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Sexually Violent Predator Treatment Provider Standards

Background

Under Pennsylvania law, the Sexual Offenders Assessment Board (SOAB) is responsible for the development of standards for the evaluation and treatment of persons found by the courts to be sexually violent predators or sexually violent delinquent children. See 42 Pa. C.S. §9799.24.
 
In 1998, the SOAB convened a sexually violent predator treatment and management standards workgroup, comprised of SOAB Members, private sector service providers, victim advocates, representatives of the Court of Common Pleas, the Governor’s Office, the Pennsylvania Departments of Corrections and Public Welfare, the State Board of Probation and Parole and the Pennsylvania Commission on Crime and Delinquency.
 
The standards developed by this workgroup reflected its research into national standards for best practice in the treatment and management of sexually violent predators. The SOAB treatment standards were thoroughly reviewed and revised again in 2012, after the passage of the Adam Walsh Act in Pennsylvania (42 Pa. C.S. §9799.10, et seq.)
 
Pennsylvania’s Adam Walsh Act defines a sexually violent predator as a person convicted of one or more of the a sexually violent offenses specified in the law and who has a mental abnormality or personality disorder that makes the person likely to engage in predatory sexually violent offenses. See 42 Pa. C.S.  § 9799.12.
 

Mission

These Sexually Violent Predator Treatment Standards shall provide a basis for the systematic assessment, treatment and management of sexually violent predators, by requiring best practice, sex-offender specific assessment and treatment interventions that are integrated into and coordinated with the offender supervision provided by probation and parole, corrections and other criminal justice authorities. 
 
The primary goals of these standards are the enhancement of public safety and victim protection. These standards advance these goals by ensuring that the treatment provided to sexually violent predators offers them the carefully supervised opportunity to develop the self-awareness, self-control and skills necessary:
   • to foster victim impact awareness, where clinically appropriate
   • to accept full responsibility and accountability for past and present behavior without cognitive distortion
   • to identify, modify and control their sexually deviant behaviors by minimizing the internal and external precursors to such behaviors
   • to comprehend and cooperate fully with treatment and supervision of indefinite duration
   • and to understand the consequences to self of re-offending.
  

Principles

Current research suggests that although there may be some neurological component, sexual predation is primarily learned/acquired patterns of behavior that function to meet the need of deviant sexual arousal that cannot be cured, but must be managed over a lifetime. Motivated offenders can learn through treatment and supervision to identify, change and manage their offending behaviors, identify and control the internal stimuli and external circumstances which promote these offenses, and thereby decrease their risk of offending. Even internal motivation and treatment compliance cannot permanently, and with certainty, eliminate the risk of future offenses.
 
For treatment to succeed in reducing risk, it must be paired with on-going objective assessments of progress and with external sources of control and supervision, which continually monitor behavior and limit offender access to the persons, situations, and contexts that increase risk.
  
Sexually violent predators, by definition, have disorders and characterological disturbances thought to be lifelong and without known cure. Definitive prediction of the risk to re-offend sexually is not currently totally reliable. Risk is also a fluid process; and for these reasons, treatment of sexually violent predators in Pennsylvania is mandated for life.
 
Progress in treatment and level of risk are not constant over time, because of the repetitive nature of offense patterns, fluctuating life stresses, and changing opportunities for offending. Consequently, relapse/re-offense prevention must be incorporated into treatment. Comprehensive assessment, using objective techniques consistent with or equivalent to the polygraph, objective measures of sexual interest, drug and alcohol screening, as well as victim and other collateral reporting, must be performed on a regular basis throughout the treatment and supervisory process.
 
Community treatment must be consistent, intensive and collaborative with any probation or parole supervision of the sexually violent predator. In addition, both treatment and supervision require all parties to be appropriately intrusive and confrontive of the offender, directly asserting the relevant issues in a respectful manner.
 
