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Article 21

Deviant Sexuality in Children and Adolescents

A Protocol for the Concurrent Treatment of Sexual Victimization and Sex Offending Behaviors

David D. Hof, Julie A. Dinsmore, Catherine M. Hock, Michael A. Bishop, & Thomas R. Scofield

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Paper based on a program presented at the 2009 American Counseling Association Annual Conference and Exposition, March 19-23, Charlotte, North Carolina.

Increased attention has recently been given in mental health literature to better understanding the impact of personal victimization on child and adolescent sex offending behaviors (Burton, 2003, 2008; Hunter & Figueredo, 2000; Kulesz & Wyse, 2007; Veneziano, Veneziano, & LeGrand, 2000). During the 1990s, the number of sex offenders processed through court systems increased by 50%, highlighting the need to identify effective interventions for this growing client population (Snyder & Sickmund, 1995). Studies have found that between 40 and 80% of sex offenders have been sexually abused themselves (Hunter, Goodwin, & Becker, 1994; Ryan & Lane, 1997). Research supports the idea that youth who are victimized or see others victimized may go on to repeat this behavior (Burton, 1999, 2008; Burton & Meezan, 2004), which would suggest that treatment of offending behaviors should concurrently address sexual victimization and engage the client in trauma resolution. Specific attention to victimization issues can enhance clients’ goal attainment in their sexual offending treatment in several ways. It not only helps them gain a better understanding of the root cause of their anger and their need for power, control, and revenge, but it can also help clients conceptualize and implement more appropriate replacement behaviors. However, currently there are no universally accepted treatment protocols that address concurrent treatment of offending behaviors and victimization issues (Burton, 2008; Ryan & Lane, 1997).

This article provides an overview of a suggested treatment protocol for use with children and adolescents who display offending behaviors and also have a history of sexual abuse. It treats victimization issues and sexual offending behaviors simultaneously, integrating evidence-based treatment methods of both issues for the most effective treatment (see Table 1 for detailed protocol). The protocol goals are considered beneficial for the treatment of a child or adolescent who is considered to be sexually reactive. Sexually reactive children have been exposed to inappropriate sexual activities and engage in a variety of age-inappropriate sexual behaviors as a result of their own exposure to sexual experiences. They begin to engage in sexual behaviors or relationships that may include excessive sexual play, inappropriate sexual comments or gestures, mutual sexual activity with other children, or sexual molestation and abuse of other children. These children may not understand the harmfulness of their behaviors (Cavanaugh Johnson, 1999). Conversely, sex offenders would be individuals who understand the unlawfulness and harmfulness of their sex offending behaviors and yet choose to offend repeatedly (Ryan & Lane, 1997). Based on years of experience using this protocol, the authors recommend that the goals, as well as the steps to implement them, be addressed in the order given. Although the intention is to provide a universally accepted protocol for concurrent treatment of this population’s issues, the protocol can be customized to meet individual clients’ needs.

Summary of Treatment Protocol

Goals 1-3 of the protocol focus on building rapport and creating a safe environment for clients. This can be challenging for individuals with offending behaviors, as therapy is often court ordered. Similar to other therapeutic relationships, trust is essential to the change process (Ivey & Ivey, 2003), and working with individuals with offending behaviors is no different. Because participation is not voluntary, clients may feel isolated and incapable of making change. It is essential for the therapist to join with clients, helping clients not feel alone. Court-ordered clients cannot choose whether or not they attend therapy, so giving power to clients in how they would like to participate can be a key factor in helping to increase client motivation.

Goals 4-5 are designed to help clients openly share their stories of offending behaviors and personal victimization as well as their entire sexual histories, both healthy and unhealthy behaviors. Initially, therapists should have clients share their offending behaviors in detail, both verbally and in writing. At times, clients may only self-disclose offending behaviors they have been caught doing or legally charged with. By coming back to the written history throughout the course of treatment, the therapist is able to facilitate further self-disclosure by clients and uncover additional offending behaviors the client has not disclosed as well as unrecognized victimization experiences. When writing and discussing the client’s victimization history it is often helpful to talk not only about sexual abuse, but also physical and emotional abuse. Clients may need assistance differentiating between offending behaviors, victimization, healthy sexual behaviors, and unhealthy sexual behaviors.

In implementing Goals 6-8, therapists use clients’ histories to help them explore how their offending behaviors are illegal and unhealthy and to take ownership for ways in which they abused other human beings. It is equally important for clients to identify unhealthy and illegal behaviors that were done to them, which can help them make sense of how they developed unhealthy patterns of sexual behavior.

