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Cognitive-Behavioral Treatment of the Paraphilias

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Cognitive-Behavioral Treatment of the Paraphilias Isr J Psychiatry Relat Sci - Vol. 49 - No 4 (2012) Cognitive-Behavioral Treatment of the Paraphilias Meg S. Kaplan, PhD, and Richard B. Krueger, MD Columbia University, College of Physicians & Surgeons, Department of Psychiatry, and Sexual Behavior Clinic, New York State Psychiatric Institute, New York, New York, U.S.A. a paraphilia are “recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors generally involving ABSTRACT 1) nonhuman objects, 2) the suffering or humiliation Background: Sexual offenders continue to occupy of oneself or one’s partner, or 3) children or other non- the public’s attention; a significant proportion of this consenting persons that occur over a period of at least 6 population is diagnosed with paraphilias. Cognitive- months (Criterion A)” (2, p. 566). A reduction in sexual behavioral treatment has been the mainstay of treatment offending will depend on the ability of clinicians to for sex offenders and for the paraphilias for the past three identify the most effective treatments for this popula- decades. This article will review the history of cognitive- tion. Currently the most widely recognized treatment for behavioral therapy, its techniques, and its efficacy. sexual offenders and paraphilias is cognitive-behavioral treatment, including relapse prevention (2-6). This Method: A literature review was conducted of PubMed article will review the theoretical base for cognitive- and PsychInfo Databases. behavioral therapy, describe the specific techniques Results: A significant literature exists describing used, present information on efficacy, reviewing major cognitive-behavioral therapy and presenting outcome reports from specific treatment programs and meta- studies and meta-analyses evaluating its efficacy. analyses, and discuss limitations of the current evidence base. Suggestions for future directions will be offered. Limitations: This study is based on a literature review and influenced by the knowledge and biases of the authors. Conclusions: Cognitive-behavioral therapy is the most METHOD prominent therapy for sexual offenders. Although reports A literature search was conducted on the non-pharma- from individual programs and meta-analyses support cological treatment of the paraphilias using PubMed its efficacy, overall, the strength of the evidence base and PsychInfo databases from the years 1990 through supporting this therapy is weak and much more empirical April of 2011. The non-pharmacological treatments research is needed. emphasized cognitive-behavioral therapy and relapse prevention therapy. The PubMed search included any pertinent Cochrane Reviews. The search used search terms of “paraphilias,” “exhibitionism,” “voyeurism,” “frotteurism,” “sadism,” “masochism,” fetishism,” “transvestic fetishism,” “paraphilia-related disorder,” BACKGROUND “paraphilic coercive disorder,” and “paraphilic rape.” In Public concern about sexual offenders has escalated. addition, the authors reviewed secondary references, A significant proportion of this population has been textbooks, and textbook chapters. Relevant literature diagnosed with paraphilias (1). The essential features of was selected and reviewed. Address for Correspondence: Meg S. Kaplan, PhD, Sexual Behavior Clinic, New York State Psychiatric Institute, 1051 Riverside Drive, Unit #45, New York, New York 10032, U.S.A. [email protected] The first author received travel support from Ferring, Inc. and was a consultant to the Paraphilias Subworkgroup of the Sexual Disorders Workgroup of DSM-5. The second author is on the Paraphilias Subworkgroup of the Sexual Disorders Workgroup of DSM-5 & on the World Health Organization International Classification of Disease Working Group on Sexual Disorders and Sexual Health. 291 COGNITIVe-BehavioraL TREatmENT OF THE PARAPHILias RESULTS other) were reported by less than 2% of the programs. Similar results were reported for residential programs HISTORY OF Cognitive-BEHAVIORAL THERAPY and in earlier surveys. In Canada, 47.4% of adult com- In a recent review (5, 6) of behavioral and cognitive munity programs identified cognitive-behavioral treat- behavioral approaches to sexual offenders, Laws and ment as their primary theory, 15.8% relapse prevention, Marshall concluded (p. 110): It is evident from this 10.5% good lives, and 5.3% biomedical, multisystemic, review of the history of sexual offender treatment that psycho-socio-educational, risk-need-responsivity, and cognitive behavioral procedures have developed into self-regulation. Among adult residential programs in a comprehensive approach that is widely shared and Canada 50.0% identified cognitive-behavioral treatment appears to be effective. The breadth of treatment