For Sex Offenders, a Dispute Over Therapy's Benefits

By Abby Goodnough and Monica Davey

New York Times - March 6, 2007

ATASCADERO, Calif. — During five years of psychotherapy at a treatment center here for sex offenders who have finished their prison terms, Bill Price, a pedophile who admits to 21 victims as young as 3, has constructed a painstaking plan for staying straight.

A requirement of his treatment, the plan catalogs on five single-spaced pages the tactics Mr. Price has learned to stop molesting.

There are 42 so far, including avoiding places where children congregate, abstaining from alcohol, shunning the Internet and sniffing ammonia whenever he has a deviant thought.

"It was just like a hunt for me," Mr. Price, 59, a former Sunday school teacher, said of his sexual crimes. "I kept choosing children because they were easier prey; they were easier to deal with than women."

Treatment plans like Mr. Price's, known as relapse prevention, have been a cornerstone of efforts to reform sex offenders for the past 20 years. Yet there is no convincing evidence that the approach works, or that others do either.

Similar to aspects of Alcoholics Anonymous, relapse prevention has sex offenders own up to wrongdoing and resign themselves to a lifelong day-to-day struggle with temptation. But one of the few authoritative studies of the method, conducted in California from 1985 to 2001, found that those who entered relapse prevention treatment were slightly more likely to offend again than those who got no therapy at all.

Clinicians who work with sex offenders cling to relapse prevention nonetheless, and its durability speaks volumes about the troubled, politically fraught science of treating sex offenders. Not only is relapse prevention of questionable value, but so are the tests to gauge whether sex offenders in treatment still get inappropriately aroused, the drugs used for so-called chemical castration and the methods of predicting risk of reoffending.

Treatment methods have become particularly topical as thousands of sex offenders are confined or restricted beyond their prison terms under civil commitment laws on the books in 19 states. The laws have been found constitutional in part because they aim to provide treatment if possible; New York legislators announced last week that the state would soon allow civil confinement.

On average, the civil commitment programs cost four times more than keeping sex offenders in prison. But too little research has been conducted into how to treat sex offenders, experts say, putting psychotherapists and others working in civil commitment centers at a distinct disadvantage.

"It has never been regarded as a legitimate and recognized topic for research by psychologists," said Robert A. Prentky, director of research at the Justice Research Institute in Boston. "There is a very strong undercurrent of disrespect for this area of research and perhaps even skepticism, frankly."

As recently as the 1970s, research on treating sex offenders was practically nonexistent. Barbara Schwartz, a psychologist with New England Forensic Associates in Arlington, Mass., said that when she wrote her first paper on rehabilitating sex offenders in 1971, "I read everything there was to read, and I had a half of one page of references."

That is partly because sex offenders present major challenges as research subjects. There are far fewer convicted sex offenders than most other kinds of criminals, so sample groups are unreliably small. And sex offenders tend to be so secretive that "it's really hard to get information from them that you can have confidence in," said Ted Shaw, a forensic psychologist in Gainesville, Fla., who has treated offenders since 1982.

Even now, in an advanced phase of California's treatment program for the most persistent sex offenders, Mr. Price says he questions his ability to keep his urges in check. His relapse prevention plan says that if let out, he will seek more treatment at Pure Life Ministries in Kentucky, whose Web site says its goal is "leading Christians to victory over sexual sin."

"I'm very afraid of just being out there," Mr. Price said, sitting near the nasturtiums and petunias he had grown in a courtyard of the Atascadero State Hospital here, which includes a wing for civilly committed offenders. "I'm less dangerous than I was, but I'm definitely in touch with my dangerousness."

Treatment in Phases

During one therapy session, Mr. Price and five other men aggressively tested one another's ability to stay straight, while two social workers moderated. Sitting in a circle in a locked conference room, briefly sealed off from the loud, grim bustle of the hospital halls, they fell into an argument over whether to protect a young new arrival from predatory older residents.

"If I can save this kid from being hustled or taken advantage of," said Paul George, a convicted pedophile who has admitted roughly 100 offenses, "I'm going to at least try to make that effort."

But another man pointed out that Mr. George had habitually groomed child victims by acting as their protector, asking him, "How was that different from this situation?"

At most civil commitment centers around the nation, offenders young and old meet several times a week for group therapy rooted in relapse prevention as well as what are known as cognitive-behavioral techniques. While the former is meant to curb sex offending in particular, the latter are intended to change broader destructive patterns of thinking and reacting, and are commonly used in treating other ailments like anxiety.

