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Offender variables and treatment outcomes of participants in a residential sex offender program

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Offender variables and treatment outcomes of participants in a residential sex offender program
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Shaw, Theodore A., 1945-
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vii, 146 leaves : ; 29 cm.

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Antisocial personality disorder ( jstor )
Criminal offenses ( jstor )
Criminal punishment ( jstor )
Criminals ( jstor )
Marital status ( jstor )
Medical treatment outcomes ( jstor )
Prognosis ( jstor )
Psychological assessment ( jstor )
Sex offenders ( jstor )
Treatment programs ( jstor )
Behavior therapy ( lcsh )
Counselor Education thesis Ph. D
Dissertations, Academic -- Counselor Education -- UF
Psychotherapy ( lcsh )
Sex offenders -- Rehabilitation -- Florida ( lcsh )
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bibliography ( marcgt )
non-fiction ( marcgt )

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Thesis:
Thesis (Ph. D.)--University of Florida, 1991.
Bibliography:
Includes bibliographical references (leaves 138-145).
General Note:
Typescript.
General Note:
Vita.
Statement of Responsibility:
by Theodore A. Shaw.

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University of Florida
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Copyright [name of dissertation author]. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
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OFFENDER VARIABLES AND TREATMENT
OUTCOMES OF PARTICIPANTS IN A
RESIDENTIAL SEX OFFENDER PROGRAM











By

THEODORE A. SHAW


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


1991






















Copyright 1991

by

Theodore A. Shaw
















ACKNOWLEDGMENTS

I would like to acknowledge the following

individuals: my doctoral chairperson, Dr. Ellen

Amatea, for her never ending patience and perseverance;

my doctoral committee members including Dr. George

Barnard, Dr. Harry Grater, Dr. Larry Loesch, and Dr.

Gus Newman for their support and guidance; Lynn Robbins

for her friendship and invaluable assistance; Denny

Gies and the administration and clinical staff of North

Florida Evaluation and Treatment Center; and the

dedicated staff of the Sex Offender Unit of NFETC.

I would also like to acknowledge my wife, Dr.

Jamie Funderburk, for her patience and continuing

support, guidance and technical assistance, my

children, Amanda and Alex, for their patience with my

preoccupation, and my mother, Micki, who has always

inspired me to greater achievement.


iii

















TABLE OF CONTENTS

page

ACKNOWLEDGMENTS............................. ......... iii

ABSTRACT.............................................vi

CHAPTERS

1 INTRODUCTION............................... 1

Scope of the Problem........................ 4
Need for the Study......................... 13
Purpose of the Study...................... 14
Research Questions......................... 15
Context for the Study..................... 16
Definition of Terms....................... 18
Significance of the Study.................. 20

2 REVIEW OF LITERATURE...................... 22

Research on Sex Offender Treatment
Amenability.............................. 22
Basic Assumptions, Techniques, Settings,
Populations Treated (Focus), Research
Findings and Related Literature......... 36
Treatment Center Study/Setting............. 45
Treatment Amenability Factors............. 57
Independent Variables..................... 62
Treatment Outcome Categories.............. 72
Summary..................................... 75

3 METHODOLOGY................................ 76

Research Design ........................... 77
Population ............................... 80
Resultant Sample.......................... 82
Procedures................................ 83
Instrumentation......................... 91
Hypotheses................................. 96











Data Processing and Analysis.............. 97

4 RESULTS .................................. 98

Descriptive Statistics for Treatment
Outcome Groups........................... 99
Differences Among Treatment Outcome
Groups.................................... 100
Summary ................................... 114

5 DISCUSSION................................ 116

Discussion of Results..................... 116
Limitations............................... 123
Implications.............................. 127
Summary and Conclusions................... 135


APPENDIX.......................................... 136

REFERENCES........................................ 137

BIOGRAPHICAL SKETCH.. ............................. 144
















Abstract of Dissertation Presented to the Graduate
School of the University of Florida in Partial
Fulfillment of the Requirements for the Degree of
Doctor of Philosophy

OFFENDER VARIABLES AND TREATMENT
OUTCOMES OF PARTICIPANTS IN A
RESIDENTIAL SEX OFFENDER PROGRAM

by

Theodore A. Shaw

December, 1991

Chairperson: Ellen Amatea, Ph.D
Major Department: Counselor Education

Growing awareness of the frequency of sexual abuse

and its terrible impact on victims and society has led

to the development of more systematic approaches to the

evaluation and treatment of sex offenders. Little is

known concerning which treatment models and settings

are effective with which populations of sex offenders.

This study was conducted to examine the relationships

among six offender variables and offender outcome

status in a residential sex offender treatment program

which emphasized a multi-modal treatment approach. The

six offender variables were (a) age, (b) reading

ability, (c) degree of discrimination in the selection

vi











of victim and offense type, (d) instant offense

(offense for which the offender is currently

incarcerated), (e) presence of antisocial personality

disorder, and (f) marital status. The three

categories of treatment outcome were (a) not amenable

for treatment, (b) amenable for treatment but

discharged with a poor prognosis, and (c) amenable for

treatment and discharged with a good prognosis.

Results of a discriminant function analysis revealed

that the six offender variables together did not

discriminate significantly among offenders in the three

outcome groups. Results of analyses of variance and

Chi-square analyses revealed that offenders who were

married or in a committed relationship and offenders

who had higher reading ability were more likely to be

found in the treatment group discharged with a good

prognosis than in the other two treatment status

groups. Presence of antisocial personality disorder,

degree of discrimination in offense or victim type,

age, and instant offense did not discriminate

significantly among offenders in the various outcome

groups. Limitations, implications for theory and

clinical practice, and recommendations for future

research are also discussed.

vii
















CHAPTER I
INTRODUCTION

The challenge of treating sex offenders has taken

on new importance in light of the staggering reports on

frequencies of types of sexual abuse and rising

awareness of the human and financial costs of coping

with the problems ineffectively. Of particular concern

are the increased reports of rapes of adult women and

men as well as reports of intrafamilial and

extrafamilial child sexual abuse. Recent research

reveals that a pattern of repeated, unreported offenses

is more the rule than the exception among sex offenders

(Barnard, Fuller, Robbins, & Shaw, 1989; Finkelhor,

1988; Furby, Weinrott, & Blackshaw, 1989; Knopp, 1984;

Salter, 1988). In their study of 411 parapheliacs,

Abel and associates discovered that these subjects had

engaged in over 138,000 sex offenses involving over

115,000 victims (Abel, Becker, Mittelman, Cunningham-

Rathner, Rouleau, & Murphy, 1987). Moreover, many had

never been arrested, few had ever been incarcerated,

and most had never received specific sex

offender treatment.













The enormous financial and psychological costs to

victims and society are major factors that underscore

the need to treat sex offenders. Through reports by

sociological researchers such as Finkelhor and

clinicians working in the relatively new Adults

Molested As Children (AMACS) movement, it is clear that

vast numbers of men and women have been sexually

victimized and that such victimization has profound

traumatic effect on these individuals (Burgess, Groth,

Holmstrom, & Sgroi, 1978).

Growing awareness of sex offense problems has led

to the development of many specialized treatment

program efforts for sex offenders. For example, a

national survey of adult and juvenile residential and

outpatient sex offender programs conducted by Knopp and

Stevenson in 1989 revealed that between 1986 and 1988

the number of specialized treatment programs increased

by 56% nationwide, to a total of more than 1000.

Relatedly, of the adult treatment services polled, 28%

(119) were residential, the majority of which were

located in adult prisons, and 72% (310) were

outpatient, the majority of which were provided by

mental health private practitioners. There was a

similar distribution for juvenile services: 20% (117)












were residential, with almost half located in private

facilities, and 80% (456) were outpatient, with about

the same number provided by private practitioners and

mental health centers. However, the demand for

specialized sex offender treatment continues to outpace

its availability. In Florida, for example, by 1989

more than 5000 sex offenders were incarcerated in the

prison system. Of these, more than 300 were found

eligible (i.e., met entry criteria) for treatment and

had been placed on a waiting list. Although only 75

offenders were admitted to treatment that year, more

than 150 had been placed on the waiting list. As in

Florida, many states are facing situations where

treatment opportunities are limited by funding which

determines the number of available treatment beds.

With many more offenders in need of treatment than

available beds, it becomes crucial to determine which

offenders might profit most from specialized treatment.

There is little empirical evidence available,

however, concerning who is most likely to benefit from

sex offender treatment (Abel, Mittelman, Becker,

Rathner, & Rouleau, 1988; Laws, 1985), and few studies

have been undertaken to determine treatment specific

amenability. Because most of the current research on













sex offender treatment has focused only on examining

official and unofficial reports of rearrest,

reconviction, or self-report of reoffense as measures

of treatment outcome, the present state of knowledge

regarding amenability in terms of interim measures such

as the offender's status at the time of discharge from

treatment is relatively sparse. Therefore, the

correlation among six offender characteristics and

three sex offender treatment outcomes was examined in

this study.


Scope of the Problem

Because the development and widespread use of

specialized treatment procedures for sex offenders are

relatively recent, very little is known regarding

either the types of treatment procedures most effective

with particular types of sex offenders or

characteristics which distinguish offenders who benefit

from particular treatments from those who do not.

Although syndromes relating to sexual deviance have

been known to the medical/psychological field for

centuries, organized approaches to treating and

assessing the impact of treatment of this population












are relatively recent (Barnard et al., 1989; Greer &

Stuart, 1983).

The problem with outcome research in the sex

offender treatment area is less one of quantity than

methodology, particularly in regard to outcome

measures. In a recent review of the state of tne art

of sex offender treatment outcome research, Furby et

al. (1989) concluded that it has not been adequately

demonstrated that specialized sex offender treatments

reduce recidivism more effectively than other

strategies (including no treatment).

Recently, researchers have begun to evaluate

critically both the quantity and quality of research on

sex offender treatment. For example, in reviewing the

recent research on sex offender treatment, Murphy

(1988) contended that current providers of sex offender

treatment still know very little about the efficacy of

any of their treatment approaches and that much more

research needs to be done to speak with assured

confidence about the nature of specialized treatment of

sexual abusers. In commenting on the lack of

definitive research in this area, Murphy (1988)

criticized the methodology used in sex offender

treatment research and proposed a set of questions to












guide future research. Among these was, "Which

offender characteristics predict amenability for which

treatment?" Other researchers have concurred that a

key issue in improving sex offender treatment efficacy,

as well as in development of clearer understanding of

treatment impact for sex offenders, centers on

identifying those individuals most likely to benefit

from treatment (Abel et al., 1989; Furby et al., 1989;

Knopp, 1984; Marshall & Barbaree, 1988, 1990; Murphy,

1988; Shaw, Spears, Cunningham, Butler, Barnard,

Robbins, & Newman, 1987).

Only a limited number of researchers have examined

the characteristics of offenders as a means of

predicting success in completing sex offender

treatment. Further, most researchers who have examined

offender characteristics have focused predominantly on

outpatient populations (in the community) and have done

so secondarily to some other research focus. Their

findings from outpatient samples suggest that offenders

who are relatively more intelligent (Marshall &

Barbaree, 1988), have stable marital relationships

(Abel et al., 1988), have committed only one type of

sex offense on only one type of victim (e.g., among

pedophiles only) are likely to complete treatment












successfully and have relatively low recidivism rates

(Abel et al., 1988). Little is known, however,

regarding the amenability for treatment of incarcerated

offenders in secure treatment programs (i.e., prisons

or maximum security mental institutions) where fear of

reprisals, presumed relatively high prior offense

rates, low socioeconomic status, and minimal

educational attainment are likely to be factors

negatively influencing amenability (Knopp, 1984).

Populations of incarcerated offenders are likely to

contain fixated (i.e., repetitive) pedophiles, rapists,

and other violent offenders who are routinely excluded

from outpatient treatment due both to the obvious risk

to the community and their high likelihood, even on a

first conviction, to be incarcerated instead of

receiving probation or community control based on the

perceived seriousness of their offenses (Knopp, 1984).

Because of these factors, the findings of studies based

on outpatient samples appear to have limited

generalizability to incarcerated offenders.

Despite limited empirical investigation, however,

it has been customary for practitioners treating

incarcerated sex offenders to assume that not all sex

offenders are amenable for treatment and to screen












potential treatment candidates based on these

assumptions (Schwartz, 1988b). Because there are

limited empirical data, guidelines for determining

amenability for treatment usually have been established

on the basis of clinical judgment, tradition,

limitations of the treatment setting (including

therapeutic skills of the clinicians), or funding

considerations. New Jersey, Minnesota, and Oregon, for

example, are among the few states that offer rapists

the opportunity for treatment because they have long-

established, secure residential treatment facilities

(Knopp, 1984).

Among the assumptions commonly used to select

offenders for treatment is the notion that sex

offenders with antisocial personality disorders are

less likely to complete treatment successfully due to

their documented history of frequent job changes,

adolescent conduct problems and unwillingness to follow

rules (Abel et al., 1988).

Sex offenders have been categorized traditionally

according to their most recent charge (instant offense)

or most common offense if the instant offense is

uncharacteristic of the documented offense history.

Incest offenders are generally considered the most












amenable for treatment as well as the least likely to

reoffend whether they receive treatment or not. Child

molesters are considered less amenable for treatment

than incest offenders but more amenable than rapists.

Rapists are generally excluded from treatment because

they frequently have a diagnosis of antisocial

personality disorder and because of the nature of their

offenses (which makes them "too dangerous" for

outpatient settings) (Knopp, 1984; Schwartz, 1988b).

Moreover, rapists are often physically aggressive and

threatening and are likely to engage in rule violations

which could cause them to be prematurely terminated

from treatment. A widespread clinical assumption in

the field is that as offenders get older they become

less likely to engage in aggressive behaviors and more

concerned with the consequences of their criminal

behavior. It follows that the older the offender, the

more likely he is to make the necessary effort to

complete treatment successfully.

Although not demonstrated definitively in the

literature, intelligence (IQ) and reading level also

have been assumed to be important predictors of

amenability for sex offender treatment (Marshall &

Barbaree, 1988; Rosen, 1964; Schwartz, 1988b). The













fact that there are still virtually no treatment

programs for retarded sex offenders is one indication

that a certain level of mental ability is considered

important in the treatment process. As

cognitive/behavioral strategies have become more

integral to sex offender treatment, adequate reading

ability and intelligence have become important criteria

for program admission. It has been assumed that the

more intelligent the treatment candidate and the better

able to read, the more likely the individual is to

complete treatment successfully. Requirements for

successful completion of many treatment programs

include compliance with extensive reading and related

homework assignments and integration of the learned

material into daily behavior patterns (North Florida

Evaluation and Treatment Center, 1988; Rosen, 1964).

A fifth assumption undergirding the selection of

offenders for treatment concerns the sex offender's

degree of discrimination in offense and victim types

and its impact on treatment participation and success.

In a recently published study Abel and associates

(1988) found that lack of discrimination in offense and

victim types predicted dropout of offenders from an

outpatient treatment program. In addition, this













variable predicted recidivism for those who did

complete treatment. Significantly, more than half of

the participants in the study of Abel et al. (1988)

reported multiple deviations. This assumption has been

considered only recently by clinicians and is supported

by empirical evidence (Marshall & Barbaree, 1988).

Suggesting that the disorder of individuals with

multiple victim and offense types may be more

entrenched in their deviant behaviors and thus

resistant to change through treatment has important

implications for determining amenability for treatment.

This finding from a community-based program population

has potential significance for residential programs

which are likely to be treating those with documented

reoffenses and long histories of deviant behavior

(Knopp, 1984).

A sixth assumption regarding selection of

treatment candidates which has recently received

research support is marital status. It has long been

thought by clinicians that offenders with intact,

supportive families were more likely to both

successfully complete treatment and refrain from

reoffending, and this may contribute to the incest

offender's reputation for successful treatment outcome.











12

Recently Abel and associates found that marital status

was the single demographic variable which predicted

both dropout and recidivism. Those who were married

were more likely to complete treatment and less likely

to reoffend than offenders who were separated, divorced

or never married (Abel et al., 1988).

In summary, despite the absence of empirical

corroboration, practitioners in the field of sex

offender treatment have routinely based their selection

decisions on a number of shared assumptions. These

assumptions are that persons who are single or divorced

and who have low intelligence, poor reading ability, an

antisocial personality disorder, history of violent

sexual assaults (i.e., rape), a documented repetitive

history of offending, and history of different types of

sex offenses against victims of differing age or sex

will be less likely to complete treatment successfully.

Conversely, most practitioners have assumed that those

who are married, have high intelligence, adequate

reading ability, lack of antisocial personality traits,

absence of a history of violent sexual assaults or

repetitive offending, and who engage in a single type

of offense (i.e., incest) against a particular age

group of a particular sex (e.g. pre-pubertal boys) will













be more likely to successfully participate in

treatment.


Need for the Study

In virtually every state in America the number of

sex offenders in need of treatment far exceeds the

available treatment opportunities (Knopp, 1984; Salter,

1988). While more and more treatment programs are

opening in an effort to meet this need, there exist no

empirically derived selection standards for these

programs. Nonetheless, program clinicians and

administrators are routinely expected to determine

amenability and provide a treatment regimen. Although

numerous researchers and clinicians have offered

reasonable models for determining amenability (Barnard

et al., 1989; Salter, 1988; Schwartz, 1988b), at the

present time these models are untested. Such a lack of

research evidence on amenability has a distinctly

negative impact on the ability of programs to maximize

their efforts and to replicate their successes or

improve their treatment programs. Thus, more needs to

be learned concerning what types of treatment are most

effective with which types of offenders (Schwartz,

1988b). Studies must be undertaken in a variety of












settings to test the generalizability of the findings

reported from the few studies which have been

conducted. Although several researchers have recently

presented data on amenability for treatment, these

programs have been community based and limited to

incest offenders or pedophiles (Abel et al., 1988;

Dwyer & Ambersson, 1985). Little has been demonstrated

concerning indicators of amenability for treatment of

populations of incarcerated sex offenders.

As has already been noted, leaders in the sex

offender treatment field concur that more research

needs to be undertaken in an effort to predict

successfully who will benefit from the emerging

specialized treatment models.


Purpose of the Study

This study was designed to assess the degree of

correlation among six offender characteristics and

three treatment outcome groups in a residential sex

offender treatment program. The six offender

characteristics were (a) reading level, (b) presence of

an antisocial personality disorder, (c) degree of

discrimination in offense and victim types

(operationalized as "total deviance score"), (d) age,












(e) marital status, and (f) instant offense (offense

for which the offender is currently incarcerated). The

three outcome groups consisted of (a) those not

accepted after an 8-week pretreatment evaluation phase,

(b) those accepted for treatment and subsequently

discharged from the treatment program with a poor

prognosis, and (c) those accepted for treatment and

subsequently discharged from treatment with a good

prognosis.


Research Questions

The following set of research questions were

addressed in this study:

1. What is the influence of reading level,

degree of discrimination in the choice of victim or

paraphilic act, presence of antisocial personality

disorder, age, marital status, and instant offense in

classifying offenders into outcome groups?

2. Are there differences in reading level of the

offenders among the three outcome groups?

3. Are there differences in the degree of

discrimination in the choice of offense and victim type

among the three outcome groups?













4. Are there differences

antisocial personality disorder

groups?

5. Are there differences

outcome groups?

6. Are there differences

the three outcome groups?

7. Are there differences

among the three outcome groups?


in the presence of an

among the three outcome



in ages among the three



in marital status among



in instant offense


Context for the Study

The setting in which the study was conducted is a

maximum security residential mental health treatment

center operated by the State of Florida Department of

Health and Rehabilitation Services (HRS) which offered

a model, structured sex offender treatment program. In

the same institution there were programs designed to

return offenders found Incompetent to Proceed (ITP) to

court and to treat until deemed no longer dangerous

offenders found by the court Not Guilty by Reason of

Insanity (NGI); those successfully treated might be

discharged to the community or some other less

restrictive setting.


I










17

The sex offender program had recently been revised

(Barnard et al., 1989) and has been described as a

model for the multi-modal or integrated approach to sex

offender treatment in a residential setting (Knopp,

personal correspondence, 1988). Although this implies

the use of many methods in an integrated whole, the

predominant treatment theories underlying the program

were cognitive/behavioral and psychodynamic.

Cognitive/behavioral sex offender treatment programs

are generally characterized by structured learning

modules built around a Relapse Prevention foundation

(Barnard et al., 1989). This type of treatment relies

heavily on the offender's ability to read, learn, and

understand reading assignments as well as his ability

to integrate group experiences and demonstrate an

integration of the covered material. Its location in a

maximum security forensic mental health facility with

twenty-four hour staff supervision and extensive

electronic controls made it hard for offenders not

interested in fulfilling the spirit of treatment and

integrating treatment material to make reasonable

progress. For this reason it is assumed that it was

unlikely that repetitive offenders or those with an

extensive criminal history and likely concommitant













antisocial personality disorders would have been able

to successfully complete the program.


Definition of Terms

Multi-Disciplinary Treatment Team (MDT) acceptance

staffing is a formal meeting with the offender to

review his general behavior within the milieu,

compliance with treatment plan directives, knowledge of

material covered in the evaluation phase modules,

results of any psychological testing, and any other

data relevant to the demonstration of his amenability

for treatment. The staffing occurred at the conclusion

of an eight week evaluation phase, or during the phase

at the request of the offender or his primary

therapist.

Multi-Disciplinary Treatment Team (MDT)

termination staffing is a formal meeting of the MDT to

review the offender's progress in treatment, status at

the time of termination from treatment, and

recommendations after discharge.

Amenability for treatment is the likelihood of an

individual to benefit from a treatment procedure in

some describable or measurable way.












Evaluation phase refers to the first 8 weeks of

treatment in the Mentally Disordered Sex Offender

(MDSO) Program at North Florida Evaluation and

Treatment Center (NFETC), Gainesville, Florida.

Instant offense is the most recent offense or

group of offenses for which the offender has been

convicted and sentenced.

Recidivism has been variously defined as a

reoffense, rearrest, reconviction or reincarceration.

When not otherwise specified in the text, recidivism is

herein defined as a reoffense. Recidivism is

frequently used as a measure of treatment success with

criminals and individuals with repetitive or addictive

behaviors including deviant sexual behavior.

Reading level as measured by the Wide Range

Achievement Test (WRAT-R), can be described by a raw

score or a grade equivalent.

Age refers to how old the offender was upon

admission to NFETC.

Marital status refers to whether the offender was

married, divorced, separated or never married at the

time of admission to NFETC.

Antisocial personality disorder is a diagnostic

category from the personality disorder section of the













Diagnostic and Statistical Manual III (DSM III) (now

the Diagnostic and Statistical Manual III Revised), a

standard guide in the field of psychology and

psychiatry for making diagnoses of patients, which is

characterized by a history of delinquent behavior prior

to age eighteen followed by a history of irresponsible

behavior which might include criminal behavior,

substance abuse, frequent job changes, etc.

Degree of discrimination in offense and victim

types (total deviance score) refers to how many

different types of victims (e.g., pre-pubescent males

vs. pre-pubescent females) the offender has had and how

many different types of offense types (e.g., hands-on

vs. hands-off) the offender has engaged in.


Significance of the Study

The long-term consequences of systematically

studying the characteristics of those who do not appear

to profit from sex offender treatment are varied.

Learning who is more likely to benefit from a

particular treatment model has some very clear value,

particularly in a program that serves as a model for

the latest evolution in residential sex offender

treatment (Barnard et al., 1989). The cost of sex













offender treatment is significantly higher than the

cost of incarceration but, if effective in reducing

recidivism, treatment could prove to save society both

significant financial burdens and severe emotional and

physical trauma associated with virtually every

reoffense (Prentky & Burgess, 1990). Not only is sex

offender treatment more costly than incarceration, but

it is not available to all sex offenders. In fact,

even in systems with an extensive screening process and

a policy requiring volunteers, there are waiting lists

and offenders who request but never receive treatment.

This makes all the more important systematically and

correctly identifying those offenders who are most

likely to benefit from treatment.

Given the diversity of treatment programs

throughout the world and the lack as yet of a

recognizable standard for either screening or

treatment, it is essential that studies such as this

one be undertaken to attempt to determine who is most

likely to benefit from a specific treatment.

















CHAPTER II
REVIEW OF LITERATURE

This chapter describes the research and practice

literature concerning sex offender treatment

amenability. Literature describing the characteristics

of incarcerated sex offenders is reviewed. In

addition, assumptions commonly held by practitioners

regarding amenability of sex offenders for treatment

will be discussed. Finally, the literature regarding

the predictor variables examined in this study is

reviewed.


Research on Sex
Offender Treatment Amenability

With society's growing awareness of the terrible

effects of sexual abuse have come greater demands on

the mental health treatment, correctional, and judicial

fields to deal effectively with sexual offenders. One

response to these demands has been the significant

increase in treatment programs available for offenders

(Knopp, 1984; Knopp, Rosenberg, & Stevenson, 1986;

Knopp & Stevenson, 1989). A second response has been











23

the development of national and international networks

of professionals to share treatment ideas (e.g.,

Association for the Treatment of Sexual Abusers [ATSA]

and National Adolescent Perpetrator Network [NAPN]).

Unfortunately, there is little empirical evidence

available regarding the level of effectiveness of sex

offender treatment programs or the appropriateness of

selection procedures (Earls & Quinsey, 1985; Furby et

al., 1989). With few exceptions, professionals

implementing sex offender treatment programs do not

evaluate their programs systematically but rather do

what they consider correct, often basing their

decisions as to who gets treatment and how they are to

be treated more on clinical intuition and assumptions

than on empirical evidence. Ultimately, the field of

sex offender treatment must answer its own specificity

question: What types of offenders, in what types of

treatment contexts, with what types of treatment

experiences/components, demonstrate what levels of

"cure" both initially and ultimately? This question

has been extremely difficult to answer with regard to

psychotherapy in general (Finkelhor, 1988; Knopp,

1984). Thus it is not surprising that there are so few

answers regarding either the appropriateness or the

effectiveness of treatment of sex offenders.













Although there is little empirical evidence

regarding treatment amenability based on sex offender

recidivism, there is even less empirical evidence

regarding amenability for treatment of offenders based

on treatment program outcome (Furby et al., 1989;

Marshall & Barbaree, 1990). Recognizing that

ultimately it will be necessary to consider a

comprehensive set of factors in answering the

specificity question for sex offender treatment, there

is a need for modest studies which can provide a basis

for more ambitious studies in this area (Earls &

Quinsey, 1985; Furby et al., 1989). Murphy (1988) has

proposed a set of questions that target variables which

partialize the specificity question for sex offender

treatment and thus can serve as a guide to research.

Among these is the question of who is amenable for what

types of treatment. This interim measure, which has

been alluded to in several papers and studies (Abel et

al., 1988; Green, 1988), is important for a number of

reasons. First, given the universally limited sex

offender specific treatment resources and their

frequently high cost, there is a pressing need to use

these resources efficiently. In 1989 in Florida, more

than 300 offenders were routinely maintained on a













waiting list; many of these offenders were discharged

from incarceration without treatment as a result of the

long waiting list (Alcohol, Drug Abuse and Mental

Health Program Office, Florida Department of Health and

Rehabilitative Services, 1989). Knowing who is most

likely to benefit from treatment or conversely who is

most likely to fail early on or drop out during the

course of treatment could maximize the treatment

prospects for offenders likely to benefit.

Although clinical assumptions abound, little

empirical evidence is available to provide direction

for developing sound amenability criteria for treatment

programs. Concommitantly, there is a recognized

absence of reliable outcome data for the variety of

treatment methods and program models in operation today

(Furby et al., 1989; Knopp, 1984). Earls and Quinsey

(1985), noted Canadian researchers and clinicians, in

summing up their conclusions regarding the need for

effective assessment and treatment of sex offenders,

suggest that there is a clear need for modest studies

to lay the foundation necessary to answer the pressing

questions in the sex offender treatment field. Among

other issues Earls and Quinsey (1985) suggest that the

specificity question has yet to be addressed in earnest

in the sex offender treatment research literature.













