Glynis Murphy, Tizard Centre, Kent University & oxleas NHS Trust g.h.murphy@kent.ac.uk

1. Group cognitive behaviour therapy for sexually abusive men with LD: outcomes in the SOTSEC-ID project Glynis Murphy, Tizard Centre, Kent University & oxleas NHS Trust g.h.murphy@kent.ac.uk

2. Plan • What is known about non-disabled sex offenders? • Treatment for non-disabled sex offenders: what does it consists of & does it work? • What is known about sex offenders with learning disabilities? • Treatment for sex offenders with learning disabilities: what does it consist of & does it work?

3. Sexual offending by non-disabled men • Grossly under-reported to police (fewer than 50% of people ever tell anyone; around 20% are notified to police; few convictions) • Victim surveys (Britain and Ireland): - about 50% women have been victims of exhibitionism- around 20% of women (fewer men) victims of contact abuse- around 5-10% of women (fewer men) victims of rape • 90-95% of sex offenders are men; most are known to victim • Offenders often engage in grooming & stalking of victims; may do complex planning of offending • Used to be thought sex offenders had one paraphilia (deviant sexual interest), targeted one age group, either inside or outside family. This no longer considered correct. • Issues of contact vs non-contact offences

4. Treatment for non-disabled sex offenders: recent years • 1960s & 1970s: Sexual abuse seen as result of deviant sexual interests & arousal (also some occasional recognition of role of poor social skills) • Led to behavioural techniques eg aversion therapy, orgasmic reconditioning & covert sensitisation • Belief in medical model & anti-androgens • Little evidence of effectiveness; under-provision of treatment • Move to CBT approach – partly due to recognition of importance of cognitive distortions in the 1980s (e.g. work of Wolf, Abel, Finklehor & Marshall)

5. Wolf’s (1988) cycle of offending

6. Finklehor’s 4 pre-conditions for child sexual abuse (1984, 1986) 1. Motivation to offend (resulting from emotional congruence, sexual arousal & blockage) 2. Overcoming internal inhibitions (e.g. by telling himself it is just a bit of fun) 3. He must overcome external obstacles to offending (eg by finding privacy & victim) 4. He must overcome the victim’s resistance (eg by ‘befriending’ them)

7. The role of cognitions • 1980s: Recognition of role of cognitions & cognitive distortions in sexual offending (denial, victim blaming, minimisation, etc) –eg Abel et al, 1984 • Lots of ways of classifying cognitive distortions • One way of classifying them:- Denial: ‘It wasn’t me, they’ve got wrong guy’- Victim blaming: ‘He led me on all the time’, ‘She wanted me to’- Minimisation: ‘It’s good for children to learn about love this way’ or ‘I didn’t hurt her - just a bit of fun’ • Importance of peer challenges in changing these distortions

8. Marshall’s model of sex offending

9. Components of cognitive behavioural treatment • Enhancing self-esteem • Challenging & changing cognitive distortions • Developing victim empathy • Developing social functioning • Modifying sexual preferences • Ensuring relapse prevention See Marshall et al.’s 1999 book for an excellent guide

10. Does it work for non-disabled men? • Hanson et al, 2002: Meta-analysis of 43 CBT studies of sex offender treatment (over 9,000 participants overall) - sexual offence recidivism rate: 12% for treated men vs 17% for untreated men • Aos, Miller & Drake 2006: reviewed controlled CBT studies. CBT produced reduction in recidivism (31% reduction in community & 15% in prison sample) • Kenworthy et al, 2006: Cochrane review of 9 RCTs (over 500 offenders), mostly paedophiles; variety of treatment methods:- one large CBT trial showed a definite reduction in recidivism- one large group psychotherapy trial showed treatment increased risk.

11. Men with learning disabilities at risk of sexual offending: numbers • Methodological difficulties: different samples (prison, hospital, community); ignoring filtres & diversion in CJS; suggestibility & evasion issues • Early studies: ? high prevalence of offending but v. poor methodology (eg. prison studies; & Walker & McCabe (1973) study) • 50% of perpetrators of sexual abuse in LD services themselves have LD (Brown et al, 1995) • Susan Hayes (1991): Prison survey found that 4% of offenders with LD had been convicted of a sex offence (& ditto for non-LD)

12. Men with learning disabilities at risk of sexual offending: characteristics • Characteristics: often from violent, chaotic, neglectful families; frequently have other CB &/or convictions; often have mental health problems (Gilby et al, 1989; Day, 1994; Lindsay et al, 2002) • Show cognitive distortions (Lindsay et al, 1998a,b,c) • Recidivism: recidivism rate was 31% in convicted men with LD (Austr.) - about 2-3 X as high as that of non-disabled men - Klimecki et al (1994) • History of abuse: Lindsay et al (2001) found 38% of sex offenders with LD had been abused c.f. 13% non-sex offenders with LD • NOT less knowledgeable about sex than other pwld (Langdon study & Lindsay study, both 2007)