Civilly confined men move from one phase of treatment to the next, learning to recognize which situations, thoughts and behaviors have led them to offend, developing skills to avoid them, and applying those skills to their daily lives. They try to learn empathy by writing detailed letters to their victims and even essays in their voices.

"It's a slow business," said David Thornton, the treatment director at Wisconsin's civil commitment center. "You're talking about years of work, two steps forward, one step back."

Dr. Thornton said relapse prevention forced sex offenders to focus too heavily on a concrete list of high-risk situations — sometimes as long as 50 pages — that could overwhelm them and lead to failure. Wisconsin's program rejects relapse prevention and sticks to cognitive-behavioral techniques in an effort to change deep-rooted traits and behaviors.

"It's much less dependent on the guy having some conscious, deliberate self-control plan in his head," Dr. Thornton said. "You're trying to change how he automatically functions."

Instead of helping a sex offender compile a list of specific situations to avoid, therapists in Wisconsin might seize on the fact that he reacts impulsively when something upsets him, teaching him self-regulation skills. Instead of having the offender recount every last detail of his crimes, they might help him correct long-held misperceptions about children (that they enjoy sex), power (that it is best attained by raping or molesting) and so forth.

Some who represent offenders in Wisconsin, though, say that even the new program there has not answered offenders' frustrations about their ability to progress in it and to demonstrate that progress.

"The program has gotten larger, more involved and progressively longer," said Robert W. Peterson, a lawyer in Wisconsin who has worked on such cases since 1998 and says he has seen the state's program shift repeatedly in design and focus.

"Regardless of the structure of the treatment program, the duration of the treatment program, the nature of the treatment program," Mr. Peterson said, "what we basically have is living experiments."

Research Is Sparse

Reliable studies on the treatment of civilly committed offenders do not exist, since so few have been set free. Much of the research into the treatment of sex offenders has come out of Canada, where national criminal history records are easily accessible.

Canadian psychologists have studied not only treatment outcomes but also risk assessment, or determining who is likely to reoffend.

Combining findings from hundreds of smaller studies, R. Karl Hanson, senior research officer for the Department of Public Safety and Emergency Preparedness in Canada, has found that roughly 15 percent of convicted sex offenders are caught reoffending after five years and that those driven by deviant sexual interests, like pedophiles and exhibitionists, are the likeliest to do so.

Dr. Hanson's research has also suggested that even lifelong offenders tend to stop, for the most part, by the time they reach their 70s.

He said various studies had shown that "most treatments don't work very well," but that, over all, treatment had a modest beneficial effect. One analysis that he published in 2002 found that 12 percent of offenders who got treatment were caught committing new sex crimes, compared with 17 percent of untreated offenders.

Researchers have found that chemical castration, or using hormonal drugs to curb sexual appetite, can be problematic, too.

Doctors have experimented for decades with antiandrogens, which block the effects of sex hormones like testosterone and are most commonly used to treat advanced prostate cancer. But while some consider antiandrogens crucial for the most predatory offenders, the drugs remain controversial, not least because they are expensive and can cause weight gain, osteoporosis and breast development. It is also hard to ensure that released offenders keep taking the drugs.

More than half of states with civil commitment programs say they allow voluntary antiandrogen treatment, but as of last fall, only California, Illinois, Washington and Wisconsin had more than one offender taking the drugs, which can cost several hundred dollars a month. Dr. Fred S. Berlin, founder of the Johns Hopkins Sexual Disorders Clinic in Baltimore and a longtime critic of civil commitment, said he was troubled by the scant use of antiandrogens.

"I get letters from men around the country, in prison or sometimes civil commitment, asking if I can help them in their efforts to have it made available," Dr. Berlin said, "because the administrations in their facilities are not even willing to discuss it with them."

Here in California, where about 40 civilly committed men took antiandrogens several years ago but only four do now, Jesus Padilla, a clinical psychologist at Atascadero State Hospital, said the drugs did not address the underlying emotional problems that lead to offending, nor even necessarily eliminate sex drive.

"I've had numerous situations where they say they are working just fine," Dr. Padilla said of civilly committed men on antiandrogens, "only to catch them having sex with each other or engaging in deviant sexual fantasies even though their testosterone level was down to zero."

Some doctors see more potential in antidepressant drugs, which can dampen sexual desire while also curbing compulsive behaviors like chronic masturbation, which can preclude offenders from participating in treatment. Some civil commitment programs prescribe antidepressants sparingly or not at all, while others, including South Carolina's and Wisconsin's, have dozens of men taking them.

