Journal of Intellectual & Developmental Disability, June 2007; 32(2): 106116

Group treatment for men with intellectual disability and sexually

abusive behaviour: Service user views

SARAH-JANE HAYS1, GLYNIS H. MURPHY1, PETER E. LANGDON2, DAVID ROSE3 &

TRACY REED3
1

University of Kent, Canterbury, UK, 2University of East Anglia, Norwich, UK, and 3Oxleas NHS Trust, UK

Abstract
Background Men with intellectual disability (ID) and sexually abusive behaviour are a disempowered and marginalised
group. Nevertheless, as service users, they can be consulted and involved in a variety of different ways, including
ascertaining their views of the services they receive.
Method A group of 16 men with ID and sexually abusive behaviour were interviewed to ascertain their views approximately 2
months after completing a 1-year group cognitive behavioural treatment (CBT) for sexual offending. Two raters
independently reviewed interview transcripts and participant responses were summarised.
Results The most salient components of treatment recalled by participants were: sex education; legal and illegal behaviours
and their consequences; and discussions about specific sexual assaults. Only 3 of the 16 participants stated that they had
problems with sexual offending, and only 1 identified that he had learnt about victim empathy, although this is an important
component of treatment. Having support, the knowledge that they had the same problems as other group members, and
talking through problems, were appreciated as some of the best things about the group, while the worst things were
generally person-specific. Participants had mixed views on talking about their own offences during group sessions and,
overall, viewed the experience as difficult but helpful.
Conclusions Valuable insights into the aspects of treatment that group members found useful were explored. Such insights
are often not captured by studies that assess the efficacy of treatment models using treatment-specific measures only, and
these are important in defining the quality of services provided.

Keywords: Intellectual disability, sexual offending, user view, cognitive behavioural treatment, sensitive research,
empowerment

Introduction
Since the 1980s, the views of people with intellectual
disability (ID) about the services they receive have
been considered in the literature (McKenzie,
Murray, & Matheson, 1999). Many studies have
examined the views of service users with regard to
changes in residential service provision (e.g.,
Murphy, Estien, & Clare, 1996; Smyly & Elsworth,
1997), and on current residential service provision
and quality of life (e.g., Azmi, Hatton, Emerson, &
Caine, 1997; Burchard, Pine, & Gordon, 1990;
Dudley, Calhoun, Ahlgrim-Delzell, & Conroy,
1998; Felce & Perry, 1995; Flynn & Saleem, 1986;
Holland & Meddis, 1997; Lowe, 1992; McVilly,
1995). Other studies have assessed service users
satisfaction with the service they receive from
community support teams (Crocker, 1989; Witts &
Gibson, 1997), or following specific intervention
approaches (e.g., Barber, Jenkins, & Jones, 2000;

Fox & Emerson, 2001; MacDonald, Sinason, &

Hollins, 2003). Such attention to service user views
stems from the belief that the consumers view of a
service is the most important in terms of defining the
quality of the service (Dagnan, Jones, & McEvoy,
1993; Flynn, 1986; McKenzie et al., 1999). Similarly,
the UK Department of Healths White Paper
Valuing People emphasises the views of people
with ID and their families as being central to the
implementation of government initiatives, through
the development of Partnership Boards that include
people with ID as equal members (Department of
Health, 2001, p. 108). The Department now insists
that community ID teams provide evidence that they
are listening and responding to consumer views
(Department of Health, 2001, p. 68), and a research
initiative has been launched to review the literature on
the views and experiences of service users and their
families (Ramcharan & Grant, 2001).