Short-term treatment outcomes are frequently

described as program evaluations; bureaucratic agencies

who routinely engage in program evaluations and

"quality assurance" reviews tend to focus on areas

other than treatment outcome except in terms of

percentages of admissions. For example, the 19d0

Report to the Florida Legislature concerning the two

residential sex offender programs focuses on a

comparison of the percent of graduates compared to the

total admissions. The assumption is that a "good"

treatment program would have a high percentage of

graduates. Yet experts stress the need for short-term

outcome measures in order to develop accurate measures

of treatment efficacy and specificity. Dr. Green

stated:

Another important reason for making program
evaluation an integral part of sex offender
treatment programs centers around the fact that
there actually exists very little scientifically
collected information regarding the efficacy of
sex offender treatment, in terms of recidivism and
behavior change. At this time, it has not been
established which treatment works best with what
type of offender, fundamental data which is
potentially vital to program managers, agency
policy makers, and legislators. (Green, 1988,
p.61)

There are a number of factors which may, in part,

account for the dearth of research on sex offender











27

treatment selection. Perhaps most significantly, there

is little consistency in the sex offender treatment

field regarding criteria for determining amenability

for treatment, amenability being a combination of

initial eligibility for inclusion in a given treatment

program and the ability to progress satisfactorily and

attain some specified outcome, usually treatment

program specific. A number of factors have contributed

to this absence of consistency. First, the haphazard

development of treatment programs in isolated settings

around the United States and Canada has led to a

diversity of treatment models and methods and an array

of amenability criteria which are only program specific

(Knopp, 1984). Since there is no single model for the

treatment of sex offenders which is accepted by all

clinicians and there is reason to assume that

amenability may be program specific, it follows that

there exists no accepted method of determining

eligibility for treatment (Knopp, 1984). A second

reason is that the consistency which does exist

regarding salient criteria appears to emanate more

often than not from clinicians' assumptions rather than

empirical evidence (Knopp, 1984).

Still another factor which complicates the issue

of amenability for sex offender specific treatment is











28

the variety of external conditions with which programs

must contend. Constraints imposed by outside systems

within which the program functions may include (a)

specific populations from which treatment candidates

are selected (such as prisons, courts or other

institutions); (b) specific directives from funding

sources (such as targeting only the most "disturbed"

offenders still eligible for treatment); (c) specific

treatment models (which may be more difficult for some

individuals to complete); (d) particular settings in

which the program is provided including outpatient,

nonsecure residential, secure residential and prison;

(e) length of treatment (which may disqualify certain

offenders because they do not have enough time as in

the case of treatment programs for incarcerated

offenders where some offenders [e.g., youthful

offenders] routinely receive very short periods of

incarceration during which there is insufficient time

to be screened for treatment, transferred to a program

and complete it); and (f) competing philosophical

positions.

There is little question that the specific

treatment model/approach employed by the treatment

program is likely to have an effect on who is

considered amenable for that treatment.













Most programs recognize the limitations of the
clinical methods currently used with sex
offenders. Thus, they impose eligibility criteria
which reflect the perceived strengths and
limitations of their treatment programs. (Smith,
1988, p. 40)

For example, several authors have noted that a

particular model may require some minimum reading

skills or the ability to integrate material into daily

life (Barnard et al., 1989). Impacting on this dilemma

are the competing theories regarding treatment

candidate selection which differentially affect

eligibility criteria and which can be found throughout

the literature in the sex offender field. One theory,

championed by A. Nicholas Groth, argues that the most

dangerous and/or most likely to reoffend candidates

should be treated to the exclusion, if necessary, of

more amenable, less dangerous candidates (Knopp, 1984).

Programs, generally in secure, residential settings,

which have followed this strategy tend to have

relatively high rates of reoffense, if any, and have

had difficulty defending their position when funding

considerations arise (North Florida Evaluation and

Treatment Center, 1988a) because this model tends to

emphasize dangerousness/liklihood of reoffense over

amenability. A competing theory favors a triage model













which specifies that some criteria should be used to

determine who is most likely to benefit from treatment

and who is less likely to successfully complete or

significantly benefit from treatment. An example of

the latter is an outpatient treatment model which may

exclude individuals with extensive histories of

violence or previous crimes (Barnard et al., 1989).

A fourth contributing factor is the lack of

financial support for the testing of assumptions

regarding who is amenable for treatment. Because sex

offender treatment is not popular, most treatment

programs struggle to function with minimal and

unpredictable funds. Thus, although many new programs

are designed with a research component, funding cuts

often result in the elimination of such research

efforts. Therefore, it is not uncommon for programs to

have no organized approach to receiving feedback on

treatment efficacy and to focus only on publicized or

special cases of reoffending on the one hand and

standard case management measures such as progress

notes, treatment plans, and daily behavior while in

treatment on the other. Furthermore, the cost of

acquiring re-arrest data (a measure of treatment

efficacy) in both staff time and actual money and the

need to report reoffenses if they are revealed by













offenders or their families further block efforts at

systematic program evaluation.

A fifth contributing factor is that although

several studies have been published attempting to

describe, delimit or delineate one or another subtype

of sex offender (Stermac, Segal, & Gillis, 1990), the

findings of such studies reveal that sex offenders are

surprisingly heterogeneous. It appears they are linked

primarily by their offense and little else. For

example, when demographic variables such as income,

education, marital status, age, and intelligence were

examined, several studies have found results which

follow normal distributions (Abel et al., 1988; Shaw,

Barnard, Robbins, Spears, Cunningham, Butler, & Newman,

1988); incarcerated sex offenders differ little on

these same variables from other populations of

incarcerated offenders (Stermac et al., 1990). This

heterogeneity becomes yet another factor inhibiting the

delineation of specific eligibility criteria as this

population is difficult to differentiate from both

other criminal populations as well as among its own

subtypes.

Consequently there is very little research

literature available on treatment amenability in the











32

sex offender treatment field. That which is available

is limited to pedophiles treated in outpatient programs

(Furby et al., 1989). Given this limitation, there is

no assurance that any set of eligibility or amenability

criteria will be effective in identifying the best

candidates for a particular treatment program (zurby et

al., 1989).

Recently, Abel et al. (1988), reporting data

consisting of a one year follow-up using self-report of

reoffense, the dependent variable, as a measure of

recidivism from a sample of pedophiles being treated in

the community, found only one demographic variable to

be predictive of reoffense: marital status.

Demographic variables which did not distinguish between

nonrecidivists and recidivists were age, race, social

class, education, employment status, religious

preference, motivation for seeking treatment, frequency

of pedophilic acts before entering treatment, lifetime

number of molestation or sexual victims, and reported

self-control over pedophilic behavior before entering

treatment.

When the multiplicity of age categories, gender
categories and hands on versus hands off
categories of pedophilic behavior were combined,
the combination proved to be a very significant
predictor of recidivism, with p < .0001. (Abel et
al., 1988, p. 230)











33

Although a significant, ongoing study, the limitations

of treating exclusively pedophiles in a community

setting makes these data unrepresentative of

incarcerated treatment populations which often include

as many as one third rapists and where as many as half

the offenders have an antisocial personality disorder

diagnosis (Barnard et al., 1989). Moreover, the

finding of marital status as a predictor of recidivism,

while it must be tested with incarcerated offenders,

bodes ill for incarcerated populations, who, for the

most part, are single, separated or divorced (Barnard

et al., 1989).

Treatment outcome data have been reported by

several other researchers with outpatient populations

(Abel et al., 1988; Maletsky, 1987; Marshall &

Barbaree, 1988; Knopp, 1984). Marshall and Barbaree

(1990) found that although higher intelligence

predicted successful outcome, all programs reported

relatively low recidivism rates (under 15%).

Randy Green, clinical'director in the sex offender

treatment field from the Forensic Services Unit of

Oregon State Hospital stated:

The only other serious experimental controlled
study in the field of sex offender treatment in
this country is being conducted in Tampa, Florida












by Richard Laws. Sponsored by the National
Institute of Mental Health (NIMH), Laws began this
outpatient study in August 1986, comparing effects
of a combined regimin of Relapse Prevention and
aversive conditioning, in contrast to a
traditional therapeutic model. (1988, p. 64)

Unfortunately, this study was prematurely terminated

primarily due to inability to achieve the necessary

sample size within the specified time, and federal

funds were withdrawn (D. R. Laws, personal

communication, November, 1989).

Furby's review of empirical studies of sex

offender recidivism was intended to summarize what is

known regarding the efficacy of sex offender specific

treatment, particularly as it compares to no treatment.

The authors' conclusions regarding the current status

of outcome research in the sex offender field were

generally quite negative. They found that methodology

was very poor in general, and they specifically noted

that treatment programs being studied were rarely

described clearly enough to determine why a particular

treatment worked or did not work. Furthermore, the

authors concluded that there was as yet no evidence

that treatment reduces sex offenses in general. Among

their conclusions was the need for developing short--

term data from which long-term data can be predicted

(Furby et al., 1989).













In the absence of empirically based amenability

criteria, treatment programs are nonetheless forced to

institute limits regarding eligibility and amenability

in hopes of using the treatment resource most

effectively and efficiently. In Faye Honey Knopp's

seminal work, Retraining Adult Sex Offenders: Methods

and Models, (1984) the problem of treatment candidate

selection is examined along with other key issues. The

majority of treatment programs for sex offenders use

some set of admission criteria to screen potential

candidates (Knopp, 1984). Residential treatment

programs continue to be relatively costly and limited

in availability; community based treatment programs

must consider their potential legal liability when

developing admission criteria and routinely exclude

violent offenders. Consequently, each setting has

evolved a set of eligibility criteria. These criteria

may be determined by law as in California and Florida,

or they may be derived from a consensus of program

officials or expert clinicians (e.g., Task Force of the

National Adolescent Perpetrator Network), tradition,

program design or multidisciplinary committees as in

Dr. Groth's now defunct program in Connecticut. The

members of the Governor's Task Force on Sex Offenders













and their Victims in their 1984 Report on Treatment

Programs for Sex Offenders regarding the state operated

sex offender treatment programs stated:

At present we are unable to pick out in advance
those individuals who are most likely to reoffend
unless treated and who will also respond well to
treatment. A high priority has to be given to
research to find methods of picking out those
offenders whose treatment will best serve the
needs of the community. (1984, p. 20)


Basic Assumptions, Techniques, Settings,
Populations Treated (Focus), Research
findingss and Related Literature

The various debates concerning the use of

outpatient vs. inpatient strategies, chemical vs.

behavioral vs. psychodynamic models, specialized vs.

generic treatments, incarceration vs. community

placement, with or without treatment, and determining

who is amenable for treatment and who should be

excluded remain unresolved in the sex offender field.

To date, researchers have offered very little in terms

of resolving any of these questions; they remain to be

answered by current (Marques, Day, Nelson, & Miner,

1990) and future researchers. However, in spite of

clinical imprecision, these questions are being

resolved routinely by bureaucrats and politicians

around the country (Knopp, 1984).












In a 1988 publication, Nationwide Survey of

Juvenile and Adult Sex Offender Treatment Programs and

Models (Knopp & Stevenson), the authors chronicle the

enormous growth in the number of sex offender treatment

programs in America as well as the variety of treatment

approaches offered. The report, based on a survey of

1002 respondents, elicited updated information

regarding sex offender treatment programs from a prior

(1986) survey. Additionally, a second part, including

responses from 574 adolescent and adult sex offender

treatment providers, elicited information regarding

"perceived program models, 43 treatment modalities, and

3 modes of treatment delivery." Responses from the

survey were structured so as to provide information

regarding the setting in which the treatment was

provided as well as the treatment models and modalities

employed. In the study a total of 429 adult

specialized sex offender treatment programs were

identified. Residential programs accounted for 28% of

all services (119); of these, 89% (106) were public

(eg. state funded) and 11% (13) were private (eg.

requiring payment from the client). It was found that

73% of residential programs were housed in prisons

(87), 16% were housed in mental health facilities (eg.











38

NFETC) (19), and 11% were located in private facilities

(13).

Almost three quarters of the specialized treatment

programs for adult offenders identified in the survey

were outpatient, community based (310 or 72% of all

adult services). Of these, 62% (191) were private

services, 31% (97) were located in mental health

centers, 4% (13) were court related services, and 3%

(9) were community based prison related services.


Residential Treatment Model

The 1988 Nationwide Survey conducted by Knopp and

Stevenson reported on "selected treatment methods" used

by respondents. The seven methods reported were family

therapy, peer-group treatment, "thinking errors,"

behavioral methods, aversive conditioning, Depo-Provera

(synthetic female hormones), as well as one evaluation

tool, the penile transducer or plethysmograph. Peer-

group treatment was the most widely used, being the

preferred method in 86% (371) of the 429 programs.

Family Therapy was included in 79% (341) of identified

adult sex offender programs, although only 54% (64) of

the 119 residential programs reported using it.

Behavioral methods were used in 65% (277) of the











39

identified programs. In descending order the frequency

of the remaining methods was Penile Transducer (26%),

Aversive Conditioning (24%) and Depo-Provera (18%).

Most often treatment programs offer one treatment

regimen which treatment candidates are required to

successfully complete. A diligent effort to define who

is amenable for a particular treatment model, however,

would be an important step in understanding individual

offender variables in terms of a given treatment design

and serve as a model for future research (Earls &

Quinsey, 1985).


Integrated/Multi-Modal

Basic assumptions. Recently an integration of

cognitive-behavioral and psychodynamic models has been

suggested by several clinicians in the field as a means

of more effectively achieving positive long-term

results than cognitive-behavioral therapy programs have

thus far demonstrated by incorporating techniques

derived from psychodynamic therapies into a structured

treatment program. While as yet no outcome data exist

to specifically support this model, its supporters

believe it may be the answer to treating offenders with

more severe disorders who tend to be treated in













residential settings (Barnard et al., 1989; Shaw,

Hutchinson, & Longo, 1989).

Common techniques. Unique to the integrated

approach is the use of numerous theoretical models

within a coherent whole. Specifically cognitive-

behavioral modules are used in conjunction with

psychodynamic, experiential modalities such as gestalt

or psychosynthesis, as well as family systems to create

an integrated treatment program (Barnard et al., 1989).

Settings. Integrated treatment strategies are

found in both inpatient and outpatient programs for

both adult and juvenile sex offenders (Shaw et al.,

1988).

Populations treated. Integrated treatment

strategies have been used with all types of sex

offenders, both adult and juvenile.

Research evidence. Review of official arrest data

from Florida in 1988 and 1989 revealed that no

graduates of the integrated treatment program at NFETC

had been arrested for a sex offense up to the date of

the Annual Report to the Florida Legislature (Alcohol,

Drug Abuse, and Mental Health Program Office, Florida

Department of Health and Rehabilitative Services,

1989).













Psychodynamic

Basic assumptions. Therapies based on

psychodynamic models assume that sexual deviance is the

result of early perceived trauma and includes:

castration anxiety; reaction to seductive mother;

inadequate ego/superego; reenactment of sexual trauma;

confusion of aggressive and libidinal drives, and

narcissistic representation of self as child (Schwartz,

1988c).

Common techniques. Psychodynamic treatment

techniques include insight oriented individual therapy,

including traditional analysis, and group counseling

including Gestalt therapy, Psychosynthesis, and

Psychodrama. These techniques are used to assist the

client/offender in becoming consciously aware of his

underlying motivations and subsequently developing new

ways of coping with his needs.

Settings. Psychodynamic treatment of sexual

offenders today is limited to individual therapy and

programs offered in several psychiatric hospitals. Due

to the length of time this treatment usually takes,

clinicians are frequently constrained by financial

considerations as well as time.











42

Populations treated. Psychodynamic treatment has

been used with a variety of sex offender populations

including rapists, pedophiles, exhibitionists, voyeurs

and other sexual deviants who may not be considered

offenders such as transvestites and various other

fetishists.

Research evidence. The majority of research

evidence for the efficacy of this approach has been in

the form of single case studies and has been less

evident in the last decade (Kilmann, Sabalis, Gearing,

Bukstel, & Scovern, 1982).


Cognitive-behavioral

Basic assumptions. Cognitive-behavioral treatment

programs comprise the most widely accepted approach to

sex offender treatment today. This approach is based

on the assumption that behaviors are learned responses

and that individuals can learn new behavioral responses

and develop new beliefs to support those responses.

Cognitive therapies comprise a relatively new branch of

behavior therapy and focus on the thoughts, beliefs,

and fantasies which "drive" behavior. Deviant behavior

is often dependent upon distorted thinking (Marshall &

Barbaree, 1990).












Common techniques. Treatment programs variously

focus on preventing reoffense using some

combination/integration of Relapse Prevention,

cognitive restructuring, stress and anger management,

social and communication skills training, sex

education, and arousal reconditioning (Laws, 1990;

Pithers, 1990; Salter, 1988). Techniques employed by

these modalities include psychoeducational experiences

such as reading and viewing videotapes, modelling,

roleplaying and practice.

Settings. Cognitive-behavioral therapies are used

today in virtually all settings, whether the primary or

adjunctive therapy focus (Knopp et al., 1986; Knopp &

Stevenson, 1988).

Populations treated. Cognitive-behavioral

therapies have been used with virtually every sexually

deviant population treated; behavioral strategies such

as arousal reconditioning tend to be used for those

with evidence of deviant arousal or histories of

repetetive deviant behavior (Knopp et al., 1986; Knopp

& Stevenson, 1988).

Research evidence. Leaders in the outcome

research on cognitive--behavioral treatments, which

focus on arousal reconditioning (changing the focus of










44

arousal from a deviant to a non-deviant object or act),

include Abel and associates (1988), Earls and

Castonguay (1989), Laws and O'Neil (1981), and Marshall

and Barbaree (1988). William Pithers has designed and

implemented several studies using Relapse Prevention

based treatment programs in Vermont, including an

innovative approach which includes the training of

probation officers in Relapse Prevention (Pithers &

Cumming, 1989). He found that when both treatment and

follow-up probation supervision were based on Relapse

Prevention, recidivism in terms of probation violations

and rearrests for sex offenses was significantly

decreased. A proposal to compare a cognitive-

behavioral treatment program designed specifically for

sex offenders with a more generic treatment model based

on Sullivanian Interpersonal therapy was first approved

by the National Institute of Mental Health and then

rejected by the Human subjects review committee which

felt the control treatment was not likely to be

sufficiently effective (Laws, 1989, personal

communication).

In their review of outcome research in cognitive-

behavioral treatment therapies, Marshall and Barbaree

(1990) found promising results regarding use of these













modalities with exhibitionists and child molesters.

They concluded, however, that future outcome studies

must focus more on the specific changes induced by

treatment such as sexual preferences, social competence

and cognitive distortions to improve the ability of

clinicians to make predictions regarding likelihood of

recidivism.


Treatment Center Study/Setting


Context

The sex offender program which is the setting for

this study was located at North Florida Evaluation and

Treatment Center (NFETC) in Gainesville, Florida.

Operating from 1976 until September, 1989, the program

was one of four treatment units within the treatment

center and one of two sex offender treatment programs

operated by the Florida Department of Health and

Rehabilitative Services (HRS).

The 63-bed MDSO unit was situated in three secure,

electronically controlled treatment buildings. Two

buildings housed 18 men in a two-pod floor plan and one

housed 27 men in a three-pod floor plan, with nine

individual rooms per pod. Each pod had a common area

for group or recreational activities which was












monitored visually and audibly by staff in a single

building control room. While the treatment program and

daily activities were facilitated by professional and

paraprofessional treatment staff, the secure perimeter

was maintained by uniformed security staff who were

available for backup in the event of a crisis or

emergency. Staff maintained 24 hour supervision.


Treatment Program Rationale

In 1985 the treatment program was redesigned to

reflect a multi-modal or integrated approach to sex

offender treatment, based on the belief that sex

offenders develop their deviant urges and behaviors for

a variety of reasons (Finkelhor, 1988).

The basic philosophy underlying the comprehensive
treatment program offered at NFETC is that sex
offenders develop their deviant behavior through
multiple and diverse ways and consequently require
a variety of treatment approaches to alter this
aberrant behavior. (Barnard et al., 1989, p. 126)

This model, consistent with the multi-factor

theory of offender etiology espoused by David Finkelhor

(1988) and heralded as a model for comprehensive

residential treatment, combined a cognitive-behavioral

treatment program, milieu therapy, and experiential

therapies designed to interface with each other

(Barnard et al., 1989). For example, an offender may

have been enrolled in Role Play (offense reenactment)











47

module where he and eight other offenders would reenact

their offenses in group in videotaped sessions. Later,

the offender would review the videotape of the role

play with his "Pod group" and primary therapist (i.e.,

case manager).


Treatment Program Format

Sex offenders participated in an initial screening

while in prison and were placed on a waiting list for

transfer to one of the two treatment facilities if

found eligible. Once transferred to NFETC offenders

underwent a 4-day period of evaluations while being

maintained in relative isolation to prevent treatment

from beginning until after the pretreatment evaluation

process was complete. This evaluation included a

Psychiatric interview, a computerized psychosocial

assessment including a plethysmograph assessment of

arousal patterns (Barnard, Robbins, Tingle, Shaw, &

Newman, 1987), and a WRAT-R. Following this battery

the offender participated in an 8-week "Evaluation"

phase which included several structured modules

(Criminal Thinking Errors, Psychosexual Process), other

structured activities including production of a

"Lifeline" and an "Offense Description," "Role Play" of












Offense, and unstructured group experiences at least

several times per week. At the end of this 8-week

Evaluation phase the offender was interviewed by the

multidisciplinary treatment team (MDT) which consisted

of the Unit Director, the 7 unit professional

therapists, the Unit Psychaitrist, the Unit Health

Coordinator (nurse), and available paraprofessional

staff. During this "staffing" the offender's response

to treatment was reviewed in terms of the following:

(a) his willingness and ability to actively participate

in the treatment components of the evaluation phase

such as lifeline creation, role play of offense and

thinking errors module (response to treatment); (b) his

willingness and ability to abide by program rules; (c)

his presentation in the staffing in terms of his

willingness and ability to describe and "own" his

offense, and his understanding of the precursors and

subsequent impact of his offense; and (d) a

psychological evaluation was also reviewed in this

staffing. Two decisions were possible at the

conclusion of the staffing. Based on consensus, the

team could decide to (a) accept the offender into the

"Treatment" phase (approximately one year) or (b)

reject the offender and return him to the custody of

the Department of Corrections (DC) as "not amenable for












treatment." A third decision, very rarely used, was

that in special cases (such as offenders with perceived

high motivation but marginal abilities) the evaluation

phase could be extended for another month.

During the treatment phase, offenders' progress in

treatment was reviewed at least monthly; offenders were

staffed formally at the end of one year, by which time

they were expected to have completed the modules, when

they were presented for completion of treatment, or

when either the offender or his primary case manager

requested a "termination" staffing, which could occur

at any time during the treatment process.

The treatment program was divided into three

stages, each with a set of specific activities and

expectations for the resident. In Stage I, the

evaluation phase, the offender was sequestered in

relative isolation until he completed the entire

psychosocial/psychosexual pre-test evaluation which

generally took from two to four days. Thereafter, he

was introduced to the other residents of the

intake/evaluation/advanced resident building and

expected to learn the rules of the program, attend pod

group two mornings per week, complete several standard

assignments including Lifeline, a structured













autobiography, offense descriptions for each separate

victim and type of offense he committed, a role play or

reenactment of either his instant offense or an

alternate agreed upon in advance by him and his

therapist, and psychosexual disorder process diagrams;

these had to be approved by both his therapist and his

pod group. In addition, the offender attended several

modules including the Criminal Thinking Errors module

facilitated by advanced residents, the Psychosexual

Disorder Module, Clinically Standardized Meditation

Module, resident government meetings which included

pod, building and unit functions, and special groups

called by staff or residents. The resident was

expected to meet at least once per week with his

primary therapist, his resident activity monitor (RAM),

a paraprofessional assigned to him to assist in the

completion and review of his "homework" assignments,

and his Triad members. Triads consisted of one

advanced resident and two residents in the evaluation

phase; triad members were required to be available to

each other at all times for support as well as for

confrontation.

At the end of the 8-week evaluation phase the

offender was interviewed by the MDT. During this











51

staffing the resident's response to treatment was first

reviewed for the group, usually by the primary

therapist, as well as results of a psychological

evaluation. After this review, the resident was then

interviewed, and his ability to describe his offense

without minimization, blaming or denial, his

understanding of his offense cycle including criminal

thinking errors he employed and any special issues or

questions pertaining to his amenabiilty were assessed

by the team. After the resident was dismissed from the

staffing, the team would complete a discussion of the

resident and vote on whether to accept or reject him

and return him to the department of corrections.

An offender who was accepted into Stage II of the

treatment program was expected to be enrolled in at

least three modules at any given time, each meeting

once per week, his pod group twice per week, structured

recreational activities including art, music, sports,

computer or video training, education classes for those

without a high school diploma, work program and

resident government activities. Stage II generally

lasted for eight to ten months, and most residents

completed this phase around one year from their date of

admission. At the end of phase II or one year from













date of admission, whichever came first, the resident

was staffed again. The staffing was basically the same

as the admission staffing except that during the

staffing the resident's progress through the modular

program was reviewed both in terms of modules completed

(grades) and his ability to describe how he could use

what he was learning to prevent future reoffenses and

other dysfunctional thinking and behavior. A report of

his progress was forwarded to the department of

corrections resultant from this staffing.

Stage III of the treatment program involved

retaking modules in areas where the offender appeared

weak (e.g., social skills), participating in pod

groups, resident government, Triad groups, facilitating

certain modules and developing release plans and

strategies. A final staffing was held when the MDT

determined that the resident had either maximized

benefits, made significant progress or had successfully

completed the program. This staffing was generally

structured around a review of progress including

available post-tests, recommendations from his primary

therapist and RAM, and an interview focused on release

planning, relapse prevention, and victim empathy.












Treatment Program Components

The following is a brief description of the

structured module components of the treatment program.

Residents were expected to rotate through these

modules, taking approximately three at any given time,

until all were successfully completed. Each module

lasted for approximately twelve sessions and was co-

facilitated; each session lasted from 1 1/2 to 2 1/2

hours.

The core treatment philosophy was presented

through the Empathy Development/Trauma Work component.

This set of modules was designed to increase the

offender's awareness of the impact of his offense on

both perpetrator and victim, assist the offender in

defining the purposes served by commission of the

offense, and promote the development of empathy for

victims. In the Role Play, a group experience, the

offender had the opportunity to act as both the

perpetrator of his own crime and as the victim in the

offense of a peer during the course of the module.

Each session of the module could be videotaped for

subsequent review by the offender.

A traumatic events component provided the offender

with specific skills to resolve traumatic events in













personal history in order to decrease resultant

cognitive distortions, emotional distress and

maladaptive behavior patterns. This was accomplished

through a series of therapist-facilitated structured

learning experiences and practical exercises

experienced in the "safety" of the therapeutic

environment using any number of modalities including

Gestalt Therapy and Neuro-Linguistic Programming.

A sensitivity training component assisted the

offender in developing an awareness of the connection

between body and mind, to facilitate their integration,

and to sensitize the offender to his own affective

experience and the experience of others, through the

use of therapist facilitated Bio-energetic, Gestalt and

structured training exercises.

A number of modules were designed to train the

offender in more adaptive life skills. These included

the following:

(a) The Relapse Prevention module was designed to

prepare the offender to take responsibility for his

behavior, particularly as it relates to his sex

offending, by identifying specific high risk situations

where offending is likely to occur, predicting their

occurrence, and acquiring specific coping skills and













developing action plans based on those skills to

prevent reoffense.

