive behavioral therapy, relapse prevention, behavior modification, harm-reduction, and self-regulation (Bumby, 2006).

 

Background of Addictions Treatment

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), approximately 8.2% of Americans meet the criteria for a substance use disorder (Bergman, Kelly, Nargiso, & McKowen, 2016).

One of the most prevalent approaches to treating substance use disorders is the Cognitive Behavioral Model. This model encourages mastery over one’s environment and internal experience by identifying triggers and how this influences their internal experiences and external reactions. This method also teaches assertiveness skills, identification, and avoidance of high-risk people, places and situations, with ways to examine positive and negative consequences of continued substance use. Using this model, therapists and clients work together using problem solving and communication skills to identify, construct and implement a treatment intervention plan (Bergman, Kelly, Nargiso, & McKowen, 2016).

An example of a behaviorally based intervention is AA’s 12-step program. This intervention encourages belief in a Higher Power, recognition of helplessness, the importance of sustained motivation with social support, and complete abstinence. These philosophies have been deeply rooted in substance use treatment in the US. However, the 12-step program has been subjected to criticism when compared to other evidence-based practices due to the reliance on internal rather than external motivators.

Opposite the behavioral model is the method of medically assisted treatment. This model attests that substance use is an illness that is largely outside of individual control and should be treated in the same manner as other medical illnesses.  The US Food and Drug Administration has approved several medications to facilitate medically assisted treatment starting with the approval of disulfiram in 1951. Other approved medications include methadone, acamprosate, naltrexone, and buprenorphine. However, medically assisted treatment does not indicate isolation from therapeutic treatment methods. Ideally, medically assisted treatment would be utilized in conjunction with other psychosocial treatments. However, due to its reliance on chemicals, the medically assisted treatment method could be seen as adversative to behavioral and abstinence-based models (Edmond, Aletraris, Paino, & Roman, 2015).

While abstinence is a large proponent of many substance use treatments, lifelong abstinence is not necessary. In one study of alcoholism recovery, it was discovered that three years of abstinence increased the likelihood of a stable recovery. Another study suggested that five years of abstinence from any substance should be standard practice and that after five years of abstinence the risk of relapse is no longer greater than that of the general population. While the precise duration of abstinence from any substance is still a topic of debate, it has been indicated as an essential part of the recovery process (DuPont, 2015).

In the past, there was a significant stigma attached to treatment for substance abusers. More recently this stigma has been reduced, and access to affordable treatment services has increased. Contributions to these changes can be partially attributed to the implementation of multiple health care reforms within the federal, state and private sectors. Examples of this are, the Affordable Care Act (ACA) and the Mental Health Parity and Addiction Equity Act (Parity Act). These pieces of legislation require health insurers to cover, and health care organizations to provide, prevention, screening, brief interventions and treatment for substance use disorders. Due to the expansion provided by the ACA, an estimated 1.6 million Americans with substance use disorders have gained insurance coverage in Medicaid expansion states (Abraham, et al, 2017).

Together, the Affordable Care Act and the Mental Health Parity and Addiction Equity Act assure that care for substance users has the comparable type, range and duration of services as other medical conditions. Additionally, this legislation mandates that financial burden for patients seeking substance use treatment be comparable to patients seeking treatment for an equivalent physical illness.  Illnesses considered “comparable” to addiction are acquired, chronic illnesses. Equally important, this legislation has mandated accessible care delivery such as treatment available within mainstream health care settings including primary care (DuPont, 2015). Implementation of the ACA and its expansion to substance use disorders is still new, and as such, we are unable to determine how it has impacted long-term changes in substance use treatment.

 

Comparison of Treatment Models

Substance use treatment and sex offender treatment have similar backgrounds in that they both were previously addressed in a punitive manner. More recently, access to substance use treatment has been addressed, and these treatment options have become more affordable with the passage of the ACA. While there are medically assisted options for both substance use and sex offender treatment, this option is deemed more acceptable for substance use than for sex offender treatment. Both models utilize group treatment, however, in the case of sex offender treatment these groups are time limited and follow a strict curriculum. Groups for substance treatment utilize an “open-ended” model which allows for participants to be in different stages of recovery, this allows for better peer accountability. Another significant difference in sex offender and substance use treatment is that sex offender treatment is primarily provided in prison settings whereas community-based options for substance users are readily available.

 

Alternative Treatment Design

Bardach (2011), provides many definitions of “alternatives”, and the definition most appropriate for this paper is “alternative strategies of intervention to solve or mitigate the problem” (p. 16). For this paper, the identified problem is the prevalence of sex offenders and the possible shortcomings of current treatment. Attempts to mitigate this problem include examining possible alternatives to current treatment and designing approaches based on harm reduction.

Studies on the topic of treatment return conflicting reports. In one study, combined cognitive-behavioral treatment and relapse prevention was shown to reduce the recidivism rate by 40% (Losel & Schmucker, 2005). In a comparison study of treated and untreated sex offenders, 10% of the treated offenders were rearrested as compared to 17% of untreated sex offenders (Hanson, Gordon, Harris, Marques, Murphy, Quinsey, & Seto, 2002). However, another study found no difference in the arrest rates of treated sex offenders as opposed to untreated offenders (Marques, Wiederanders, Day, Nelson, & van Ommeren, 2005).

Notably, policy changes rarely take place by constructing a plan from scratch (Clemons, & McBeth, 2009). While there is no easy solution to the problem of sex offender treatment, we can use the positive pieces of current models of substance use and sex offender treatment to construct a more complete approach. A primary issue is the limited access to sex offender treatment. While treatment for substance abuse has recently been addressed as a health issue, sex offender treatment continues to be addressed from a punitive approach. To increase the success of treatment, it is imperative that we increase the accessibility to these services. One way of doing this is mandating that health insurance cover these services in the form of prevention, screening, brief interventions and treatment for sex offenders.

As an alternative to the current treatment model for sex offender treatment, I propose that more funding is allocated for researching alternative treatment models. Currently, data has not indicated that changes occur within these groups and research has not been done to compare this model with other types of treatment (Wakefield & Underwager, 1991).

 

Preliminary Implications

In this day of advanced knowledge and research, it seems alarming that there is such limited research on the effectiveness of treatment for sexual offenders, and that the research conducted yields such mixed results. However, current treatment programs were not developed as clinical trials with control groups and scientifically measurable outcomes. As a result, there are no specific standards used to measure success and failure rendering clinical trials nearly impossible to develop. Another limitation to the development of treatment models is the ability to determine success. One measure of success is relapse rates. While this measure works well for substance users it is more difficult for sexual offenders. For substance users, the ability to measure relapse can be as simple as a drug screen, however with sexual offenders you must rely on complete honesty from the participants. Other measure that is commonly used for sexual offenders is rearrests rates. While this measure can be useful at times, it is hard to determine how many sexual offenders may reoffend without being caught, which is further compounded by the number of sexual assaults that are never reported.

 

Conclusion

While substance use and sexual offending are community health problems that impact multiple individuals and families, there are stark differences in the approaches for treating these populations. On its surface, substance abuse may seem to be harmful to self, while sexual abuse is harm to others. However, this view does not account for the community, family and public health impacts of both these issues. There are many similarities and differences in treatment models for substance use and sexual offender treatment and the political influences impacting regulations for treating both populations. Currently, there are limited studies to illustrate proven success rates for sexual offender treatment, and this is an area that requires more extensive research and development. While there are apparent correlations for treating these two populations including cognitive behavioral therapy and group interventions, there are still significant differences in the accessibility and funding for treatment. To comprehensively address this issue, it is imperative that more attention and funding be allocated for research in this area.

 

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