Any Research Progress Yet?

Recently, while helping with the new Internet site, I realized two significant anniversaries had just passed. It was 25 years ago that Dr. Vernon Quinsey arrived here, and 20 years ago that he founded the Research Department. (Vern left in 1988 to become Professor of Psychology and Psychiatry at Queen's University.) It's interesting to look back at the problems he first tackled and ask what progress has been made. In 1971, Vern was the psychologist for the Activity Treatment Unit (ATU), a 150-bed unit for the most disturbed and unmanageable patients. He immediately set himself four very practical tasks:

Vern's look at the scientific literature struck an obvious finding -- behavioral treatments (emphasizing training and maintaining skills) were the only justifiable therapies for the ATU's chronic patients. Though many would benefit from medication, there was (and is) solid evidence that most patients require more. The effects of Vern's work establishing ward-based behavioral programs can still be seen today in efforts to revive token economies on the Behaviour Therapy Program. Members of the Research Department have studied the effects of other hospital programs, researched the clinical characteristics of our patient populations, and continue to review the scientific literature about treatment. Vern's conclusions of 1971 are even more clearly supported by research today: behaviour therapy is strongly indicated for all institutionalized psychiatric patients.

Immediately, Vern conducted follow up studies of released forensic patients. He studied how clinicians made decisions about forensic patients. This research (as well as that by many other investigators) clearly showed that clinicians' judgments about dangerousness were poor. On the other hand, certain personal characteristics, measured objectively, were consistently related to patients' future violence. This research culminated in the Violence Risk Appraisal Guide, an actuarial (or statistical) tool to appraise the risk of violent recidivism. This instrument replaces unaided clinical judgment and is the most accurate available in the field.

In 1971, the ATU was dangerous; patients committed hundreds of assaults per year. Many staff and patients were injured. Drugs and standard institutional care were not controlling assaults. Vern used his skills as a behaviour analyst to study that violence. He learned that assaults are like any other behaviour -- the result of personal and situational factors. Violence by ATU patients resembled violence elsewhere in society. Members of the Research Department continued to study inpatient violence culminating in the Crisis Intervention and Prevention Course (summarized in the book Violence in Institutions: Understanding, Prevention and Control). Research showed that the course enhanced staff skills in dealing with patients, improved staff and patient morale, and reduced assaults and staff injuries. The training is now given by the educational services department to all staff and has been adopted by many other institutions and agencies.

In 1971, there were many child molester patients who presented a serious puzzle to the clinical staff. Because of the nature of their offenses, continued good behaviour in hospital could not be taken as proof that child molesters were good candidates for release. No one knew why they committed their offenses, or what assessments and treatments should be provided for them. Vern was asked to take on this puzzle. He established a phallometric laboratory because the scientific evidence indicated that child molesters' offenses were related to sexual attraction for children. This might seem self-evident now, but it was certainly not the clinical consensus then.

Since then, studies demonstrated the sexual deviance of child molesters, showed that some men could fake their sexual preferences, and then later showed how faking could be prevented. Other studies explored technical aspects of sexual preference assessments. Others showed that the sexual attraction to children did not decrease even when the pain and suffering of victims was greatly emphasized. Still other results showed that sexual preferences predicted recidivism. Finally, the most recent results suggest a prenatal basis for deviant sexual preferences. As well of course, the work was extended to rapists where the same questions were explored. All of this research leads away from attitudes, low self esteem, and lack of insight as explanations and treatment targets for child molesters. All the results point to deviant sexuality as central to an explanation of (and, possibly, treatment for) child molesting.

With regard to treatment, the earliest work was aimed at changing sexual preferences. Early studies demonstrated that behaviour modification could bring about the changes as assessed in the laboratory. However, neither such changes nor other treatments affected recidivism. At this point the puzzle of the child molesters is far from solved. Efforts continue to understand how and why sexual preferences become deviant and what factors influence the expression of deviance.

One cannot help but be struck by four themes of this reminiscence: First is the clarity of Vern Quinsey's vision about what were the important questions facing forensic clinicians. Much of the work illustrated above was done by other members of the Research Department, and new topics have been added (psychopathy, firesetters, high school students, as examples), but Vern's major tasks are just as important today as they were in 1971. Second is the applied and practical nature of the problems he tackled. Each of the four areas described were crucial problems forensic clinicians wrestled with daily. Third is the progress achieved. Sometimes it's hard to tell that we're getting anywhere, but a historical perspective clearly shows increased knowledge about effective treatment for forensic patients, reducing institutional violence, and assessing the risk of recidivism. Of course, not all problems have yielded -- we still know little about effective treatment for sex offenders. Fourth is the gap between scientific knowledge and practice. Perhaps the biggest practical challenge for our field now is ensuring that the assessment and treatment of forensic patients matches the scientific knowledge accumulated in the last two decades.