How to Establish and Maintain Security in the Treatment of Sexual Offenders
[Sexual Offender Treatment, Volume 1 (2006), Issue 1]
The title of the 8th conference of the International Association for the Treatment of Sexual Offenders (IATSO) held in Athens, Greece, October 6-9, 2004, was Sex Offending is Everybody’s Business. In the opening address of the conference, reported here, this general motto is first reflected in a historical perspective before the question of how security in the treatment of sexual offenders may be established and maintained is discussed on a number of different levels. These levels are (1) practical ones, listing what IATSO has been and will be doing in pursuit of establishing and maintaining security; (2) political ones reflecting the context in which such endeavors are undertaken; and (3) psychotherapeutic ones.
Key words: sex offenders, treatment, security
To state that sex offending is everybody's business sounds trivial, like carrying coals to Newcastle, or - as the German saying is - owls to Athens. The origins of Greece go back to the Olympus, the place where the Gods played their sexual and power games, Godfather Zeus first and foremost (for the following details cp. Graves, 1999, Ranke-Graves, 1960). Had Arachne‘s embroidery been conserved by history, we would have a kind of video documentation of his many sexual outlets of which but a few highlights may be mentioned here: His first wife was Metis. When she was pregnant he became so frightened that he devoured her, a first case of vivisectiocannibalism combined with killing the partner and his own unborn child. He then courted Themis and had (at least) four children with her before he turned to an incestuous relationship with his sister Hera to whom he had found access by the metamorphosis into a poor little cuckoo, lost in a snowstorm, so that Hera took him to her breast to shelter him where he then returned into his male shape. Later, Zeus repeated such adventures in the gestalt of a swan and a bull – a taurós – to rape and impregnate a number of other women. Obviously Zeus did not yet know the difference between intercourse and impregnation and he did not dispose of modern contraceptives. Instead, he initiated parthenogenesis without intercourse by giving birth to Pallas Athene from his head.
Pallas Athene stayed a virgin, never gave birth to a child. Most attendants of the conference will have seen her temple on the Acropolis, the Parthenon temple. One should not deceive oneself; the virgins originally posted there were kidnapped by the English and are now detained in the British Museum in London. Kidnapping of virgins is a very modern sex offence. It is not a joke. Rape in war times produces most rapists and victims of rape. Only rarely is it tackled by sex research or treated in sex offender programs, although it might teach much about the most ordinary personality structure of many rapists. In war times, sex offending is truly everyman‘s business when the combating parties meet each other on a personal level and not only men but even women turn, as could just be learned again from prisons in Iraq, into sadistic perpetrators.
In the old times of Zeus it was everybody's business to know what was happening on the Olympus. One might insinuate that the stories about his sexually deviant behavior also described an ideal model of such behavior. Obviously he was never prosecuted and never sanctioned for his outstanding sexual activities. He was almighty and free to do sexually whatever he wished. And that is what he finally did. Everybody was fascinated by him, admired and perhaps even envied him for the privilege of his power.
Instead of discussing the short intermezzo of the Christian tradition, one might want to focus on our present situation. Some of the old power has been pulled down. Heterosexual intercourse and pregnancy have become two separate things. Most people have enough power to sexually do what they wish as often as they wish and with whom they wish. Lust and satisfaction are democratized and the responsibility for pregnancy can be easily controlled. If they do not succeed in being loved by their partner, people may travel to other countries and behave like gods empowered by their money. Or they may buy a video, switch on TV, or download the bacchanalia from the internet at home. This is everybody's right.
