Sex Work
May 26, 2025
Sex Offenders
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Therapy in Fiorensic Settings
Lorem ipsum dolor sit amet, In previous chapters we have looked at many different examples of ‘mad’ or ‘bad’, exploring how people who are experiencing mental health problems or who commit criminal offences are classified and treated by formal medical and criminal justice systems. The focus of these chapters has tended to be on the treatment of people after a diagnoses or verdict, but here we turn our attention to how mental health and offending behaviour might be prevented, and to discern the synergies and contrasts between the different approaches and the aspirations of prevention. In addition, we will concentrate on childhood and adolescence, in part because it is simply not possible to deal with every aspect of prevention in a single chapter, but also because it is often most effective to conduct interventions at this stage of life. However, this focus is not meant to suggest that approaches to prevention in adulthood are not worth conducting, as they have certainly proved to be effective
It is proposed that there are essentially three levels of prevention: primary, secondary and tertiary (Leavell & Clark, 1965). Primary prevention has been likened to a public health strategy where the intervention is universally applied to the whole population with a view to preventing a few from becoming perpetrators of crime or having to deal with mental health problems. Strategies employed by those seeking primary prevention could include protective policies that tackle structural causal factors such as marginalisation from employment or discrimination, or that encourage individuals to change their behaviour through media campaigns. In secondary prevention, the intervention efforts target either indicated or selected groups of individuals. Indicated individuals are those who are showing early signs of mental health problems, but the signs have not met the criteria for a particular diagnosable disorder, or those who have engaged in anti-social or delinquent behaviour (which is often seen as a precursor to offending behaviour). Selected groups are those who, by dint of characteristics that broadly match risk factors for offending behaviour or developing mental health issues in the future, are deemed to be the populations of interest. Thus, delivery of the intervention is targeted to subsections of the population, particularly those who are deemed to be the most likely to benefit. Finally, tertiary prevention targets those who have already offended or who have already manifested mental health issues. The aims of the interventions here are to reduce the likelihood of reoffending or to restore mental health/reduce symptoms to facilitate adaptive functioning.
Conceptualising mental health
Mental health is typically conceptualised as the absence of negative mental health problems (e.g. depression, anxiety, psychosis, etc.). However, the World Health Organisation argues that psychological well-being is more than just a lack of negative mental health, but should also include provision for positive mental health (WHO, 2004). For instance, the WHO (2001, p. 1) define mental health as ‘a state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses and is able to make a contribution to his or her community’. Within psychology, the positive psychological approach, which focuses on what makes people flourish and be happy, argues that rather than being placed on the same continuum, positive and negative mental health are two distinct, yet related qualities each with their own continuum (Joseph, 2015).
Consequently, from this perspective, focusing on preventing negative mental health issues only would be insufficient to promote mental health (Keyes, 2007). However, there is some evidence to suggest that initiatives that promote positive mental health can also lead to a reduction in negative mental health issues, but that initiatives which target negative mental health are less likely to also have an impact on positive mental health (Jane-Llopis et al., 2005).
The difference between positive and negative mental health is therefore an important one and to concentrate solely on the prevention of negative health outcomes is to ignore a considerable part of the picture. Nonetheless, although there is an ever-growing focus upon mental well-being in many societies, as we will see, the primary focus of prevention programmes tends to be on the avoidance of negative health outcomes.
Preventing mental health issues
Proponents of preventative psychiatry contend that since many treatments have limited efficacy in terms of ameliorating the symptoms and enhancing functioning for a proportion of patients who experience mental health problems, it might be prudent to direct efforts towards the prevention of the emergence of these issues (Trivedi et al., 2014). If we consider that the onset of more than half of all diagnosable mental health problems commences in early adolescence, around the age of 14 (Kessler et al., 2007), it would seem wise to direct preventative interventions towards factors that impact on children and childhood circumstances. Indeed, a review of age of onset and timing of intervention for mental health problems concluded that there is emerging evidence that early intervention might be able to reduce the persistence and severity of initial mental health problems and to prevent the emergence of secondary problems (McGorry et al., 2011).
The development of preventative interventions is informed by the existing knowledge of risk factors that contribute to the mental health prognosis, and protective factors that are associated with resilience (see Chapter 7). Here, prognosis is conceptualised in terms of the severity of symptoms, the age of onset of symptoms, the duration of the episode(s) and the responsiveness to treatment, while resilience is deemed to be the ability to maintain mental health despite exposure to multiple risk factors for negative mental health. Importantly, protective factors that have been found to increase resilience are also associated with positive mental health (Davydov et al., 2010). Consequently, there are two broad approaches to preventing mental health problems, which are based on two different models of mental health: the disease and the building resilience models.
