Download History of Behavioral and Cognitive

The Histories
Volume 3 | Issue 1
Article 13
History of Behavioral and Cognitive-Behavorial
Treatments for Sexual Offenders
Raisa Manejwala
La Salle University, [email protected]
Follow this and additional works at: http://digitalcommons.lasalle.edu/the_histories
Part of the History of Science, Technology, and Medicine Commons
Recommended Citation
Manejwala, Raisa () "History of Behavioral and Cognitive-Behavorial Treatments for Sexual Offenders," The Histories: Vol. 3: Iss. 1,
Article 13.
Available at: http://digitalcommons.lasalle.edu/the_histories/vol3/iss1/13
This Paper is brought to you for free and open access by La Salle University Digital Commons. It has been accepted for inclusion in The Histories by an
authorized administrator of La Salle University Digital Commons. For more information, please contact [email protected].
History of Behavioral and Cognitive-Behavioral Treatments for Sexual Offenders
By: Raisa Manejwala
Background
The study of human sexuality began in the 19th century. In particular, scientists studied
both conventional and deviant sexual practices during this time. Sexual acts that are considered
deviant are not practiced by the majority of society and are therefore considered abnormal
behavior. For example, deviant acts involve being sexually aroused to non-human objects,
children, and non-consenting individuals. Prior to and throughout most of the 20th century,
homosexuality was also viewed by society as a deviant sexual act that was due to a mental
illness. Charcot and Magnan (1882) were the first to publish research on an attempt to treat
unconventional sexual behavior, specifically homosexuality. Additionally, Richard von-KrafftEbing published Psychopathia Sexualis in 1886, which remains one of the most complete
descriptions of unconventional sexual behavior. As a result of these leading figures in the study
of human sexuality, a scientific interest in deviant sexual behavior was well established by 1900.
In 1905, Sigmund Freud published Three Essays on the Theory of Sexuality. These essays were a
psychodynamic approach to understanding sexual deviations, infantile sexuality, and sexuality in
puberty. This book was widely discussed in professional circles and Freud finally began to
receive the acclaim that he had always felt he deserved (Laws & Marshall, 2003).
Even though Freud is one of the significant figures in the study of sexuality,
contemporary approaches to sexual deviance owe little to classical psychoanalytical or
psychodynamic theory or practice. Instead, these approaches are most heavily influenced by
behaviorism. Edward Thorndike and Ivan Pavlov significantly contributed to this shift in
understanding the development and treatment of sexual deviance in the early 1900s. In
particular, they empirically demonstrated the laws of learning and the laws of classical
conditioning, respectively, which played a role in the development of behaviorist theory. By the
mid-1900s, it was generally acknowledged that the specific expression of sexual behavior were
learned phenomena (Ford & Beach, 1952; Kinsey, Pomeroy, & Martin, 1948). Thorndike’s use
of reinforcement and Pavlov’s condition reflex significantly impacted the work of John B.
Watson. Watson’s work was guided by his goal to establish psychology as a science, which he
believed involved the prediction and control of behavior. The radical behaviorism of Watson,
along with the descriptive taxonomic approach of Alfred Kinsey, is crucial to the current
treatment for sexual deviance.
Kinsey, like Freud, believed that sexuality was a fundamental engine that drove human
behavior. The comprehensive study of human sexual diversity begins with Kinsey’s research.
By interviewing American citizens of various ages and ethnicities about their sexual experiences,
Kinsey and his colleagues produced a taxonomic picture of human sexual diversity. Over 60
years later, these data remain the largest body of empirical information on human sexual
diversity ever compiled. Kinsey’s research showed the absolute necessity of obtaining complete
details on sexual interests, preferences, and practices, which contributed to the assessment and
treatment of sexual offenders (Laws & Marshall, 2003).
