week 4 The efficacy of CBT based interventions to sexual offenders- A systematic review of the last decade literature.pdf

International Journal of Law and Psychiatry 87 (2023) 101856 Contents lists available at ScienceDirect International Journal of Law and Psychiatry journal homepage: www.elsevier.com/locate/ijlawpsy The efficacy of CBT based interventions to sexual offenders: A systematic review of the last decade li...

International Journal of Law and Psychiatry 87 (2023) 101856 Contents lists available at ScienceDirect International Journal of Law and Psychiatry journal homepage: www.elsevier.com/locate/ijlawpsy The efficacy of CBT based interventions to sexual offenders: A systematic review of the last decade literature Isabella Carvalho Oliveira Rocha *, Alexandre Martins Valença Department of Forensic Psychiatry, Psychiatry Institute (IPUB), Federal University of Rio de Janeiro, Av. Venceslau Brás, 71, Botafogo, Rio de Janeiro, RJ 22290-140, Brazil A R T I C L E I N F O A B S T R A C T Keywords: Sexual violence Sex offender Sex crimes Cognitive behavioral therapy CBT Sexual violence is a significant public health problem and a devastating issue for mental health throughout the world. Clinicians and researchers have worked, over the last decades, to develop effective strategies aimed at reducing sexual abuse rates. Multiple treatment approaches for sex offenders have been developed, with Cognitive Behavioral Therapy (CBT) been the most widely used therapy model with recognized effectiveness. In this sense, the present study aimed to analyze and evaluate the effectiveness of CBT based interventions in the treatment of individuals convicted of sexual crimes. For this purpose, a systematic review of articles published between 2012 and 2022 was carried out in the databases Pubmed, Science Direct, APA PsycNet and Scielo, with the keywords “cognitive behavioral therapy”, “CBT”, “sexual offender”, “sexual crimes” and others. As a result, eight studies were selected that met the defined inclusion criteria. Cognitive-behavioral interventions have shown great promise in reducing sexual crime recidivism and improving self-control, emotional regulation, intra and interpersonal social skills, supporting the hypothesis that CBT may be a promising model of intervention in forensic settings with sex offenders. Sexual violence is a significant public health problem and a devas­ tating issue for mental health throughout the world. The World Health Organization (WHO) (Krug, Mercy, Dahlberg, & Zwi, 2002) defines it as “any sexual act, attempt to obtain a sexual act, unwanted sexual com­ ments or advances, or acts to traffic, or otherwise directed, against a person's sexuality using coercion, by any person regardless of their relationship to the victim, in any setting, including but not limited to home and work.” Several studies have shown an important association between being a victim of sexual violence and the risk of developing a wide range of psychological problems, such as higher rates of depression and anxiety disorders, substance abuse, suicidal risk, autoimmune and eating dis­ orders (Gibbels, Kneer, Hartmann, & Krueger, 2019; Grady, Edwards, & Pettus-Davis, 2017). Survivors of sexual abuse experience many different consequences, such as later victimization and high-risk sexu­ alized behaviors, as well as cognitive difficulties, academic problems, acting-out behaviors, and interpersonal difficulties (Wurtele & Kenny, 2010). Its consequences are not only disastrous for victims but are also extremely costly for society (Brooks-Gordon, Bilby, & Wells, 2006; Gibbels et al., 2019). Moreover, sexual offenses carry a huge social stigma and, justifiably, evoke feelings of intense personal insecurity. As an example of a social stigma component, it's observed that, when in jail, sex offenders are often rejected by other prisoners. A study involving a literature review (Mazza et al., 2020) found that common prisoners often engage in stigmatized behavior towards sex offenders, such as social exclusion, isolation, and psychic violence, as well as physical and sexual violence, as a form of revenge. Consequently, sex offenders often receive unequal treatment during intramural work and recreational activities (Mazza et al., 2020). Particularly, sex offenders released after serving their sentences usually generate public concern and alarm (Martínez-Catena & Redondo, 2017). For all these reasons, as a result of such potentially outcomes, cli­ nicians and researchers have worked, over the last decades, to develop effective strategies aimed at reducing sexual abuse rates (Grady et al., 2017). Successful treatment of sexual offenders is clearly an important goal for society as well as for victims and offenders themselves (Gibbels et al., 2019) and the efficacy of interventions is an important measure in psychiatric management of offenders (American Psychiatric Associa­ tion, 1999). What is known is that multiple treatment approaches for this popu­ lation have been developed over the