The Ethics of Involuntary Treatment

Should some sex offenders be hospitalized indefinitely?

Magazine Issue
September/October 2004
The Ethics of Involuntary Treatment

Networker News

In the past year, a rapist and two child molesters–all of them repeat offenders designated as “sexually violent predators” by evaluators and juries–have been released from an eight-year-old, mandatory-treatment program at Atascadero State Hospital in California. Though clinicians said the men were ready to return to the community, under strict supervision, and were unlikely to commit new sex crimes, their attempts to move into northern California communities sparked outrage, picket signs, and protests, along with wall-to-wall media coverage.

One of the men–who’d been convicted of four sexual assaults, including two against teenage boys, and had spent 10 years in prison and 6 more at Atascadero–was driven from motel to apartment to church shelter, from Marin County to Oakland to San Jose. Another man, a serial rapist, hunkered down in his wife’s house, while his neighbors staked signs such as “Neutered Animals Still Bite” in their front lawns. In other states, releases from similar programs, where “sexually violent predators” or SVPs are sent at the conclusion of their prison sentences, have also triggered passionate outcries.

These releases shine a spotlight on policies for dealing with sex offenders and raise some provocative questions: Can treatment actually help sexual offenders change their destructive patterns? And when, if ever, is mandatory hospitalization of sex offenders a valid use of psychiatry?

Like many criminal-justice initiatives, this approach to dealing with hard-core offenders began with a horrific event. In the late ’80s, Earl Shiner, a convicted rapist and murderer, bragged to inmates and staff at a Washington State prison that he fantasized about torturing and killing boys. Then he was released and did exactly that, kidnapping, raping, and mutilating a 7-year-old.

The outcry over Shiner’s crime led Washington State legislators to pass a law in 1990 allowing for indefinite civil commitment of repeat sexual offenders judged by mental health experts to be likely to reoffend. Over the next decade, 15 other states and the District of Columbia passed similar laws.

These laws are patterned on long-standing statutes that allow for involuntary commitment of people with severe psychiatric disorders. There’s one key difference, however: under the terms of a 1997 Supreme Court decision, “sexual predators” don’t need to be diagnosed as “mentally ill,” but, rather, must be repeat offenders who are determined by clinicians to have a “mental abnormality” that makes them likely to reoffend.

Today, 14 years after passage of the Washington State law, the use of civil commitment for SVPs has almost come to a halt. Legal advocates and mental health professionals have criticized the programs as a hoax–preventive detention masquerading as treatment. An American Psychiatric Association (APA) task force called the programs, and the laws that established them, an “assault on the integrity of psychiatry.” “They pretend to be about treatment, but they’re really about keeping people confined who’d otherwise have to be released,” says Lawrence Fitch, director of forensic services for the Maryland Department of Mental Hygiene and a member of the APA task force. Most offenders assigned to these programs, including 80 percent of those at Atascadero, refuse to take part in treatment because they believe the programs are unfair.

The release of violent sexual offenders or “predators,” men who’ve repeatedly committed heinous acts against children or adults, evokes raw, visceral reactions from the public. But these men represent only a small slice of the sex-offender population. An estimated 450,000 registered offenders–most convicted of less violent offenses, such as exhibitionism or incestuous fondling–live in communities across the country. Yet people like Shiner, and the lurid press coverage they draw, tend to shape the public’s perception of all sex offenders as violent recidivists.

That’s too simplistic, argue experts like Michael Miner, a sex-offender researcher at the University of Minnesota. Miner says there are three key elements to the public’s view of sex offenders: that most sex crimes are committed by strangers, that sex offenders are highly likely to reoffend, and that they can’t be effectively treated. “All three of these are wrong,” he says.

Miner notes that, in surveys, three out of four victims of sexual abuse say they knew the perpetrator before the assault, while more than half of child sexual abuse is committed by parents or stepparents. Overall, it doesn’t appear that most sex offenders commit new sex crimes. A review of 10 studies including 4,724 offenders in the United States, Canada, and Great Britain published this year found that 73 percent hadn’t committed another sexual offense 15 years after being released from prison. It also found striking differences among different types of offenders: 35 percent of men who molested boys committed another such act within 15 years of leaving prison, compared to 16 percent of those who molested girls. Among rapists, 24 percent committed a new offense. But since many sex crimes go unreported, such figures are, at best, crude estimates.

Today, treatment programs use varying approaches, and the most intensive–for hard-core offenders like SVPs–may combine multiple techniques. Offenders may be shown the impact of sex crimes on their victims as a way to develop or increase their feelings of empathy. Cognitive-behavioral therapy may be used to expose and confront the distortions that permeate the thinking of many offenders and to undercut the rationalizations and lies they tell themselves. Some offenders choose surgical castration or, more commonly, “chemical castration,” to cut their testosterone levels and thus their sexual drive.

At Atascadero, the few offenders who want treatment must take responsibility for their past by admitting to and discussing their offenses in detail, says Johnson Chang, a hospital psychologist. They can then enter the program’s second phase, in which they review in great detail the history of their lives and sexual offenses, focusing on the process that led up to their crimes. In the third phase, offenders identify life events that can lead to trouble and discuss their strategies for managing these events. In the fourth phase, they rehearse ways of dealing with problems or triggers likely to arise outside.

Most experts agree that the key to success with sex offenders generally isn’t just psychological treatment or incarceration, but a mix of community-based services and supervision–carrots and sticks–that, together, form what policy wonks call the “containment model.” Under this approach, sex offenders report regularly to probation officers, who ensure they follow the rules; to social workers, who provide psychological support and services; and to polygraph examiners, who can assess an offender’s truthfulness about, say, contacts with children or possession of pornography. “The more structure that’s given to a sex offender, the fewer sexual reoffenses occur,” says Charles Onley, a research associate with the Center for Sex Offender Management, a technical-assistance group funded by the Department of Justice.

As support wanes for civil-commitment programs like those in Washington and California, other states are exploring different options. Some, like Colorado, are now using a two-step approach. The state has stiffened its criminal sentences for violent sexual offenders, so they’ll spend more time in prison for acts of sexual violence. It also requires “lifetime” supervision for the most violent repeat offenders. They must participate in treatment in prison in order to get out, and once outside, must be supervised by probation officers and therapists until they’re no longer seen as a threat. In trying to balance the public’s right to be protected from dangerous people and an offender’s right to be treated fairly, the Colorado approach may prove to be a more ethical and effective way to go.

Rob Waters

Rob Waters is the former editor of the men’s health channel at WebMD and a former contributing editor to the Psychotherapy Networker.