Cognitive behavioral therapy and psychoanalytical therapy in sex offender treatment

Cognitive Behavioral Therapy vs Psychoanalytical Therapy in Sex Offender Treatment

The overall goal of sexual offender treatment programs is to reduce the likelihood that the offender will engage in future acts of sexually abusive behavior. Research has proven this goal an unenvious task because the variables leading to sexual abuse are not yet fully understood and there is often considerable resistance on the part of the offender to become engaged in the treatment process. Cognitive behavioral therapy has been the modality of choice for sex offender treatment, however recent studies indicate an increase in the acceptance of psychoanalytical therapy. This article will describe the benefits and limits of psychoanalytical and cognitive therapy while contrasting the use of these theories in treating sex offenders.

Background of Cognitive Behavioral Therapy & Sex Offender Treatment

Clinical interest in issues of denial and accountability in sexual offenders can be traced as far back as the 1960s and 1970s (Cowden & Morse, 1970). The origin of cognitive behavioral therapy dates back to the late 1970's, as the dominant approach to the treatment of sexual offenders (Marshall & Barbaree, 1990). The overall aim of cognitive behavioral treatment is to strengthen sex offenders with the self-management skills necessary to manage or avoid situations that increase their risk of recidivism.

To successfully accomplish this, offenders are trained to alter their views in a pro-social direction, attend to negative consequences of their actions both for themselves and others, establish a less distorted view of their deviant behavior, develop more acceptable responses to meet their needs, and learn strategies to control deviant sexual arousal (Marshall, & Barbaree, 1990). As with any remedial measure in individuals, the effectiveness of these approaches rests in part on the offender's cooperation and dedication to the treatment process.

Recent studies indicate that sex offenders often deny any involvement in the sexual offense, and may even continue to deny critical aspects of their offense after conviction (Denton, Konopasky, & Street, 1994). As a result, offenders are likely to show resistance to accepting treatment and quick to succumb to the denial of their sexual deviations (Brake & Shannon, 1997). Accountability and denial are interrelated and should be approached as treatment targets rather than treatment obstacles. These basic principles laid the foundations for the acknowledgment of the role of cognition in explaining sexual abuse (Finkelhor, 1984). Research on cognition supported the contention that offenders must overcome both internal and external inhibitions as well as the resistance of the victim in order for abuse to occur (Finkelhor, 1984).

Further research indicated that that the personality constructs commonly used to differentiate sexual offenders were less useful to clinicians than problem focused dimensions such as denial, sexual arousal, sexual fantasies, cognitive distortions, social sexual deficits, and other psychological and social problems (Conte, 1985). Other studies conceptualized cognitive distortions to consist of rationalizations developed by offenders prior to and during offending to justify their continued abuse of children (Murphy, 1990).

Sex Offender Treatment

Sex offender treatment attempts to change sexual arousal patterns through behavior conditioning techniques, but places little or no emphasis on emotional health. Most offenders undergoing this kind of treatment have been court-mandated for treatment, so the approach is primarily adversarial. Cognitive behavioral sex-offender treatment is usually provided by private, hospital, and university clinics that work in concert with the criminal justice system.

Their goal is to prevent sexual re-offending, rather than to change sexual attraction or to promote the development of mental health. Since the development of sexual attraction is not understood, sex offender treatment uses approaches that are chosen for their effectiveness at reducing illegal behavior, without necessarily understanding underlying causes.

Behavioral methods have as their goal the reduction or elimination of deviant arousal and the increase of non-deviant arousal. All behavioral methods are based on the idea of conditioning, or associating pleasant feelings with desired behavior, and associating unpleasant feelings with undesired behavior. Cognitive methods are based on findings that many sex offenders in general exhibit aggressive sexual behavior, manipulate others, lack empathy for their victims, and minimize, deny, and rationalize their abusive behavior. Cognitive methods assume that their sexual behavior is addictive and results from incorrect beliefs, anti-social attitudes, maladaptive thoughts, a lack of sexual knowledge, and impaired communication and social skills.

Social skills training may help offenders learn to develop peer relationships rather than turn to children as sexual partners. Social skills are also seen as crucial for the offender to successfully implement his newly acquired normal sexual arousal to adults. They are often taught through role-playing. Offenders learn how to interact with women and how to express feelings and thoughts while respecting the rights of others. Sex education includes information about sexual deviancy. I t is thought that sexual ignorance may increase anxiety toward normal adult sexuality.

Cognitive methods usually rely on the relapse prevention model to help offenders cope with situational variables that may lead to offending, such as negative emotional states, interpersonal conflicts, and tempting environmental factors. This model has been adapted from addiction recovery models, based on the assumption that the offender's sexual behavior is addictive and compulsive. Offenders are taught to think of their thoughts that may lead to offending as deviant, temporary, controllable, and stoppable, and to develop the ability to recognize and intercept them. They are taught to recognize and avoid situations that may increase temptation, and to turn away from decisions which may lead to increased exposure to such situations.

Psychoanalytical Therapy in Sex Offender Treatment Programs

Psychotherapy differs from cognitive behavioral therapy in that it is intended not to decrease or change sexual arousal, but to help the patient understand and control his behavior.

In individual psychotherapy, the therapist should maintain a helping role modeled on the parent-child relationship by showing respect, interest, and understanding. The therapist encourages openness and honesty on the part of the patient. This parent-like role gives the therapist the power to influence the patient positively, and to interpret his self-defeating behavior and distorted beliefs about reality. The patient must be able and willing to profit from it. Since offenders are assumed to suffer from denial, lack of motivation to change, and unwillingness to cooperate with voluntary treatment, individual psychotherapy is generally thought to be ineffective. Suspicion and lack of rapport in the criminal justice context also interfere with effective use of the method. There are few reports on individual psychotherapy with sex offenders against children.

