It’s been a long life and especially long 2 weeks since I broke rwo bones in my right foot and was separated from my computer!  So, from a new setting I bring you last week’s overdue chapter, Treatment for Incest Offenders, from my book  FALLOUT,  a Survivor talks to Incest Offenders.

TREATMENT
To be considered for release from Wisconsin’s Sand Ridge Secure
Treatment Center, a civil commitment facility, inmate “patients”
must demonstrate that they have sustained change in their thoughts,
attitudes, emotions, behaviors, and their management of arousal
(Harkins, Beech and Thornton 2013, 7). This chapter describes
some treatment approaches towards that goal, but please note that
it is not all-inclusive…

The field of sex offender treatment is still young, and was in its
infancy in 1986, when our program began. As staff we diligently
read master pockets and took lengthy histories, searching for etiological clues that might suggest the best treatment approaches. We
turned to the research, the professional literature and professional
organizations, even became clinical members of the Association
for the Treatment of Sexual Abusers. We attended annual conferences. We ordered books, had a victims’ group visit the program,
attended training workshops, watched Oprah and Geraldo, and developed a mnemonic device to aid overlearning the effects of child
sexual abuse. We came to realize that we could not think in terms
of a cure for sex offending, only of decreasing the likelihood that
the men would reoffend.

The sex offenders seemed most open to rehabilitation when they
first entered the prison system. We admitted them to treatment immediately if they took responsibility for their offense.
After several years in the program, however, most received lengthy
“flops” from the parole board. Working with an incest offender
who receives a five-year flop after four or five years in the program
is discouraging for the offender, the treatment staff, and other
group members.

By the time I could retire, treatment at our prison had pretty much
ground to a halt. There was pressure not to admit men into treatment until they had served a significant amount of time. Unfortunately, by that time the offenders had usually acclimated to prison
mentality and were not good prospects for treatment.
It is fortunate that there is a new movement afoot in the treatment
of child molesters. As recently as 1972 one could find procedures
in the literature for “aversive therapy,” based on the 1966 work of
Azrin and Holtz, whose guidelines based on animal experiments
included such recommendations as no unauthorized escape is possible; the punishing stimulus should be as high as possible; the frequency should be as high as possible, etc. Serber and Wolpe quote
the recommendations, writing that “the use of these guidelines in
clinical practice may be expected to enhance materially the use of
aversive therapy” (Serber and Wolpe 1972, 246).

Despite the seriousness of the topic I had to laugh when I read in
Azrin and Holz (1966):
‘”A frequent reason for attempting to eliminate punishment is that aversive stimuli in general, and punishment in particular, produce disruptive and undesirable
emotional states.” (439)
and
“The changes in the punished response per se appear to
be distinctly secondary in importance to the social
products of the use of punishment.” (443).
My copy editor said she didn’t think it was funny. Maybe I do have
a weird sense of humor, but the idea of serious researchers having
to conclude that people don’t like being shocked made me laugh.
Marshall and Barbaree (1988, 505) reported on their own study,
which utilized a mild electric shock at an intensity which was set
by the patient at “an unpleasant but tolerable” level. As early as
1990 Quinsey and Earls observed that electrical aversion had gone
out of fashion (285). By 2009 no programs reported using electrical
aversive conditioning to control sexual arousal in a Safer Society
survey (McGrath et al. 2010).

