Download Paedophilia : therapeutic issues

Paedophilia: Therapeutic Issues.
N. McConaghy
Abstract
Evidence that in treatment of paedophilia, behavioural interventions such as
aversivetherapy, directed masturbation and masturbatory satiation modify deviant
sexual interest is scientifically unacceptable. It was based on the inappropriate use of
single-case design and the invalid outcome measure of penile circumference responses
to pictures of nude subjects. It is suggested that rather than attempt to modify deviant
urges, treatment aim at giving subjects control over them.
The only randomized control study of relapse prevention has shown it to be
ineffective in the treatment of incarcerated paedophiles. It is suggested that treatment
to give sex offenders control over their deviant impulses may need to focus on
reducing compulsive aspects of their behaviour and be administered in the community
where they are exposed to the cues which appear to drive such compulsivity.
The first attempts to scientifically evaluate treatments of sex offenders were
made with the behavioural therapies introduced in the 1960's and early 1970's. These
therapies which are still widely employed, aimed to modify offenders' sexual
preference by such procedures as conditioning deviant urges to aversive stimuli or
increasing acceptable urges by reinforcing them with masturbation. The therapies were
usually evaluated not by comparing the response of treated subjects with that of
untreated subjects but by single-case designs. The American behaviourist model which
was dominant at that time, mainly used operant conditioning to change human
behaviour stimulated by the successful demonstration that operant conditioning
changed the behaviour of animals. For example, individual pigeons were shown to
peck more frequently if pecking was reinforced by the administration of food.
Confirmation that the reinforcement was the operative factor was provided by
demonstration of reversal of the effect in single subjects. TR 1 Once the increase in
frequency had been established, pecking ceased to be reinforced with food. The
frequency then decreased. This reversal provided the required evidence that the
increase had been produced by the reinforcement. The procedure of establishing the
effect and reversing it could then be repeated to demonstrate beyond doubt the
connection between reinforcement and response.
The American behaviourist theory of the time emphasized that only observable
behaviour should be taken into account, and the existence of cognitive factors was
ignored - in fact denied (McConaghy, 1987). Hence it was merely necessary to
demonstrate that a human subject showed a response to a treatment which disappeared
when the treatment was no longer administered to conclude that the treatment had
produced the response specifically. The fact that unlike animals human subjects could
respond to treatments nonspecifically due to the cognitive effect of suggestion was
ignored. Yet it was well established that placebos which human subjects felt confident
would be effective produced a response by suggestion, which would disappear
following withdrawl of the treatment. Also the basic lack of logic in this model was
never confronted. This was the conclusion that a treatment was of permanent value
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when its effect disappeared when it ceased to be administered. A further problem with
many of these single-case studies was that the periods for which the treatments were
administered and then withdrawn were not fixed in advance but extended during the
procedure until the sought for appearance or disappearance of the response occurred.
Chance effects could thus be interpreted as treatment effects.
Apart from these problems with the use of single-case design in human
subjects, the other major problem with these studies was that they used the single
subject's penile circumference responses to still pictures of nude men and women as
the outcome measure to demonstrate the changes in strength of his sexual urges that
the treatments aimed to modify. It had been shown by the Czech psychiatrist Freund
who introduced penile response assessment that penile volume responses to such still
pictures identified most men individually as to whether they reported predominant
heterosexual or homosexual feelings. I replicated his finding in a series of studies. It
was assumed by workers in the U.K. and U.S, that penile circumference responses
were identical to volume responses so that it was not considered necessary to establish
their validity independently. Subsequent to the early 1970's when the single-case
studies used to justify the use of behaviour therapies to modify sexual urges were
carried out, it was shown that unlike penile volume responses, penile circumference
responses to still pictures of nude men and women do not identify most men on the
basis of their reported heterosexual or homosexual interest. For circumference
responses to do so required the use of the stronger stimuli of videos of same-sex
subjects engaged in sexual intercourse.
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Hence the use of penile circumference responses to pictures of nude men and women
to demonstrate modification of heterosexual and homosexual interest in individuals is
invalid.
Nevertheless aversive procedures, directed masturbation and masturbatory
satiation remain widely used and continue to be recommended (Laws & Marshall,
1991) on the basis of these invalid single-case studies.
