Ineffective treatment of sex offenders fails victimsBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h199 (Published 27 January 2015) Cite this as: BMJ 2015;350:h199
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Ho and Rampling highlight the debate that is occurring in mental health and criminal justice circles regarding sex offenders and has recently been reignited in the national press as well as the pages of this journal. The case is not as simple as sex offenders are perpetrators who should be punished, and they have often been victims themselves. Similarly, mental disorder is not uncommon and indeed there may even be a genetic link (Långström et al, 2015).
We already know that current approaches to sex offender treatment in the Criminal Justice system are of disputed efficacy (and in certain circumstances may actually increase risk), and are unfortunately post hoc attempts to put a band aid on a bullet wound. Much more urgently needed is a preventive strategy which is capable of acknowledging that individuals with risk factors for sex offending may indeed desire help, but that current societal attitudes and policy and legislation is not oriented to incentivise help-seeking on the part of these potential (or undetected) offenders.
The “Dunkelfeld” system in Germany is a clear example of how dynamic risk factors can be reduced if potential offenders can be encouraged to access services without the fear of criminal retribution. In this system, which maturely and pragmatically acknowledges and attempts to address the significant amount of undetected sexual offending against children for which the perpetrators receive neither punishment nor rehabilitation, targeted therapy is delivered in the form of psychological and pharmacological interventions. The caveat, which is the more difficult balance strike for politicians and services, is that individuals who have already carried out acts which are of criminal interest, such as child pornography , non-contact and even contact offences, are not mandatorily reported to Criminal Justice authorities for investigation and prosecution. Results from the programme are encouraging in terms of reducing dynamic risk factors (Beier et al 2015).This is an uncomfortable, but perhaps necessary tension, one which is of current interest in England and Wales given the consultation on the mandatory reporting of child sex abuse which would render such an approach infeasible.
Forensic psychiatry, psychology and psychotherapy have clear roles, in our opinion, when it comes to sex offenders and paraphilias, no different than towards that of other types of offender: not only is that is to work with mentally disordered offenders in whichever setting is appropriate with a view to reducing recidivism, drawing upon the evidence base to both inform this; but also to use our understanding of the evidence to inform public health policy and indeed legislation with the overall aim of reducing sex offending at a societal level and break the victim-perpetrator-victim vicious circle which imprisonment simply postpones. It is high time for maturity in our society’s attitude towards sex offending and a pilot “Dunkelfeld” of our own.
Beier, K. M., Grundmann, D., Kuhle, L. F., Scherner, G., Konrad, A. and Amelung, T. (2015), The German Dunkelfeld Project: A Pilot Study to Prevent Child Sexual Abuse and the Use of Child Abusive Images. Journal of Sexual Medicine, 12: 529–542. doi: 10.1111/jsm.12785
Långström, N, Babchishin, KM, Fazel, S, Lichtenstein, P & Frisell, T. (2015) Sexual offending runs in families: A 37-year nationwide study Int. J. Epidemiol. first published online April 8, 2015 doi:10.1093/ije/dyv029
Competing interests: No competing interests
The field of sex offender treatment outcome research is characterised by much debate. Some reviewers have concluded that the accumulation of evidence derived from observational studies indicates that psychological treatments reduce recidivism (Hanson et al., 2002; Lösel & Schmucker, 2005). Others however have adopted more parsimonious appraisals, concluding that the evidence is insufficient, or that scientific designs are below what is required for the outcome data to be minimally informative (Kenworthy, Adams, Brooks-Gordon, & Fenton, 2004; Rice & Harris, 2003). Results from recent systematic reviews indicate that better quality research is required before we can conclude on whether such programmes are effective or not (Walton & Chou, 2014; Långström et al. 2013; Dennis et al. 2013). In his personal view, Dr Ho does not appear to have fully considered the current need for improved research designs in supporting the conclusion that treatment is ineffective. Ho focuses his attention on the National Offender Management Services’ (NOMS) suite of accredited Sex Offender Treatment Programmes (SOTPs). In particular, he briefly reports on the ‘Core Programme’, suggesting that there is a current lack of evidence to indicate the intervention is effective at reducing recidivism. In this response, we draw attention to the state of affairs in the literature, and in particular the problems inherent with fixed claims about effects of treatment, when these are borne out of suboptimal studies fraught with systematic bias which threatens the validity of inferences drawn.