A less controversial—and less painful—form of behavioral therapy is covert sensitization, discussed by Fernandez, Shingler, and
Marshall (2006), utilizing the imagination. A deviant fantasy is
paired with negative consequences that are realistic to the offender—involving for example disgust, fear, being caught, beaten,
etc. Positive outcomes for avoiding offending may also be imagined.
For those in outpatient treatment, the use of smelling salts is one
way of countering deviant thoughts. When experiencing deviant
arousal, the patient “is to hold his bottle of smelling salts, with the
cap removed, and take a rapid and deep inhalation. This reduces
deviant thoughts and provides the opportunity to initiate more positive thoughts” (Marshall and Barbaree 1990b, 366).
While the treatment we engaged in during the eighties and nineties
was not overtly punitive, I realize that in some ways we de-humanized the men in our program. In the literature today slaves are rarely
called slaves, but “enslaved people.” A similar case has been made
for men who molest. Fernandez (2006, 191–92), for instance, states
that adopting positive language in therapy can help offenders identify their existing strengths and find adaptive ways to meet their
needs more appropriately. “One particularly valuable way to do
this is to refrain from describing clients as ‘sex offenders,’ ‘rapists,’ ‘child molesters,’ or whatever legal/forensic term is applicable. Distinguishing people from their behaviors has a long tradition
in behavioral research and treatment. … It is also important not to
allow clients to label themselves.” (But of course AA does.) With
the goal being to help the man who molests to identify with his core
self rather than with his destructive behavior, some programs even
correct him if he refers to himself as an offender rather than as a
man. It isn’t realistic to practice that convention in this book, where
there’s so much to say and only so many ways to say it, but I recognize the point (despite the book’s title—sorry).
Fernandez (ibid., 188) also speaks out strongly against aggressive
confrontation. “If there was one thing we could recommend to sexual offender therapists it would be to avoid an aggressive confrontational approach with clients. Therapists inevitably serve as mod-els to their clients, thus their actions should exemplify social behaviors and attitudes.” What better way to teach empathy than for
therapists to model it in treatment group? Instead, we prided ourselves in our skills at confrontation, despite S alter’s (1988, 92) caution about the need for empathy:
The critically important factor is the simultaneous capacity for the therapist to extend respect to people as
human beings, to empathize with their pain, and to believe in their capacity to do better in the future while
not colluding with sexual abuse a single inch.

Negativity and excessive confrontation have been observed to deprive the man who molests of hope that he can meet his needs more
appropriately. Fernandez (2006, 188) observes that “apparent treatment gains of clients exposed to confrontational challenging are
either superficial or do not generalize outside of the treatment context.”
In treatment a difficult task for the therapist is to help the offender
accept responsibility for his actions, to realize the destructiveness
of sexual abuse—especially incest—to become motivated never to
repeat the abuse, and to learn how to get his needs met in less destructive ways.

According to Anna Salter (1988, 178):
“The single most vital issue in sex offender treatment is
whether or not the offender can change his behavior.
An offender must begin to understand that behavioral
change is more than simply announcing, ‘I won’t do it
again.’ Behavior change involves a series of lifestyle
changes designed to minimize the risk of reoffending.
It involves learning techniques for intervening when
deviant impulses arise, and showing a willingness to
implement them.
While strengthening the role of choice in behavior and taking responsibility for it are important, so are other contributing factors,
all of which need to be addressed in treatment. Helping offenders
understand what thinking errors are and how they contribute to offending also needs to be non-threatening.
In this approach the offender is told:

“After awhile, the things you say to yourself become almost automatic and you may not even realize you are
saying them. Our job is to help you identify these
things and try to show you why many of them are not
true. We call these things you say to yourself excuses,
justifications, minimizations, and cognitive distortions.” (Murphy 1990, 337)
Murphy also recommends that treatment staff need to guard against
contaminating treatment by immediately attempting to change the
molester’s distortions (no matter how convoluted). Some molesters
deny “because of their elaborate network of distorted ideas, which
have been arrived at through biased processes” (ibid).

Determining the factors that have weakened the perpetrator’s inhibitions against molesting a child is an early but difficult task in
treatment, since it must be done without encouraging excuse-making. An initial and ongoing history is taken and expanded as additional documents are extracted from the inmate’s master file. To
what extent is he being truthful? How well does he remember?
Since a full and accurate report of his offense history is almost
never forthcoming, there is heavy reliance on an educational approach in treatment. Soon after initiation of our prison program it
became apparent that there was a need for education in a number
of areas, including assertiveness training, child development, why
men molest, thinking errors and, yes, even human sexuality. Another advantage of the educational modules was that members of
our IDDI group (the I-Didn’t-Do-Its) could be involved in most of
them.

