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Unexpected lessons and connections in sex offender counseling

By Lavinia Magliocco January 16, 2023

In my final year of graduate school, I interned at a nonprofit agency where I was fortunate to have a great supervisor and experienced colleagues. They asked me whether I would feel comfortable working with Steve (pseudonym), a client who was on parole for sex offenses and was seeking additional support beyond mandated treatment.

Several factors emboldened me to say yes. First, I would be this client’s ancillary counselor; he was already working with another clinician with expertise in this population. The fact that his issues were beyond my competence would have precluded my working with him except for this contingency.

Second, at 58 years old, I’m not easily intimidated. Still, I was conscious of my limitations as a new counselor with no experience with this population and no training specific to this type of client. But ultimately, my support among a team of solid practitioners and a great supervisor made me think, “If not now, when?” So I took the leap and said yes.

This opportunity to work with a person who had committed sex offenses confirmed my trust in the power of a strong therapeutic alliance. Although this client tested me and I struggled at times, I discovered a capacity within myself that I had not experienced before. I learned about the barriers this population faces in rehabilitation from incarceration and developed a unique approach to help him regain a sense of connection to others. In the process, I gained a deep appreciation for the client. The following is the story of my experience working with Steve, who gave me permission to share his story, and what I learned.

Meeting Steve

I started working with Steve in the middle of the pandemic. Because Steve had spent the last several decades incarcerated, he was not up to speed with computers and was unsure about how to do telehealth. I arranged to meet him at a local Starbucks so I could help him set up Google Meet or Zoom on his computer. As a clinical rehabilitation counselor, helping clients with accessibility issues is important to me. Steve’s physical health and mobility were challenges for him and critical considerations in our work together.

When I walked into Starbucks, I saw a large man seated in a corner, arms crossed over his chest and a guarded expression on his face. It was Steve. He offered me a coffee, which I declined, but I told him I needed to visit the restroom before we started. I purposely left my jacket and handbag on the table where we sat. This was not a preplanned gesture but an instinctive response to his body language. Establishing trust would be crucial to working together. And what better way to gain trust than to give it?

In those 45 minutes, we focused on practical issues and had a few laughs around computer frustrations. I later learned Steve spent most of his life in various prisons. The last stint meant he’d entered prison before personal computers were common and the social media that we know today was not invented yet. He told me later that my willingness to help him with his computer in person was a deciding factor in his ability to let me into his confidence.

Finding the right approach

Another clinician worked with Steve on his sexual impulses, and I consulted with her once a month. We developed a good working relationship, and her support and expertise allowed me to focus on other issues Steve had. Steve’s stated goal for our work together was socialization. This posed some challenges, however, because his opportunities for socializing were severely restricted by his parole. At the very least, our counseling sessions provided the much-needed human contact he craved.

I scoured libraries, the internet, and the Association for the Treatment and Prevention of Sexual Abuse for articles on working with people who commit sex offenses to glean recommended evidence-based treatments. Several articles recommended using cognitive behavior therapy (CBT), motivational interviewing, self-regulation and other skills-based interventions. I knew Steve’s other therapist was working with him on self-regulation, so I consulted a colleague who encouraged me to use motivational interviewing.

I also received support from our agency’s psychiatric nurse practitioner who identified that most of Steve’s issues stemmed from complex posttraumatic stress disorder. It took months for Steve to trust me because of traumatic experiences with mental health clinicians who, 40 years ago, had tried to “cure” him of his attraction to men and had deemed him “incurable.” Steve signed a release of information form so that his two mental health clinicians and psychiatric nurse practitioner could communicate with each other about his case.

During his counseling sessions with me, Steve vented his frustrations about his parole officer and expounded on how he had been victimized by his family, friends and the system. He was initially unwilling to take responsibility for his predicament, but he provided me with opportunities to validate his feelings: He had been victimized early in his life like many who later commit sex crimes. His experiences included traumatic attachments, early seduction and sexualization, assault, and traumatic brain injury. It took months before he could admit that he was responsible for his subsequent actions. But through the use of CBT interventions, he was able to understand that just as adults had taken advantage of him sexually without his consent, he had replicated that behavior with others because it was all he knew.

In a 2013 article, “Treatment of sex offenders: Research, best practices, and emerging models,” published in the International Journal of Behavioral Consultation and Therapy, Pamela Yates said that counselors can help maximize treatment gains with this population by “demonstrating empathy, respect, warmth, friendliness, sincerity, genuineness, directness, confidence, and interest in the client.” Yates also noted that establishing a positive treatment environment contributes to positive outcomes, meaning clients are less likely to reoffend. After reading Yates’ list of characteristics, I felt reassured that the best approach with Steve was to lean into cultivating unconditional positive regard.

I asked permission when offering interventions. For someone who has been stripped of power in repeatedly traumatizing ways and who then acted out by traumatizing others, using this motivational interviewing protocol dramatically changed the tenor of our sessions and created a more collaborative environment.

Mindfulness, on the other hand, which is a clinical approach I often use with clients, was not something Steve could tolerate yet. I learned that many people with complex and chronic trauma find somatic mindfulness, which puts them in intimate touch with their bodies, to be overwhelming. Steve had difficulty connecting with mindfulness exercises and said he preferred to talk instead.

Using art to build connection

I was aware that society’s implicit assumptions around people who commit sexual crimes were influencing me negatively even before meeting Steve, so I knew I had to be mindful of my own biases or prejudices. To avoid any personal biases, I approached our sessions with curiosity and empathy.