A few of Watson’s successors, B.F. Skinner and Edward Tolman, contributed to the field
of sexual offender treatment with their studies about operant conditioning and metacognition,
respectively. Even though operant conditioning was not widely used with this population,
Tolman incorporated a cognitive aspect which is currently used in sex offender treatment
programs. Specifically, in 1932, Tolman designed experiments where he demonstrated that
organisms think about their behavior while engaging in it, which is now known as
“metacognition.” “Metacognition” is used in the construction of cognitive behavioral chains, in
which clients monitor their thoughts related to factors that influenced their offending behaviors.
Emergence of Behavior Therapy
In 1958, the South African psychiatrist, Joseph Wolpe, published Psychotherapy by
Reciprocal Inhibition, in which systematic desensitization emerged. This intervention was
effective in the treatment of anxiety disorders and effectively applied to problems in
conventional sex (Brady, 1966; Haslam, 1965; Kraft, 1967; Kraft & Al-Issa, 1967; Lazarus,
1963) as well as to deviant sexual behavior (Bond & Hutchinson, 1960; Stevenson & Wolpe,
1960). Wolpe’s work served as a catalyst for the development of behavior therapy. British
psychiatrists Stanley Rachman and John Bancroft expanded the developing behavioral
approaches to the assessment and treatment of the paraphilias (Marks & Gelder, 1967; Marks,
Gelder, & Bancroft, 1970; Marks, Rachman, & Gelder, 1965).
Early behavioral interventions for a variety of unusual sexual behaviors were primarily
case studies using some form of aversion therapy. Typically, a noxious stimulus was paired with
images of the target behavior (Pavlovian conditioning) or enactment of the deviant behavior
(operant forms of punishment). Additionally, electric aversion, which involves an uncomfortable
shock to the arm or leg, was associated with deviant images or acts (primarily of homosexuals,
transvestites, and fetishists). Aversion therapy has not been demonstrated to produce permanent
changes in sexual behavior (Quinsey & Earls, 1990; Quinsey & Marshall, 1983). However, this
research led directly to the application of behavior therapy with sexual offenders.
Emergence of Penile Plethysmography (PPG)
In 1957, Kurt Freund in Czechoslovakia developed what he called a “phallometric
assessment” procedure that could accurately measure the amount of penile enlargement during
presentations of erotic visual stimuli. Bancroft, Jones, & Pullan (1966) introduced a much
simpler tool that measured changes in the circumference of the penis. A variation of this tool was
later developed in the United States by Barlow, Becker, Leitenberg, and Agras (1970). This
assessment was seen as objective and a more accurate measure of the client’s sexual preferences
than his self-report because it did not seem to be influenced by the client’s voluntary control. As
a result, measures of erectile response quickly became the standard in establishing the degree of
deviance in clients and in evaluating the effectiveness of behavioral interventions. Even though
the PPG continues to be widely used, the research on this procedure has shown mixed results and
remains controversial (Laws & Marshall, 2003).
Nonbehavioral Approaches with Sexual Offenders
Prior to 1969, several nonbehavioral programs were established for treating sexual
offenders. For example, psychodynamic therapy was used to discover, bring to the surface, and
express hidden issues, thereby understanding unconscious motivators and experiences that shape
and drive clients’ emotions, cognitions, relationships, and behaviors (Laws & Marshall, 2003).
There are a few reasons why these programs played a role in the development of cognitivebehavioral programs for this population. First, they portrayed that sexual offenders could be
engaged in treatment and contributed to the understanding of the characteristics of these
individuals. Additionally, the discouraging data of the effectiveness of these programs began the
search for alternative treatment approaches
Emergence of Cognitive-Behavioral Therapy
Behaviorism dominated the field of psychology from 1920 until the late 1960’s because it
was scientific, experimental, practical, and useful (Laws & Marshall, 2003). As mentioned
earlier, early behavior treatment for the sexual offender population targeted clients’ arousal to
deviant images or acts with the use of noxious stimuli or electrical aversion to countercondition
the paired responses. Since there was no evidence of enduring changes in sexual preferences as a
result of these simple behavioral approaches, treatment began to include other components, such
as teaching sex education, appropriate arousal, social skills, and anger management. By the mid
to late 1970s, it was clear that treatment interventions had to become more comprehensive. These
broader-based programs began a continuous expansion in treatment and assessment of targets.