tar- as their main theory, 37.5% self-regulation, and 12.5% gets has progressively increased and research has been bio-medical. Thus, in North America, clearly cognitive- implemented to evaluate the basis for these expanded behavioral and relapse prevention modalities have been targets. Theoretical and classification efforts have moved the predominate theory guiding treatment. in harmony with both the expansion of treatment pro- grams and the associated generation of research. DESCRIPTION OF TECHNIQUES Social learning theory approaches have been cited as important contributing factors in the development and Decreasing Inappropriate Arousal maintenance of paraphiliac sexual interest; the impor- The principle treatment approach of behavior therapy for tance of conditioning is emphasized over intrapsychic paraphilias is to eliminate the pattern of sexual arousal to processes (7). Behavior therapy interventions for this deviant fantasy by assisting the patient with decreasing population were originally derived from Pavlov’s classical inappropriate sexual arousal. A variety of techniques conditioning (8) and Skinner’s operant conditioning (9) that have been used have been reviewed by Marshall and and used to attempt to modify sexual preferences (10). Laws (5, 6, 14-16). Some of these will be described here: According to McGuire, Carlisle and Young (11), “The Covert Sensitization: This is a method that has been theoretical basis for such treatment, as for all behavior used effectively to disrupt fantasies and behaviors that therapy, is that the symptom or behavior to be treated has are antecedent to the offending behavior. It pairs urges been learned at some time in the past and can be changed and feelings that lead an individual to engage in a devi- by the learning of a new pattern of behavior” (p. 185). ant act with aversive images which reflect the adverse Thus, the goal of treatment is to reduce inappropriate consequences of continuing with the deviant behavior sexual arousal and increase appropriate arousal (12). (17, 18). This treatment is conducted by having the patient tape record the session in private. A therapist PROMINENCE OF Cognitive-BEHAVIORAL THERAPY then reviews it and offers feedback in either individual The Safer Society Program, a non-profit organization in or group sessions. This technique has been used suc- the United States dedicated to ending sexual abuse, has cessfully to treat exhibitionists (19, 20). since the 1980s regularly conducted surveys of sex offender Satiation: Masturbatory satiation is a technique that treatment programs in the United States and Canada. is effective in decreasing deviant sexual arousal by mak- These surveys clearly demonstrate that the predominant ing the deviant fantasy boring. This therapy consists modality for treatment is cognitive-behavioral and relapse of having the patient masturbate at home in private prevention therapy (13). For instance, in the most recent to non-deviant adult fantasies until ejaculation has survey of 1,379 sexual abuser treatment programs from occurred. Satiation works by pairing deviant sexual all 50 states (13), the District of Columbia, and nine fantasies with the aversive task of masturbating for 55 Canadian Provinces during 2008, for community pro- minutes post orgasm. These sessions are audiotaped at grams, 65.1% reported that cognitive-behavioral theory home and brought to therapy sessions where tapes are best described their program, followed by relapse preven- reviewed and critiqued. Several studies have supported tion (14.8%), the good lives model (5.2%), multisystemic the value of this technique (12, 21-23). theory (3.1%), and risk-need-responsivity (3.1%). Other Systematic Desensitization: This is a technique that theoretical approaches (biomedical, family systems, harm aims at the decrease of maladaptive anxiety by pairing reduction, psycho-dynamic, psycho-socio-educational, relaxation with imagined scenes depicting anxiety- self-regulation, sexual addiction, sexual trauma, and producing situations (24). 292 MEG S. KAPLAN AND RICHARD B. KRUEGER Enhancing Appropriate Sexual Arousal to Adult Partners attitudes and beliefs to be consistent with their behaviors. The second component of cognitive-behavioral treat- This results in cognitive distortions, misbeliefs, and a ment with individuals with paraphilias is to assist the rationale to support their behavior. Treatment focuses patient with enhancing sexual interest and arousal to on recognition of the offender’s own distortion. adult partners or to appropriate behavior with adult Assertive Skills Training: Some paraphiliacs are partners. There are a variety of techniques, some of unable to express positive or negative feelings, state which will be described here. what they want, or ask others to change their behavior. Orgasmic Reconditioning:
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