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Rape: Behavioral Aspects - Treatment

sexual cognitive victim offenders

The rationale for the modification of any unwanted behavior stems from the informed consideration of those factors that are most importantly associated with the emergence and the sustenance of the behavior. In a relatively simple case, such as reactive or acute depression, we attempt to identify the precursors of the depression. Although sexual aggression derives from a substantially more complex amalgam of factors and typically reflects a chronic pattern of maladaptive behaviors, the principles remain the same. That is, before designing strategies for modifying sexually aggressive behavior, we first must identify those factors that are most importantly related to the behavior. The overarching model that is used to treat sex offenders is an adaptation of relapse prevention, with a practical emphasis on cognitive-behavior therapy as the modality of choice. Specific interventions are used to target each of the critical areas of deficit. Given limitations of space, only several of the most important target areas will be discussed.

Lack of empathy. In all domains of interpersonal violence, a general lack of empathic relatedness for one's victim can be regarded as a powerful disinhibitor. Alternatively, the presence of empathic concern will serve to inhibit aggression. Although capacity for emotional relatedness and empathic concern have long been a focus of treatment for sex offenders, these issues have, until recently, been included in the larger topic of social skills deficits.

At this point most sex offender treatment programs include a separate component for increasing victim empathy. In addition to the standard exercises and tapes (video and audio) used in victim empathy training, expressive therapy may be used to increase the offender's emotional or affective response to the distress of the victim. Some programs introduce victim advocates, victim counselors, and occasionally victims to increase further the emotional ante. Moreover, increasing the offender's affective appreciation of his own childhood experiences of victimization can instill a greater awareness of his victim's experience of abuse.

Anger. The recognition of the importance of anger as a driving force in sexual offenses has resulted in the inclusion of treatment techniques to reduce and contain anger. The most commonly employed of these techniques is anger management training, which uses cognitive-behavioral strategies to increase self-control as well as the timely and appropriate expression of angry feelings. In addition, relapse prevention, which also focuses on increasing self-management skills, and stress management can assist the offender to gain control over chronic and situationally induced anger. Lastly, early life experiences of victimization can fuel lifelong anger that is periodically triggered by real or imagined provocations. A group that focuses on childhood victimization can help the offender to cope more adaptively with these traumatic events.

Cognitive distortions. Cognitive distortions are "irrational" ideas, thoughts, and attitudes that serve to: (a) perpetuate denial around sexually aggressive behavior; (b) foster the minimization and trivialization of the impact of sexually aggressive behavior on victims; and (c) justify and sustain further sexually aggressive behavior. Cognitive distortions are presumed to be learned attitudes that are instilled at an early age by care-givers, reinforced by peers during childhood and adolescence, and further strengthened in adulthood by the prevailing social climate.

The importance of cognitions in moderating sexual arousal has been repeatedly demonstrated. Moreover, clinical observations have suggested that most sexual offenders harbor offensejustifying attitudes and that these attitudes are importantly related to the maintenance of the "sexual assault cycle." Thus, the modification of irrational attitudes has been a major focus of treatment intervention. Although there are a variety of treatment modalities that may impact these distortions, the most commonly employed technique is cognitive restructuring. For cognitive restructuring to be most effective, it is critical that cognitive and affective components be addressed. That is, it is insufficient merely to confront the "distorted" nature of the attitudes, to discuss the role that such distortions play for the individual, or to provide accurate information about sexual abuse (all cognitive components). It is equally important to create discomfort by focusing on the victim's response (e.g., fright, pain, humiliation)—the affective component. This latter exercise is also integral to victim empathy training.

In addition to cognitive restructuring, a group that focuses on childhood victimization can also be very helpful. Since the origin of these distorted attitudes is often a primary caregiver who was an influential role model as well as exposure to peer role models, often in institutional settings, a group that focuses on these early life experiences can help to trace the cognitions to their source, thereby challenging their generality and diminishing their sense of "truth" or "reality."

Sexual fantasy and deviant sexual arousal. The frequent targeting of rape fantasies for therapeutic intervention reflects the widely held belief that deviant fantasies not only lead to and maintain deviant sexual behavior but also impede normal sexual adaptation. Behavioral techniques for modifying sexual arousal patterns are grouped into two categories, those that decrease deviant arousal (e.g., covert sensitization, aversion, masturbatory satiation, biofeedback, shame therapy) and those that increase appropriate arousal (e.g., systematic desensitization, fantasy modification and orgasmic reconditioning, "fading" techniques, exposure to explicit appropriate sexual material). Although over twenty different behavioral techniques have been reported in the literature, the most widely used method has involved some variant of aversive therapy.

In addition to the repertoire of behavioral interventions, organic treatment has become increasingly popular as a complement to psychological treatment. These organic or drug treatments consist primarily of antiandrogens and antidepressants (primarily the selective serotonin reuptake inhibitors such as fluoxetine).

Antisocial personality/lifestyle impulsivity. Clinicians have long recognized the importance of impulsivity for relapse and have introduced self-control and impulsivity management modules into treatment. In addition to groups that focus specifically on impulse control, most treatment programs include components of relapse prevention. Relapse prevention begins by identifying the chain of events and emotions that lead to sexually aggressive behavior. Once this "assault cycle" is described, two interventions are employed: (a) strategies that help the offender avoid high-risk situations; and (b) strategies that minimize the likelihood that high-risk situations, once encountered, will lead to relapse. There is also reasonable evidence in the literature that supports the efficacy of selective serotonin reuptake inhibitors for impulse disorders.

Conclusion. The verdict as to the efficacy of treatment for sexual offenders will inevitably be a complex one that addresses: (a) optimal treatment modalities for specific subtypes of offenders; (b) optimal conditions under which treatment and follow-up should occur; and (c) selection (or exclusion) criteria for treatment candidates. At the present time, the most informed and dispassionate conclusion must be that the jury is still out. The evidence submitted thus far, however, is encouraging. In a meta-analysis that included twelve studies of treatment with mixed samples of sexual offenders (N=1,313), Hall reported an overall effect size of .12 for treatment versus comparison conditions. The overall recidivism rate for treated sex offenders was .19, compared with .27 for untreated sex offenders. As Hall reported, these effect sizes were larger in studies with longer follow-up periods, studies with higher base rates of recidivism, studies that included outpatients, and studies that included cognitive-behavior and/or hormonal treatment. It is thus clear that treatment can work, and it is increasingly clear what factors lead to optimal treatment outcomes.

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