Correspondence: Glynis H. Murphy, University of Kent, Canterbury, Kent CT2 7LZ, UK. E-mail: G.H.Murphy@kent.ac.uk
ISSN 1366-8250 print/ISSN 1469-9532 online # 2007 Australasian Society for the Study of Intellectual Disability Inc.
DOI: 10.1080/13668250701413715

User views of group treatment

Research with men with ID who sexually offend
Bartlett and Canvin (2003) describe a number of
ethical issues that are relevant to research with
forensic populations, including the difficulties of
gaining access to participants; the participants
capacity to consent and to be free from undue
pressure when making this decision; and the
researchers interpretation and representation of
the participants views and experiences. Bartlett
and Canvin also acknowledge the vulnerability of
the forensic population: Prisoners and hospitalised
patients are vulnerable because of their lack of
resources and personal autonomy (p. 59).
In addition to their vulnerability as forensic
clients, men with ID and sexually abusive behaviour
also face the disempowered status of those with ID
in the criminal justice system (e.g., Hayes, 1998), in
mental health services (see Flynn, Griffiths, Byrne,
& Hynes, 1997), and in society in general (Miller &
Keys, 1996). Even so, Brown and Thompson (1997)
have argued that men with ID who sexually offend
have impaired autonomy (as a result of chaotic
and often abusive upbringings), which results in
them being unable to reflect on the damaging nature
of their sexually abusive behaviour, and thus they
have diminished responsibility for their actions.
Brown and Thompson also suggest that unequal
power relationships with services seeking their
consent, the damaging effect of their sexual offending behaviour on others, and impairments
in cognition, knowledge and decision-making,
should justify intervention in the absence of full
consent. By contrast, we would argue that full and
informed consent should be gained for any treatment or research unless this is completely impracticable (in which case researchers might need to rely on
formal systems for gaining proxy consent). We
would also argue that professionals working with
people with ID and sexually abusive behaviour must
be careful to remain non-judgemental towards those
they are trying to help, for example, by defending
their rights to access appropriate treatment, to
consult legal counsel, and to make choices (albeit,
at times, within a restricted range of alternatives).
These rights must be carefully negotiated, of course,
since the rights of these individuals cannot extend to
opportunities to prey on vulnerable others.
Service users with ID and sexually abusive
behaviour can be consulted and involved in research
in a variety of different ways, including ascertaining
their views of the services they receive. Bartlett and
Canvin (2003) caution against the service users
voice being undermined because of their status as
prisoners, patients or offenders. For exam-

107

ple, they describe prison staff warning researchers to

not believe everything that they are told (p. 62),
and they acknowledge that staff may be suspicious
about the motives of individuals participating in
research when they are detained against their will.
Methodological issues
Ascertaining the views of service users with ID is not
as straightforward as it may seem (Finlay & Lyons,
2002; Flynn, 1986; Flynn & Saleem, 1986). Indeed,
defining and quantifying the concept of satisfaction
is fraught with difficulties (Clare, Corney, &
Cairnes, 1984, cited in Flynn, 1986). In addition,
people with ID have a tendency to acquiesce to
closed questions, especially when they do not
understand the question or how to answer it, and
they also tend to be more suggestible than people
without ID (see Clare & Gudjonsson, 1993; Prosser
& Bromley, 1998). Moreover, they may have
difficulty remembering choice alternatives in multiple-choice questions (Prosser & Bromley, 1998).
Felce and Perry (1995) argue that open-ended
qualitative interviewing based around a topic list,
such as that employed in Flynn and Bernard (1999),
has possible advantages over measures of satisfaction
employing Likert-type scales, as it does not provide
model answers and is less prescriptive. However
qualitative approaches to ascertaining user views
have their own disadvantages due to lowered
response rates to open-ended questions (Sigelman,
Budd, Winer, Schoenrock, & Martin, 1982) and
difficulties in understanding abstract questions and
concepts (Prosser & Bromley, 1998).
Views of men with ID who sexually offend
There is very little research into the views of people
with ID who engage in sexually abusive behaviour.
In one study Flynn and Bernard (1999) interviewed
20 offenders (16 male and 4 female) with ID,
including some who had engaged in sexually abusive
behaviour, about their experiences of the criminal
justice system (CJS) in medium and high security
services in the UK. A number of themes emerged
about generally negative experiences, including
difficulties in understanding what was happening,
feelings of anxiety and stress both before and during
the court process, and fears of being locked up.
Participants reported many negative aspects of
prison, high security services and medium security
services (e.g., victimisation by prison officers and
inmates, bullying, and assaults in medium security
services, and rigid treatment regimes in high security
services), but also some positive views (e.g., having

108

S-J. Hays et al.

