Assessment-Based Treatment

The value of using assessments to design treatment can be thought of in two ways.  First is to inform therapists about clients’ strengths and weaknesses that can help guide treatment targets. In the highly successful Andrews and Bonta Risk-Needs-Responsivity (RN) model (e.g., 2006; Andrews, Bonta, & Wormith, 2011), assessment forms the basis of their second principle—address criminogenic needs in treatment. Hanson, Gourgon, Helmus, and Hodgson (2009) conducted a meta-analysis of RNR treatment outcome studies of sexual offenders and found that such treatments reduce sexual recidivism. They also analyzed the three components of RNR treatment and found that both needs and responsivity independently predicted lower recidivism. In contrast, those at low risk benefited as much from treatment as those at high risk, although there was a significant relation between the number of principles (1, 2, or 3) and lower sexual recidivism.

The second use of assessment in treatment is in therapeutic or collaborative assessment in which the therapist shares assessment results with the client. This has been done in a variety of ways, from immediate feedback with a directive-confrontational style (Miller, Benefield, and Tonigan, 1993) to Finn and collaborator’s therapeutic assessment, which starts with the clinician and client together developing an assessment plan and includes not only feedback on the assessment but use of the assessment to instigate therapeutic change. Several recent meta-analyses have concluded that sharing feedback assessment with clients results in more positive outcomes, whether the assessment feedback is defined narrowly as conforming to Finn’s therapeutic assessment (Durosini & Aschieri, 2021) or more broadly inclusive of any kind of feedback (Poston & Hanson, 2010; Hanson & Poston, 2011).

References

Andrews, D. A., & Bonta, J. (2006). The psychology of criminal conduct (4th ed.). Newark, NJ: LexisNexis. 

Andrews, D. A., Bonta, J. , and Wormith, J. S. (2011). The risk-need-responsivity (RNR) model: Does adding the good lives model contribute to effective crime prevention? Criminal Justice and Behavior, 38(7), 735-755, DOI: 10.1177/0093854811406356

Durosini, E., & Aschieri, F. (2021). Therapeutic assessment efficacy : A meta-analysis.  Psychological Assessment, 33(10). 962-972. DOI: 10.1037/pas0001038

Hanson, R. K., Bourgon, G., Helmus, L., & Hodgson, S. (2009). The principles of effective correctional treatment also apply to sexual offenders: A meta-analysis. Criminal Justice and Behavior, 36(9), 865-891. DOI: 10.1177/0093854809338545

Hanson, W. E., & Poston, J. M. (2011). Building confidence in psychological assessment as a therapeutic intervention: An empirically based reply to Lilienfeld, Garb, and Wood (2011). Psychological Assessment, 23(4), 1056-1062. DOI: 10.1037/a0025656 

Miller, W. R., Benefield, R. G., & Tonigan, J. S. (1993). Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles. Journal of Consulting and Clinical Psychology, 61, 455– 461. 

Poston, J. M., & Hanson, W. E. (2010). Meta-analysis of psychological assessment as a therapeutic intervention. Psychological Assessment, 22(2), 203-212.

Is Self-Report Valid?

Self report is considered by many to be an invalid means of gathering information about people, particularly people who have something to lose. That is definitely true of self-reports that could get the respondent into trouble–of crimes, undesirable behaviors and the like. One should certainly expect respondents to lie in such circumstances.

Nonetheless, asking respondents, even offenders about their feelings, attitudes, and beliefs is quite different. For example, patients who are given self-report questionnaires about their rheumatoid arthritis give information that is as effective in explaining their status as traditional measures of physical, radiographic, and laboratory results (Pincus et al., 1989). Specific to offenders, Walters’ (2006) meta-analysis found that self-report instruments that focused on criminal offending or antisocial behavior were as effective as risk instruments in predicting recidivism or institutional adjustment. In addition, he found that both risk-appraisal and self-report contributed variance independently. When self-reports that were not content-relevant were included in the meta-analysis, risk instruments predicted recidivism better.

