treatment of sexual offenders has changed dramatically over the years. This is
reflected in the history of treatment, which fluctuates depending upon the
observer, as reflected in numerous interviews conducted by M. Carich (Carich,
Smith, & Cameron, in press; see also Laws & Marshall, 2003; Marshall
& Laws, 2003).
offender treatment has been dominated over the last 25 to 30 years by
cognitive-behavioral therapy (CBT) with a heavy emphasis on relapse prevention
(RP), until recently (Laws, 2003). However, some (e.g., Yates & Ward, 2009)
have suggested throwing out RP and replacing it with a combination of the Good
Lives Model (GLM) and Self-Regulation Model (SRM). RP has been under scrutiny
for a number of reasons (Laws, Hudson & Ward, 2000). Carich, Dobkowski
& Delehanty (2009) have suggested integration and balance. Likewise, over
the years, treatment targets have also changed (Carich & Adkerson, 1995;
Carich & Adkerson, 2003; Carich & Calder, 2003; Carich & Calder,
2012; Carich & Mussack, 2001; Marshall, 1996; Marshall, 1999; Marshall,
Anderson & Fernandez, 1999; Marshall, Marshall, Serran & Fernandez,
2006; Marshall, Marshall, Serran & O’Brien, 2011; Metzger & Carich,
1999). Typically, mental health types want to treat everything whether it needs
it or not. Paradoxically, most therapy programs do not have the time, resources,
or luxury to treat numerous targets. Therefore, given the current state of
affairs, the question arises, what are the essential elements of treatment?
program theory, it is suggested that within a particular program treatment
targets are converted into treatment elements and examined for themes (Carich
& Calder, 2011). Every program, even if consisting of one group, has a
recognized or underscoring program theory. Thus, treatment goals are targeted
via treatment elements (Carich & Calder, 2003). The purpose of this paper
is to briefly outline what are considered to be the essential elements or
themes of contemporary treatment, realizing the field is undergoing a rapid
Mark S. Carich, Ph.D.
Bruce Cameron, M.S.
Heather Young, M.A.
Monica Parkins, M.S.
Parameters of Treatment
mentioned earlier, treatment has evolved over time, starting out
psychodynamically, then moving to behavioral treatments, followed by cognitive therapy
with an intensive shame-based and confrontational punitive methodology leading
to contemporary CBT treatment with a heavy emphasis on RP. The current push is
on totally abandoning RP, replacing it with GLM and SRM (Yates & Prescott,
2011; Yates, Prescott & Ward, 2010; Yates & Ward, 2009). Interestingly,
and ironically, Adler (1934, 1941, 1956) may have been one of the first to
treat paraphilias in modern times and was definitely the forerunner of CBT,
group work, family systems, and even the GLM.
classical CBT model is based on the reciprocal influential relationship between
cognitive and behavioral experiential domains. By the late 1980s, RP was
attached to CBT, creating a CBT-RP approach. It is interesting that traditional
treatment is changing, as all experiential domains are recognized, including
the emotional, as Marshall, Marshall, Serran and Fernandez (2006) have added an
emotional component to their program approach title, moving beyond CBT, as well
as recognizing the importance various theories of GLM (Marshall, Marshall, Serran
& O’Brien, 2011). The GLM can easily be integrated into contemporary
treatment (Carich, Dobkowski & Cameron, 2012; Ward & Gammon, 2006; Ward,
Mann & Gannon, 2007; Yates Prescott & Ward, 2010).
key connecting theoretical points hinge on self-determinism as people make
complex choices to offend, and the theological view that behavior is goal
oriented and serves purposes. Within this, people are held accountable for
their behavior. However, one’s view of self and change of self plays a role. Part
of the integration occurs by adopting a holistic view of self, thus
appreciating all the various experiential domains of self and the recognizing
the complexities of change (Carich & Dobkowski, 2007; Carich, Dobkowski
& Cameron, 2012; Carich, Williamson & Dobkowski, 2008). Social learning
theory remains an important theoretical component, as well.
GLM adds various needs, or what are referred to as primary goods (or goals) that
one tries to obtain or fulfill according to life plans (Ward, 2002; Yates,
Prescott, & Ward, 2010). These are either fragmented (chaotic) or coherent
(stable). As treatment is transformed, at some level, treatment elements or
themes need to reflect life plans to some degree via targeting the “right” or
key dynamic risk factors (DRFs).