two meals per day in prison, having a private cell,

access to therapy in medium security services, and
work opportunities in high security services).
Similar findings were reported by Murphy et al.
(1996), who followed up 26 people with ID (all of
whom had a history of offending behaviour, but not
all of whom had been convicted) following their
discharge from a low security service in London.
Semi-structured interviews were conducted to ascertain users views about the service. The majority of
respondents described positive aspects of the care
they had received, including staff generally being
interested in and concerned about them, enjoying
engaging in leisure activities, and the service providing a relaxed and friendly atmosphere. While most
respondents were positive about the therapeutic
options offered to them, a number disliked talking
about their past, were sad about being in hospital,
and angry when physical restraint was used.
Similarly, the views of participants attending two
psychodynamic psychotherapy groups (5 females
attending a womens group and 4 males attending a
sex offenders group) were described by MacDonald
et al. (2003). Participants described feeling valued
and listened to in the group. Talking about difficult
experiences was seen to be both a positive and a
negative aspect of psychodynamic group therapy (a
finding that is consistent with Murphy et al., 1996).
Some respondents did not believe that the group was
helping with their problems and described frustration with other group members.
The current study took place in the context of a
collaborative project evaluating group cognitive
behavioural treatment (CBT) for men with ID who
engage in sexually abusive behaviour. The project
was coordinated through the Sex Offender
Treatment Services Collaborative Intellectual
Disability Group (SOTSEC-ID: see www.sotsec.
org). The purpose of the present study was to
ascertain the views of men with ID following such
treatment.

Method
Participants
A group of 16 men were interviewed following
completion of group cognitive behavioural treatment
for sexually abusive behaviour. Criteria for participation in the group treatment program included: a
history of involvement in ID services; being aged
between 18 and 65 years (with each group having a
maximum age range of 30 years); a history of
engaging in sexually abusive behaviour; and being
in a stable residential placement (i.e., not living

rough) at the commencement of therapy. Prior to

being invited to participate in the treatment,
potential participants were informally assessed for
suitability for cognitive therapy and for working in a
group. All individuals who took part in the first three
treatment groups were invited to participate in this
research. Five participants (31%) had attended more
than one treatment group, and were interviewed
separately on their views of each group.

Measure
Service User Interview. The Service User Interview is
a semi-structured interview developed by one of the
authors (GM). It comprises 14 interview questions
which are designed to access the participants views
and understanding following group cognitive
behavioural treatment (CBT) for individuals with
ID who sexually offend or are at risk of sexual
offending. The interview questions fall broadly into
3 categories: (i) Factual/memory-related questions
designed to check participant-recalled basic aspects
of the group (e.g., Where did the Mens Group1
meet?, On what days did the Mens Group
meet?); (ii) Content questions concerning the
material covered during the group treatment
program (e.g., Did the group have some rules?
[probe what they were]); and (iii) Views of treatment
questions requesting the participants views on the
group (e.g., What was the best and worst thing
about the Mens Group?).
The purpose of the memory-related questions was
to provide a context for the interview and for the
interviewer to ascertain what the participant remembered about the treatment group (and whether the
interview should proceed). It is well known that
people with ID often have difficulties with cognitive
functions such as memory (e.g., Clare &
Gudjonsson, 1993; Clements, 1987). Moreover,
the participant might also attend other groups
(e.g., in day services) and so could become confused
as to which group is being asked about. The
questions on content (while also assessing memory
for the treatment group), provided information on
the participants understanding of concepts learnt in
treatment. The final set of questions provided an
opportunity for the participant to describe their
views on the group.
The interview was designed to be used by people
who are accustomed to working with individuals
with ID. The interview was flexible and there was
scope for the interviewer to ask additional questions
in order to clarify responses and to obtain additional
views.