The disease-based model focuses on the reduction of risk for specific diseases which are deemed to have genetic or neurobiological origins. In contrast, the resilience-building model aims to build the individual’s psychological resilience and social strength to enable the developing child to be better able to cope with potential adverse events that might occur later in life. The effectiveness of interventions which aim to enhance resilience in young people have been associated with fewer depressive symptoms for the treated samples. For example, Brunwasser, Gillham and Kim’s (2009) meta-analysis of a group-based, cognitive-behavioural intervention, known as the Penn Resiliency Programme, was found to demonstrate positive effects in both targeted and universally applied programmes. Additionally, the benefit of the programme on depressive symptoms appeared to remain at one-year follow-up for both genders, and irrespective of baseline levels of symptoms and who provided the intervention. Consistent with the notion that preventative interventions are best delivered in childhood, the analysis also revealed that the benefits were less evident for older adolescents and adults.
There is evidence to suggest that the attachment behavioural system (see Chapter 13) mediates the individual differences found in the way individuals cope with life stressors and their capacity for maintaining resilience in the face of adversity (Mikulincer & Shaver, 2007). This is exemplified by the fact that insecurely attached children have been shown to experience difficulty in coping with the transition points in their education, for example starting nursery school or moving between schools (Coie, 1997).
The strategies used for building children’s resilience have included training in interpersonal problem solving, building social competencies, raising self-esteem and enhancing the availability of social support (Bloom, 1997). Guralnick and Neville (1997) proposed that between the 1970s and 1990s the predominant focus of prevention work with children focused on developing social competence. Social competence is rooted in the ability to form secure emotional attachments to others (Egeland, 2009). In turn, secure attachments facilitate the ability to trust others, regulate one’s own emotions and to develop the capacity to mentalise and empathise, and to be self-reflective (see Chapter 13). All of these attributes are seen as essential to permitting adaptive functioning when confronting the turmoil and uncertainty of adult life.
Insecure attachments, on the other hand, have been associated with a number of attributes which reduce the individual’s ability to cope with stress and uncertainty. Two broad categories of attributes that render the individual more vulnerable are destructive self-representations and the poor capacity to regulate emotions. With regards to problematic self-representations, insecurely attached individuals have a propensity for being self-doubters, perfectionists, overly self-critical and depend on the approval of others, and for being troubled by sensations of hopelessness and helplessness (Wei, Heppner & Russell, 2006). The problems with emotional regulation manifest differently for anxious and avoidant insecure attachment styles. Individuals with avoidant attachment are more likely to suppress negative emotions and less likely to seek social support to deal with life stressors (Berant, Mukulincer & Shaver, 2008). Conversely, individuals who demonstrate anxious attachment experience exaggerated emotional responses to negative events which trigger their attachment hypersensitivity. This can result in excessive worrying, depression proneness, intrusion symptoms of post-traumatic stress disorder (e.g. flashbacks and nightmares), impulsivity and explosive outbursts of anger (Mikulincer & Shaver, 2007).
Indication of the protective quality of secure attachments comes from Turanovic and Pratt’s (2015) analysis of the data from America’s National Longitudinal Study of Adolescent Mental Health. The data consisted of an average of a seven-year follow-up of 13,555 young people from early adolescence until their early-to-mid-twenties. The findings revealed that positive attachment to both family and school mitigated the risk posed by violent victimisation in adolescence leading to adverse outcomes in early adulthood. The outcomes assessed in the study included negative mental health issues (e.g. depression, anxiety, suicidality, etc.) and substance misuse, as well as revictimisation and adult offending. Turanovic and Pratt speculate that the pro-social attachments formed can lead to a protective effect, and that this effect may be the result of the individual developing adaptive coping resources. The authors contend, therefore, that secure attachments bestow developmental advantages to young people which are not only enduring, but which may also accumulate over time. They refer to this notion as ‘cumulative continuity’.
Conceptualising offending behaviour and offenders
While officially ‘offending behaviour’ is that which breaks a particular law of the country, it is also possible to include other behaviours which breach moral codes or social norms in the definition. For example, many young people are deemed to be ‘at risk’ for offending due to their anti-social or delinquent behaviour. Importantly, this broader definition can also mean that young people are at risk of being labelled as offenders for engaging in what are deemed age-inappropriate behaviours (under-age drinking, smoking and sex, truanting from school, running away from home/going missing). These are known as ‘status-offences’ and it is questionable as to whether they should be labelled as ‘offences’ due to the negative implications this can have for the young person who carries such a label.