At this point in time it has to be considered what kind of sexual behavior should be prohibited and sanctioned when now everybody has the right and the power of gods. As far as it is known, Zeus had no inclination or preference for children. That may, however, be due to the fact that children did not count in those days. The long-lasting childhood and adolescence that we now experience is a result of the Western process of individuation which started only two or three centuries ago (Ariès, 1982). In times of peace, our societies do not accept rape, sexual murder and cannibalism. Considering a recent court ruling in a case of cannibalism in Germany where the perpetrator was not sanctioned for sexual murder as the victim had consented to the act, one might ask if we are presently looking for new boundaries or if we are more interested in those ‘everybodies’ who set the boundaries according to their individual likening, to their narcissism and sensation-seeking.
The goddess of love, Aphrodite, was born in Cyprus: This island is presently divided. Whenever people do not want to share their prosperity and peaceful life, they draw a boundary, divide the state. One part of Cyprus is now part of the European Union, the other one is not: The Eastern neighbor Turkey wants to join the European Union. Interestingly enough, the international public opinion or ‘everybody’, frowned at Turkey's intention to again criminalize adultery in Turkey. Zeus does not appreciate that, although the Christian world should be expected to agree to the Turkish intentions according to their own morals. Due to the pressure exerted by the European Union, Turkey has dropped the draft of the new law on adultery. Adultery shall not be criminalized. Because this kind of sex is everybody's business, was it in everybody's interest in the European Union not to criminalize such behavior, and not even the Pope protested.
In essence it can be stated that those in power decide what shall be defined as a sexual offence. This seems to have been the most important criterion in the course of history. When treating sexual offenders we should be aware of that and of the double meaning of everybody's business.
Establishing and maintaining security
The International Association for the Treatment of Sexual Offenders (IATSO) is not quite as old as the Olympus but started with the initiative of Margretta Dwyer and Eli Coleman who set up the first international conference in Minneapolis, Min., U.S.A., in 1989, followed by two further conferences in the same city in 1991 and 1993. In 1995, the 4th conference was held in Amsterdam, The Netherlands, the 5th in 1998 in Caracas, Venezuela, the 6th in 2000 in Toronto, Canada, and the 7th in 2002 in Vienna, Austria. IATSO was founded as an organization in its own right in March 1998 during the 5th International Conference on the Treatment of Sexual Offenders in Caracas, Venezuela.
The statutes of IATSO advocate for
- humane, dignified, compassionate, ethical, and effective treatment of sexual offenders
- furthering the knowledge about the individual and social conditions that lead to sexual offending, and
- improving treatment methods, evaluate them scientifically, and spread them wherever they are needed.
The members of IATSO are convinced that
- sexual offender treatment and research is enhanced through international communication
- treatment will result in the reduction of recidivism and victimizations thus enhancing public security
- punishment is not a sufficient deterrent for sexual crimes, and
- treatment is a human right.
Although the membership is yet still small, – professionals are invited to join IATSO – the outreach of the organization is however large. How is this achieved? By publishing Standards of Care for the Treatment of Adult Sex Offenders (Coleman et al., 2001), abstract books of the conferences (Giotakos et al., 2004, Eher & Pfäfflin 2002), and selected papers (Eher et al., 2003), as well as exchanging manuscripts, and, most important, mutual visits for training, supervision, and practical learning from each other.
To give just one example: In recent years, the Catholic Church was faced with a great number of court cases against priests and religious being accused of the sexual abuse of minors. Especially in the United States of America victims of sexual abuse succeeded in achieving high sums of financial compensation which added to the moral damage of the priests’ and religious’ behavior large financial damage to the Church. The 7th IATSO conference in 2002 in Vienna was attended by an observer from the Vatican to get information about treatment options for their transgressing staff. A number of IATSO members, having presented at the Vienna conference, and some other experts were invited to the Vatican in April 2003 to discuss preventive strategies and treatment options for the clergy. The results of this consultation were published in 2004 (Hanson et al., 2004) and distributed to all Catholic bishops as guidelines for handling the problem within the Catholic church.
The example just mentioned is not only a practical but also a political one. IATSO is very effective as regards treatment programs and the scientific evaluation of treatment outcomes.