User views of group treatment

Treatment model
The model of treatment provided to the three groups
was that developed by the Sex Offender Treatment
Services Collaborative Intellectual Disability
Group (SOTSEC-ID) as described in Sinclair,
Booth, and Murphy (2002). Treatment groups were
for 510 men, meeting once per week for a 2-hour
session over a period of 1 year. The main topics
covered during the program were: group purpose
and rules; initial group social skills and development
of a common language; human relationships and sex
education; the cognitive model; the sexual offending
model (Finkelhors four-stage model: Finkelhor,
1986); the development of general empathy and
victim empathy; and relapse prevention. These
topics were not presented as discrete modules;
rather, facilitators were encouraged to move between
topics according to the clinical needs of group
members (see www.sotsec.
org and Sinclair et al., 2002 for details).
In the present study, men from the first three
treatment groups provided according to the above
model were invited to join the research. Two
treatment groups were conducted in a community
setting (these groups included some men detained
under the Mental Health Act, 1983, who had to be
escorted to and from the group), and the other group
was conducted in a secure setting.
Procedure
Following a review of the study by UK NHS ethics
committees, members of the treatment groups were
asked for their consent to participate in the research,
which was part of a larger study assessing the
effectiveness of the CBT program for men with ID
and sexually abusive behaviour. (Research consent
was obtained separately from consent to treatment.)
Participants were informed that they had the right to
refuse to participate in the research; they were told
that they could still continue with their treatment
even if they refused to take part in the research.
A trainee clinical psychologist and an assistant
psychologist, neither of whom were involved in
providing treatment, interviewed participants from
two of the groups. These participants were first
contacted by telephone to ascertain whether they
were happy for the interview to take place (after they
had already consented to the research). For the third
group, either one of the main group facilitators (a
clinical psychologist) or an assistant clinical psychologist interviewed the participants about their views
on the group. In this case, the men were approached
directly by the group facilitator and invited to
participate in the interview and research.

109

Participants were interviewed individually,

approximately 2 months after completion of the
group treatment program. Each interview took
approximately 30 minutes. Two-thirds of the interviews were audio-taped for later transcription.
Participants responses for the remaining interviews
were recorded in writing at the time of the interview.
Two participants had a support person with them
during the interview by choice.
Inter-observer reliability
Two raters independently rated each of the transcripts. The number of occurrence categories varied
for each of the interview questions. Simple percentage agreements were calculated for the measure of
agreement between the two raters, and chance
agreements were corrected for by using kappa. A
kappa value of .70 is considered an acceptable level
of inter-observer agreement (Sattler, 1992).
Percentage agreement between the two raters for
the factual/memory-related questions ranged from 81
100%. When these ratings were corrected for chance
agreements, the mean kappa was .90, ranging from
.4551.0 for the various questions (the low figure of
0.455 was for the question Where did the Mens
Group meet?, which reflected three instances of
non-agreement between the two raters).
Percentage agreement between the raters for the
content questions ranged from 73100%. The mean
kappa was .82, ranging from .60 (for coding
responses to the question Why were you
referred?) to 1.0.
Percentage agreement for the views of treatment
questions ranged from 73100%. The mean kappa
was .88, ranging from .831.0 for the various
questions.

Results
Background characteristics
Background characteristics of the participants are
given in Tables 1 and 2. All participants had been in
contact with either psychiatric/psychology services or
ID services as adults (in three cases for under 3
years; in two cases for between 3 and 4 years; and in
11 cases for over 4 years). Eight participants had a
statutory requirement to attend treatment: seven
were detained under the Mental Health Act (1983)
and one had a community rehabilitation order
(previously known as a probation order). The
remaining eight participants were not legally
required to attend treatment.

110

S-J. Hays et al.

Table 1. Demographic characteristics of group treatment

participants (N516)
Characteristic

Range

Mean SD

Age
2061
36.5 11.6
IQ
5183
66.0 8.8
Comorbid psychiatric diagnoses
(Percentage)
Autistic spectrum disorders
38% (n56)
Personality disorders
31% (n55)
Sexual and gender identity disorders 25% (n54)
Mood disorders
19% (n53)
Schizophrenia/other psychotic
13% (n52)
disorders

Participants had a range of index sexually abusive

incidents,2 including public masturbation, nonpenetrative acts with children and adults, voyeuristic
behaviour, frotteurism, indecent assault, attempted
rape, and rape. Seven participants had come into
contact with the police for their index behaviour
and, of these, four cases had proceeded to court,
with all four being convicted of rape (of a man or
woman). One of the four received a community
rehabilitation order and the other three participants
received hospital orders. The majority of participants also had a history of previous sexually abusive
incidents, including convictions for sexual offending.
Only one participant had no known previous history
of sexually abusive incidents.
Interview results
Results for the factual/memory-related questions for
all participants are presented in Table 3. The
majority of participants recalled the correct location
of the Mens Group, the correct day on which the
group met, and the length of each session. All
participants (for whom data were available) were
Table 2. Residential status prior to and following group
treatment for sexually abusive behaviour

