International Journal of Law and Psychiatry 34 (2011) 239–245

Contents lists available at ScienceDirect

International Journal of Law and Psychiatry

Sexual offenders with serious mental illness: Prevention, risk, and clinical concerns

Jill D. Stinson ⁎, Judith V. Becker

⁎ Corresponding author. Fulton State Hospital, 600Fulton, MO 65251.

E-mail address: jill.stinson@dmh.mo.gov (J.D. Stinso

0160-2527/$ – see front matter. Published by Elsevierdoi:10.1016/j.ijlp.2011.04.011

a b s t r a c t

a r t i c l e i n f o

Available online 27 April 2011

Keywords:Sex offenders and serious mental illnessSex offender mental healthSex offender preventionPsychiatric sex offender needs

Individuals with serious and persistent mental illness who have also engaged in illegal sexual behaviorpresent a unique challenge for our legal and clinical systems. Frequently, these individuals may engage inproblematic sexual behaviors which result in hospitalization rather than incarceration, and an overburdenedand resource-deficient public community mental health system is ill-equipped to address the seriousness ofthese sexual behaviors. We have a rather limited understanding of how prevention programs, interventionstrategies, and risk assessment would work with this population. Here we evaluate data from a sample of245 inpatient psychiatric sexual offenders in a forensic mental health setting and compare these with whatinformation has already been presented in some of the literature. Through an examination of seriouslymentally ill sexual offenders and their clinical presentation, legal history, and risk management concerns,we illustrate a variety of tertiary prevention needs. Future directions in the area of prevention and riskmanagement for seriously mentally ill sexual offenders are also discussed.

E. Fifth Street, GFC - MS 320,

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Ltd.

Published by Elsevier Ltd.

1. Introduction

Sexual offenders who present with serious and persistent mentalillness are often underrepresentedwithin the sex offender and generalforensic literature. Much of what we know about the sex offenderpopulation stems from correctional research, utilizing samples ofconvicted sexual offenders residing within prisons and jails. Whilethis populationmay represent themajority of known sexual offenders,other subgroups exist which may present unique challenges to thoseinterested in treatment, risk management, and effective policydevelopment.

Some data have been presentedwhich describe one such subgroup—those with serious mental illness who may require long-term psychi-atric care. However, these studies are still comparatively limited andinvolve varied sex offender populations, including those who reside inpsychiatric institutions, those who are diagnosed with mental illnesswithin correctional settings, sexually violent predators who have beencivilly committed, and those who present for specialized residentialtreatment due to paraphilic diagnoses. These groups present withheterogeneous psychiatric diagnoses, demographic characteristics, andintervention and risk management needs, though they are typicallyamalgamated within the literature as “seriously mentally ill” (SMI)sexual offenders.

In this paper, we will explore this diverse subpopulation of sexualoffenders in greater detail, highlighting important differences be-tween the “general” and the “SMI” sex offender population and sub-

groups within the SMI population. We will also discuss importantpolicy implications for this group dependent on these differences andaddress in some detail prevention strategies necessary for effectivemanagement and reduction of future sexual violence in the com-munity. In order to better illustrate some of these principles, we willalso include data from a sample of 245 forensic psychiatric inpatientsresiding within the Midwestern United States.

2. The current sample

Archival data were obtained from the medical and legal records of245 adult psychiatric inpatients with histories of problematic or illegalsexual behaviors in both community and residential settings. Thissample includes both males (91%) and females (9%). The average ageof these individuals is 42.1 years (range 22–73 and sd=12.2), andmost have been hospitalized for an average length of 8.9 years atthe time of the current study (range 2–39 and sd=6.1). The majorityof these persons (43.3%) are admitted as voluntary patients bytheir guardian either due to dismissal of official legal charges due tocompetency concerns or aggressive behaviors in other psychiatric orrehabilitation facilities. The remainder are admitted as not guilty byreason of insanity (26.1%), incompetent to stand trial (23.3%), or othertemporary civil commitments (7.3%). Most reside in either maximum(40%) or intermediate security placement (45%), though several re-side in the minimum security units within the facility (15%). Demo-graphically, most of the samples are Caucasian (53.9%) or AfricanAmerican (42.4%), with the remainder Hispanic (1.6%) or other/unknown (2.0%). Permissions to collect and use these data weregranted by the Institutional Review Boards of the participating agencyand an affiliated academic institution.

