THERAPY FOR PAEDOPHILESBehavioural Treatments Cognitive Programmes [Page 192] The range of therapies used with paedophiles is extensive. Some may not be generally applicable.
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(i) thinking about doing the deviant act, |
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(ii) going to a situation in which the act might be expected to occur, |
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(iii) seeking out the object of the deviance, |
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(iv) approaching that object, |
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(v) beginning the deviant act and |
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(vi) finishing the deviant act and achieving orgasm. |
The therapist and client had previously determined an aversive level of an electric shock.
The fantasies were played back to the client. During each segment he was given the painful electric shock. Just before the shock was delivered the therapist shouted "stop" in order that the word served as a conditioned punishment to replace the electric shock itself. Initially, each segment was accompanied by a shock but eventually
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only 50% were on a spasmodic basis. Intermittent rewards and punishments are known to be more effective than continuous ones. For each client, deviant fantasy was paired with actual or conditioned punishment more than 300 times over a one- to two-month period.
During a postal follow-up several months later, a large proportion of the men claimed no further deviant behaviour. Marshall claims a 75% success rate.
Cautela (1966) was the first to report the use of covert sensitization. In some of its forms, covert sensitization is quite similar to aversion therapy. The big difference is that the punishment is a psychogically unpleasant fantasy image rather than electric shock or a similar physical punishment. The client is helped to fantasize a situation similar to his offence. An unpleasant consequence such as a prison term is then incorporated into the fantasy. The fine detail varies.
One group of therapists describe their procedures with paedophiles as follows:
"... there are four categories of thoughts:
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neutral thoughts, |
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child- molesting thoughts, |
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aversive thoughts, and |
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pleasurable thoughts associated with consensual sex with an adult partner. |
The offender is asked to develop detailed fantasies and scenes involving these four categories. With the child-molesting scene he breaks down the sequence in discrete steps, going from thought to cruising to approaching and on to molesting behaviour.
Using a tape recorder, he tapes fantasies from the different categories of neutral, child molesting, aversive, and consensual sex thoughts. For the aversive scenes he must come up with several different types of unpleasant effects that may occur if he is caught molesting a child. These are highly individualized, but include such things as being verbally rebuked by his family, having his own children harassed by other children when they learn that their father is a child molester, the thought of imprisonment and rape by inmates when they learn that he is a child molester, or contracting the deadly disease AIDS."
(Barnard et at., 1989, p. 142)
In fantasy, the offender follows the child molesting sequence through but breaks into it with an aversive fantasy episode. This effectively stops him reaching the stage of abusing the child in fantasy. He dispels the aversive thoughts by moving into fantasy of pleasant consensual sex with an adult partner. When successful, the
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covert sensitization process will have ensured that his future abuse fantasies will be short-circuited by aversive thought intrusions. In this way the process of building up to real-life abuse through fantasy is stopped.
Rather than interrupting a fantasy, orgasmic reconditioning employs fantasy during masturbation. This procedure, derived from studies using homosexuals as participants (e.g. Conrad and Wincze, 1976), was improved and adapted to paedophiles by Van Deventer and Laws (1978). The aim is for the client to learn new, socially acceptable, fantasies to replace deviant fantasies about children. The treatment is described as follows:
"... the subject is first instructed to shift his masturbation fantasy from a deviant to a non-deviant theme at the moment of orgasmic inevitability: later in training he is instructed to move the introduction of the non-deviant fantasy forward in time toward the start of masturbation. ... deviant and non-deviant masturbation themes were alternated on a weekly basis for a period of six weeks. ...
In the first week, the subject masturbated to the deviant fantasy theme of sexual relations with young boys. Each was instructed to masturbate to ejaculation as rapidly as possible or for 20 min. whichever occurred first, while speaking the masturbatory fantasy aloud ...
During the second week the conditions were identical except that the theme was sexual relations with adult females. This weekly alternation continued throughout treatment."
(Van Deventer and Laws, 1978, p. 750)
The two clients discussed in the report were both paedophiles predominantly or exclusively attracted to boys. Their offences included anal intercourse. Many of the desired changes in fantasy and sexual arousal were achieved. Some evidence emerged of increased sexual responsiveness to women.
The authors suggest that it is the sexual confusion created by alternating deviant and non- deviant fantasy that might be responsible for the changes. Uncertainty, depression and anger were typical of their clients' feelings halfway through the treatment:
"Our subjects indicated that the switching made them aware of differences in their feelings. As one put it, 'It's not that I feel bad when masturbating and thinking about kids, it's just that I feel better when doing it to thoughts of women.' Both subjects denied that masturbating to fantasies about children was aversive."
