Abstract

Although many writers have provided a theoretical framework for treatment of mainstream sex offenders, this research has not been extended to sex offenders with mild intellectual disability. My purpose here is to bring together several research strands to provide a theoretical model for working in this field, including theories of sex offending, developmental theories for offending, and work on quality of life. In addition to dealing with issues of sex offending, researchers should also investigate developmental and societal issues crucial in the genesis of sex offending and offending in general. Because societal issues are also important for treatment, engagement and identification with society are suggested. Quality of life and issues directly related to sex offending are of central importance.

Ward and Hudson (1998) noted that comprehensive etiological theory on sexual offending should account for onset, development, and maintenance of the offenses. In the present paper, I do not purport to offer an extensive global theory describing links between causal factors and their relationship to the development of sex-offending strategies and maintenance of cognitions, behavior, and strategies. Rather, it is an attempt to pull together the various ad hoc developments in the field of cognitive therapy for people with intellectual disabilities and place them alongside theories and models of sex offending in criminology research in the general population. In relation to intellectual disability, I reviewed issues of etiology/motivation, strategies for offending, theories of criminality, and, finally, their integration with implications for treatment.

Motivation and Etiology for Sex Offenses

Inappropriate Sexuality

For the purposes of this paper, I define inappropriate sexuality as sexual preference for children, coercive or violent sex (rape or sexual assault), stalking, indecent exposure, and bestiality. Early models of sexual offending and corresponding treatments were based on a model of anomalous sexual preference and sexual arousal in the presence of inappropriate stimuli (Abel, Barlow, Blanchard, & Guild, 1977). There is a rich literature on sexual preference in males based mainly on phalometric response (Quinsey & Chaplin, 1988) and viewing time (Harris, Rice, Quinsey, & Chaplin, 1996) to a range of stimuli, including adult women, adult men, children, and situations involving sexual violence. As part of a series of studies, Blanchard et al. (1999) investigated patterns of sex offending in 950 participants. They found that sex offenders with intellectual disabilities were more likely to commit offenses against younger children and male children. Although the proportion of variance is not large, this information, coming as it does from a well-conducted series of studies, constitutes evidence that inappropriate sexual preference plays at least some role in this client group. This is certainly more persuasive evidence than the somewhat anecdotal and uncontrolled evidence from previous studies (Day, 1993; Hayes, 1991).

There are numerous reports of behavioral treatments in which the main components are techniques to address inappropriate sexuality (Abel et al., 1977; Marshall & Barbaree, 1988). It is often difficult to separate this component of treatment from other aspects, such as social skills training (e.g., Marshall & Barbaree, 1988), counseling (Hanson et al., 1993), or cognitive therapy (Hildebran & Pithers, 1989). Authors who have reviewed this literature have come to different conclusions; Marshall et al. (1999) viewed the available research as indicating the positive effects of treatment, whereas Harris and Quinsey (2001) concluded that the design faults of studies were such that there is no strong evidence for the positive effects of treatment. In a recent collaborative exercise sponsored by the Association for the Treatment of Sexual Abusers, Hanson et al. (2002) conducted a careful review of methodologically sound studies and weighted the evidence. They concluded that “we believe that the balance of available evidence suggests that current treatments reduce recidivism, but that firm conclusions await more and better research” (p. 186). However, because many, or indeed most, of these studies were multifaceted and included a number of treatment procedures in addition to addressing inappropriate sexuality, the available evidence on the success of such reorientation is highly tentative. Unfortunately, this evidence does not extend to sex offenders with intellectual disabilities. Plaud, Plaud, Colestoe, and Orvedal (2000), in a review of treatments for sex offenders with intellectual disabilities, wrote that behavioral approaches were the most common form of management. Although they reviewed masturbatory reconditioning techniques, they did not provide any examples from the literature on the use of these techniques with men who have intellectual disabilities. Therefore, it is important to review studies on mainstream offenders in order to consider relevance of their results for this client group.

Personality

Whatever one thinks of the concepts of personality and psychopathy, there is no doubt that with mainstream offenders clinical measures of antisociality are highly associated with offending and sexual offending. Harris et al. (2003) noted that assessment of antisociality (The Psychopathy Checklist, Hare, 1991) in addition to phalometric measures are highly predictive of sexual recidivism. There are currently several developments in relation to personality disorder in offenders with intellectual disabilities (Reid, Lindsay, Law, & Sturmey, 2004), and several authors have noted that the concepts of both personality disorder and psychopathy may be employed and measured in this population, with modest changes to the various criteria (Lindsay, Gabriel, Dana, Young, & Dosen, 2005; Morrisey, 2003). Alexander and Cooray (2003) reviewed a number of studies and commented on the lack of reliable diagnostic instruments, the difference between International Statistical Classification of Diseases (ICD-10) and Diagnostic and Statistical Manual of Mental Disorder-fourth edition— DSM-1V diagnostic systems, confusion of definition of personality, and the difficulties of distinguishing personality disorder from other problems integral to intellectual disability (e.g. communication problems, sensory disorders, and developmental delay). They do not, however, deny the importance of personality disorder per se and recommend that tighter diagnostic criteria and greater use of behavioral observation and informant information should be used.