years. Several studies have * Corresponding author. E-mail address: [email protected] (I.C.O. Rocha). https://doi.org/10.1016/j.ijlp.2022.101856 Received 28 July 2022; Received in revised form 1 December 2022; Accepted 17 December 2022 Available online 2 January 2023 0160-2527/© 2023 Elsevier Ltd. All rights reserved. I.C.O. Rocha and A.M. Valença International Journal of Law and Psychiatry 87 (2023) 101856 demonstrated the relevance of understanding dysfunctional cognitions and behaviors and emotional regulation for the treatment of sexual of­ fenders and, in this sense, Cognitive Behavioral Therapy (CBT) has been the most widely used therapy model with recognized effectiveness (Burdon & Gallagher, 2002; Carpentier & Proulx, 2021; Gibbels et al., 2019; Hanson et al., 2002; Mpofu, Athanasou, Rafe, & Belshaw, 2018; Olver, Marshall, Marshall, & Nicholaichuk, 2020, Osborn, 2007). Osborn (2007), in fact, has shown as the best treatment for sex of­ fenders a cognitive behavioral intervention based on a relapse preven­ tion model employing individual and group therapy. The author, in his studies, reported positive results regarding the effectiveness of CBT in­ terventions, with lower recidivism rates when offenders are treated, and also when they finish their treatment. CBT have been considered the more promising rehabilitative treat­ ments for criminal offenders. Reviews of the comparative effectiveness of different treatment approaches have generally ranked it in the top tier regarding the effects on recidivism (Lipsey, Landenberger, & Wilson, 2007). The CBT approach is more considered to be a first-line treatment, whether in groups or individually (Bereiter & Mullen, 2012) and in­ terventions of this nature are administered across the world (Mazza et al., 2020). The “First Report of the Collaborative Outcome Data Project on the Effectiveness of Psychological Treatment for Sex Offenders” (Hanson et al., 2002) describes a meta-analysis evaluating data from forty-three studies, showing the cognitive behavioral model with positive effec­ tiveness on both sexual recidivism and general reducing. CBT postulate the interaction between dysfunctional thoughts, emotions, and behaviors, addressing, in this way, the influences of be­ liefs on harmful behaviors as maladaptive responses. According to Mpofu et al. (2018), in forensic settings, the aim of CBT is to adjust cognitive distortions or decisional lapses believed to be behind mal­ adaptive behaviors, including criminal behavior. For Martínez-Catena and Redondo (2017), cognitive distortions about sexual interactions have a leading etiological role in sexual offending behavior. Some in­ dividuals show severe deficits in empathy and social skills and dysfunctional thoughts may hamper their capacity to properly interpret and recognize the emotions, needs and desires of others (specially of their victims). For this purpose, CBT is an effective approach to develop emotional and behavioral self-regulation skills, in addition to social skills. Inter­ vention involves work on accountability for abusive behaviors, the improvement of empathy, cognitive restructuring and reducing deviant sexual interests. Generally, the interventions include relapse prevention strategies and the development of internal and external control strate­ gies that reduce recidivism risk (Carpentier & Proulx, 2021). These cognitive behavioral treatment programs also usually incorporate offense-oriented strategies for preventing sexual reoffense, like under­ standing the offense responsibility, intimacy/relationship skill building, social problem solving, and emotion regulation. CBT's major mechanisms include enhancing behavioral self-efficacy through a range of decisional risk-weighting techniques to maximize prosocial outcomes, besides maintaining behavioral recovery from criminogenic need impulses (Landenberger & Lipsey, 2005). With sexual offender populations, enhancing decisional choice in the face of crimi­ nogenic impulses is at a premium for preventing reoffending and then, CBT can be an important intervention model of preventive or rehabili­ tative therapy to reduce risk of recidivism (Burdon & Gallagher, 2002; Mpofu et al., 2018). Despite cognitive distortions are strongly related to the etiology of sexual offense behavior, it's a complex issue to determine their rela­ tionship with treatment efficacy. In terms of treatment, Martínez-Catena and Redondo (2017) suggest that cognitive distortions are assessed and treated both as crime precipitant and maintaining factor. In this context, current research has sought to evaluate the effectiveness of intervention strategies with sex offenders in forensic contexts, in order to better support treatment models, aiming to reduce criminal recidivism, in addition to improve social skills, emotional regulation, conflict man­ agement and coping. In this sense, since CBT based interventions have shown to be an important treatment model in sexual offenders' populations, evaluating the effectiveness of specific