SOCW 6135

Forensic_Mental_Health_Assessment_A_Casebook_----_13_SEX_OFFENDER_SENTENCING.pdf

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Chapter 13

Sex Offender Sentencing

This chapter focuses on considerations in the sentencing of adult sexual offend- ers. The principle preceding the first case addresses the importance of consider- ing both relevance and scientific validity in considering how to seek informa- tion and select data sources in forensic assessment. The teaching point in the first case discusses the strengths and weaknesses of classification systems for sex offenders. The principle associated with the second case in this chapter—use scientific reasoning in assessing the causal connection between clinical condi- tion and functional abilities—discusses the importance of hypothesis formula- tion, testing, falsifiability, parsimony in interpretation, awareness of the limits on accuracy, and the applicability of nomothetic research to forensic mental health assessment. Finally, the teaching point for the second case includes a discussion of the development and empirical underpinnings of taxonomic sex offender typologies and their limitations.

Case 1

Principle: Use relevance and reliability (validity) as guides for seeking

information and selecting data sources

This principle is discussed in some detail in Chapter 9. Therefore, we move directly to address how the present report illustrates the application of this principle.

The first report in this chapter provides a good example of the application of relevance and reliability to the selection of data sources in a FMHA. The purpose of the evaluation was to determine: (1) whether the individual being assessed could be classified as “repetitive and compulsive,” which would place him under the New Jersey Sex Offender Act (making him eligible for special- ized treatment services and subject to increased community notification re- quirements); (2) what risk the individual being assessed presented to the com- munity; and (3) a suitable treatment plan. Generally, statutes such as the New Jersey Sex Offender Act (1997) require that (1) the offense be sexual (usually

259 Heilbrun, Kirk, et al. Forensic Mental Health Assessment : A Casebook, Oxford University Press, 2002. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/waldenu/detail.action?docID=241493. Created from waldenu on 2021-02-07 21:13:04.

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260 • Forensic Mental Health Assessment

involving force, aggression, or minors), (2) the conduct be repetitive (actual demonstration of specific past offenses is not always required—repetition may be satisfied by the prediction of future conduct), (3) there is a mental illness (broadly defined), and (4) a treatment plan is needed (Melton et al., 1997). In this case, relevance and reliability served as guides for determining which sources of information should be considered in addressing the requirements of the New Jersey Sex Offender Act.

We noted earlier that relevance in a forensic context can be considered by describing the logical basis for a connection between a mental health construct and the relevant forensic issue(s). In this case, the forensic clinician was asked to provide a risk assessment and to determine if the individual being assessed was “repetitive and compulsive” in his behavior. There are a variety of mental health constructs and historical data that might be relevant to these forensic issues, with some data sources more relevant than others when the forensic issues are considered.

For example, in this report, the forensic clinician chose historical and psy- chometric data sources that are directly relevant to the forensic issues being considered. Specifically, the New Jersey Sex Offender Act requires repetitive and compulsive behavior and the presence of a mental illness, broadly defined. Relevant historical information was obtained through a collateral document review and a clinical interview. These sources of information revealed a pattern of sexual offending over a period of years, and a history of recurrent behavior in both sexual and nonsexual areas that might be relevant to the forensic issue of repetitive and compulsive. The personality characteristics suggested by his- tory relevant to this forensic characteristic were measured, in part, using psy- chological testing. Specifically, the Million Clinical Multiaxial Inventory-III (MCMI-III; Millon, 1994)—a measure designed to assess personality style, the presence of specific symptom patterns, and the presence of severe mental dis- orders—suggested paraphilias focusing on child molestation, sexual coercion, and exhibitionism. In addition to verifying the self-report of the individual, the MCMI-III suggested the presence of a DSM-IV disorder (paraphilia), which is required under the New Jersey Sex Offender Act. The use of the MCMI-III also provided some empirical evidence about the strength of the relationship between such profiles and paraphilia, based on the empirical data used to vali- date the instrument.

Additional examples of empirically relevant measures can be found in the risk assessment section of the report. The Multiphasic Sex Inventory (Nich- ols & Molinder, 1984) was used to describe the individual’s static and dynamic risk factors for sexual reoffending. This tool was constructed after review of available empirical studies on sex offender characteristics and recidivism rates. It is not supported by empirical research performed specifically with using the MSI and validated against the outcome of sexual reoffending with large sam- ples across multiple studies. However, it does use risk factors that are com- monly cited in the literature, allowing a better description of empirically rele- vant (as opposed to empirically validated) risk factors.

Heilbrun, Kirk, et al. Forensic Mental Health Assessment : A Casebook, Oxford University Press, 2002. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/waldenu/detail.action?docID=241493. Created from waldenu on 2021-02-07 21:13:04.

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Sex Offender Sentencing • 261

PSYCHOLOGICAL REPORT • Registrant Risk Assessment Scale The RRAS is an instrument developed by the New Jersey Attorney General’sName: John J Office to evaluate and place sex offend-Age: 45 years ers in risk tiers. It evaluates seriousnessDate(s) of Examination: 9/8/98 of the offense, characteristics of the of-Examiner: Philip Witt, Ph.D. fender, characteristics of the offense, and community support.

REASON FOR REFERRAL

REVIEW OF DISCOVERY MATERIALSMr. J was referred for a psychological evaluation by his attorney, Robert Singleton, Esq., after hav- The records indicate that Mr. J has been charged ing been charged with sexually abusing a 9-year- with one instance of fondling the vaginal area of old girl. Mr. Singleton requested opinions as to: a 9-year-old girl; the girl reported digital penetra-

tion during this offense. He has two prior sexual1. whether Mr. J is repetitive and compul- charges for exposing himself to teenage girls.sive, which would place him under the These prior charges resulted in probation in mu-purview of the New Jersey Sex Offender nicipal court.Act, thus making him eligible for the spe-

cialized treatment services (and increased community notification requirements) as- INTERVIEW OF JOHN J sociated with such a finding,

Mr. J presented as a tall, thin white male who2. what risk Mr. J presents to the commu- appeared his stated age. He was oriented to time,nity, and

3. what treatment plan would be suitable for place, and person. His thought processes, as as- Mr. J? sessed through the interview, were relevant and

coherent. There were no signs of hallucinations or delusional thinking, or of suicidal thoughts orSOURCES OF INFORMATION intent. In summary, there was no evidence of a

1. Individual interview of John J. thought disorder. 2. Review of Discovery materials. Throughout the interview, Mr. J was open, 3. Psychological assessment instruments: verbal, and cooperative. He answered all ques-

• Millon Clinical Multiaxial Inventory-III tions and provided information spontaneously, of (MCMI) his own accord. In fact, he readily recounted his The MCMI is a 175 true-false objective

life history in detail, requiring very little prompt-personality test designed to assess per- ing. Included in this life history were a variety ofsonality style, presence of specific symp- actions that cast him in a non-flattering light, sug-tom patterns, and the presence of se- gesting a high level of candor. He showed pres-vere mental disorders. The MCMI also sured speech; it was difficult to get a word inhas validity scales that evaluate the atti-

tude with which the individual an- edgewise once he began his account of his life. swered the test questions. In his junior year in high school, he began a

• Multiphasic Sex Inventory (MSI) romantic relationship with a female high school The MSI is a 300-item objective person- classmate with whom he had sexual intercourse. ality test specifically standardized on a By his senior year, however, he was dating four sex offender population. Its scales mea- or five different high school girls, and had sexual sure qualities of relevance in assessing

intercourse with two or three. He hid all of thesesex offenders, such as extent of justifi- relationships from his then-girlfriend. During col-cations of deviant sexual practices, de- lege, Mr. J became, by his own description, evengree and type of deviant sexual fantasies more sexually promiscuous. He had sexual rela-and deviant sexual behavior, presence tions with scores of age-appropriate women, onof specific fetishes, presence of sexual

dysfunctions, and sexual history. more than one occasion contracting sexually trans- Heilbrun, Kirk, et al. Forensic Mental Health Assessment : A Casebook, Oxford University Press, 2002. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/waldenu/detail.action?docID=241493. Created from waldenu on 2021-02-07 21:13:04.