In 2009 the Prison Reform Trust declared that the UK incarcerated more children than anywhere else in the Western world. They claimed that the number of children incarcerated trebled between 1991 and 2006. However, a large proportion of these young people had not technically committed a criminal offence. Paylor (2011) suggests that many children are being incarcerated for the breach of Anti-Social Behaviour Orders (ASBO). She states that 42% of all ASBOs are breached and 55% of all breaches result in a custodial sentence. As you saw in Chapter 7, while adult men accounted for the majority of ASBOs, a disproportionately high number were applied to children aged 10–17 (Home Office and Ministry of Justice, 2014). Moreover, young people aged 15–17 years were one of the age groups most likely to breach their ASBO, meaning that the introduction and use of ASBOs was an important factor in the criminalisation of young people in mid-to-late adolescence.
In Chapter 7 you were introduced to Moffitt’s (1993) approach to categorising offending behaviour across, and in relation to, the lifespan. Moffitt’s developmental taxonomy of offenders would clearly separate out those who commit status offences from those who commit more serious types of crime. The taxonomy split the population into three groups based on their potential for criminality. These included abstainers, adolescent-limited offenders (which would include the status offenders) and the life-course persistent offenders.
n Moffitt’s original conceptualisation of abstainers, this group were seen as somewhat abnormal and their abstinence from offending was seen as a consequence of their life circumstances that prevented their inclusion in peer groups (e.g. responsibilities as a carer, having a disability which precluded an age-appropriate level of independence, or having a characteristic that rendered them vulnerable to being rejected by peers). However, later research by Piquero, Brezina and Turner (2005) found that abstainers were in fact embedded into peer groups, but that these peer groups appeared to have a greater involvement in pro-social behaviour. Additionally, parental monitoring of the young person and the young person’s attachment to their teachers were both factors associated with engagement with pro-social peer groups that are likely to have also acted to limit the potential for criminality.
For adolescent-limited offenders, offending is limited to this life stage. In other words, the onset of offending coincides with puberty and desistance coincides with the attainment of adult social roles. Offending in this group tends to be committed as a group and to be relatively minor. However, when violent offences do occur these are likely to be status-oriented (e.g. to be about ‘saving face’) rather than instrumental (e.g. to be a means of getting a desired object or behaviour from others). Importantly, Moffitt (1993) referred to a number of factors that could delay or prevent desistence for ‘what would have been’ adolescent limited-offenders. These ‘snares’ included gaining a criminal record, a truncated education, unwanted pregnancy, drug or alcohol dependency and incarceration.
Finally, life-course persistent offenders tend to begin offending at an earlier age, offend alone, have a higher frequency and variety of offending, be more likely to engage in violent crime and be less likely to desist in adulthood. As was described in Chapter 7, the interaction between the person (particularly through vulnerabilities to offending resulting from specific bio-psycho-social factors) and their environment shaped a personality structure that supported criminal behaviour (Moffitt, 1993). More recently, research has also pointed to the importance of genetic factors in explaining life-course-persistent offending (Barnes, 2012). Although the presence of neurobiological and genetic factors might appear to be problematic for the creation of effective prevention programmes, it is important to remember that environmental factors have been found to exert significant ameliorative or exacerbating effects on the long-term outcomes of such neurobiological challenges. One of the modifiable exacerbating factors is the quality of parenting, particularly attachment bonds to caregivers in early childhood. Importantly, if we are considering preventing serious offending, this is possibly the group who are most likely to be targeted for interventions.
Preventing offending
The Crime and Disorder Act 1998 established that the primary aim of the Youth Offending Service was to identify and manage or reduce the risk factors that were linked to offending. According to Paylor (2011), the rationale for this emphasis on what is known as the ‘risk factor prevention paradigm’ (Farrington, 2007) was a response to the perceived inefficiency and costliness of the existing youth justice system. The prevention paradigm became focused on risk assessment and the identification of variables that predict offending. In the UK this led to the introduction of two actuarial risk assessment tools, Asset and Onset, which are used to identify young people at risk of offending. Asset was introduced in 2000 and was used by all Youth Offending Teams on young people who had already come into the service due to their offending behaviour. The tool was used to ensure that the level of intervention received by the young person was proportionate to the risk that they posed and that the interventions selected targeted the risk factors that were present for each particular individual, thereby ensuring the most cost-effective use of resources. Onset, which is a little more controversial, was introduced in 2006. This is also an actuarial risk assessment tool, but on this occasion the tool is used on younger children who have not yet shown signs of offending.
