Should an individual, committed to a psychiatric hospital as a sexually violent person, be released if he doesn't receive treatment according to his requests?
In 1996, Ruven Seibert was convicted of sexually assaulting a child in the mid-1980s. He was committed to a secure facility as a sexual predator. The appellate court affirmed the trial court's denial of Seibert's petition for supervised release. Seibert claimed he was not afforded the treatment he was entitled to, because the program was not specially tailored to fit his personal needs. He requested individual counseling sessions and declined to participate in group sessions. Evidence was presented that individual sessions were offered to Seibert, but such therapy failed due to his denial of his condition. Furthermore, Seibert had referred to group therapy as a "joke" and any effort in treatment seemed to be merely in order to effectuate his release.
Seibert argued that to hold him in the facility, the State must prove he is treatable. The trial court found that the State offered treatment to Seibert and that his lack of progress was solely due to his refusal to participate.
The appellate court agreed and recited a Wisconsin statute requiring the State to prove only that Seibert remains a sexually violent person in order to keep him in a secure mental institution. Expert testimony was presented which proved Seibert to be just such an individual. The State's expert stated that there was a high probability that Seibert would commit further acts of 'nonconsensual sexual violence" if released, and that Seibert held no remorse for his victims. Furthermore, evidence demonstrated that the facility did tailor treatment programs to meet patients' individual needs and that group therapy was, in fact, the most beneficial form of treatment for sex offenders.
The court acknowledged that although Seibert was entitled to the patient's right to receive prompt adequate treatment this "right to treatment does not equate to treatability." The goal is not only to treat individuals but also to protect them and society from the dangerousness of such violent acts. Furthermore, the fact that a treatment program does not meet Seibert's wants or desires, does not prove it ineffective. Seibert has the right to refuse treatment, but such refusal does not support granting his release.
| Robert Prentky, Ph.D. Director of Assessment and Modular Unit Director |
Dr. Prentky comments: In reality, sex offenders run the full gamut of treatability. Sex offenders who are of average intelligence, are free of major mental illness (e.g., psychosis), take responsibility for their offenses, evidence some willingness to discuss their offenses and their offense history and demonstrate some willingness to cooperate with the treatment program, will be higher on the continuum of treatability. The more that someone is deeply entrenched in denial, is pervasively angry at society and "the system," harbors deeply rooted distorted attitudes that justify and sustain his crimes, evidences clinical symptoms of psychopathy (such as grandiosity and narcissism, pathological lying, conning and manipulativeness, callous indifference to others, lack of remorse or guilt and little or no feelings), and has a below average level of intelligence (making it more difficult to benefit from cognitive behavior therapy), the lower on the continuum of treatability he will be. Some sex offenders, like exclusive incest offenders, are excellent treatment candidates. Other sex offenders, like serial, longtime predatory offenders and those with traits of psychopathy, will be much more difficult to treat and will continue to pose a much higher risk.
The state-of-the-art treatment for sex offenders is group therapy that follows a standard cognitive-behavioral treatment model, with a focus on relapse prevention. Relapse prevention was developed by Marlatt and Gordon almost twenty years ago as a maintenance program for treatment of addictive behaviors, such as alcohol abuse, drug abuse, overeating and cigarette smoking. The single most important feature of the relapse prevention model, which distinguishes it from the earlier medical-disease model of addiction, is the emphasis on self-management viewing the offender as responsible for the solution and not just the origin of the problem.
RELAPSE PREVENTION TREATMENT OF RAPISTS
Identify stressors that provoke distressing feelings
Identify situations that bring rapist near potential victims
Identify risky behaviors that typically occur before the offense
Promote offender's conscious awareness of these risk factors
Teach the offender to recognize when his risk is increasing
Teach the offender to properly manage and express feelings as an alternative to offending
For most of the offenders that we treat, a unique series of events and feelings led to their sexual crimes. We generally think of these events as risk factors that occur with some degree of repetition (i.e., a cycle) and lead ultimately to sexually coercive and aggressive behavior Although these risk factors do not always lead to a sexual offense, they do place the individual at high risk to commit an offense. These high risk factors, co-occurring with opportunity, are likely to lead to some form of relapse.
An offense chain can be thought of as having four stages. Stage 1 is characterized by life stressors that lead to very distressing or disturbing feelings. Stage 2 is characterized by high risk situations (the presence of or increased opportunity for contact with a victim). Stage 3 is characterized by lapses or risky behaviors that come right before relapse (fantasies about victims, arousal to those fantasies and distorted thinking that permits acting on the fantasy). Stage 4 is relapse (reoffense).
Our task as clinicians is to identify, as accurately as possible, the risk factors that exist for each offender and to help him internalize those factors so that they become a part of his conscious awareness. The offender must learn to recognize when he is at risk and when the risk is increasing. Metaphors are simple. For instance, if we are at risk to get poison ivy, then random walks through the woods place us at risk. Therefore, going for a stroll in the woods becomes a risk factor. Avoiding the woods and learning what poison ivy looks like are obvious strategies for reducing risk.
Obviously, the risk factors that are associated with behaviors such as sexual aggression are much more complex and are more difficult to identify accurately. It is critical to remember that these risk factors not only will be different for everyone, but they can, quite literally, be anything.
Often, risk factors involve activities that are technically legal (such as hanging out at a bar, "cruising" near school grounds, being gainfully employed as a carnival worker, a school bus driver or a camp counselor, etc.). Indeed, risk factors may even involve normative activities, such as having "normal" sex with an "of age" consenting partner. Because these activities are legal and/or normative does not mean that they are not risky. It is not our task as therapists to make value judgments or legal judgments about a given behavior. It is our task to clearly identify those high risk activities and to help offenders avoid them.
Although we must never minimize the difficulty of changing hard-wired, long-standing behavioral responses, what we ask of offenders is relatively simple: to recognize the links between their behaviors and a maladaptive (or bad) outcome (sexual crimes). They do not have to understand the origins of the behavioral responses. It is not, therefore, necessary to understand why poison ivy causes an irritating rash in order to avoid the plant. Thus, we do not ask our patients to engage in insight-oriented therapy. If they are capable of developing insights into their behavior, so much the better. Insight is, however, a higher level demand that is out of reach for many offenders. By way of comparison, cognitive-behavior therapy is very practical and behavior-oriented. It deals with everyday events that offenders understand (getting into a spat with your wife, girlfriend or boss, then going to a bar to drink it off, starting to think about ways of getting home, and getting into your car, high, and starting to cruise).
Perhaps the greatest challenge that therapists face is getting offenders to experience, properly manage and express their feelings. The reason that this is so critical is that feelings (often sadness, loneliness, rejection, resentment and anger) are usually the fuel that drives an offense cycle. Feelings are often the first risk factor that puts an offense cycle in motion, and feelings often drive and sustain the cycle until an offense is committed.