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3. Characteristics of sexual offenders withserious psychopathology

Research examining rates of illness among general correctionalinmates has indicated that the rates of psychiatric and personalitydisorders are oftentimes high, with diagnoses of psychoactive sub-stance disorders and antisocial personality disorders quite commonand psychotic or serious mood disorders less common (e.g., Beck &Maruschak, 2001). Among sex offender populations, these rates areelevated, with greater prevalence of major mood disorders, psychoticdisorders, and other forms of personality psychopathology. This ishighly dependent on the sample, however, as those with co-morbidparaphilias or who reside in psychiatric residential settings maypresent with more serious forms of psychopathology than thosewithout paraphilic diagnoses or who reside in primarily correctionalsettings. In Table 1, we have provided a summary of some of theavailable research, differentiating these subsamples and their diag-nostic characteristics.

With regards to samples of sexual offenders referred for psy-chiatric or residential treatment from a correctional setting, rates ofsubstance abuse disorders and antisocial personality disorder appearto largely mirror those of a general inmate population, though rates ofmood and anxiety disorders, paraphilias, impulse control disorders,ADHD, and other personality disorders are increased (e.g., Dunseithet al., 2004; Kafka & Hennen, 2002; McElroy et al., 1999). How-ever, many available studies utilizing correctional or other residentialsamples exclude those with psychotic spectrum diagnoses or in-tellectual or developmental impairments (e.g., Dunseith et al., 2004;Harsch, Bergk, Steinert, Keller, & Jockusch, 2006; McElroy et al.,1999), which may obscure the true rates of psychiatric disorderor psychiatric co-morbidity in these groups. Research which doesemphasize the presence of schizophrenia and other psychoticdisorders reveals that in general samples of male and female sexoffenders, paraphilic male sex offenders, or civilly-committed sexu-ally violent predators, rates of psychotic diagnoses range from 5 to10% (Fazel, Sjostedt, Langstrom, & Grann, 2007; Fazel, Sjostedt, Grann,& Langstrom, 2010; Kafka & Hennen, 2002; Vess, Murphy, & Arkowitz,2004). However, among samples of more psychiatrically-based sexoffender populations, rates of psychotic disorders are significantlyhigher, ranging from 50 to 100% (e.g., Alish et al., 2007; Harris, Fisher,Veysey, Ragusa, & Lurigio, 2010). Further, research comparing sexoffenders with other offender groups has indicated that male sexualoffenders are five times more likely than non-sex offending malesto be diagnosed with a psychotic disorder and six times more likelyto be psychiatrically hospitalized (Fazel et al., 2007), and that femalesex offenders are sixteen times more likely to be diagnosed with apsychotic disorder and fifteen times more likely to be psychiatrically

Table 1Psychiatric diagnosis across different SMI sex offender populations.

Study Sample location Sample

Alish et al., 2007 Forensic inpatient unit, Israel 36 sex offenders withschizophrenia

Dunseith et al., 2004 Residential treatment facility, US 113 sex offenders referredfrom corrections

Fazel et al., 2007 All convicted sex offenders, Sweden 8495 convicted sex offendHarsch et al., 2006 Forensic inpatient unit, Germany 40 inpatient psychiatric se

offendersKafka & Hennen, 2002 Outpatient referrals, US 120 outpatients referred

for paraphiliasMcElroy et al., 1999 Residential treatment facility, US 36 sex offenders referred

from correctionsRaymond et al., 1999 Residential treatment facility, US 45 outpatient sex offende

with pedophiliaCurrent sample(Stinson & Becker)

Forensic inpatient hospital, US 245 inpatient psychiatricsex offenders

hospitalized (Fazel et al., 2010). Similar research suggests those withpsychotic diagnoses with co-morbid substance use disorders or per-sonality disorders are six times more likely to have been arrested forviolent sexual crimes (Alden, Brennan, Hodgins, & Mednick, 2007).Thus, individuals who manifest psychotic illness and sexual behaviorproblems present with greater psychopathology and additionalpsychiatric management needs than other sex offender groups.

Those in the current sample of 245 psychiatric inpatient offendersdemonstrate serious histories of psychiatric illness andmultiple formsof psychopathology. Ninety percent have at least one prior psychiatrichospitalization, with an average of 7.6 prior psychiatric placementsand 9.6 prior placements total, including correctional, medical, orfoster care. The average age at which these individuals were firsthospitalized for psychiatric reasons is 18.2 years. Thus, these in-dividuals have lengthy histories of inpatient psychiatric care begin-ning typically in adolescence. They present with a wide variety ofpsychiatric diagnoses, as determined by hospital psychiatry andpsychology staff. Rates of psychotic disorders, mood disorders, andpersonality disorders were relatively high (see Table 2 for additionalinformation). Of note is the high number of individuals with AxisII diagnoses of cognitive impairments or pervasive developmentaldisorders. Of those with diagnoses of Mental Retardation, 30% werein the Mild range, 30% were in the Moderate range, and 40% werediagnosed with borderline intellectual functioning. Oftentimes,offenders with such serious cognitive impairments are not includedin correctional research, as they either do not reside in correctionalsettings, have not been formally adjudicated for their offenses, or areeliminated from consideration in residential treatment due to theirdifficulties with comprehension and retention of treatment materials.Thus, this is a sub-population of the seriously mentally ill sex offenderpopulation, which remains distinct from traditional sex offendersamples.