Directed masturbation aims to increase male subjects' heterosexual interest by
encouraging them to masturbate using heterosexual fantasies. I showed using the valid
penile volume assessment that regular heterosexual experience did not increase men's
heterosexual interest, indicating that directed masturbation would be ineffective
(McConaghy, 1978). Also in a series of studies using the valid penile volume
assessment of subjects' sexual feelings I demonstrated that though aversive procedures
gave subjects increased control over homosexual urges they previously experienced as
compulsive, these procedures did not do so by altering the direction of the subjects'
sexual feelings (McConaghy, 1976).
Despite the low level of validity of penile circumference assessment of
heterosexual and homosexual feelings the use of this assessment has been extended to
identification and evaluation of response to treatment of rapists and paedophiles.
Evidence of its validity for this purpose has been markedly inconsistent as I
summarised in two reviews (McConaghy, 1989, 1992). Nevertheless its use was
strongly recommended and even workers aware of this contrary evidence appear
reluctant to abandon it.
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The most disturbing lack of critical response to evaluation of treatment of sex
offenders in recent years has been to the study of relapse prevention by Marques and
colleagues (Marques, Day, Nelson, & West, 1994). Their study had the strength that its
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subjects were randomly allocated, a procedure which is rarely employed in studies of
treatment of sex offenders although it is virtually essential to control all the variables
known or unknown that could influence their outcome.
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Marques's study reported the follow-up of 602 sex offenders an average of 3 years
after their leaving jail; 421 were child molesters and 181 rapists. Offered possible
treatment 229 volunteered to accept it; 132 of the 229 were randomly selected for
treatment and the remaining 97, matched to the treatment subjects on age, type of
offense and criminal history, were not. When they learned the details of treatment 26
of the 132 of the volunteers decided against it. Of the 373 who did not volunteer for
treatment 96 were matched to the treated group on age, type of offense, and previous
criminal history.
Treatment was relapse prevention and was quite intensive. Subjects spent 14-30
months in a state hospital receiving group treatment for 4.5 hours a week plus
individual treatment for 1 hour per week from a psychologist or psychiatric social
worker and for 2 hours per week by members of the nursing staff. In addition there
were specialty groups for relaxation training, sex education, social skills training, stress
and anger management, preparation for release and where relevant substance abuse
management. Behavioural reconditioning (i.e. such techniques as directed
masturbation and masturbatory satiation) was provided for those who showed deviant
sexual arousal patterns assessed by penile circumference responses. After completing
the hospital programme subjects as a condition of parole participated in a Sex Offender
Aftercare Program for 1 year, carried out in the community by trained clinicians.
Response were measured in terms of sexual and non-sexual violent crimes
committed after discharge. There was no significant difference in outcome of the
treatment and the control group. Eight of both treated and untreated child molesters
carried out a further sexual crime.
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The significant finding of the study was the importance of the characteristics of the
offender in determining the outcome. Younger subjects were more likely to commit a
new offense (p < .001) and there was a strong trend for those with a prior felony
conviction to do so (p < .08).
The subjects with the best outcome were those who appeared to show
evidence of mature judgment.
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Twenty-six initially volunteered for treatment but decided against it for such realistic
reasons as stigmatization of being a mental patient (treatment was carried out in a state
hospital over a period of approximately 2 years), their safety during transfer, family
resistance, better vocational opportunities in prison, or the lack of incentives for
participation (such as early or conditional release opportunities).
Eight offenders who withdrew or were withdrawn from treatment prior to one
year did worst. Three committed further sexual offenses. Some had presented severe
management problems in hospital and Marques et al. commented that those who were
the most impulsive and exercised the least amount of self-control were likely to be the
ones to withdraw or be terminated from treatment.
Despite the high quality of the design in that subjects were randomly allocated
to the two conditions, there were problems in the authors' interpretation of their data. In
one analysis the 26 who decided against treatment but had by far the best outcome
were included with the subjects treated to form a "treatment as assigned" group.
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Combining these untreated subjects with treated subjects enabled the authors to report
in the abstract that "the treatment group had the lowest reoffense rates for both sex and
other violent crimes". This disguised the fact the subjects who were offered but
rejected treatment had the lowest reoffense rates.
