Although the largest extant literature containing detailed theoretical formulations regarding PAs is psychoanalytic and/or psychodynamic, there are few data to suggest that this type of psychotherapy, as a primary treatment, is likely to be effective specifically in reducing paraphilic arousal or behaviors in large samples of men (Person 1989). Psychodynamic psychotherapy, however, may help to uncover developmental antecedents of PAs and PRDs, reduce anxiety and depression, improve social adjustment, and develop an empathic perspective toward the victim’s experience. The informed individual psychotherapist, regardless of theoretical persuasion, may function as the practitioner who selects and integrates different therapeutic interventions, akin to the model of “primary-care therapist” advocated by Khantzian (1986) for the recovering substance abuser.
Individual psychotherapy with a cognitive-behavioral orientation can facilitate the learning of relapse prevention principles and the exploration of behavioral sequences that precede and contribute to the “deviant cycle.” Such individual therapy can complement group therapies using the same theoretical model. Especially in the treatment of sexually aggressive paraphilic individuals, multimodal treatment approaches, including individual, cognitive-behavioral, group, psychoeducational, and pharmacological treatments, are commonly prescribed and are tailored to the specific needs of the offender (Maletzky 1998).
In the sexual addiction literature, the most commonly prescribed combination of therapies associated with successful outcome is that of 12-Step group therapy (see “Group Psychotherapies” subsection below) and individual psychotherapy with a clinician familiar with PRDs (Carnes 1991; Corley et al. 1998; Schneider and Schneider 1990; Swisher 1995). This outcome literature, however, is based on skewed samples collected by surveys of self-selected 12-Step attendees.
Mr. H is a 42-year-old married man who had repetitively molested his stepdaughter. When referred for treatment, he was diagnosed with current major depression; dysthymic disorder, early-onset subtype; social phobia, generalized subtype; and alcohol abuse. His social phobia and substance abuse were in remission. In addition to pedophilia, Mr. H had a history of compulsive masturbation and pornography dependence. He had been molested by a neighbor during his own childhood and described his mother as intrusive, anxious, and overprotective.
After pharmacotherapy with an SSRI antidepressant and ongoing relapse prevention group therapy, Mr. H greatly benefited from individual psychotherapy, which helped him to understand and then change his hostile-dependent relationship with his spouse. It was hypothesized that internalized anger at women and a passive/submissive approach to the expression of appropriate aggressive feelings had substantially contributed to the sexualizing of his stepdaughter.
Professionally facilitated cognitive-behavioral-oriented group therapies are the most common treatment modalities for confronting denial in sex offenders and exploring the developmental antecedents that may have contributed to symptom formation. Such groups may include modules (or feature separate therapy groups) for learning the principles and practice of relapse prevention, victim empathy, anger management, or social skills (Laws 1989).
Relapse prevention is an integrated cognitive-behavioral and group therapy treatment approach that originally evolved from a theoretical understanding of, and treatment for, addictive disorders such as alcohol abuse, nicotine dependence, and overeating (Marlatt and Gordon 1980). The techniques developed were based on the clinical observation that although habitual behaviors (i.e., addictions) may respond positively to a variety of short-term interventions, maintenance of remission was problematic, and relapse was a common outcome in follow-up studies of addiction treatments.
Relapse prevention techniques aim to 1) identify specific recurrent cognitive distortions and inappropriate beliefs and then implement “cognitive restructuring,” 2) sensitize the paraphilic individual to recognize and then anticipate high-risk situations, and 3) identify specific behavioral/affective/cognitive precursors to relapse. Following identification of recurrent affective and behavioral chains preceding paraphilic behavior, behavioral rehearsal of new, comprehensive problem-solving techniques and social and sexual skills training are implemented (Laws 1989). Individual and group therapies can be enhanced by providing homework and specialized workbooks (Bays and Freeman-Longo 1989; Bays et al. 1990; Freeman-Longo and Bays 1988).
Although long-term outcome studies (i.e., ?10 years) using these techniques with sexually aggressive paraphilic individuals still remain to be published, initial outcome data (i.e., on recidivism rates) from comprehensive programs using these methodologies are encouraging in some (Hall 1995; Hildebran and Pithers 1992; Marshall and Anderson 1996; Pithers 1990) but not all studies (Marques 1999; Rice et al. 1991). As mentioned previously in this chapter, the relapse prevention model of treatment has predominated in specialized sex offender treatment programs in North America (Freeman-Longo et al. 1994).
Men with PRDs have also been treated with professionally administered group psychotherapy. Quadland (1985) reported favorable outcomes in 30 gay/bisexual men enrolled in a semistructured 20-week group therapy program aimed at controlling promiscuity. Other clinicians have reported on the use of group therapy for PRDs (Earle and Crow 1989; Turner 1990) but have not discussed outcome results.
Since the formation of Alcoholics Anonymous and the articulation of the 12-Step recovery program, self-help groups based on 12-Step methodology have been established for many forms of impulsive/addictive behaviors, including substance abuse disorders, eating disorders, “sex addictions,” gambling, and kleptomania. These programs can have a profound effect on the process of recovery, especially if the program is zealously adhered to. For example, 12-Step recovery programs commonly require daily attendance at a 12-Step meeting for the first 3 months of recovery from alcoholism (Galanter et al. 1990), and positive outcomes in bulimia nervosa have been associated with attendance of five or more 12-Step meetings per week for at least 3 years (Malenbaum et al. 1988).