Goal 9 involves exploration and understanding of clients’ fantasies and how they played a role in their choice to offend. Clients may be reluctant to share their darkest fantasies; however, it is essential for clients to learn how to recognize and replace, rather than reinforce, unhealthy fantasies.

Goal 10 requires clients to write their thoughts, feelings, and behaviors before, during, and after their offense. In this way, clients begin to understand what thoughts and feelings trigger their offending behaviors and to see moments during the offending cycle when they may be able to intercede. In this goal area, it is important to help the client understand that many people do not offend for enjoyment of a sexual act, but to meet their needs for power, control, revenge, and/or expression of anger. A better understanding of the impact of being victimized may help the client understand the feelings triggering the offending behaviors.

Goals 11-15 focus on teaching clients a model of healthy human sexuality, a process necessary to help them create and nurture healthy relationships and have better understanding as to how their current perspectives on gender roles, sexual orientation, intimacy, relationships, and reproduction were impacted by their victimization.

After clients have a better understanding of healthy relationships, Goal 16 asks them to reexamine their current relationships and determine which are healthy and how their offending behavior has damaged those relationships. It may also be helpful to identify multigenerational abuse and victimization patterns within the family system. This awareness is often helpful in clients’ taking responsibility for how they have impacted others’ lives.

Goals 17-18 expand the focus on clients taking responsibility for their actions by asking clients to identify by name the individuals they victimized, how they impacted their victims, and how their victims might respond to them. This process begins to build empathy and an increased awareness of their long-term impact. It may be beneficial for clients to write a letter of clarification to the survivor of their offense to aid in taking full responsibility and to aid in the treatment of the survivor.

Goals 19-22 incorporate education about the sex offender assault cycle and lapse contracts to help clients understand what they have control of in their lives and what they do not, especially within the context of their own victimization. Clients should begin by mapping the steps in the assault cycle so they can see their patterns of sexual offending and visualize getting out of their cycle before offending. A lapse contract helps clients identify realistic and useful replacement behaviors at each step in their cycle. In helping clients develop their lapse contracts, it is important to help them understand how their victimization has impacted their decision making process.

As clients gain a better understanding of healthy relationships and their decision-making processes in relationship to their assault cycles, it is time to create and maintain healthy relationships. Goals 23-24 facilitate the building of clients’ support systems. Their support systems should start with individuals who are least likely to trigger their assault cycles, should be in writing, and should be carried on clients’ bodies so that they have access to these names at all times.

Goals 25-26 encompass the development of a relapse prevention plan (RPP; Laws, Hudson & Ward, 2000) for offending behaviors that includes cues, risk factors, replacement behaviors, and primary support persons who can keep clients accountable. In addition to the RPP that is specific to offending behaviors, a separate process of identifying risk factors that increase likelihood of being re- victimized and replacement for these behaviors is equally as important.

Aftercare, addressed in Goals 27-28, provides a safety net if client’s struggle to maintain healthy behavior and follow through with their treatment. The termination process should include reviewing the aftercare plan with clients’ primary support systems. A referral to an aftercare group should be required if such a group is available.

Discussion

The counseling profession is attempting to respond to the needs of the growing number of clients experiencing the impact of sexual victimization and displaying sexual offending behaviors. This suggested treatment protocol provides a holistic approach to these issues while allowing for the flexibility to respond to individual client needs. It is hoped this protocol provides direction for those seeking a uniform and integrated approach to concurrent treatment of offending behaviors and victimization for sexually reactive children and adolescents that can be implemented in both inpatient and outpatient settings.

Table 1

Protocol for Concurrent Treatment of Sexual Victimization and Sexual Offending Behaviors

(Offending Behavior Goal = O; Victimization Goal = V)

Goal 1: Develop Rapport (O & V)

• Get to know each other

• Understand purpose and process of therapy

Goal 2: Making it Safe (O & V)

• Discuss fears and expectations

• Review confidentiality

Goal 3: Develop Trust (O & V)

• Define trust and distrust, and why it is important to be able to trust others

• Understand how sexual abuse has affected ability to trust self and others

• Develop an atmosphere that encourages disclosure

Goal 4: Disclose and discuss healthy and unhealthy sexuality history including offending behaviors (O)

• Write and present sexual history in therapy

• Write and share weekly sexuality journal

Goal 5: Share victimization story in a safe and supportive environment (V)

• Identify fears around disclosing

• Increase understanding of reason for maintaining the secret, addressing feelings of responsibility, blame, and helplessness

• Validate disclosure of abuse and discuss other people’s denial and minimization at previous disclosures

