R.J.O’Shaughnessy MD

Address social deviance vs Mental Disorder

Review outcome studies of sex offender treatment programs

Identify role and ethical conflicts and their management

Boundary between social/ legal deviance vs Mental Disorder

Paraphilia diagnosis criteria Assessment procedures Risk assessment and consequences Legal involvements: SVP, Sentencing Treatment vs Rehabilitation vs Management/

punishment

Heterogeneity of programs Variable goals and priorities Correctional: Custodial – Parole/probation Mental health: Forensic hospital – outpatient

programs – private practitioner

Min of Health, OPD based Multidiscipline Assessment including Psychiatric,

Psychological testing, Family assessment, Phallometry evaluation

Defined limits in communication/ relationship with Corrections

Helping patient will reduce recidivism Deviant sexual interests Social skills deficits Lack of empathy Lack of motivation for treatment Minimization and denial of responsibility CBT group/ individual delivery Relapse prevention

Correctional settings: institutions – parole Prime goal: Reduce recidivism Management focused Increased P.O. involvement Reduced confidentiality

Primary Duty: Protection of public Therapist seen as part of “management

team” Demand admission previous uncharged

assaults Use of Polygraph Mandatory physical or “chemical” castration

before release Values/ roles frequently in conflict

Social Deviance: Incidental offending Dissocial/ antisocial lifestyle Mental Disorder:

Paraphilia Personality Disorder Neuropsychiatric Disorder Comorbid Mood – Anxiety - SUD

Are Diagnoses based on facts or values? Values may outweigh facts Interpretation of facts based on our values Szasz: “ norms of mental disorders are

psychosocial, ethical and legal” vs structural or anatomical

Bodily Disorders: Values usually shared Cancer is ‘bad’ Disorder explained externally: ‘ have cancer’ Mental Disorders: Values often diverse/ in

conflict: sx’s defined by emotions, sexuality, desires

Disorder seen as internal: ‘you are a pedophile’ Social Stigma highest for Pedophilia

Moral Wrongfulness Test in Dx ( Franken 2005)

ASPD: ? What is left after removing value statements

Circular thinking critique ? Confounding legal and moral wrongfulness

with Mental Disorder ? Medicalization of deviance/ criminality

Are we treating the punished or is treatment punishment?

Should we ‘treat’ people with questionable Diagnosis of mental disorder?

Should psychiatrists be involved with reforming criminals?

Should psychiatrists contribute to system whose primary purpose is punishment / public protection?

Variable definitions Treatment: early intervention, evidence

based, reduction of relapse Rehabilitation: normalization of function Management: Reduce risk of offending

punishment, supervision, monitoring, SO registration, public notification

Research challenges: Definition/ measurement of recidivism Low base rates Need for long follow up to measure recidivism - lost data, lost subjects Treatment definitions/ integrity High treatment dropout Heterogeneity of populations Difficulty in random assignment

Guidelines for Collaborative Data Committee 25/130 studies accepted 5/25 ‘good’ or ‘strong’ Treatment outcome based on recidivism ? Adherence to RNR principles

TG CG

Sex offenses 10.9% (.1 - 33%) 19.2% (1.8 - 75%)

Any Offenses 31.8% 48.3%

Andrews, Bonta: Psychology of Criminal Conduct, 3rd Ed. 2003

Risk: Higher risk offenders warrant greater TX

Need: Focus on those criminogenic factors associated with recidivism, e.g.; SUD, Impulsivity

Vs Non-criminogenic factors e.g. Anxiety, low self esteem

Responsive: Apply interventions in manner that offender is able to understand / use

Professional discretion: Able to over-ride if necessary

80% of programs targeted Social Skills training, victim empathy, responsibility assumption

ODDS RATIO

0 Principles applies 1.17

1 .64

Any 2 .63

All 3 .21

General Offenders (Gourgon, Armstrong 2005 )

Low Risk No Treatment

Moderate Risk 100 hours

High Risk or High Needs

200 hours

High risk + High Needs

300 hours

Sexual deviance Lifestyle instability/ criminality Social intimacy deficits Response to supervision/ treatment Poor cognitive problem solving Age

NOT significant: - Lack of empathy - Denial of sexual crime - Minimization - Lack of motivation for Tx - Major Mental Illness - Psychological distress