cognitive-behavioral strategies for this population is scientifically useful to subsidize interventions not only to reduce the likelihood of reoffending, but also to help them to improve intra and interpersonal skills. The main objective of the present study is to conduct, based on a systematic literature review, a survey of researches that evaluate the effectiveness of CBT based interventions in the treatment of individuals convicted of sexual crimes. In addition, the review focuses on identifying possible gaps in this area of knowledge, to encourage future research. The relevance of the present study is highlighted as it allows analyzing and enhancing scientific understanding of sexual offending behavior in order to improve prevention and to apply more effective treatment with this population. 1. Method For the survey of studies, PubMed (Medline), Science Direct, APA PsycNet and Scielo databases were chosen, as they are internationally important reference bases for the search for scientific studies in the field of Psychology, Psychiatry, and mental health in general. The review method was based on the PRISMA Statement criteria (Preferred Reporting Items for Systematic reviews and Meta-Analyses) (Page et al., 2021), opting for a survey of international articles published in the last decade, between 2012 and 2022. To identify the research topic in the different databases, varied de­ scriptors were used, as well as the combination between them, since there is no single definition of the terminology used, nor exact corre­ spondence between the terms in different languages. The keywords chosen were those most found in the reference literature on the topic in question, such as “cognitive behavioral therapy”, “CBT”, “sexual offender”, “sexual abuser”, “sexual crimes” and others. To expand the research methodology, as well as the obtained results, a search for studies that fit the objective of this review was carried out, based on the analysis of the bibliographic references cited in each article found. Finally, contact was also made with the identified studies' authors in the research results that, in the databases, presented themselves without access to the full text. Table 1 presents the keywords, search fields and the respective filters applied in each database, according to the advanced search options offered by each platform, in order to better select the results. The initial search in the different databases using the descriptors and filters above resulted in 129 productions in their entirety. Then, in the identification phase, based on a preliminary analysis of the titles regarding the presence of the selected keywords and their relevance to the topic in question, 38 publications were identified. After excluding duplicate items between databases (n = 4), the results totaled 34 studies. Of these, in the selection stage, 14 studies were removed from the sample by the following exclusion criteria: (1) articles that did not have a full text available or those that only had an abstract, due to the impossibility of analyzing the results of the study; (2) book chapters; (3) publications with a different objective from that of this review. At the end of the selection, 20 articles were screened and their respective abstracts were evaluated regarding the inclusion criteria of the eligibility stage, including in the sample composition those that: (1) had as a central theme the evaluation of the effectiveness of CBT-based interventions in populations of sexual offenders; (2) carry out research on clinical samples in forensic contexts and (3) through validated psy­ chometric instruments (questionnaires, inventories, scales, self-report measures). In addition, the exclusion criteria of the eligibility stage excluded from the analysis studies that did not present sufficient descriptive content in the results to allow psychometric evaluation of CBT interventions effectiveness in this population, or that presented any 2 I.C.O. Rocha and A.M. Valença International Journal of Law and Psychiatry 87 (2023) 101856 Table 1 List of descriptors, search fields and filters used by database. Database PUBMED APA PsycNet Science Direct SCIELO Bibliographic References Analysis Contact with authors Descriptors Search Fields (“cognitive behavioral therapy” OR “CBT” OR “cognitive behavioral”) AND (“sexual offender” OR “sex offender” OR “sexual abuser” OR “sexual crime” OR “sexual violence” OR “sexual offense”) (“cognitive behavioral therapy” OR “CBT” OR “cognitive behavioral”) AND (“sexual offender” OR “sex offender” OR “sexual abuser” OR “sexual crime” OR “sexual violence” OR “sexual offense”) (“cognitive behavioral therapy” OR “CBT” OR “cognitive behavioral”) AND (“sexual offender” OR “sex offender” OR “sexual abuser” OR “sexual crime” OR “sexual violence” OR “sexual offense”) (“cognitive behavioral therapy” OR “CBT” OR “cognitive behavioral”) AND (“sexual offender” OR “sex offender” OR “sexual abuser” OR “sexual crime” OR “sexual violence” OR “sexual offense”) (“cognitive behavioral therapy” OR “CBT” OR “cognitive behavioral”) AND (“sexual offender” OR “sex offender” OR “sexual abuser” OR “sexual crime” OR “sexual violence” OR “sexual offense”) not applicable TOTAL Filters * Results Identified Any field Year: 2012 a 2022 54 20 Any field Year: 2012 a 2022 17 6 title/ abstract Year: 2012 a 2022 54 9 All fields Year: 2012 a 2022 1 0 Title not applicable 2 2 not applicable not applicable 1 1 129 38 *The choice of search filters among the databases was based on the options offered by each of them. other objective different from that of this review. At the end of this stage, 08 full-text articles were included in the final sample for analysis. Table 1 summarizes the results obtained in each database only in the identification phase. The complete search system described is shown in Fig. 1, with the respective flowchart according to the PRISMA recommendation (Page et al., 2021). 2. Results The 08 selected articles were initially evaluated quantitatively regarding the year of production, in addition to the number of times they appeared in the different databases. Subsequently, they were qualita­ tively analyzed regarding the characterization of the sample, type of Idenficaon of studies via databases and other methods Id e n t if ic a t io n Records idenfied from databases 126 Idenficaon via other methods 3 Idenfied from preliminary tle analysis 38 Selection (4 duplicated records) Records screened 20 Records excluded (aer exclusion criteria on selecon stage) 14 Elegibility Records aer duplicated records removed 34 Records assessed for eligibility (aer inclusion criteria) 08 Removed records (aer exclusion criteria on elegibility stage) 12 Fig. 1. PRISMA flowchart with the systematic review phases. 3 I.C.O. Rocha and A.M. Valença International Journal of Law and Psychiatry 87 (2023) 101856 study performed, type of CBT intervention used, and results obtained regarding the effectiveness evaluation. Detailed information on each analysis criterion is found below. comparison between groups of sex offenders who received treatment in this approach and those who did not. Another three studies (Carpentier & Proulx, 2021; Kelley et al., 2022; Martínez-Catena & Redondo, 2017) conducted the evaluation based on the measurement of varied thera­ peutic results (relapse prevention and criminal recidivism, behavioral self-control measures, emotional regulation, and others) pre and post CBT intervention, based on psychometric measures in a specific group of sex offenders. A single study (Aebi et al., 2022) had its evaluation from the comparison between two treatment modalities based on different cognitive behavioral interventions. Finally, the single-case study (Chakhssi et al., 2014) mentioned before evaluated the effectiveness of Schema Therapy, a third-generation model of cognitive therapy, from independent measures of psychopathic traits, early maladaptive sche­ mas, and risk behaviors. 2.1. Year of production There was a considerable production of studies in the last three years, with half of the publications found, with a greater concentration in the year 2021 (25%), as shown in Table 2. From this analysis, it can be inferred that this is a contemporary topic, relatively recent and still little studied. 2.2. Results by databases Quantitatively analyzing the obtained results from the different da­ tabases researched, as shown in Fig. 2, it was observed that PubMed (Medline) was the one with the highest concentration of selected articles (56%). It was also revealed to have the highest number of results before and after the identification phase of the studies, proving to be a relevant and effective database in the search for scientific productions, capable of giving visibility to publications. 2.4. Studies' outcomes The overall analysis of the studies suggested good results in terms of the effectiveness of cognitive-behavioral interventions in groups of in­ dividuals convicted of sexual crimes, either compared to non-treated individuals, or those who didn't respond to treatment or when even evaluating recidivism rates or other therapeutic outcomes. Of the three studies that conducted comparisons between treatment and non-treatment groups, two (Beech et al., 2012; Grady et al., 2017; Olver et al., 2020) shown lower rates of relapse in sexual criminal behavior for those who received CBT-based treatment, indicating this approach as effective in reducing their risk of recidivism once they re­ turn to the community after serving their sentence. Only one (Grady et al., 2017) did not present significant differences in the results between the two groups for recidivism reduction specifically in sexual crimes. However, it showed significantly lower recidivism rates for violent crimes in general among treatment participants. Olver et al. (2020) compared two Canadian prison-based sex offender treatment programs based on CBT model combined with the Risk-Need-Responsivity (RNR) model to determine its relative effec­ tiveness: Standard Sex Offender Treatment Program (SOTP) operated in several