Results of several studies point to an increase in reported child sexual abuse offences in Germany and an even higher number of undetected cases are assumed. In addition, even more cases regarding the distribution of child pornography have been reported. On behalf of victims of child sexual abuse and for the general public, a preventive treatment approach for people with a sexual interest in children is of prime importance. Currently, there is no published, evaluated therapeutic approach for treating potential offenders, dark field offenders and bright field offenders with a sexual interest in children in an outpatient setting. We designed a cognitive-behavioral therapeutic approach that integrated need- and resource-oriented concepts for the specific treatment of those people. This treatment program comprises thirteen modules and is established for a period of about one and a half years. The therapy concept is presented in detail and we report experiences with two male clients. We found a reduction of child abusive behavior (on- and off-line), cognitive distortions and subjective psychological distress, an increase of the extent of self-perceived sexual self-regulation, life satisfaction and self-efficacy in general and a high level of clients’ satisfaction with the therapy concept. The present therapy concept shows promising results as a potential viable treatment program to protect children by reaching out to people with a self-reported sexual interest in children in an outpatient setting, but further research is necessary.
Deviant sexual interest represents one of the strongest determining factors in recidivism among sexual offenders in general and among child sexual abusers (CSA) in particular [
In the Year 2012, 12,623 reported cases of child sexual abuse were recorded in Germany. Between the years 2011 and 2012, cases of sexual offences against children have increased by 1.4%. Similarly, there was an increase in the distribution of child pornography by 3.7%. In contrast, the possession and acquisition of child pornography have decreased by 16.9% [
It should be noted that statistics regarding sexual offences against children include only detected cases (bright field offences). However, a higher number of undetected cases (dark field offences) must be assumed [
The present therapy concept was developed and applied in an outpatient setting. Clients were people with a self-reported sexual interest in children, including those who are afraid of committing a first sexual crime (called: potential offenders), people who have already committed a sexual offence, unknown to the authorities (called: dark field offenders), as well as people with a pending criminal charge, during an ongoing investigation or after a sentence for sexual offence with children (called: bright field offenders).
Currently, there is no published, evaluated therapeutic approach for treating these groups of clients in an outpatient setting. In order to develop a new therapy concept, we reviewed several published approaches for stationary group treatment of sexual offender (Sex Offender Treatment Program, SOTP [
The present therapy concept is a cognitive-behavioral therapeutic approach based on the SOTP, BPS, Rockwood Program and Good Lives Model (GLM) [
The program consists of 13 modules, divided into 45 - 60 sessions of individual and group therapy. We have closed groups of five to nine members with session duration of 120 minutes, which take place three times a month. The individual therapy is delivered weekly with duration of 60 minutes.
Module 1: Motivation to Change/Group Constitution. The first module is used not only to increase the motivation to change and to define approach goals of the therapy, but also to build a therapeutic alliance between therapist and client as well as group cohesion. The most critical difference between individual and group therapy consists of the therapeutic use of some specific factors like group cohesion, trust, openness, support and modeling [
Module 2: Life History. The second module focuses on life history. The clients are asked to prepare their personal autobiography for the next therapy sessions by using a list of questions based on the BPS about important events from their family background, education, work, social contacts, relationship and sexual experiences. These life histories are presented by the clients in a group or individual therapy session. They are used for generating first hypotheses about the client’s underlying needs that lead to offending according to the GLM approach. Thereby, we are minding a potential need for control behind a collection of child pornography material or a need for affiliation behind an exchange of child abusive pictures in a group of like-minded people [
Module 3: Risk Factors. The next sessions are used for identifying the clients’ relevant risk factors. Thus, we are working with the Finkelhor model [
Module 4: Victim Empathy. After this, a module follows in which the clients learn to adopt the perspective of their (potential) victim(s) to increase victim empathy. Various studies found that sex offenders show primary empathy deficits towards their own victims (e.g. [
Module 5: Pathway I. The fifth module serves as a first therapy summary. Clients are asked to prepare an overview worksheet about their offence path way(s). They have to establish a connection between personal appreciable factors from their life history, their Finkelhor model, their seemingly unimportant decisions and cognitive distortions before their sexual offences and the consequences for their own victim(s). Subsequently, the overview will be presented to the group or therapist. At this point, the clients should be able to identify cognitive distortions and seemingly unimportant decisions and the needs behind their offence(s), to take full responsibility for their crime(s) and to feel a sympathetic response for their victims.
