DOCUMENT RESUME

ED- 153-165= CG 012 573

Becher,, Edward M. TITLE Treatment, Programs for Sex Offenders. INSTITUTION American Correctional Association, College Park, lid. SPOILS AGENCY National Inst. of Law Enforcement and Criminal Justice (Dept. of Justice/LEAA) , Washington, D.C. RUB DATE Jan 78 GRANT 75-NI-99-0125 NOTE 112p. AVAILABLE FROM Superintendent cf Documents, U.S. Government Printing Office; Washington, L.C. 20402 (Stock number 027-000-00591-8)

EDRS PRICE MF-$0.83 HC-$6.,01 Plus Postage. DESCRIPTORS *Aggression; Community Involvement; Correctional Rehabilitation -;*Corrective Institutions; *Criminals; Program Descriptions; *Rage; *Rehabilitation Programs; Sexuality; Socially Deviant Behavior IDENTIFIERS *Sex Offenders

ABSTRACT This survey report presents information or 20 treatment programs in 12 states which are directly concerned with the existing sexual problems and future behavior of correctional inmates, probationers, and parolees. Three additional programs which are no longer in oglration, but have considerable historical interest, are also described. The programs reviewed fall into two broad categories: institutions, mental hospitals, or special institutions for sex offenders; and community-based programs fcr offenders (including probationers and parolees) living in the community. No attempt is made to evaluate each program individually, cr to rank them comparatively. Rather, report recommendations call attention to the -wide range of alternatives being explored, and from which those planning to launch additional prograTis can lake a selection appropriate to their problems, goals, and resources. Excluded from this_survey is a wide range of treatment programs, both institutional and community, which are available to offenders generally, including sex offenders, but whiCh are not tailoted to- the specifically sexual problems of sex offenders. Appended material includes descriptions of nine additional treatment programs, an evaluation of sex offender treatment programs, and a state-by-state list cf directors of treatment programs for sex offenders. A list of bibliographic references is proirided. (Author)

*************************************4********************************* Reproductions supplied by EDRS are the best that can be made from the original document. *************************************4********************************* IIIIM=11111/ TREATMENT PROGRAMS FOR SEX OFFENDERS

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U.S. DEPARTMENT OF HEALTH, EDUCATION IL WELFARE NATIONAL INSTITUTE OF EDUCATION THIS DOCUMENT HAS BEEN REPRO. DUCE° EXACTLY AS RECEIVED FROM National Institute of I aw Enforcement and ,Criminal Justice THE PERSON OR ORGANIZATION ORIGIN!! ATING IT POINTS OF VIEW OR OPINIONS Law Enforcement Assistance Administration STATED DO NOT NECESSARILY- REPRE SENT OFFICIAL NATIONAL. INSTITUTE OF United States Department of Justice EDUCATION POSITION OR POLICY 2 TREATMENT PROGRAMS FOR SEX OFFENDERS

By

EDWARD M. BRECHER'

This project was supported by Grant No. 75NI-99-0125 awarded to the American Correctional- Association by -the National Institute of Law Enforcement and Criminal Justice, -Law Enforcement Assistance Adminis- tration, U.S. Department of- Justice, under the Omnibus Crime Control and Safe Streets Act of 1968, as amended. Points of view or opinions stated in this document are those of the author and do not necessarily represent the official position or policies of the U.S. Department of Justice.

January 1978

NATIONAL INSTITUTE OF LAW ENFORCEMENT AND CRIMINAL JUSTICE LAW- ENFORCEMENT ASSISTANCE ADMINISTRATION U.S. DEPARTMENT OF JUSTICE

3 NATIONALINSTITUTE OF LAW ENFORCEMENT AND CRIMINAL JUSTICE

Blair G. Ewing, Acting Director

LAW ENFORCEMENT ASSISTANCE ADMINISTRATION

James M. H. Gregg, Acting Administrator

For sale by the Superintendent of Documents, U.S Government Printing Office Washington,D.C.20402 Stock Number 027 - 000 - 00591 -8 CONTENTS

Page ABSTRACT

ACKNOWLEDGMENTS vii

PART I.GENERAL CONMERATIONS 1

1.1.Scope of This Survey 1,- 1.2."Sex Fiends" vs Sex Offenders 2 L3. The Common Sex Offenses 3 1.4.Impact of New Public Policies Toward Sex 5 1.5.Therapeutic Models 7 1.6."New DirectionsinTreatment" 7 1.7.Why Provide Treatment?...... , ...... 9 1.8.Types of Treatment Programs 10 1.9.The Need for Statewide Planning 11

PART H. FIVE INNOVATIVE PROGRAMS 13

A. The Fort Steilacoom Program 13 2.1.First Impressions 13 22.History of Program 17 2.3.Basic Theory of the Program 18 2.4.Some Program Details 19 2.5.Some ShOrtcomings 21 B. The South Florida Program 22 2.6.Origins ...... 22 2.7.Social Role of the South Florida Offender 2.8.Aftercare 24' 2.9.Miscellaneous Comments 25

C. The Santa Clara County Program 25 2.10. The Incest Problem 25 2.11. Some Preliminary Lessons 26 2.12. Current Procedures 27 2.13. Role of the Courts and Correctional System 29 2.14. Role of "Parents United" 30 2.15 Successes and Failures- 32

D. Program for Juvenile Sex Offenders, Seattle 33 2.16. Juvenile Rapists and Child Molesters 33 2.17. Need for a Juvenile Treatment Program 36 E. The Albuquerque Program 36 2.18. Origins 36 2.19. -Goals 37 2.20. Strengths and Weaknesses 38 Page

PART III.FOUR OTHER INSTITUTIONAL PROGRAMS 39 3.1.The _NorwalkProgram(1948-1954) 39 3.2.The Atascadero Program 41 3.3.The Adult3Diagnostic and Treatment Center, Avenel, New Jersey 43 3.4.Minnesota Security Hospital (St. Peter) Programs 45

PART IV.FIVE OTHER COMMUNITY-BASED PROGRAMS 48 4.1.Individual Court Arrangements 48 4.2.Center for Rape Concern, Philadelphia 49 4.3.Castration and Reversible ChemicalCastration 52 4.4.Phipps Clinic Program, The Johns Hopkins Hospital, Baltimore, Maryland 53 4.5."Behavior Modification," "Aversive Conditioniag," "Brain-wash- ing," and "Human Experimentation Without Consent" 54 4.6.Program at the University of TennesseeTennessee Psychiatric Hospital and Institute, Memphis 55 4.7.The Center for Behavior Modification, Minneapolis, Minnesota 58 4.8.The SOANON Program, Van Nuys, California 59

PART V. CONCLUSIONS AND RECOMMENDATIONS 61 5.1.The Need for Statewide Planning 61 5.2.Planning for Juvenile Sex Offenders 62 5.3.Planning for Sex Offender "Volunteers" 62 5.4.Planning for Nuisance Offenders 63 5.5.Planning for,the Serious Offenders on Probation 64 5.6.Planning for Serious Offenders Incarcerated for Treatment in State Mental Hospitals 65 5.7.Planning for Serious Offenders Incarcerated for Treatment in Me- dium-Security and Minimum-Security Correctional Institutions- 65 5.8.Planning for Serious Offenders Incarcerated for Long Termsin Maximum-Security Correctional Institutions 66 5.9.Planning for Sex Offenders on Pa_ roie 66 5.10. Modernizing the Criminal Laws 66 5.11. Improving Sentencing Procedures 67 5.12. Release Provisions 68 5.13. The Funding of Treatment Programs 69 5.14. The Staffing of Treatment Programs 70 5.15. Geographical Considerations 70 5.16. Program Size 71 5.17. A Look Backwardand Ahead 71

APPENDIX A.NINE ADDITIONAL TREATMENT PROGRAMS 73 A.1. Center for the Diagnosis and Treatment of Sexually Dangerous Offenders, Bridgewater, Massachusetts 73 A.Z. The Florida state Hospital (Chattahoochie) Program 74 A.3. Patton State Hospital (California) Program 76 A.4. The Wisconsin Program (1951-1970) 77 A.5. The Colorado State Reformatory (Buena Vista) Program 79 A.6. The New Jersey State Prison (Trenton) Program 80 Page A.7. Outpatient Treatment Clinic for Special Offenders, Baltimore, Mary- land 81 A.8. Program of-the University of Southern California-Institute of-Psychia- try and the Law, Los Angeles 82 A.9. The Denver Program (1974-1976) 83

APPENDIX B.EVALUATION OF SEX OFFENDER' TREATMENTPRO- GRAMS-by-Daniel-Glaser, Ph.D., U_ niversity of Southern California. 85 B.1. Problems of- Evaluation 85 B2. Goals and Statistical Indicators of Their Attainment 85 B.3.Desirable and Feasible Evaluation Research Designs- 87 BA. Controlled Experiments 88 B.5. Employing Comparison Groups B.6.Differences That Make a Difference :89 B.7. Who Should Evaluate Whom? .

APPENDIX- C.DIRECTORS OF TREATMENT PROGRAMS FOR SEX OFFENDERS 93

BIBLIOGRAPfIY 95

7 ABSTRACT

What should be done about sex offenders after they have been sentenced and turned over to the correctional system? Nothing in particular is being done about the vast majority of them and little or no attention is being paid to the particular factors which made these men sex offenders.--=and-1,vhich may (or may not) lead them to commit futuresex offenses. There are, however, some notable exceptions. Thissurvey report presents information on 20 treatment programs in llstates whichare directly concerned with the existing sexual problems and future behavior of correctional inmates, probation- ers, and parolees. Three additional programs which are no longer in operation, but have considerable historical interest, are also described. Theprograms reviewed fall into two broad categories: institutions, mental hospitals,or special institutions for sex offenders; and community-based programs for offenders (including- proba- tioners and parolees) living in the community. No attempt is made-to evaluate each program individually, or to-rank them comparatively. Rather,report recom- mendations call attention to the wide range of alternatives being- explored, and from which- those planning to launch additional programscan Make a- selection appropriate to their problems, goals, and resources. Excluded from thissurvey are a wide range of treatment programs, both institutional and community, which are available to offenders generally, including sex offenders, but whichare not tailored to the specifically sexual problems of sex offenders. Appended material include descriptions of nine additional treatment programs, an evaluation ofsex offender treatment programs, and a state-by-state list of directors of treatment programs for sex offenders. A list of bibliographic references is provided. GOT A MOMENT?

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9 vi ACKNOWLEDGMENTS

This survey of treatment programs for -sex offenders-covers 20 existing programs and three which have been discontinued. During the Fast year and a half, I- visited all 20 of the existing programs and talked with their directorsand staffs.' My primary indebtedness is to these men andwomen who work with sex offenders_directly. The =names of the program directors and the addresses ofthe programs .are listed in Appendix C, page 93. So far as I have been able to determine, these 20 programs were the only ones in operation during 1976. The program directors and staff members I visitedwere without exception astonished to know that there were 20 programs currently in operation; they knew only a few at first hand and a few more by reputation. The otherprograms, mostly small- and new, had escaped- their attention. They accordingly 'saw thepresent survey as a welcome opportunity to learn about recent developments in other parts of the country, and to inform the outside public of their ownprograms. My visits, as a result, were not- seen- as intrusionson= an already overcrowded work schedule but as a welcome way to bring tbgether the first national overview of the sex offender treatment movement. Three pioneers in -the field who are no longer actively associated with treatment programs were also visited, and helped to provide a historical perspective: Dr. Asher Pacht of the Wisconsin Department of Corrections, Dr. Seymour L. Halleck of the University of North Carolina, and Dr. H. L. P. Resnik of College Park, Maryland. My talks with them impressedme with the- many puritanical restrictions under which treatment programs operated during- the 1950's and 1960's, and with the rapid progress being made under the much less restrictive circumstances prevailing since 1972 (see pp. 5-7). A psychologist and sociologist served as an "advisory panel" for this project; Dr. Jennifer James of the University of Washington, Seattle, and Dr. John Gagnon of the State University of New- York at =Stony Brook. Their advice and suggestions are gratefully acknowledgedbut they are not responsible forany of the statements made. .Joan Gauche of the District of Columbia bar surveyed state laws concerning sex offenders as well as recent laws decriminalizing sexual acts among consenting adults in private, and advised on other portions of the study. My thanks are similarly due -to the more than a hundredsex offenders with whom- I rapped individually, in small groups, and in largegroups at treatment centers throughout the county. These informal rap sessions, sometimes stretching far into the night, buttressed the evidence from more formalsources: many sex offenders, including many rapist and child molesters,can in- fact be rehabilitated through soundly planned, staffed, and administered treatment programs. Others who have come to know sex offenders within the treatment setting, let me add, have been similarly impressed. The effect is quite different'from the effect of rapping with ordinary criminal offenders ina conventional correctional- institu- tion. Indeed, today's treatment programs have been able to attract- and hold

Two new programs were launched in Gainesville, Florida, and Edina, Minnesota, following the conclusion of my survey. They are not described in the text but are listed in Appendix C.

vii 1 -0 outstanding directors- and staffs primarily because of the sense of accomplishment which comes from watching sex offenders mature, develop skills, and assume responsibilities as the program's effects become visible. Three of,the.programs ,here reviewed are headed by women (see Appendix C), and almost all of-tigtm employ women in positions of responsibility. I made a particular effort to talk asSully and frankly as possible with these womenall of whom share a common detestation of rape, child molestation, and other sex offenses, and all of whom see themselves as potential -rape victims. Their sense that treatment programs make sense and warrant public support impressed- me particularly, for I could hardly dismiss them as being "soft on rape" or as blinded by,male chauvinist prejudices. In addition to talks with women staff members, I benefited particularly from talks with Ms. Carole Anne Searle of the Canadian Penitentiary Service; Ms. Deborah S. Anderson, Director, Sexual Assault Services, Office of the Hennepin, County Attorney, Minneapolis, Minn.; Ms. Bart Delin of the American Association of University Women's Committee on Sex Offender Treatment Programg, Minne- apolis; Ms. Fay Honey Knopp of Prison Research Education Action Projects in Westport, Connecticut; and Ms. Lucy Rupe Watt of Rochester, Indiana, who served for more than five years as a one-day-a-week i/oltinteer in the sex offender treatment program at Fort Stei1acoom, Washington. I also visited in several cities with the women in charge of rape education centers, rape treatment- centers, 'and service programs for rape victims, asking their views of the treatment program in their vicinity. Without exception, these women professionally concerned with rape andlamiliar with a local treatment program for sex offenders spoke well of it. In the course of research for this survey, I was privileged to participate in a variety of activities concerned with the problems of rape and other sex offenses: A treatment program subcommittee of the Sex Crimes Analysis Unit, Connecticut State Police, which meets periodically under the chairmanship of Lieutznant Doris Hughes, director of Connecticut's Sex Crimes Analysis Unit. A two-day conference on "Sexual Assault: The Lonely Crime," held in Minneapolis November 9-10, 1976, under the sponsorship of the Minnesota Program for Victims ')f Sexual Assault, Ms. Peggy Spektor, Director. A Joint Project Advisory Committee which is planning a series of twelve regional conferences on rape and sexual assault to be held during 1977 and 1978. The conferences will be under the auspices of the National Center for the Prevention and Control of Rape, National Institute of Mental Health, Rockville, Maryland, and will be administered- by -the Verve - Research Corporation. Treatment programs for sex offenders will- be one of the topics considered at several of the regional conferences. A study of sex offender treatment programs currently being made by Correctional Service of Minnesota for the Minnesota Department of Corrections, under a mandate of the Minnesota Legislature. Out of this study will emerge the first statewide plan for sex offender treatment programs, to be presented to the legislature in 1977 (see pp. 11-12). Dr. Thomas C. Correll of Correctional Service of Minnesota is in charge of this study. The First Annual Conference on the Evaluation and Treatment of Sexual Aggressives, held in Memphis, Tennessee, April 14-16, 1977. The meeting was chaired by Dr. Gene G. Abel, Department of Psychiatry,University of Tennessee Center for the Health Sciences. It was funded by the National Center for tilePrevention and Control of Rape. This meeting was the first opportunity for1 the directors of the treatment programs here described -to viii z1. meet with one another and with researchers and women concerned with rape, to exchange views and data and to plan for future cooperation: A Second National Conference, again sponsored by the National Center for the Prevention and Control of Rape, is planned for 1978. While the bulk of the data here presented- came from my visits to treatment programs, interviews with directors, staffs, sex offenders, and others, and partici- pation in the activities listed, I also made full use of the relatively meager supply of reports and "-papers, published and, unpublished, concerning these programs; these sources are listed in the Bibliography (pages 95-98). As a check on accuracy,,portions of this study were circulated in manuscript form to-directors of all of the programs described and to most of the other persons listed above. Their comments and corrections were enormously helpful. I am particularly indebted to 1Dr. Pacht, Ms. Searle, Ms. Knopp, Dr. Resnik and Audrey Resnik, R.N., Dr. Gloria Levin of the National Center for the Prevention- and Control of Rape, and Dr. Suzanne M. Sgroi, Connecticut Child Abuse and Neglect Demonstration Center, Hartford, for their comments on portions of the manuscript. -Dr. Daniel GlaSser of the University of Southern California, who prepared Appendix B on the Evaluation of Sex Offender Treatment Programs (pages 85-92), also reviewed the manuscript and made useful suggestions. Any remaining errors and all interpretations are, of course, my responsibility. Virginia Brecher prepared thesBibliography, typed and retyped the manuscript, and made helpful editorial suggestions. Raymond S. Olsen of the American Correctional Association and Louis G. Biondi of the Law Enforcement Assistance Administration watched over this project and guided it from its origins early in 1975 to the final editing in February 1977. My indebtedness to them both is-very -great.

Edward M. Brecher Yelping Hill West Cornwull, Connecticut 06796

12 ix WT.

PART I.GENERAL CONSIDERATIONS

1.1. Scope of This ,Survey are less than six- years old. Most of them are-small. They are treating only a very small- proportion, of Are sex offenders being 1,,t off too easily in sentenced sex offenders. But, for two reasons, they American courts, or are they being punished too are of national,significance. harshly? Are some sex offenders serving terms' in First; these 20 programs are gaining fresh-insights correctional institutions who might-better be, treated into the nature of the offenses with,which 'ociety on probation? Are some who should be incarcerated is currently concerned and into thc "f4,hist4.4 es Of being released.on probation? Are sentences too long the men Who are committin' ..1ses: The or -too- short? Are incarcerated sex offendersbeing insights available from the- pt grams can sogn -or is parole too long delayed? .castration, for besecured-inno-otherway:--What-theprograrnshave- Should- unconventional approaches been learning about sex Offendersnlay-prOVe ofvery. e _ ---greatimportancetereafteritrplanningfOrthe -preven----- Iniportant as they are, questions such as 'these are 'treatment Lion of future sex offenses,_:inimodernizingloin laws not: the primary concern of this survey of governing sex offenses,- and indesignittg additional programs. Rather, this Survey starts with the facts of treatment prograMs for sex offenders. sentencing as they -now- exist. A 'substantial number Of -sex offenders are today in 'fact locked up in Second, many- of these r:ograms have developed Correctional institutions, and -a somewhat larger num- within the past :few yearS -a- remarkable range of ber are in fact out on probation or parole. What sensible, hopeful, and innovativeapproaches to the should be done about them after they have been treatment- of sex- offendersapproaches which are sentenced and turned over to the correctional sys- significantly altering the lives of the- men undergoing treatment. tri;,:men themselves are -certainly benefit- tem? Currently, nothing in particular is being done ing; and there is considerablelikelihood that-society about- the vast majority of sentenced sex offenders. will also benefit through fewer subsequent sex offen- Those serving time in correctional institutions are ses. lodged in the= same cell blocks as-those incarcerated The rich array of innovative approaches unearthed its for non-sex offenses, and are subjected to the same in-the course of this survey came as a surprise tO he correctional routines. Those out on probation ilnd author, and to authorities on sex- Offenses whom consulted. This is uecause most of the programs parole are with few exceptions treated like other of probationers and parolees: Little or no attention is have been operating quietly, with a minimum paid to the particular factors which made these men publicity even in their own -communities. Only a few published sex- offenders,--and which may (or m_ aynot) lead have been -even briefly described in The literature. Even workers in a particular treatment them to comrrq future sex offenses. of what is being There are; "hOwever, some notable- exceptions. In program have little 'knowledge programs. the course of research for this survey, 20 treatment accomplished or attempted in the other 19 No one before has made -the rounds of the programs prograjns in12 states have been identified and visitedprograms which are directly concerned with to observe them in perspective. the current sexual problems and future sexualbehaV- This pioneering survey, accordingly, is designed ior ofoOrrectional inmates, probationers, and parol- primarily to bring news of some remarkable recent- ees. Three additional programs-which are no longer developrnents both to the concerned public and to in- operation -but have considerable historical interest those professionally concerned with offenses. No are also described. attempt will be mail:: to.evatuate each program A:few-programs now in operation may have been individually, or to rank them comparatively. Rather, missed; if so, they are almost certainly new, small, the recommendations in Part V will-call-attention' to and-little known outside their own communities the wide range of alternatives which are currently Sixteen Of the 20 existing programs here .desctibed being explored, and from which those planning to

1 launch additional programs can make a selection ...Convulsions at the age of nine months. appropriate to their problems, goals, and resources. Later he suffered from disturbed sleep; was nerv- ous, and developed tardily and imperfectly. With puberty he became irritable, showed evil inclina- 1.2. "Sex Fiends" vs. Sex Offenders tions, was lazy, intractable, and in all trades The treatment programs here described represent proved to be or no use. He grew no better even in a repudiation of a traditional attitude toward sex the House of Correction. He was made a Marine, offenders still widely held by the public as well as by but there, too, he proved useless. When he legislate3, judges, and others in positions of influ- returned home he stole from his parents, and spent ence. That traditional attitude is now 90 years old; it his time in bad conyany. He did not run after stems directly from the most powerful and terrifying women, but gave himself up passionately to mas- treatise on sex offenses ever publishedPsychopa- turbation, and occasionally indulged in sodomy thia Sexualis (1886), by Dr. Richard von Krafft- with dogs. His mother suffered from mania men- Ebing (18401902). strualis periodica. An uncle was insane, and Krafft-Ebing was the foremost psychiatric consult- another a drunkard. The examination of Menes- ant to the criminal courts of his generation, repeat- clou's brain [after his execution] showed morbid edly called upon to testify in sex eases by judges not changes of the frontal lobes, of the first and only in-Germany and Austria but throughout Europe. second temporaLconvolutions,.and_of a,part_of the He thus had abundant opportunity to examine at first occipital convolutions. *hatid some of The most vicious sex criminals in Decade after decade sihceKrafft=Ebirig Witte; human history. In Psychopathia Sexualis, he de- rape-murders and rape-mutilations have continued to scribed -these offenders and their crimes in gruesome occur. There is no evidence that such crimes are detailso gruesome that his -case hstories have left either rarer or more common than in Krafft-Ebing's their mark on the popular consciousness throughout day; but they continue to,exert a powerful hold on the Western world. His rapists, for example, were public attention, and to perpetuate the false notion of not just rapiststhey mutilated, and murdered, and the "sex fiend" as the typical sex-offender. incinerated -the bodies; they maimed and tortured and desecrated. Some details were so morbid' and # # # nauseating that Krafft-Ebing veiled them in scholarly Latin to protect the sensitivities of lay readers. A visit to- a treatment program for American sex Having thus aroused feelings of horror and loa- offenders in the 1970's provides a very different thing in his readers, Krafft-Ebing then went on to perspective. Those currently in treatment cannot by describe a wide range of far less threatening of- the widest stretch of the term be classified as "sex fendersthe voyeur ("peeping Tom"), the exhibi- fiends" of the kind Krafft-Ebing described. The tionist ("flasher"), and especially the homosexual fraction of one percent of lust-murderers and rape- in much the same horror-inspiring manner, all as mutilators are not found in treatment programs but examples of "psychopathia sexualis." This pattern are immured in maximum security institutions. of grouping non-violent sexual deviations together Not one of the programs here described makes with the most brutal of all human acts remains with any claim that- it can rehabilitate or safely restore to us today, enshrined in the familiar term "sex of- society the exceedingly small- group of sex of- fender." The term "sexual psychopath," still found fendersperhaps a dozen per year in the entire in the laws of many states, is derived directly from countrywhose murders, tortures, and mutilations Krafft-Ebing's Psychopathia Sexualis, a reminder of make newspaper headlines. Treatment programs do his continuing and pervasive influence. not want these "sex fiends," and do not get them, In another respect, too, Krafft-Ebing profoundly Rather, treatment programs are concerned with the influenced subsequent thinking and legislation. He vast bulk of sex offendersthe more than 99 percent believed that the causes of sexual psychopathy are whose offenses fall far short of the Krafft-Ebing in part hereditary and, in part the result of actual pattern. physical degeneracybrain deterioration, for exam- It is possible, of course, that an alumnus of one of ple. He therefore believed that psychopathia sexualis these treatment programs may commit a lust-murder is incurable. Here is his explanation of why Menes- of the Krafft-Ebing type tomorrow. The same is true clou, in one of his most gruesome cases, killed and of an alumnus of your local high school or a member butchered a four-year-old girl: of your church choir. Treatment programs are specif-

2 14 ically designed -to minimize the likelihood- that an enforcement and crinninal justice systems. None of offender following treatment will commitanysex the participants in the sex offender treatment pro- offense following releaseeither a ,crime of the grams here reviewed are there for fornication: Krafft -Ebing-type or the lesser offenses -these men Adulteryis sexual intercourse between two per- have committed in the past. sons, at least one of whom -is married to someone else. This also remains a crime in most states, rarely punished and never leading to participation in a 1.3. The Onnmon Sex Offenses treatment program. Any analysis of sex offenses is complicated by the Male homosexual conductand other acts classed offenses; fact that- state legislatures-are-often-too-inhibited to assodomyare the most common of all-sex describe specifically the acts they are seeking -to the Kinsey reports and more recent data indicate punish. Thus punishment maybe decreed -for "lewd that millions of sodomy offenses are committed each and lascivious conduct," "acts against nature," week. "carnal knowledge," "imperiling the morals of a TheSe offenses were not lightly punished during minor," and so on. Almost any sexual activity may past eras of American history. In the1640's in be-prosecuted under one or another of these vague Massachusetts, for example, "buggeiy"anal-inter- and broad rubrics. The same term, moreover, means course with man,- woman, or beastwaSpunishable different -things-in different' states: Thus-sodomy; -by-death-for-both-parties:-In-1648-rape=also.becathe- which in many states refers primarily to male homo- punishable by death. Rapists whose lives were sexual at'ts, may -or -marnot'also--be-applied-to--spared-might 7be- sente nced-to -have-thei r-nostril s.Slit-- heterosexual oral or anal intercourse or to sexual and to wear halters around their necks: Adultery contacts with animals. Highly misleading terms may with- a married- or engaged woman- was punishable be -used such asstatutory -rapefor an offense which by death for both- parties; but adultery-'between a is not rape-at all but sexual intercourse with a fully married man and a single; unbetrothed woman was consentineemale who has not yet reached- the age considered mere fornication, punishable-by a public oflegalconsent (18 in Some states). Discussions of whipping. Also punishable by public whipping was sex_offenses are further complicated by the fact that sexual intercourse between unmarried persons and a man charged with a seriousoffense such as rape pregnant); in unmarried women. From 5 to 20 may be permitted, in the course ofplea-bargaining, strokes of the lash,,Were commonly laid onor 39 to plead guilty to a lesser offense; hence- menwho strikes for more detestable offenses. are in fact rapists may be lodgedin correctional Times have changed, however. Thirteen states at institutions for such apparently non -sexual offenses this writing have repealed their laws against so- as breaking and entering or assault. Inthe discussion domyincluding both male homosexual. acts and which follows, we shall be considering the actual heterosexual oral ands- anal -acts. Most states which offenses committed rather than the vague legal have repealed their sodomy laws have similarly terminology often used or the lesser offenses to repealed their laws against fornication, adultery, and which a man may plead. other sexual activities engaged in by- consenting Until the past few years, the term "sex offense" adults in private. Similar repeals are nnder consider- commonly called to mind a lust-murder of the Krafft- ation in other states. Even' in-Siates where Such-laws Ebing type. More recently, the intense and proper remain on the books; theyaresarely enforced,and' concern of the women's movement with rapeand even more rarely do they lead to participationin a related crime.,, suctkas assault with intent to commit treatment program for sex offenders. rape, has tended to make rape' thepredominant sex Laws. governing public indecency and solicitation- offense in the minds of many people. Certainly rape both solicitation for Orcistitution and for male homo- is among the most important of the sex offenses, and sexual contactare still- enforced in many jurisdic- itis an- offense with which this survey will be tions; but they commonly lead to fineS, probation, or continuously concerned. By far the most common short sentences in local correctional institutions. sex offenses, however, are three which arerarely Rarely if ever do they lead to participation in a sex prosecuted: fornication, adultery, and male homosex- offender treatment-program. ual contact. With these enormous categories of Offenses elimi- Fornication,which -is sexual- intercourse between nated or almost eliminated, and with the very small persons not married to one another. remains acrime number rape - murders, sex -torture =cases, and sex- in most states, but is generally ignored by the law dismemberments similarly eliminated as grounds for 15 3- providing treatment, there remain five categories of Exhibitionism is one of the two most common sex sex offenses which account for the overwhelming offenses which lead to participation- in a treatment majority of treatment program participants: program. The typical exhibitionist seeks out a woman in a lonely place, often in broad daylight, Rape, attempted rape, assault with intent to and displays his genitals to her; he may masturbak ,rape, etc. and even ejaculate in the course of his exhibiting. Child molestation Some treatment programs report that as many as a Incest third of their participants are there for exhibitionism. Exhibitionism and voyeurism This is true in part because "flashing" is a common Miscellaneous offenses (breaking and entering, offense and in part because judges-are more likely to arson, etc.) in cases where there is a sexual prescribe treatment in- such cases than in cases motivation. where a victim is physically assaulted. Voyeurism or Rape and rape-related offenses vary in several "peeping" appears- to-be less- common --or- perhaps respeCts. There is the rapist, for example, who first peepers are less commonly apprehended and prose- physically beats up his intended victim, and who cuted; they constitute a modest proportion of partic- then .proceeds to the sex act only after intense ipants in treatment programs. physical pain has been inflicted and all resistance has Child molestation, the second- most common of- -been.overcome. There is the rapist who holds-a-knife fense for-which -treatment 'is-prescribed, is -a -broad- to his victim's throat, informs her thafhe will kill her and vague rubric covering a variety of actions then, savoring - involving- either childrerbr -Mitiors-pastliuberty. fully -the. terror he has inspired, carries out -the -rape. Offenders who attack children violently are com- A rather different example -is a sex offender'known monly sentenced to maximum- security institutions; as "Mr. M," who "was found guilty of nine separate those found in- treatment programs are usually there counts of assault with intent to commit rape. ... He for the- fondling of children or other non-violent admitted -to over 200 assaults over a -4-year period. behavior. Mr. M would walk the streets in search of a woman walking alone at night, or would follow one off a Incest is the legal term for sexual intercourse or subway or bus. He would come up from behind and other intimate sexual contact with a member of one's place one hand on her breast and the other up her immediate family. Criminal prosecutions and convic- dress. His fantasy was that the victim would become tions are very rare these days in cases involving [sexually] aroused and readily. submit to intercourse. brothers and sisters, or consenting adults in private. When she struggled or screamed he would flee." The incest offenders found in treatment programs are The decision whether rapists of these and other in almost all cases men convicted of having had types should be committed to a treatment program sexual relations, usually sexual intercourse, with or =locked up in a maximum-security institution their children or foster children too young to give depends in most states primarily on the sentencing legal consent. judge. In general, judges-tend to send to the treat- The miscellaneous 'offenders are mostly fetishists ment programs only those rapists who seem likely to whose sexual behavior leads to a variety of offenses. benefit from treatment; rape with violence or with Typical is the young -man whose sexual arousal is weapons is more likely to lead-to a -long term-in a dependent-on soiled-female undergarments-and-who maximum-security institution without treatment or, repeatedly breaks into homes to secure such gar- in some states, to a death sentence.' ments. Many sex offenders in treatment programs are there following conviction and sentencing under the ' Since 1930, at least 455 rapists havvbeen executed in the ordinary criminal laws. In addition, programs in United Statesof whom 89 percent have been black. Currently, Florida and Mississippi laws provide the death sentence for the some states receive offenders committed under the rape of minors and Georgia has the death sentence for the rape so-called "sexual psychopath laws." These laws of adult women. Four men have been sentenced to death for provide for a wholly indefinite period- of incarcera- rape in Georgia since 1973 and are in-Death Row awaiting the tionfrom one day- to life. Release -is dependent outcome of appeals. One of these cases was argued before the upon a finding that a so-called "sexual psychopath" Supreme Court of the United States early in 1977; in this case, seven women's organizations (including the National Organiza- is no longer a danger to society or to himself. More tion of Women) fled a brief opposing the death sentence for than 30 states now have laws of this type on their rape. No decision has been announced at this writing. statute books, but in many states -they are not used 4 16 at-all and innther states they are used only on rare no doubt differ in significant respects from :occasions: 2 those who reach the courts. The.. -great majority, of sex offenders currently Of those prosecbted, a- small_ntimber are found participating in treatment programs are ,predomi- not guilty and- a very -large number (mostly nantly- heterosexual and are there for heterosexual minor offenders) receive suspended sentences offenses- though some of them, like some hetero- or are placed on-probation -without assignment Sekual non-offenders, have had oc"asional or inci- to a treatment program. dental homosexual contacts. Most homosexual par- Of the offenders remaining after these three ticipants in treatinent prograMs.are:there- for .sexual basic sorting processes, judges send- some to- contacts, rarely violent, with male children or adoles- ordinary- correctional institUtions -and others to centS: Some are hoMosexual incest - offenders. A few treatment :programs. Which will be sent 10 'have cOmmitted honiosexual rape or rape-related treatment _programs depends in part on state offenses. law, in part -on- the judge, and in -part on the Substantially all sex offenses prosecuted in the availability Of a treatment program. United States today (except prostitution-related of- Finally; inost treatment programs- can:(andtdo) fenSes':and offenses involving indecent stage perform- reject or transfer to-othe institutions offenders ances)rait ,committed by men. The only significant they deem unsuitable for treatment. The net _excePtions-are_rare _cases of child molestation in effect of these -five sortingrocestes- is a- which a woman is prosecuted airing with a man, population -of program participants --from -which ---often=her.husband..Ala,rougli.estiMate, two er three most-ofthe -very serious-nffenders and-most--of -hundred males are- prosecuted-for sex offenses for the very minor offenders _have- been screened every feinale prosecuted. It is possible, of course, out. that the ratio of offenses committed by .females is higherthan the-ratio of prosecutions. The number of 1.4. Impact of New Public Policies toward women- enrolled -in sex offender treatmentprograms is- exceedingly small; indeed; 'the Washington State Sex treatment- program at Fort Steilacoom,Washington, The first four American -treatment programs for and the program at Philadelphia General Hospital are sex offenders were established byCalifornia -in -1948, the only t-(6 which currently have female offenders by- Wisconsin in 1951, and by Massachusetts and in- treatinent. Washington- State in 1958. All four programs during The- vast majority of sex offenders in treatment their early years reflected to a considerable degree programs- are aged 18 to 35; a significant minority the ,traditional policies toward sex and toward sex (mostly child molesters) are past 50. offenses prevalent in the United States at that,time. How do the sex offenders enrolled in treatment Those policies might be roughly summarized as programs differ from the remainder of sexoffenders? decreeing that almost all sexual activities are by their At least five "sorting processes" serve to distinguish nature evil-and subject to criminal sanctionsexcept .the two groups. for a limited number of activities.permitted between Some sex offenses are reported to the police; a husband and wife behind closeddoors. others are not. Most rapes and a wide range of Since the 1950's, however, a profound change has lesser offenses go unreported. No man ends up occurred. Current policiesjn-many jurisdictions in- a treatment program as- a result of an come increasingly close to providingthat all forms unreported offense. of sex are legally tolerated, with three simple_excep- After an offense is reported, the perpetrator tions: may or may not be apprehendedand prose- Acts such as rape, involving force or duress cuted, Those who escape arrest and prosecution (threats) Sexual contacts with children. --- Acts in public which are deeined a public A "recent study entitled Psychiatry and Sex Psychopath nuisance. Legislation: The 30's to the 80's, by the Committee on Legislatures, as noted above, have recognized the Psychiatry and Law of the Group for the Advancement of new attitudes by repealing a widevariety of laws Psychiatry (GAP Publication No. 98) reviews these laws and providing criminal penalties -for acts between con- -reecintriieilds`theit- repeal. Copies are available from the Group for the Advancement of Psychiatry, 419 Park Avenue South, senting adults in private. Law enforcement agencies New York, N.Y. 10016 ($4). are devoting less and lesseffort to enforcing laws of

5 this kind- which remain on the statute books. The the 1950's; today they are readily and legally avail- courts, too, are increasingly accepting the change able and are used for sex education in a number of from "all sex is prohibited except..." to "all sex is treatment prograMsin the hope that, by helping permissible eicept..." And,- as might be expected, open the doors to sexual- activities which society this change in policy has had a profound impact on deems acceptable, they will lessen the likelihood of treatment programs for sex offenders. post-treatment sexual behavior subject to arrest and One major effect has been to alter the definition of prosecution. successfultreatment, and -to make success much The changed attitude toward masturbation has also easier to achieve. To cite the most conspicuous profoundly- affected some treatment programs. Many example, a- significant minority of offenders in the sex offenders enter these programs with stern mas- early programs were male adults incarcerated for turbation taboos; some rarely masturbate and many homosexual acts with other consenting adults. Suc- feel guilty and worthless following masturbation. It is cessful treatment in those days meant that these an astonishing fact that some -r, 'en have committed men, following treatment. would no longer engage in rape- repeatedly, but are too deeply guilt-laden about homosexual activities. As judged by that standard, masturbation to perform that-act. Some of the newer treatment almost always failed. Under today's poli- treatment programs do their best toencourageguilt- cies, success with homosexual offenders is judged by free masturbation as one alternative to illicit- sexual the same standards_ =as_success_with. heterosexuals. activities. Some .programs,also seek to reshape the Treatment of a homosexual offender (usually a child fantasies which commonly accompany- masturba- molester).,is_deemed_successful_iffollowing_treat, tion,from.the_fantasizing_of.rape_or_other .criminaL _ ment, he meets the same three criteria: acts to the fantasizing of sex acts =which society deems acceptable. (1) No use of force or duress A major handicap in the early treatment prOgrams (2) No sexual contacts with children was the absence of participation by_women, except (3) No acts in public which might be deemed a rarely and in minor roles. Dr. Asher Pacht, a public nuisance. psychologist who headed the pioneer Wisconsin Changesin public policy 'have similarly profoundly treatment program during most of its existence, affected- the treatment of heterosexual offenders. commented: "It is incongruous for an individual who Recall, for example, the fetishist with multiple con- may have primary problems in his relationships- with victions for breaking and enteringcrimes commit- mature women to be sentenced -to the all-male ted in order io secure the soiled- female undergar- environment of the typical-prison. That is hardly an ments he needed for sexual arousal. Under today's ideal atmosphere for the development of the socio- less restrictive policies, such an offender may con- sexual skills necessary for establishing such relation- tinue his fetish without violating any law. Strip- ships." The revolutionaiy change in public attitudes teasers and go-go girls in many cities do a brisk trade toward sexuality since 1960 has included the-rise of in their soiled undergarmentsand for fetishists too the women's movement and greater female freedom remote from such cities or too shy to purchase soiled in the sexual sphere. As a direct result, women are panties openly, there are mail-order sources, adver- today employed in large numbers in treatment pro- tised in the underground press. Even sadism and grams for sex offenders, as therapists and in a masochismsexual arousal-through-the inflicting of variety of other significant- roles. Women-volunteers pain on -someone else or through suffering pain or also participate. Three treatment programs (South bondagecan now be engaged in with consenting Florida, Philadelphia; and Colorado State Peniten- partners and -with negligible risk of arrest or prose- tiary) are headed by women.3 cution. The police in several cities tolerate S-M bars and other meeting places where sadomasochistic 3 In many cases the sexual offender is fearful of women, even hostile towards them, and therefore unable to approach adults can establish social contacts with other con- them except in an abusive manner. Also many view women senting adults; such- contacts can also be secured only as objects for sexual gratification. It is essential that the through advertisements in the underground press. offender be given opportunity to learn differently; that he can A significant proportion of participants in treat- have a normal, friendly relationship with women. This can be ment programs are utterly ignorant of the basic done only when he is placed in situations which bring him into physiology of sexfor example, the physiology of daily contact with women who are willing to work through problems with him and participate in the role-playing socializa- female sexual arousal. Materials providing this infor- tion process. He must learn to talk to and be heard by women, mation were deemed, "pornographic" as recently as discuss ideas, learn to laugh with them, argue on occasion and

6 18 learn new Changes in public attitudes toward sexuality have many programs; offenders are expected to made possible yet another developmentinconceiva- sociosexual skills, new patterns of self-control, new in the attitudes toward family members and friends, toward ble when the pioneer programs were launched and espe- 1950'sthe employment of ex-sex-offenders as ther- sexual partners and prospective partners, apists and in other roles. One remarkable program cially toward themselves. they do makes use- of a team composed of a maleand a Finally, most programs today areeclectic; and a little there female therapist; the male co-therapist is an ex-sex- not hesitate to borrow a little here offenders. This offender and the female co-therapist was an incest to enhance their total impact on victim during several years of her childhood and survey of 20 programs, itis hoped, will be of calling adolescence. (Both are qualified clinical psycholo- particular use to these eclectic programs by pioneered gists as well.) their" attention to fresh approaches being This is far from a complete catalog of the many elsewhere. firm ways in which the problem of treatmenthas been All 20 of the programs are based on a human beings can in fact change, made easier, or of the many new treatmentpossibil- conviction that finds ities opened up in recent years. Others will benoted and that the environment in which a man himself is a major determinant of change. The 1 throughout this survey. These examples maybe sufficient- to explain, however, why a new hopeful- traditional correctional institution is -a striking exam- ple_otthis principle. During, a year or two in such an ness infuses-the- newerand more-innovative pro- grams, and why a- reviewof these innovations is institution, as correctional- officers well know, pro- lound.changes_occurin most inmates. Mary become particularly timely-today. more manipulative, more- concerned toachieve by 1.5. Therapeutic Models hook or by crook even- the pettiest advantagean extra half-slice of bread, a position two stepscloser The ,pioneer treatment Trograms ;Jere headed by to the-headof This-manipulative "conning,' psychiatrists or clinical psychologists, and were indeed, is -the badge of the "convictpersonality." based on themedicalorpsychiatricmodel. Sex Many inmates =learn in a correctional institution to offenders were calledpatients,and were seen as suppress their anger and theirhostilityuntil- they patients; therapy was designed either- to cure them explode in so_ me act of senseless violence.Inmates, or to achieve a sufficient remission oftheir illness so in order to survive, form antisocialhierarchies in that-they could-be safely released. The chief forms which a few dominant leaders gain controland of treatment were individual psychotherapy sessions govern in ways which maximize 'their ownpower. involving one therapist and one patient, plus group These and other dramatic changes in humanbehavior psychotherapy sessions involving one therapist and are not theintendedresult of incarceration; they are several patients. While individual and group therapy incidental side-effects of the traditional correctional are still used in most programs, mostof them are environment. also exploring alternatives to the medical model. By establishing anintentionally planned environ- Several of the programs, for example, are based mentquite different from the environment in a on aself-help-groupmodel, of which- Alcoholics traditional- correctional institution, today's treatment Anonymous is the best-known-example. Several are programs for sex offenders seek to effectchanges of modeled= after thetherapeutic community,as devel- an altogether different kind=in -the attitudes and oped by Maxwell Jones- in England and bySynanon behavior of their participants. They also seek,in a and other drug treatment programs in the United variety of ways reviewed below, to increase -the States. Some programs stresssocialfactors; of- likelihood that these changes will persist following fenders learn to function effectively and appropri- release. ately within their social group. Others stress sound interpersonal relationships withsignificant persons in their lives. Aneducationalapproach is included in 1.6. "New Directions in Treatment" The year 1972 was in two respects a turningpoint understand that they are not threatening or dangerous,-thus learning that there is more to a male-female relationshipthan in the treatment of sex offenders. Three new treat- sexual confrontation. In essence, they mustunderstand the ment programs were launchedin that year, and deep truth of Ullman and Krasner's observation thatextensive twelve more in the next four, years. Also in1972. a interpersonal relationships with women areprerequisite to clarion call for new approaches to the problem was Anne normal sexual adjustment in our society."Carole published by a Maryland psychiatrist, Dr. H. L.P. Searle, Canadian Penitentiary Service, Ottawa, Canada.