Harris and Tough (2004) have suggested that risk assessment procedures that incorporate personality disorder measures and evaluations of antisociality should be employed with sex offenders who have mild intellectual disability and borderline intelligence. Quinsey, Book, and Skilling (2004), in a study of 58 participants with intellectual disabilities, have demonstrated the empirical utility of such a measure. Morrisey and Lindsay (2003) reported some pilot work in which they found psychopathy, as measured by the Psychopathy Checklist Revised (Hare, 1991), was significantly higher in a group of offenders in high security settings than in a group of offenders in community settings. Although this result might be expected, it suggests that measured psychopathy in this client group follows the same lawful pattern as in mainstream offenders. Interestingly, these authors also found a degree of overlap in the two populations. The effectiveness of treatments for personality disorder, as with inappropriate sexual preference, is a highly contentious issue. There have been reports of treatment for borderline and histrionic personality disorders (Hopko, Sanchez, Hopko, Dvier, & Lejuez, 2003; Linehan, 1993; Pulakos, 1993) but very little for antisocial personality disorder or psychopathy and nothing in relation to individuals with intellectual disabilities. Therefore, at this point, we have no evidence and can have no current optimism about remediation of antisocial personality.

Some work has been conducted on impulsivity, which is clearly a personality characteristic (Plutchick & Van Pragg, 1995). There is an extensive literature relating impulsivity to violent and nonviolent offending (Nussbaum et al., 2002), and impulsivity is considered a significant variable in the prediction of violent recidivism (Hanson & Harris, 2000). Parry and Lindsay (2003) used the Barratt Impulsiveness Scale (Barratt, 1994) to compare 22 sex offenders with groups of nonsexual offenders and nonoffenders, all with intellectual disabilities. They found that sexual offenders reported significantly lower impulsiveness traits in all areas when compared to the other groups. These authors noted that the high frequency of grooming behavior, albeit simple grooming behavior, by such offenders suggested that they were aware of the importance of gaining the victim's trust and friendship and further suggested an ability to delay gratification, which is exactly opposite to the features of impulsiveness. However, they also noted that diverse categories of sexual offenders may differ on impulsiveness. For example, offenders against children may have a greater ability to plan and delay gratification than do offenders against adults, who may have a greater tendency to act on the spur of the moment. Parry and Lindsay (2003) also made the important distinction between trait (static personality features) and state (transitory) impulsiveness and agitation; they reported that they assessed trait impulsiveness, and more transitory states of agitation and impulsiveness may have different effects.

Counterfeit Deviance

One motivation for sexual offending in clients with intellectual disabilities that has been mentioned relatively frequently is that of exploration resulting from poor sexual knowledge (Hingsburger, Griffiths, & Quinsey, 1991; Luiselli, 2000). This has led to the concept of counterfeit deviance in which sexual offenses are perceived as precipitated by factors such as lack of sexual knowledge, poor social and heterosocial skills, limited opportunities to establish sexual relationships, and sexual naivety rather than inappropriate sexuality.

Surprisingly, until recently, no one has actually tested the sexual knowledge of sex offenders with intellectual disabilities in comparison to control with nonsexual offenses. Griffiths and Lunsky (2003) presented some group comparisons in their redevelopment of the Sociosexual Knowledge and Attitudes Assessment Tool (SKKAAT-R). They compared a cohort of men with mild intellectual disabilities who had committed inappropriate sexual acts with a control cohort with mild intellectual disabilities who had not committed such acts. The counterfeit deviance hypothesis would suggest that those men who had committed inappropriate sexual acts would score lower on at least some sections of the SSKAAT-R. In fact, there were no significant differences between the groups on any of the sections. This lack of difference in the hypothesized direction is itself an important finding. Lindsay, Michie, Martin, and Grieve (2005) compared a group of 36 sex offenders with 36 control subjects, both with intellectual disabilities, on an earlier version of the SSKAAT-R. On most measured variables, sex offenders were significantly more knowledgeable than were control subjects. However, they also found that sex offenders' knowledge was far from optimum, with significant gaps, especially in the areas of sexually transmitted disease and birth control. Therefore, their conclusion was consistent with that of Baroff (1996), who stated in relation to a wide variety of his clients that:

Although relatively few retarded offenders will be unaware of the illegality or ‘wrongfulness’ of their acts …there is still the question of whether the defendant who is retarded should be held to the same standard of responsibility as those who are not. (p. 319)

Psychological/Developmental Factors

Psychological and developmental factors represent a large group of etiological factors that have been extensively researched in comparison with other motivational factors already mentioned. Quinsey (2003) revealed pessimism about the possibility of finding a cause for pedophilia, particularly in developmental, social, and early sexual experience. He stated that “the evidence supporting the early sexual experiences hypothesis is very weak, mostly consisting of the retrospective reports of identified offenders contrasted with inadequate comparison groups” (p. 6). There is no doubt, however, that a great deal of theoretical work has been conducted on psychological processes and early developmental experiences in relation to the genesis of sex offenses, and it is this area of work that I review now.