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262 • Forensic Mental Health Assessment

mitted diseases. Throughout college, he ostensi- while high school girls were walking home from school. In 1993, he was arrested for exposingbly had a steady girlfriend, but without her knowl-

edge, he was having sexual relations with a vari- himself while in his car to teenage girls near a high school. This led to a charge for exhibition-ety of other women. He also began frequenting

massage parlors for casual sexual encounters with ism, eventually pled down to municipal disor- derly persons charges.prostitutes.

During high school, he began to engage in He then began psychiatric treatment with Martin Clark, M.D., who prescribed Prozac. Hesports betting. By college, he was heavily in debt

because of his betting, and his father settled his also began attending Gamblers Anonymous meet- ings, but has had a number of gambling relapses.debts on more than one occasion. His involve-

ment with gambling has continued intermittently Unfortunately, Mr. J has had a serious relapse with regard to deviant sexuality. This year he fon-to the present. He described times when he would

be obsessed with sports betting, on the phone dled the genitals of a 9-year-old girl under her bathing suit in his swimming pool. He acknowl-continually with bookies and forever looking for

a big win that would recover his losses. edged digitally penetrating the girl during this in- cident. At the time he was experiencing strongMr. J reported that since his early teens, he

has felt sexually attracted toward younger girls. pedophilic urges, and he impulsively put his hand under the girl’s bathing suit.On one occasion in his teens, he slept at his cous-

in’s home, and he went into a younger cousin’s Mr. J expressed distress regarding his actions. He considers himself to have a serious sicknessbedroom and masturbated in her presence.

After graduating college, Mr. J attended op- and appears highly motivated to do whatever necessary to prevent any recurrences.tometry school; during optometry school, he vis-

ited massage parlors approximately every other week. At the same time, he dated age-appropriate

PSYCHOLOGICAL TEST RESULTS women. He eventually married his then-girlfriend. During his marriage, Mr. J increased his gambling On the MCMI-III, Mr. J presented himself in a

negative manner. His self-esteem is low. He viewsand frequented massage parlors more often, sometimes as often as four times per week. He himself as having done many reprehensible things

in his life and berates himself as a result. He is athen began masturbating while driving in his car. He would cover his penis with a map or newspa- depressive, pessimistic man who has a bleak, neg-

ative view of himself, his life, and the future.per, pull over, and ask teenage girls directions while sexually aroused. He occasionally exposed These characteristics were evident in his re-

sponses of “true” to: “I’ve had sad thoughts muchhimself to adult women as well; once he drove completely naked on the NJ Turnpike, obtaining of my life since I was a child”; “I’ve always had a

hard time stopping myself from feeling blue andchange for his toll from a startled female toll- taker. He convinced himself that he wasn’t harm- unhappy”; “I’ve never been able to shake the feel-

ing that I’m worthless to others”; and “Even ining anyone (other than himself), so he continued this activity throughout his first marriage. good times, I’ve always been afraid that things

would soon go bad.”During 1990, his sexual compulsivity led to serious consequences: He was arrested for lewd- His MCMI results indicate that he has a deep

self-defeating streak. He acts impulsively, causingness. He had masturbated in his car while watch- ing two teenage girls rollerskating. One of the disruptions in his life and the lives of his loved

ones. He finds it difficult to control his rash, reck-girls felt threatened, and she notified the police. He received probation on the condition that he less acts, after which he experiences deep guilt

and contrition. His moods can fluctuate wildlyenter psychotherapy; unfortunately, he did not discuss his pedophilic sexual urges openly while depending on whether he has recently experi-

enced some unpleasant consequence of his im-in treatment. Rather, he convinced his therapist that he was guilty only of poor judgment—having pulsive actions.

On the MSI, Mr. J displays a high level of sex-been inadvertently seen masturbating in his car. Through the 1990s, Mr. J frequented streets ual drive and interests; he appears preoccupied

with sex and acknowledges significant difficultynear local high schools, masturbating in his car Heilbrun, Kirk, et al. Forensic Mental Health Assessment : A Casebook, Oxford University Press, 2002. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/waldenu/detail.action?docID=241493. Created from waldenu on 2021-02-07 21:13:04.

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Sex Offender Sentencing • 263

controlling his sexual urges. He also reports a petitive; these acts have continued despite legal consequences and Mr. J’s best efforts to cease.variety of thoughts and urges regarding serious

paraphilias, focusing on child molestation, sexual Moreover, he has a history of compulsive sexual- ity in a variety of areas. Consequently, in mycoercion, and exhibitionism. He reports interest

in a variety of lower level paraphilias as well, in- opinion Mr. J is repetitive and compulsive. cluding voyeurism, obscene phone calls, and bond-

What risk does Mr. J present to the community?age and discipline. His MSI in general indicates On both risk assessment scales, Mr. J scores ina high level of paraphilic interest and substantial

the moderate risk range. He receives a score ofdifficulty managing his urges. 72 points on the RRAS, and a score of 9 points on the ASORAS. His risk total is higher than that

RISK ASSESSMENT of the typical probationer, more similar to that of an individual incarcerated at New Jersey’s spe-On the RRAS, Mr. J receives a score of 72, plac- cialized sex offender treatment facility, the Adulting him at the upper limit of the moderate risk Diagnostic and Treatment Center. His illegal sex-range (37 to 73 points). He receives many points ual acts have escalated from his exposing himselffor seriousness of offense, involving digital pene- to minor females to his present hands-on offense.tration of a young victim, and the extensiveness

and duration of his illegal sexual activity, involv- What treatment plan would be suitable for Mr. J?ing years of gradually escalating exhibitionistic ac- It is my opinion that Mr. J requires intensive,tivity focused on teenage girls and culminating in

long-term, sex-offender-specific treatment. I rec-the instant offense with a prepubescent girl. ommend the following treatment plan:

1. Relapse prevention training: Mr. J shouldINTEGRATION OF FINDINGS complete relapse prevention exercises de-AND RECOMMENDATIONS signed to increase his awareness of the in-

John J is a 45-year-old optometrist presently ternal (emotional) and external (situa- charged with sexually abusing a 9-year-old girl. tional) risk factors that led to his deviant Mr. J has a long history of sexual interest in minor sexual behavior. Presently, he has little

awareness of these factors, particularly offemales, which has resulted in two prior charges the internal factors.for exposing himself to teenage girls. He has

2. Victim empathy: Mr. J should completestruggled to manage his urges toward young fe- victim empathy exercises. Such exercisesmales for many years. Unfortunately, his behavior are designed to raise the awareness of therecently escalated to an offense involving physical patient to the negative emotional conse-contact with a young victim. quences that his actions have had on the

Mr. J also has a long history of compulsive victim. gambling. During high school, he began sports 3. Sexual reconditioning exercises: Conserva- betting, and by college, his father had to settle his tive treatment would require that he com- gambling debts on more than one occasion. He plete sexual reconditioning exercises de- had to take a loan from his father 10 years ago to signed to help him disrupt and moderate

any deviant sexual arousal that might besettle additional gambling debts. He has managed present. Mr. J reports strong pedophilicto avoid heavy gambling debts since then, al- urges, and he lacks the skills to effectivelythough he still has difficulty with strong impulses disrupt such urges.to gamble.