7 1 -9 Resnik, and a- Penn Sylvania criminologist, Professor the treatment; if he has a girlfriend, she can be Marvin E. Wolfgang. involved if she is willing to stand- by him." The Dr. ;Resnik, in addition to his psychoanalytic program might even include opportunities for sexual training, and psychiatric experience, had= been (with intercourse in a "private visitation- section." As his wife Audrey Resnik, apsychiatricburse-clinician) treatment progresses, this could be followed by among the -first trainees in the new- approaches to "weekly home visits. Where distance is involved, sex therapy pioneered by-Dr. William H. Masters prisoners could be transported by bus for meetings and Virginia E. Johnson at the Reproductive Biology with their wives in- their own home communities." Research- Foundation in St. Louis. He wascon- Difect confrontation."Opportunity should be-pro; cerned-with the applicability of the Masters-Johnson vided," Drs. Resnik and Wolfgang next suggested, approach in the therapy of sex offenders. Both Dr. "for certain impulse ridden offenders to 'act out' in Resnik and Prof. Wolfgang had been involved in a situation from which they cannot escape." Exhibi- planning the only scientifically controlled evaluation tionists, for example, "might be urged to masturbate of a sex offender treatment program evercom- in front of, or to exhibit to, a paid female mental pleteda project in Philadelphia (see Section 4.2 health-worker. The offender would have an opportu- below) in which sex offenders were assigned at nity to- see what response, if any, would be elicited. random -to either a treatment program or conven- A direct confrontation between the reality... and -fional probation, The.recidivism_rates for the_ two, ,the offender's highly. structured-fantasy-of-what -the- groups were quite low=bin showed no significant response would be should result." advantage for the treatrrientsrograul Following that___ .Clinical use _sof.nakedness....nAn-adaptation-of .a.- sobering- experience, -Drs. Resnik and Wolfgang practice-like nudism might be-helpful for some," the asked themselves what other treatment posSibilities Resnik-Wolfgang analysis continues. "Voyeurs or existedwhat new approaches _developed in. other exhibitionists_ .could_be_encouraged_to_ join,,nudist. -fields; or never "tried anywhere, might prove useful camps in an effort to afford them an-opportunity to in the treatment of sex offenders. Followinga series look or exhibit in an- entirely different context= of of brain-storming sessions and discussions with oth- social acceptability. Such experience, when coupled ers- in the field, they reviewed in their 1972 essay, with group therapy, could= bring them face to face "New Directions in Treatment," a Substantial list of with, their -own feelings about sexuality, nakedness possibilities. Many of these possibilities are currently (quite a different concept), and their own bodies. being tried in the newer and more innovative- treat- ...Learning to be comfortable with one's own ment programs for sex offenders described below. body, as well as learning to handle a sexual stimulus Sex reeducation.A high proportion of sex of- overload from others, could result in greater impulse fenders are ignorant of even the simplest facts about control." human -sexual response, and are imbued with deeply Personalizing the victim."Sex offenders -act as if puritanical, anti - sexual feelings. "Reeducation [of the victims are unknown to them," Drs. Resnik and sex offenders] might be effected," Drs. Resnik and Wolfgang point out; this "depersonalitation" occurs Wolfgang wrote, "by offering (1) sex anatomy lec- even when the victim is personally known. "This tures, (2) sexual photographs, or (3) films of normal phenomenon accounts for a variety of antisocial lovemaking followed by factual sexual information actions ranging from -the My Lai massacre to the and professionally supervised discussions. An oppor- rape of civilian- women as conquests of war. A tunity to see, to talk, to exchange information, and clinical approach would -be to personalize the victims to learn can have positive benefits by encouraging ..., forcing -the offenders to- become aware of and the offender to develop normal sexual attitudes and reactive to their victims as individuals and human behaviors." beings." Participation of wives."Rather than deprive pris- This could be accomplished in- part, Drs. Resnik oners of female sexual partners," Drs. Resnik and and Wolfgang continue, through discussions between Wolfgang contin:ed, "institutions should make it women and offender-group members. "These fe- possible for their wives and girlfriends- to visit males could be paid and recruited among psychiatric frequently and regularly.... These visits could be social workers, psychiatric nurses, clinical psychol- accompanied by group marriage counseling and ogy students, psychiatric residents, and sophisticated group discuSsions. volunteers. Specialized training programs to prepare "If the offender is married, his wife can be these volunteer's would be needed, as well as ongoing introduced into the joint planning and execution of clinical supervisors for support. The technique could

8 2 -0; utilize tape recordings, or be elaborated to the use of the possibility of the similar use of sexual surrogates videotape or direct television - communication. in the treatment of sex offenders. "The ultimate use of these 'personalized' women "One of the authors (Dr. Resnik) . .believes that would be attendance at regular meetings of prison surrogate partnerships for sex offender rehabilitation groups within the prison. For the majority of the are possible," the Resnik-Wolfgang paper states. offenders it would-be a unique opportunity for a first "We know that our society is not yet at the point honest and sustained dialogue with women." Pre- where it will allow a trained woman employed in a cisely such "honest and sustained dialogues" have professional capacity to interact with a sex offender become a- commonplace of sex offender treatment in a normal, pleasurable manner that can serve as a programs since Drs. Resnik and Wolfgang wrote. model for preferred sexual activity. Yet, this might Use of female cotherapists. On this score, Drs. will be the optimal treatment when the high- costs Resnik and Wolfgang recommended a therapy team and poor results of psychotherapy and incarceration composed of one male and two females. "More than are considered." one woman would be needed," they explained, "to No use of sexual surrogates has as yet been share the stress of female isolation, antifeminine reported from any treatment program for sex of- attacks, or the heightened hypersexual interest of the fenders. One case has been reported, however, of men." Here Drs. Resnik and Wolfgang were mis- the use of a homosexual volunteer as a sexual taken. Teams composolof one male and -one- female surrogate, outside -the correctional= system, in -the therapist are functioning in many programs without treatment of a homosexual- child molester who excessive stress-on-the -female .therapist. one_or, wished...to _transfer_his_se xual_interests..from pre pubm two situations, itis true, a "token" woman sex ertal male children to adult male partners (see pages therapist in an all-male program has complained of 57-58). her isolation; but where there are several women Group therapy mix. Finally, Drs. Resnik and staff members in a program, it has not proved Wolfgang pro-posed that instead of therapy groups necessary for two of them -to work with a particular composed entirely of sex offenders plus one or two offender group at a particular session. therapists, experiments be triedwith deviants and Treating sexual inadequacy. "Where sexual activ- nondeviants mixed together, the number of- nondev- ity between husband and wife has been- unsatisfac- iants being greater than, or at least equal to, the tory," Drs. Resnik and Wolfgang state, "involve- number of deviants" so the nondeviants would set ment of the wife may lead her to understand her the tone of the sessions. The nondeviants, male and husband's offense as a marital rather than an individ- female, would be recruited as volunteers from the ual problem." This is particularly true in the very community. "Anxiety, guilt, shame, the pains of frequent cases where sexual inadequacyeither po- deviance, the rewards of conformity, and many other tency problems or premature ejaculation in the [themes] could be explored within this proposed husband, or lack of sexual arousal or orgasm in the setting.... Mixed therapy groups, indeed, might female--lies at the root of marital dissatisfaction. generate, and perhaps even accelerate, the process "Masters and Johnson have reported high cure of learning a set of values that does not conflict with rates with:a number of these conditions in a highly the culture of which both [deviants and nondeviants] motivated population," Drs. Resnik and Wolfgang are a part." note. The availability of similar procedures for sex In 1972, when -the Resnik - Wolfgang -paper was .offenders and their wives might significantly affect published, many of their suggestions appeared wildly the marital relationship and hence the sex offender's implausibleobviously unachievable on this planet future sexual behavior. in this century. The extent to which-Most of those Use of surrogate partners. But what of sex suggestions are already being tried out in treatment offenders who do not have wives or sexual partners programs here and there around the country, as willing to cooperate in a program of sex therapy? In described- below, is a striking indication of the rate several sex therapy programs outside the correctional of change in American sexual attitudes and attitudes system, the services of a "surrogate partner" are toward sex offenders during the past five years. enlisted. These surrogates enter into a sexual rela- tionship with an impotent or prematurely ejaculating 1.7. Why Provide Treatment? patient for the duration of therapy, and participate with him in the sociosexual procedures prescribed by The reason commonly given for establishing sex the therapist. The Resnik-Wolfgang essay discusses offender treatment programs is to reduce recidivism

9 ratesthat is, to prevent future offenses by today's parolees) living in the community. Some community- convicted offenders. Two other reasons, however, based program.s are publicoperated .and financed deserve at least equal stress. by a court, probation or parole system, or other, One justification is research. We need to know public agency; private community-based programs much more about sex offenders than is currently are sponsored by agencies outside the correctional known if we are to prevent the appearance of future system. The table below shows the distribution of cohorts of sex offenders. No better way of studying existing treatment programs among these categories. the dynamics of sex offenses has been found than through the establishment of treatment programs. TABLE I Further, the knowledge arising from existing treat- 20 INSTITUTIONAL AND COMMUNITY ment programs is surely the most likely guide to the PROGRAMS FOR THE TREATMENT OF SEX establishment of far more effective treatment pro- __ OFFENDERS grams in the future. Treatment programs can also be justified in part as A. Institutional programs a service to sex offenders themselves. Our society (a) in correctional institutions provides a variety of services to a wide range of 1. ColoradoState Reformatory, subgroups in the populationthe physically ill, the Buena Vista mentally mentally retardedthe.exceptionally 2.. Trenton.State.Prison,..New_Jersey- bright, the very poor, and so on. Sex offenders (b) -in state mental hospitals similarly_ need, and many of them want and seek, 3. Atascadero_Statt.HospitaLAtas- treatment. The treatment they need and want should cadero, California be supplied, like any other social service, for the 4. Patton State- Hospital, Patton, Cal- benefit of the recipients. ifornia The basic approach =of this study is that the 5. Western State Hospital, Fort Stei- launching of a new treatment program can best be lacoom, Washington justified by a combination of these three motivations. 6. South Florida State Hospital, -Hol- Like services to other population groups, treatment lywood, Florida services for sex- offenders are- a proper (though low- 7. Florida State Hospital, Chattahoo- priority) function of our _social system. The priority chie, Florida is greatly enhanced by our need to know more about 8. Minnesota Security Hospital, St. sex offenseshow they can be prevented and how Peter, Minnesota recidivism can be minimized. Finally, the need for (c) in special institutions for the treatment of additional programs is made even more urgent by the sex offenders likelihood, or hope,'that present or future treatment 9. Treatment Center for the Diagno- programs will in fact lower recidivism ratesto the sis and Treatment of Sexually benefit of society as well as of sex offenders. Dangerous Persons, Bridgewater, Rape and child molestation are naproblems about Massachusetts which we can afford to sit back and do nothing. 10. Adult Diagnostic and Treatment Treatment programs for sex offenders are not the Center, Avenel, New Jersey (for- only societal responses to rape and child molestation. merly ROARE, Rahway, New Jer- But they are among the appropriate responses; and sey) as such deserve support along with rape education B. Community-based programs programs, rape prevention programs, victim assist- 11. Child Sexual Abuse Treatment ance programs, and the routine activities of the Program, Juvenile Probation De- criminal justice and correctional systems. partment, Santa Clara County, San Jose, California 12. Outpatient Treatment Clinic for 1.8. Types of Treatment Progranis Special= Offenders, Baltimore, The programs here reviewed fall into two broad Maryland categories: institutional programs for inmates held in 13. Juvenile Sex Offender Program, correctional- institutions, mental hospitals, or special Adolescent Clinic, University of institutions for sex offenders; and community-based Washington Hospitals, Seattle, programs for offenders (including probationers and Washington

10 22 14. SOANON (Sex Offenders Anony-offenders lodged in its custody. As a result, each mous), Los Angeles, California program is concerned with only a part of theoverall 15. Program for Sex Offenders, Insti- problem, and commonly serves only a- portion of a tute of Psychiatry and Law, Uni- state's needs. Minnesota' is the first state which has versity Of Southern California, Los committed itself to. viewing the- problem as a whole, Angeles, California and to planning a statewide approach to all of the lb. SEX Offender Program at Phipps many problems in the treatment of sex offenders. Clinic, The 'Johns Hopkins Hospi- The pioneer study-currertly-under way in Minnesota tal Baltimore, Maryland may become a model for similar statewideplanning 17. Center for Behavior Modification, in other states. Minneapolis, Minnesota The Minnesota planning began back in 1972, when 18. Alternatives House, Albuquerque, psychiatrists, lawyers, and ;others at the University New Mexico of Minnesota compiled a monumental six-volume 19. Center for Rape Concern, Philadel- Report on Sex Offenders: A Sociological, Psychiat- phia General Hospital, Phi:adel- ric, and Psychological Studywhich reviewed both phia, Pennsylvania the history and the current status of sex offenders_in. 20. Program for Sex Offenders, De- Minnesota. Shortly thereafter, a committee of the, partment-of,Psychiatry, University Minnesota-chapter, of the.Americat,Association of_ of Tennessee Center for the Health University Women, chaired- by Ms. Bart Delin of Scienees,_MemphiS,. Tennessee. _ _ Minneapolis,_began.holclinga,..series of.regional and statewide conferences on the treatment of sex- of-- The addresses of these programs, and the names fendersconferences which alerted- the entire state of the current directors, will be found in Appendix C to the need for action. (p. _93). Aware that most of the proposals -then under While most of the community programs listed consideration were piecemeal, the Minnesota Depart- above are operated under private auspices, they ment of Corrections contvacted with a non-profit accept sex offenders on probation or paroleand organization, Correctional Service of Minnesota, to many of them receive public funds fcr the treatment draft a comprehensive statewide- plan covering -all of these an& other offenders. aspects of sex offender treatment. Funds- were pro- All of the 20 programs are for adult offenders vided by the Law Enforcement Assistance Adminis- except- the very new program for juvenile sex of- tration of the U.S. Department of Justice. The fenders in Seattle. contract specified that the final plan shall be submit- The program of the Office of Psychohormonal ted by August 1, 1977. Research at The Johns Hopkins Hospital in Baltimore Dr. Thomas C. Couelltof Correctional Service of (see page 53) is the only one of the 20 which has tried a Minnesota, in charge of preparing the plan, is hormonal approach. currently drawing on a- wide variety of resources The program at Trenton State Prison enrolls only both in Minnesota and throughout- the country. He rapists. The Santa Clara County program in Califor- has, for example, been visiting-many of the programs nia is solely for child molestersmost of them described- in -this survey, consulting with program -fathers or stepfathers involved in incest with their - directors and with others, and-bringing visitors-from children. The other programs enroll a broad mix ofother states to consult with his Minnesota associates. offenders. He -has also assembled- a -task force of eminent Excluded from this survey are a wide range ofMinnesotans, whose help- is being sought both in treatment programs, both institutional and commu- preparing a plan suitable to Minnesota's circumstan- nity, which are available to offenders generally, ces and in providing needed support when the plan including sex offendersbut which are not tailored is completed and ready for implementation to the specifically sexual problems of sex offenders. A surprising preliminary finding of the Minnesota group concerns the many agencies withinthe state 1,9. The Need for Statewide Planning which- are already deeply involved in providing Most of the treatment, programs for sex offenders treatment for sex offendersmostly in isoiation from currently- in operation arose, almost by accident, one another. In addition to the state'scorrectional through the activities of one dedicated individual or institutions,. _there are the state's psychiatric hospi- one institution baffled by what -to do about the sex tals, probation and. parole departments, police "sex

11 23 squads," prosecuting attorneys, community mental Florida, and perhaps other states during 1976, in a health centers, private psychiatric clinics, family similar effort to view each state's problem as a service agencies, halfway houses, and even drug whole. The August 1977 Minnesota plan, it is hoped, treatment programs (several of which also treat sex may encourage other states to organize and fund the offenders). Providing leadership and-cooperatiie ap- preparation, and subsequent- implementation, of proaches among these existing services may prove statewide plans for the treatment of sex offenders an important part of the ultimate Minnesota plan. bdth in the state's institutions and in community Less formal groups were meeting in Connecticut, settings.

12 24

t. PART II.FIVE INNOVATIVE PROGRAMS

institu- beforeand his suspicions are aroused.These sus- The first two-programs here described are the same tional or inpatient programs for incarcerated of- picions are reinforced- when he notes that bind fenderS. The other three are community-based out- ties of respect; affection, and trust appear to program's patient prOgramsone for juvenile offenders, one for members of the group to the treatment director. incest_ offenders and their families, and the third staffincluding the- director and associate serving primarily sex offenders on probation or What kind of a con game is this,anyway? rituals;,one-is,the way parole. Fort Steilacoom has many in which a group greets-a=new-Member.Seated in a circle, each man introduceshintelf by name and A. The-Fort Steilacoom Program, states his offense,oroffenses. "I raped three women- and tried to rape 2.1. First Impressions more." The-Fort Steilacoom program can best be seen as "I'm_arflaslier---4iundredS Ofiimes:"' time she it appears to a sex offender sent to the programby a "I had sex with my daughter from the period, during was- eleven-until ShebleWrthe whistle." state court for a 90-day observation himself which the program will decide whether heis eligible When the new man's turn comes, he finds himself for treatment and he will decide whetherhe wants quite unable to admit his offenSe=either to treatment.' The observation period is prescribedby or to the,group. consented and the Washington "sexual psychopathstatute," and is "I'm here by mistake. This chick an alternative' to convictionunder the state's ordi- then screamed rape." "I don't know what happened; I wasdead drunk nary- criminal laws. fiend." What -the newly admitted offender finds atFort at the time. I'm awalcoholic, nota sex 150 sex The other men nod knowingly.They-have-heard Steilacoom is a population of approximately they made the offenders divided into 10 treatment groups.He is all the alibis many times; indeed, his same excuses themselves,early in their treatment. assigned-at random to one group, which remains of them group as long as he staysand throughout- his "If you're going to stay here," one informs- the- new man, "you're going tohave to stop 'subsequent aftercare period. admitted sex justifying." Like the rest of society, the newly con- offender hasa very low opinion of sexoffenders; he Later in the day the newcomer observes a confront- sees them as "losers,"unfit for ordinary society, frontation: thirteen of- the -_men mercilessly- He ing -the fourteenth concerning what appearsto be a laden with guilt, liars, exploiters, untrustworthy. This is therefore amazed to find, in- his groupof 15, minorpecadifiousing a saucer as an ash tray. the target --a social severaloffenders who come on as competent,effec- is a grueling experience for listening, tive, functioning human beingsself - respecting, un- disaster. The newcomer, watching and ties shudders and decides he'd rather sit-in prison. But derstanding, open, and bound to one another by attracted to the of mutual respect, affection, and trust. Inall proba- he is at -the same time enormously of its leaders. Then bility, he has never experienced anythinglike this group, and fantasizes being one he returns to reality. No way, he tellshimself. I couldn't make it here. I'm a- loser andalways will ' This account is based on two visits to Fort Steilacoom distrust of (1975 and 1976), during the second of which the author of this be. This tension between the newcomer's study. spent three days and nights living on the unit with the group and his desire to belong toitreally and offendersplus similar observations by a Canadian criminolo- truly belongmay continue forweeks, perhaps gist, Carole Anne Searle, who lived in the Fort Steilacoom months. program for a- much longer period. Direct observations were From the first day on, the new man istoldboth buttressed by published and unpublished materials listed in the of him. A Bibliography (p. 95). orally and in writingwhat is expected

13 25 handout written by one of Fort Steilacoom's ten in 'his lifethat he must enter into an open, honest, groups begins: meaningful relationship with an adult female. Even if Welcome -to Star Groupthat is, if you have he happens to draw a male therapy supervisor, he an honest desire to change your offensive habits will be faced with the need to establish an open and of behavior, and if you wish to accept your honest relationship with the group volunteerusually share of the responsibilities which are given to an attractive married woman in her thirties assigned this group by the hospital. If you do not, then to a particular group. you are wasting your time and ours. As part of his: early indoctrination, the newcomer You are here because of your socially unac- must learn his responsibilities. Here is what Star ceptable sex acts--but your problems are not all Group tells him: sex. Sex is an outlet much like drinking is to an We are responsible to ourselves to know what alcoholic and both can become habitual. Your our responsibilities are, to Understand them, to problems may be many and various. Ingroup accept, and to do our best to take care of them. therapy we will learn what these problems are, We are each responsible, first of all for the and why we used sex as an outlet. Some best reflection of the group, and this program to problems are: self-pity, mistrust, hostility, self- the public and its opinion. centeredness, inability to accept responsibility, We are directly _responsible to our therapy inability-to express yourself-properlyand many supervisor, and also to Dr. MacDonald, [direc- others. tor of the program] for any conduct on our part Upon-entering-group you-may-make excuses or observed on the part of any -other- member for what you have done. But, you will discover that will or could be interpreted as unacceptable that most of these are based on rationalizations, to public opinion,of our confinement here. or on justifications. If you are inclined to be We are directly responsible to the group that rebellious, you will probably rebel against being it be informed of any conduct that is inany way criticized for offensive personality traits you detrimental to the group, or program.... may have; but sooner or later, you will see Any member condoning an irresponsible act them yourself. You may quickly learn why you or planned act will be held responsible for each react the way you do and begin to understand act. things about yourself that you may never have We are responsible to all future members in realized before. that the program be continued and continues to One of the hardest things to do is to under- progress. . stand yourself. We all quickly recognize the faults of others and have difficulty with seeing To a typical newcomer, this means- that he is our own. ... expected to be a stool-pigeon, or rat, or snitch When you are letting yourself down, you are spying on his fellows and reporting their shortcom- letting your group and the hospital down also. ings. To men who have served time ina conventional We are very proud of our group and we remain correctional- institution, this is particularly frightefir- that way only with your help. You might re- ing; for they have been deeply indoctrinated ina member that kindness is something that you code which identifies authority as the enemy, and can't give awayit comes right backjust the cooperation -with- the enemy"ratting"-=as a se- same as unkindness. verely punishable act of treason. At Fort Steilacoom, all this is turned upside down; some menespecially Much of this is meaningless to the newcomer; but ex-inmates from conventional correctional institu- as the weeks and months roll by, such attitudes may tionscannot make-the switch and are returned- to become the most meaningful aspects of his life. court for sentencing to some other institution. As the newcomer adjusts to- the group, he must Because the program's expectations are clear and also gradually adjust to the representative of author- explicit, the newcomer gradually understands what ity within the groupnot the therapist, as in most is expected of him. In many cases, he decides that groups, but a staff member called the therapy this is a new kind of con game which hemay as well supervisor. The theory at Fort Steilacoom is that the play during his 90-day observation period. -So he men accomplish their own therapy. Three of the ten "plays ball" with the group. He confesses just therapy supervisor- are women; and a newcomer to enough of his past to give the impression of frank- the group may thus findperhaps for the first time ness and openness; he joins in the confrontations,

14 26 and he seeks in other ways to be a "model decides when a newcomer is ready for suchprivi- his prisoner." This superficial conforming, of course,is leges. If he abuses themby talking longer than them; precisely the opposite of trueparticipation--but the allotted six minutes, for examplehe may lose for reinstate- group is tolerant for a time. They seethe newcomer's and he must then apply to the group pseudo-conformity as "trying it on for size." Perhaps ment of the privilege. Much moreimportant, the he'll like his new pseudo-role as a responsible group group decides at the end of the90-day period member; if so, it's a good first step. He isgiven whether to recommend that the man beadmitted for much "positive feedback"group approvaland treatment. The group's recommendation mustbe even overt praise for his newattitude. ratified by the treatment program staff, -by the But Fort Steilacoom is structured 'as a ladderin hospital, and by the court; but in ix highproportion which each change in attitude and behavior is seen of cases, it is the group decision whichprevails.2 as the foundation for the next stepupward. After a The man himself is present during the finaldiscus- newcomei.decides to "Play the game;"'he musr next sion of his acceptability.. -That-is-a-deeply-moving learn tostopplaying games. experience. If he is rejected, the rejection is ge,fitle. At some point during the 90-dayobservation The group may feel, for example, thatthis man period, accordingly, the newcomer faces hisfirst really isn't in need of a year ror two at-Fort major confrontation. It may begin with a trivial Steilacoom--and that his chances are good ofbeing faultoversleeping, for example. The newcomer released on probation when he goes back to court. makes an excuseand the fat is in the fire. Fifteen Or it may conclude that he needs a lessrigvrously Why does he always try to structured environment. If the -man is accepted,his men descend upon_him. Fort lie his way out of trouble? Doesn't he realizethat it attention is called to -the long climb up the is precisely such behavior which makes himalways Steilacoom ladder he still has ahead of himbut the He is made to feel that a loser, always an outsider?Why can't he face up to acceptance is whole-hearted. his shortcomings and do something aboutthem he has succeeded, and that he now belongs. that a instead of always alibiing? One group member recalls All sex offender treatment programs agree that this guy did the same thing last weekunder feeling of inner worthlessness is the single most similar circumstances; and another points outthat in common attribute shared byconvicted sex of- front. addition to making excuses, the new man hasseveral fenderseven those who put up a blustering other- marks against him. The oversleeping forwhich They are already at the bottom of thebarrelso he was initially confronted is soon drownedin a what do they have to lose? Their lack ofself-control stake review of his entire behavior pattern. arises in considerable part out oLthis lack of a Procedures such as thisand there are many in society, something they may lose if theylose othersare tendered particularly effectivebecause control. They may fantasize becoming richand toward each Fort Steilacoom group functions almostcontin- powerful; but taking the first small steps uously. The members of the group all sleep oniron those or any other goals are not withintheir reper- view of cots in one overcrowded dormitory.They are awak- toire. That, at least, is the Fort- Steilacoom ened each morning at 6 a.m. by a memberof the the problem. group assigned that responsibility;often- the wakeup Success breeds success. The Fort Steilacoom is itself a sort of ritual, breedin_,a sense ofcomrade- program teaches a manoftenfor the first time here and there ship in adversity. The group eats breakfasttogether that he is not a bit of flotsam washed his in the hospital refectory. Then they split upfor work by -the waves, with little or no influence over assignments around the hospital; but often two or own destiny. Here, soobviously no one can miss is the direct more group members share -the-same assignment. the lesson, what happens to a man Afternoons and evenings they are mostlyback in outcome of his own attitudes and actions.Acceptable rewarded- their unit together.Formalgroup meetings fill per- behavior is immediately and continuously haps 25 hours a week; but group interactioncontin- ues throughout the otherwaking hours. There are 2 01154 sex offenders evaluated during the 90-dayobserva- be sexual also "one on one" rituals; a particular groupmember tion period in fiscal 1976, 65 percent were deemed to psychopaths within the meaning of the WashingtonState singles out another for a rap, a confrontation, or a statute and were judged to be amenable to treatment;these discussion. men entered the treatment program.An additional 22 percent The group process is enhancedby the fact that were judged to be sexual psychop4ils notamenable to treat- almost allprivilegesare controlled by the group. ment; thet, were not_accoptcd_for treatment.The remainder Telephoniiig is one example among many. The group were dented not to be sexualpsychopaths. 27 15 and acceptance into the ,program at the end of the "thought control," or "1984." In effect, according observation period is-the first ofmany such earned to this view, overwhelming psychological pressures rewards. are put upon participants to convert them from freely The offender has an option. He may decide in the functioning human beings into automatonsgoose- course,of the observation program, or at the end of stepping to the tune of law-and-order. -it, that he would rather take his chances with An alternative view is that the sentencing under the criminal law than stayon at group members at Fort Steilacoom are being subjected Fort Steilacoom. But many motives make sucha to very much choice unlikely. the "shaping" processes that law-abiding citizens In the first place, Fort Steilacoom offers offenders went through during childhood and adolescence the possibility Of getting outif allgoes wellin a processes designed to turn out conforming, law- period much shorter than a criminal sentence would abiding citizens. Having somehow escaped these p rocesses.,earlie provide:- The-usual-period` of-incarceration at Fort the .Fort-Steilacoom-`-tgroup-proc-- ess" is giving them a second chance.,This, Steilacoom is 15 to 20 months. A man-may be of course, is the view taken by the staff at'Fort expelled from the program and sent backto court at Steilacoom. any time, it is true;3 but if so, his stay at Fort A choice between these two. views- depends inpart Steilacoom counts as time served. And conditionsat upon the gain for the individual participantas well as Fort Steilacoom are generally more agreeable thanat for society. Clearly the Fort Steilacoom techniques conventional institutions. Thus a man may decide_ he could not be properly used for turningSocialists into wants to stay even though he distrusts the program Democrats or Communists into Republicans.The and has noTititention of honestly participating in it. issue is not quite- the-same when the purpose is to Here the- grdup process is particularly effective. turn rapists and child molesters into law-abiding The sentencing of a sex offender ordinarily depends citizens. A more difficult issue-concerns the use of upon a judge who may have only a few minutes Fort Steilacoom techniques for exhibitionists,voy- rarely as long as an hourtc devote to an individual eurs, and fetishists. offender. He ordinarily has to assist him reports from one or more psychiatrists and from Another approach contrasts what happensto a a probation man at Fori Steilacoom with what- could happen to officer, plus a man's record as it appears in the the same man if he were- incarcerated instead in formal- documents. Psychiatrists and probation offi- a maximum-security correctional institution. There, cers readily concede that they can on occasion be too, he would have been subjected to conned; the formal record is rarely complete. Thus peer pressures and procedures reminiscent of brain=washing, sentencing is sometimesperhaps usuallyaguess- ing game. thought control, and 1984but without the obvious benefits of die Fort Steilacoom experience. The Fort Steilacoom group process providesenor- mous barriers to conning. A man who can readily The Fort Steilacoom program is clearlyan effort con even a skilled psychiatrist finds it hard to con at behavior modificationan effort to modify the 15 fellow- offenders -with whom he-has*-been living in behavior of rapists, child molesters, and othersex close quarters for 168 hours -a- week, week after offenders in the direction of social- conformity.To week. During his subsequent stay at Fort Steila- those who object in principle -to modifyingthe coom, moreover, the same pry,.ss continues; about behavior of sex offenders, there isno possible a- third- of those who survive the observation-period answer. are returned to court before "graduation." Thus Fort For those who object only that the methods of Steilacoom's successful "graduates" form avery behavior modification used at Fort Steilacoomare select -group among whom recidivism should berare. ruthless or brutal, however, there isa very clear answer. They did not appear ruthlessor brutal during a 72-hour site visit-for this study; and they didnot To some critics, the "group process" at Fort appear ruthless or brutal -to other female and male Steilacoom may sound like "brainwashing," or observers locked up in the:unit foreven longer stays. Indeed, in comparison with the ambienceof the typical maximum-security correctional institution, 3 -Of 89 sex offenders who terminated inpatient treatmentat Fort Steilacoom during fiscal 1976. 60 graduated to work the "group process" at Fort Steilacoomappears release. Most-orthe remaining;29-were returned to court with extremely- benign --not only-to- observers butto most a negative recommendation. participants who have experienced both. 16 28 2.2. History of Program beginning gradually led to a much more intensive program. Since adequate staff was notavailable to In 1951, the Washington State legislature (like lead additional sessions, the men beganholding many other state legislatures from 1937on) passed a sessions without leaders. "New staff members "sexual psychopath" statute, designed in part to brought to the group the concepts of honesty with make it easier for the state to incarcerate sex one's self and in interpersonal relationships. Respon- offenders and in part to hold them for longer periods sibility for the program shifted more and more from than was possible under the ordinary criminal laws. the staff to the program participants. As in other states, these goals were to be accom- plished by calling the incarceration "treatment" The message to the new patient was no rather than punishment. This, indeed, was how the longer, "You are sick and we (the staff) are concept of treatment for ,.c.tx offenders entered the going to treat you," but instead, "You have --American.correctional-system. been an irresponsible person and this whole A history of Fort Steilacoom by Dr. George J. group will help you learn how tobehave respon- MacDonald, psychiatrist and director of the Fort sibly enough to be free in the community Steilacoom program from 1965 to date, and Robinson again." A. -Williams, a social worker and associate director Two major steps during- this growth period were from 1966-to 1976, describes what happened nexta the selection of Fort Steilacoom as the treatment series of events common to other states as well: center for sex offenders from throughoutthe state, and the setting aside of a separate ward in the During the years 1951-58, sex offenders were hospital for each sex- offender groupso that mem- committed in increasing numbers to hospitals bers of the group were together- throughout theweek already overcrowded with psychotic patients, and could interact continuously. This168-hour-a- badly understaffed, and not prepared to offer week. "total push" concept is found inonly a few any special treatment to this new typeof patient. These "offender-patients" were therefore segre- treatment programs. The process of group responsibility, however, was gated on ntodmum security wards or distributed carried-too far during a period when the head of the throughout the hospital among psychotic pa- treatment program was promoted to headthe whole tients on locked wards. With no treatment hospital and when his chief assistant was- in -the available and little hope of regaining their free- process of leaving the hospital. Someleaders among dom [commitment could continue for life under the sexual psychopath statute), the offenders the program residents: grew discontent and restless. Thisresulted in established themselves as a "privileged .class", manipulative and disruptive behavior, frequent more concerned with theirpersonal comforts unauthorized leaves, and much staff anxiety and and perquisites than with their responsibilities to resentment which was often expressed inin- the group members and the hospital.They creased and even punitive over-control. The manipulated to avoid work or get theeasiest situation became steadily worse until a legisla- hospital- job assignments. They monopolized tive investigation of hospital conditions in gen- money-making hospital jobs; set themselves up eral in 1957-58 resulted in major reforms in the most comfortable living quarters; estab- throughout the hospital. lished a private off-ward "pad" forvarious illegal fun and games; andengaged in petty The initial reform at Fort Steilacoom was grossly larctny of hospital supplies.They managed this inadequate; a staff psychologist was assigned to hold by enforcing a "no-ratting" code amongthe a two-hour group therapy session with the sex group members similar to thatexisting among offenders once a week. "Initially, therapy was non- prison inmates. ...The Senior Leader's sole specific and not predicated on any stated hypothesis had be 3ome much- like that of the topprison about the nature or course of sexually deviant "politician"....In the course of investigating behavior. Treatment was directed toward somehow a suicide attempt by oneof the general- mem- developing 'insight' which was presumed to augur a bers, the Senior Clinical Director became aware change in behavior." of- the corruption and intervened to restore the During the years from 1959 to 1965, under the program to therapeutic effectiveness. direction of a psychiatrist, Dr. Giulio di Furia, and a psychologist, Dr. Hayden L. Mees, this meager As part of this reorganization, apsychiatrist, Dr.

17 29 George J. MacDonald, was brought inas director of acceptable explanationand the assurance that they the program, andtdevoted'his full time to it. During can change. Thus their lives begin to make sense to the next few years, he and-a social worker, Robinson themselves. Further, the theory offersa framework Williams, M.S.W., who served as associate director within which offenders and -staffcan, in full agree- until 1976, developed the program-as it now exists. ment, work to effectuate-change. As,changes toward greater social acceptability=in.fact occur,-the- question 2.3. Basic- Theory-of-the- Program' of the correctness of the theory losescogency. The usefulness of the theory becomes the important The basic theory at- Fort Steilacoom has, been consideration. enunciated by Dr. MacDonald and others: Throughout Fort Steilacoom'S IiiStory, Dr. Mac- A pattern of sexual deviation is a conscious Donald adds: hut-habitual-way--of -seeking-relief from-emo- Three- basic precepts have remained unchanged: tional stress. The offender's predatoryor irre- The first is that deviant sexual behavior is sponsible behavior toward another human being, learned behavior and therefore subject to modi- however, achieves only temporary relief at best, fication if methods can be developed to break and such behavior is invariably self-defeatingas up old habit patterns and teach new ones. The it further alienateS him from others and himself. second is that sex offenders, following the [Further, the offender] perpetuates his basic example set by- Alcoholics Anonymous and problem of deep feelings of inferiority and other groups, can do a great deal to help each insecurity by self- defeating habits of relating to other overcome their deviant behavior if given himself and others in deceitful and anger-pro- the right kind'of direction and guidance by staff. ducing ways. That belief forms the basis of the program's guided self-help approach... The Fort Steilacoom treatment philosophygrows . The.third-precept directly out of this view. is that the hospital's environment -and theproc- ess for relearning acceptable behavior must-- Treatment focuses on ,breaking up these rejec- replicate and confront the realities of living in tion-producing behavior patterns by daily de- the community as much as possible. mands for rigorous self-examination, intensive involvement with others, constant demands for The same points can be made froma more familiar honest and responsible behavior, and rewards psychiatric perspective. The self-respecting,rela- and punishments based solely on responsible tively law-abiding adults who constituteour domi- behavior. nant society were not born- that way. They had to learn acceptable modes of behaviorat home, in The changes demanded of a man constitute four their relationships with parents and siblings;at basic "treatment objectives": school; and later in the community. In the sociosex- The offender must learn. to recognize hisown ual sphere, for example, they had to learn howto antisocial behavior patterns. talk with girls,-how to play with them, howto go on He must understand the origin, development, dates with them, how to kiss and cuddle with them. and operation of these patterns. They had to learn to be sensitive to the feelingsof He must accept responsibility for his deviant others, and to see themselvesas others saw them. behavior and make a commitment to change; For whatever reasonsand the early childhoodhiS- and tories of sex offenders are replete with reasons* He must develop new patterns of- behavior most of the participants in a- sex offender training which will gain him community acceptanceat program have failed to progress through this series first within the program, and subsequently in of growth experiences or through key portionsof the the world outside. series. Fort Steilacoom offers thema second chance. The Fort Steilacoom thebry that sexual deviation is a self-defeating and habitual patio -n ofresponse to Most Fort Steilacoom sex offenders, like offenders in stress may or may not be true. Er,k, if it is not, it ger,cral, report the familiar causes of delinquency of all kinds performs an important- therapeutic role. Most of- broken homes, brutal or impotent.fathers, uncaringor overpro- tective mothers, physical and emotional deprivations ofmany fenders are baffled by their own behavior.-They d9 kinds. A substantial portion were'physically abusedas children; not understand themselves or the reactions of others and of these, a remarkable number were themselves the victims to them. The Fort _Steilacoom theory offers them an of sexual abuse. 18 30 fifteen minutes a day -Much as learning a-foreign language ir. your 20's to a geriatric ward may spend after a or_ 30's is far more difficult than learning your native holding the hand of a senile woman patient; and to smile tongue at the natural time and in the natural way, so few days she begins to recognize him, the Fort Steilacoom type of learning is a difficult and at him, and even, later on, to exchange afew'Words arduotis undertaking. Graduates may still speak the with him. He may thus, perhaps for thefirsttinie in new 'language with an accent, to continue the meta- his life, get that inner glow that comes fromknowing human phor..But -the goal is- not to. turn out saints; it is -to that he has indeed been of service to another turn out men capable of =living in society without being worse off than himself. That is one of the roots raping, or molesting children, or otherwise'behaving of self-respect and self-esteem; andit is a powerful offender. in ways society will not tolerate. factor in the social rehabilitation of a sex Couples therapy.About half of the men admitted to Fort Steilacoom are married."The reactions of '2:4: -Some- Program =Details- their i;viVe§Thi,vardthehtishatid's -sexoffense- who While Fort Steilacoom places =major emphasis on varied," reports Emily Wurster Hitchens, R ;N., the group process itself for the reeducation of its has worked with Fort Steilacoomoffenders and their offenders, it also employs a wide -range of other wives. "MoSt were shocked, sorrie`-felthumiliated, treatment methodsa few of which will be noted others took the offense to:mean that.theirhusbands did not love them; and a few felt directlyresponsible here. Some seek imme- Therapy supervision.While each therapy group for their husbands' aberrations." Meets many hours a week with no staff member diate divorce, but many do not. FortSteilacoom wives in the present, supervision is nevertheless close. The ther- makes a strenuous effort to -involve apy supervisor sits in on manymeetings and can treatment program. visit any meeting at any time; the program director Wives often come during visiting hours, for;exam- and associate diFECIOiraffrattend some meetings. ple, and on-weekendrbring-theirchildren:-It-is-an, Some sessions are -tape- recorded; the therapy super- amazing sight to see offendersmany -of them incar- visor can later play back the session or portions of cerated for child molestation=interacting simply and it. FoUowing each meeting without staff, the meeting appropriately with those thildren;.not a single-unto- leader summarizes -the highlights for therapy ward "incident" has ever occurred. supervisor; and together they plan for suusequent A feature of each unit is a "Couples room" with a meetings. Finally, the therapy supervisor and the bed and other fittings, and with a'keylthat locks the director and associate director are available to any door from the inside. These rooms were fitted out-by member of a group with complaints or suggestions. the wives of Offenders and by community volunteers; These supervisory measures have proved adequate one room is even equipped with aking-size wa- since 1965 to pm vent abuses of group power; but terbed. A married offender, when he has earned-the Fort Steilacoom stresses that the possibility of abuse privilege and is deemed ready for it, may spend the is always present and that administrative vigilance evening there with his wife. Also available is a can never be relaxed. cottage on the hospital grounds where a man in a Work assignments.Each program participant, after later stage of his treatment may spend- the weekend the observational period, is expected to devote 15 with his wife and children. hours or more a week to unpaid work for the benefit All of this husband-wife interaction is made more of the hospital. significant by a couples' group which meets one Work in a mental hospital can be a frustrating and night a week. Emily Hitchens, the nurse who served depressing experience, as paid employees well know. for a time as co-leader of this couples' group,'has But participants in the sex offender treatment pro- described the three goals of the group: (1) to'help the gram have aplace to bring theirtroublesthe group. wife gain a better understanding and, acceptance of How do they react to frustration on the job? To the program so that she could support her husband's conflicts with supervisors? Do they find their old therapy; (2) to help the couple examine the commu- (and deviant) sex fantasies creeping back on them? nication patterns in their relationship in order to The work assignments constitute an encounterwith identify malfunctions which could be contributing outside reality which provides much current grist for factors in the husband's sex offense; and (3) to help the therapy sessions. the couple establish a sharing and problem-solving In addition, of course, there are satisfactions to relationship which might be a- control on the hus- work in a mental hospital. A sex offender assigned band's behavior after his release. 31 19 Many problems are brought to the couples' hardly likely to win him favor on the outside. So the groupforexaniple: "Our son is coming home from volunteers rehearse with the men in their group a the-arrny. What should weAell him about his father variety of simple procedures: how to establish eye being -ill a Sex, offender program?" The familiar contact, how to start a conversation, how -to accom- prineiPies of .couples' therapy and family therapy pany a woman to dinner, how to eat properly and used.iti other settings,_ Fort Steilacoom has found, dress appropriately, and all the other simple socio- can also:proVe useful in this setting. sexual skills which are taken for granted in respecta- .rsychodrama- and role-playing. It is here that the ble society but which many of these sex offenders worrian volunteer attached to each Fort Steilacoom have missed during their first growing-up period. A grohp is Of special -value; indeed, the volunteer man who has mastered socially acceptable ways of prOgram was first launched in order to provide approaching adult women may have less need-for an women for the female roles.s ascaultive approachor for sexually approaching -One -voluriteer-who-spent-five-years--with- a-Fort. thildren. Steilacoom group recalls: Social interactions- with the women volunteers are I would go to -the hospital each Tuesday buttressed by social interactions with a variety of afternoon and spend an- hour with the gyoup other mature women--,-with the wives of offenders leaders and =therapy supervisor to catch up on who come visiting, and who get to know other what had happened during the week, and to members of the husband's therapy group; with the plan =the afternoon program. three (out of ten) therapy- supervisors who are Sometimes in -the course of the afternoon I women; and, at- times, with women sex- offenders would take on the role of a rape victim and who are in treatment in the program. (In tecentyears express feelings of anger and terror.,Or I would four women convicted-of child Molestation in concert portray- a-mother of a child who had been with their husbands have been committed to Fort - molested, wondenng hOTTO comfort the child Steilacoom;- and - assigned- at-random -to--therapy after such an encounter. groups.) Finally, and of great iinportanee, there_ are For most sex offenders, the victim is not- a interactions with women stafftnembers and patients person but an object to be used. Little if any in other parts of the hospital, whom -the offenders thought is given to the victim as a.human being meet during their daily work assignments. For some with feelings. But in these psychodramas with men in the prOgram, the Fort, Steilacoom program mesomeone bound to. the group by deep ties comes closer to being a normal heterosexual environ- of mutual commitmentplaying the role of ment than anything they have experienced- during victim, the men were able -to share my feelings their lives as "loners" on the Outside. of shock, rage, terror, or whatever. The ladder. Like Alcoholics Anonymous and numerous other self-help groups and therapeutic The volunteers also help to teach the elementary communities, the Fort Steilacoom program is struc- social graces. One man, a volunteer recalls, couldn't tured as a ladder, with ten or twelve steps leading even speak to her or look at her early in his upward. The group itselfcletermines, in consultation treatment; the only way he knew to attract her with its therapy supervisor, when a man is ready to attention was to tug _on-a lock of her hair--behavior move up; and the group may =also demote a man one or more steps. Privileges are geared to the step a $ "Despite thevery unattractive image the public has of sex man has achieved; -the higher he climbs, the more offenders, the-program has managed to recruit enough volun- freedom of action he earns. Each man must spend at teers for each psychotherapy group to have at least one least one month on,each step; hence one year is the volunteer working with it on a regular basis. The volunteers, minimum time in residence. Most men take some- -forthe-most-part-maturc~and-attractiveyoung married women, participate in weekly psychodrama or sociodrama sessions what longer tot:reach the top, and eligibility for designed to help the offender learn to deal with women in other releasebut rarely longer than two years. Men who than .immature, selfish, or hurtful ways. As the volunteers gain aren't likely to make it in that length of time are experience, a number of them become directly involved in mostly sent back -to court for reassignment else- weekly group therapy sessions for married offenders and their where. wives..'.. Once volunteers become 'regulars,' they becomeso enthused with their work that the program's only, problem has Step Seven of the ladder is particularly significant, been setting limits on the amount of time they spend." for it makes a man eligible for election to the offices Annual Report,1973-1974. There were 29 volunteers during of Junior Leader and Senior Leader. Groups tend to fiscal.1976. rotate men through these offices, so that- each -man 20 32 has the leadership experience when -he is ready for spectrum around them in their group sessions: other ita major contribution to the education of men who new men like themselves, losers, liars, withdrawnin have always been either followers or loners, and a their shells; plus men who have accepted the pro- major contribution to their self-esteem as well. They gram and are beginning to make progress;plus the now have something of value to losetheir leader- leaders, self-confident and looking forward to a new ship status. way of life on the outsideplus those on work Security is also linked to the ladder. Men on release and outpatient status who are almost home observation may not leave their locked yard alone; free. they must be accompanied at all times by a respon- That array from new men to men on outpatient sible group member. The privilege of leaving the status is a highly impressive onenot only for locked ward for other parts of the hospital is earned newcomers to the program but for visiturs as well. A by climbing the ladder. visitor can literally see the difference the- program _ _ Work release and Outpatient treatment.Comple- -has made in its members. tion of the inpatient .program at Fort Steilacoom is The number of men who commit new sex offenses followed by a period, usually of three months, during while on work release or outpatient status-is exceed- which a man is on "work release." This means that ingly lowpartly, nn doubt, because of the pro- he may leave the program five days a week to find a gram's effectiveness, but also because the men job and to work at it. He comes back to the program released- constitute a very selected group. No ade- each evening and weekend; continuing to participate quate followup study of alumni beyond outpatient in the same group which was his during inpatient status is available; but- the omens are good. (For a therapy. Following work release he spends an addi- further discussion of program evaluation, see Appen- tional period, usually 18 months, on "outpatient dix B.) status"; this means he may live out but must return one-evening-a-week-to-meet-with-his-old-group. 2.5. Some Shortcomii Couples therapy for a man and his wife may also continue throtigh this period. In the account above, stress has -been laid:on the The value of these aftercare procedures cannot be affirmative virtues of Fort Steilacoomand espe- overemphasized. During the arduous and perilous cially on those features worth study by other pro- period of adjusting to the world outside, a man grams and by those planning to launch new pro- continues to have the support of the same group, the grams. The same emphasis will be followed in the same therapy supervisor, and the same woman review of other programs. Brief mention should be volunteer who saw him through his inpatient period. made, however, of some Fort Steilacoom weak- He can bring his troubles and frustrations to the nesses. group for both its critical- insights and its emotional Almost all of Fort Steilacoom's successes have support. The tie between the man leaving for work been with heterosexual offenders. The program release and the group he leaves behind is strength- receives relatively few homosexual offenders ened by a special ritual: the group takes up a for observation, keeps few of these for treat- collection out of its own pockets to provide a ment, and graduates even fewer. The reason grubstake for the work release period. may be in part the men's own unaccepting The value of work release and outpatient status is attitudes toward homosexuality and homosex- also very great for the group left behind. The men uals; other factors may contribute. returning from the outside each evening or each Fort Steilacoom is- an open hospital. The sex week bring back news of what itisreallylike out offender units have locked doors;- but keys are there, and thus substitute realism for fa_ ntasy in each in the hands of the group leaders, and men man's "cognitive rehearsals" of what it will be like leave the locked units for meals, for work when his turn comes to go out. assignments, and for other purposes. There Finally, to return to the first impressions of new have as a result been some escapesat least men just entering the program for their observation one of them widely publicized. One result has period, the men who have already completed the been anxiety and hostility in the immediate program and are now on work release or outpatient vicinity of the hospital; another has been a- new status constitute role models and assurances that the series of security restrictions resented both by newcomer, too, can "make it" if he sets his mind to the men and by the treatment staff; a third has it and works hard at it. The new men see the entire been an unwillingness of some judges to send to

21 33 Fort Steilacoom men who might benefit greatly most of the efforts of Dr. Boozer and her staff are there. focused on- these groups rather than on individual The program serves best the offenders and their offenders. Irideed, much of Dr. Boozer's effort is families from thel-state's-main centers of popu- devoted to deemphasizing anything which, in her lation, Seattle and Tacotaa; but it also draws words, might "dilute the group process." Thus an men from distant parts of the state for whom offender immured in Dr. Boozer's unit has really work release 'and- outpatient status constitute a only two options: he can become a loyal, striving, severe hardship. Moreover, the program may functioning member of his group or accept thd role have grown 'beyond optimum size. The Fort of antisocial outcast. Those who stubbornly choose Steilacoom staff itself has recommended that-a the latter course are transferred out. similat program be established in Eastern Wash- "Self-government" is a familiar concept in _correc- ington AlglApP95e5411}1. further- growth at Fort tional programstoday, It_ may_ be_anythingirom_a_ Steilacoom. facade behind which a dictatorial adminiStration, As subsequent portions of this -study -will demon- reaches its own_ decisions to a genuine- consultative strate, -the Fort Steilacoom; model is not a panacea machinery for reconciling the interests of inmates forthe.ptoblems of all sex offendetS..:Other programs and staff. At- South Florida, self-government- is in as well have- much- to offer; and many possibilities fact the major governing influence within the treat have not to date been tried out by any prograni._ A ment unit. Dr. Boozer genuinely believes that the neW-program may- well consider adopting some Fort group has insights richer than her own, and is quite SteilacoOmleatures, sortie 'features:from other :pro- willing to adopt its insights as her policy over a srams, and some whiCh it develops on its own. broad range of Operating-decisions. Recently, to cite Those planning a -new program for operation Within a minor example, a program for the wives and an =institution, however, should at least give serious partners of offenders was being planned: Should the "*----cOnSideratiortesalidnt-fdataterpionetted at- Fort----StafriTAirtlirifarvalions or should eac Arian Steilacoom. whom herpleased? The question was put to-the men. Their decision:- Men_ who wished`to, issue their own The- South Florida Program invitations should do so. The others-should --give the B. staff the names of those they wished= the staff to 2.6. Origins invite. In -this as in much mere important self- government matters, Dt. Boozer did- not present a The Treatment Program for Sex Offenders at the plan to the group for its approval. She did not seek South Florida State Hospital in Hollywood, Florida, a confrontation between a staff view and the men's was launched in 1966 by Dr. Geraldine Boozer, a view.-She was obviously and openly seeking the best clinical psychologist, and it remains today under her solution to the problem, and saw the group as the direction. best source of wisdom available. Her own continu- Like the Fort Steilacoom program, the South ous reliance on and respect for,the group is clearly Florida program is housed in -a state-hospitaland is one of the factors which builds up the confidence- an almost wholly independent enclave within the and respect of the men for their group. hospital which houses it. Offenders spend 168 hours A trustworthy group of this kind, of course, does a week within the sex offender treatment- unit: -This- not arise full-blown through some magical process. unit has its own nursing staff independent of the At South Florida as at Fort Steilacoom, it arose hospital staff. Correctional personnel from the rest of through a prolonged and often difficult process. the hospital enter the treatment unit only on -rare At South Florida, the first step was taken a decade occasions when they are summoned. ago. Dr. Boozer's role in those days was that of a Like Dr. MacDonald, Dr. Boozer places primary forensic psychologist for patients throughout- the reliance on the group process; the group itself is the hospital. The sex offenders, she observed, were not therapist for each of its members. Indeed, South in fact "mentally ill" like the other hospital patients, Florida carries this principle to considerably greater and did not need the usual types of therapy. Since extremes than Fort Steilacoom. There are no women they shared a common social -oroblern, deviant volunteers, for example, working with the South sexual behavior, they might benefit ftom group Florida offenders. The nursing staff plays only a discussions. Little aware =of what lay ahead, she minor role in the unit's program. The 75 offenders in accordingly brought together a doien sex offenders residence are divided into 5 functional groups; and for a series of weekly group meetings.