Childhood sexual abuse has been cited as a cause of sexual offending in this client group in relation to the “abused to abuser” cycle of offending. Several authors have reported a high incidence of sexual abuse among samples of abusers (Thompson & Brown, 1997). Sequeira and Hollins (2003) noted that in the few existing studies on sexual abuse of people with intellectual disabilities, researchers have suggested that behavioral problems such as sexual disinhibition may be a consequence of sexual abuse in childhood. Beail and Warden (1995), in a study of 35 men with intellectual disabilities who had committed sexual abuse, found a high incidence (82%) of abusive events in offender's own childhood. On the other hand, Lindsay, Law, Quinn, Smart, and Smith (2001) compared 48 sex offenders and 50 nonsexual offenders, all with intellectual disability, and found that the rate of sexual abuse in the sex offending cohort was significantly higher than in a cohort of other offenders. However, although there were significantly higher rates of sexual abuse in the sex offending cohort and physical abuse in the other offending cohort, it was still true that those reporting physical and sexual abuse counted for less than 50% in both cases. Therefore, sexual abuse would appear to be an insufficient etiological explanation for sex offending.

In a series of papers, Dagnan and his colleagues (Dagnan & Chadwick, 1997; Dagnan & Sandhu, 1999; Dagnan & Waring, 2004) have broadened models of cognitive therapy to include social models of disability involving negative social constructions of the self. Continued negative life experiences and reduced opportunities to develop normal social networks and experience key life events play an important role in shaping self-perception. In a study of 39 individuals with intellectual disabilities, Dagnan and Waring found positive correlations between the perception of stigma, negative self-evaluation, and perceived low social attractiveness. This is an interesting finding in relation to sex offenders because current influential models of sex offending emphasize the existence of both positive and negative pathways in the development of sex offending incidents (Hudson, Ward, & McCormack, 1999). Although this finding will be discussed more fully below, it is important to note here that the negative pathway emphasizes the importance of perceived negative living circumstances, negative affect, negative self-evaluations in relation to victims, and negative evaluations of guilt and self-blame in relation to pro-offense behavior and thoughts. Pert, Jahoda, and Trower (1998) and Pert, Jahoda, and Squire (1999) have developed these concepts in relation to aggression and assault. It is likely that negative self-evaluation is at least as relevant if not more relevant for the genesis of some sexual offenses. In addition to a sense of stigma and negative self-evaluation, positive engagement with society has long been seen as important for the internalization of societal values. If positive engagement with society has been disrupted, it represents an extremely important set of risk factors for future offenders (Hanson & Harris, 2000; Quinsey, Harris, Rice, & Cormier, 1998).

For some years, mental illness and emotional problems have been associated with sex offenders who have intellectual disabilities (Day, 1993). However, this association should be placed in the context that diagnosis of mental illness in individuals with intellectual disabilities generally is high. Lindsay, Smith et al. (2004) found no difference in rates of mental illness between sex offenders and other types of offenders, both with intellectual disabilities. In relation to emotional lability, the evidence is even more equivocal. Although Hanson and Harris (2000) found impulsivity to be a significant factor in the prediction of sexual recidivism in mainstream offenders, Parry and Lindsay (2003) found that sex offenders with intellectual disabilities reported lower levels of trait impulsiveness. Lindsay and Lees (2003) also found that a group of sex offenders with intellectual disabilities reported significantly lower depression and anxiety than did a control group of nonoffenders with intellectual disabilities. Therefore, emotional instability appears to be an unlikely cause in the etiology of sex offenses in this offender group. Exceptions might be hostile attitude and impulsivity. A number of researchers have found that hostile attitude in the days and weeks prior to the offense was an important variable in the immediate perpetration of sex offenses (Dempster & Hart, 2002; Hanson & Harris, 2000; Quinsey, Coleman, Jones, & Altrows, 1997). Lindsay, Elliot, and Astell (2004) found that antisocial attitude correlated significantly with re-offending in a follow-up study of 52 sexual offenders. In relation to impulsivity, Parry and Lindsay (2003) concluded that although sex offenders with intellectual disabilities as a group showed lower levels of impulsivity than did controls with intellectual disabilities, there may be a subgroup of clients who do indeed have higher levels of disinhibition and impulsivity.

