Evaluating the effectiveness of treatment A review of evidence

A number of factors make assessing the effectiveness of treatment outcome with paraphiliacs problematic.

1. Many paraphilias, such as paedophila and rape, are felonies. The accurate determination of recidivism requires that the paraphiliac reports his own commission of another felony, and thereby risks prolonged incarceration.

2. Quantification of treatment effectiveness requires a control group that either receives no treatment or receives a treatment that is not specific to sex offenders. Such a control group would be unethical because, without treatment, individuals in the control group would be allowed, albeit indirectly, potentially to commit additional felonies, which would pose a threat to the general population. Attempts to select a naturally occurring control group are also problematic, since assignment to a treatment or control group cannot be randomized, and therefore treatment outcome may be considerably influenced by the control group selection process.

3. Paraphilic treatment programmes are frequently implemented within the prison environment. As a consequence, established criteria for behavioural improvement are based upon some measure of treatment responsiveness from within the prison environment rather than treated and non-treated groups being released from prison and the recommission rate determined.

4. A subgroup of paraphiliacs fit classification and diagnostic criteria consistent with concomitant psychopathy. (59) Recent studies have shown that individuals with paraphilic sexual interests and psychopathy do not respond well to treatment, and in fact are made worse. When treatment involves paraphiliacs with concomitant psychopathy, treatment outcome can become problematic since paraphiliacs without psychopathy may improve, while paraphiliacs with psychopathy become worse, and the net effect shows minimal response to treatment across the total group. Hence, this problem contaminates treatment outcome results with paraphiliacs.

5. Until recently, treatment outcome variance has resulted from criteria of recidivism varying from study to study (e.g. self-reported recidivism versus charges for sex crimes versus incarcerations for sex crimes). However, outcome variants can also result from variation in the length of follow-up efforts. Recidivism studies based upon a 4-year follow-up period yield markedly better outcomes than studies with 10 or 25 years of follow-up. Outcome studies cannot provide reliable information to clinicians or researchers if they are not designed to control for the factor of the paraphiliac's opportunity to recommit a paraphilic act. Survival curves have been utilized recently as one method of controlling for this problem, but older outcome studies have been impervious to this issue. ^i0)

6. Great variation exists regarding the specific populations of paraphiliacs being studied. Some outcome studies involve responsiveness to treatment within prison settings, where individuals' sex crimes have been severe enough to warrant incarceration, while other studies are conducted on outpatient populations, where the extent of perpetrators' paraphilic acts did not warrant incarceration. Comparison of treatment outcome data from different studies, because of disparity between groups of sex-offending populations, makes effective outcome investigations very difficult to carry out, with results from one study to the next often not yielding sufficient data for prediction purposes.

These limitations make it difficult to determine the overall effectiveness of treatment, especially for treatment implemented within prison settings. Treated inmates are usually released from prison into a probation and/or parole setting, where accurate reporting of additional offences would lead not only to a new charge, but also to incarceration for the remainder of their probation and/or parole time, or to extended incarceration time. Marshall et alS61) describe outcome related to a cognitive-behavioural approach to the treatment of predominantly paedophiles. Their findings are important because not only did they review police records regarding recidivism, but owing to the rural nature of the setting where many of the paedophiles in their investigation were treated, it was possible to corroborate reports from local legal authorities and various social services who were contacted to evaluate new alleged cases of child molestation. Results of this work indicate that after cognitive-behavioural treatment recidivism was reduced by 20 per cent below baseline rates of untreated offenders. They also reported that when a re-offender was apprehended, on average he had molested two further victims. Therefore these findings also suggest that, since recidivism was reduced by 20 per cent, treatment of 100 paedophiles resulted in stopping 20 child molesters, who had a high likelihood of re-offending without treatment, from molesting the 40 children they might have assaulted if they had not been treated.

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