(Van Deventer and Laws, 1978, pp. 760-761)
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Laws (1985) essentially argues that this form of therapy is especially suitable for clients who are much more aroused to deviant imagery than to non-deviant imagery.
There is little point or prospect in trying to change the fantasy of offenders unaroused sexually by deviant imagery. Those highly aroused by normal imagery do not need new fantasy conditioned; they need their paedophiliac fantasy eliminated.
In Marshall's (1973) version of orgasmic reconditioning, deviant and non-deviant fantasies were not alternated. Normal fantasy was used to block deviant fantasy throughout the treatment. Heterosexually orientated pornography was used to help the men to generate fantasies. They were told to eliminate deviant material from their fantasy, otherwise their deviance would be reinforced. Fantasy around the point of ejaculation is the most important since the contents of this are most closely reinforced by orgasm:
"He was told to use his deviant fantasies to initiate masturbation, and to continue to imagine them until immediately before ejaculation at which time he was to switch to the appropriate fantasy. The patient carried on this practice until he was able to control his fantasy content at ejaculation. At this time the therapist advised the patient to begin to extend the appropriate fantasy further back in the sequence until it would finally serve as the initiating stimulus."
(Marshall, 1973, p. 560)
There are no studies comparing the relative effectiveness of these two approaches.
One of the oddities about orgasmic reconditioning as described in the previous subsection is that it involves the use of masturbation to deviant fantasy. Given the lack of clear understanding about how orgasmic reconditioning works, there is an ethical uncertainty about encouraging paedophiliac fantasy as part of treatment.
Kremsdorf, Holmen and Laws (1980) describe a variant of orgasmic reconditioning using only socially acceptable fantasy material.
The paedophile involved was confined at a California state hospital for the molestation of a 6-year-old girl. He was highly sexually aroused
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by girls between the ages of 1 and 12 years. Although in his 20s, he was hardly aroused by women of this age and his sexual experiences with adults were minimal.
"Following a baseline measurement period, the subject began to masturbate to non-deviant fantasies on a daily basis for a period of 8 weeks. He was instructed to masturbate to ejaculation as rapidly as possible or for 20 min, whichever occurred first, while speaking the masturbatory fantasy aloud. This latter procedural variation was included to allow greater control over the fantasy the subject was actually utilizing. ...
The subject was further instructed that when he masturbated outside the laboratory he was to use themes solely of a non-deviant nature."
(Kremsdorf, Holmen and Laws, 1980, p. 204)
Using slides, it was found that his erections prior to treatment were to girls under the age of seven years. Following treatment, women generated the biggest erections. Eventually, over the course of treatment, the time he took to ejaculate to normal fantasy decreased.
The use of punishment to inhibit paedophiliac behaviour appears uncommon within therapy (although Rosenthal (1973) used electric shock in his behavioural treatment of a retarded offender). Shame aversion therapy, a currently recognized behavioural treatment of sex offenders, uses humiliation as a punishment.
In this the client re-enacts his offence in front of a cooperative panel which disapproves of the activity. There would, in general, be no legal or ethical problems associated, say, with having an exhibitionist do his act to such a group. It is more problematic to imagine how a paedophile's offences could be portrayed in this way, unless his sexual fantasy was made the focus rather than his acts.
Marshall (1979) argues that a good alternative to shame aversion therapy is to have offenders masturbate to paedophiliac fantasy to the point of physical satiation and beyond. That is, masturbation is continued well beyond the time it is pleasurable. This is satiation therapy.
One of Marshall's case studies involved the masturbatory satiation of a 33-year-old married man with children. The couple's sex life seemed satisfactory and intercourse took place three times or so each week. Intercourse involved deviant sexual fantasy so was actually part of the problem; furthermore, he had a fetish for female clothing. Despite having a long history of paedophilia with girls in the 4-14
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year age group, he had not abused his own children. Exposure, genital fondling and reciprocal oral sex had been its extent until the most recent offence, when he had full intercourse with an adolescent neighbour. His heterosexual paedophilia was confirmed by his erections to nude photographs of girls in the 6-8 and 11-13-year-old age groups:
"... the patient was required to seat himself in a darkened room where his only contact with the therapist was via an audio- intercommunication system. The subject was instructed to remove his trousers and commence masturbating, while at the same time verbalizing aloud every variation he could think of on the fantasies associated with the targeted category ...
