Cognitive-Behavioral Therapy

Cognitive-behavioral therapy is typically a structured, short-term type of treatment (Beck, 1995). It is deeply rooted in behaviorism, cognitive therapy, and a combination of the two (Beck, 1995; Gonzalez-Prendes & Resco, 2012). This type of therapy is used for a broad range of psychological disorders, including but not limited to, depression, anxiety, post-traumatic stress disorders, and sex crimes. It began to emerge in the late 1960s and is presently the most common type of treatment for sex offenders (Laws & Marshall, 2003).

Cognitive-behavioral therapy has been described by the National Alliance for the Mentally Ill (2012, n.p.) as "a form of treatment that focuses on examining the relationships between thoughts, feelings and behaviors." Individuals are encouraged to explore patterns of thinking that led to self-destructive behavior, including committing sex crimes. The objective is for sex offenders to change their current thought patterns to reduce or eliminate undesirable behavior. The client and therapists actively work together (National Alliance for the Mentally Ill, 2012). The therapist is "problem-focused, and goal-directed in addressing the challenging symptoms" (n.p.). Thus, the therapist and client address specific problems (e.g., commission of sex crimes) and assist the client in selecting specific strategies for countering the thought process that leads to the behavior. Cognitive-behavioral therapy is an active intervention, and the client can expect to do homework outside of sessions with the therapist (National Alliance for the Mentally Ill, 2012).

Cognitive-behavioral therapy is based on three assumptions. First, it is assumed the client can access and be aware of cognitive processes that occur. This may require training and practice, as the client may not be immediately able to access such information. Second, it is assumed that one's reaction to events is highly dependent upon one's thinking. Thus, if someone has had a negative experience with a given event or person in the past, he or she may avoid a similar situation, given the history. Third, it is assumed that the way one thinks and feels about a certain situation, event, or person can be identified. Those thoughts and feelings can then be modified and changed (Dobson & Dobson, 2009).

An example of these assumptions can be found easily in cognitive-behavior treatment for sex offenders. For example, an offender may have the belief that it is acceptable to view children as sexual objects. This can lead to perceiving a certain situation (e.g., children in bathing suits playing at a local swimming pool) as a cue to commit a sex crime. This type of thought may be formed from a person's past experiences with children. This type of thought is a cognitive distortion and can be targeted for change through a myriad of processes. For example, it can involve group therapy, where others confront the person with information to the contrary—children are not sexual objects and should not be targeted for a sex crime.

Cognitive-behavioral therapy programs vary widely in how they treat sex offenders (Terry, 2013). Many commonalities, however, also exist among them. Terry (2013) identified nine goals of cognitive-behavioral programs for sex offenders. These include the following goals that offenders should be able to attain:

  • 1. Recognize their problems and behaviors.
  • 2. Understand the feelings that led to their deviant behavior.
  • 3. Identify and eventually eliminate their cognitive distortions.
  • 4. Accept responsibility for their behavior.
  • 5. Reevaluate their attitudes and behaviors.
  • 6. Acquire pro-social expressions of sexuality.
  • 7. Gain a higher level of social competence.
  • 8. Be able to identify their high-risk situations.
  • 9. Understand the repetitive nature of their behavior and be able to break the sequence of offending.

It is also critical when applying cognitive-behavioral therapy to known sex offenders that not only are the needs of the offender addressed, but the community is protected as well (Moster et al., 2008).

Cognitive-behavioral therapy for sex offenders can involve several areas of focus, including addressing cognitive distortions, learning to manage emotions, increasing interpersonal skills, addressing empathy deficits, reducing deviant sexual behavior, and ensuring relapse prevention, along with learning self-management skills (Moster et al., 2008). Cognitive distortions are false beliefs that support offending behaviors (Marshall, Anderson, & Fernandez, 1999). The rape myths discussed in Chapter 3 are cognitive distortions. An example of this includes: if a woman is dressed provocatively, she must want to have sex. Research has found that sex offenders often have cognitive distortions that justify or minimize their sex crimes (Blumental, Gudjonsson, & Burns, 1999).

Through a process of cognitive restructuring, the therapist explains the role of the falsely held belief and provides the offender with information regarding how to correct it (Marshall et al., 1999). Subsequently, the offender distinguishes cognitive distortions from reality, paving the way for the offender to no longer have the cognitive distortion (Murphy, 1990). Group therapy also can be utilized during this process. Members of a group can evaluate an offender's false beliefs as he describes the sex crime in detail (Marshall et al., 1999).

Managing emotion is also a critical component of cognitive-behavioral therapy with sex offenders. Psychological well-being is positively related to how well one can cope with negative emotion and events (Endler & Parker, 1990). Offenders are asked to identify emotions that can lead to committing a sex crime. For some offenders, it may not be just negative emotions, but positive ones as well, that can lead to offending. For example, a positive event can lead to a sense of entitlement and subsequently lead to the commission of a sex crime (Howells, Day, & Wright, 2004). A diagram may be drawn of the offense cycle for the offender to identify the chain of events. Offenders are asked to be aware when they experience such emotions and be mindful of these as they occur (Moster et al., 2008).

With regard to interpersonal skills and sex offenders, such areas as intimacy, loneliness, attachment deficits, self-esteem, and relationships have been identified as of critical importance (Marshall et al., 1999; Moster et al., 2008). It has been theorized that interpersonal skills are directly affected by inadequate attachments formed in childhood (Marshall, 1989). Thus, communication skills are necessary to create and maintain intimate relationships with appropriate partners (Correctional Services of Canada, 1995). Topics addressed should include intimacy along with developing and maintaining appropriate relationships (Moster et al., 2008).

Empathy deficits should also be addressed in cognitive-behavioral therapy (Moster et al., 2008). Empathy refers to the ability to recognize another person's perspective by recognizing his or her emotions and having compassion for that person's feelings (Pithers, 1999). It is hypothesized that when sex offenders empathize with their victims, future sex crimes are prevented (Fernandez & Marshall, 2003). Techniques to increase empathy include the use of videos, victim-impact statements, and letter writing (to/from victim and offender) (Moster et al., 2008). Videos can involve documentaries where a victim has detailed his or her struggle with a sex crime. Victim-impact statements are often provided during the criminal justice process and involve victims detailing how the offender's action affected their lives. Occasionally, victims write letters directly to the offender about their experience. The offender can share with group members and discuss their reactions to this letter.

Cognitive-behavioral therapy for sex offenders often involves addressing deviant sexual behavior, which is sexual behavior that involves children and/or violent sexual activities (Dougher, 1996). This is usually measured during the assessment process by using a plethysmograph or the AASI-3. Several techniques are available to reduce deviant sexual behavior. One example involves covert sensitization, which involves introducing a negative stimulus (e.g., noxious smell, electrical impulse, or simply imagining a negative feeling such as nausea) while engaging in the deviant sexual behavior (Dougher, 1996).

A critical component to many cognitive-behavioral programs includes relapse prevention and self management. The goal is to assist sex offenders to maintain behavioral changes through anticipation and use of coping strategies (Center for Sex Offender Management, 2000). Relapse prevention involves development of a plan that identifies triggers and dangerous situations. Strategies are developed to avoid high-risk situations and to cope with them when they occur. For example, a child molester may be asked to babysit a friend's child. This is a high-risk situation for him, as he is sexually attracted to children. He can develop strategies for responses he may have to this type of situation, which may include telling the friend that he is not able to watch the child as he is not good with children or has a prior engagement.

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