One approach that civil commitment centers have avoided is surgical castration, though at least one state, California, allows it if the offender pays for the procedure himself.

In Virginia, the General Assembly considered a proposal last year to allow voluntary surgical castration as an alternative to civil commitment, but took no action. One pedophile in Virginia castrated himself in a jail shower with a shoelace and a razor blade as his civil commitment trial approached.

Douglas Carlin, a convicted rapist who completed treatment and was released a year ago from the commitment center in Florida, said he thought a lot of offenders there were deceiving their therapists.

"Most of those guys, they are just faking it to make it," Mr. Carlin said. "They're just waiting to get released so they can go right back to what they were doing."

Tools of Assessment

Therapists can gauge the success of various treatments by observing offenders' behavior, interviewing them and using two instruments. All have serious shortcomings.

One instrument, the polygraph, is routinely used to determine if people continue to offend once conditionally released or have deviant thoughts in the course of treatment. Civil commitment centers also use polygraphs to make sure an offender has admitted all his crimes, a requirement for progressing past the early stage of relapse prevention treatment.

"Usually they will give up lots of information soon after failing a polygraph test," Dr. Thornton, the Wisconsin treatment director, said.

But polygraphy, which measures blood pressure, breathing rate and perspiration while a series of questions is asked, is generally considered so unreliable that its results are inadmissible as proof in court. Some offenders, especially psychopaths who feel no anxiety when lying, can beat it, experts said.

"Polygraph on its own isn't the answer to anything," said Dr. Don Grubin, a forensic psychiatrist at Newcastle University in Britain who has studied the tests. "As part of a bigger package it seemed to have an effect — to help reduce the risk of reoffending."

The other device routinely used at civil commitment facilities is the penile plethysmograph, which measures changes in the circumference of the penis while the offender is shown sexually suggestive pictures of men, women or children.

Some clinicians and offenders say it is easy, particularly in a laboratory, to stifle arousal and thus cheat on a plethysmograph test.

Mr. Carlin, the Florida rapist, said that during one plethysmograph test, "I just stared at a shelf of cleaning products and read the labels."

The field of risk assessment, or determining which sex offenders are likely to repeat their crimes once released, has been equally slow to evolve, even as judges and juries are keeping more men locked up after their prison sentences in the belief that they will be dangerous on the outside.

A cottage industry of professionals who diagnose sexually violent predators has developed in the last two decades, and several hundred psychologists, often with little or no background treating sex offenders, make a lucrative business of recommending who should be committed.

During a recent commitment trial in St. Augustine, Fla., one psychologist with hardly any experience treating sex offenders told a jury he had evaluated 350 candidates for civil commitment and testified in dozens of commitment trials since 2000.

Some in the field question why professional organizations like the American Psychological Association have not set ethical and training standards for the many psychologists entering the civil commitment field.

"I don't think, in my personal experience, that the vast majority of the examiners I've come across have sufficient working knowledge of the empirical literature," said Dr. Prentky of the Justice Research Institute.

But that literature is still of limited use. Most actuarial tools used to predict someone's risk of recidivism consider only unchanging factors, like their number of past offenses and the sex of their victims. Some scientists say that so-called dynamic factors — how much treatment an offender gets, for example, and how old he has grown — should factor heavily into actuarial risk assessment, too.

"Science hasn't gotten there yet," said Eric Janus, a professor at William Mitchell College of Law in St. Paul, Minn., who opposes civil commitment.

Professor Janus said he hoped for "an explosion of knowledge" about how to prevent sexual violence before it happened, which he said would prevent far more sex crimes than civilly committing offenders.

That sort of research is unlikely to happen in the United States, Dr. Berlin and other experts said, because so many Americans believe that the only investment in sex offenders should be punitive.

"People need to recognize that these are not just criminal justice problems but also public health problems," Dr. Berlin said, "and the surgeon general as well as the attorney general ought to be supporting research in this area."

Earlier efforts to rehabilitate sex offenders, like Freudian psychoanalysis and electric shocks to the skin, failed definitively decades ago. A recent case in Orange Park, Fla., offered more evidence that relapse prevention treatment is no solution, either.

There, the authorities say, a convicted rapist who had spent 12 years in prison and 5 at the Florida Civil Commitment Center raped and killed a young woman before dawn on Jan. 23 after following her into the veterinary clinic where she worked.

The suspect, Michael Renard Jackson, 37, won release from the commitment center in 2005 after reaching the highest levels of a relapse prevention treatment program, people familiar with the case said.