For the initial six 1-hour treatment sessions ... the targeted category was female children aged 6 to 8 years. The patient was told to masturbate continuously throughout the 1-hour session so that even if he ejaculated he was to continue, stopping only to wipe himself clean if he found this necessary. Monitoring through a one-way screen and the sound system revealed that the patient followed the instructions closely ."
{Marshall, 1979, p. 380)
Once erections to the younger girls declined, the 11- to 13-year-olds were satiated to. Finally, the underwear fetish was tackled. When these changes in responsiveness to young females had been achieved, orgasmic reconditioning was carried out to adult female images. This worked in that he achieved erections to pictures of nude women and ejaculated to them increasingly quickly. At a six-month follow-up meeting, his wife reported that the improvement in their sex life had lasted and laboratory assessment showed that the new pattern of erections to nude women remained.
Detailed discussions of assertiveness training for paedophiles are surprisingly rare, given claims that paedophiles have problems with dominance or relating to other adults.
Edwards (1972) treated the three major problems of a 40-year-old doctor:
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(i) twice monthly sexual activity with his sons following his wife's extra-marital affair; |
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(ii) interpersonal difficulties with adults, especially his wife; and |
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(iii) intermittent impotence. |
When his wife found out that he had persuaded one of their sons to bugger him the marriage "hit on the rocks". She had known of the abuse for two years but this was the final straw.
The man's family history included an overbearing mother
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and a disciplinarian father. Experiences with prostitutes when he was 17 were bad; both episodes gave him venereal disease. A few months later, he had his first paedophiliac contact. This was with the four-year-old son of a friend.
He met his wife at medical school. Intercourse took place after about six months. Sexual activity was rapacious, when they sneaked a holiday together unbeknown to her parents. They were discovered and her parents forced their marriage but from then on sex was not at all the same. His wife had little sexual interest in him and, for example, the marriage's consummation did not take place for nearly a week. They divorced for a while after her affair but remarried. After this she became sexually the aggressive partner but his interest lessened.
During treatment he was required to stop sexual activity with anyone; instead his objective was to get to know people. "Thought stopping" procedures were demonstrated, although these are nothing to do with assertiveness training as such. When a paedophiliac image was conjured up, the therapist banged a table loudly and shouted "stop". The fantasy was thereby disrupted. This startle reaction could be brought back by the patient simply saying the word "stop". According to the man, this worked well with deviant thoughts, reducing them to once or twice a week.
Assertiveness training given by the therapist was supplemented by a training book which described assertiveness techniques in more detail. In its own terms this seems to have worked quite well but the detail of his assertive behaviour seems from another era of marriage partnerships:
"At the fourth session he reported that he had again stated clearly that
he would be the decision-maker on finances, on the bringing up of the children, and 'as a matter on fact, on all things'.
She was argumentative and angry at first, but he felt himself in control the entire time. She ultimately accepted his edict which he found a highly satisfying experience. He then told her that her sexual aggressiveness upset him because she had challenged him on the 'no sex' issue and become seductive. He had, however, felt like sex with her on several occasions. Since he seemed ready to approach her, I instructed him to do so but assume at least equality in control, not to allow her to domineer."
(Edwards, 1972, p. 57)
It is suggested that the paedophiliac behaviour stopped, although the case for this is largely based on anecdotes. Incest offenders, as we will see, tend not to re-offend following detection. This may emphasize the need for caution about the success of the treatment, especially as
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two different therapies were confounded. Modern assertiveness training would normally see dominance and aggressiveness as inappropriate ways of asserting oneself.
An early treatment programme for paedophiles was described by Serber and Keith (1974). This is unusual in so far as it directly tied the treatment of paedophiles with homosexuality. The programme was known as the Atascadero project after the state hospital which housed it.
About 15% of the men in this large hospital were "homosexual", meaning mainly paedophiles. For the most part, the homosexual patients had either severe difficulties in relationships with other homosexuals or absolutely no experience at all with adult homosexuals. They were seen as lacking the interactive skills required for adult friendships and relationships. Feelings of inferiority in relation to other adults, according to the authors, encouraged the men into relationships with children. The homosexual patients, typically, either had never been in contact with other adult homosexuals or had experienced difficulties in relating to them. In general, the men were fairly ignorant of community groups and the support they could give.