13. Men with learning disabilities at risk of sexual offending (cont’d) • Victims: mainly other people with LD, sometimes children (less often non-disabled adults); usually victims known to the perpetrator – Gilby et al 1989 • Offences more opportunistic & less planned (less grooming & stalking) • Often long history of sexual problems & multiple placements • Often ‘offences’ not reported to police & even when reported, men mostly not prosecuted nor treated (eg Thompson, 1997)

14. Cognitive behavioural treatment for men with & without LD in UK • For men without LD, group CBT recognised as the leading method of treatment (Hanson et al) • Beckett, Beech et al. have evaluated: CBT for convicted sex offenders in prison sentenced to 4yrs+ (SOTP) & community-based programmes, run by probation, clinical psych & SW • Men with LD mostly excluded from these: group CBT in few places only - some prisons (ASOTP), Janet Shaw clinic in Solihull (ASOTP), Northgate hosp programme near Newcastle, Bill Lindsay’s programme in Scotland

15. Does group CBT work for men with LD? • Lindsay et al (1998a, b) showed some improvements in 6 men with LD & paedophilic offences & 4 men with LD & exhibitionism, after CBT • Lindsay & Smith (1998): showed 2 years CBT was more effective than 1 yr CBT for men with LD on probation • Rose et al (2002): CBT 2hrs/week for 16 weeks, for 5 men; found reduced (improved) scores but changes not significant • Craig et al 2006: no changes in cognitive distortions in 7mth CBT • Lindsay et al 2006: 70% harm reduction in 29 repeat sexual offenders with LD, after CBT • Williams et al, 2007: significant improvements in scores from pre-group to post-group in 150 men following CBT in ASOTP programmes in prisons (not all with LD)

16. Research in this field: problems • Small numbers of potential participants • Geographically dispersed • Difficulty of establishing a control group • Difficulty in obtaining ethical approval for research on vulnerable participants • DOH ethical and operational approval procedures

17. SOTSEC-ID • Sex Offender Treatment Services Collaborative - Intellectual Disability • About 15 sets of therapists providing sex offender treatment for men with intellectual disabilities in England (& WL controls) • Run training events & meet every 8 weeks or so • Set up sex offender treatment groups, shared treatment manual to guide therapy (ttmt lasts 1 yr; 2hr sessions, once per week, closed groups) • Sharing core assessments measures • Research funded by DoH, Care Principles, Bailey Thomas fund

18. SOTSEC-ID members with data in the next slides • Glynis Murphy, Sarah-Jane Hays, Kathryn Heaton, Nancy Hampton, Univ of Kent • Neil Sinclair & colleagues, S.E. Kent • John Williams & John Stagg, Southampton • Geetha Langheit & colleagues, Surrey • Tessa Lippold & Janina Tufnell, Surrey/Hamps • Peter Langdon & colleagues, Norfolk • Kim Mercer & colleagues, York • Jenny Scott & colleagues, Middlesborough • Guy Offord & colleagues, W. Kent • Simon Powell & colleagues, Bexley & Greenwich • Wendy Goodman & Janice Leggett, Bristol • Frank Baker & colleagues, Cornwall

19. Core assessments • Once only: measures of IQ, adaptive behaviour, language, & autism • Pre & Post group treatment:- Sexual Knowledge & Attitude Scale (SAKS)- Victim Empathy scale, adapted (Beckett & Fisher)- Sex Offender Self-Appraisal Scale (Bray & Foreshaw’s SOSAS)- Questionnaire on Attitudes Consistent with Sex Offending (Bill Lindsay et al.’s QACSO) • Recidivism

20. Treatment content • Group purpose, rule setting • Human relations & sex education • The cognitive model (thoughts, feelings, action) • Sexual offending model (based on Finklehor model) • General empathy & victim empathy • Relapse prevention Compared to non-LD programmes: Far more slow offence disclosure; more on sex education; far more pictorial material & less sophisticated on cognitive side

21. Results: first 13 groups (52 men) • About 40% men who enter treatment are not required to come by law (60% on MHA or CRO) • Mean age 35 yrs; mean IQ 68 (range 52-83); mean BPVS 10.9yrs • ASD diagnoses: 23%; personality disorders 28%; mood disorders 23%; mental illness 9% • Offences: stalking, sexual assault, exposure; rape; victims children and adults, male / female • Most have long history of similar behaviour (35 with 3 or more such behaviours known) • 55% were sexually abused themselves in past