22 34 -!-As in other correctional settings, the assembling of to learn more about both sex offenses and the men a group- of sex offenders had far-reaching conse- who commit them. quences. Group solidarity, as it gradually blossomed, The offenders participating in these rap sessions began to spread far beyond the confines of,the see\themselves as public relations representatives of therapy-hours. In some respects, perhaps,,it became seToffenders in general, eager to make themselves a headache for the hospital administration. Dr. understood and -to encourage more- enlightened ap- Boozer accordingly proposed and was granted a proaches to- the problem of sex offenses. They also Major change iri structurean independent Unit see themselves in these sessions as contributing within the hospital where, as at Fort Steilacoom, the members of society, eager to help society solve the group process. could flourish uninterruptedly 168 problems of sexual assault. On one dramatic occa- hourS a week. In Our conclusions and recommenda- sion, police officials concerned with an unsolved tions below (Part V), we shall recommend a similar rape brought the meager data available to the South srifalPseale, step-by-step launching 'far other new Florida group;-the-men-made-numerous-suggestions- treatment programs.. for ways to apprehend the- offender, based on their The South Florida program has one major- short- personal knowledge of- the modus operandi of rap- coming: its actual day-to-day operations are poorly ists. On numerous other occasions, women from documented. Dr. Boozer- is an administrator par South- Florida organizations. concerned with rape excellencemuch too =busy and concerned with the prevention, -rape education, and the treatment of administration of her program to write about it; and rape victims have rapped with the treatment group until the addition of an associate directorto her staff and report that the sessions were of very great value in 1976, there was no one else to- document the in expanding their perspectives on the rape problem. program, either. Perhaps the most urgent need at It isn't often that an incarcerated offender of any Souttalorida is fOr a qualified observer capable of kind can feel that he is contributing to- social well- describing-anthrecording-the-day-to-dayactivities-of beingr-Nothing-contributes-more-to-his-sense.of-self, the Booier programboth for analysis by the pro- worthand it,is the absence of a sense of-self-worth, graM ,itsellind for =the benefit _of-other Institutions. as noted at length above, which may increase the The description which follows stresses those aspects offender's likelihood of reoffending. Behavioral re- of the:South Florida program which differ from the straints are weak-in a man who has nothing to lose. program at Fort Steilacoom; it is based on a two-day By giving these men a sense that they are contribut- visit id South Florida plus talks with Dr. Boozer, ing members of society, dedicated to a worthy cause, with the group, and with-observers in the commu- the South Florida rap sessions with outsiders consti- nity. tute a significant and highly innovative feature of the South Florida rehabilitation program. 2.7. Social Role of the South Florida At least equally important, the South Florida rap sessions have built an understanding of and respect Offender for the treatment program in the outside community. Like- Dr. MacDonald at Fort Steilacoom, Dr. Unlike many of the programs visited for-this study, Boozer at South Florida sees service to others as a the South_ Florida program has thus developed an major factor in the social rehabilitation of sex of- enthusiastic constituency on the outside. When sex fenders. In both programs, this takes the form of offender issues arise in the state legislature, there are service to patients in other parts of the hospital. In legislators who have rapped with -the South Florida addition, service to other sex offenders and to the inmates and who can bring their. insights to bear on cause of sex offenders in general plays an important those issues. When someone demands the death role in the South Florida program. sentence or castration-for all sex offenders, there are A steady stream of social workers, judges, legisla- women in the women's movement and elsewhere tors, police officials, probation and parole officers, who can and do call attention to alternative ap- reporters, and others flows through the treatment proaches to the problem. Judges who have rapped unit at South Florida. Of special importance in this with the Fort Steilacoom group have a much better stream are women from the women's movement understanding of what manner of offenders should concerned with community problems of rape and be sent there--and of who should not be sent. Any child molestation. Each visitor is introduced to the effort to curtail the treatment program or to slash its entire offender population and invited to rap with modest expenditures would- no doubt be met with them on open termsto ask and answer questions, concerted- opposition from respected and powerful 35 23 interests in the state. The mass media communicate children at a Good Humor wagon, strike up an at least part of this respect for the South Florida acquaintance with a likely child, buy him or her a program to the public at large. Good Humor bar, and then proceed to build on that Rap sessions with the South Florida offender opening gambit. It doesn't take much insight for him group are not, however, the only factor in building to know that he isin trouble if he finds himself the prestige orthe program in the outside commu- standing in line for a Good Humor bar. By then, nity. Dr. Boozer herself is the other factor. As a however; it may be too late. By conscientiously woman personally active in the women's movement, exploring his earlier behavior, he may come upon a she has managed to make her treatment program for much more useful signal. In the course of weeks or offenders an integral-part of the community anti-rape months, an ex-child-molester may discover, he programalong with rape prevention, rape educa- comes within earshot of the Good Humor wagon's tion, services to rape victims, and the law enforce- -bell many timesbut f he is simply going about his ment and criminal justice approaches. This integra- business, he doesn't actually hear it. It is just one of tion of a sex offender treatment program into the the countless noises of the city to which he pays no community's other responses to rape and child attention. molestation, along with South Florida's development On the day when he feels restless and out of sorts, of a "total push" program based on the group however, he does hear the bell, and responds-to-it, process, constitute South Florida's two most signifi- and gets in line with his dollar bill in hand. His early cant and innovative contributions to the planning and warning signal, accordingly, is not getting into that operation of treatment programs elsewhere. line but consciously hearing the bell. The -ex- offender who pulls himself up short when he first hears the 2.8. Aftercare bell rather than when he is standing in line with At South Florida as at Fort Steilacoom, the those attractive children may- stand a better chance Inherent worth of the program can be seen by even of-curbingtirsubsequenrbehlVior. the casual observer who compares the stance of An alumnus of Dr. Boozer's treatment program, newcomers just entering the treatment unit with the moreover, knows just what to do when he first hears stance of men who have experienced the group that Good Humor bellor encounters any of the process for many months and have been transformed other early warning signals which he has learned- to by it. But will the transformation survive release recognize during his therapy at South Florida. The from the program and the confronting of the over- procedure established to help him is patterned whelming problems which a released ex-offender closely on a procedure developed by Alcoholics must face when he returns to the free community? Anonymous. This, of course, is a major concern of Dr. Boozer as In his pocket the ex-offender carries the number it is of Dr. MacDonald. of a telephone "hot line" which he can dial at any One approach Dr. Boozer stresses is the "early hour of the day or night. He knows from his warning signal." Neither rape nor child molestation experience in the program that -the phone will be is commonly an act of the moment, performed as a answered only by another sex offender. The hot line whim when allis going well. Rather, the typical phone terminal is in the treatment unit at South offender knows in advance when the "urge" is Florida. Over itis a sign: "Staff keep away; this creeping up on him. He may wake up in the morning phone is to be answered only by an offender." The feeling restless. As the day progresses, he may find program alumnus has seen the phone and the sign his thoughts turning more and more often toward his daily'for many months during his incarceration in the "outlet"his preferred offense. The offense itself program; he has confidence that anything he says may occur that night or next week or next month; over that phone will not be used against him. only rarely does it occur without such a warning or Posted near the phone is a list of treatment "prodrome." In the course of therapy at South program alumni who are currently doing well in the Florida (as at other programs), the men explore these community, and who have volunteered their services early warning signals in an effort to recognize the to help other alumni. When the phone rings and an prodrome at a very early stagewhen the process offender answers it, he can put the ex-offender in which may lead to an offense can still be curbed or touch with one of these ex-offender volunteers. The thwarted. two ex-offenders can then rap on the phone, or meet To cite a typical example, one child molester's and discuss the problem until the emergency fades. modus operandi may be to get in line with the Manning the hotline and helping the ex-offender in

24 36 trouble contributes, of course, to the sense of self- 2.9. Miscellaneous Comments worth of the helpers and thus contributes also to A major assetperhaps the major assetOf the their rehabilitation. The ex-offender faced with an South Florida program is its location in close prox- early warning signal can also reach Dr. Boozer or be imity to the communities it serves (four- counties put in touch with other helpful community resources. centered on- Miami, Hollywood, and Fort Lauder- Like Dr. MacDonald at Fort Steilacoom, Dr. dale). This relative proximity of the program to its Boozer is concerned that the transition from the catchment area makes possible -a- continuing-relation= status of incarcerated offender to the status of ex- ship between the program and its alumni, the in- offender free in the community not be too abrupt. volvement of the offender's family in his treatment, The released ex- offender -needs particularly intensive visits from family and friends which provide conti- support during the first days and weeks on the nuity between institution and community, and com- Outside. South Florida has developed several tech- munity support of the_program. The_ numer_ous ad- niques for supplying this essential support. vantages of geographic proximity are particularly One is the week-end furlough under supervision. conspicuous when the South Florida program is the supervision of an ex-offender doing well on the contrasted with the sex offender treatment program outside. In a typical-case, a South Florida alumnus at the Florida State Hospital in Chattahoochie, which who is living in the vicinity of the program with his serves more than 60 counties comprising the remain - wife and children, and who isstill imbued with a der-of the state (see below, section A.2). loyalty to "his" group, may agree to supervise a Late in 1976, both the-South Florida program and still-incarcerated offender for week-end furloughs. the Florida State Hospital program faced a new and He comes to the hospital Friday night, signs the man potentially disastrous threat. As these programs out, and takes him home. The man spends the earned increasing community respect, and as public weekend as house guest the host returns the man to concern with sex offenses swelled, judges during the program and signs-him back in Sunday night 1976 began sendiiignoreaTdfRrOTfetiErrio reporting when he does so on how the week-end these treatment programs rather than sentencing went and what problems were encountered. Re- them to prison or probation. (Much the same process peated furloughs under this type of supervision was also reported during 1976 from the program at constitute useful rehearsals for the day of total Fort Steilacoom.) No compensating increases in release. The process also reinforces the self-image of building space, staff, or budgets were available. The the -ex-offender who supervises the weekend and familiar results which have ruined so many sound thus contributes his bit to the rehabilitation of others. treatment programs in other settingsovercrowding As -a clinical psychologist, Dr. Boozer also leads a and understaffingwere beginning to make their private group of sex offenders and ex-offenders appearance. Thus success might itself prove destruc- Meeting outside of the institution. Alumni of the tive to the successful programs. 6 South Florida program who feel the need for contin- The basic flaw, obviously, lies in the lack of ued therapy can voluntarily enroll in this group coordination among- judges, legislators, treatment another useful bridge between the program and life programs, and other elements in the criminal justice on the outside for offenders who want it. and correctional systems. The need for statewide planning to provide this coordination will be stressed Dr. Boozer -'s group outside of the institution in this survey's recommendations in Part V, section serves a second essential purpose. In a jurisdiction 5.1. where the only available treatment program for, sex offenders is =in an institution, judges will frequently be tempted to sentence to the institution offenders C. The Santa Clara County Program who need treatment but are not in need of incarcer- ation. The result is unnecessary incarcerationat a 2.10. The Incest-Problem high cost to the taxpayers, th° institution, and the offenders unnecessarily incarcerated. Judges in the The Child'Sekual Abuse Treatment Program of the South Florida area can instead place such an of- Santa Clara County Juvenile Probation Department fender on probationwith attendance at a commu- in San Jose, California, is primarily concerned with nity treatment program such as Dr. Boozer's speci- fied as a condition of probation. Thus th, costs of A third Florida program was opened in Gainesville too late unnecessary incarceration are minimized. for inclusion in this study; it is, however. listed in Appendix C.

25 incest offenses. It is a:community -based program for friends. She has failed both as wife and mother. families in which there has been sexual exploitation Her feelings toward her daughter alternate be- of a- daughter (or, much less commonly, a son) by tween jealousy and motherly concern. Her emo- the father or stepfather. Many of the principles and tional state vis-a-vis her mate is also ambivalent. 'proeedures_of the program, however, should prove At first she -is blinded with disgust and hate at equally applicable to other- types of sex offenders the cruel blow he has dealt her and vows to with intact families. divorce him. Her friends and relatives insist this Prior to 1971, when the program was launched, is her only recourse. But the rest of the children the discovery otan incest offense meant disaster not begin to miss him immediately and she recog- only for the offender but also for his wife, for his nizes that on the whole, he has been- a good sexually exploited child, and for other children in the father. She is a' so sharply reminded that- he has tamily. In a typical case, the child involved was been a depend*-provider- as she faces the removed from her home and Iodged in a childr-eirs shameful. task of appiiii-ig fOr welfare. shelterdeprived of emotional support at the. mo- Much the same series of events, of course, follows ment she needed it most. The- offender was arrested the arrest of a husband and father for any other sex and held in jail until he could secure a lawyer and offense. Giarretto sums up: the traditional kinds of raise bail; securing a lawyer might mean signing a community intervention, "rather than being con- retainer agreement at a fee ranging from $3,000 to structive, -have the effect of a knock-out blow to a $10,000 or even morea bankrupting sun.' for most family already weakened by serious internal families. The offender iromptly lost his job. His stresses." usual sentence was from one to fifty years' impris- The socially disruptive effects of this approach to onment. The wife and her remaining children com- incest were clearly seen by Santa Clara County's monly lost their home and went on welfare. Thus for juvenilerobation officers. Visiting a family shortly any-familien-the-legal-processing-of-the-incest--after the offense was uncovered, and, again a month offense was as traumatic an experience as the incest or two later, they could hardly fail to note the -gross itself. deteriorationmuch of it the result of their own Henry Giarretto, the psychologist who -founded procedures. In-971, they rebelled. "There- must be and now directs the Santa Clara County program, a- better way," one ofthem, Eunice C. Peterson, told has- described the psychological impact of this pro- the probation department's psychiatric consultant, cedure on a sexually exploited child: Dr. Robert S. Spitzer. She feels alone and threatened. This is the At Dr. S_pitzees suggestion, Hank Giarretto was first time she -has been forcibly separated from invited- to- provide ten hours -a week of counseling her family. She is overwhelmed by mixed emo- and family therapy to incest families for a limited tions of fear, guilt, and anger and convinced that ten-week period; the Santa Clara County program, she will never be able to rejoin her family or now in its sixth year, is the direct descendant of that face her friends and-relatives. If transferred to a very modest first step. foster home, she will not adjust to the new family as-this would confirm her fears that she has been banished from her own family. Though 2.11. Some Preliminary Lessons often told that she was the victim of the When he met for.the first time with his first incest incestuous relationship, she believes she is the family, Hank Giarretto recalls, it was easy -to main- one who is being punished. She enters a period tain his professional attitude of acceptance toward of self-abusive behavior manifested variously the wife and children through hostility, truancy, drug abuse and prom- iscuity. but in preparing myself for the session with the father, I read- the lurid details of his sexual What Giarretto calls "the explosive reaction of the activities with his daughter, which included criminal justice system" also produces "shock and mutual oral copulation- and sodomy [anal terror" for the wife: intercourse] at the age of ten. The compassion- She is certain her family has been destroyed. ate, therapeutic attitude which I can now write There are subtle hints that she may have con- about so freely and perhaps pompously, com- doned the incestuous affair in the questioning by pletely dissipated. I was forced to go into deep._ police and even others she once regarded as exploration of my own unconscious....

26 38 Only-after coming to terms with his own complex stream of boys who keep coming to the house. feelings about incesLand child molestation, Giarretto With a- sinking feeling he notices that she is found, waste able to function effectively with incest beginning to respond to one of -the boys. He families. "I cannot overemphasize the importance of cannot control the feelings of balefill jealousy self-work on the ,part of the therapist. This is the the boy evokes, or his Craven attempts to stop central theme of workshops -I conduct for individuals his daughter from seeing that boy. The daughter who want to help incestuous families." complains to a friend, who tellshermother. Another lession Giarretto learned early during the Hence Jim's- trance suddenly ,shattered,one pilot= phase of-the-Santa-Clara County program -was eVeriing as he returns home :from work: A the remarkable ease)with which a father and daughter policeman emerges from the car parked in front intoincest:, of his home and inforins him that he is_under arrest. Numb with shame and fear, he is trans- Jim, a successful accountant, is in his mid - -ported-to.the-police-station-for-qiiestioning.- thirties when he beccimeS aware of deep 13ore- -dont and disenchantment with his life. He feels stalemated in his job and his prospects for What kinds of families become involved in incest? This was another of the suprises during the early -advancement are -poor. There is gowing es- months of the Santa Clara County program. The trangement- between himself and his wife. She older published literature on incest suggests. that it no longer seems proud of him. In fact, most of occurs primarily in poverty-stricken families where her remarks concerning,hisability as a provider, housing is excessively crowded, where the parents father, or husband are critical and harassing. are of subnorrnal intelligence, and in remote rural Their sexual encounters have no spark and areasthe "Tobacco Road" stereotype. It is also serve only to relieve nervous tension. He fantas- alleged to be most 'common- in non-white ethnic izes romantic liaisons with young women at populations. Among the -first 3(X) incest families in ork7butte-harneitherthe-skill-norcourage-to- the-Santa-Clara-Cciunty program, in contrast, the exploit his opportunities.- average income was over $13;000. Many Were Jim fmds himself giving increasing attention to professionals, semi=professionals, and skilled blue- one daughter. Of all his children, she has always collar workers. The median educational level was been his favorite. She is always there for him, high-12:5 years. Three-quarters of the incest fami- accompanies him on errands, snuggles close lies, like- three-quarters of the county's population, beside him as they spend hours together watch- were white. ing TV. His wife has no interest in this pastime. The frequency of incest n the community also .At night she is either taking classes or studying proved- a surprise. During the program's -first year, with her classmates. 36 families were referred. Three years later, the As his daughter -cuddles beside him he be- annual intake had risen to 180-;-with a high probabil- comes acutely aware of her warmth and soft- ness. At times she wiggles on his lap sen- ity that most cases Were still going unreported in a county with a population of 1.1 million. suously, somehow knowing that this gives him The program developed over- the past five years pleasure. He begins to caress her and "relives has two main facets-_--a professional staff for coun- the delicious- excitement of forbidden sex play during childhood," as one incest father ex- seling and psychotherapy- under the county's juvenile probation department, plus a self-help group, Parents pressed it. But this phase is soon engulfed by United, operated by the incest families themselves. guilt feelings as the relationship gets out of hand and he finds himself making love to her as if she was a gown woman. 2.12. Current Procedures Between episodes he chokes with self-disgust and vows to stop. But as if driven by unknown Today, immediately after the arrest of a father on forces, he continues to press his sexual atten- an incest-charge, the wife receives a phone cal:from tions on her. He now senses that she is trying to one of the wives already participating in Parents avoid him and is no longer receptive to his United. "I've heard you have a problem in your advances. Though he doesn't use force, he relies family. We had the same problem in our family two on his authority as parent to get her to comply. years ago. Would you like me to come over so we He becomes increasingly suspicious of her out- can talk about it?" Almost always, the answer is side activities and the seemingly continual yesand salvage operations have begun. In the 39 27 course of that firstwoman-to-woman rap, the newly listened to with compassion, as natural expres- distraught wife is told, of Parents United and invited sions of inner states. Awareness and acceptance to thenext Thursday evening meeting. of current feelings, without evaluation, allows The :husband receives a similar call from one of the clients to assimilate them and to move on the men in Parents United, and usually responds with their lives. I know that _I must continually - similarly. Among other immediate benefits, he may work at developing this attitude within myself. reconsider the advisability of bankrupting himself Giarretto recognizes that reconstructing the family with an exceSsive legal retainer fee. is not always either possible or desirable;- divorces Instead of a one-to-fifty-year sentence in a maxi- do occur. But in a remarkable proportion of cases, mum security institution, the incest offender today close to 90 percent, husband and wife decide to commonly receives a three-month or six-month sen- make another try at it--and the program dcies its tence in an open community institution. This means best to make the second try successful. 'in a high proportion of casis-that'he-Can keel-) his job Like the Port Siena:Winn prograin, the-Santa-Clara- during the,day, returning to the institution evenings County program finds that a major problem among and weekends. He thus remains the family- provider, sex offenders and -their families is low self-esteem. and the foundations of the family are_safeguarded in The

28 40. As one step in this process, families learn to take provocative behavior by his daughter, his ac- an inventory of their own strengths and weaknesses: tions betrayed his child and wife and their reliance on him as father and husband. Initially, during this exploration, I underscore the ,positive traits. What does the girl, for The wife and child, t63, are encouraged to face up example, like about herself? What does she to their roles in the incest situation: appreciate in other family members and the As a general rule, the mother will admit family as a whole? Before she can be motivated eventually that she was party to the incestuous to work actively for personal and family growth, situation and must have contributed to the she must be convinced that she and the family underlying causes. Certainly, something must are worth the.,effort. From this positive stance, have been awry in her relationships with her the clients car then proceed to identify weak- husband and daughter. In order to relieve the nesses-and maiadaptive habits that need to be daughter of feelings of self-blame and guilt for improved or eliminated. These might include endangering the family, she is firmly told by her uncontrolled use of drugs, food, alcohol and mother, and as soon as possible by her father, cigarettes; hostile-aggressive behavior that inter- that she was the victim of poor parenting. This feres with progress in family, school and work step is also important for regaining her trust in relations; sexual promiscuity; inconsistent study her father and mother as parents. In time, and work habits; and typically, the inability to however, she will confide she was not entirely a communicate effectively, especially with impor- helpless victim and is gently encouraged to tant persons in their lives. explore this self-revelation. As the clients gain confidence in their search for self-knowledge, they begin to probe the Hank Giarretto describes himself as a humanistic painful areas connected with the incest. In what psychologistdrawing on the prior work of thera- may be termed a confrontation-assimilation pists like Carl Rogers, AbrahamH.Maslow, Virginia process, I encourage the child, father and Satir, Frederick Penis, Haridas Chauduri, and Eric mother as well as other family members to face Berne. He emphasizes in particular his reliance on a and express the feelings associated- with their process known as psychosynthesis developed by incestuous experience. It is indicated that buried Robert Assagioli. Itis unlikely that any other pro- feelings (fear, guilt, shame, anger, etc.) if not gram will find a director with this particular set of confronted, will return as ghosts to harass them. theoriesbut there is also no reason to doubt that The feelings cannot be denied; they will have the Santa Clara County results can be duplicated by their effect somehow. If confronted now, they equally skilled and dedicated therapists holding other will lose their power to hurt them in the future. theories. With some clients, the pain-provoking memories can,.be. dealt- with fairly early in the .therapy; 2.13. Roles of the Courts and Correctional with others I find it prudent to proceed more System slowly. Visitors impressed with the Santa Clara County As at Fort Steilacoom and in other programs, the program sometimes wonder why it need be attached Santa Clara County program places much emphasis to the criminal justice system. Why not operate it as on the need for an offender to confront his own an independent program serving the community like behavior and to accept responsibility for it: any other social agency? Giarretto is opposed to such a- plan, and cites Although I listen with compassion and under several types of evidence against abolishing the standing to the father's feelings, I will in no way incest law and relying solely on the mental health condone the incestuous conduct or go along approach. with pleas for mercy, such as, that he is cursed It often happens, he points out, that a wife and forced into incest by evil forces, or that he becomes aware of incest in her family and threatens suffers from an exotic mental disease. He even- to break up the marriage if her husband does not tually is induced to admit the bald fact that he agree to psychiatric treatment. "The offender tem- was totally responsible for the incestuous ad- porarily complies, but stops going after a few ses- vances to his daughter. No matter what the sions. A month or two later, he resumes the sexual extenuating circumstve-es, including possible abuse of his daughter. In two [Santa, Clara County]

29 cases, the fathers continued their offenses while That set Giarretto* thinking. One feature most undergoing [voluntary psychiatric] treatment. The incest families have in common issocial isolation; motivating drive and the therapy were not sufficient they have few friends before the incest is uncovered and the troubled family was left with its problem." and fewer afterward. Why not a self-help-grnup? A The "shock effect" of legal intervention alters the week after the three-hour phone call, "three of the whole situation and provides the needed base for more advanced mother-clients met face-to-face for family restructuring. the first time" in the probation offices of Santa Clara Nor is punishment by itself enough: "In five cases County's juvenile probation department; and "after a in which punishment alone was employed, the deter- few more meetings, to which several other women rent effect hoped for proved utterly inadequate. After were invited, Parents United was formally designated serving long sentences, the five men came to the and launched." The group soon grew to include most attention of our program for repeating the offense of the-families in therapy, began admitting offenders with otheedaughters or step-daughters." as well as wives, and was later joined by a second On the basis of Santa Clara County's experience, organization, Daughters United, set up by teen-age accodingly, Giarretto concludes: girls who had been involved in incest. In all cases, the authority of the criminal Parents United now meets one evening a week in justice system, and the court process, seems the juvenile probation department's large and com- necessary in order to satisfy what might be fortable conference rooms. Like the Fort Steilacoom termed an expiatory factor in the treatment of "-ogram, the Parents United program makes effec- the offender and his family. It appears that the tive use of simple rituals. The meeting opens with offender needs to know unequivocally that the participa-'q sitting in a circleperhaps 50 or 60 of community will not condone his incestuous them, ink: tg 8 or 10 daughters and a few sons behavior and that he must face the conse- who have t :a the targets of incestuous relationships quences. The victim and her mother also with their fathers. There may also be two or three [derive] comfort from knowledge of the com- grandfathers in the circle who have molested their munity's clear stand on incest. grandchildren. This meeting is short. It may open with a few minutes of meditation, and with -a_ poem, From this point of view, Giarretto's major achieve- a chant, or some other attention-focusing ritual. ment has been to develop a system in which the intervention of the criminal justice system is coupled Husbands and wives coming to their first Parents with an effective therapeutic approach. He points United meeting, together or separately, approach in out, however, that the coupling requires a tempering fear and trembling. Like the rest of society, they of the criminal justice system: "All family members have an extremely low opinion of incest families, will do their best to frustrate the system if they and expect to meet "sex fiends"social outcasts anticipate that the punishment will be so severe that with whom they could not possibly establish amica- the family will be destroyedthat they, in turn, will ble relationships. What they find is altogether differ- become 'victims' of the criminal justice system, ent: a rather well-dressed and extremely weal -be- including the child-victim herself." haved assemblage of families who at first sight might be mistaken for attenders at a church social in any middle-class suburb. Eight or ten- members of the 2.14. Role of "Parents United" circle are staff members and therapists-in-training; it is quite impossible at first to distinguish the staff Early in the Santa Clara County program, at a members from the offenders and their wives. Also time when he was busiest, Hank Giarretto received present are one or two of the first three families who a phone call from a- distraught and near-hysterical founded Parents Unitedand who, after five years, woman who had juet learned that her husband was continue to see it as a worthy social cause in which engaged in incest with her daughter. Unable to spare they can be enormously helpful to others. time for a prolonged -discussion then and there, Giarretto arranged to have another incest-family Newcomers receive handouts which describe the motherfrom one of the first families successfully essential purpose of Parents United"to assist fam- treatedphone the distraught mother. "The ensuing ilies having a problem that involves a sex offense by conversation went on for three hours," Giarretto enabling them to get the kind of help they need for recalls, "and had a markedly calming effect on the their particular situation during the initial crisis new client." period; by showing them they are not alone and problems can -be resolved with a positive attitude; women who have split from their husbands continue and by encouraging- them to seek proper guidance to come to Parents Unitedeither alone or with their and counseling." new male friends. The Santa Clara County group has also written its It is an amazing fact of life that when human own creedquite similar in tone and feeling to the beings assemble in a therapy groupeven people -Star-Group handouts to- newcomers at Fort Steila- with very little in common--a group process is coom, quoted above: engendered_which most members of such groups find intense and very helpful. When members of the Creed group have a traumatic past experience in common, To extend the hand of friendship, understand- ing, and.xompassion, NOT to judge or con- and when in addition they currently face the same practical and emotional problems, the group can play demn. an enormously significant -role in their lives. In the To better our understanding of ourselves and course of a typical Parents United evening, for our children through the aid of the other mem- example, a father may raise the question: How can I bers and professional guidance. To reconstruct and channel our anger and reestablish my- authority -and discipline over-a daugh- ter with whom for years I- have had sexual relations? frustration in other directions, NOT on or at our Every head nods; others know the problem well. children.... One man describes how, during the past three years, To recognize that we do need help, we are all he and his daughter have been able to live doWn the in the same boat, we have all been there many incest experience and develop a father-daughter times. relationship- which both find rewarding. Another To remember that there is no miracle answer group member questions -the terms authority and or rapid change; it has taken- us years for us to discipline: "Why do you have to be the boss? A get this way. family isn't a sweatshop with a boss and some To have patience with ourselves, again and sweated laborers." A staff member wonders whether again and again, taking each day as it comes. the question shouldn't be explored next time -the father and his daughter meet with their counselor. A Hank Giarretto, like the directors of other treat- mother asks whether the father with the question has ment programs, is fully aware of the extent to which discussed the matter directly with either his wife or- playing a helpful role toward others is a highly his daughter. A final comment summarizes the group effective ingredient _in= rebuilding self - esteem -and in feeling: "Straighten out your feelings- toward your the -personal rehabilitation of the helper. Parents daughter tind her feelings toward your discipline will United is the framework within which this helping then take care of themselves." The responses are occurs. The group members seek to provide many critical; but underneath the criticism the father wor- kinds of help for newly admitted members faced with ried about discipline recognizes the deep concern the common-crises: finding jobs, baby sitters, finan- and emotional- support -the group is providing. cial and legal aid, and so on. They've been there, `34:). They understand. Much of the effectiveness of Parents United, Parents United also has a continuing concern with however, is the direct result of the small-group the many families out there in the community in meetings which follow the ritual of the opening which incestuous exploitation of children still contin- circle. Attenders are, free to decide which small ues undiscoveredand-with the community preju- group each will attendan all-male group for of- dices against incest families which makes it so hard fenders; an all-female group for wives; and an for them to secure jobs, housing, and other survival intensive group for wives and husbands together. needs. Both concerns are expressed through a com- This group is limited to five couples and gets much munity relations Prograrn designed to make the facts more deeply into the dynamics of incest and its about incest better known and better understood in sequelae. There -is--also a Daughters United group the community. Members of Parents United have and a group for males and females who are not accordingly appeared with members of -the profes- married to' 'one another. An offender or wife may sional staff at service club lunches and other public choose to attend this mixed group rather than a one- functions to tell their own stories; they have been sex group. In, some cases, too, an offender whose interviewed for newspaper and= magazine features wife has split from him- may bring his new woman- and have made radio appearances. In 1976 these friend to the group. More remarkable still, some public relations activities were extended to include a

43 31 television series on -the area's largest station. Two molesting children to whom they are not related, for kinds of benefits-are expected to accrue: a greater example, ar, commonly. excluded. But there are willingness of incest familieS Ito "come out of the exceptions even to this rule. Four habitual child closet", and the mobilization of broader community molesters of the type commonly classified as "pedo- support, including financial support, for-the program. philiacs" were accepted because they were allied to Staffing a program-like -this costs far less than loyal-wives, had good jobs, and-seemed to-be "good incarcerating offenders in a correctional institution. bets.",None, at last account, had reoffended. -Giarretto-has kept-costs doi,viLin part by making the The defenses against recidivism built into the Santa Clara County program a training center for Santa Clara County program are well illustrated by graduate students in psychology, social work, family the case of an offender convicted of incestuous counseling,, and= other fields. Trainees provide much relations with one daughter who successfully, com- of -the counsek:i. (Parents United is largely self- pleted treatment and was released from individual supporting, but was helped initially with a grant from therapybut who one year later began-fidticing the Rosenberg Foundation, a local philanthropy.) sexual arousal with another of his daughters. Three The California legislature in -1976 enacted Assem- events promptly followed. The man himself called bly Bill 22::, to establish "a demonstration center the program to ask for an- appointment with a for the prevention of the sexual abuse of children." counselor. Next day the daughter he, had originally Among the center's functions will be "the develop- molested- called Giarretto and said, "Hank, I wish ment of programs- for city and county personnel you wouldialk to Dad. I think he's acting funny with throughout the state relating to the prevention- of Betty." At about the same time, -too, the mother sexual abuse of children." It is expected that the voiced misgivings about her husband's increasing Santa Clara County program will form the nucleus of attentions to Betty at a group session she was the new statewide demonstration center; but funds attending. The father returned to therapy and did not have not as yet been- appropriated. Members of reoffend. Parents United lobbied intensively for S.B. 2288; Giarretto stresses the numerous benefits of the many journeyed to the state capitol to -urge its Santa Clara County program: passage. Children are returned to their families sooner than under the conventional system-90 percent 2.15. Successes and Failures within the first month, 95 percent eventually. The self-abusive behavior of the children, Usu- Giarretto frankly concedes that the Santa Clara ally amplified after exposure of the incestuous County program "is not equally effective with all situation, has been reduced in both intensity clients. About 10 percent of referrals will elude our and duration. efforts. They will not come in for the initial inter- Marriages have been saved (about 90 percent). view, or drop out soon after treatment has begun. many confiding that- their relationships are bet- Four couples were dismissed from the program ter than they were before the crisis. because- the father and/or his wife would not admit The Parents United formula is proving to mem- culpability and placed the blame entirely on the bers that they can become,a strong voice in the child-victim and her seductive behavior. In these communitya significant realization to those instances extraordinary effort was required- in the members-who used to regard themselves as the treatment of-the deserted child. The four girls, after pawns of civil authorities. many attempts, successfully adjusted to foster The high cost of long-term incarceration- of homes. Three are now married and apparently doing incest offenders is avoided. well." Hank Giarretto urges that similar Child Sexual In the more than 250 families who have stuck with Abuse Treatment Programs (CSATP) be launched the program until their treatment is deemed complete elsewhere: and formally terminated, Giarretto reports, the ivism rate has been-zero. "No subsequent ince% has By working integrally with the Criminal Jus- been reported in any such family." tice System the CSATP shows promise of Part-of this success, of course, is due to selection developing into a model for other American procedures. The Santa- Clara County program can, communities. Each community must be given and on occasion does, refuse to accept an offender the opportunity to treat incestuous families in a referred for treatment. Men with a long history of manner that is neither permissive or cruelly

32 44 ,punitive. A national position must be taken on program available, there will also be adverse conse- the incest taboo and laws enacted that are quences. He will inevitably be tempted to entrust to effective and consistent. The community must the community progrom offenders who need treat- publicize these Statutes and the penalties for ment but who also need isolation. This means taking violating -them To preyont incest the ,public risks with the community's safety which would not must be ducated to bedtime aware of predis- be taken if an institutional alternative were also posing- conditions and to take appropriate action. available. Thus the community program will receive Finally, comprehensive procedures similar to at least some offenders it is not adequately equipped the CSATP must be established in each com- to handle. Its effectiveness with those it is qualified [flunky to treat sexually abused children and to treat will be impaired. If some- of the unsuitable their families to enhance their Chances for-recon- offenders reoffend, the program's-reputation-will be stitution and to prevent future violations. damaged; indeed, a single widely publicized crime by Many= aspects of the Santa Clara County program, a participant or alumnus may destroy a community including especially its family therapy approach, may program or seriously impair its effectiveness. also prove -Useful for the treatment of sex offenders Havingbothan institutional inpatient programand whose offenses are not incestuous. Such a- program, a community outpatient program -is -also invaluable for example, might accept an sex offenders who for continuing the treatment of incarcerated offenders have intact families_ and who are eligible for proba- following -their release on parole. This- issue too, is tion rather than incarceration. In addition, it might explored further in the Conclusions and Recominen- accept incarcerated sex offenders with iitact families dations below. folloWing their release on paroleand work with the families might begin prior to release of the offender. D. Program For Juvenile. Sex These are possibilities which will be explored more Offenders, Seattle fully- in. -Part V, Conclusions,and Recommendations. 2.16. Juvenile Rapists and Child Molesters The Fort Steilacoom and South Florida institu- When sex offenders begin to talk frankly in a tional programs and the Santa Clara Countycom- treatment program, or when they write their autobio- munity program have been presented here in parallel graphies, their stories almost always begin with their, because they complement one another effectively. adolescence, perhaps soon after pubertyor even The question of which is better is misleading.Both earlier. Often their actual criminal offensesthe institutional and community programs are essential, raping of girls or boys their own age, the sexual for a variety of reasons. molestation of boys and girls much younger than To- see why, place yourself in the position of a themselvesbegan this Yearly. Even where overt judge who must consider what disposition he will offenses came later, there may have been an early select following the conviction of a sex offender. He fantasizing of bizarre sex crimes and an inability to, first must decide whether the offender is amenable take part in- the customary sociosexual learning to treatment. If so, what treatment? processes in which their classmates and neighbors If only an inpatient program for incarcerated were involved. These autobiographical data make it offenders is available, the judge will inevitably be clear that any program designed to curb the appear- tempted to send to the institution many offenders ance of yet another cohort of adult sex offenders who need- treatment but donotneed incarceration must begin at least as early as adolescence. either for their own benefit or -for the safety of But little more than this can be saidfor very little society. As a result, the institutional treatment pro- is directly -known about juvenile sex offenders. The gram will be increasingly filled with offenders who reminiscences of adult offenders are vague on some do not require its services. Since the cost of incar- points, and consciously or unconsciously distorted ceration is very high, there will be a waste of public on other points. Repeatedly, during site visits for this funds.- Because it receives offenders who do not study, sensitive and dedicated therapists remarked, need incarceration, the program will have less room in effect: "If only we had had .these men in their for offenders who do need itand who will therefore teens instead of in their 20's or 30's, we might have serve their time in conventional institutions without accomplished much more." Staff members in the treatment. adult programs visited were without exception enthu- If the judge has only a community treatment siastic when informed that the first program for adolescent sex offenders was currently on the draw- apprehended molesting- some of the younger boys ing boards at the University of Washington in within the institution. When confronted with this Seattle. behavior, he says that he is not able to control Another very frequent feature in the autobiograph- himself and wants help with the problem." ical accounts of adult sex offenders is their early Dr. Deisher also calls attention to cases outside experiences as victimstheir sexual abuse or exploi- the juvenile correctional system: tation by older adolescents or adults during their A 13-year-old boy-was referred to the Univer- childhood. But here, too, the details, as recalled sity of Washington Adolescent Clinic because of decades later, are of doubtful reliability, and the learning problems and difficulty at school. He relation between the experience as juvenile victim was significantly behind in his readingability, and as adult offender remains vague. Studying juve- did not like school, and was sometirms a nile sex offenders and sex offenses at the time of behavior problem in school. After some discus- might turn up occurrence rather than decades later sion of these problems with the mother, she rn,17 y clues tn'techniques of prevention. went on to tell us that she was even more To-cite-a-simple-example, alfficist every neighbor- concerned about another problem which she hood has children who for one reason or another had never discussed with anyone. Although this exclude themselves or are excluded from the ordi- problem had existed for over three years, and neigh- nary sociosexual learning experiences of the she was now hardly able to sleep at night for borhoodthe Boy Scout- hayride, the junior high worrying about- it, she had not been able to school dance, the birthday parties of classmates. By bring herself to talk to anyone about it. It began the time these excluded boys reach high school, three years ago when the mother, who did some what was originally a quite minor sociosexual- handi- part-time babysitting to supplement the family cap may have swollen out of all proportioncutting income, found the boy on several occasions ,them off from the socially acceptable modes- of locked in the bathroom with younger girls, sexn21-acculturation enjoyed by their classmates and between 2 and 4 years of age. Frequently, he shaping precisely the kinds of sexual misfits who had undressed them and was bouncing them up later turn up in sex offender treatment programs. and down on his lap in a sexually stimulating Can intervention very early in this process of socio- manner. She had spoken to him ,aboutthis sexual exclusionshortly after puberty or during several times, but -the behavior persisted and adolescence, for examplealter the outcome? No she had to keep an eye on him at all times. She one knows. No one has tried it. did not tell the parents for fear of losing her In Seattle, -these possibilities have been a concern business, but after she found that threats and of Dr. Robert W. Deisher, professor of pediatrics talking to him did not stop the behavior, she and director of the Adolescent Clinic at the Univer- gave up babysitting altogether. Withinthe past sity of Washington School of Medicine. The Adoles- year, another type of disturbingbehavior oc- cent Clinic provides psychiatric as well as medical curred. The boy had been burglarizing homes in diagnosis and treatment services, including referrals the neighborhood, taking almost nothing except from the juvenile courts and from juvenile probation women's underclothing. He had alidden these and parole services as well as from juvenile institu- undergarments in several hideouts in the neigh- tions. Thus Dr. Deisher gradually became aware that borhood, as well as -in his -own room. The there are 15-year-old rapists, homosexual and heter- mother discovered that many of the undergar- osexual; 15-year-old molesters of 4-year-old children; ments had been burned and slashed and she has 15- year - olds fixated on soiled female undergarments; now reached the point of beingconcerned 15-year-old exhibitionists and voyeursindeed. the enough to want to talk with someone about it. whole range of socially condemned sexual behavior arising relatively early after puberty. What happens to such young people within the "I was, recently asked to see a 16-year-old boy in juvenile correctional system? A- young psychologist a state juvenile institution," -Dr. Deisher reports. and a young sociologist, Toni F. Clark and William "This boy had been there for approximately six E. Henry, both employed within the Washington months. He had been placed in the institution for State correctional system, were given a three-month rape or attempted rape of at least threegirls in his leave from their usual duties to find out. Their neighborhood. After being placed in the correctional findings are no doubt equally applicable in many institution, on numerous occasions he had been other states; indeed, few states -have as effective a

34 46 juvenile correctional system as does Washington also affect the child's perception of himself; he may State. try to live up to the label. The label thus becomes a In the-first- place, Clark and Henry found that the self-fulfilling prophecy. The diagnostic staff in a state's juvenile courts, in accordance with long- juvenile correctional setting is naturally loath to established principles which are sound in many institute such a cycle by labeling a child as a sex cases, was relatively little concerned with the details offender. .of a child's offense. The commission of an offense Finally, the staff at a diagnostic center quite was necessary to establish the court's jurisdiction; properly asks, what good will labeling- do? Neither but once jurisdiction was established, the court was the juvenile correctional institutions nor juvenile -concerned with the "whole child" and with provid- probation or parole workers are specially qualified to ing as effectively as possible for his or her future. In handle these sexually aberrant juveniles. There, is no this process, the specifically sexual nature of the program anywhere -in the -juvenile -sy stent addressed child's,- problem- is-likely-tcr be- diluted or soft- specifically to their sexual problems. pedaled. The net effect, in Washington State as in most In the juvenile courts as in adult courts, moreover,___.other juvenile correctional systems, is that youthful a process of plea-barganing may-occur. A child who rapists, child molesters, and other sex offenders has raped or molested three-year-olds may, on the move through the courts, the diagnostic centers,,the face of the correctional system's records, be admit- juvenile institutions, and the juvenile probation and ted= for Some lesser, usually non-sexual offense -such parole systems with little or no attention paid to their as assault. Thus he moves on -to a- correctional specifically sexual problemsindeed, with little or institution, or to probation, with no indication of his no indication- in their records thatthe_yhavesexual sexual problems in his record. problems. Washington State maintains a fully staffed and One further factor may be cited. Many juvenile equipped diagnostic center, known as Cascadia, for correctional systems are concerned with the specifi- its juvenile offenders; but here too, Clark and Henry cally sexual misbehavior ofgirlsthe- "sexually found, members of the stafffor the very best of promiscuous female adolescent." There is a substan- motivestended to soft -pedal and even keep out of tial literature on- this problem, and many juvenile the- records altogether the specifically sexual nature correctional institutions for girls address themselves of many offenses. directly to sexual issues. But, perhaps as -a reflection One reason for this was a very- sound belief that of the double sexual standard in adult society, there early adolescence is a period of sexual exploration. is sometimes a tolerant feeling that in the sexual One or a few deviant sexual acts shortly after sphere, "boys will be boys," and that intervention is puberty are exceedingly common in the life histories unnecessary. The-approach-is clearly mistaken when of the most respectable citizens as well as in the applied to the cases cited above of 15-year-olds who reminiscences cf adult sex offenders. To make a repeatedly rape both girls and boys or who sexually mountain out of a molehill is not sound therapeutic molest children aged 2 to 4. practice. Alerted by his owe experience and by the Clark- Closely related -was the quite proper concern in Henry report, Dr. Deisher in June 1975 called a,day- the juvenile courts and throughout the juvenile long "Conference on the Male Juvenile with Sexual correctional system, in Washington State as else- Offenses," sponsored jointly by =the Washington where, thatlabelinga child as delinquent or deviant State Office of Juvenile Rehabilitation and the Uni- may have a profoundly adverse effect on his subse- versity of Washington Adolescent .Clinic. Those in quent development. Neighbors steer clear of a child attendance included representatives from the police, labeled as- a sex offender, and keep their own juvenile courts, juvenile probation, juvenile institu- children away from him. The school treats him tions, and juvenile parole services, as well as inter- differently. Thus he is further cut off from the ested individuals from various helping professions. sociosexual_development of his cohort. The diagnos- The purpose of the conference, Dr. Deisher notes, tic staff is concerned that labeling a child as a sex was "to discuss the current state of knowledge in offender may have equally adverse effectswithinthe the field and to begin to establish recommended juvenile correctional system; it mavaffect the labeled priorities for activities to be conducted at each level child's relations with his juvenile parole worker, with in the system to change the way in which the system the staffs of juvenile correctional institution_and as a whole responds to young people with serious with other children in the institution. The label may sexual problems."