The programme aimed simply to orientate the patients to adult partners rather than convert them to adult heterosexuality. Successfully functioning homosexual models were introduced to the hospital:
"The group depended upon gay student volunteers from a local college campus who are successfully integrated into straight society and who functioned as instructors and behavioral models. ... Role playing situations were first used with the models. ... The scene used was that of a gay bar where social contacts are frequently made. After observing many behavioral samples by the gay models we isolated specific verbal and nonverbal components of gay social interactions which served as a 'behavioral base' upon which further social skills could be built."
(Serber and Keith, 1974, p. 95)
A lesbian led consciousness raising groups dealing with matters such as problems involved in being gay in a heterosexually orientated world, as well as ways of dealing with family members in relation to homosexuality. The authors' report no increase in sexual acting out as a result of this. Since this apparently means homosexual acts it is difficult to know how successful the programme had been.
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It is not known what proportion of therapists rely exclusively on behavioural approaches. Most modern practitioners appear to use behavioural treatments such as orgasmic reconditioning and satiation just as components of their work. The reasons for this shift are not documented, although they may include a general disenchantment with purely behavioural methods, the higher profile given to sex abuse treatment, the need to provide corporately run treatment programmes and greater awareness of alternatives to traditional individual psychotherapy (such as group work).
The failure of research to effectively identify a single cause of paedophilia may also encourage "broad-front" therapy. Research has highlighted numerous factors that may contribute to sexual involvement with children, and no single factor is generally held to be essential or sufficient in itself. Thus, a wide a range of factors are addressed in therapy.
Since the social and psychological difficulties of paedophiles are often similar to those of people in general, ignoring the wider social, personal and emotional difficulties of offenders might be counterproductive.
A three-phase programme for the treatment of paedophilia is described by Rowan (1988a) and provides a useful illustration of this sort of approach. The three aspects involved are:
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(1) Social skills:
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(2) Stress management and communication skills:
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(3) Patients may
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Progress in therapy is assessed on the basis of the discrepancy between a patient's own ratings of his personal progress and a pooled
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assessment by the staff of the institution; the smaller the discrepancy, the greater the improvement.
One case study describes a man who had undergone the therapy:
"Subject A is a 42-year-old man who reported that his alcoholic father had abused his sister but not him. As an adult, Subject A was also an alcoholic and never married. Twice, when intoxicated, he made sexual contact with his niece.
In treatment he was an active participant in ward government and therapy groups and Alcoholics Anonymous. ...
Victim identification exercises led to great remorse and he reestablished contact with his sister, the victim's mother, to begin family reconciliation.
Subject A rates his progress as high, and the staff agreed because of his openness, insight, increased self-esteem, and sincere effort to control his alcoholism. He returned to prison with a recommendation for parole."
., (Rowan, 1988b, p. 208)
In another publication, Rowan (1988a) adds to the list of treatments the correction of cognitive distortions. Education and insight-orientated therapy are described as the means of doing this:
"First the perpetrator has to admit and accept responsibility for his own behavior. It is not generally true that sex-starved seven-year-olds jump out of the bushes and attack innocent, passing men.
The 'why me?' question can be addressed using the four-factor model [Araji and Finkelhor, 1985] and determining how the individual meets the criteria of each factor and how these combine to explain behavior. The role of the victim must be clarified as behavior may be rationalized by observations such as 'she kept coming back' and the adult fails to take appropriate responsibility for his own actions."
(Rowan, 1988a, p. 94)
Clearly, much of the above relies on changes quite distinct from those of erotic orientation.
Lanyon (1986) suggests that a systematic treatment for paedophiles should include the following steps:
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(1) Immediate crisis and life problem management. |
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(2) Deficiencies in sex education should be remedied. |
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(3) Attention to existing and continuing adult relationships. |
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required to further the emotional quality of that relationship. In the case of incest, each member of the family will normally need to be involved in the therapy at some stage.
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( 4) Where there is no adult relationship the client should be helped to work towards achieving one. |
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(5) Behaviour therapy procedures should be employed to stop deviant behaviour and the associated fantasy. |
While they differ in fine detail, Lanyan's and Rowan's treatment programmes overlap in significant ways. A more extensive but overlapping programme was that developed at the North Florida Evaluation and Treatment Center (Barnard et al. , 1989). Several hundred offenders have been treated there using the basic philosophy that:
"... sex offenders develop their deviant behavior through multiple and diverse ways and consequently require a variety of treatment approaches to alter this aberrant behavior ."
(Barnard et at., 1989, p. 126)
Again, treatment overlaps with that of the smaller scale programmes already discussed. Nevertheless, the programme contains features that may be of interest where resources are available.
