Sexual Disorder Case Study: Pedophilia (Albert Gatton)
Albert Gatton was referred by a prominent psychiatrist in another state for assessment and possible treatment of heterosexual pedophilic behavior. At the time of his presentation, Albert was a 51-year-old married Caucasian minister from the Midwest. He had three grown children, two girls and a boy, the youngest of whom was a 19-year-old daughter who was attending college in another state. He was tall and quite serious and, although he was cooperative, Albert did not volunteer a great deal of information during the initial interview.
Albert reported that he had been touching and caressing girls between the ages of 10 and 16 for more than 20 years. He estimated that he had had some interaction with at least 50 girls. Most typically this interaction was restricted to hugging or caressing their breasts. On occasion, he would also touch their genitals. Albert did not expose himself to girls or ask them to touch him in any way. Generally, he reported achieving a partial erection during these contacts but never ejaculated during any of these encounters. He did not report this to be primarily an erotic experience but rather continued to suggest that the emphasis was on an exchange of affection. During the initial interview, in fact, Albert reported feeling little remorse about his activities for this reason, although he was deeply concerned over the effect on his family and his career from being “found out.”
Clinical History
Some 12 years before presenting for treatment, Albert’s activities were discovered for the first time, and he was forced to leave his church in another state in the Mid-west. The matter was kept relatively quiet, and Albert was able to take up a new position in a different state, a position he retained until just prior to treatment. Although he sought treatment and agreed to refrain from any physical interaction with young girls in his new church, he was soon as sexually active as ever. This behavior continued until several months before he presented for treatment.
According to Albert, in most of the cases, the young girls responded positively to his advances and did not seem offended or frightened. In several instances, this activity would continue with the girl for several months, and it was with these girls that genital touching occurred. During these years, although responsible administratively and spiritually for the entire parish, Albert took particular interest in activities involving young adolescent girls, such as the local Girl Scout troop. In addition to this activity, Albert, who was particularly attracted to small breasts characteristic of young adolescent girls, would masturbate once or twice a week to pictures of girls with these features that he found in what he referred to as “nudist magazines.” In fact, Albert subscribed to a rather extensive series of pedophilic pornographic magazines, which, much to his embarrassment and that of his family, continued to arrive at his old rectory in the Midwest for months, to be received by the new occupants.
Several months before presenting for treatment, Albert was confronted by the parents of an 11-year-old Girl Scout who were hearing “strange stories” about physical touching from their daughter and wanted to discuss them. This behavior was presented by Albert as a misunderstanding, and the incident died down until the parents of another girl who reported similar experiences mentioned them to the parents of the first girl. The story spread and quickly led to outrage, Albert’s dismissal from the parish by the bishop, and Albert’s suspension as a minister with strong recommendations that he seek treatment.
Albert grew up a rather inhibited teenager with few lasting social contacts with girls. He was married at age 26 and engaged in sexual intercourse for the first time. He had begun dating at approximately age 22, and on only one occasion before marriage had he engaged in even light petting. During high school, most of the fantasies Albert used when masturbating were centered on pubescent girls with developing breasts.
After discovery 12 years ago at his previous parish, Albert had engaged in a number of long-term psychotherapeutic relationships. He reported that none of these treatment programs seemed to have any effect on his sexual arousal patterns. At least one of his previous therapists had taken the approach that there must be something wrong within his marital relationship. In addition to angering Albert, this notion was disconfirmed by his wife, who reported a normal and satisfying sexual and marital relationship.
Despite the incident, Albert’s relationship with his family remained excellent, and his wife was extremely supportive, determined to stick by him through thick and thin. His children were also quite supportive but seemed to largely dismiss the incidents or deny that they were anything but exaggerations and innuendo. Albert had never approached any of his children sexually.