Several different 12-Step programs for recovering “sex addicts” now exist, some of which are distinguished by geographic location or differing philosophies as to what constitutes recovery, abstinence, and “bottom line” in the context of normalizing sexual behaviors (Salmon 1995). Naditch and Barton (1990) and Carnes (1991) noted a positive long-term outcome associated with 12-Step sexual addiction programs in conjunction with individual psychotherapy in a retrospective survey of men and women recovering from nonviolent PAs and PRDs. In many respects, the program based on zealous adherence to the 12-Step recovery model for PRDs bears some resemblance to a cognitive-behavior therapy-based relapse prevention program for the treatment of sex-offending paraphilic individuals (Carnes 1991; Laws 1989).
Mr. J was a 36-year-old married man who was referred for treatment of persistent low self-esteem, anxiety, and continued paraphilia-related sexual behaviors. He met DSM-IV diagnostic criteria for dysthymic disorder (early-onset subtype) and cocaine abuse (in remission), and he had subclinical obsessive-compulsive disorder. Mr. J’s sexual diagnoses included compulsive masturbation, protracted promiscuity (homosexual subtype), and pornography dependence. There was no developmental history of physical, sexual, or emotional abuse. Several months of intensive treatment with individual psychotherapy and near-daily attendance in 12-Step sexual addiction groups resulted in substantial amelioration of Mr. J’s PRDs.
Behavior therapy techniques are used frequently in treatment centers specializing in the assessment and treatment of sexually aggressive paraphilic individuals, and these techniques can be applied to nonviolent PAs and PRDs as well (Maletzky 1991b). Although these techniques have a different theoretical approach than relapse prevention, they are sometimes integrated with cognitive-behavioral therapy treatments (Maletzky 1993).
Aversive techniques, for example, can be applied to a wide range of human behaviors, including sexual behaviors, when accompanied by the voluntary consent and understanding of the patient. The use of imagined but highly detailed aversive consequences interrupting the arousal inherent in specific imagined sexually arousing scenarios represents a palatable form of aversion therapy when the technique is applied repetitively (Cautela 1967). Despite its common use in treatment programs, however, this technique has not produced robust treatment effects (Maletzky 1998).
Olfactory aversion is designed to reduce unconventional sexual arousal with aversive smells, utilizing foul odors such as ammonia (Colson 1972) or rotting animal or human tissue (Maletzky 1991a). The advantage of olfactory aversion derives from the immediacy of a powerful aversive odor paired repetitively with conditioned sexually arousing fantasies. For example, ammonia aversion involves encapsulated ammonia ampoules that are portable and can be broken and inhaled in conjunction with both behavioral homework and in vivo practice, as well as in situations that trigger sexual impulses. Theoretical support exists for the use of smells that produce nausea (e.g., rotting animal tissue) rather than pain (ammonia) for the aversive treatment of consummatory behaviors (Maletzky and George 1973); however, such smells are not easily packaged for in vivo use.
Mr. K was a 35-year-old divorced male who was referred to me following his third arrest for exhibitionism. As a preadolescent, Mr. K was repetitively molested by an uncle. In addition, Mr. K’s father was alcoholic during his formative years. Mr. K was diagnosed with DSM-IV dysthymic disorder, early-onset subtype; major depression (in remission); ADHD, inattentive subtype; social phobia; and both alcohol and cocaine abuse (in remission). Mr. K’s sexual diagnoses included exhibitionism, voyeurism, pornography dependence, compulsive masturbation, and protracted promiscuity, heterosexual subtype. Prior to his arrest, Mr. K masturbated at least 12 times per week in addition to engaging in partnered sex.
Mr. K had been in a highly structured cognitive-behavioral therapy program involving closely monitored probation. Although this had been helpful, he still was hypersexual and continued to experience strong urges to expose himself, accompanied by “cruising” parks where he might do so. Mr. K was eventually treated with fluoxetine 40 mg/day, to which methylphenidate-SR 40 mg/day was subsequently added. This combination of medications markedly reduced his sexual arousal, improved his chronic low self-esteem and depressive symptoms, and helped him to be moderately more socially interactive.
After pharmacotherapy, Mr. K additionally benefited from ammonia aversion therapy, which he reported helped him specifically to cope with residual urges to expose himself. He was motivated to practice the aversion therapy, carried the ammonia ampoules with him at all times, and practiced using them to extinguish self-generated “homework” sexual fantasies that were arousing.
Nonaversive or “positive” conditioning techniques are not as widely established as primary treatments for sexually aggressive paraphilic individuals. Reconditioning behavioral techniques employ the shifting of the content, timing, or sequence of events present during unconventional sexual fantasies, urges, and activities. The shift is aimed at “fading” the intensity of the conditioned unconventional stimulus and strengthening the presence, proximity, and arousal produced by “conventional” sexual fantasies during masturbation (Marques 1970). A variant of this technique has also been developed that is called masturbatory satiation (Laws and Marshall 1991; Marshall 1979). During masturbatory satiation, the subject is instructed first to masturbate to orgasm using socially acceptable sexual fantasies, and then, for 30-60 minutes during the postejaculatory latency period, to continue to masturbate to deviant fantasy. The theory supporting this technique is that prolonged masturbation following ejaculation is aversive.
McConaghy and Armstrong (1985) reported that imaginal desensitization was effective in reducing compulsive sexual behaviors (promiscuity) in a group of 20 men with PAs and PRDs at both 1-month and 1-year follow-ups. Since men with PAs report social and interpersonal anxiety, a hierarchical systematic desensitization could be of assistance in reducing interpersonal anxiety and, perhaps, could be combined with other learning-based techniques to improve interpersonal relationships and assertiveness.
Revision date: June 20, 2011
Last revised: by Dave R. Roger, M.D.