Gold Award: Improving Community Safety by Providing Treatment to a Highly Marginalized Clinical Population
Treatment of sexual offenders is often considered a daunting task, and the mental health profession has largely neglected this population. The result is that after serving their custodial sentences, sex offenders are often released untreated into the community with few social supports and even fewer treatment options. In 1983, forensic psychiatrist John Bradford, M.B.Ch.B., established a clinic devoted solely to treating sexual offenders and people with problematic sexual interests as a way of protecting children and others from potential victimization.
Located at the Royal Ottawa Mental Health Centre (“The Royal”) in Ottawa, Ontario, Canada, the Sexual Behaviors Clinic (SBC) quickly established itself as a pioneer in the use of antiandrogens for suppression of sex drive. Together with J. Paul Fedoroff, M.D., a codirector then and director of the SBC since 2001, the clinic has developed partnerships with community agencies that monitor and support sex offenders in the community, such as the Ottawa Police, the Circles of Support and Accountability (CoSA), the Children’s Aid Society (CAS), and Probation and Parole. The combination of effective treatment strategies and collaboration with community agencies helps sex offenders reintegrate safely with their communities and live prosocial, offense-free lives.
In the past 14 years, there have been virtually no documented “hands-on” sexual reconvictions by patients treated in the clinic. Patients report a dramatic increase in quality of life due to elimination of sexual urges to commit sex crimes. In fact, the clinic increasingly focuses on primary prevention initiatives, helping persons with dangerous sexual fantasies before they commit any sex crimes, thereby preventing any sexual victimization.
In recent years, the SBC has received increased attention for its research on the measurement of sexual arousal patterns. Its findings suggest that these patterns may be more plastic than was commonly believed. According to Dr. Fedoroff, there is reason to hope that “sexual interest patterns are changeable and can be normalized.”
In recognition of its efforts to improve community safety by providing treatment to a highly marginalized clinical population, the SBC of the Integrated Forensic Program (IFP) at the Royal Ottawa Mental Health Centre has been selected to receive the APA’s 2015 Gold Achievement Award in the category of academically or institutionally sponsored programs. The winner of the 2015 Gold Achievement Award in the category of community-based programs is described in an accompanying article.The award will be presented October 8, 2015, at the opening session of the Institute on Psychiatric Services in New York City.
An Innovative Model
As the primary clinic in Eastern Ontario for assessment and treatment of problematic sexual behaviors, the SBC has made treating diverse patient populations a priority. Services are conducted in English and French, and although most patients are men or male adolescents, about 5% are women and some are children. The youngest patient seen at the clinic was ten and the oldest was 86. Most patients are involved in varying stages of the criminal justice system, including postarrest, pretrial, and presentencing, or have returned to the community after serving time in jail. Assessment and treatment in the SBC are free of charge to all Canadian citizens.
The clinic treats about 175 new patients each year, mostly with a combination of medication and individual and group-based psychotherapy, according to Dr. Fedoroff. The immediate goal of therapy is to protect the community by preventing sex crimes and improving patient well-being so they establish successful and productive lives in the community. Pharmacologic treatment reduces sexual impulses that would normally preoccupy the patient, allowing the patient to establish better relationships and a healthier sexuality. Selective serotonin reuptake inhibitors are particularly effective at controlling abnormal sexual impulses, according to Dr. Fedoroff, and antiadrenergic drugs reduce—and, in some cases, completely suppress—sex drive. The use of these medications is completely voluntary, as is all treatment offered by the SBC. Treatment in the SBC can include a combination of medications, group therapy, couples therapy, and individual therapy.
Treatment is provided by a multidisciplinary team, including psychiatrists (Dr. Fedoroff, Dr. Bradford, Brad Booth, M.D., Jonathan Gray, M.D., LL.B., and Dominique Bourget, M.D.), criminologists, an occupational therapist, a social worker, and psychotherapists. The staff also includes a clinic coordinator, laboratory clinician, and research assistants.
As explained by Rakesh Jetly, M.D., who visited the program in August on behalf of the awards committee, “Assessment and treatment are based on a team-centered approach using clinicians and technology to provide the best possible course of action. Dr. Fedoroff is the clear leader and inspires the team, and the passion and commitment by all staff was heartening.”
The SBC is also able to tap the professional skills of IFP staff from nursing, psychology, social work, and criminology. In addition, its location in a teaching hospital that is fully affiliated with the University of Ottawa provides access to university facilities, including specialty clinics, the library, and databases. As for funding, in the past five years the clinic has received more than $2 million in grant funding to support innovative research and clinical work. Psychiatrists generate their own income from clinical (Ontario Health Insurance Plan), third party (such as the CAS), and legal (such as the courts and defense attorneys) billing or receive compensation for administrative duties from The Royal; the Institute of Mental Health Research (IMHR), the hospital’s world-class research facility; or the Faculty of Medicine at the University of Ottawa.