4. Sex offender treatment group: Involve-I will address the referral questions in turn. ment in a sex offenders treatment group would have a variety of benefits for Mr. J.

Is Mr. J repetitive and compulsive? First, he would have a support group to Mr. J’s pattern of illegal sexual behavior ex- whom he could talk openly regarding his

tends over a period of years and has escalated in offense, a support group that he would his current offense. On the sexual preoccupation feel would not reject him for having com- factor of one risk assessment scale, he scored mitted an illegal sexual act. Second, he

would be able to receive feedback fromquite high. His illegal sexual acts are clearly re- Heilbrun, Kirk, et al. Forensic Mental Health Assessment : A Casebook, Oxford University Press, 2002. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/waldenu/detail.action?docID=241493. Created from waldenu on 2021-02-07 21:13:04.

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264 • Forensic Mental Health Assessment

other offenders regarding his rationaliza- ated for a mood-stabilizing agent—such as lithium—as well. His pressured speech intions and justifications for having commit-

ted the deviant sexual acts. Frequently, the interview and his history of impulsive, excitement-seeking behavior and sexualsuch feedback has more impact from

other offenders than from a treating pro- compulsivity suggest the possibility of hy- pomania, so a mood-stabilizing agent mayfessional.

5. Individual psychotherapy: Mr. J requires be helpful. 7. Continued involvement in Gamblersindividual treatment focused on broader

personality issues, such as his reckless, Anonymous: Mr. J has a longstanding gam- bling problem. He has been productivelystimulation-seeking interpersonal style,

which may be related to his offenses. His involved in Gamblers Anonymous, and he needs to maintain his involvement in acompulsive gambling is one indicator of

this problem and would need to be ad- gambling-related support group. dressed in treatment as well.

6. Medication review: Mr. J is presently be- Philip Witt, Ph.D.ing prescribed Prozac, an antidepressant. I

suggest that he be psychiatrically evalu- Diplomate in Forensic Psychology, ABPP

Teaching Point: Strengths and weaknesses of classification systems

Classification systems for sex offenders were in existence in the 1960s. How- ever, current classification systems owe much of their development to the sem- inal work of Nicholas Groth (Groth & Birnbaum, 1979), who proposed that child molesters could be considered either fixated or regressed, with fixated offenders having sexual interest patterns focused entirely on children and re- gressed offenders having adult-oriented sexual interest patterns, but lapsing back under stress to earlier sexual attachment figures. Rapists, in Groth’s framework, were motivated by power, anger, or sadism. While intuitively ap- pealing, Groth’s child molester and rapist taxonomy systems remained specula- tive, with no empirical support.

While many sex offender taxonomy systems exist, most lack empirical sup- port, as does Groth’s. As a consequence, in the 1980s, Knight and Prentky (Knight, 1988, 1989; Knight & Prentky, 1987) empirically validated a sex of- fender taxonomy system, perhaps the best validated system to date. Knight and Prentky’s child molester typology system involved two decision trees. The first decision tree, or axis, had decisions for level of sexual fixation on children and level of social competence. The second decision tree had decisions for amount of contact with children, extent of physical injury, meaning of the sexual contact (purely exploitive or interpersonal), and sadistic or nonsadistic motivation. Knight and Prentky’s rapist taxonomy focused on the motivation of the rapist—opportunistic, pervasively angry, sexual, or vindictive—with high and low social competence decisions within most of these motivational types.

Such taxonomies can serve a number of purposes. First, they can help clinicians and researchers think clearly about sex offenders by carefully examin-

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Sex Offender Sentencing • 265

ing the characteristics of the individual offender under consideration. Second, taxonomy systems are useful for treatment planning, allowing treatment needs to be clarified. For example, a sex offender with a high degree of pedophilic sexual fixation and drive might be suitable for sexual reconditioning exercises or medication to dampen sex drive. Third, a taxonomy can guide research. Different subgroups might have different recidivism rates or respond differen- tially to treatment interventions.

Although initially promising, taxonomy systems have generated relatively little discussion or research in recent years. More effort has been devoted to developing sex offender risk assessment scales, such as the Mn-SOST-R (Ep- person, Kaul, & Hesselton, 1998), Static-99 (Hanson, 2000), HCR-20 (Web- ster, Douglas, Eaves, & Hart, 1997), and RRAS (Witt, DelRusso, Oppen- heim, & Ferguson, 1996; Ferguson, Eidelson, & Witt, 1998). Such tools are used in different jurisdictions to place sex offenders in risk tiers, which are then used in accord with community notification and civil commitment stat- utes. Much of the same information can be gathered from a risk assessment instrument, which systematically samples criteria empirically associated with relapse. Not surprisingly, factor analytic studies of these instruments show two stable predictive factors: a psychopathic, antisocial personality or lifestyle, and a paraphilia (Witt et al., 1996).

Case 2

Principle: Use scientific reasoning in assessing the causal connection between

clinical condition and functional abilities

This principle describes the importance of using scientific reasoning in FMHA. Several aspects of scientific reasoning are particularly relevant to this principle. These include hypothesis formulation and testing, falsifiability, parsimony in interpretation, and awareness of the limits on accuracy. These in turn affect the applicability of nomothetic research to the immediate case.

In any FMHA, there may be several competing explanations for the clinical symptoms or personality characteristics, deficits in relevant legal capacities, and causal relationship between the two. An important goal in FMHA is to test these competing “hypotheses” to determine which is best supported by the available data. For such hypothesis testing to be meaningful, however, the hypotheses must be evaluated in a way that allows them to be fairly tested, and rejected when they are not supported.

Sources of ethics authority in psychology provide direct support for the application of several kinds of scientific reasoning in FMHA, including hypoth- esis testing, the application (and misapplication) of psychological assessment

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266 • Forensic Mental Health Assessment

procedures, and the parsimonious interpretation of psychological test results. The Ethical Principles of Psychologists and Code of Conduct (APA, 1992) con- tains several sections relevant to this principle. Appropriate operationalization depends, to some extent, on selecting procedures that have been developed for a purpose comparable to the purpose of the evaluation: “Psychologists who develop, administer, score, interpret, or use psychological assessment tech- niques, interviews, tests, or instruments do so in a manner and for purposes that are appropriate in light of the research on or the evidence of the usefulness and proper application of the techniques” (APA, 1992, p. 1603). Selecting inappropriate procedures can adversely affect the successful operationalization of variables. This error would limit the overall accuracy of the findings and the extent to which nomothetic results would be applicable:

Psychologists refrain from misuse of assessment techniques, interventions, results, and interpretations. . . . Psychologists do not base their assessment of intervention decisions or recommendations on data or test results that are outmoded for the cur- rent purpose. . . . Similarly, psychologists do not base such decisions or recommen- dations on tests and measures that are obsolete and not useful for the current pur- pose. (p. 1603)

The Ethics Code also addresses the importance of personal contact with the individual being evaluated: “Except as noted . . . , psychologists provide written or oral forensic reports or testimony of the psychological characteristics of an individual only after they have conducted an examination of the individ- ual adequate to support their statements or conclusions” (1992, p. 1610). In this context, personal contact is important because it can facilitate hypothesis formulation and testing. When personal contact is not possible, hypothesis test- ing is considerably more difficult, as the evaluator cannot observe the reaction of the individual to specific questions or procedures.