Conclusions

In terms of motivation for the commission of sex offenses, there would appear to be good support for inappropriate sexuality playing a role in at least a significant proportion of sexual offenses against children. Blanchard et al. (1999) reported that their results suggest that choices of male or female victims by offenders with mental retardation were not primarily determined by accessibility (or other circumstantial factors) but, rather, by their relative sexual interest in male and female children (p. 119). Lindsay et al. (2002) found that for 62% of referrals, there was either a previous conviction for a sexual offense or clear documented evidence of sexual abuse having been perpetrated by the individual. When one considers that any incidence of sexual abuse is typically met with a great deal of criticism towards the offending individual on the part of his victim's family or his caregivers, which would be a considerable disincentive for the further commission of additional sexual offenses, then one must conclude that sexual drive and sexual preference are likely to be significant factors. Indeed, Blanchard et al. (1999) went so far as to postulate that pedophilia or some types of pedophilia may be a developmental disorder. Given our current knowledge of developmental disorders and the fact that sexual preference has never featured as an issue in any of the literature on developmental disorders, this seems highly unlikely to me; however, the fact that Blanchard et al. made this hypothesis indicates the strength of the relationships they found.

The concept of counterfeit deviance cannot be ruled out, and several authors have cited its importance, but at the moment there is not a great deal of evidence for or against this hypothesis. In an earlier study (Lindsay, 2004), I reported on a clear individual case of an offense against an adult female in which lack of knowledge on the part of the offender was evident in the offense and noted that lack of knowledge and exploration may be important in a small number of individual cases. Lindsay et al. (2005) found that the sexual knowledge of a group of sex offenders was significantly greater than a group of nonsexual offenders on every measured facet.

The role of psychosocial factors is more equivocal. In reasonably well-controlled studies of offenders with and without intellectual disabilities, researcher found that a sizeable minority of sexual offenders reported that they themselves were abused in childhood (Gebhard, Gagnon, Pomeroy, & Christenson, 1965; Lindsay, Law, Guinn, Smart, & Smith, 2001). Gebhard et al. found that the proportion of mainstream sex offenders reporting sexual abuse in childhood was no higher among men who sexually offended against children than men who had committed nonsexual offenses. Lindsay et al. (2001) found that childhood sexual abuse was significantly higher in sex offenders than in nonsexual offenders but still represented a minority of the sample. Quinsey (2003) concluded that the evidence supporting the early sexual abuse hypothesis is very weak because it consists mainly of retrospective reports by identified sex offenders. Fascinatingly, Williams, Siegel, Banyard, Jasinksi, and Gartner (1995) conducted a retrospective/prospective study and investigated two groups of males who had presented at emergency rooms in two hospitals in Baltimore and Philadelphia. One group had gone because of sexual abuse and the other group, for general medical reasons, such as a sports injury and so on. There were no differences in the subsequent incidences of sexual offending for the two groups.

Mental illness and emotional disturbance seem unlikely contenders for primary motivation in the genesis of sex offenses for this client group. There are no studies showing increased level of mental illness or emotional disturbance for sex offenders with intellectual disabilities. Rather, the opposite is the case, with all studies showing similar levels of major mental illness or lower levels of emotional disturbance in groups of sex offenders when compared to appropriate control groups. They may, however, be contributing factors and studies on dynamic/immediate risk factors for sex offending would suggest that hostile attitude may be an important variable in the days prior to the perpetration of a sexual offense.

Although there is very little work on personality in relation to sex offending, Morrisey and Lindsay (2003) conducted a study and found that higher levels of antisocial behavior are likely to be associated with more serious offenders. However, these authors noted that one interesting part of their study was the considerable overlap in measured psychopathy between the two groups of offenders drawn from high security and community settings.

Strategies for Offending

I have considered motivation for offending and now view the means by which such motivation is realized in instrumental terms in order to propose a model for sexual offending. In the last 15 years, researchers have concentrated on the cognitive processes involved in the development of sexual offenses and, correspondingly, intervention has been focused on changing offense sequences at this level rather than the motivational level.

One of the first and most enduring cognitive processes to be invoked in relation to sex offending is denial. Marshall, Anderson, and Fernandez (1999) outlined a comprehensive model of types of denial: complete denial (false accusation, the wrong person), partial denial (victim consented, my intentions were misconstrued), minimization of offense (there was no coercion, it only happened once), minimizing responsibility (parents were neglectful, an unusual state such as drunk or stressed), minimizing harm (victim was not harmed), minimizing planning (it happened on the spur of the moment), and minimizing fantasizing (I did not think about it before or after the incident). Barbaree (1991), in an assessment and treatment study of denial, concluded that many of these features represent minimization of the seriousness and impact of the offense. Therefore, they represent excuses for the perpetration of sexual offenses. and Barbaree found that 98% of his sample of sexual offenders denied or minimized the impact of the offense. Although there is no specific study on denial in sex offenders with intellectual disabilities, it is interesting that in an investigation of adolescent sex offenders, Sefarbi (1990) found not only that 50% of the adolescents denied committing an offense, but also that their families supported them in the denial. Clinically, I have found similar family support among sex offenders with intellectual disabilities.