It is perhaps first important to clarify the conclusions drawn by the authors of the systematic review and meta-analysis Ho refers to in supporting his assertion that the Core Programme is ineffectual. Incidentally, the other piece of evidence he refers to (Ho & Ross, 2012) is an editorial criticising the NOMS “fact sheet” of outcome evidence. In our view, this has already been satisfactorily rebutted by Mann, Carter & Wakeling (2012). In following, Lösel and Schmucker (2005), whilst including in their data synthesis, one observational study that investigated the effect of the Core Programme on recidivism (Friendship et al., 2003), concluded that cognitive-behavioural interventions (incidentally, a therapeutic modality central to the Core programme itself) were more effective than other psychosocial approaches. Hence, it is curious that Ho draws on this meta-analysis to support his position that treatment is ineffective. On the contrary, there is a need for cautious interpretation of Lösel and Schmucker’s findings, given that the majority of included studies (60%) were rated as methodologically weak owing to the non-equivalence of comparison and treatment groups. In a field laden with weak inference studies, literature can become matted with biased outcomes, due to decisions taken in scientific design, which either artificially inflate or decrease the chances of finding a treatment effect. With observational designs especially, non-comparable groups are observed or supposed based on actual or a prior group differences which directly impact outcomes of interest independent of treatment. Therefore, there is a need to determine the direction of overall systematic bias on the observed recidivism rates (Walton & Chou, 2014). Notwithstanding their optimistic findings, the conclusion that Lösel and Schmucker (2005) support is the need for the implementation of more randomised studies.
Randomised Controlled Trials (RCTs) have been regarded as the optimal design for treatment evaluation (Harris, Rice & Quinsey, 1998; Rice & Harris, 2003; Seto et al., 2008; although see Hollin, 2008; Marshall, 2006; Marshall & Marshall, 2007; 2008 for an alternative view). Randomised assignment should offset differences that exist between large groups as well as inadvertent bias caused by the researcher during allocation. Dennis et al. (2013) limited their inclusion criteria to RCTs and concluded that there was the need for further randomised studies, since current available evidence does not support the belief that treated individuals pose a reduced risk of recidivism. Only two of the ten randomised studies they included reported recidivism rates. Results from the most well recognised randomised study reporting final data from the Sex Offender Treatment and Evaluation Project (SOTEP, Marques et al. 1994; Marques et al. 2005), indicate that a structured relapse prevention (RP) therapy has no effect on recidivism. The extent to which the SOTEP represents current treatment practice is debatable (see Seto et al. 2008; Marshall & Marshall, 2007; 2008). Nevertheless, important learning from the SOTEP has been documented (Marques et al. 2000). Certainly, dynamic risk factors (Hanson & Morton-Bourgon, 2004; 2005) which are now popularised treatment targets in modern interventions were either absent or deficient. In addition, the RP model has been criticised (Laws Hudson & Ward, 2000; Yates, 2007), and among international treatment programmes (see McGrath et al. 2010) is becoming gradually replaced by future-orientated approaches (Ward, Mann & Gannon, 2007) and the self-regulation (SR) model of relapse (Ward & Hudson, 2000). The second RCT showed that a group psychodynamic intervention had no effect on recidivism (Romero, 1983). This therapeutic modality has been replaced by cognitive-behavioural approaches, and is not representative of current practice (McGrath et al. 2010). In light of these unfavourable results, no randomised trials of primary adult sex offender treatments have been completed in what is fast approaching two decades. The bearing that results from dated interventions have on the efficacy of current treatments is debatable. Reliance on weak scientific designs, often poorly implemented, has it seems delayed the gathering of generally agreed upon knowledge. Therefore, incautious assertions about treatment effects or lack thereof, are premature until either more randomised designs are carried out or the standards of observational studies are improved such that bias is significantly reduced.
Friendship et al. (2003) have reported results that indicate the Core Programme is effective for medium risk offenders. No effects were found for higher risk offenders; a group which according to the risk principle (Bonta & Andrews, 2007) would require a higher dose of treatment than the Core Programme alone. However, these data were drawn from an observational study which has either been rated as methodologically weak (Lösel & Schmucker, 2005; Hanson et al. 2009), or excluded from systematic reviews on basis of its suboptimal design status. Therefore, bias is likely to have impacted results. NOMS cognitive-behavioural interventions for sexual offenders are centralised around Risk, Need and Responsivity principles. The clinical landscape of commissionable SOTP provision is now entering into a period of considerable change reflecting up to date intervention targets, and a need to effectively prioritise finite resources for offenders who are most likely to benefit. Use of strong inference designs to evaluate recidivism rates for offenders treated on these developing programmes would provide clearer indication as to their impact on recidivism than could be established for their predecessor.
