MODELS OF TREATMENT FOR OFFENDERS
WHO ABUSE CHILDREN
prevention model from an addictions perspective,
as well as formulating social learning theories ofsexual offending behavior. Further, a wide variety
of programs described targets such as sexual preferences, sex education, victim empathy, social skills,
self-esteem, substance abuse, anger management
and relapse prevention .

OVERVIEWTreatment for sexual offenders has changed drastically over the past half-century (Laws andMarshall, 2003) . Even though earlier non-behavioral treatment approaches were important inestablishing that child sex offenders could beengaged in treatment, John B . Watson and Alfred
Kinsey were prominent in the development of
behavioral treatment approaches in the early to
mid-20th century . Kurt Freund developed penile
plethysmography (PPG) in 1957 in response to thesexual preference hypothesis . Despite many criticisms of the PPG, it remains popular and continues
to be widely used.

Contemporary sex offender treatment programs(both in the U .S . and internationally) employ a multidimensional approach that includes cognitivebehavioral techniques, relapse prevention strategiesand psychopharmacology to treat child sex offenders . Although there is no "cure" for individuals
who sexually molest children, the above treatment
approaches appear to be successful with regard toreducing recidivism rates (Barbaree & Marshall,
1991 ; Eccles & Walker, 1998 ; Fisher & Beech,
1999 ; Wood et al ., 2000; Aytes et al ., 2001) .

The earliest behavioral approaches to treatment
reflected the view that deviant sexual behavior wasa distorted manifestation for pedophilia and otherparaphilias . Exhibitionists and child molesters weretreated with electrical aversion ; the modification ofsexual fantasies was the target of efforts applied tosadists and voyeurs . However, limited information
existed about the long-term effects on overt behavior of these techniques .

COGNITIVE-BEHAVIORAL TREATMENT
AND RELAPSE PREVENTION
Cognitive-behavioral treatment has emerged as theprincipal type of treatment used to modify deviant
sexual arousal, increase appropriate sexual desires,
modify cognitive distortions and improve interpersonal coping skills . As a comprehensive structured
treatment approach, cognitive-behavioral treatment
integrates cognitive restructuring methods andbehavioral techniques . According to Nicholaichuk
and Yates (2002), this treatment approach is basedon the premise that "cognitive and affective
processes and behavior are linked, and that,cognitions, affect, and behavior are mutually influential ." Therefore, treatment typically includes targeting the following : (1) deviant sexual behavior andinterests, (2) a wide range of social skills/relationaldeficits and (3) cognitive distortions, which permit
the offender to justify, rationalize and/or minimize
the offending behavior (Marshall & Barbaree,1990 ; McGrath et al ., 1998) .

A combination of behavioral and cognitive behavioral treatments began to emerge in the late 1960s .
This decade is also noted for the further development of phallometric evaluations in assessment andthe associated focus on modifying sexual preferences, introduction of cognitive processes and thefirst description of more comprehensive treatment
programs . In the early 1970s, cognitive psychology
began to penetrate the field of treating child sex
offenders - social skills training, assertiveness, sexual dysfunctions and gender role behavior . The first
conference, at which sexual offender issues werediscussed from a behavioral or cognitive behavioral
perspective, was in 1975-this subsequently became
known as the Association for the Treatment ofSexual Abuse (ATSA) . The most significant innovation of the 1980s was the adaptation of the relapse

185lotion, empathy and intimacy, anger management,
self-confidence and the use of intoxicants are targeted (Laws & Marshall, 2003) . Educational modules, which include role-playing of specific types ofsocial interactions, behavioral assignments and presentations on various aspects of social skills are thetechniques utilized to address these social difficulties .

DEVIANT SEXUAL BEHAVIOR AND INTERESTS

Combinations of behavioral approaches are frequently used in an attempt to address deviant sexual behavior/interests . These approaches include
covert sensitization, aversion therapy and masturbatory satiation . The objective of these approaches
is to reduce deviant sexual behavior/fantasy while
maintaining and/or increasing sexual arousal toappropriate stimuli (Abel et al, 1992 ; Becker, 1994 ;Marshall, & Barbaree, 1990 ; Quinsey & Earls,
1990 ; McGrath et al ., 1998) .