(b) The Arousal Reconditioning module included one

or both of the following components: Covert

Sensitization pairs aversive imagery and associated

negative affect with the antecedents to offending

behavior through directed, taped sessions; Self-

Administered Satiation focuses on decreasing deviant

arousal through the use of extended verbal repetition

of deviant fantasies in taped sessions with or without

concurrent masturbation in a controlled setting.

(c) The Cognitive Restructuring module, based on

Rational Emotive Therapy, was designed to directly

challenge the irrational beliefs which support the

offender's deviant behavior and to replace them with

beliefs grounded firmly in reality. This module helps

the offender develop responsibility for his own

experience and become more effective in relationships

with peers.

(d) The Stress Innoculation/Anger Management

module was designed to teach offenders how to better

cope with their anger and stress and to develop more

socially acceptable and personally effective

expressions of anger and stress coping responses.












(e) The Criminal Thinking Errors module, adapted

from the work of Yochelson and Samenow (1977), assists

the offender in identifying and replacing distorted

cognitions which support ongoing patterns of offending

behavior.

(f) The Social Skills Training module was designed

to help the offender develop clearer, more effective

verbal and non-verbal communication skills, become more

assertive and develop socially appropriate and

effective hetero-social skills including dating,

courting and sexual interaction.

(g) The Healthy Sexuality/Sex Education module was

designed to improve the offender's knowledge of human

sexuality and to decrease distorted perceptions or

beliefs about sexuality.

(h) The Life Skills Training module could be

adapted on an individual basis depending on the

specific needs of the offender and the setting in which

the treatment is occurring.

(i) The Substance Abuse module was designed to

help the offender recognize substance abuse problems as

well as provide general information on the causes and

effects of substance abuse.

(j) The Psychosexual Disorders module presents an

introduction to the concept of the core process of the












psychosexual disorder which serves to provide a

foundation for integration of later treatment

experience into a comprehensive and cohesive model for

ongoing recovery.


Target Population

The sex offender unit at NFETC is a treatment
program for men who have been convicted of a
sexual offense and sentenced to a prison term.
The MDSO population is comprised of child
molesters, incest offenders, exhibitionists and
rapists who volunteer for treatment and pass
screening by a prison psychologist and a
professional staff member of the Sex Offender
Treatment Unit. Final selection into the
treatment program is determined at the end of an
eight week clinical evaluation period.
The following criteria are used in the screening
process for accepting sex offenders into the
program: (1) there must be evidence of a
psychosexual disorder; (2) the inmate must
volunteer for treatment; and (3) the inmate must
accept responsibility for the crime. Inmates are
automatically excluded from MDSO treatment if they
present one of the following characteristics: (1)
have a sentence in excess of 15 years or less than
18 months; (2) show significant evidence of a
major mental illness (e.g., psychosis); (3) have
murdered their victimss; (4) are actively
appealing their conviction or sentence; or (5)
have significant medical problems which may be
exacerbated by the stress of the treatment
program. (Barnard et al., 1989, pp. 122-123)


Treatment Amenability Factors

There is little question that the theoretical

approach employed by the treatment program is likely to

have an effect on who is considered amenable for that












treatment. Characteristics of offenders likely are

important indicators of amenability for treatment.

These can be divided into four categories: (a)

intellectual factors, (b) personality factors, (c)

offense factors, and (d) demographic factors.

Intellectual Factors

Several authors have noted that a particular model

requires some minimum reading skills or the ability to

integrate material into daily life which is frequently

referred to in the literature (Barnard et al., 1989).

Some form of intelligence and/or performance evaluation

is routinely considered in amenability decisions

although there is little consensus in the literature as

to what the ideal should be. A residential sex

offender program in California requires a minimum of 80

IQ for consideration in treatment (Marques, et al.,

1990). Summarizing his views on the ideal treatment

candidate, Smith (1988) states that offenders should

have normal intelligence.


Personality Factors

Marcus (1971), in listing criteria which would

negatively affect amenability, included delinquent acts

between the ages of 8 and 13, interrelated criminality












with sexual offenses, lack of concern for victim.

Numerous other clinicians and researchers have offered

sets of eligibility criteria. For example, co-

directors of a treatment program for sex offenders in

New York report that assessment is particularly

important to assess personality characteristics. They

rule out offenders who are "actively psychotic,

predominantly antisocial, or heavy substance abusers"

(Travin, Bluestone, Coleman, Cullen, and Melella,

1985).


Offense Factors

Although few researchers have set out to predict

amenability based on treatment outcome measures, the

most notable data derive from measures within a long-

term study. Recently, Abel et al. (1988) published a

study predicting response to outpatient treatment of a

group of child molesters. The two outcome variables

for this study were dropout (initiated by either the

offender or clinician), a short-term outcome variable,

and recidivism (self-report of reoffense as determined

through structured interviews at six months and one

year post-treatment), a long-term treatment outcome

variable. There were 192 subjects, all pedophiles, who













were divided into 19 groups. Groups received the

treatment modules in varying orders in order to test

the efficacy of each module. The treatment program

consisted of thirty 90-minute weekly group sessions.

Each module or treatment component consisted of ten

sessions. The three treatment components were (1)

decreasing deviant arousal, (2) sex education/sex

dysfunction and cognitive restructuring, and (3) social

and assertiveness skills training.

The first dependent variable, dropping out of

treatment, can be viewed as a short-term outcome and a

measure of amenability. Approximately one third of the

subjects either dropped out (88%) or were expelled

(12%) prior to completing the thirty sessions. A

series of t-tests were conducted to determine if

significant differences on a number of demographic and

offense variables could be found between the group

which completed treatment and the group which did not.

Interestingly, most of the demographic variables (age,

race, social class, marital status, education,

employment status, and religious preference), referral

source as well as degree of motivation for seeking

treatment, lifetime reported number of pedophilic acts

prior to entering treatment, and self-reported current

ability to control urges all failed to discriminate












between the two groups. However there were three

characteristics which significantly differentiated

those who dropped out from those who completed

treatment: "(1) the amount of pressure the subject was

under to participate in treatment (p <.05), (2) the

diagnosis of an antisocial personality disorder (p

<.01), and (3) the lack of discrimination in the choice

of sexual victim or paraphilic act (p <.0001)" (Abel

et al., 1988). The dropout group reported greater

pressure to participate in treatment, was more likely

to have a diagnosis of antisocial personality disorder

and was less discriminating in the choice of sexual

victim or paraphilic act. A discriminant function

analysis was performed to estimate the degree to which

dropping out of treatment could be predicted using

variables that significantly differentiated the two

outcome groups. Using the variables stated above, the

discriminant function analysis could correctly classify

72.4% of subjects entering treatment as to whether they

would drop out of treatment.


Demographic Factors

Researchers have begun to test assumptions of

clinicians regarding demographic variables likely to

affect treatment amenability. One of the most













promising is marital status. Others which have not

received empirical support are age, race, socio-

economic status, education, employment status,

religious preference and lifetime number of reported

offenses (Abel et al., 1988).



Independent Variables


Reading Ability

As has already been suggested, predictors of

amenability are likely to be program specific. Perhaps

the most common feature of contemporary sex offender

treatment programs is the requirement that offenders

learn information in treatment modules, understand this

information, and integrate it in a way such that they

can effectively use what they have learned to prevent

engaging in a reoffense at some later date. While IQ,

as measured by the WAIS-R, is the most common measure

of ability, reading achievement, as measured by the

WRAT-R, is a more pragmatic measure, easier to

administer and score than the WAIS-R, yet positively

correlated with the WAIS-R (Margolis, Greenlief, &

Taylor, 1985; Spruill & Beck, 1986; Cooper & Fraboni,

1988).












As has been noted, numerous references are to be

found in the literature suggesting that intelligence

and reading achievement are predictors of successful

completion of treatment. An exception to this is

Marcus (1971) who wrote that high IQ offenders should

be screened out of treatment programs because of the

likelihood that they would manipulate the staff and

thereby avoid the full impact of the treatment process.

This aside, the predominant notion in the field is that

it takes some finite and measurable degree of

intelligence to complete a treatment program

adequately, and this has been suggested by numerous

authors (e.g., Marshall & Barbaree, 1988). But it is

clinical experience which overwhelmingly supports the

contention that the lower functioning offenders will

take longer to complete treatment and may not, in fact,

be amenable to cognitive-behavioral or insight oriented

therapies. No doubt for this reason virtually every

treatment program for sex offenders has an IQ and/or

reading achievement cut off as part of the admission

criteria.

In a chapter titled "Clinical Assessment of Sex

Offenders" the author comments, "A lack of intellectual

ability might preclude certain verbal therapies or

imagery-based behavior therapy" (Dougher, 1988, p. 78).











Smith, of the National Academy of Corrections, in

discussing treatment of mentally ill and mentally

retarded sex offenders, further stated:

The experience of programs that integrate low
functioning or mentally ill men into confrontative
or cognitively oriented programs has not been
promising. (1988, p. 35)

Interestingly, as mentioned above, Marcus (1971) took a

minority position that high IQ is an undesireable trait

because it could be used by the offender to manipulate

the staff or therapist and consequently avoid the full

impact of the treatment process. Nonetheless, his

notion further underscores the need to study the

corellation of this variable with treatment outcome.


Antisocial Personality Disorder

Although only appearing briefly in the research

literature as a factor predicting dropout (Abel et al.,

1988), a diagnosis of Antisocial Personality Disorder

(APD), determined primarily by history, is considered

by many clinicians to suggest a poor prognosis for

lasting participation in treatment programs or

resultant meaningful change.

Among the criteria of APD which clearly would

predict problems in treatment are the following:

Onset before age 15 as indicated by a history of three












or more of the following before that age: truancy;

expulsion or suspension from school; persistent lying;

thefts; vandalism; school grades markedly below

expectations in relation to estimated or known IQ;

chronic violations of rules at home and/or at school;

initiation of fights. At least four of the following

manifestations of the disorder since age 18: inability

to sustain consistent work behavior; failure to accept

social norms with respect to lawful behavior;

irritability and aggressiveness as indicated by

repeated physical fights or assault; failure to plan

ahead, or impulsivity; disregard for the truth as

indicated by repeated lying; recklessness. (DSM III,

1980)

Any one of the above mentioned criteria, if it

were detected repeatedly or, in cases of extreme

examples, even once, in a treatment program would

likely result in the offender being terminated from

treatment (North Florida Evaluation and Treatment

Center, Sex Offender Unit, 1988b); if not detected,

these behaviors would be likely to disrupt the

treatment milieu and cause the offender to benefit less

from treatment. Consequently, many programs routinely

exclude these individuals, particularly those in












community, outpatient settings. In programs designed

to treat incarcerated offenders, excluding those

offenders with APD is more difficult because they

comprise a large percentage of treatment referrals and

volunteers.

Schwartz describes a treatment program at the

Chittenden Correctional Facility in South Burlington,

Vermont that selects offenders

with demonstrated histories of prosocial
behaviors, and those who don't have a number of
circumstances which threaten the individual's
sense of self control, e.g., alcoholism.
Candidates must accept responsibility and
acknowledge the harm done. Sadistic offenders are
excluded. (1988b, p. 47)

In Abel's landmark study the authors commented:

It should also not be surprising that individuals
with antisocial personality are more likely to
drop out of treatment, since a characteristic
frequently seen in such personalities is
manipulativeness of others to get what they want.
In this situation, admission to a treatment
program was probably helpful to them at the
moment; and as soon as they had satisfied someone
by their entrance into treatment, they quickly
terminated the treatment program. (Abel et al.,
1988, p. 229)

Even if the antisocial personality disordered

offender did not terminate himself from treatment it

appears likely that he would be frustrated by the

control the residential program exerted over him;

instead of working diligently to make meaningful










67

changes in himself, he would focus on manipulating the

staff and his peers, on avoiding the true thrust of

treatment in ways he had developed in his past such as

missing classes, failing to complete homework

assignments, or faking illnesses. Consequently, it

could be predicted that he would not do well in

progress staffing, either from poor treatment

participation or due to program rule infractions, the

other serious behavioral manifestation of APD. The

individual with APD does not generally respect rules

and follows them begrudgingly; he focuses on not

getting caught and in a residential program might be

likely to cheat on tests, copy homework assignments

from others, steal, threaten, fight, use drugs,

manufacture alcoholic beverages and other behaviors

generally against program rules and often requiring

termination from the treatment program. If any of

these behaviors were discovered, they would negatively

impact on perceived treatment outcome by the MDT.

"Career" criminals and others with entrenched

antisocial personalities rarely respond positively to

treatment (Dougher, 1988). Therefore, it is reasonable

to assume that a diagnosis of Antisocial Personality

Disorder would be positively correlated with either

dropout or unsuccessful completion of treatment.













Degree of Discrimination in the Choice of Offense and
Victim Type

This variable has been included for testing for

several reasons. Abel and associates (1988) found, in

a sample of outpatient pedophiles, that this variable

predicted both poor response to treatment in the form

of dropout as well as recidivism using self-report of

reoffense as the outcome measure. In fact, Abel found

that, "All 30 offenders who dropped out during the

first 10 weeks of treatment had committed acts against

both males and females and against both children and

adolescent victims. More than half of the subjects who

dropped out before the end of the 30 week treatment

showed this same multiplicity of diagnoses, which was

significant at the p <.0001 level" (p. 227).

It was also found that offenders who had committed

both "hands-on" assaults of children as well as "hands-

off" assaults (such as exhibitionism or voyeurism) had

higher rates of dropping out than those who had

committed only one type or the other (p <.0001).

When the authors combined these characteristics they

found that 89.9% of the offenders who dropped out of

treatment had committed acts against males and females,

children and adolescents, both "hands-on" and "hands-

off". These findings were significant at the p <.0001












level. When relationship to the victim, described as

incest and nonincest, was considered with the above

factors the percentage of those dropping out remained

high (88.1%, significant at the p <.0001 level).

Concluding his review of the findings related to

dropping out, Abel et al. stated:

Combining all the mutiplicities of target
characteristics, it was found that 35 subjects had
committed pedophilic acts against males and
females, children and adolescents, and incest and
nonincest victims using hands-on and hands-off
molestation. Almost all of them (32 subjects, or
91.4%) dropped out of the treatment program. Of
the 157 subjects who did not report such
multiplicity of behaviors before treatment, only
22.3% dropped out of the treatment program. (Abel
et al., 1988, p. 228)

In interpreting their data the authors suggest

that a multiplicity of offense and victim interests and

behaviors may make behavioral techniques aimed at

decreasing deviant interests ineffective. They

further suggest that the individuals with the greater

diversity of interests and behaviors may be

qualitatively different from other offenders, more

deviant or suffering from a more serious "dose" of the

disorder which is more resistant to treatment induced

change and therefore more likely to resist treatment in

the form of dropout or unsuccessful completion and more

likely to recidivate.













Age

How age affects amenability continues to be a

clinical issue in sex offender treatment; there are

several components to this issue. Numerous studies of

incarcerated offenders have shown that the majority of

individuals entering prison for violent crimes are

between the ages of eighteen and thirty-five; a sub-

group of this population is comprised of rapists

(Scully, 1990). The treatment of adolescent sex

offenders is supported in part by the assumption that

early intervention is likely to stop a pattern of

behavior before it becomes deeply entrenched. But

recent studies have shown that most sex offenders, by

their mid-twenties, are already deeply entrenched in

their deviant patterns. Many of these offenders remain

relatively immature, defiant and may be resistant to

change. The maturing process has long been assumed by

clinicians to be an ally of treatment. Thus, once

offenders have reached adulthood, their amenability for

treatment is likely to improve as they get older; as

they mature they may be more likely to consider the

consequences of their behavior and be more willing to

seek alternatives to their deviant interests.












Marital Status

Several researchers have found that a stable

marital relationship is a predictor of successful

completion of treatment as well as nonrecidivism.

Schwartz (1977) found that intact marriage was a

predictor of nonrecidivism in a sample of sex

offenders, including rapists, being treated in the

community; Abel and his associates (1988) found that

being married was a predictor of successful completion

of treatment as well as nonrecidivism for the

pedophiles in their outpatient treatment program.


Instant Offense

The instant offense, or the one for which the

offender is currently incarcerated, is often used as

identifying data; an offense for which the offender was

convicted is not dependant upon self-report for

verification. Perhaps one of the most commonly held

clinical assumptions in the sex offender field is that

among rapists, child molesters (extrafamilial

pedophiles) and investors (intrafamilial), rapists will

have the poorest prognosis for successful treatment,

incest offenders will have the best prognosis, and

child molesters will fall somewhere in between.













Outcome data from incest offender treatment programs

are frequently disregarded by clinicians working in

secure, inpatient facilities where, at best, incest

offenders comprise perhaps one-third of the treatment

populations and where they are considered the easiest

clients. Clinicians in these programs, recognizing the

need for programs capable of treating rapists and child

molesters, grudgingly accept these clients inspite of

their poor prognosis, recognizing the need to decrease

their dangerousness, while, at the same time, fearing

the negative publicity should one of these offenders

reoffend.


Treatment Outcome Categories

Very few sex offenders volunteer for treatment

without having been coerced or ordered into it by some

form of the judicial or corrections systems.

Frequently, reports on progress and ultimately

prognosis in terms of prediction of reoffense are

required by these agencies and information and opinions

provided often have a significant impact on judicial

and corrections decisions concerning the offender. As

a result of this and the fact that a significant number

of sex offender treatment programs are operated by













agencies with public funds, formal, documented

decisions concerning amenability, prognosis, progress

and dangerousness are frequently required of clinicians

in this field.


Termination at the End of the 8 Week Evaluation Phase-
-Group (a)

The criteria for membership in group (a) are as

follows: discharged during or at the conclusion of the

evaluation phase of treatment either at the resident's

request or as a result of a decision by the MDT and

officially designated "not amenable for treatment"

(those discharged due to severe medical problems would

be excluded from the study, since they should have been

excluded from the waiting list and were inappropriately

referred for treatment); not accepted into the

treatment phase at the acceptance staffing attended by

the mdtt after the 8-week evaluation phase.


Termination During the Treatment Phase with a Poor
Prognosis--Group (b)

The criteria for membership in group (b) are as

follows: accepted into the treatment phase at the

acceptance staffing attended by the MDT after

successfully completing the 8-week evaluation phase;

subsequently determined to be no longer amenable for












treatment at an official termination staffing for one

or more of the following reasons: inappropriate

behavior such as repeated threats of violence, an act

of violence, sexual misconduct or other serious rule

violation; failure of treatment modules; failure to

follow treatment plan; resident request for termination

from the treatment program; a combination of the above,

or determined by the MDT to have made "no progress" or

"limited progress."


Termination at the End of the Treatment Phase with Good
Prognosis--Group (c)

The criteria for membership in group (c) are as

follows: accepted into the treatment phase after

successfully completing the 8-week evaluation phase;

subsequently determined to have made "significant

progress" or to have "successfully completed" the

treatment program at the time of discharge.

Criteria for a rating of "significant progress"

included successful completion of most or all treatment

modules; demonstration by observable behavior of

significant integration of treatment material into

daily behavior; ability to describe the causes and

effects, long- and short-term, and possible

interventions of the sex offending behavior. Criteria

for a rating of "successful completion" included being













accepted into the treatment phase after successfully

completing the 8-week evaluation phase; successful

completion of all treatment modules; demonstration by

observable behavior of consistent integration of

treatment material into daily behavior; ability to

describe the causes and effects, long- and short-term,

and possible interventions of the sex offending

behavior; having an approved release plan.


Summary

Although much work has been done in recent years

developing strategies to treat sex offenders, there

remains little empirical evidence in the research and

practice literature regarding the effectiveness of

these strategies and even less regarding the more

specific question of which types of treatment are

effective with which sex offenders. In this chapter

the research and practice literature has been reviewed,

and common assumptions held by clinicians have been

discussed. A set of offender variables have been

described which are examined in this study.
















CHAPTER III
METHODOLOGY

This study was designed to determine if six

offender variables, assessed during the first 8 weeks

of a residential sex offender treatment program, were

correlated with membership in one of three treatment

outcome groups. The offender variables consisted of

(a) reading level, (b) presence of antisocial

personality disorder, (c) degree of discrimination in

the selection of offense and victim type (operationally

defined as total deviance score), (d) age, (e) marital

status, and (f) instant offense. The treatment outcome

groups consisted of (a) offenders who were discharged

at the end of eight weeks as nonamenable, (b) offenders

who were judged amenable for treatment at the end eight

weeks but were subsequently discharged prior to

completing treatment with a poor prognosis, and (c)

offenders who were judged amenable for treatment at the

end of eight weeks and were subsequently discharged

after completing the program with a good prognosis.

This chapter consists of sections describing the

research design, population and sample, procedures for













treatment and data collection, instrumentation,

hypotheses, data analyses, and limitations of the

study.


Research Design


Criterion Variable

In this study an ex post facto design was used to

evaluate the interrelationships among six offender

variables and three treatment outcome groups: (a)

offenders judged nonamenable for treatment during an

evaluation phase of a residential treatment program,

(b) offenders judged amenable for treatment during an

evaluation phase, but later discharged with a poor

prognosis, and (c) offenders judged amenable for

treatment during an evaluation phase and subsequently

discharged with a good prognosis.

The criteria for membership in group (a) were

discharged during or at the conclusion of the

evaluation phase of treatment either at the resident's

request or as a result of a decision by the MDT, and

not accepted into the treatment phase at the acceptance

staffing attended by the treatment team after the 8

week evaluation phase and officially designated "not

amenable for treatment." The criteria for membership










78

in group (b) were accepted into the treatment phase at

the acceptance staffing attended by the MDT after

successfully completing the 8 week evaluation phase and

subsequently determined to be no longer amenable for

treatment at an official termination staffing for one

or more of the following reasons: inappropriate

behavior such as repeated threats of violence, an act

of violence, sexual misconduct or other serious rule

violation; failure during treatment modules; failure to

follow treatment plan; resident request for termination

from the treatment program; a combination of the above;

or determined by the MDT to have made "no progress" or

"limited progress." The criteria for membership in

group (c) were being accepted into the treatment phase

after successfully completing the 8 week evaluation

phase and subsequently being determined to have made

"significant progress" or to have "successfully

completed" the treatment program at the time of

discharge.

Criteria for a rating of "significant progress"

included (a) successful completion of most or all

treatment modules, (b) demonstration by observable

behavior of significant integration of treatment

material into daily behavior, and (c) ability to










79

describe the immediate and long-term causes and impact

of the sexual offending and to demonstrate knowledge of

approved methods for preventing future sex offending

behavior. Criteria for a rating of "successful

completion" included (a) successful completion of all

treatment modules, (b) demonstration by observable

behavior of consistent integration of treatment

material into daily behavior, (c) ability to describe

the immediate and long term causes and impact of the

sexual offending and to demonstrate knowledge of

approved methods for preventing future sex offending

behavior, and (d) an approved release plan.


Independent Variables

The six variables examined in relation to the

outcome variables were (a) reading level, reported as a

raw and converted score from the administration of the

Wide Range Achievement Test-Revised (WRAT-R); (b)

presence of an antisocial personality disorder,

documented by the primary case manager who was

responsible for integrating the consensus diagnoses of

the MDT; (c) degree of discrimination in the selection

of offense and victim type (total deviance score) based

on the documentation in the clinical summary of offense












history from official reports and self-report of the

offender during the evaluation phase; (d) age at time

of admission; (e) marital status, and (f) instant

offense.


Population

The population from which the sample was drawn

consisted of 167 males who (a) were convicted of sex

offenses including rape, child molestation and incest,

(b) were incarcerated in the Florida prison system

between the years of 1985 and 1989, (c) were between

the ages of sixteen and seventy, (d) had a minimum of a

third grade reading level and a score of 70 or higher

on the WAIS-R, (e) had no organic, psychotic or other

major mental disorder, (f) volunteered for

participation in a Health and Rehabilitative Services

(HRS) residential sex offender treatment program, (g)

were placed on a waiting list for treatment, and (h)

were subsequently transferred to NFETC when they reached

the top of the waiting list.

Each male sex offender who was convicted and

sentenced to a period of incarceration with the Florida

Department of Corrections (DC) was required by statute

to be evaluated for possible participation in one of












the two HRS Mentally Disordered Sex Offender (MDSO)

treatment programs. Preliminary screening was

accomplished by DC psychological staff to identify

those offenders who were administratively qualified for

transfer to HRS for sex offender treatment and who

volunteered for that treatment. Such offenders were

subsequently interviewed by a joint screening team

composed of representatives of the DC psychological

staff and the staff of one of the HRS sex offender

treatment programs. The following criteria were used

in the joint screening process to determine potential

eligibility for treatment: (a) evidence of a

psychosexual disorder, (b) willingness of the offender

to volunteer for treatment, (c) demonstration by the

offender of sufficient motivation and capacity for

insight to indicate a possibility of successful

treatment completion, and (d) A score of 70 or above on

the WAIS-R or equivalent and WRAT-R of third grade or

above.

Offenders who were determined to be potentially

eligible for consideration for treatment as a result of

this joint screening process were then placed on a

waiting list to await transfer to HRS custody for

treatment. This waiting list was prioritized according












to the length of time remaining on the offender's

sentence, with those having the least time being

afforded the earliest opportunities for treatment.

Those offenders with shorter sentences which precluded

a minimum of at least eight months treatment were

excluded from participation.


Resultant Sample

The resulting sample of 114 offenders consisted of

those individuals from the population described who had

not been accepted for treatment prior to the

establishment of the new treatment program in July,

1986 and had sufficiently progressed in treatment to

receive a completion rating at the time of the closing

of the program in June, 1989. Excluded from the sample

were offenders found not amenable for treatment, once

at the facility, due to criteria which would have made

them ineligible at the time of original screening such

as a chronic physical problem (e.g., heart disease) or

major thought disorder.

The sample of offenders whose records were studied

consisted of 114 male sex offenders who attended the

sex offender treatment program at North Florida

Evaluation and Treatment Center (NFETC) between March,












1986, and August, 1989. The mean age of these

offenders on admission to the treatment facility was

31.4 years of age with the youngest being 16 and the

oldest being 59. Of the 115 offenders, 47 (40.87%) had

been incarcerated for a most recent charge (instant

offense) of incest or intrafamilial child molestation.

Extrafamilial child molesters, those who victimized

children outside of the home, numbered 37 (32.17%).

There were 31 (26.96%) men incarcerated for rape.

Examining the marital status of the offenders revealed

that 40 (35.09%) were married, 39 (34.21%) had never

been married, 9 (7.89%) were separated, and 26 (22.81%)

were divorced. There were 27 (23.48%) black offenders,

87 (75.65%) white offenders, and one (0.88%) hispanic

offender in the sample.


Procedures


Treatment Procedures

The residential treatment program from which data

for this study were collected was housed at North

Florida Evaluation and Treatment Center (NFETC), a

maximum security forensic mental health institution

operated by HRS in Gainesville, Florida since 1976. The

MDSO program, which comprised approximately one-third










84

of the institutional population, had a maximum capacity

of 63 beds dedicated to the treatment of convicted male

sexual offenders. The NFETC sex offender program

physical plant included three buildings, two of two

wings (called pods) housing offenders who had been

accepted for the treatment phase, and one of three pods

which included two pods of offenders in the 2-month

evaluation phase and one pod of advanced offenders

approaching successful completion of treatment. Each

pod was comprised of 9 offenders, each of whom was

assigned an individual room. Each of these offenders

had been screened and approved for transfer at one of

various DC institutions throughout Florida prior to

transfer to the MDSO unit.

The treatment program integrated three broad areas

of therapeutic focus: (a) assisting the offender in

replacing distorted or irrational thinking and

maladaptive behaviors commonly associated with the

psychosexual disorder (e.g., cognitive restructuring,

behavioral module); (b) training offenders in the

skills necessary to improve their interpersonal and

intrapsychic functioning (e.g., their communication

skills and stress/anger management); and (c) assisting

the offender in identifying and remediating impediments












to healthy functioning that were the result of early

trauma and/or lifelong acquired patterns of dysfunction

through corrective emotional experiences using

techniques derived from Gestalt Therapy,

Psychosynthesis and Neuro-Linguistic Programming as

well as modified aversive behavioral rehearsal therapy

(Knopp, 1984).

