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Invited paper
A sex offender treatment group for men
with intellectual disabilities in a community
setting
John Rose, David Rose, Cliff Hawkins and Caitlin Anderson
Abstract
Purpose – This paper aims to provide a rationale for the development of a community-based group for
men with intellectual disability who have been involved in sexually inappropriate behaviour but may not
have been charged.
Design/methodology/approach – The group was based on a cognitive behavioural model: group
process and adaptations are briefly described. The group has been run on two occasions and
preliminary data on outcome are provided.
Findings – Participants show a reduction in attitudes consistent with offending, an increase in sexual
knowledge, and a more external locus of control on completion of the group. One of the 12 men who
attended was recorded as offending again within 18 months of group completion; however, three moved
to less well supervised placements.
Originality/value – It is concluded that this style of treatment has some advantages over other models
and may be more effective, yet further research is required.
Keywords Sex offenders, Intellectual disability, Cognitive behaviour therapy, Group work, Treatment,
Sexual behaviour
Paper type Research paper
Introduction
In many community services, staff in intellectual disability services work with people who
have engaged in behaviour that could have resulted in a conviction for a sexual offence.
However, due to the severity of their intellectual disability or other mitigating factors, they are
often diverted from the criminal justice system. In a recent audit of individuals with forensic
behaviours and an intellectual disability who were known to a community service in the UK
(Rose et al., 2008), only five of the 23 individuals in the sample who had been involved in
sexually inappropriate behaviours were prosecuted for their actions. A larger number (14)
had been subject to proceedings under mental health legislation. However, there is often a
lack of treatment options for these individuals, and if treatment is available, it is often located
within an institutional context well away from their normal place of residence. Many
individuals can still be deemed too disabled to benefit from conventional treatment
strategies (Langdon, 2010). Some individuals have no formal consequences placed on
them by the courts as a result of their inappropriate sexual behaviour, and even if there are
consequences such as admission to more secure accommodation, many remain untreated
and are discharged back into community settings (Langdon, 2010). As a result, they can be
left with no real prospect of effective active treatment. The suggestion has been made that
DOI 10.1108/14636641211204432 VOL. 14 NO. 1 2012, pp. 21-28, Q Emerald Group Publishing Limited, ISSN 1463-6646
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John Rose and David Rose
are both based at Black
Country Partnership NHS
Foundation Trust and The
University of Birmingham,
Birmingham, UK.
Cliff Hawkins is based at
The Black Country
Partnership NHS
Foundation Trust,
Wolverhampton, UK.
Caitlin Anderson is based at
Birmingham and Solihull
Mental Health Trust,
Birmingham, UK.
treatment is most likely to be effective when delivered in community settings and tailored to
the needs of the individuals concerned (McBrien et al., 2010). The provision of treatment for
people with intellectual disabilities for a range of challenging behaviours in the setting in
which they live has been championed by a number of authors, including those advocating
positive behavioural support (Allen et al., 2009). The provision of therapeutic support to
individuals while living in their own homes and community is integral to this approach, by
providing more opportunities for skill development and the rehearsal of therapeutic
techniques that may not be available in institutional settings (Hopkins and Clover, 2010).
Treatment groups for intellectually disabled sex o ffenders have been developed
predominantly based on a cognitive behavioural methodology (see Courtney and Rose,
2004; Keeling et al., 2008 for reviews; Sex Offender Treatment Services Collaborative, 2010).
Most have involved some element of compulsion to attend under a probation order or
supervised release order, as many participants would not attend if they were not directed to
(Lindsay and Smith, 1998). The provision of a comprehensive active assessment and
treatment programme for men with intellectual disabilities should be a priority for
commissioners of intellectual disability services (McBrien et al., 2010). One element of such
a service is the provision of sex offender treatment groups, and this presents a number of
treatment challenges. It would seem important to retain key elements of a cognitive
behavioural programme, whilst also ensuring that motivation to attend is nurtured and
developed within the group. A range of possibilities exist that can be used to improve
motivation to attend, including developing effective therapeutic relationships between the
therapists and group members (Sandu and Rose, in press), and using techniques from
motivational interviewing (Miller and Rollnick, 2002) within a group setting similar to those
that have been used effectively with people who have intellectual disability in residential
settings (Rose and Walker, 2000).