DRFs into Treatment Elements
risk factors are those behavioral and lifestyle factors related in some degree
to offending. These are issues, targeted dysfunctional behavior problems,
criminogenic factors, etc. (Carich, Spilman, & Stanislaus, 2008). These
factors can change and are dynamic in nature. Typically, DRFs are translated
into treatment goals, which have been addressed in the literature (Carich &
Adkerson, 1995; Carich & Adkerson, 2003; Carich & Calder, 2003; Carich &
Calder, 2011; Metzger & Carich, 1999). In terms of program theory, we
distinguish DRFs, treatment goals, and treatment elements or themes. Targeting DRFs
via goals and objectives is reflected in various themes within the program
(Carich & Calder, 2011).
are numerous DRFs, treatment goals or targets, elements and typologies, etc.
throughout the literature from over the last 30 years (Beech & Fisher,
2002; Carich & Adkerson, 1995; Carich & Adkerson, 2003; Carich &
Calder, 2003; Carich & Calder, 2011; Hanson & Harris, 2001; Marshall,
1996; Marshall, 1999; Marshall et al., 2006; Marshall et al., 2011; Marshall
& Serran, 2005; Metzger & Carich, 1999; Mussack & Carich, 2001;
Thornton, 2002) summarized by Carich, Spilman & Stanislaus (2008). A brief
outline of several are found in the following – Common DRFs:
- Hanson & Harris (2001): SONAR/Stable-2000
- Intimacy skills/deficits – meaningful relationships, attachments…
- Social influences
(not in Stable 2007)
self-regulation skills- preoccupation controls…
functioning- loneliness, esteem, passive victim stance, intimacy, aggression,
attitudes- entitlement, justifications
(1999): Treatment Targets
survivors of sexual abuse
use of leisure time
(2006): Current Treatment Targets—Offense Specific
signs (self & others)
groups (professional & personal)
plans (work, accommodation, leisure activities)
skills (now called reasoning & rehabilitation)
& Fisher (2002): Four Factors of Treatment
minimization & justification
areas are thought to be related to offending to varying degrees. Interestingly,
some of these DRFs are not supported in the classical meta-analysis conducted
by Hansen and colleagues (Hansen & Bussiére, 1996; Hansen & Bussiére,
1998; Hansen & Morton-Bourgon, 2004; Hansen & Morton-Bourgon, 2005).
For example, denial and related responsibility, empathy deficits, motivation,
relapse prevention skills, social skills, etc. are not strongly (or at all) correlated
with sexual recidivism. Yet, there are bodies of literature that indicate
deficits in these areas summarized by a variety of authors (beech & Fisher,
2002; Carich & Adkerson, 1998; Carich & Adkerson, 2003; Carich &
Calder, 2003; Carich & Calder. 2011; Carich, Spillman & Stanislaus,
2008; Marshall, 1996; Marshall, 1999; Marshall & Eccles, 1991; Marshall et
al., 2006; Marshall et al., 2011).
Furthermore, it has been pointed out
that these same factors are either defined differently across studies and/or
very complicated to define. Some factors dovetail with other factors or can be
subcategorized under others (Carich, 1991; Carich, 1997; Carich, 1999; Carich
et al., 2008). Interestingly, Hanson (2000) maintained two key risk factors:
antisocial personality and deviant sexual interest. More recently, Mann, Hanson,
and Thornton (2010) reviewed the literature, focusing on DRFs based on the
empirical research. Their findings are found below. The meaningful DRFs are
considered key criminogenic treatment targets. Marshall, Marshall, Serran and
O’Brien (2011, p.139) have provided a more concise list of criminogenic
should dominate/control women
views of women
women deserve to be raped
abuse supportive beliefs
children as sexual beings
identification with children
themselves as low risk to reoffend
of relationship skills
of sexual knowledge
deviant or paraphilic sexual interest
Throughout all of the controversies, and
with some common sense, there are several categories of DRFs that contain two
Summary List of DRFs (Treatment Targets)
factors (distortions, core schemas, attitudes, etc.) including responsibility
issues, relationships, skills…
sexual deviance and/or interest/preoccupation
(i.e., pattern) and general self-regulation deficits
empathy, social interest related factors
needs and/or core causative motivational factors/issues
behaviors (impulsivity, etc.)
These categories of DRFs or treatment
targets can be refined and translated into treatment goals and objectives. For
example, Metzger and Carich (1999) developed a comprehensive 36-page treatment description
serving as an effective “master plan” from which additional, user-friendly
treatment plans can be developed. Conceptually, treatment targets can be
encompassed or viewed in terms of treatment elements.
Elements and Themes
has been summarized over the years into various treatment targets, elements,
and components (Carich & Calder, 2003, 2011; Carich & Mussack, 2001;
Marshall, 1990, 1995, 2005; Marshall, Marshall et al., 2006, 2011; Marshall,
Anderson & Fernandez, 1999; Schwartz, 1995. Treatment elements are themes
of treatment within one’s program theory that reflect what areas exactly are
being treated within any particular program, consisting of one group or rather
a complex series of groups. These are elements of the intervention that reflect
the core components of one’s program or treatment activities. Ten key themes
and elements central to sexual offender treatment are presented below:
specific/related cognitive restructuring
process (pattern)/Intervention (regulation) skills
maintenance via pattern identification and intervention
empathy and related prosocial perspective taking
control or regulation skills
(core) issue resolution
skills, interpersonal issues/relationships
the question remains, what are the essential elements of sex offender treatment
in general? The following is a list of essential elements that can be
considered key treatment themes:
and cognitive restructuring
intervention regulation skills
maintenance strategies (RP related)
patterns/processes and regulation (coping) skills
(skills, issues, attachments)
and core issues
motivational and emotional needs and issues
It is noted that interpersonal skills
and attachment issues or relationships will be naturally addressed throughout
the group process. Furthermore, high risk clients need to address core needs
and motivated core issues. Otherwise, unless time permits, core issues
typically are not addressed. It is further noted that motivational core issues
may also be targeted if necessary as background risk factors, again, time
permitting. More specifically, a summary
list of core treatment elements includes the following: a.) cognitive
restructuring and responsibility, b.) empathy (perspective taking), c.)