A basic assumption underlying this treatment

approach was that there is an endless variety of

combinations of behavioral, experiential and cognitive

antecedents that sex offenders describe in their

offense cycles. The idea that one treatment modality

would successfully ameliorate the problems of so

diverse a population seemed optimistic at best and

grossly inadequate at worst. Based on their treatment

experience, the staff concluded that the best strategy

for treating such a diverse population was to offer a

variety of treatment modalities, individualizing the

treatment by stressing some components over others

based on evaluations of the offender's behavior,

progress, and personality configuration.

A second concept underlying the treatment program

was that, whenever possible, treatment would be

delivered using a structured module format to










86

facilitate accurate replication for quality control and

future research. Topics addressed by structured

modules ranged from educational material such as sex

education to sensitivity training which included

experiential components. Although some modules were

appropriate for all offenders in the program,

individuals with extensive histories of abuse were

considered to require more emphasis on repairing the

effects of early trauma and more supportive therapy

than those with less abuse in their early history.

Preliminary assessment phase. Upon admission,

each offender was required to participate in a

preliminary treatment assessment phase. During this

phase each offender participated in an initial intake

interview with members of the MDT and then took a

battery of assessment instruments. Also during this

phase, each offender was sequestered in his assigned

room except when participating in an initial

comprehensive assessment battery.

Evaluation phase. The 8 week evaluation phase,

which began with the Computer Assisted Psychosocial

Assessment (CAPSA), was designed to begin the process

of treatment while testing the offender's ability and

motivation to participate successfully in the program


__












components. To this end this phase consisted of

learning the program rules, participating in structured

and unstructured groups on a daily basis, completing

chores, completing frequent structured assignments

designed to increase awareness of the offender's

offense cycle, and revealing to his therapist and group

members significant information from his past regarding

his development including his offenses as well as his

own traumas. Structured modules included criminal

thinking errors and offense cycle (central process).

During this phase each offender received a

psychological evaluation which was included in his

clinical record. Each offender's progress was reviewed

weekly by the MDT including the paraprofessional staff

person called a Resident Activity Monitor (RAM), who

tracked the offender's compliance with treatment plan

directives. At the conclusion of the evaluation phase

the offender was evaluated by the MDT in a formal

review known as the Acceptance Staffing where the

offender's progress, amenability for treatment as

predicted by the psychological evaluation, and the

offender's ability to respond to stressful questioning

were considered in determining his eligibility to

continue into the treatment phase of the program.










88

Treatment phase. The treatment program utilized a

therapeutic community to create an emotionally safe

environment within which to explore past traumatic

experiences, faulty learning, and inappropriate

behavioral reponses to stressful situations.

Responsible for this milieu were the 7 professional

therapists and 45 paraprofessional staff who managed

the three treatment buildings. This therapeutic

community included a resident government, peer-

facilitated groups and impromptu encounters providing

the background upon which this modularized program was

superimposed. Material learned in the modular program

was expected to be demonstrated in the milieu in new,

more appropriate behavior.

Additionally, the program included therapist-

facilitated pod groups which met twice weekly to focus

on here-and-now interpersonal conflicts and progress

using core program components such as "central process

of the psychosexual disorder," bodywork and meditation,

the offender work program, Alcoholics Anonymous, basic

adult education, evening study halls, structured

training groups, and art, music, and recreation

therapy.

Treatment participants who had completed all the

treatment modules and had advanced to the integration












phase assisted in facilitating groups and also served

as primary facilitators for structured evening training

modules on a regular basis in the evaluation building.

Offenders provided support and facilitation to one

another throughout the treatment week in the form of

Triad Sessions (small group teams of three) and special

group attendance.

There was also a peer-facilitation/peer-evaluation

process interwoven into the structure of the overall

treatment program which was directed by the Offender

Government. Regularly scheduled, periodic reviews of

the offender's progress were conducted by offender

review boards comprised of elected peers, and the

results were presented to the offender and his case

manager as feedback.

Evaluation of each offender's progress in

treatment was conducted by staff in accordance with

standards mandated by HRS. Progress in treatment was

reviewed with each offender on a weekly basis during

the initial two month evaluation phase and biweekly

during the remainder of his treatment. Regular

progress staffing were scheduled and conducted

annually, and special staffing were scheduled as

therapeutically indicated on a case by case basis.













The treatment program at NFETC was structured to

be 18 months in duration. Although a few offenders

were able to complete all of the modules and

demonstrate integration of the skills taught into daily

behavior within as little as 15 months, most required

at least 18 months to successfully complete the

program. Regardless of the length of time an offender

spent in the treatment program, he received regular

feedback on his progress from the treatment team.


Data Collection Procedures

Data for the study were drawn from case files in

the Medical Records department of NFETC. Each

offender's record was reviewed to determine the WRAT-R

raw score and grade equivalent. These scores were

either documented in the offender's record from his DC

evaluation or in the psychological evaluation conducted

at NFETC.

Also reviewed was the diagnosis. In order to

maximize reliability, the diagnosis in the initial

clinical summary was used because it documents a

consensus decision of the MDT. A zero (0) was scored

for no diagnosis or no features of antisocial

personality disorder. A one (1) was scored for a












diagnosis with features of antisocial personality

disorder, and a two (2) was scored for a diagnosis of

antisocial personality disorder.

The clinical summary(ies) were also reviewed to

determine the number of different victim types (age and

gender) as well as the number of different types of

paraphilic acts. If the information regarding victim

type and/or paraphilic acts was unclear in the summary,

a further review of the case file including

documentation of self-reports of previously unknown

offenses revealed by the offender during clinical

interviews or documented from other treatment

modalities was conducted. The clinical summary(ies)

was also reviewed to determine the resident's age upon

admission, marital status and instant offense.


Instrumentation

This section contains descriptions of the

instruments used to assess the variables of interest in

this study. Included are the Wide Range Achievement

Test-Revised, the evaluation phase clinical summary,

and the NFETC clinical case record.

Wide Range Achievement Test-Revised (WRAT-R)

The Wide Range Achievement Test-Revised (WRAT-R)

will be used to measure reading level. The WRAT was










92

first developed and standardized in 1936 as an adjunct

to intelligence tests and measures of behavior

adjustment. Since its development it has been revised

five times and has been experimentally administered to

thousands of people from pre-school through adulthood.

Although the 1984 WRAT-R contains many changes

from the original, it remains basically the same in

form, content and commitment to remaining a simple

assessment instrument (Jastak & Jastak, 1979). The

thrust of recent revisions has been to make the WRAT-R

an up-to-date psychometric instrument using improved

methods for item analysis and scaling (i.e., Rasch

model).

The WRAT-R provides data regarding the level of

reading skills in both raw score form and as equivalent

school grades. It provides a more direct measure of

ability than the WAIS-R with which it is, however,

highly correlated, particularly the verbal IQ and full-

scale IQ (Cooper & Fraboni, 1988; Margolis, Greenlief &

Taylor, 1985; Ryan & Rosenberg, 1983; Spruill & Beck,

1986). This high correlation holds for geriatric

populations (Margolis et al., 1985); mixed mental

health patients (Ryan & Rosenberg, 1983); and normals

(Cooper & Fraboni, 1988; Spruill & Beck, 1986). The












advantage of using the WRAT-R as a measure of ability

instead of the WAIS-R is that the WRAT-R is relatively

easy and quick to administer and is therefore more

likely to be available to most programs, regardless of

size and psychological resources.


Assessment of Antisocial Personality Disorder

The presence of Antisocial Personality Disorder or

other diagnoses were determined by an initial intake

interview, subsequent social history, information

revealed during the Evaluation Phase and a

psychological evaluation and were documented in the

Evaluation Phase clinical summary. The Evaluation

Phase clinical summary is a document developed by the

staff of NFETC for reporting of the results of the

eight week evaluation phase of the sex offender

treatment program and sent to the Department of

Corrections. It was the responsibility of the

offender's primary case manager to produce following

NFETC summary guidelines. It included information

derived from interviews, treatment procedures, and

previous documentation. Among its contents was a

consensus Axis II diagnosis opinion of the MDT

attending the 8-week evaluation staffing generally




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81,9(56,7< 2) )/25,'$



OFFENDER VARIABLES AND TREATMENT
OUTCOMES OF PARTICIPANTS IN A
RESIDENTIAL SEX OFFENDER PROGRAM
By
THEODORE A. SHAW
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
1991

Copyright
by
Theodore A
1991
Shaw

ACKNOWLEDGMENTS
I would like to acknowledge the following
individuals: my doctoral chairperson, Dr. Ellen
Amatea, for her never ending patience and perseverance;
my doctoral committee members including Dr. George
Barnard, Dr. Harry Grater, Dr. Larry Loesch, and Dr.
Gus Newman for their support and guidance; Lynn Robbins
for her friendship and invaluable assistance; Denny
Gies and the administration and clinical staff of North
Florida Evaluation and Treatment Center; and the
dedicated staff of the Sex Offender Unit of NFETC.
I would also like to acknowledge my wife, Dr.
Jamie Funderburk, for her patience and continuing
support, guidance and technical assistance, my
children, Amanda and Alex, for their patience with my
preoccupation, and my mother, Micki, who has always
inspired me to greater achievement.
iii

TABLE OF CONTENTS
page
ACKNOWLEDGMENTS iii
ABSTRACT vi
CHAPTERS
1 INTRODUCTION 1
Scope of the Problem 4
Need for the Study 13
Purpose of the Study 14
Research Questions 15
Context for the Study 16
Definition of Terms 18
Significance of the Study 20
2 REVIEW OF LITERATURE 2 2
Research on Sex Offender Treatment
Amenability 22
Basic Assumptions, Techniques, Settings,
Populations Treated (Focus), Research
Findings and Related Literature 36
Treatment Center Study/Setting 45
Treatment Amenability Factors 57
Independant Variables 62
Treatment Outcome Categories 72
Summary 7 5
3 METHODOLOGY 7 6
Research Design 77
Population 80
Resultant Sample 82
Procedures 83
Instrumentation 91
Hypotheses 96
xv

Data Processing and Analysis
97
4 RESULTS 98
Descriptive Statistics for Treatment
Outcome Groups 99
Differences Among Treatment Outcome
Groups 100
Summary 114
5 DISCUSSION 116
Discussion of Results 116
Limitations 123
Implications 127
Summary and Conclusions 135
APPENDIX 136
REFERENCES 137
BIOGRAPHICAL SKETCH 144
V

Abstract of Dissertation Presented to the Graduate
School of the University of Florida in Partial
Fulfillment of the Requirements for the Degree of
Doctor of Philosophy
OFFENDER VARIABLES AND TREATMENT
OUTCOMES OF PARTICIPANTS IN A
RESIDENTIAL SEX OFFENDER PROGRAM
by
Theodore A. Shaw
December, 1991
Chairperson: Ellen Amatea, Ph.D
Major Department: Counselor Education
Growing awareness of the frequency of sexual abuse
and its terrible impact on victims and society has led
to the development of more systematic approaches to the
evaluation and treatment of sex offenders. Little is
known concerning which treatment models and settings
are effective with which populations of sex offenders.
This study was conducted to examine the relationships
among six offender variables and offender outcome
status in a residential sex offender treatment program
which emphasized a multi-modal treatment approach. The
six offender variables were (a) age, (b) reading
ability, (c) degree of discrimination in the selection
vi

of victim and offense type, (d) instant offense
(offense for which the offender is currently
incarcerated), (e) presence of antisocial personality
disorder, and (f) marital status. The three
categories of treatment outcome were (a) not amenable
for treatment, (b) amenable for treatment but
discharged with a poor prognosis, and (c) amenable for
treatment and discharged with a good prognosis.
Results of a discriminant function analysis revealed
that the six offender variables together did not
discriminate significantly among offenders in the three
outcome groups. Results of analyses of variance and
Chi-square analyses revealed that offenders who were
married or in a committed relationship and offenders
who had higher reading ability were more likely to be
found in the treatment group discharged with a good
prognosis than in the other two treatment status
groups. Presence of antisocial personality disorder,
degree of discrimination in offense or victim type,
age, and instant offense did not discriminate
significantly among offenders in the various outcome
groups. Limitations, implications for theory and
clinical practice, and recommendations for future
research are also discussed.
vi 1

CHAPTER I
INTRODUCTION
The challenge of treating sex offenders has taken
on new importance in light of the staggering reports on
frequencies of types of sexual abuse and rising
awareness of the human and financial costs of coping
with the problems ineffectively. Of particular concern
are the increased reports of rapes of adult women and
men as well as reports of intrafami1ial and
extrafami1ial child sexual abuse. Recent research
reveals that a pattern of repeated, unreported offenses
is more the rule than the exception among sex offenders
(Barnard, Fuller, Robbins, & Shaw, 1989; Finkelhor,
1988; Furby, Weinrott, & Blackshaw, 1989; Knopp, 1984;
Salter, 1988). In their study of 411 parapheliacs,
Abel and associates discovered that these subjects had
engaged in over 138,000 sex offenses involving over
115,000 victims (Abel, Becker, Mittelman, Cunningham-
Rathner, Rouleau, & Murphy, 1987). Moreover, many had
never been arrested, few had ever been incarcerated,
and most had never received specific sex
offender treatment.
1

The enormous financial and psychological costs to
victims and society are major factors that underscore
the need to treat sex offenders. Through reports by
sociological researchers such as Finkelhor and
clinicians working in the relatively new Adults
Molested As Children (AMACS) movement, it is clear that
vast numbers of men and women have been sexually
victimized and that such victimization has profound
traumatic effect on these individuals (Burgess, Groth,
Holmstrom, & Sgroi, 1978).
Growing awareness of sex offense problems has led
to the development of many specialized treatment
program efforts for sex offenders. For example, a
national survey of adult and juvenile residential and
outpatient sex offender programs conducted by Knopp and
Stevenson in 1989 revealed that between 1986 and 1988
the number of specialized treatment programs increased
by 56% nationwide, to a total of more than 1000.
Relatedly, of the adult treatment services polled, 28%
(119) were residential, the majority of which were
located in adult prisons, and 72% (310) were
outpatient, the majority of which were provided by
mental health private practitioners. There was a
similar distribution for juvenile services: 20% (117)

3
were residential, with almost half located in private
facilities, and 80% (456) were outpatient, with about
the same number provided by private practitioners and
mental health centers. However, the demand for
specialized sex offender treatment continues to outpace
its availability. In Florida, for example, by j.989
more than 5000 sex offenders were incarcerated in the
prison system. Of these, more than 300 were found
eligible (i.e., met entry criteria) for treatment and
had been placed on a waiting list. Although only 75
offenders were admitted to treatment that year, more
than 150 had been placed on the waiting list. As in
Florida, many states are facing situations where
treatment opportunities are limited by funding which
determines the number of available treatment beds.
With many more offenders in need of treatment than
available beds, it becomes crucial to determine which
offenders might profit most from specialized treatment.
There is little empirical evidence available,
however, concerning who is most likely to benefit from
sex offender treatment (Abel, Mittelman, Becker,
Rathner, & Rouleau, 1988; Laws, 1985), and few studies
have been undertaken to determine treatment specific
amenability. Because most of the current research on

4
sex offender treatment has focused only on examining
official and unofficial reports of rearrest,
reconviction, or self-report of reoffense as measures
of treatment outcome, the present state of knowledge
regarding amenability in terms of interim measures such
as the offender's status at the time of discharge from
treatment is relatively sparse. Therefore, the
correlation among six offender characteristics and
three sex offender treatment outcomes was examined in
this study.
Scope of the Problem
Because the development and widespread use of
specialized treatment procedures for sex offenders are
relatively recent, very little is known regarding
either the types of treatment procedures most effective
with particular types of sex offenders or
characteristics which distinguish offenders who benefit
from particular treatments from those who do not.
Although syndromes relating to sexual deviance have
been known to the medical/psychological field for
centuries, organized approaches to treating and
assessing the impact of treatment of this population

5
are relatively recent (Barnard et al., 1989; Greer &
Stuart, 1983).
The problem with outcome research in the sex
offender treatment area is less one of quantity than
methodology, particularly in regard to outcome
measures. In a recent review of the state of tne art
of sex offender treatment outcome research, Furby et
al . ( 1989) concluded that it has not been adequately
demonstrated that specialized sex offender treatments
reduce recidivism more effectively than other
strategies (including no treatment).
Recently, researchers have begun to evaluate
critically both the quantity and quality of research on
sex offender treatment. For example, in reviewing the
recent research on sex offender treatment, Murphy
(1988) contended that current providers of sex offender
treatment still know very little about the efficacy of
any of their treatment approaches and that much more
research needs to be done to speak with assured
confidence about the nature of specialized treatment of
sexual abusers. In commenting on the lack of
definitive research in this area, Murphy (1988)
criticized the methodology used in sex offender
treatment research and proposed a set of questions to

6
guide future research. Among these was, "Which
offender characteristics predict amenability for which
treatment?" Other researchers have concurred that a
key issue in improving sex offender treatment efficacy,
as well as in development of clearer understanding of
treatment impact for sex offenders, centers on
identifying those individuals most likely to benefit
from treatment (Abel et al., 1989; Furby et al., 1989;
Knopp, 1984; Marshall & Barbaree, 1988, 1990; Murphy,
1988; Shaw, Spears, Cunningham, Butler, Barnard,
Robbins, & Newman, 1987).
Only a limited number of researchers have examined
the characteristics of offenders as a means of
predicting success in completing sex offender
treatment. Further, most researchers who have examined
offender characteristics have focused predominantly on
outpatient populations (in the community) and have done
so secondarily to some other research focus. Their
findings from outpatient samples suggest that offenders
who are relatively more intelligent (Marshall &
Barbaree, 1988), have stable marital relationships
(Abel et al., 1988), have committed only one type of
sex offense on only one type of victim (e.g., among
pedophiles only) are likely to complete treatment

7
successfully and have relatively low recidivism rates
(Abel et al., 1988). Little is known, however,
regarding the amenability for treatment of incarcerated
offenders in secure treatment programs (i.e., prisons
or maximum security mental institutions) where fear of
reprisals, presumed relatively high prior offense
rates, low socioeconomic status, and minimal
educational attainment are likely to be factors
negatively influencing amenability (Knopp, 1984).
Populations of incarcerated offenders are likely to
contain fixated (i.e., repetitive) pedophiles, rapists,
and other violent offenders who are routinely excluded
from outpatient treatment due both to the obvious risk
to the community and their high likelihood, even on a
first conviction, to be incarcerated instead of
receiving probation or community control based on the
perceived seriousness of their offenses (Knopp, 1984).
Because of these factors, the findings of studies based
on outpatient samples appear to have limited
general izabi1ity to incarcerated offenders.
Despite limited empirical investigation, however,
it has been customary for practitioners treating
incarcerated sex offenders to assume that not all sex
offenders are amenable for treatment and to screen

8
potential treatment candidates based on these
assumptions (Schwartz, 1988b). Because there are
limited empirical data, guidelines for determining
amenability for treatment usually have been established
on the basis of clinical judgment, tradition,
limitations of the treatment setting (including
therapeutic skills of the clinicians), or funding
considerations. New Jersey, Minnesota, and Oregon, for
example, are among the few states that offer rapists
the opportunity for treatment because they have long-
established, secure residential treatment facilities
(Knopp, 1984).
Among the assumptions commonly used to select
offenders for treatment is the notion that sex
offenders with antisocial personality disorders are
less likely to complete treatment successfully due to
their documented history of frequent job changes,
adolescent conduct problems and unwillingness to follow
rules (Abel et al., 1988).
Sex offenders have been categorized traditionally
according to their most recent charge (instant offense)
or most common offense if the instant offense is
uncharacteristic of the documented offense history.
Incest offenders are generally considered the most

amenable for treatment as well as the least likely to
reoffend whether they receive treatment or not. Child
molesters are considered less amenable for treatment
than incest offenders but more amenable than rapists.
Rapists are generally excluded from treatment because
they frequently have a diagnosis of antisocial
personality disorder and because of the nature of their
offenses (which makes them "too dangerous" for
outpatient settings) (Knopp, 1984; Schwartz, 1988b).
Moreover, rapists are often physically aggressive and
threatening and are likely to engage in rule violations
which could cause them to be prematurely terminated
from treatment. A widespread clinical assumption in
the field is that as offenders get older they become
less likely to engage in aggressive behaviors and more
concerned with the consequences of their criminal
behavior. It follows that the older the offender, the
more likely he is to make the necessary effort to
complete treatment successfully.
Although not demonstrated definitively in the
literature, intelligence (IQ) and reading level also
have been assumed to be important predictors of
amenability for sex offender treatment (Marshall &
Barbaree, 1988; Rosen, 1964; Schwartz, 1988b). The

10
fact that there are still virtually no treatment
programs for retarded sex offenders is one indication
that a certain level of mental ability is considered
important in the treatment process. As
cognitive/behavioral strategies have become more
integral to sex offender treatment, adequate reading
ability and intelligence have become important criteria
for program admission. It has been assumed that the
more intelligent the treatment candidate and the better
able to read, the more likely the individual is to
complete treatment successfully. Requirements for
successful completion of many treatment programs
include compliance with extensive reading and related
homework assignments and integration of the learned
material into daily behavior patterns (North Florida
Evaluation and Treatment Center, 1988; Rosen, 1964).
A fifth assumption undergirding the selection of
offenders for treatment concerns the sex offender's
degree of discrimination in offense and victim types
and its impact on treatment participation and success.
In a recently published study Abel and associates
(1988) found that lack of discrimination in offense and
victim types predicted dropout of offenders from an
outpatient treatment program. In addition, this

11
variable predicted recidivism for those who did
complete treatment. Significantly, more than half of
the participants in the study of Abel et al. (1988)
reported multiple deviations. This assumption has been
considered only recently by clinicians and is supported
by empirical evidence (Marshall & Barbaree, 198a).
Suggesting that the disorder of individuals with
multiple victim and offense types may be more
entrenched in their deviant behaviors and thus
resistant to change through treatment has important
implications for determining amenability for treatment.
This finding from a community-based program population
has potential significance for residential programs
which are likely to be treating those with documented
reoffenses and long histories of deviant behavior
(Knopp, 1984).
A sixth assumption regarding selection of
treatment candidates which has recently received
research support is marital status. It has long been
thought by clinicians that offenders with intact,
supportive families were more likely to both
successfully complete treatment and refrain from
reoffending, and this may contribute to the incest
offender's reputation for successful treatment outcome.

12
Recently Abel and associates found that marital status
was the single demographic variable which predicted
both dropout and recidivism. Those who were married
were more likely to complete treatment and less likely
to reoffend than offenders who were separated, divorced
or never married (Abel et al., 1988).
In summary, despite the absence of empirical
corroboration, practitioners in the field of sex
offender treatment have routinely based their selection
decisions on a number of shared assumptions. These
assumptions are that persons who are single or divorced
and who have low intelligence, poor reading ability, an
antisocial personality disorder, history of violent
sexual assaults (i.e., rape), a documented repetitive
history of offending, and history of different types of
sex offenses against victims of differing age or sex
will be less likely to complete treatment successfully.
Conversely, most practitioners have assumed that those
who are married, have high intelligence, adequate
reading ability, lack of antisocial personality traits,
absence of a history of violent sexual assaults or
repetitive offending, and who engage in a single type
of offense (i.e., incest) against a particular age
group of a particular sex (e.g. pre-pubertal boys) will

13
be more likely to successfully participate in
treatment.
Need for the Study
In virtually every state in America the number of
sex offenders in need of treatment far exceeds the
available treatment opportunities (Knopp, 1984; Salter,
1988). While more and more treatment programs are
opening in an effort to meet this need, there exist no
empirically derived selection standards for these
programs. Nonetheless, program clinicians and
administrators are routinely expected to determine
amenability and provide a treatment regimen. Although
numerous researchers and clinicians have offered
reasonable models for determining amenability (Barnard
et al., 1989; Salter, 1988; Schwartz, 1988b), at the
present time these models are untested. Such a lack of
research evidence on amenability has a distinctly
negative impact on the ability of programs to maximize
their efforts and to replicate their successes or
improve their treatment programs. Thus, more needs to
be learned concerning what types of treatment are most
effective with which types of offenders (Schwartz,
1988b). Studies must be undertaken in a variety of

14
settings to test the generalizabi1ity of the findings
reported from the few studies which have been
conducted. Although several researchers have recently
presented data on amenability for treatment, these
programs have been community based and limited to
incest offenders or pedophiles (Abel et al., 1988;
Dwyer & Ambersson, 1985). Little has been demonstrated
concerning indicators of amenability for treatment of
populations of incarcerated sex offenders.
As has already been noted, leaders in the sex
offender treatment field concur that more research
needs to be undertaken in an effort to predict
successfully who will benefit from the emerging
specialized treatment models.
Purpose of the Study
This study was designed to assess the degree of
correlation among six offender characteristics and
three treatment outcome groups in a residential sex
offender treatment program. The six offender
characteristics were (a) reading level, (b) presence of
an antisocial personality disorder, (c) degree of
discrimination in offense and victim types
(operationalized as "total deviance score"), (d) age,

15
(e) marital status, and (f) instant offense (offense
for which the offender is currently incarcerated). The
three outcome groups consisted of (a) those not
accepted after an 8-week pretreatment evaluation phase,
(b) those accepted for treatment and subsequently
discharged from the treatment program with a poor
prognosis, and (c) those accepted for treatment and
subsequently discharged from treatment with a good
prognosis .
Research Questions
The following set of research questions were
addressed in this study:
1. What is the influence of reading level,
degree of discrimination in the choice of victim or
paraphilic act, presence of antisocial personality
disorder, age, marital status, and instant offense in
classifying offenders into outcome groups?
2. Are there differences in reading level of the
offenders among the three outcome groups?
3. Are there differences in the degree of
discrimination in the choice of offense and victim type
among the three outcome groups?

16
4. Are there differences in the presence of an
antisocial personality disorder among the three outcome
groups?
5. Are there differences in ages among the three
outcome groups?
6. Are there differences in marital status among
the three outcome groups?
7. Are there differences in instant offense
among the three outcome groups?
Context for the Study
The setting in which the study was conducted is a
maximum security residential mental health treatment
center operated by the State of Florida Department of
Health and Rehabilitation Services (HRS) which offered
a model, structured sex offender treatment program. In
the same institution there were programs designed to
return offenders found Incompetent to Proceed (ITP) to
court and to treat until deemed no longer dangerous
offenders found by the court Not Guilty by Reason of
Insanity (NGI); those successfully treated might be
discharged to the community or some other less
restrictive setting.