The inclusion of empathy-enhancement in treatment is based on the belief that the attitudes of sexual offenders toward their victims will change ifthey understand how the victim feels . The subsequent development of empathy will inhibit future
sexual abuse since empathy is something that people learn, rather than an instinct. This is achieved intreatment through utilization of audiovisual methods and materials to demonstrate the pain associated with victimization . These methods include
writing assignments, wherein the offender describes
his sexual assault from the victim's view point, andthe use of role-play wherein the offender plays therole of himself confronted by a peer as well as therole of his victim, respectively (Mulloy & Marshall,1999) .

Covert sensitization involves the pairing of a nega-tive consequence (aversive event) with the sexual
arousal stimulus . An example of this techniquewould consist of having the offender imagine aparaphilic event in order to elicit arousal, and atthat point, imagine the humiliation of getting
arrested for the event while at work or at homewith his family.
Aversion therapy is similar to covert sensitization ;however, the sexual arousal stimulus is paired withan aversive event (i .e ., mild electric shock, sniffing anoxious odor such as ammonia, sniffing rotting
meat or tissue or boredom/fatigue) . The goal ofboth of these approaches is to teach the offender toassociate negative consequences/events with sexually deviant arousal/thoughts .

COGNITIVE DISTORTIONS

Cognitive restructuring is an integral part of cognitive-behavioral treatment . As mentioned previously,child sex offenders construct internal rationalizations, excuses and cognitive distortions in order tomaintain their sexually deviant behavior. Therefore,
it is paramount that an offender's cognitive distortions are challenged so that he can comprehend his
faulty thinking and recognize its distorted, self-serving nature (Marshall & Barbaree, 1990) .
Additionally, the clinician will present more sociallyappropriate and adaptive views, and the benefits ofaccepting such views are identified . This is achievedby examining the role of rationalizations, excusesand cognitive distortions from a non-sexualapproach in the lives of average people, thereby
normalizing the process while showing its hazards .
Role-play is also utilized in which the therapist
plays the role of the offender, elaborating on thecognitive distortions elicited throughout the offense
process, while the offender plays various roles,
including that of a victim's parent and/or an oldfriend, who supports his taking responsibility forhis behavior and admitting his distortions .

requires the offender tomasturbate to ejaculation while verbalizing anappropriate sexual fantasy . The offender then continues to masturbate for 50-120 minutes while verbalizing deviant sexual fantasies . Since masturbationis unlikely to result in orgasm during the given time
period, it is hoped that the offender will learn toassociate deviant fantasy with unsatisfactory sexualactivity. Furthermore, sexual gratification becomes
associated with appropriate sexual behavior.
Masturbatory satiation

SOCIAL SKILLS/RELATIONAL DEFICITS ,Cognitive-behavioral treatment seeks to enhancethe offender's interpersonal functioning, which
includes enhancing relationship skills, appropriatesocial interaction and empathy (Marshall, 1989 ;McFall, 1990 ; Seidman et al ., 1994; Marshall et al .,1999) . Social problem solving, conversational skills,
managing social anxiety, assertiveness, conflict reso-1 86

THE RELAPSE PROCESSThe classical relapse prevention treatment approach
was initially developed in response to the clinicaldifficulties associated with the treatment of addictive behaviors, such as alcoholism and drug
dependency . This approach was subsequently
altered for use in the treatment of sex offenders(Eccles & Marshall, 1999 ; Laws, 1999 ; Laws et al .,2000) . In the classical model of relapse prevention,a lapse, which is perceived as a momentary indulgence but not a relapse, involved an actual reindulgence in the problem behavior (i.e ., drinking) .
However, in the sex offender model of relapse prevention, a lapse is defined as "offense precursor
activities such as deviant fantasies, purchasing
pornography or cruising for potential victims," andperceived as a relapse (Laws et al ., 2000) .
Therefore, in the treatment of sex offenders, therelapse prevention approach pays considerableattention to behaviors that might lead to sex
offending as opposed to the actual reindulgence inthe aberrant behavior. Relapses are regarded as theculmination of a series of events and situations
through which the offender proceeds prior tooffending (Eccles & Marshall, 1999) .

