Section 4: Treatment
2 Hours

Lecture Topic TOPIC: TREATMENT

Frameworks for Treatment

We’ll start by reviewing the models commonly used as a foundation of juvenile sex offender treatment. As we discussed earlier, for the most part, treatment programming for juvenile sex offenders has been largely modeled after adult sex offender treatment programs.33 Understandably, this has been the source of quite a bit of controversy in recent years, given the growing recognition of some important differences between adult and juvenile sex offenders.34 Indeed, it is very important that treatment programs for juveniles take into account these differences, as well as the developmental issues that are common during the period of adolescence.

And of course, it is important that treatment for these youth addresses the multiple determinants of their behavior problems.  As I highlighted earlier, MST is a very good example of such an approach, and it appears to be a promising model for juvenile sex offender treatment.  Yet only a handful of treatment programs for juvenile male sex offenders—less than 7 percent—report that their primary approach is multi-systemic in nature.35  By far, most treatment programs, when listing the primary theory that drives treatment in their juvenile programs, endorse cognitive-behavioral approaches.36  Many programs also report using relapse prevention frameworks for treating sexually abusive youth.37  So let’s talk about what those theoretical frameworks are all about.

Use SlideUse Slide #13: Most Common Theoretical Frameworks Reported Nationwide

Cognitive–Behavioral

In the most broad and basic terms, cognitive–behavioral approaches assist individuals with changing patterns of thinking that are unhealthy or dysfunctional and that impact the way in which they ultimately feel and behave. The focus tends to be on the “here and now” of how one thinks, feels, and behaves—and less on trying to identify “root causes” of the person’s behavior. In addition, cognitive–behavioral approaches focus on helping people develop and practice new skills and competencies. As such, cognitive–behavioral treatment is not simply “talk therapy,” so to speak. Rather, it is structured and directive, and relies on the use of homework assignments so that clients are able to consider and practice strategies in the “real world” outside of the treatment sessions.

Cognitive–behavioral approaches are effective for treating a range of symptoms and disorders including depression, anxiety, obsessive–compulsive disorders, eating disorders, relationship problems, and anger management difficulties—to name just a few. In fact, because of the extensive research support, the use of cognitive–behavioral interventions is often cited as a key to effective programming in criminal and juvenile justice systems.38 And again, cognitive–behavioral treatment is currently the most popular model for sex offender treatment, and the one for which there appears to be the most research support.39

In the more traditional sense, the cognitive–behavioral framework for juvenile sex offender treatment has focused primarily on the youth alone. But as you know, it is also important to address other influences in the youth’s life, such as peers, environment, and family variables. This is probably one of the reasons that MST seems to have so much promise. So, in order to be more comprehensive in their approaches, the emphases in treatment programs should also address family and other environmental elements.

Relapse Prevention

Relapse prevention is a subset of the broader cognitive–behavioral framework. You may already know that relapse prevention was originally developed and found to be effective for addictive disorders such as gambling and substance abuse and, of course, it has since been applied to sex offender treatment.40 Generally speaking, relapse prevention is designed around a “no cure” philosophy. In other words, treatment does not “fix” the person or make the problem behavior “disappear.”  Rather, relapse prevention is considered to be a long-term behavior management strategy.

Through relapse prevention treatment, sexually abusive individuals learn to identify a range of risk factors—which are often a combination of thoughts, feelings, and situations—that increase their likelihood of engaging in problem behavior in the future, and then they develop and practice effective coping strategies to deal with, or manage over the long-term, these risk factors.41 Relapse prevention also helps people to effectively deal with the inevitable lapses, slip-ups, or near-misses that occur as they struggle with maintaining change.

For sex offender management, the relapse prevention model also includes an external, supervisory dimension, because it was recognized that relying solely on the individual offender to manage his or her behavior may not be sufficient, and that other supports should be put in place to assist the offender.42 We’ll talk more about that component when we get to the supervision section.

I should note, though, that some experts have expressed concerns with some of the traditional applications of relapse prevention with juvenile sex offenders because of the “no cure” philosophy.43 For example, given the research that suggests low sexual recidivism rates for these youth—sometimes even in the absence of intervention—emphasizing a “no cure” approach may be misleading in some ways. In other words, the strict application of the traditional relapse prevention model to juveniles may result in these youth being labeled as “incurable.”

In turn, this may even cause people to believe that juveniles who commit sex offenses are destined to continue into adulthood, which we know is not the case. And it may cause youth to feel hopeless and reduce feelings of self–efficacy and optimism. Inadvertently, this could lead to a self–fulfilling prophecy. As a result, some practitioners who work with juvenile sex offenders have adapted the relapse prevention model to be more developmentally and socioecologically sensitive, including modifying the language, style, and approach to activities and treatment tasks and reframing the “incurabilty” emphasis to avoid the potentially negative impact it may have on self–esteem, motivation, and confidence to make positive life changes in treatment.44

Which Framework Should be Used?

We’ve briefly discussed Multisystemic Therapy, the cognitive–behavioral approach, and relapse prevention as frameworks for providing treatment to juvenile sex offenders. And you may be wondering which one is the best to use with these youth.

Some experts have argued that there are insufficient rigorous and well–controlled studies of juvenile sex offender treatment approaches to indicate which models of treatment are most effective or more superior to others.45 For now, in the absence of a comprehensive and well–designed series of empirical evaluations, we will focus our discussions around what seems to have the most support—albeit limited—and the model that most programs seem to be using. Keeping in mind the limitations and concerns of the field in its current state, the remainder of this section of the training will describe programming for juvenile sex offenders that is delivered within the cognitive–behavioral and relapse prevention framework.

Suffice it to say that as we continue to learn about these youth, their similarities to and differences from adult sex offenders, and the types of interventions that “work”—and work best—with these youth, it will be important that we adjust our approaches to treatment for sexually abusive youth.

Treatment Modalities

Let’s spend just a few minutes discussing the vehicles by which treatment is provided within the cognitive–behavioral and relapse prevention framework.

Group Therapy

The most common treatment modality is the use of groups, with up to ten youth per group. Having more than that in a group can make the group more difficult to manage, and doesn’t allow enough “air time” for each of the youth to be able to work through their issues when the group meets. Some groups are more traditional “therapy” groups, in which specially-trained mental health professionals use specific therapeutic techniques, strategies, and processes, and the dynamics of the group as a whole, as a means of addressing clinical issues.

Other groups are psychoeducational in nature, which means that the facilitator of the group—who may or may not be a mental health professional—provides instruction about specific topics or issues to the group. Although group members are often expected to relate to their own circumstances the information which is being “taught,” the group is more didactic in nature. In other words, it appears much more like “classroom” instruction than a group therapy session.

Individual and Family Therapy

Although group treatment is the most common mode of clinical intervention with juvenile sex offenders, professionals in the field generally agree that treatment should also include individual and family therapy.46 The use of individual and family interventions with youth is important for several reasons.

Use SlideUse Slide #14: Multiple Modes are Important
Use SlideUse Slide #15: Use of Various Modalities Nationwide

As you can see, it is very promising that the majority of juvenile sex offender programs across the country report that they do not rely exclusively on group as the only mode of treatment; rather, these treatment programs appear to use a more comprehensive and integrated approach by incorporating group, individual, and family interventions.47 However, simply because these programs indicate that they use these modalities does not mean that they are used at a high frequency. In fact, the data suggests that the absolute numbers of hours of services provided on an individual or family basis remains very low, especially compared to units of service for group therapy.48

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