Treatment will also need to consider that the individuals who are likely to need such
interventions may have relatively lower ability as they are not generally charged formally with
their offence or provided with existing treatments due to their (relatively severe) disability. A
range of adaptations to treatments have been developed for people with intellectual
disabilities (Keeling and Rose, 2005; Lindsay, 2009; Rose et al., 2002), and these
adaptations can be developed further, for example, using a slower pace of delivery and
repetition within the treatment groups. Involving care staff who work with individuals in their
homes within group treatments has also been shown to help engage individuals more
effectively and improve the efficacy of therapeutic interventions for people with intellectual
disabilities (Rose, 2010).
To address these issues, this paper will describe the development and initial evaluation of a
sex offender treatment programme adapted for individuals with relatively more severe
intellectual disability in a community setting, all of whom had no compulsion to attend.
The main aims of the project were to motivate individuals with an identified need to attend a
fairly lengthy adapted community group work programme to address issues around sexual
offending without any formal compulsion to attend. A preliminary evaluation was conducted
as to whether a group treatment programme incorporating adapted cognitive behavioural
treatment approaches, and direct support staff as part of the group, would work with
individuals with more severe levels of intellectual disability in community settings.
Method
Treatment content and context
This programme was adapted from existing cognitive behavioural treatment programmes
(Lindsay, 2009). However, this group was delivered while individuals were currently living at
home, by therapists who were also working with them in their homes. There was no
compulsion to attend the group. As a result, the importance of motivation was addressed
even before the groups began. Referrals were sought from local clinicians who were already
actively working with participants, and as part of the referral process local clinicians were
required to spend time explaining the group and what it would involve to both the participant,
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and their support staff. This would include the potential benefits and costs of attendance.
Potential participants were also given options that, while the group would be closed and for a
fixed term, they would be allowed to opt in for certain portions of the group, and they would
be given clear choices about whether they wished to continue or not. If the individuals
consented to attendance, they were asked to participate in a series of formal assessments.
The length of the programme was 40 weeks, with one session per week, each lasting two
hours. A Speech and Language therapist supported the group by advising on the
development of materials, their use and their application by acting as a group facilitator in
some sessions. The first ten sessions of this programme were based upon an existing sex
education and relationships programme. Providing these sessions at the start of this
treatment programme enabled the group to develop a sense of cohesion and ensured that
all participants had a basic understanding of the issues raised in the remaining sessions. It
also gave participants a common language to discuss their offences and introduced
sexuality and relationships as an accepted topic for discussion.
Other themes covered within the group included: emotional recognition in themselves and
others; examining their life stories and analysing motivation to offend; describing their offences
in detail and introducing the offence cycle; anger management; excuses, cognitive distortions
and alternatives to offending; victim empathy; relapse prevention. While the participants were
engaged in a variety of group activities designed to develop group cohesion, they were also
challenged about their behaviour and cognitions by both staff and other group participants.
However, they were also given opportunities to reflect. The group finished with a review and
the development of individual ‘‘keeping safe’’ plans, in the form of an accessible booklet.
These were given to the participants and shared with staff working closely with them either in
community or residential settings. The group included a considerable amount of role-play and
modelling to help participants understand the content of sessions.
Staff accompanied the majority of the individuals to the group, where required, and
remained with them throughout. However, for some of the activities they sat outside of the
main group. Staff were prepared for the group content by providing them with both written
and verbal information, and they were encouraged to participate in some activities. Through
their involvement and participation within sessions it was anticipated they would act as
therapeutic change agents and also assist in the implementation of the therapeutic work in
home settings. Two of the men lived in their parental homes and so did not have any staff,
whilst a third man travelled to/from the group independently and did not bring any staff with
him. The consent and information procedures used in the group and the evaluation of the
groups were approved by the appropriate trust committees. All of the individuals who
participated in the project consented to participate in the evaluation of the programme.
Systemic supervision was provided to group facilitators over the course of the programme.
