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A Clinical Evaluation of Possible Sex Offenders - Part I
By Gene G. Abel, MD
This monograph was developed after a l985 training institute, "The Incest Offender, The
Victim, The Family: New Treatment Approaches" sponsored by MHA. As noted in the
introduction to the monograph, the articles by Dr. Abel and Dr. Groth "provide the reader
with syntheses of two different perspectives about the nature of the disorder and suggest
solutions for treating the offender." These articles present their thinking and practice as
of l985. Times and practice change and these articles do not necessarily reflect best
practice in 2002. We will post a discussion of these articles written from the perspective
of current practice. This monograph is presented now for its historical value, to raise
awareness of these important issues and hopefully to stimulate discussion among
interested individuals.
This is the first of two articles in the Monograph...The Incest Offender, the Victim, the Family, New Treatment Approaches.
Clinicians Are Increasingly Faced with Evaluating and Treating Paraphiliacs
Mental health professionals usually evaluate patients who are neurotic, psychotic or those with psychosomatic illness, avoiding patients with more
violent behavior, such as sex offenders (sexual deviates). Greater interest has recently developed in the assessment and treatment of the
paraphilias as a result of the rising rate of sex offences and advancements in assessment and treatment of those individuals. Heightened public
awareness of sex crimes and the increased availability of rape crisis centers and sex crimes squads has allowed increased case reporting of these
crimes, greater attention to the treatment needs of victims and more recently, greater awareness that offenders need treatment. As a result, the
clinicians are increasingly faced with evaluating and treating paraphiliacs.
The paraphiliac poses unusual problems for clinicians because of the confidentiality of the records, the paraphiliac's frequent denial of the severity
of his problem and his lack of motivation for treatment. To further complicate treatment, clinicians have generally been trained in an era that de-
emphasized assessing and treating sex offenders. The clinician is thus faced with evaluating a difficult patient having problems that the clinician
has had limited training and experience in evaluating and treating. The following recommendations have evolved from the author's experience
evaluating and treating paraphiliacs in various clinical and research settings and are offered as possible solutions to dealing with this difficult
population.
Confidentiality
Confidentiality of the materials obtained during a clinical interview is of major importance, since without a confidential relationship, the
paraphiliac is likely to remain uncooperative and provide little information to assist in his own treatment. The greater the efforts taken by the
clinician to establish confidentiality and to clarify the steps taken to protect the patient's confidentiality, the greater will be the validity and cost
efficiency of the clinical interview. The key to confidentiality is to not obtain specifics of any particular deviant behavior that would clarify who
the offenders victim had been. The criminal justice system and social agencies attempting to gain access to confidential information will only do
so if the clinician has what they want, that is, specific details of specific crimes.
The clinician can prevent attempts by others to gain access to confidential information by not acquiring such information. The clinician needs to
protect the patient by not recording (or obtaining such information as the specific age of the victim, the physical characteristics of any victim, the
time of day or the place in which any particular sexual crime has been committed. This can be modeled for the patient by telling him "I don't want
you to tell me the specifics of any of these acts. For example, if you molested a 10-year-old girl named Sarah at the comer of 86th and Broad
Street, last Tuesday at 5:30 p.m., I would only want you to tell you molest girls less than 12 and you have done so recently. I want to learn the
general characteristics of your sexual urges and the target of those sexual urges, but I want to protect your records and the best way to protect them
is to not have the specifics of any of your actual involvements". This approach should be further clarified in a written consent form for the patient.
A second step is the filtering of information that is presented to the clinician. If the patient does inadvertently begin to talk about the specifics of
his paraphiliac behavior, he should be immediately stopped, taught once again not to reveal specifics. Even it the interviewer hears the specifics of
a crime he should filter the information reported. The clinician's notes should be devoid of the specifics of the sex offender's deviant acts. If you
don't have what others want, they are less likely to try and obtain it from you.