DSM-IV-Diagnosis
On the basis of this information, Albert was assigned the following DSM-IV-TR (Diagnostic and Statistical Manual, 4th ed., Text Revision) diagnosis:
Axis II: V71.09 No diagnosis on Axis II
Axis III: None
Axis IV: Recent job termination
Axis V: Global Assessment of functioning 60 (current)
Pedophilia is a form of paraphilia. In DSM-IV-TR, paraphilias are defined as “recurrent, intense sexual urges, fantasies, or behaviors that involve unusual objects, activities, or situations that cause clinically significant distress or im- impairment in social, occupational, or other important areas of functioning.” Other types of paraphilias besides pedophilia include exhibitionism (recurrent exposure of one’s genitals to an unsuspecting stranger), fetishism (recurrent and intense sexually arousing fantasies, urges, or behaviors involving the use of nonliving objects such as shoes or undergarments), frotteurism (recurrent and intense sexually arousing fantasies, urges, or behaviors involving touching or rubbing against a nonconsenting person), sexual masochism (recurrent and intense sexually arousing fantasies, urges, or behaviors involving the act of being humiliated, beaten, bound, or made to suffer), sexual sadism (recurrent and intense sexually arousing fantasies, urges, or behaviors involving acts in which the psychological or physical suffering of the victim is sexually exciting to the person), and voyeurism (recurrent and intense sexually arousing fantasies, urges, or behaviors involving the observation of an unsuspecting person who is naked, getting undressed, or engaging in sexual activity).
Albert’s presentation was quite consistent with the DSM-IV-TR definition of pedophilia (American Psychiatric Association, 2000). In DSM-IV-TR, the key criteria for pedophilia are as follows: (a) over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children (generally age 13 years or younger); (b) the fantasies, sexual urges, or behaviors cause clinically significant dis- tress or impairment in social, occupational, or other important areas of functioning; and (c) the person is at least 16 years of age and at least 5 years older than the child or children in criterion. The last criterion was included in DSM-IV-TR in part to prevent the improper diagnosis of pedophilia in adolescent patients. For exam- ple, a 16-year-old male would not be diagnosed with pedophilia for having sexual contact with a 12-year-old female. However, for persons who are in late adolescence, DSM-IV-TR does not specify a precise age difference; thus, clinical judgment must be exercised to determine whether a diagnosis of pedophilia is warranted, taking into account both the sexual maturity of the child and the age difference between the child and the patient.
As seen in Albert’s five-axis DSM-IV-TR diagnosis, when the diagnosis of pedophilia is assigned, the clinician must indicate the type of pedophilia by three types of specifiers: (a) arousal pattern (sexually attracted to males, sexually attracted to females, sexually attracted to both), (b) whether the pedophilic behavior is limited to incest, and (c) whether the patient is attracted only to children (exclusive versus nonexclusive type). Accordingly, Albert’s diagnosis included the specifier “sexually attracted to females” because all his sexual contact involved prepubescent females (no reported history of homosexual fantasies, urges, or behavior). The specifier “nonexclusive type” was assigned because Albert was sexually attracted to both juvenile and adult females (normal sexual relationship with his wife). The specifier “limited to incest” was not assigned because none of Albert’s pedophilic behavior occurred with his daughters.
Case formulation using the integrative model
Unlike models of other disorders presented in this book (e.g., panic disorder, major depression), the integrative model of paraphilia has little current scientific support (Barlow & Durand, 2009). For example, the model of paraphilia includes no biological dimensions. However, as is the case with many other psychological disorders, there could be strong biological elements contributing to the development of paraphilias (e.g., excessive sexual arousal). This important question needs future research. Despite its speculative nature, the integrative model of paraphilia can be quite useful in treatment planning. The model asserts the following phenomena, occurring in childhood through late adolescence, as factors that may contribute to the vulnerability for developing a paraphilia: (a) inappropriate sexual associations or experiences, (b) inadequate development of consensual adult arousal patterns, and (c) inadequate development of appropriate social skills. Some evidence in support of the first vulnerability factor comes from findings that individuals with pedophilia very often were victims of childhood sexual abuse themselves (Fagan, Wise, Schmidt, & Berlin, 2002; Seto, 2008). With regard to the other two vulnerability factors, the inability to develop adequate sexual or social relationships with the appropriate people is associated with the development of inappropriate sexual outlets (Barlow & Wincze, 1980; Marshall, 1997). Certain aspects of Albert’s history are consistent with the model. For example, Albert’s social development through adolescence was inadequate, as he reported being inhibited and recalled few lasting social contacts with girls. Similarly, Albert was late in his development of appropriate sexual relationships (e.g., he did not begin dating until age 22; heterosexual activity did not occur on a regular basis until he was married at age 26).