In the early 1970’s, cognitive psychology emerged and cognitive processes began to be
included in the behavioral treatment used with sexual offenders. Gene Abel, an American
psychiatrist, heavily contributed to the dominance of using behavioral and cognitive-behavioral
approaches with this population. Both Mahoney (1974) and Meichenbaum (1974) described a
variety of approaches that targeted changes in the cognitive mediating processes (i.e.
perceptions, memory, attitudes, beliefs, and other thoughts) that directed behavior. From these
influences emerged what became known as cognitive behavior therapy. Treatment programs for
sexual offenders began a shift in the 1970’s toward targeting empathy for victims, low selfesteem, and the perceptions offenders had of others. Although not described until 1980,
Brownell’s multifaceted program included the use of cognitive restructuring (Beck & Weishaar,
1995) to improve clients’ view of themselves and their perceptions of the actions of others.
However, it was not until the 1990’s that a more general conceptualization of cognitive processes
was to focus on what became known as “cognitive distortions.” (Marshall & Laws, 2003).
Conferences
In 1975, the Association for the Advancement of Behavior Therapy held a convention in
San Francisco where they first discussed sexual offender issues from a cognitive-behavioral
perspective. At this conference, Gene Abel organized a symposium where he invited speakers. In
1977, Abel organized the first conference solely devoted to the treatment and assessment of
sexual offenders in Memphis, Tennessee. Individuals from the Memphis conference were joined
by a group of clinicians from the west coast in 1987 to form the Association for the Behavioral
Treatment of Sexual Abusers (later the term “Behavioral” was dropped to reflect the broader
approaches of many members). Currently, ATSA is an international, multi-disciplinary
organization dedicated to preventing sexual abuse.
Relapse Prevention Plan
In 1982, Janice Marques made the first proposal for an adaptation of Alan Marlatt’s
relapse prevention model for substance abuse treatment (Marlatt, 1982). Marques published the
initial authoritative account of the application of a relapse prevention framework to the treatment
of sexual offenders (Pithers, Marques, Gibat, & Marlatt, 1983). Relapse prevention provided
clients with a way to combat risks and temptations after treatment was over and they had
reintegrated back into the community. The relapse prevention plan is a psychoeducational and
cognitive-behavioral tool designed to help the offender operationalize his learning about the
sexual assault cycle, thinking errors, coping skills, and alternatives to offending (Rich, 2003). Its
intent is to help clients recognize and avoid the sorts of situations and interactions that may set
off a sequence of feelings, thoughts, and behaviors that may result in a relapse, or a return to the
offending behavior. For many programs, the relapse prevention plan represents the core approach
to treatment (Association for the Treatment of Sexual Abusers, 1996).
Current Approach
These significant figures throughout history have contributed to the contemporary
treatment approach for sexual offenders. Many of the treatment targets already discussed, such as
the identification of cognitive distortions, meta-cognition, sex education, development of
empathy, social skills, and anger management, remain in modern cognitive-behavioral treatment
programs. The following treatment model is based on the current research and is an example of a
typical approach to working with juvenile male sexual offenders.