Module 6: Self-Esteem. At the next step, we target the self-esteem of our clients to enhance the clients’ belief in their capacity to change (e.g. [
Module 7: Personal Consequences from Sexual Abuse Offences. Next, a SOTP- module for personal consequences from sexual abuse offences follows. In this module, clients should consider positive and negative short- and long-term consequences of their offence(s). These considerations stimulate clients to realize that they were focusing only on short-term positive consequences (e.g. sexual satisfaction) when they committed their crime(s), but disregarded long-term negative consequences (e.g. losses, fear, guilt, preventing a happy relationship). The problem of direct satisfaction is explained. By making a list of consequences, clients learn the negative consequences and establish a further barrier against reoffending.
Module 8: Intimacy and Attachment Styles. Sexual offenders often have inadequate intimacy skills and poor attachment styles [
Module 9: Emotion Management and Problem-Solving. Based on the previous module, this module is aimed at developing and enhancing coping strategies to deal with negative emotional states. Sexual offenders often abuse substances (e.g. [
Module 10: Sexuality (Normative & Deviant). Sexual offenders are frequently reported to have deficits in knowledge about sexuality [
Module 11: Pathway II. Module eleven consists of a second therapy summary (extension of module five) as a basis for a detailed and individual relapse prevention plan in module 12. The clients are asked to use and edit their overview from module five and add their individual consequences (module 7) to draw conclusions about their individual risk situations and how they can handle them. Results are presented and discussed in group or individual therapy sessions. At home, clients are asked to write a continuous text about their offence pathway to understand links, check their knowledge about the main risk concepts and keep them in mind. Furthermore, they are asked to use this text to prepare their relapse prevention plan.
Module 12: Relapse Prevention Plan. The relapse prevention plan should list the main risk situations, such as feelings, thoughts, fantasies, hobbies, jobs, persons and locations and how the client would handle them. Thereby, the clients should distinguish coping strategies they have mastered and strategies that need more practice. Thus, missing or dysfunctional coping strategies are identified and discussed. Sometimes clients have to handle difficult risk situations in fantasy to make sure that they are prepared for several situations. At the end, each client is assisted in generating a list of indicators (warning signs) that they may be moving toward a risk situation: one set that would alert them and one set that would be observable to others. At home, clients should keep a risk situations diary to be continuously sensitized and to become confident in using their coping strategies.
Module 13: Future Plans. As the relapse prevention plan cannot possibly identify all future risks, it is also important to help the client formulate goals for the future at the end of the therapy. These approach goals should help clients to build up alternative pro-social ways of living that are likely to enhance life satisfaction and thereby minimize the risk for (re)-offences. For example, an important issue is what the client will do with his leisure time. Often, our clients have had little in the way of constructive leisure pursuits prior to coming to us, which typically leads to the experience of boredom. Boredom appears to be a significant risk factor [
We present two cases, one for the illustration of the process of individual therapy and another for the process of group therapy. Both clients gave a written declaration of informed consent.
The procedure started with up to ten pre-treatment diagnostic sessions. After that, the first six therapy modules were concluded before an intermediate measure took place. The post measurement was scheduled after the last therapy session. For case 2, we can also report data from a follow up measurement (one year after therapy). The study was approved by the local ethics committee.
Self-Efficacy Scale Related to Minors―Coping (SESM) [
High Risk Situation Test (HRST) [
Questionnaire about sexual fantasies and behavior (Fragebogenzusexuellen Phantasien und Verhaltensweisen, SPV)―The SPV is an unpublished inventory assessing the frequency of sexual contacts with children and adolescents, of consuming child and juvenile pornography for masturbation and of sexual fantasies with children and adolescents. It is also used for assessing the frequency of non-sexual contacts with children and adolescents and of non-sexual watching of children’s programs. Clients have to report their frequency on a six-point Likert Scale from 1 (never) to 6 (daily) within the last six months.