All treatment providers and supervisory personnel (including corrections, probation and parole and judicial staff) responsible for the treatment and management of the offender must have access to the same comprehensive information about the offender. Sexual offenses are committed covertly, and rely on deception, secrecy and offender denial. Fully informed treatment and supervisory staff are essential to effective offender treatment and management. The sexually violent predator must waive confidentiality of evaluation, treatment, case management, supervision, and criminal history information to allow all treatment and supervisory staff equal access to accurate information.
 
Assessment, supervision and treatment of sexually violent predators must be sex-offender specific. Traditional mental health modalities and approaches will not reduce the likelihood of re-offending behavior. Persons providing sexually violent predator treatment and supervision shall have appropriate training and experience in the dynamics, treatment approaches and supervisory techniques demonstrated to be most effective in modifying the behavior of sex offenders and safeguarding the community. 
 
Each offender has experienced individual circumstances that resulted in the development of patterns of faulty, deviant and criminal thinking, which distorts the offender’s perceptions, beliefs, values and emotions. These patterns have ultimately led to deviant and destructive behavior. Consequently, cognitive/behavioral therapies are a cornerstone of treatment of sexually violent predators. Pharmacology and psychopharmacology, when clinically appropriate, are adjunctive to the treatment process, but are not substitutes for sex-offender specific treatment and intensive supervision. 
 
The selection of a community-based treatment program for sexually violent predators on probation or parole rests with probation and parole officials, not with the offender.  If there are multiple approved programs available to the offender, the offender’s initial choice of a program is not prohibited. Changing providers during the course of treatment is discouraged. Any change of provider should be in a collaborative effort between supervision and provider and should be in the interest of public safety and based on sound clinical reasoning. The provider shall attest to the offender and the criminal justice authority having jurisdiction that the treatment to be offered and its collaboration with supervising agencies will meet the minimum requirements established by these standards.  
 
These standards shall be reviewed at least annually by a committee appointed by the Executive Director of the Sexual Offenders Assessment Board, and updated to reflect the most current research and standards of practice.
  

Minimum Standards for Sex Offender Treatment Programs

The provider shall have had a minimum of three year’s appropriate experience treating sex offenders, collaborating with other agencies, and working with probation and parole departments and agencies. The provider shall be licensed in his or her respective discipline. In addition, the provider shall have had a minimum of 2000 post graduate degree supervised hours of face-to-face clinical contact with persons who sexually offend.
 
Any unlicensed person on the program's staff who provides treatment services to sexually violent predators shall be under the direct supervision of the qualified Pennsylvania licensed professional. Any unlicensed staff members shall have at minimum a bachelor’s degree.
 
Any individual offering treatment services as a sole practitioner shall be licensed in his or her respective discipline and have had a minimum of 2000 post-graduate degree supervised hours of face-to-face clinical contact with persons who sexually offend.
 
The treatment shall be configured to follow current best practice standards, including, but not limited to, the reduction of risk to re-offend sexually. Said treatment can be intrusive, investigative and challenging to the individual being treated. It is at the same time respectful of the individual.  It is always conducted collaboratively with agencies relevant to the individual’s treatment. Treatment is always individualized, relevant to the individual being treated. It is the responsibility of the treatment provider to establish an individualized treatment plan to reduce the risk of sexual re-offense; secondary treatment goals are always part of individualized treatment.
 
The program shall employ a cognitive behavioral treatment approach that emphasizes group counseling and peer confrontation/ support. Treatment components may include, but need not be limited to, cognitive restructuring, values clarification, recognition of offense behaviors, behavior therapy, identification of risk factors, enhancement of coping skills, relapse/re-offense prevention, victim impact awareness, social competence, assertiveness training, anger and affect control, impulse control, sex education, improvement of appropriate sexual functioning, substance abuse treatment, and improvement of primary relationships. 
 