17
The sex offender program had recently been revised
(Barnard et al., 1989) and has been described as a
model for the multi-modal or integrated approach to sex
offender treatment in a residential setting (Knopp,
personal correspondence, 1988). Although this implies
the use of many methods in an integrated whole, the
predominant treatment theories underlying the program
were cognitive/behavioral and psychodynamic.
Cognitive/behavioral sex offender treatment programs
are generally characterized by structured learning
modules built around a Relapse Prevention foundation
(Barnard et al., 1989). This type of treatment relies
heavily on the offender's ability to read, learn, and
understand reading assignments as well as his ability
to integrate group experiences and demonstrate an
integration of the covered material. Its location in a
maximum security forensic mental health facility with
twenty-four hour staff supervision and extensive
electronic controls made it hard for offenders not
interested in fullfilling the spirit of treatment and
integrating treatment material to make reasonable
progress. For this reason it is assumed that it was
unlikely that repetitive offenders or those with an
extensive criminal history and likely concommitant

18
antisocial personality disorders would have been able
to successfully complete the program.
Definition of Terms
Multi-Disciplinary Treatment Team (MPT) acceptance
staffing is a formal meeting with the offender to
review his general behavior within the milieu,
compliance with treatment plan directives, knowledge of
material covered in the evaluation phase modules,
results of ar.y psychological testing, and any other
data relevant to the demonstration of his amenability
for treatment. The staffing occurred at the conclusion
of an eight week evaluation phase, or during the phase
at the request of the offender or his primary
therapist.
Multi-Disciplinary Treatment Team (MPT)
termination staffing is a formal meeting of the MDT to
review the offender's progress in treatment, status at
the time of termination from treatment, and
recommendations after discharge.
Amenability for treatment is the likelihood of an
individual to benefit from a treatment procedure
some describable or measurable way.
in

19
Evaluation phase refers to the first 8 weeks of
treatment in the Mentally Disordered Sex Offender
(MDSO) Program at North Florida Evaluation and
Treatment Center (NFETC), Gainesville, Florida.
Instant offense is the most recent offense or
group of offenses for which the offender has been
convicted and sentenced.
Recidivism has been variously defined as a
reoffense, rearrest, reconviction or reincarceration.
When not otherwise specified in the text, recidivism is
herein defined as a reoffense. Recidivism is
frequently used as a measure of treatment success with
criminals and individuals with repetitive or addictive
behaviors including deviant sexual behavior.
Reading level as measured by the Wide Range
Achievement Test (WRAT-R), can be described by a raw
score or a grade equivalent.
Age refers to how old the offender was upon
admission to NFETC.
Marital status refers to whether the offender was
married, divorced, separated or never married at the
time of admission to NFETC.
Antisocial personality disorder is a diagnostic
category from the personality disorder section of the

20
Diagnostic and Statistical Manual III (DSM III) (now
the Diagnostic and Statistical Manual III - Revised), a
standard guide in the field of psychology and
psychiatry for making diagnoses of patients, which is
characterized by a history of delinquent behavior prior
to age eighteen followed by a history of irresponsible
behavior which might include criminal behavior,
substance abuse, frequent job changes, etc.
Degree of discrimination in offense and victim
types (total deviance score) refers to how many
different types of victims (e.g., pre-pubescent males
vs. pre-pubescent females) the offender has had and how
many different types of offense types (e.g., hands-on
vs. hands-off) the offender has engaged in.
Significance of the Study
The long-term consequences of systematically
studying the characteristics of those who do not appear
to profit from sex offender treatment are varied.
Learning who is more likely to benefit from a
particular treatment model has some very clear value,
particularly in a program that serves as a model for
the latest evolution in residential sex offender
treatment (Barnard et al., 1989). The cost of sex

21
offender treatment is significantly higher than the
cost of incarceration but, if effective in reducing
recidivism, treatment could prove to save society both
significant financial burdens and severe emotional and
physical trauma associated with virtually every
reoffense (Prentky & Burgess, 1990). Not only is sex
offender treatment more costly than incarcertion, but
it is not available to all sex offenders. In fact,
even in systems with an extensive screening process and
a policy requiring volunteers, there are waiting lists
and offenders who request but never receive treatment.
This makes all the more important systematically and
correctly identifying those offenders who are most
likely to benefit from treatment.
Given the diversity of treatment programs
throughout the world and the lack as yet of a
recognizable standard for either screening or
treatment, it is essential that studies such as this
one be undertaken to attempt to determine who is most
likely to benefit from a specific treatment.

CHAPTER II
REVIEW OF LITERATURE
This chapter describes the research and practice
literature concerning sex offender treatment
amenability. Literature describing the characteristics
of incarcerated sex offenders is reviewed. In
addition, assumptions commonly held by practitioners
regarding amenability of sex offenders for treatment
will be discussed. Finally, the literature regarding
the predictor variables examined in this study is
reviewed.
Research on Sex
Offender Treatment Amenability
With society's growing awareness of the terrible
effects of sexual abuse have come greater demands on
the mental health treatment, correctional, and judicial
fields to deal effectively with sexual offenders. One
response to these demands has been the significant
increase in treatment programs available for offenders
(Knopp, 1984; Knopp, Rosenberg, & Stevenson, 1986;
Knopp & Stevenson, 1989). A second response has been
22

23
the development of national and international networks
of professionals to share treatment ideas (e.g.,
Association for the Treatment of Sexual Abusers [ATSA]
and National Adolescent Perpetrator Network [NAPN]).
Unfortunately, there is little empirical evidence
available regarding the level of effectiveness of sex
offender treatment programs or the appropriateness of
selection procedures (Earls & Quinsey, 1985; Furby et
al . , 1989). With few exceptions, professionals
implementing sex offender treatment programs do not
evaluate their programs systematically but rather do
what they consider correct, often basing their
decisions as to who gets treatment and how they are to
be treated more on clinical intuition and assumptions
than on empirical evidence. Ultimately, the field of
sex offender treatment must answer its own specificity
question: What types of offenders, in what types of
treatment contexts, with what types of treatment
experiences/components, demonstrate what levels of
"cure" both initially and ultimately? This question
has been extremely difficult to answer with regard to
psychotherapy in general (Finkelhor, 1988; Knopp,
1984). Thus it is not surprising that there are so few
answers regarding either the appropriateness or the
effectiveness of treatment of sex offenders.

Although there is little empirical evidence
regarding treatment amenability based on sex offender
2 4
recidivism, there is even less empirical evidence
regarding amenability for treatment of offenders based
on treatment program outcome (Furby et al., 1989;
Marshall & Barbaree, 1990). Recognizing that
ultimately it will be necessary to consider a
comprehensive set of factors in answering the
specificity question for sex offender treatment, there
is a need for modest studies which can provide a basis
for more ambitious studies in this area (Earls &
Quinsey, 1985; Furby et al., 1989). Murphy (1988) has
proposed a set of questions that target variables which
partialize the specificity question for sex offender
treatment and thus can serve as a guide to research.
Among these is the question of who is amenable for what
types of treatment. This interim measure, which has
been alluded to in several papers and studies (Abel et
al . , 1988; Green, 1988), is important for a number of
reasons. First, given the universally limited sex
offender specific treatment resources and their
frequently high cost, there is a pressing need to use
these resources efficiently. In 1989 in Florida, more
than 300 offenders were routinely maintained on a

25
waiting list; many of these offenders were discharged
from incarceration without treatment as a result of the
long waiting list (Alcohol, Drug Abuse and Mental
Health Program Office, Florida Department of Health and
Rehabilitative Services, 1989). Knowing who is most
likely to benefit from treatment or conversely who is
most likely to fail early on or drop out during the
course of treatment could maximize the treatment
prospects for offenders likely to benefit.
Although clinical assumptions abound, little
empirical evidence is available to provide direction
for developing sound amenability criteria for treatment
programs. Concommitant 1y, there is a recognized
absence of reliable outcome data for the variety of
treatment methods and program models in operation today
(Furby et al., 1989; Knopp, 1984). Earls and Quinsey
(1985), noted Canadian researchers and clinicians, in
summing up their conclusions regarding the need for
effective assessment and treatment of sex offenders,
suggest that there is a clear need for modest studies
to lay the foundation necessary to answer the pressing
questions in the sex offender treatment field. Among
other issues Earls and Quinsey (1985) suggest that the
specificity question has yet to be addressed in earnest
in the sex offender treatment research literature.

26
Short-term treatment outcomes are frequently
described as program evaluations; bureaucratic agencies
who routinely engage in program evaluations and
"quality assurance" reviews tend to focus on areas
other than treatment outcome except in terms of
percentages of admissions. For example, the 1939
Report to the Florida Legislature concerning the two
residential sex offender programs focuses on a
comparison of the percent of graduates compared to the
total admissions. The assumption is that a "good"
treatment program would have a high percentage of
graduates. Yet experts stress the need for short-term
outcome measures in order to develop accurate measures
of treatment efficacy and specificity. Dr. Green
stated:
Another important reason for making program
evaluation an integral part of sex offender
treatment programs centers around the fact that
there actually exists very little scientifically
collected information regarding the efficacy of
sex offender treatment, in terms of recidivism and
behavior change. At this time, it has not been
established which treatment works best with what
type of offender, fundamental data which is
potentially vital to program managers, agency
policy makers, and legislators. (Green, 1988,
P.61)
There are a number of factors which may, in part,
dearth of research on sex offender
account for the

27
treatment selection. Perhaps most significantly, there
is little consistency in the sex offender treatment
field regarding criteria for determining amenability
for treatment, amenability being a combination of
initial eligibility for inclusion in a given treatment
program and the ability to progress satisfactorily and
attain some specified outcome, usually treatment
program specific. A number of factors have contributed
to this absence of consistency. First, the haphazard
development of treatment programs in isolated settings
around the United States and Canada has led to a
diversity of treatment models and methods and an array
of amenability criteria which are only program specific
(Knopp, 1984). Since there is no single model for the
treatment of sex offenders which is accepted by all
clinicians and there is reason to assume that
amenability may be program specific, it follows that
there exists no accepted method of determining
eligibility for treatment (Knopp, 1984). A second
reason is that the consistency which does exist
regarding salient criteria appears to emanate more
often than not from clinicians' assumptions rather than
empirical evidence (Knopp, 1984).
Still another factor which complicates the issue
of amenability for sex offender specific treatment is

28
the variety of external conditions with which programs
must contend. Constraints imposed by outside systems
within which the program functions may include (a)
specific populations from which treatment candidates
are selected (such as prisons, courts or other
institutions); (b) specific directives from funuing
sources (such as targeting only the most "disturbed"
offenders still eligible for treatment); (c) specific
treatment models (which may be more difficult for some
individuals to complete); (d) particular settings in
which the program is provided including outpatient,
nonsecure residential, secure residential and prison;
(e) length of treatment (which may disqualify certain
offenders because they do not have enough time as in
the case of treatment programs for incarcerated
offenders where some offenders [e.g., youthful
offenders] routinely receive very short periods of
incarceration during which there is insufficient time
to be screened for treatment, transferred to a program
and complete it); and (f) competing philosophical
positions.
There is little question that the specific
treatment model/approach employed by the treatment
program is likely to have an effect on who is
considered amenable for that treatment.

29
Most programs recognize the limitations of the
clinical methods currently used with sex
offenders. Thus, they impose eligibility criteria
which reflect the perceived strengths and
limitations of their treatment programs. (Smith,
1988, p. 40)
For example, several authors have noted that a
particular model may require some minimum reading
skills or the ability to integrate material into daily
life (Barnard et al., 1989). Impacting on this dilemma
are the competing theories regarding treatment
candidate selection which differentially affect
eligibility criteria and which can be found throughout
the literature in the sex offender field. One theory,
championed by A. Nicholas Groth, argues that the most
dangerous and/or most likely to reoffend candidates
should be treated to the exclusion, if necessary, of
more amenable, less dangerous candidates (Knopp, 1984).
Programs, generally in secure, residential settings,
which have followed this strategy tend to have
relatively high rates of reoffense, if any, and have
had difficulty defending their position when funding
considerations arise (North Florida Evaluation and
Treatment Center, 1988a) because this model tends to
emphasize dangerousness/1iklihood of reoffense over
amenability. A competing theory favors a triage model

30
which specifies that some criteria should be used to
determine who is most likely to benefit from treatment
and who is less likely to successfully complete or
significantly benefit from treatment. An example of
the latter is an outpatient treatment model which may
exclude individuals with extensive histories of
violence or previous crimes (Barnard et al., 1989).
A fourth contributing factor is the lack of
financial support for the testing of assumptions
regarding who is amenable for treatment. Because sex
offender treatment is not popular, most treatment
programs struggle to function with minimal and
unpredictable funds. Thus, although many new programs
are designed with a research component, funding cuts
often result in the elimination of such research
efforts. Therefore, it is not uncommon for programs to
have no organized approach to receiving feedback on
treatment efficacy and to focus only on publicized or
special cases of reoffending on the one hand and
standard case management measures such as progress
notes, treatment plans, and daily behavior while in
treatment on the other. Furthermore, the cost of
acquiring re-arrest data (a measure of treatment
efficacy) in both staff time and actual money and the
need to report reoffenses if they are revealed by

31
offenders or their families further block efforts at
systematic program evaluation.
A fifth contributing factor is that although
several studies have been published attempting to
describe, delimit or delineate one or another subtype
of sex offender (Stermac, Segal, & Gillis, 1990), the
findings of such studies reveal that sex offenders are
surprisingly heterogeneous. It appears they are linked
primarily by their offense and little else. For
example, when demographic variables such as income,
education, marital status, age, and intelligence were
examined, several studies have found results which
follow normal distributions (Abel et al., 1988; Shaw,
Barnard, Robbins, Spears, Cunningham, Butler, & Newman,
1988); incarcerated sex offenders differ little on
these same variables from other populations of
incarcerated offenders (Stermac et al., 1990). This
heterogeneity becomes yet another factor inhibiting the
delineation of specific eligibility criteria as this
population is difficult to differentiate from both
other criminal populations as well as among its own
subtypes.
Consequently there is very little research
literature available on treatment amenability in the

32
sex offender treatment field. That which is available
is limited to pedophiles treated in outpatient programs
(Furby et al . , 1989). Given this limitation, there is
no assurance that any set of eligibility or amenability
criteria will be effective in identifying the best
candidates for a particular treatment program (Furby et
al . , 1989 ) .
Recently, Abel et al. (1988), reporting data
consisting of a one year follow-up using self-report of
reoffense, the dependent variable, as a measure of
recidivism from a sample of pedophiles being treated in
the community, found only one demographic variable to
be predictive of reoffense: marital status.
Demographic variables which did not distinguish between
nonrecidivists and recidivists were age, race, social
class, education, employment status, religious
preference, motivation for seeking treatment, frequency
of pedophilic acts before entering treatment, lifetime
number of molestations or sexual victims, and reported
self-control over pedophilic behavior before entering
treatment.
When the multiplicity of age categories, gender
categories and hands on versus hands off
categories of pedophilic behavior were combined,
the combination proved to be a very significant
predictor of recidivism, with p < .0001. (Abel et
al . , 1988, p. 230 )

33
Although a significant, ongoing study, the limitations
of treating exclusively pedophiles in a community
setting makes these data unrepresentative of
incarcerated treatment populations which often include
as many as one third rapists and where as many as half
the offenders have an antisocial personality disorder
diagnosis (Barnard et al., 1989). Moreover, the
finding of marital status as a predictor of recidivism,
while it must be tested with incarcerated offenders,
bodes ill for incarcerated populations, who, for the
most part, are single, separated or divorced (Barnard
et al., 1989).
Treatment outcome data have been reported by
several other researchers with outpatient populations
(Abel et al., 1988; Maletsky, 1987; Marshall &
Barbaree, 1988; Knopp, 1984). Marshall and Barbaree
(1990) found that although higher intelligence
predicted successful outcome, all programs reported
relatively low recidivism rates (under 15%).
Randy Green, clinical director in the sex offender
treatment field from the Forensic Services Unit of
Oregon State Hospital stated:
The only other serious experimental controlled
study in the field of sex offender treatment in
this country is being conducted in Tampa, Florida

34
by Richard Laws. Sponsored by the National
Institute of Mental Health (NIMH), Laws began this
outpatient study in August 1986, comparing effects
of a combined regimin of Relapse Prevention and
aversive conditioning, in contrast to a
traditional therapeutic model. (1988, p. 64)
Unfortunately, this study was prematurely terminated
primarily due to inability to achieve the necessary
sample size within the specified time, and federal
funds were withdrawn (D. R. Laws, personal
communication, November, 1989).
Furby's review of empirical studies of sex
offender recidivism was intended to summarize what is
known regarding the efficacy of sex offender specific
treatment, particularly as it compares to no treatment.
The authors' conclusions regarding the current status
of outcome research in the sex offender field were
generally quite negative. They found that methodology
was very poor in general, and they specifically noted
that treatment programs being studied were rarely
described clearly enough to determine why a particular
treatment worked or did not work. Furthermore, the
authors concluded that there was as yet no evidence
that treatment reduces sex offenses in general. Among
their conclusions was the need for developing short--
term data from which long-term data can be predicted
(Furby et al., 1989).

35
In the absence of empirically based amenability
criteria, treatment programs are nonetheless forced to
institute limits regarding eligibility and amenability
in hopes of using the treatment resource most
effectively and efficiently. In Faye Honey Knopp's
seminal work, Retraining Adult Sex Offenders: Methods
and Models, (1984) the problem of treatment candidate
selection is examined along with other key issues. The
majority of treatment programs for sex offenders use
some set of admission criteria to screen potential
candidates (Knopp, 1984). Residential treatment
programs continue to be relatively costly and limited
in availability; community based treatment programs
must consider their potential legal liability when
developing admission criteria and routinely exclude
violent offenders. Consequently, each setting has
evolved a set of eligibility criteria. These criteria
may be determined by law as in California and Florida,
or they may be derived from a consensus of program
officials or expert clinicians (e.g., Task Force of the
National Adolescent Perpetrator Network), tradition,
program design or multidisciplinary committees as in
Dr. Groth's now defunct program in Connecticut. The
members of the Governor's Task Force on Sex Offenders

36
and their Victims in their 1984 Report on Treatment
Programs for Sex Offenders regarding the state operated
sex offender treatment programs stated:
At present we are unable to pick out in advance
those individuals who are most likely to reoffend
unless treated and who will also respond well to
treatment. A high priority has to be given to
research to find methods of picking out those
offenders whose treatment will best serve the
needs of the community. (1984, p. 20)
Basic Assumptions, Techniques, Settings,
Populations Treated (Focus), Research
Pindings and Related Literature
The various debates concerning the use of
outpatient vs. inpatient strategies, chemical vs.
behavioral vs. psychodynamic models, specialized vs.
generic treatments, incarceration vs. community
placement, with or without treatment, and determining
who is amenable for treatment and who should be
excluded remain unresolved in the sex offender field.
To date, researchers have offered very little in terms
of resolving any of these questions; they remain to be
answered by current (Marques, Day, Nelson, & Miner,
1990) and future researchers. However, in spite of
clinical imprecision, these questions are being
resolved routinely by bureaucrats and politicians
around the country (Knopp, 1984).

37
In a 1988 publication. Nationwide Survey of
Juvenile and Adult Sex Offender Treatment Programs and
Models (Knopp & Stevenson), the authors chronicle the
enormous growth in the number of sex offender treatment
programs in America as well as the variety of treatment
approaches offered. The report, based on a survey of
1002 respondents, elicited updated information
regarding sex offender treatment programs from a prior
(1986) survey. Additionally, a second part, including
responses from 574 adolescent and adult sex offender
treatment providers, elicited information regarding
"perceived program models, 43 treatment modalities, and
3 modes of treatment delivery." Responses from the
survey were structured so as to provide information
regarding the setting in which the treatment was
provided as well as the treatment models and modalities
employed. In the study a total of 429 adult
specialized sex offender treatment programs were
identified. Residential programs accounted for 28% of
all services (119); of these, 89% (106) were public
(eg. state funded) and 11% (13) were private (eg.
requiring payment from the client). It was found that
73% of residential programs were housed in prisons
(87), 16% were housed in mental health facilities (eg.

38
NFETC) (19), and 11% were located in private facilities
(13).
Almost three quarters of the specialized treatment
programs for adult offenders identified in the survey
were outpatient, community based (310 or 72% of all
adult services). Of these, 62% (191) were private
services, 31% (97) were located in mental health
centers, 4% (13) were court related services, and 3%
(9) were community based prison related services.
Residential Treatment Model
The 1988 Nationwide Survey conducted by Knopp and
Stevenson reported on "selected treatment methods" used
by respondents. The seven methods reported were family
therapy, peer-group treatment, "thinking errors,"
behavioral methods, aversive conditioning, Depo-Provera
(synthetic female hormones), as well as one evaluation
tool, the penile transducer or plethysmograph. Peer-
group treatment was the most widely used, being the
preferred method in 86% (371) of the 429 programs.
Family Therapy was included in 79% (341) of identified
adult sex offender programs, although only 54% (64) of
the 119 residential programs reported using it.
Behavioral methods were used in 65% (277) of the

39
identified programs. In descending order the frequency
of the remaining methods was Penile Transducer (26%),
Aversive Conditioning (24%) and Depo-Provera (18%).
Most often treatment programs offer one treatment
regimen which treatment candidates are required to
successfully complete. A diligent effort to define who
is amenable for a particular treatment model, however,
would be an important step in understanding individual
offender variables in terms of a given treatment design
and serve as a model for future research (Earls &
Quinsey, 1985 ) .
Inteqrated/Multi-Modal
Basic assumptions. Recently an integration of
cognitive-behavioral and psychodynamic models has been
suggested by several clinicians in the field as a means
of more effectively achieving positive long-term
results than cognitive-behavioral therapy programs have
thus far demonstrated by incorporating techniques
derived from psychodynamic therapies into a structured
treatment program. While as yet no outcome data exist
to specifically support this model, its supporters
believe it may be the answer to treating offenders with
more severe disorders who tend to be treated in

40
residential settings (Barnard et al., 1989; Shaw,
Hutchinson, & Longo, 1989).
Common techniques. Unique to the integrated
approach is the use of numerous theoretical models
within a coherent whole. Specifically cognitive-
behavioral modules are used in conjunction with
psychodynamic, experiential modalities such as gestalt
or psychosynthesis, as well as family systems to create
an integrated treatment program (Barnard et al., 1989).
Settings. Integrated treatment strategies are
found in both inpatient and outpatient programs for
both adult and juvenile sex offenders (Shaw et al.,
1988).
Populations treated. Integrated treatment
strategies have been used with all types of sex
offenders, both adult and juvenile.
Research evidence. Review of official arrest data
from Florida in 1988 and 1989 revealed that no
graduates of the integrated treatment program at NFETC
had been arrested for a sex offense up to the date of
the Annual Report to the Florida Legislature (Alcohol,
Drug Abuse, and Mental Health Program Office, Florida
Department of Health and Rehabilitative Services,
1989).

41
Psychodynamic
Basic assumptions. Therapies based on
psychodynamic models assume that sexual deviance is the
result of early perceived trauma and includes:
castration anxiety; reaction to seductive mother;
inadequate ego/superego; reenactment of sexual trauma;
confusion of aggressive and libidinal drives, and
narcissistic representation of self as child (Schwartz,
1988c).
Common techniques. Psychodynamic treatment
techniques include insight oriented individual therapy,
including traditional analysis, and group counseling
including Gestalt therapy, Psychosynthesis, and
Psychodrama. These techniques are used to assist the
client/offender in becoming consciously aware of his
underlying motivations and subsequently developing new
ways of coping with his needs.
Settings. Psychodynamic treatment of sexual
offenders today is limited to individual therapy and
programs offered in several psychiatric hospitals. Due
to the length of time this treatment usually takes,
clinicians are frequently constrained by financial
considerations as well as time.

42
Populations treated. Psychodynamic treatment has
been used with a variety of sex offender populations
including rapists, pedophiles, exhibitionists, voyeurs
and other sexual deviants who may not be considered
offenders such as transvestites and various other
fetishists.
Research evidence. The majority of research
evidence for the efficacy of this approach has been in
the form of single case studies and has been less
evident in the last decade (Kilmann, Sabalis, Gearing,
Bukstel, & Scovern, 1982).
Cognitive-behavioral
Basic assumptions. Cognitive-behavioral treatment
programs comprise the most widely accepted approach to
sex offender treatment today. This approach is based
on the assumption that behaviors are learned responses
and that individuals can learn new behavioral responses
and develop new beliefs to support those responses.
Cognitive therapies comprise a relatively new branch of
behavior therapy and focus on the thoughts, beliefs,
and fantasies which "drive" behavior. Deviant behavior
is often dependent upon distorted thinking (Marshall &
Barbaree, 1990).