In some instances, self-report has been found to be superior to other measures.  Self-report compared to results from penile plethysmography (PPG) has often been found to provide greater group differentiation (Day, Miner, Sturgeon, & Murphy, 1989; Laws, Hanson, Osborn, & Greenbaum, 2000; Seto, Lalumière, Harris, & Chivers, 2014; Stinson & Becker, 2008).

Likewise, self-report sometimes yields better results than observer measures. One circumstance is when the domain of concern is enduring affective dispositions (Grove & Tellegen, 1991; Meehl, 1959). Another circumstance is self-report of early abuse experiences by youth, which have been found to predict outcomes better than either caseworker or parental reports (Eckenrode, Izzo, & Smith, 2007). Kendrick and Funder (1988) discovered one variable that suggests why. They found that generally self-report measures agree moderately well with ratings of knowledgeable observers, but that the less observable the trait (e. g., neuroticism rather than extraversion) the less related self-report and observer ratings were. This suggests that the respondents reveal aspects of abuse that are different than what observers are able to observe.

Finally, people often are more willing to reveal sensitive information, such as male-male sex, in computerized self-report assessments than they are in either live interviews or in paper-and-pencil surveys in which it is easy to skip questions (Gribble, Miller, Rogers, & Turnser, 1999).

References

Day, D. M., Miner, M. H., Sturgeon, V. H., & Murphy, J. (1989). Assessment of sexual arousal by means of physiological and self-report measures. In D. R. Laws (Ed.), Relapse prevention with sex offenders (pp. 115–123). New York: Guilford Press. 

Eckenrode, J., Izzo, C. V., & Smith, E. G. (2007). Physical abuse and adolescent development. In R. Haskins, F.Wulczyn, & M. B.Webb (Eds.), Practical knowledge for child welfare practitioners: Findings from the National Survey of Child and Adolescent Well-being (pp. 226–242). Washington, DC: Brookings Institute. 

Gribble, J. N., Miller, H. G., Rogers, S. M., & Turner, C. F. (1999).Interview mode and measurement of sexual behaviors: Methodological issues. Journal of Sex Research, 36, 16–24. 

Grove, W. M., & Tellegen, A. (1991). Problems in the classification of personality disorders. Journal of Personality Disorders, 5, 31–42.

Kenrick, D.T., & Funder, D. C. (1988). Profiting from controversy: Lessons from the person- situation debate. American Psychologist, 43, 23–24. 

Laws,D.R.,Hanson,R.K.,Osborn,C.A.,& Greenbaum,P.E.(2000).Classification of child molesters by plethysmographic assessment of sexual arousal and a self-report measure of sexual preference. Journal of Interpersonal Violence, 15, 1297–1312. 

Meehl, P. E. (1959). Some ruminations on the validation of clinical procedures. Canadian Journal of Psychology, 13, 102–128.

Pincus, T., Callahan, L. F., Brooks, R. H., & Fuchs, H. A.  (1989). Self-report questionnaire scores in rheumatoid arthritis compared with traditional physical, radiographic, and laboratory measures. Annals of Internal Medicine, 110(4), 259-266.

Seto, M. C., Lalumière, M. L., Harris, G.T., & Chivers, M. L. (2012).The sexual responses of sexual sadists. Journal of Abnormal Psychology. 121, 739–752, http://dx.doi.org/10.1037/ a0028714

Stinson, J. D., & Becker, J. V. (2008).  Assessing sexual deviance: A comparison of physiological, historical, and self-report measures. Journal of Psychiatric Practice, 14, 379–388.

How Can Andrews and Bonta’s RNR Model Help Us Develop Treatment Plans?

The Risk-Needs-Responsivity (RNR) model (Andrews & Bonta, 2010) is one of the most widely recommended and studied evidenced-based practices in criminal justice settings (Bonta & Andrews, 2007; National Research Council, 2013), and it is an empirically validated model for guiding the treatment of individuals who have sexually offended (Hanson et al., 2009).