35 47 At the conference, "the issue of labeling juveniles members better able to distinguish between adoles- as sex offenders was discussed atlength. It was cent sexual "horseplay" and symptoms of serious recognized that inappropriate application of labels sexual problems. Another is -to make staff members may lead to the establishment of sexualoffender more comfortable with adolescent sexuality--rsothat roles in individuals who have not developed, and they do not "freak out" when confronted with either who might not develop, self-concepts as sexual minor or major examples of adolescent sexual behav- offenders. At the same time, it was recognized that ior in a child's records. without appropriate labels and descliptions of behav- A third goal of sex education for staff members ior, effective evaluation and treatment at the different might be making them comfortable with their own system levels were not possible. _Becauseof-this, it sexuality, and- thus 'better able to discuss sexual was felt that the development of reliableevaluation matters comfortably with young people in their care. criteria was imperativeboth to protect juveniles At this writing (April 1977), the funding problems from mislabeling, as well as to provide indications of the Adolescent Clinic treatment program have still for the most appropriate treatment mode at the most not-been resolved; but individual juveniles were appropriate level in the system for those who do already in treatment at the Adolescent Clinic. The have sexual problems." national significance of this program the first in the Out of this conference, accordingly, arose a con- country to address itself to the specifically sexual crete proposal for launching the country'sfirst pro- problems of male juveniles committing serious sex gram for- the diagnosisand treatmentof juvenile offensescan hardly be overestimated. Other states male sex offenders. The diagnostic portion of the currently planning treatment programs foradultsex program- was promptly begun atthe University of offenders should consider the simultaneous launching Washington Adolescent Clinic. When visited in the of at least modest programs for seriousjuvenilesex spring of 1976, however, a delay in funding was offenders in institutions and in the community. delaying-thetreatment portion of the program.

2.17. Need for a Juvenile Treatment E. The Albuquerque Progrcm Program 2.18. Origins Two basic principles of the WashingtonState approach warrant emphasis here. From the begin- Albuquerque's program for sex offenders arose ning, Dr. Deisher and his associates saw the enor- out of a problem common to manycities and mous importance of making treatmentavailableat all counties: the almost 'total absence of alternatives to three levels of the juvenile correction systemthe imprisonment for nonviolent or "passive" sex of- probation level, the institutional level, and the parolefenderssuch as exhibitionists, voyeurs, and child level. This need is the precise parallel of the need, molesters who exhibit no violence in their offenses. stressed repeatedly in this study, to have both Since no treatment progranis were available in New institutional and community-based programs for adult Mexico's correctional institutions, imprisonment sex offenders. If Washington State were toestablish seemed a wasteful, fruitless, and perhaps- counter- only a program for juvenile sex offendersdomiciled productive procedure for these offenders in urgent in one of the state's juvenile correctional institutions, needA' treatment. The problem surfaced when a juvenile court judges would be under strong pressure psychiatrist at the Bernalillo County Mental-Health to take out of their homes and schoolsand to lodge Center interviewed twelve county judges concerning in that institution children who would be better off at their sentencing problems. "The judges recognized home. Conversely, if only a program for children on that many such offendeeswere primarily in need of probation or parole was established, children in need treatment rather than incarceration and that such of treatment would almost certainly be left in their treatment was either difficult to provide, or- unobtain- homeseven though they needed institutional care. able, in a correctional setting." All .twelve agreed The- second principle stressed in the Clark-Henry that if a community treatment program were estab- report and elsewhere in the Washington Stateplan is lished for nonviolent sex offenders, they- would the need for education concerning humansexuality make use of itin their sentencing determinations. and specifically adolesgEnt sexualityfor staff mem- They estimated that 90 percent of the offenders bers, throughout the juvenile courts andjuvenile coming before them might be eligible for community correctional system. One goal is to make staff treatment rather than imprisonment.

36 48-, The program which subsequently arose was spon- femaleproviding the-offenders, perhaps for the first sOred initially by the Bernalillo County Mental time in their lives, with an opportunity to establish :Health Cerer, and opened its doors 1972. The significant relationships with adult women. program was at that time called PASO (Positive Approaches to Sex Offenders), and was financed by 2.19. Goals a three-year- grant from the U.S. Law Enforcement The Albuquerque program formally described its Assistance Administration to the Mental Health treatment objectives as follows: Center: PASO's initial staff consisted of a psychiatric To help clients develop interpersonal social social workerWallace Crowe, M.S.W.who skills through group therapy served as both director and counselor, plus one To help clients develop strong conditioning secretary. During- the next four years, under Wally against a repetition of offensive sexual behavior Crowe's direction, the program expanded continu- To help clients develop- a compassionate con- ously and remodeled itself periodically in response cern with the welfare and interests of others to communitymeeds. To:- enable clients to express and handle their One early change was the moving of the program hostilities and resentments from the Mental Health Centerwhich many of the To present opportuhitieS for growth and matu- sires in treatment felt to be an inappropriate setting rity in-social responsibility to a storefront building close to other community To_enable clients to enhance their self-image as services. A second major change was the extension mature adults of PASO's services to rapists and other violent or To develop awareness that sexual behavior aggressive- offendersmost of whom entered the involves responsibilities as well as gratification program after serving time in a state correctional In marked contrast to the Santa Clara County institution or following release from a state- mental program, which focuses primarily on the incest hospital. Three-quarters of the clients are now ag- offender in-the context of his wife and children, the gressive offenders. The admission of these men to Albuquerque program serves primarily a- youthful the program,.-in turn, focused attention on the need unmarried population (70 percent under 30 and 19 for treatment-facilities within the state's institutions percent under 20; only one-third of clients are and PASO periodically sent small teams- into- the currently married). Thus major emphasis -is placed institutions to conduct group therapy sessions and to on individual and group- therapythough marital and assist in preparing release plans for men returning to family counseling are- available. the community. A counseling service for rapevictims Essentially,- for these young men cast loose in a` was also added to the program, plus counseling for city, the treatment program is aplace -to -take their the wives and-families of offenders. problems before their problems overwhelm them. Upon expiration of the three-year LEAA grant, Their feeling toward the program is molded in part PASO was split off from the Mental Health Center by the fact that counselors are available when and became temporarily an independent social needed, without advance appointmentsa -rarity in agency financed by the City-of Albuquerque. Shortly social programs. "Fifteen minutes at a moment of thereafter it was merged with other programs for ex- crisis may be worth many hours of therapy when no offenders and became the Sex Offender Treatment need for help-is- felt," Wally Crowe explains. Program of Alternatives House, a community In 1976, the Albuquerque sex offender program, agency. along with the other programs for ex-offenders, The expansion of services required, of course, an joined together in Alternatives, Inc., has restructured expansion of staff. Two full-time counselors were its services in terms of a contract with each client. added. Additional staffing was made possible through The contract, which may be either verbal or in the program's close association with the University writing, specifies the services which the program will of New Mexico; two candidates for the doctoral provideindividual counseling, group therapy, mar- degree in guidance and counseling plus -four candi- ital or family counseling, job-training or placement, dates for the master's degree served on the staff etc. It also specifies the length of time over which part-time. One full-time and several part-time volun- each service will be providedand the client's teers were also recruited. The majority, of the staff is responsibilities for making use of these services. The contract may be amended or extended by mutual 7 Wally Crowe resigned in the fall of 1976; the account which agreement at any time. It may be terminated "at the follows is limited to the period prior to his resignation. completion of the contract, or when the -client 49 37: voluntarily requests termination, or when the client ment program for sex offenders was launched, a fails, through negligence, to fulfill his/her part of the treatment program for rape victims and a rape contract.' education program were also launched. The three programs, in Albuquerque as in South Florida, were seen as parts of a concerted community response to 2.20. Strengths and Weaknesses sex offenses. All three programs, in cooperation with During itsfirst four years of experience with other agencies, were instrumental in establishing the several hundred sex offenders, only three serious New Mexico Task Force on Sex Crimes, an agency crimes were reported among those involved in the which over a period of three years significantly program; all three were rapes. It was notonly or altered the handling of sex offenses and victims primarily the community treatment program which throughout the state. failed in these cases, however. One of the rapists One achievement of the task force, for example, had spent five years in prison and another thirteen was the modernization of New Mexico's laws gov- years before entering the Albuquerque program. erning sex offenseslaws which dated from the days Currently the Albuquerque program is composed when New Mexico was still a territory rather than a of two parts. One part, which provides an alternative state. State and local police and prosecution proce- to imprisonment for "passive offenders" in need of dures were similarly modernized. There is even a treatment rather than incarceration, is headed by suggestion that the program has had national reper- Margot Berger. The other part is a program forcussions; New Mexico Senator Pete V. Domenici, "active offenders" following their release from im- an active supporter of the,task force, was cosponsor prisonment; it is headed by Judy Fleischman. of the Federal law establishing aNational Center for Essentially, the quality of the services rendered in the Prevention and Control of Rape in the National the Albuquerque program, or in any other commu- Institute of Mental Health. nity program for sex offenders, depends primarily on Communities concerned\ with developing a rational the quality of the staff and its dedication to the response to their loeal sex offense problems can thus program. On both of these points, theAlbuquerque learn a basic lesson from the Albuquerque experi- program appears to have earned high scores.Equally ence. A program for the treatment of sex offenders important, the program has played an important rale is an essential and useful- ingredient in- the -total in the entire structure of New Mexico's social responsealong with such parallel, efforts as reform responses to sex offenses. in the sex offense laws, rape education, and services At about the same time that Albuquerque's treat- to rape victims.

50 38 PART III.FOUR. OTHER INSTITUTIONAL PROGRAMS

3.1. The Norwalk Program (1948-1954) pletedthat is, until Jie -was found- by a judge or Michigan' was the first state to enact, in 1937, a review board to be no longer a danger to the "sexual psychopath" law; and similar laws were community. If no such finding were made, offenders could be (and some were) kept loCked up as sexual enacted thereafter in many- other states: psychopaths until death terminated their incarcera- Illinois, 1938 tion. The likelihood that they could win releaSe,as California, 1939 "cured"' was severely impaired, of-Course, by the Minnesota, 1939 fact that no treatment was in- fact provided' them Vermont; 1943 dwing their incarceration.' Ohio, 1945 The r.onstittitionality of-these sexual TSychopath Massachusetts, 1947 laws was, of course, repeatedly challenged. Defenk Washington, 1947 lawyers harmer away particularly at,:the Achilles' Wisconsin, 1947 heel of the laws: locking offenders,upzfis r treatthent District of Columbia, 1948 yet failing to prOvide-the treatihent. Perhaps to avoid Indiana, 1949 such,a court-challenge, Califemia in 1948,=hine years New Jersey, 1949 after the law- was passed' there; actually began On their face, these sexual psychopath laws providing treatment at- its Metropolitan_ State Hospi- tal in Norwalk-, California. looked like liberal- reform measures. They provided that-persons found to be "sexual psychopaths," a The program at Norwalk lasted only six years, and it left behind few traces=in .the-pdhlishedl or unpub- term derived =from Krafft -Ebing, should be provided lished literature; AMong its early visitors, hoWever, with treatment in an effort to cure them of this dread were Dr. Alfitd:C. Kinsey and his closest associate,_ disease. In fact, however, the state legislatures which Dr. Wardell Pcitheroy. Dr. liomeroy's and of that passed these laws, often by very large majorities and with little or no debate, neglected thereafter to visit constitutes 'perhaps -the fiat account of a sex establish or fund any treatment programs. (Some -offender=treatthent program in the United 8taies. Kinsey got a:letter one day," Pomeroy later have still not established a treatment program.) The recalled, "inviting -him td°_talk to the sexual psycho- two underlying purposes of these laws were never- path patients therelat Metropolitan State= Hospital], theless achieved at least iii part: in return for which he would-be able to get their First, a- person could =be locked up in a mental histories. At the time there were about two htindred hospital following a finding that he was mentally ill of these patients in the [hospital]. ,KinSey saw -the without many of the constitutional safeguardsright invitation -as a special- opportunity. We had inter- to trial by jury,,right to cross-examine witnesses, and so .on=to which an accused person is entitled in a viewed only a few such people, and:he was anxious to talk to more of them,, and learn how they were criminal trial. The sexual psychopath laws were first and foremost an effort to incarcerate persons ac- different from other people." cused of sex offenses as if they were mentally ill, In the course- of the visit, all but one of, the 200 sexual psychopaths voluntarily gave Drs. Kinsey and= without convicting them of a particular sex offense. Pomeroy their sexual histories. Pomeroy was equally Because the incarceration was (allegedly) for treat- impressed, however, by the institution itself. "The ment rathef than punishment, the constitutional safe- whole situation seemed sounusual to me," he wrote guards of the criminal law were thought not to apply. in his biography of Kinsey, Dr. Kinsey and the Second, most sexual psychopath laws provided no specific terms of imprisonmentor even minimum ' While these sexual psychopath laws remain on the statute and maximum terms, such as one-to-ten-year sen- books in many states, they are rarely or never used in some tences. Rather, a sexual psychopath could be kept statesand legal amendments or judicial decisions have tended locked up until treatment was successfully com- to limit their harshness in some states where they are still used.

39 51 Institute for Sex Research (1972), "that -I- thought it 10. Patients were free to have any pictures they worthwhile -to -make my own record of what hap- wanted. One large calendar picture hanging in pened- there. the dining room was the famed nude photo- "._..- California had passed a law governing sexual graph of Marilyn Monroe. Suppression, said _psychopaths Which -had simply resulted ,in taking the hospital, would- have been worse, and so these -two hundred inmates bodily and transporting homosexuality was not suppressed either. -thein _to _Norwalk, whose administrationAiiew .flpth- 11.Young children came on visiting days, because ink:about tow to -handle theni, since this was- a it was believed that pedophiles must- learn to standard-mental-hospital which did-not- deal in such live with them without danger. There-were no cases. -New they had two hundred prison inmates incidents. who had been transforMed suddenly into hospital 12. A group of Norwalk housewives, known as patients. These men were in custody for offenses the Bib and Apron Club, asked if theycould covering a broad range of sexual behavior, including telp and were told they could come in once a homosexuality, peciophilia, rape, incest, exhibition- week and give a dance. so that patients could and-voyeurisinAll of them had been convicted; be taught-how to observe the amenities. These all had been declared psychopaths." occasions would also give them a connection Sinee the staff at Metropolitan 'State had no with the outside world. pritoneeived ideas of how sexual psychopaths 13. Inmates had the privilege of "firing" any should be treated, and -no model- developed else- guard or officer they did- not like. These where which they could follow, they had to innovate. people would simply, be transferred elsewhere Dr. Pomeroy listed seventeen innovations which in the hospital. impressed him particularly: 14. Women therapists were part of the staff. 15. The entire,=program was therapy oriented, and 1. The men wore their own civilian clothing. went on twenty-four hours a day.Formal- 2. Wives and family members were allowed to therapy was developed in Whit was calledthe visit the men in their quarters. "doctors' group." -Eight to ten patients spent 3. They- were allowed to have privacy with their about two hours a week in the group with a wives, but after one became pregnant this had therapist. to be stopped. 16. There was also a patients' group. Notrained 4. Previous patients who had been released were therapist sat with these patients, but certain welcomed back to visit. atients from the doctors'group were assigned 5. There was unlimited and uncensored corre- -tit. spondence. 17. Inmates often proved to betetter judges than 6. Work assignments were based on the patient's the therapists of whether a = particularinmate need, not on what -the institution might re- was going to adjust well-in the outside: world. quire. For example, an experienced plumber might be assigned to the kitchen detail on the "Under the program I have justoutlined," Pr. ground that his homosexuality might be helped Pomeroy added, "there was about a 5 percentretixiii. ihcontrast to a_20= by contact with women kitchen workers, even rate after the men Were released; though plumbers were badly needed. to 50 percent return' in other groups. situation 7. There was freedom of movement among the ''"One would think that -this sensible group, and they were evenpermitted to go would have been not only encouraged butbroadened, into the town of Norwalk under certain con- in the state penal .system. Instead-Californiatitilva trolled conditions. At the beginning there were $20 million institutionlAtascadero State Hospital] to several escapes, but when the patients re- which 01 sexual psychopaths were sent,and the turned they were ostracized by the others, and Norwalk program was ended. The newinstitution feeble, this kind of social pressure ended the escapes. had no such spark, and although some 8. Patients were allowed to have unlimited cash halfhearted attempts were Made-to copy the original in-their pockets. idea, it was never as successful. 9. Unlimited gambling was permitted. The "Ironically, the administration at Norwalk had no administration reported that the professional realization- of what a remarkable thing it had done. gamblers among the men quickly won all the Its members were not aware that theyhad been others' money, then gave it back so the game innovators, and -that other hospitals treated these the could go on. patients quite differently. Since -that was true,

40 52 Norwalk story was, never told in its entirety, but I The innovative features stemmed from a 1971 bellieve it still stands today as a model for treating "Hospital Improvement Grant" (HIP) from the Na- `those whose sexual- behavior has been condemned tional Institute of Mental Health to Atascadero State by law." Hospitalone of the few such grants in the histoiy of sex offender treatment programs. Dr. 'Michael Serber, a psychiatrist, was the project director for 31. The Atascadero Program the grant; and he drew freely on the Resnik-Wolfgang The institution to which the Norwalk patients were essay, "New Directions in Treatment" (see page iransferred_initme 1954, Atascadero State Hospital 7) when developing the new Atascadero program. iri Atascadero, California, was a hybrid=institution Almost immediately, however, dissension arose part-. maximum= security prison and part mental hos- between Dr. Serber and his newly recruited staff on Pital---locateditithe middle of the state, remote from the one hand, and Atascadero's director and his bothncirthern and southern centers of population. It senior staff on the other. had a capacity of 1-,200much too big for maximum "The HIP Project ,met with so much resistance therapeutic effectiveness. In addition -to sexual psy- and hostility from the hospital administration," a chopaths renamed "mentally disordered sex of- staff member subsequently wrote, "that at one time fenders" or MDSO's when the sexual psychopath every employee hired with grant funding, including law was amended=-Atascadero contained a number Dr. Michael Serber, the =project director, was dis- of groups known as the "criminally insane": persons missed and an attempt was made... -to- returnall unable to stand trial-by reason of insanity, persons funds to NIMH. Naturally, this was seen as a rather found not guilty by reason of insanity, psychotic unusual request, there being no ready mechanism to patients_ transferred from the correctional system, accept returned funds in the middle of the year. and others deemed a menace to society, in need of There was some delay along with investigations into maximum security precautions. About half of the treatment and forensic abuses at the hospital. As a Atascadero population is commonly composed of result of these official inquiries;the HIP grant and its MDSO's. personnel were reinstated -and the entire,hospital was An informal history of the institution, distributed soon 11972] to begin the task of a total reorganization in 1975, reports that Atastadero opened "with the into-treatment programs designed and geared to meet philosophy that good therapy could be carried on in the needs of its patients." a security setting and that modern methods of Pursuant to this -1972 reorganization, ten treatment psychiatric treatment, based on a 'therapeutic com- units were establishedof which the "sexual Ivo= Munity' concept, would most likely succeed. rientation program" was of particular interest. This "The problems of 'therapy vs. security' and was the joint responsibility of Dr. Serber himself and `prison vs. hospital' immediately developed and a woman associate, Ms. Claudia G. Keith; it was hindered_ successful treatment. The belief that crimi- concerned with the approximately -180 homosexuals nals- should be punished for their crime and not held at Atascaderomost of them for offenses 'babied' 'haunted- the hospital program. For several involving male partners or victims under the age of yearsrbeginning in 1959, a series of unfortunate and 18. tragic accidents occurred at the hospital. A number "The history of -treatment for the homosexual at Of escapes and violent incidents in addition to this institution," Dr. Serber wrote, "has mainly widespread community concern led to a special centered around inadequate and sometimes cruel investigation of the hospital's problems which ulti- attempts at conversion to heterosexuality or asexual- mately resulted in- a revamping of its organization, ity. There is an intermittent history of aversive adthinistration, and treatment programs" beginning conditioning. These aversive techniqw-, had ex- in 1961. tended even to the use of succinylcholine and The 1960's were also a troubled decade-for Atas- electroconvulsive shock treatment as punishment for cadero, plagued by internal dissension, staff rebel- homosexual offenders who had 'deviated' within the lions, and occasional scandal; the details are irrele- hospital. At the very minimum, homosexuals were vant to this study. Our primary concern is with a frequently degraded by staff whose attitudes con- three -year period beginning in 1972, when Atascad- cerning homosexuality were punitive -and judgmental. ero was briefly -the site for a number of innovative More homosexual patients than heterosexual had treatment-approaches-which-warrant-full considera- been defined as unamenable to treatment after a 4ion. period of hospitalization and then were sent to prison

53 41 via the courts under the ambiguous judicial system the problems of being gay in a predominantly straight that determines the fate of sexual- offenders in the society; (b) the means of dealing with family mem- state of California." One important facet of the new bers in relation to the group member's homosexual- program, accordingly, was to provide for "the desen- ity; (c) difficulties in finding work, keeping it, and-- sitization and education of staff members in relating associating with employer and fellow employees; (d) to homosexuals." social alternatives for homosexuals; (e) association In lieu of the old goal of converting homosexuals with straight friends; and (f) the situations to be into heterosexuals or suppressing their sexuality avoided in order not to be subsequently rearrested." altogether, the expectation of the Serber-Keith pro- The CR sessions also familiarized each participant gram was that"patients would attain adequate with "the gay organizations that will be open to him knowledge and skills necessary to return to their when he is released and how these organizations can communities, keep out of trouble with the law, and provide social, professional, and therapeutic sup- not molest young boys." Viewed from this point of view, most of Atascad- Quite early in the program, Ms. Keith states, ero's homosexual offenders were seen to resemble several advantages became visible. "Some patients quite closely most heterosexual offenders; "gener- have learned new skills and feel more knowledgeable ally, these patients lack the basic verbal and nonver- and self-confident in both gay and straight settings." bal skills necessary to successfully interact -with Opponents of the new program had feared -that it others. Often they _feel so inferior with people their would lead to increased homosexual activity within own age that they prefer the company of children or the institution; but "no increase in sexual acting out juveniles." This theme ofinferiority feelings asa has been reported by group membersor nongroup barrier to mature sexual functioning- is common to members throughout the institution. The homosexual almost all- treatment programs. "In addition, most patients, on their own initiative, are in the process of homosexuals in -this hospital have no knowledge offorming a club within the hospital that will serve as what social alternatives are available to them in the a self-help organization and a communityliaison community or with what groups they might identify service. ...We have demonstrated in a very short or enlist for support upon release from the hospital." time significant advantages to both patients and staff. To implement the goals, Ms. Keith reports, she Follow-up may well reveal advantages to the com- and Dr. Serber secured "gay student volunteers from munity as well." inte- a local college campus who are successfully In addition to the program for homosexuals, Ms. gated into straight society and who functioned as Keith reports, "a sexual preference group was orga- instructors and behavior models." nized...in order to help patients who are unsure Role playing was the first mode of therapy tried of their sexual orientation. An attempt is made to aid much as role-playing was used in another part of the patient in determining whether his interests lie Atascadero to teach heterosexual social skills. "The with homosexuality, heterosexuality, or bisexuality. social scene used was that of a gay bar where Although not specificially a part of the homosexual contacts are frequently made." The men learned treatment program, this group hasbeen an important how to enter such a bar, how to establish eye adjunct to the treatment of many patients." contact, how to start a conversation, and so on. Later a living-room scene was substituted for the Ms. Keith added, however: "Despite our suc- bar; homosexuals complained that use of a bar scene cesses, we have and are experiencing manyproblems perpetuated an unfair stereotype. and, like any conscientious treatment program, we Another facet of the program was the launching of are constantly in a state of evolution.Perhaps the a consciousness-raising (CR) group, modeledafter most frustrating realization which we have had to the CR groups found in the women's movement. "A make is that the homosexual treatment program does gay, female paraprofessional with experiencerunning not offer the golden solution to the treatment of male consciousness-raising groups [ for women on the child molesters as we had once hoped. A major outside] was asked to assume leadership of 10 problem which we as yet are not effectively treating extended group sessions." As in women'sCR is that these patients are really turned on by male groups, the emphasis in this gay group was on children for various reasons and many actually prefer emotion-laden problems which are rarely confronted them. We currently must rely on other aspects of the from a rational point of view. "Certain subjects were Sexual- Reorientation Program to aid- the patient in repeatedly and extensively discussed. They were: (a) developing the necessary self control to choose the

42 54 behavioral alternatives provided by the homosexual,_ogy was taught; but more stress was placed on treatment program instead of child molestation." sexual psychologS17"We feel that any successful, Half a dozen other innovative features can be intimate sexual relationship is based on the attitudes more briefly/described: of the partners," Mr. Burkhardt wrote. "Too many Family Mteractions Skills Program.Under the times patients who have sexual-difficulties find that direction of Dr. Robert E. Hiller, a psychologist, this they and their partners have entirely different e,..t.ec- program sought to involve the wives and families of tations of each other. This course is designed- to offenders =in -their treatment. Family therapy proved teach people how to enjoy a sexual relationship and of great value despite two shortcomings: lack of each other by reaching a common understanding of adequate professional staff and the hundreds of miles each other's needs and:expectations." Areas covered many families had to travel to reach Atascadero. included the history of sex, the nature of Jwirian Aggressive Behavior Management Program.This sexual responses, male and female; "pleasuring" program -from 1972 to 1975 was under-the-direction (foreplay), oral-genital sex, sexual intercourse, post- of Dr. Paul Bramwell. "A stnalf segment of the coital responses, and such sexual dysfunctions as [Atascadera] patient population,': Dr. Bramwell absence of female orgasm, problems of ,male erec- noted, "exhibits uncontrolled aggressi which con- tion, and premature ejaculation. To minimize the stitutes a-danger to themselves and to rs and difficulty of teaching such a course in an all-male which also seriously impedes therapy tot- nie pa- institution, women staff members were used' as tient's more basic problems." His project he de- teachers and counsellors to the extent possible. scribed as "a specialized and intensive treatment An unhappy ending.In 1975, the NIMH grant for program which is designed to control and modify the funding of innovative treatment approathes at that behavior." Atascadero expired and was- not renewed. Dr. Ser- Assertive Skills Trainir . too, ..Under the 'ber, the clinical director primarily responsible for the direction of William Ernst, 'tl,. program wasde- innovations launched in 1972, had died and no signed =to "provide patients with additiontA methods successor had takep.his place. By the spring of 1976, of emot'Ainal expression and problem-solving skills a.numberof the others associated with the 1972-1975 which will lead to more behavioral options 41 regard innovationsBramwell, Goodman, Hiller, Keith, to making and keeping friends, finding employment, ErnSt=had left Atascadero and their programs were and solving Other probleMs inherent in daily living." discontinued. The sex education program under Paul Interpersonal Communications Skills Program. Burkhardt, Diane Serber's aftercare program, and a Under the direction of Dr. Alan S. Goodman, this small-scale-research program under Dr. Richard program was designed to serve Atascadero residents Laws still functioned;2 but little else was visible "with gross deficiencies in effective methods of which was.addressed specifically to thesexu iirob- communicating thoughts and feelings- to others and lems of sex offenders. Note: An additional California those that are inarticulate, passive, dependent, or prograin was launched at the Patton State Hospital incapable of assessing the communications of oth- in Patton, California, in the Spring of 1976.Itis 'ers." described in Appendix A, p. 76. Community Planning, Orientation, and Transfer Piograni.This program, headed- by Diane Serber, 3.3. The Adult Diagnostic and Treatment was designed to help bridge the gap between institu- Center, Avenel, New Jersey (formerly tion and community for those about to be released and for tho! already out. Once again, remoteness of the Rahway Treatment Unit, Rahway the institution from the centers of population served State Prison) made release planning and aftercare exceedingly Prior to 1963, sex offenders sentenced under New difficult. Jersey's sexual psychopath law were deemed men- Sex Education.A major facet of Atascadero tally ill and were incarcerated in secure units in the during its "golden age"'from 1972 to 1975 was a sex state's mental hospitals. As in most other states, education program under the direction of Paul -Burk- these hospitals provided no special treatment pro- hardt. This program, like several others, made use of gram for sex offenders. In 1963, howeVer, a state- sex education films developed by the Multi-Media Resource Center in San Francisco for educational 2 Since this was written. Atascadero's Sexual Behavior use; in addition, the NIMH gra;'funded three films Laboratory under Dr. Laws has been expanded into a treatment mtt.le specifically for sex offenders. Sexual physiol- as well as research facility. See Bibliography.

55 43 wide scandal involving- seieral state hospitals re- childhood experience as a victim underlay the sub- sulted in widespread community protestsand in the sequent compulsive behavior as-a- sex- offender: gradual transfer of sex offenders from the state Further, he believes that many offenders who deny hqspitals to the maximum security prison at Rahway, having been sex: ally molested as children have had New Jersey. similar experiences but have forgotten them. Out of The Rahway State Prison officials did not want the these beliefs arose a treatment approach which sex- offenders and neither did the state's Division of Prendergast labeled ROARE (Reeducation of Atti- Correction and Parole. A compromise was accord- tudes and Repressed Emotions). ingly arranged- which may be of interest to other During a ROARE therapy session, offenders are states planning sex offender treatment programs. given the opportunity to "regress" to an early age; In brief, a sepaiate building within the walls of the in the course of the regression they often report Rahway State Prison was set aside for the sex uncovering a traumatic sexual assault :upon them- offenders. Treatment was placed under the jurisdic- selves at an early ageand they relive that experi- ,tioa of the Division of Mental Health, while the ence, often with deep or even violent emotional. pnson maintained security. Offenders lodged in the accompaniment. The procedure resembles the treatment unit left the unit for meals and for work "abreaction" in traditional Freudian therapy. The assignments elsewhere in the prison; but in other ROARE approach also includes various methods of respects these_x offender unit was an independent helping the offender to assimilate this newly enclave within the prison. unearthed experience and to restructure his future In -1967 a psychologist, William E. Prendergast, attitudespresumably in ways which do not include Jr., became director of the Rahway Treatment Unit; compulsive sexual offenses. The ROARE experience and during the next nine years, he made it one of the is an emotionally very moving one--Which some best-known, treatment programs for sex offenders in observers have likened to a religious "conversion" the counts f. One result- was that New Jersey voters experience. in a statewide referendum passed a bond issue for Evaluating either the ROARE theory or the the construction of a new building specifically for the ROARE experience is hardly possible, however, on sex offender treatment program; -the building, which the basis of the data availablethough numerous is in Avenel, New Jersey, but is only a few hundred observers agree that it has produced remarkable yards from the Rahway State Prison, received the effects in selected cases. Several -other. Prendergast sex offender population- from the prison in February innovations may be of more general interest.to other 1976. Itis the only structure in the country built programs and to those planning future programs. specifically for a sex offender treatment program. One is the intensive and-innovative use of closed- Curiously enough, the physical move from the circuit television. Not only ROARE therapy experi7 prison to an independent site in 1976 was accom- ences but a variety of other therapeutic procedures panied by a reverse bureaucratic move; jurisdiction are routinely videotaped in a studio excellently was transferred from the Division of Mental Health equipped forthe-purpose7The-videotape-circuiris- and Hospitals to the Division of Correction and wired 'through Prendergast's office so that he can Parole. Simultaneously, the -inste ,tion was renamed monitor therapeutic sessions anYwhere in- the build- the Adult Diagnostic and- =Treatment Center and Dr. ing. Material of interest- from any videotape can be ha-Mintz, a clinical psychologist, was named super- transcribed onto a master tape for future reference indendent. The Center now has two unitsa diag- or for training purposes. A participant- in a ROARE nostic unit for service to the courts and the correc- sessionis expected -to play back the tape for his own tional system, and a treatment unit. Bill Prendergast information within a day or two, so that he can "see remains on -Director of Professional Services in himself as others see him." A number of human the treatment unit. growth centers outside of the correctional system As director of the program from 1967 to 1976, Bill have found this use of videotape playbacks of very 'Prendergast developed a very personal theory about great value in putting participants in touch with their sex offenders, and a yery personal mode of therapy own feelings and with the image they project; -the growing out of that ,theory. Like other therapists New Jersey experience indicates -that the videotape working with sex offenders, Prendergast noted that playback can similarly be of very great value In a in a remarkable proportion of cases the sex offender treatment program for sex offenders. had himself in childhood been the victi#1 of one or A second Prendergast principle is the emphasis on more sex offenses. Prendergast concluded that the vocational training for sex offenderson the theory

44 56 that a man skilled in a job he enjoys is less likely to Appendix A: The Program at the Trenton State reoffend. By far the most successful vocational Hospital (page 80), and the Program at the Colorado training approach- has been the training of sex State Reformatory (page 79). offenders in the use and maintenance of the audiovis- ual equipment. Indeed, during the move from Rah- 3.4. Minnesota Security Hospital (St.;Peter) way State Prison to the new center in Avenel, Programs offenders handled the installation and very complex wiring- of all- equipment, and currently operate the The Minnesota Security Hospital has been the site of equipment in accordance with sound professional two quite distinct treatment programs for -sex of- standards. Alumni_of the training are fully qualified fenders, and a third was in the planning stage during as audiovisual technicians. The possibility of intro- the fail of 1976. ducing other innovative forms of vocational training The first experimental program, known as BEAD withima treatment program should be considered by (Behavioral, Emotional, and Attitudinal Develop. other programs. ment), treated fifteen sex offenders between April .Further, the prograrri at Rahway and now at and November 1974, and a second group of fourteen Avenel places major emphasis on "patient-directed between August 1974 and May 1975. Some of -the -responsibility," or-PDR. A PDR program participant twenty-nine participants were offenders serving-time decides for himself the form which a therapy session in the Minnesota State Prison who were transferred shall take, what other participants or staff members to the Minnesota Security Hospital- for the BEAD he wa.its present, and.so on. On some occasions, he program; others were already in the custody of the may choose to be alone in thestudio, engaging in a hospital. BEAD was- funded- by a grant from -the soliloquy or "acting out" his feelingsfor subse- Bush Foundation, a private philanthropy with head- quent replay by himself-and his therapist. On other quarters in St. Paul. Dr. H. L. P. Resnik,whose occasions he may prefer a session with a single innovative suggestions for the treatment of sex therapist, or with a fellow participant or two, or with offenders have been described above (pages 8-.9) was his entire group. He may also specify what roles he called in to advise the foundation; and in this way a wishes the others to playwhether they should number of his suggestions found =their way into the confront him, or provide emotional support, or BEAD program. remain passive and silent. Like the programs at Fort Steilacoom, South Finally, the Avenel schedule includes a number of Florida, and elsewhere, the BEAD program was "paraprofessional groups" under the leadership of built around is tensive group therapy sessions- involv- individual sex offenders. At an appropriate stage in ing every aspect of the offenders' lives; but there his own therapy, any offender may submit a proposal were differences at BEAD. In addition to thefifteen_ for such a group, to be held under his leadership offenders in residence, five young women from the under the supervision of a professional staff member. nearby St. Peter: community participated in the group The proposal specifies the subject matter to be sessions. These "co-participants" were volunteers covered and the approach to be used. One offender "recruited on the basis of their maturity, emotional concerned with alcohol problems, for example, leads stability, and sensitivity." Individual- therapy -was a group on alcoholism. Another leads a"KEY" also a feature of the program. group aimed at "Knowledge throughExploring Buttressing the therapy sessions was an intensive Yourself." A third leads a group concerned specially sex education program under the direction ofRichard with-the problems of recidivists and parole violators. Seeley. Ten other women and men from the com- Sessions are tape-recorded, and may be played back munity participated in the sex education sessions -during training sessions for the group leaders. One along with the 15 sex offenders and the five young obvidus effect of these "paraprofessional groups" is women volunteers; several -of these additional vol- that the total program is enriched beyond the avail- unteers were teachers or volunteers already involved able time of staff therapists. A second advantage is in the hospital's general education activities. increased program relevance; the paraprofessional The sex education sessions included, many films, groups which survive are thosewhich strike a filmstrips, slides, recordings, and other audiovisual responsive chord in other offenders, and the partici- aidssome -of them containing sexually explicit ma- pants in each group are those in whom thatchord terials of the kind- commonly med in college and has been struck. Note: Two other programs operated medical school human- sexuality courses. The two in state .correctional institutions are described in basic purposes of this educational approach, Dick

45 Seeley explains, were (I) "to obtain and discuss months). Too little time was available for advance accurate sex information under proper education planning and the laying of firm foundations. Asa auspices," and (2) "to inquire into and clarify result, BEAD became an episode in the lives of its attitudes about a wide variety of human sexual participants-rather than a concerted correctional feelings and behaviors." Simple exercises of the kind program for the identification, treatment, evaluation, used in behavior therapy and Gestalt therapywere release, and aftercare of sex offenders. These short- introduced "to assist participants in comprehending comings are not here described as criticisms of either and appreciating their feelings and the quality of their BEAD or of its dedicated and innovative staffbut interpersonal relationships." The presence ofwomen as a warning to future programs to establish firm and men from the community, of course, vastly foundations, start slowly, and secure in advance the enriched this concern with interpersonal relation- cooperation of all the other components in both the ships., correctional and mental health systems. The large group of 25 or 30 split from time to time into smaller groups of six or seven "to' facilitate In May 1975, following termination of the second BEAD group, a rather different Sex Offender Unit greater- f-eedom of expression. Topics dealt with was established at -the Minnesota Security Hospital. included "ethical questions, interpersonal affectional It is under the direction of Richard Seely, who had relationships, the distinction between fantasy and participated in the BEAD program and who had also behavior, and the mutual responsibility that sexual visited the Fort Steilacoom program. In considerable partners have toward one another." part, the program Seely is currently developing is The climax of the BEAD sex education program based on -the Fort Steilacoom precedentplus a was the holding of a SAR or "sex attitude reassess- major emphasis on sex education in accordance with ment." (The SAR- approach to sex education was the BEAD model. pioneered at the National Sex Forum in San Fran- cisca and spread from there to a number of univers- The focus of the present program, Seely reports, ities and medical schools, including- the Human is "to help residents develop self -help skills andthe Sexuality Unit at the University of Minnesota Medi- milieu within which personal problemsare dealt with cal School.) Each BEAD group was transported, in an open, honest, and supportiveway. Mandatory under security precautions, to the University for its group therapy sessions are held 14 hours per week. SAR. Some wives and close friends of offenders also Crisis intervention therapy is availableon a need participated, along with outsiders from the commu- basis. Small task-oriented groups, team meetings, ad nity. Essentially, a SAR is a "marathon" experience; hoc committee meetings, and staff-council sessions for two days and one evening participants were provide,ongoing therapy land staff contacton a 24- continuously exposed to sexual audiovisual mate- hour-a-day basis.... The therapeutic community rials, descriptions of sexual behavior, and small- concept provides a continuous therapeutic milieu." group discussions of the materials presented. Volunteers from outside the institution, including An evaluation of the BEAD program was made by women volunteers, participate in many activities. Dr. Resnik, who pointed out many shortcomings and The program's ultimate aim, Seely adds, "is the difficulties. Some of the sex offenders participating protection of society. It hopes to develop within the in BEAU were' clearly unsuited for this kind- of offender a new sense of pride in being able to program. TN. BEAD staff was wholly inexperienced recognize and control his deviant impulses- and to in the treatment of incarcerated sex offenders. Fric- govern his relationships with other, human beings by tions and communication problems arose between concern for their feelings and rights. The program is the BEAD staff and the staff of the hospital. Respon- based on the premise that this growth process can be sibility was fragmented among the BEAD staff, the achieved only in an environment providing opportun- hospital staff, the Department of Public Welfare, the ities and choices similar to community living. Basic Department of Corrections, and the Minnesota Cor- components are respect and concern for the offender rection Authority which alone had power to parole as a human being, close daily observation, confron- offenders held in the correctional system. There tation, and psychotherapywith privileges based were no provisions for aftercare following BEAD. solely on behavioral performance. All residents are Shortages of trained.and experienced personnel.com- expected to become completely involved in the pounded these difficulties. Stated differently, BEAD treatment process. Any elopement, contraband, had bitten off more than it could chew with available physical assaultiveness, or sexual misconduct consti- staff and time span (the duration of the grant was 18 tutes a violation of the resident's contract and may

46 58 result in immediate transfer out of the Sex Offender throughout the state have considered the cs.-ue of Unit." treatment piograms for sex offenders, and there has ,Further = changes in the Minnesota program may lie been widespread involvement of both state officials ahead. In July 1976, as noted above (page 45), the and private citizens. A foundation has thus been laid Minnesota legislature ordered a study of the subject for -a statewide approach to sex offender treatment to be made, with recommendations for action. The programs going considerably beyond both the BEAD study is being funded by the U.S. Law Enforcement and the current Minnesota Security Hospital ap- Assistance Administration. Discussion groups proaches.