43
Common techniques. Treatment programs variously
focus on preventing reoffense using some
combination/integration of Relapse Prevention,
cognitive restructuring, stress and anger managment,
social and communication skills training, sex
education, and arousal reconditioning (Laws, 1990;
Pithers, 1990; Salter, 1988). Techniques employed by
these modalities include psychoeducational experiences
such as reading and viewing videotapes, modelling,
roleplaying and practice.
Settings. Cognitive-behavioral therapies are used
today in virtually all settings, whether the primary or
adjunctive therapy focus (Knopp et al., 1986; Knopp &
Stevenson, 1988).
Populations treated. Cognitive-behavioral
therapies have been used with virtually every sexually
deviant population treated; behavioral strategies such
as arousal reconditioning tend to be used for those
with evidence of deviant arousal or histories of
repetetive deviant behavior (Knopp et al., 1986; Knopp
& Stevenson, 1988).
Research evidence. Leaders in the outcome
research on cognitive--behavioral treatments, which
focus on arousal reconditioning (changing the focus of

44
arousal from a deviant to a non-deviant object or act),
include Abel and associates (1988), Earls and
Castonguay (1989), Laws and O'Neil (1981), and Marshall
and Barbaree (1988). William Pithers has designed and
implemented several studies using Relapse Prevention
based treatment programs in Vermont, including an
innovative approach which includes the training of
probation officers in Relapse Prevention (Pithers &
Cumming, 1989). He found that when both treatment and
follow-up probation supervision were based on Relapse
Prevention, recidivism in terms of probation violations
and rearrests for sex offenses was significantly
decreased. A proposal to compare a cognitive-
behavioral treatment program designed specifically for
sex offenders with a more generic treatment model based
on Sullivanian Interpersonal therapy was first approved
by the National Institute of Mental Health and then
rejected by the Human subjects review committee which
felt the control treatment was not likely to be
sufficiently effective (Laws, 1989, personal
communication).
In their review of outcome research in cognitive-
behavioral treatment therapies, Marshall and Barbaree
(1990) found promising results regarding use of these

45
modalities with exhibitionists and child molesters.
They concluded, however, that future outcome studies
must focus more on the specific changes induced by
treatment such as sexual preferences, social competence
and cognitive distortions to improve the ability of
clinicians to make predictions regarding likelihood of
recidivism.
Treatment Center Study/Setting
Context
The sex offender program which is the setting for
this study was located at North Florida Evaluation and
Treatment Center (NFETC) in Gainesville, Florida.
Operating from 1976 until September, 1989, the program
was one of four treatment units within the treatment
center and one of two sex offender treatment programs
operated by the Florida Department of Health and
Rehabilitative Services (HRS).
The 63-bed MDSO unit was situated in three secure,
electronically controlled treatment buildings. Two
buildings housed 18 men in a two-pod floor plan and one
housed 27 men in a three-pod floor plan, with nine
individual rooms per pod. Each pod had a common area
for group or recreational activities which was

46
monitored visually and audibly by staff in a single
building control room. While the treatment program and
daily activities were facilitated by professional and
paraprofessional treatment staff, the secure perimeter
was maintained by uniformed security staff who were
available for backup in the event of a crisis or
emergency. Staff maintained 24 hour supervision.
Treatment Program Rationale
In 1985 the treatment program was redesigned to
reflect a multi-modal or integrated approach to sex
offender treatment, based on the belief that sex
offenders develop their deviant urges and behaviors for
a variety of reasons (Finkelhor, 1988).
The basic philosophy underlying the comprehensive
treatment program offered at NFETC is that sex
offenders develop their deviant behavior through
multiple and diverse ways and consequently require
a variety of treatment approaches to alter this
aberrant behavior. (Barnard et al., 1989, p. 126)
This model, consistent with the multi-factor
theory of offender etiology espoused by David Finkelhor
(1988) and heralded as a model for comprehensive
residential treatment, combined a cognitive-behavioral
treatment program, milieu therapy, and experiential
therapies designed to interface with each other
(Barnard et al., 1989). For example, an offender may
have been enrolled in Role Play (offense reenactment)

47
module where he and eight other offenders would reenact
their offenses in group in videotaped sessions. Later,
the offender would review the videotape of the role
play with his "Pod group" and primary therapist (i.e.,
case manager).
Treatment Program Format
Sex offenders participated in an initial screening
while in prison and were placed on a waiting list for
transfer to one of the two treatment facilitiies if
found eligible. Once transferred to NFETC offenders
underwent a 4-day period of evaluations while being
maintained in relative isolation to prevent treatment
from beginning until after the pretreatment evaluation
process was complete. This evaluation included a
Psychiatric interview, a computerized psychosocial
assessment including a p1ethysmograph assessment of
arousal patterns (Barnard, Robbins, Tingle, Shaw, &
Newman, 1987), and a WRAT-R. Following this battery
the offender participated in an 8-week "Evaluation"
phase which included several structured modules
(Criminal Thinking Errors, Psychosexual Process), other
structured activities including production of a
"Lifeline" and an "Offense Description," "Role Play" of

48
Offense, and. unstructured group experiences at Least
several times per week. At the end of this 8-week
Evaluation phase the offender was interviewed by the
multidisciplinary treatment team (MDT) which consisted
of the Unit Director, the 7 unit professional
therapists, the Unit Psychaitrist, the Unit Health
Coordinator (nurse), and available paraprofessional
staff. During this "staffing" the offender's response
to treatment was reviewed in terms of the following:
(a) his willingness and ability to actively participate
in the treatment components of the evaluation phase
such as lifeline creation, role play of offense and
thinking errors module (response to treatment); (b) his
willingness and ability to abide by program rules; (c)
his presentation in the staffing in terms of his
willingness and ability to describe and "own" his
offense, and his understanding of the precursors and
subsequent impact of his offense; and (d) a
psychological evaluation was also reviewed in this
staffing. Two decisions were possible at the
conclusion of the staffing. Based on consensus, the
team could decide to (a) accept the offender into the
"Treatment" phase (approximately one year) or (b)
reject the offender and return him to the custody of
the Department of Corrections (DC) as "not amenable for

49
treatment." A third decision, very rarely used, was
that in special cases (such as offenders with perceived
high motivation but marginal abilities) the evaluation
phase could be extended for another month.
During the treatment phase, offenders' progress in
treatment was reviewed at least monthly; offenders were
staffed formally at the end of one year, by which time
they were expected to have completed the modules, when
they were presented for completion of treatment, or
when either the offender or his primary case manager
requested a "termination" staffing, which could occur
at any time during the treatment process.
The treatment program was divided into three
stages, each with a set of specific activities and
expectations for the resident. In Stage I, the
evaluation phase, the offender was sequestered in
relative isolation until he completed the entire
psychosocial/psychosexual pre-test evaluation which
generally took from two to four days. Thereafter, he
was introduced to the other residents of the
intake/eva1uation/advanced resident building and
expected to learn the rules of the program, attend pod
group two mornings per week, complete several standard
assignments including Lifeline, a structured

50
autobiography, offense descriptions for each separate
victim and type of offense he committed, a role play or
reenactment of either his instant offense or an
alternate agreed upon in advance by him and his
therapist, and psychosexual disorder process diagrams;
these had to be approved by both his therapist and his
pod group. In addition, the offender attended several
modules including the Criminal Thinking Errors module
facilitated by advanced residents, the Psychosexual
Disorder Module, Clinically Standardized Meditation
Module, resident government meetings which included
pod, building and unit functions, and special groups
called by staff or residents. The resident was
expected to meet at least once per week with his
primary therapist, his resident activity monitor (RAM),
a paraprofessional assigned to him to assist in the
completion and review of his "homework" assignments,
and his Triad members. Triads consisted of one
advanced resident and two residents in the evaluation
phase; triad members were required to be available to
each other at all times for support as well as for
confrontation.
At the end of the 8-week evaluation phase the
offender was interviewed by the MDT. During this

51
staffing the resident's response to treatment was first
reviewed for the group, usually by the primary
therapist, as well as results of a psychological
evaluation. After this review, the resident was then
interviewed, and his ability to describe his offense
without minimization, blaming or denial, his
understanding of his offense cycle including criminal
thinking errors he employed and any special issues or
questions pertaining to his amenabiilty were assessed
by the team. After the resident was dismissed from the
staffing, the team would complete a discussion of the
resident and vote on whether to accept or reject him
and return him to the department of corrections.
An offender who was accepted into Stage II of the
treatment program was expected to be enrolled in at
least three modules at any given time, each meeting
once per week, his pod group twice per week, structured
recreational activities including art, music, sports,
computer or video training, education classes for those
without a high school diploma, work program and
resident government activities. Stage II generally
lasted for eight to ten months, and most residents
completed this phase around one year from their date of
admission. At the end of phase II or one year from

52
date of admission, whichever came first, the resident
was staffed again. The staffing was basically the same
as the admission staffing except that during the
staffing the resident's progress through the modular
program was reviewed both in terms of modules completed
(grades) and his ability to describe how he could use
what he was learning to prevent futre reoffenses and
other dysfunctional thinking and behavior. A report of
his progress was forwarded to the department of
corrections resultant from this staffing.
Stage III of the treatment program involved
retaking modules in areas where the offender appeared
weak (e.g., social skills), participating in pod
groups, resident government, Triad groups, facilitating
certain modules and developing release plans and
strategies. A final staffing was held when the MDT
determined that the resident had either maximized
benefits, made significant progress or had successfully
completed the program. This staffing was generally
structured around a review of progress including
available post-tests, recommendations from his primary
therapist and RAM, and an interview focused on release
planning, relapse prevention, and victim empathy.

53
Treatment Program Components
The following is a brief description of the
structured module components of the treatment program.
Residents were expected to rotate through these
modules, taking approximately three at any given time,
until all were successfully completed. Each module
lasted for approximately twelve sessions and was co-
facilitated; each session lasted from 1 1/2 to 2 1/2
hours.
The core treatment philosophy was presented
through the Empathy Development/Trauma Work component.
This set of modules was designed to increase the
offender's awareness of the impact of his offense on
both perpetrator and victim, assist the offender in
defining the purposes served by commission of the
offense, and promote the development of empathy for
victims. In the Role Play, a group experience, the
offender had the opportunity to act as both the
perpetrator of his own crime and as the victim in the
offense of a peer during the course of the module.
Each session of the module could be videotaped for
subsequent review by the offender.
A traumatic events component provided the offender
with specific skills to resolve traumatic events in

54
personal history in order to decrease resultant
cognitive distortions, emotional distress and
maladaptive behavior patterns. This was accomplished
through a series of therapist-facilitated structured
learning experiences and practical exercises
experienced in the "safety" of the therapeutic
environment using any number of modalities including
Gestalt Therapy and Neuro-Linguistic Programming.
A sensitivity training component assisted the
offender in developing an awareness of the connection
between body and mind, to facilitate their integration,
and to sensitize the offender to his own affective
experience and the experience of others, through the
use of therapist facilitated Bio-energetic, Gestalt and
structured training exercises.
A number of modules were designed to train the
offender in more adaptive life skills. These included
the following:
(a) The Relapse Prevention module was designed to
prepare the offender to take responsibility for his
behavior, particularly as it relates to his sex
offending, by identifying specific high risk situations
where offending is likely to occur, predicting their
occurrence, and acquiring specific coping skills and

55
developing action plans based on those skills to
prevent reoffense.
(b) The Arousal Reconditioning module included one
or both of the following components: Covert
Sensitization pairs aversive imagery and associated
negative affect with the antecedents to offending
behavior through directed, taped sessions; Self-
Administered Satiation focuses on decreasing deviant
arousal through the use of extended verbal repetition
of deviant fantasies in taped sessions with or without
concurrent masturbation in a controlled setting.
(c) The Cognitive Restructuring module, based on
Rational Emotive Therapy, was designed to directly
challenge the irrational beliefs which support the
offender's deviant behavior and to replace them with
beliefs grounded firmly in reality. This module helps
the offender develop responsibility for his own
experience and become more effective in relationships
with peers.
(d) The Stress Innoculation/Anger Management
module was designed to teach offenders how to better
cope with their anger and stress and to develop more
socially acceptable and personally effective
expressions of anger and stress coping responses.

56
(e) The Criminal Thinking Errors module, adapted
from the work of Yochelson and Samenow (1977), assists
the offender in identifying and replacing distorted
cognitions which support ongoing patterns of offending
behavior.
(f) The Social Skills Training module was designed
to help the offender develop clearer, more effective
verbal and non-verbal communication skills, become more
assertive and develop socially appropriate and
effective hetero-social skills including dating,
courting and sexual interaction.
(g) The Healthy Sexua1ity/Sex Education module was
designed to improve the offender's knowledge of human
sexuality and to decrease distorted perceptions or
beliefs about sexuality.
(h) The Life Skills Training module could be
adapted on an individual basis depending on the
specific needs of the offender and the setting in which
the treatment is occuring.
(i) The Substance Abuse module was designed to
help the offender recognize substance abuse problems as
well as provide general information on the causes and
effects of substance abuse.
(j) The Psychosexual Disorders module presents an
introduction to the concept of the core process of the

57
psychosexual disorder which serves to provide a
foundation for integration of later treatment
experience into a comprehensive and cohesive model for
ongoing recovery.
Target Population
The sex offender unit at NFETC is a treatment
program for men who have been convicted of a
sexual offense and sentenced to a prison term.
The MDSO population is comprised of child
molesters, incest offenders, exhibitionists and
rapists who volunteer for treatment and pass
screening by a prison psychologist and a
professional staff member of the Sex Offender
Treatment Unit. Final selection into the
treatment program is determined at the end of an
eight week clinical evaluation period.
The following criteria are used in the screening
process for accepting sex offenders into the
program: (1) there must be evidence of a
psychosexual disorder; (2) the inmate must
volunteer for treatment; and (3) the inmate must
accept responsibility for the crime. Inmates are
automatically excluded from MDSO treatment if they
present one of the following characteristics: (1)
have a sentence in excess of 15 years or less than
18 months; (2) show significant evidence of a
major mental illness (e.g., psychosis); (3) have
murdered their victim(s); (4) are actively
appealing their conviction or sentence; or (5)
have significant medical problems which may be
exacerbated by the stress of the treatment
program. (Barnard et al., 1989, pp. 122-123)
Treatment Amenability Factors
There is little question that the theoretical
approach employed by the treatment program is likely to
have an effect on who is considered amenable for that

58
treatment. Characteristics of offenders likely are
important indicators of amenability for treatment.
These can be divided into four catagories: (a)
intellectual factors, (b) personality factors, (c)
offense factors, and (d) demograhic factors.
Intellectual Factors
Several authors have noted that a particular model
requires some minimum reading skills or the ability to
integrate material into daily life which is frequently
referred to in the literature (Barnard et al., 1989).
Some form of intelligence and/or performance evaluation
is routinely considered in amenability decisions
although there is little consensus in the literature as
to what the ideal should be. A residential sex
offender program in California requires a minimum of 80
IQ for consideration in treatment (Marques, et al.,
1990). Summarizing his views on the ideal treatment
candidate, Smith (1988) states that offenders should
have normal intelligence.
Personality Factors
Marcus (1971), in listing criteria which would
negatively affect amenability, included delinquent acts
between the ages of 8 and 13, interrelated criminality

59
with sexual offenses, lack of concern for victim.
Numerous other clinicians and researchers have offered
sets of eligibility criteria. For example, co¬
directors of a treatment program for sex offenders in
New York report that assessment is particularly
important to assess personality characteristics. They
rule out offenders who are "actively psychotic,
predominantly antisocial, or heavy substance abusers"
(Travin, Bluestone, Coleman, Cullen, and Melella,
1985).
Offense Factors
Although few researchers have set out to predict
amenability based on treatment outcome measures, the
most notable data derive from measures within a long¬
term study. Recently, Abel et al. (1988) published a
study predicting response to outpatient treatment of a
group of child molesters. The two outcome variables
for this study were dropout (initiated by either the
offender or clinician), a short-term outcome variable,
and recidivism (self-report of reoffense as determined
through structured interviews at six months and one
year post-treatment), a long-term treatment outcome
variable. There were 192 subjects, all pedophiles, who

60
were divided into 19 groups. Groups received the
treatment modules in varying orders in order to test
the efficacy of each module. The treatment program
consisted of thirty 90-minute weekly group sessions.
Each module or treatment component consisted of ten
sessions. The three treatment components were (1)
decreasing deviant arousal, (2) sex education/sex
dysfunction and cognitive restructuring, and (3) social
and assertiveness skills training.
The first dependent variable, dropping out of
treatment, can be viewed as a short-term outcome and a
measure of amenability. Approximately one third of the
subjects either dropped out (88%) or were expelled
(12%) prior to completing the thirty sessions. A
series of t-tests were conducted to determine if
significant differences on a number of demographic and
offense variables could be found between the group
which completed treatment and the group which did not.
Interestingly, most of the demographic variables (age,
race, social class, marital status, education,
employment status, and religious preference), referral
source as well as degree of motivation for seeking
treatment, lifetime reported number of pedophilic acts
prior to entering treatment, and self-reported current
ability to control urges all failed to discriminate

61
between the two groups. However there were three
characteristics which significantly differentiated
those who dropped out from those who completed
treatment: "(1) the amount of pressure the subject was
under to participate in treatment (p <.05), (2) the
diagnosis of an antisocial personality disorder (p
c.Ol), and (3) the lack of discrimination in the choice
of sexual victim or paraphilic act (p <.0001)" (Abel
et al . , 1988). The dropout group reported greater
pressure to participate in treatment, was more likely
to have a diagnosis of antisocial personality disorder
and was less discriminating in the choice of sexual
victim or paraphilic act. A discriminant function
analysis was performed to estimate the degree to which
dropping out of treatment could be predicted using
variables that significantly differentiated the two
outcome groups. Using the variables stated above, the
discriminant function analysis could correctly classify
72.4% of subjects entering treatment as to whether they
would drop out of treatment.
Demographic Factors
Researchers have begun to test assumptions of
clinicians regarding demographic variables likely to
affect treatment amenability. One of the most

62
promising is marital status. Others which have not
received empirical support are age, race, socio¬
economic status, education, employment status,
religious preference and lifetime number of reported
offenses (Abel et al., 1988).
Independent Variables
Reading Ability
As has already been suggested, predictors of
amenability are likely to be program specific. Perhaps
the most common feature of contemporary sex offender
treatment programs is the requirement that offenders
learn information in treatment modules, understand this
information, and integrate it in a way such that they
can effectively use what they have learned to prevent
engaging in a reoffense at some later date. While IQ,
as measured by the WAIS-R, is the most common measure
of ability, reading achievement, as measured by the
WRAT-R, is a more pragmatic measure, easier to
administer and score than the WAIS-R, yet positively
correlated with the WAIS-R (Margolis, Greenlief, &
Taylor, 1985; Spruill & Beck, 1986; Cooper & Fraboni,
1988) .

63
As has been noted, numerous references are to be
found in the literature suggesting that intelligence
and reading achievement are predictors of successful
completion of treatment. An exception to this is
Marcus (1971) who wrote that high IQ offenders should
be screened out of treatment programs because of the
liklihood that they would manipulate the staff and
thereby avoid the full impact of the treatment process.
This aside, the predominant notion in the field is that
it takes some finite and measurable degree of
intelligence to complete a treatment program
adequately, and this has been suggested by numerous
authors (e.g., Marshall & Barbaree, 1988). But it is
clinical experience which overwhelmingly supports the
contention that the lower functioning offenders will
take longer to complete treatment and may not, in fact,
be amenable to cognitive-behavioral or insight oriented
therapies. No doubt for this reason virtually every
treatment program for sex offenders has an IQ and/or
reading achievement cut off as part of the admission
criteria.
In a chapter titled "Clinical Assessment of Sex
Offenders" the author comments, "A lack of intellectual
ability might preclude certain verbal therapies or
imagery-based behavior therapy" (Dougher, 1988, p. 78).

64
Smith, of the National Academy of Corrections, in
discussing treatment of mentally ill and mentally
retarded sex offenders, further stated:
The experience of programs that integrate low
functioning or mentally ill men into confrontative
or cognitively oriented programs has not been
promising. (1988, p. 35)
Interestingly, as mentioned above, Marcus (1971) took a
minority position that high IQ is an undesireable trait
because it could be used by the offender to manipulate
the staff or therapist and consequently avoid the full
impact of the treatment process. Nonetheless, his
notion further underscores the need to study the
corellation of this variable with treatment outcome.
Antisocial Personality Disorder
Although only appearing briefly in the research
literature as a factor predicting dropout (Abel et al.,
1988), a diagnosis of Antisocial Personality Disorder
(APD), determined primarily by history, is considered
by many clinicians to suggest a poor prognosis for
lasting participation in treatment programs or
resultant meaningful change.
Among the criteria of APD which clearly would
predict problems in treatment are the following:
Onset before age 15 as indicated by a history of three

65
or more of the following before that age: truancy;
expulsion or suspension from school; persistent lying;
thefts; vandalism; school grades markedly below
expectations in relation to estimated or known IQ;
chronic violations of rules at home and/or at school;
initiation of fights. At least four of the following
manifestations of the disorder since age 18: inability
to sustain consistent work behavior; failure to accept
social norms with respect to lawful behavior;
irritability and aggressiveness as indicated by
repeated physical fights or assault; failure to plan
ahead, or impulsivity; disregard for the tr"th as
indicated by repeated lying; recklessness. (DSM III,
1980)
Any one of the above mentioned criteria, if it
were detected repeatedly or, in cases of extreme
examples, even once, in a treatment program would
likely result in the offender being terminated from
treatment (North Florida Evaluation and Treatment
Center, Sex Offender Unit, 1988b); if not detected,
these behaviors would be likely to disrupt the
treatment milieu and cause the offender to benefit less
from treatment. Consequently, many programs routinely
exclude these individuals, particularly those in

66
community,
to treat i
offenders
comprise a
volunteers
outpatient settings. In programs designed
ncarcerated offenders, excluding those
with APD is more difficult because they
large percentage of treatment referrals and
Schwartz describes a treatment program at the
Chittenden Correctional Facility in South Burlington,
Vermont that selects offenders
with demonstrated histories of prosocial
behaviors, and those who don't have a number of
circumstances which threaten the individual's
sense of self control, e.g., alcoholism.
Candidates must accept responsibility and
acknowledge the harm done. Sadistic offenders are
excluded. (1988b, p. 47)
In Abel's landmark study the authors commented:
It should also not be surprising that individuals
with antisocial personality are more likely to
drop out of treatment, since a characteristic
frequently seen in such personalities is
manipulativeness of others to get what they want.
In this situation, admission to a treatment
program was probably helpful to them at the
moment; and as soon as they had satisfied someone
by their entrance into treatment, they quickly
terminated the treatment program. (Abel et al.,
1988, p. 229)
Even if the antisocial personality disordered
offender did not terminate himself from treatment it
appears likely that he would be frustrated by the
control the residential program exerted over him;
instead of working diligently to make meaningful

67
changes in himself, he would focus on manipulating the
staff and his peers, on avoiding the true thrust of
treatment in ways he had developed in his past such as
missing classes, failing to complete homework
assignments, or faking illnesses. Consequently, it
could be predicted that he would not do well in
progress staffings, either from poor treatment
participation or due to program rule infractions, the
other serious behavioral manifestation of APD. The
individual with APD does not generally respect rules
and follows them begrudgingly; he focuses on not
getting caught and in a residential program might be
likely to cheat on tests, copy homework assignments
from others, steal, threaten, fight, use drugs,
manufacture alcoholic beverages and other behaviors
generally against program rules and often requiring
termination from the treatment program. If any of
these behaviors were discovered, they would negatively
impact on perceived treatment outcome by the MDT.
"Career" criminals and others with entrenched
antisocial personalities rarely respond positively to
treatment (Dougher, 1988). Therefore, it is reasonable
to assume that a diagnosis of Antisocial Personality
Disorder would be positively correlated with either
dropout or unsuccessful completion of treatment.

68
Degree of Discrimination in the Choice of Offense and
Victim Type
This variable has been included for testing for
several reasons. Abel and associates (1988) found, in
a sample of outpatient pedophiles, that this variable
predicted both poor response to treatment in the form
of dropout as well as recidivism using self-report of
reoffense as the outcome measure. In fact, Abel found
that, "All 30 offenders who dropped out during the
first 10 weeks of treatment had committed acts against
both males and females and against both children and
adolescent victims. More than half of the subjects who
dropped out before the end of the 30 week treatment
showed this same multiplicity of diagnoses, which was
significant at the p <.0001 level" (p. 227).
It was also found that offenders who had committed
both "hands-on" assaults of children as well as "hands-
off" assaults (such as exhibitionism or voyeurism) had
higher rates of dropping out than those who had
committed only one type or the other (p <.0001).
When the authors combined these characteristics they
found that 89.9% of the offenders who dropped out of
treatment had committed acts against males and females,
children and adolescents, both "hands-on" and "hands-
off". These findings were significant at the p <.0001

69
level. When relationship to the victim, described as
incest and nonincest, was considered with the above
factors the percentage of those dropping out remained
high (88.1%, significant at the p <.0001 level).
Concluding his review of the findings related to
dropping out, Abel et al. stated:
Combining all the mutiplicities of target
characteristics, it was found that 35 subjects had
committed pedophilic acts against males and
females, children and adolescents, and incest and
nonincest victims using hands-on and hands-off
molestation. Almost all of them (32 subjects, or
91.4%) dropped out of the treatment program. Of
the 157 subjects who did not report such
multiplicity of behaviors before treatment, only
22.3% dropped out of the treatment program. (Abel
et al., 1988, p. 228 )
In interpreting their data the authors suggest
that a multiplicity of offense and victim interests and
behaviors may make behavioral techniques aimed at
decreasing deviant interests inneffective. They
further suggest that the individuals with the greater
diversity of interests and behaviors may be
qualitatively different from other offenders, more
deviant or suffering from a more serious "dose" of the
disorder which is more resistant to treatment induced
change and therefore more likely to resist treatment in
the form of dropout or unsuccessful completion and more
likely to recidivate.

70
Age
How age affects amenability continues to be a
clinical issue in sex offender treatment; there are
several components to this issue. Numerous studies of
incarcerated offenders have shown that the majority of
individuals entering prison for violent crimes are
between the ages of eighteen and thirty-five; a sub¬
group of this population is comprised of rapists
(Scully, 1990). The treatment of adolescent sex
offenders is supported in part by the assumption that
early intervention is likely to stop a pattern of
behavior before it becomes deeply entrenched. But
recent studies have shown that most sex offenders, by
their mid-twenties, are already deeply entrenched in
their deviant patterns. Many of these offenders remain
relatively immature, defiant and may be resistant to
change. The maturing process has long been assumed by
clinicians to be an ally of treatment. Thus, once
offenders have reached adulthood, their amenability for
treatment is likely to improve as they get older; as
they mature they may be more likely to consider the
consequences of their behavior and be more willing to
seek alternatives to their deviant interests.

71
Marital Status
Several researchers have found that a stable
marital relaationship is a predictor of successful
completion of treatment as well as nonrecidivism.
Schwartz (1977) found that intact marriage was a
predictor of nonrecidivism in a sample of sex
offenders, including rapists, being treated in the
community; Abel and his associates (1988) found that
being married was a predictor of successful completion
of treatment as well as nonrecidivism for the
pedophiles in their outpatient treatment program.
Instant Offense
The instant offense, or the one for which the
offender is currently incarcerated, is often used as
identifying data; an offense for which the offender was
convicted is not dependant upon self-report for
verification. Perhaps one of the most commonly held
clinical assumptions in the sex offender field is that
among rapists, child molesters (extrafami1ial
pedophiles) and incestors (intrafami 1ial), rapists will
have the poorest prognosis for successful treatment,
incest offenders will have the best prognosis, and
child molesters will fall somewhere in between.

72
Outcome data from incest offender treatment programs
are frequently disregarded by clinicians working in
secure, inpatient facilities where, at best, incest
offenders comprise perhaps one-third of the treatment
populations and where they are considered the easiest
clients. Clinicians in these programs, recognizing the
need for programs capable of treating rapists and child
molesters, grudgingly accept these clients inspite of
their poor prognosis, recognizing the need to decrease
their dangerousness, while, at the same time, fearing
the negative publicity should one of these offenders
reoffend.
Treatment Outcome Categories
Very few sex offenders volunteer for treatment
without having been coerced or ordered into it by some
form of the judicial or corrections systems.
Frequently, reports on progress and ultimately
prognosis in terms of prediction of reoffense are
required by these agencies and information and opinions
provided often have a significant impact on judicial
and corrections decisions concerning the offender. As
a result of this and the fact that a significant number
of sex offender treatment programs are operated by

73
agencies with public funds, formal, documented
decisions concerning amenability, prognosis, progress
and dangerousness are frequently required of clinicians
in this field.
Termination at the End of the 8 Week Evaluation Phase-
-Group (a)
The criteria for membership in group (a) are as
follows: discharged during or at the conclusion of the
evaluation phase of treatment either at the resident's
request or as a result of a decision by the MDT and
officially designated "not amenable for treatment"
(those discharged due to severe medical problems would
be excluded from the study, since they should have been
excluded from the waiting list and were inappropriately
referred for treatment); not accepted into the
treatment phase at the acceptance staffing attended by
the mdtt after the 8-week evaluation phase.
Termination During the Treatment Phase with a Poor
Prognosis--Group (b)
The criteria for membership in group (b) are as
follows: accepted into the treatment phase at the
acceptance staffing attended by the MDT after
succesfully completing the 8-week evaluation phase;
subsequently determined to be no longer amenable for

treatment at an official termination staffing for one
or more of the following reasons: inappropriate
behavior such as repeated threats of violence, an act
of violence, sexual misconduct or other serious rule
violation; failure of treatment modules; failure to
follow treatment plan; resident request for termination
from the treatment program; a combination of the above,
or determined by the MDT to have made "no progress" or
"limited progress."
Termination at the End of the Treatment Phase with Good
Proqnosis--Group (c)
The criteria for membership in group (c) are as
follows: accepted into the treatment phase after
successfully completing the 8-week evaluation phase;
subsequently determined to have made "significant
progress" or to have "successfully completed" the
treatment program at the time of discharge.
Criteria for a rating of "significant progress"
included successful completion of most or all treatment
modules; demonstration by observable behavior of
significant integration of treatment material into
daily behavior; ability to describe the causes and
effects, long- and short-term, and possible
interventions of the sex offending behavior. Criteria
for a rating of "successful completion" included being

75
accepted into the treatment phase after successfully
completing the 8-week evaluation phase; successful
completion of all treatment modules; demonstration by
observable behavior of consistent integration of
treatment material into daily behavior; ability to
describe the causes and effects, long- and short-term,
and possible interventions of the sex offending
behavior; having an approved release plan.
Summary
Although much work has been done in recent years
developing strategies to treat sex offenders, there
remains little empirical evidence in the research and
practice literature regarding the effectiveness of
these strategies and even less regarding the more
specific question of which types of treatment are
effective with which sex offenders. In this chapter
the research and practice literature has been reviewed,
and common assumptions held by clinicians have been
discussed. A set of offender variables have been
described which are examined in this study.