Symptom Checklist-90-Revised (SCL-90-R) [
Questionnaire about life satisfaction (Fragebogenzur Lebenszufriedenheit, FLZ) [
Bumby Child Molest Scale (BCMS) [
Aachen self-efficacy questionnaire (Aachener Selbstwirksamkeitsfragebogen, ASF, [
Case Study 1 is a late-30’s Caucasian male, with average IQ, who has been diagnosed with dysthymic disorder (DSM-IV-TR, 300.4) and an incurable tumor disease. He consumed child and juvenile pornography, due to a current proceeding and the anxiety of being a threat for children and adolescents he sought help. The client was in a diminished mental health status, because he suffered from strong sense of inferiority, he brooded, was unemployed, in debt, unable to accept the rejection of a women he loved, had no techniques to cope with frustration and everyday stress, had only few social contacts and spent the most part of the day playing online games. Prior to attending therapy, pre-assessment findings showed that he had high levels of subjective psychological distress (SCL-90-R, TGSI = 69, see
Case Study 1 | SESM-C | HRST | SCL-90 | BCMS | FLZ | ASF | |||
---|---|---|---|---|---|---|---|---|---|
score | score | GSI | TGSI | score | score | stanine | score | PR | |
Pre | 68 | 73 | 1.14 | 69 | 53 | 214 | 3 | 3.45 | 70% |
Intermediate | 74 | 65 | 0.73 | 64 | 54 | 222 | 3 | 3.15 | 50% |
Post | 77 | 62 | 0.57 | 61 | 55 | 259 | 5 | 4.1 | 100% |
Case Study 2 | |||||||||
Pre | 62 | 62 | 0.02 | 37 | 94 | / | / | / | / |
Intermediate | 73 | 58 | 0.05 | 41 | 74 | 245 | 4 | 3.5 | 70% |
Post | 72 | 77 | 0.02 | 37 | 57 | 272 | 6 | 3.5 | 70% |
follow Up | 77 | 76 | 0.04 | 39 | 57 | 283 | 6 | 3.5 | 70% |
At the beginning of therapy, the client did not have any hypothesis about why he was consuming child and juvenile pornography within the last two years. After the first therapy modules he analyzed that he has a preference for small, delicate women and by searching for adult pornography with such women he found and consumed female child pornography. However, it was not a sexual preference for children or adolescents per se which guided his consumption behavior, but the assumption: “The younger, the weaker. With weak girls, there is a higher probability that she needs me and that I can give her something despite my low self-esteem, my incurable tumor disease and bad financial situation”. According to the GLM-approach, the client could identify a strong need for affiliation and appreciation behind his offence behavior. Therefore, one part of the therapy focused on finding pro-social ways to fulfill these needs. After identifying and changing dysfunctional cognitive schemata and cognitive distortions as well as learning to take the victims’ perspective in role-play there were a lot of feelings of guilt and regret, so for stabilization module six for building up self-esteem was very important. The intermediate assessment findings showed no improvements in life satisfaction (FLZ, Stanine = 3), but more satisfaction in aspects of social contacts (FLZ, from Stanine = 3 to Stanine = 5) and the client stopped consuming child und juvenile pornography completely (SPV). There was also an improvement in levels of subjective psychological distress (SCL-90-R, TGSI = 64), although these scores had been of clinical relevance. There was also an increase in the perceived ability to maintain sexual self-control (SESM-C, score = 74), a decrease in the perceived risk to reoffend (HRST, score = 65), whereby the level of cognitive distortions remained relatively stable (BCMS, score = 54). On the other side a decrease in the experienced self-efficacy in general (ASF, score = 50%) was observed.
In the second part of therapy, the client realized that consuming child and juvenile pornography was a coping mechanism for occupational and emotional frustration, while other coping strategies were missing. He discerned that he had always had a feeling of inability to control his life originating from several negative experiences. He had had frustrating experiences in relationships, suffered from recurrences of his tumor disease, needed to be on welfare and got to hear from his father, that everything he did was not good enough. The client also realized that consuming child and juvenile pornography was an effort to find an aspect of life he could control. Therefore, it was necessary to spend a lot of work on finding and practicing new functional coping strategies and finding a new hobby that provides a feeling of control. In the end, the client used autogenic training, mindfulness exercises and ACT-exercises for relaxation from everyday stress and to calm himself down when he experienced frustration, was able to step back cognitively from dysfunctional thoughts and systematically analyzed his coping options and problem-solving skills. He also trained himself in accepting things he could not change instead of wasting resources by fighting against them (ACT-ap- proach). He learned to improve his relationship skills and tried to enjoy social situations more often instead of isolating himself and wasting time in sullen brooding. He reactivated his old hobby of collecting and building up model railways. Towards the end of the therapy, he was able to cope with several cases of death in his family. His relapse prevention plan was very detailed and elaborate. He formulated realistic approach goals for the future. The post-assessment findings showed a marked improvement in life satisfaction (FLZ, Stanine = 5) with more satisfaction in aspects of personal health (FLZ, from Stanine = 1 to Stanine = 4), work and career (FLZ, from Stanine = 1 to Stanine = 7), leisure time (FLZ, from Stanine = 6 to Stanine = 7), own person (FLZ, from Stanine = 3 to Stanine = 5) and sexuality (FLZ, from Stanine = 3 to Stanine = 5). There was no relapse in consuming child pornography (SPV). Despite spending a lot of time on the Internet (like in the past), the client more often met with others, spent time enjoying a coffee in a café and building up model railways. There was also an improvement in levels of subjective psychological distress (SCL-90-R, TGSI = 61) and an increase in the perceived ability to maintain sexual self-control (SESM-C, score = 77), a decrease in the perceived risk to reoffend (HRST, score = 62), whereas the level of cognitive distortions remained relatively stable (BCMS, score = 55). Also, the client experienced himself as very self-efficient in general (ASF, score = 100%).