Despite the inconsistent findings in the field, even for those preferring to rely on the most rigorous of randomised scientific trials, of which very few exist, one should be cautious as not to hastily conflate absence of evidence, with evidence of absence. Doing so increases risk of Type II error. Given that for various political and logistical reasons, observational designs will likely continue to be used in place of randomised trials, we have outlined ways forward for improvement in their implementation, so that internal validity is enhanced and greater confidence can be gained from outcome results (Walton & Chou, 2014). In our view it is also important that systematic reviewers and programme evaluators make an effort to assess the direction of bias on observed outcomes an essential part of their analytical procedure. Where directions of bias significantly diverge between individual sets of data, statistical aggregation of such data is at increased risk of being misleading. Therefore, at the very least, this process reduces chances of such misinformed analyses, and at best may have the potential to inform patterns between observed outcomes and decisions taken in scientific design. We believe that Ho’s conclusion is premature. Claiming that treatment is ineffective in the absence of consistent high quality evidence to support such a claim does not accurately convey the state of affairs in the field. Only through increasing the rigor of studies in the field together with efforts to identify the influence of residual bias on outcomes of interest can progress occur.
Dr Jamie Walton
Registered Practitioner Psychologist (Forensic) and Chartered Psychologist
HM Prison Service
North West Area Psychological Services
Dr Shihning Chou
Assistant Professor of Forensic Psychology,
Centre for Forensic and Family Psychology,
Division of Psychiatry & Applied Psychology, School of Medicine, University of Nottingham
Floor B, Yang Fujia Building, Jubilee Campus, Wollaton Road, Nottingham, NG8 1BB, UK
Jamie Walton is employed in HM Prison Service and is a current Treatment Manager of the Core Sex Offender Treatment Programme (SOTP) within a regional Treatment Management team. The commentary submitted represents his own views together with those of Shihning Chou and not intended to directly represent the views of HM Prison Service or the National Offender Manager Service.
Bonta, J., & Andrews, D. A. (2007). Risk-need-responsivity model for offender assessment and rehabilitation (Corrections Research User Report No. 2007-06). Ottawa, ON: Public Safety Canada.
Dennis, J. A., Khan, O., Ferriter, M., Huband, N., Powney, M. J., & Duggan, C. (2012). Psychological interventions for adults who have sexually offended or are at risk of offending. (CD007507; Cochrane Database of Systematic Reviews Issue 12). Chichester, UK: John Wiley & Sons.
Friendship, C., Mann, R. E., & Beech, A. R. (2003). Evaluation of a national prison-based treatment program for sexual offenders in England and Wales. Journal of Interpersonal Violence, 18, 744–759.
Hanson, R. K., Bourgon, G., Helmus, L., & Shannon, H. (2009). The principles of effective correctional treatment also apply to sexual offenders: A meta-analysis. Journal of Criminal Justice and Behaviour, 36, 865–891.
Hanson, R. K., Gordon, A., Harris, A. J. R., Marques, J. K., Murphy, W., Quinsey, V. L., & Seto, M. C. (2002). First report of the collaborative outcome data project on the treatment of convicted adult male sex offenders. Sexual Abuse: Journal of Research & Treatment, 14, 169–194.
Hanson, R. K., & Morton-Bourgon, K. E. (2004). Predictors of sexual recidivism: An updated meta-analysis (Corrections User Report No. 2004-02). Ottawa, Ontario, Canada: Public Safety Canada.
Hanson, R. K., & Morton-Bourgon, K.E. (2005). Predicting relapse: A meta-analysis of sexual offender recidivism studies. Journal of Consulting and Clinical Psychology, 66, 348–362.
Harris, G.T., Rice, M. E., & Quinsey, V. L. (1998). Appraisal and management of risk in sexual aggression; implications for criminal justice policy. Psychology, Public Policy, and Law, 4, 73–115.
Ho D. K. & Ross C. C (2012) Cognitive behaviour therapy for sex offenders: too good to be true? Criminal Behaviour Mental Health, 22, 1-6.