CHAPTER III
METHODOLOGY
This study was designed to determine if six
offender variables, assessed during the first 8 weeks
of a residential sex offender treatment program, were
correlated with membership in one of three treatment
outcome groups. The offender variables consisted of
(a) reading level, (b) presence of antisocial
personality disorder, (c) degree of discrimination in
the selection of offense and victim type (operationally
defined as total deviance score), (d) age, (e) marital
status, and (f) instant offense. The treatment outcome
groups consisted of (a) offenders who were discharged
at the end of eight weeks as nonamenable, (b) offenders
who were judged amenable for treatment at the end eight
weeks but were subsequently discharged prior to
completing treatment with a poor prognosis, and (c)
offenders who were judged amenable for treatment at the
end of eight weeks and were subsequently discharged
after completing the program with a good prognosis.
This chapter consists of sections describing the
research design, population and sample, procedures for
76

77
treatment and data collection, instrumentation,
hypotheses, data analyses, and limitations of the
study.
Research Design
Criterion Variable
In this study an ex post facto design was used to
evaluate the interrelationships among six offender
variables and three treatment outcome groups: (a)
offenders judged nonamenable for treatment during an
evaluation phase of a residential treatment program,
(b) offenders judged amenable for treatment during an
evaluation phase, but later discharged with a poor
prognosis, and (c) offenders judged amenable for
treatment during an evaluation phase and subsequently
discharged with a good prognosis.
The criteria for membership in group (a) were
discharged during or at the conclusion of the
evaluation phase of treatment either at the resident's
request or as a result of a decision by the MDT, and
not accepted into the treatment phase at the acceptance
staffing attended by the treatment team after the 8
week evaluation phase and officially designated "not
amenable for treatment." The criteria for membership

78
in group (b) were accepted into the treatment phase at
the acceptance staffing attended by the MDT after
succesfully completing the 8 week evaluation phase and
subsequently determined to be no longer amenable for
treatment at an official termination staffing for one
or more of the following reasons: inappropriate
behavior such as repeated threats of violence, an act
of violence, sexual misconduct or other serious rule
violation; failure during treatment modules; failure to
follow treatment plan; resident request for termination
from the treatment program; a combination of the above;
or determined by the MDT to have made "no progress" or
"limited progress." The criteria for membership in
group (c) were being accepted into the treatment phase
after successfully completing the 8 week evaluation
phase and subsequently being determined to have made
"significant progress" or to have "successfully
completed" the treatment program at the time of
discharge.
Criteria for a rating of "significant progress"
included (a) successful completion of most or all
treatment modules, (b) demonstration by observable
behavior of significant integration of treatment
material into daily behavior, and (c) ability to

79
describe the immediate and long-term causes and impact
of the sexual offending and to demonstrate knowledge of
approved methods for preventing future sex offending
behavior. Criteria for a rating of "successful
completion" included (a) successful completion of all
treatment modules, (b) demonstration by observable
behavior of consistent integration of treatment
material into daily behavior, (c) ability to describe
the immediate and long term causes and impact of the
sexual offending and to demonstrate knowledge of
approved methods for preventing future sex offending
behavior, and (d) an approved release plan.
Independent Variables
The six variables examined in relation to the
outcome variables were (a) reading level, reported as a
raw and converted score from the administration of the
Wide Range Achievement Test-Revised (WRAT-R); (b)
presence of an antisocial personality disorder,
documented by the primary case manager who was
responsible for integrating the consensus diagnoses of
the MDT; (c) degree of discrimination in the selection
of offense and victim type (total deviance score) based
on the documentation in the clinical summary of offense

80
history from official reports and self-report of the
offender during the evaluation phase; (d) age at time
of admission; (e) marital status, and (f) instant
offense.
Population
The population from which the sample was drawn
consisted of 167 males who (a) were convicted of sex
offenses including rape, child molestation and incest,
(b) were incarcerated in the Florida prison system
between the years of 1985 and 1989, (c) were between
the ages of sixteen and seventy, (d) had a minimum of a
third grade reading level and a score of 70 or higher
on the WAIS-R, (e) had no organic, psychotic or other
major mental disorder, (f) volunteered for
participation in a Health and Rehabilitative Services
(HRS) residential sex offender treatment program, (g)
were placed on a waiting list for treatment, and (h)
were subsequently transfered to NFETC when they reached
the top of the waiting list.
Each male sex offender who was convicted and
sentenced to a period of incarceration with the Florida
Department of Corrections (DC) was required by statute
to be evaluated for possible participation in one of

81
the two HRS Mentally Disordered Sex Offender (MDSO)
treatment programs. Preliminary screening was
accomplished by DC psychological staff to identify
those offenders who were administratively qualified for
transfer to HRS for sex offender treatment and who
volunteered for that treatment. Such offenders were
subsequently interviewed by a joint screening team
composed of representatives of the DC psychological
staff and the staff of one of the HRS sex offender
treatment programs. The following criteria were used
in the joint screening process to determine potential
eligibility for treatment: (a) evidence of a
psychosexual disorder, (b) willingness of the offender
to volunteer for treatment, (c) demonstration by the
offender of sufficient motivation and capacity for
insight to indicate a possibility of successful
treatment completion, and (d) A score of 70 or above on
the WAIS-R or equivalent and WRAT-R of third grade or
above.
Offenders who were determined to be potentially
eligible for consideration for treatment as a result of
this joint screening process were then placed on a
waiting list to await transfer to HRS custody for
treatment. This waiting list was prioritized according

82
to the length of time remaining on the offender's
sentence, with those having the least time being
afforded the earliest opportunities for treatment.
Those offenders with shorter sentences which precluded
a minimum of at least eight months treatment were
excluded from participation.
Resultant Sample
The resulting sample of 114 offenders consisted of
those individuals from the population described who had
not been accepted for treatment prior to the
establishment of the new treatment program in July,
1986 and had sufficiently progressed in treatment to
receive a completion rating at the time of the closing
of the program in June, 1989. Excluded from the sample
were offenders found not amenable for treatment, once
at the facility, due to criteria which would have made
them ineligible at the time of original screening such
as a chronic physical problem (e.g., heart disease) or
major thought disorder.
The sample of offenders whose records were studied
consisted of 114 male sex offenders who attended the
sex offender treatment program at North Florida
Evaluation and Treatment Center (NFETC) between March,

83
1986, and August, 1989. The mean age of these
offenders on admission to the treatment facility was
31.4 years of age with the youngest being 16 and the
oldest being 59. Of the 115 offenders, 47 (40.87%) had
been incarcerated for a most recent charge (instant
offense) of incest or intrafami1ial child molestation.
Extrafami 1ial child molesters, those who victimized
children outside of the home, numbered 37 (32.17%).
There were 31 (26.96%) men incarcerated for rape.
Examining the marital status of the offenders revealed
that 40 (35.09%) were married, 39 (34.21%) had never
been married, 9 (7.89%) were separated, and 26 (22.81%)
were divorced. There were 27 (23.48%) black offenders,
87 (75.65%) white offenders, and one (0.88%) hispanic
offender in the sample.
Procedures
Treatment Procedures
The residential treatment program from which data
for this study were collected was housed at North
Florida Evaluation and Treatment Center (NFETC), a
maximum security forensic mental health institution
operated by HRS in Gainesville, Florida since 1976. The
MDSO program, which comprised approximately one-third

84
of the institutional population, had a maximum capacity
of 63 beds dedicated to the treatment of convicted male
sexual offenders. The NFETC sex offender program
physical plant included three buildings, two of two
wings (called pods) housing offenders who had been
accepted for the treatment phase, and one of three pods
which included two pods of offenders in the 2-month
evaluation phase and one pod of advanced offenders
approaching successful completion of treatment. Each
pod was comprised of 9 offenders, each of whom was
assigned an individual room. Each of these offenders
had been screened and approved for transfer at one of
various DC institutions throughout Florida prior to
transfer to the MDSO unit.
The treatment program integrated three broad areas
of therapeutic focus: (a) assisting the offender in
replacing distorted or irrational thinking and
maladaptive behaviors commonly associated with the
psychosexual disorder (e.g., cognitive restructuring,
behavioral module); (b) training offenders in the
skills necessary to improve their interpersonal and
intrapsychic functioning (e.g., their communication
skills and stress/anger management); and (c) assisting
the offender in identifying and remediating impediments

85
to healthy functioning that were the result of early
trauma and/or lifelong acquired patterns of dysfunction
through corrective emotional experiences using
techniques derived from Gestalt Therapy,
Psychosynthesis and Neuro-Linguistic Programming as
well as modified aversive behavioral rehearsal therapy
(Knopp, 1984).
A basic assumption underlying this treatment
approach was that there is an endless variety of
combinations of behavioral, experiential and cognitive
antecedents that sex offenders describe in their
offense cycles. The idea that one treatment modality
would successfully ameliorate the problems of so
diverse a population seemed optimistic at best and
grossly inadequate at worst. Based on their treatment
experience, the staff concluded that the best strategy
for treating such a diverse population was to offer a
variety of treatment modalities, individualizing the
treatment by stressing some components over others
based on evaluations of the offender's behavior,
progress, and personality configuration.
A second concept underlying the treatment program
was that, whenever possible, treatment would be
delivered using a structured module format to

86
facilitate accurate replication for quality control and
future research. Topics addressed by structured
modules ranged from educational material such as sex
education to sensitivity training which included
experiential components. Although some modules were
appropriate for all offenders in the program,
individuals with extensive histories of abuse were
considered to require more emphasis on repairing the
effects of early trauma and more supportive therapy
than those with less abuse in their early history.
Preliminary assessment phase. Upon admission,
each offender was required to participate in a
preliminary treatment assessment phase. During this
phase each offender participated in an initial intake
interview with members of the MDT and then took a
battery of assessment instruments. Also during this
phase, each offender was sequestered in his assigned
room except when participating in an initial
comprehensive assessment battery.
Evaluation phase. The 8 week evaluation phase,
which began with the Computer Assisted Psychosocial
Assessment (CAPSA), was designed to begin the process
of treatment while testing the offender's ability and
motivation to participate successfully in the program

87
components. To this end this phase consisted of
learning the program rules, participating in structured
and unstructured groups on a daily basis, completing
chores, completing frequent structured assignments
designed to increase awareness of the offender's
offense cycle, and revealing to his therapist and group
members significant information from his past regarding
his development including his offenses as well as his
own traumas. Structured modules included criminal
thinking errors and offense cycle (central process).
During this phase each offender received a
psychological evaluation which was included in his
clinical record. Each offender’s progress was reviewed
weekly by the MDT including the paraprofessional staff
person called a Resident Activity Monitor (RAM), who
tracked the offender's compliance with treatment plan
directives. At the conclusion of the evaluation phase
the offender was evaluated by the MDT in a formal
review known as the Acceptance Staffing where the
offender's progress, amenability for treatment as
predicted by the psychological evaluation, and the
offender's ability to respond to stressful questioning
were considered in determining his eligibility to
continue into the treatment phase of the program.

88
Treatment phase. The treatment program utilized a
therapeutic community to create an emotionally safe
environment within which to explore past traumatic
experiences, faulty learning, and inappropriate
behavioral reponses to stressful situations.
Responsible for this milieu were the 7 professional
therapists and 45 paraprofessional staff who managed
the three treatment buildings. This therapeutic
community included a resident government, peer-
facilitated groups and impromptu encounters providing
the background upon which this modularized program was
superimposed. Material learned in the modular program
was expected to be demonstrated in the milieu in new,
more appropriate behavior.
Additionally, the program included therapist-
facilitated pod groups which met twice weekly to focus
on here-and-now interpersonal conflicts and progress
using core program components such as "central process
of the psychosexual disorder," bodywork and meditation,
the offender work program, Alcoholics Anonymous, basic
adult education, evening study halls, structured
training groups, and art, music, and recreation
therapy.
Treatment participants who had completed all the
treatment modules and had advanced to the integration

89
phase assisted in facilitating groups and also served
as primary facilitators for structured evening training
modules on a regular basis in the evaluation building.
Offenders provided support and facilitation to one
another throughout the treatment week in the form of
Triad Sessions (small group teams of three) and special
group attendance.
There was also a peer-faci1itation/peer-eva1uation
process interwoven into the structure of the overall
treatment program which was directed by the Offender
Government. Regularly scheduled, periodic reviews of
the offender's progress were conducted by offender
review boards comprised of elected peers, and the
results were presented to the offender and his case
manager as feedback.
Evaluation of each offender's progress in
treatment was conducted by staff in accordance with
standards mandated by HRS. Progress in treatment was
reviewed with each offender on a weekly basis during
the initial two month evaluation phase and biweekly
during the remainder of his treatment. Regular
progress staffings were scheduled and conducted
annually, and special staffings were scheduled as
therapeutically indicated on a case by case basis.

90
The treatment program at NFETC was structured to
be 18 months in duration. Although a few offenders
were able to complete all of the modules and
demonstrate integration of the skills taught into daily
behavior within as little as 15 months, most required
at least 18 months to successfully complete the
program. Regardless of the length of time an offender
spent in the treatment program, he received regular
feedback on his progress from the treatment team.
Data Collection Procedures
Data for the study were drawn from case files in
the Medical Records department of NFETC. Each
offender's record was reviewed to determine the WRAT-R
raw score and grade equivalent. These scores were
either documented in the offender's record from his DC
evaluation or in the psychological evaluation conducted
at NFETC.
Also reviewed was the diagnosis. In order to
maximize reliability, the diagnosis in the initial
clinical summary was used because it documents a
consensus decision of the MDT. A zero (0) was scored
for no diagnosis or no features of antisocial
personality disorder. A one (1) was scored for a

91
diagnosis with features of antisocial personality
disorder, and a two (2) was scored for a diagnosis of
antisocial personality disorder.
The clinical summary(ies) were also reviewed to
determine the number of different victim types (age and
gender) as well as the number of different types of
paraphilic acts. If the information regarding victim
type and/or paraphilic acts was unclear in the summary,
a further review of the case file including
documentation of self-reports of previously unknown
offenses revealed by the offender during clinical
interviews or documented from other treatment
modalities was conducted. The clinical summary(ies)
was also reviewed to determine the resident's age upon
admission, marital status and instant offense.
Instrumentation
This section contains descriptions of the
instruments used to assess the variables of interest in
this study. Included are the Wide Range Achievement
Test-Revised, the evaluation phase clinical summary,
and the NFETC clinical case record.
Wide Range Achievement Test-Revised (WRAT-R)
The Wide Range Achievement Test-Revised (WRAT-R)
will be used to measure reading level. The WRAT was

92
first developed and standardized in 1936 as an adjunct
to intelligence tests and measures of behavior
adjustment. Since its development it has been revised
five times and has been experimentally administered to
thousands of people from pre-school through adulthood.
Although the 1984 WRAT-R contains many changes
from the original, it remains basically the same in
form, content and commitment to remaining a simple
assessment instrument (Jastak & Jastak, 1979). The
thrust of recent revisions has been to make the WRAT-R
an up-to-date psychometric instrument using improved
methods for item analysis and scaling (i.e., Rasch
model).
The WRAT-R provides data regarding the level of
reading skills in both raw score form and as equivalent
school grades. It provides a more direct measure of
ability than the WAIS-R with which it is, however,
highly correlated, particularly the verbal IQ and full-
scale IQ (Cooper & Fraboni, 1988; Margolis, Greenlief &
Taylor, 1985; Ryan & Rosenberg, 1983; Spruill & Beck,
1986). This high correlation holds for geriatric
populations (Margolis et al., 1985); mixed mental
health patients (Ryan & Rosenberg, 1983); and normals
(Cooper & Fraboni, 1988; Spruill & Beck, 1986). The

93
advantage of using the WRAT-R as a measure of ability
instead of the WAIS-R is that the WRAT-R is relatively
easy and quick to administer and is therefore more
likely to be available to most programs, regardless of
size and psychological resources.
Assessment of Antisocial Personality Disorder
The presence of Antisocial Personality Disorder or
other diagnoses were determined by an initial intake
interview, subsequent social history, information
revealed during the Evaluation Phase and a
psychological evaluation and were documented in the
Evaluation Phase clinical summary. The Evaluation
Phase clinical summary is a document developed by the
staff of NFETC for reporting of the results of the
eight week evaluation phase of the sex offender
treatment program and sent to the Department of
Corrections. It was the responsibility of the
offender's primary case manager to produce following
NFETC summary guidelines. It included information
derived from interviews, treatment procedures, and
previous documentation. Among its contents was a
consensus Axis II diagnosis opinion of the MDT
attending the 8-week evaluation staffing generally

94
comprised of the primary case manager, Unit Director,
Unit Psychiatrist, Unit Health Coordinator (RN), Unit
Psychologist, and other primary case managers in the
unit.
The diagnoses themselves were based on the
Diagnostic and Statistical Manual - III (DSM-III), the
standard for making diagnoses during the period under
investigation. The DSM-III, published in 1980,
represents the work of many clinicians, and is itself a
consensus guide to diagnosis.
Assessment of Degree of Discrimination in the Choice of
Offense and Victim Type (Total Deviance Score)
The sexual offense history was compiled as a
result of an initial intake interview, a social
history, a psychological evaluation, and unstructured
activities during the Evaluation Phase designed to
elicit disclosure of offense history; this information
was documented in the Evaluation Phase clinical
summary. The Evaluation Phase clinical summary was
reviewed to derive a total deviance score comprised of
the number of different victim ages and sex and the
different types of offenses (including hands-on, hands-
off, incest, non-incest, violent and non-violent)
documented in the summary as a result of admission by

95
the offender or documentation in official records. The
following procedure was used to derive a total deviance
score for each offender: (a) a score of 1 was given for
hands-off only or hands-on only and a score of 2 for
both hands-on and hands-off; (b) a score of 0 was given
for no child molestation, 1 was given for non-incest
child molestation only or incest child molestation only
and a score of 2 for both incest and non-incest child
molestation; (c) a score of 0 was given for no
molestations, 1 for molestation of female victims only
or male victims only and a score of 2 for both male and
female victims; (d) a score of 0 was assigned for no
molestations, 1 for child molestation with use of force
only or no use of force only and a score of 2 for
molestation with and without use of force; (e) a score
of 0 was assigned for no rapes, 1 for rape of females
only or rape of males only and a score of 2 for rape of
males and females; and (f) a score of 0 was assigned
for no other paraphilic acts and 1 each up to 3 for
other paraphilic acts including voyerism, exhibitionism
and frottage. The total deviance score, therefore, was
the sum of (a) through (f) (See Appendix A).

96
Age, Marital Status and Instant Offense
This information was routinely provided in the
first paragraph of the clinical summary and derived
from DC records, including court documents, and
offender self-report.
Hypotheses
Hoi. There are no significant relationships among
offenders' reading level, total deviance score,
presence of antisocial personality disorder, age,
marital status, instant offense and membership in the
three outcome groups.
Ho2. There are no significant differences in
reading level among the three offender groups.
Ho3. There are no significant differences in total
deviance score among the three outcome groups.
Ho4. There is no association between presence of
an antisocial personality disorder and outcome group
membership.
Ho5. There are no significant differences in age
among the three outcome groups.
Ho6. There is no association between marital
status and outcome group membership.
Ho7. There is no association between instant
offense and outcome group membership.

97
Data Processing and Analysis
To address Hoi, a multiple discriminant f
analysis was conducted to estimate the extent
the various offender variables could be used t
correctly classify subjects into one of the th
outcome groups. One-way analyses of variance
were performed to test whether there were diff
in the three outcome groups in the variables o
interest in Ho2, Ho3 and Ho5. A series of chi
analyses were used to assess differences among
three outcome groups in the offender variables
specified in Ho4, Ho6, and Ho7.
unction
to which
o
ree
(ANOVA)
erences
f
square
the

CHAPTER IV
RESULTS
This study was designed to explore the
relationships among six offender characteristics and
final treatment outcome status for offenders
participating in a residential sex offender program.
These characteristics were reading ability, age,
marital status, instant offense, presence of antisocial
personality disorder, and total deviance score. A
second purpose of the study was to determine whether
offenders who differed in treatment outcome status
differed in terms of certain offense and offender
characteristics. The sample consisted of 114 men who
had participated in a residential sex offender
treatment program in the state of Florida between
April, 1986, and August, 1989. In this chapter, the
results of the study are presented as they pertain to
each of the research questions posed. These results
are organized into three sections. First, descriptive
data on the treatment group are provided. Second, the
results of the analyses to assess the contribution of
98

99
the variables in classifying offenders into the three
outcome groups are reported. Finally, results of the
analyses concerning possible differences among the
three groups in the variables of interest are
presented.
Descriptive Statistics for Treatment Outcome Groups
The mean age of these offenders on admission to
the treatment facility was 31.5 years of age with the
youngest being 16 and the oldest being 59. Of the 114
offenders, 47 (41.22%) had been incarcerated for a most
recent charge (instant offense) of intrafami1ial child
molestation (incest). Extrafami 1ial child molesters,
those who victimized children outside of the home,
numbered 36 (31.58%). There were 31 (27.19%) men
incarcerated for rape. Examination of the marital
status of the offenders revealed that 40 (35.09%) were
married, 39 (34.21%) had never been married, 9 (7.89%)
were separated, and 26 (22.81%) were divorced. The
mean total deviance score for the total sample was 5.26
with a standard deviation of 1.79 and a range from 2 to
10. The mean WRAT raw scores for the sample was 58.68
with a standard deviation of 15.55 and a range of 27 to
86. There were 54 (47.37%) offenders without features

100
or a diagnosis of antisocial personality disorder, 25
(21.93%) offenders with features of antisocial
personality disorder, and 35 (30.70%) offenders with a
diagnosis of antisocial personality disorder.
The three outcome groups were (a) discharged from
the evaluation phase as not amenable for treatment
(group 1), (b) accepted after the evaluation phase but
later discharged with a poor prognosis (group 2), and
(c) accepted after the evaluation phase and later
discharged with a good prognosis (group 3). There were
32 (28.07%) offenders who were discharged as not
amenable (group 1), 66 (57.89%) discharged with a poor
prognosis (group 2), and 16 (14.04%) discharged with a
good prognosis.
Differences Among Treatment Outcome Groups
Hypothesis 1
Hypothesis 1 stated that there were no significant
relationships among offenders' reading level, total
deviance score, presence of antisocial personality
disorder, age, marital status and instant offense and
membership in the three outcome groups. This
hypothesis was tested using a multiple discriminant
function analysis, with the six offender

101
characteristics serving as independent or predictor
variables. Membership in one of the three treatment
outcome groups was the dependent variable. A Wilks'
lambda test was conducted to test the equality of the
mean vectors of the six predictor variables. The
Wilks' lambda calculated values are reported in Table 1
along with the results of the Chi-square analyses. The
table indicates that neither discriminant equation
discriminated significantly among members of the three
outcome groups.
Table 1. Wilks' Lambda Test of Equal Mean Vectors
Function Wilks' lambda Chi-square D.F. Significance
1 0.8443775 18.353 12 0.1054 (N.S.)
2 0.9719383 3.0882 5 0.6864 (N.S.)
The normalized and scaled vectors are presented in
Table 2. The normalized vectors are the coefficients
of the variables in each of the discriminant equations
generated. The scaled vectors show the relative
contribution of each variable in the discriminant
equations. The first equation accounted for 83.95% of
the variance, and the second accounted for the
remaining 16.05%.

Table 2. Normalized and Scaled Vectors for
Discriminant Functions 1 and 2 on 6 Variables
102
Characteristics
Vectors
Normalized Scaled
1
2
1
2
Read. 1vl.
0.74290
0.11808
0.64328
0.14812
Age
-0.11501
0.24116
0.30108
0.14628
Tot. Dev.
-0.20986
0.87362
-0.16074
0.85802
Mar. Stat.
0.64794
-0.25487
0.61996
-0.06767
APD
0.11514
-0.00431
-0.07407
-0.21457
Inst. Off.
-0.35520
-0.41023
-0.36439
-0.43750
In Table 3 frequencies and percentages of subjects
classified into each of the three outcome groups by
means of the discriminant function equation are
presented. The average of 45.6% classified correctly
by the analysis compared favorably with the expected
percentages of 33.33% for each category. The highest
percentage of correctly classified subjects was for
group 3 (discharged with a good prognosis) with 68.8%
correct; this was more than twice the expected
percentage. The percentage classified correctly into
group 1 (discharged as not amenable) was 53.1%, and the
percentage correctly classified into group 2
(discharged with poor prognosis) was 36.4%.

103
Table 3. Classification into Outcome Groups
Using Offender and Offense Variables
Discriminant Function Analysis (n=114)
Group 1
Group 2 Group 3
Group
1
53.1
28.1
18.8
Group
2
33.3
36.4
30.3
Group
3
6.3
25.0
68.8
Variables:
Age, WRAT reading
1 eve 1,
presence of
Antisocial Personality Disorder
diagnosis, Total Deviance Score, marital
status, and instant offense.
Post hoc analyses. A series of Pearson moment
correlation coefficients was computed to determine if
there existed a high degree of correlation among the
independent variables which may have contributed to the
low discriminative power of this set of variables.
Table 4 contains the intercorrelations among the six
variables in the discriminant equation. Although most
of the correlations were moderate in size, five
correlations were statistically significant; two of
these were in a positive direction, and three were in a
negative direction. The highest of the significant
correlations was between age and marital status. The
positive correlation (significant at the .0001 level)

104
suggests that older offenders were more likely to be
married or in a committed relationship. Age was also
negatively correlated with antisocial personality
disorder. Older offenders were less likely to have a
diagnosis or features of antisocial personality
disorder (significant at the .05 level). Age was
negatively correlated with instant offense (significant
at the .01 level) suggesting that older offenders were
more likely to be incarcerated for incest than for rape
or child molesting. Marital status was also negatively
correlated with instant offense (significant at the .01
level); married offenders or those in a committed
relationship were more likely to be incarcerated for
incest than for rape or child molesting. Finally,
antisocial personality disorder was positively
correlated with instant offense (significant at the
.001 level) suggesting that offenders with features or
diagnoses of antisocial personality disorder were more
likely to have been incarcerated for a charge of rape
or child molesting than for a charge of incest.
Because only 5 of the 15 pairwise correlations
among the independent variables were significantly
greater than chance, all correlations were low to
moderate, and two variables (WRAT and total deviance

105
score) failed to correlate with any other independent
variables, hypotheses 2-7 were tested with univariate
procedures, maintaining the alpha level at .05 for each
test.
Table 4. Correlation Coefficients for Intercorrelations
Amonq
Independent Variables
Var.
Age Mar.
WRAT
APD
Inst.
Tot.
Stat.
Off .
Dev.
Age
0.37
0.17
-0.20
-0.23
-0.13
****
*
**
Mar.
0.01
-0.11
-0.24
0.01
Stat.
**
WRAT
-0.07
0.05
0.003
APD
0.31
-0.07
***
Inst.
-0.05
Off .
Tot.
Dev.
Significance * =
.05
** =
.01
* * * —
.001
* * * * —
.0001
Hypothesis 2
Hypothesis 2 stated
that
there would
be no
significant differences
in reading ability
1evels
, as
measured by the reading
achievement scale
of the
Wide

106
Range Achievement Test (WRAT), among offenders from
each of the three treatment outcome groups. This
hypothesis was tested using an Analysis of Variance
(ANOVA) with WRAT reading level as the dependent
variable and treatment outcome group membership as the
independent variable. The results of this analysis are
presented in Table 5. As Table 5 indicates, the model
proved significant, F_( 2 , 114) = 3.51, p_<.05.
Table 5. Mean WRAT Reading Level and Treatment Progress
Analysis of Variance
Source
df
Sum of
F value p. > F
Squares
Between Groups
2
1625.333
3.51 .033
Within Groups
111
25695.658
Total
113
27320.991
Table 6 shows the means, standard deviations and
ranges for the WRAT reading ability scores for the
three treatment outcome groups and the total sample.

107
Table 6. Means, Standard Deviations and Ranges of
Reading Achievement Scores for Treatment Outcome Groups
and Total Sample
1
2
3
Total
Not
Amen
Poor
Prog
Good
Prog
Sample
Sample
(n= 32)
(n= 66)
(n=16)
(n=114)
WRAT mean
55.53
58.03
67.63
58.68
Grade equiv.
9th
10th
>12th
10th
Std. Dev.
14.58
16.06
12.50
15.55
Range
30-86
21-84
38-83
21-86
In order to determine how the means of the three
outcome groups differed in terms of reading level,
Duncan's New Multiple Range Test was used. The results
of this test are summarized in Table 7. An examination
of the means in Table 7 shows that the mean reading
level for offenders who were discharged with a poor
prognosis was greater than those found not amenable and
that the mean reading level for the group who was
discharged with a good prognosis was greater than that
of the other two groups. The difference between the
means of the offenders in the good prognosis group
(group 3) and those of the offenders in groups 1 and 2
was significant at the .05 level of significance. No
other comparisons yielded significant differences.