Some of the promising techniques for assessment and treatment with sex offenders with intellectual disabilities have focused on cognitions directed precisely at these denials and minimizations. In assessment, Boer, Tough, and Haaven (2004) have reported on a comprehensive risk assessment for sex offenders with intellectual disability, which takes into account cognitive distortions and thinking errors. Lindsay, Michie, Whitefield, Martin, Grieve, and Carson (2005) have described the Questionnaire on Attitudes Consistent with Sexual Offenses, which is designed to be used by men with mild intellectual disabilities and borderline intelligence. They reported two studies in which men who offended against adult women evidenced significantly more cognitive distortions in relation to rape, whereas men who had offended against children evidenced significantly more cognitive distortions in relation to offenses against children. In relation to treatment, Swanson and Garwick (1990), O'Conner (1996), Lindsay and colleagues (Lindsay, Marshall, Neilson, Quinn, & Smith, 1998; Lindsay, Neilson, Morrison, & Smith, 1998; Lindsay, Olley, Jack, Morrison, & Smith, 1998; Lindsay, Olley, Baillie, & Smith, 1999), and Rose, Jenkins, O'Connor, Jones, and Felce (2002) all reported treatments employing cognitive interventions for various forms of denial and mitigation of offenses in addition to self-control procedures, work on empathy, problem-solving, and development of social and personal skills. Swanson and Garwick (1990) reported a re-offending rate of 40%; Rose et al. (2002) reported no re-offending at one year follow-up. Lindsay and his colleagues have reported low re-offending rates 4 to 7 years following initial conviction in several studies. Therefore, there is some evidence that therapy directed at cognitive processes may have a positive impact.

One of the best developed and most widely employed cognitive models to explain strategies of offending and intervention has been relapse prevention. This model was developed from addiction research, and cognitive distortions and decision-making processes in the cycle of sex offending are stressed. The relapse prevention model highlights seemingly unimportant decision or acts in relation to, for example, personal stress, boredom, leisure, and work, which by themselves might seem individually trivial and defendable, but taken together construct a clear cycle and pathway of offending. Intervention on this cycle provides the offender with the knowledge and capacity to alter and avoid these decision, cognitions, and situations that might lead to lapses and relapses in the offense cycle. Offenders are provided with a relapse prevention plan that is shared with others in their life so that they can identify salient aspects and support the offender in avoiding entrance into the offense cycle. Although relapse prevention has been invaluable in providing a coherent model for sex offender treatment (Laws, 1999; Pithers & Gray, 1996), it has been criticized on both theoretical and practical basis.

Ward and Hudson (1996) based their theoretical criticisms on the fact that lapses and relapses in addictions are very different to these concepts in sex offending, where one lapse constitutes a relapse and treatment failure. This leads to several conceptual difficulties, moving gratification effects close to violation effects. It also proposes a single overall conceptual model for sexual offending. Ward and Hudson (1998) proposed a multiple pathways model of sexual offending, which incorporates positive and negative pathways and self-regulation and has been supported by subsequent research (Bickley & Beech, 2002; Hudson, Ward, & McCormack, 1999). More importantly from the point of view of professionals working with individuals who have intellectual disabilities, Marshall, Anderson, and Fernandez' (1999) practical criticisms are extremely salient. They pointed out that the language of relapse prevention is very complex, and the personal relapse prevention plans are extremely elaborate. If this is the case for mainstream sex offenders, it will certainly be the case for sex offenders with intellectual disabilities. A second practical criticism these authors make is that the complex relapse prevention plans involve extensive postrelease supervision by others in the offenders' life. This allows sex offenders to invoke others in excusing any relapse in that they can be blamed for being insufficiently vigilant, allowing the offender too much leeway, and so on. It reduces the extent of personal responsibility the offender must assume in preventing relapse. As noted below, this is particularly important for offenders with intellectual disabilities.

Ward and Hudson (1998) employed the concepts of approach strategies, avoidance strategies, and self-regulation in their offense-related pathways model of sexual offending. Avoidant pathways are associated with poor coping skills to prevent sexual offending or the use of counterproductive strategies that lead to sexual offending. Approach/positive pathways involve impulsive and poorly planned behavior or careful, well-directed plans to execute sex offenses. Therefore, inadequate, counterproductive, and poor and effective self-regulation are all involved in pathways leading to sex offending. Hudson et al. (1999) studied the offense transcripts from 86 sexual offenders and found that almost all of the offenders could be classified within this system. Bickley and Beech (2002), in a study of 89 sexual offenders, found that all could be successfully classified according to this model.