It is not, however, as yet, effective in stopping the prevailing politics in the Western world and elsewhere to incarcerate more and more sexual offenders in either prisons or high security psychiatric forensic clinics for longer and longer times although in many cases adequate outpatient treatment programs would be as effective or even more effective.
Picking up the slogan sexual offending is everybody's business one has to be cautious. Not everybody is, in fact, an expert, and some self-declared experts are dangerous for the whole field, e.g. the present German Chancellor. When recently asked, what to do with sexual offenders, he publicly suggested locking them up forever. From a psychotherapist's point of view, this is a nihilistic position and counter to the convictions, evidence, and intensions of the IATSO membership. Similarly, in Switzerland, there was a public poll in 2004, asking everybody about their opinion on what to do with sexual offenders, and the majority voted in the same direction as the German Chancellor.
Some German States, e.g. Bavaria and Baden-Württemberg, have passed laws in recent years allowing a court to order indefinite detention for sexual offenders not only in the trial where their sentence is passed, but even at the end of the time when the prisoner has served his full sentence. When two psychiatric experts and the court come to the conclusion that the prisoner is still dangerous, state laws allow indefinite detention. These state laws were brought before the Federal Constitutional Court of Germany, which ruled in February 2004, that they were unconstitutional, but for formal reasons only, because the individual German States lacked the competence to issue such laws, only the Federal Parliament could do so. The Federal Constitutional Court of Germany did non challenge the content of the respective rulings, however, and authorized holding prisoners behind bars until the passing of a new law by the Federal Parliament, which rapidly happened in July 2004.
In the United Kingdom, an up-date of the Mental Health Act pointing in the same direction is being presently discussed, possibly allowing indefinite detention under civil commitment after having served the full sentence of a criminal court. It is with great concern that we observe the shift from laws sanctioning certain acts that have actually occurred to preventive unlimited detention, regardless of whether this is ruled by criminal law or by mental health acts.
It is unlikely that the European Court of Human Rights will stop this development because it can only interfere if national law is broken and human rights are obviously violated. One and a half years ago, I was called as an expert to visit prisons, mental hospitals and border camps in a country of the former Soviet Union together with the Committee for the Prevention of Torture and Inhuman and Degrading Treatment (CPT) of the Council of Europe. Having seen the mostly disastrous living conditions of the detainees, I cannot imagine that anybody will improve or stop his deviant sexual behavior when detained there. It is welcome that the European Committee on Crime Problems of the Council of Europe has now started an initiative to improve such conditions as was explained in the contribution of Mrs. Taneva in her welcome address to this conference.
Psychotherapy with sexual offenders is effective and reduces recidivism, i.e. new victimization of other persons in a statistically significant manner. It is not everybody's business but needs qualified staff. This is certainly its major goal: to contribute to public safety. This goal can however only be reached when the patient/client/prisoner sexual offender is respected and treated with dignity.
Control, no cure has become the slogan for sexual offender treatment during the last decade, and one may readily subscribe to that aim. For many perpetrators it is an aim they also can live with, especially so when the steps towards reaching the goal are operationalized and when they can observe and measure their progress themselves. The slogan control no cure was once polemically coined against a psychoanalytic and psychodynamic approach that aimed at structural change of the personality and at cure much more than at removing or reducing symptoms.
Aversive techniques were the first behavioral steps to tackle symptoms, e.g. sexually deviant behavior, and at a first glance they seemed to work. In the long run, however, they are not successful. On the contrary, they are harmful and even may increase recidivism. The cognitive behavioral approaches applied nowadays – there will be many respective contributions during this conference – are much more refined.
The different schools of thought in psychotherapy have much more in common than quarrels between the various schools may suggest. They can be summarized in four major factors which promote insight and behavioral change (the following list parallels cognitive-behavioral terminology with psychodynamic terminology):
- problem actuation – transference
- clarification of meaning – interpretation
- mastery/coping – working through
- activation of the patients’ resources.