22. Changes in cognitive distortions, sexual knowledge & empathy • Sexual Attitude and Knowledge Scale (SAKS): significant improvement by end of group, maintained at follow-up • QACSO (Lindsay): ditto • Victim Empathy (Beckett & Fisher): ditto • Sex Offenders Self- Appraisal Scale (Bray): ditto

23. Cognitive distortions, sexual knowledge & empathy

24. Further sexually abusive behaviour • During the year of the treatment group: most men did not show further sexually abusive behaviour; in 6 cases (4 men) they DID show non-contact ‘offences’ • In the 6 mths follow-up period: most men did not show further sexually abusive behaviour; in 7 cases (5 men) DID show non-contact ‘offences’ (5 cases) or sexual touch through clothing (2 cases) • Re-offending: No relationship with pre- or post- group scores; IQ, presence of mental health problems, personality disorder, living in secure setting, being victim of SA, history of offending. • Poor prognosis: Concurrent therapy & diagnosis of autism / aspergers syndrome • Longer follow-up: data just collected (by Kathryn Heaton) & above findings still hold

25. Service user views from first group • Good understanding of basic facts (duration, venue, facilitators, & rules, e.g. confidentiality rule) • Good understanding why referred: ‘Because of my probation because of my sex offence to see if it would do me any good’‘To help my sex urges and keep them under control; to be a better person when meeting women in the community’‘To help us stop getting into trouble with the police; because I go out to masturbate’

26. Service user views (cont’d) Most could list some of what they did in group (not very coherently) What they learnt:‘Stopped me touching girls’‘How people feel about us masturbating’ (in public)‘Learnt not to go after women’‘Learnt .. to put a condom on’‘Learnt to help other people in the group’ ‘What the police do when they arrest you’

27. Service user views (cont’d) Best things • ‘Having support every week’ • ‘We … talked about feelings about things, sorting the problems out’ • ‘Working together, helping each other’ • ‘We helped each other discuss ... work on ways of preventing problems in the future’ Worst things • ‘Telling people very private stuff, keeping people on trust’ • ‘Some didn’t talk’

28. Strengths • Multi-site study with sufficient N • Early results look promising for changes in sexual knowledge, cognitive distortions and empathy • Establishment of a long-term data base to track recidivism and other relevant data on this group (100+ variables on data file) • SOTSEC-ID established and supporting clinical research in an under-serviced and under-researched area

29. Weaknesses • Problem with obtaining sufficient controls • Non-randomised assignment to treatment/control conditions • Problem of getting clinicians to collect data when they are very busy • Problems of comparability of groups/treatment across time and location • This treatment is only suitable for men with good verbal skills (i.e. mild learning disabilities)

30. Key references • Craig et al (2006) Treating sexual offenders with learning disabilities in the community: a critical review. International Journal of Offender Therapy & Comparative Criminology, 50, 369-390. • Hanson, R.K. et al (2002) 1st report of the collaborative outcome data project (etc.) Sexual Abuse: Journal of Research & Treatment, 14, 169-94. • Journal of Applied Research in Intellectual Disabilities (Several articles in issue, 15 (2), 2002 and in issue 4, 2004) • Keeling, J.A., Rose, J.L. & A.R. Beech (2008) What do we know about the efficacy of group work for sexual offenders with an intellectual disability? Where to from here? J. of Sexual Aggression, 14, 135-144 • Lindsay, W.R. (2004) Sex offenders: conceptualisation of the issues, services, treatment and management. In W.R.Lindsay, J.L. Taylor & P. Sturmey (Eds) Offenders with Developmental Disabilities. Wiley& SonsLindsay, W. R. et al 2006) A community forensic intellectual disability service: 12 year follow-up of referrals etc. Legal & Criminological Psychology, 11, 113-120. • Marshall, W. L. et al. (1999) Cognitive Behavioural Treatment of Sexual Offenders. Wiley. • Murphy G.H. & Sinclair, N. (2009) Treatment for men with ID & sexually abusive behaviour. In A.R. Beech, L.A. Craig & K.D.Browne (Eds) Assessment & Treatment of Sexual Offenders: A Handbook. Wiley • Murphy, G.H., Sinclair, N. Hays, S-J, Heaton K. , et al. (in press) Effectiveness of Group Cognitive-Behavioural Treatment for Men with Intellectual Disabilities at Risk of Sexual Offending. Journal of Applied Research in Intellectual Disabilities • Ward, T., Polaschek, D.L.L. & Beech, A. (2006) Theories of Sexual Offending. Wiley. • Williams, F., Wakeling, H. & Webster, S. (2007) A psychometric study of six self-report measures for use with sexual offenders with cognitive and social functioning deficits. Psychology Crime and Law, 13, 505-522.