When, despite reasonable efforts, such an examination is not feasible, psy- chologists “clarify the impact of their limited information on the reliability and validity of their reports and testimony, and they appropriately limit the nature and extent of their conclusions or recommendations” (APA, 1992, p. 1610). Finally, the Ethics Code addresses the interpretation of FMHA results in two ways. The first involves the applicability of validation research for a test or procedure used with an individual:

Psychologists attempt to identify situations in which particular interventions or as- sessment techniques may not be applicable or may require adjustment in administra- tion or interpretation because of such factors as individuals’ gender, age, race, ethnic- ity, national origin, religion, sexual orientation, disability, language, or socioeconomic status. (p. 1603)

Second, the Ethics Code addresses the interpretation of FMHA test results:

Psychologists recognize limits to the certainty with which diagnoses, judgments, or predictions can be made about individuals. . . . When interpreting assessment results

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Sex Offender Sentencing • 267

. . . psychologists take into account the various test factors and characteristics of the person being assessed that might affect psychologists’ judgments or reduce the accu- racy of their interpretations. (p. 1603)

Support for the use of scientific reasoning in FMHA, particularly hypothe- sis testing, can also be found in the ethical guidelines for both forensic psychol- ogy and psychiatry. The Specialty Guidelines for Forensic Psychologists (Commit- tee on Ethical Guidelines for Forensic Psychologists, 1991) emphasizes the value of hypothesis testing:

In providing forensic psychological services, forensic psychologists take special care to avoid undue influence upon their methods, procedures, and products, such as might emanate from the party to a legal proceeding by financial compensation or other gains. As an expert conducting an evaluation, treatment, consultation, or scholarly/empirical investigation, the forensic psychologist maintains professional in- tegrity by examining the issue at hand from all reasonable perspectives, actively seek- ing information that will differentially test plausible rival hypotheses. (p. 661)

Similarly, the Ethical Guidelines for the Practice of Forensic Psychiatry (AAPL, 1995) indirectly supports hypothesis testing by emphasizing the distinction between “verified” and “unverified” information.

Legal support can also be found for this principle. Both the U.S. Supreme Court’s decision in Daubert (1993) and the Federal Rules of Evidence under- score the importance of reasoning in cases involving scientific evidence.1 In Daubert, the Supreme Court, in dicta, used the phrase “reasoning or methodol- ogy” in outlining the criteria that might be used to determine the scientific validity of the evidence. The Daubert opinion also suggested that the Supreme Court took a broad view of “science,” with both data and reasoning considered as expert evidence.

Rule 703 of the Federal Rules of Evidence provides some role for reasoning in FMHA: “The facts or data in the particular case upon which an expert bases an opinion or inference may be those perceived by or made known to the expert at or before the hearing.” The nature of this reasoning is elaborated in Rule 702: “If scientific, technical, or other specialized knowledge will the assist the trier of fact to understand the evidence or determine a fact in issue, a witness qualified as an expert by knowledge, skill, experience, training, or edu- cation, may testify thereto in the form of an opinion or otherwise.”

There is relatively little empirical evidence regarding the role of scientific reasoning in FMHA. However, one recent study involving forensic psycholo- gists and psychiatrists examined the perceived desirability of various elements of FMHA, including elements that are clearly relevant to reasoning (Borum & Grisso, 1996). In rating the value of providing a “mental illness rationale” that describes how the examiner reached an opinion about the presence/absence and degree of mental illness, the majority of responding psychologists and psy- chiatrists rated this rationale as either essential or recommended. Other ele- ments of FMHA relevant to reasoning were also strongly endorsed, with more

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268 • Forensic Mental Health Assessment

than 75% of responding psychiatrists and psychologists rating each as either essential or recommended (Borum & Grisso, 1996).

Heilbrun (1992) stressed the importance of reasoning in FMHA, particu- larly in the context of hypothesis formulation, testing, and test interpretation. He compared the process of FMHA to a scientific experiment:

Following the formulation of falsifiable hypotheses, the verification process can pro- ceed much as it would in a scientific experiment. Does the defendant exhibit behav- ior consistent with the presence of the hypothesized psychological characteristic? (A researcher might call this construct validity.) Does the defendant show the absence of behaviors that are not consistent with the presence of the hypothesized construct? (We could analogize this to discriminant validity.) The remaining task is then to offer conclusions in terms that reflect the consistency of support for the hypothesis that was framed in psychological rather than legal terms (e.g., psychosis, cognitive awareness and volition rather than insanity). (p. 269)

The present report provides a good illustration of this principle. The evalu- ation was conducted to determine the individual’s risk to others and treatment needs and amenability in the context of a specialized sentencing evaluation. The evaluator demonstrates the applicability of scientific reasoning in the oper- ationalization of variables (through the selection of appropriate and relevant testing procedures), hypothesis formulation and testing, parsimonious interpre- tation, and an awareness of the limits on accuracy.

The evaluator selected psychological tests that were relevant to the pur- pose of the evaluation. For example, because the individual presented with a history of sadistic sexual fantasies, the evaluator selected tests that would pro- vide information in this area. Hypothesis formulation and testing was facili- tated through the evaluator’s personal contact with the individual, which al- lowed the evaluator to observe the reactions of the individual to specific lines of questioning. These observations were subsequently integrated into the “Clinical Impressions” section of the report.

The evaluator also used scientific reasoning in the interpretation of the psychological test results and considered the characteristics of the individual that could potentially affect the accuracy of interpretation of test results. For example, the evaluator considered conflicting data from the clinical interview when interpreting test results. This facilitated a parsimonious, “best” explana- tion for the existing clinical symptoms and relevant personality characteristics.

The evaluator supported his conclusion about the individual’s level of risk by referring to data gathered throughout the evaluation. Specifically, the evalu- ator indicated that the level of risk for violence toward self or others was based on factors such as the individual’s history of violence and violent fantasies, feelings of anger and low threshold for insults, history of alcohol and drug abuse, lack of compliance with medication, and blurring of fantasy and reality.

Finally, the evaluator recognized the limits on the accuracy of his data, reasoning, and conclusions. In making a prediction about the individual’s future behavior, the evaluator clearly specified the behavior being predicted. For ex-

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ample, the evaluator stated that the individual “is at very high risk to engage in acts of extreme interpersonal violence” (emphasis added). This specification of outcome limits the scope of the prediction being made, and facilitates the communication of a particular conclusion. The information obtained in this evaluation did not allow a conclusion regarding the likelihood of success in therapeutic intervention, however, as the evaluator conveyed the limits on ap- plicability of these FMHA data.