These three factors are vulnerability dimensions. As such, they do not ensure the emergence of a paraphilia; many people have early experiences of this nature yet do not develop deviant sexual arousal. Rather, when combined with other factors, these vulnerability dimensions increase the likelihood of a deviant sexual arousal pattern. The most salient of these factors is the recurrent reinforcement of sexual fantasies and behavior through sexual pleasure associated with masturbation. Indeed, almost every current model of sexual disorders underscores deviant masturbatory fantasies as key to the maintenance of the various paraphilias; accordingly, this factor is the primary target of most treatment interventions (Seto, 2008).
Consider the following as an illustration of the role of masturbatory fantasies in the development of a paraphilia: During masturbation, a person may almost exclusively fantasize about peeping into the bedroom of his neighbor while she is un- dressing. These fantasies, and later the act of voyeurism itself, are repeatedly reinforced by their pairing with a pleasurable consequence (e.g., orgasm). Accordingly, the deviant arousal pattern is maintained or strengthened by the repeated association of strong sexual arousal with these fantasies, urges, and actions. This dimension of the integrative model was clearly evident in Albert. All of his masturbatory fantasies during high school were centered on girls whose breasts were developing. As an adult, Albert masturbated once or twice a week using pictures in pornographic magazines of adolescent girls with small breasts. By adulthood, Albert’s deviant sexual behavior went well beyond masturbating to adolescent fantasies and pictures. Indeed, the actual act of engaging in pedophilic behavior with young girls was quite reinforcing to him (e.g., touching the breasts of young girls always produced at least a partial erection).
After the deviant arousal pattern has developed, paraphilic thoughts, fantasies, and behaviors may increase in frequency and intensity as the result of a person’s repeated attempts to inhibit or suppress them. Like other problems such as eating disorders, whereby the strong drive to restrict one’s food intake may precipitate binge eating, the person with paraphilia who attempts to suppress his deviant fantasies and behaviors may experience a paradoxical increase in them. Albert’s at- tempts to refrain from physical contact with girls after he was first discovered were short-lived. After these brief periods of restraint, Albert was just as active, if not more active, than he had been prior to being forced to leave his church.
In addition to failed attempts at suppression or restraint, Albert displayed a common characteristic of pedophilia: the strong tendency to rationalize one’s pedophilic behavior as being acceptable. The primary rationalization found in patients with pedophilia is the notion that they are somehow providing love and affection, or possibly sex education, to children that is beneficial to them and that this affection may be restricted or absent from other sources. One of the most striking as- aspects of Albert’s clinical presentation was his absence of remorse. Albert himself commented on his absence of remorse and seemed puzzled by it because he had at least an intellectual appreciation for the seriousness of his acts. Indeed, the tendency for rationalization was clearly evident in Albert, who considered his behavior to be “affectionate,” despite his occasional genital contact with young girls and his masturbatory activity to “nudist magazines.”
Treatment goals and planning
Before attempting formal intervention to directly target his deviant sexual arousal patterns, the therapist had to address Albert’s motivation for change, which would most likely affect his compliance with other treatment procedures. Thus, the initial treatment goal was to strip away some of Albert’s rationalizations. The primary component of Albert’s treatment would be covert sensitization (Cautela, 1967; Cautela & Kearney, 1993). It would target Albert’s pattern of deviant sexual arousal, which is considered in the integrative model to be the most important factor in the maintenance of paraphilia. The goal of this procedure is to change the associations and context of deviant arousal patterns from arousing and pleasurable to neutral or aversive. It is accomplished through repeated pairing, in the patient’s imagination, of the pleasurable but undesirable scene of paraphilic behavior with an aversive or noxious consequence. If performed systematically, this procedure reconditions the patient’s deviant thoughts, fantasies, and behaviors. Through covert sensitization, material that was once linked to pleasurable consequences becomes associated with aversive consequences, thereby breaking down a key factor contributing to the maintenance of the paraphilia.
