Maintaining Treatment Gains and Preventing Relapse
Treatment programs for pedophiles do not assume that treatment is something to be delivered only in the therapist’s office and that once it is delivered, the pedophile is cured. Instead, treatment programs approach pedophiliac behavior as an ongoing problem to which the patient must always be attentive, and treatment as a training ground for new skills that are practiced by the patient with supervision by the therapist. Supervision and ongoing treatment are major parts of therapy and involve not only the patient and the therapist but potentially the patient’s family, friends, work associates, and, when applicable, a probation or parole officer.
Maintenance therapy was addressed by Marshall et al. (1993) in their discussion of a three-tier approach to treatment in the prison setting. Tier 1 involves the cognitive-behavioral approach, as previously described, but takes place in a maximum-security setting. Tier 2 involves treatment maintenance and relapse prevention strategies in a medium-security setting. Tier 3 consists of implementation of those treatment maintenance and relapse prevention strategies and ongoing treatment outside of the prison setting.
Abel and Rouleau (1990) described surveillance groups and the development of specific feedback forms for individual pedophiliac patients. Surveillance group members include individuals from the patient’s family, work environment, and social group. When the pedophiliac individual is on probation or parole, the probation or parole officer is also usually involved. Members of the surveillance group, the patient, and the therapist meet. The patient describes his or her pedophiliac behavior and, more importantly, identifies the typical antecedents to reoffense based on his or her history. Twice a month, based on their observation of the patient, members of the surveillance group complete a short questionnaire, to be given to the therapist, that identifies any evidence of such antecedents they have observed during the reporting interval, including the pedophiliac patient’s emotions, situations, conflicts, or behaviors. Surveillance members are not expected to be detectives or to go out of their way to observe the patient in his or her environment. Instead, within the normal course of his or her life, each surveillance member is asked to provide feedback to the therapist, thereby expanding the therapist’s awareness of any potential problems that the patient may be having and enlarging the opportunity for feedback regarding possible relapse behavior.
Relapse prevention has been outlined in the work of Pithers, Marques, and colleagues (Marques and Nelson 1989; Marques et al. 1989; Pithers 1990; Pithers et al. 1988, 1989); these authors offer the most clearly defined model of the integration of treatment with relapse prevention, a model that was based on the relapse prevention strategy expounded by George and Marlatt (1990). Relapse prevention is a self-management enhancement methodology. In it, relapse or reoffense occurs as a result of the following sequence: 1) the pedophiliac patient makes apparently inconsequential or minor decisions that ultimately place him or her in a risky situation without his or her being aware of this; 2) a high-risk situation occurs in which the patient experiences emotional states, stress, or interpersonal conflicts that have frequently preceded child molestation in the past; 3) the patient’s coping mechanisms fail (successful coping mechanisms would avert possible relapses); 4) a lapse occurs (e.g., recurrence of deviant fantasies, reminiscences of prior child molestation experiences, visitation of environments in which child molestation has occurred in the past); 5) an abstinence-violation effect occurs (i.e., the patient loses self-esteem as a result of the lapse, which he or she views as reflecting treatment failure); and 6) an actual relapse occurs (e.g., molestation of a child).
Relapse prevention treatment involves the following:
Identification of the factors that have inhibited the patient’s motivation for doing something about his or her pedophiliac behaviors and challenging the validity of these inhibitors
Identification of high-risk situations
Acquisition of support networks to assist the patient in making the transition to a nonpedophiliac lifestyle
Implementation of appropriate structuring of the patient’s lifestyle, and implementation of tension-reducing activities to minimize the stressors antecedent to child molestation
Learning of pedophiliac urge control techniques and other coping mechanisms (especially in high-risk situations) to block relapse
Specific identification of assessment criteria that the patient can use to detect when he or she has overextended the current treatment plan and needs further treatment
Treatment focuses on helping the patient avoid lapses and teaching the patient procedures to reduce the likelihood of a lapse resulting in an actual relapse.
Harold completed the intensive portion of his treatment successfully. Although it was initially difficult for him to recognize and admit that he had sexual interest in young boys, he eventually became forthcoming and open with his group. He expressed great relief that he could “finally be open and discuss feelings that had mystified [him].” Harold shared deeply about his feelings of shame that he was attracted to boys and that he knew that most of society was repulsed by him. Harold reported a significant decrease in his sexual drive after being placed on an SSRI. He stated that he felt relieved that he was in control of his thoughts as opposed to his thoughts controlling him. He also found that he had much more energy available to devote to his marriage now that his secrets were in the open and he could talk with other men who were struggling with the same thoughts and behavior. Like other pedophiliac individuals, Harold reports that he has been able to monitor and manage his own sexual drives, thoughts, and behavior and is especially able to recognize when he is at risk for acting-out. As Harold moved into the maintenance phase of treatment, he credited his pastor, his wife, and several good friends with giving him support to be able to keep from acting on inappropriate sexual urges. The above-named individuals were also enrolled as members of Harold’s surveillance group.
Revision date: July 4, 2011
Last revised: by Jorge P. Ribeiro, MD