This model comprises three principles:

1. The risk principle: those who are at higher risk of recidivism should receive more intense service,
2. The need principle: treatment should target those factors that contribute to an individual’s risk of reoffending (criminogenic needs), and 
3. The responsivity principle: styles and modes of therapy should be tailored to each client’s abilities and learning styles.

General Criminogenic Needs

Bonta and Andrews (2007) identified seven major risk/need factors for criminals and suggested  potential interventions and treatment goals (they recommend cognitive social intervention strategies).

Table 1. The seven major risk/need factors 

Factor	Indicators	Intervention Goals
Antisocial personality pattern	Impulsive, adventurous pleasure seeking, restlessly aggressive and irritable	Build self-management skills, teach anger management
Pro-criminal attitudes	Rationalizations for crime, negative attitudes towards the law	Counter rationalizations with prosocial attitudes; build up a prosocial identity
Social supports for crime	Criminal friends, isolation from prosocial others	Replace procriminal friends and associates with prosocial friends and associates
Substance abuse	Abuse of alcohol and/or drugs	Reduce substance abuse, enhance alternatives to substance use
Family/marital relationships	Inappropriate parental monitoring and disciplining, poor family relationships	Teaching parenting skills, enhance warmth and caring
School/work	Poor performance, low levels of satisfactions	Enhance work/study skills, nurture interpersonal relationships within the context of work and school
Prosocial recreational activities	Lack of involvement in prosocial recreational/leisure activities	Encourage participation in prosocial recreational activities, teach prosocial hobbies and sports

Criminogenic Needs of Sex Offenders

In addition to the seven risk factors described above, individuals who have committed sexual offenses have specific criminogenic needs. To identify these Hanson and colleagues (Hanson & Bussiere, 1998; Hanson & Morton-Bourgon, 2005; Mann, Hanson & Thornton, 2005) have conducted a series of meta-analyses designed to identify those characteristics that both are plausible causes of sexual misconduct and are correlated with recidivism. 

These studies found that the following characteristics were related to sexual recidivism.

• Sexual deviancy
• Sexual preoccupation 
• Sexualized violence
• Sexual identification with children
• Antisocial tendencies
• Conflicts in intimate relationships

Equally important to what is related to recidivism is what is not related. For example, these meta-analyses found that the following do not relate to sexual recidivism:

• General psychological problems (e.g., anxiety, low self-esteem, major mental illness)
• Clinical presentation variables [e.g., denial, victim empathy, motivation for treatment]
• Sexual abuse as children 

The sexual variables that were strongly related to sexual recidivism were not related to other forms of recidivism, neither to violent nonsexual crimes nor to general recidivism (sexual and nonsexual).  The strongest correlate of nonsexual violent crime was antisocial tendencies. Variables correlated with general recidivism included problems with self-regulation, impulsivity, lifestyle instability, sexual attitudes (not sexual deviancy), and psychopathy (as measured by the PCL-R total score).

Effectiveness of RNR Intervention

Surprisingly, Andrews and Bonta (2006) demonstrated that therapies (particularly in residential/custodial situations) that used none of the RNR principles were criminogenic. The efficacy of interventions increased as a function of the number of RNR principles present.  When all three RNR principles were implemented , recidivism was reduced by 17% in residential/custodial situations and by 35% in community settings.  

A meta-analysis of 23 recidivism outcome studies for individuals who had sexually offended (Hanson et al., 2009) found that they had lower recidivism in both sexual and general domains. Programs that followed RNR principles showed the largest reduction in recidivism. Furthermore, they also found that the relation between number of RNR principles and positiveness of outcomes held for sex offenders, but that the Needs and Responsivity principles were both more powerful than the Risk principle and contributed unique variance.

The RNR model is not meant to exclude therapy interventions beyond criminogenic needs (Andrews et al., 2011). Therapists can and should also incorporate issues that are personal to the client if such issues are interfering with the treatment of criminogenic needs. The objective is to move clients to more prosocial functioning.