There is much more empirical evidence for the effectiveness of cognitive behavioral than for psychodynamic and psychoanalytic treatments programs. When one evaluates the evolution of cognitive-behavioral theory and practice over the last three decades, and when one is familiar with psychodynamic theory and practice, one will, however, easily observe, that there are many more similarities than differences between the schools although the terminology and practical procedures may differ widely. Here, interpreters are needed, enhancing mutual understanding instead of wasting time for fighting each other. There is much to learn from each other.
A theory and practice fruitful for both or all approaches in psychotherapy and also for sexual offender treatment is attachment theory, originally developed as a split-off branch from psychoanalysis and other sources by Bowlby (1969), then experimentally tested in infant research by Ainsworth et al. (1978) and in work with adults by Main and co-workers (Main & Goldwyn, 1994) and many others (e.g. Fonagy, 2004). This approach is now eagerly assimilated and integrated by both cognitive behavioral as well as by psychodynamic clinicians (Pfäfflin & Adshead, 2004).
Most outcome criteria today are drawn from statistical data. They give important hints concerning where to go and how to improve our techniques. Nothing at all or only little do they tell about the needs of the individual perpetrator, his history, his impasses and his resources. These will only be revealed in detail in direct clinical work. Burdensome as this may be, it is also rewarding. During my professional life I have met many excellent therapists from various backgrounds, but most of them never write up the stories of their patients. Checking my own writings on the treatment of sexual offenders, I was amazed to find that I also mostly wrote case vignettes only when there was a critical stalemate in the treatment with the specific offender, a kind of impasse. Therapists seem to shy away from writing about their successes, be it that many of these stories are so specific that the anonymity of the patient cannot be guaranteed, or be it because, when the patient is cured, there is no longer much to say about him and the work with him. The aim is reached, he mourns about what he did, and the therapist mourns about what he experienced in the work together. There is nothing spectacular to talk about any more. As an aside: The afternoon before this conference was opened, I was asked by a Greek TV-journalist to say something about my most violent, most spectacular case. I refrained from doing so as I did not want to re-spectacularize a history that had come to a good end. It took me about five years to produce the special issue of the German journal Recht & Psychiatrie (Law and Psychiatry), collecting case reports of sexual offender treatments from various backgrounds (psychodynamic, psychoanalytic, cognitive-behavioral) and various settings (out-patient, in-patient; in prisons and in high security mental hospitals; individual and group settings) often with unexpectedly good results (Beek & Kröger, 2004, Beek & Bullens, 2004, Gramigna, 2004, Mika, 2004, Preuss & Lietz, 2004, Schott, 2004). It is gratifying that a number of the authors are attending this conference. They did not describe miracles although some of the results may seem to be miraculous. What they described was their engaged and effective work with sexual offenders, some of whom – one would have thought in the beginning of the treatment – could never be cured.
As most of you will not read enough German, this paper shall be closed with the recommendation of a book by Alice Theilgaard, from Copenhagen, and the late Murray Cox from London, both group psychotherapists who have dedicated most of their lives to working with violent and sexual offenders and who have demonstrated how rewarding this can be, for the client, for the therapist and for society at large (Cox & Theilgaard, 1997).
- Ainsworth, M., Blehar, M., Waters, E., Wall, S. (1978). Patterns of Attachment: A Psychological Study of the Strange Situation. Hillsdale, NJ: Erlbaum.
- Ariès, P., Béjin, A., Foucault, M. (eds.) (1982). Sexualités occidentales. Paris: Edition du Seuil.
- Beek, D.v., Kröger, U. (2004). Ein kognitiv-verhaltenstherapeutisches Behandlungsprogramm für Sexualstraftäter in einer forensisch-psychiatrischen Klinik. Recht & Psychiatrie 22 (2): 74-84.
