With reference to their offending behaviors, the majority (56%) offended with adult females only; 16% were exclusively pedophilic. About half of the offenses involved violence, but the vast majority of patients (79%) scored very low on the Rapid Risk Assess-ment for Sexual Offense Recidivism (RRASOR). The RRASOR is a 4-item scale that examines prior sex offenses, current age, victim gender, and relationship to victim to rate the potential for recidivism.
This cohort of sexual offenders represented an actuarially low-risk, heterogeneous group who were diagnostically distinguishable from sexual offenders without mental illness. The approach to assessment and intervention should be equally distinguishable.The approach
The assessment approach my colleagues and I advocate begins by examining the overlapping causes of sexual offending behavior with which our patients present (Figure). The 3 Ps—psychosis, paraphilia, and psychopathy—are our shorthand for the various contributions of serious mental illness, primary sexual deviance, and underlying character pathology, respectively.
Serious mental illnesses (eg, schizophrenia or bipolar disorder) may be associated with delusions, command hallucinations, or impulsivity and hypersexuality that drive the offending behavior; the associated social dysfunction or awkwardness may also be a contributing factor. Individuals with paraphilias are, by definition, driven primarily by inappropriate sexual desires. Those with character pathology, such as psychopathy, may be so grossly self-centered and unempathic that the offending behavior fits in with a pattern of self-serving and rule-breaking behavior in other arenas.
Each of these P components requires a unique intervention, some of which are more associated with traditional mental health treatment than others. Our patients often present with 2 or more of these factors, but this template is a good starting point for structuring our thinking. (Substance abuse, a well-established risk factor for sexual offending behavior, may exacerbate the predispositions driven by any of the Ps.)CASE EXAMPLES
A 43-year-old man with the diagnoses of schizophrenia and polysubstance abuse, characterized by auditory hallucinations, delusions of control, and suicide attempts was admitted to a hospital upon conditional release from prison. He was incarcerated for the rapes of a 3-year-old and a 5-year-old. He had a history of a "revenge" rape of a 5-year-old at the age of 13.Case 2
A 28-year-old with the diagnosis of schizophrenia and polysubstance abuse characterized by delusions, hallucinations, agitation, and thought disorder, was admitted from the local hospital. The patient's presentation was noteworthy for a history of obscenity and public lewdness in the community, exhibitionism, and touching women in the hospital.Case 3
A 56-year-old with a diagnosis of schizophrenia was admitted to the hospital upon conditional release from prison where he had been incarcerated for multiple rapes of women committed over several weeks. The patient's history included early antisocial behavior; his presentation on admis-sion was characterized by severe negative symptoms.
General characteristics particularly associated with sexual offending behavior include deviant sexual interest, cognitive distortions, anger management difficulty, poor social skills, denial, and lack of victim empathy. Although these characteristics may be present in sexual offenders without mental illness, they may be a symptom of, or exacerbated by, an underlying mental disorder.
In a person with mental illness, deviant sexual interest may be related to the hypersexuality of a manic phase in bipolar disorder or a response to the command hallucinations in schizophrenia. Common cognitive distortions, such as a pedophile who thinks that children want to have sex with him, may rise to the level of a delusional belief that a sexual relationship with a child actually exists. One patient with whom we worked had the delusion that he himself was a child; thus, he reasoned that his sexual interest in children was as a peer rather than as a partici-pant in an adult-child relationship.
Negative symptoms of mental illness are often associated with poor social skills that can exacerbate a tendency toward sexually inappropriate behavior. Denial, in a seriously mentally ill person, may also rise to the level of a delusional belief that nothing occurred, making it harder to confront than with a nonmentally ill sexual offender. Finally, victim empathy presumes a differentiation between self and others that may not be present, especially when an individual is in the throes of an acute decompensation.Assessment procedure
The assessment should begin with a thorough chart review followed by a clinical interview, informed or structured by the Psychopathy Checklist Screening Version (PCL-SV). The structure of the PCL-SV captures the general psychiatric and psychosocial information necessary for diagnosis while focusing on areas of interpersonal relationships, conflict, and criminality that are particularly relevant in an offending population. The data collected are used in the service of an actuarial risk assessment to determine level of risk that, as noted above, is usually low. Most commonly, we use the aforementioned RRASOR. While there are more comprehensive actuarial tools, we have the data to complete the RRASOR on all of the cases we assess. In addition, our focus in clinical treatment planning is on the assessment of the dynamic risk issues (eg, diagnosis, symptoms, and cognitions).
Our assessment of the patient's cognitive functioning includes batteries specific to sexual offenders as well as routine psychological testing. Through broad-prompted inquiry, the offender-specific batteries seek to uncover the range of deviant sexual interest and behavior as well as cognitive distortions that may go along with these behaviors and desires.
Routine psychological testing includes both personality disorder assessment tools, such as the Personality Assessment Inventory and the Minnesota Multiphasic Personality Inventory, and projective testing, such as the Thematic Apperception Test (TAT) and Person Object Drawing and Rorschach tests. In persons with mental illness, these tests have the added value of improving diagnostic accuracy and uncovering internal events such as psychotic experiences, sexual and nonsexual fantasies, distorted cognitions, and unrealistic perceptions of self and others. For example, when presented with a TAT card depicting a man and older woman looking down pensively, one patient reported, "They had words and now he's standing up looking at a corpse he can't see. He's thinking of who he can f**k next." As with some of our other patients, the projective testing opened up an area of sexually and violently charged ideation for this patient who, when confronted directly, calmly denied sexually inappropriate interest or activity.