Reviewed RCT’s + prospective studies 8/167 outcome studies deemed low to

medium bias Conclusions: Major weaknesses in scientific

support for treatment efficacy

Maryland Scientific Methods criteria III to V 29/3000 met criteria TG = 4,939

CG = 5,448

TG CG

Sex Offending

10.1% 13.7%

Any Offending

32.6% 41.2%

CBT/ MST Medium to high risk offenders Individualized treatment with group tx Affirmed RNR principles No benefit for low risk offenders Unable to assess pharmacological treatments

as none met criteria for inclusion

Prison Based: no benefit Hospital/ opd: better outcomes Voluntary vs Mandated : no difference

Randomized clinical trial CBT- Relapse prevention model 167 SO’s treated 1985 – 1995 in custody 225 controls 220 comparison group Tx group included dropouts [ 18%] No difference in recidivism

Collaborative Outcome Data Committee standards

512 inmates completing CBT/ skills based treatment matched retrospectively

F/U: 4 – 14 years No difference in sex offender recidivism Significant difference in general offending

Khan (Cochrane Data Base 2015) 7 studies, N=123 total All published 20 years ago No controlled studies for SSRI, GnRH Limited studies do not allow conclusion to

support pharmacological treatment

WFSBP (Thibaut 2010)

6 Levels based on severity of Paraphilia: I CBT

II CBT + SSRI

III CBT + low dose TLM

IV CBT+ full dose TLM

V CBT + GnRH

VI CBT + GnRH + full TLM

Turner 2013 German forensic hospitals/ opd’s 611 SO’s

GnRh 10.6% CPA 5.1% SSRI 11.5% Antipsychotics 9.8%

Ethical Conflicts: 1. Dual agency 2. Communication issues 3. Accuracy of risk assessment 4. Treatment efficacy 5. Balancing beneficence vs. public

protection

Applebaum model: Role based Profession’s ethical code is justified by

society’s desire to promote Profession’s values

Determination of preeminence of moral rule is dependent on identification of value society wishes to promote

Treatment of symptoms will reduce risk Patient welfare given priority Minimize intrusion of legal demands to

address protection of public More consistent with traditional treatment

model e.g., National Commission on Correctional

Healthcare

Protection / management given priority Goal primarily to prevent violence to victims Justifies action not justified by traditional

ethics e.g., lie detector testing, shared

communication with non- treatment staff, urine screens, monitoring etc.

Potential for harm to ‘client / patient’ high

Roles/ responsibilities may be confounded Argues for broader view of roles Include common morality of Profession and

personal morals/ integrity Add narrative of parties to further

perspective Determine if professional role is compatible

with institution/ program role Recognizes may not be able to resolve

Recognize conflict between values is integral to nature of values

Process: 1. Premise of mutual respect 2. Work in framework of explicit shared

values 3. Use narrative to reach balanced decisions

within shared values

Purpose Respect Participation Resources Least restrictive alternative

Good Lives model (Ward) Positive psychology Treat patients with respect Strength building approach Assist SO to meet personal needs/ goals

through prosocial manner Evidence of improved engagement and

motivation

Non-criminal justice program Recruit subjects via media Empathic; minimize shaming/ stigma/

discrimination CBT/ Good Lives Model

Recruit volunteers without criminal hx Preventell: “helpline for unwanted sexuality” RCT approved by regulators GnRH antagonist Degarelix vs placebo Crowd funding

SOTP’s have modest effect on sex offending recidivism but better outcome for general offending

RNR approach shows best outcome Pharmacological interventions are used

routinely but lack good quality scientific support due to methodological limitations

Prison based SOTP’s have little benefit Best approaches use CBT + individual tx

Role definition may be rationally based on risk / needs /protections applicable to specific group

Must be compatible with Institution policy / legal demands

Must achieve general agreement amongst treatment staff / administration

Weight given different ethical values must be consistent with role definition

Role definition must be explicit: Clear Institutional Policy Program based ? Patient based Staff in specific programs must agree with role

definition / expectations

‘Patients / clients’ must be given full disclosure re: extent therapy is focused on public protection:

What will be communicated / to whom Extent of monitoring What info will be collected for court

purposes

Inherent role and ethical conflicts are endemic to correctional based SOTP’s

Identification and avoidance of role conflicts is paramount

If unable avoid role conflict, careful ethical analysis is required

Antiandrogen treatment under duress or compulsory orders raise substantial ethical issues that require detailed analysis and preferably external consultation

Role of psychiatrists in prison based SOTP’s are highly questionable give lack of treatment efficacy + frequent role conflicts

SOTP’s based in Hospital/ mental health facilities offer least ethical conflicts

Psychiatrists should ‘treat’ and maintain primary goal of beneficence with