Not dealing with the issue of confidentiality with paraphiliacs will only obstruct the evaluation and treatment process and thereby block the
development of an effective treatment program. Since treatment can only be effectively planned if the therapist is aware of what the patients
problems are, obtaining accurate information is critical for treatment. Sex offenders will not provide this information unless their confidentiality is
protected. If the clinician is unwilling to take measures to protect the offender's confidentiality, it is probably best that he not deal with sex
offenders. No therapist is expected to deal with every kind of problem. If the therapist's personality characteristics are such that dealing with
offenders who commit dangerous sexual acts is too uncomfortable, it would be best to refer the patient to another therapist. An unfortunate
circumstance occurs when the interviewer, because of his or her discomfort about working with sex offenders provides no system of
confidentiality, conducts an interview and assumes that the information provided is valid. The faulty conclusions that result from such an
interview may lead the clinician to suggest that no treatment is indicated, or equally as bad, the clinician continues to see the patient for another
problem not related to his deviant behavior. The net effect is that the more serious sexual deviations are left unattended while the patient
participates in "therapy", concealing the real problem and possibly convincing himself that since he is in treatment, everything will be all right.
Unfortunately, if no treatment to prevent sex offenses occurs recidivism and further victimization is likely.
The Clinical Interview
Interviewing techniques with sex offenders should start from the supposition that the offender has committed a sex offense and will discuss it with
the interviewer. Questions such as "Have you committed any sex crimes? Are you aroused to children?" suggest to the offender that denial is an
option for him. Given this option, he is highly likely to use it. Questions should instead focus on the expectation of reporting sex crimes, such as
"How long have you been involved with children? How does your family feel about involvement in exposing yourself?"
It is important to avoid the offender's use of labels, that is, the clinician should be interested in the paraphiliac's behavior, not how he might label
it. For example, some individuals will describe themselves as child molesters, implying that they have a hands on activity with children. When
questioned however they will report no hands on behavior, but instead describe the behavior of exposing themselves to children. The interviewer
should obtain details about the duration of the problem, the first occurrence of the deviant behavior, any possible precipitants or antecedents that
initiate the paraphiliac's interests, and the frequency of the behavior (the latter is most-easily obtained by reviewing year by year the estimated
occurrences; considerable year to year variance appears to be the rule rather than the exception).
Common Interview Error
One common interview error is not questioning the patient about all types of sexual deviations. At least fifty percent of individuals coming for
treatment have more than one paraphilia, with some patients having 10 or 11 different deviations. The patient assumes that if no specific question
is asked regarding other types of deviant sexual behavior, there is no need to report that deviant behavior. Most offenders only report that
deviation that has come to the attention of the family, police or other authorities. Although it may appear a bit simplistic, it is probably best to
have a list of the more common paraphilias and to go through the list questioning the paraphiliac about each of the types of deviations. It should
not be too surprising that paraphiliacs involve themselves in more than one deviant sex behavior. Whatever the differentiation system is that leads
to sexual arousal, or whatever the control system is for suppressing arousal to specific paraphiliac objects or behaviors, once these systems become
dysfunctional and one deviant behavior develops, other deviant interests may develop through the same faulty system.
The antecedents of deviant behavior are especially important for the clinician to elucidate. Clinicians are accustomed to conceptualizing deviant
behavior as the act itself, with limited attention to the details of the numerous antecedents. In terms of developing treatment intervention, it is
essential to know these antecedents, since treatment should help the patient disrupt the very early elements of his deviant behavior. For example,
an exhibitionist may ultimately expose himself to adult females, but frequently, there is an extensive chain of events leading to that behavior. He
may have conflicts about his job, family relations or himself, and elect to get in his car and "drive around". He may then find himself driving in
the particular area where he has exposed himself in the past. He then finds himself slowing down his car to watch females walking along the
street. He may then begin to fantasize about times that he has exposed himself, thinking of the particular women he's exposed himself to, and the
most enjoyable of these experiences. He might then pull his car over to the curb, watching from his car. He then identifies a specific target to
expose himself to, calls her over to the car, and then actually exposes himself.
In terms of treatment, this patient not only needs reduction of his interest to expose himself to adult females, but also must begin to conceptualize
his deviant act as including the blow up that was antecedent to his getting in the car. His getting in the car with no particular plan other than to
think for a while about his recent conflicts, driving around in areas that he has exposed himself in the past, fantasizing previous exposures, pulling
his car to the side of the road, fantasizing exposing himself to the specific target, etc. All of these antecedent events are part of his deviant
behavior, and if he is to gain control over exposing himself, he must learn to intercede as early as possible in this sequence of events. Treatments
that are intended to disrupt late events in this sequence will probably be less effective than those directed at the early elements of this chain. The
patient's control is greatest early in the chain, and progressively decays as he gets further into the chain. Without knowledge of this entire
sequence, treatment is less likely to be effective.
Continuing First Article, A Clinical Evaulation of Possible Sex Offenders
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