federal prisons across Canada (n = 625) and Rockwood's pro­ gram conducted in a single federal Canadian prison (n = 579). They also added a comparison with a group of untreated men (n = 107) convicted for the same type of crimes. As psychometric measures, a Brief Actuarial Risk Scale (BARS) was used to control for baseline risk status when comparing treated and untreated groups of men convicted for sex of­ fenses. Recidivism data were also used as risk and treatment variables. The results indicated that non-treatment group tended to be a higher risk group on average, having higher total scores on BARS compared with the two treatment groups. Rockwood clients displayed significantly lower sexual and violent reoffense rates than did the untreated group over the 8-year as well as overall follow-up periods. The SOTP clients also showed lower rates of reoffending than did men in the nontreatment group with these results being most evident in the highest risk groups. Both programs addressed almost the same issues, as over­ coming cognitive distortions, raising victim awareness, enhancing empathy, increasing social and intimacy competence, sexual education, and the development of post-release plans (Olver et al., 2020). Grady et al. (2017) examined recidivism outcomes for a sample of 240 incarcerated sex offenders who participated in a cognitivebehavioral-skills based treatment program. The Sex Offender Account­ ability and Rehabilitation (SOAR) is a program focused on reducing criminogenic needs by targeting core treatment areas, such as address­ ing offense supportive attitudes, intimacy/relationship skills, victim awareness and empathy. Differently from the first one, the findings of this study indicated that participation in (SOAR) does not significantly decrease the rates of recidivism for sexual or violent crimes for those inmates. However, there was a significant reduction in the recidivism rate for non-violent crimes by 34% for those who participated in the treatment program (Grady 2.3. Sample description Analyzing the publications regarding the sample characterization, it was observed that most of them (n = 6) investigated groups of adult males serving sentences for sexual crimes (Aebi et al., 2022; Beech, Mandeville-Norden, & Goodwill, 2012; Grady et al., 2017; Kelley, Hol­ lows, Pransky, Kryvanos, & Bowen, 2022; Martínez-Catena & Redondo, 2017; Olver et al., 2020). Of these, one study focused on investigating sex crimes specifically against adolescents or children under the age of 14 (Beech et al., 2012). Only one study directed the investigation into a sample of adolescents, aged between 12 and 18 years, evaluated in an outpatient setting after committing crimes of sexual assault (Carpentier & Proulx, 2021). Finally, another single article was a case study of a 25-year-old male, sentenced to compulsory treatment as a result of committing a sexual crime (Chakhssi, Kersten, de Ruiter, & Bernstein, 2014). The fact that publications that carried out the investigation in female populations were not presented in the searches is an expected result in the literature, that shows the presence of gender-related issues when it comes to the topic of sexual violence. As for the size of the samples, what is noticeable is that most studies (N = 6) conducted investigations in groups with significant numbers of participants (with N between 100 and 625), which gives greater reli­ ability to the results obtained. (Beech et al., 2012; Carpentier & Proulx, 2021; Grady et al., 2017; Kelley et al., 2022; Martínez-Catena & Redondo, 2017; Olver et al., 2020). Regarding the design of the 08 selected studies, the results showed three of them (Beech et al., 2012; Grady et al., 2017; Olver et al., 2020) that evaluated the effectiveness of interventions in CBT from the Table 2 Productions x year of publication. Year of publication Productions % 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 TOTAL 1 0 1 0 0 2 0 0 1 2 1 08 13% 0% 13% 0% 0% 25% 0% 0% 13% 25% 13% 4 I.C.O. Rocha and A.M. Valença International Journal of Law and Psychiatry 87 (2023) 101856 Nº of studies Studies found by databases 6 5 4 2 1 1 APA PsychNet Science Direct 2 0 0 Pubmed Outras Fontes Scielo Databases Fig. 2. Studies by databases. et al., 2017). The authors give possible explanations for the results, like some limitations of the study. With the same objective, Beech et al. (2012) examined sexual reof­ fense rates in a sample of 413 child molesters, who had completed a U.K. probation-based sex offender treatment program, comparing those deemed responding to treatment with those that did not. The research used scales to measure pro-offending attitudes, the offenders' level of socioaffective functioning and also their sexual recidivism risk. The re­ sults shown that a significantly smaller proportion of those responding to treatment (9%) had recidivated, compared to those who had not responded to treatment (15%), indicating a 40% reduction in recidivism in those who had received treatment and responded to it. In