Development of Treatment Plans

How does this help us develop treatment plans? High scores on criminogenic needs relative to community samples and to samples of other individuals who have sexually offended identifies these needs as important treatment targets (Andrews et al., 2011). For target priority in treatment it is important to determine the relative contribution of sexual and nonsexual behaviors and fantasies to offending. A profile that is high in one or more sex-related characteristics suggests a problem specific to sexuality. If the client scores high only on antisocial-related tendencies, this suggests that the sex crime for which the client has been referred to therapy is not at the core of their issues and general criminogenic needs may be the first priority of treatment.

If a client is high on more than one sexual dimension, there is little empirical guidance about the optimal sequence for treatment. Here assessment-based sharing of evaluation results and consultation with the client about their perceived treatment needs should be a guide. Working on and modifying client perceived problems is an excellent way to enhance the therapeutic alliance. Obviously, as the therapeutic relationship develops, clients will hopefully reveal more of themselves and open avenues to treating additional problems. 

References

Andrews, D. A., & Bonta, J. L. (2006). The psychology of criminal conduct (4th ed.). Newark, NJ: LexisNexis. 

Andrews, D. A., & Bonta, J. L. (2010). Rehabilitating criminal justice policy and practice. Psychology, Public Policy, and Law, 16(1), 39-55. https://dio.org/10.1037/a0018362

Andrews, D. A., Bonta, J. L., & Hoge, R. D. (1990). Classification for effective rehabilitation: Rediscovering Psychology. Criminal Justice and Behavior, 17(1), 19-52.  https://doi.org/10.1177/0093854890017001004

Andrews, D. A., Bonta, J. L., & Wormith, J. S. (2011). Does Adding the Good Lives Model Contribute to Effective Crime Prevention? Criminal Justice and Behavior, 38(7), 735-755. https://doi.org10.1177/0093854811406356

Bonta, J. L., & Andrews, D. A. (2007). Public Safety Canada: https://www.securitepublique.gc.ca/cnt/rsrcs/pblctns/rsk-nd-rspnsvty/rsk-nd-rspnsvty-eng.pdf)

Hanson, R. K., Bourgon, G., Helmus, L., & Hodgson, S. (2009). The principles of effective correctional treatment also apply to sexual offenders: A meta-analysis.  Criminal Justice and Behavior, 39(9), 865-891.

National Research Council. (2013). Reforming juvenile justice: A developmental approach. The National Academics Press. https://doi.org/10.17226/14685

Hypersexuality – its structure and impact on treatment planning?

Hypersexuality or extreme normophilic sexual urges and behavior, has been found to covary with recidivism among Individuals who have sexually offended (e.g., Hanson & Morton-Bourgon, 2004; Hertz et al., 2023; Kingston & Bradford, 2013).  Consequently, it should be an important target for assessment and treatment for individuals who have sexually offended (Andrews & Bonta, 2010; Marshall & Marshall, 2006).  Furthermore, it has been found to play an important role in the etiological and typological models of sexually aggressive behavior (Knight, 2024; Knight & Sims-Knight, 2003, 2004, 2011).

Nonetheless, the construct is riddled with problems that range from global issues about its core theoretical conceptualization to specific issues about the content and structure of the scales used to measure it (Knight & Du, 2021). After its contentious and ultimately failed consideration as a mental disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (Kafka, 2010), it was successfully included in the most recent version of the International Statistical Classification of Diseases and Related Problems, 11th Edition (ICD-11, 2019) as an impulse disorder and labeled CompulsiveSexual Behavior Disorder (CSBD).