Paylor (2011) was highly critical of the use of these tools and the implications they had for conceptualisations of youth offending. She contends that the Home Office erroneously interpreted factors that predict risk as being aetiological factors (i.e. causal factors). Paylor goes on to point out that despite many researchers concluding that it is virtually impossible to assess whether the relationship between a specific factor and the probability of reconviction is causal or not (e.g. Garside, 2009), the Home Office lists some of the risk factors included in Asset under the heading of ‘What Causes Crime?’ (Home Office, 2010b).
In addition, there is a concern that the inevitable over-emphasis of negative factors (since the tool takes little account of protective factors) could potentially encourage practitioners to adopt narrow and hopeless views of the young people with whom they work (Smith, 2007). An additional impact of this erroneous interpretation of the risk factors is that the focus on individualised factors meant that structural barriers to health, well-being and community participation (e.g. school exclusion, poverty, unemployment, etc.), drifted out of focus for policy-makers, despite these being the strongest predictors in adolescence. Instead, young people came to be viewed as possessing multiple needs rather than being subjected to them, their behaviour became problematised and exploration of the causes of their behaviour became obsolete (Barry, 2007).
We mentioned earlier in this chapter the distinction between status offences and criminal offences. This distinction, combined with Moffitt’s taxonomy of offenders, has implications for intervening to prevent offending. Indeed, it is questionable as to whether or not we should consider intervening in offending that is limited to adolescence, particularly when this relates specifically to status offences. For example, Jennings, Gibson and Lanza-Kaduce’s (2009) analysed the Klein and Maxson’s (2010) data which examined the effectiveness of three different types of intervention for young people who had engaged in status offences in the US. The three approaches employed by the interventions were: deterrence, treatment and normalisation. They found that the treatment approach was associated with the poorest self-concept, whereas the normalisation model was associated with the best self-concept. A negative correlation was found between number of prior arrests and self-concept, which might lend some support for the notion of a stigmatising effect of involvement with the criminal justice system; a ‘snare’ according to Moffitt (1993) for would-have-been adolescent-limited offenders. Finally, positive associations were found between self-concept and time spent with family, support from extended family and level of engagement in homework. Overall, the findings suggested that agencies that adopted the normalisation approach, which viewed status offences as just part of normal adolescent behaviour, had a favourable impact on young people’s self-concept that was twice that found to be associated with agencies that adopted deterrence-based interventions (e.g. those that deliver quick and severe penalties for transgressions).
Promoting positive mental health and preventing offending behaviour
While most parents automatically form secure attachments with their off-spring, there are others who are likely to experience difficulty in this endeavour. Factors that have been found to impact on the quality of the emotional bond between parents and their young children can be classified as being parent-related, child-related or contextual issues. Parent-related factors are those that are more highly associated with insecure attachments and include teenage parenthood, maternal depression, having a period of out-of-home care, unresolved trauma or loss, learning disability, chronic/enduring mental illness, substance misuse, dysfunctional attitudes towards the child and own lack of security. Child-related factors include premature birth, low birth-weight and difficult temperament. Social factors relate to the availability of role models and social support, poverty, poor education and lack of employment opportunities for the parents of the child.
Importantly, most risk factors do not manifest in isolation. Rather, one risk factor is likely to be associated with a host of other risk factors. For example, women who have experienced out-of-home care are more likely to have unresolved trauma, become teenage parents (which poses a greater risk of having a premature and hence low birth-weight baby), to have their own attachment insecurities, to live in poverty and to lack social support from the wider family. This means that there are some groups of individuals who are likely to be seen as ‘risky’ parents by dint of their own life circumstances. Although this is not to say that all people with these combinations of circumstances will be bad parents.
There are three levels of intervention that have been developed to assist such parents to create secure and protective environments for their children (Svanberg, 1998). These are educational, social and emotional support, and psychological treatments and therapy. More recently, Egeland (2009) proposed that there are just two broad types of intervention programmes that aim to enrich the quality of the relationship between infants and their primary caregivers:
First, there are interventions which aim to assist caregivers to become appropriately responsive to the infant’s needs and able to more accurately recognise their signalling cues. Such interventions are most likely to take the form of psycho-educational training, which can be applied to groups of parents, particularly those who are deemed at risk for experiencing difficulties with parenting.