Goal 6: Understand how client was sexually, physically, and emotionally abused and the impact of this abuse (V)

• Write abuse history to include story previously shared

• Explore how client survived abuse

• Begin to understand how to nurture self in healthy ways

• Name the abuser

Goal 7: Understand the difference between sexually reactive behavior and sex offending behavior (O & V)

• Review written histories

• Identify ways both types of behavior have contributed to client development

• Identify illegal behaviors

Goal 8: Gain awareness of what client is feeling and why (O & V)

• Identify and name feelings

• Translate feelings expressed through behaviors into words

• Identify appropriate and inappropriate expression of feelings and encourage appropriate expression

Goal 9: Explore healthy and unhealthy fantasies and how these fantasies impacted offending behaviors (O)

• Chart fantasies in writing and present in therapy

• Review fantasies related to sexual offense

• Replace with healthy sexual fantasy

Goal 10: Understand thoughts, feelings and behaviors specific to sexual offenses (O)

• Write and present thoughts, feelings, and behaviors, before, during, and after offense

• Identify why client acted out sexually

Goal 11: Teach healthy intimacy, relationships, sex, reproduction, and touch (O & V)

• Gain a comprehensive understanding of healthy human sexuality

• Begin to implement into client’s life

Goal 12: Learn about and begin to develop healthy human relationships (O & V)

• Understand sexual identity

• Understand and begin to accept sexual orientation

Goal 13: Increase client’s awareness of how victimization impacted identity development (V)

• Identify qualities client likes and dislikes about self

• Examine positive/negative memories and how they influence self-image and the power client has over internalizing those messages

• Identify characteristics client would like to associate with self, the motivation behind their desire, and if healthy, steps to adopt these characteristics

Goal 14: Identify etiology of client feelings about the person who abused him/her (V)

• Understand and normalize what client currently feels about abuser

• Help client understand etiology of feelings

• Help client let go of feelings getting in the way of promoting recovery

Goal 15: Understand client’s beliefs specific to gender roles and the impact of these beliefs (O & V)

• Write and discuss beliefs related to gender roles

Goal 16: Understand how relationships have changed between client, family, and friends (O & V)

• Examine client’s relationship with family before and after abuse

• Examine client’s relationship with friends before and after abuse

• Identify how client would like to change these relationships

Goal 17: Increase client capacity for empathy and ability to validate, support, and understand others (V)

• Become more open to the emotional responses of others

• Continue to normalize victimization

Goal 18: Name individuals client has abused and understand immediate and long-term impact on their lives (O)

• List each individual the client victimized

• Write and discuss how victim(s) may have felt then and now

• Write clarification letter(s) to each victim

Goal 19: Understand assault cycle and how it applies to client’s offending behaviors (O)

• Write and present in therapy client’s assault cycle: (a) deviant fantasy, (b) reinforcement of fantasy, (c) objectification, (d) victim selection, (e) decision to offend, (f) planning, (g) grooming, (h) offense, (i) rationalization, (j) shame, and (k) back to normal

Goal 20: Understand how victimization affected client in the past and present: emotionally, physically, sexually, and psychologically (V)

• Write and examine in therapy how specific abuse impacted client in the past and present: emotionally, physically, sexually, and psychologically

• Determine changes client would like to make emotionally, physically, sexually, and psychologically

Goal 21: Understand elements of client’s life over which they have control and how to exercise change (O & V)

• Identify what client has control of and want they want to change

• Create plan of change

Goal 22: Understand assault cycle and know how to get out of it before offending (O)

• Write and present lapse contract in therapy

Goal 23: Creating healthy relationships (O & V)

• Understand client’s personal space and boundaries issues

• Create a plan to assert boundaries in client’s life

Goal 24: Identify and create support system (O & V)

• Identify individuals client can talk to about abuse and offense

• Identify individuals who may not know about client’s abuse and offense yet can be supportive

• Formally contact individuals and ask them to be part of support system

• Create a list of names and numbers that can be carried on client

Goal 25: Develop and implement relapse prevention plan (O)

• Create relapse prevention plan

• Share plan with support system

Goal 26: Identify risk behavior for victimization and create plan for replacement behaviors (V)

• Identify risk behavior that may get in the way of recovery and overall mental health

• Create replacement for risk behaviors

• Plan how to implement replacement behaviors into everyday life

Goal 27: Develop and implement aftercare plan (O & V)

• Create and present aftercare plan in therapy

Goal 28: Provide closure and reinforce aftercare plan

• Review aftercare plan with support system

• Refer to aftercare group

• Terminate