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sexual behaviour, |
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character, |
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behaviour in general and |
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physical and psychological wellness: |
The techniques used are masturbatory satiation and covert sensitization, much as described earlier in this chapter .
Self-insight into the offender's own character with the intention of reducing maladaptive behaviour. The training modules involved include:
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a. Interpersonally orientated groups. |
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b. Peer-facilitated groups.
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c. Role-playing. | ||||||||||||||||||
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d. Sensitivity training module.
In addition
are also available. |
This aims to improve skills at dealing with the ordinary problems of life. The training methods include the following:
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a. Cognitive restructuring.
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b. Communication skills. |
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c. Social skills. |
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d. Relapse prevention. |
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e. Substance abuse. |
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f. Stress inoculation for anger and impulse control. |
Better self-esteem and physical wel-being are the main purposes of development in this area. Modules include:
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a. Personal health project. |
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b. Sex education. |
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c. General learning. |
All of this is far removed from the "cheap and cheerful" behaviour modification techniques. Justification for the use of extensive programmes seems to be based almost entirely on clinical experience rather than research.
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include enhancing offender empathy (Hildebran and Pithers, 1989). Usually this is carried out in mixed offender groups (child abusers and rapists of adult women) in order that these alternative viewpoints (and antipathies) can work towards change.
Materials on the experiences of the victims of offending are used to stimulate responses concerning victims of sex crimes. The offender is encouraged to write an account of his own offending from the point of view of his own victim. The distancing styles adopted by offenders towards their own offending need attention -- these can include
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speaking in the past tense rather than in the present tense, |
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extensive abuse may be reduced to a couple of phrases and |
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the experience may be turned into a highly theatrical or dramatic scenario distanced from reality. |
Resisting offenders may be asked to role play the abuse as the victim with another member of the group acting as the victimizer.
Inevitably, the process of doing therapy takes place in a far broader context than the time spent in the therapist's office. A wide range of external factors impinge on the likely therapeutic outcomes. Thus, there is a need to ensure commitment to therapy rather than the alternatives.
Perkins (1991) suggests several means of helping offenders to move along the therapeutic path:
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(1) The treatment options should be described, together with the likely outcomes of not going through therapy. |
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(2) Detailing to the client the rewards and punishments that are possible outside of therapy. These include the possibilities of further and longer terms of imprisonment, losing contact with his own children and the loss of his wife or other partner. |
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(3) The client is encouraged to view the therapy as being of his own choosing rather than the consequence of external pressures from within the institution or elsewhere. Perkins suggests that this is likely to maximize the genuine attitude changes following from therapy. |
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(4) Short-term benefits of therapy such as time out from tedious prison routine can be emphasized. |
An illustrative case study involves a prisoner with a history of indecent assaults against girls, given a life sentence for girl rape. The man maintained that realizing the gravity of this offence had shocked
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him out of offending in future. He did not believe that he could be helped by therapy and saw himself, essentially, as posing no future risk. In comparison to other sex offenders, he felt himself harshly and unfairly dealt with:
"Work with this offender began from the position of taking matters from his perspective, that is wanting to get out of prison. He accepted that the authorities would need to be convinced of his safety to the public and that this would require assembling a good deal of information about his past offending and his current propensity for offending ...
He proved to be amenable to discussion about his past life and gained some insight into the reasons for his offending. ...
Discussion about his past sexually deviant interests and masturbation fantasies involving both young females and a degree of sadism led to the issue of how any changes in these features of his makeup might be demonstrated to the authorities. After much weighing of the pros and cons, the offender took part in an auditory [penile plethysmograph] assessment, which clearly indicated the presence of very strong sexual responses both to young females and to certain sadistic acts."
(Perkins, 1991, p. 172)
The evidence provided by this directly led him to reveal how distressed he was about still having deviant fantasies. For the first time in the therapy, useful discussion was possible about his sexual deviance and what could be done about it.
Some recent approaches to the treatment of sex offenders use techniques that help the client who has largely graduated out of therapy but has not altogether proven himself as a non-offender (Pithers et al., 1988; Marshall, Hudson and Ward, 1992).
The techniques are applied throughout the range of addictions (Wilson, 1992). Relapse into old ways is a clear possibility on release from an institution, and there is evidence that relapse tends to occur in the period immediately after cessation of treatment in the case of physical addictions. For sexual offences this period of maximum vulnerability is claimed to be the first nine months following discharge (Frisbie, 1969). It is important to supply the offender with the appropriate tools and techniques to recognize the danger signs of circumstances likely to enhance the risk of re-offending against children.