47 59 PART IV.FIVE OTHER COMMUNITY-BASED PROGRAMS

Three of the sealoils belowsection 4.1 on indi-_ specified as a condition of probation.,A judge is very vidual court arrangements, section 4.3 on castration likely-to accept such a joint recommendation. and reversible chemical castration and section 4.5 on No study, has ever been made of these Individual behavior modificationare concerned with general court arrangements. No one knows -how frequent principles rather than specific programs. The remain- they are, or the-ultimate outcome. The psychiatrists ing sections describe five innovative community- who handle substantial numbers of such cases no based treatment programs. (Five additional commu- doubt learn from_their own experience, and,frorn the nity-based programs are described in the appendices.) experience of other psychiatrists, AVhich cases can be safely- handled on an outpatient haSisin this_way and which cannot. Every psychiatrist-is keenly aware of 4.1. Individual,ourt Arrangeerients the hazard he that one of-Ns patients may Long before -the pioneer sex offender treatment commit a community-shocking, headline-engendering programs were established in- California and other offense and that the Psychiatrist himself may be states, a limited number of selected sex- offenders blamed. He is therefore=eareful to .accept- for treat -_ received outpatient treatment rather than incarcera- ment only those patiehts whose likelihood. of reef- tion as a result of individual court arrangements. fending is acceptablylow. Such arrangements are still available in many, per- More research- is- clearly Called for in this area of haps most, jurisdictions. private court arrangements. EVen in the absence of. A typical case concerns a respected corporation such research, however,. no good reason :apPears vice president, aged- 50, with no prior criminal why such arrangethents should be curtailed: On the record, who is arrested on a charge of child moles- contrary, a substantial expansion of such arrange- tation. His first step, of course, is to retain coursel ments appears warranted. In many jurisdictions an eminent local attorney familiar with the local day, the benefits of individual- court arrangements courts and psychiatrists. The attorney's first step, in are available only to well-to-do defendents who can_ turn, is- to retain as a consultant an eminent local afford high- quality legal representation and private psychiatrist well-known to the local judges; indeed, psychiatric fees for-both examination and treatment. he may be the same psychiatrist whom the local The sons,of well -to-do fathers Wray 'similarly benefit. judges themselves consult when_ faced with a difficult The -obvious need is' to-make similar arrangements sex-offender case. Sometimesfie psychiatrist viho available for otherwise- qualified- defendants who plays thir, role, both for the courts and on behalf of cannot afford to pay for such services out of their individual defendants, is a professor of psychiatry at own pockets. the localinedical schoola man whose specialty -is A number of the community treatment programs forensic psychiatry. for sex offenders- described below accomplish pre- The psychiatrist- in such a case will thoroughly cisely this.-they accept court referrals for diagnosis, examine the defendant, take a psychiatric and sexual make recommendations to the courts, and provide, history, make a diagnosis, and submit to the defense treatment on an outpatient basis for sex offenders- attorney, to the court, or to both a detailed report who could not otherwise -afford -these services. inelriding a proposal for outpatient treatment. The Examples are the Philadelphia program described psychiatrist may also agree to provide the prescribed below, and the University of Maryland, University treatment himself. of Southern California, and Denver programs de- In a high proportion of such cases, the prosecuting scribed in Appendix A.' attorney will agree with the defense attorney to A new program at the Fairview Southdale Hospital in recommend- probation- rather than incarceration fol- ,Edina, Minnesota, a suburb of Minneapolis.-was launched too lowing a plea of guilty to the offense charged or to a late for inclusion in this survey but is listed in Appendix C. It lesser offensewith treatment on an outpatient basis is the only program sponsored by -a voluntary general hospital.

48 6 4.2. Center for Rape Concern, Philadelphia ommendations. This procedure was continued; but in addition, selected offenders. who appeared to be in Of the outpatient treatment programs described in need of therapy were required as a condition of this study, this program at Philadelphia General probation to attend at least 16 group therapy sessions Hospital is by far the oldest and best- documented. It at the Philadelphia General Hospital. A probation has passed through three distinct pmses, separately officer was assigned to the program to check attend- described below. ance, to provide liaison between the program and the Phase I was launched in 1955 by a psychoanalyst, probation department, and to be helpful in other the late Dr. Joseph J. Peters,2 with little community ways. Thus, in effect, the Philadelphia program support at first beyond his own professional interest offered to sex offenders generally the service previ- in trying out psychoanalytically oriented group.ther- ously available only to well-to-do offenders. apy with sex offenders. He found in the greater During the next ten years, some 1,600 sex of- Philadelphia psYthiatric community several other fenders received group therapy at Philadelphia Gen- fully qualified psychiatrists who were willing to eral Hospital. As the program grew, the city began devote one evening a week to sex offenders, without paying for the psychiatric services which had initially payment, in return for further training in psychon- been volunteered. At first the offenders were divided alytic principles and in the practice of group therapy. into three groups: child molesters, exhibitionists, and Securing sex offenders for the program proved homosexuals. (Homosexual acts and homosexual more difficult. A major feature of probation for many solicitations in those days frequently led to criminal decades has been the principle that offenders must convictions; indeed, the homosexual group was the not associate or congregate together. Indeed, this largest.) A fourth group was composed of- miscella- was an explicit condition of probationand stillis in neous sex offenders. In 1966 a fifth group, for many jurisdictions. A bank robber found conversing rapists, was added. Dr. Peters believed that a group with two other bank robbers may have his probation composed solely of child molesters, or rapists,or revoked. Judges approached with a request that they offenders sharing some other offense in common, refer sex offenders to the Peters program back in could function more effectively than a mixed group; 1955 replied that the program itself was illegal; this is not the belief of most other treatment- pro- "group tueetings would require-criminals to congre- grams. gaie. The judges initially offered the greatest objec- Each group contained from 12 to 15 members at tions to and questions about the outcome of arrang- any given time; it met once a week for an hour are, ing meetings for homosexuals and dnrg addicts. They a half, and it was open-endedthat is, as o envisioned exchange of deviant partners and sale of offender completed the program or dropped out, a drugs in court-sponsored group programs." A judi- newcomer was added. Absenteeism reduced the cial distrust of psychoanalysis may have reinforced actual attendance each week to eight or ten partici- this strictly legal objection. pantssome newcomers, some approaching- termi- Dr. Peters' response was to meet periodically with nation of therapy, and some intermediate. the judges and with the court administrator to discuss The Philadelphia experience was subsequently other problems of !mutual interest. As a result, he summed up in a series of papers (see Bibliography) learned more about judges and the judges learned by Dr. Peters, Dr. H. L. P. Resnik, Dr. Robert L. moreabout him; "what to do for the-offender could Sadoff, Dr. Joseph Steg, Dr. James J. McKenna, Jr., then be discussed in an atmosphere of mutual trust Dr. James M. Pedigo, and Hermann A. Roetherall by the courts and the clinic." This approach is therapists associated with the program. "During the strongly recommended to the directors of other first ten years," =one report in this series notes, "sex treatment programs; for close cooperation between offenders deny involvement in the act for which they the courts and a treatment program is essential to have been arrested and convicted. Pedophiles (child program effectiveness. molesters) are most vocal in their denig; they object The procedure-agreed upon was simple. Judges in a direct, verbal barrage. On the other hand, the were currently placing many sex offenders on pro- exhibitionists express their denial by passive-aggres- bationwhich meant that an offender had to meet sive behavior such as absenteeism, silence, and with a probation officer once a month, review his withdrawal during the session." life situation, and follow the probation officer's rec- Many offenders are unwilling to discuss the cir-, 2 Dr. Peters died in November 1976: Ms. Linda Meyer is cumstances of their offenses at all initially; the few now acting director. who-d:, speak up "describe themselves as victims of

49 61 other people such as wife, neighbors, and police." A behavior. Thus the expressions of character disturb- few admit their offensebut insist that their problem ance are channeled away from the community into has already been completely solved merely by arrest the graip sessions where each member's behavior and 'conviction. "It won't ever happen again." Other and attitudes can be by discussion, peer new members agree with these denials, citing exam-. interaction, and new identifications." pies (mil- their own historiesand thatis where During the terminal phase of treatment, the Phila- involvement- in the group process begins. The new delphia report notes, "some men talk of positive men, in the course of supporting one another's feeling for the group and the benefit derived from it. denials, become functioning members of the group. They may express realistic gains. The most impor- Some offenders, the Philadelphia therapists found, tant seem to be increase in job stability and increase never pass this initial phase and terminate treatment in self-esteem"which for the Philadelphia program with little progress. But many progress to the middle as for most others is a major goal. Some men-in, the phase, with more verbal participation in the group terminal phase, the report adds, are still "playing the and more interactions with other group members. con game"; they say nice things to impress the "There is less denial of involvement in the offense therapistbut other group members are quick to and less time is spent expressing, hostility toward recognize and challenge this ploy. "It is common to authority. As peer identification increases, the defen- find members [in -the terminal phase] acting as co- ses of detachment, social isolation, and passive- leader," doing their best to reinforce the therapist's aggressive behavior decrease. Some middle-phase attitudes. members challenge the denials of-initial-phase mem- Readers desiring a fuller account of this group bers by stressing their own similar denials when new process are referred to the publications from the to the group. Absenteeism drops." Philadelphia program listed in the Bibliography (page Some middle-phase members begin to "assert 96). independent leadership. They start the session. They After ten years of experience, Dr. Peters and his interview new members. They assume the role of associates launched a study to determine whether therapist instead of following blindly a code of these changes visible during therapy affected -behav- loyalty-to fellow offenders. This small core of active ior following the termination of therapy. For this individuals moves the [rest of the] group beyond the purpose, they followed up 92 alumni of the treatment initial stage of denial, projection, and rationalization." program for a period of two yearsand compared Therapeutic attitudes are promulgated through mem- what had happened to them with what had happened bers of the group rather. than on the authority of the to a generally similar group of sex offenders who had therapist. been placed on probation,without therapy. Some group members gain relatively deep insights The two groups were different in some reipects. into their own motivation, Dr. Peters and Dr. Resnik The therapy group had committed more offenses, continue. A pedophile, for example, may begin by and more serious offenses, than the group placed on blaming his offense on his wife's rejection. Later he probation without therapy. If the therapy group did may realize that his unconscious fear of women has as well as the probation group despite the presence kept him from establishing a satisfactory relationship of men with more prior offenses and more serious at homeand he may further realize that itis his offenses, it might be deemed a success. feelings of masculine inadequacy which makes him Actually, the treatment group seemed= to have approach little girls rather than adult women; little fared much better than the probation-group. Twenty) girls "make fewer demands at the emotional level seven percent of the probation group were rearrested and are less, likely to reject him." Such deeper during the two-year followup period, as compared factors, when unearthed, come as revelations to the with only three percent of the therapy group. Rear- other group members, and they begin to consider rests for sex offenses were low for both groups-8 their own deeper motivations. Some discover, for percent for the probation group versus oae" percent example, -that being caught was not just sad" (one arrest) for the group which had received treat- "their behavior passively invited rather than avoided ment. arrest." In some sense, they sought punishment. Psychiatrists also interviewed both groups during In the Process of group interaction, "persons) the followup study and rated them on their adjust- passivity diminishes. The members soon discover ment to work, sex relationships, and other factors. that they can express hostility, experience anxiety, The only notable difference between the two groups and-tolerate tension without resorting-to antisocial was in sexual adjustment; members of the group

50 .62 which had received treatment were rated much bation officers who were specialists vs. men in the higher. treatment program. Forty group sessions were re- These preliminary findings were encouraging, but quired of the men in the treatment program, as subject to many qualifications. Thus 44 percent of compared with only sixteen during the prior decade. the treatment group were there for homosexual Under these circumstances, both groups did well offenses with consenting adultssodomy or solicita- about equally well. About ten percent of both groups tion for sodomy; and 12 percent were there for were rearrested for a sex offenseduring a -two-to similar offenses officially listed as- "public inde- three-year followup period. An additional twenty cency." Such offenses, so very commonly, prose- percent were rearrested for nonsexual offenses. cuted in Philadelphia during the period 1955-1%5, Those assigned to treatment who actually attended have almost disappeared from today's treatment twenty or more group sessions did significantly programs. The Philadelphia findings of that era may better than the parole groupbut this may have not apply to today's mix of sex offenders. Further, been due to their inherent-differencesrather than to theiwo-year followup period was short, and the use the benefits of therapy. of a comparison group rather than a control group Numerous other findings of this second Philadel- that- is, the failure to start with a common pool of phia study will_ be found in Dr. Peters' 1973 report offenders and then assign individuals by lot to one (seeBibliography). group or the otherlimited the reliability of the PhaseIII. The current Philadelphia program rep- findings. resents a major innovation in one important respect: Phase II.To remedy these a Id other shortcom- the treatment of sex offenders and non-medical ings, Dr. Peters and his Philadelphia General Hospi- services for rape victims are now both parts, of a tal,associates launched a much more strictly designed single ongoing program known as -the Center for study withfundingfrom the National Institute of Rape Concern. Mental Health. During this phase the program was The history of this merger of services is of known as The Center for Studies of Sexual Devi- considerable interest. As early 8 -1970; the "Emer- ance. From November 1966 -to October1969, 264 gency Room of Philadelphia General Hospital devel- sex offenders convicted in thePhiladelphia courts oped a special program for the emergency medical were all subjected to the same intakeevaluation care of rape victimsincluding 'child victims.Subse- procedures; they were then assigned by lot either to quently, standing orders to ,the Philadelphia police a therapy group or to a probation group.This is one directed them to bring all sexual victims -to of the very few fully controlled studies in the history Philadelphia General. The numbers brought were of the correctional systemfor obvious reasons. substantial-1,039 victims in 1973; 1,084 victims- in When a judge is sentencing an offender, he wants to 1974. Of these, more than -half were adults aged 18 determine the outcome himselfnot have it depend or over, about a third were adolescents aged 13 to,. on a subsequent flip of the coin.Similarly those who 17; and the remainder were children aged 127 Or adMinister the intake procedure are appalled when younger. they examine a man who clearly needs therapybut It soon became apparent, however, -that many who, by the flip of a coin, is placed on probation rape victims need non-medical carefollowing treat- instead. Great ingenuity may be used in defeating the ment ina hospital emergency room. Under the random-choice procedure. Despite these and other direction of Dr. Peters, accordingly, a home-visit obstacles, random assignment proved successful in program was launched, under which a socialworker this program. wa3 assigned to visit each victim in her homewithin Another change was made in the- Philadelphia 48 =hours after :her. visit to -the hospital- emergency program concurrently. Instead of being spread out room, to provide supportive services and to arrange among the probation staff, all sex offenders in the for subsequent care if indicated, Plans also called for study were assigned -to six probation officers who a visit to a program psychiatrist andfor three -thus became specialists in the handling of sex subsequent home visits spread over the following offenders and their problemsa procedure which year in an effort to determine and meet the long-term other jurisdictions are urged to study and try out. needs of rape victims. This program for victims, Also, the men in the treatment program were no merged with the pre-existing treatment program for longer required to meet monthly with their probation sex offenders, secured funding from theNational officers in addition. Thus the two groups were Institute orMental Health. sharply differentiatedmen on probation with pro- The sex-offender portion of the program continues

51 63 in Phase III as in Phase II, but with several A somewhat different issue wa3 raised in -the innovations. Sex offenders assigned to the program courts of California in 1973, when two 45-year-old are expected to continue in their therapy groups until sex offenders, both guilty of child molestation, ap- their probation ends or until released by the pro- plied to a California court for voluntary surgical gram--rather than merely for 16 weeks (as in Phase castration. Both had been sent to Atascadero State I) or 40 weeks (as in Phase II). Women co-therapists Hospital for treatment. Both were subsequently have been provided for.,;several groups. Offenders returned- to court with a finding that they were not continue to see their parole officers as well as amenable to treatment and were still "dangerous to participating in the treatment program. A spe_cial_society." The next stop would-be incarceration in a "couples group" for offenders and their wives has California prison under the state's sexual psychopath been added, with one male and one female co- or "mentally disordered sex offender" statute. The therapist. Sex education is provided. In these re- period of incarceration would be indefinitequite spects, the Philadelphia program for many years a possibly for lifer with little or no possibility of parole. stronghold of the strictly psychoanalytic approach Faced with Such a bleak future within the conven- is moving in the same direction as the newer tional correctional system, the men quite reasonably programs stressing a sociosexual approach. Note: sought an alternativesurgical castration with the Three other community programs modeled on Phases likelihood that it might lead to parole. I and II of the Philadelphia programs are described There were California precedents. Indeed, Califor- in Appendix A: nia courts approved voluntary castration on- numer- Outpatient Treatment Clinic for Special Offenders, ous occasions prior to 1968, when a civil suit brought Baltimore, Md. (p. 81). by the American Civil Liberties Union against a Program of the University of Southern California's judge and surgeon involved- in such a castration put Institute of Psychiatry and the Law, Los Ange- an end to the practice. To get around this problem, les (p. 82). the two applicants for castration in 1973 filed waivers Sex Offender Treatment and Evaluation Program, releasing their lawyers, the judge, and the surgeon Violence Research Center, Denver, Colorado from any civil liability. (p. 83). Thus the ethical dilemma which society faces in 4.3. Castration and Reversible Chemical these and other situations was clearly posed. The ethical conscience of the community readily tolerates Castration life imprisonment; why should it refuse to tolerate an Surgical castration is sometimes proposedand alternative such as castration whichsome offenders has in the past been usedeither as a form of at least may greatly prefer to lifelong imprisonment? punishment for rapists and other sex offenders or as Is the objection in fact an ethical one, arising out of a forfn of treatment. a concern for the offender, or isit a disguised Surgical castration is worthless as a form of punitive insistence that sex offenders be drastically punishment, however; for the castrated offender can punished rather than escape with mere castration? readily reverse the hormonal effects of castration by In the 1973 California case, interestingly enough, securing at small cost periodic injections of the male the issue-was settled without regard for the interests sex hormone, testosterone, or of a related drug and- or wishes of the two- applicants for castration. The thus escape the intended punishment. Cosmetic sur- surgeon who had initially consented- to perform the gery can erase the visible signs of castration. operation if the court approved withdrew his consent As a form of involuntary surgical cas- following- consultation with medical colleagues, in- tration offends the ethical sense of many, perhaps cluding the Malpractice and Ethics Committees of most people; it. is unlikely that the courts in any the San Diego Medical Society. Medical Society American jurisdiction would today approve surgical officials informed the surgeon that the legal waivers castration of an unwilling offender.3. signed by the offenders and his malpractice insurance Both Nebraska and Lalifornia passed laws during the 1930's would protect him from civil suits by the men if they providing for the involuntary castration of sex offenders, and were castratedbut that nothing would protect him the California law remained on the books until 1971. The from subsequent criminal prosecution for mayhem or Nebraska castration law was repealed earlier. European expe- for assault and battery. Thus the two applications for rience with the castration of sex offenders has been reviewed by Georg- K. Stirrup. M.D.. of the Herstedvester Detention castration did not fail because of any concern for the Center. Albertslund. Denmark, in "Castration: The Total applicants but out of a concern for the safety of the Treatment" (see Bibliography). surgeon. 4 52 64 In Europe, the possibility of areversiblealterna- days, and after another two months to 150 milligrams tive to surgical castration was opened up in the early every 15 days. On this latter dosage, plasma testos- 1960's with the discovery of a new drug, cyproterone terone tended to return to - normal by the end of each acetate, which is a testosterone antagonist or antian- 15-day period. It became possible for the patient to drogenthat is, a substance which negates the have an erection again, though less frequently than effects of the male sex hormone and thus produces a formerly. The followup has been for six months, for condition akin to castration, reversible when the which period transvestite and incestuous impulses antiandrogen is withdrawn. Beginning in 1966, cypro- have been in remission." teront acetate and another drug, methyloestrenolone, This patient's subsequent career is also of consid- have been tried out, as an alternative to long-term erable interest. After a total of two years, both imprisonment, at several European clinics. Depo-Provera injections and psychological counsel- ing were discontinued. There was no return of either 4.4. Phipps Clinic Program, The Johns the urge to dress-in feminine clothing or the inces- Hopkins Hospital, Baltimore, Maryland tuous impulses. "Intercourse continued on a 2-3 times a week basis, and without the addictive type At a medical meeting in England in 1968, Dr. John of masturbation formerly experienced. The life style Money, clinical psychologist and director of the and the weekly round of activities manifested an Office of Psychohormonal Research at The John about-face, into an almost idealized mold of the Hopkins Hospital, reported the first case of reversi- suburban husband and father." ble chemical castrationin an American sex This condition continued for an additional nine offender"a case of incest in the management of months without treatment, "at which time the patient which Dr. Claude Migeon, Dr. Marco Rivarola, and and his family made a vacation- visit in the home of I collaborated. The offender was a transvestite father a former transvestite friend who claimed to be who began to dress his six-year-old son in girl's reformed. There were several visible signs to the clothes and later tried to engage him in mutual contrary. Upon returning home, the patient began to fellatio." If arrested and convicted of such an feel his old feeling of 'emptiness inside,' his old offense, of course, the father was in imminent danger insomnia, and his old masturbatory compulsion. He of prolonged, perhaps lifelong, incarceration. His was much afraid that he would lose all he had wife, who discovered the- offense, called Dr. gained, and wondered whether he should return to Money's Office of Psychohormonal Research rather Depo-Provera therapy preventively. After two injec- than the policeand the outcome was therefore tions of 300 milligrams ten days apart, his symptoms different. were in remission. He discontinued treatment and Dr. Money's initial plan was to try cyproterone has remained symptom-free for ten months, as of the acetate, as in the European clinics, along with present, writing. The total time elapsed since his first psychological counseling. Since oypro,terone had not injeditin is now 31/2 years." been cleared for such use by the U.S. Food and At the outset of treatment, Dr. Money reported in Drug Administrationand has stillnot been 1970, this patient "put his female wardrobe in clearedan alternative antiandrogen was used. storage. He did not want to dispose of it, since he Depo-Provera was given intramuscularly every week had no feeling of guarantee that he could perma- or ten days. On the dosage selected, the circulating nently quit his habit. Actually, he has never returned testosterone level of the patient was reduced by to his clothes. More importantly, he has not felt the more than 90 percent from the normal male level. urge to cross-dress, and has not had to carryon an "Behaviorally, the patient became completely impo- inner battle of resistance against temptation. In like tent, lost the feeling of libido and had a remission of fashion, there has been no temptation toward his his compulsive dressing and incest urges. He was son. In sum, there has been a psychic realignment so cooperative in accepting these changes, since he that bizarre eroticism, once expressed, is- now nega- wanted to save his marriage and be reinstated with tively coded in the mind and brain, and its expression his wife. The wife and son, along with the patient, vetoed. In its place are those manifestations of love were given psychologic counseling. After one month, in the heterosexual relationship that were formerly the dosage was reduced to- 200 milligrams every 15 prohibited, but are now positively coded and ex- "Everything that is not compulsory is forbidden." Before pressed." 1968, California sex offenders could be castrated against their Following this 1970 report, the patient suffered will; thereafter even those who sought castration were denied another relapse to cross-dressing. "It was brought it. 65 53 under control with another period of treatment," Dr. major purpose and 'major justification is to modify Money noted late in 1976. "The patient now reports the behavior of sex offenders so that society will be for followup four times a year." protected and offenders will similarly be protected Encouraged by this case, Dr. Money and his Johns from future arrests, convictions, and incarcerations. Hopkins-associates over the next few years tried the Despite the obvious value of modifying the behavior same approach in a variety of other caseseight of not only of sex offenders but of other criminal which were reviewed in 1970 and several more in offenders, however, a surprisingly widespread hostil- 1975 (see Bibliography). Some patients, Dr. Money ity to "behavior modification" programs has arisen reports, welcome the "erotic apathy" which Depo- in some parts of the country. The objection to Provera produces. Others view it as a temporary behavior modification appears to arise inconsidera- "respite or reprieve from -a sex life that has become ble part out of hostility to a particular technique for too demanding and trouble-producing. While the modifying behaviorthe technique known as aver- respite lasts, something else may happen which, for sive conditioning. lack of a -better tern, may be called psychic realign- To start with a very simple example of aversive ment"a substitution of licit for illicit activities as conditioning, a mother uses it when she scolds or forms of sexual expression. By providing a "vacation spanks a small child for running out into the street. from sex drive," Dr. Money believes, the antiandro- Her unvoiced theory is that an act such as running gens may- make such a realignment possible in a Out into the street will-be deterred if it is repeatedly significant proportion of cases. followed by an unpleasant experiencea scolding or In 1975, Dr. Money transferred responsibility for spanking. A simple axiom, "the burnt child avoids the program to a psychiatrist and psychiatric nurse, the fire," lies at the heart of aversive conditioning, Dr. Michael Spodak and Ann Falck, R.N., of Phipps Incarceration may also -be viewed as a form of Clinic at the Hopkins. Dr. Spodak and Ms. Falck aversivi conditioning. If an offense is followed by are now working with three groups and comparing 'incarceration, according to this point of view, repeti- the results: (1) patients participating only in group tions of the offense may be deterred. therapy; (2) patients on Depo-Provera receiving Aversive conditioning is often coupled with reward group therapy; and (3) patients on Depo-Provera conditioning, in which desired behavior is rewarded. receiving, individual- counseling. Thus the child who is spanked for running into the One of Dr. Money's associates, Dr. Paul A. street may be given an ice cream cone at the end of Walker, is currently director of the Gender Clinic at a day in which he or she has played without straying the University of Texas Medical Branch, Galveston. from- the -yard. He and another graduate of the Money group, Dr. There are reasons for believing that the very Walter Meyer, were planning, late in 1976, to launch intense and vocal hostility- to "behavior modification a similar Depo-Provera program for selected Texas therapy" arises in considerable part out of the sex offenders. A number of physicians in various equating of that term with aversive conditioning. parts of the country have also used Depo-Provera This is not, however, the whole explanation. There with individual sex offenders. also appears to be a hostility in some people to any "scientific" approach to changing behavior. It is 4.5. "Behavior Modification," "Aversive proper, they seem to believe, to incarcerate an Conditioning," "Brain-washing," and offender for long periods. But- any effort to use scientific methods of discouraging criminal behavior "Human Experimentation Without or encouraging socially acceptable behavior during Consent" incarceration or during probation and parolec-is-seen The two progams reviewed in sections 4.6 and as "brainwashing"even though the offender him- 4.7 below, are the only two programs among the 23 self may vastly prefer aversive conditioning -to pro- in this study which describe themselves as "behavior longed incarceration. modification programs." Both ,make limited use, in Opposition to scientific approaches in the correc- selected cases, of "aversive conditioning." A prelim- tional system may also arise out of the belief that inary discussion of these terms is necessary: to avoid such approaches constitute "experimentation -with confusion. human subjects," without= the consent of the human From one point of view, all 20 of these programs subjects. indeed, all conceivable programs for sex offenders Nor does this objection- disappear if a program are in fact "behavior modification programs." Their secures the written consent of participants; for it is

54 66 said that men under legal duressincarcerated or on If is the only program whose patientsrapists and probation- or,paroleare not free agents and there- child molestersare allvolunteers.No one is sen- fore cannotgive uncoerced consent to an experimen- tenced to the Memphis program, nor will the' pro- tal program. This view has arisen quite naturally out gram accept a rapist or child molester who is forced of past abuses in using correctional inmates _as to apply for admission.as a condition of his probation -experimental guinea pigs in programs which could or parole. This limitation to volunteers is a condition not possibly benefit them but could accomplish of,the program's NIMH grant. substantial harm. The extreme reaction to these Treatnient is offered both on an outpatient and an abuses, however, has reduced the correctional in- inpatient basis. The duration of treatment ranges mate, the probationer, and the parolee to a position from three to nine months; but patients are free to in which he cannot consent to an experimental leave the program at any time. program even though it is unlikely to harm him and Finally, this is abehavior modification program. may be to his very great benefit. All treatment programs aim at the modifying of Yet another source of hostility to behavior modifi- behavior so that offenders will not reoffend; but in cation and aversive conditioning is their frequent use the technical language of psychology, behavior mod- iii the past in efforts to "cure" homosexuality a ification refers to a specific approach which has three procedure which has grown' increasingly unpopular hallmarks: in recent years. Hostility to behavior modification Behavior is analyzed into discrete units which for the "cure" of homosexuals appears to have can be objectively tested. "spilled over" to its use for other purposes. Techniques are then devised to alter each type The hostility to .behavior modification programs of behavior independently. and -to human experimentation has been sufficiently Objective tests are run repeatedly during the strong to secure the abolition of such programs in treatment and at its conclusion to- determine several state correctional institutions, and= to block whether the treatment is accomplishing its goal. the launching of one such program in the Federal Dr. Gene G. Abel, the psychiatrist who heads the penal system. Those planning new treatment pro- Memphis program, began his research at the Univer- grams- for sex offenders should be aware of the sity of Mississippi Medical Center during the 1960's, possibility of attack on grounds of "brainwashing" in collaboration- with three pSychologistsDrs. Ed- or using "behavior modification" techniques, or ward B. Blanchard; Judith V. Becker, and David H. "engaging in human experimentation." Such opposi- Barlow. In 1975, Drs. Abel, Blanchard,_and Becker tion- is particularly likely if "aversive conditioning" transferred to the University of Tennessee, where is included in a program. they established a treatment model- based on four Against this background, two programs which major hypotheses: make use of aversive conditioningboth of them Most -rapists are far more responsive sexually independent of the correctional systemcan be de- than other people to visual or verbal' cues scribed. involving,violence, dominance, or the infliction of pain. Child molesters are- similarly ,over- 4.6. Program at the Department of responsive to sexual cues involving prepubertal Psychiatry, University of Tennessee physical development. One goal of the Memphis program is to make such cues less sexually Center for the Health Sciences, stimulating to patients in treatment. Memphis Many- rapists- and child molesters are less re- This program differs from- all of the others =here sponsive -than- other people to ordinary adult reviewed in a variety of important respects. sexual cues involving neither violence nor- un- Itis the only program which is adequately de- derage partners. Specific techniques are being scribed,- explained, and documented in the published sought which can increase the responsiveness literature (see Bibliography, page 95). Readers are of sex Offenders to such cues. accordingly referred to the publications there cited Many sex offenders turn to rape or child for a much fuller account. molestation, at times of-extreme stress or psy- Itis the only sex offender treatment program chological conflict. Techniques are accordingly whose funds come largely from a Federal grant--a sought which will reduce these stresses and grant from the National Institute of Mental Health conflicts. (NIMH). Finally, many sex offenders are so- lacking in

55 67 ordinary social skills that they are unable to sation during the week, and was rewarded for his enter into serial relationships not involving account by strong praise from the woman therapist force or children. The Memphis program seeks in the language of behavioral modification, "strong to develop these skills. social reinforcement." Next the two role-played a There,is nothing unique to the Memphis program, scene on a bus in which the rapist not only opened a of course, in these four goals. Many of the other sex conversation but continued it following the -thera- offender treatment programs here reviewed also seek pist's smiling response. The dialogue was video- to- lessen- arousal- to deviant forms of sexuality, taped, and at its conclusion- the tape was played increase arousal to tiondeviant sexual activities, back. Thus the rapist had an opportunity to see lessen stress and conflict, and develop sociosexual himself as others saw him, and the therapist had an skills. The analytic and testing techniques used in opportunity to provide further praise for the progress Memphis, however, are quite different. he was makingfurther positive social reinforce- With respect to- social skills, for example, the ment. It also gave her an opportunity to call attention Memphis researchers initially set up a very simple gently to vi ays in which his social approach might be social situationman meets woman, strikes up con- still further improved. The session concluded with versation, suggests a further meeting. Twenty so- this dialogue: cially skilled males and eleven socially inadequate Rapist: Well, I sure don't know everything offenders were then asked to act out this scene with about talking with women yet, but I've a trained female partner; all 31 encounters were learned a few things. videotaped. Two- independent raters noted- the spe- Therapist: You really have. I'rn pleased with how cific differences between the detailed behavior of the you've picked up on followup ques- socially adequate and socially inadequate partici- tions and statements so- quickly. pantsin terms of words used, facial expressions, Knowing ,how to start a conversation posture, eye contacts, gestures, tone of voice, and and continue it in this way is the basis so on. From these videotaped encounters a measur- of a conversation and getting to ,know ing scale was prepared in which behaving like the someone. You're doing excellent. I'm socially adequate partiCipants le_ d to a high score really proud of you. Now remember to while behaving like the socially inadequate partici- practice and I'll see you net week. pants lowered the score. The theory is, of course, that an offender who 'Use-of this Memphis scale -is illustrated by the knows how -to start a conversation with a woman, case of a 19- year -old- rapist whose history of sexually and to enjoya conversation with her, is less likely to aggressive behavior began at age 13. "At that time grab at her vaginal region as an opening-gambit--or he began cruising shopping centers, would identify to rape her. The success of the social skills training an attractive female, approach her as she entered her is measured periodically by having the patient take car and grab her in the vaginal area. ... He began the social skills test again. raping women at age 17-." By the age of 19, he had The -many other treatment routines developed by attempted rape five times and had completed the act the Abel group, and the tests developed to gauge the on- two of -these occasions. When tested on the need for these routines,and to determine the success heterosocial skills scale, he showed serious deficits. or failure of the training, fall ()inside the scope-of Social- skills training was accordingly prescribed this survey. Readers are again referred to the publi- along with training designed to reduce his sexual cations listed in the Bibliography. One additional arousal to rape cues. feature of the Memphis program, however, warrants The social skills procedure followed a carefully mention. planned series of very small steps. At the first There, as elsewhere, "assertiveness training" is session, he met with his woman therapist, who used when indicated to enhance a rapist's or child talked with him about ways to open a conversation molester's social functioning. Assertiveness training with a woman he didn't knowsomeone sifting next consists essentially, of practicing the art' of stating to him on the bus, for example. Sample one-line your own feelings and opinions rather than suppress- openings were tried; and at the end of the session he ing them or superficially agreeing with someone else. was instructed to try using such openings in the "Although it may seem a contradiction in terms, course of the coming week. some rapists are underassertive," Dr. Abel points At the second session, the rapist was asked to outand other therapists agree. "They react to report on his success or failure in opening a conver- interpersonal conflict with unexpressed anger and

56 68 hostility. Later this anger is overexpressed in the The patient reported occasional sexuaLeontacts form of very angry, hostile, aggressive outbursts with adult males; but these were unsatisfactory and ... orin rape behavior." never ended in orgasm for him. He could not recall Development of the Memphis program has been "ever being attracted to adult females and claims his slow, largely -because of the requirement that only only self-satisfying contacts have been with dale volunteers may be accepted`into the program. By the children." fall of 1976, eleven rapists had volunteered; and by Mr. M. was not, however, content with his lot. the spring of 1,977, the program had enolled 35 He "stated that his desire for children was immoral' rapists and child' molesters. Plans call for following and had ruined his life. He had sought- treatment their post-treatment careers,-to determine whether twice before and had had three years of individual the measurable changeS in behavior which,occur in and one year of group therapy. Mr. felt this the course of the program will lead to significant therapy has given him some understanding of his changes in recidivism and other measures following behavior but had not led to any changes in his desire termination of treatment. for young finales." Dr. Kohlenberg's treatment -plan for this patient involved two phases; the use of aversive conditioning One technique for enhancing a sex offender's in Phase I to lessen his responsiveness to male boys; sexual responses to non - deviant sexual cues has plus the 14,,e of the Masters-Johnson approach in been discussed in the published literature but ha.=not Phase IF to enhance hi': responsiveneSs to male been tried out in the Memphis program or in any adults. To- check on thy: effectiveness of the- treat- other treatment program for sex offenderS. This is ment, the patient was 4es1ructed to keep a daily the use of a trained "sexual surrogate" with whom record showing (a) the minter of times.per day his the offender may actually practice the techniques of thoughts were- centered on- male children, (b) the sexual enhancement pioneered- by Dr. William H. number of "prowling" incidents, and (c) the:number Masters and Virginia E. Johnson at the Reproductive of sexual encounters with adults who were sexually Biology Research Foundation in St. Louis. Drs. H. arousing. L. P. Resnik and Marvin E. Wolfgang, itwill be The first four weeks of treatment were devoted to recalled, discussed this approach in their 1972 essay, Preliminary interviewing. The- record' showed high "New Directions in- Treatment" (see page 9).It levels of thinking about male children and prowling was frequently raised as a possibility by treatment in search of them, but no sexual encounters with program directors during site visits for this study. adults. The next four 'sessions -were devoted to The only reported case of the use of a sexual aversive conditioning. There was no improvement.. surrogate in the treatment of a sex offender, how- Dr. Kohlenberg accordingly preceeded to Phase H. ever, comes from outside the correctional system. "The basic goal of this phase was to produce In 1973, Dr. Robert J. Kohlenberg, a psychologist sexual arousal and orgasms for Mr. M. with an adult at the Canter for Psychological Services and Re- male partner." Dr. Kohlenberg states, "Since the search, UniverSity of Washington, Seatte, reported therapy was to involve a series of sessions attended on the treatment of a 35-year-old male, Mr. M., who by 'Mr. M. and a sexual partner, the first task had been twice arrested for molesting male children involved finding a suitable partner. The requirements and was fearful of -further arrests. "The patient for the sexual partner were as follows: (a) he -was to considered his sexual orientation to be homosexual, be at least 30 years old; (b) he was willing to commit but he became aroused only with young males of himself to attending at least ten weeks of therapy about 6 tol's years of age. He claimed -that he sessions and at least two encounters with- Mr. M. 'prowled' or actively lookedfor sexual contacts with during [each] week; and (c) he was willing to follow male children abou ,twice each week by going to a the therapeutic regimen which included sexual en- .playground or swimming pool where he would be counters that- did not lead to orgasm. Mr. M. contacted a 32-year-old man, Mr. C., who- met the Akely to see childre, , Mr. M. reported that this 'prowling' or active looking did not currently result above requirements. Mr. C. had been an acquaint- in sexual -- contacts but did result in both sexual ance of Mr. M. for several years and waswilling to arousal and subsequent discomfort and distress. ... participate out of friendship for Mr. M. Fantasies during masturbation were also centered on "The therapy sessions were conducted on a once male children and masturbation occurred several a week basis with both Mr. M- snd Mr. C present. times a week." ...Instructions were_'' M. and Mr. C.

57 69 to engage in at least two encounters during the week. M. also reported that he found Other adult men These first encounters were to take place with both attractive and had sexual contacts with adults (other men in bed without clothes. As described in Masters than Mr. C.) that were sexually arousing.... and Johnson for heterosexual couples, they were "Mr. M.,reported that he had become less preoc- instructed to take turns giving each other sensate cupied and attracted to children. He ceased 'prowl- pleasur.. Touching, caressing, etc., of any .kind.was ing' for children, after -the 'sixth week of Phase 2 permissible, but there was to be no touching of -the treatibent, and at the six-month followup he re- genital or anal- area and sexual arousal was not a ported that he had not actively sought any sexual goal. contact with children since the termination of treat- "During the second treatment sessi53-i"-,of this ment." phase, Mr. M. reported that he was very tense and The patient's:daily record confirmed the success perspired profusely during the previous week's en- of the treatment. Mr. M.'s "prowling" ceased alto- counters with Mr. C. Mr. C. found the encounters gether after the 15th sessionexcept for a single pleasant and arousing. incident- reported at the 22nd session. Sexual "According to Masters and Johnson, a primary thoughts of male children became much rarerone source of inhibition to sexual- arousal is that. of or ,two a weekat about the same time. And also at performante- anxiety wherein the patient act:. .as an about the same time, sexually arousing contact- with `observer' of his own sexual behavior. In the present adult males began and continued: In this particular case, Mr. M. seemed to have been concerned about case, the carrot had proved more effective than the his performance during the previous week's encoun- stick; the enhancement of arousal to adult male ters and was also concerned about Mr. C.'s negative stimuli had succeeded in lowering the response to evaluation of his own (Mr. M.'s) lack of sexual immature male stimuli after aversive efforts to ac- arousal. The importance of eliminating the observer complish that goal had failed. role and its inhibitory effects was emphasized to Mr. At least two women experienced in the heterosex- M. and Mr. C. Mr. C. reassured Mr. M. that it was ual surrogate role using the Masters-Johnson ap- okay with him if Mr. M. did not become sexually proach are known to have discussed with treatment aroused. A restatement of the goals for the coming program staffs the possibility of using a similar week's encounter was made. The goal was to procedure with heterosexual sex offenders, and to beconie relaxed and have pleasant feelings; sexual have volunteered.their services. The political risks of arousahwas not a goal. attempting suchdfil.,cedure, however, have acted "The-second week of encounters was reported to as a deterrent. ''Pras is known the heterosexual be relaxing and pleasant by Mr. M. Mr. M. inciden- surrogate approach has not been tried. tally, reported that he also became sexually aroused. "The following steps were taken during the re- 4.7. The Center for Behavior Modification, mainder of the program. Instructions to proceed to Minneapolis, Minnesota the next step-were given only after the patient was completely relaxed at the preceding item: (a) touch- This center is a private, free-standing psychologi- ing for sensate pleasure; no genital involvement; (b) cal clinic which accepts private clients of many touching for- sensate pleasure, some exploratory kinds. More than a hundred of these clients over the touching of genital area; (c) simultaneous genital past five years have been sex offendersself-re- touching, orgasm not permitted; (d) simultaneous ferred or referred by physicians, prosecuting and genital-touching and belly rubbing with genital con- defense attorneys, probation and parole officers, and tact, orgasm not permitted; (e) no restrictions, or- others. Each client is treated in accordance with a gasm permitted. schedule individually tailored to his circumstances. "The last step of treatment was reached during the Most of the treatment of these sex offenders has thirteenth week of Phase 2. Mr. M. was seen six been provided by William W. Duffy, a psychologist months 'later for a followup interview, at which time who is executive director of,the center, or by others he turned in daily reports covering some of the under his- supervision. previous six months' behavior. Despite the Center's use of the term "behavior "The:piimary result of treatment was that Mr. M. modification," the psychological treatment of many became sexually aroused with Mr. C. as a partner. sex offenders at this clinic is quite similar to treat- Reports of-fantasy during masturbation also indicated ment at 3thcr p:ychological or psychiatric- clinics that Mr. M.'s sexual object was becoming older. Mr. which do not use the term. The same counseling

58 70 procedures are used, goals are set, problems are sexually deviant behavior," either at the center or discussed; and so on. The prime difference is in outside. At this point, aversive conditioning was theory rather than practice. Duffy sees his program discontinued and "attention was turned to positive as an effort to modify behavior by rewarding behav- behavior-change counseling procedures." ior which is socially acceptable and which can take Marriage counseling was provided for the client the place of the socially hazardous behavior. The and his wife, from whom he was separated; this primary reward used, as in other programs, is the "subsequently led to a therapeutically wise divorce." therapist's approvalplus the self-rewarding effect The client was also counseled "in such areas as of behaviors which the offender finds enjoyable and dealing more effectively with his parents ..., voca- socially acceptable. For a minority of sex- offenders, tional counseling and educational counseling. Since however, "aversive conditioning" is also usedthat the client was a fairly bright but underachieving is, techniques designed to deter unwanted forms of individual, much emphasis was placed on having him_ behavior. enroll in the University of Minnesota and to begin Duffy cites as a typical case one 27-year-old preparing for a new vocational area. The subsequent married man referred to the center- after having success this client experienced wasin part greatly committed eight rapes. From the age of 12, "this facilitated by the initial. ..aversive conditioning. individual compulsively masturbated using women's Instead of being continually preoccupied with deviant undergarments and extremely deviant sexual fanta- fantasies and being in constant fear of compulsively sies" as modes of arousal. Subsequently "he began raping woman, this'ttan was able to devote his acting out these fantasies and started assaulting concentration and energies to learning amore func- women sexually." Duffy's analysis of this sequence tional and socially acceptable repertoire of behav- is that the masturbatory orgasm constitutes a very iors." Though couched-in:the language of behavioral' powerful reward which reinforces and encourages modification, the process is clearly similar to that in repetition of the immediately preceding behavior other programsafter the aversive-conditioning until it becomes compulsive. phase. "The aversive conditioning program used for this "On followup, approximately two years after the individual," Duffy continues, "consisted of using a onset of treatment at the Center," Duffyadds, "this combination of women's undergarments paired with client would occasionally have fantasies related to sexually deviant fantasies" as masturbatory stimu- undergarments," but "he_was able to control these lants, as in the past. Now, however, the behavior fantasies and -not reinforce then through masturba- occurred in a private room at the-Center for Behavior tion. In place of these fantasies he was able to Modification. At specified points in--the procedure, substitute more appropriate sexual fantasies and to the client received an unpleasant shocks(eight mil- reinforce these through masturbation. Additional liamperes for half a second) in his forearm. Thus the counseling was aimed at helping him broaden his stimuli (women's undergarments and deviant sexual social interaction in general." fantasies) were followed by an aversive shock rather than by an orgasmic reward. A- major feature of behavior modification therapy 4.8. The $0ANON Program, Los Angeles is its effort to secure objectively measurable changes. In this case, -the measure of change was the time This is a free-standing, non-profit program, orga- elapsing between the onset of the procedure and the nized personally by an ex-sex offender, Richard occurrence of sexual arousal and deviant fantasies. Bryan, and his wife Rosemary. SOANON standsfor At first, arousal occurred within 20 seconds or so. Sex Offenders Anonymous; and the programhas a This "fairly quickly progressed to latencies of over self-help structure modeled after Alcoholics Anony- four minutes. In other words, after a series of ... mous except for the religious componentof AA. shock pairings, it became more difficult for the client SOANON accepts referrals from probation and pa- to engage in. ..sexually deviant behaviors. Addi- role officers but is otherwise independent.Groups tionally, pornographic films depictin^ fetishes and meet in churches or other publicbuildings. The v;.olent interactions were paired with- shocks. The modest expenses are met by contributions from the results were similar to the initial aversive condition- participants themse!ves; the Bryans donatetheir ing trials." services. In due course, Duffy reports, "the client stated Richard Bryan is a disciplinarian with very firm that it was too anxiety-producing to... engagein views on how sex offenders can and should discipline 71 59 themselves. A sex offender whose mode of operation penis, and that the compulsion may pass during the is to pick up hitchhikers for sexual exploitation, fordistracting minutes it takes to remove the device. In example, is instructed to'bolt the right-hand door ofaddition, of course, SOANON provides the usual his car permanently shut, so that if an impulse tomutual support and practical help and guidance pick up a hitchhiker arises, the bolted-door_ willcommon to other self-help groups. In addition to constitute pn obstacle. Similarly, exhibitionists andgroup meetings for offenders, -there are meetings for other sex offenders are instructed to wear a devicewives only, and for wives and offenders together. which takes several minutes to unlace and repove--rSOANON works with professional therapists, ac- in the hope that the device -will constitute a barriercepts referrals from them, and refers members to to a sudden compulsion to exhibit or masturbate theprofessional therapists when indicated.