A Contemporary Cognitive-Behavioral Treatment Program for Juvenile Male Sex Offenders
Introduction
The Association for the Treatment of Sexual Abusers (1997) and the current literature on
sexual offenders state that cognitive-behavioral approaches appear to be the most effective
treatment method with this population. In support of CBT’s efficacy, Marques, Day, Nelson, and
West (1994) found that compared with groups receiving no treatment, the group receiving CBT
had the lowest re-offense rates, both for sexual and nonsexual offenses. This interest in the
cognitive-behavioral model is in part due to a desire to get to sexually aggressive behavior as
quickly and as directly as possible and treat the thoughts and attitudes that are believed to drive
the behavior. The following CBT model is based on the work of several researchers (Bingham,
Turner, & Piotrowski, 1995; Heinz, Gargaro, & Kelly, 1987; Lundrigan, 2001; Perry & Orchard,
1992) and incorporates the current body of knowledge in the field of juvenile sex offender
treatment. Three treatment modalities are used to facilitate the treatment process: group,
individual, and family therapy.
Treatment Module 1: Disclosure of the Committing Offense and Taking Responsibility for
Actions
The first module in the treatment process is clients’ disclosure of their offenses and
taking responsibility for their actions. Disclosure of the committing offense is the first step
toward commitment to the treatment process, and although clients provide details of the event, it
is often not until further along in treatment that they begin to actually take responsibility for their
actions. During the process, clinicians effectively attend and respond to clients to promote client
exploration and establish trust within the professional alliance. As Blanchard (1998) stated,
“when the fundamentals of relationship-building are not applied to sex offenders, little
movement or growth will take place in counseling,” thus reinforcing revisions to cognitivebehavioral therapy that reflect the importance of the therapeutic relationship. Over time, clients
become more willing to engage in more detailed, complete, and honest disclosures of behaviors.
Without disclosure, it is not possible for clients to actively engage in treatment. Disclosures often
occur in group therapy, where members who are “street smart” and not easily manipulated are
able to confront the attempts at minimization and denial (Shaw, 1999). Group treatment also
allows for varying levels of support, challenge, encouragement, and other forms of feedback.
Taking accountability helps keep the behavior alive in clients’ minds daily, which is important in
treatment and in the development and use of the relapse prevention plan (Rich, 2003).
Treatment Module 2: The Cognitive Autobiography
The second module involves having clients construct timelines and genograms which
help them identify significant life events and family relationships that have played a role in their
developmental process. These assignments help them to explore their history in order to better
understand their current functioning. It is through this level of exploration that sexual assault is
reinforced not as a primarily sexually motivated behavior, but a behavior whose origins lie in the
clients’ psychological development (Calley, 2007). Reinterpreting the meaning of past events
that may have shaped current behaviors empowers clients to believe that change is possible.
During this stage, the client can present these assignments to the family if the family is willing to
be included in the treatment process. Family members explore how their relationships and
practices with each other have influenced the development and maintenance of offending
behaviors. With this exploration, families can begin to work towards improving their
functioning.
Treatment Module 3: Affective Autobiography and Trauma History
The affective autobiography uses the timeline and genogram from the previous stage to
explore the emotional experiences of the client’s significant life events and relationships. For
instance, a client’s loss of a loved one noted in the cognitive autobiography is discussed in depth
in this stage by exploring the resulting emotional and behavioral factors (grief, fire setting).
Because “offenders as a group tend to have a very restricted understanding of emotions” (Perry
& Orchard, 1992), this task is designed to facilitate the development of affect within the
offender. Once affective awareness is developed, clinicians may use relaxation techniques and
guided imagery to facilitate exploration and assist clients in identifying and dealing with painful
memories. Clients can further express their feelings through drawings, writing tools, music, tape
recording devices, and reading materials. Taken together, the cognitive and affective
autobiographies portray a complete picture of clients’ development. Only after clients have both
awareness and internal experience can they turn toward healthy and conscious outer expression
(Brems, 2001).
Treatment Module 4: History of Delinquency, Sexuality, and Substance Abuse
The fourth stage of treatment focuses on clients’ history of delinquency, substance abuse,
and sexuality. Exploring these components of their backgrounds aid the clinician in further
understanding their development and promotes a comprehensive examination, which helps to
establish specific treatment targets. It is during this stage that the psychological factors that are at
the root of clients’ offending behaviors, both sexual and nonsexual, become illuminated (Calley,
2007). In particular, they recognize how these behaviors were their strategy to gain a sense of
control and serve as a substitute for various unmet needs. Additionally, clients explore the role
that sexual arousal plays in their offending behaviors and are taught about normative and
nonnormative sexual environments. It is through this discussion of human sexuality and sex
education where the treatment model promotes clients’ nondeviant sexual interests.