Participants
As the number of eligible participants for this type of work within any one locality was
relatively small, it was necessary for four neighbouring Community Learning Disability
Services to collaborate in order to both develop and deliver the programme, but also to
ensure that there was a sufficient number of referrals for the programme. In this way it was
possible to recruit 16 men who agreed to participate in two groups. However, two men
dropped out after taking part in only a single session, another individual withdrew from the
group after the sex education sessions (but did complete individual work aimed at treating
his sexual offending) and a fourth individual had to withdraw after he committed a violent
(non-sexual) offence. This paper will only report information on the 12 men that completed
the programme. The average age of the men was 39.5 ranging from 20 to 65 years, and they
had committed a range of sexual offences. Three of the men had primarily offended against
children while the others offended against adult women, of which a number had intellectual
disabilities. The range of offences also varied including rape, indecent assault, stalking and
indecent exposure. The men were assessed using the WAIS III and their average score on
this measure was extremely low: 58 (range 49-70). Two of the men who successfully
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completed the group lived in their parental home, where all of the other men lived in
supported living or residential care with staff.
Assessments
A range of assessments were administered as part of a structured interview before and after
the group, including the Questionnaire of Attitudes Consistent with Sexual Offending
(QACSO, Lindsay et al., 1998a, b, 2000, 2007). This is an attitude scale specifically
developed for sex offenders with an intellectual disability, and which assesses sexual
attitudes and beliefs related to sexual offending. It has been identified as a useful tool in
assessing treatment progress (Broxholme and Lindsay, 2003) and contains seven sub-
scales (rape, voyeurism, exhibitionism, dating abuse, homosexual assault, child offences,
stalking). It has a reported satisfactory one month test-retest reliability (r ¼ 0.962).
The Nowicki-Strickland Locus of Control Scale (NS, Nowicki, 1976) was also used. This is a
40 item measure of locus of control for adults. This scale measures the degree to which
people believe that reinforcement is a result of their own actions or a result of chance.
Participants respond ‘‘yes’’ or ‘‘no’’ to each item, with each response in the external direction
receiving a point. Scores range from 0 (internal locus of control) to 40 (external locus of
control) (Nowicki and Strickland, 1973). Administration was adapted in this study so that
items were read to participants and responses were recorded by the person who read the
items. Test-retest reliability has been reported with a six-week interval at 0.75 (Nowicki and
Duke, 1983).
Socio-Sexual Knowledge and Attitudes Assessment – Revised (SSKAAT-R; Griffiths and
Lunsky, 2003) was used, and which is a measure of sexual knowledge and attitudes. This
measure was developed specifically for people with intellectual disabilities in the USA and
has good reliability and validity, the test-retest reliability for the total knowledge scale is
reported as 0.96 (Griffiths and Lunsky, 2003).
A follow up was also conducted with the QACSO for most participants six months after the
group had finished. As local clinicians remained in contact with the individuals in the group it
was also possible to monitor whether any further offences or any significant changes were
reported by members of the group for a period of 18 months from completion of the group.
Any changes in the accommodation of participants were also monitored over the same
period.
Results
Scores on the QACSO, SSKAAT and NS recorded from participants were compared before
and after treatment using paired sample t-tests.
Table I shows that there was a significant improvement in attitudes as measured by the
QACSO, a significant change in Locus of Control as recorded on the NS, with participants
reporting a more external view on completion and a significant increase in knowledge after
the group had finished. It was possible to follow up nine individuals on the QACSO. While a
drop was observed in QACSO scores from pre-group to follow up (37.33-27.11) this
difference was not significant.
Table I Results from the paired sample t-tests
Mean n Standard deviation T df Sig. (two-tailed)
Pre-QACSO 37.33 12 10.77 6.177 11 0.000
Post-QACSO 23.45 12 7.98
Pre N-S 16.00 10 4.75 2 2.447 9 0.037
Post N-S 18.45 10 2.91
Pre-SSKAAT 135.44 9 25.70 2 3.804 8 0.005
Post-SSKAAT 159.33 9 24.40
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Reliable change
Results from statistical analyses like t-tests, conducted on small sample sizes may be prone
to low power and susceptible to Type I error. Calculations of reliable change enabled us to
investigate individual treatment responses and provided an opportunity to support the
results from the t-tests. The reliable change index (RCI) allows us to identify how much
change has actually occurred as a result of treatment and whether the change is statistically
reliable. The Jacobson and Truax (1991) procedure for calculating the RCI was used and
they state that when the RCI is equal or above 1.96, it is most likely that the post-treatment
score is reflecting real change.