In another analysis the response of the eight who withdrew or were withdrawn
from treatment was removed from the response of the treated subjects. This again is
methodologically unacceptable and illogical. The response of offenders equivalent to
them (that is, impulsive and lacking in self-control) who were randomly allocated to no
treatment could not be excluded. Hence the treatment group was being compared with
a group whose outcome could be expected to be worse.
The major problem with the design of the study was that it did not control for
the possibility that denying treatment to offenders who had volunteered for it could
have a negative effect. It has been pointed out (McConaghy, 1990a; 1993) that this is a
problem with evaluations of psychological treatments using no treatment controls. The
most consistent findings of metaanalyses of such evaluations is that no treatment was
much less effective than placebo treatment, and frequently produced a negative effect.
Marshall (1996) considered that the addition of a relapse prevention approach has been
the most significant innovation in the treatment of sexual offenders in the past 20
years. The study of Marques et al. casts significant doubts on its effectiveness and it
might have been expected that it would have lead to immediate calls for evaluations of
relapse prevention in comparison with other approaches, including those requiring
much fewer resources which allow the treatment of many more offenders
(McConaghy, 1990b; 1993). In contrast, the study has been cited as demonstrating that
the relapse prevention model is effective in reducing recidivism (Bumby, 1996;
Schlank & Shaw, 1996).
Why should this intensive treatment which is widely considered to be highly
effective, have proven ineffective? Possibilities include
1. Its failure to focus on the issue of control of deviant sexual urges as central, rather
than including attempts to modify the direction of subjects' sexual impulses based on
the behavioural techniques criticised earlier as improperly validated by single-case
design and penile circumference assessment.
2. Failure to attempt to identify and treat deviant sexual urges as compulsive. As stated
earlier, my research evaluating aversive procedures indicated that they did not modify
the direction of subjects' sexual urges but nevertheless gave the subjects increased
control over those urges they had previously experienced as compulsive. I argued that
a neurophysiological behaviour completion mechanism was responsible (McConaghy,
1980). This mechanism increased the subject's feeling of arousal or tension if they
attempted not to complete the deviant sexual behaviour when stimulated to do so by
being in situations where they had previously offended. This increased tension drove
the subject to complete the behaviour against his will. On the basis of this model I
introduced a variant of systematic desensitization I termed imaginal desensitization to
reduce this compulsivity. Subjects were initially trained to relax and then to repeatedly
visualize being in the situations where they had previously acted out the deviant
behaviour, but to visualize not completing it while remaining relaxed. In a random
design this procedure was shown to be more effective than the aversive procedure,
covert sensitization in reducing sexual compulsions (McConaghy, Armstrong, &
Blaszczynski, 1985). In a subsequent random design study the temporary use of
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medroxyprogesterone to reduce subjects' testosterone level and consequently the
strength of their sexual urges was also shown to enable them to learn to control
compulsive sexual urges (McConaghy, 1990b).
3. Carrying out active treatment on incarcerated offenders may be ineffective as
learning control of compulsive urges could require exposure to the situations
experienced in life outside jail where they have previously offended and which act as
cues for the urges.
4. The cognitive component of relapse prevention includes education and attempts to
correct offenders' faulty cognitions concerning their deviant acts. A commonly
recommended focus is on what are termed myths: For example, offenders' beliefs that
sexual abuse of children is not harmful; and that children have initiated sexual activity.
These myths are challenged by insisting on the opposite: that child sexual abuse
invariably produces marked harm and that children never initiate sexual activity.
Research has established that the beliefs also are not always correct. Hence most
offenders must at times
have had experiences when child abuse did not produce harm or the child initiated
sexual activity. Rather than force offenders to pretend to believe what they know to be
false, the occasional reality of these behaviours should be acknowledged, along with
emphasis that this reality must not be used to justify their behaviour and that adult
sexual activity with children is invariably inappropriate as children are never able to
give informed consent.
All of these possible reasons for the demonstrated ineffectiveness of relapse prevention
with paedophiles need evaluation in controlled random studies. Yet currently such
research is not being carried out and the treatment of relapse prevention continues to
remains the model for new programmes introduced to treat incarcerated sex offenders.
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