Sex offenders with a history of serious psychiatric illness alsopresent with a number of other adaptive impairments which implydifficulties with relationships, employment, residential stability, andeducation. In the current sample, 77% have never been married, only46% of them report any history of normative sexual or intimaterelationships, defined at the most basic as a “dating relationship,” andjust 28% have parented one or more children. With regards to otherfunctional variables, the average participant has a tenth gradeeducation, over half were enrolled in special education courses(54%), and only 30% have maintained continuous employment for aperiod of greater than six months. Twenty percent have never heldgainful employment. This compares with other similar groups of sexoffenders with mental illness, in which these offenders are noted tohave a greater reliance on social welfare systems (Fazel et al., 2010,2007), less education among those with serious psychotic symptoms

Any Axis Idisorder

Mooddisorders

Psychoticdisorders

Substanceuse disorders

Paraphilias AnyAxis II

ASPD

100% – 100% 44% 33% – 36%

74% 58% Excl. 85% 74% 87% 56%

ers – – 5% 13% b1% 6% –

x 80% 8% Excl. 55% 53% 85% 50%

91% 72% 4% 41% 100% – –

97% 61% Excl. 83% 58% 94% 72%

rs 93% 67% 2% 60% 100% 60% 23%

97% 60% 67% 52% 14% 61% 46%

Table 2DSM-IV-TR Axis I and Axis II diagnoses in the current sample (n=245).

Axis I Diagnosis % Axis II Diagnosis %

Mood disorder 60% Cognitive or Pervasive devl. disorder 56%Anxiety disorder 14% Any personality disorder 61%Psychotic disorder 67% Cluster A personality disorder 9%ADHD/Impulse control disorder 14% Antisocial personality disorder 46%Substance abuse disorder 52% Borderline personality disorder 11%Paraphilia 14% Any other Cluster B personality disorder 7%

Cluster C personality disorder 4%

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(Alish et al., 2007; Fazel et al., 2007), and overall lower levels ofpsychosocial functioning on a variety of measures (Harsch et al.,2006) when compared to non-mentally-ill sex offenders and otherviolent offender groups. These functional deficits carry implicationsfor these offenders' abilities to maintain prosocial relationships incommunity settings, engage in adaptive vocational pursuits, or obtainthe knowledge and skills necessary for effective and independent self-management.

Often, sexual offenders with serious mental illness, co-morbidpersonality disorders, and/or paraphilias also present with histories ofsignificant trauma. The literature notes increased rates of childhoodabuse reported by these offenders, ranging from 18 to 58% for sexualabuse (Dunseith et al., 2004; Kafka & Hennen, 2002; McElroy et al.,1999). This compares with the current sample, in which rates ofdocumented and corroborated aversive or traumatic experiencesare high, with 69% of the sample impacted by the following: verbalor emotional abuse (24%), physical abuse (47%), intrafamilial sexualabuse (28%), extrafamilial sexual abuse (24%), any experience ofsexual abuse (46%), and neglect (14%). Additionally, parental sub-stance abuse problems (50%) and foster or other placement duringchildhood or adolescence (38%) were also noted. Oftentimes, theseindividuals experienced multiple forms of trauma or abuse, and onlythat which was the most serious or easily corroborated was reportedin the available records (i.e., physical abuse reported over otherexperiences of emotional abuse or neglect). Such histories of traumaand abuse may impact these individuals' emotional and interpersonaldevelopment and contribute to later difficulties with self-regulationand forming adaptive interpersonal relationships.

With regards to their history of illegal and problematic sexualbehavior, research suggests that SMI sex offenders are perhaps re-sponsible for greater rates of sexual crimes than comparison sampleswithout such psychiatric diagnoses, with a greater number of overallsexual crimes committed per person (e.g., Alden et al., 2007; Fazelet al., 2007; Harsch et al., 2006). Differences in victim characteristics,onset of offending, or differences in rates of other violent, non-sexual offending, however, are less clear (e.g., Alish et al., 2007). In thecurrent sample, nearly all (89%) of the sample have at least one arrestfor criminal behavior, with an average of 4.8 arrests each. Theseinclude both violent arrests (46%; average of 1.8 each) and sexualarrests (57%; average of 1.6 each). Over half (52%) were previouslyincarcerated on one or more occasions, for an average period of3.3 years. These individuals have committed sexual offenses in bothcommunity (72%) and residential (74%) settings, with high rates ofsexual acts involving children (49%) and rape or attempted rape (39%)in the community, and non-consensual sexual contact or rape (58%)or public masturbation (75%) in residential care. The majority of theseoffenders (85%) had engaged in at least one contact sexual offense,regardless of setting. Victims were most frequently female (75%),though male victims (49%) and victims of both genders (25%) werealso common.

