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Intervensi psikologi untuk orang dewasa yang telah melakukan kesalahan seksual atau berisiko melakukan kesalahan seksual.

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Abstract

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Background

Sexual offending is a legal construct that overlaps, but is not entirely congruent with, clinical constructs of disorders of sexual preference. Sexual offending is both a social and a public health issue. Victim surveys illustrate high incidence and prevalence levels, and it is commonly accepted that there is considerable hidden sexual victimisation. There are significant levels of psychiatric morbidity in survivors of sexual offences.

Psychological interventions are generally based on behavioural or psychodynamic theories.

Behavioural interventions fall into two main groups: those based on traditional classical conditioning and/or operant learning theory and those based on cognitive behavioural approaches. Approaches may overlap. Interventions associated with traditional classical and operant learning theory are referred to as behaviour modification or behaviour therapy, and focus explicitly on changing behaviour by administering a stimulus and measuring its effect on overt behaviour. Within sex offender treatment, examples include aversion therapy, covert sensitisation or olfactory conditioning. Cognitive behavioural therapies are intended to change internal processes ‐ thoughts, beliefs, emotions, physiological arousal ‐ alongside changing overt behaviour, such as social skills or coping behaviours. They may involve establishing links between offenders' thoughts, feelings and actions about offending behaviour; correction of offenders' misperceptions, irrational beliefs and reasoning biases associated with their offending; teaching offenders to monitor their own thoughts, feelings and behaviours associated with offending; and promoting alternative ways of coping with deviant sexual thoughts and desires.

Psychodynamic interventions share a common root in psychoanalytic theory. This posits that sexual offending arises through an imbalance of the three components of mind: the id, the ego and the superego, with sexual offenders having temperamental imbalance of a powerful id (increased sexual impulses and libido) and a weak superego (a low level of moral probation), which are also impacted by early environment.

This updates a previous Cochrane review but is based on a new protocol.

Objectives

To assess the effects of psychological interventions on those who have sexually offended or are at risk of offending.

Search methods

In September 2010 we searched: CENTRAL, MEDLINE, Allied and Complementary Medicine (AMED), Applied Social Sciences Index and Abstracts (ASSIA), Biosis Previews, CINAHL, COPAC, Dissertation Abstracts, EMBASE, International Bibliography of the Social Sciences (IBSS), ISI Proceedings, Science Citation Index Expanded (SCI), Social Sciences Citation Index (SSCI), National Criminal Justice Reference Service Abstracts Database, PsycINFO, OpenSIGLE, Social Care Online, Sociological Abstracts, UK Clinical Research Network Portfolio Database and ZETOC. We contacted numerous experts in the field.

Selection criteria

Randomised trials comparing psychological intervention with standard care or another psychological therapy given to adults treated in institutional or community settings for sexual behaviours that have resulted in conviction or caution for sexual offences, or who are seeking treatment voluntarily for behaviours classified as illegal.

Data collection and analysis

At least two authors, working independently, selected studies, extracted data and assessed the studies' risk of bias. We contacted study authors for additional information including details of methods and outcome data.

Main results

We included ten studies involving data from 944 adults, all male.

Five trials involved primarily cognitive behavioural interventions (CBT) (n = 664). Of these, four compared CBT with no treatment or wait list control, and one compared CBT with standard care. Only one study collected data on the primary outcome. The largest study (n = 484) involved the most complex intervention versus no treatment. Long‐term outcome data are reported for groups in which the mean years 'at risk' in the community are similar (8.3 years for treatment (n = 259) compared to 8.4 in the control group (n = 225)). There was no difference between these groups in terms of the risk of reoffending as measured by reconviction for sexual offences (risk ratio (RR) 1.10; 95% CI 0.78 to 1.56).

Four trials (n = 70) compared one behavioural programme with an alternative behavioural programme or with wait list control. No meta‐analysis was possible for this comparison. For two studies (both cross‐over, n = 29) no disaggregated data were available. The remaining two behavioural studies compared imaginal desensitisation with either covert sensitisation or as part of adjunctive drug therapy (n = 20 and 21, respectively). In these two studies, results for the primary outcome (being 'charged with anomalous behaviour') were encouraging, with only one new charge for the treated groups over one year in the former study, and in the latter study, only one new charge (in the drug‐only group) over two years.

One study compared psychodynamic intervention with probation. Results for this study (n = 231) indicate a slight trend in favour of the control group (probation) over the intervention (group therapy) in terms of sexual offending as measured by rearrest (RR 1.87; 95% CI 0.78 to 4.47) at 10‐year follow‐up.

Data for adverse events, 'sexually anomalous urges' and for secondary outcomes thought to be 'dynamic' risk factors for reoffending, including anger and cognitive distortions, were limited.