If the sexually violent predator is not to be treated in a group setting or with cognitive behavioral therapy, the justification for such treatment shall be set forth in the clinical assessment. Female sex offenders, for example, should not be treated in male sex offender groups; insufficient numbers of female sex offenders may warrant individual treatment.
 
The program shall employ a written Individual Treatment Plan (ITP). ITP’s should be offender-specific, tailored to the offender’s criminal history, cognitive patterns, sexual arousal patterns, offense patterns, co-occurring conditions, risk assessment, relapse profile and current circumstances. It shall contain measurable treatment goals, objectives and treatment interventions, and indicate the persons responsible for treatment and supervision. It shall integrate the collaborative efforts of all criminal justice and treatment agencies responsible for treatment and supervision of the offender.
 
The program shall have the capacity to provide for the administration of objective measures such as the Abel Sexual Interest Inventory or Plethysmography to ascertain deviant sexual interest and arousal patterns. If objective measures are not to be used, the individual case plan shall state why they are not employed.
 
The program shall have the capacity to provide for the administration of sex offender specific clinical polygraph testing to measure program compliance and progress in treatment. The polygraph is a tool of treatment. The polygrapher is not required to be a member of the program staff and may be employed on a contractual basis.  
 
The program shall ensure that victim protection and restitution are an integral part of sex offender treatment and management. Primary, secondary, and potential victim notification, contact, and/or participation in the treatment and decision making process shall be victim-driven and clinically appropriate. All victim protection shall be a paramount goal of offender management.
 
Family reunification goals shall be victim-driven, tailored to the victim’s best interests, and pursued when clinically appropriate. Any identified victims should have their own qualified therapist participating in any potential reunification plans. In addition, any non-offending parent shall participate in treatment.
 
The program shall have the capacity to provide or arrange for physician evaluation and prescription of anti-androgen and other pharmacological therapies as an adjunct to the cognitive behavioral approach for treatment of sexual deviance.
 
The program shall provide two co-therapists to conduct any therapy group that exceeds eight sex offenders, including any sexually violent predators. Didactic and education groups may involve larger participant numbers, and may be led by only one therapist.
 
The program shall provide or arrange for referral to specialized ancillary services for sex offenders who display other special needs or co-occurring disorders (e.g., substance abuse, mental retardation, mental illness or learning disorders).
 
The program shall keep accurate, uniform and timely records of treatment. It shall provide written reports on progress to the responsible criminal justice, correctional and probation or parole authorities at least once every six months, and provide same with immediate notice of serious violations of program rules.
 
The program shall conduct and document case conferences with team members from parole and probation, other treatment services, criminal justice agencies, and social service agencies not less than once per month, and facilitate the participation of these agencies in actual group treatment processes, as appropriate to actively monitor community risk, treatment compliance and progress.
 
Treatment staff interaction with sexually violent predators shall encompass compassion for the humanity of the offender, while recognizing the offender’s criminal sexual behavior as reprehensible. Treatment staff interaction with sexually violent predators, while intrusive and confrontive at times, is never disrespectful or abusive.
 

Assessment and Evaluation

Sexually violent predators shall have a comprehensive formal assessment at the onset of treatment, in order to establish an individualized treatment plan and a baseline. These assessments shall include objective measures of treatment compliance such as polygraph testing and, wherever possible, objective measures of sexual interest. Psychometric testing alone does not provide accurate assessment of risk; sex offender specific risk assessment tools shall be used. 
 
Assessments shall address current risk, including the level of risk, and the contexts in which the risk is likely to occur, using current best practice tools.
 
At least once a year during treatment, the provider shall review with the client, his or her progress toward the goals and objectives established in the individual treatment plan, and the plan should be updated or modified as appropriate.   
 
Clinical polygraph testing to promote honest self-reporting shall be incorporated into the individual treatment plan and shall be conducted once per year (or more frequently at the discretion of the treatment provider). (For offenders who are under probation or parole supervision, polygraph testing shall be performed in collaboration with the criminal justice agency providing supervision.) Polygraph operators shall adhere to the standards of best practice established for the administration of clinical polygraphs with sex offenders, and shall possess the credentials needed to practice their profession. 
 
