Thus, the assessment of such patients is enhanced by combining traditional assessment techniques and psychological testing with tools targeted at offending cognition and behavior.
Treatment modifications
Psychotherapeutic treatment of individuals with serious mental illness often has to be flexible enough to accommodate the intrusion and distractions of psychotic symptoms. This flexibility is not always built into structured and confrontational interventions that are designed to break the cycle of sexual offender recidivism. In the same way that substance abuse treatment had to be modified to address the needs of the patients with mental illness who also abuse substances, we need to think creatively about how to reach the individual with mental illness who is also a sexual offender.
Two approaches are used at our hospital: psychoeducation and modified relapse prevention. The psychoeducational intervention, "Intimacy and Coercion," is predicated on the notion that many patients have social-skills deficits, do not correctly perceive or interpret social cues, and are not familiar with the concept of intimacy and coercion. To that end, the group's coleaders explore the differences between appropriate social interaction and coercive interaction in a nonjudgmental atmosphere. By using neutral examples from commercial films, patients are not forced to speak about their own offenses. The coleaders replay relevant scenes, point out salient features, and initiate brief discussions. Individuals may cycle through the group more than once, which allows for needed repetition of concepts. Pretesting and posttesting provide efficacy and evaluation data. We found that, over time, patients began to share details of their offending behaviors, even though it was not a necessary part of the group interaction.
The focus of the relapse prevention group is to identify the specific inappropriate behavior of the participants, delineate the cycle of events that led to the behavior, and devise a prevention plan. There are some important modifications made to customize this treatment modality for patients with mental illness (as opposed to sexual offenders without mental illness). First and foremost, the recurrent intrusion of symptoms and deficits required the coleaders to deviate from a straightforward, sequential learning of relevant concepts. Not all intrusions were managed. Crucial offense-cycle material was revealed through the psychotic associations of some members. Again, repetition was critical. Treatment goals and concepts had to be reviewed in almost every session. Additional coaching was provided in individual sessions for homework assignments (eg, writing offense-cycle scripts).
Psychopharmacological treatment for the mentally ill sex offender begins with treating the underlying psychiatric disorder, particularly when the origin of the sexually inappropriate behavior falls within the psychosis or seriously mentally ill circle. A decrease in delusions, hallucinations, impulsivity, hostility, and hypersexuality can be associated with decreased untoward sexual behavior. When more specific psychopharmacological intervention is required, SSRIs may provide a decrease in libido and an increase in impulse control.
Although we have not used specialized agents to date, there are no specific contraindications to the use of other libido-decreasing agents such as depot-leuprolide acetate or medroxyprogesterone in a population with serious mental illness. Androgen reduction therapy with depot-leuprolide acetate is being used in other facilities to treat individuals with paraphilias and those who have a predisposition to sexual aggression. This strategy usually is implemented after pharmacological treatment of other psychiatric disorders has been optimized and after trials of SSRIs (personal communication, Richard Krueger, December 2006). (The prescription of SSRIs and depot-leuprolide acetate for the management of sexual impulsivity is considered off-label use.)
Summary
I have herein described our approach to treating individuals with serious mental illness and sexually inappropriate and/or offending behavior. This approach is based on 2 key principles: (1) recognition of our responsibility to address all the untoward behaviors with which our patients present and that can lead to problems with their successful community reintegration; and (2) recognition that sexual offenders with mental illness are a subpopulation of offenders and their unique clinical contributions to their sexually inappropriate behavior require modifications in assessment and treatment. In particular, we have learned that our targeted assessment must also include a screening for cognitive deficits, given the prevalence of low IQ scores among the offenders.
In addition, we have found routine psychological testing valuable in delineating the patient's underlying condition and diagnosing personality disorder as well as uncovering sexual ideas, preoccupations, distortions, and delusions that may not be evident in structured or general clinical interviews. With respect to treatment, our patients can learn about general offending behavior and their specific risk issues, but the intervention requires active leadership, repetition, and an expectation for a nonlinear process of learning and recovery.
The most refractory symptoms that preclude recovery appear to be denial and impulsivity, but a decrease in sexually inappropriate behavior has been achievable in our inpatient setting. Outpatient follow-up that continues to target this behavior would seem to be critical to maintain inpatient gains.
The treatment of individuals with sexual offending behavior remains a controversial area within mental health care, particularly in its increasingly popular form (ie, involuntary civil commitment to psychiatric hospitals). However, making attempts to address all of the needs of those patients who come to us with more traditional indications for psychiatric care should and can include the assessment and treatment of sexually inappropriate behaviors.