Hollin, C.R. (2008). Evaluating offending behavior programs: Does only randomization glister? Criminology and Criminal Justice, 8, 89-106.
Kenworthy, T., Adams, C. E., Brooks-Gordon, B., & Fenton, M. (2004). Psychological interventions for those who have sexually offended or are at risk of offending (CD004858; Cochrane Database of Systematic Reviews, Issue 3). Chichester, England: John Wiley.
Långström, N., Enebrink, P., Laurèn, E., Lindblom, J., Werkö, S. & Hanson, K. R (2013). Preventing sex abusers of children from reoffending: systematic review of medical and psychological interventions. British Medical Journal, 347, 1 – 11.
Laws, D. R., Hudson, S. M., & Ward T. (Eds.). (2000) Remaking relapse prevention with sex offenders: A sourcebook. Newbury Park, CA: Sage.
Lösel, F., & Schmucker, M. (2005). The effectiveness of treatment for sexual offenders: A comprehensive meta-analysis. Journal of Experimental Criminology, 1, 117–146.
Mann, R. E., Carter, A. J. & Wakeling. H. C (2012) In defense of NOMS’ view about sex offending treatment effectiveness: A reply to Ho and Ross. Criminal Behaviour Mental Health, 2, 7-10.
Marshall, W. L. (2006). Appraising treatment outcome with sexual offenders. In W. L. Marshall, Y. M. Fernandez, L. E. Marshall, & G. A. Serran (Eds.), Sexual Offender Treatment: Controversial Issues (pp. 17–32). New York, NY: Wiley.
Marshall, W. L., & Marshall, L. E. (2007). The utility of randomised control trials for evaluating sexual offender treatment: The gold standard or inappropriate strategy? Journal of Sexual Abuse, 19,
Marshall, W. L., & Marshall, L. E. (2008). Good clinical practice and the evaluation of treatment: A response to Seto et al. Sexual Abuse: A Journal of Research and Treatment, 20, 256–260.
Marques, J. K., Day, D. M, Nelson, C., & West, M. A. (1994). Effects of cognitive-behavioral treatment on sex offender recidivism: Preliminary results of a longitudinal study. Special Issue: The assessment and treatment of sex offenders. Criminal Justice and Behavior, 21, 28–54.
Marques, J. K., Wiederanders, M., Day, D. M., Nelson, C., & Van Ommeren, A. (2005). Effects of a relapse prevention program on sexual recidivism: final results from California’s sex offender treatment and evaluation project (SOTEP). Sexual abuse: A Journal of Research and Treatment, 17, 79–107.
McGrath, R., Cumming, G., Burchard, B., Zeoli, S., & Ellerby, L. (2010) Current Practices and Emerging Trends in Sexual Abuser Management: The Safer Society 2009 North American Survey. Brandon, Vermont: Safer Society Press.
Rice, M. E., & Harris, G. T. (2003). The size and sign of treatment effects in sex offender therapy. Annals of the New York Academy of Sciences, 989, 428–440.
Romero JJ, Williams LM (1983) Group psychotherapy and intensive probation supervision with sex offenders. Federal Probation 47: 36–42.
Seto, M. C., Marques, J. K., Harris, G. T., Chaffin, M., Lalumie`re, M. L., Miner, M. H., . . . Quinsey, V. L. (2008). Good science and progress in sex offender treatment are intertwined: A response to Marshall and Marshall (2007). Sexual Abuse: A Journal of Research and Treatment, 20, 247–255.
Walton, J. S. & Chou, S. (2014) The Effectiveness of Psychological Treatment for Reducing Recidivism in Child Molesters: A Systematic Review of Randomized and Nonrandomized Studies. Trauma, Violence & Abuse, 1 – 17.
Ward, T., & Hudson, S. M. (2000). A self-regulation model of relapse prevention. In D. R. Laws & S. M. Hudson & T. Ward (Eds.), Remaking Relapse Prevention with sex offenders: A sourcebook (pp. 79-101). Newbury Park: CA: Sage.
Ward, T., Mann, R. E., & Gannon, T. A. (2007). The Good Lives Model of offender rehabilitation: Clinical implications. Aggression and Violent Behavior, 12(1), 87-107.
Yates, P.M. (2007). Taking the leap: Abandoning relapse prevention and applying the self-regulation model to the treatment of sexual offenders. In D. Prescott (Ed.). Knowledge and practice: Challenges in the treatment and supervision of sexual abusers (pp. 143-174). Oklahoma City, OK: Wood ‘N’ Barnes.
