Title: Treating the sexual offender
Author(s): Barry M. Maletzky
Affiliation: Department of Clinical Psychiatry, Oregon Health Sciences University
Citation: Maletzky, B., Treating the sexual offender, Newbury Park, California: Sage Publications, 1991.
The author writes that behavior therapy is a promising method for changing the behavior of sex offenders, and that its accounts in the scientific literature are a source of satisfaction to its proponents. Although behavior therapy cannot fully explain the origin or course of a condition, it can treat the condition effectively. Most studies of the effectiveness of behavior therapy with sex offenders are restricted to a small number of subjects.
A major goal of treatment is the elimination of deviant sexual arousal; simply strengthening the offender’s resistance to deviant impulses is not enough. This elimination can be accomplished through aversion therapy, desensitization, plethysmograph biofeedback, masturbatory satiation, covert sensitization, and educational efforts such as social skills training and sex education.
Treatment will often be unpleasant for the patient because he will need to reveal embarrassing sexual histories, endure restrictions on his liberty, bear an expense in time and money, and tolerate unpleasant stimuli.
The animal conditioning literature demonstrates that this method is very powerful, yet it is used on humans only to eliminate inappropriate approach disorders (such as overeating and substance addiction) and sexual deviance. Only in the area of sexual deviance is aversive conditioning a major weapon in the therapeutic armamentarium. Several methods of aversive conditioning are available.
The goal of covert sensitization is to have the offender pair an imagined aversive consequence with his deviant thoughts or behavior in order to eliminate such thoughts or behavior. In this technique, the offender listens to a story which contains the following three parts: (1) the offender’s preferred deviant stimulus and a build up of sexual arousal, (2) an aversive consequence (something which causes intense disgust, pain, or humiliation), and (3) release from the adverse consequence by reversing the activity.
The following example could be used to treat a child molester:
You’re on the prowl again, looking for boys at night. You pull up by a video game store where the kids hang out. There is a boy, maybe 13 or 14,…You offer to take him home and he accepts. He is so pretty, blond, blue-eyed, just reaching puberty…You park by his house and reach over to put your arm around his shoulder. He does not resist—he likes your touch! You start to caress his shoulder and neck…You slowly unzip his fly and pull it out, stroking it. You can hear his heavy breathing as you go down on him…but suddenly there is a foul odor; it is disgusting, like rotting flesh, putrid and nauseating. You glance down and there is a sore on the underside of his penis. It’s red and full of pus and it’s broken and some of the blood and pus have gotten into your mouth and down your throat. It’s nauseating…You upchuck all over him and your clothes. The smell is driving you mad as big chunks of vomit dribble down your chin…You leave the car and get a rag to clean yourself off. As you get away from the boy, that smell goes away and you can breathe the fresh night air…now, you can relax again.
It is best if the therapist creates this scene with contributions from the offender. Each session should be preceded by relaxation (or hypnotic) induction techniques. In a case study the method was effective.
Overt techniques have the same goal as do covert techniques, but actual rather than imagined aversive stimuli are presented during or immediately after the deviant stimulus. The deviant stimulus may involve slides, videos, or movies. The aversive stimuli may be electric shock, foul odors, lemon juice, or ammonia. Electric shock has never been popular except in sex offender therapy, but it is very effective. The therapist should administer the aversive stimulus to himself to demonstrate that the unpleasantness or pain is only temporary.
The following is an example of aversion therapy by electric shock: A patient with homosexual pedophilia is instructed to sort cards containing words and phrases associated with deviant sexual arousal, such as “teenager,” “pubic hair,” and “prick,” rank ordering them from least to most arousing. Then he is instructed to do the same with pictures of graphic scenes of homosexual pedophilia. [Pedophiles by definition are preferentially attracted to pre-pubescent children, rather than to teenagers. –R.K.]
A brief electric shock is administered when these stimuli are projected onto a screen. After the successful inhibition of arousal, the patient removes homosexual words or images within 3 seconds. If he fails to do so, a red light flashes to indicate he must self-administer the shock. Escape from shock coincides with presentation of appropriate heterosexual stimuli.
An alternative to electric shock is noxious odors. One example of odor aversion is the use of putrifying tissue, such as human placenta inoculated with bacteria. Advantages of this method stem from the fact that the aversive odor can be precisely timed, little technical equipment is required, the odor is long-lasting, patient acceptance of the method is relatively high, and the odor can be “doped” as needed with the addition of meat, fish, urine, or feces.
Physical irritants, such as ammonia, have also been used as the aversive stimuli, but they have some disadvantages. First, they produce a burning sensation that is transmitted to the thalamus, which may limit the method’s effectiveness in deconditioning work. Secondly, they can lead to inflammation and ulceration of the patient’s nasal mucosa.