4. Outcomes for SMI sexual offenders

Considering the severity and pervasiveness of their psychiatricillnesses, the frequency of psychiatric hospitalization, and the nature

of their violent and sexual behavior problems, one can see that thispopulation, while similar in many ways to other sex offender groups,may also present with crucial differences. First, their adaptive deficitswith regards to education, employment, social relationships, andmaintaining independence in the community, suggest that they maybe more functionally impaired than the average individual in acorrectional environment. The severity and co-morbidity of theirpsychopathology indicate that while some correctional samples mayhave small subsamples of seriously mentally ill offenders, largergroups of these individuals exist in other settings. Their sexualbehaviors may be as severe as those seen in correctional or com-munity outpatient treatment settings, and just as deserving of assess-ment and treatment.

Given these findings, what happens to these seriously mentally illsexual offenders? As can be seen from these data and prior research,rates of psychiatric hospitalization are often higher than the rates ofprior incarceration, despite the frequency of arrest for both violentand sexual crimes. For many of these individuals, such psychiatricplacements were not only prompted by prominent symptoms ofmental illness (e.g., suicidality or self-harm behaviors and acutepsychosis) but also aggression or sexual perpetration against others.Thus, when these offenses occur, the individual's known history ofmental illness or obvious presentation of psychiatric symptoms maylead law enforcement officers to suggest hospitalization as a pref-erable and needed alternative to incarceration.

Similarly, these individuals may experience different outcomeswhen they do interact with agents of the criminal justice and legalsystems. While offenders without serious mental illness may progressthrough the courts in a typical fashion, those with serious mentalillness or related cognitive impairments might be diverted to mentalhealth settings for questions of competency or responsibility for theiractions. This may lead to alternative forms of adjudication for theseindividuals, including attempts at competency restoration, findingsof permanent incompetence to stand trial, dismissal of charges inexchange for a period of court-mandated treatment, or findings of notguilty by reason of insanity, or other similar determinations. Again,these routes would lessen the likelihood of further legal involvement,maintaining the individual in a mental health or psychiatric treatmentfacility instead.

A third consideration involves the high rates of problematic orillegal sexual behaviors which occur in residential settings amongSMI sexual offenders. In many cases, as the individual is already anidentified offender and is residing within a secure placement setting,the continued behavior does not result in formal legal charges oradditional adjudication. Thus, the official legal record is often anunderestimate of the frequency and severity of these offenses forthese individuals. This may not be the case for those sexual offenderswho continue sexual perpetration against others in other settings,including community or correctional placements.

5. Risk management and policy concerns

A primary area of concern for this population is the effectivemanagement of risk. A number of instruments have been developed todetermine sex offenders' risk of future sexual offending in communitysettings. However, many of these instruments were developedutilizing largely correctional samples, comprised of individuals whohad been formally convicted of their offenses, variables that may besignificant determinants of risk for these offenders may differ fromthose most relevant to seriously mentally ill sexual offenders. Forexample, many of these instruments focus on historical factors relatedto arrest, conviction, and incarceration for sexual and violent offenses,but as one can see from the psychiatric offender data described herein,these offenders may have committed a number of offenses for whichthey were neither arrested nor convicted, but instead hospitalized.Thus, their official legal record may be an underestimate of the

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frequency and severity of their sex offending behaviors. Also, theseinstruments often fail to include measures of psychiatric historyand stability, cognitive impairments, medication history, and socialdeficits which may be predictive of their success or failure in certainsettings. Though some do include static variables such as “history ofschizophrenia” (e.g., Sex Offender Risk Appraisal Guide — SORAG;Quinsey, Harris, Rice, & Cormier, 1998) or dynamic variables assessingpsychiatric wellness (Stable/Acute, 2000, 2007; Hanson, Harris, Scott,& Helmus, 2007), the normative samples were comprised of largelynon-SMI sex offenders, so differentiating between SMI sex offendersat high risk and those at lower levels of risk may be difficult todetermine. And while treatment progress is often viewed as a crucialdynamic risk factor, little research exists evaluating the factors whicheither contribute to or hinder treatment progress in the seriouslymentally ill sex offender population.