Another treatment technique for altering deviant sexual arousal patterns is mas- turbatory extinction (sometimes referred to as masturbatory satiation or orgasmic reconditioning; Alford, Morin, Atkins, & Schoen, 1987; Maletzky, 2002; Marshall, 1979). Although there are variants of this technique (e.g., Davison, 1968), this procedure usually entails having the patient masturbate to orgasm in the presence of appropriate sexual stimuli (e.g., videos of heterosexual intercourse). Following orgasm, the patient is instructed to masturbate for protracted periods of time (often 1 hour or more) in the presence of stimuli depicting his deviant sexual behavior (e.g., for Albert, pictures of unclothed, prepubescent females). That the patient has just reached orgasm prevents him from becoming sexually aroused to the deviant stimuli. As per principles of learning (classical or operant conditioning), the repeated pairing of the patient’s typical deviant stimuli in the absence of sexual arousal breaks the association between the paraphilic material and arousal (a process referred to as extinction). In addition to extinguishing arousal responses to deviant stimuli, these procedures may help establish appropriate sexual arousal patterns because they involve the repeated pairing of sexual arousal and orgasm to material depicting normal sexual behavior.
The course of treatment and treatment outcome
Beginning in the first session and continuing throughout treatment, Albert was provided self-monitoring forms to record the frequency and intensity of normal and pedophilic sexual thoughts, fantasies, and behaviors. Prior to the first treatment session, a physiological assessment of sexual arousal patterns was conducted with penile strain gauge measures (Barlow, Becker, Leitenberg, & Agras, 1970; Harris & Rice, 1996). This assessment involved the presentation of videos depicting adult heterosexual activity and pictures of unclothed school-age girls. While Albert viewed these materials, his sexual response was recorded with a gauge designed to measure the circumference of his penis (i.e., his erectile response). The results of this assessment revealed a high level of responsiveness to pedophilic stimuli.
As noted previously, it was important first to address Albert’s motivation for treatment because he displayed a strong tendency to rationalize his pedophilic activities. Albert was instructed to make a list of various specific rationalizations. He be- gan working on these rationalizations at home. He was also asked to contemplate how his contacts were received by the girls and whether he was oblivious to any negative cues. It became apparent that he had established a strong boundary between “proper and improper” pedophilic behavior. For example, intercourse with a child or sexual coercion of a child was just as repugnant to him as it would be to most people. But Albert considered fondling breasts and genitals to be affectionate. Evidence for this rationalization was present in the following: (a) Albert re-ported that most children were very responsive to his advances; (b) his description of many of his episodes was objectified by his use of third-person speech; (c) he was very indignant over the angry manner with which most of his congregation re- responded to him after his discovery, thinking they were somehow ungrateful for all of his years of service to the parish (including his bishop, whom he accused of not providing appropriate support); and (d) he established boundaries between “good and bad” pedophilic behavior.
To break down some of these barriers, Albert was requested to consider two scenarios. First, Albert was asked how he would react if he discovered that one of his daughters had been fondled or molested by a strange adult male. Initially, Albert digressed into problems of hypothetical questions but then replied that he had never considered that possibility and had probably blocked it out. In fact, in the remainder of the session he refused to consider the topic despite the therapist’s subsequent attempts to introduce it. Second, in regard to the reaction of his parishioners, Albert was asked what his response would be if his bishop were discovered to have been raping women in the back alleys of the city for several years on Saturday nights. He was able to admit that his behavior was at least as repugnant as the hypothetical behavior of his bishop and that it would seem quite shocking indeed.
Thinking about these issues during and between the first several sessions sensitized Albert to several facets of his problem. Consequently, he was able to recognize, at least at a rational level, the horror that his behavior evoked in others and, by inference, the repugnant nature of the behavior itself. Nevertheless, he was now requested within sessions to imagine that his daughter was being molested and to picture it as vividly as possible. He was instructed to “feel it emotionally” and then report his reactions. Second, he was asked to imagine a similar situation in which he was engaging in genital contact with his most recent victim with all of the parishioners watching.
During this time, Albert was also given materials to read on the consequences of sexual abuse of children. In fact, he reported that he had been familiar with some of these materials before but had read them in a more abstract, intellectual manner. During the next several weeks, Albert reported that his masturbatory fantasies be- gan to incorporate images of nameless, faceless people watching him and that his fantasies became fuzzy, much like static on a television set.
By the fourth session, Albert clearly began to experience some of the horror and aversiveness of his behavior and actually demonstrated some negative affect and a few tears. This was a marked change from previous sessions in which Albert displayed little or no emotion while discussing his behavior. Albert’s self-monitoring records indicated that masturbation of any kind had stopped. At this point, steps preliminary to implementing covert sensitization were begun.
