La inclusión educativa con desafíos en el escenario de la nueva obligatoriedad

The recognition of cognitive distortions in offending behaviour was fundamental in influencing rehabilitation (e.g. Lipsey et al., 2001) and Abel and Blanchard’s (1974) work emphasised the importance of deviant fantasies and thought patterns in sexual offending, and of addressing these rather than focusing just on the reduction/elimination of overt behavioural manifestations of deviant desires alone.

The cognitive behavioural model utilises the relationship between thoughts, feelings and behaviours, seeking to identify and address automatic thoughts and core beliefs that translate into sexual offending behaviours. For example, seeing a woman in a short skirt and experiencing the automatic thought (a cognitive distortion) of “she’s looking for sex”

can translate into a core belief regarding a sense of entitlement (Figure 4) and potentially underlie an act of rape.

Figure 4: Breakdown of automatic thoughts and core belief in response to seeing a woman in a short skirt

Current CBT programmes stem from addiction models used to treat disorders of impulse (Laws et al., 2000). In considering sexual offending within such framework, treatment not only seeks to reform behaviours as described above, but also provides the second aspect of Wade and Jong’s (2000) ‘treatment’ aspect of rehabilitation in providing support in the form of relapse prevention. These feature as maintenance strategies (Larimer & Marlatt, 2004), enabling an offender to (i) recognise high-risk situations (antecedents to offending, such as risky thought patterns, ‘chain’ behaviours on the offending cycle, or parallel behaviours), and (ii) manage high risk strategies (awareness of the determinants of relapse, use of adaptive coping strategies, seeking support and utilising protective factors identified in treatment) (Laws et al., 2000; Hanson, 2000).

As such, typical CBT treatment programmes consist of challenging cognitive distortions and attitudes consistent with offending, increasing victim empathy and developing a relapse prevention plan to aid in the self-management of risk factors (Laws et al., 2000). For sex offenders with intellectual disabilities, they also include a sex education and relationships

AUTOMATIC THOUGHT: "She's looking for sex"

"She looks sexy" "I find her attractive"

"I want to have sex with her" CORE BELIEF:

"I'm entitled to have sex with her because I

component as well as teaching the cognitive model (as described above) and, a (simplified) version of the offending cycle (see Figure 1: Finklhor Model).

Seminal rehabilitation theory concepts of Risk, Need and Responsivity feature heavily in traditional offending treatment programmes (Andrews & Bonta, 2007, 2011). The Risk- Need-Responsivity model (RNR) incorporates an assessment of: (i) the potential harm that an individual poses to society through re-offending (risk), (ii) their dynamic risk factors or criminogenic needs (need), and (iii) their engagement or accessibility to treatment (responsivity). For example, an individual at a high risk of sexually reoffending would be recommended a higher intensity treatment than someone who is at a lower risk, with the treatment programme being tailored (as far as is possible owing to a number of practical, theoretical, financial and resource restraints) to the individual’s learning or engagement style to address their individual criminogenic needs. Responsivity concerns not only the offender or individual at risk, but also the therapist and programme components. It can be divided into internal and external responsivity, with the former referring to the individual’s internal characteristics such as personality, cognitive ability, etc. and the latter

encompassing the actual techniques used in delivering the treatment and the relevant environmental factors (Serin & Kennedy, 1997).

Treatment programmes using the RNR model have historically utilised avoidance goals in treatment. These operate on the premise of inhibiting behaviour in order to refrain from committing a sexual offence. However, some research has shown poorer treatment outcomes in focusing on avoidant goals, in contrast with approach goals (aiding the

individual in working towards gaining something) which show better results for engagement and investment in treatment and not returning to offending behaviours (Mann et al., 2004). There is a great deal of empirical support for the principals within the RNR model (e.g. Bonta & Andrews, 2007; Duwe, 2015), however it is not unchallenged and a number of criticisms have been levelled at the RNR model and those advocating the recidivism-risk approach. These include a preoccupation with the offender’s ‘risk profile’ and disregarding social or contextual factors, as well as a passive approach to therapy and the above-mentioned focus on avoidance goals (Duwe & Kim, 2018; Ward & Maruna, 2007).