Authors' conclusions

The inescapable conclusion of this review is the need for further randomised controlled trials. While we recognise that randomisation is considered by some to be unethical or politically unacceptable (both of which are based on the faulty premise that the experimental treatment is superior to the control – this being the point of the trial to begin with), without such evidence, the area will fail to progress. Not only could this result in the continued use of ineffective (and potentially harmful) interventions, but it also means that society is lured into a false sense of security in the belief that once the individual has been treated, their risk of reoffending is reduced. Current available evidence does not support this belief. Future trials should concentrate on minimising risk of bias, maximising quality of reporting and including follow‐up for a minimum of five years 'at risk' in the community.

Ringkasan bahasa mudah

Intervensi psikologi untuk pesalah seksual atau mereka yang telah melakukan kesalahan seksual atau berisiko melakukan kesalahan seksual

Melakukan kesalahan seksual adalah isu sosial dan kesihatan awam. Kaji selidik mangsa menunjukkan penderaan seksual adalah lazim dan kebanyakannya tidak dibawa ke perhatian sistem keadilan jenayah.

Intervensi psikologi secara umumnya berdasarkan teori tingkah laku atau psikodinamik. Intervensi mungkin direka untuk mengubah pemikiran, perasaan atau pandangan pesalah terhadap hubungan, dengan tujuan utama mengubah tingkah laku mereka.

Satu ulasan Cochrane yang diterbitkan 10 tahun yang lalu mempertimbangkan bukti untuk rawatan psikologi bagi pesalah seksual dan mendapati tidak cukup data untuk mencapai sebarang kesimpulan (Kenworthy 2003). Ulasan semasa kami adalah berdasarkan protokol baru dan carian kesusasteraan yang dijalankan pada September 2010.

Kami meneliti bukti keberkesanan intervensi psikologi untuk pesalah‐pesalah seksual atau merekan yang dianggap mungkin melakukan kesalahan seksual. Kami mengecualikan intervensi bagi pesalah‐pesalah seks dengan ketidakupayaan untuk belajar kerana ini adalah subjek ulasan Cochrane yang berasingan (Ashman 2008).

Kami mengenal pasti 10 kajian relevan yang melibatkan data daripada 944 orang dewasa, semuanya lelaki. Beberapa kajian tersebut memberi maklumat mengenai hasil utama ulasan ini, iaitu mengulangi kesalahan seksual. Ini adalah kerana kajian‐kajian tidak mengumpul data untuk tempoh yang cukup lama di luar penjara atau persekitaran rawatan. Banyak kajian bergantung kepada ukuran hasil lain (contohnya kemarahan atau kemahiran sosial) yang dipilih oleh penyiasat dengan harapan ia berkait dengan beberapa cara melakukan kesalahan akan datang, walaupun tidak dapat dinyatakan dengan pasti bahawa kaitan tersebut boleh meramalkan dengan yakin pesalah mengulangi kesalahan.

Lima kajian yang kami dapati melibatkan 664 lelaki dan terutamanya menggunakan intervensi tingkah laku kognitif (CBT). Dalam kajian terbesar, yang mempunyai 'pakej' rawatan paling kompleks dan sengit di dalam dan di luar penjara, tiada perbezaan di antara kumpulan yang telah menerima CBT dan mereka yang tidak berisiko mengulangi kesalahan, yang mana diukur oleh sabitan semula untuk kesalahan seksual.

Satu kajian, melibatkan 231 lelaki, membandingkan intervensi psikodinamik dengan penjagaan piawai, iaitu percubaan, dan mencadangkan bahawa percubaan adalah sedikit lebih baik dari segi mengurangkan kesalahan seksual berulang.

Program tingkah laku dilihat dalam empat kajian yang melibatkan 70 orang lelaki. Untuk dua kajian, tiada cukup data yang dilaporkan untuk menilai keberkesanan rawatan. Bagi baki dua kajian, keputusan yang menggalakkan berhubung sabitan semula dan desakan yang dilapor sendiri perlu diberi perhatian teliti kerana kajian adalah agak lama, bermaksud ramai peserta tidak akan mencari atau ditawarkan rawatan, kerana beberapa tingkah laku yang disasarkan tidak lagi dianggap jenayah/menyalahi undang‐undang.

Data untuk peristiwa buruk, 'desakan anomali seksual' dan bagi hasil sekunder yang dianggap sebagai faktor risiko 'dinamik' untuk kesalahan berulang, termasuk kemarahan dan gangguan kognitif, adalah terhad.

Kami membuat kesimpulan bahawa kajian rawak terkawal lanjutan sangat diperlukan dalam bidang ini, agar masyarakat tidak terpedaya dengan anggapan palsu merasakan seolah‐olah selamat dengan mempercayai bahawa apabila individu telah dirawat, maka risiko mereka mengulangi kesalahan dikurangkan. Pada masa ini, bukti tidak menyokong kepercayaan ini.