Both the DSM-5 controversy and the subsequent consideration for and inclusion in the ICD-11 have had a positive effect on the amount of research that has been generated on hypersexuality (Grubbs et al., 2020). This recent research has found that hypersexuality comprises two distinct, but correlated subcomponents, which have been labelled Sexual Drive (SD) and Problematic Sexuality (PS) (Carvalho et al., 2015, Du & Knight, 2024, Štulhofer et al., 2016). In Du and Knight’s (2024) factor analytic solution SD is defined by scales measuring frequent sexual activity, preoccupation with sexual fantasies, a predilection for impersonal sexual behavior, and facile sexual arousal. PS is defined by scales measuring sexual compulsivity, using sex as a coping mechanism, and the negative consequences of sexual behavior. These three scales are the most consistently found factor scales among self-report measures assessing CSBD (see Knight & Du, 2021 for a review). 

Du and Knight (2024) also found that SD and PS covaried differentially with two kinds of impulsivity. SD correlated significantly more with a Risk-Taking Callousness factor than it did with an Emotional Dysregulation factor, and PS correlated significantly more with Emotional Dysregulation than did SD. These results provide external validation for these two subcomponents, and they provide a potential solution to the confusing relation between hypersexuality and impulsivity in the recent empirical literature (Knight & Du, 2021).

Clinical Application

As a firmly established criminogenic need, the assessment of hypersexuality should be a central concern in the development of a treatment plan for clients with sexual problems.  Studies on multiple samples of both males and females, offenders, and nonoffenders (Kingston et al., 2018; Graham et al., 2017; Walters et al., 2011) have found that both subcomponents of hypersexuality are distributed as dimensions, which means that we need to establish specific cutoffs for various clinical decisions. This can be done by comparing a client’s score to that of a known comparison group, such as convicted offenders. Even so, cutoffs must be carefully applied.  Kingston et al. (2020)have recently established that cutoffs for SD are likely to be more problematic than PS. 

The search for empirically supported treatments for hypersexuality remains elusive. The support for both pharmacotherapeutic interventions (Borgogna et al., 2023) and behavioral treatments (Borgogna et al., 2022) have garnered limited empirical support. Lacking is a measurement of and focus on the specific components of hypersexuality, which might help advance the search for more targeted effective interventions. It is reasonable to speculate that the two subdimensions of hypersexuality will respond to different interventions. Whereas SD should respond better to pharmacological interventions, impulse control treatments, and behavioral interventions, PS should respond better to interventions that are effective for affective difficulties (e.g., Cognitive Behavior Therapy, Acceptance and Commitment Therapy, Mindfulness, Dialectic Behavior Therapy). The MIDSA currently has two scales measuring SD (Sexual Preoccupation and Hypersexuality) and one scale measuring PS (Sexual Compulsivity). In all scales respondents are compared both to a community male sample and a sample of individuals incarcerated for sexual offenses, thereby providing an objective estimation of a respondent’s relative level on the scales and suggesting the focus of treatment.

References

 Andrews, D. A., & Bonta, J. (2010).  The psychology of criminal conduct.  New Providence, New Jersey: Matthew Bender & Company, Inc. 

Borgogna, N. C., Garos, S., Meyer, C. L., Trussell, M. R., & Kraus, S. W. (2022). A Review of Behavioral Interventions for Compulsive Sexual Behavior Disorder. Current Addiction Reports, 9(3), 99-108. https://doi.org/10.1007/s40429-022-00422-x

Borgogna, N., Owen, T., Johnson, D., & Kraus, S. W. (2023). No Majic Pill. A Systematic Review of the Pharmacological Treatments for Compulsive Sexual Behavior Disorder. The Journal of Sex Research. Advanced online publication. https://doi.org/10.1080/00224499.2023.2282619

Carvalho, J., Štulhofer, A., Vieira, A. L., & Jurin, T. (2015). Hypersexuality and high sexual desire: Exploring the structure of problematic sexuality. The Journal of Sexual Medicine, 12(6), 1356-1367. https://doi.org/10.1111/jsm.12865

Du, R., & Knight, R. A. (2024). The structure of hypersexuality and its relation to impulsivity. Archived of Sexual Behavior. Advanced online publication. https://doi.org/10.1007/s10508-024-02828-2