The primary goal of risk assessment, as implicated by currentlyavailable risk assessment instruments, is to predict long-term risk ofviolent and sexual recidivism. While these are obviously valid andimportant prediction goals, with seriously mentally ill offenders, wemay need to consider other factors. First, recent research has raisedthe issue of risk status versus risk state (Douglas & Skeem, 2005).Here, there is a recognition that one's risk status, based on staticvariables or constants, may not be as informative as one's risk state,which is informed by immediate and dynamic variables, includingenvironmental stressors, substance use, medication non-compliance,or psychiatric instability. Thus, for seriously mentally ill offenders, thecomplex and dynamic factors which impact offense behaviors are alsothose which should be considered in the prediction of risk. These riskstate variables may be critical for estimating the ever-changing riskand intervention needs of this population. Further, an exclusive focuson violent and sexual recidivismmay obscure other relevant concernsfor the well-being of this population. This may be true for othersexual offenders as well, but for SMI offenders, continuing difficultieswith illness management, substance use, residential stability, employ-ment, and adaptive relationships should also be considered treat-ment “failures.” Thus, indicators of problems in these areas should beincorporated into assessment of risk.

Finally, risk assessment for seriously mentally ill sexual offendersshould include identified supports which are needed for continuedsuccess in other settings. Importantly, it should be noted that whilemany forms of sex offender risk assessments assume that thecommunity is the most likely destination for many offenders, giventhe reality of not only serious mental illness but also sexual violence,many mentally ill sexual offenders may be sent to live in other, lessrestrictive placement settings where not only their behavior but alsotheir mental health needs may be served. Therefore, part of theassessment of risk should include some discussion of appropriateplacement, in addition to other supports which may be necessary.These could include such supports as special precautions or super-vision, follow-up care, contacts with supportive others, prosocialopportunities, environmental structure, or other forms of treatmentwhich may be necessary to address social skills and functional deficitsor other problems like illicit substance use.

With regards to sex offender policies, though these offendersclearly demonstrate the problematic and illegal sexual behaviorswhich are the targets of such policies, because of their limited legalinvolvement, likelihood of hospitalization rather than conviction, andpersistence of maladaptive sexual behavior in residential settings,many of the relevant policies may not apply to these individuals. Forexample, because community registration and notification legislationare designed for community placement and for offenders with officiallegal convictions of sexual offenses, they may not be applicable tooffenders who are placed in residential care rather than communitysettings, or to those who were not formally convicted of their offensesdue to competency or responsibility concerns. And due to limitationsin the research literature, we do not know whether or not residential

sexual offenses would be predictive of community sexual offenses,so that we cannot say whether or not residential offenses – seldomreported to legal authorities – should result in any residential restric-tions or community notification practices. In other words, policiesdesigned to target the typical sexual offender in a correctional settingmay not have the same impact on a seriously mentally ill offenderresiding in psychiatric placement.

6. Prevention in an SMI sex offender population

Sex offenders with serious psychiatric illness have specific needswhich must be addressed by those mental health professionals whoare providing for their care, as well as for those individuals within thecriminal justice system who might be responsible for managing theirbehavior while in the community. A number of factors contribute tothe link between psychopathology and problematic sexual behavior,including histories of trauma, difficulties with self-regulation of moodand behavior, overt psychosis, and deficits in interpersonal skills andrelationships. In order to develop effective prevention strategies forthis population, each of these factors must be addressed. Further, theneed for comprehensive aftercare planning and support, interven-tions designed to address individualized problems for SMI offenders,and the development of prosocial support networks are also crucial.

6.1. Links between psychiatric instability and problematicsexual behavior

It is not simply a given that SMI sex offenders engaged inproblematic or otherwise illegal sexual behaviors because of theirpsychiatric illness. In some cases, there are clear links betweendelusional beliefs, personality psychopathology, or affective instabil-ity and a sex offending outcome. However, in many cases, thepsychiatric disorder is one of many contributing factors that mayplace that individual at risk for a number of maladaptive behaviors,including sexual offending. General difficulties with self-regulatoryfunctioning, deficits in mood and behavior management, andinterpersonal problems may not only result from psychiatric illnessbut can also exacerbate current symptoms, as well as contribute tocontinuing sexual and other behavioral problems.