Marlatt and Donovan (2005) reported that the major therapeutic
approach for treating individuals with Borderline Personality Disorder (usually survivors) might also be used with perpetrators,
along with Relapse Prevention. The approach is dialectical behavior therapy (DBT), developed by Marsha Linehan, who has since
“come out” in the New York Times as a survivor of Borderline Personality Disorder (Carey 2011, A1).
Addressed in DBT are four areas of relevance to both survivors and
perpetrators:
1. The “mindfulness” module addresses maladaptive thought
processes and teaches skills for improved self-monitoring and
regulation.
2. The “emotion regulation” module addresses mood lability and
affective dysregulation and teaches skills for effectively identifying and managing emotions.
3. The “distress tolerance” module addresses maladaptive coping behaviors and teaches skills for managing impulsive/harmful behaviors in the face of inevitable life stressors.
4. The “interpersonal effectiveness” module addresses interactions with others and teaches skills for more effectively getting needs/goals met without violating the rights/needs of others.
(Marlatt and Donovan 2005, 342)
I have come to realize that several approaches can be profitably
used for both perpetrators and survivors, including assertiveness
training, schema work, and even, as reported by Naitove (1988),
arts therapies.
A treatment approach relating to shame that targets adolescent sex
offenders struck me as also appropriate for use by victims’ therapists. See Chapter 18 for more on the issue of shame.

Most sex offender treatment occurs in a group setting. Effective
exercises may include role-playing (having the offender role-play
a policeman or other individual whose job it is to confront distortions; the therapist then role-plays a child molester who uses various distortions, and gets confronted by the molester). Many variations of this format are possible, as is a Gestalt approach in which
a perpetrator may speak alternately as a molester and the policeman. .
Having the perpetrator write an apology letter to his victim (but not
to mail it) is another useful exercise. These letters can then be
scanned in order to reveal the offender’s continued lack of empathy
for his victim (Webster 2002). Statements are also checked for evidence of the offender’s intellectualized reabuse/reabusive stance
(overt and/or covert use of language that reabuses the victim), minimization of responsibility, and the participant’s egocentric
stance/self as important (for example, “I feel better now I have
written to you.”) Webster provides extremely helpful scoring templates for rating the letters of both child molesters and rapists in his
article (Webster 2002, Appendices).

During a training presentation in 1989 Jan Hindman described her
Thinking Errors component, in which members of a treatment
group keep a Thinking Errors Journal. If any of them verbalizes a
thinking error and 6 seconds pass without other members confronting it, all members must own the thinking error and claim it in their journal.
Group work is also useful in exploring schemas, using the analogy
of what one sees depending upon what kind of sunglasses one
wears. “Making use of humor, clients explore different situations
as they would be seen through different pairs of schema-spectacles.
“The exercises aim to make learning as light-hearted and engaging
as possible” (Mann and Shingler 2006, 182).

TAKE THIS TEST
A responsibility scenario may be posed to the sex offenders:
Mary and her husband live on the south bank of a river.
Her husband wants her to stay at home and not cross
the river to the town. She wants to go to town. There is
a bridge across the river, but men have been robbing
and killing people who cross the bridge, and Mary’s
husband won’t give her money for the ferry. Mary begins saving the grocery money and crossing the river
to town on the ferry while her husband is away. Finally, she meets a man in town and takes him as a lover.
She crosses the river more frequently and he gives her
money to get back home. He gets mad at her one day
and refuses to give her the return fare home. She asks
the ferryman to let her charge the return trip but he refuses, saying it is against company policy. Finally, she
crosses the bridge and is killed.
The discussion question is, “Whose fault is it that Mary was
killed?” (Responses and answer are on the last page of this chapter.)

ACCEPTING RESPONSIBILITY
The purpose of encouraging the offender to take responsibility for
his behavior is to enable him to realize that in the future he can also
be responsible for making a different choice.
During treatment, sex offenders try to find their place within the
motivational framework in order to better understand their own offending dynamics. Despite lip service to accepting responsibility
for the offense, it usually takes a long time for the men to realize
and/or admit to having actually planned the molestation with forethought. There is a focus on “it just happened” —a thinking error—
an approach that allows them to feel less responsible for their actions. A period of fantasizing about and grooming the destined victim almost always precedes the abuse (Christiansen and Blake
1990).