Plethysmographic assessments, when used, shall be conducted under the standards promulgated by the Association for the Treatment of Sexual Abusers (ATSA). The ABEL Assessment and any other objective measure of sexual interest, when used, shall be administered under the current guidelines established by their originators.
 
Assessment results, including results of physiological measures, shall be communicated to the criminal justice agency having jurisdiction over the offender’s supervision.
 
Providers shall create mechanisms to manage staff countertransference, stress, burnout and isolation, including peer review and continuous quality improvement measures.
 
Providers shall create a mechanism to consult with other sex offender treatment providers on individual cases as well as for professional development.
 
Providers will not knowingly assess or treat a sexually violent predator currently in treatment with another professional without attempting to consult with the other provider to determine if this new relationship is in the best interests of the client and the community.
 
Providers will ask the sexually violent predator to provide information about his or her involvement with any other therapists/clinicians at the time of initial contact and obtain a release of information in order to consult with and secure the records of the other clinician.  Where the client will not cooperate, providers should consider whether it is appropriate to continue a professional relationship with the client who will not sign the release.
 
Where a provider discovers a sexually violent predator previously received sex offender treatment and/or mental health services from another provider, the provider shall obtain a release of information from the sexually violent predator and attempt to receive the records before continuing with treatment.
 
Sexually violent predator treatment providers recognize that clients have the right to change providers.  Note is made that statute requires sexually violent predators to seek that treatment with providers approved by the SOAB.
 
Further note is made that sexually violent predators under the jurisdiction of the court or the Pennsylvania  Board of Probation and Parole may have further restrictions governing their provider selection.
 

Provider Credentials

The provider shall have had a minimum of three year’s appropriate experience treating sex offenders, collaborating with other agencies, and working with probation and parole departments and agencies.  The provider shall be licensed in his or her respective discipline.  In addition, the provider shall have had a minimum of 2000 post graduate degree supervised hours of face-to-face clinical contact with persons who sexually offend.
 
Any unlicensed person on the program's staff who provides treatment services to sexually violent predators shall be under the direct supervision of the qualified Pennsylvania licensed professional. Any unlicensed staff members shall have at minimum a bachelor’s degree. The licensed supervisor shall retain written records of all supervision sessions.
 
Any individual offering treatment services as a sole practitioner shall be licensed in his or her respective discipline and have had a minimum of 2000 post-graduate degree supervised hours of face-to-face clinical contact with persons who sexually offend.
 
When pharmaceuticals are used as an adjunct to treatment, a physician licensed to practice medicine in Pennsylvania shall perform their prescription and monitoring.
 
All provider staff shall participate in an ongoing program of professional development to update their awareness of current research in the field of sex offender treatment and management and to enhance treatment skills. Providers and staff shall document the ongoing continuing education, including conferences, workshops, seminars and other relevant professional training.
 
Providers shall have the necessary training, education and experience required to evaluate, treat and manage sexually violent predators. Providers will, at a minimum, demonstrate knowledge and competency in the following areas:
  • Assessment and diagnosis
  • Counseling and psychotherapy
  • Cognitive behavioral therapy
  • Psychopathology
  • Risk assessment
  • Psychopathy
  • Family dynamics
  • Psychometric and psychophysiological testing
  • Ethics
  • Ethics and forensic populations
  • Relapse prevention
  • Sexual arousal control
  • Interviewing techniques
  • Group therapy
  • Family reunification (as related to sex offenders)
  • Assessment and treatment of mental illness
  • Assessment and treatment of neuropsychological disorders
  • Substance abuse treatment
  • Pharmacology 

Confidentiality

Offenders have the right to be informed of the limits to confidentiality afforded during sex offender treatment. Limits of confidentiality shall be stipulated in writing, and written consent to release treatment and assessment information to all members of the treatment and supervision team, as well as the Sexual Offenders Assessment Board shall be obtained as a condition of treatment. 
 