Treatment Module 5: The Offense Cycle
The fifth stage of treatment, the offense cycle, is viewed as the crux of the treatment
program, bridging past work and historical factors with a plan for moving successfully into the
future (Calley, 2007). Each cycle is unique to the client’s own history, as they illustrate the
complex nature of the interrelationships of thoughts, feelings, and behaviors which led to their
sexual offenses. The offense cycle is regarded as a clinically useful intervention model and
several versions have been proposed in the literature (Freeman-Longo & Bays, 1999; Heinz et
al., 1987; Lundrigan, 2001; Perry & Orchard, 1992).
This stage brings about two major concepts related to cognitive-behavioral and
behavioral theories: cognitive distortions and conditioning. Cognitive distortions, originally
proposed by Beck, Rush, Shaw, and Emery (1979), consist of errors occurring in reasoning that
subsequently lead to faulty assumptions and misconceptions. Distortions frequently exhibited by
the male sex offender often include feelings of superiority and being above the law, chronic
anger when being unable to gain control, not recognizing how one’s behavior affects others, and
blaming others to avoid accountability. Although distortions consist of faulty thinking patterns
that are used to interpret various stimuli, conditioning comprises the automatic responses that
occur as thoughts, feelings, and behaviors are reinforced over time (Calley, 2007). It is crucial to
identify how these behaviors were learned as well as how they continue to be maintained if
counterconditioning techniques are used to discontinue this behavior. Clients learn to identify
these thinking errors that promote such behaviors as well as the triggers and maintenance factors.
Clients are then instructed to identify daily behavior problems and use the cycle as a method to
better understand the role that their thinking, affect, and behavior play in influencing these
problems (Calley, 2007). This self-monitoring can teach clients how to identify problematic
behaviors so that they can use coping skills before acting in unhealthy ways. These coping skills,
such as confronting irrational thoughts and anticipating and solving problems, give the client a
sense of control through self-management.
Treatment Module 6: Empathy and Restorative Justice
The development of empathy is a critical part of the treatment process for sexual
offenders. Their lack of understanding of the feelings of others, especially feelings related to
hurt, pain, and suffering, must be addressed in treatment so that they may be empowered to make
different decisions based on affect (Calley, 2007). Developing empathy can interrupt the offense
cycle by helping clients to recognize the pain that will be caused to the victim. The goal of this
stage is to help the client regain control of personal behaviors by linking offensive behaviors
with their feelings and effect on others.
Restorative justice involves the client transforming from an offender who has harmed
others to a productive citizen who benefits the community. The framework of justice thus shifts
from one of punishment or retribution to one of responsibility and restoration. It should be noted
that the use of restorative justice is reminiscent of the historical roots of the juvenile justice
system, namely, Adler’s (1959) individual psychology and his focus on social interest and
building a collective society. Community restoration may consist of volunteer work such as
gardening or other beautification methods to refurbish community properties. By engaging in
this type of work, clients witness the positive effects of one’s personal behavior on an individual
and a community, thus reinforcing this significant link between behaviors and feelings that is
inherently connected to empathy (Calley, 2007).