Community
Supported in own home
In own home unsupported
Living with family or close
relative
Group residential home
With support person in
support persons own home
Secure provision
Low secure
Medium secure

Prior to start of
group treatment
(N516)

At completion
of group
treatment
(N516)

(n57)
2
0
1

(n510)
2
1
1

2
2

4
2

(n59)
4
5

(n56)
3
3

able to identify who had invited them to attend the

group and correctly recalled that other participants
were involved in the group. Almost all of the
participants could remember at least some of the
facilitators names.
Participants responses to the content questions are
given in Table 4. Participants were asked to identify
the aim of the Mens Group and to say why they
were referred to the group. The majority of
responses (75%) specified that the group concerned
sexual issues or getting into trouble, and most
participants (75%) either admitted to having done
something wrong or acknowledged having sexual
problems.
The majority of participants (81%) also recalled
that the Mens Group had rules and most were able
to name a number of the group rules. When asked
what they did while in the Mens group, 13
participants were able to recall and name at least
some of the content (excluding vague responses or
responses simply indicating that participants helped
each other). Four participants recalled 1 treatment
component, six participants recalled 2 treatment
components, and one participant each recalled 3, 4
and 5 treatment components.
Table 5 contains results for the views of treatment
questions. Most men reported that they wanted to
come to the group and most said they were able to
stick to the group rules. Some participants were able
to specify precisely what they had learnt in the
group, but many of the answers provided to this
question (47%) were rather vague. A variety of
answers were provided in response to the question
What were the best things about the Mens
Group? (see Table 5).
The majority of features identified by participants
as the worst things about the group were personspecific. For example, one participant identified the
worst thing as having someone else who lived with
him present at the same group, and he was
hoping theyd keep it confidential. Youre not
supposed to tell anyone. Confidential stuff in the
group.
Another participant identified that the timing of
the group was important to him: It would have
been better to have talked about these things in the
daytime. In the evening I dont want to know. If it
was during the daytime I could talk about it....
For another participant, it was what the Mens
Group signified which was the worst thing for him:
I think the worst thing was knowing that we were
there because weve got problems and wishing that
we didnt have the problems.
For other participants (19%), talking about their
own offences was the worst thing about the group.

Dont know
n51 (8%)

Dont know
n50 (0%)
Dont know
n50 (0%)
Incorrect response (unable to
name any group facilitators)
n51 (6%)
Irrelevant person mentioned
n50 (0%)
No
n50 (0%)
Partially correct response (able to name
some group facilitators)
n59 (56%)

Responses

Dont know
n50 (0%)
Dont know
n52 (13%)
Dont know
n51 (7%)

Incorrect location
n54 (25%)
Incorrect day
n50 (0%)
Incorrect answer
(less than 1K hours; more than 2K hours)
n52 (14%)
Incorrect number of months
n54 (31%)

User views of group treatment

111

For example, one said: I think it was trying to bring

up all the things that had happened to me in the past
and letting everyone listen to them and what
everyone else had about everyone elses problems
as well. It makes you stop and think sometimes I
think. Trying to [bring] up the things that werent
very nice [unclear].
Others (19%) provided vague answers such as it
was boring. Two participants (13%) mentioned
specific group content, while two others said that the
worst thing about the group was that it was not long
enough and that it finished.
The majority of participants (69%) indicated that
they would like to attend another Mens Group.
However of these, 5 participants stipulated conditions that would need to be met if they were to
attend another group, for example, the time of day
any new group would be run, or the location of the
group (If it wasnt so far away). For another
participant, having the same group facilitators for
any future group was important: If different
peoples are taking it, what is the point? Another
participant identified that his attendance at a future
group would depend on whether he remained in a
low security service.

Who said you should go (to the Mens Group)?