Individuals with psychotic spectrum disorders, bipolar disorderor other major mood disorders, or a personality disorder may inparticular have difficulty with self-regulating their behavior. Manag-ing medication compliance, psychiatric symptomology, and solicitingcontinued psychiatric care will all be important targets for those withcontinuing symptoms of mental illness. A specific concern is thatmany mentally ill individuals who are on medication may stop takingtheirmedication. Thismay happenwhen they start feeling better, mayhave difficulty paying for medication, or may lack support for takingtheir medication. Co-morbid substance use disorders also presentunique challenges for sexual offenders with serious psychopathology.While the literature does suggests similar rates of substance usedisorders in both correctional and psychiatric sex offender popula-tions, the use of alcohol or illicit substances may have a differentialimpact on these two groups. In many cases, the use of such substancesmay interfere with psychiatric medications, or may cause theindividual to discontinue using or improperly use such medications.Additionally, the effects of these substances may trigger or exacerbateexisting psychiatric symptoms. It is important that aftercare services,including substance abuse treatment services, are developed andmade readily available for such individuals, with particular attentionto their psychiatric needs.

Unfortunately, in a number of instances when mentally ill sexoffenders have been incarcerated and later released, a “safety net” hasnot been put in place for them. Thus, they may have difficulty findinghousing, employment, and are without any social contacts. Theseare risk factors which can increase stress and thereby hinder the

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individual's ability to self-regulate behavior. We are in need of a“seamless” system in which these individuals receive not onlymonitoring and management of sexual risk but also quality psychi-atric treatment and aftercare and assistance with post-incarcerationor post-hospitalization community reintegration.

6.2. Specialized interventions for SMI sex offenders

While psychiatric medication and illness management may becrucial parts of an overall treatment and prevention plan for SMIsex offenders, their problematic sexual behaviors must also beaddressed. As was noted above, from a discussion of the literaturemany research studies involving sexual offenders exclude those withpsychotic disorders, intellectual and developmental disabilities, orother forms of serious psychopathology. This represents not onlyexclusion from research, but often also indicates an exclusion fromavailable sex offender treatment programming. In addition to psy-chiatric stabilization, treatment, and aftercare, these offenders needinterventions designed to address their sexual problems. Such inter-ventions may involve skills training, problem solving training, angermanagement, sex education, and more traditional sex offender treat-ment for addressing any inappropriate sexual fantasies that a clientmight have.

As can be seen from the sample data described above, many ofthese offenders demonstrate significant deficits in their adaptive andfunctional skills, including relationship skills, vocational abilities, andself-care. These limitations may leave them vulnerable to continuedproblems with developing healthy relationships, understandingnormative and appropriate boundaries with others, and maintaininga prosocial lifestyle which does not support sexual offendingbehaviors. Thus, increasing adaptive skills and abilities and fosteringhealthy relationships with others may also be critical in providingcomprehensive services for these clients. Also, with such high rates oftrauma – particularly sexual trauma – it will also be important toaddress these issues in treatment. It is recommended that a casemanagement approach be taken with SMI sex offenders in thecommunity, so that these many issues may be simultaneously andcomprehensively address and managed.

6.3. Aftercare planning

Some providers of treatment services to non-seriously mentally illsex offending clients may feel that their clients are ready to re-enterthe community once a term of treatment has been completed withminimal follow-up or aftercare. The assumption is that once the toolshave been provided and major issues have been addressed, thecombination of social support, commitment to change, and progressin treatment may be sufficient to sustain positive outcomes for theseclients. However, in the case of seriously mentally ill sexual offenders,due to the complexity of their emotional, cognitive, interpersonal, andbehavioral needs, more intensive, long-term aftercare services may benecessary. Assistance with daily living skills, residential and voca-tional placement, medication management, and behavioral supportmay be necessary in order to ensure these same positive outcomes.Seriously mentally ill sex offending clients are perhaps more easilydetoured by the mere occurrence of change, and they often facegreater deficits in developing a social support network than their non-mentally ill counterparts. So while society may present greatchallenges for the reintegration of sexual offenders into communitysettings, these challenges may be even more significant and at timesseemingly insurmountable for sexual offenders also struggling tomanage serious mental illness. As was mentioned above, an indi-vidualized case management approach may be most effective withpreventing further sex offending problems in this population.

6.4. Development of support networks

An additional preventative concern relates to the need for healthysocial supports to minimize risk, provide prosocial opportunities, andassist in monitoring important risk factors. Many mentally ill sexoffenders come from dysfunctional homes where they may havebeen the victims of neglect or maltreatment. Returning to suchenvironments, or failing to become involved in supportive relation-ships which differ from earlier dysfunctional ones, may render themless capable of effectively managing sexual urges and risk. Addition-ally, mental illness during critical developmental periods may haverendered them in many ways isolated from their peers, and withoutthe opportunity to develop appropriate social–sexual skills. A numberof SMI sexual offenders have lost the support of or contact with theirfamilies due to lengthy periods of institutionalization or incarceration,or victimization of family members. Thus, it is important to assistthese individuals in identifying resources in the community such asday treatment programs, group homes, or other resources whereindividuals have been trained to work with SMI clients as well asthose with sexual behavior problems. Just as treatments for psycho-active substance use very often utilize sponsors in helping individualsadhere to their goals of sobriety, it is recommended that sponsorsbe identified for mentally ill sex offenders who are being returned tothe community.