All of these models involve cognitive and behavioral strategies for sex offenses. They have clear repercussions for treatment in that intervention should be focused on critical periods in the cycle of offending, justifications for patterns of behavior leading to offending, cognitions involved in denial and minimization of offenses, attitudes that shift blame for the offense onto the victim, and, most important, strategies of self-regulation. All of these have been employed by one researcher or another in the treatment of sex offenders with intellectual disabilities.

Theories of Criminality

One problem, not mentioned in the literature on relapse prevention, that is clearly relevant to the field of intellectual disabilities, is the assumption that the individual has some level of supportive relationships around him. We know that in the field of intellectual disabilities, this is not necessarily the case, and, furthermore, it may never have been the case. Dagnan and Waring (2004) found a relationship between core negative evaluative beliefs about the self and experiences of feeling different. They postulated that this effect may have arisen through a process of repeated exposure to stigma that the individual internalizes or accepts for themselves. Social and psychological theorists have found clear links between personal characteristics, developmental experiences, and criminal careers. In an extensive series of studies based on learning and reinforcement theories, Patterson and his colleagues (Patterson, Reid, & Dishion, 1992) found that from as early as 18 months, some families may promote a child's coercive behavior, such as temper tantrums and hitting, because those behaviors have functional value in terminating conflict. With repeated transactions, these behaviors are strengthened and firmly established.

In other families, children learn interactions that are quite distinct from those learned in distressed families. In nondistressed families, prosocial behaviors are reinforced and the child learns that interaction such as talking and negotiating are followed by a termination of conflict. In distressed families, not only are coercive behaviors promoted, prosocial behaviors may not be particularly effective in terminating family conflict (Snyder & Patterson, 1995). Therefore, as these boys develop, they fail to learn prosocial behaviors, problem-solving, and language skills but become highly skilled in antisocial behaviors. These theories are associated with the development of delinquency, but it is not difficult to make the link between this work and that of Dagnan and Waring (2004).

Farrington (1995, 2000) has found that delinquency in early adolescence is significantly associated with troublesome behavior at 8 to 10 years, an uncooperative family at 8 years, poor housing at 8 to 10 years, poor parental behavior at 8 years, and low IQ at 8 to 10 years. Farrington's studies of crime and deviancy in later years revealed that the best predictors were invariably previous convictions from 10 to 13 years. Adult criminal convictions at 21 to 24 years were best predicted by convictions in previous age ranges. An unstable job record, low family income, and a hostile attitude towards police at the age of 14 years also made additional predictive contributions to the probability of an adult criminal career. The higher number of risk domains (e.g., families, childhood behavior, schooling), the higher probability of later delinquency and criminality (Stouthamer-Loeber, Loeber, Wei, Farrington, & Wikstrom, 2002). These are variables that are clearly relevant to offenders with intellectual disabilities. For my purposes in the present paper, the extent of the relationship is not important; it is important for future investigators to test this hypothesis. The significant point is to establish a hypothesis concerning the relationship between societal and environmental factors and criminality.

Identification and engagement with societal values has long been a core concept in sociological theories of criminality, and Patterson, Farrington, and their colleagues have demonstrated important variables and mechanisms in the establishment of such engagement. Control theory (Hirschi, 1969) is focused on both positive learning of criminal behaviors, through association with criminal subcultures and family influences, as well as the development of self-control through appropriate social learning and being law-abiding. Hirschi wrote of his belief that the success of social training was dependent on four factors: attachment, commitment, involvement, and belief. Attachment referred to the extent to which the individual identified with the expectation and values of others within society, such as parents and teachers. Commitment invokes a rational element in criminality. Individuals make subjective evaluations about the loss that they will experience following arrest and conviction. Involvement simply points out that many individuals are engaged in ordinary activities, such as work, education, or other occupational activities, and have little opportunity to consider delinquency. The less that individuals are involved with the day-to-day activities of society, the more likely they are to engage in criminal activity. Hirschi defined belief as the extent to which individuals accepted laws of society as being reasonable mores to which they would conform.

There is a wealth of evidence consistent with Hirschi's (1960) control theory. Schuerman and Kobrin (1986) felt that within any particular urban area, an increase in the long-term unemployed population who were no longer seeking employment and a corresponding decrease in semi- and unskilled job holders, was a major factor in the increase of crime in an area. This is evidence that engagement with society decreases the frequency of crime. Negative attitudes toward schoolwork and authority are indeed associated with delinquent and antisocial activity (Elliot, Huizinga, & Ageton, 1985). Patterson and his colleagues (Patterson & Yoerger, 1997) provided a more subtle analysis of attachment in that they have demonstrated that dysfunctional attachment rather than lack of attachment will promote criminal activity whereas functional attachment promotes engagement with social conventions and laws.

