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Section 4: Lecture Content and Teaching Notes
Sex Offender Specific Treatment in the Context of Supervision

2 hours

TOPIC: SEX OFFENDER TREATMENT
(60-70 minutes, including Learning Activity)

New Topic IconDISTINCTIONS FROM OTHER TYPES OF TREATMENT

Use Slide # SymbolUse Slide #10: Traditional vs. Sex Offender Treatment
[Click to Enlarge]
One of the most helpful things for probation/parole officers to be aware of is that the cognitive-behavioral therapy proving to be successful with sex offenders is distinctively different from traditional counseling or psychotherapy.

  • Traditional therapy focuses on the offender as the "client" or "patient" primarily, whereas sex offender treatment has a goal of preventing future victimization and striving to ameliorate the harm done by the offender to the victim of the crime. Some therapists say that the community and potential future victims are their real clients. Indeed, as states begin to develop standards for treatment, at least one has adopted the "victim/community as client" perspective officially in its standards.21

  • Traditional psychotherapy seeks to reduce feelings of anxiety and inadequacy, while sex offender therapy seeks to confront the offender with his thinking errors and to bring him to accept accountability for his actions.

  • Where traditional treatment may take place in the context of individual psychotherapy /counseling or in a group setting, most sex offender therapists find that the group therapy setting is essential to treatment. The group setting including offenders with similar backgrounds helps to undermine the secrecy and denial typical in a sex offender's view of himself.

  • Traditional therapy is undertaken voluntarily by the client, while sex offender treatment is often ordered by the court and may not be considered entirely voluntary.

  • Therapists traditionally operate in a context where the patient-client privilege shields both parties from disclosing the matters discussed during treatment. In the sex offender treatment process, a waiver of confidentiality is usually required, allowing the therapist to freely exchange information with criminal justice system agencies and other stakeholders such as the polygraph examiner. A sex offender therapist must also be willing to testify in court.

    Use Slide # SymbolUse Slide #11: Traditional vs. Sex Offender Treatment
    [Click to Enlarge]

  • Therapists who engage in traditional psychotherapy are often accustomed to working as individuals, without insights or information from professionals in other fields. In the context of a larger, more comprehensive approach to sex offender management that includes treatment, the therapist may be working as a member of a case management team, exchanging information and sharing in decisions with the probation/parole officer and the polygraph examiner, and perhaps others, including the victim's therapist.

  • Traditionally, therapists have seen their training as preparing them to handle a wide variety of emotional and psychological issues. In the sex offender treatment arena, for precisely the reasons listed above, specialized training and experience are essential.

Learning ActivityLEARNING ACTIVITY: DISCUSSION QUESTIONS
(5-10 minutes)

Refer to Handout Symbol Refer to handout: Section 4 discussion questions.
Before we go further in the agenda to discuss the specific elements of specialized sex offender treatment, let's discuss the practical question of whether and to what degree participants have access to treatment of this or any kind for sex offenders under their supervision.

  1. Is treatment routinely available for sex offenders under your supervision? If no, please explain availability issues.

  2. Would you say that the treatment programs to which you have access appear to exhibit the characteristics listed above? To what degree? If there are differences, please explain and discuss them.

New Topic IconWHAT COMPRISES SEX OFFENDER TREATMENT?

Goals of Treatment

In order to begin to understand specialized sex offender treatment, it is perhaps most important to review its goals. First of all, the primary, overall goal is to reduce recidivism. According to Georgia Cumming and Maureen Buell, some of the typical steps toward reaching that goal in sex offender treatment include:22

  • Use Slide # SymbolUse Slide #12: Means of Reducing Recidivism Through Treatment
    [Click to Enlarge]
    Accepting responsibility and modifying cognitive distortions. Offenders are masters of deceit—even of themselves. The treatment process will confront thinking errors and attempt to correct them so that the offender will accept responsibility for his actions.

  • Developing victim empathy. Part of the denial and deceit that sex offenders employ is that the victim is somehow complicit in the activity, did not really mind, and—at least—was not really harmed. Being able to understand the fear and trauma experienced by the victim is an important goal of therapy.

  • Controlling sexual arousal. Treatment will focus on sexual arousal as a part of the offense cycle, along with methods of controlling or rechanneling arousal toward acceptable partners and activities.

  • Improving social competence. Difficult social situations may generate the type of anxiety that is a precursor to re-offending. Treatment will help offenders identify those situations and develop skills to address them.

  • Developing relapse prevention skills. Treatment will help offenders understand the sequence of events that leads to their offense behavior. Offenders will then be helped to interrupt that cycle or chain of events in order to prevent future victimization.

    Refer to Handout Symbol Refer to Handout: Section 4 discussion questions.

  • Establishing supervision conditions and networks. Working with probation or parole officers, treatment providers will help identify high-risk situations, behaviors, and locations to help the officers customize supervision conditions that will assist in managing risk. They may also identify other individuals in the community who might become part of a supervision network.