regulatory (coping) skills, including mood and arousal control, d.) change maintenance
skills (pattern intervention), e.) motivational core issues, and f.)
interpersonal issues and attachments.
These elements matter depending on how
treatment services are delivered. Since each client is uniquely different in
terms of risk level and needs, the degree to which these elements are addressed
will vary as well. In terms of the Good Lives Model, specifically, primary
goods (and sometimes secondary goods) are reflected within the treatment
elements. These needs or goods are mostly related to the established DRFs.
Delivery and Risk-Needs-Responsivity (RNR)
delivery is best conducted with the RNR principles as a driving force (Marshall, Marshall, et al.,
2011). The client’s risk levels and needs are matched with treatment dosage and
overall elements used. Responsivity refers to the clinician being responsive in
matching treatment interventions with the client’s learning style and needs.
Treatment is ineffective if the client cannot relate to the clinician and/or
process. Thus, a treatment context needs to be considered change-oriented and
user-friendly. Many of these dynamics hinge on the therapist style, therapeutic
alliance, therapist skill level, etc.
days of shame-based therapy or treatment are over, as favor has shifted to more
positive psychology approaches (Carich & Dobkowski, 2009; Carich,
Williamson. & Dobkowski, 2008; Marshall et al., 2006; Marshall et al.,
2011; McMurran & Ward, 2004; Prescott, 2009; Yates, Prescott, & Ward,
2010). Treatment delivery hinges on process variables, or variables related to
the clinician in delivering treatment processes. There are a number of key
process factors that are considered important. This specific topic is somewhat beyond
the scope of this article; however, the reader is referred to the following
authors for clarification of the research: Carich and Dobkowski (2009), Carich,
Williamson and Dobkowski (2008), Marshall et al. (2006), Marshall et al. (2011),
Marshall and Serran (2000), and Prescott (2009). However, there are four key
factors that need to be addressed.
Key Process Factors
all the tedious research conducted by Bill Marshall and colleagues, several factors
paralleling some of Assay and Lambert’s (1992) research on successful
psychotherapy remains important. Marshall (2005, 2007 interviewed by Carich and
Scott Smith) outlined four key functions that need to be incorporated in any successful
sex offender treatment context:
connection at some level with the client
(reinforcement) or positive behavior and responses
for change or something different
to a degree
level of structure and guidance
There are numerous dynamic risk factors
(DRFs) that can be targeted in treatment (Carich, Spilman, & Stanislaus,
2008). DRFs can be complex and interrelated with each other, varying in levels
of risk correlation to sexual offending behavior. DRFs are translated into
treatment targets and/or goals. Treatment targets will vary amongst individuals
depending upon any number of factors (e.g., background history, personality
characteristics, level of deviant fixation, motivation, program resources,
offense pattern processes, etc.). Yet, there seem to be common factors amongst
the clientele that vary as well. These factors are translated into, and
reflected as, program elements or themes. Questions always arise as to what are
the key treatment themes and/or elements? Several were proposed, including:
It was suggested that attachment and
interpersonal skills will naturally be addressed within the group process. It
would appear from clinical experience that this summary applies primarily to those
in low to moderate risk groups. The very high risk groups usually found in
civil commitment programs are typically clients with chronic, fixated, sexually
deviant patterns, and dysfunctional personality characteristics—most with
complex trauma histories requiring even more additional work.
The last thing addressed was treatment
delivery. Treatment delivery is based on the process variables (Marshall,
2005). The summary of essential elements will be reflected by the Risk-Need-Responsivity
principles as applied to the client. A clinician can target all the right DRFs and
have all the right treatment elements; however, the outcome hinges on treatment
delivery. Ineffective treatment delivery usually yields ineffective results. Effective
treatment delivery involves the use process variables alluded to by Marshall
(2005) and Marshall, Marshall, Serran, and O’Brien (2011). The use of process
variables is included in positive psychology, and the current push in the field
is integrating positive psychology. However, with the integration of positive
psychology via the Good Lives Model (GLM), the field is moving beyond basic CBT
towards a Cognitive-Behavioral Dynamics therapy incorporating a holistic view.
This appears to be the future of the field.
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