Alternative approaches to the RNR model, stem from a strength-based treatment paradigm which proposes that treatment includes personal growth and social development. Such treatment models draw on theories discussed in Section 1.2 and 1.3, including Marshall and Barbaree’s (1990) Integrated Model of Sexual Offending and Ward and Siegert’s (2002) Pathways Models, which seek to explain sexual offending beyond deviant interests and to incorporate poor social skills, attachment problems, and interpersonal/intimacy difficulties. Strength-based approaches are predicated on the idea that by incorporating the individual’s strengths and protective factors into treatment and assisting them in developing pro-social skills and alternative, adaptive methods of meeting their needs, will assist in reducing criminal behaviour (Ward & Brown, 2004; Aspinwall & Staudinger, 2003).

An example of a strengths-based programme is The Good Lives Model (GLM) (Ward & Brown 2004; Ward & Marshall, 2004) which argues that focusing on risk alone is not sufficient to reduce recidivism. The GLM proposes that in addition to risk reduction, treatment programmes should aim to improve the individual’s quality of life and/or their ability to lead a more fulfilling life – ‘the good life’. The GLM hypothesises that offenders attempt to attain primary ‘goods’ (relationships, sense of acceptance, achieving mastery, autonomy, etc.) (Ward, Mann and Gannon, 2007) through maladaptive strategies and/or have insufficient means to achieve a good life. The model seeks to address these

insufficiencies and promote attainment of pro-social goals, equipping offenders with the skills and abilities to do so. The treatment strives to do this in addition to managing risk, proposing that anything which is seen as beneficial or advantageous by the individual will be more motivational and likely to result in internalised, lasting change (Ward, Mann and Gannon, 2007). Although developed separately, the GLM incorporates positive psychology (e.g. Seligman & Csilszentmihalyi, 2014; Aspinwall & Staudinger, 2003) and the

criminological ‘strain theory’ approach discussed in Section 1.2 (Agnew, 1992), in treating sexual offending.

The GLM is a relatively new model, therefore the evidence-base and empirical support are limited. However, work by Lindsay et al. (2007) has shown promising results and the theoretical grounding has led to suggested adaptations for individuals with intellectual or developmental disabilities and children and young people (Ayland & West, 2006;Malovic et al., 2018).

Despite reported inconsistencies, recidivism rates of sexual offending are generally lower than non-sexual recidivism (Hanson & Bussière, 1998). However it should be noted, as identified in Section 1.1, that there is wide recognition of persistent under-reporting of sexual abuse/assault (Davies & Leitenburg, 1987; Furby et al., 1989), including in those with intellectual disabilities (Murphy, 2007).

The spheres of efficacy in sexual offending treatment could be widened to include measures of rehabilitation success such as personal development and reduced frequency or severity of abuse. However, issues remain regarding how severity of abuse for a victim could be measured and, indeed, whether non-criminogenic needs or behaviours are pertinent to the Criminal Justice System or fall within the realm of health and social services.

Findings regarding recidivism rates following CBT treatment for sexual offenders are inconsistent, with some studies reporting very small or no effects (see Schmucker & Lösel, 2008), however most studies show reliable and positive effects. For example, a meta- analysis of specialised psychological treatment by Gannon and colleagues (2019) reported a 32.6% reduction in sexual recidivism following sexual offending treatment, and recidivism rate of 9.5% for treated individuals compared to 14.1% in untreated individuals. The meta- analysis further identified that consistent facilitation of treatment by a qualified licensed psychologist (rather than occasionally present or not present) in a group (as opposed to individual treatment or a mixture of group and individual) was associated with decreased sexual recidivism, as was regular staff supervision. In addition, supervision effects were optimal when provided by a psychologist. Despite a large evidence-base of studies, and whilst not advocating as strong a position as Martinson, questions have been raised over the efficacy of CBT programmes for sexual offenders in reducing re-offending. For example, Cochrane reviews in 2003 and 2012 demonstrated no significant difference in CBT