MEDICAL TREATMENT
Harrison has authored a thorough introduction to treatment by
pharmacotherapy, which she defines as “the use of drugs to lower
testosterone and in consequence lower and in some cases eradicate
libido, fantasies and deviant behavior” (Harrison 2010, 136).
A combination of psychotherapy and medical treatment has inreduce sexual desire in the offender. “Some argue that the offending ‘organ’ is the brain, not the penis, and physical castration will
some cases resulted in zero recidivism, although there are side effects that need to be taken into consideration. Its main use is to
not prevent an individual from using some other means to rape or
molest” (Meyer and Cole 1997, 13).
However, one cannot overlook the fact that biology
does play a major role here. The endocrine system, in
this case the testes, does affect behavior, particularly
the quality and intensity of sexual arousal, whether
normal or deviant. … This subject is clearly controversial and even regarded as barbaric by some. However,
one could argue that society needs to carefully explore
a variety of means to help reduce the epidemic of sexual violence and prevent further victimization. (Ibid.)
Harrison (2010) observes that one of the most contentious issues
concerning the use of pharmacotherapy is whether it should be provided on a voluntary or mandatory basis (that is, whether it is treatment or punishment).

SEX EDUCATION
Although it may appear incongruous, sex offenders—who are often prudish—are usually in need of sex education. After exploring
what’s illegal, one leading program emphasizes the normative nature of a whole range of sexual activities:
Within this context we attempt to relieve guilt associated
with masturbation and reduce prudishness relating to various precoital acts and to various positions during coitus.
We attempt to counter myths concerning sexuality, such as
the relevance of the size of the male penis, the goal of simultaneous orgasm, and, indeed, the idea that orgasm is the
only goal of sexual interaction. (Marshall and Barbaree
1990a, 368.)
As Becker and Coleman (1988, 200) point out,
It is important that offenders have accurate information
regarding male and female anatomy, sexual response
cycles, and sexual behavior and attitudes. The
knowledge can reduce the offender’s feelings of sexual
inadequacy and result in a more satisfying sexual relationship with his [adult] partner.
In order to de-sensitize both offenders and staff to talking about
sex, one day we retired to a classroom with a large blackboard, shut
the door and wrote the vernacular words for everything sexual we
could think of. As someone pointed out, the windows were damp
with condensation by the time the session was over.
RELAPSE PREVENTION
Two significant pieces of writing were required in our treatment
program—an autobiography and a relapse prevention plan. The autobiography is written and re-written to include more data as suggested by treatment staff. Getting an overview of one’s life is therapeutic, and filling in the details as requested can be enlightening,
often revealing unrecognized patterns and schemas. The autobiography is assigned toward the beginning of treatment,
and the relapse prevention plan a little later. In writing a relapse
prevention plan, therapist and offender pull together information
which helps the recovering offender recognize and itemize risk factors, triggers, coping responses and sources of support. Relapse
prevention is hard work and needs to be continuing. William
Pithers, addressing an Ohio conference in 1988, likened relapse
prevention to walking up a down escalator. If one stops walking he
is carried back in the direction of re-offending. “Men ask me when
they will get a certificate of completion of treatment. I tell them
that their next of kin will get it—it will be their death certificate.
Treatment will be a life-long process of vigilance.”
Since most treatment programs operate within a relapse prevention/cognitive behavioral framework, most include the following
components, as listed by Murphy and Smith (1996, 185):
1. Confronting denial
2. Identifying risk factors
3. Decreasing cognitive distortions
4. Increasing victim empathy
5. Increasing social competency
6. Decreasing deviant arousal
7. Where appropriate, addressing offender’s personal victimization
Finkelhor (1984) has drawn together factors from a number of researchers in the field and has conceptualized The Four-Preconditions Model of Sexual Abuse, which can be utilized along with relapse prevention. The first precondition, which may often be overlooked, is that the potential offender must want to molest. Otherwise, there would be nothing for his inhibitions to struggle with. If
he wants to, then at that time he will need to struggle with his internal inhibitions. If they are sufficiently robust, that precondition
will not come into play and there will be no sexual assault. However, if he wants to and his inhibitions fail, then he must overcome
any impediments to committing a sex offense, such as getting the
intended victim alone. Finally, he must find a way to undermine or
overcome the child’s possible resistance to sexual abuse. So there
are four pre-conditions, the absence of any one of which will prevent the potential sex offense from occurring.
Of course it’s far easier to avoid a tempting situation than escape
from one. When you find you have not successfully avoided the
situation, you can always escape, but it will be more difficult than
avoiding. Even if you haven’t escaped and you find yourself about
to cross the final line, take emergency measures! As Pithers pointed
out in 1988, “Even when one senses a sneeze coming, one can still
turn away, cover one’s mouth, or leave the room.” You have
learned that you are in control of your life and responsible for your
actions.
If well crafted and taken to heart, the relapse prevention plan will
become an important document for the offender. Ideally, it is a personalized blueprint for not reoffending, to be kept and updated forever. The molester who is no longer in treatment, or who has never
had treatment, will have to delve into his own mind and heart and
“work on himself.” Perhaps he will seek whatever therapy is available in his community.