- Beek, D.v., Bullens, R. (2004). Manualisierte ambulante Gruppentherapie für pädosexuelle Straftäter. Recht & Psychiatrie 22 (2): 84-94.
- Bowlby, J. (1969). Attachment and Loss, Vol. 1: Attachment. London: Hogarth Press and the Institute of Psycho-Analysis.
- Coleman, E., Dwyer, S.M., Abel, G., Berner, W., Breiling, J., Eher, R., Hindman, J., Langevin, R., Langfeldt, T., Miner, M., Pfäfflin, F., Weiss, P. (2001). Standards of Care for the Treatment of Adult Sex Offenders. Journal of Psychology and Human Sexuality 13 (3/4): 115-121.
- Cox, M., Theilgaard, A. (1997). Mutative Metaphors in Psychotherapy. The Aeolian Mode. 2nd ed. London and Bristol, PA: Jessica Kingsley Publishers.
- Eher, R., Pfäfflin, F., Miner, M. (eds.) (2003). Sex-Offender Treatment. Special Issue of the International Journal of Offender Therapy and Comparative Criminology 47 (4): 361-488.
- Eher, R., Pfäfflin, F. (eds.) (2002). Sexual Violence and Sexual Abuse. From Understanding to protection and prevention. 7th confernce of the International Association for the Treatment of Sexual Offenders. September 11-14, 2002, Vienna, Austria. Forensische Psychiatrie und Psychotherapie. 9 (Suppl.): 1-168.
- Fonagy, P. (2004). The Developmental Roots of Violence in the Failure of Mentalization. In: Pfäfflin, F., Adshead, G. (eds.) A Matter of Security. The Application of Attachment Theory to Forensic Psychiatry and Psychotherapy. London, New York: Jessica Kingsley Publishers, pp13-56.
- Giotakos, O., Eher, R., Pfäfflin, F. (eds.) (2004). Sex Offending is Everybody’s Business. 8th International conference of the International Association for the Treatment of Sexual Offenders (IATSO), October 6-9, 2004, Athens, Greece. Forensische Psychiatrie und Psychotherapie. 11 (2): 1-200.
- Gramigna, R. (2004). Psychotherapie im Spannungsfeld zwischen Patientenbehandlung und Tätertherapie. Recht & Psychiatrie 22 (2): 56-62.
- Graves, R. (1999) The Greek Myths. Vol 1 & 2, 7th ed. London: The Folio Society.
- Hanson, R.K., Pfäfflin, F., Lütz, M. (eds.) (2004). Sexual Abuse in the Catholic Church. Scientific and Legal Perspectives. Proceedings of the conference „Abuse of Children and Young People by Catholic priests and religious“, Vatican City, April 2-5, 2003). Vatican City: Libreria Editrice Vaticana.
- Main, M., Goldwyn, R. (1994). Adult Attachment Rating and Classification System. Manual in Draft, Version 6.0. Unpublished manuscript: University of California at Berkeley.
- Mika, J. (2004). Sexualstraftäterbehandlung. Kasuistik einer psychodynamischen Einzeltherapie. Recht & Psychiatrie 22 (2): 51-56.
- Pfäfflin, F., Adshead, G. (eds.) (2004). A Matter of Security. The Application of Attachment Theory to Forensic Psychiatry and Psychotherapy. London, New York: Jessica Kingsley Publishers.
- Preuss, W., Lietz, K. (2004). Gruppendynamik und individuelle Psychodynamik im Hamburger Modell der Gruppenpsychotherapie für pädosexuelle Männer. Recht & Psychiatrie 22 (2): 67-73.
- Ranke-Graves, R.v. (1960). Griechische Mythologie, vol 1 & 2. Reinbek: Rowohlt.
- Schott, M. (2004). Unzerstörbare Liebesfähigkeit oder die Macht früher Erfahrungen. Eine psyhoanalytisch orientierte Langzeitbehandlung. Recht & Psychiatrie 22 (2): 62-66.
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