a similar way, the following three studies that conducted the evaluation of CBT effectiveness from the measurement of pre- and posttreatment therapeutic outcomes also revealed significant improvement in overall therapeutic changes. A study of Martínez-Catena and Redondo (2017) investigated the therapeutic efficacy and possible therapeutic changes in a sample of 153 male rapists after participation in a Sexual Offending Control Program (SOCP) in Spain. SOCP is a cognitive-behavioral intervention based on the RNR model that lasts for one or two years. It is a group-based treatment, administered to both rapists and child molesters, focused on cognitive distortions, coping strategies, empathy, self-control about sexual impulse and relapse prevention. Results indicated significant differences in treated participants for almost all elements: decrease of sexual anxiety, assertiveness development, impulsivity decrease, aggressiveness reduction, self-esteem, and empathy improvement. Similarly, Carpentier and Proulx (2021) evaluated the effectiveness of a cognitive-behavioral treatment in reducing recidivism by adoles­ cents who have sexually offended (n = 327). The treatment approach targeted three main objectives: (1) fostering a better comprehension of the offending process; (2) developing self-control and avoidance stra­ tegies that prevent recidivism; and (3) favoring a return to healthy psychosexual development, particularly by addressing factors that are not specifically related to sexual aggression (e.g., self-control, emotional regulation, relational and social skills, prosocial cognitions, self-esteem, empathy). The results of this study provided evidence to support the effectiveness of a specialized cognitive-behavioral treatment program in reducing violent (including sexual) recidivism in this population over a mean follow-up period of almost 8 years. On another way, Kelley et al. (2022) tested the efficacy of a CBT based treatment supplemented with a principle-based correctional counseling (PBCC) for improving the self-control and mental health in a sample of 132 males incarcerated for sexual violence. The results indi­ cated that, compared to a control group that received only CBT in­ terventions, participants receiving CBT supplemented with intensive PBCC showed a significant improvement in thought recognition and selfcontrol, lower rates of depression, anxiety, and anger and an increase in affective well-being. As mentioned before, the results of this systematic review also found a single case study (Chakhssi et al., 2014), that examined the process of an individual Schema Therapy (ST) in a patient that had been sentenced to a mandatory treatment order in relation to a sexual assault. The founds shown that, after the 4-year treatment and 3-year follow-up, the patient no longer displayed prominent psychopathic features, displaying more empathy, shame and guilt, besides significantly more insight and better communication skills compared to his pre-treatment scores. The patient also developed meaningful interpersonal and intimate relationships. The findings of this study indicate that ST reduces risk and speeds reentry into the community in forensic patients with Cluster B person­ ality disorders, including psychopathic ones (Chakhssi et al., 2014). La Tegola et al. (2021) suggest that the presence of a psychopathic dimension, a factor that, notoriously, constitutes an almost insur­ mountable obstacle to a real change in dysfunctional sexual behavior, represents an important fact to be considered, especially when specific treatment/prevention programs are developed for these populations. The last publication evaluated in the results of this review (Aebi et al., 2022) discussed whether specialized treatment is effective to reduce sexual recidivism in juveniles who have sexually offended. It aimed to evaluate two versions of a short-term CBT based treatment program for this population in Switzerland. The first one, ThePaS-I (Therapy Program for Adequate Sexual Be­ haviors Version) focused on understanding the sexual offending-specific skills, including acceptance of responsibility, and breaking sexual offense cycle by increasing the awareness of triggers, improvement of internal and external behavior controls and development of individual plans to reduce the risk of recidivism. The second version, the ThePaS-II, focused on the enhancement of social/affective and sexual skills, including improved mindfulness and control of sexual arousal, coping strategies, conflict management and increasing moral judgment. The most important finding indicated that CBT based on the understanding of an individual's harmful sexual behaviors and focused on offendingspecific skills appears to be more effective in preventing sexual recidi­ vism than the only training of general social skills (Aebi et al., 2022). 