Competing interests: No competing interests
In his “personal view” Dr. Ho claims “no evidence from academic or policy research has shown” that the Sex Offender Treatment Programme (SOTP) “significantly reduces sexual reoffending.” Ho notes that SOTP is “the standard psychological talking therapy used in prisons and secure psychiatric hospitals in England and Wales since 1991.” We therefore agree with him that evidence of its effectiveness deserves to be scrutinised closely. However, we think that Ho’s personal view is somewhat misleading. In support of his claims, the piece overlooked research that suggests findings contrary to his conclusions, and he infers uniformity of outcomes from heterogeneous studies.
Ho cites three pieces of evidence in support of his view, without mentioning details contained therein. The first is a Cochrane Collaboration review of psychological programmes applied to adult sex offenders. This review is based on a few, mainly North American randomized controlled trials (RCTs) that showed heterogeneous results. Even the authors of this review discussed whether RCTs are the only appropriate design in the difficult field of sex offender treatment. The second piece of evidence cited by Ho is not systematic research but an editorial he himself has co-authored. This critiqued a NOMS factsheet on SOTP, the claims of which were satisfactorily addressed (and, in our view, mitigated) by Mann et al. The third piece of evidence Ho quotes is an international meta-analysis (MA) of a wide variety of treatments applied to adult and juvenile sex offenders, co-authored by the second author of this response. This reference triggered our present letter.
As Ho cites the international MA of Lösel and Schmucker  in support of his view he obviously does not only comment on a specific British SOTP, but more broadly on psychosocial interventions for sex offenders. This is plausible insofar as there are several SOTPs for different target groups in Britain and only very few controlled evaluations (e.g., Friendship et al. with relatively positive results). However, contrary to Ho’s view the MA of Lösel and Schmucker  does not support his claim of ineffective sexual offender treatment. In fact a majority of the 80 primary evaluations in the MA showed positive effects on sexual recidivism, although these were only partially statistically significant due to small sample sizes. Hormonal treatment was most effective, but the respective evaluations were of low quality (a situation that still prevails [2,7]). Among psychosocial interventions cognitive/behavioural interventions had a clear significant effect. This finding is in agreement with other MAs on SOTPs (for an overview see Lösel & Schmucker ). Programmes that meet the Risk-Need-Responsivity model seem to be particularly effective. We agree with Ho that many evaluations of SOTP are not based on well-controlled designs. Therefore, Schmucker and Lösel  carried out an updated MA, which relied only on evaluations with equivalent treatment group (TG) and control group (CG) and reported a statistically significant mean reduction in sexual reoffending (TG = 10.1%, CG = 13.7%). Due to the generally low base rate of (official) sexual reoffending, this looks like a minor difference, but it indicates a reduction of approximately 26% in TGs compared to CGs. This effect size accords with the wider landscape of meta-analyses on sex offender treatment.[8,10]
The MA of Schmucker and Lösel  also found various moderator effects: Cognitive-behavioural and multi-systemic treatment as well as studies with small samples, medium to high risk offenders, more individualised treatment, and good descriptive validity revealed better effects. In contrast to treatment in the community and forensic hospitals, treatment in prisons did not show a significant mean effect, but some prison studies had rather positive outcomes. In relation to the prison vs. community topic Koehler and Lösel  carried out a systematic review of six MAs to investigate how the reoffending outcomes for sex offender treatments differ between settings. We found consistently greater mean effects among treatments delivered in the community (OR: 2.11; CI95%: 1.69 – 2.63) than for those delivered in custodial settings (OR: 1.49; CI95%: 1.15 – 1.82). Such disparities suggest that the conditions of confinement may attenuate the therapeutic effects of SOTPs, and also that community treatment (where it is possible for legal reasons) may make it easier to transfer learned thoughts and skills to the real world. Consequently, the view of Ho on SOTP should not be taken as emblematic of sex offender treatment as a whole. Inter alia, some diminution of effectiveness may be expected when treatments are delivered in custodial settings; however, this is not to say that there is a general absence of evidence for sex offender treatment.