For those who still have contact with their families, it is imperativethat with the individual's consent the family members and involvedothers are educated as to the nature of the mental health problem aswell as the relevant sexual problem, behavioral disorder, and riskpresented by these conditions. Family members should be informedabout the dynamic risk factors, including those factors which maymost impact the individual's ability to self-regulation mood andbehavior.

6.5. Problems with implementing these strategies

Sadly, a number of systemic problems may hinder preventionefforts. In difficult economic times, as are faced by many nations,funding community and rehabilitation services become all the moreproblematic. This is particularly the case for public sector mentalhealth and rehabilitation agencies. While recent decades have shownan increase in funding for corrections and the establishment of moreand larger prisons, there has been a dearth of mental health resourcesfor seriously mentally ill sex offenders in community or public psy-chiatric institutions, and many of these individuals are without thefinancial support necessary to provide for treatment outside of thepublic sector. In addition to funding and service deficits, serviceproviders in publically funded community and psychiatric agenciesoften carry unmanageable caseloads and cannot provide the level ofindividualized care which may be needed.

There also may be significant discrepancies in training, whichaffect this population in unique ways. For example, many individualswho work within community mental health or even residential psy-chiatric settings lack training and education with regards to sexoffending and working with sexual offenders. Similarly, those whowork with sexual offenders in community or institutional agenciesoften lack corresponding training in managing serious mental illness.This gap between service providers may limit the availability ofneeded resources and negatively impact client services. This likelyresults in not only a limited number of trained providers, but alsoperhaps a limited number of placementswhich are adequately equippedto serve the complex needs of SMI sex offenders.

Legislative and policy decisions made on behalf of public pro-tection may further alienate SMI sex offenders from the aftercareservices and social supports they so need. Residency restrictions,required reporting, and other similar policies may limit their appro-priateness for typical community psychiatric placements or supported

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living environments, though comparable substitute services for sexoffenders with psychiatric illnesses are currently unavailable. Andwhile many correctional offenders are placed on lengthy periods ofparole or probation following their release from a correctional in-stitution or agency, similar follow-up and management services arenot readily and consistently available for many who have progressedthrough the public mental health sector. Diversionary practices whichresult in hospitalization rather than incarceration, though perhapsbest for these offenders in terms of immediate treatment and sta-bilization, may unintentionally result in the denial of importantaftercare and follow-up planning which has been implemented forsexual offenders in other settings.

Consequently, lack of funding, lack of training and experience,lack of placement facilities and some of the social control policiesthat have been enacted by policy makers impede SMI sex offendersfrom obtaining the services that they need to be able to live functionallives in the community. Preventative measures such as managingpsychiatric illness, developing comprehensive aftercare services,forming social support networks, and individualizing sex offendertreatment approaches for these offenders may thus be limited by aresource-deficient and overburdened mental health care system andsex offender systems which are unequipped to cope with psychiatricclients.

7. Summary and future directions

Sex offenders with seriousmental illness represent a small, thoughsignificant, subpopulation of those who engage in problematic orillegal sexual acts. General population studies of sexual offendersindicate that as a larger group, relatively few present with psychoticspectrum disorders or serious affective disorders (e.g., Fazel et al.,2007; Harsch et al., 2006; Kafka & Hennen, 2002; Raymond, Coleman,Ohlerking, Christenson, & Miner, 1999; Vess et al., 2004), thoughthese numbers are significant when compared to similar disorders inthe general population or other offender samples (Alden et al., 2007;Fazel et al., 2007). These numbers still represent hundreds if notthousands of SMI sex offenders in sum, all of whom are in need ofcrucial treatment services. These individuals manifest maladaptivebehaviors or deficits across a variety of domains, including adaptivefunctioning, interpersonal relationships, psychiatric stability, self-regulation, and self-management. Risk management, prevention, andpolicy concerns may be substantially altered with this subpopulationof offenders, and some early steps toward the prevention and reduc-tion of sexual violence may be beneficial for this group. In lookingtoward the future andwhat is needed to make our society safer and toprovide comprehensive services to mentally ill sex offenders, thefollowing recommendations are offered.