Treatment Module 7: Relapse Prevention and Reintegration
As mentioned earlier, Marques adapted Marlatt’s substance abuse relapse prevention
model to the treatment of sexual offenders. This final treatment stage reflects the perception of
sexual offending behaviors as an addiction and, as such, recovery is addressed as a continuous
process in which clients must constantly act against their addiction. This plan includes factors
that led to offending, situations that place one at risk for re-offending, methods to cope with
these risky situations, self-protection and self-monitoring strategies, and supportive family
members, friends, mental health professionals, or religious community should they be facing
relapse (Perry & Orchard, 1992). The community support relationship functions in the same way
that a sponsor is traditionally used in Alcoholics Anonymous, providing frequent support as
clients experience challenges and success, promoting implementation of the client’s safety plan,
and reviewing recovery gains with the client (Calley, 2007). During this stage, clinicians
evaluate the client’s treatment gains to reinforce the client’s growth and success.
Conclusion
This review of the history of behavioral and cognitive-behavioral treatments for sexual
offenders has portrayed how significant figures, along with their research and practices,
contributed to the contemporary approach in working with this population. Over time, treatment
targets continued and still continue to progressively increase, resulting in a more comprehensive
approach. However, there remains considerable room for improvement and efforts must be made
to strengthen the effectiveness of treatment and reduce recidivism rates in our society.
References
Adler, A. (1959). Understanding human nature. New York: Premier Books.
Association for the Treatment of Sexual Abusers. (1996). Reducing sexual abuse through
treatment and intervention with abusers [Position paper]. Beaverton, OR: Author.
Association for the Treatment of Sexual Abusers. (1997). Ethical standards and principles for the
management of sexual abusers. Beaverton, OR: Author.
Bancroft, J.H.J., Jones, H.E., & Pullan, B.R. (1966). A simple device for measuring penile
erection. Some comments on its use in the treatment of sexual disorder. Behaviour
Research and Therapy, 4, 239-241.
Barlow, D.H., Becker, R., Leitenberg, H., & Agras, W.S. (1970). A mechanical strain gauge for
recording penile circumference change. Journal of Applied Behavior Analysis, 3, 72.
Beck, A.T., Rush, A., Shaw, B., & Emery, G. (1979). Cognitive therapy of depression. New
York: Guilford Press.
Beck, A.T., & Weishaar, M.E. (1995). Cognitive therapy. In R.J. Corsini & D. Wedding (Eds.),
Current psychotherapies (5th ed.). Itasca, IL: F.E. Peacock Publishers.
Bingham, J.E., Turner, B.W., & Piotrowski, C. (1995). Treatment of sexual offenders in an
outpatient community-based program. Psychological Reports, 76(3), 1195-1200.
Blanchard, G.T. (1998). The difficult connection: The therapeutic relationship in sex offender
treatment. Brandon, VT: Safer Society Press.
Bond, I.K., & Hutchinson, H.C. (1960). Application of reciprocal inhibition therapy to
exhibitionism. Canadian Medical Association Journal, 83, 23-25.
Brady, J.P. (1966). Brevital-relaxation treatment of frigidity. Behaviour Research and Therapy,
4, 71-77. Brems, C. (2001). Basic skills in psychotherapy and counseling. Belmont,
CA: Wadsworth/Thomson Learning.
Calley, N. G. (2007). Integrating theory and research: The development of a research-based
treatment program for juvenile male sex offenders. Journal Of Counseling &
Development, 85(2), 131-142.
Charcot, J.M., & Magnan, V. (1882). Inversion du sens genital. Archives of Neurology, 3, 53-60.
Ford, C.S., & Beach, F.A. (1952). Patterns of sexual behavior. London: Methuen.
Freeman-Longo, R., & Bays, L. (1999). Who am I and why am I in treatment? Holyoke, MA:
New England Adolescent Research Institute Press.
Haslam, M.T. (1965). The treatment of psychogenic dyspareunia by reciprocal inhibition. British
Journal of Psychiatry, 11, 280-282.
Heinz, J.W., Gargaro, S., & Kelly, K.G. (1987). A model residential juvenile sex offender
treatment program: The Hennepin County Home School. Syracuse, NY: Safer Society
Press.
Kinsey, A.C., Pomeroy, W.B., & Martin, C.E. (1948). Sexual behavior in the human male.