There are valid criticisms to be made about sex offender treatment in general, and perhaps about British SOTP in particular. However, Ho’s portrayal mis-characterises the evidence at his disposal, overlooks other findings, and does not differentiate between features that are associated with treatment outcomes. In so doing, he risks discarding the promise of effective treatment suggested by the very “evidence of efficacy, provided through robust research” for which he calls. Instead of sweeping controversies about sex offender treatment we need hard empirical work on what works with whom, in what contexts, under what conditions, with regard to what outcomes, and also why. We assume Dr. Ho agrees on that.
 Dennis JA, Khan O, Ferriter M, Huband N, Powney MJ, Duggan C. Psychological interventions for adults who have sexually offended or are at risk of offending. Cochrane Database Syst Rev 2012;12:CD007507.
 Duggan C, Dennis J. The place of evidence in the treatment of sex offenders. Crim Behav Ment Health 2014;24:153-162.
 Ho DK, Ross CC. Cognitive behaviour therapy for sex offenders: too good to be true? Crim Behav Ment Health 2012;22:1-6.
 Mann RE, Carter AJ, Wakeling HC. In defense of NOMS’ view about sex offending treatment effectiveness: A reply to Ho and Ross. Crim Behav Ment Health 2012;22:7-10.
 Lösel F, Schmucker M. The effectiveness of treatment for sexual offenders: a comprehensive meta-analysis. J Exp Criminol 2005;1:117-46.
 Friendship C, Mann RE, Beech AR. Evaluation of a national prison-based treatment program for sexual offenders in England and Wales. J Interpers Viol 2014;18:744-759.
 Schmucker M, Lösel F. The effects of sexual offender treatment on recidivism: An international analysis of sound quality evaluations. Under review.
 Lösel F, Schmucker M. Treatment of sex offenders. In: Weisburd D, Bruinsma G, editors. Encyclopedia of criminology and criminal justice. New York: Springer; 2014. p. 5323-5332
 Hanson K, Burgon G, Helmus L, Hodgson S. The principles of effective correctional treatment also apply to sexual offenders: A meta-analysis. Crim Justice & Behav 2009:36: 865-891.
 Lipsey MW, Cullen FT. The effectiveness of correctional rehabilitation: A review of systematic reviews. Annual Rev Law & Soc Sci 2007;3:297-320.
 Koehler J, Lösel F. 2014. Can prisons reduce reoffending? A meta-evaluation of custodial and community offender rehabilitation programs. Paper presented at the Stockholm Criminology Symposium 2014; Stockholm, Sweden.
 Maguire M, Grubin D, Lösel F, Raynor P. ‘What works’ and the Correctional Services Accreditation Panel: Taking stock from an inside perspective. Criminol & Crim Justice 2010;10:37-58.
Competing interests: Friedrich Lösel is a member of the Correctional Services Accreditation and Advice Panel (CSAAP) of England and Wales and a past chair of the prior accreditation panel CSAP. These are independent roles that do not imply any conflict of interest. In contrast, they enable a differentiated view on the practice of offender treatment in Britain.
The evidence base for sex offender rehabilitation is contentious and inconsistent and Dr Ho is justified in sharing his concerns with the medical fraternity(1), but he argues for doctors to ‘take ownership’ without presenting evidence for psychiatric intervention.
Continued mental health detention is only appropriate if we can demonstrate the availability of relevant medical treatment, which may include pharmacological, psychological, occupational or nursing care. Yet if Dr Ho argues that this does not exist in the criminal justice system, then it seems hard to argue for its existence in a healthcare setting. His closing paragraph implies that the mandatory detention of sex offenders in secure settings may, of itself, be the objective in some cases but this contravenes the Mental Health Act Code of Practice which states that ‘simply detaining someone does not constitute medical treatment’(2). Further, in the absence of evidence for treatment, detention under the Mental Health Act could be challenged by the tribunal system leading to premature returns to the community for such offenders and an increase in risk to the public.
Diagnostic classification remains imperfect, and the inclusion of paraphilic behaviour closely associated with offending within current DSM/ ICD manuals does not justify diversion to hospital for such offenders without evidence of comorbid and treatable psychiatric diagnoses. Resources in secure mental health services are limited and admissions are expensive. There are many people with psychotic illness in our prisons awaiting hospital transfer for whom clear and unambiguous treatment pathways with robust evidence base exist. In this climate of austerity, secure services should allocate their resources on a patient group for whom they have the specific and exclusive therapeutic skills to treat.
1. BMJ 2015; 350:h199
2. Department of Health (2013) Code of Practice: Mental Health Act 1983 (4th edition).
Competing interests: No competing interests