Empirical research on paedophiles has identified some of the precursors to offending (Pithers et al. , 1988, 1989).
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These immediate signs include
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planning of sexual offences (73%), |
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anxiety (46%), |
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depression (38%), |
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alcohol abuse (23%), |
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deviant sexual fantasies (51 %) |
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and many others. |
There is a sort of pattern that many pass through:
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(1) Affective/mood changes:
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(2) Fantasies of performing aberrant sexual acts; | ||||||
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(3) These fantasies were converted to thoughts such as the child needing to be educated into sex; | ||||||
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(4) Passive planning of the abuse, possibly during masturbatory fantasies. |
In other words, the offence is not the result of "impulse".
The offender can be taught to understand the signs of imminent further offending. It is important to make realistic claims about therapy's benefis. "Cure" is unlikely and many offenders will have deviant thoughts and sexual arousal patterns after treatment. Education into the likelihood of lapses is one way of making the client more fully insightful into his situation.
A few concepts from relapse prevention work can be mentioned for the purposes of illustration.
One of these concepts is the Apparently Irrelevant Decision (AID; Jenkins-Hall and Marlatt, 1989). These are things that the offender decides to do which superficially may have little to do with offending in the mind of the offender but lead to risk situations. These are not accidents, but part of the engineering of a relapse. He needs to learn to recognize that hiring a Walt Disney film from a video store is unhealthy if he intends to use it to stimulate sexual imagery about young children. Similarly, making casual offers to babysit neighbours' children is not as casual as the offender may pretend to himself:
"A paedophile in outpatient treatment described how he had a hectic day at work and was asked at the last minute to run an errand for his boss. This made him increasingly anxious about being late for dinner at his mother's, so anxious that he decided to take an alternate route because it would be faster. This route took him near an area of town where he had offended in the past. However, he would save about 10 minutes.
As he drove through the area, he saw a child he knew from his neighborhood who looked exhausted and was carrying a heavy load. He was unaware of any sexual interest in the child, only that the child needed his assistance.
The client took the time to stop and ask if the child needed a lift ... The child spontaneously gave the client a hug upon exiting the car ."
(Jenkins-Hall and Marlatt, 1989, p. 49)
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Later he had urges which resulted in him masturbating to fantasies of a boy similar in appearance to the boy he had helped. The offender could not see the connections, but the sequence of events described demonstrates the ways in which behaviour that facilitates offending is subject to rationalization, its intention denied and the offender's feelings projected onto a child.
One exercise to help prevent lapses is for the offender to fantasize a future scenario of a lapse involving a sequence of these apparently irrelevant decisions in order to see how they come together in the fantasized offence.
The Abstinence Violation Effect (AVE) is largely the consequence of the mismatch between the offender's new view of himself as a reformed person and knowing that he had lapsed in some way, thus putting himself at risk of re-offending. Such circumstances can lead the individual to revert to self-perceptions of being an offender:
"The probability of relapse is a function of the following factors:
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(1) The extent to which the individual feels controlled by (or helpless relative to) the influence of another individual or group (e.g., criticism from others, anger at others) or by external events 'beyond the control' of the individual (e.g., financial hardship, boredom, depression); |
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(2) The immediate availability of a coping response as an alternative to the dysfunctional behavior in a high-risk situation; |
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(3) An individual's expectations about the consequences of the behavioral alternatives in the risk situation; and |
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(4) The availability of victims (i.e., opportunity)." |
Relapse prevention requires a highly individualized programme designed to help a particular offender to cope with his special pattern of precursors to offending, to develop his own coping mechanisms and to develop his own contract with the therapist.
Pithers et al. (1988) argue that relapse prevention is highly cost effective. For example, it needed only $61 000 to provide relapse prevention for 15 outpatient therapy groups. The relapse rate for paedophiles following treatment was only 3% reconvictions.
Superficially at least, most forms of psychological treatment have the individual as their focus. In many ways, they seek to provide a degree of autonomy for the participants in the programme. But this is not universal; there are treatments with an ethical foundation in an attitude more hostile to the offender and more geared to protecting what are believed to be broader social interests.
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These seek to psychologically control and contain paedophilia as their first objective. They assume that paedophilia is an addiction, to be tackled much as any other addiction would be.
