Excerpt pages 25 to 33 on sex offender treatment, effectiveness and cost
Association for the Treatment of Sexual Abusers
I. Treatment of Adult Sex Offenders
3. Effectiveness • Does Treatment Work? A popular misconception is that “nothing can cure a sex offender.” This myth can be traced largely to a paper published by Lita Furby in 1989. Furby's paper, however, focused on the lack of sophisticated, reliable data with which to evaluate treatment regimes. It concluded only that evidence of the effectiveness of psychological treatment was inconclusive. Politicians and the mass media picked up this judgment, often converting it to the claim: "Nothing Works!"
100 That conclusion, however, is against the general weight of the evidence. Most research shows that sex offenders do indeed respond positively to treatment. A comprehensive analysis by Margaret Alexander of the Oshkosh Correctional Institution found far more studies reporting positive results than otherwise.
101 Despite the efforts of many talented clinicians through the past several decades, the question of whether sex offender treatment works is still hotly debated. Part of the problem is that relatively few well-designed studies of treatment effectiveness have been conducted. Opportunities for controlled experimentation in this field are rare, largely because of the major investment of time and resources that follow-up studies require. Also fueling the debate is the fact that although the question, "Does sex offender treatment work?" is an empirical one, nearly everyone already seems to have an answer. As a result, experts in this field – perhaps more so than in any other – find that answers based on outcome data are not always welcome.
102 Given these obstacles, progress in the area of determining the effectiveness of sex offender treatment has been slow. Nonetheless, it is clear that continuing efforts to measure and report treatment outcomes is the best way to improve the quality of the debate. Not only is there a need for solid information regarding the overall effect of treatment on sex offenders, but also for answers to more specific (and probably better) questions such as: Which treatments work with which kinds of offenders? What is the optimal combination of inpatient and aftercare services? How do we determine when offenders are ready for less restrictive treatment environments?
103 • Research Findings Several attempts have been made to evaluate the effectiveness of treatment programs.104 Studies on SO recidivism vary widely in the quality and rigor of the research design, the sample of SOs and behaviors included in the study, the length of follow-up, and the criteria for success or failure. Due to these and other differences, there is often a perceived lack of consistency across studies of SO recidivism. For example, there have been varied results regarding whether the age of the offender at the time of institutional release is associated with subsequent criminal sexual behavior. Different studies have reached different conclusions, including:
o there was no relationship between age and criminal sexual behavior;
o that younger offenders were more likely to commit future crimes;
o that older sex offenders are more likely to have a more developed fixation and thus are more likely to reoffend;
o that those serving longer periods of incarceration had a lower recidivism rate;
o that those serving shorter periods of incarceration had a lower recidivism rate.
105 For the most part, there is little consistency in the conclusions drawn from meta-analyses and literature reviews with regard to the effectiveness of sex offender treatment on reducing recidivism.
The recent reviews and meta-analyses concerning the efficacy of sex offender treatment provide conflicting viewpoints. Some studies found that there was "no convincing evidence that treatment reduced recidivism" rates among sex offenders, while others concluded that treatment does positively affect recidivism among treated sex offenders.
107 Just as it is difficult to arrive at definitive conclusions regarding factors that are related to sex offender recidivism, there are similarly no definitive results regarding the effect of interventions with these offenders. Sex offender treatment programs and the results of treatment outcome studies may vary not only due to their therapeutic approach, but also by the location of the treatment (e.g., community, prison, or psychiatric facility), the seriousness of the offender’s criminal and sex offense history, the degree of self-selection (whether they chose to participate in treatment or were placed in a program), and the dropout rate of offenders from treatment
.108 To a large degree, the variation across individual studies can be explained by the differences in study populations. Schwartz and Cellini (1997) indicated that the use of a heterogeneous group of sex offenders in the analysis of recidivism might be responsible for this confusion: “Mixing an antisocial rapist with a socially skilled fixated pedophile with a developmentally disabled exhibitionist may indeed produce a hodgepodge of results.”
109 There are too few studies focusing on particular types of sex offenders (e.g., exhibitionists, child molesters, adult rapists, and high-risk sex offenders) to enable the authors to draw conclusions about the effectiveness of the programs for different types of sex offenders. This is important to consider when attempting to draw conclusions about what is effective for reducing recidivism among sex offenders. More specifically, sexual offenders vary with regard to the type and number of victims they target. For instance, a study of adult rapists found that, on average, a rapist had attacked 7.5 victims, whereas the average number of attacks among child molesters was found to be at least 10 times that number (i.e., approximately 75 victims per offender). It cannot be assumed, therefore, that programs that are effective with exhibitionists will automatically transfer and be effective with rapists or child molesters.
110 Though more research is always helpful and needed, enough is now known to draw some broad conclusions: treated or untreated, few sex offenders reoffend after being caught. Sex offenders actually reoffend less than other types of offenders, and treatment works to lower reoffense rates.