(N514)
Did other people go to the Mens Group?
(N516)
Who led the group?
(N516)

How many months did the Mens Group meet for?

(N513)

Correct location
n512 (75%)
Correct day
n513 (87%)
Correct answer
(1K2K hours)
n511 (79%)
Correct number of months
( 2 months)
n58 (62%)
Relevant person mentioned
n514 (100%)
Yes
n516 (100%)
Full response (able to name
all group facilitators)
n56 (38%)
Where did the Mens Group meet?
(N516)
On what days did the Mens Group meet?
(N515)
How long did the sessions last (on each day?)
(N514)

Factual/memory questions

Table 3. Participant responses to factual/memory-related questions

Discussion
This sample of men with ID and sexually abusive
behaviour forms part of a larger study assessing the
effectiveness of group cognitive behavioural treatment with this population (Murphy, Sinclair, Hays,
Heaton, & SOTSEC-ID Group, 2006). The background characteristics of this sample are similar to
those described in other studies (e.g., Hayes, 1991;
Lindsay, Law, Quinn, Smart, & Smith, 2001;
Thompson & Brown, 1997), and are fully documented elsewhere for the larger sample (see Murphy
et al., 2006).
The factual/memory-related questions of the Mens
Group interview provided a prompt to participants
and a lead in to the content and views of treatment
questions. They also allowed the interviewer an
opportunity to assess whether participants recalled
enough about the group to be able to answer more
in-depth questions. The majority of participants
recalled the day and timing of the Mens Group, why
they had been asked to attend, and who else was
involved in the treatment group. This is probably not
surprising given that the interviews were conducted
approximately 2 months after completion of the
treatment.
The content questions explored what the participants had learnt in treatment. Less than half (44%)
stated that the aim of group was to help with sexual

112
S-J. Hays et al.

Table 4. Participant responses to content questions

Content questions

Responses

What was the Mens group for

(what was the aim of the
group?) (N516)

To talk about
problems/to
get help
n53 (19%)

To stop getting into

trouble (no mention
of sexual offending)
n54 (25%)

To learn about
relationships/sex
education
n51 (6%)

Mention of sexual
problems/sexual
offending/offending
n55 (31%)

Mention of self
having sexual
offending problems
n52 (13%)

Why were you referred (why

did you go?) (N516)

To talk about
problems/get help/
talk about past
n52 (13%)

Mention of self having

sexual problems/specific
sexual offending example
n53 (19%)

Admitted that did

something wrong,
but not that it was
sexual
n59 (56%)

Said that did not know

why referred
n51 (6%)

Asked question but

no answer provided
n51 (6%)

Did the group have some

rules? (N516)

Yes
n513 (81%)

No
n52 (13%)

Unsure
n51 (6%)

What were they?* (N513)

Be on time/start
on time
n53 (23%)

No interrupting/talking
when someone else is
speaking
n54 (31%)

No swearing at each
other/no swearing
n55 (39%)

Confidentiality rule
and exceptions
n511 (85%)

What did you do while in the

Mens group? (N516)

Review of week
good things and
bad things
n52 (13%)

Helping each other

n52 (13%)

Mentioned talking
about sexual problems/
sexual assaults
n55 (31%)

Legal and illegal

behaviours/consequences
of illegal behaviours
n57 (44%)

Reasons for sexual

offending (e.g.,
four-stage model)
n52 (13%)

Relapse prevention
description/example
given
n52 (13%)

Vague answer (e.g.,

mentioned watching
videos/looking at
pictures, but nothing
about content
n55 (31%)

*For rules common to all three groups.

