Treating Sex Offenders in a State Hospital

As an avid reader of Psychiatric Times, I have followed the controversy surrounding civil commitment of sex offenders. I have noticed that those who oppose it have little or no experience treating sex offenders in an institutional setting. I want to share the experience of our state hospital staff, with the hope of stirring up some debate and perhaps opening a few minds.

Logansport State Hospital has a 22-bed unit dedicated exclusively to the treatment of sex offenders. All individuals on the unit are under civil commitment for mandatory treatment. The program is labeled the "Sexual Responsibility" unit. Responsible sexual behavior is the goal of treatment. Labeling the program the "Sex Offender" unit would be an inappropriate use of emotionally charged words.

In the unit's eight and a half years of existence, the re-offense rate has been less than 10% for individuals who successfully completed the program and entered the community, based on conversations with mental health care centers and known arrests. This recidivism rate for sex offenders seems better than the relapse rate for patients with schizophrenia or bipolar disorder treated in a typical state hospital.

It is inappropriate to waste precious health care dollars treating patients with schizophrenia in a state hospital due to the lack of long-term efficacy and the high relapse rate. I say this tongue in cheek, but those who argue against state hospital treatment of sex offenders need to demonstrate that resources spent treating sex offenders provide less benefit than resources spent treating those "deserving" of state hospital care. I detect a lot of countertransference (in the broad sense) and very little evidence when I hear arguments against civil commitment of sex offenders. If chronic shoplifting or temper problems can be considered psychiatric disorders, why not sex offenses? A particular constellation of behaviors can be both a psychiatric and criminal issue. If our expertise can be used to modify maladaptive behavior patterns, then those behavior patterns are worthy of our professional attention.

Key elements of our program include stimulus avoidance, development of personal prevention plans, gaining insight into the circumstances in which one is at high risk of re-offending, and treating the disorder as a chronic unremitting condition. Due to small sample size and selection bias, we can only provide the reader with some educated and possibly idiosyncratic guesses about the prognostic features of mandatory sex offender treatment through civil commitment. We hope to have an adequate discharge sample for regression analysis in the future, but selection bias will always remain an issue.

• Ego-dystonic pedophilia seems to be a good prognostic feature.

• Pedophiles who masturbate to pedophilic fantasies or smuggle pictures of children onto the unit have a poor prognosis.

• A strong religious commitment in a nonpsychotic individual seems to be a protective factor against further offenses after lengthy institutional treatment.

• Psychiatric comorbidity is the rule. Individuals with comorbid psychiatric disorders of any type do as well as those without comorbidity, provided the comorbid disorder is stable and substantially improves during treatment. However, more than one or two comorbid disorders worsen the prognosis.

• People with schizophrenia in remission or residual phase without prominent negative symptoms seem to do well in achieving treatment goals. Patients with chronic active psychotic symptoms have never successfully completed the program, perhaps due to the cognitive demands required to develop a prevention plan and gain insight into when one is at high risk, or "high in one's cycle."

• Individuals with personality disorders don't do as well as psychotic individuals in a residual/remitted state unless the personality disorder substantially improves during treatment. Treatment of patients with personality disorders seems to be lengthier than the treatment of previously psychotic individuals in a remitted/residual state.

• The number of offenders with a current or past diagnosis of attention-deficit/hyperactivity disorder (ADHD) is higher than one would expect in a typical state hospital population. Provided those offenders are of normal intelligence with good control of their ADHD symptoms, they have a good prognosis.

• Individuals who spent a substantial amount of time planning or thinking about sex offenses are high risk. Impulsive or poorly planned sex offenses are a good sign, particularly after some prison time and several years of treatment.

• Antisocial personality traits are a poor prognostic feature, primarily related to lack of motivation and remorse.

• Borderline intellectual functioning does not seem to interfere with the achievement of treatment goals, but progress is a little slower in these individuals.

• Individuals who are severely lacking in, or are unable to acquire through treatment, basic adult social skills seem to be at higher risk. Individuals who are basically solitary and do not generally enjoy the company of other adults are high risk.

• Sex offenders from prison, particularly those who were not high on the pecking order, seem to be more cooperative and maintain a better attitude initially during treatment, compared to those referred directly from the courts. Individuals referred from other mental health care agencies without involvement of a criminal court are the least motivated initially.

If you or your organization is interested in developing a sex offender treatment program, congratulations! I wish to welcome you to the cutting edge of psychiatric care. Treating sex offenders has the added benefit of guaranteeing full beds and minimal competition from other treatment providers. Taxpayers and governing bodies at this time seem willing to spend money for mandatory sex offender treatment. The following paragraphs may be useful in planning or developing your own inpatient sex offender program.

Funding organizations must understand that proper sex offender treatment is costly and time-consuming. If the funding organization is not aware of this, a facility could find itself in trouble when unrealistic expectations are not met and the next state budget is being prepared. Some states may actually prefer long stays and perhaps a lifetime of treatment if the patient continues to meet commitment criteria. Try to clarify this issue from the beginning so you can determine which individuals are appropriate for your program. If your state wants you to take the hardest of the hard core, and there is no concern over length of treatment, then you can eliminate selection bias and better clarify treatment and recidivism issues for the rest of us.

Our average length of stay is well over two years. If we included people who were transferred to other units but remained in the hospital, our average length of stay would be significantly longer. It is easy for sex offenders to con their way through a limited-stay program. It is much harder to keep the con going for several years. Understand from the beginning that there may be individuals who should never leave an institutional setting in spite of careful scrutiny at the outset for motivated individuals with good prognostic features. Some can be dangerous both to others and your career if you are in a hurry to discharge them. Ideally you will have step-down units and comprehensive outpatient care. Most likely, you will have no community support and will meet resistance when referring even your lowest-risk patients to outpatient care. Length of stay could be decreased substantially with comprehensive, competent outpatient care and residential treatment for motivated sex offenders.

Aggressively treat comorbidities. Unstable or severe psychiatric comorbidity of any type increases the risk of relapse and/or failure to achieve treatment goals. Offer hormonal treatment, psychiatric management, and specialized psychological and behavioral therapies. Most patients who need hormonal therapy will voluntarily take leuprolide (Lupron) if approached in the right way. Many sex offenders are willing to do anything possible to avoid re-offending.

Forcefully advocate criminal sanctions for those who relapse during or after treatment. Develop a working relationship with the local prosecutor from the beginning. Sex offenders should have only one chance. If they believe further recidivism will result in admission to a nice, clean psychiatric facility, then the risk of relapse increases. Sex offenses are a psychiatric and criminal issue. Our patients understand we will advocate for a lengthy prison sentence (life preferably) for those who commit a serious sex crime. Pedophiles in our program are aware that they run a higher than average risk of injury or death in prison. We clip newspaper articles showing lengthy sentences for repeat offenders. We use every tool available to reduce relapse, including our view of reality.

Trust your judgment if countertransference is under control. Sex offenders cannot hide their true self when monitored 24 hours per day for several years. You will eventually realize who is trying to con you and who is committed to treatment (no pun intended). Some con artists eventually take treatment seriously and begin to make a sincere effort. Avoid making quick judgments on any individual. After all, you have several years to make any major decisions.

Finally, you may be surprised by your enjoyment of the work. Most pedophiles can be fairly likable and motivated for treatment, provided you select those with good prognostic features and treat them with respect in a humane, enriched environment. Psychiatric care of the standard hospital patient in modern times is not much different than working on an assembly line. If you are bored with factory work, then developing a sex offender program may reinvigorate your career.

Did I stir up any debate? I hope so!