Salter (1988) makes the point strongly that general psychotherapy and that for sexual offenders differ fundamentally. She suggests, among other things:
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(1) That voluntary treatment is not to be preferred. Too often the client will use the opportunity to avoid the consequences of his crimes. Treatment mandated by a court of law has the back-up threat of further judicial punishment required to keep the offender in line. |
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(2) It is for the therapist to set the goals of the treatment rather than the client and to forcibly reject inappropriate and exculpatory goals. |
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(3) The therapist must set a clear value stance against abuse and the harm done by it. |
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(4) The therapist must set limits on the behaviour of the offender and react strongly if the limits are exceeded. The incestuous father who engages in "tickling" sessions with his child may well be exceeding what is allowable during a course of therapy. |
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(5) The offender is not to be trusted as a reliable source of information. He is regarded as a liar. |
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(6) Confrontation is the typical style, and comments by the therapist such as "I wouldn't believe that if my grandmother swore it on her death bed" are regarded as appropriate. |
It is not seen as right to regard the addict as a trustworthy person, someone who is determined to "kick" the habit.
This comes across very clearly in the viewpoint of Wyre (1989) when describing the treatment programme employed by his co-workers and himself:
"I feel the most important thing to do is to shift the power and the knowledge base from the offender to the worker. I want [him] to feel that I know what he is up to, what he thinks about and what he does."
(Wyre, 1989, p. 19)
The strategy, especially early on in treatment with incest cases, may involve the use of offenders' distorted justifications for their offences. The approach is one of "appearing to collude" with the offender; skilful use of enabling comments can prompt disclosure concerning patterns of offending. These take the form of the usual cognitive distortions common among offenders:
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"I expect you found her very promiscuous when you joined the family?" |
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"I suppose she saw you make love to your wife?" |
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"I expect you usually told her to go away?" |
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"Sometimes when you were cuddling she touched your penis and asked questions." |
Such leading questions are geared mainly to obtaining evidence of guilt. Apart from their role in treatment, they also provide the means of preventing further abuse by having a profile of the offender for future forensic or preventative purposes.
Wyre regards it as a crucial part of dealing with the offender to investigate the characteristics of the man's offending.
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Just how does he form the social relationships that become the basis for the sexual abuse of children? |
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Is there a particular sort of child that typically becomes targeted by the offender? |
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Are they characteristically a certain age or physical type? |
This information is then available as a profile to match with future offences for forensic purposes or to use to prevent possible offending:
"We are meant to disclose any information we have about a known child molester ..."
(Wyre, 1989, p. 19)
There is something of a culture shock for those with a foundation in traditional psychotherapy when confronted with Wyre's views. Further insight into the approach's ideology is revealed by the following:
"If you use the psychotherapeutic model ... you're almost certain to run into trouble. It starts on the premise that you are treating the offender more as a victim than as a perpetrator -- you're colluding with him to see what made him carry out these offences. ... I have to make them confront the reality of the abuse, make them see the damage and understand that they had a choice as an adult which their victim as a child didn't have."
(Wyre, reported in Tate, 1990, p. 264)
Although the addiction control programmes share a great deal with other forms of psychotherapy, it is important to remember the nature of their special assumptions because this highlights the distinctive ideology involved.
Theory in this area is not yet systematic enough to make any great claims about major schools of thought; it may be that many of the programmes not proclaiming their basis in addiction
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control are de facto similar. After all, the approach is as much to do with the distinctive attitude of the therapist as substantially different therapeutic techniques.
McConaghy (1989), writing of similar techniques mixing confrontation with support, suggested:
"Such techniques are disturbingly reminiscent of those used to provide data for political and religious show-trials. Their underlying acceptance of a guilty until proven innocent attitude suggests the accused sex offender has become the contemporary witch, victim of the projected unacceptable sexual fantasies of the good citizen."
CMcConaghy, 1989, pp. 618-619)
Perhaps this is a major debate just waiting to happen.
While the addiction model dominates in his work also, Valcour (1990) describes therapy that is steeped in the Alcoholics Anonymous philosophy but integrated with religious attitudes.
Twelve steps are involved in the treatment employed by the Catholic Church in the USA, apparently very successfully. At one treatment centre, 55 child molesters who completed therapy reported no recidivism or new allegations at follow-up. Over 30 of the men had returned to work in some form of ministry.
Valcour insists that what he calls "Sexaholics Anonymous" does not require that the addiction concept be satisfactory in research or theoretical terms for the treatment based on it to be effective.