FORENSIC EVALUATION be designated as a sexual predator, defined as “any person convicted of a sexually violent act

March 31, 1999 under Section 9793 (B) and who suffers from a Re: John D. mental abnormality, or personality disorder which

makes that person likely to engage in predatory violent offenses.”REASON FOR REFERRAL

John is a 24-year-old Caucasian male who was FOCUS AND CONDUCT convicted of Sexual Battery, which occurred on OF THE EVALUATION 2-10-98, and is awaiting sentencing. A forensic

The evaluation took place over an 8-hour periodpsychological evaluation was ordered pursuant to on March 15–16, 1999. The evaluation included42 Pa. Con. Stat. § 9794, as amended in 1996, to a 5-hour interview with John, 2 hours of psycho-be conducted by a member of the Sexual Of- logical testing, and a 1-hour psychiatric consulta-fender Assessment Board to provide the sentenc- tion regarding medication. He was informed prioring court with the following information: to the beginning of the evaluation that it was be-

• age of the offender ing conducted to assist the court at sentencing, • offender’s prior criminal record, sexual of- that a report would be written describing the fenses as well as other offenses findings of the evaluation, and that testimony of

• age of victim the undersigned at sentencing was also possible. • whether the offense involved multiple vic- The interview with John included inquiry into tims

his family, developmental, victimization, educa-• use of illegal drugs by the offender tional, social, sexual, vocational, and psychiatric• whether the offender completed any prior history. In addition to gathering historical infor-sentence and whether the offender partici- mation that might shed light on his current levelpated in available programs for sexual of- of functioning, we focused on his understandingfenders

• any mental illness or mental disability of of the sadistic fantasies and behavior associated the offender with his recent conviction.

• the nature of the sexual contact with the Psychological testing included the administra- victim and whether the sexual contact was tion of the Millon Clinical Multiaxial Inventory- part of a demonstrated pattern of abuse III (MCMI), a widely used standardized personal-

• whether the offense included a display of ity test that examines distinctive, longstanding unusual cruelty by the offender during the

features of personality, such as depression, anxi-commission of the crime, and ety, social discomfort, passivity, dependence, self-• any behavioral characteristics that contrib- confidence, and aggression, as well as acute symp-ute to the offender’s conduct. toms; Briere’s Trauma Symptom Inventory (TSI); Putnam’s Dissociative Experiences Scale (DES);This information is to be provided to assist the

court in determining whether the defendant shall Speilberger’s State Trait Anger Expression Inven-

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270 • Forensic Mental Health Assessment

tory (STAXI); the Beck Depression Inventory in Hell. During one visit to California to see his stepfather, he (stepfather) arranged a surprise re-(BDI); and Davis’s Interpersonal Reactivity Index

(IRI), a multidimensional measure of empathy. ligious ceremony that was intended to rid John of homosexuality.Because of his high level of distress after com-

pleting the above-mentioned tests, I decided not John stated that he loved his mother and hated her at the same time. He described beingto have him complete the two remaining compo-

nents of the battery that focus on sexual fantasies enmeshed with his mother and that he continues, to this day, to be enmeshed with her. He re-and behavior (New England Sexual Compulsive

Disorder scale and the Multidimensional Assess- marked that he loved her because she could be fun to be with, and she was proud of him. Whenment of Sex and Aggression). asked why he hated her, he stated that he was always receiving confusing and disturbing mes- sages from her. At times she could be very fair in

FAMILY AND VICTIMIZATION her treatment of him, and at other times she

HISTORY would lash out at him in a loud angry voice and smack him in the face. He said that, “this was herJohn stated that he was an only child born to un-

wed parents on February 9, 1975. He reported rage,” commenting that his mother would fre- quently give him the silent treatment, whichthat his home environment was unstable, and

that his father was a drug addict who was not would make him feel, “Like I had no ID. I felt like nothing.” He also reported that his motherinvolved with his care. During his childhood, he

lived in many places with his mother and her nu- had improper physical boundaries. He stated that, “When she hugged me, it was too close, toomerous boyfriends. He recalled no memories of

his father prior to the age of 8. He stated that his hard, long and lingering.” He noted that he often felt like a surrogate husband to his mother, be-mother told him that his father would visit him,

but he has no recollection of these visits. At age cause whenever it was time to kiss her goodnight, she would stick her tongue out. He also recalled8, he recalled playing with and smelling some-

one’s feet. He recalled that it was dark, he was slow dancing with his mother at parties. Al- though he has vague memories of sleeping withscared, and that there were other people there.

He further recalled that, “Something really bad his mother, he did not recall being sexual with her. He denied, moreover, ever being sexuallyhappened. I don’t know why, but it scares me

when I think about it.” He reported a fragment aroused by his mother. Although John recalled these behaviors when he was as young as 6 yearsof another memory in which his father’s hands

were pulling his knees apart. He stated, “I wanted old, it seemed to get worse after his father died. John was 8 years old at the time, and he remem-to be asleep. I remember looking down like I was

on the ceiling, sort of floating.” He reported being bered that his mother started calling him “Daddy.” He stated that her inappropriate behavior alwaysvery scared of men and feeling particularly vul-

nerable at night. made him feel “silly and uncomfortable.” He reported that because of his mother’s fre-John reported that his father died when John

was 9 years old. His mother married after his quent moves, he spent a considerable time living with his maternal grandparents. He stated thatdeath, and John attempted to get close to his

stepfather. He stated that these attempts always his grandmother was frequently intrusive and had very improper boundaries. He reported that sheended in failure, and that he was estranged from

his stepfather for many years. At the age of 20, would walk in on him when he was changing his underwear and would always find an excuse towhen he was a college student, he initiated con-

tact with his stepfather. He always had “bad feel- come into the bathroom and wipe him after he made a bowel movement. He never questionedings” about these meetings. Despite his attempts

to gloss over his stepfather’s neglect, he could his grandmother’s intrusive behavior, stating that “I felt it was necessary.” John added that he didn’tnever forgive him. His stepfather could not ac-

cept his homosexuality, stating that he (step- realize his grandmother’s behavior was inappro- priate until later.father) told him that he (John) was going to burn

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Sex Offender Sentencing • 271

PSYCHIATRIC HISTORY summer after high school when he began drink- ing beer more frequently and started drinking

John has an extensive psychiatric history, which hard liquor. He also reported that he began

is briefly reviewed below. smoking marijuana during the summer after high school. He stated that he drank at least three bot-

1992 [age17]: inpatient psychiatric commit- tles of beer daily while in college, and that he

ment for sexually assaulting a 13-year-old. smoked marijuana four times per week. He beganJohn strangled the victim and fantasized that to cut classes in order to get high and often drankhe would render him unconscious and play until he blacked out. He admitted that he triedwith his feet cocaine, crack, and amphetamines. He stated that1994 [age 19]: inpatient psychiatric stay. He his more recent use of alcohol and drug was tosigned himself in because he feared hurting avoid painful memories and to bring back his sexsomeone. drive, which the Provera dampens.1995 [age 20]: drug rehabilitation. He reported that he has had several periods of

1996 [age 21]: suicide attempt (liquor and an- sobriety since he joined AA in 1994. His longest

tidepressants). period of sobriety was for 3 years. His last re-

1997 [age 22]: inpatient psychiatric commit- ported use of alcohol was February 7, 1999. His ment for depression and fear of violent fanta-

last reported use of marijuana was February 11, sies.

1999. 1998 [age 23]: inpatient psychiatric commit- ment for depression and suicidal ideation.