Sex education/learnt
about sex/sexual
health/relationships
n510 (63%)

Asked question but

no answer provided
n51 (6%)

Victim empathy
(e.g., talked about
how the victim felt)
n50 (0%)

Table 5. Participant responses to views of treatment questions

Views of treatment questions

Responses
Yes
n59 (60%)

No
n55 (33%)

Unsure
n51 (7%)

Did you find it hard to stick

to the rules? (N510)

Yes
n52 (20%)

No
n56 (60%)

Unsure
n52 (20%)

What do you think you learnt

in the Mens Group? (N515)

Mentioned sex
education/relationships
or aspects of sex
education (e.g., how
to put on a condom)
n54 (27%)

Mentioned legal and

illegal behaviours/
example given/legal
processes
n54 (27%)

Mentioned victim
empathy (e.g., how
victim feels)
(N516)
n51 (6%)

Four-stage
model why I
committed my
offence. Mentioned
any of the stages or
examples provided
n52 (13%)

Relapse
prevention
description/
example
provided
n52 (13%)

Vague answer: stopped

me to sexual abuse,
helped me, how
not to get into trouble
with people outside.
n57 (47%)

Other answer (relevant)

provided (e.g., learnt
how to listen to other
people
n56 (38%)

Other answer
(irrelevant) provided
(e.g., budgeting
n51 (6%)

Meeting people
n54 (25%)

Mentioned that the

group finishing was
the best thing; coffee
break during the group
n56 (38%)

Mentioned specific
group content (e.g.,
books/pictures good);
mentioned aspects of
the treatment model
n53 (19%)

Mentioned having
support; same
problems as other
group members;
talking through
problems
n54 (25%)

Mentioned
helping each
other
n52 (13%)

Vague answer
(e.g., enjoyed it.)
n53 (19%)

Talking about own

offences
n53 (19%)

Mentioned specific
group content as
worst thing
n52 (13%)

Vague answer
(e.g., it was
boring.)
n53 (19%)

Other reason given

n59 (56%)

What were the best things about

the group? (N516)

Other reason given

n52 (13%)
What were the worst things about
the group? (N516)

Mentioned that the

group finishing was
the worst thing; group
not long enough
n52 (13%)

Group went on too long

n50 (0%)

Would you like to go to another

Mens Group? (N516)

Yes no conditions
n56 (38%)

Yes but with conditions No

n55 (31%)
n55 (31%)

User views of group treatment

Did you want to go to the

Mens Group? (N515)

113

114

S-J. Hays et al.

problems, sexual offending or offending, and

only three (19%) mentioned these issues when
specifically asked why they were referred to the
group. These low numbers may in part reflect the
stigma attached to the label of sex offender, as
well as the fact that the majority of participants were
interviewed by a person who was not directly
involved in providing the group treatment. In
addition, denial is a common feature in the majority
of sexual offenders (see Marshall, Anderson, &
Fernandez, 1999), which may explain why most
participants said they were referred to the group
because they had done something wrong (56%) or
to talk about problems/get help/talk about the past
(13%), without any reference to sexual offending.
Participants recalled a number of the group rules,
including the confidentiality and exceptions to
confidentiality rule (85%), the no swearing rule
(39%), the no interrupting rule (31%), and the
start on time rule (23%). In particular, the
confidentiality and exceptions to confidentiality
rule appears to have been important to the men.
Some participants identified that the worst thing
about the group was having to trust other group
members to obey this rule, which perhaps highlights
the need for group facilitators to regularly discuss
this rule in group and to gauge each participants
investment in it.
Many participants appreciated social aspects of
the group such as having support, learning that they
had the same problems as other group participants,
and talking through problems. It appears that some
men gained a sense of increased self-efficacy through
participation in the group, and the knowledge that
they were not alone with their difficulties was
important. Unfortunately, men with ID and sexually
abusive behaviour rarely receive any treatment for
their problems.
The social stimulation provided by the group was
also important, as was learning about aspects of the
treatment model and helping other group members.
The group could possibly be viewed as empowering
to some members, for example by being able to learn
as well as teach relevant and appropriate skills to
other group members.
Encouragingly, 13 participants were able to recall
at least one component of the treatment program,
and of these, 9 recalled two or more treatment
components. The highest proportion of participants
recalled the sex education/sexual health/relationships component, followed by the legal/illegal
behaviours/consequences of illegal behaviours
component, while approximately one-third recalled
that the group had discussed sexual problems/
sexual assaults.