Detailed descriptions of Albert’s behavior were obtained during the early sessions. Self-monitoring revealed infrequent pedophilic fantasies at this time. Most likely, the decrease in the frequency of his fantasies was related to the punishing effect of his recent discovery of the aversiveness of his pedophilic activities. Nevertheless, Albert’s pattern of pedophilic behavior was fairly consistent. Typically, he would playfully approach a young girl who happened to be alone in a room at the church recreation center or perhaps in his car if he were driving her somewhere. Albert would then put his arms on her or around her and gradually move his hands to the breast area or, on occasion, the genital area. He would be very careful to ascertain if the girl was likely to be responsive beforehand and if she remained responsive during the encounter. If there was any sign of resistance or lack of responsiveness, Albert would quickly desist or revert to wrestling or playing the type of activity that did not involve breast or genital contact. On rare occasions, the same behavior might occur during the summer while he was swimming in a nearby lake.
In addition to these rather restricted behavioral patterns, Albert experienced urges upon seeing young girls in various locations. These urges ranged from a full-blown sexual thought sequence while watching a young girl to what he called a “glimpse,” during which Albert was not aware of any frank sexual thoughts but would notice himself glancing at a young girl who was not directly in his line of sight and, therefore, represented someone who probably would not attract his attention if she were not the appropriate age and sex.
Because no deviant behavior was occurring at this time and because fantasies (sexual thoughts in the absence of young girls) were also absent, self-monitoring was restricted to “urges,” defined as sexual thoughts, images, or impulses upon see- ing a young adolescent girl. Albert recorded all sexual urges on a self-monitoring record that he was instructed to continue to carry with him at all times. The record was divided into daily segments in which he could total the number of full-blown urges and “glimpses” each day. Albert was instructed to record these urges and glimpses as soon as possible.
One further assessment procedure that precedes covert sensitization is the determination of the worst possible consequences of the behavior in the patient’s own mind. Consistent with his reaction during the first several sessions of treatment, Albert reported that being observed while engaging in this behavior provoked a particularly strong negative emotional reaction in him. He also displayed some sensitivity to images of nausea and vomiting, which comprise a common set of aversive scenes in covert sensitization. If nausea and vomiting are not particularly aversive, scenes of blood and injury or of snakes or spiders crawling on one’s skin can be very effective. With this information, Albert was ready to begin covert sensitization trials.
Prior to initiating covert sensitization, Albert was presented with a therapeutic rationale. After determining that Albert understood the rationale, the covert sensitization sessions were begun. Because Albert had identified being “caught in the act” or being observed by his family and close friends as perhaps the most aversive naturally occurring event he could think of and because he showed some sensitivity to nausea and vomiting, two aversive scenes were utilized throughout covert sensitization trials. The first scene entailed the following:
Sit back in the chair and get as relaxed as possible. Close your eyes and concentrate on what I’m saying. Imagine yourself in the recreation room of the church. Notice the furniture … the walls … and the feelings of being in the room. Standing to one side is Joan (a 13-year-old girl). As she comes toward you, you notice the color of her hair … the clothes she is wearing … and the way she is walking. She comes over and sits by you. She is being flirtatious and very cute. You touch her playfully and begin to get aroused. She is asking you questions about sex education and you begin to touch her. You can feel your hands on her smooth skin … on her dress … and on her breasts under her shirt.
As you become more and more aroused, you begin taking off her clothes. You can feel your fingers on her dress as you slip it off. You begin touching her arms … her back and her breasts … Now your hands are on her thighs and her buttocks. As you get more excited, you put your hands between her legs. She begins rubbing your penis. You’re noticing how good it feels. You are stroking her thighs and genitals and getting very aroused.
You hear a scream! As you turn around you see your two daughters and your wife. They see you there—naked and molesting that little girl. They begin to cry. They are sobbing hysterically. Your wife falls to her knees and holds her head in her hands. She is saying, “I hate you, I hate you!” You start to go over to hold her but she is afraid of you and runs away. You start to panic and lose control. You want to kill yourself and end it all. You can see what you have done to yourself.
The aversive scenes were presented in great detail in order to elicit arousal and to facilitate the imagery process. Initially, they were presented late in the chain of behavior (e.g., after Albert had begun to fondle the girl). As treatment progressed, the aversive scenes were introduced earlier into the arousing sequence (e.g., after Albert experienced the urge to touch the girl).