72 60 PART V. CONCLUSIONS AND RECOMMENDATIONS

1 Most convicted sex offenders today, as noted are convicted in state courts of violating state laws, above, are treated .precisely like other convicted and many are sentenced to state institUtions. There offenders;=they are lodged in the same cell blocks in is also an opportunity; however, for the 100 coor- the same correctional institutions, or theyare re- dination of programs in a metropolitan- areainclud- leased on probation or parole under thesame super- ing plans for those on probation or, parole in the area visory- arrangements. No special heed is paid to the and those lodgedini:zcal institutions. Similarly, there specifically sexual problems Which led to their past is a role for a national concern with the problem sex offenses,and which may lead to 'future sex including the launching of a national organiiatidn of offenses. sex offender treatment- prograins:andftredinient pro- The- 20 existing and three discontinued sex of- gram personnel; a national newsletter and Other fendertreatment programs- described in -this survey communications facilities which will bring existing are the exceptions. The; shave- explored many new and projectled progrnmsfintotouchiwiti One anotrier; approaches to -the sex offender prOblem. These a national program for evaltiating treatrnent prograMs' Conclusions and Recommendations are based largely and for disseminating the_ evaluation' findings; and -a on the experience thus accumulated. national-policy of funding pildt projects -and innova- But many pOssible approaches remain unexplored tive approaches which* give -promise of becoMing as yet; and barely a beginning has been made in useful national models. coordinating the -efforts of the- numerous agencies Both those preparing statewide plans and those -concerned with sex offenses within: each state and involved- at the local- and: nationallevels shOtild- be metropolitan area. These Conclusions and RecoM- concerned with -at f4ast eight sex=offender categories: mendations will therefore go beyond the experience of treatment programs to date, suggesting several as 1) Juvenile sex dimdeis. yet untried approaches and stressing -the need for 2) Volunteersoffenders who haVe, not as yet areawide and statewide coordination. fallen afoul the criminal law but who voluntarily seek treatment becatise they are concerned -with their 5.1. The Need for Statewide Planning socially unacceptable patterns of sexual behavior and with the hazard of future arrest and'conviction. Instead of thinking solely of individual treatment 3) Nuisance offenders. Examples are exhibition- programs serving the sex offenders- who happen- to ists, voyeurs, fetishists, and others who are com- be immured in a particular state mental hospital- or monly arrested and released with a warning, or correctional.,inStitution, or who happen to be on placed On probation, orsentenced to-a short term in probation or parc:e.in a particular metropolitan area, a local correctional institution (jail). With these futUre thinking about and planning for sex offender offenders as with common drunks, the result is often programs should be concerned with the whole broad a species of-. revolving-door justice"; little is accom- flow of sex offenders found guilty by the courts. plished either for the individual offender or for Minnesota, as noted above in section 1.9, has society. proceeded farthest in this direction. A statewide 4) RapiSts, child Molesters, and pther.serious Minnesota plan covering all convicted sex offenders offenders convicted in the state courts.and sentenced is currently being drafted and is scheduled for to incarcerationbut with sentences suspended and completion in August 1977. Other states similarly probation mandated. should view their problems as a whole rather than 5) Serious offenders incarceratea for treatment _in limiting themselves to iSolated programs in particular state mental hospitals. institutions or communities. 6) Serious offenders incarcerated-in medium-secu- -Emphasis is here placed -on statewide rather than rity and minimum security state correctional institu- -national or local planning because most sex offenders tions.

61 73 7). Serious offenders incarcerated in maximum - there is every reason to hope that treatment will security state correctional institutions. prove effective if made available early in the'process 8) Offenders released on parole or aftercare status which develops an adult sex offender. Further, we following incarceration in a correctional institution desperately need additional data concerning the fac- or state hospital. tors, before and after pubeity, whic'! produce sex In- the sections which follow, we shall consider offenders; these data will almost certainly emerge treatment programs for each of those eight categories from- programs which address the specifically sexual in turn. problems of these juvenile sex offenders. Statewide planning projects and_national-organiza- At least -threecaveatsmust be attached, however, dons should' be concerned with all eight major to this recommendation. First, any program for categories. Local groups should have a- particular juveniles must scrupulously distinguish between se- concern with offenders remaining in the community: rious juvenile offenses and the ordinary !earning and juveniles, volunteers, nuisance offenders in local "horsing around" experiences, heterosexual and institutions,, sex offenders on probation, and sex homosexual, which are, common features in -the offenders,on parole or aftercare status. Almost any developmental histories of law-abiding citizens as metropolitan area will find, if it examines its local welLas of sex offenders. Second, care should be situation, that it has far more sex offenders.(including take,,to minimize the adverse impact oflabelinga serious offenders) remaining in the community than juvenile as a sex offender (see page 35). Third, it has lodged- in institutions. treatment should be made available both for juveniles Within the eight major categories, numerous in- the community- and for those lodged in 'juvenile subgroups can be recognized. Offenders with intact correctional institutions. If treatment inbothsettings faMiliei, for example, may benefit from treatment is notavailable_, asnoted freqtently above, judges procedures (such as family therapy) inappropriate for will be under pressure to send to institutions for single, separated, divorced, or widowed offenders treatment juveniles who do not need incarceration-r- and vice versa. Incest offenders (see Section 2.10) or to leave in the community for treatmentthose may benefit from a special program and so may who are unsafe to be at large. offenders- with = a basically homosexual orientation. Future studies will no doubt reveal significant 5.3. Planning for Sex Offender "Volunteers" subgroups within the juvenile sex-offender category. A statewide planning project should be concerned Lawyers, psychiatrists, clinical psychologists, with the extent- to which it is both advisable and mental health clinics, community mental health -cen- feasible to address the specialized needs of such ters, and other local agenciese from time to time subgroups. approached for help by prospective patients or clients whose behavior places them in jeopardy of being arrested and convicted as,sex Offenders tomor- 5.2. Planning for Juvenile Sex Offenders row, next- month, or next year. During the research inany large metropolitan area, as noted in section for this study, indeed, -its author was thus ap- 2.16 above, there are 15-year-old rapists, heterosex- proached on several occasions for advice on where ual and homosexual, 15-year-old child molesters; to find treatment. Some- of these volunteers for exhibitionists, voyeurs, and fetishists; the entire treatment have past arrest or conviction records; range of adult sex offenses can be found- at the some do not. They come seeking help; what helpis juvenile level. These cases are commonly processed available to them? through the juvenile courts and the juvenile correc- Some practitioners and agencies, public and pri- tional and probation and parole systemssystems vate, see th3e volunteers as falling outside their overburdened with other problems and rarely staffed proper function and send- them away= or refer them or equipped to address the specifically sexual prob- elsewhere Others would like to be helpful but don't lems of juvenile sex offenders. know how. Still others provide therapy or counsel- For several reasons, a concern with juvenile sex ingbut may do so in relative ignorance of the many offenders should be placed high on the priority list of available alternatives. allstate _planning projects, national organizations, A start in improving services to volunteers might and local groups concerned with sex offender treat- be -made by calling a- one-dayconference,in any ment programs. First- and for, most, these young major metropolitan area, for personnel in'the'helping people are in urgent need of treatment. Second, professions and for interested social agencies. (For 74 an example of such a conference for persons inter- punishment are the best ways to discourage peeping ested injuvenilesex offenders, see pages 35-36.) and flashing. Such a conference might be concerned with three The available evidence indicates thatas with goals: improving the services offered by practitioners other forms of "revolving-door justice," very little is and agencies which accept patients or clients in this accomplished. Peepers and flashers may continue category; informing other practitioners and agencies their behavior following dozens or scores of arrests, of where they can refer volunteers; and devising convictions, and jail terms. The establishment of methods of encouraging potential sex offenders to treatment programs for peepers and flashers may volunteer for treatment-before arrest and conviction. accomplish little; but the odds are good that such Two obvious modes Of encouragement area "hot- programs will prove at leastslightlymore effective line" which an offender can call' at the moment he than processing through the- courts and the correc- 'feels he needs help, and an absolute assurance tional system and no more expensive. (based on state law) that his confidences will be Suggestions have repeatedly been made that pee- respected. A statewide planning project might be pers and flashers ,be encouraged to attend nudist concerned with fostering conferences and hot-lines in resorts and other places where nudity is legally the state's, major metropolitan areas, and withspon- tolerated (see, for example, page 8 above). The soring whatever amendments to the state's confiden- common answer is that for the the excite- tiality laws may be needed to encourage volunteer- ment of peeping is dependent upon his doing so ing. surreptitiously, without his being observed; and that an exhibitionist's interest in exhibiting is similarly dependent on the "startle reaction" of the woman to 5.4. Planning for "Nuisance Offendere whom he exhibitsa reaction which would fail to occur, of course, in a setting where everyone is Society appears to be in the process of reducing nude.These objections, however, are based on no the incidence of "nuisance" sex offenders simply by evidence whatever.No one has introduced a dozen redefining the term, "sex offense." A significant peepers or a dozen flashers to a nudist setting and example is the ,transvestite or cross-dresserthe reported that there was no change in the subsequent male or female who customarily or on occasion incidence of peeping of flashing. It is -time at least to appears in public in the apparel of the other gender. try. Even a decade ago, transvestites were commonly Meanwhile, the purveyors of pornography in many found serving time in jails-and even in prisons; -some cities are offering their own solution for the peeper were also sentenced to treatment programs. While who does not want to risk arrest. For a modest sum, quantitative data are not available, knowledgeable a peeper can stand or sit in an enclosed booth' and observers agree that arrests and incarceration for watch an incredible variety of sexual scenes por- crbss-dressing are much less common today. The trayed on a screen in front of him. In some establish- popularization of slacks, jeans, and other tradition- ments, he may watch a live woman strip off her ally male apparel among women, in fact, make it clothes and engage in sexually provocative behavior almost impossible to define or identify female cross- while he himself remains unobserved in his booth. In dressing. some European cities there are similarly night-club It is possible that, in some communities, exhibi- settings where male exhibitionists can display their tionists and voyeurs are similarly being tolerated penises in public and even masturbate. Perhaps, it rather than arrested and convicted. Some women in may be said, more can be accomplished for civic the women's movement, however, are quite properly order by making such facilities available than by concerned that this may be going toc far. They see fruitless revolving-door procedures of the criminal "peeping" and "flashing" as an at least symbolicjustice system. assault on women, and quite properly want both One objection to this approach is that the public modes of behavior curbed. They insist, with very availability of peeping and flashing facilities may good reason, that .a woman in the privacy of her increase the incidence of such behavior by attracting home should be free of the annoyance -of beingpatrons who would not otherwise peep or flash. peeped at, and that a woman at home or away from Another objection is that peeping and flashing are it should be free from being confronted with a view commonly found in the' sexual histories of more of male genitals which she has no desire to see. Theserious sex offendersrapists, for example. Peepers question is thus whether arrest, conviction, and and flashers, it is therefore said, should be punished

63 75 or treated before they progress to moreserious have committed such serious offenses as rape or offenses. child molestation are today being placed on proba- The latter- notion, however, has little practical tion; and that first offenders, offenders who exhibit merit. A parallel from the field of illicit drug use will no violence, offenders who appear tobe good make this clear. Years ago, superficial students of candidates for rehabilitation, and perhaps other sub- the drug problem observed that almost all herokp categories will in fact be placed on probation under users smoked marijuana beforethey tried heroin. almost any changes in the criminal justice system. This led them to the view -that marijuana leads to How should they be treated while on probation? heroin and that suppressing marijuana would help The first and simplest approach, pioneeredin solve the heroin problem. Experience has-now Philadelphia (section 4.2) and Baltimore.(section A.7), shown that, while almost all heroin users were is to build up expertise within the probation system. former marijuana- smokers, a very small proportion This means providing specialized training and super- of marijuana smokers in fact progress to heroin. vision for a particular probation officer or small group Either in the presence or absence of marijuana, some of officers, and then assigning to-them-all sex offen- alcohol drinkers progress to heroin, too. Thus the ders on probation. An opportunity for frequent and total suppression of marijuana would have little if intensive consultation with treatment program staffs any effect on heroin consumption.Similarly, the and other experts irthe vicinity should be a part of the suppression of peeping and flashing by legal sanc- training and supervision. tions is unlikely to have even a-slight-effect on the In addition, Parts II and IV above andAppendix incidence of rape. A below describe a wide range of community-based The major justifications for providing treatment for treatment programs addressed to the specifically (See peepers, flashers, fetishists, andother nuisance of- sexual problems of sex offenders on probation. fenders are to abate the nuisances- they causeand in particular Sections 2.10-2.15, 2.18-2.20, 4.1-4.8, to help them live morefulfilling lives. Peepers, and A.7-A.9.) A statewide planning project should flashers, and fetishists are not notably happy people review and perhaps visit -those community:Med relevant to P'.ely to reject alternative modes of sexual fulfilment programs on this list which appear to be if they could find- enjoyable alternatives. Nobody the state's concerns-and resources. knows whether a treatment program based on sex In the course of the Minnesota statewideplanning education, the development of social skills, the repair project, as noted- above, it became -clear -that a of damaged self-images, and the building of self- surprising number of public and private clinics, esteem could open welcome alternatives forthem, community mental health centers,._ family service for few efforts have as yet been made. agencies, child welfare agencies, drug treatment resources were In surer;' a statewide planning project should con- programs, and other community sida 'alternatives to the revolving-door systemof already directly or indirectly concerned with the justice for nuisance offendersthe repeated arrests, treatment of sex offenders. Incorporating these agen- convictions, suspended sentences, and jail terms or cies into the statewide:pia, eliciting the cooperation longer-term incarcerations at high social cost with of additional community-agencies, and providing negligible payoffs. No very high priority can be given coordination and consultation among agencies should to this problem, since rape andchild molestation be one function of any statewide or local planning obviously have a greater claim on limited societal project. this resources. But the problem iswidespread in some No example was found, in the course of cities and neighborhoods; it should no longer be survey, of a half-way house orhostel for those sex handled solely by processing nuisance offenders offenders on probation who need this kind of facility. through a revolving door. In Minneapolis, several drug treatment programs with live-in facilities accept sex offenders as well as drug offenders; and in Florida, plans are on the 5.5. Planning for Serious Offenders on drawing board for a hostel-type facility. Both state- Probation wide planning projects -and local groupsconcerned One basic problem here is how to determine which with sex offender problems in a particularmetropol- serious offenders can safely be treated on probation itan area should consider the need andfeasibility of and which should be incarcerated. This issue will be providing intensive treatment in an open, commu- considered below (section 5.11). nity-based hostel or half-way houseboth for sex The fact is, however, that some offenders who offenders or probation and for those who are now

64 76 Serving time in local jails but might better be treated be presented in Appendix A below;see especially weir sucb,a facility. sections 2.1-2.9, 3.1-3.4, and A.2A.3. A statewide planning project should review theseprograms in detail, make visits to, selectedprograms, and either 5.6. Planning for Serious Offenders provide treatment programs forsex offenders in all Incarcerated for Treatment in State of the state's mental hospitals or else provide for the Mental Hospitals incarceration of sex offenders only in those hospitals which have treatment programs addressed specifi- This is an area of very high priority-for statewide cally to the sexual problems ofsex offenders. planning projects in the many states wheresex offenders are currently being held-for-treatment in state hospitals-but are being provided with little-or no treatment directly addressed to their sexual prob- 5.7. Planning for Serious Offenders lems. Incarcerated for Treatment in Medium- In the first place, both state and federal courts Security and Minimum-Seturity have repeatedly -held that itis unconstitutional to incarcerate an offender in a hospital for treatment Correctional Institutions without providing treatment. There is a considerable The U.S. correctional system has lagged behind likelihood,that future decisions will-similarly hold it the mental health system in establishing treatment unconstitutional to hold a sex offender for treatment programs for sex offenders. TheT discontinued Wis- in a hospital where the available- treatment is irrele- consin program (section AA), the two New Jersey vant to his needs. This is peculiarly true where the programs (sections 3.3 and A.6), and the Colcndo laws prOVide for continuing incarceration until the State Reformatory program (section A.5) are the treatment is successful. only four operating under correctional auspices found Even in the - absence of court intervention, such a in the course of research for this survey. -In addition, "Catch -22 "- situation should be intolerable to the there is the Massachusetts program (section A.1), conscience of society. Yet in most states, state housed within a correctional institution but operated mental hospitals today hold sex offenders for whom under mental health auspices. the only treatment available is= treatment addressed Statewide planning projects need not iimit them- to the needs of the criminally insane, psychotic selves, however, to these four or five models. Most patients, and others having little or nothing in features of the. treatment programs in the state common with the needs of sex offenders. Itis mental hospitals can be equally well introduced into surprising that states which follow this irrational medium-security and minimum-security state correc- pattern do not suffer from even higher recidivism tional institutions if .two basic prerequisites are met: rates than the current rates. a) The program should be operated as an enclave This holding of sex offenders in hospitals which within-the correctional institution, responsible for its offer little or no treatment relevant to ;,heir needs is own security and staffing, with the sex offenders peculiarly abhorrent because itis so unnecessary. housed together in the separate unit and provided to The costs of providing relevant treatment are no the fullest extent feasible with- other facilities inde- higher than the costs of providing the irrelevant pendent of the rest of the institution. treatment currently provided. Indeed, several of the b) The program should be adequately staffed, at menial hospital programs listed in Parts II and IV both the professional and paraprofessional levels, above and in Appendix A below are actually spend- with personnel dedicated to the goals of the treat- ing less per patient on their sex offender programs ment program and fully qualified by education, than on their programs for criminally insane, psy- experience, or both, for their roles in the program. chotic, and other patients. Starting a program ad- Granted independence and appropriate staffing, it dressed to the specifically sexual= problems of sex probably makes.little difference whether a program offenders in a state hospital which already holds sex is lodged"in,and administered by- a correctional offenders requires littleor no additional staff or system or a mental health system. A correctional resources merely the sound redeployment of exist- system can base a treatment program on any of the ing staff and resources. state hospital models described in this survey, or can Numerous models for sex offender programs in borrow features from those models in designing its state hospitals have been presented above and will own program.

77 65 5.8. Planning for Serious Offenders parolees (who have already served time) should not Incarcerated for-Long Terms in be overlooked. As with probationers (section 5.5), parolees may Maximum-Security Correctional benefit from a halfway house or hostel where Institutions intensive treatment can be provided duringtheir Here are found the most serious of all sex period of readjustment. The possibility maybe offendersthose serving long terms for crimes in- considered of a halfway house serving bothproba- volving major violence, including some who fit the tioners and paroleesonce again, with an awareness Krafft-Ebing stereotypelust-murderers, rape-muti- of the differences between these two groups. lators, and the like (see page 2). An argument can As, in Albuquerque (section 2.18),community- of- be made against providing treatment at all for these based' treatment programs serving primarily sex fenders on probation may also involve themselves major offenders. is true If treatment is provided early in their incarcera- with sex offenders on paroleand the same tion, it may be said, it will be wastedsince no of other community agencies and resources. possi- judge or parole board will release them no matter Reviewing these and numerous other parole how successful treatment appears to be. Nor is bilities should be giyen a very -highpriority by treatment toward the end of a long sentence of any statewide planning projects and by localplanning large sums on use, since long years ofincarceration in a maximum- groups. It is self-defeating to spend without security institution produce a "convict personality" the incarceration of sex offenders, with or them which ruins a man for a treatment program based on treatment during incarceration, and then to turn honesty, openness, and the building of self-esteem. loose in the community with littleassistance or A partial answer will be found insection A.5, supervision during the critical weeks and months when -they are learning again how -to live infreedom. where a program for rapists serving termsof 25 in a maximum-security The period ,of parole following incarceration years or longer in New Jersey's following institution is described. Such programs may not correctional system or of work release accomplish much, but they may be better than no incarceration in a state hospital is the period when a sex offender's resolve toavoid reoffending will be program at all. Further,significant data may emerge He-needs and de- data which may help prevent either reinforced or destroyed. from such programs provide. future sex offenses and the rise of another cohortof serves all the help society can There is little reason to believe that the programs major offenders from among today'schildren and for paroled offenders reviewed in this survey arethe young peOple. While a programfor those serving Giarretto in is hardly best possible models. Just as Hank long terms in maximum-security institutiorfs devel- of a statewide planning proj- Santa Clara County.,California (section 2.10), a high-priority concern oped a wholly new model -for treatingincest of- ect, it warrants carefulconsideration. fenders on probation and their families, so other innovative professionals should be encouraged to 5.9. Planning for Sex Offenders onParole develop innovative community-based programsfor other types of offenders on eitherprobation or Asis the case with sex offenders on probation, this area following incarceration need parole. The 'funding of pilot projects in sex offenders on parole and and can benefit from much moreintensive treatment should have a high priority among federal, state, private funding agencies (see below, section 5.13). than is commonly provided parolees. probation In planning programs for offenders either on At a minimum, parole departments, like planning departments, should develop a competenceand ex- probation or on parole, state and local offendersby provid- groups should bear in mind that twomajor sub- pertise in the handling of sex families ing special training and supervision for one or afew categories of offendersthose with -intact from quite parole ,officers- in each area, and byassigning all and those withoutmay need and benefit paroled sex offenders to those speciallyqualified different procedures. officers (see section A3). The possibility that -the same qualified officer orofficers be employed to 5.10. Modernizing the Criminal Laws handle both probationers and parolees isworth considering and perhaps trying outthough the ma- Very early in its deliberations, any group consid- jor differences between probationers(who are in ering the future of sex offender treatment programs general new to the criminal justicesystem) and will find itself face to face with major difficulties

78 arising; out of the gravely outmoded provisions of the completion of their sentences they will be turned state criminal- statutes defining and governing sex loose in the community without even the minimum offenses. -In -most states, acts no -longer. deemed of services and supervision commonly prOvided -for criminal'by-the-conscience of the community are still parolees. A more sensible law would provide pre- defined as criminal, and subject to very harsh cisely the oppositethat no serious offenders;(such ,penalties. Adultery, fornication, and sexual acts in as rapists) be released from correctional institutions private 'between adults of the same sex are a few except on parole. Striking ekamples from among the many available This is hardly a comprehensive account- of the .(see above, -pages 3-4). Even though such laws are ways in which modernizing a state's criminal statutes Only rarely enforced in most states,-thetels mile11 to may improve its responses to the problem of sex be-gained by eradicating them from the statute books offenses. The examples cited, however, should be rather than relying on law enforcement authorities to sufficient to alert state and local agencies to the need refrain- from enforcing them. To encourage respect for sex law reform. for law, states should, make their-laws respectable. Another prObleiii which should be faced concerns 5.11. Improving Sentencing the "age of consent," especially as it affects child Procedures molestation. An adult who engages in sexual- acts Whether an offender is placed on probation, or with-a six-year-old, for example, is clearly engaging sentenced -to a treatment program, or sentenced -to in .child- molestation,- regardless of whether the child serve a term in a conventional correctional institution protests or willingly participates. But suppoSe that without treatment, depends in- large part on- the the "child victim" is 18 years oldand not only judge's decision at the moment of sentencing--and consents but initiates the encounter? Where shall the judges have relatively little data available to guide line-be drawn? their decisionS. They must rely in part on their New Mexico and several other states; have re- "hunch" at the time of sentencing; in part on a sponded by drawing:two linessetting the age of psychiatric report (if- there is one), o_ ften based on a consent at 14 or thereabouts for sexual conduct in single psychiatric interview with the offender; and in -general, but at- or -close to 18 if the adult participant part on a conventional probation report which may is the father or other close relative, or a guardian, (or may not)- tell more about an- offender's sexual teacher,- physician, clergyman, scoutmaster, or other problems than -is shown on the face of his prior adult in a positron. -of authority. This proposal also arrest-and-conviction record. eliminates the traditional incest laws; it is no longer One of the few merits of the outmoded "sexual the blood relationship which determines the- offense psychopath statutes" is ..a-sound solution, to this but the sexual- exploitation of the young by adults problem. These old statutes provided, and_still-pro- with authority over them. vide in some states, that following conviction for a In some states judges have almost unlimited power major sex offense, a judge may commit a sex to turn a convicted offender loose or sentence him to offender to a- treatment program for a period- of any term including long-term or lifelong imprison- observation not exceeding 60 or 90 days (see section ment. In other states, judges are left with little or no 2.1 above). During this observation period, the discretion; -a conviction for a specific offense such as experienced staff-of the treatment program, and =the rape may carry a mandatory sentence which a judge other sex offenders-in the program, have an oppor- may increase but may not decrease. Considering the tunity to study the convicted sex offender in depth, degree of discretion which judges should-have when to see how he reacts in a variety ofsituations and to sentencing sex offenders may prove necessary in reach an informed opinion concerning the two points considering ways to improve a state's handling of at issue: (1).does he need incarceration or can- he sex offenders. Improvements in parole procedures safely be left-on-probation in the community, and (2) may also-prove'desirable or necessary. if he is to be incarcerated, will he benefit from the Repeal of outmoded state "sexual psychopath" treatment program available inthis institution or statutes is also being urged in some quarters (see should he be committed elsewhere? Following the section 1.2 above). A few features of these outmoded observation period, the sex offender is then returned statutes, however, should be retained (see below). to court with a recommendation for sentencingand Some state- criminal statutes provide that certain with the detailed grounds for the recommendation. categories of sex offendersrapists, for example The judge can thus reach a decision with some shall not be eligible for parole. This means that on confidence that he is not acting capriciously. States

79 67 impris- not currently using-this procedure shouldinstitute it; for release on parole, were sentenced to life and states currently using it .should retain it even onment on return to court can readily beappreciated. though they may repeal other provisions of their The program was only able to survive theblow by exerted both seival psychopath statutes. assurances that every effort would be A cautionary note should be sounded, however. It to correct these miscarriages of usticeand to prevent is easy for a state'sjudgesto inundate a sex offender recurrences. treatment program with large numbers of sexof- The time to prevent such disasters, obviously,is fenders sent for observationso that little space or when an offender is firstsentenced to a treatment staff resources remain for the major function of the program. Judges should be informedthat -a sentence program, treating patients. Theobservation period as to the program carries with it acommitment to an' aid- to judicial sentencingwill work only if the release the man on parole following successful com- treatment program- is provided wi01 the necessary pletion of the program. In any case where the judge diagnostic resourceswithout impoverishing its is unwilling to make this commitment, he should not In treatment resources. sentence the offender to the treatment prcgram. A serious-problem in some sex offender treatment states where release is dependent upon-the parole pmgrams is the recc;pt from the courtsof-offenders board rather than the sentencing judge, parole au- who are wholly- unsuited_ to 'the programeither thorities should similarly agree in advance that suc- because they are not in need of incarceration or cessful completion of the program will be a ticket to becatise they_are unlikely to benefit from the treat- release on parole. Offenders not eligible for such an ment available. To avoid being clogged-with unsuit- agreement should not be admitted to treatment able offenders, a treatment program should-haVe a programs. veto power-over -its ownadmissions--the power to Thisis-no_t a -novellywithin the correctional refuse admission to an offender either becausehe is system. It- is merely the application to sexoffenders not suitable or because tht -e -is no roomfor him. of a concept known asMutual-Agreement Program- Along -with this should- go the power to transfer an ming (MAP),- available- to- other offendets in at least offender to- another part of the institution, or to a dozen states. Under the MAPplan, an individual return him to court for transferelsewhere. offender can entera legally binding agreement-with the correctional system and parole =board at an appropriate point in his incarceration. The agreement 5.12. Release Provisions specifiesprecisely What the offender proposes to do towar&his own rehabilitation during a specified A statewide planning project should concern itself similarly -with the provisions for the release ofperiod of time; and it provides that if the offender lives up to 'his part of the agreement, the parole offenders following successful completion of treat- board is legally bound to release him at the-endof ment.Specifically, a sex offender who has success, fully completed a treatment program and who is the period specified. returned- to court or -to a parole board with a "The MAP- concept has been testedexperimen- recommendation for release on parole or aftercare tally Wisconsin, Arizona, add California with status should' kt assured of release.Otherwise, the favorable results,William Parker reported in 1975 whole treatment program becomes a farce unable to (see Bibliography). "Currently, both Michigan and command the cooperation of either offenders or Wisconsin have extended MAP statewide, and it is staff. being tested on a- pilot basis in Maryland, Maine, One program experienced the disastrous effects of Florida, North Carolina, and the District ofColum- is a failure to abide by thisprinciple two years ago. It bia. The New York State Department of Probation returned to court, with a recommendation for release testing its use in four counties with probationers; on parole, -two sex offenderswhose rehabilitation Alabama is testing it with parolees contracting for was obviously complete. Both menhad gone through early release from- parole; andboth- Maryland and: the changes described in ,earliersections of this Massachusetts have received: grants from the Law Enfoicement Assistance Administration- to- test (a survey and had become leaderswithin the program. One was described as "our best man" and was modification of the MAP contract]. Models have in offered- a paid professional job within the program been developed and are under consideration" following his anticipated release. The blow to both eight other states. "In addition, the Canadianfederal staff and offender morale when these two program authorities are i the procePR of using MAP as the graduates, despite the program's recommendations basis for modernizing programs of rehabilitation." Applying the MAP contract to sex offenders in But the power these groups represent must be treatment programs is even simpler-and more logical mobilized. than its use elsewhere in a correctional system. Itis here that a statewide planning project can Instead-of requiring the development of an individual have major impact. In the course of -its planning treatment plan -for each offender, the MAP contract activities, such a project will consult with all of the cani Specify release when the established treatment helping professions and agencies concerned, and will program is successfully completed. seek to secure their support of the plan decided upon. Thus the stage is set for mobilizing the support of these powerful cooperating forces when the fund- 5.13. The Funding of Treatment Programs ing of the plan reaches theistate legislature. Ineacerating an offender in a state correctional The funding of community-based treatment pro- institution costs considerably more than the cost of grams for sex offenders may prove more difficult. roam, board, tuition, and incidental expenses for a Such programs can hardly be launched through the student at the state's universityindeed, a year in redeployment of existing funds and, resources; they most correctional institutions costs more than a year require additional expenditufes. But the same- politi- at Harvard or Yale. Much the same is true of the cally powerful forces which can be mobilized to cost of holding a sex offender for a year in a state support- institutional treatment programs can be mo- mental hospital. bilized to support community programs recom- As noted above, it costs little or nothing more to mended in a statewide plan. provide a- sex offender with relevant treatment in a It costs much less, of-course, to treat an offender state hospital than it does to provide the irrelevant in a community-based program than in an institu- modes of treatment most state hospitals now pro- tional setting; the enormous costs of providing room, vide; indeed, it may cost less. Though data based on board, and security are avoided. In the absence of experience are not available, the same- may also community-based programs, many sex offenders prove true for treatment programs in medium-secu- who do not need incarceration -will= inevitably be rity and minimum - security correctional institutions. incarcerated. Thus it can be argued that expenditures The =cost of additional treatment personnel may be on community-based programs can be recouped at balanced by a- saving in correctional personnel- not least in part by savings in institutional expenditures. needed by- treatment programs which maintain their Legislators are commonly skeptical of such argu- own security. The redeployment ,of existing funds, ments for indirect savings, and perhaps rightly so. personnel, and resources rather -than additional But another argument, if cogently presented, is likely funds, personnel, and resources may prove sufficient to strike a more responsive cord. Everyone,- includ- or almost sufficient in many situations. ing members of legislative appropriations commit- Where additional funds are needed, the state tees, is concerned to curb sex offenses. Despite even legislature which already supplies funding for state the harshest laws, the vast majority of sex offenders mental hospitals_and correctional institutions is the and potential sex offenders are at present and .will obvious source of the additional funds as well. State inevitably remain free in the communityincluding legislatures are notoriously loath, of course, to sup- juvenile offenders, unconvicted offenders, offenders ply more than minimum funding for such institutions, on probation, and those released on parole or work- and very few politically potent pressure groups exist release status. Community facilities constitute one to urge more adequate appropriations. In the case of bulwark against further offenses by these offenders. sex offender treatment programs, however, there-are A ,community which = fails -to provide community- numerous possibilities for securing -Very powerful based treatment programs is thus much like a com- support at appropriation time. munity which fails to provide police protection. This Judges are one group highly sensitive to the folly argument, which can and should be fully documented of sentencing sex offenders to institutions which in the course of planning for treatment programs, provide no treatment, or inadequate treatment, or can be. cogently presented to local and state appro- irrelevant treatment. So are Trosecutors, defense priating bodies by the powerful forces in the com- attorneys, psychiatrists, psychologists, social work- munity which help prepare the plan. ers, community service agencies, and others con- Two other potential sources of funding deserve cerned with the problems of sex offenders. Equally mention: federal agencies and foundations or other concerned are the women's groups involved in anti- private philanthropies. rape programs and disturbed about child molestation. Since correctional services are state and local

81 69- functions, federal agencies refuse to fund the operat- fostering of such programs in their future funding ing expenses _of sex offender treatment programs plans. and rightly so. Foundations and other private philan- thropies refuse to supply operating funds 5.14. The Staffing of Treatment Programs for what are pbperly governmental functions. But Whenever a new business enterprise or agency, there are at least three possible exceptions to this private or public, is launched, a qualified staff must rule. be assembled. Three ways are commonly recognized First, federal funds may be available for the for finding qualified personnel. One is to hire them planning of treatment facilities. Thus Minnesota's away from existing business enterprises or private or current project for preparing a statewide plan was public agencies. A second is to consult educational fundedby-agranttothe state from the Law institutions where qualified personnel are trained. Enforcement Assistance Administration. Funds from The third is to provide on-the-job-training. All three local foundations may similarly be available for are relevant to the launching of new -sexoffender planning. treatment programsand all three involve major Second, either federal funds or private philan- difficulties. thropic funds may be available for the launching of Existing treatment programs are small, few in pilot projects likely to prove of value as models for number, aud very meagerly staffed. Thus "raiding" other programs. As noted above, a few innovative them to staff new programs, though it no doubt will programs have in the past secured such "seed occur, will hardly solve the personnel problem.Not money" from the Law Enforcement Assistance until treatment programs are expanded far beyond Administration, from the National Institute of Mental their present size and number will the raiding of old Health (including its National Center for the Preven- programs provide a significant amount of staffingfor tion and Control of Rape), and from private founda- new programs. tions. So far as can be determined, moreover, no educa- Third, either federal funds or private philanthropic tional institution in the country is currently providing funds may be available for the independent evalua- training in the sex offender field at either the tion of treatment programsagain on the theory that professional or-paraprofessional level. The need for the funds will prove useful to treatment programs in such training will become increasingly visible as general rather than solely to the program being plans for new programs are developed. A statewide evaluated. (For a general consideration of evaluation plan might therefore properly include a provision for procedures, see Appendix B, pages 85-92). a training program to be launched in oneof the Finally, federal or private philanthropic funding state's educational institutions. The first few such may be available for the training of personnel(see training programs are likely to attract participants below). The securing of -both federal funding and from all over, the country as well as from the states foundation or other priVate philanthropic funding, where they are located. however, commonly proceeds in two stages. There Finally, provisions for on-the-job training should must first be a decision on -the part of the funding be included in any statewide plan. agency to devote funds, to a particular -field or Federal- agencies and foundations or other private activity. Only following that initial decision does the philanthropic agencies may also develop an interest second issue arise: whatI particular projects within in this problem of staffing new programs. Funding the field shall be funded? Federal and private funds might help in either of two respects: by helping to for sex offender treatment programs are in very short establish training programs in one or more educa- supply in part because there has as yet been no tional institutions, or by funding existing treatment decision that this is an area worth funding. programs to train personnel for new programs. Itis possible that the April 1977 meeting of The crucial importance of including women in the treatment program directors (see pages viii-ix) will staffing of treatment programs atall levels, often consider this problem and take steps to call attention stressed in prior sections of this survey, should- be to the need for both federal and private fundingnot stressed once more in connection with the training of for routine treatment program operations but for treatment program personnel. planing, pilot projects. evaluation, and the training of personnel. It is possible also that this survey of 5.15. Geographical Considerations existing treatment programs will influence federal agencies and private philanthropies to include the It has long been the policy of most states to locate

70 82 their correctional institutions and state mental hospi- The program director may have visited Fort Steila- tals in rural areas remote from centers of population. coom or South Florida and may have noted the high This policy represents a major handicap for sex morale, the self-reliance, and the sense of-responsi- offender treatment programs, as well as for other bility displayed by the participants in those pro- programs, for several reasons reviewed in prior grams. When he launches his own program, how- sections: a.- remote location makes itdifficult to ever, the results are very different. The men cheat, recruit and hold qualified staff, and difficult or lie, steal, and shirk, sabotage, conspire, andcom- impossible to include the families of sex offenders in plainin short, behave like "cons." 'the prograM; and it also-makes-liaison between the The highly skilled director of one outstanding drug program and its patients on parole or aftercare status treatment program La correctional setting describes difficult or impossible. For all of these reasons, his formula for avoiding such an outcomea formula statewide planning projects should do everything equally applicable to sex offender programs. possible to encourage the siting of new treatment "I started this program with just two participants," programs close to the centers of population from he recalls, "myself and my associate director. To- which their future staffs and offenders will be drawn. gether, over a period of several weeks, we planned the entire program, wrote out the schedules, set the rules, allocated space, spelled outur goals. 5.16. Program Size "Next we interviewed all of the eligible offenders While a state should plan treatment facilities for all ire the institutional population and selected theone of its convicted sex offenders likely to benefit from man who seemed best suited for leadership role. treatment, each particular program should remain We admitted him to the program and went through relatively small. Some program directors felt that,for the whole planning process again with him. `They an institutional program, 75 offenders constitute a won't buy ti:* one,' he'd remark, or `why_donlAve reasonable maximum; others suggested a ceiling at do it this way instead?' 100. Institutional programs which grow beyond that "When the three of us were unanimous and size lose the intimate association among- the of- constituted-an ongoing, functioning team, we admit. fenders, and between the staff and offenders, de- ted two more carefully selected offenders. We didn't scribed above as a major factor -in rehabilitation. consult with them; we told them how things were to Instead of expanding a- program beyond the appro- bebut we were alert to what worked and what priate ceiling, a new program should be launched at didn't. Then we revised our program again-until the another site. five of us were working well together. All this took If -a new structure is intik to house sex offenders, about three months. keeping it small is of special importance. Itis an "From there on, it was easy. New men were axiom of institutions that any bed which exists will admitted one or two at a time, and promptly adapted fsr ilisturical examples are numerous of insti- themselves to the prevailing customs--including ab- tutions which kept themselves full, despite a declin- solute honesty and openness, loyalty to the program, ing need for their services, by admitting and holding and so on. They wanted to beinsiders;and we had patients or inmates who might equally well be cared established in advance the rules for becomingan for on the outside. The time to avoid unnecessary insider. Tradition is a major factor in thesuccess of incarceration is when planning new structures. Build- any program; the best way to establish sound pro- ing them small k the best assurance that they will be gram traditions is t, s'ut very small and very slow." used only for those actually in need of incarceration The small slow start is strongly recommended for Much the sar.,.! considerations apply to commu- new sex offender treatment programs, both institu- nity-based treatment programs. A program which tional and community-based. grows too large loses its personal qualityand can re; illy become a neighborhood nuisance. Several community- baked programs strategically sited in var- ious parts of a metropolitan area a t. better than one 5.17. A Look Backwardand Ahead overgrown grogram: This first review of sex offender treatment programs Startinga program with a very small offender is hardly a definitive study; the time has not yet group- has major advantages, as an example will come for that. Similarly, the Conclusions and Rec- show. Several- of the pre rams here described suf- ommendations here presented are far from compre- fered "growing pains" during their early months. hensive. Many questions remain unanswered. This is

71 83 s*. a- field' for pioneering and a timefor pioneering. remain to be explored. Let- us lope that a- decade Altered-public- attitudes toward sex and toward sex hence, or even five, yeam_hence, the next nationwide offenses (see above, page; 5) have rendered- the survey of sex offender`treatment programswill find experience of past-fiecades largely iiielevantto -far mare programs in operation, each with more data current- problems. Recent - treatment prograMs have to reports6 that a far broader range of Conclusions opoled up many new possibilitiesbut many more and Recommendations can be preSented._

8

7 2 APPENDIX A.NINE ADDITIONAL TREATMENT PROGRAMS

The programs treated in this Appendix fall into To a greater extent than any other treatment three distinct groups: program, the program at Bridgewater accepts and -retains "hard-core offenders whose likelihood of 1) Three institutional programs under the auspices of state departments of mental health (the renabilitation.is...minimal.." It :hasearo,.alternative; for :unlike most programs, it kis neither -the power to -MassachusettS program at Bridgewater, Mass.; refuse admission to an,offender fotmd to be sexually a Florida program at the Florida State Hospital dangerous nor the power to transfer an offender to, in Chattahoochie, Fla.; and a' California pro- another maximum Security institution if he proves gram at Patton State Hospital in Patton, Cal.) 2) Three programs under correctional auspices not amenable 'to treatment. Inmates at Bridgewater (the Wisconsin program, at Waupun State are stratified into maximum- security, moderate-secu- rity, and minimum - security groups; but even scl the Prison, discontinued in 1970 but of substantial presence of -substantial numbers of inmate's not historical significance; the program at the Colo- amenable to ktreatment constitutes an obvious -drag i.ado Reformatory, Buena Vista, Colo.; and the on the treatment of those able to benefit from program at the New Jersey State Prison, Tren- ton, N.J.) treatment. A second major handicap is the almost medieval 3) Three community-based programs (at the Uni- primitiveness of -Bridgewater's physical facilitieS. For versity of Maryland, Baltimore; the University of Southern California, Los Angeles; and a many years this primitiyeness was exaceThated- by overcrowding as men sentenced to Bridgewater -Program at the Violence=Rescarch Center, Den- stayed on year after year-with little hope of mng ver, Colorado, discontinued in April 1976.) released as "cured:" A court decision has now,made A.1. Center for the Diagnosis and it easier for long-term inmates to- secure release without a determination- that they are no lOnger Treatment of Sexually Dangerous dangerous. Each offender is entitled to =a review, of Offenders, Bridgewater, Mass. his case by a,court once-a year; and the burden-is Massachusetts enacted a "psychopathic personal- now on the state in such cases to prove he isstill ity" statute for sex offenders in 1947 and a modified dangerous. As the years roll by, this burden of proof version, the "sexually dangerous persons" law, in becomes harderto maintain and prosecutors are less 1954;, but it- was not until -1959 that a "Center For eager to maintain it. The result i3 two streams of sex the Diagnosis and Treatment of Sexually Dangerous offenders leaving Bridgewater--one composed of Offenders" was established at Massachusetts men. whose treatment has been judged successful Correctional Institute in Bridgewater. and the other composed of men who are deemed still Administratively, this Massachusetts program is a dangevous by the treatment program but who the hybrid. The center is under the jurisdiction of the courts are no longer willing to keep incarcerated. As Massachusetts Department of Corrections and is a result of this and other-factors, the overcrowding- housed in a superannuated structure within a maxi- has been relieved; the census is down from- more mutrr security institution. The treatment program, than 150 to about 90. Further, funds have been however, is in the hands of the Department of appropriated by the state legislature for- a= -new Mental Health. From 1960 until August 1976, the building. The new building and the retirement of Dr. -program was under the direction of a psychiatrist,, Kozol maku, it very likely.that Bridgewater's futuiv Dr.. Harvey L. Kozol. For many years, treitinent'ai will not resemble its past. Bridgewater meant primarily psychiatric treatment A primary interest of Dr. Kozol and his associates with both individual and group psychotherapy; in through the years has -been "the diagnosis of danger- recent years, several innovative features have been ousness." A steady stream of papers on this subject added. and on the character of sex offenders -has emerged

73 85 1 from Bridgewater (see Bibliography, pages 97-98). duced the impression; however, that such activities One recent paper in this seriesby Dr. Murray constituted ,relatively little of the patient's total Cohen, Dr. A. Nicholas Groth, and Richard Siegel experience. presents a noteworthy review of features'found in A.2. The Florida State Hospital the histories of many sex offenders. (Chattahoochie) Program He had ,a history of repetitive difficulties with Florida State Hospital:is a large mental hospital women. serving the entire state except for the four southeast- There: was an overidealization of some women ern counties served by the Smith Florida State and a fear of, and contempt for, others. Psycho- Hospital (see above, page 22), The hospital's Foren- logical pain 'brought about by an experience sic Unit is a medium-security unit for mentally ill with an idealized woman resulted in feelings of persons- from the criminal justice and coirectioaal anger displaced onto other women. systemsincluding persons found-,inable to stand A supernormal posture of self confidence thinly trial by reason of insanity, persons found not guilty veiied a sense of worthlessness, inadequacy and by reason rf insanity, and mentally ill inmates helplessness. A premium was placed on aggres- transferred to the hospital from the state's correc- sion as the method for rectifying or re-establish- tional institutions. Persons found guilty of sex offen- ' ing a sense of well being. Thus aggressive ses-under Florida's sexual psychopath_law may also -behaVior, was high on the response hierarchy be committed to the>hospital. with little ability to control its expression. Prior to 1974, the sex offend_ ers were held and He did not perceive the active part he played in treated in the Forensic Unit's general, population. putting himself in situations with women which This is a pattern still common in many state hospi- could- have no consequence other than his tals. Unlike the vast majority of others held in such feeling used and hurt. His experience was that hospitals, however, few sex offenders give any he was a helpless victim. obvious evidence of being "mentally ill." In 1974, He had no real, intimate attachments to either accordingly, a Florida psychiatrist, Dr. Benjamin men or women, and as part of this isolation, the Ogburn, launched a-Sex Offender Program within emotional qualities of compassion, love, the Forensic Unit, desItmed to meet so far as warmth, empathy and trust were noticeably possible the special needs of the sex offender group. absent. After two years, this program- appears to be a His general mood state was dysphoric, charac- conscientious and competent effort to adapt th: state terized by a -dull depression, but at times the hospital milieu to the needs of sex offenders. The depression would become acute and lead to a program stands midway between the "total push sense of panic and overwhelming feelings of programs" as Fort Steilacoorn and South Florida hopelessness. Once again agression was his (pages 22-25, above) and the "minimal programs" characteristic way of fending off the distress of found elsewhere. the depression. Like the rest of the hospital, Florida State's S'ex He was a steady ant food worker, but he Offender Program follows the medical-psychiatric refused to take a promotion with its attendant model.' A newly admitted offender spends nis first increase in responsibility. Although errors or months in a ward where there is heavy emphasis on mistakes at work caused him great discomfort, diagnosis and evaluation by the usual psychiatric he received no great pleasure from good Work teama psychiatrist, a social worker, -a psychologist, or accomplishments. Although, in general, perception, attention, rea- ' Like other psychiatric programs, however. Florida State soning and judgment were relatively intact, appears to be moving more and more toward a social-educa- serious impairment in these basic perceptual- tional model. "Our future plans," Dr. Ogburn wrote late in 1976, "include ... a -ward for sexual education and social cognitive functions would occur under stress. skills. We feel that we have a certain number of patients who During recent years, Bridgewater, like the other are intellectually and educationally somewhat deprived. These programs here reviewed, has tended- to add more patients' primary offenses, we feel, are due to their lack of and more supplemental approaches to the basic knowledge and lack of social skills. They have been unable to medical-psychiatric modelapproaches more closely make meaningful relationships with peers andwith members of the opposite sex due to these problems." Sex education, social targeted toward the characteristics of sex offenders skills training, heterosexual recreational programs, and other listed above. A visit to Bridgewater in the fall of programs involving contacts -with women will be developed "in 1976, immediately after Dr. Kozol's retirement, pro- a very carefully supervised and structured atmosphere."