Group psychotherapy gives members the opportunity to share experiences, gain insight, learn to control unacceptable impulses, and find acceptance. Although used more commonly than individual psychotherapy, the effectiveness is unknown. There have been no replicable, controlled studies. One review found that studies were based on contradictory premises, could not be replicated due to vague descriptions, were not based on any theoretical understanding of adult-minor sexual behavior, did not include sufficient follow-up, and included vague assessments of effectiveness. There is as yet no evidence that sexual attraction of any sort can be altered.

An Analyzation of Both Approaches

Some studies suggest that sex offender treatment use multiple methods since offenders tend to have many problems (Langevin, 1983). No controlled studies have been conducted, and.

A blanket use of the same method on all offenders is ineffective because offenders differ according to their reasons for offending. Therefore, improved assessment is necessary.

The major goal of treatment for sex offenders is the prevention of sexual offenses in the future. However, there has been little evidence that treatment reduces recidivism. The type of treatment most likely to succeed is an individually tailored approach that includes careful assessment and uses many different cognitive-behavioral techniques to support individual behavior change. Unfortunately, there is little evidence for the effectiveness of many commonly used treatment approaches.

The most common approach to psychoanalytical therapy is group therapy that relies heavily upon punitive and hostile confrontation and a nonsystematic blend of psychoanalytic concepts and traditional talking therapy. There is often little or no effort to provide a theoretical base for the program. The result is a procedure that is essentially highly moralistic and reflects the judgmental emotional response of the society. Treating people with disordered behavior patterns as morally defective and requiring a change in moral commitments has a long history (Siegler & Osmond, 1974). Psychotherapy is a venture much studied and researched and there is an extensive literature on psychotherapy processes and outcomes (Siegler & Osmond, 1974).

VI. The Effectiveness of Therapeutic Treatment

The effectiveness of therapeutic treatment is often measured by its contribution to restoration of emotional health and normal functioning along with the subjective sense of well being of the individual. Normal behavior may be defined either by reference to the applicable social norms or by statistical frequency. Subjective well being or conformity to generally accepted norms in other areas is not sufficient to measure treatment outcomes. Some research has pointed out the negative effect of the therapy process. When a person is sentenced to sex offender treatment as part of a plea bargain or sentencing, the therapy itself may become punishment (Langevin, 1983). The person is ordered to attend treatment with an indeterminate sentence and usually cannot select the therapist or the program; therapy programs must be approved by the agencies in control (Langevin, 1983).

The therapist who provides such court-ordered treatment for sexual offenders must make regular reports to parole officers, judges, and child protection workers. The therapist is given the power to judge when the treatment has been successfully completed and discharge is granted.

If an admission of guilt is required before being admitted into a program, additional complications and potential hindrances to successful treatment are generated. There are no empirical data to demonstrate that a threshold admission of guilt has any relationship to outcomes.

The most important goal of treatment for sex offenders is that they refrain from committing sex offenses in the future. This goal is more important than emotional health or adjustment, self-esteem, feelings of well being, self-actualization, reported satisfaction with therapy, or improvement as measured by psychological tests. A review of the literature concludes that there are no studies wherein the empirical data provides strong evidence in favor of the positive effects of treatment (Finkelhor, 1983). These studies found little consensus about the continuance of sexual offenses following treatment and conclude that there is no evidence that clinical treatment effectively reduces recidivism (Finkelhor, 1983). Also, there are no data at present for assessing the relative effectiveness of treatment for different types of offenders.

Groups are seen as necessary and appropriate for all sexual offenders, regardless of their individual personalities and the factors underlying their abusive behavior.

The expression of feelings is absolutely required. Cognitive, learning theory-based approaches therefore may be seen as a way of allowing the accused to avoid dealing with feelings of remorse, guilt, or shame which are considered to be essential parts of treatment. Common treatment goals include bringing the perpetrator to the point where he admits all of his abusive behaviors, expresses guilt and remorse for them, and is willing to admit and apologize to the victim.

Conclusion & Final Analysis

The therapy modalities that have been used in treating sex offenders include cognitive behavior therapy and psychoanalytical therapy. The research clearly indicates that use of cognitive behavioral therapy is the superior methodology. Research has indicated that sexual preference is a powerful and persistent feature of human behavior and there is no evidence that therapy in any form can change it (Langevin, 1983). Since a key factor in the success in any treatment of sex offenders is motivating them to change, most offenders are resistant to giving up a sexual behavior pattern that they perceive as positive and rewarding.

Although there are little outcome data on treatment for sexual offenders, the approach that is most supported by what data are available is cognitive behavioral (Langevin, 1983). A large number of specific techniques and methods are included in the therapy possibilities that learning theory and a cognitive-behavioral strategy generate (Langevin, 1983). Cognitive behavioral techniques such as aversive conditioning, cognitive restructuring, covert sensitization, satiation, role playing, social skills training, and relaxation training are used in relapse prevention. Offenders learn to identify and anticipate high-risk situations, control their urges, develop more effective coping skills, maintain a more balanced lifestyle and gain a sense of control and self-efficacy. Through this process, it is hoped that they will be less apt to relapse and recommit a sexual offense. The relapse prevention model appears to be a promising treatment approach, although more data are needed in order to generalize the results of this outcome study.