Aiming for Zero
From the beginning, the SBC has had a mission to reduce sexual victimization. Although not the first to use group therapy for sex offenders, the clinic’s variations on the format of the groups have been well received by patients. For example, it conducts groups with a heterogeneous mix of offenders, including patients with different paraphilias, offense histories, and intellectual abilities and both male and female sex offenders. During group sessions, according to one patient, “You can say what you want, and the other members are there for you with information that could help you. You can get all the current information here, and when you leave you have something you take home with you every week.”
In 2010, the SBC introduced another innovative group format called “Friends and Family.” This group is for the “secondary victims” of sexual crimes—spouses and partners of individuals with deviant sexual behaviors. These 90-minute sessions allow friends and family to participate as “guests” of the patients during group therapy.
The SBC also specializes in assessment and treatment of people with intellectual disabilities and regularly includes them in group therapy with other offenders, another example of an innovative group format. The program has assessed and treated hundreds of individuals with developmental disorders at an off-site SBC clinic in Southern Ontario, and lessons learned in the outpatient clinics have informed treatment at the Ottawa clinic.
“I am impressed by the way in which the program has expanded its “reach” to help as many as possible,” said Dr. Jetly. “Including males, females, and the intellectually challenged all in the same open groups is quite innovative,” he added. In fact, in 1999 the Ontario chapter of the National Association for the Dually Diagnosed honored Dr. Fedoroff and Debbie Richards on behalf of the clinic for its outreach to persons with intellectual disabilities and developmental delays.
The clinic is also proud of its association with community partners, such as CoSA, a volunteer group that provides friendship, support, and referrals for services to former offenders. It also collaborates with the high-risk sex offenders unit of the Ottawa police and conducted a public presentation called “Aiming for Zero,” which seeks to eliminate reoffending among persons convicted of sex crimes. “Positive social supports,” according to Dr. Fedoroff, “combined with sexual-behavior counseling and treatment, are key to ensuring former offenders do not fall back into their old patterns, leading to more victims.”
The SBC’s innovations have made it a model for treatment of sex disorders worldwide. It regularly receives and accepts requests from international organizations and scientific conferences to present its innovative work. Recently, the core SBC group (Dr. Fedoroff, clinic coordinator Lisa Murphy, Rebekah Ranger, and Natasha Knack), along with international collaborator Gregg Dwyer, M.D., from the Medical University of South Carolina (MUSC), participated in an invited panel on the assessment, treatment, and community management of sex offenders at Sigmund Freud University for the International Congress on Law and Mental Health in Vienna. Heather Tarnai-Feeley, M.S.W., of the SBC provided an additional invited presentation.
A Primary Prevention Clinic
In recent years, the clinic has adopted a primary care approach to the treatment of sexual disorders. This shift in focus has coincided with an increasing number of referrals—including self-referrals—for persons who have never offended despite problematic sexual interests.
“We are seeing people come in and say ‘I have these interests, I don’t want to have these interests, I don’t want to act on them, and I need help,’” said Lisa Murphy. New patients are typically offered an appointment within 24 hours, and the main delay from initial assessment and commencement of treatment is usually due to the patient’s schedule. In fact, the clinic manages its resources so well that there are virtually no wait lists. Thanks to SBC clinician Rebekah Ranger, assessments are offered in both official languages.
“Our aim is no longer to simply incapacitate people but to prevent sex crimes and improve the lives of former offenders and their families,” explained Dr. Fedoroff. “We are actively involved in true primary prevention of sexual abuse by offering services to men, women, and adolescents before they offend.” In doing so, he said, “the clinic has improved community safety, improved use of criminal justice resources, and the quality of the lives of both the patients and their potential victims.”
“The focus on prevention is an exciting development with the potential to have effects far beyond treatment of an individual patient,” agreed Dr. Jetly. “The idea that we can intervene when people are having thoughts before they act on them is encouraging,” he said. Patients also endorse the focus on prevention. One wrote, “I wish I knew they had a program like this before I committed my offense and I would never be waiting for my trial.”
Education is Essential
Teaching and training are essential elements of the program, said Dr. Jetly. “This program is a model for those that aspire to be a ‘center of excellence,’” he said, adding that a program cannot make significant contributions without a commitment to research and education. The clinic’s education component is especially important, Dr. Jetly noted, in a “murky” clinical domain that is not well understood in mainstream psychiatry.
Through collaboration with the University of Ottawa and Carleton University, the SBC has become a true clinical research center that provides valuable clinical and research experience that students and researchers can apply to multiple fields, including psychiatry, psychology, criminology, nursing, social work, law, and medicine. Dr. Fedoroff and other psychiatrists on the SBC staff conduct seminars for psychiatry residents about paraphilias and contribute lectures to a fellowship seminar series on forensic psychiatry. The SBC has also provided education to probation officers and Children’s Aid Society employees working for the Ministry of Ontario. “Teaching and training open up the program to a scrutiny like no other,” said Dr. Jetly. “Trainees ask questions and demand explanations for approaches that they are seeing. This ensures that the program is committed to best practices and truly understands its craft.”