For the QACSO full scale score 10 out of 12 men who completed the course recorded
reliable change on completion of the course. At follow up, even though the difference
between pre group and follow up scores was not significant when measured using a t-test
seven of the nine men who completed the questionnaire at this time were still showing
reliable change on the QACSO.
Only one of the 11 men who completed the NS both before and after the group met the
criteria for reliable change on completion of the group. On the SSKAAT-R, seven of the nine
men who completed this assessment showed reliable change on this measure. Follow up
data was not collected on these measures.
Follow up
As clinicians remained in contact with the individuals who had participated in the group it
was possible to monitor whether the participants were known to have committed further
sexual offences over 18 months. One of the men did go on to commit a sexual offence during
this period and had to move from a community placement to a low secure setting. However,
three other men were able to move to placements where there was relatively less supervision
compared to their previous placements.
Discussion
The results obtained from this group suggest that community-based groups for sex
offenders with intellectual disabilities may be effective at improving attitudes and increasing
the knowledge of participants. Results also suggest that Locus of Control becomes more
external. However, the magnitude of this change seems small, suggesting that it may not be
a significant clinical change. The results on the QACSO compare favourably with previous
research on the efficacy of group interventions of this type. For example, Keeling et al. (2006)
only found reliable change on the QACSO for seven of 11 participants after a group
intervention lasting for longer (12 months) and held more frequently, four sessions each
week and for longer (2.5 hours each session). The Keeling et al. intervention was a prison-
based programme suggesting that community-based programmes like this one may be
more effective, although, this would require further consideration.
The change in locus of control, with men expressing a more external LOC on completion of
the group, also replicates previous research (Langdon and Talbot, 2006; Rose et al., 2002).
However, the significance of this change is called into question by the relatively small size of
the changes recorded for most of the participants. No follow up was collected for this data
which also means that the robustness of these changes was also not confirmed. Treatment
programmes for sex offenders without intellectual disability suggest that a more internal LOC
is consistent with successful completion of the programme (Fisher et al., 1998). It may be
that the measure used in this study needs further adaptation for people with intellectual
disability or that the result reflects a particular aspect of treatment, such as increasing
awareness of the consequences of the participants actions.
The improvement in sexual knowledge is also gratifying. Some authors suggest that sex
offenders with intellectual disabilities often have better knowledge of sexual matters than
matched controls (Lockhart et al., 2009; Lunsky et al., 2007; Michie et al., 2006). However,
it was clear that most of these men had some significant gaps in sexual knowledge and that
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the majority were able to improve their knowledge after attending the group. The educational
content of the group was also used to develop relationships within the group and improve
group cohesion prior to the more challenging work of challenging offending behaviour.
These results were achieved even though the individuals in the group had relatively lower
assessed ability than in many other group interventions for sex offenders with intellectual
disability (Lindsay et al., 2002). However, there was a large range in IQ scores that seems to
have been managed successfully through the group leaders knowing the participants
relatively well, using appropriately adapted materials, taking care to adapt the group to
individual needs where possible, and using the experience and skills of group facilitators
and support staff.
These results were also achieved without compulsion to attend on the part of participants.
The design of the sessions may have contributed to this success but there were other factors
at play. These included sessions being conducted with therapists who knew the individual
well and who could visit the participants at home, if necessary, to encourage them to
continue their attendance at the group. It was notable that some of the men continued to
make their way to the group independently throughout, despite being challenged about their
behaviour on many occasions. While no economic analysis was conducted on this group, all
of the services were provided through existing services and as a result it is likely that the
costs associated with treatment of this type are likely to be less than referral to specialist
service provision.
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Implications for practice
B
This paper demonstrates that it is possible to run community-based sex offender treatment
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B
A range of adaptations to traditional programmes were used.
B
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B
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B
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Corresponding author
John Rose can be contacted at: j.l.rose@bham.ac.uk
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