Taste aversion methods have also been used. Although most foul tasting substances are dangerous, propantheline is one that is safe to use. It comes in tablet form, and is normally intended to be swallowed whole. However, when chewed, it has a bitter and nauseating taste.
The patient can be instructed to chew it for one minute, then spit it out. If he swallows it, the worst possible effects are dry mouth and temporary constipation, although such effects are rare. One advantage of this method is that it can be administered at home whenever the patient becomes aroused by a deviant stimulus.
Another aversive method is shame therapy, in which the patient acts out his molestation on a mannequin in front of observers (staff or family members) who do not respond. The goal is to produce a feeling of extreme anxiety and shame surrounding the deviant activity in order to “unhook” it from its sexual gratification.
The effectiveness of these methods suggests that the offender’s sexual behavior was initially caused by learning errors acquired through faulty experiences, perhaps at a critical stage of his childhood sexual development. For example, the author is acquainted with a homosexual pedophile who as a young child was shown nudist magazines by a male baby-sitter. The babysitter called his attention to pictures of naked boys, and the child noticed the babysitter had an erection inside his pants. [Scientists do not generally accept a post hoc argument from a single case study as strong support for a theory. –R.K.]
A number of patients using aversive methods did not believe their improvement was as satisfying as the plethysmograph indicated. They continued to have difficulty being aroused by normal adult heterosexual stimuli. Thus, three things should be kept in mind when using aversive conditioning. First, once the deviant arousal is eliminated, it is often necessary to create non-deviant arousal to appropriate adult female stimuli. Secondly, it is important to address the offender’s social difficulties that often accompany his deviance.
Thirdly, pedophilia and other deviations are considered to be facades that mask deeper problems which must be addressed. For example, a 14 year old boy who interacted sexually with younger boys was cured with odor aversion and electric shock, but then his grades dropped and his home behavior became difficult. [Researchers would also consider alternative explanations, including the possibility that the deterioration in the boy’s school and home behavior was induced by the treatment. –R.K.]
The goal of arousal reconditioning is to weaken deviant sexual arousal and simultaneously strengthen appropriate arousal. One method of doing this is to expose the offender to his preferred deviant stimulus until he is aroused, then have him switch to an appropriate stimulus.
For example, slides of sexual scenes with boys are shown to the patient while a plethysmograph records his arousal level. These slides are followed by movie clips of consenting adult heterosexual activity. At successive sessions, the therapist decreases the duration of the deviant scenes and increases the duration of the normal scenes in order to transfer arousal from the first to the second.
Another method involves biofeedback. The plethysmograph produces a display of lights visible to the offender. While he is shown the deviant stimulus, he attempts to keep the lights off by suppressing his arousal.
A third method, called masturbatory satiation, involves the offender masturbating to consenting adult heterosexual pornography while tape recording his fantasy. Just after ejaculation (when sex drive is assumed to be lowest), he continues masturbating but switches to pornography involving sex between a man and a child. He does this for 30 minutes, continuing to record his fantasies. Then the tape is submitted to the therapist.
The rationale of this method is that it causes the deviant fantasy to become conditioned to low sex drive as well as to excessive masturbation—an aversive stimulus—while the normal fantasy becomes conditioned to the pleasure of ejaculation.
Another method is called masturbatory fantasy change. One example involved a 13 year old boy who had attacked younger girls. He was instructed to masturbate to fantasies of his attacks, but just before climax, switch to scenes of “forcible sexual activities with consenting [sic] teenage girls or adult women.” Then he was instructed to gradually change those fantasies to ones involving consenting activities with girls or women.
Another technique, orgasmic reconditioning, is based on the assumption that orgasm reinforces fantasies. Thus, the offender is instructed to gradually decrease the frequency of his deviant masturbatory fantasies, and increase the frequency of those that are normal. [Other writers have used the term “orgasmic reconditioning” to refer to the first arousal reconditioning method described above. –R.K.]
Desensitization techniques, or relaxation techniques, have also been used to reduce anxiety around social situations with adults in order to increase arousal toward them.
Another method, called positive olfactory conditioning, involves administering a pleasant smell in conjunction with a normal sexual stimulus.
Finally, operant conditioning methods have also been used. They reward the patient when he decreases his plethysmograph readings in response to deviant stimuli. Rewards can include allowing the patient to see his family, reducing the therapist’s fees, or providing unbilled therapy time. In one case, the therapist arranged for the parents of an adolescent offender to add a bonus to his allowance if he decreased his plethysmograph readings. The author writes that an advantage of operant conditioning is that it can turn a negative experience in therapy to a positive one.