  • Clarification. Many treatment providers have as a goal that their offender clients will complete a process of clarification regarding their sexual offending. The purpose of the clarification process is to have offenders express full responsibility for their offense to victims in order to relieve victims of any responsibility for the sexual abuse and to clarify what occurred in language victims can understand. Victims may or may not play a role in this process, through their choice. Clarification involving victims is permitted only after offenders and victims have adequately completed the majority of their respective treatment programs. It is often done through a letter. However, such a letter is never presented to a victim without the approval of the therapist and probation/parole officer, the approval of the victim's treatment provider, and custodial parent or guardian.23 Ideally, clarification should always occur before any victim recontact or reunification.
Learning ActivityLEARNING ACTIVITY: DISCUSSION QUESTIONS
(10-15 minutes)

One suggested approach to supervision includes close collaboration between treatment and supervision. Refer to your discussion questions:

  1. Please consider the goals of treatment listed above. To what extent do those goals match the goals you may have for an offender under supervision? What are the ways in which these goals—if achieved—might be of benefit to the offender's supervision?

  2. Are there any goals in this list that create a conflict or tension between supervision and treatment?

New Topic IconMETHODS OF TREATMENT

Use Slide # SymbolUse Slide #13: Methods of Treatment
[Click to Enlarge]
Research and current practice point strongly to the need for sex offender-specific treatment to emphasize cognitive-behavioral and relapse prevention modalities, along with whatever adjunctive treatments are included. A comprehensive treatment approach for sex offenders addresses a variety of issues that reflect the variety of causes or sources (or etiology) of sex offending. Denial is often confronted prior to the formal start of treatment with the use of a deniers' group or the polygraph to confront the offender with objective facts. Although some treatment programs are hesitant to accept sex offenders who are in denial, most will accept these offenders on the condition that they work through their denial either in individual therapy before joining a group or within a set timeframe after beginning treatment. Specialized treatment can take the form of psychoeducational groups, cognitive-behavioral groups, administration of medication for deviant arousal reduction or mental health, individual therapy, and such psychological and physiological testing as the polygraph. Therapists may also refer offenders for other specialized treatment if necessary for issues like substance abuse. Some forms of educational groups are recommended for the family and extended supervision network as well.

The overall goal of treatment is to reduce recidivism. Each factor named above that contributes to recidivism requires various techniques to address them.

To modify cognitive distortions and cause an offender to accept responsibility, treatment might include—

  • Use Slide # SymbolUse Slide #14: Components of Treatment
    [Click to Enlarge]
    Education about denial;
  • Support for incremental steps toward accountability;
  • Making the acceptance of some responsibility a prerequisite for admission into treatment, and full acceptance a prerequisite for successful completion;
  • Confronting denial and other cognitive distortions by challenging discrepancies between different versions of the events, educating the offender about the relationship of cognitive distortions to sex offense behavior, and modeling accountability.

To develop victim empathy, treatment might include—

  • Use Slide # SymbolUse Slide #15: Components of Treatment
    [Click to Enlarge]
    Psychoeducation on the effects of abuse on victims;
  • Opportunities for an offender to develop an emotional understanding of the impact of sexual abuse, such as role playing or writing exercises;
  • Teaching empathy skills, such as recognizing emotional distress and communicating empathy;
  • In some instances, an offender may meet with his victim(s) face to face.

To control sexual arousal, treatment might include—

  • Use Slide # SymbolUse Slide #16: Components of Treatment
    [Click to Enlarge]
    Education about deviant sexual fantasy and its relationship to sexual behavior;
  • Cognitive-behavioral interventions that help offenders:
    1. Develop, maintain, or increase appropriate sexual arousal patterns;
    2. Interrupt deviant sexual fantasies and urges;
    3. Help reduce deviant sexual fantasies and urges. Some techniques include aversion therapy (association of inappropriate sexual stimuli with a foul odor or other unpleasant sensation), orgasmic reconditioning (the gradual substitution of appropriate stimuli for inappropriate stimuli during masturbation), covert sensitization (the reinforcement of the relationship between inappropriate behavior and ensuing negative consequences), and satiation (compulsory repetition of a paraphilic fantasy to the point of boredom);
  • Providing methods for practicing arousal control in everyday situations;
  • Psychopharmacological interventions to manage sexual arousal. Drugs can be helpful for a percentage of sex offenders in the context of a comprehensive treatment program, particularly where deviant sexual arousal is particularly intense, frequent, or lengthy. The two primary categories of medication are:
    1. Anti-androgens such as medroxyprogesterone acetate (Depo-Provera); and
    2. Mood stabilizers such as fluoxetine (Prozac).

Treatment to improve social competence can include—

  • Use Slide # SymbolUse Slide #17: Components of Treatment
    [Click to Enlarge]
    Using the group setting to model, practice, and rehearse appropriate and effective social interactions. Social deficits that can afffect sexual offending behavior include, but are not limited to: anger management, assertiveness, conflict resolution, leisure time skills, problem solving, stress management, conversational skills, parenting, and substance use;
  • Referral to specialized treatment, such as marriage and family therapy, substance abuse treatment, or anger management; and
  • Involvement of significant others in treatment, if appropriate.