approaches over other forms of treatment for sexual offenders, and within the Gannon et al. meta-analysis higher reductions in sexual recidivism were noted when CBT was paired with a behavioural component (some form of arousal reconditioning), compared to CBT programmes without (or behavioural components were unknown) The 2003 Cochrane review showed a positive ‘trend’ in reduction in recidivism using group CBT approaches, however this was not found in the 2012 review. Furthermore, a recent evaluation of the National Offender Management sexual offending CBT treatment programmes (Core SOTP)

reported that treated sex offenders committed more re-offences than non-treated (10% compared to 8%) over an average follow-up period of 8.2 years (Mews Mews, Di Bella & Purver, 2017).

However, rather than citing this inconsistency as evidence that treatment is ineffective, it has been suggested that these discrepancies may be the result of methodological issues or difficulties in attaining ‘quality’ research, such as the challenges associated with conducting randomised controlled trials and identifying appropriate comparison populations , rather than the efficacy of the treatment itself (Dennis et al., 2012; Duggan and Dennis, 2014; Hanson et al., 2009; Marshall & Marshall, 2007;Mews et al., 2017; Sturgeon et al., 2018). Furthermore, Gannon et al.’s (2019) meta-analysis of sexual offending treatments included the Mews et al. paper and still reported significant reductions in sexual recidivism for treated offenders compared to non-treated (with the paper excluded10 _{a larger effect and} higher significance levels were found). Undertaking randomised control trials with control groups raises ethical issues in withholding or delaying access to treatment. Alternatively, the use of ‘drop out’ or ‘treatment refusal’ groups as a comparison has the potential to bias findings due to motivational or individual variables differing between the treatment and control group participants (Långström, 2013). Gannon et al. (2019) attempted to address this caveat in rating the quality of the studies included within the analysis, including the matching of control and treatment group participants. Their findings illustrated that

recidivism reductions in violence and sexual offending in specialised treatment programmes were impacted little by study design and matching of participants (Gannon et al., 2019). Whether coming from the RNR model or a strength-based approach, there has been recent debate over the relevance of some components within sex offender treatment programmes (e.g. victim empathy) and whether they have any impact upon the individual’s decision to offend. Both RNR and strength-based programmes include addressing victim empathy, however a meta-analysis by Hanson et al. (2005) demonstrated that only deviant sexual interests and anti-social behaviour/personality was predictive of sexual recidivism (this was found in both adults and adolescents). Within this analysis, Hanson et al. also looked at

10 _{Random and fixed effects models were calculated to include and exclude the Mews et al. paper due to the} sample size rendering the paper an outlier.

psychological distress, denial and stated motivation in addition to victim empathy levels and found no relationship between these and recidivism.

Regardless of the ongoing challenges and deficiencies identified in CBT models of sexual offending treatment, programmes are available both for individuals with intellectual and developmental disabilities and those without, in mental health and forensic settings from community and secure services, as well as in prisons and via probation services (Marshall, 1996; Lindsay et al., 1998; Rose et al., 2002). This approach remains current best-practice, with a number of empirical studies, systematic reviews and meta-analyses advocating its continued use for both non-intellectual disabilities (e.g. Marshall, Fernandez & Serran, 2003; Losel et al, 2005; Mews et al., 2017) and intellectual disabilities groups. Systematic reviews exploring the use of such treatment programmes for individuals with intellectual disabilities continue to advocate for the use of such programmes with positive treatment outcomes identified in changes of attitude, sexual knowledge and empathy (Cohen & Harvey, 2016; Jones & Chaplin, 2017; Marotta, 2017). However similarly to neurotypical reviews, these reviews highlight the low quality of study methodologies, short follow up periods and need for more stringent investigation with adequate control-comparison groups before being able to draw conclusions regarding reductions in recidivism following treatment.

1.4.3 Alternative Treatment Approaches to CBT