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

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.

Surveillance Groups

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

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).