1999 January [age 23]: inpatient psychiatric EDUCATION AND SOCIALIZATIONcommitment for suicidal ideation. He stated HISTORYthat, “I was feeling real bad over not feeling

anything about strangling my friend’s friend. I John stated that school was his lifesaver. He at-was still masturbating over the strangulation tended high school in a suburb of Boston, MA.incident.” He stated that he was an A student. He reported that he had several friends, but he would not callWhen asked about his history of suicidality, them close friends. He had one best male friendJohn reported that most of his suicide attempts in high school, with whom he was infatuated. Heresulted from his “disgust” with his homicidal fan- stated that his friend was never aware of his infat-tasies and impulses. He reported that his most re- uation.cent psychiatric hospitalization was because he He reported that he attended college for awas despondent over breaking up with his boy-

year, then dropped out during the first semesterfriend and feeling “unworthy.” of his sophomore year due to drug and alcohol abuse. He stated that he was “an emotional wreck” during this time period. He told peopleCURRENT MEDICATION that he had Huntington’s Disease so that people would feel sorry for him and hug him. WhenProvera, 20 mg q A.M. questioned further about this, he stated that, “It’sFluoxetine, 20 mg, IV tab Q.D. a great cop out. If you can’t handle somebody

Trazodone, 100 mg, I tab q hs feeling angry with you, you try to get them to feel

Depakote, 250 mg, II caps q A.M., II caps q sorry for you.” During this time period, his favor- eve, I cap q noon ite television shows were Batman and The Wild

Wild West, because they played out his fantasy of one male getting hurt while the other male rushes

SUBSTANCE ABUSE HISTORY in to comfort him. He stated that, “In movies, the man had to be dying to be held.”John reported that he started drinking in high

school, mostly beer on weekends. He reported He called himself a “chameleon,” because while in college he associated with many differentthat his alcohol consumption escalated during the

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272 • Forensic Mental Health Assessment

types of people such as “jocks, band members, victims, he hasn’t always been sure that his victim was alive when he left. He reported that the lastand nerds.” He reported that he had a girlfriend

in college, but he could only get aroused by her time that he acted on his fantasies was in October 1997, when he attacked and strangled a youngif he fantasized about his male roommate.

He reported having had approximately 10 man that he picked up in a bar and brought home. He stated that he was about to drown hismale sex partners since leaving college in 1995.

He described these relationships as “healthy, with victim in a trash can when the victim became semiconscious and pleaded for his life. He re-lots of touching, kissing, and hugging.” John re-

ported that he had no violent fantasies in these ported that he remembers thinking at the time, “If I keep going, he will die. If I stop, he will live.”relationships. He stated that his last male lover

lasted approximately 6 months. The relationship He further stated that, “The fantasy was that I could get away with it and hide the body.” Hisended in December 1998 because his lover

wouldn’t commit to him. He said that he felt fantasized victims are mostly white, slim, emo- tionally unavailable men.“unworthy” and began having increasingly intense

suicidal and homicidal fantasies. His drug use in- creased in response to distress from the fantasies.

RESULT OF PSYCHOLOGICAL He was hospitalized approximately 1 month later.

TESTING

John’s score on the Beck Depression Inventory SEXUAL AND HOMICIDAL FANTASIES

places him in the severe range, indicating the presence of clinical depression. John’s responsesJohn recalled that the first time he fantasized

about playing with feet was when he was 4 years on the Interpersonal Reactivity Index were in the average range for Empathic Concern, an affectiveold, and he wanted to play with his friend’s feet.

He stated that the first time he acted on this fan- measure of the ability to feel compassion for those in distress, but about 2 standard deviationstasy was when he was about 12 or 13 years old.

He stated that he hit a friend over the head with below average in Perspective Taking, a cognitive measure of the ability to appreciate other peo-a shovel, knocked him out, and played with his

feet. He reported having his first wet dream when ple’s point of view. The most noteworthy scale score, however, was on Personal Distress, a mea-he was 16 years old. He dreamed about knocking

out his friend and playing with his feet. He stated sure of the extent to which an individual is ca- pable of sharing the distress that other are experi-that in his homicidal fantasies, “I’m drowning

them [his victims] in a trash can. I reach a climax encing. John’s score on this scale was 1.5 standard deviations above the mean. Since a low score onwhen I’m holding their legs and they stop strug-

gling.” He also reported fantasizing about putting this scale often reflects one’s inability to tolerate or cope with their own distress, we may infer thathis victims in a trance or drugging them so that

they don’t remember anything and then “I can do Mr. D is aware that he is coping with a very high level of distress.what I want with their body.” He acknowledged

frequently masturbating to these violent fanta- John’s responses on the STAXI reveal fre- quent, very intense angry feelings. His scores onsies. He also indicated that the fantasies and sub-

sequent masturbation were soothing and helped two scales, reflecting both the suppression of angry feelings and the behavioral expression ofhim cope with his anger. He stated that he was

preoccupied with these violent fantasies “25 out anger were well above the 90th percentile. John’s anger appears to be chronic, rather than situa-of 30 days.” He reported that his medication de-

creases the amount and the intensity of the fan- tionally determined. He is highly sensitive to crit- icism, perceived insults, and negative or devalu-tasies. John further remarked that, “The line

between fantasy and reality has always been a ing remarks and is likely to experience anger in those situations. John does not appear, however,problem for me.”

He admitted to acting on his fantasies at least to be quick tempered and implusive in the ex- pression of anger. He is more likely to brood forfive times. He stated that although he thought he

has been able to stop himself short of killing his some time before expressing his anger.

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Sex Offender Sentencing • 273

John’s response on the MCMI-III provide no provides an unclear symptom picture with regard to dissociation. Although John endorsed manyevidence of psychosis (i.e., Thought Disorder or

Delusional Disorder). John scored very high on a items, the frequency with which he has these ex- periences is highly variable (4 of the items lessnumber of Clinical Syndromes, however, includ-

ing Anxiety, Dysthymia, Alcohol Dependence, than 10% of the time, and 12 of the items less than 20% of the time).and Drug Dependence. There is evidence, more-

over, of longstanding and pervasive character pathology, most notably Borderline Personality

CLINICAL IMPRESSIONS Disorder. Consistent with this, John has shown evidence of impulsive and volatile outbursts, John presented as a pleasant, cooperative 24-

year-old Caucasian male, who was mildly anx-markedly labile mood with shifts from normality to extended periods of depression interspersed ious. He was fully oriented. In the early part of

the interview, he made frequent use of humor.with anger and anxiety, rapid fluctuations in thoughts and perception about life about events, Although self-disclosing, his facial expression

was tense, and he appeared to choose his wordsand a highly confused, wavering sense of identity. In addition to this constellation of traits associ- carefully. His speech appeared to be without

pressure. He often spoke in great detail, thoughated with Borderline Personality Disorder, there also is evidence of egotistic self-involvement, as seemingly without circumstantiality, looseness

of association, or flight of ideas. He frequentlyindicated by his interpersonally exploitative style and features of personality that would be associ- displayed poor eye contact, particularly when he

appeared to be daydreaming with the imagery ofated with Passive Aggressive (or Negativistic) Personality Disorder. Not surprisingly, John also these events that he was reporting. His respira-

tion appeared rapid at times, and the interviewscored in the “trait range” for Aggressive/Sadistic Personality. was stopped on several occasions due to the

acute distress that he exhibited (e.g., reachingJohn’s scores on all 10 of the Trauma Symp- tom Inventory scales were above the 90th percen- up and grabbing his hair). He often grew agi-

tated, and on several occasions he became visiblytile. His scores on seven of those scales were at 99th percentile. Overall, his responses reflect a upset about a particular topic, stating, “I don’t

want to say anything more about that.” Short-very high degree of trauma-related symptomatol- ogy. This profile indicates a high level of sexual term memory was instant. Long-term memory

was roughly intact. Both insight and judgmentdistress and dysfunctional sexual behavior, chronic depression, and constant, vigilant attempts to were poor.