The increasing focus on prevention has also prompted the clinic to conduct public education about services for curbing deviant sexual interests. For example, the SBC and the high-risk sex offenders division of the Ottawa police recently teamed up for a televised lecture about “Aiming for Zero” (www.youtube.com/watch?v=DQJCS5jGo94), precisely to emphasize the clinic’s success in treating patients with sex disorders. “In the old days, people thought treatment didn’t exist, and if it did, it didn’t work,” Dr. Fedoroff explained. “But that’s not true. Treatment does exist, and it does have dramatic normalizing effects on their interests and behaviors.”
In 2010, the role of the SBC in public education resulted in an invitation to Dr. Fedoroff and Lisa Murphy to testify as experts before the Canadian Senate on Legal and Constitutional Affairs on implications of potential changes to the National Sex Offender Registry. Their testimony contributed to legislative changes for community management of sex offenders and public protection at large.
The SBC also provides expert education to colleagues. For example, in 2009 it conducted a weeklong course for psychiatrists who had been selected by New York State to assess and care for sexually violent offenders. In 2014, the SBC presented peer-reviewed seminars and workshops at the annual meetings of the American Psychiatric Association, the Canadian Psychiatric Associations, and the American Academy of Psychiatry and the Law. In fact, professionals from the United States, Japan, South Korea, the United Kingdom, and elsewhere in Europe have visited the SBC to learn about its innovative approaches to treatment.
The Vital Role of Research
As a component of the IMHR, the SBC is a key driver of the hospital’s research mission. In the past five years, SBC staff have published 73 academic and clinical publications in peer-reviewed journals and books and conducted 255 scientific presentations, lectures, or invited talks around the world. “The clinic recognizes its responsibility to capture, analyze, and report on the valuable data it has compiled,” said Dr. Jetly, and has made research a “core function.” Funding for research has been received from the Canadian Institute of Health Research, the Canadian counterpart of the National Institutes of Health; the Social Sciences and Humanities Research Council; the Ontario Mental Health Foundation; and the University of Ottawa Medical Research Foundation.
As proof of its success as a true clinical research agency, Dr. Jetly noted, virtually every patient voluntarily consents to be contacted for future research. The clinic is particularly proud of its research and clinical interventions on recidivism, which match or outperform those of similar programs. In an effort to more accurately document long-term outcomes, the clinic is currently reviewing over 2,000 independent criminal records of former SBC patients obtained through the Royal Canadian Mounted Police. “Capturing treatment outcomes is key for the community at large to appreciate that there is hope for these often disturbing conditions,” said Dr. Jetly.
Hoping to build on its expertise in the assessment of sexual disorders, the clinic has begun a partnership with researchers at Charles University, in Prague, Czech Republic, and the Medical University of South Carolina to develop new technologies to assess sexual arousal patterns. In November, members of the SBC traveled to Charleston, South Carolina, to test the simultaneous use of functional magnetic resonance imaging and phallometric testing in assessing sexual interest. The research may reveal central nervous system arousal patterns that provide clues to the etiology of pedophilia and improved treatments. The team has also received funding to develop more accurate techniques for phallometric assessment as well as to develop and test universally acceptable stimuli for assessing sexual arousal patterns.
The SBC is also collaborating with Cindy Meston, Ph.D., at the University of Texas at Austin to develop better protocols for assessment of sexual arousal patterns among female offenders. It is also involved in research with Dr. Dwyer of MUSC to test new stimuli using “real child” voices and with Patrice Renault, Ph.D., of the University of Montreal, to test mobile avatars and virtual reality in measuring sexual arousal.
One of the goals of better assessment, according to Dr. Fedoroff, is to test the possibility that deviant sexual arousal patterns can change. In fact, earlier research by the clinic suggests that these patterns are not static. In that study, 21 of 43 patients experienced a significant decrease of sexual arousal in response to pedophilic stimuli and a significant increase of sexual arousal in response to nonpedophilic stimuli. “If verified and replicated, these results will be groundbreaking,” said Dr. Fedoroff, “since it will mean that people with paraphilias can look forward to lives in which they never offend and in which they establish healthy, noncriminal relationships.” The SBC has recently received a grant from the University of Ottawa Medical Research Fund to conduct a prospective study replicating these findings in a larger population.
“You’re not Incurable”
By any measure—treatment, research, and training—the SBC is outstanding and deserving of recognition, according to Dr. Jetly. But perhaps what is most remarkable, he added, is the program’s message—not only does treatment work, but those with distressing sexual fantasies can get help before they criminally act. Its efforts, he said, may help change what has been a hopeless view of recovery among persons with sexual disorders.
As Lisa Murphy explained, “We are seeing more people seek treatment before they offend. This is obviously ideal in that we are able to treat these individuals before they act on their interests and create a victim. More people with problematic sexual interest are learning what we have found is true, ‘You’re not incurable. There is effective, humane treatment for you.’”