Sexually violent predators entering treatment shall be informed in writing that information or disclosures during treatment concerning criminal activity shall be reported immediately to the offender’s probation or parole officer or other law enforcement agencies as necessary.
 

Consent to Treatment

Before enrollment in treatment, offenders shall be informed of the assessment and treatment measures that may be offered, and provide written consent to treatment and assessment.  
 
Statutory requirements for sexually violent predators, as it relates to treatment, shall be explained to each offender.
 
The potential consequences for failure to comply with or fully participate in treatment shall be explained to the offender, in writing. The provider shall immediately, by phone or fax, notify criminal justice authorities having legal jurisdiction over offender supervision regarding significant non-compliance.
 
Written informed consent shall be obtained before the administration of pharmaceutical, physiological, and aversive interventions.
 

Definitions

Board: The Pennsylvania Sexual Offenders Assessment Board

Clinical Experience: Clinical experience means those activities directly related to providing evaluation and/or treatment to individual sex offenders, e.g. face-to-face consultation or therapy, report writing, administering, scoring and interpreting of tests, providing training; participating on case management teams; and clinical supervision of  therapists treating sex offenders.
 
Cognitive Behavioral Approach: Cognitive behavioral approaches adhere to the premise that modification of cognitions and behaviors are necessary for more adaptive functioning. Cognitive behavioral approaches strive to identify, assess, develop, modify, and support cognitions and behaviors that reinforce adaptive functioning through the use of a variety of techniques.
 
Cognitive Distortions: Cognitive distortions are thoughts and attitudes that allow offenders to minimize, justify and rationalize their deviant behavior.  Cognitive distortions allow the offender to overcome prohibitions and progress from fantasy to behavior. These distorted thoughts provide the offender with an excuse to engage in deviant sexual behavior, and serve to reduce guilt and responsibility.
 
Mental Abnormality: A congenital or acquired condition of a person that affects the emotional or volitional capacity of the person in a manner that predisposes that person to the commission of criminal sexual acts to a degree that makes the person a menace to the health and safety of other persons.
 
Objective Assessment: In this context, objective assessment refers to the professional use and interpretation of instruments designed to objectively measure or ascertain physiological variables relating to truthful disclosure of sexual interest and sexual arousal, including, but not limited to, the ABEL Sexual Interest Inventory and the Plethysmograph.
 
Plethysmography: In the field of sex offender treatment, plethysmography means the use of an electronic device for determining and registering variations in penile tumescence associated with sexual arousal. Physiological changes associated with sexual arousal in women are also measured through the use of plethysmography. Plethysmography includes the interpretation of the data collected in this manner.
 
Polygraph: Polygraph examination means the employment of instrumentation used for the purpose of detecting deception or verifying truth of statements of a person under criminal justice supervision and/or treatment for the commission of sex offenses. A clinical polygraph examination is specifically intended to assist in the treatment and supervision of convicted sex offenders. Polygraphs include specific-issue, sexual history, and periodic monitoring examinations. Polygraphs, when treating sex offenders, are a tool of treatment.
 
Predatory: An act directed at a stranger or at a person with whom a relationship has been established or promoted in whole or in part for the purpose of victimization.
 
Sexually Violent Predator: A person who has been convicted of a sexually violent offense as set forth in section 9799.14 (relating to sexual offenses and tier system) and who is determined to be a sexually violent predator under section 9799.24 (relating to assessments) due to a mental abnormality or personality disorder that makes a person likely to engage in predatory sexually violent offenses.
 
Treatment Team: The treatment provider and any other persons necessary to facilitate the treatment and safe management of the individual sexually violent predator in the community. Members of treatment teams will vary from offender to offender as these teams are formed to respond to the specific needs of each sexually violent predator.