referred to as the "Abstinence Violation Effect"(AVE), determine whether a lapse becomes arelapse . A major aspect of the AVE is a conflict
between the offender's definition of himself as an
abstainer and his recent indulgence in a behavior
that is part of his relapse process (e .g ., self-deprecation, the expectation to fail, his need for immediategratification) . At this stage, if the offender does not
use treatment effectively to cope with his beliefs
and/or urges, and to regain his confidence in selfmanagement, a relapse is inevitable (Pithers et al .,1983 ; Pithers et al ., 1983; Pithers, 1990 ; Eccles &Marshall, 1999 ; Marques et al ., 2000 ; Launay,
2001) . Ward and Hudson's (2000) self-regulation
model expanded the original relapse prevention
process to incorporate more comprehensive cognitive, affective and behavioral factors . Further,
within Ward and Hudson's model, post offense factors are considered .
The self-regulation model of relapse prevention
contains nine phases (life event, desire for deviant
sex or activity, offense-related goals established,strategy selected, high-risk situation entered, lapse,
sexual offense, post offense evaluation and attitude
toward future offending) and four pathways(avoidant-passive, avoidant-active, approach-automatic and approach-explicit) . According to Wardand Hudson, an important aspect of this model isthat the offender can "exit the relapse process at
any time by implementing appropriate coping
strategies . . . move back and forth between different points in the offense chain . . . [and] remain at
specific phases for a relatively long time before
moving on to the next phase ."The relapse process (sometimes called a cycle or achain) is based on the offender's capacity to copewith high-risk situations . These situations aredefined as a set of circumstances that threaten theoffender's sense of self-control . In treatment, therelapse process begins with the offender declaring
his intent to abstain from the deviant behavior . Selfmanagement skills and the anticipation of adaptive
coping mechanisms are reinforced . As the offender
encounters high-risk situations, his self-management skills and coping mechanisms are challenged .
Should the offender successfully cope with this situation, his sense of self-management survives andabstinence remains intact . Conversely, should theoffender fail to successfully cope with the situation,
his sense of self-management decreases, and a tendency to passively yield to the temptation of thenext high-risk situation ensues . Each time theoffender fails to cope with a high-risk situation, hewill engage in one of the behaviors involved in hisrelapse process (i .e ., deviant fantasy, the purchaseof pornography) . However, at this stage, thesebehaviors are considered lapses as opposed to arelapse. Several factors, subsumed by a concept

In 2002, Bickley and Beech evaluated the ability ofthe self-regulation model to classify sexual offenders. The sample consisted of 87 child abusers whoranged in age from 21 to 75 . The majority of theparticipants (62%) had offended outside the family,
15% had offended inside the family, and 23% hadoffended both inside and outside the family . Of theparticipants, 36% had offended against boys, 33%
against girls, and 31% had offended against bothsexes . Fifty-three percent of the sample had a previous conviction for a sexual offense . The participants were classified as belonging to one of the four
pathway groups identified by Ward and Hudson's
self-regulation model of sexual offense process .

1 87priate sexual desires, modifying distorted thinking
and improving interpersonal coping skills (Marshall& Barbaree, 1990 ; Marshall & Eccles, 1999 ;Marshall & Pithers, 1994 ; Becker, 1994; Hall,
1995 ; Abracen & Looman, 2001 ; Burdon et al .,2002; Nicholaichuk et al ., 2002 ; Craig, 2003) .
Further, Marshall and Anderson (2000) found thatcognitive-behavioral treatment programs that havean internal self-management relapse prevention
component appear to be the most successful in
reducing recidivism rates .

Results indicated that the profile of the "fixated"child molester is consistent with the self-regulation
model's description of an approach pathway. In
contrast, the "regressed" offender is consistent withWard and Hudson's description of an avoidantpathway. Bickley and Beech concluded that the selfregulation model could be reliably employed in theclassification of child molesters, with inter-rater
agreement found in more than 80% of the sample .
Furthermore, differences across the two group distinctions (i.e., avoidant vs. approach, active vs . passive) in both the psychometric and offense demographic data provided objective support for thevalidity of the framework .

Studies of the effects of treatment completion onrecidivism have also supported the effectiveness oftreatment (Hall, 1995 ; Hanson & Bussiere ;Hanson, 2002) . A retrospective study, conducted by
McGrath et al . (2003), found that the reduction in
the sexual recidivism rate among those offenders
who participated in treatment was statistically, aswell as clinically, significant . Treatment completers
were almost six times less likely to be charged witha new sexual offense than were offenders whorefused, dropped out or were terminated fromtreatment.