Graham, F., J., Walters, G. D., Harris, D. A., & Knight, R. A. (2016). Is hypersexuality dimensional or categorical? Evidence from male and femalecollege samples. Journal of Sex Research, 53(2), 224-238. https://doi.org/10.1080/00224499.2014.1003524

Grubbs, J.B., Hoagland, K. C., Lee, B. N., Grant, J. T., Davison, P. M., Reid, R., & Kraus, S. (2020). Sexual addiction 25 years on: A systematic review of empirical literature on compulsive sexual behavior and an agenda for future research. Clinical Psychology Review, 82, Article 101925. https://doi.org/10.1016/j.cpr.2020.101925

Hanson RK, Morton-Bourgon K. (2004). Predictors of sexual recidivism: An updated meta-analysis (Corrections User Report No. 2004-02). Ottawa: Public Safety and Emergency Preparedness Canada.

Hertz, P. G., Rettenberger, M., Turner, D., Briken, P., & Eher, R. ((2022): Hypersexual disorder and recidivism risk in individuals convicted of sexual offenses. The Journal of Forensic Psychiatry & Psychology. Advance online publication. https://doi.org/10.1080/14789949.2022.2053183

Kafka, M. P. (2010). Hypersexual disorder: A proposed diagnosis for DSM-V. Archives of Sexual Behavior, 39(2), 377-400. https://doi.org/10.1007/s10508-009-9574-7

Kingston, D.A., Bradford, J.M. (2013). Hypersexuality and recidivism among sexual offenders. Sexual Addiction and Compulsivity, 20(1-2), 91–105. https://doi.org/10.1080/10720162.2013.768131.

Kingston, D. A., Olver, M. E., Levaque, E., Sawatsky, M. L., Seto, M. C., & Lalumière, M. L. (2020). Establishing Canadian metrics for self-report measures used to assess hypersexuality. The Canadian Journal of Human Sexuality, 29(1), 65-78. https://doi.org/10.3138/cjhs.2019-0055

Kingston, D. A., Walters, G. D., Olver, M. E., Levaque, E., Sawatsky, M., & Lalumière, M. L. (2018). Understanding the latent structure of hypersexuality: A taxometric investigation. Archives of Sexual Behavior, 47(8), 2207–2221. https://doi.org/10.1007/s10508-018-1273-9

Walters, G. D., Knight, R. A., & Långström, N. (2011). Is hypersexuality dimensional? Evidence for the DSM-5 from general population and clinical samples. Archives of Sexual Behavior, 40(6), 1309–1321. https://doi.org/10.1007/s10508-010-9719-8

World Health Organization (2019). International Statistical Classification of Diseases and Related Health Problems (11th ed.; ICD-11). https://icd.who.int/

Knight, R. A. (2024). Classification models for individuals who have sexually aggressed. In R. Tully, G. Bohall, & D. Prescott (Eds.), Best Practices in Sexual Offender Assessment and Management (pp. XX-XX). London:Springer.

Knight, R. A., & Du, R. (2021). The structure, covariates, and etiology of hypersexuality: Implications for sexual offending. Current Psychiatry Reports, 23, 50. https://doi.org/10.1007/s11920-021-01260-w

Knight, R. A., & Sims-Knight, J. E. (2003). Developmental antecedents of sexual coercion against women: Testing of alternative hypotheses with structural equation modeling. In R. A. Prentky, E. Janus, & M. Seto (Eds.), Sexual coercion: Understanding and management (pp. 72-85). New York: New York Academy of Sciences. https://doi.org/10.1111/j.1749-6632.2003.tb07294.x 

 Marshall, L. E., & Marshall, W. L. (2006). Sexual addiction in in incarcerated sexual offenders. Sexual Addiction & Compulsivity, 13, 377–390. https://doi.org/10.1080/10720160601011281 

Štulhofer, A., Jurin, T., & Briken, P. (2016). Is high sexual desire a facet of male hypersexuality? Results from an online study. Journal of Sex & Marital Therapy, 42(8), 665-680. https://doi.org/10.1080/0092623X.2015.1113585