In addition to these scenes where Albert was caught by his family, other images involving nausea and vomiting were utilized. In these images, as Albert would begin genital contact with young girls, he was guided in imagery to feel himself becoming more and more nauseous: “Feel nausea working its way up into your throat and as you begin to swallow hard to attempt to keep it down. You begin to gag uncontrollably until nausea and mucus begin to spill out of your mouth and nose all over your clothes and the clothes of the young girl.” In later sessions, this scene was embellished by having Albert imagine that he was continuing to vomit all over the lap of the young girl until the girl’s flesh would actually begin to rot before his eyes and worms and maggots would begin crawling around in it. Although these embellishments are not effective with everyone, they were very effective with Albert. During these scenes, Albert would become visibly tense, rise in his chair, and be quite drained by the end of the session. In later sessions, Albert occasionally brought a fresh shirt for fear that he might actually vomit during the covert sensitization trial.
The initial trials allowed Albert to progress rather far into the chain of sexual behaviors before the aversive scene was introduced. However, in later sessions, the aversive scenes were introduced earlier in the arousing sequence. In this fashion, aversive scenes were paired with the very early parts of the chain, often the first glimpse, by the end of treatment. These scenes were presented to Albert in two dif- ferent formats. In the first format, referred to as “punishment,” the sexually arous- ing scene was presented and resulted in aversive outcomes. In the second format, described as “escape,” Albert was instructed, in imagination, to begin the sexually arousing scene, briefly contemplate the aversive consequences, and then turn and flee the situation as quickly as possible, feeling greatly relieved and relaxed as he got farther away from the situation.
During this phase of treatment, a typical session usually involved presenting five of the scenes, either three punishments and two escapes, or vice versa. The location of the scenes conformed to the typical locations that were relevant to Albert. The two aversive scenes would also be alternated in a random fashion or sometimes integrated or combined.
When Albert could imagine these images vividly and was fully processing the information, he was asked to go through the trial himself in the presence of his therapist. Methods for overcoming difficulties in achieving clear images were discussed and practiced. The self-administered practices within sessions were interspersed with therapist-conducted trials. After several sessions, when it was clear that Albert could self-administer the procedure as effectively as his therapist, homework was assigned. Albert monitored the intensity of his self-administered sessions on a scale of 0 to 100, where 0 equaled no intensity whatsoever and 100 represented an intensity as vivid as real life. Albert rated his initial practice sessions in the 10% to 50% range. As time went on, Albert more consistently rated the practice sessions in the 50% to 70% range. Albert’s therapist judged this range to be sufficiently intense to produce the desired effects. Initially, sessions were prescribed once a day in which he would be asked to imagine three scenes. After several weeks, this schedule was cut back to two practices a week in order to maximize the intensity.
During this time, self-monitoring revealed occasional urges and glimpses but still no fantasies or masturbatory activity. In fact, Albert had cut back on masturbatory activity shortly after his apprehension and ceased altogether just before treatment began. Nevertheless, occasional interviews with his wife, who remained extremely supportive, revealed some increase in sexual relationships, averaging two to three times per week. Both described these relationships as improved and entirely satisfactory.
At this time the final phase of covert sensitization was introduced. In this phase, Albert used the aversive images in real-life situations whenever an urge or even a glimpse occurred. Accordingly, Albert was instructed that any urge or glimpse should be immediately followed by an aversive image. Albert reported initial difficulties and then increasing facility in carrying out his part of the treatment, and he noted a gradual decrease in the number of urges and glimpses.
Rather early in the course of treatment, a community reaction to Albert’s behavior threatened to disrupt progress. Although Albert had moved out of the rectory and away from the church, some of his family remained in his hometown. On occasion, Albert would return to town from his temporary residence to assist with some practical matters concerning an upcoming move that he and his wife were planning. He would also see a few old friends. During this period, a very ugly reaction to his earlier apprehension occurred in the community. Rumors circulated with very exaggerated accounts of his behavior and claims that he was living in another state simply to wait out the statute of limitations and avoid criminal charges. It was also rumored that he had stopped seeking treatment and had a cavalier attitude toward his problem. This community reaction, which also affected his family, had a serious impact on therapy. Brief but deep depression retarded his progress and forced the covert sensitization sessions to stop temporarily while the implications of the community reaction were discussed. In fact, Albert was deeply distressed by the incident, not only because of the vicious allegations but also because of the illusions he still harbored that the community, which had showed deep support and respect for him during his years of service, would somehow welcome him back with open arms once his treatment was completed. Only when Albert fully appreciated that this was not going to happen and began to make realistic plans about permanently relocating was he able to continue on with therapy.