74- 86 and,anurSe. Inthe course of evaluation the patient's step for various "freedom of movement activities"_ :program for the mOnths ahead is peoscribed and permission to leave the ward to visit some other part scheduled. of the hospital with a companion, then without a AllTatients,are assigned to therapy groups which comp? lion, and eventually even freedom to leave constitute the heart of the program. Each therapy the hi spital grounds without a companion for attend- group is composed of ten to fourteen patients plus a ance at college classes, for vocational training, -orfor member of the professional/ staff and -a member of wage-paying jobs in the "patient labor program:" the nursing staff; one of the -co- therapists is always a Thus, the patient sees himself as climbing,a ladder woman. Each group meets two or three times -per much as at Fort Steilacoom. week for: P/2 hours :per session. These theilipy Of even greater importance, the advanced ward is groups are concerned specifically with each patient's structuredlike Fort Steilacoom -and South Florida problems as a. sex offender. The remainder- Of his to b,,'!1 group rapport and group interaction through- schedule is composed of activities in which he out rujst of the 168 hours of the week. Group participates with patients from other parts of the therapy sessions in this ward are held three -times a 1&'orensic _Unit. The available activities, and the week instead-of two. The 14 members of the therapy number of sex offenders assigned to each,are listed group are assigned to the same sleeping quarters; below; this, Dr. Ogburn reports, "promotes an air of Occupational Therapy togetherness and confidence plus a chance to discuss Programs 100 patients assigned prOblems and feelings at times other t An group Vocational Training sessions. The patients also- receive peer-pressure to School 27 patients assigned 'live as you preach.' Peeepressure is felt by the staff Patient Labor Program- 9- patients assigned to be one of the most iiripoetant -aspects of ward,,, "Freedom of Movement" living situations"as at Fort Steilacoomand -South Activities 2 38 patients assigned Florida. "It can be very effective in modifying Art Therapy Program 65 patients assigned undesirable behavior problems." Musk Therapy Program 22 patients assigned Patients who complete the advanced ward pro- Bible Study 12 patients assigned gram successfully and who are deemed ready for Alcoholics Anonymous 28 patients assigned release are returned to court with- a release recom- Recreation Programs 125 patients assigned mendation; the average length of stay before this After a period of months, the offender is trans- happens is about two years. Patients who do not ferred from the admission ward to one of the sections earn a release recommendation may he transferred of Ward 10 East, a-ward with a capacity of 42. While out of the Sex Offender Program and into other parts in Ward 10 East, he is encouraged to participate in of the Forensic Unit; or they may be returned to all of the activities to which he has been assigned, court with a recommendation for transfer to another and he is oriented to his new situation by other institution. patients. In- particular, he is indoctrinated with the A major advantage of the Chattahoochie prOgram Patient-Ward- Government rules, which are set jointly from the point- of view of other state hospitals by the staff and the Patient Government. Periodi- planning sex offender programs is the ease with cally, /As activities schedule may be modified, either which existing patterns of operation can be modified athiS(request or by staff decision.. to make room for the new program. The -program A patient earns transfer from Ward IC East to the requires little or no additional staff or ,facilities 42-bed advanced ward, Ward 10 West, whenever he merely a redeployment of existing staff and facilities. meets certain standards; these standards concern The sex offender program thus becomes an accepted "the patient's attitude toward treatment, his motiva- and inconspicuous part of the hospital structure, tion toward rehabilitation, his ability to accept and along with the other programs. -It is still too early to demonstrate responsibility." Some patients move to gauge how much is lost in terms of intensity of the advanced ward quite promptly; others may treatment and of ancillary activities specifically de- remain in Ward 10 East for long periodsor may signed for sex offenders (such as sex education and never reach the advanced ward. sociosexual training) in the Chattahoochie model as As patients in the advanced ward demonstrate compared with the "total push" Fort,Steilacoom and increasing reliability, they become eligible step by South Florida programs. Chattahoochie is located close enough to Tallahas-

2See third paragraph below. see, the state capital and site of the state university,

75 87 to make possible exchange of staffs and -the use of ;earning is to be a realistic and potent experience, visiting volunteers. Because it draws its patients treatment must reflect, magnify, and deal- with the iom almost all counties in a very large state, demands of community living. The learner must be however, visits from the families of patients are hard faced with real choices and decisions every hour of to arrange in-many cases, and the involvement of the day, and must learn to-make decisions on the -families in the treatment program is very nearly basis of honesty and concern for others. impossible for most patients. -Because-more-than 60 The Price of Discharge.A free society is held counties are served, moreover, it is exceedingly together by a network of contracts, written or _difficult -to maintain close relationships with the unwritten, to respect each other's rights. The of- judges throughout the state who send- offenders to fender-is released when he demonstrates responsible Chattahoochie--and who must approve their re- daily behavior and sensitivity towards others which lease.3 follow adequate insight into his problems and irre- A.3: Patton State Hospital (California) sponsible behavior. TreatmentApproach:. The length of an offender's Program stay is based on his accomplishment of certain Offenders committed under California's sexual definite objectives. These objectives are .(1) recogni- psychopath-laws are known as "mentally disordered tion of his hurtful behavior patterns;-(2) understand- sex offenders" (MDSO's) and were, unt.. recently, ing of the origin and operation of these patterns; (3) commonly committed to the Atascadero State Hos- acceptance of responsibility for changes; and (4) pital. All offenders requiring maximum security are application- of new patterns of responsible behavior still sent to- Atascadero; but in the fall of 1975, a in dealing with people. second Califomialprogram was launched at Patton Duzing'his hospital residence the offender is under State Hospital near San Bernardino, an hour-and-a- the watchful eyes of his psychotherapy group and half drive from Los Angeles, for medium-security staff, but he is given ample opportunity to interact offenders from the southern portion of the state. with other patients, staff, and visitors every day. His The program was barely six months c'd when thoughts, feeling's, and behaviors are then closely visited in the spring of 1976; but preliminary indica- monitored in group psychotherapy sessions. The tions were that Patton might develop into an impor- offender's progress is 'measured' by the increased tant center. Its founder and director, Dr. Frank understanding and better self-control he is able to Vanesek, a clinical psychologist, was formerly on achieve as well as by his demonstration of greater the staff at Atascadero State Hospital and is familiar concern and a more responsible manner of 'relating with the self-help-group approach pioneered at Fort to peoplethe basic treatment objective. Steilacoom. He has adapted features of these and Like other state- hospitals, Patton is understaffed. other programs to the conditions prevailing at Patton. The Sex Offender treatment Program has been The Patton program's "treatment philosophy," as attempting to- eke out the available staff through explained to entering sex offenders, isin some training arrangements with Loma Linda and Cain-bi- respects reminiscent of Fort Steilacoom's: nia Polytechnic Universities, and with other educa- Treatment is Leaining.Irresponsible behavior is tional institutions in the area. Approximately half of learned. Treatment therefore is a re-learning process. the staff is female; and the presence of women The Learning Objective is Responsible Human trainees and volunteers from the educational institu- Relationships.The offender has treated whei human tions also helps- to, provide a comfortably. aeterosex- beings as mere objects for his own use and pleasure. ual ambience. Much emphasis is placed, as at Foci He must learn to govern his behavior by respect for Setilacoom, on the learning of simple sociosexual the feelings and rights of other human beings. skillshow to greet a woman acquaintance, how to The Vehicle of Learning is the Guided Self-Help establish eye contact, how to start a conversation, Learning Group.Learning happens best when the and so on. learners themselves are expected to carry the major Family visits are encouraged, and there are facili- responsibility. The role of staff is to organize, guide, ties or plans for invciIng families in family and and assist small self-help groupS. marital counselling within -the program. There has The Material of Learning is Everyday Reality.If also been outreach to community programs in the Southem California area, in an effort to establish 3 Following conclusion of this survey, a third Florida pro- gram for the treatment of sex offenders was established at arrangements for the aftercare of patients returning Gainesville (see Appendix C. page 93). to the community.

76 88 I

As at- South Florida and elsewhere, there is What kinds of offenders were treated? More than *<"- emphaiis on each man discovering his own "early half were child molesters (mostly convicted of "in- warning signals," and men leaving the program are decent behavior with- a child"). The second largest assured that "help is as near as the nearest tele- group was composed of 139 men foundguilty of phone." "sexual perversion"in almost all cases homosexual Because itis the most rezently established- pro- acts. During the eleven-year period, only 43 rapists - gram, still facing the difficulties of any new venture, and 54 rape-attempt offenders entered the program 'the Patton program may be of particular interest -to for treatmentas compared, for example, with 414 others planning new programs. Patton also demon- in the program for "indecent behavior with a child." strates the way in which a new,program can borrow The basic approach of the Wisconsin program was `features from a variety of established programs, psychiatric; sex offenders were there to receive adapting them as necessary to the local situation. individual psychotherapy from psychiatrists or clini- cal psychologists much as in private psychiatric A.4. The Wisconsin Program (1951-1970) practice. That approach soon feundered __however; for enough psychiatrists and clinical= psychologists Wisconsin enacted a "sexual psychopath law" in could not be recruited. Hence group psychotherapy 1947 which was so obviously unjust and unworkable was added to individual psychotherapy as a more that a citizen's committee was established to draft a economical mode of treatment. It soon became better lawand to plan a treatment program which apparent, in Wisconsin as elsewhere, that group might actually be of use to incarcerated offenders. therapy has numerous other'advantages, in addition The improved law was passed in 1951, and that same to low cost, in the treatment of many sex offenders. year a treatment program for sex offenders was During most of its 20 years, the Wisconsin pro- established at Wisconsin's maximum security insti- gram was headed by a clinical psychologist,Dr. tutkin, Waupun Sfate-Prison. Asher R. Pacht, -with Dr. Seymour L. Halleck, then Under the Wisconsin law, persons prior to incar- professor of psychiatry at the University of Wiscon- ceration had first of all to be convicted of a sex sin, as chief consultant. In a number of respects,ithe offense, with all the usual- constitutional safeguards. Pacht-Halleck team found, Wisconsin's sex offenders Following conviction but before sentencing, judges resembled its other offenders: were required to send serious se_ xoffenders to the "Most of our patients come from lower socioeco- treatment program for a 60-day observation period. nomic groups. Their histories often reveal severe This mandatory observation period api: ed to of- trauma and emotional deprivation-during early child- fenders guilty of rape, "assault-intending rape," and hood. Broken homes as well as-excessive drinking several other serious sex offenses. In addition, judges and promiscuity on the part of their parents are could, at their discretion, similarly commit for- obser- commonplace." Other programs have reported -simi- vation persons found guilty of lesser sex offenses or lar findings. sex-motivated offenses. The treatment grogram was Drs. Pacht and Halleck continued, "Our experi- required to return the convicted but still unsentenced ence indicates that sex deviates, as a group,fuiction offender to court within 60 days, with a finding that in the world a.. -inadequate individuals. They are he either was or was not a "sexual deviant"a term impulse-ridden, show poor controls in most areas of not defined in the law. In practice, this meant that their and have considerable difficulty in expe- the treatment program could decide whether the riencing the possibility that they have some role in offender (a) needed treatment, and (b) could benefit their own destinies. We have been impressed by the from treatment. overwhelming passive needs of our population. They During -its first eleven years of operation (1951- constantly verbalize their lack of responsibility for 1962), the Wisconsin program received 2,125 sex their behavior and express a desire for somebody to offenders for observation and kept 901 of them for provide direction for them." These findings, too, are treatment.' common to other treatment programs. Therapyis 918 offenders were deemed not to be "sexual deviants- addressed in part to altering these factorsimpul- ar.d were returned to court for sentencing under the ordinary siveness, lack of control, passivity, and Go on. criminal laws; 87 were _Sound to oe psychotic or mentally The major shortcomings of the Wisconsin program deficient and were transferred to appropriate non.correctional stemmed from the- fact thatit was housed in a institutions; 209 were found to be "sexual deviants" but were maximum security institution and had very little released on probation; and 10 cases were disposed of in other ways, autonomy within that institution. Sex offenders in

77 89 the treatment program lived and worked with the problems. After years of delay,.-however, the Wis- other correctional inmates. They were subjertea to consin legislature ultimately refused to appropriate the same institutional routines and discipline. Thus funds for a separate institution, and the program at the few hours a week they- spent in psychotherapy the Wisconsin State Prison was discontinued. was only apart of their total institutional experience. Sex offenders committed under the 1951 Wiscon- In many respects, the routines of a maximum-secu- sin statute are currently held at the Waupun State rity institution operate at cross-purposes with the Hospital, an institution where treatment'addressed to goals of a therapy programand this was true 1,. the specifically sexual problems of sex offenders is Wisconsin. not- available, and which therefore falls outside the One very serious handicap in the Wisconsin-pro- scope of this study. gram was the absence of female participation. Few An outstanding feature of the Wisconsin program, maximum-security institutions in the 1950's permitted rare in- programs today, was, .the inclusion almost women inside the prisoner areas; Wisconsin was not from the beginning of a research component. Statis- one of them. tical data were maintained on those- ad_ mitted to the Many sex offenders are married, and a remarkable program for observation, on those admitted for proportion of their wives stick with them despite treatment, and on those paroled following treatment. their conviction- and incarceration for sex offenses. In 1965, a study was_published of 461 sex offenderS Married offenders,: several ?tudies suggest, do better paroled between July 1951 and June 1963; all were_ following release than those. , without family ties. The followed up for a period of two full years. Wisconsin_program-did what. it could to enhance the Of the 461 parolees, Dr. Pacht and Dr. Leigh M. value of such ties through the,use of family therapy. Roberts reported, only 29 (6 percent) committed new In this approach, Dr. Pacht explained, "the entire sexual or other criminal offenses during- the subse- family is seen as operating in a maladaptive fashion. quent two years. This was much better than the- It is the dysfunctional-family rather than the individ- records of a comparable groupof non:sex-offenders ual thatis helped to develop the requisite social 15 percent of whom committed new criminal offenses climate that will lead- to offender rehabilitation." during the two-year period following their release on Several of the newer programs make intensive use of parole. family therapy; wives are familiar figures within The 6 percent recidivism figure should-not be these programs. But alas, Dr. Pacht pointed out, taken- as evidence that -the Wisconsin program per- "we tend to build our institutions as far from formed miracles. The evaluation of a treatment civilization as possible. It is therefore, difficult for program is a highly complicated matter, involving far families to participate." The Wisconsin program was more than a crude recidivism rate during a relatively remote from the state's major centers of population. brief two-year followup period., A program's recidi- Remoteness also made itdifficult to staff the vism rate may be low because it accepts only the Waupun treatment program. "It is unfortunate but most readily treatable cases, or because it holds for true," Drs. Pacht and Halleck noted, "that mental very prolongid periods all but -the very best bets, health ,.disciplines, particularly psychiatry and psy- rather than because it is doing a good job. There is chology, have not encouraged their finest members rarely an answer to the question: would the men actually released have done _equally well without a,- to enter the correctional field. ...This field has still, with few exceptions, negative status value." Adding treatment program? These arid- other evaluation- is- geographic remoteness to the low prestige of jobs in sues are considered in Appendix B (p. 85). a correctional institution and to relatively low pay- Nevertheless, the crude 6 percent Wisconsin recid- ment scales for professional therapists, made staff ivism figure makes it clear that despite the treatment recruitment a continuing bottleneck. program's numerous handiCaps and shortcomings, To overcome these and numerous other handi- and despite the relatively short duration of- tl.e caps, Drs. Pacht and Halleck hoped and expected treatment it offered,5 it was not turning loose hordes that the Wisconsin treatment program would in due of dangerous "sex fiends" eager to resume without course be established as.o. separate institution where delay their sexual depredations,-on-women and-chil- the entire milieu, 168 hours per week, could be dren. Followup studies from other treatment pro- shaped to therapeutic ends, as was done at Fort grams-confirm this reassuring view. Steilacoom and South Florida. The new institution 5 More than two-thirds were held and treated for less than 18 was to be built near Madison, the state capital, close months; 39 percent were held and treated for less than one to the University of Wisconsin to ease staffing year.

78 90 r

A*. The Colorado State Reformatory as a first step toward personal change. Once the offense is on the table, the group helps him explore "(Buena Vista) Program the reasons- for his offense. Along the way, changes The Colorado State Reformatory is a medium begin--to--occur 'in -his-manner of relating- to-Dr. security institution; inmates are in- general younger Steele, to other (lumbers of th , group, and to the and are serving shorter terms than those in- the state institution as a whole. penitentiary. The Buena Vista treatment- program for Most sex offenders are also assigned- to an aca- sex offenders, was launched in -thereformatory in demic course, "Marriage and the Family," which 1972 by, Dr. Nancy Steele, a clinical psychologist. seeks to explore the entire range of human sexuality All ininates involved in- sex offenses are assigned-to and in particular to 'give the men some sense of the treatment prOgramwhether or not the technical female sexuality. The academic course, like the offenses of which they were convicted were sexual. treatment Program as a whole, is subject to a major Treatment consists essentially of'one group session disability: the absence of :female participation except perieek lasting an hour and .::half. There are four for Dr. Steele herself. suchigroups, all led by Dr. Steele and each com- This disability, in turn, appears to be an inevitable prised of from seven to ten- men. In addition, Dr. result of the reformatory's geographical- location. Steele is available for ifidiVidual therapy sessions to Buena Vista is a town- with a populatien of 2,000, the extent-that -her schedule permits. offering little opportunity to bring into the program 'Two of the groups; Dr. Steele explains, "are for either part-time female staff or women volunteers. men- who were primarily aggressively(rather than The nearest large city or academic center is Denver, sexually) Motivated for their offenses. Frequently a five-hour round-trip drive over mountain roads they are older than the men in their twenties orearly when the weather is good and- with no-alternative thirtiel who comprise the bulk of the reformatory transportation. A visitor to Buena Vista-'finds it Population. Many are married and have led very difficult to-suggest ways in which the program could active sex-lives. Some of these men have been quite be enriched without moving it -to a less isolated successful academically and vocationally. 'I heir cen- location. This handicap exacerbates the problem that tral emotional problem is angeranger which they the therapy sessions and sex education classes to- cannot express toward the important women:intheir gether occupy only a few hours of an offender's time lives. Therapy, therefore, centers upontechniques per week. for dealing with anger which are lesssocially dam- Dr. Steele herself takes a realistic view of her aging than rap_ e °Dassault." program's shortcomings. Treatment at' Buena Vista, The other two therapy groups are comprised she states, "has tnbe completed outside the confines mostly of what Dr. Steele calls "sexually inadequate of the institution, where -the ex-offender has an offenders. These men are g. nerally younger; many opportunity to associate with women and to work of them- are single and lacking regular sexual part- out improved; realistic relationships with them. For ners. They have failed to adjustvocationally and this reason, all of the men who- leave the program socially as well as sexually. Their offenses are ate referred for followup outpatient treatmentin their motivated primarily by a sexual urge. Frequently own communities." their victims -are relatively helplesschildren,older By September 1975, fifty sex offenders who had women, the physically handicapped.They rarely use participated in Dr. Steele's program had been pa- Weapons, and may run away if a victim offers rOled:/aud had lived in their communities for periods resistance." One goal of Dr. Steele's therapy with ranging from three to eighteen months. Letters to these men, as in a number of other treatmentTheir parole officers, elicited followup reports on programs, is to build up their senseof self-worth, of thirty-nine of the fifty. The results. competence and adequacy. Dr. Steele believesthat 24 of the 39 men (61 percent).r.ad remained free Academic and vocational training may contribute; of any known criminal involvement. along with group therapy, to these goals. 13 men (33 percent) had committed no sexual Newcomers -to Dr. Steele's groups, like newcom- offenses but had been involved in other kinds ers to other programs, commonlybegin by denying of criminal charges (such as theft, absconding, any responsibility for their offenses.They explain- or robbery). Most of these charges were that they were victims of mistaken identity, or drunk, dropped or handled at the county level; only 3 or out of their minds." Aselsewhere, the group then of the 13 were back in state institutious. focuses in on the man, helping him to face thefacts 2 men (5 percent)'were convicted of subsequent 79 91 assaults on women. One was returned to the ports, are readily visible and may be highly relevant reformatory; the other was sentenced to the to the rapist's sociosexual adjustment following re- state prison. lease. The shortcomings of such _follow-up studies are The program has also contributed significantly to well-known and, are rliscussed elsewhere in this a more realistic understanding of rapists on'the part study, They serve, nevertheless, to buttress two of Women Against Rape. Women who spend a day general findings from other follow-up studies: (I) sex rapping with the men in the Trenton program no offender treatment programs are not turning loose longer have a vague stereotype of- the rapist as a hordes of sex fiendS to continue their sexual depre- malevolent superman. Their hostility to rape remains dations on society, and (2) the recidivism rate for unchanged, but they -.Pm/ to see the rapist as- also sex offenses is significantly lower than for crimes being a victim of a .tint male-dominatei society. against property. A second area explored in the group therapy sessions concerns the day-to-day problems of rapists lodged in a maximum- security correctional institu- tion. By helping the men come to grips with the A.6. The New Jersey State Prison (Trenton) prisormilieu,Rotgers believes, the program may set a pattern which will- help-them come to grips with Program the outside milieu following-release. The New Jersey State Prison is a maximum- Some of the men volunteer for the program security institution which receives only inmates because they believe participation may influence the whose maximum sentences run for 25 years or parole board rather than because of any sincere longer though -many, of course, are paroled in less desire to restructure -their sociosexual attitudes. In than 25 years. Its treatment program, launched in the several Lases, indeed, men "volunteered" only after fall of 1974, is solely for rapists. Any rapist in the the board turned down their parole applications but institution may volunteer for the program; to qualify, told them that a subsequent application might be he must concede that he has in fact committed one more favorably considered if they participated in the or more rapes. Very few rapists apply for admission program. This tendency of inmates to "play the early in their incarceration; many have spent five or parole game" is sometimes cited as an argument more years in the institution before applying. There against= institutional therapy programs; how can a are usually eight to ten rapists enrolled in the therapy group function effectively when participants treatment group. are only there to "con" the parole board? Rotgers Limitations in staff time limit the program to one replies that when a group is functioning well, at least two - hour -group therapy session per week. Frederick some of the men who originally volunteer as part of Rotgers, the institution's director of psychology who the "parole game" become genuinely caught- up- in heads the program, concedes that this is much too the group process. Their attitudes toward therapy little; :.e reports that the men themselves often changea harbinger of even more important changes request additional therapy sessions. Within those two in their attitudes toward rape, toward women, and hours a week, however, Rotgers believes that prog- toward their own life patterns. If those changes do ress can be made in two essential directions. not occur, the titan is likely to feel himself an outcast One is a restructuring of the rapist's attitude in the group and to drop out. toward women. Essential in this restructuring is the Two hours -a week of thelapy, of course, cannot participation of women in the therapy. Two female be expected to accomplish what can be accomplished clinical psychologists, Dr. Carol Gould and Ms. during 168 hours a week- in programs like Fort Ellen Collin, have served as co-therapists with Rot- Steilacoom or South Florida. Nevertheless, -the es- gers; and a social worker, Ms. Sally Schiedemantel, tablishment of minimal programs on the Trenton is also active -with the group. Liaison is maintained pattern in other maximum-security institutions may with the Mercer Area (Trenton)' Women Against be warranted. Rotgers reports, on two grounds: Rape, affiliated with the National Organization of A minimal program addressed directly to the Women; women from this group- on occasion visit problems of sex offenders may be better than with the rapists. For some of the men, the program none at all. pffers -their first experience in associating with A minim& program may constitute an entering women as equals on a basis of open communication. wedge for a more intensive program in the The changes in attitude which occur, Rotgers re- future.

80 92 A.7. Outpatient Treahhent Clinic for assigning sex offenders to a specialized probation officer, using-the sex offender treatment program as `Special Offenders, Baltimore, a training site for probation officers, andmaintaining Maryland close rapport between treatment progam and pro- ,program, established in 1972, is patterned bation services are heartily recommended to other rather closely on the Philadelphia program ( 'e pages community treatment programs. 49-52). In addition to sex offenders, the Baltimore pro- The criminal court of the City of Baltimore -is gram is addressed to a particular subgroup ofviolent called the Supreme Bench of Baltimore; and the offendersthose who are not pirt of the criminal Supreme Bench maintains a Medical Service with a subculture but who on occasion suffer bouts of psychiatrist as Chief Medicat:'Officer. For many explosive-assaultive behavior. The two types of of- years, this post was held by a nationally known fender are treated separately; this dekription is forensic psychiatrist, the late Dr. Manfred Gutt- concerned solely with the sex offenders. macher, who had a special- interest in sex offenders. Like Dr. Peters in!iPhiladelphia, Dr. Rappeport His_successor, Dr. Jonas Rappeport, who is also initially sought to ide referrals to- the clinic at clinical associate professor of psychiatry at the random into a group receiving treatment and a University of Maryland, has continued that interest. control group receiving probation services only. The In May1972, Dr. Rappeport launched the Outpatient effort failed. Judges often insisted -that particular Treatment Clinic for Special Offenders at the-Univer- offenders receive treatment as well as probation; this sity of Maryland's Institute of Psychiatry and Human by itself destroyed the principle of random assign- Behavior, financed by a grant from the Governor's ment. In addition, the. members of the clinicstaff Cominission on Law Enforcement and Criminal sometimes concluded that certain patients required 3ustice to the State Division of Parole and Probation. treatment and should not be assigned at random to a Like -the Philadelphia prograin, this Baltimore 'Pro- non-treatment control group. As a- result; the effort gram offers' to sex offenders generally Weservices to make a controlled eValuation was abandoned. ordinarily available only to wealthy defendants. During its first three years the clinic provided The Outpatient Clinic was set up to serve of- treatment for 45 sex offenders,- of whom 29 werein fenders referred by the courts of Baltimore, Balti- treatment in June 1975. Of these, 12 were exhibition- more County, and severalsurrounding counties. ists convicted of indecent exposure, 12, were con- Since Dr. Rappeport was Chief Medical Officer of victed of sexual assaults, and= one each was in the Supreme Bench of Baltimore, and had been treatment following conviction-for peeping, at- Court Psychiatrist for Baltimore County, Baltimore tempted arson, incest, sodomy, and "perverted.prac- City and County judges lacked the common judicial tice." distrust of psychiatric procedures; but referrals from Clinic sessions are held- on the University of other counties remain few. The Clinic also serves Maryland's Baltimore campus; the university pro, patients released on parole from Maryland- correc- vides space and administers the program's finances. tional institutions; the State Parole Board makes The sex offender groups meet one day a week, from these referrals, and there have been problems in the 5:15 -to 6 :45- p.m.; attendance is compulsory and referral of unsuitable offenders and the failure to repeated absence may be deemed a violation of refer offenders who might benefit. As an independent probationthough this sanction is rarely invoked. institution, the Outpatient Clinic canand does Participants are charged from $1 to $5 per session, refuse-to-accept unsuitable referrals. dependirg on income; there have been problems in The Baltimore program, like the Philadelphia pro- collecting and =the fees are a very small part of the ,gram,_has both a ,probation and a treatment compo- total clinic costs. The -goals of treatment are de- nent. Substantially all sex offenders acceptedfor scribed as (1) helping participant:. achieve greater treatment are assigned to a single probationofficer; awareness of their problems, and (2) helpingthem since July 1973 this officer has been Senior Probation attain sufficient. control over their impulses so that Officer Paul Sivert, whose office is in the clinic and antisocial acting-out behavior will not recut. who administers the clinic as well as providing An evaluation of the program by its assistant liaison with other- probation officers. Several proba- director, Dr. James E. Olsson,. was made for -the tion officers have served as co-therapists ,in, the three-year period ending in mid-1975. Dr. Olsson program for periods of six months orlongeras part concluded that the sex-offender program was more of their, advanced training. These techniques of effective than the program for assaultive offenders,

81 93 and that the recidivism rate for sex offenderswas during a week-long "Institute on the Sex Offender comparable -to- that reported by other treatment and the Law" held at U.S.C. in August 1972. The programs. As in Philadelphia, significant changes 709-page manual prepared for that s-minar soughtto were noted in the attitudes and behavior of most bring together from a variety of souict-s relevant data participants as treatment progressed. and insights on all aspects of the sex offender; it has, unfortunately, not been published. A.B. Program of the University of Southern On countless occasions, when preparinga report California Institute of Psychiatry and on a particular sex offender for a judge, a practicing Law,los Angeles attorney, or a pubic defender, Dr. Pollack became acutely aware of an unmet community need. The Dr. Seymour Pollack is a psychiatrist and psy- offender he was examining, Dr. Pollack often con: choanalyst whose field of major interest has long eluded, was in need of psychiatric treatment butnot been forensicTsychiatrythat is, the role =of psychia- in ,need of incarceration. Servinga term in the try in advising the criminal justice system. As county jail, in a state correctional institution, or director of the Institute of Psychiatry and Law at the locked up in Atascadero State Hospital might consid- University of Southern-California,-lie-latight-thiS--erably-WorSeirliisc-oliditibn, and make recidivism subject to psychiatrists in training; and througha more likely. The proper approach was clearly visible: series of workshops and seminars, he brought to- a period of probation with psychiatric treatment as a gether judges, attorneys, legislators and others to condition of probation. The same kind ofcase explore problems in forensic psychiatry with himself repeatedly surfaced during Dr. Pollack's 1972 "Instir and with other specialists. cute on the Sex Offender and the Law." Both defense lawyers and judges through the years If the offender was well-to-do,- the recommenda- frequently enlisted Dr. Pollack's services to examine tion for treatment without incarceration made sense. a- defendant and answer relevant_ questions: Is this A wealthy offender could almost always find a person suffiziently sane to stand trial? Was he or she psychiatrist interested in his kind- of problem and sane at the- time of the offense or should a defense prepared to accept him as a patient. Few sex of insanity lie accepted? Is this person safe to be at offenders, however, can afford intensive private large? In need of psychiatric treatment? Likely to psychiatric therapy. In 1973, accordingly, Dr. Pollack reoffend? A danger to the community? With respect took the next step. Just as his Institute of Psychiatry to sex offenses there was another crucial question: and Law had long been examining and making Is this person a "mentally disordered sex offender" recommendations concerning sex offenders without (MDSO) within the meaning of the California sexual regard for ability to pay, so after 1973 the Institute psychopath statute? Pubrc defenders with indigent began accepting a limited number of selected sex clients could also secure Dr. Pollack's services on offenders for outpatient treatment without regard for such issues. ability to pay. In California as elsewhere, this whole area of During the three years since then, scores of forensic psychiatry was in a state of disorder. with offenders have received treatment at -the Institute. no common body of agreement among psychiatrists Major reliance is placed on group therapy, but with themselves and grave difficulties of communication individual therapy available as needed. Several mem- among the lawyers, judges, and psychiatrists con- bers of the Institute staff assist in this therapy cerned in particular cases. These difficulties were programincluding, since 1975, Dr. Alan S. Good- peculiarly visible with respect to sex offenses. One man, the clinical psychologist who had developed psychiatrist, for example, might conclude that an the communication-skills program under Dr. Michael offender was an MDSO because he believed the man Serber at Atascadero State Hospital (see page 43). needed psychiatric treatmenteven though he rep- The treatment services offered at the Institute can resented no substarti:al danger *.o the community. be-described as highly skilled but minimal. Some of Another psychiatrist might apply the MDSO, label the services available at the two more fully devel- only to men so highly dangerous and so severely oped community programs in Santa Clara Codnty, psychotic or otherwise deteriorated as to leave little California, and Albuquerque, New Mexico, (pages hope that treatment would- he of any use. Dr. 25 and 36) are lacking. Sex education and training Pollack's Institute of Psychiatry and Law did its best in sociosexual skills are obvious examples. The to resolve such disagreements and to establish University of Southern California program, neverthe- agreedlupon approaches and proceduresnotably less, may well serve as an initial model for other 94 community programs7--providing for sex offenders in regulations to protect our building against fire and ..general, a treatment program without incarceration of against breakdown of electrical service and various the kind still available only to well-to-Ao offenders in kinds of structural collapse," Dr. Selkinnoted, "but many . communities. we have never developed housing-codes to protect living units from crime." Through interviews with women who had been A.9. The Denver Program raped and with others who had successfully fore- Like the University of Southern California pro-stalled or warded off rape, Denver's Violence Re- gram, -the Sex Offender Treatment and Evaluation search Center was able to develop other suggestions Program of.Denver's Violence Research Center was for rape prevention. But one key body of data was designed to make therapy available in the community missing: an intimate understanding of rapists them- without regard for ability to pay. Its origins, how- selves, which could hardly be secured through inter- ever, were quite different. views solely with victims. A treatment program for Denver General Hospital is a public hospital rapists- also seemed called forand it could be serving' Denver's inner-city area. As far back as justified as a community -effort to lower the recidi- 1966,, 50,000 -patients -a-year--were-c o ming-to Denver vism rate. The same -logic should_be equally relevant General's Emergency Room-5,000 of them for the in other communities which have well-organized rape treatment of psychiatric rather than medical- emer- prevention services, rape education services, and gencies. The largest group among these 5,000 were rape victim assistance servicesbut which lack the persons- whoa had .attempted suicide or were afraid fourth component of a coinprehensive anti-rape ap- that -they were about to kill themselves. "An effort proach, a treatment program for rapists and other was- made to refer these patients to local Mental sex offenders. health centers," says Dr. James Selkin, a clinical The Violence Research Center's Sex Offender psychologist then associated with the hospital's Treatment and Evaluation Program, accordingly, was Emergency Room; =but that effort "failed dismally." launched in November 1974, under the direction of a Fewer than one suicide- attempter in ten showed up clinical psychologist, Dr. Harry H. Chapman, with a twice-following referral. "So -then Ave developed a one-year grant from the Denver Anti - Crime- Council. program with the Visiting NurSe Service in the city, During its first eleven months it provided treatment and we began to serve suicide attempters by sending for 45 sex offendersincluding 18 rapists and 11 a visiting nurse to visit them in their home and talk persons guilty of "sex assault," five exhibitionists, to them and their families on- the day following the four incest offenders, and seven offenders of other suicide attempt. That program worked out quite well types. Though-some offender g,roup sessions were and is still in existence today. scheduled, primary emphasis was placed on individ- "Some time after this, a youngster came to the ual therapyin part, no doubt, because the program Emergency Room following a sex assault, and she remained small and professional, time was available suicided a few days later." The community was for individual sessions; and in part because the yield aroused by this front-page event; and Denver's of research data concerning the nature, motivations, Department of Health and Hospitals responded by and modes of operation of offenders might be richer. contracting-with-the -Visiting Nurse Service to visit A site visit was paid to the Denver program late in the victims of sex crimes as well as suicide attemp- April 1976but the program was discontinued a,few ters. days later when the one-year grant and its six-month The data concerning the nature and consequences extention expired. The need remains clear for other of rape- which emerged from .this program proved community programs which can become effective very rich; and Dr. Selkin, as headof Denver's componentsalong -with rape prevention, rape edu- Violence Research Center, subsequently made the cation, and services to rape victimsin a concerted findings available through a series of published and community response to the sex offense problem. unpublished papers. One small example will illustrate In a 1976 paper summarizing the experience of the the thrust of his. approach. In Denver as in other Denver program, Dr. Chapman made v.:Vera' points large cities, rapes are far more common in the older of general interest. In the Denver area, he noted, sections of the city filled with substandard housing aoout one percent of all children are reported to vulnerable to illegal entry. A rapist or burglar can suffer from child abuse (including sexual abuse). secure entry into such crime-vulnerablebuildings Among rapists and sexual assaulters in the Denver with little or no difficulty. "We develop housing program, however, 56 percent reported having been

95 83 abused as children, and among other categories of and/or depression seethed to be a chronicsense of sex offenders 36 percent reported having been low self-esteem; specifically, a basic sense of not abused. The Denver figures confirm the remarkable being worthwhile. It appeared to be this underlying frequency-6f child abuse (including sexual abuse) in basic feeling of worthlessness that our patients were the case histories of sex offenders elsewhere. unable to tolerate; it was easier or more comfortable The sex offenders in the Denver program, Dr. for them to experience anger and act on it than to Chapman- similarly noted, experience the same feel- experience the pervasive sadness that underlies their ings as other peoplefeelings of anxiety, guilt, superficial behavior." sadness, fear, self-distrust, worthlessness, and so on; Before dealing with this sadness and sense of but many of them lack the:vocabulary necessary to worthlessness, Dr. Chapman reports, the Denver identify these feelings verbally and to think about program sought to help the patient develop a "con- them. Because the feelings are unrecognized and ceptual framework" within which he could fit his life unlabelled,- they are not consciously associated with experiences and his responses to those experiences the internal and external events which trigger them. so that his life would begin to -make some sense to One of the Denver program's first goals, accordingly, the patient himself. "When the patient had begun to was "to teach the patient how to recognize his own feeling states" and their origins. "The methods by utilize the framework in a -way which enabled him to relate life events and feelings to-it, then-the therapist which this was accomplished were purely didactic. For example, we might simply ask the patient to could begin to work with the patient in exploring his underlying chronic feelings of worthlessness and describe a recent incident in which he felt anxious, alternatives to them. Typically, this- was the most nervous, angry, uptight, or, more generally, just felt painful time in therapy for the patient and `bad.' We then might- ask him to visualize the a time when his emotional resources were most stressed. It incident in his mind and describe how he felt as he followed that this. was the period in treatment when did this. We then would label the feeling for him, if the patient was the most likely to act out and the he was unable to do so himself, and-then generalized most dangerous of the offenders in the program were the label to other similar feelings and incidents in his most apt to recommit their crime. It behooves the experience." Further, a patient might be asked "to therapist to be alert to this and to encourage the practice monitoring his own feeling states between patient to I,his newly acquired controls instead of sessions and then to describe at his next appointment acting out. In some cases, medication or brief what he did about them. When the patient achieved hospitalization was needed at this point. It was also these simple skills, he-could then discuss his feelings true, in our experience, that once the patient grasped with significant others and with the project staff the significance, for him, of his underlying feelings of rather than act then out." In the process he also low esteem, he rather quickly made major changes learned -the kinds of incidents or events -that tended in his relationship -with others and in his lifestyle to trigger negative-feeling states. All this, of course,-generally." meant progress towardimpulse controlthatis, "the capacity to use cognitive skills to deal with problems Dr. Chapman adds that this approach to thesex rather than having to act out his, feelings in a sexual offender, though developed independently, closely assault." parallels an approach described by Dr. John R. Lion As in other programs, the Denver program found in 1975 (see Bibliography) for violent offenders in that "underlying the feeling states of anxiety, anger, general.

84 96 APPENDIX B. EVALUATION- OF SEX OFFENDER TREATMENT PROGRAMS By Daniel Glaser, Ph.D. Department of Sociology and Anthropology, University of Southern California, Los Angeles 90007

BA. Problems of Evaluation of their attainment? What research designs are desir- able and which are feasible? What distinctions among The- preceding pages describe a large variety of`cases should be most relevant to treatmentoutcome? relatively new treatment programs for sex offenders, Who should assess whom? For reasons that will be especially ,what seem to be proffising ways of indicated, in a majority of our states the answers to making these law violators less prone to repeat their these questions are much- more complicated -for sex crimes. But the innovations can now-be evaluated offenders than-forothertypes of criminals. only by intuition, by whether we feel -they make sense. It- is impressive that at several centers of- 8.2. Goals and Statisticalindicators=of-Their fenders who have misused people and have little Attainment regard for themselves.are inspired to help others in a responsible manner, and thereby develop more fa- Since a correctional agency is part of the criminal vorable self-concepts. It seems appropriate that het- justice system and is given control over people otiiV erosexual men who -were inept in seeking feminine because they are con Acted= of offenses, its- primary- affection are instructed in social-skills-for-developing treatment goal presuniabljt should be to reduce better relationships with women, and that this is recidivism rates. Since- a- mental hospital -is part of done witl female staff and volunteers. It is- logical the public health systeni, its goal-in patient treannent that persons whose crimes apparently are related to is to restore mental health, if possiblie. The fact that their =utter fantasies about- the psychophysiology of the sex offenders in many of the programs described sexual arousal in women, or in- some cases their in the preceding sections of this monograph are panic at normal changes- accompanying old age, are shuttled- back and forth-between-the-mental- health given realistic education in these matters. and criminal justice systems complicates evaluation Despite fine impressions and plausible justifica- of their treatment. Most of these programs deal with tions, no one can demonstrate with great precision persons committed in- civil- courts to-statehospitals sand conclusiveness that these new programs are under what were called "sex psychopath laws" (but more effective in reducinvex crimes thantraditional often have-more euphemistic names now) that apply prisons or mental hospitals.,-Case illustrations of both only to perSons whom criminal courts convict of sex success and failure in behaVior change can befound crimes. among the graduates of every long-establishedfacil- About 30 states have some type of civil commit- ity for sex offenders. -In the few instances where ment law for convicted sex offenders, but notwo of followup statistics are available that suggest a new these statutes are: identical. In a few states the law program's alumni commit fewer crimes, itis not applies in principle to a broader range of criminals clear whether this is because the program actually than sex offenders, to everyone whom some laws works better or just receives cases that have better call "defective delinquents" regardless of age, but in prOspects. practice even these stattites are used mainly for sex Evaluation is the process of obtaining more objec- offenders. In- several of -the states with the most tive and precise knowledge on what treatment works developed treatment programs, after someone is best for whom, and at what cost. Problems in convicted of a sex crime the court.may---and usually collecting this information become evident in consid- doescommit him (it is seldom applied to women) ering the-four broad questions that will be addressed to the mental hospital_ unit treating such cases for 30 here: What are the goals of treatment and the indices to- 90 days of observation and diagnosis. If the 97 85 hospital deems the offender amenable to treatment, rate when not committed to this program but jailed, the judge usually commits him to it for an indeter- imprisoned or placed on probation; (e) for those minate period, sometimes with an upper limit, and treated then released, the recidivism rates for differ- usually with a minimum frequency of reporting on ent categories of assessment of treatment progress; the patient's-progress. -(f) a variety of rates other than recidivism from Even after an offender receives civil commitment followup of cases after release, such as later- psychi- to a state hospital and treatment has been attempted atric diagnoses, personality test scores, divorce rates, for months or years, the hospital can in some states rates of disruptive use of alcohol or drugs, unemploy- return him to the court with the diagnosis that he is ment rates, and other data reflecting treatment goals; unamenable to treatment, often also advising (g) a breakdown of recidivism into separate rates by whether he is "sexually dangerous" or, in California, sex crime and other offense, or by particular types a "mentally disordered- sex offender." Whenever a of sex crime or other infraction. patient is returned to court, whether after the diag- Quite different but also diverse goals may be nostic period alone or after treatment beyond that, pursued simultaneously when offenders are on -pro- the judgenot bound by the hospital's diagnosis or bation with the stipulation that they participate in recommendationcan decide to impose a prison psychiatric treatment or conform to other probation sentence because the crime was serious and the man conditions. Unique goals also are associated with is regarded as dangerous; alternatively, the judge particular -types of offense. Thus in Santa Clara may release him, either dismissing the case or County'i distinctive program -for incest cases, de- placing the man on probation, often because the scribed in Sections 2.9 through 2.15, attainment of ,involuntary confinement already imposed in a hospi- various goals-may be indicated by such measures as tal and perhaps pretrial in jail is deemed more than (a) percent of families who participate in the pro- sufficient retribution for the crime. Thus a person w-am; (b) attendance rates in psychiatric outpatient convicted on misdemeanor charges for sexual peep- treatment for the father and sometimes for other ing or exhibitionistic "flashing," with many prior family members; (c)-rates of participation by fathers convictions for -the same offense, who shows no and mothers in Parents United; (d) rates of partici- insight or cooperation in treatment, may be returned pation by daughters in Daughters United; (e) percent to court by the hospital- as unamenable, but may of families that live together after the daughter then be released as confined already more -than the initially is placed- in a foster home; (f) incest recidi- criminal code's maximum penalty for the offense. vism rates; (g) incest recidivism rates separately for Yet if the hospital deemed him amenable, it might those families that participate in the program (re- hold him months longer for further treatment. Ulti- ported to be zero for the more than 90 percent that mately_the court, or in some states a parole board or do) compared with these rates for nonparticipants; a hospital board, decides on the release of an (h) marriage and divorce rates for girls involved in offender from hospital treatment, and sometimes at a incest and divorce rates for their parents, compared later date, on discharge from aftercare or from parole to averages for women in the county who are similar in the community. in age and other demographic characteristics; (i) These many types of decision, each-an exercise of probation violations other than incest. much discretion by judges or others, create a large For heterosexual offenderssuch as rapists, about variety of:2possible error rates that should be esti- 90 percent of child molesters, and almost all exhibi- mated for comprehensive evaluation of such pro- tionists and voyeursa goal of many of the treat- grams, as all are related to the goals of reducing ment programs described in preceding- sections is to recidivism and improving mental health. Such rates increase social and sexual skills in dealing with include: (a) the gercentage committed to hospitaliza- women. One measure of attainment, described in tion who later axe judged unamenable and returned Section 4.10, is a rating form developed by Dr. Gene to court for a new disposition; (b) the recidivism rate G. Abel at the Tennessee Psychiatric Hospital and for those deemed unamenable and dangerous but Institute in Memphis, which-is scored by observers released; (c) the recidivism rate for those deemed of videotapes made when the clients were conducting unarnenable but nondangerous and immediately re- conversations with women therapists or volunteers. leased, compared to those with the same diagnosis Also employed at this center and elsewhere are- jailed or imprisoned before release; (d) for those penile transducers which measure the rates of male deemed amenable, the recidivism rate when treated genital response to various legal or illegal stimuli, for in- the civil commitment program compared to the example, attractive adult women or small children.