Of concern is the fact that relatively few of the

participants recalled work in the group on victim
empathy. Victim empathy is a component in almost
all mainstream sex offender treatment programs, and
there is some evidence to suggest that sexual
offenders have deficits in specific empathy (i.e.,
towards their own victim) rather than deficits in
general victim empathy (Marshall et al., 1999). The
inclusion of this component in treatment programs is
also based on the belief that enhancing empathy will
change the attitude of sex offenders towards their
victims and thereby potentially inhibit future sexual
abuse (Williams & Khanna, 1990, cited in Marshall
et al., 1999).
The worst things about the group, as expressed by
the majority of group members, were generally
person-specific, for example, issues about confidentiality, timing of the group, and the realisation that
the participant and others in the group were there
because they had problems. Talking about ones
own offences in front of the group was also identified
as one of the worst things about the group. This
finding is consistent with two other published
studies, one of which interviewed people with ID
about their views of an inpatient treatment service
(Murphy et al., 1996), and the other which interviewed people about a group psychodynamic sex
offender and a separate womens group treatment
(MacDonald et al., 2003). The participants in
Murphy et al.s study found talking about the
past, which included past offending, was emotionally difficult. MacDonald et al. also found that there
were a number of negative themes related to sharing
difficult emotional experiences such as offending.
However, as in the current study, participants also
identified that talking through their problems was a
positive experience. The men had often kept their
sexually abusive behaviour a secret from as many
people as possible, and for some of these, talking
about their secret was a relief as well as a very
difficult experience.
Future treatment planning by clinicians could
benefit from asking treatment recipients about what
was good or not so good about their treatment,
whether they would attend another group, and their
conditions on any future attendance, as we have
done in this study.
Benefits and limitations of the research
This study has been useful in providing valuable
insights into the aspects of treatment that group
members found most helpful. Such insights are often
not captured by studies that address the efficacy of
treatment models using treatment-specific measures

User views of group treatment

only, and these are equally important in defining the
quality of services provided (Dagnan et al., 1993;
Flynn, 1986; McKenzie et al., 1999).
Most interviews in this study were conducted by
interviewers who were not directly responsible for
providing the group treatment. This methodology
had the advantage of minimising the possible impact
of participants trying to appease the interviewer
(which could have been problematic if group
facilitators had interviewed the participants).
However, it may also have had the disadvantage of
making some participants reluctant to share what
they considered to be very private information about
themselves. Interestingly, when a later set of Mens
Group graduates were asked who they would prefer
to do the post-group interviews, the unanimous view
was that they wanted the group facilitators to do
them.
One advantage of this study over other studies of
its type is that participant responses were coded by
two raters, allowing inter-observer reliability to be
calculated. However, this research would have
benefited from the views of a larger number of
participants.
Future directions
Our research has subsequently been extended to
obtain further input from men who have graduated
from other SOTSEC-ID treatment groups (i.e.,
using the same treatment model). Following a focus
group, a number of revisions have been made to the
Service Users Interview that was employed here,
including the use of pictures to assist understanding
and the addition of six new questions (all suggested
by graduates of SOTSEC-ID groups).
We firmly believe that it is important to seek the
views of men with ID and sexually abusive behaviour, particularly given that they are a marginalised
and oppressed group. We cannot as yet be certain
that the methodology used in this study is the best
method of obtaining their views. It is feasible that a
qualitative methodology would produce different
results, and may allow a more in-depth exploration
of the topics discussed.
Author note
The authors have no financial interest in the
publication of this paper.
Acknowledgments
We wish to thank all the men who agreed to participate
in this research for sharing their experiences and views

115

of treatment. We are grateful to assistant psychologists Sam Durvance and Jenny Reeve who
provided support to one of the treatment groups
and assisted with some of the Mens Group
interviews. Many thanks also to Kathryn Heaton,
research worker, for her rating of the transcripts.
Finally we would also like to thank the UK
Department of Health for funding this research.
Notes
1 Mens Group was the title given to the group for men with
ID who sexually offend.
2 As many men with ID do not come into contact with the
criminal justice system, the term sexually abusive incident(s) will be used throughout this paper to refer to
sexually related behaviour for which the other person was
non-consenting, and the behaviour would be defined as illegal
within the jurisdiction in which it occurred (Sinclair et al.,
2002, p. 4). Index sexually abusive incident refers to the
most recent incident prior to the start of the treatment group,
whether or not it came to the attention of the police.

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