7.1. Education for corrections, mental health systems, and policy makers

Probation, parole, and correctional personnel, as well as mentalhealth care providers and policy makers should be educated as to thenature of these offenders, their offenses, and the realities of ongoingcare and treatment for this population. Sex offenders are a hetero-geneous group, yet many people – including professionals in charge oftheir care andmanagement – view them as a homogenous population.There is tremendous variability in the types of behaviors demon-strated by SMI sex offenders, ranging from inappropriate touchingor fondling, to oral, anal, or vaginal penetration, to severely violentand sadistic sexual offenses. Themajority of these offenders, however,are not violent and sadistic, though significantly more attention maybe paid to those on the higher end of the spectrum of harm. A lackof knowledge about these offenders, both regarding their sexualoffenses and their psychiatric illnesses can lead to inefficient andineffective service delivery. This will ultimately result in failures toprevent future maladaptive behaviors. There are treatments available

for mentally ill sex offenders, and many of them can be managed inthe community with appropriate medications, interventions, supportand supervision.

Institutions and agencies should provide ongoing training oppor-tunities for staff who work with these offenders. Expert consultationshould be considered in order to address the complexities presentedby this population. Funding should be made available by mentalhealth and correctional agencies to ensure that staff can attend eitherlocal or national meetings by organizations that provide training forworking with sex offenders.

7.2. Interventions made available in multiple settings

In a discussion by Harris et al. (2010), the authors note that with-in the past decade, policy makers have recognized the challengesmentally ill persons face when interacting with the criminal justicesystem and have enacted legislation and funding initiatives to ad-dress the plight of mentally ill offenders, including “first responder”initiatives, mental health courts and diversion programs, treatmentservices in jails or prisons, and re-entry models designed for seriousmentally ill offenders. They also reference a team-based model ofcommunity corrections, such as the Forensic Assertive CommunityTreatment model. All of these efforts should be applauded; unfortu-nately, such initiatives have not been developed for mentally ill sexoffenders.

The approaches for these two populations are philosophicallydivergent: for SMI individuals, the goal is community integration withregards to housing, employment, rehabilitation, and psychiatric andsubstance abuse services, whereas for sexual offenders, the goals areisolation and separation from community members and the veryservices they may need. Very restrictive legislation, including stricterand mandatory sentencing, sexually violent predator civil commit-ment laws, community notification and registration, have beenenacted for sexual offenders, which may limit the availability of thecomprehensive services otherwise available for mentally ill persons.Once a person has been labeled a sexual offender, that appears tobecome primary and other needs secondary (e.g., mental health treat-ment, residential assistance, etc.).

How do we integrate the needs of these dually diagnosed patientsand assist in holding them responsible for their behaviors (if theywere at the time of their offense), meeting all of their treatment needsand working towards reintegrating them into the community? Oneapproach taken by the Massachusetts Department of Mental Healthinvolves a specialized clinical case management program, providingservices to seriously mentally ill clients with sexual problematicbehaviors (Harris et al., 2010). Of those offenders receiving suchservices within the Massachusetts program, 67% were diagnosed withpsychotic disorders, and 50% were in the highest risk group of sexualoffenders registered with the State Sex Offender Registry Board.Hopefully research will be forthcoming indicating whether or notsuch a program model will facilitate integration of these individualsinto the community and at the same time make our society safer. Ifsuch a programmatic model is effective, other jurisdictions shouldconsider implementing similar services so that resources are morereadily available for this population.

7.3. Increased research and knowledge base for SMI sex offenders

A number of researchers have previously identified a number ofgaps in the present literature base (e.g., Guidry & Saleh, 2004; Harriset al., 2010). First, an epidemiological study needs to be conductedassessing the prevalence of mental illness among sex offenders whohave come into contact with the criminal justice system. Second,research needs to be conducted to determine whether or not theproblematic sexual behavior or the sex offending behavior is an out-come of the mental illness or whether or not other factors contribute

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to the behavior. Perhaps more specifically, does the mental illnessfacilitate sexual offending, or did an individual with a paraphilia orwho had engaged in sex offending behavior develop mental healthproblems as a result of other factors? Third, gaps in service capacity andprofessional expertise should be identified and corresponding trainingneeds addressed. As noted above, there are individuals with expertisein working with SMI populations and individuals with expertise inworking with sex offenders, however there is little data availablein terms of individuals who have expertise with both populations.Fourth, numerous policies (e.g., registration, civil commitment, andcommunity notification) are designed to control the behaviors of sexualoffenders, but there is very little data available regarding the impactof these policies on offender rehabilitation and community safety.This is particularly relevant for those individuals who have seriousmental illness and who have engaged in problematic or illegal sexualbehaviors. Finally, more research is needed on the development ofrisk assessment instruments for this population, focusing on dynamicrisk factors as well as the development of treatment models and theevaluation of treatment models for this specific and unique population.

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