108
Table 7. Duncan's New Multiple Range Test of the
Reading Level Means of the Three Outcome Groups
Not
Amen
1
2
Poor
Prog
3
Good
Prog
Shortest
Significant
Ranges
Means
55.531
58.030 67.625* R2 = 8.144
R3 = 8.564
(a)
*significant at the .05 level.
(a) Values under the same line do not differ
significant!y.
Hypothesis 3
Hypothesis 3 stated that there would be no
significant differences in the total deviance scores
among offenders from each of the three treatment
outcome groups. This hypothesis was tested using an
Analysis of Variance (ANOVA), with offender groups
(discharged as not amenable, discharged with a poor
prognosis, and discharged with a good prognosis) as the
independent variable and total deviance score as the
dependent variable. The results of the analyses are
presented in Tables 8 and 9 respectively. As can be
seen, there were no statistically significant
differences in the total deviance score means among the
three outcome groups.

Table 8. Mean Total Deviance Score and Treatment
Progress Analysis of Variance
109
Source
df
Sum of
Squares
F value
> F
Between
Groups
2
8.887
1.40
NS
Within
Groups
111
353.219
Total
113
362.105
In Table 9 the means, standard deviations and
ranges for the Total Deviance Scores for the three
treatment outcome groups and the total sample are
reported.
Table 9. Means, Standard Deviations and Ranges of Total
Deviance Scores for Treatment Outcome Groups and Total
Sampl e
1
Not
Amen
Sampl e
/ s
(N
CO
II
a
Tot. Dev.
Score Means
4.969
Std. Dev.
1.823
Range
2-9
2 3 Total
Poor
Prog
Good
Prog
Sample
(n= 66)
(n=16)
(n=114)
5.500
4.875
5.263
1.883
1.147
1.790
2-10
4-9
2-10

110
Hypothesis 4
Hypothesis 4 stated that there would be no
significant differences in the presence of antisocial
personality disorder among offenders from the three
treatment outcome groups. This hypothesis was tested
using a Chi-square analysis to test for significance in
the frequency of occurrence of this disorder among the
three outcome groups. As can be seen in Table 10, the
test revealed no significant differences among the
three groups on this measure.
Table 10. Rates of Occurrence of Antisocial Personality
Disorder Amono the Three Outcome
Groups
Frequency
Percent
Row Pet
Col Pet
1
2
3
Total
no APD
14
32
8
54
12.28
28.07
7.02
47.37
25.93
59.26
14.81
43.75
48.48
50.00
features
18
34
8
60
or diag.
15.79
29.82
7.02
52 . 63
of APD
30.00
56.67
13.33
56.25
51.52
50.00
Total
32
66
16
114
28.07
57.89
14.04
100.00
Statistic
DF
Value
Prob
Siq .
Chi square
2
0.245
0.884
NS

Ill
Hypothesis 5
Hypothesis 5 stated that there would be no
significant differences in the mean ages among
offenders from each of the three treatment outcome
groups. This hypothesis was tested using an Analysis
of Variance (ANOVA), with offender groups (discharged
as not amenable, discharged with a poor prognosis, and
discharged with a good prognosis) as the independent
variable and age on admission as the dependent
variable. The results ofthe analysis are presented in
Table 11. As can be seen, there were no significant
differences in age noted among the three outcome
groups.
Table 11. Mean Age and Treatment Progress Analysis of
Variance
Source
df
Sum of
Squares
F value
p_ > F
Between
Groups
2
151.295
0.79
NS
Within
Groups
112
10571.205
Total
114
10722.500

112
Table 12 shows the means, standard deviations and
ranges for ages of offenders in the three treatment
outcome groups and the total sample.
Table 12. Means, Standard Deviations and Ranges of Age
for Treatment Outcome Groups and Total Sample
1
2
3
Total
Not
Poor
Good
Sample
Amen
Prog
Prog
Sample
(n= 32)
(n= 66)
(n=16)
(n=114 )
Mean Age
30.38
31.41
34.13
31.50
Std. Dev.
10.60
9.60
8.53
9.74
Range
16-55
19-59
20-47
16-59
Hypothesis 6
Hypothesis 6 stated that there would be no
significant differences in the marital status of
offenders among the three treatment outcome groups.
This hypothesis was tested using a Chi-square Analysis
to test for significance in the marital status rates
among the three outcome groups. As can be seen in
Table 13, the test revealed significant differences
among the three groups on this measure. While observed
frequencies for those not amenable and those with poor
prognosis were close to expected frequencies, marital

113
status was clearly significant for those discharged
with a good prognosis. Married offenders observed
frequency was almost double the expected frequency of
5.6.
Table 13.
Rates of
Marital Status
Amonq the
Three
Outcome Groups
Frequency
Percent
Row Pet
Col Pet
1
2
3
Total
Unmarried
23
45
6
74
20.18
39.47
5.26
64.91
31.08
60.81
8.11
71.88
68.18
37.50
married
9
21
10
40
7.89
18.42
8.77
34.78
22.50
52.50
25.00
28.13
31.82
62.50
Total
32
66
16
114
28.07
57.89
14.04
100.00
Statistic
DF
Value
Prob
Siq .
Chi square
2
6.270
0.044
p.< .05
Hypothesis 7
Hypothesis 7 stated that there would be no
significant differences in the instant offenses among
offenders from the three treatment outcome groups.
This hypothesis was tested using a Chi-square analysis

114
to test for significance in the rates of instant
offenses among the three outcome groups. As can be
seen in Table 14, the results of this test revealed no
significant differences among the three groups on this
measure.
Table 14.
Rates of Occurrence of Instant Offenses Amonq
the Three
Outcome Groups
Frequency
Percent
Row Pet
Col Pet
1
2
3
Total
Incest
10
28
9
47
8.77
24.56
7.89
41.23
21.28
59.57
19.15
31 .25
42.42
56.25
Child
22
38
7
67
Molest
19.30
33.33
6.14
58.77
or Rape
32.84
56.72
10.45
68.75
57.58
43.75
Total
32
66
16
114
28.07
57.89
14.04
100.00
Statistic
DF
Value
Pr ob
Siq .
Chi square
2
2.844
0.241
NS
Summary
In this chapter, results of the data analyses
utilized to determine whether a sample of 114 sex
offenders who were categorized in three treatment
outcome groups differed in terms of six offender

115
characteristics were presented. The six offender
characteristics were reading level, age, marital
status, instant offense, total deviance score and
presence of antisocial personality disorder. The three
treatment outcome groups were discharged as not
amenable for treatment, having a poor prognosis, and
having a good prognosis. A discriminant function
analysis using all six offender variables was
conducted. A Wilks' lambda test of the equality of
group centroids revealed that the two discriminant
equations were not significant in classifying offenders
into outcome groups. The discriminant function did
result in correct classification of 45.61% of offenders
in the total sample. This observed rate was greater
than the expected frequency of 33.33%. However, for
group 3 (discharged with a good prognosis) alone, 68.8%
of offenders were classified correctly. Results of the
analyses of variance and Chi-square analyses revealed
significant differences in reading level and marital
status between offenders in outcome group 3 (discharged
with a good prognosis) and offenders in outcome groups
1 (not amenable) and 2 (discharged with poor
prognosis). Other offender characteristics were not
found to differ significantly across the outcome
groups.

CHAPTER V
DISCUSSION
The purpose of this study was twofold. First, the
power of six offender variables to correctly
discriminate among offenders in three different
treatment outcome groups was tested. Second, the six
offender variables were tested to determine if there
were significant differences among three outcome groups
for each of the variables. In this chapter a
discussion of the results for each of the research
hypotheses is presented. In addition, the limitations
of the study, implications for theory and clinical
practice, and recommendations for future research are
considered.
Discussion of Results
Ability of Reading Level, Total Deviance Score,
Antisocial Personality Disorder, Age, Marital Status.
and Instant Offense to Classify Correctly Offenders
into Treatment Outcome Groups (Hypothesis 1)
Hypothesis 1 stated that offenders in the three
treatment outcome groups would not be discriminated
significantly by means of the six offender and offense
116

117
variables. This hypothesis failed to be rejected in
this study.
It is the inevitable responsibility of every sex
offender treatment program provider to make decisions
regarding eligibility for treatment. Selection of the
six offender variables used to discriminate among the
offenders in this study was based upon both prior
research and clinical assumptions common to the sex
offender field. Results of the discriminant function
analysis were not significant in correctly classifying
offenders into outcome groups. A Wilk's lambda test
yielded calculated values of 0.8443775 and 0.971 9383
respectively for the discriminant functions. Chi-
square analyses for each calculated value were not
significant. For example, by means of these variables,
68.75% of offenders who were discharged with a good
prognosis were classified correctly. Although this
represented more than twice the expected percentage
classified by chance (33.33%), it represented only 16%
of the total sample. Offenders found not amenable for
treatment were correctly classified 53.1% of the time.
It is not surprising that the largest group, those
accepted into the treatment program but later
discharged with a poor prognosis, were not as

118
successfully classified (36.4%). Offenders in this
group tended to share features of offenders in the
other two groups. For example, many offenders in this
group had been accepted with reservations and resembled
those offenders found not amenable, while others in
this group had been progressing satisfactorily but were
discharged as a result of a serious rule violation or
other relatively unpredictable event and might
otherwise have been discharged later with a good
prognosis.
Reading Level (Hypothesis 2)
The second hypothesis stated that there are no
significant differences in the reading level among the
offenders in the three outcome groups. This hypothesis
was not supported by the findings of this study.
Given the complexities of the integrated approach
to treatment as practiced by NFETC it is not surprising
that there was a positive correlation between reading
level and treatment outcome. The importance of
learning new information, developing new ways of
thinking, and integrating this new learning into daily
lifestyle makes the ability to read and comprehend
extremely important. Those found not amenable during

119
the evaluation phase had the lowest mean WRAT scores
(55.53) and grade equivalent (ninth) while those who
were accepted into the treatment program but later
discharged with a poor prognosis had a mean of 58.03
and grade equivalent of tenth grade. Those who
completed the program with a good prognosis had mean
WRAT scores of 67.63 with a grade equivalent greater
than the twelfth grade.
Total Deviance Score (Hypothesis 3)
The third hypothesis stated that there are no
significant differences in total deviance score among
the offenders in the three outcome groups. This
hypothesis failed to be rejected in this study.
Some form of total deviance score has been
purported to predict treatment outcome by several
researchers, most notably Abel and associates (1988).
Abel et al. (1988) found that treatment program
completion and recidivism could be predicted using a
scale described as lack of discrimination in the
selection of victim type and paraphilic act for an
outpatient program treating incest offenders and child
molesters. Recently, Rice and associates (1991) have
drawn similar conclusions for a treatment program

120
consisting of arousal reconditioning for child
molesters. Data collected for this study did not
reflect significant differences in total deviance score
means among the three outcome groups.
Antisocial Personality Disorder (Hypothesis 4)
The fourth hypothesis stated that there is no
association between presence of antisocial personality
disorder and treatment outcome group membership. This
hypothesis failed to be rejected in this study.
Clinicians in the sex offender field have long
assumed that the presence of antisocial personality
disorder was predictive of poor treatment outcome, and
as a result, many programs exclude offenders with this
diagnosis. Results of this study revealed that there
were no significant differences in the presence of
antisocial personality disorder among the three outcome
groups. One possible explanation for this finding may
be that in a controlled environment offenders with
antisocial personality disorder are able to manifest
meaningful change through treatment as well as other
offenders. Whereas in the community these individuals
have numerous opportunities and outlets to reinforce
their dysfunctional attitudes and behaviors, in a

121
secure treatment setting with high staff-to-client
ratios these behaviors are better controlled. A second
possibility is that individuals with antisocial
personality disorder are better able to manipulate the
treatment team when they are engaged in residential
treatment where treatment boundaries are less rigid
than in outpatient treatment settings. They are then
able to act as if they are changing long enough to be
discharged with a good prognosis. The likelihood that
this latter explanation is true diminishes in
consideration of the intensity and frequency of
therapeutic contacts in the therapeutic milieu and
specific manifestations of antisocial personality
disorder (Barnard et al., 1989).
Age (Hypothesis 5)
Hypothesis 5 stated that there are no significant
differences in age among offenders in the three
treatment outcome groups. This hypothesis failed to be
rejected in this study.
There are two competing clinical assumptions
regarding the impact of offender age on treatment
amenability. One theory suggests that younger
offenders are likely to be better treatment candidates

122
because they have had less time to engage in deviant
behavior; their resultant disorders are likely to be
less entrenched than in older offenders. This is
supported by Abel and associates (1987) who found that
more than 50% of a sample of outpatient sex offenders
reported onset of deviant arousal by age fifteen. A
second theory suggests that older offenders might be
better treatment candidates because they have
recognized the consequences of their deviant behaviors
and are truly ready to change (Barnard et al., 1989).
Results of this study revealed no significant
differences in the mean ages of the offenders in the
three outcome groups.
Marital Status (Hypothesis 6)
The sixth hypothesis stated that there is no
association between marital status and treatment
outcome group membership. This hypothesis was not
supported by the findings of this study.
In comparing those offenders who were married or in
a committed relationship with those who were unmarried,
divorced or separated, a significant difference in
marital status was noted between the offenders in group
3 (discharged with good prognosis) and the offenders in

123
the other two outcome groups (jd <.05). Analysis of the
data revealed that while only 8% of the unmarried
offenders were discharged with a good prognosis, 25% of
the married offenders had a positive treatment outcome.
In other words, though married offenders comprised only
34.78% of the treatment population, they accounted for
62.5% of the offenders discharged with a good
prognosis. This finding (i.e., that offenders in
committed relationships including marriage are more
likely to succeed in treatment than unmarried
offenders) is similar to findings by Abel and
associates (1988). Others, including Rice and
associates (1991), have also reported that an offender
having been married at any time predicted positive
outcome where recidivism was the outcome variable.
Researchers and clinicians have theorized that an
offender's history of marriage may be correlated with
attraction to adults and that this ability to be
attracted to consenting peers is what differentiates
these offenders from those more likely to recidivate.
Another theory, more relevant to this study, is that
offenders who are married have a positive support
system which can be accessed during and after the
therapy process to help the offender

124
maintain the gains made during treatment (Abel et
al . ,1988) .
Instant Offense (Hypothesis 7)
Hypothesis 7 stated that there is no association
between instant offense and otucome group membership.
This hypothesis failed to be rejected in this study.
There were no significant differences in the
frequencies of instant offenses for the three outcome
groups. Incest offenders have long been thought to be
the easiest offenders to treat and the least likely to
recidivate. One possible explanation for the results
of this analysis is that in spite of their differences
in terms of instant offense, most of the offenders in
the sample had committed numerous other types of
offenses. This is confirmed by the lack of significant
variance for the total deviance scores of the offenders
in the study.
Limitations
This study had several methodological limitations.
These limitations concern the sample, design, and
instrumentation. In terms of sampling limitations,
this study purported to test the ability to
differentiate treatment outcomes among incarcerated sex

125
offenders who were screened and who subsequently
volunteered for a multimodal treatment program in a
maximum security, state mental institution using WRAT-R
reading level, presence of a diagnosis of antisocial
personality disorder, degree of discrimination in the
choice of offense and victim type, age, marital status
and instant offense. Because offenders were excluded
from the waiting list during the screening process if
their projected release date or projected parole date
were less than 12 months, their reading level was below
third grade, their intelligence was below 70 on the
WAIS-R or equivalent, they denied culpability in their
instant offense or any prior recurrent deviant urges or
acts, they had a history of psychosis or other major
mental disorder, or they failed to volunteer for
transfer, the population was limited somewhat in its
variability on these key factors. Furthermore, because
each type of sex offense and each individual offender
earn different sentences, some offense categories were
unrepresented or underrepresented in this sample. The
population from which this sample is drawn consists
primarily of individuals incarcerated for offenses of
incest, child molestation, and rape. Moreover, it is
not known if data derived from this population

126
significantly correlate with data derived from
populations of offenders participating in outpatient
treatment programs. Finally, only those offenders who
were involved in treatment between June, 1986 and
September, 1989, who had sufficient time to complete
the program prior to the closing of the sex offender
program in August, 1989 and who were not discharged due
to medical or legal reasons unrelated to the instant
offense or the treatment program will be included in
the sample.
Of the design limitations, the most significant was
the inconsistent documentation of data available for
analysis as a result of the ex post facto design. If
the study had been planned at the time of the
development of the treatment program, data could have
been documented and collected with outcome research in
mind. A second design limitation involves the use of
the decision of the MDT at the time of discharge as the
outcome variable. Although it has been argued that
this is an important and frequently missing measure of
treatment amenability, the reason for sex offender
treatment, the decrease in offender recidivism, is not
addressed.

127
There were several limitations in regard to the
instrumentation used in the study. One is potential
assessor bias in that WRAT-R scores were determined at
different facilities and scored by different
evaluators. Further, when consensus diagnoses were
determined for the offenders in the study, not all
members of the MDT were always present; documentation
of the consensus diagnoses was made by one of nine
primary case managers and could have been influenced by
those individuals in spite of review by other members
of the MDT. In addition, documentation of prior and
instant offenses was not consistently documented in
clinical records or DC files. Furthermore, data
compiled as a result of interviews and treatment
procedures during the evaluation phase most likely do
not represent the data which would have been documented
by the completion of treatment. Moreover,
documentation of prior offenses was not always
categorized in such a way that determination could be
made as to the age and/or type of offense. This is
particularly true where plea negotiation may have taken
place prior to final disposition or where the only
official documentation of sexual offenses is stated in
legal rather than clinical terms. For example, the

128
offense known as lewd and lascivious acts on a minor
child under the age of eleven does not clearly indicate
whether the act involved penetration or not, or exactly
how old the victim was at the time of the
victimization. Moreover, in the absence of a Federal
Certificate of Confidentiality waiving a researcher or
clinician's responsibility to report all instances of
knowledge of child abuse to state abuse registries,
offenders might be expected to limit their self¬
disclosure of unreported sexual abuse of children.
Implications
Theory
Results of this study have several important
implications for theory. As has been noted, offenders'
treatment outcome was not impacted significantly in
this study by the presence of antisocial personality
disorder, by instant offense, or by the degree of
discrimination in offense or victim type. Numerous
authors have documented either clinical opinion or
empirical findings (Abel et al., 1988) to support the
notion that sex offenders with antisocial personality
disorder are not desirable treatment candidates;

129
however, these have tended to be reported by behavioral
or cognitive/behavioral treatment program providers
such as Marshall, Abel, and Laws (Shaw et al., 1989).
Abel and associates (1988) have reported that more
deviant offenders are less likely to complete treatment
and more likely to recidivate. Little is known
regarding the amenability for treatment of rapists.
Although the treatment program at NFETC was designed by
clinicians concommitant1y with the development of a
four factor model of etiology of sexual deviance by
Finkelhor (1988), the two are extremely compatible
(Barnard et al., 1989). Moreover, Barnard and
associates (1989) have noted that the NFETC treatment
program was specifically designed to treat the most
disturbed sex offenders entering the Florida prison
system. An example of this is the inclusion in the
evaluation phase of treatment of a criminal thinking
errors module based on the work of Yochelson and
Samenow to address disinhibition, an etiological and
maintenance factor in much deviant sexual behavior
(Barnard et al., 1989). Results of this study provide
some support for the notion that the multi-modal,
integrated approach to treating sex offenders may, in
fact, posess sufficient potency to effectively treat

130
rapists, offenders with antisocial personality
disorder, and those with multiple offense and victim
types. Further study is needed, including follow-up
studies of recidivism as well as controlled treatment
outcome studies, to test this treatment model.
Although more difficult to study than behavioral
treatments due to the complex nature of the treatment
program, recognition of the possible need for a
comprehensive approach to treatment of seriously
disturbed sex offenders imposes the need for continued
study.
Another implication for theory results from the
finding that marital status was found to significantly
differ among the three outcome groups. Finkelhor
(1988), Salter (1988), and Abel and associates (1988)
have theorized that social support is an important
element in effective treatment outcomes. The finding
in this study lends further support to the notion that
support, in the form of a current marriage or committed
relationship, may increase a sex offender treatment
program participant's chance of successfully completing
treatment. This is particularly noteworthy since
participants in the NFETC program, unlike offenders in
outpatient programs such as Abel's (Abel et al., 1988),
had limited access to their partners.

131
Practice
There are a number of interesting implications for
program design, practice and treatment program
participant selection suggested by the results of this
study. First, there appears to be a strong
relationship between reading ability and success in
this program, which can be described as a
comprehensive, multi-modal treatment program heavily
dependent upon cognitive-behavioral therapies. In
order for lower functioning offenders to have a fair
chance of participating successfully in treatment,
tutoring and other forms of educational preparatory
programs could be administered prior to beginning
treatment. Alternatively, treatment programs less
intensely dependent upon cognitive abilities could be
developed to serve the needs of lower functioning
offenders, in new facilities or as separate tracks
within existing treatment programs.
The eligibility criteria for admission to the
program at NFETC had been defined by the State
Legislature. In the absence of studies such as this
one, the program's clinical administration had no way
of assessing the efficacy of admission criteria and
adjusting the criteria to be more effective in

132
selecting offenders for inclusion who were the most
likely candidates to benefit from treatment. Clearly,
only ongoing program evaluations and follow-up studies
focused on pairing treatment outcome with recidivism
data would provide the kind of feedback necessary to
effectively adjust admission criteria (Furby et al.,
1989). Relatedly, treatment modalities themselves
cannot be thoroughly evaluated for their effectiveness
in preventing reoffense, their ultimate objective,
without linking within treatment goals and decisions
regarding prognosis and treatment completion with
recidivism data.
Perhaps one of the most promising conclusions to be
suggested by the data is that those offenders
traditionally considered the least amenable, those with
features or diagnosis of antisocial personality
disorder and those with multiple offense and victim
types, appeared to do as well as other offenders. One
possible interpretation of this finding is that the
comprehensive, integrated treatment approach presented
in a secure, residential setting provided the necessary
conditions for effectively treating less traditionally
amenable offenders. In such a setting, offenders are
not likely to be able to gratify their deviant

133
interests. With virtually all of their waking hours
monitored by program staff, criminal thinking
(Yochelson & Samenow, 1977) and overtly victimizing
behaviors are not likely to be positively reinforced.
Instead, offenders are consistently encouraged to
engage in pro-social behaviors and to give up deviant
and criminal interests, both in structured treatment
modalities as well as confronted directly and
indirectly by advanced treatment participants and
staff.
Research
There are several important implications for future
research suggested by the results of this study.
First, the use of treatment outcome as the criterion
measure was intended as an important and heretofore
missing link in sex offender outcome research (Furby et
al., 1989). In order to fully realize the potential
value of the study, a long-term treatment outcome study
should be undertaken, using a similar sample, with
several measures of recidivism as the dependent
variables. This would render the data from this study
more comparable with data from other sex offender
treatment outcome studies. More globally, however,
v

134
this study can serve as a model for future outcome
research in that interim measures have been noticeably
absent from the majority of studies, with the important
exception of Abel and associates (1988).
Second, the absence of statistical significance for
instant offense and antisocial personality disorder
diagnosis points to the need to include rapists and
offenders with antisocial personality disorder features
or diagnosis in future studies of sex offender
treatment effectiveness. Because this population of
offenders are often excluded, little has been studied
regarding their amenability for treatment and their
recidivism after completion of a comprehensive
treatment program.
Third, future researchers may wish to consider
coding the total deviance score in a different way
using data gathered from numerous sources. This
important variable, while it was not found to be
significant in differentiating the offenders in the
three outcome groups, might be more powerful if the
data were drawn from other sources. Recently,
instruments including the Multiphasic Sex Inventory,
the Clarke Sexual Interest Inventory, and the Abel and
Becker Sexual Interest Card Sort have been developed

135
specifically to elicit se 1f-disc 1osure of deviant
interests and acts from sex offenders (Barnard et al.,
1987). The authors have reported on a computerized
assessment which utilized these instruments, among
others, to develop an explicit profile of offenders'
sexually deviant interests. As data collection
regarding deviant interests and behaviors become more
standardized, conclusions from these data may have more
utility in predicting treatment outcome.
Summary and Conclusions
Results of this study suggest that offenders with
higher reading ability who were married or in a
committed relationship were more likely to be
discharged from a residential sex offender treatment
program with a good prognosis than other program
participants. Further, a set of six offender variables
were able to correctly classify offenders into three
outcome groups with moderate success. Further study
must be undertaken to establish empirically based
eligibility criteria for costly residential sex
offender treatment programs. Treatment outcome studies
must combine interim outcome measures, as in this
study, with recidivism data, to ensure that offenders

136
receive effective treatment likely to reduce their risk
of reoffense.

137
Appendix
Sample data collection form:
off. code (a) (b) (c) (d) (e) (f) (tot)
examp 1es:
1 (CM) 1 1 1 1 0 0 4
2 (R) 1 0 0 0 1 0 2
3 (R/CM) 111110 5
4 (R/CM) 222223 13
Example 1: A hands-on, non-incest, no use of force
child molester of boys only, no history of rape or
other paraphelias.
Example 2: A rapist of men or women only.
Example 3: A hands-on, non-incest, use of force
child molester of girls only and rapist of women only.
Example 4: A hands-on and hands-off, incest and non¬
incest, use and non-use of force molester of boys and
girls, rapist of men and women with history of
voyerism, exhibitionism and frottage.

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BIOGRAPHICAL SKETCH
Theodore A. Shaw was born in New York City in
1945. He graduated from McBurney School for Boys in
1962 and received his Bachelor of Arts degree in
English from University College of Arts and Sciences of
New York University in 1968. In 1990 Mr. Shaw received
his Master of Education and Specialist in Education
degrees in counseling. Areas of specialized training
included agency and marriage and family counseling.
Mr. Shaw completed his internship in counseling
psychology in 1982 at the Student Mental Health Center
of the University of Florida's Infirmary.
In 1989, Mr. Shaw co-authored a book entitled, The
Child Molester: An Integrated Approach to Evaluation
and Treatment. He is a clinical member of the
Association for the Treatment of Sexual Abusers. Mr.
Shaw expects to receive his Doctor of Philosophy degree
in December, 1991.
146

I certify that I have read this study and that in my opinion
it conforms to acceptable standards of scholarly presentation and
is fully adequate, in scope and quality, as a dissertation for the
degree of Doctor of Philosophy.
Ellen Amatea, Chair
Professor of Counselor
Education
I certify that I have read this study and that in my opinion
it conforms to acceptable standards of scholarly presentation and
is fully adequate, in scope and quality, as a dissertation for the
degree of Doctor of Philosophy.
George Barnard
Professor of Psychiatry
I certify that I have read this study and that in my opinion
it conforms to acceptable standards of scholarly presentation and
is fully adequate, in scope and quality, as a dissertation for the
degree of Doctor of Philosophy.
./
£<•
Harry Grater
Professor of Psychology
I certify that I have read this study and that in my opinion
it conforms to acceptable standards of scholarly presentation and
is fully adequate, in scope and quality, as a dissertation for the
degree of Doctor of Philosophy. /
a
Larry Loesch
Professor of Counselor
Education
I certify that I have read this study and that in my opinion
it conforms to acceptable standards of scholarly presentation and
is fully adequate, in scope and quality, as a dissertation for the
degree of Doctor of Philosophy.
xi X
[ I ' V
Gustave Newman
Professor of Psychiatry

This dissertation was submitted to the Graduate Faculty of the
College of Education and to the Graduate School and was accepted
as partial fulfillment of the requirements for the degree of Doctor
of Philosophy.
December, 1991
Dea
Dean, Graduate School

UNIVERSITY OF FLORIDA
3 1262 08556 8672




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