There was no evidence of auditory or visualavoid extreme internal (often posttraumatic) dis- tress. His high score on Tension Reduction Be- hallucinations or delusions. He acknowledged

having extremely vivid, intrusive fantasies, whichhavior reflects the frequency with which he en- gages in behaviors intended to interrupt, discharge, he often finds disturbing as well as arousing. These

fantasies have both an obsessive-compulsive qual-or attenuate negative or aversive feelings. His high score on Dissociation suggests a high fre- ity to them (i.e., he experiences acute distress, if

he can’t act on them). He has a long history ofquency of avoidance responses to overwhelming emotional distress. These responses may include substance abuse, primarily ETOH and marijuana.

He has a long history of both suicidal and homi-cognitive disengagement, depersonalization and derealization, and emotional numbing. Given his cidal ideation, which he has acted on in the past.

He denied any current suicidal or homicidal ide-high score on the DIS scale, I administered the Dissociative Experience Scale (DES). John en- ation. dorsed 19 of the DES items, slightly below the median of 22 for people with Post Traumatic

DIAGNOSTIC IMPRESSIONS Stress Disorder (PTSD). His median score for those 19 items, however, was 18, which is sub- Based on historical, clinical, and psychometric

data, the following DSM-IV classifications wouldstantially lower than the median score of 39 found among people with PTSD. Thus, the DES be appropriate:

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274 • Forensic Mental Health Assessment

Axis I: Major Depression in partial remission, tionnaires that, in reality, were quite be- nign (i.e., they did not inquire about anysevere, recurrent (296.35), Dysthymia

(300.4), Alcohol Dependence (303.90), Can- potentially “high voltage” subjects such as childhood abuse or sexual behavior,nabis Dependence (304.30), and Sexual Sa-

dism (302.84); thoughts, or fantasies); 5. He has a long history of chronic relapsingAxis II: Borderline Personality Disorder to use of alcohol and drugs, undoubtedly(301.83). for purpose of self-medication. His reli- ance on substances fulfills the criteria for dependence;RISK ASSESSMENT

6. He acknowledged intentional lack of com- pliance with medication in order to inten-John should be regarded as being at very high risk sify his sexual fantasies and sexual drive.of violence toward self or others. This conclusion He reports that masturbation to these sex-is based on consideration of the following factors: ual fantasies are “soothing” and attenuate feelings of intense anger;

1. He has a long history of acting on his fanta- 7. Lastly, it should be noted that he often expe- sies. He reported having at least five vic- riences a blurring of fantasy and reality. As he tims of strangulation; commented, “The line between fantasy and

2. He reported clear evidence of planning in reality has always been a problem for me.” these offences, including the use of manip- ulation and subterfuge. In his October 1997 offense, for example, he brought to

CONCLUSIONShis apartment a young man that he picked up in a bar under the pretext of “getting

Based on all of the above, we would recommendhigh.” Once high, he rendered his victim that the court consider the following in determin-unconscious; ing whether John D should be classified as a sex-3. He reported active, intrusive, at time pre- ual predator. He appears to have serious psychiat-occupying fantasies of strangulation and ric difficulties in the form of sexual sadism andpostmortem sexual acts that consume him

80% of the time. When he does not act on borderline personality disorder that would in- these fantasies, he feels “intense frustra- crease his risk of further sexual offending. He also tion,” as well as “extreme disgust” due to has a substantial history of intrusive and violent his enjoyment and lack of remorse over sexual fantasies and a tendency to act on these his homicidal fantasies. His recent hospital- fantasies. The nature of past sexual conduct in ization in January 1999 for suicidal ide- this area suggests a consistent pattern of abuse ation was precipitated by constant preoc-

and cruelty to his victims. John also appears to becupation with highly arousing sexual an individual with a number of other active riskfantasies about a prior (October 1997) of- factors associated with interpersonal aggressionfense and consequent “self-loathing” be- toward others, namely substance abuse, sporadiccause of these fantasies; medication compliance, poor anger and impulse4. He lives, on a daily basis, with very in-

tense angry feelings, and he possesses a control, a history of trauma, and poor judgment. very low threshold for experiencing what Accordingly, his current risk factors would seem he perceives to be insults and abuse from to increase the risk for reoffending in both a sex- others. His controls, even in the presence ual and nonsexual context. of medication, are fragile. He was unable, John should be closely monitored and stabi- for example, to complete the battery of in- lized on medication, with consideration to fur- ventories and questionnaires for this evalu-

ther reduction in the intensity of his sexual andation, because he found them to be too violent fantasies. In this regard, I would recom-upsetting. Indeed, he reported in the be- mend a combination of an antiandrogen and anginning of a second session that he had a SSRI. His lack of compliance with medication“bad weekend” because he had been con- must be addressed and appropriate means of moni-sumed by anger. What prompted all of his

anger was several general personality ques- toring compliance instituted. Following stabiliza-

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Sex Offender Sentencing • 275

tion, he should be treated for symptoms of Post trauma therapy before he can effectively work on his own victimization of others.Traumatic Stress Disorder, followed by cognitive-

behavioral treatment for his cycle of sexualized If I can clarify any aspects of this report or provide any further assistance to you on this mat-violence (including substance abuse) and aversive

counterconditioning to decrease arousal associ- ter, please feel free to call. ated with his violent fantasies. John’s own victim- ization history, the precise nature of which is un- Yours sincerely,

Robert A. Prentky, Ph.D.clear at this point, may have to be addressed in

Teaching Point: Sex offender typologies in sentencing

Science has traditionally proceeded by simplifying complex, diverse domains of information. Simplification is typically achieved through a methodical pro- cess of assigning members of a large heterogeneous group to subgroups that possess common characteristics, thereby bringing some degree of order to di- versity. The process of classification (“taxonomy”) is fundamental to all science. The task is to uncover the laws and principles that underlie the optimal differ- entiation of a domain into subgroups that have theoretically important similari- ties. The resulting subgroups or subtypes are not simply notational; they con- nect the content of science to the real world. In fact, one might argue that classification reflects a normal cognitive process of integration and reduction. Through such a process of classification we make sense of our experiences. The process that helps us to apprehend our world at a sensory level is the same process that scientists use to order and simplify their world at an empirical level.

Over the past 40 years, classification systems have been designed, imple- mented, and tested on virtually every aspect of human behavior. The profusion of these systems during the past several decades resulted from the proliferation of clinical data and the need for an organized approach to complex and diverse behavioral domains. One area that certainly has been the beneficiary of classi- ficatory efforts has been depression. We have witnessed something of a revolu- tion in the treatment of depression and anxiety-related disorders through the identification of increasingly homogeneous subgroups. The clinical literature clearly indicates that valid classification models lead to more informed deci- sions.