Second, there are the interventions which aim to encourage parents (particularly mothers) to reflect on and possibly alter their own perspectives of being the object of parenting. This type of intervention aims to assist parents to resolve their own experiences of insecure attachments. The rationale for this comes from evidence of the intergenerational transmission of attachment insecurity. For example, a child’s attachment style at one year, as indicated by their reaction in the Strange Situation Test (SST, see Chapter 13), has been predicted pre-birth purely on the basis of the mother’s description of her own childhood experiences and relationships with caregivers, with accuracies of 75% (Steele, Steele & Fonagy, 1996) and 81% (Beniot & Parker, 1994). This type of intervention is more likely to consist of individual counselling or psychotherapeutic sessions.
With regards to the effectiveness of the interventions, Egeland (2009) contends that the longer-term cost-benefits of attachment interventions remain largely speculative. That is, there is a paucity of research which prospectively assesses the impact of early interventions on later mental health or offending outcomes. Rather, most of the intervention evaluations have been based on fairly limited periods of follow-up and the outcomes assessed have typically been restricted to changes in parental sensitivity and infant attachment. One such comparative evaluation was conducted by Cicchetti and colleagues and the results were published in 2006 and 2013. The study examined the potential differential impact of two different interventions to a no-intervention control group for mothers of infants who had been abused. The two interventions were infant–parent psychotherapy (IPP) (Lieberman, Weston & Pawl, 1991) and the Nurse Family Partnership Programme (Olds et al., 1986), a psycho-educational training programme which focused on parenting skills, stress management and social support.
Information box 20.1: Infant–parent psychotherapy
Infant–parent psychotherapy (IPP) is based on the work of Fraiberg, Adleson and Shapiro (1975) and has proven to be effective in engendering secure attachment in high-risk families, particularly immigrant families with a low income (Lieberman, 1992). Rather than see problems as arising from a lack of parenting knowledge or skill alone, IPP focuses on the idea that maltreating parents may have difficulties relating to their infant because of internal, insecure models that arose due to their own experiences in childhood. Moreover, interactions with the infant can evoke memories and emotions from the parent’s relationship with their own parents, which in turn can be projected onto the infant, leading to distorted perceptions and insensitive care. Rather than an individual (a parent or infant) being the patient, in IPP it is the relationship between the mother and the infant that is central. Sessions involve the mother and therapist jointly observing the infant and exploring the parent’s understanding and misperceptions of the infant. The therapist attempts to allow any distorted emotions and perceptions of the infant that are displayed by the mother to become associated with emotions and perceptions from the mother’s own childhood. The aim of this process, which is conducted through an unfailingly positive, supportive and non-directive approach (which also includes developmental guidance), is for the mother to learn to differentiate their current relationship with their infant from their own past relationships, and ultimately to form positive representations of their current relationship with their infant.
The study recruited 137 infants, who were approximately 12 months old, from maltreating families, and a non-maltreated comparison group of 52 infants. Both interventions were delivered for a 12-month period, during which time both interventions were equally associated with improvements in both parent sensitivity and an increase in attachment security in comparison to the no-intervention control group (Cicchetti, Rogosch & Toth, 2006). However, at the subsequent 12-month follow-up the psychotherapeutic intervention demonstrated a superior impact above that found for both the educational training programme and the no-intervention condition (Stronach et al., 2013).
However, these findings have not always been replicated. A number of meta-analyses have been conducted on the effectiveness of attachment interventions to enhance parental sensitivity and the infants’ attachment security (e.g. Van Ijzendoorn et al., 1992). These have produced inconsistent findings regarding which type of intervention is preferable.
Conclusion
Throughout this chapter we have explored possible factors, and preventative interventions, that can help individuals avoid negative health outcomes and offending behaviour. It is worth remembering that all too often prevention programmes, particularly those provided through state agencies, focus on stopping negative outcomes rather than on fostering positive outcomes, and that although prevention is usually preferable to treatment, there are downsides to models that locate problems at an individual level and ignore structural problems such as poverty. Nor should the power of labelling be ignored, and it is critical that in designing and implementing prevention programmes, marginalised and at-risk individuals and families are not demonised further by being branded with yet another negative label.
In the end, though, it certainly seems likely that a far greater emphasis needs to be placed on prevention rather than treatment, in the case of both mental health and offending behaviour. We began the chapter by looking at the case of Peter Woolf, and it is worth reflecting just how different his life might have been if the intervention that eventually helped him had been introduced before the addiction and criminal offending that ruined the first part of his life.