Engagement with society is a core concept in the literature on intellectual disabilities; researchers have found that there is a clear tendency to stigmatize and exclude such individuals. There is a considerable literature on promoting community integration of people with intellectual disabilities precisely because it is not an automatic process (Cummins & Lau, 2003). Indeed, different aspects of integration and exclusion have been considered, such as dissimulation, integration, marginalization, and segregation (Minnes, Buell, McColl, & McCreary, 2002).

These issues come together in relation to sex offenders with intellectual disabilities, leading to a number of linked hypotheses. Dysfunctional and segregated upbringing may lead to negative self-perceptions through repeated exposure to stigma. Negative views of self and continued lack of engagement with society increases these asocial effects in a vicious circle. Lack of engagement in society has two important sequelae. First, if the individual is not engaged in occupational, leisure, and social activities, they have more time to engage in antisocial or deviant activities. Second, their number of prosocial influences is correspondingly reduced. With a reduction in such influences, an individual's only recourse is to his or her own segregated dysfunctional experience. Therefore, there will be a corresponding increase in personal dysfunctional cognitive frameworks associated with all human aspirations, including sexuality. Such an effect may be seen in other groups within the population, but it seems specifically salient in relation to sex offenders with intellectual disabilities precisely because of these two significant variables (inappropriate sexuality and intellectual disability).

Community Engagement and Quality of Life (QOL)

Control theory (Hirschi, 1969) suggests that we should promote methods that will increase attachment, commitment, and engagement to society and social values as a major strand for treatment for all offenders, including sex offenders. Therefore, it is not only important to investigate strategies for self-restraint and promote extensive techniques for self-control and cognitive-restructuring at crucial points in the offense cycle, it is also important to promote greater commitment and engagement with society. Fortunately, in the field of intellectual disabilities, this is a common procedure. There is a wealth of literature on provision of accommodation with varying levels of support, the development of leisure opportunities, and the organization of supported employment for this client group. This leaves us in the favorable position of being able to focus on societal engagement as a specific theoretical and practical method for the treatment of sex offenders. Because these practices are so widespread with this client group, this approach has been used frequently. However, the theoretical importance has never been elucidated explicitly and because it is theoretically important, this lack of focus has a number of practical repercussions. Quality of life of offenders becomes a central issue in their treatment. If the individual has, for example, an impoverished quality of life, with low levels of personal relationships, lack of prosocial influences, poor community integration, impoverished housing, one would predict, on the basis of this theoretical model, that it would increase the likelihood of sex offending and recidivism.

Researchers using comprehensive treatments that have included attention to quality of life have, incidentally, reported good outcomes. Griffiths, Quinsey, and Hingsburger (1989) and Haaven, Little, and Petre-Miller (1990) reported comprehensive treatments, including behavioral management, self-control, and attention to quality of life; Griffiths et al. (1989), in a review of over 30 cases, reported no re-offending. In their reports on cognitive treatments, Lindsay colleagues (Lindsay, Marshall et al., 1998, Lindsay, Neilson et al., 1998, and Lindsay, Olley et al., 1998), found that our participants received no other treatment directed at sexual offending. However, Lindsay, Smith et al. (2002) reported that occupational and educational placements were also organized. Sturmey (in press) wrote that nonspecific effects from these procedures might account for behavioral change. The current model suggests that organization of occupational and educational placements are specific therapeutic techniques from which one would theoretically expect therapeutic gains through the mechanisms of commitment to and engagement with society.

One further important ramification of this analysis is that placing people in secure accommodation, away from society, is precisely the wrong thing to do and will simply encourage disengagement and lack of commitment to society's mores, functioning, and activities. Such a course of action is increasingly seen in services where individuals with forensic difficulties are sent to secure private or public institutions distant from their own community. Although such therapeutic solutions might be useful for the self-restraint aspects of treatment, isolation is the antithesis of the societal engagement/quality of life component of this treatment model. For a relatively small number of individuals, this may be the only solution. Their offending may be of such serious, persistent, and driven nature that the prospect of societal integration cannot be envisaged. However, the treatment model currently being proposed would state that we should be aware of the explicit antitherapeutic nature of such placements as a management solution.

Another practical consequence of this model for treatment is that quality of life becomes an important consideration for the effective treatment of sex offenders with intellectual disabilities. Quality of life should not be considered in terms of physical and material surroundings only (although these are important—Emerson et al., 2000) but, rather, in terms of prosocial influences and community integration. Community integration and subjective perception of community connectedness has produced a complex literature into which it is not necessary to delve for the present purposes (Bigby, 2004; Bonham et al., 2004; Cummins & Lau, 2003). The main self-perceptions for offenders with intellectual disabilities are related to friendship, engagement with occupational and leisure activities, and a sense of being part of a community in which the individual is valued. Correspondingly, that community should be an ordinary part of society and shared social values.