In general, the more heterogeneous the area of inquiry, the more critical is classification. One of the few indisputable conclusions about sexual offenders is that they constitute a markedly heterogeneous group (Knight, Rosenberg, & Schneider, 1985). The childhood and developmental histories, adult compe- tencies, and criminal histories of sexual offenders differ considerably. The mo- tives and patterns that characterize their criminal offenses differ considerably. Sex offenders can, quite literally, come from any walk of life and present with any composite or profile of attributes. As such, reliable and valid classification

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276 • Forensic Mental Health Assessment

of sexual offenders is, arguably, more important than for any other group of criminals. Although sexual offenders have been the subject of intense clinical interest and speculation for at least 50 years, it is only within the past 20 years that progress has been made on the development of empirically validated systems for classifying this population (Prentky & Burgess, 2000). Indeed, clas- sification research reveals that rapists and child molesters are each very hetero- geneous and that each offender group may include a half dozen to a dozen discrete subtypes (Knight & Prentky, 1990).

Classification systems do not serve all purposes. Classification research typ- ically begins by pinpointing the purpose that the resulting model is intended to serve. For example, a taxonomy may be designed to classify the structural, biochemical, or reproductive characteristics of a particular genus or species of plant or animal. In the case of criminal offenders, the same principle holds. A classification system that is intended to assist with treatment planning and clini- cal decision making may look quite different from a classification system that is intended to inform forensic decision making (e.g., risk).

In the criminology domain, the clear purpose of most taxonomic efforts has been to inform discretionary decisions about offenders, and to assist with decisions about dangerousness or reoffense risk. However, because sex offend- ers are often placed in treatment programs, voluntarily as well as involuntarily, the need for assisting with more informed treatment-related decisions has also been a high priority.

A valid classification system can inform and improve the discretionary and dispositional decisions made by the criminal justice system. These decisions include reoffense risk, risk of violence, appropriateness for probation, custody level (i.e., security risk), parole risk, and discharge from community-based treatment or other conditions of parole. This clearly is an area where classifica- tion can serve a very useful purpose. Although there has been relatively little research on validating a classification system specifically for this purpose, recent validity studies on several empirically derived taxonomies are promising.

In one 25-year follow-up study of 111 child molesters, for example, the predictive efficacy of several critical dimensions of an empirically derived clas- sification system for child molesters (MTC:CM3; Knight & Prentky, 1990) was examined. It was found that Fixation (degree of sexual preoccupation with children) and number of Prior Sexual Offenses were significantly related to sexual recidivism, while Amount of Contact with Children was significantly related to nonsexual, victim-involved, and violent recidivism (Prentky, Knight, & Lee, 1997). In that study, it was evident that classification as high in Fixation on Axis I and low in amount of Contact with Children on Axis II were associ- ated with increased risk of recidivism.

Similarly, in a 25-year follow-up of 106 rapists released from a maximum- security treatment facility, Prentky, Knight, Lee, and Cerce (1995) examined impulsivity, a dimension critical to the classification of rapists (MTC:R3; Knight & Prentky, 1990). We found that the hazard rate for the high impulsiv-

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Sex Offender Sentencing • 277

ity rapists was at least twice as great as the hazard rate for the low impulsivity rapists, across all domains of criminal behavior. In fact, the hazard rate for committing a new sexual offense was almost three times greater for the high impulsivity rapists. For nonsexual, victimless offenses, the hazard rate was al- most four times greater for the high impulsivity rapists. In other words, the simple construct of lifestyle impulsivity was a powerful predictor of those who reoffended, even in a sample comprised entirely of “hard core” offenders classi- fied as “sexual psychopaths.”

A second possible benefit of classification would be to inform treatment planning and clinical decision making. To the extent that rehabilitation within the criminal justice system remains a viable goal and to the extent that limited resources require prudent allocation, classification systems that shed light on optimal interventions for different types of offenders are very important. This is not a novel application of classification. Over 25 years ago, Quay (1975) remarked, “This question of the match between offender characteristics and treatment modalities, i.e., differential classification and treatment, remains per- haps the most important problem for research in applied corrections” (p. 412).

Using the MTC:R3 taxonomic system for rapists, John was easily classified as a Type 4 (Overt Sadism). In John’s case, his report of a long history of fantasy and behavior consumed by sexual sadism was ample evidence for this classification. Using the component rating sheet for the MTC:R3, four of the eight Category A criteria for sadism were coded as present. Only one Category A criterion is required for Type 4 classification. The Type 4 offender is charac- terized by the following: (1) a high level of aggression and gratuitous violence, typically in sexual offenses; (2) a history of pervasive (undifferentiated) anger may be present; (3) sexual offenses evidence a fusion of aggression with sexual arousal; (4) a moderate history of impulsive, antisocial behavior in adolescence and adulthood is often present; (5) a history of other paraphilias is often pres- ent; and (6) offense planning and premeditation are evident.

John’s treatment needs are numerous, including trauma therapy for a his- tory of victimization, anger dyscontrol, impulse dyscontrol, and highly intru- sive and repetitive sexual fantasy that is dominated by sexual sadism. Because of the high potential for dangerous behavior inflicted against self or others, I emphasized that such treatment should be provided in a secure, specialized setting, and that John be stabilized on medication prior to treatment. Although John had been on the anti-androgen Provera for a brief time, he was essentially noncompliant by using alcohol and street drugs to restore his sexual drive. Thus, ensuring compliance should also be a focus in the beginning of treat- ment. I recommended, in this regard, consideration of a GnRH medication (gonadotrophin releasing hormone) such as Lupron, which can drop testoster- one down to castrate levels. I further recommended that trauma therapy pre- cede offender therapy, because of the overwhelming influence of the distal effects of trauma on his life, most notably extreme anger and depression, and intrusive memories.

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278 • Forensic Mental Health Assessment

Because of the very nature of its use by the criminal justice system, classi- fication systems must be applied with utmost care and caution. When applied properly, classification can inform and increase the accuracy of difficult deci- sions made by the criminal justice system. When applied improperly or mis- used, classification can lead to erroneous decisions that can adversely affect individual liberty interests. In an article three decades old on the “care and feeding of typologies,” Toch (1970) warned that, “Classifying people in life is a grim business which channelizes destinies and determines fate. A man be- comes a category, is processed as a category, plays his assigned role, and lives up to the implications. Labeled irrational, he acts crazy. Catalogued dangerous, he becomes dangerous, or he stays behind bars” (p. 15). Hans Toch, who has spent much of his professional life attempting to classify violent people, re- minds us that, “Individuals can be jailed as representatives of a probable cate- gory” (p. 18).

Toch’s message, which is as true today as it was 30 years ago, is a sobering one. Although we should not reject the benefits afforded by classification be- cause of the potential for misuse, we must adhere to scientific rigor in the development and validation of classification systems and employ utmost care in the application of those systems. Casual or careless assignment of individuals to categories is far worse than no assignment at all, and improper use of a classification system is far worse than no use at all.

Note

1. Because the U.S. Supreme Court has also decided (in Kumho v. Carmichael, 1999) that expert evidence that is “technical” or “other specialized knowledge” may be scrutinized in the same way as “scientific” evidence under Daubert, it is clear that Dau- bert may be applied to FMHA regardless of whether the latter is considered to be scien- tific, technical, or other specialized knowledge.

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