To develop relapse prevention skills, which extend the effects of treatment over time, treatment may include—

  • Use Slide # SymbolUse Slide #18: Components of Treatment
    [Click to Enlarge]
    Education about relapse prevention as a model for identifying and interrupting the offense cycle;

  • Requiring offenders to analyze the behavior, emotions, thoughts, and settings that lead to their sex offense behavior, and assisting them to develop strategies to interrupt their cycles (offenders learn to recognize the "seemingly unimportant decisions" that can lead them into high risk situations);

  • Refer to Handout Symbol Refer to handout: It might be useful here to refer to the handout on relapse prevention from Section 3 to indicate the points at which these strategies are used.
    Teaching strategies to avoid lapses, which might include stimulus control (making changes to the immediate environment to avoid contact with the stimuli that can provoke lapses), avoidance strategies (similar to stimulus control—avoiding altogether circumstances that may provoke lapses), programmed coping responses (using a strategy that has been selected, evaluated, and practiced in advance), and escape strategies;

  • Teaching strategies to minimize the extent of lapses, and to prevent lapses from becoming relapses. These might include cognitive restructuring (learning to think of lapses as opportunities for the offender to practice new skills and learn more about his relapse process), reminder cards (an aid to cognitive restructuring which summarizes the points the offender should remember), and therapeutic contracts (signed by the offender and which define the extent to which a "lapse" is allowed to go forward safely).

To establish supervision conditions and networks, the treatment provider works in close collaboration with the supervising agency. This is essentially the "external supervisory dimension" of relapse prevention.

  • Use Slide # SymbolUse Slide #19: Components of Treatment (cont,)
    [Click to Enlarge]
    The supervising agency is responsible for setting the conditions, but the treatment provider can advise about conditions that are consistent with and appropriate to the individual offender's offense cycle.

  • The treatment provider can assist with assessing when modifications of supervision are safe and appropriate;

  • The treatment provider can help work with the members of the supervision network to educate them about sexual offending and helpful interventions, and encourage their participation in other forms of treatment if appropriate (such as family counseling).

To assist with clarification, the offender is instructed to write a letter in which the offender verbalizes to the victim(s) full responsibility for the offense and for making the victim endure the abuse. It is not a request for understanding or forgiveness and the process does not require victim participation in the form of receiving the letter or meeting with the offender, although it can take that form when appropriate. The letter is often rewritten many times with input from the therapist and group members. Elements can include—

  • Use Slide # SymbolUse Slide #20: Components of Treatment (cont,)
    [Click to Enlarge]
    Acknowledgement of deliberate grooming processes and setups;
  • Details of the offense;
  • Support for the victim's decision to report the offense; and
  • Acknowledgment of ongoing need to manage the deviancy and the steps he is taking to do that.24

If appropriate, clarification can lead to a process of recontact or reunification in which the therapist should also play an active part.

New Topic IconEVALUATING PROGRESS IN TREATMENT

Much of an offender's progress in treatment is measured by observing and testing knowledge, behavior, and skills. Some issues rely on self-reporting, some on the corroboration of others in the supervision network. There are also physiological tests available to measure offenders' progress. Although use of the polygraph has been on the increase in recent years, it is by no means a universally used tool. The plethysmograph is even less widely used, but is considered by many to be an extremely helpful tool in treatment, particularly in assessing deviant sexual arousal.

The Polygraph

Many jurisdictions have found the postconviction polygraph to be a particularly useful tool to help monitor treatment progress and to evaluate the nature and severity of treatment-related problems and issues. Information that is obtained from polygraph examinations is used to inform and update the treatment plan and as a supervision tool. Many treatment providers feel that they are much more able to design a meaningful treatment plan and then make appropriate adjustments to it with the additional insights provided them by the use of the polygraph.

The Plethysmograph

Note: Participants may voice concern over the intrusiveness of the plethysmograph. Trainers should acknowledge that this aspect of the plethysmograph has given rise to controversy and may be one reason that it is not more widely used.
One method of evaluating an offender's progress in treatment and determining his level of dangerousness is the use of the penile plethysmograph. The plethysmograph is a physiological tool that measures an offender's arousal pattern or erectile response to certain stimuli. It is typically used in two ways: to measure the offender's sexually deviant interests and ascertain if he has any non-deviant sexual interests, which serves as an aid in developing a behavioral program to decrease the deviant arousal and increase the positive, if necessary; and as an evaluation tool to measure the success or failure of the behavioral interventions.

The penile plethysmograph is considered by some to be one of the more intrusive techniques used in the field of sex offender management. However, deviant sexual arousal is a significant contributing factor in sex offending (research indicates that deviant sexual arousal is positively correlated with re-offense25), and the self-report of offenders regarding their sexual arousal is not always reliable. The Association for the Treatment of Sexual Abusers (ATSA) has also developed guidelines for the use of the plethysmograph with sex offenders.26