111 The public trial, shame and humiliation of getting caught appears to deter most sex offenders from further misconduct. Sex offenders who have been identified, convicted and punished probably present less of a threat to society than do most other offenders.
112 A number of studies have produced findings that suggest that sex offender treatment does help reduce recidivism. A study was conducted in 1999 that included an analysis of a large group of treatment outcome studies, encompassing nearly 11,000 sex offenders. In this study, data from 79 sex offender treatment studies were combined and reviewed. Results indicated that sex offenders who participated in relapse prevention treatment programs had a combined rearrest rate of 7.2 percent, compared to 17.6 percent for untreated offenders. The overall rearrest rate for treated sex offenders in this analysis was 13.2 percent.
113 In 1995, a meta-analysis was conducted consisting of 12 sex offender treatment studies, which compared treated and untreated offenders. The study found that the treated sexual offenders had fewer sexual rearrests (9 percent) than the sexual offenders in the control group (i.e., the group not receiving treatment) (12 percent).
ATSA has established a Collaborative Data Research Project with the goals of defining standards for research on treatment, summarizing existing research, and promoting high quality evaluations. As part of this project, researchers are conducting a meta-analysis of treatment studies. Included in the meta-analysis are studies that compare treatment groups with some form of a control group. Preliminary findings indicate that the overall effect of treatment shows reductions in both sexual recidivism, 10 percent of the treatment subjects compared to 17 percent of the control group subjects, and general recidivism, 32 percent of the treatment subjects compared to 51 percent of the control group subjects.
114 Another study compared the long-term recidivism rates of 296 high-risk sex offenders with a stratified matched sample of 283 incarcerated sex offenders. The follow-up period was, on average, six years. The study measured sexual and nonsexual reconvictions as the outcome variable, and found that sex offenders in the treatment program had a lower proportion of sexual offenses
(regardless of the penalties incurred) (14.5 percent) compared to the control group (33.2 percent). Also, the findings indicate that sex offenders in the treatment program had a lower proportion of sexual reconvictions that resulted in a return to federal prison (6.1 percent) than the control group
(20.5 percent). Both of the findings regarding sexual reconvictions are statistically significant.
115 Yet another study found a substantial difference in the recidivism rates of extra-familial child molesters who participated in a community based cognitive-behavioral treatment program, compared to a group of similar offenders who did not receive treatment. Those who participated in treatment had a recidivism rate of 18 percent over a four-year follow-up period, compared to a 43 percent recidivism rate for the nonparticipating group of offenders.
116 The conclusion that treatment reduces recidivism can be refined further by distinguishing between different kinds of sex offenders. Treatment cuts the recidivism rate among exhibitionists and child molesters by more than half, yet cuts recidivism among rapists by just a few percent. Juveniles respond very positively to treatment, indicating that treating sex offenders as soon as they are identified can prevent an escalation of their pathology.
117 Another study found that child molesters who participated in a cognitive-behavior treatment program had fewer sexual rearrests than the sex offenders who did not receive any treatment. Both groups of offenders were followed for up to 11 years. The recidivism data was obtained not only through official sources (i.e., police records) but also through unofficial reports (i.e., self-reports). Sex offenders in the cognitive-behavioral treatment program had significantly fewer sexual rearrests than the untreated sex offenders (13.2 percent vs. 34.5 percent, respectively).
118 A study comparing the recidivism rates of exhibitionist offenders in a cognitive-behavioral treatment program with sex offenders who did not receive any treatment found that, after a fouryear follow-up, treated exhibitionists were reconvicted or charged with a sexual offense less than the untreated exhibitionists (23.6 percent vs. 57.1 percent, respectively).
119 Other studies do not produce such positive results. One study examined the long-term recidivism rates of 197 child molesters released from maximum-security prisons between 1958 and 1974. The follow-up period for both treated and untreated child molesters spanned up to 31 years. The study measured sexual and nonsexual offense recidivism as the outcome variable. Recidivism was determined as a reconviction for a sexual offense, violent offense, or both. The study found that offenders in the treatment program had fewer reconvictions (44%) than offenders who were incarcerated prior to the inception of the treatment program (48%) but not compared to offenders who were sentenced to the same institution, at the same time, as the treatment group but did not participate in treatment (33%). These differences are not statistically significant.
120 In addition, no positive effect of treatment was found in several other quasiexperiments involving an institutional behavioral program (Rice, Quinsey, and Harris, 1991) or a milieu therapy approach in an institutional setting (Hanson, Steffy, and Gauthier, 1993)
4. Costs and Benefits With respect to the costs of sex offender treatment, psychological counseling is expensive, but not as expensive as prison. The average cost of building a new prison cell is about $55,000 and the average cost of operating it for a year is $22,000. A year of intensively supervised probation and treatment may cost between $5,000 and $15,000 per year, depending on the regimen. Thus, a full year of treatment costs far less than an additional year of prison.