Case Study 2 is anearly-50’s Caucasian male, with average IQ, who has been diagnosed with pedophilic disorder (nonexclusive type, DSM-5, 302.2) and hebephilic preferences. The client reported never having experienced sexual intercourse or a stable relationship. The reason for his help-seeking behavior was anxiety about being a pedophile and consuming child and juvenile pornography. He was relieved to have been detected to consume child and juvenile pornography a year before, because he was scared about what would have happened, if he had not been detected (anxiety to commit a child sexual abuse).He remembered the time of the proceeding as the worst time of his life until he received a suspended sentence. At the beginning of the therapy, the client seemed to be very dissatisfied with his life (FLZ was not yet established at that time). He felt lonely because he had lost a lot of relatives in his life (mother committed suicide, father was never interested in him and an alcoholic, his mother’s parents had an important educational influence on him). He had a lot of social contacts in a club, but did not trust anybody in a way that he could speak with them about his fears, worries and wishes. The client reported sexual contacts with his 16-years old niece many years ago, but did not see them as a kind of sexual offence. He had always suffered from being shy because he was scared of being rejected and disgracing himself. As he had known her since her birth, his niece was the only person he trusted and so he was able to initiate sexual contacts. At this point, the client believed that his niece wanted these sexual contacts as well and so he could not understand why she had spoken with her parents about them (some years later) leading to his sister and niece breaking contact to him. To him, it seemed that he had done something wrong when initializing sexual contacts to a person he liked and was punished with refusal and loneliness. Prior to attending therapy, pre-assessment findings showed that he had low levels of subjective psychological distress (SCL-90-R, TGSI = 37 see
The client was recommended participation in group therapy. He was initially hesitant to join the group because he was scared of opening up to others. After some sessions, he became more open; he enjoyed the support of the group members more and more as well as supporting them. He was always prepared for the therapy sessions and took part regularly. During the first part of therapy, the client realized that he used child and juvenile pornography to fulfill his need for affiliation and his need for control by collecting and sorting pornographic material. His shyness and fear of rejection prevented him from fulfilling these needs using different activities. Furthermore, he learned to identify cognitive distortions and seemingly unimportant decisions and modify them in an appropriate way. Thereby, he often helped other group members in identifying and modifying their own cognitive distortions. During the module victim empathy, the client learned not only to understand and feel what victims of sexual abuse think and feel but also to access his own emotions and share them with the group. He also understood the reason why his niece did not refuse sexual contact with him, but still suffered from them long-term. He analyzed that he exploited the trust of his niece, hurt her and recognized his guilt for losing her and her mother (his sister). It was difficult for him to understand, that he could not undo what had happened and he could not forgive himself for hurting people he loves. So again, the module self-esteem was necessary for stabilization. In this module, he received a lot of positive feedback and compliments from other group members and learned to value the positive things in his life and give them more attention. He was getting more active and learned to do something good for himself and seemed to be more satisfied with his life (FLZ, Stanine = 4). The intermediate-assessment findings showed marked improvements in the level of cognitive distortions (BCMS, score = 74) as well as improvements in the perceived ability to maintain sexual self-control (SESM-C, score = 73) and a lower perceived risk for committing a hands-on sexual offence again (HRST, score = 58). He experienced himself as relatively self-efficient in general (ASF, score = 70%). His low feelings of psychological distress remained relatively stable (SCL-90-R, TGSI = 41). But within the first part of therapy he was unable to avoid consuming child and juvenile pornography completely and used it less frequently than once a month within the last six months again (SPV).
During the second part of therapy, the client especially benefited from the module dealing with emotions and problem-solving. He started to systematically analyze his problems and solve them. For example, after he had concluded that boredom, loneliness and losing himself in negative experiences and feelings were main risk situations for him, he started jaunting, thereby training mindfulness skills. In addition, he bought himself a camera for taking photos on his trips. He took a lot of time enjoying nature and editing his photos. Instead of collecting child and juvenile pornography material, he started watching historical documentaries and found a new task in writing online articles about them. To remind himself to never consuming child and juvenile pornography material again and to remind him of the what he has learned in therapy, he always takes his victim empathy letters with him and puts a note with a list of negative consequences for himself of committing a sexual offence again on his computer monitor. He has support from a friend and tries to enjoy more time in his club. He formulated a detailed relapse prevention plan and realistic approach goals for the future. Maybe because of discussing risk situations in detail at the end of therapy the post-assessment findings showed an increase in the perceived risk for committing a sexual offence again (HRST, score = 77). The perceived ability to maintain sexual self-control remained relatively stable (SESM-C, score = 72), although the client used child and juvenile pornography material less than once a month within the last six months again (SPV). Again, he did not feel psychological distress (SCL-90-R, TGSI = 37) and he became more satisfied with his life (FLZ, from Stanine = 4 to Stanine = 6). At the end of therapy there was a marked improvement in the level of cognitive distortions (BCMS, score = 57), which was well below the average score compared to a group of child sexual abusers (BCMS, M = 76.8). His experience of self-efficacy in general remained stable (ASF, score = 70%).
