Advice about management

Clinicians providing treatment for paraphilias should not approach case management as if once treatment is delivered, follow-up is no longer important. Sex offending should be viewed as a chronic condition that requires surveillance of the offender and periodic maintenance therapy post-treatment in order to ensure the protection of the public.

Probation and parole officers are an exceedingly important part of treatment maintenance. Officers of the court have the authority and responsibility to ensure that sex offenders maintain their treatment contacts and fulfil probation and/or parole requirements. Mental health providers have historically avoided working with the court system in order to maintain complete independence within the patient- therapist relationship, hence protecting that relationship from outside sources of influence. However, complete independence from the legal system is inappropriate given the realities that sex offenders frequently are treated when on probation or parole. The consequences of treatment failure are vastly different for sex offenders than for individuals with neurotic or personality dysfunctions and, in many cases, are much more serious even than in individuals with psychotic conditions. Under the latter conditions, the usual victim is the patient himself, not a member of the general public. When working with paraphiliacs, the mental health provider must assume a new and challenging role of working with the legal system to ensure compliance with treatment and the safety of the public. Regular meetings with probation officers that provide updates of therapeutic progress help the sex offender understand the importance of completing psychological treatment and complying with probation and/or parole requirements.

Surveillance of sex offenders is especially critical because the therapist spends only a brief amount of time with the offender. Some sex offenders are exceedingly adept at convincing their therapist that they are following through on treatment and avoiding environments that in the past have acted as antecedents to sex offending. It is strongly recommended that a surveillance team be developed by the sex offender and the therapist to include five people, at least one of whom comes from the patient's family, one from the patient's work site, and one from the patient's social environment. With the assistance of the therapist, the offender teaches the surveillance team those behavioural precursors that previously may have led to an increased risk of re-offence. The surveillance team, with the assistance of the therapist, develops a surveillance check list that identifies these antecedent behaviours. The offender then teaches the surveillance team how to check specifically on each of these potential antecedents to sex-offending behaviour. Following adequate training, the surveillance team members provide the therapist, on a bimonthly basis, with their observations of the offender based upon this checklist, so that the therapist can be alerted to behaviours that suggest an offender's increased risk of recidivism.(62)

In general, the average sex offender can be successfully treated on an outpatient basis with intensive treatment occurring once or twice per week for approximately 90 sessions. Upon completion of the intensive portion of treatment, the offender can go into a maintenance phase of treatment when he is seen as frequently as once a week, or as infrequently as once every 3 months, depending upon the severity of the individual case. A number of factors increase the need for more frequent therapeutic visits and, in some cases, day-patient, residential treatment, or institutionalized treatment. A number of factors also necessitate the institution of medication, one-to-one supervision by the patient's family, or the use of electronic monitoring or house arrest.

Factors that increase the need for more frequent visits, or more invasive treatment procedures, include a high baseline frequency of the deviant behaviour. Additionally, some behaviours, although infrequent, are potentially so dangerous to the victim that treatment must be intensive and extensive. The sadistic offender, the brutal rapist, the aggressive paedophile, and the brain-damaged sex offender are a few examples of these more dangerous perpetrators. Finally, when there is no independent surveillance of the offender, when there is a lack of involvement from the offender's family or friends, when denial by patients precludes their viewing themselves as having a dangerous sexual behaviour, and/or when the victims are less able to defend themselves (e.g. institutionalized, retarded, or psychiatrically ill potential victims), more rapid intrusive therapy is indicated.

With the combination of currently available medications, the incorporation of surveillance groups, and limited access of potential victims, most sex offenders can be treated on an outpatient basis. However, given the realities of the criminal justice system and the illegality of sex-offending behaviour, many sex offenders are incarcerated before or during the initial phase of their treatment. Economic concerns, which are abundant with sex offenders for whom incarceration has historically been considered a preferable option, should be closely scrutinized because of the limited resources currently available for imprisoned sex offenders and the immense cost of imprisonment. The assessment and management of sex offenders is considered further in Chapter.11.4,2.

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