122 Treated offenders can generally be fully integrated into society as normal productive citizens after completing treatment. Offenders in prison, on the other hand, will continue to cost taxpayers $22,000 a year for as long as they are incarcerated, perhaps even the rest of their lives. Treatment is therefore an essential means of protecting the community at a relatively affordable cost.
123 The Washington State Institute for Public Policy (Institute) released a document in May of 2001 that describes the “bottom-line” economics of programs that try to reduce crime. The Institute systematically analyzed evaluations of prevention programs produced in the United States over the last 25 years, independently determining whether program benefits, as measured by the value to taxpayers and crime victims from a program’s expected effect on crime, are likely to outweigh costs.
124 What follows is an overview of their findings regarding the costs and benefits of Cognitive- Behavioral Sex Offender Treatment. The principle findings from their review are summarized on Table 1. All monetary figures are expressed in 2002 dollars. The table includes five columns, each describing different results from the analysis.
125 • The first column shows the number of studies that was reviewed in determining the crimerelated effects for Cognitive-Behavioral Sex Offender Treatment. This is the number of studies that passed the Institute’s minimum research design standards to be included in the analysis.
• The second column contains two numbers: the average “effect size” that they expect for the treatment program and the associated “standard error” of the estimated effect size. The effect size is a summary statistic measuring the degree to which research evidence indicates the program can affect an outcome, in this case, crime. A negative effect size means the program reduces crime.
• The third column shows the estimated net direct cost of the program, per program participant. The cost estimate is a “net” estimate because some programs have an immediate displacement of other program costs. Note, however, that this cost is only up-front – it does not include the present value of any downstream costs stemming from the program’s effect on crime or recidivism rates.
• The fourth and fifth columns provide the main results of the analysis. These are the estimated net economics of the program – that is, the benefits that the program is expected to produce in terms of future crime reduction, less the costs of the program as listed in column (3). The Institute analyzes benefits from the perspective of the taxpayer and the crime victim. For the taxpayer view, the question is whether spending a taxpayer dollar now on a program will save more than a taxpayer dollar in the years ahead. Adding the crime victim view, if the program can reduce rates of future criminal offending, not only will taxpayers receive benefits but there will also be fewer crime victims. Column (4) shows the taxpayer-only perspective while column (5) provides an estimate that includes taxpayer and crime victim benefits. Thus the information on column (5) provides that broadest public policy implication afforded from the analysis in the report
.126 Table 1: Summary of Program Economics127 Number of Program Effects in the Statistical Summary Average Size of the Crime Reduction Effect Net Direct Cost of the Program, Per Participant Net Benefits Per Participant
(i.e., Benefits minus Costs) Lower End of Range: Includes Taxpayer Benefits Only Upper End of Range: Includes Taxpayer and Crime Victim Benefits Adult Sex-Offender Treatment Programs
(compared to no treatment) Cognitive-Behavioral Sex Offender Treatment 7 -0.11 (0.05) $6,504 -$810 $20,339 The Institute studied the sex offender evaluation treatment literature by separately analyzing several different types of sex offender treatment. These categories include:
o Cognitive-behavioral sex offender treatment
o Psychotherapeutic approaches
o Behavioral approaches
o Chemical treatment
o Surgical treatment
For this cost-benefit review, however, they only estimated the effects and the economics of cognitive-behavioral sex offender treatment programs. This treatment modality has emerged as the principal type of sex offender treatment and most recent evaluations of sex-offender treatment have been conducted on this type of program. The cognitive-behavioral approach targets reducing deviant arousal, increasing appropriate sexual desires, improving social skills, and modifying distorted thinking. The treatment occurs both in-prison and in the community.128
The Institute's review of the international research found that relatively few sex offender programs have been evaluated, and fewer still have a strong research design. Using the Institute's weighting scheme to combine the seven studies that met their minimum research design requirements, the evaluations have an average effect size of -.11 (standard error .05) for overall recidivism, and a slightly higher effect size (-.13, standard error .04) for sex crime recidivism. This difference is taken into account when the Institute calculates the costs and benefits.129 They estimate that the typical cognitive-behavioral sex offender treatment program costs about $6,246 per participant.
At that price, taxpayers don't break even (-$788 net present value per participant). There is, however, a substantial positive benefit when the crime victim perspective is included. The total estimated net present value is $19,534 per programs participant, producing a benefit to cost ratio of $4.13 of benefits per dollar spent on the typical program. The reason the benefits increase quickly when the crime victim perspective is included is that sex offenders tend to specialize in sex offenses, which are very costly to crime victims.
Thus when sex treatment programs are successful in lowering recidivism rates, especially sex offense recidivism rates, the benefits to society increase significantly.130 Their conclusion is that the average cognitive-behavioral sex offender treatment program is costbeneficial. That is, compared to not treating sex offenders with this approach, the typical cognitivebehavioral sex offender treatment program saves more than it costs.131
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