Four months after treatment, his pedophilic urges had dropped to zero and remained there. At this time, Albert and his wife permanently relocated to another state, where he obtained work in a local hardware store. He would continue to commute approximately 5 hours each way for the remaining treatment sessions to attend one long session every 2 weeks. A full assessment was completed 6 months after treatment began. The results of this evaluation indicated an excellent treatment response. Treatment was terminated, with plans for the first follow-up session to occur 1 month later and then at decreasing intervals as indicated.
Periodic follow-ups were conducted during the ensuing 18 months. A full evaluation at that time, which included a physiological assessment with the penile strain gauge, revealed no return of pedophilic arousal patterns. This pattern of results was supported by lengthy interviews with Albert, as well as separate interviews with his wife. Both Albert and his wife reported a satisfactory adaptation to their new location, where Albert had worked steadily and productively for the same employer and had been asked to take on supervisory responsibilities. The marital relationship, if anything, had continued to improve during the past year. Albert had begun to engage in extensive volunteer activity in his community.
More than 2 years after this contact and nearly 4 years after treatment began, another follow-up visit confirmed that no pedophilic arousal patterns had returned. Albert continued to do extremely well in his new job and was now second in command of a small chain of hardware stores. He continued to be active in the community. The church continued to ignore his occasional letters asking for clarification of his status, and he had given up all hope of any return to even part-time duties. Nevertheless, Albert still hoped against hope that someday the church that he had served so long might at least lift the suspension and allow him to occasionally conduct religious services for his immediate family. Beyond that, Albert’s thoughts centered on his day-to-day life in his new community and a distant plan of retirement with his wife somewhere in the South in another 10 or 15 years.
Discussion
Although estimates of the prevalence of pedophilia are not available, surveys have indicated that 10% to 20% of people have been victims of sexual molestation as children or adolescents (Fagan et al., 2002; Finkelhor, 1979; Lanyon, 1986). These studies indicate that girls are approximately twice as likely to be victimized as boys. Indeed, available data suggest that close to three-quarters of male abusers choose female victims exclusively, about one-quarter choose male victims, and a small minority abuse both sexes (Lanyon, 1986). The offender is usually a friend or relative of the victim. Usually, the molestation does not include physical violence; instead, the perpetrator often uses his authority as an adult to persuade the child to acquiesce to his sexual advances (Finkelhor, 1979). As is the case with the other paraphilias, pedophilia is diagnosed almost exclusively in males (Fagan et al., 2002). Left untreated or if treated with nonspecialized interventions, the disorder runs a chronic course (Hanson, Steffy, & Gauthier, 1993; Seto, 2008). Whereas a person with paraphilia was once thought to usually participate in one type of deviant sexual behavior, evidence indicates otherwise. For example, in a large study of 561 nonincar- cerated men with paraphilia, 89.6% had engaged in more than one type of paraphilic behavior (Abel, Becker, Cunningham-Rathner, Mittelman, & Rouleau, 1988); in fact, 37.6% of the sample had committed 5 to 10 different types of deviant sexual activities. Although Albert had an extensive abuse history (he had fondled at least 50 girls), fortunately he had participated in only one type of paraphilia (hetero- sexual pedophilia)—fortunate in light of recent evidence that multiple paraphilias are associated with poorer treatment outcomes (Maletzky, 1991, 2002).