TREATMENT EFFICACY STUDIESMost studies conducted on treatment efficacy focus
on the rate of recidivism among offenders . In studying recidivism rates, researchers compare sexoffenders who have participated in treatment tothose who have not. Further, they consider specificvariables such as the type of treatment implemented
and whether or not an offender completed thetreatment process .

PHARMACOLOGICAL INTERVENTIONS

In a follow-up study conducted on 89 sex offenders
in Ontario, Looman et al . (2000) found that thoseoffenders who participated in treatment had a sexual recidivism rate of 23 .6%, whereas the thoseoffenders who did not participate in treatment hada sexual recidivism rate of 51 .7% . Similarly, when
296 treated and 283 untreated offenders were followed for a six-year period, Nicholaichuk et al .
(2002) found that convictions for new sexual
offenses among treated sex offenders were 14 .5%
versus 33 .2% for untreated offenders . Further, during the follow-up period, 48% of treated offenders
remained out of prison as compared to 28 .3% ofuntreated offenders . Time series comparisons oftreated offenders and comparison samples also
showed that treated offenders reoffended at significantly lower rates after ten years .

Physiologically, the androgen (hormone) testosterone is the major activator element of sexualdesire, fantasies and behavior, and basically controls the frequency, duration and magnitude of
spontaneous erections . Given this, medications used
to treat deviant sexual behavior are aimed at thereduction of testosterone and/or totally suppressing
testosterone action at the levels of the receptor(Rosier & Witztum, 2000) . These medications
include antiandrogens such as Cyproterone Acetate(CPA), Medroxyprogesterone (MPA or DepoProvera) and Long-Acting Analogues ofGonadotropin-Releasing
Hormone(GnRH)(Berlin, 1983 ; Bradford, 1990 ; Grubin, 2000 ;Rosier & Witztum, 2000) .
Further, given the compulsive nature of pedophilic
behavior, benefits with regard to the containment ofsuch behavior have been seen through treatment
with selective serotonin reuptake inhibitors (SSRIs)
such as Sertraline, Fluoxetine, Fluvoxamine,
Desipramine and Clomipramine .

In reviewing studies pertaining to the efficacy of aparticular type of treatment, there is significant evidence that cognitive-behavioral treatment has
emerged as the principle type of sex offender treatment targeting deviant arousal, increasing appro-1 88

Even though there are a number of studies on the efficacy of the above medications with regard to thetreatment of sexually deviant behavior, most studies
conclude that a combination of medical and psychological treatment has proven to be the most beneficial .

SEX OFFENDER TREATMENT
FOR PREISTSIn 1993, Loftus and Camargo published a study
evaluating their Southdown Treatment Center forclergy offenders . They found that the majority ofthe patients were diocesan priests ; between the agesof 49 and 60 when they were first referred for treatment; ministered in parishes and educational settings ; had no criminal or psychiatric history ; andhad no history of substance abuse . The offense data
illustrates that the abuse occurred frequently (fouror more times) and the ages of the victims varied . In
evaluating their treatment, the authors urge thatclerics should be treated no differently from othersex offenders . There has been some evidence infavor of the utilization of non-verbal psychotherapies because the patients provided evidence that
there appears to be a sense of alienation from thebody. Recidivism is discussed with caution since
only 40 out of the 111 men in the sample areaccounted for in the study . With that issue taken

into account, there appears to be a recidivism rateof 10% .
The 1996 article by Warberg, Abel, and Osborn
explored the uses of cognitive behavioral therapy
with clergy through analyzation of case studies .
Through various measures, therapists are able toteach clergy that the behavior is anything but
impulsive and can be interrupted early in theprocess . Failure to appreciate the power differentiation between minister and parishioner, naivety
about sexual issues/minimal training in transference/counter transference, and desensitization of
the intimacy of the minister/laity relationship all
combine to affect victim empathy . Paraphilias mustalso be evaluated when assessing treatment needs inorder to render a comprehensive plan . The authors
assert that 20% of professional sexual misconduct
cases were found to have a history of prior paraphilias . It is stressed that interpersonal and emotional factors (anxiety, stress, depression, deficits insocial/assertive skills, alcohol/drug abuse, personality
disorders/intrapsychic conflicts) play a role in thedevelopment of professional sexual misconduct . In
order to ensure the safety of the minister and congregation, those who have engaged in sexual misconduct must be thoroughly evaluated and placed
under constant surveillance by staff members .

1 89