Philadelphia: Saunders.
Kraft, T. (1967). A case of homosexuality treated by systematic desensitization. American
Journal of Psychotherapy, 21, 815-821.
Kraft, T., & Al-Issa, I. (1967). Behavior therapy and the treatment of frigidity. American Journal
of Psychotherapy, 21, 116-120.
Laws, D. R., & Marshall, W. L. (2003). A brief history of behavioral and cognitive behavioral
approaches to sexual offenders: Part 1. Early developments. Sexual Abuse: Journal Of
Research And Treatment, 15(2), 75-92.
Lundrigan, P.S. (2001). Treating youth who sexually abuse: An integrated multi-component
approach. Binghamton, NY: Haworth Press.
Mahoney, J.J. (1974). Cognition and behavior modification. Cambridge, MA: Ballinger.
Marks, I. M., & Gelder, M.G. (1967). Transvestism and fetishism: Clinical and psychological
changes during faradic aversion. British Journal of Psychiatry, 113, 711-730.
Marks, I.M., Gelder, M.G., & Bancroft, J.H.J. (1970). Sexual deviants two years after electric
aversion therapy. British Journal of Psychiatry, 117, 173-185.
Marks, I.M., Rachman, S., & Gelder, M.G. (1965). Methods for assessment of aversion treatment
in fetishism with masochism. Behaviour Research and Therapy, 3, 253-258.
Marlatt, G.A. (1982). Relapse prevention: A self-control program for the treatment of addictive
behaviours. In R.B. Stuart (Ed.), Adherence, compliance and generalization in
behavioral medicine (pp. 329-378). New York: Brunner/Mazel.
Marques, J.K., Day, D.M., Nelson, C., & West, M.A. (1994). Effects of cognitive-behavioral
treatment on sex offender recidivism: Preliminary results of a longitudinal study.
Criminal Justice and Behavior, 21, 28-54.
Marshall, W. L., & Laws, D. R. (2003). A brief history of behavioral and cognitive behavioral
approaches to sexual offender treatment: Part 2. The modern era. Sexual Abuse:
Journal Of Research And Treatment, 15(2), 93-120.
Meichenbaum, D.H. (1974). Cognitive behavior modification. Morristown, NJ: General Learning
Press.
Perry, G.P., & Orchard, J. (1992). Assessment and treatment of adolescent sex offenders.
Sarasota, FL. Professional Resource Press.
Pithers, W.D., Marques, J.K., Gibat, C.C., & Marlatt, G.A. (1983). Relapse prevention with
sexual aggressors: A self-control model of treatment and maintenance of change. In
J.G. Greer & I.R. Stuart (Eds.), The sexual aggressor: Current perspectives on
treatment (pp. 214-239). New York: Van Nostrand Reinhold.
Quinsey, V.L., & Earls, C.M. (1990). The modification of sexual preferences. In W.L. Marshall,
D.R. Laws, & H.E. Barbaree (Eds.), Handbook of sexual assault: Issues, theories, and
treatment of the offender (pp. 279-295). New York: Plenum.
Quinsey, V.L., & Marshall, W.L. (1983). Procedures for reducing inappropriate sexual arousal:
An evaluation review. In J.G. Greer & I.R. Stuart (Eds.), The sexual aggressor:
Current perspectives on treatment (pp. 267-289). New York: Van Nostrand Reinhold.
Rich, P. (2003). Understanding, assessing, and rehabilitating juvenile sexual offenders.
Hoboken, NJ US: John Wiley & Sons Inc.
Shaw, J. A. (1999). Practice parameters for the assessment and treatment of children and
adolescents who are sexually abusive of others. Journal Of The American Academy
Of Child & Adolescent Psychiatry, 38(12,Suppl), 55S-76S.
Stevenson, I., & Wolpe, J. (1960). Recovery from sexual deviations through overcoming
nonsexual neurotic responses. American Journal of Psychiatry, 116, 737-742.