86 98 The validity of these measures for prognosis of get and compare criminal records from all these normal or deviant sexual conduct can be determined sources; it usually is presumed= that statearrest by also procuring the ultimate criteria of treatment reports include local as well as other arrests,but outcome, rates of sex offense recidivism after re- often the local record is not fully included in the leak, and POssibly_rharriagt and divorce rates. state document due- to incomplete reporting, or re- Sometimes a change in public attitude and in- the cording, confusion of identities from aliases, and criminal law can alter the goals of a sex offender other sources of error. treatment program. Thus Section 3.2 indicates that Any official criminal record usually is incomplete, at Ataseadero State Hospital in California, anticipat- of course, since it does not include offenses for ing the 1976 change in- California Statutes which which the offender was not caught. Therefore, -it is decriminalized homosexual acts between consenting most important in evaluation by recidivism rates to adults In private, the previously futile efforts to use -the same sources of criminal record-information change those convicted for homosexual acts into for all groups comparedfor example, thOse in a heterosexuals orasexuals were abandoned. Instead, special treatment- program and similar offenders not persons associated with the GayLiberation Move- in it. It is then assumed that the proportion of error ment were brought in to teach these patients how to in recidivism rates is about the same in each grotip; be homosexuals legally by- seeking amorous contacts thus, an appreciable difference in official recidivism or conducting sex acts morediScreetly, and only rates of two large groups presumably showsthat with adults; goal attainment with them is indicated they actually have different postrelease crime rates; by low rearrest rates. because the recidivism of each group is underre- -Obviously, all the goals mentioned require assess- ported to about the,same extent. ments of change over time. This raises questionsof Information on-family relationships, employment; short-term versus longrun evaluation. It is best to get attitudes or sexual conduct not reflected in the both. Short-term followup data are attractive because criminal record, and even details on crime, often they give prompt feedback; they show outcome of require locating the subjects for interviews and treatment under conditions and with programs gen- perhaps also -talking to other people in their houseT erally not as different from those current as are holds. But such contacts are routine in the course of assessments of outcome for clients released five or surveillance and assistance- by probation, parole and ten years ago. Long-term evaluations caninspire aftercare officers. Sometimes clients receiving post, greater confidence in the validity of conclusions on release supervision are required to submit much effectiveness; also, the correlation- between- short - information relevant to evaluation, such- as their and -long -term findings indicate how much faith can employment and family status, in monthly reports. If be placed in early results. If long-term evaluations all cases compared for an evaluation study are indicate that treatment reduces recidivism rates, they released under these conditions throughout the fol- permit estimates of the financial savings achieved by lowup period, and -if supervision records and client diminishing rearrests, new court proceedings and reports are complete and standardized,they may correctional services, as compared with the cost of suffice for most evaluation studies.. Therefore, to effective treatment in the first place. Legislators and institutionalize routine feedback on the.effectiveness other funding decision-makers often are more im- of treatment efforts, the most efficient procedure is pressed by a cost-benefit assessment in terms of to make research and supervision records-identical. dollars than one in terms of human suffering averted For this purpose it is desirable that research person- or happiness attained. nel work with supervision officers -to develop -effi- The data needed for the various types of measure cient standardized forms, and that supervision re- described here have multiple sources of diverse cordkeeping be somewhat monitoredthereafter to adequacy. Recidivism rates of released sex offenders assure that complete and accurateentries are always can be tabulated from information on rearrests pro- made in them. cured from local police or probation offices, and local court records may show reconvictions. A more 8.3. Desirable and Feasible Evaluation adequate check is provided by current criminal Research Designs record forms (rap sheets) from state-criminal identi- fication bureaus or, if available, from the F.B.I. Evaluation always is done by making comparisons Supervision data from probation or parole offices of goal attainment in one group with goal attainment may also be useful. If resourcespermit, it is best to in another group, or in some circumstances, of the

87 99 same group's attainment at different times. For groups are quite largefor example, several hundred example, a type of treatment is evaluated when in eachas the larger the groups the smaller the postrelease record of offenders receiving it is com- probability of significant differences between them; pared with that of similar offenders not given it. (2) there is no interference at any time in the purely Sometimes-all -that -is- available are followup data random separation; and (3) all the-experimentals get on a treated groupso-called "one-shot followup the treatment and none of the controls receive it. data," such as the 6 percent recidivism of sex The laws of probability dictate that under these offenders in Wisconsimcited in Section 3.1. Then the circumstances not only identifiable traits, such as age only comparison that can,be made is with what is or offense, but even subtle personality differences imagined would be the record for an untreated group, only surmised by intuition or unknowable personal such as the cited recidivism rates of non-sex of- characteristics, -will be about equally distributed in fenders in Wisconsin. Unfortunately, it often is hard the two groups. to be confident that two groups for which we can Whenever there are suspicions that chance may procure postrelease data are comparable, and in the have caused important differences between randomly Wisconsin example they clearly are not. But, when selected treatment and control groups, as_,cali readily we can show -that sex offenders in one of the occur if they are small, the groups can Abe compared programs described on the preceding pages have on whatever objective characteristics are readily lower recidivism rates than those excluded from it, tabulated from the records, such as the percentage in does this prove -that the program was effective or every age, offense, or ethnic category. If this check-is that it only received the best risk cases, those who made before the assignments to the treatment pro- would= have low recidivism rates with no treatment? gram are announced, assignments can be revised by Is a program's success -rate due to the treatment it randomly selecting cases from each group to transfer provides or to its selection of cases? to the other until similarity in the proportion of each There are a number of alternative methods for of these key characteristics is achieved in the two making comparisons in order to evaluate programs. groups. Preferable, however, is assurance of similar- All have some advantages and some disadvantages. ity in advance by using stratified random sampling Usually not all are feasible. Therefore, it is appropri- procedures to assign people. Thus all eligible of- ate to be familiar with all of them, so that the -best fenders can first be divided into subgroups by method possible under the circumstances can be variables about which one is most concerned, such used, and its limitations known. Confidence in a as age or offense or some combination of these- and generalization oil the effectiveness of a type of other factors, and then each subgroup can be ran- treatment for a kind of offender is greatest when it is domly divided- into a treatment and a control group. the conclusion supported most consistently by differ- The next section will discuss the variables that ent varieties of research in diverse settings. research and theory suggest are most relevant to treatment amenability in sex offenders. In practice, many developments impede use of a B.4. Controlled Experiments controlled experimental design in evaluation: (I) The ideal evaluation design, in many respects, is Some offenders on their own initiative, or through the classical controlled experiment. For example, if staff -interested--in -them, .thinking-the treatment is there are twice as many offenders eligible for a desirable, sareptitiously get transferred from control treatment program as it can handle, make lists of all to treatment, or protest their exclusion so effectively those eligible and divide them randomly, admitting that they are transferred, or participate in the treat- half to -the program to comprise the treatment or ment even though they are in the control group (the experimental group, the other half being the control interference of a judge with a controlled experiment group. It need not be exactly half, provided there in Baltimore was cited in Section 4.3). (2) conversely, are appreciable numbers in both groups, if a purely some think the treatment will be stressful or will randomizing method (such as a statistician's use of a result in longer confinement, whether true or not, table of random numbers) is the basis for assignment and evade participation in it. (3) staff with a vested of some to treatment and some to control. interest in a program, wanting its evaluation to be There can be maximum possible confidence that favorable, interfere with the randomization proce- experimental and control groups are similar in every dure to get the most promising cases into treatment respect except whether or not they participated in a and the worst ones out. (4) some individuals object, treatment program to be evaluated, if: (I) these two on civil rights grounds, to any random assignment of

88 humans as undignified, even when there is no caught and convicted. The offenders may differ in conclusive evidence that deliberate selection for the the extent to which they have group support or treatment can be based on valid judgment unless it is stigma, due to variations in group norms such as evaluated rigorously (they want the treatment either those on homosexuality. given to-everyone or some nonrandom method used When the subjects being treated= have a = -long in assigning people to it). (5) there is the so-called history of repeatedly committing the same offense, "HawthorMe Effect," whereby people in any special they can be their own comparison group; their crime program have unusually good morale and "try rates in a several year period- before participating in harder," so the success rate with the experimental the treatment can be compared with their offense group-is not sustained when the treatment becomes rates afterwards. Of course, this may be biased by a routine. (6) administrators accustomed to transferring tendency for most offenders to "mature out" of their patients or clients on the basis of expediency, to crime, for their recidivism rates eventually to Wei- keep all work or residence space full, or to keep off as thtgrow older (although not so true for some their clients happy if they request a change, ignore sex crimes). If traditional patternsof tapering off experimentarresearch directives, often without noti- with age can be compared with the pre- to post- fying the office responsible for evaluation. (7) there treatment change of the evacuated group, it may be just are not enough sex offenders in the organization possible to judge whether the latter change is greater at a particular location to permit a meaningful than can be accounted for just by aging. Indeed, if random division, and they are received by ones or the sample studied includes subjects of considerable twos every few weeks, so they are absorbed into range in age and all age levels show similar tapering whatever treatment program seems appropriate and off following treatment, one -may have confidence available at the time, if they are interested in it. that the program is having an impact. Pre-post All the above- obstacles also impeded the develop- comparisons of.offense rates or other characteristics, ment of experimental medicine. Sometirmzs they such as employment or addiction, can be combined occur only on a small scale and can be takeninto with controlled or quasi-controlled experiments, account in analyzing results. Most of the time, since the pre-post data can be collected for both the hoWever, they preclude the possibility of evaluation treatment group and the control or comparison by controlled experiment and alternative designs group. must be attempted, often called "quasi-experiments." When it is evident that a treatment and a compar- ison group differ, and sometimes even if they are identicalwhen they are ideally randomized control groupsit is desirable not to compare all offenders B.5. Employing Comparison Groups participating in the treatment with all who do not, If random division of sex offenders into experi- but to make separate comparisons for each important mental and control- groups is not feasible, goal type of offender represented in both groups. Thus attainment rates of those in a treatment program can one can- determine goal attainment rates forrapists be compared with the rates of what are presumed to with and without treatment, for child molesters, and be similar offenders treated much .differently. These so forth. The objective is to determine what types of comparison or "quasi-control groups," most often treatment work best for what types of client. consist either of the sex offenders dealt with by the same agency before the -treatment program- was 8.6. Differences That Make a Difference introduced, or of sex offenders in another agency perhaps in- another city or statewhere the type of Sex offenders are an extremely diverse group. The treatment program being evaluated does not exist. kinds of persons who commit each major type of The obvious risk in quasi-experiments, as com- offense that sends people to the special- treatment pared with classical controlled experiments, is that programs described in this volume usually are quite the treatment and comparison group may differ in different. Indeed, few individuals commit more than respects that significantly affect the goal attainment one of these types of sex crime, although many often measured, perhaps more than does the treatment. repeat their particular kind of law violation. Further- Thus sex offenders dealt with previously or in more, there is appreciable variation within some of another city may be a different mixture due to these separate offense groups. variations in legislation, or in police or court policy, Exhibitionists practically never have a history of that determine what fraction of all sex offenders get rape or of much other crime. Although they startle

101 89 women by "flashing," they appear to be rather timid Classifying them in age groups also should be useful, towards them in- most 'situations, and not aggressive since one would expect different styles of treatment towards men. VoyeursPeeping Tomsusually are to be optimum for those under 30, for example, than thought of as the most passive sex criminals in their for those over 50. -offense,-but-a- record-of-rape-was-found in-about-ten Rapists vary considerably by the extent- of their percent of them in the largest study of sex offenders record in other crime and delinquency. The unspe- yet undertaken, begun by Kinsey and completed by cialized offenders have a fairly high rate of recidivism Gebhard and associates after Kinsey's death. Most by other types of crime, rather than by rape. Those peepers had been unspecialized delinquents, with a convicted only once for rape generally are very good record of burglary quite frequently, and peeping by risks on parole without any special treatment. There some may have been done only when they happened are grounds for some research for expecting the upon an attractive sight while prowling for burglary rapist with a prior history of participation in delin- or even rape opportunities. Most peepers, however, quency and youth crime of various sorts to have a were more passive sexually. Until our very limited higher recidivism rate from psychotherapeutic pro- knowledge is enhanced by more rigorous statistical grams than from traditional corrections, trade train- research on these two types of offenders, it seems ing and halfway house release. Thus distinctions appropriate to investigate treatment outcome sepa- should be made among rapists by type of prior rately on each. criminal or delinquent record, if any, assessing Incest is a unique type of offense, best compre- treatmentieffectiveness for them separately. hended by study and treatment of all family members involved. Therefore, as indicated earlier, treatment 11.7. Who Should Evaluate Whom? evaluation for them may require distinctive types of data and where they are treated- with other sex Although the public's goals .11 sex offender treat- offenders, it seems appropriate to assess effective- ment programs, such as reducing recidivism and im- ness separately for them. proving skills and attitudes of clients, will be voiced Child molesters are a rather mixed group. About by program administrators, in practice their conduct half the arrestees only fondle the child, but it usually is often guided as- much or more by other goals. is alleged that in doing this they touch breasts or These include: (a) maximizing rewards and security genitals, while the rest go further; some attempt in their jobs; (b) reducing stress in their work; (c) coitus, others commit fellatio or persuade the child procuring public support and funding for their to -do it to them. They are of a very wide range in agency; (d) maintaining staff morale; (e) keeping age, from adolescents to old men. About a third are clients contented. These staff goals, of course, are involved- only with children who are strangers to not necessarily incompatible with each other or with them and they usually confine themselves to fon- public goals, although they may be at times, and they dling, while those engaging in coitus or fellatio are may also conflict with the public's interest in obtain- more often of the same household or a neighbor of :ng valid evaluations of the attainment of its goals. the child. Some problems from administrators already were Child molesters have very high recidivism rates on indicated in discussing the feasibility of research parole in most state correctional systems, but some designs. Frequently the priority they give to admin- civil commitment programs emphasizing psychother- istrative convenience, favorable evaluations, or sat- apy and sex education, such as California, claim that isfying clients, lead to their impeding not only these offenders have low recidivism rates. This controlled experiments, but rata collection of many contrast suggests that child molesters are particularly types for all varieties of evaluation. Researchers amenable to treatment, and therefore, that evaluation assessing a- treatment program need rapport -with efforts should attempt- to make separate assessments staff, however, for the evaluators must= observe the of their responses to alternative programs, rather treatment activities, and interview clients and staff, than group them with all other sex offenders in to = ascertain that what is claimed -is the type of estimating treatment effectiveness. Nevertheless, fur- treatment conducted actually -is going on. Their ther distinctions seem- appropriate if the number of reports to evaluate a trentmeot program by followup cases Termit, between child molesters who only of clients also should, as objectively as. possible, fondle children who are strangers to them, and those describe the frequency and quAity of participation in involved in more extensive and continuing genital the treatment effort; as indicated in discussing treat- activities with youngsters whom they- see frequently. ment goals, such participation- comprises a separate

90 102 goal that merits evaluation. In all such inquiries, tive, and masks reality. Administrators are especially treatmOt staff have both an interest and possible likely to avoid the kinds of situations that give them conflicts of interest. "trouble," that caused stress for them, and to base To maximize the validity of evaluations itis their policy on avoiding recurrence of the episodes desirable that reseaithers be familiar withsthe treat- that they talk about for years. Often this habit leads ment being assessed, yet have autonomy in assessing to a resistance to change and to avoiding undertak- itThey need good rapport with the treatment ings that would increase their contribution to societal personnel, administrators and clients, yet must be goal attainment, such as recidivism reduction. responsible to a .higher office of government, to the There is no simple formula for assuring regular faculty of _a university, to an independent research guidance of practice and policy by feedback from foundation or to the board of trustees of a private research, but the best guarantee is to have a lont- treatment agency, for the accuracy -of their feelings. established full -time research staff at an office higher The- affiliation of researchers often influences -the up in the government hierarchy than the immediate cooperation they receive in a treatment center, the treatment center. The research office.should..be,at- a_ priority they give to different topics of inquiry, and level of government high enough to support it, to the promulgation of findings that they favor. All give it some autonomy, and to cause treatment these considerations, plus the- size and resources of center directors and staff to feel obliged to cooperate a treatment agency, and the treatment goal attain- with it in evaluations. ment that- is to be measured, may determine an Staff of an evaluation research office will be most optimum answer to the question- of who should effective if not only well-trained, but if oriented- to conduct an evaluation. their job as a career rather -than as an adjunct to In today's era of scientific perspectives, and of their graduate study or movement to a university strict accountability expected from those who ex- faculty. Staff ability is proven not so much by pend public funds or control the liberties of people, academic laurels as by completed- research reported interest- in making systematic inquiry and obtaining in a manner that both administrators and the public objective answers- should begin with the treatment can understand and appreciate,, yet scientifically center directors. Often they can conduct small-scale acceptable-to sophisticated academics. Persons who evaluation studies, not-so much of their program as have had scientific training but have been long a whole as of specific practices and procedures. preoccupied in administrative or clinical work often Thus the topical focus of group therapy sessions and prove unsuccessful in shifting late in life to a research the participation it evokes from various clients can position, though there arc exceptions; on the other be systematically tabulated from tapes, question- hand, people who have worked-in treatment agencies naires can periodically summarize client and staff while training for research, then soon move into full- reactions to various features of a treatment program, time research, often retain the rapport- and under- aril extension of suchsurvey_s to successful alumni standing of treatment clients, staff and circumstances may reveal the aspects of a treatment program that that can make their research concerns most relevant rehabilitated offenders find most useful in their and valid. They can also work well to institutionalize subsequent lives. evaluation by developing and monitoring, in- collabo- Treatment center directors, however, usually are ration with treatment and operations staff, records so pre_ occupied with the daily pressures of opera- that serve the geas of all thgespeciAties simulta- tions, with making today's program work and solving neously, and most efficiently. quickly any immediate problems, that they cannot be Research corporations, foundations and institutes, depended on to give even research they desire the as well as universities, are especially useful for one- regular concentration it requires. They, therefore, time evaluation studies to address basic theoretical tend to start or merely contemplate more research questions,.or-guide-future,agency research. Univerei- than they complete, and drift into assessing -their ties have interests in testing theoretical explanations operations by impressions. In- such impressions, for sex offender conduct anchexplaining why partic- however, the loudest voices get the most attention, ular modes of treatment are effective or ineffective, and cases or events that confirm their prior opinions that go beyond evaluation and are most likely to or preferences become the basis for their generaliza- suggest imaginative new approaches. University per- tions. sonnel also are expected to be on the forefront; of Without systematic studies, that which is cited to international accumulation of knowledge, and thus justify policies and practices is often unrepresenta- be familiar with innovations, theory, and research

1 0 3 91 developed elsewhere that may be fruitful locally. To treatment center personnel, their supervising higher maximize -the contribution of each to the improVe- officials of state or local government, interested merit of treatment services, continual communication university specialists, and evaluation researchers at ,should be structured, formally and informally, among all levels.

104

92 APPENDIX C.DIRECTORS OF TREATMENT PROGRAMS FOR SEX OFFENDERS

California Henry King, M.D., Acting Clinical Director Sex Offender Treatment Program Dr. Henry Giarretto. Director North Florida Evaluation and Treatment Center Child Sexual Abuse Treatment Program Gainesville, Florida 32601' Juvenile Probation Department County of Santa Clara Maryland 84D Guadalupe Parkway San Jose, California 95110 Jonas R. Rappeport, M.D., Project Director Alfred J. Rucci. M.D., Medical Director Outpatient Treatment Clinic for Special Offenders Atascadero State Hospital Institute of Psychiatry and Human Behavior Drawer A University of Maryland Atascadero, California 93422 645 West Redwood Street Baltimore, Maryland 21201 Richard and Rosemary Bryan SOANON (Sex Offenders4%nonymous) Michael Spodak. M.D. P.O. Box 8287 Ann Falck, R.N. --Van -Nuys, California 91409 Office of Psychohormonal Research Phipps Clinic Seyniour Pollack, M.D.. Director The Johns Hopkins Hospital Program for Sex Offenders Baltimore, Maryland 21205 Institute of Psychiatry, Law and Behavioral Sciences Los Angeles County/University of Southern California Medical_ Center Massachusetts Room 132 1237 No. Mission Road Richard J. Boucher, Acting Director Los Angeles, California 90033 Massachusetts Center for the Diagnosis and Treatment of Sexually Dangerous Persons Dr. Frank Vanasek Box 554 Program for Sex Offenders Bridgewater, Massachusetts 02324 Patton State Hospital Patton, California 92369 Minnesota Colorado Richard Seeley. Director Dr. Nancy M. Steele Sex Offender Program Treatment Program for Sex Offenders Minnesota Security Hospital Colorado State Reformatory St. Peter, Minnesota 56082 Box R Buena Vista, Colorado 81211 William W. Duffy, Executive Director Center for Behavior Modification, Inc. Florida 3001 University Avenue, S.E. Dr. Geri Boozer Minneapolis, Minnesota 55414 Treatment Program for Sex Offenders Dr. Patrick Carnes South Florida State Hospital Sex Offender Treatment Program 1000 S.W. -84th Avenue Fairview Southdale Hospital Hollywood, Florida 33023 6401 France Avenue South Benjamin Ogburn, M.D., Director Edina, Minnesota' Sex Offender Progam Forensic Unit Florida State Hospital Chattahoochie, Florida 32324 ' Launched too late for inclusion in this survey.

93 1 New Jersey Tennessee

William Prendergast, Director of Professional Services Gene G. Abel, M.D., Director Adult Diagnostic and Treatment Center Program for the Evaluation and Treatment of Sexual Aggres- Lock Bag,R sions Rah Way, New Jersey 01065 Department ofPsychiatry. College of Medicine

FrederickR_otgers, Director of Psychology University of Tennessee Center for the Health Sciences Treatment Program for Sex Offenders 865 Poplar Avenue, 4-East State Prison Memphis, Tennessee 38104 Trenton, New Jersey 08625 WaShington New Mexico. George J. MacDonald, M.D., Clinical Director Mr. Phil Encino Treatment Center for Sexual Offenders Alternatives, Inc. Western State Hospital P.O. Box 1280 Fort Steilacoom, Washington 98494 Albuquerque, New Mexico 87103 Robert W. Deisher, M.D. Pennsylvania Juvenile Sex Offender Program Adolescent Clinic Ms..:Linda Meyer, Acting Dieector Division of Adolescent Medicine Center for Rape Concern Room CD 287 Philadelphia General Hospital CDMRC 34th Street & Civic Center -Blvd. University of Washington Hospital Philadelphia, Pennsylvania 19104 Seattle, Washington 98105

106

94 BIBLIOGRAPHY

While this survey is based primarily on site visits to the treatment programs described and on interviews at the sites, published and unpublished &nutrients were used to the extent available. These are listed below by section number.

Part I.General Considerations Steilacoom, Washington." Undated, unpublished paper. 21 pp. Lt.- 1.9. General Considerations Western State Hospital, Treatment program for sexual of- Gebhard, Paul H., Gagnon, John H., Pomeroy, Wardell B. fender's. "Guided,self-help/a new approach to treatment & Christenson, 'Cornelia V.Sex Offenders.New York: of sexual offenders/annual report, July I973-June 1974." Harper & Row, 1965. 923 pp. Unpublished paper. 18 pp. 1.2. "Sex Fiends" vs Sex Offenders Williams, Robinson A. "Community adjustment of treated Krafft-Ebing, Richard von.Psychopathia Sexualis.Franklin sexual offenders." Unpublished paper. January, 1971. 12 S. Klaf, Trans. New York: Stein & Day, 1965. 434 pp. pp. 1.4. Impact of Ned' Public Policies Toward Sex Williams, Robinson A. "Washington State's sexual psycho- Searle, Carole Anne. "A study of sexual offenders in Canada path law: a review of twenty years' experience." Unpub- and a proposal for treatment, 'we can.' " Unpublished lished paper. January, 1971. 7 pp. paper. April, 1974. 88 pp. 2.6-2.9. The South Florida Program 1.6. "New Directions in Treatment" State of- Florida, Mental Health Program Office, Hospital Resnik, H. L. P. & Wolfgang, Marvin E. "New directions in Section. "Evaluation of sex offender rehabilitation pro - Ihetreatment of sex deviance."InResnik, H. L. P. & grams-in the state of Florida." Undated, unpublished Wolfgang, Marvin E., Eds.Sexual Behaviors: Social, paper. 67 pp. Clinical, and Legal 4spects. Boston: Little, Brown & Wells, Arthur H. "The South Florida State Hospital pro- Company, 1972.pp. 397-412. Also. publishedin Interna- gram." Undated, unpublished paper. 25 pp. tional Psychiatry Clinics, Treatment of the Sex Of- 2.10-2.15. The Santa Clara County Program fender, v.8. no. 4: 211=226. Anderson, Judith. "Everyone suffers in the family."San Francisco Chronicle,April 15, 1974. Part II.Five Innovative Programs Anderson, Judith. "When the whole family breaks down, the 2.1-2.5. The Fort Steilacoom Program trauma of incest."San Francisco Chronicle,April 16, Denenberg, R. V. "Sex offenders treat themselves."Correc- 1974. tions Magazine, v.I, no. 2: 53-64. December, 1974. Giarretto, Henry. "Humanistic treatment of father-daughter Hall, David. "Usefulness of group psychotherapy marathons incest." Undated. unpublished paper. 26 pp. in treatment of the habitual sexual offender." Unpub- Gustaitis, Rita. "Incest: help for the victim ... and the lished paper. January, 1971. 3 pp. offender."The Washington Post,June 16, 1974. pp. K4, Hendricks, Larry. "Some effective change inducing mecha- K5. nisms in operation in the specialized treatment program Santa Clara County Juvenile ProbatiorhDepartment. "Child for the sex offender." Unpublished paper. April 1975. 24 sexual abuse treatment progam." Undated, unpublished ,pp. paper. 7 pp. Hitchen, Emily Wurster. "Denial: an identified theme in 2.16.-2.17. Program for Juvenile Sex Offenders, Seattle marital relationships of sex offenders."Perspectives in Clark, Toni F. & Henry, William E. "Report on the male Psychiatric Care, v.X, no. 4: 153-159. 1972. juvenile sexual offender, organization of treatment, final MacDonald, George J., Williams, Robinson, & Nichols, H. report." Unpublished paper. February. 1975: 89 pp. R. "Treatment of the sex offendera report on the first Deisher, Robert W. "The juvenile sex offender." Undated, 0 years of a hospital program." Unpublished paper. unpublished paper. 13 lip. November- I, 1968. 23 pp. MacDonald, George J. & di Furia, Giulio. "A guided self- 2.18.-2.20. The Albuquerque Program help approach to the treatment of the habitual sex Alternatives, Inc. "Policy for the delivery of services." offender." Unpublished paper. January, 1971. 9 pp. Undated, unpublished paper. 10 pp. Nichols, H. R. "Effect of treatment of the habitual sexual Bevins, Marian. "PASO (positive approaches to sex of- offender as measured by the Minnesota multiphasic fenders) final narrative report." Undated, unpublished personality inventory." Unpublished paper. January, paper. 18 pp. 1971. 7 pp. Kirschner Associates, Inc. "An evaluation, client and court Seely, Richard K. "Report on study of the treatment program opinions on the PASO program." Unpublished paper. for the sexual offender, Western State Hospital, Fort January 14, 1974. 10 pp.

95 Part III.Four Other Institutional Programs Mosbach, William C., Jr. "A.C.T./awarenens through con- scious thought (para-professional group therapy pro- The Norwalk Program (1948-1954) gram)." Unpublishedpaper.May, 1976. 3 pp. The Committee on Psychiatry and Law of the Group for the Parsons, Edward. "K.E.Y./knowledge from exploring your- Advancement-of Psychiatry. "Psychiatry and sex psy- self (para-professional group therapy program)."-Unpub- chopath legislation: the 30's to the 80's." Undated, lished paper. February. 1976. 3 pp. unpublished paper. 117 pp. Prendergast,W. E., Jr. "R.O.A.R.E./P.D.R./patient directed Pomeroy, Wardell.Dr. Kinsey and the Institute for Sex responsibil:ty." Undated, unpublished paper. 7,pp. New York: Harper & Row, 1972. pp. 211- Research. Prendergast, W. E., Jr."R.O.A.R.E.Ire-educationof atti- 214. tudes (and) repressed emotions (A.D. and T.C. intensive Sutherland, Edwin H. "The diffusion of sexual psychopath group therapy program)." Unpublished paper.April, laws." American Journal of Sociology,v. 56. Septem- 1976. 8 pp. ber, 1950. pp. 142-148. Raymunt, Stanley. "Introduction to a new para-professional Jour- Sutherland, Edwin H. "The sexual psychopath laws," therapy group B.A.R./broadening alcbholic rehabilita- nal.of Criminal Law and Criminology,v. 40, no.5:543- tion." Unpublished paper. April, 1976. 3 pp. 554. January-February, 1950. Serrill, Michael S. "Treating sex offenders in New Jersey." 3.2. The Atascadero Program Corrections Magazine, v.I, no. 2: 13-24. November/ Atascidero Stateliospital. "Mentallydisorderedoffender /a December, 1974. in programs .." new look ... a new outlook .. . 3.4. Minnesota Security Hospital (St. Peter) Programs Undated, unpublished paper. 5 pp. Minnesota Security Hospital. "The experimental phase of Burkhardt, Paul L. "A learning treatment approach for the BEAD program for sex offenders at the Minnesota involuntary committed sex offenders." Undated, unpub- Security Hospital; summary overview." Un- lished paper. 7 pp. published paper. 6 pp. Goodman, Alan S. "The teaching of interpersonal communi- Minnesota Security Hospital. "ProposaTfor use of a satellite cations skills." Unpublished paper. September, 1974. 11 unit for the Minnesota Security Hospital," Unpublished PP. paper. March I, 1976. 15 pp. disordered Hitler. Robert E. "Treatment of the mentally The Task Force on- Anti -Social Sexual Behaviors. "Adden- offender and his family." Undated, unpublished paper. dum to the report on sex offenders: a_ sociological, 11 pp. psychiatric, and psychological study." Unpublished -pa- treatment for homosexuals in Keith, Claudia G."Specialized per. January 14, 1974. 40 pp. institutions." Unpublished paper. September, 1974. II pp. Part IV,Five Other Community-Based Programs Laws, D. R. "HosPital in revolution: behavioral treatment for the mentally ill offender." Unpublished paper. Sep- 4.2. Center for Rape Concern, Philadelphia tember, 1974 7 pp. Peters, Joseph J. "Children who are victims of sexual assault Laws, D. R. and Pavcowski, A. V., "An Automated Fading and the psychology ofoffenders." American Journal of Procedure to Alter Sexual Responsiveness in Pedo- Psychotherapy, v.xxx, no. 3: 398-421. July, 1976. Peters, Joseph J. & Sadoff, Robert L. "Clinical observations; philes."Journal of Homosexuality1:149-163, 1974. VanDeventer, A. D. and Laws, D. R., "Orgasmic Recondi- on child molesters."Medical Aspects of Human Sexual- tioning to Redirect Sexual Arousal in Pedophiles," ity, v.iv, no. II: 20-31. November, 1970. Sexual Behavior Laboratory, Atascadero State Hospital, Peters, Joseph J. & Roether, Hermann A. "Group psychoth- Resnik, H. L. Atascadero, California 93422. erapy for prohationed sexoffenders." In Rada, It T.. Laws, D. R.. and Kellner, R., "Plasma P. ,& Wolfgang, Marvin E., Ed.Sexual Behaviors: Testosterone Levels in the Rapist."Psychosomatic Social, Clinical, and Legal Aspects.Boston: Little, Company, 1972. pp. 255-266. Medicine38:257-268 (1976). Brown & Peters, Joseph J., Pedigo. James M., Steg, Joseph & Mc- Serber, Michael. "The Atascadero project: model of a sexual Kenna. James J. "Group psychotherapy of the sex retraining program for incarcerated homosexual pedo- Federal Probation,September, 1963. Journal of Homosexuality, v.1, no. 1: 87-97. offender." philet." Peters, Joseph J. & Resnik. H. L. P. "Probationed paedo- 1974. philes: treatment results with out-patient group psy- 33. The Adult Diagnostic and Treatment Center, Avenel, New chothera,..j."Excerpta Medica International Congress Jersey Series No. 150, Proceedings of the IV Congress of Adult Diagnostic and Treatment Center. "Annual report, Psychiatry, Madrid, 5-11, September, 1966.pp. 3073- July I, 1975 to June 30, 1976."'Unpublished paper. 16 3076. -pp. Peters, Joseph J. & Sadoff. Robert L. "Psychiatric services Brancale, Ralph, 'Vuocolo, Alfred. & Prendergast, William for sex offenders on probation."Federal Probation, E., Jr. "The New Jersey Program for SexOffenders." September, 1971. pp. 33-37. InResnik, H. L. P. & Wolfgang, Marvin E.. Eds. Peters. Joseph J. "The psychological effects of childhood Sexual Behaviors: Social, Clinical, and Legal Aspects. rape."World Journal of Psychosynthesis,v. 6, no. 5: Bcston: Little, Brown & Company, 1972. pp. 331-350. 11-14. May, 1974. Leftwich, Jerome. "M.O.R.E./motivate ourselves thru re- Peters, Joseph J. "Success and failure of sex offenders." search (and) experimentations (para-professional group Sixth Philadelphia Judicial- Sentencing Institute, The therapy program)." Unpublished paper.September, Dangerous Offender,Cherry Hill. New Jersey, January 1975.3 pp. 26 & 27, 1973. pp. 36-42. 96 108 Resnik, H. L. P. & Peters, Joseph J. "Outpatient group Abel. G. G., "Assessment of Sexual Deviation in the Male." therapy with convicted pedophiles." The International Hersen, M. and Bellack, A. S. (eds.), Behavioral Journal of Group Psychotherapy, v. xvii, no. 2: 151- Assessment: A Practical Handbook, Pergamon Press., 158. April,` 1961. New York, 1977. Roether, Hermann A. & Peters, Joseph J. "Cohesiveness Abel, G. G., Blanchard, E., and Becker, J., "The Psycholog- and hostility in group psychotherapy." American Jour- ical Treatment of Rapists." In Clinical Aspects of the nal of Psychiatry, February, 1972. pp. 128-131. Rapist, Grune & Stratton, New York, in press. Sadoff, Robert L., Roether, Hermann A. & Peters, Joseph J. Barlow, David H. & Abel, Gene G. "Recent developments "Clinical measure of enforced group psychotherapy." in assessment and treatment of sexual deviation." In American Journal of Psychiatry, August, 1971. pp. 116- Craighead, W. E., Kazdin, A. E. & Mahoney, M. J., 119. Eds. Behavior Modification: Principles, Issues, and Steg, Joseph & Peters, Joseph J. "Outcome study on 39 Applications. Houghton Mifflin, Atlanta, 1977. exhibitionists." World Journal of Psychosynthesis, v. 6, Barlow, D. H. and Abel, G. G., "Sexual Deviation." In no. 7: 36-39. July, 1974. Craighead, W., Kazdin, A. and Mohoney, M. (eds.), Behavior Modcation: Principles, Issues, and Applica- 43. C.sstratien and Reversible Chemical Castration tions, Houghton Mifflin, Atlanta, 1976. Stump, Georg K. "Castration: 6e -total treatment." In Kohenberg, Robert J. "Treatment of a homoxual pedo- Resnik, H. L. P. & Wolfgang. Marvin E., Eds. Sexual philiac using in vivo desensitization: a study." Beh.aviorS. Social, Clinical, and Legal Aspects. Boston: Journal of Abnormal Psych'' t92-403. 1974. Little, Brown & Company, 1972. pp. 361-382. Veatch, Robert M. "Incarcerate or castrate?" Hospital Physician, July, 1976. pp. 34-37. -Pattlr.-Conclusions altditecomniendations 4.4. Phipps Clink Program, The Johns Hopkins Hospital, 5.1. The Need for Statewide Planning -Baldmare,-Maryland Correctional-Service of-Minnesota, Community-Planning-and Money, John:Diseussion in Michael, R. P., Ed. Endocrinol- Research Division. "Sex offender study, newsletter no. ogy and Human Behavior. London: Oxford University I." December I. 1976. 15 pp. Press, 1968. pp. 169. Money, J., Wiedeking, C., Walker, P., Migeon, C., Meyer, W. & Borgaonkar, D. "47,XYY and 46,XY males with 5.12. Release Provisions antisocial and/or sex-offending behavior: antiandrogen Powers, Sanger B. "Wisconsin's mutual agreement pro- therapY plus counseling." Psychoneuroendocrinology, v. gram." In American Correctional AssoCiation. Proceed- i: 165-178. 1975. ings: Second National Workshop on Corrections and Money, John. "The therapeutic use of androgen-depleting Parole Administration, San Antonio, Texas, March, hormone." In Resnik, H. L. P. & Wolfgang, Marvin E., 1974. American Correctional Association Parole Correc- Eds. Sexual Behaviors: Social, Clinical, and Legal tions Project Resource Document #4. 1974..pp. 5-12. Aspects. Boston: Little, Brown & Company, 1972. pp. 351-360. Also published in TheJournal of Sex Research, v. 6, no. 3: 165-172. August, 1970. Appendix A. Nine Additional Treatment Programs A.1. Center for the Diagnosis and Treatment of Sexually 4.6. Program at the University of Tennessee-Tennessee Dangerous Offenders, Bridgewater, Massachusetts Psychiatric Hospital and Institute, Memphis Cohen, Murry, Groth, A. Nicholas & Siegal, Richard. Abel, Gene G., Barlow, David H., Blanchard, Edward B. & "Clinical prediction of sexual dangerousness." Unpub- duild, Donald. "The components of rapists' sexual lished paper. August 20, 1975. 20 pp. arousal." Undated, unpublished paper. 37 pp. Cohen, Murry L. & Kozol, Harry L. "Evaluation for parole Abel, Gene G., Blanchard, tilward B., Barlow, David H. & at a sex offender treatment center." Federal Probation, Mavissakalian, Matig. "Identifying specific erotic cues September, 1966. pp. 50-55. in-sexual deviations by audiotaped descriptions." Jour- Cohen, Murry L., Garafalo, Ralph, Boucher, Richard & nal oRpplied Behavior Analysis, no. 3, Fall, 1975 pp. Seghorn, Theoharis. "The psychology of rapists." Sem- inars in Psychiatry, v. 3, no. 3: 307-327. August, 1971. Cohen, Murry L., Seghorn, Theoharis & Calmas, Wilfred. Abti, Gene G. & Blanchard, Edward B. **The measurement and generation of sexual arousal in male sexual de- Sociometric study of the sex offender. Journal of Abnor- mal Psychology, v. 74, no 2: 249-255. 1969.1 viates:: In Hersen, M., Eisler, R. & Miller, P. M., Eds. Kozol, Harry L., Cohen, Murry L. &- Garofalo, Ralph F. Progress in Behavior Modification, Vol. II. New York: The criminally dangerous sex. offender." New England Academic Press, Inc., 1975. pp. 99-136. Journal of Medicine, v. 275: 79-84. July 14, 1966. Abel, Gene G., Blanchard, Edward B. & Mavissakalian, Kozoi, Harry L. "Criteria of dangerousness in human Matig. "The relationship of aggressive cues to the sexual personality." Transactions of the American Bar Associ- arousal of rapists." Unpublished paper. September 3, ation, 1966-1967. 1974. 11 pages. Kozol. Harry L. "The medico-legal problem of sexually Abel, Gene G. & Blanchard, Edward B. "The role of fantasy dangerous persons." Acta Medicinal Lega!is et Social's, in the treatment of sexual deviation." Archiv-s of no. 2, Avril-Jerin, 1963. General Psychiatry, v. 30, April, 1974. pp. 467-4 ". Kozol, Harry L., Boucher, Richard J. & Garofalo, Ralph F. 97 109 "The diagnosis and treatment of dangerousness." Crime five hundred se.)ffenders." Criminal Justice and Be- and Delinquency, October, 1972. pp. 371-392. havior, v. 1, no. I: 13-20. March. 1974. Gelber, David. "Bridgewater: six days inside the state's Pacht, Asher R. & Roberts, Leigh M. "Factors related to institution for sex offenders." The Real Paper, Novem- parole experience of the deviated sex offender."Journal ber 20, 1974. pp. 5-12. of Correctional Psychology, v. 3, no. 3. January-Febru- Gelber, David.The baron of Bridgewater." The Real ary, 1968. 7 pp. Paper. December 4, 1974. pp-4-8. Pacht, Asher 12,, Halleck. Seymour L. & Ehrmann, John C. Gelber, David. "The patient/prisoner perplex." The Real "Psychiatric treatment of the sex offender." In Current Paper. December 18, 1974. pp. 4-10. Psychiatric Therapies, Vol. //, Grune & Stratton. Inc., McGarry, A. Louis & Cotton, Raymond D. "A study in civil 1962. 9 pp. commitment: the Massachusetts Sexually Dangerous Pacht, Asher R.The rapist in treatment: professional myths Persons Act." 'Harvard Journal on Legislation,v. 6: and psychological.realities." In Walker, M. & Brodsky, 263-306. 1969. S. Sexual Assault, D. C. Heath & Company, 1976. pp. Sarafian, R. "Treatment of the criminally dangerous sex 91-97. offender." Federal Probation, v. 27, 1963. p. 52. Roberts, Leigh M. & Pacht, Asher R. "Termination of Tenny, Charles W., Jr. "Sex, sanity, and stupidity in inpatient treatment for sex deviates: psychiatric, social Massachusetts." Boston University Law Review. v. and legal factors." American Journal of Psychiatry, v. -no. I: 1-31. Winter, 1962. 121, no. 9. March 3, 1965. IS pp. Uehling, Harold F. "Ten years of group psychotherapy at A.2. The Florida State Hospital (Chattahoochie) Program Wisconsin State Prison." Federal Probation, Marsh, State of Florida. "Sexual offender program-Florida State 1962. 14 pp. Hospital:"-Undated, unpublished paper. 6 pp. Wisconsin State Department of Public Welfare. Bureau of State-of-Florida. -Department of Health and- Rehabilitative Research. "Wisconsin's-firSt eleven years of experience Services. "A proposal for a comprehensive community- with its sex crimes law, July 1951 through June 1962." Jmsed treatment program for sex offenders in North Statistical Bulletin C/46. Madison, Wisconsin. Unpub- Florida." Undated, unpublished paper. 6 pp: lished paper. April, 1965. 18 pp. State of Florida, Mental Health Program Office, Hospital Section. "Evaluation of sex offender rehabilitation pro- A.S. The Colorado State Reformatory (Buena Vista) Program grams in the state of Florida." Undated, unpublished Steele. Nancy M. "Sex offenders treatment program, mental health- department. Colorado State Reformatory." Un- paper. 67 pp. published paper. April, 1976. 3 pp. A.3. The Patton State Hospital (California) Program A.7. Outpatient Treatment Clinic for Special Offenders, Patton State Hospital. "Proposed charter of the Patton Baltimore, Maryland patients representative body." Undated, unpublished Olsson, James E. "Final evaluative report: an outpatient paper. 3 pp. treatment clinic for special offenders." Unpublished' Patton State Hospital. "Psychiatric rehabilitation: personality paper. July, 1975. 70 pp. -disorders (projected program)." Unpublished paper. Jan- Rappeport, Jonas R. "Annual report, fiscal year 75-76. uary. 1974. 4 pp. Outpatient Treatment Clinic for Special Offenders." A.4. The %coign Program (1951-1970) Undated, unpublished paper. 26 pp. Anderson, Raymond E. "The exchange of tape recordings as A.S. Program of the University of Southern California Institute a catalyst in group psychotherapy with sex offenders." of Psychiatry and the Law, Los Angeles International Journal of Group Psychotherapy, v. xix. Pollack, Seymour. "Manual for the Institute on the Sex no. 2. April. 1969, -7 pp. Offender and the Law." Unpublished ,paper. August, Cowden, James E. & Pacht, Asher R. "The sex inventory as 1972. a classification instrument for sex offenders." Journal of Pollack, Seymour. "Manual on -the sex offender and the Clinical Psychology, v. xxv, no. 1: 53-57. January, 1969. law." Unpublished paper. 1972. Halleck, Seymour L. & Pacht, Asher R. "The current status of the Wisconsin State Sex Crimes Law." Wisconsin A.9. The Denver Program (1974-1976) Chapman, Harry. "The treatment of the sex offender in the Bar Bulletin, December,-I960. 13 pp. Halleck, Seymour L. "The physician's role in management community." Undated, unpublished paper. 14 pp. of victims of sex offenders." The Journal of the Ameri- Selkin, James. "Behavioral analysis of rape." Undated, can Medical Association, v. 180, April 28, 1962. pp. unpublished paper. 13 pp. Selkin, James. "A community approach to sexually deviant 273-278. Jesse, Franklin C., Jr. "Comments, criteria for commitment behavior." Unpublished paper. May, 1974. 20 pp. under the Wisconsin Sex Crimes Act." Wisconsin Law Appendix B.Evaluation of Sex Offender Review, v. 1967. Fali, no. 4: 980-987. Treatment Programs Pacht, Asher R. & Halleck, Seymour L. "Development of mental health programs in correction." Crime and Delin- B.L-B3. Evaluation of Sex Offender Treatment Programs quency, January, 1966. 10 pp. Glaser, Daniel. Routinizing Evaluatiom-Getting-Feedback Pacht. Asher R., Halleck, Seymour L. & Ehrmann, John C. on Effectiveness of Crime and Delinquency Programs. "Diagnosis and treatment of the sexual offender: a nine- National Institute of Mental Health, Center for Studies year study." The American Journal of Psychiatry, v. of Crime and Delinquency, DHEW Publication No. 118, no. 9: 802-808. March, 1962. (HSM) 73-9123. Washington: U.S. Government Printing Pacht, Asher & Cowden, James E. "An exploratory study of Office, 1973. 202 pp. 98' e U.S. GOVERNMENT PRINTING OFFICE: 1978 0-249 -058 1 1. 0 PRESCRIPTIVE PACKAGE:"Treatment Prograhls for Sex Offenders"

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