Marshall, Anderson, and Fernandez (1999) have made one particular criticism of the relapse prevention model that is specifically relevant to this aspect of the current presentation. In this model, other individuals in the offenders' life are employed to assist in aspects of identification of critical points in the offense chain. This support group is encouraged to bring warning signs to the attention of the offenders in order to support them in the development of a nonoffending solution. Marshall et al. made the point that such supervision by a support group conveys the message that problems may be so insurmountable that these offenders cannot manage on their own. In addition, it leaves the possibility of blaming others for inadequate identification of the offenders' personal problem and inadequate support leading to relapse. It is important that while developing engagement and a sense of community, therapists do not promote dependence that might lead to others being blamed for an incident of offending. The personal responsibility and self-restraint aspects of treatment should be emphasized at all times. It is the offenders' responsibility if they perpetrate an offense. Care should be taken that in the construction of a sense of commitment to social conventions, the offender does not build in excuses for committing another offense because of the lack of vigilance of others.

Conclusion

In this paper I have reviewed motivation for the perpetration of sexual offenses, pathways, and strategies for their implementation and the way in which sexual offending can be considered within the context of wider theories of offending. The implications for the treatment of sex offenders with intellectual disabilities are wide-ranging and lead to a clear model for treatment. First, one must construct treatment procedures to address motivation and strategies for offending. The evidence for the effectiveness for cognitive methods is reasonable, and there is now a breadth of literature to help professionals construct such treatment procedures. Treatment should impact primary motivation, including lack of knowledge and psychosocial factors, and an attempt should be made to address sexual orientation. The literature on personality is, at present, less sophisticated. The main purpose of treatment should be directed at self-restraint and self-control. Appropriate outlets for sexuality should be promoted and, indeed, can be encouraged successfully. However, self-restraint and self-control must be a major focus of treatment.

The second major strand of treatment should be directed at engagement with society. Every effort should be made to encourage people to develop a commitment to society's values, coherence, and conventions. This is far from an easy task, requiring the organization of occupational, social, and leisure activities so that individuals have a group of friends and acquaintances whose values will continually impinge on their own. Not only will this provide specific personal benefits in terms of engagement to society, but also direct links to gains in personal life can be made during psychological treatment sessions. If we can encourage clients to strive to maintain relationships, occupation, and interests, it is possible to use this reference as an incentive to the promotion of techniques of self-restraint, altering cognitive distortion, identifying important points in the offense cycle, and so on. In this way, these twin theoretical foundations of treatment become linked in practice. The obvious crucial caveat to encouraging a commitment to society is that society must be protected by monitoring and management of the sex offenders. The complex but crucial balance between encouraging individual self-restraint and allowing individual human rights while protecting the safety of others is one that is familiar to all who work with sex offenders. At all times, considerations of safety, appropriate supervision, and adequate monitoring should be held alongside efforts to promote identification with society.

My hope is that this model provides a description of motivation, strategies for preventing offending, and treatment that will encourage future research. The relationship between treatment for inappropriate sexuality and treatment for psychosocial factors becomes clearer, and it will, therefore, be feasible to consider experimental designs that investigate the relative contribution of each to the perpetration of sexual offenses. The model describes a hypothesis for the development of the offenses that leads to broad treatment components. Because both of these treatment components are legitimate on their own, they can be compared for relative effectiveness. Indeed, one or the other can be emphasized to investigate their impact on recidivism. The model takes account of sexual drive; mental health; psychosocial factors; and behavioral, cognitive, and environmental factors and places them in a logical context to account for perpetration of sexual offenses and the development of treatment procedures. Most importantly, the model can be challenged. Generating a sense of engagement with the community may have no effect whatsoever on offending. Treating inappropriate sexuality in isolated institutions may indeed allow for re-integration into the community with low recidivism. This model would foresee neither. The model would predict that sex offenses will not occur in the absence of inappropriate sexual preference, psychosocial factors, and/or lack of knowledge or personality disorder. It would also predict that in the absence of treatment procedures outlined, recidivism is inevitable. Although these may seem like “safe bets,” they have not been made explicit until now. The main value of this model is provision of a coherent conceptual basis for the development of appropriate assessments and the development of appropriate treatments.

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Author notes

Author: William R. Lindsay, PhD, Psychologist, Clinical Psychology Department, Wedderburn House, 1 Edward Street, Dundee, Scotland, DD1 5NS. bill.lindsay@tpct.scot.nhs.uk. The author is also affiliated with the State Hospital; NHS Tayside, and the University of Abertay Dundee