Recall that Albert’s diagnosis of pedophilia was assigned with the specifiers “sexually attracted to females” and “nonexclusive type” (versus “sexually attracted to males/both sexes” and “exclusive type,” respectively). In addition to conveying a fuller diagnostic picture, this information has relevance for the course, treatment, and prognosis of the disorder. For example, although the scientific literature is not extensive on the long-term effectiveness of treatments for sex offenders (cf., Furby, Weinrott, & Blackshaw, 1989; Maletzky, 2002), the recidivism rate (frequency of committing more sexual offenses following treatment or criminal action) for persons with pedophilia involving a preference for males is roughly twice that for those who prefer females (American Psychiatric Association, 2000; although some studies have not observed differences in the recidivism rate between heterosexual and homosexual pedophiles, cf., Maletzky, 1991; Marshall & Barbaree, 1988). One study indicated that, on the basis of penile strain gauge responses, males with a history of incest are, in general, more aroused to adult females than are males with pedophilia without a history of incest (Marshall, Barbaree, & Christophe, 1986). Although this was not the case with Albert, this study suggested that men with pedophilia and without a history of incest may be more likely to display a sexual arousal pattern that is exclusively focused on children. This information would be quite important in treatment planning because, in addition to decreasing arousal over children, therapy should focus on developing an arousal pattern for adults.
Though effective treatments such as the one described in this chapter are available for paraphilias, they are usually available only in specialized clinics. In addition to the techniques described earlier (e.g., restructuring rationalizations of deviant sexual behaviors, covert sensitization, masturbatory extinction), these treatment programs typically address interpersonal and familial aspects of the problem (Fagan et al., 2002; Lanyon, 1986; Marshall, Eccles, & Barbaree, 1991; Seto, 2008). For example, social skills training is frequently used to treat sex offenders, given the high prevalence of social skills deficiencies in these patients, a characteristic that is, in the integrative model, a vulnerability factor for the development of paraphilias. This chapter focused on the application of covert sensitization in Albert’s treatment, but effective treatments for paraphilias consist of several components, including cognitive, behavioral, and interpersonal and familial elements. In addition, these programs usually contain procedures aimed at relapse prevention (Laws, Hudson, & Ward, 2000; Marshall, Hudson, & Ward, 1992). Relapse prevention procedures are designed to assist the patient in (a) recognizing the early signs of urges to engage in deviant sexual behavior and (b) deploying a variety of self-control procedures (e.g., covert sensitization) before their arousal or urges intensify. Certain drugs (e.g., medroxyprogesterone, an anti-androgen drug [Depo-Provera]) are also available for the treatment of paraphilias. These medications produce drastic reductions in testosterone levels, thereby decreasing sexual desire and fantasy. However, these medications are used infrequently because most paraphilias are responsive to psychological interventions (Maletzky, 1991, 2002).
Whereas early studies examining the effectiveness of psychosocial treatments of paraphilia involved single-case experiments or very few patients, large sample outcome studies are beginning to appear in the literature. For example, Maletzky (1991, 2002) reported on the long-term outcome (patients were followed for as long as 17 years) of 7,000 sex offenders treated at the University of Oregon Medical School. In order to be deemed a “treatment success,” the patient was required to meet the following criteria: (a) complete all treatment sessions, (b) evidence no deviant sexual arousal on any follow-up penile strain gauge evaluation, (c) report no deviant arousal or behavior at any time since the conclusion of treatment, and (d) have no legal record of deviant sexual activity, even if the activity was not ultimately substantiated. The percentage of offenders classified as treatment successes ranged from 75.5% to 96% (Maletzky, 2002). Treatment success rates of at least 90% were found for the following categories: zoophilia (sex with animals), situational pedophilia, exhibitionism, voyeurism, public masturbation, fetishism, and ob- scene telephone calls. Persons with multiple paraphilias (including men who had both heterosexual and homosexual pedophilia) or a history of rape had the poorest outcome. Similar outcomes have been obtained in large samples of the adult (Fagan et al., 2002) and adolescent sex offenders (Becker, 1990; Fanniff & Becker, 2006). Other factors Maletzky (1991, 2002) found to be associated with poor prognosis included a history of unstable social relationships, an unstable employment history, and a strong denial that the problem exists. This last factor emphasizes why it was so important to address Albert’s cognitive rationalizations prior to beginning covert sensitization. Had these issues not been addressed, there would have been a strong chance that Albert would not have been compliant with other treatment initiatives, thereby severely jeopardizing the possibility of a favorable treatment outcome. In addition, Albert received deep and sustaining support from his family, not only during the initial crisis of being discovered but also throughout treatment. This support extended to at least some of his old friends in his community who were aware of his problem and, increasingly, friends that he met in his new community who, of course, were not aware of his problem. This support was very valuable to Albert and undoubtedly contributed to his positive and durable treatment response.
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