After the one year follow up, the client reported being fine, had used child or juvenile pornography material less than once a month again and had not committed any hands-on offences within the last six months (SPV). The one year follow up assessment showed a stable low level of cognitive distortions (BCMS, score = 57), the experience of self-efficacy in general (ASF, score = 70%), the perceived ability to maintain sexual self-control (SESM-C, score = 77) and the perceived risk for committing a hands-on sexual offence (HRST, score = 76). He did not feel psychological distress (SCL-90-R, TGSI = 39) again and feltsatisfied with his life (FLZ, Stanine = 6).
We designed a cognitive-behavioral therapeutic approach that integrates need- and resource-oriented concepts for the specific treatment of people with a self-reported sexual interest in children in an outpatient setting. This treatment program was presented and results of two cases were reported for illustration of the process of group and individual therapy. It could be observed that both clients improved across different outcome mea- sures after completion of therapy. Furthermore, it can be noted that they are generally satisfied with the therapeutic contents. It can also be noted that both clients reduced child abusive behavior (on- and off-line) and benefited concerning co-morbid disorders and problems. Thus, positive outcomes could be observed regarding undetected and detected sexual abuse offences. The therapy concept is aimed at bright field offenders besides dark field offenders to effectively reduce child abusive behavior.
Overall, the present therapy concept shows promising results as a potentially viable treatment program for protecting children by reaching out to people with a self-reported sexual interest in children in an outpatient setting. Furthermore, this study showed that this therapy concept can be effective in decreasing the risk of sexual recidivism; however caution should be taken as only two case studies were involved.
Given that we only report data from two cases, the findings are largely tentative and not to be generalized. Further research on the effectiveness of this program, preferably with a larger sample size and a control group, is needed. Based on the general framework, using a waiting group seems difficult from an ethical standpoint as the help-seeking people with a risk to sexually (re-)offend would have to wait over a period of one and a half year without any specific treatment. Another limitation is, that we had to trust the information our clients gave us as we had no official records of the clients’ criminal history.
The presented findings point at the potential efficacy of our cognitive-behavioral treatment for treating CSA as well as CPO. Further research is needed to explore the differential effectiveness of the different components (e.g. DBT skills training, ACT exercises) for people with a self-reported sexual interest in children. In the future, we plan to use more specific instruments in order to get more detailed information about child pornography use or specific coping styles. For example, boredom and loneliness are assumed to be important predictors of child pornography use [
Currently, we are working on the proving of further assessment measures. Thus, we are using the Empathy for Children Scale (ECS) [
We acknowledge support by the Open Access Publication Funds of the Göttingen University.
Schulz, T., Palmer, S., Stolpmann, G., Wernicke, M. and Müller, J.L. (2017) Presenting a Treatment Concept for People with a Self-Reported Sexual Interest in Children in an Outpatient Setting. Open Journal of Psychiatry, 7, 1-17. http://dx.doi.org/10.4236/ojpsych.2017.71001
ACT: Acceptance and Commitment-Therapy [
ASF: Aachen self-efficacy questionnaire (Aachener Selbstwirksamkeitsfragebogen) [
BCMS: Bumby Child Molest Scale [
BPS: Behandlungsprogramm für Sexualstrafttäter [
CPO: child pornography offenders
CSA: child sexual abusers
DBT: Dialectical Behavior Therapy [
FLZ: Questionnaire about life satisfaction (Fragebogen zur Lebenszufriedenheit) [
GLM: Good Lives Model [
HRST: High Risk Situation Test [
RNR: Risk-Need-Responsivity model [
SCL-90-R: Symptom Checklist-90-Revised [
SESM: Self-Efficacy Scale Related to Minors - Coping [
SOTP: Sex Offender Treatment Program [
SPV: Questionnaire about sexual fantasies and behavior (Fragebogen zu sexuellen Phantasien und Verhaltensweisen)
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