3. Discussion From the descriptive analysis of the 08 selected studies, what can be highlighted is that, although there was no consensus between the find­ ings about a standard CBT based intervention model, the results point to a strong indication that cognitive behavioral models of psychotherapy for sex offenders are in the basis of the most recent research in the literature. In fact, CBT is strongly described in literature over the last 10 years as an important intervention model for this population. Regarding the initial objective of identifying studies that evaluate the efficacy of CBT-based psychotherapy strategies for sex offenders' treatment, what is seen is that the results reveal a still scarce and rela­ tively recent number of publications in the international literature. More specifically in Brazil, the absence of national studies in the findings of this systematic review indicates the need for greater research with this direction, in order to subsidize future public treatment programs. Although almost all studies have identified good results in terms of the efficacy of the intervention models evaluated, it wasn't found a pattern about a specific CBT model that is more effective than others. One of the possible explanations is the fact that the studies found have 5 International Journal of Law and Psychiatry 87 (2023) 101856 I.C.O. Rocha and A.M. Valença used different intervention strategies and diversified methodological designs, which influences the possibility of comparing the results with each other. Another reason can be attributed to the diversity of the investigated samples, which diverged in age, the forensic context in which they were inserted and the treatment modality to which they were submitted. Also, it's important to highlight that some studies included samples with more severe psychiatric diagnoses, with comorbid personality disorders and, consequently, a higher risk of recidivism. The lack of homogeneity in the selected samples, in terms of psychiatric diagnosis, can be considered an important influence on the effectiveness of eval­ uated interventions and response to treatment. However, despite some divergences found and the lack of studies, the results of this review converge to the conclusion that CBT-based in­ terventions have an important effectiveness. What is observed is that sexual offenders, when submitted to CBT-based treatment, tend to have lower relapse rates when compared to no-treatment groups. In addition, models focused on skills training, like self-control, coping strategies, emotional regulation, social skills, prosocial cognitions, self-esteem and empathy, present promising results in the prevention of relapses and reoffense. These findings support the hypothesis that CBT may be a promising model of intervention in forensic settings with sex offenders. As proposed by Mpofu et al. (2018), CBT's major mechanisms include preventing criminal behaviors by reducing deviant social attitudes, enhancing behavioral self-efficacy through decisional risk-weighting techniques, and maintaining behavioral recovery from criminogenic need impulses. With sexual offender populations, enhancing decisional choice in the face of criminogenic impulses can be an important component of preventive or rehabilitative therapy to reduce risk of recidivism (Burdon & Gallagher, 2002). In this sense, understanding which psychotherapeutic intervention strategies have been shown to be more effective both in reducing the recidivism rates of sexual crimes and also in a better reintegration and rehabilitation of these individuals in society after the incarceration be­ comes essential to think of new forms of more effective treatments, which reinforces the relevance of this literature review. Given the lack of studies found on this systematic investigation, it is suggested that future research might be conducted in order to support a better planning of future specialized CBT-based sexual offense treat­ ment. The vast used terminology to describe sexual crimes and the dif­ ficulty in finding precise descriptors for the search may have been configured with one of the main limitations of this review, either by the excess or omission of terms. Similarly, possible methodological biases in the identification and selection of studies may also have limited the results by the possible exclusion of relevant studies. Although the limitations of this study hinder the results generaliza­ tion, the present review allowed a more comprehensive view of the literature state of the art over the last 10 years regarding the evaluation of CBT efficacy on sex offenders treatment, promoting future research in the area. In the Psychology academic field, studies with this focus are still insufficient, which corroborates the need to intensify investigations in order to rethink and propose more effective therapeutic strategies in forensic contexts, with a strong public health relevance. randomized-controlled trial of two versions of a specialized cognitive behavioral outpatient treatment program. Sexual Abuse. https://doi.org/10.1177/ 10790632211070804 American Psychiatric Association. (1999). 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