DEVIANT FANTASY TREATMENT
Sex offenders pleasure themselves by rewarding deviant fantasies
of sex with children by masturbating to orgasm. In order to establish the existence of a deviant arousal pattern, a penile plethysmograph which measures the tumescence of the penis in response to
the presentation of graphic slides, audio tapes or videos may be
utilized, Unfortunately, some sex offenders have been able to fake
the testing of their sexual preference (Quinsey and Earls 1990,
289).  In addition to the amount of arousal elicited, the procedure may be
helpful in revealing the preferred sex and age range of the child, as
well as the degree of force fantasized. This procedure would be part
of the early assessment of the offender.

For treatment of a man’s deviant arousal pattern, there are three
behavioral options. In addition to instructing the offender to abruptly stop his deviant fantasies once he becomes aware of them, he can also be encouraged to have the deviant fantasy while he
masturbates, up until the “point of no return,” and at that moment
to switch to a previously constructed fantasy of consenting sex with
another adult (which has been authored by the therapist and the
molester together.) That accomplished, the offender is instructed to
gradually move the timing of the switch earlier and earlier in the
scenario, until hopefully the deviant fantasy is totally replaced by
the vision of a successful, loving and consenting sexual encounter
with another adult.

A second approach is the use of “boredom tapes,” involving satiation, an extinction procedure in which the man climaxes and then
continues to repeatedly verbalize his strongest deviant interest
while continuing to masturbate to the point of boredom, then to
aversiveness, and finally to disgust at having to ruminate about the
deviant behavior. Salter (1988,117) has an excellent description of
this procedure. Having the offender audiotape his satiation sessions
so that the therapist can spot-check the tapes and teach the patient
to use the satiation procedure most effectively insures compliance
with the treatment. The historical development of this behavioral
approach is described by Marshall and Laws (2003).

A third behavioral technique is covert sensitization, as discussed
earlier in this chapter.
Our treatment program was in a small prison with meager material
support and minimal staff. We were limited in resources and could
not utilize the procedures described above. We were, however, extremely fortunate in state-sponsored training opportunities, a library of educational videos utilized in treatment, and access to conferences such as those sponsored by the Association for the Treatment of Sexual Abuse (ATSA), in addition to peer support from
programs in other state prisons.

THE GOOD LIVES MODEL
Ward and Stewart (2003, 23) write that “the way to reduce
reoffending is to give individuals the necessary conditions to lead
better lives (i.e. ‘good’ lives) rather than simply to teach them how
to minimize their chances of being incarcerated.” The possible
goods will vary, but might include friendship, enjoyable work, loving relationships, sexual satisfaction and positive self-regard (ibid.,
28). A 2009 survey of 1,379 sex offender treatment programs conducted by the Safer Society listed the Good Lives Model (GLM)
as one of the top three treatment choices in a third of U.S. adult and
adolescent programs and in one half or more of the Canadian adult
programs (McGrath et al. 2010).

THERAPY FOR OWN VICTIMIZATION
Thomas et al. (2012), who researched childhood experiences of
child sexual abusers, warned that “unless the victimization of sexually abused adult offenders is taken seriously, the offenders may
not be able to develop empathy for their child victims” (ibid., 187).
Their in-depth study of 23 perpetrators found that half had been
sexually abused as children.

ANSWER TO RIVER CROSSING
Of the twenty responses to the scenario earlier in this chapter, five
men said it was Mary’s own fault, with one man adding that “she
should have stayed home.” Nine men felt it was the husband’s
fault. Four thought it was the ferryboat owner’s fault. One thought
it was the lover’s fault. And ONE decided the fault lay with the
man who killed her—in other words, the person responsible for the
killing was the killer. His answer was correct. (The first time I
heard of this exercise was during a training presentation on Victim
to Victimizer by Dr. Carolyn Cunningham August 29, 1989. I have
come across it several times since.)