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(i) accepting that there is a problem that essentially is beyond our individual power to affect though not beyond our responsibility, |
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(ii) the desire for help beyond oneself as an individual and |
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(iii) the "handing over of self to that healing higher power, be it God, a fellowship or therapy group, a treatment center or some combination thereof" |
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(1) Admission that life had become unmanageable because they were powerless over their lusts. |
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(2) Coming to believe that a greater power could restore sanity. |
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(3) Placing their life in the care of God. |
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(4) Making a moral inventory of themselves. |
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(5) Allowing God to take away their character defects. |
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(6) Naming everyone harmed and becoming willing to make amends. |
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(7) Praying and meditating for strength to carry out God's will for them. |
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(8) Evangelizing the "sexaholic" message. |
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1. Idealization. |
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2. Self-loathing and guilt. |
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3. Authority conflicts. |
While it is obvious that such an approach has only limited secular applicability, it is intriguing because of the ideological slant it imposes. Overt hostility as implicit in some other addiction models is replaced by concerns about the whole person.
The use of therapeutic groups for offenders against children is characteristic of recent therapeutic programmes. Much of this is similar to what takes place in general psychotherapy for non- offenders. Careful accounts of its use in relation to paedophiles are not common. The reasons for this are probably to do with its common usage in general psychotherapy, as part of the stock-in-trade of the professional therapist.
Nevertheless, Breer (1987) goes into considerable detail but his interest is primarily in the treatment of adolescents who molest other, younger children. Since sexual offences are often committed by teenage offenders who then grow up to become middle-aged paedophiles, his discussion is very salient.
The group, according to Breer, is especially useful in providing sustained and confrontational pressure on a member determined to
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avoid the crux of the issue-his offending. Groups may achieve more than the therapist could in individual sessions. For non-residential offenders there should be no more than one group a week, lasting a minimum of two hours.
Breer uses the term "family energy" to indicate that the parents of a young offender have only finite resources to devote to his problems; taxing the family's ability to devote time, money and emotional resources is counterproductive and over-frequent therapy sessions can result in family or offender resistance. Furthermore, people and families can only change at a given pace determined by their emotional strength. To push the rate of change too greatly is fruitless.
A weekly group session is a compromise between all factors but is generally within the capacities of most offenders and their families. Meetings need to be lengthy because time is invariably wasted in excuses and the like before the nitty-gritty of the group work is achieved, often in the dying minutes of the meeting.
Breer motivates clients using a five rung "ladder of achievement". Youngsters can ask to be considered for higher levels. The lowest rung is that of denial and minimalization of the offence; the highest involves achieving sophisticated understanding of the victim and the victim's experience.
Again, the methods are unlike traditional psychotherapy in a number of ways:
"A degree of coerciveness and lack of confidentiality are modifications of traditional therapy essential to the successful treatment of the adolescent molester. They must, however, be balanced by a climate of warmth, acceptance, and support in the group itself. Everything should be done to create a climate of free expression in the group. For example, there should be no rules on the nature of the language used in discussion."
(Breer, 1987, p. 113)
One rare discussion of support therapies for the counseling of paedophiles is to be found in van Zessen (1991), who raises a number of problems with conventional treatment programmes for paedophiles.
These include that they are almost exclusively designed for prisoner or psychiatric hospital populations; deal with paedophiles alongside all other sex offenders; regard paedophilia as a homogeneous issue in which the sexual rapist of a toddler is dealt with in the same way as a man having a "paedophiliac affair" with a
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l5-year
old boy; and risk confusing a genuine desire to change sexual orientation with
a wish to get out of prison or hospital. Treatment is aimed at getting rid
of paedophiliac arousal and at increasing arousal to adults, usually women,
fails to distinguish between clear abuse and consensual acts, and never
explores the meaning of the paedophiliac attraction in the psychology of the
man.
At the Clinical
Psychology Department at the University of Utrecht, for a while non-residential
clients in the 25- to 50-year old range with a preference for 9- to 16-year old
boys were put through a therapy
programme. Only men having non-violent contacts and no signs of severe
psychopathology were eligible. The therapy was not designed to convert men from
paedophilia and so did not attempt to create heterosexual arousal or to provide
heterosexual courtship skills. The men, it was felt, were too old and lacking in
signs of heterosexuality to make conversion a realistic possibility. Rarely had
the men sought conversion.
During assessment,
it became clear that the major problems for the paedophile either concerned his
erotic/sexual attraction to boys or difficulties created when trying to express
his sexuality in relation to other people. Identity and realization therapies
formed the nucleus of individual therapy as a consequence. The focus was upon
the provision of cognitive frameworks that helped to structure understanding of
sexual/erotic desires. Guilt and insecurity were characteristic of many of
the men:
