Realist Evaluation of Adapted Sex Offender Treatment Programs for Men with Intellectual Disability

Adapted Sex Offender Treatment Programs (ASOTPs) have, as their name implies, been modified from mainstream treatment to meet the learning needs of offenders with intellectual disability (ID). They are designed to increase the offender's sexual knowledge, understanding of victim harm, ability to recognise feelings in themselves and others, to modify offence-justifying thinking and to support individuals to develop relapse prevention skills.

In this project I will explore what works on ASOTPs, for whom, in what contexts, why and how. I seek to make sense of these programs in the contexts in which they take place, in order to illuminate what social factors may help or hinder treatment success. In particular, I will examine how effective links between these forensic healthcare interventions and the offender's living context and social care provision, for instance the nature and level of supervision they receive to manage risk, during and after treatment can enhance outcomes. I aim to translate this knowledge into policy and practice recommendations, in order to inform the future targeting of public resources on the most effective treatment, supported by social care packages that can enhance effectiveness.

I will evaluate two ASOTPs, one in the UK and one in Switzerland. Both deliver group cognitive behavioural therapy, lasting about 18 months. The evaluation will entail three phases. First, a literature review will be followed by interviews with twelve international key academics and practitioners who designed ASOTPs. This will illuminate in what ways ASOTPs are intended to work.

Second, I will explore case studies of men who have attended ASOTPs to explain the impact the program had on them, whether and how it worked and in what contexts. There will be three types of data collection. Four focus groups with altogether 24 participants will look at the user experiences of treatment. Eighty patient files will be reviewed to examine how well the treatment worked for each person. From this a sample of 20 participants, ten for whom the treatment worked and ten for whom it did not, will be followed up through interviews with offenders and practitioners, to find out in more detail why the program did (not) work.

Third, the twelve key practitioners will be revisited. Ideas that were developed from phase 1 and 2 on what works, for whom and in what circumstances will be presented to them and they will offer expert commentary. They will examine the case studies from the UK and Switzerland and tease out how wider social contexts, such as public policy and social care practice, impact on treatment success by comparing the case studies to their local contexts. From this a set of recommendations will be derived on most useful policy and practice scenarios and successful social care packages that can enhance treatment success for a particular type of person.

Sex offender treatment seeks to change harmful behaviours and has the potential to contribute towards the prevention of maltreatment towards vulnerable populations. It is therefore a social issues, which is in line with the ESRC strategic priority "influencing behaviour and informing interventions".

Moreover, The ESRC review of strategic priorities 2013 identified "innovation in health and social care" as a focus for the next 24 months. This project can inform this by making suggestions on better collaborations between health and social care, an issue that has also been prioritised by UK central government. In addition, penal responses to people with ID are currently being reformed. This background and the current age of austerity make this project timely, as it can inform contemporary debates and the targeting of scarce public resources on treatment that works. Throughout the project I will network with policy makers, practitioners, disabled people's organisations and interested members of the public to maximise opportunities to impact on practice and policy development.

Sex offenders with ID tend to target those who are more vulnerable than themselves, including children and other people with ID (Beadle-Brown et al. 2010). There are currently almost 4 million adult (18-64) survivors of child sexual abuse in England, about 30% of whom are males (PANSI 2013). There are approximately 1.5 million people with intellectual disability (ID) in the UK. Incidence of sexual abuse increases for adults and children in this population; with Mencap et al. (2001) estimating it is four times more likely. Thus, the most important group of beneficiaries from this research are vulnerable populations, in that this work hopes to contribute to the prevention of future victims.

Effective treatment of sex offenders can also indirectly benefit those who have been victimised in the past and their families. This research has the potential to contribute to them knowing that treatment programmes are effective and why, which can help them to regain trust and heal.

The exact proportion of those with ID out of the over 40,000 registered sex offenders in England and Wales is unknown. Estimates are hindered by the fact that reporting of sexual offences and particularly those committed against people with ID is low and that some sex offenders with ID have been diverted from criminal justice, while the ID of others remained undetected. What we do know is that ID and other cognitive or learning difficulties such as autism or dyslexia, affect about 20-30% of the prison population (Loucks 2007). In follows that knowledge on ways of personalising interventions to cater for those with additional learning needs can potentially benefit a significant proportion of offenders.

To maximise opportunities for impact I will conduct knowledge exchange activities with a range of organisations, including the Equality and Human Rights Commission, Mencap, Respond, the Prison Reform Trust and Mental Disability Advocacy Centre (Budapest). They can benefit from this research, as it will provide them with evidence to inform disability rights campaigns, both on effective treatment of offenders and also material that may inform campaigns for justice for vulnerable victim groups.

In the short-term, I hope to inform the more effective targeting of adapted sex offender treatment programs for men with ID in forensic healthcare settings. Potential beneficiaries include users and professionals involved in the delivery of such programs. I will provide practice guidance on what works for whom and in what contexts to the Ministry of Justice, Department of Health and National Association of Probation Workers and Integras, a Swiss professional alliance of social pedagogy (professionals with an interest in ID), as well as to further networks of organisations that work with people with ID in Switzerland, Austria and Germany, including INSOS, Socialbern, CURAVIVA and GDFPI.

Medium-term, findings from this research may help to inform more effective public spending on evidence-based programs. Personalised intervention methods can be transferred to other forensic and penal intervention programs for offenders with additional support needs, including non-sexual offenders with ID, offenders with mental health problems and those whose first language is not English.

The complex evaluation methodology developed for this project can potentially be applied by other researchers to similarly complex interventions and with this benefit further offender, professional and victim groups.

Long-term the targeting of evidence-based, adapted and personalised provisions for different offender groups can potentially reduce reoffending rates amongst (sex) offenders with ID and others with additional support needs and increase public confidence in the forensic health and penal systems.

In order to instigate such change I am committed to the comprehensive public engagement and dissemination strategies outlined in the Pathways to Impact document.