As I got to know Steve, it was easy to feel warmth for him. He was affable and gallant in an old-fashioned way, and he longed for connection. Some of his affability did seem manipulative at times, yet I was moved by his vulnerability. He hungered for attachment. He was a fundamentally social person who enjoyed interacting with many kinds of people, so he found his inability to interact easily with others because of his strict parole conditions to be especially difficult.

His traumatic history often led him to objectify and sexualize people he was attracted to. He regularly mentioned young men he had seen on the bus or at the store that he found sexually attractive. During one session, Steve was telling me about his attraction to a young man who was a cashier at the supermarket he frequented. I listened, at first inwardly groaning at the repetitive, seemingly reflexive nature of his attractions; he didn’t really differentiate between one object of lust and another. In an attempt to understand and distinguish this particular attraction from the others he had mentioned, I decided to try to help him become more aware of and specific about his sexualization of these men, so I asked, “What do you find attractive about this man?” Steve became poetic as he described the cashier’s physical beauty — his face, hair, hands, posture and smile. I could picture this cashier vividly, and I could feel vicariously how this young man affected Steve.

Struck by this, I blurted out, “You’re a lover of beauty!” Steve looked startled. I explained, “You’re moved by beauty. That’s a value.” As a professional ballet dancer, I am also moved by beauty and understand viscerally how someone can be aesthetically driven.

That exchange sparked an idea of a way to help him feed his longing and loneliness. If he could not find connection with the humans that were off limits to him due to stringent parole, maybe he could find it in other kinds of beauty such as art, films and photography.

I began to share movie recommendations with him. I first recommended Wim Wenders’ documentary Pina (a film about the German dance choreographer Pina Bausch) because of the way this film handles topics such as attraction, desire, power and violence. I knew Steve may be titillated by the dancers’ beautiful bodies, but I hoped it also spurred a deeper dialogue on difficult interpersonal dynamics. I also hoped he might feel nourished by the sheer splendor of the film.

After the first time he watched the film, his comments were superficial yet enthusiastic. But his observations became more nuanced with each viewing. The film inspired him and awakened in him a love of performance, especially musical theater, and he started finding musicals and other theatrical performances to watch on his own. I found myself wondering if he might have had a career in the arts if his life had worked out differently. It also amazed me that my previous career as a professional ballet dancer enabled us to share a connection, and I began to think about how to spark a desire in him for self-cultivation and expression.

We looked at photographs of muscular, kinetic statues such as Gian Lorenzo Bernini’s Apollo and Daphne because I wanted him to see that sensuality and beauty can be found and fed in ways besides sex. I justified this clinically with the idea that sublimation is an effective, mature defense mechanism where his unacceptable impulses could be transformed into socially allowable behavior.

With my supervisor’s permission, I asked Steve to watch the classic Luchino Visconti film Death in Venice and used his identification with both characters — the older Gustav von Aschenbach as well as the young boy Tadzio to whom von Aschenbach was drawn — to explore his difficult history. Steve had been objectified like the young boy Tadzio. Steve often talked about how attractive he was in his youth and how older men had preyed on him. But now he identified more with von Aschenbach, the older, dying character who becomes longingly obsessed with Tadzio. The film allowed him to externalize his narrative and see himself portrayed in these characters. The poignancy of the film, which takes place during a cholera plague in Venice, also did not escape Steve. In his strict parole during the COVID-19 pandemic, he was as isolated as von Aschenbach was by the social restrictions of the early 1900s European society during the cholera epidemic.

Identifying with the beautiful youth and the dying man awakened an existential awareness in him that I believe helped him take responsibility for his actions. Sharing my passion for art and performance helped me connect with Steve, which then helped him see that beauty, sensuality and connection can be found in the arts. In this way, I believe he felt less alone.

People who commit sexual offenses in the United States, those labeled “registered sex offenders,” become pariahs. They cannot easily find work or places to live. On parole, they are subject to random lie detector and drug tests for which they must pay. Their crimes end up defining them for the rest of their lives. Imagine the worst thing you’ve ever done. Now imagine that is all anyone ever sees you as for the rest of your life. This negative stigma that follows people who commit sexual offenses can make it more challenging for them to change or for others to notice if they do change. By engaging Steve’s aesthetic side through the arts, I offered Steve a different way to experience himself — one that contrasted with the negative stigmas he often faced.

Doing no harm

My desire to help Steve also led to one crucial mistake. After the holidays and a health crisis, Steve became deeply depressed. I became concerned for his mental and physical health. His parole officer had forbidden his attendance at 12-step meetings and prevented any possibility of him joining a support group for LGBTQ+ individuals at a local center by divulging his entire history to the director, who decided they did not want to have him anywhere near the center.

Although Steve was no longer in prison, his current living situation resembled it: He lived in a one-room apartment, which was the size of a prison cell, and he had no contact with people other than his various doctors, mental health team and pastor. This isolation was a factor in his depression, so I met with his parole officer, the other mental health counselor and the psychiatric nurse practitioner to discuss ways to address this issue. I hoped to advocate for more lenience in allowing him outlets and contact in the community. I wanted his parole officer to understand that Steve’s depression and loneliness could lead to his reoffending because prison offered a built-in community and opportunities for sex.

The result of this meeting, however, was that the parole officer felt she was being attacked and became defensive. And Steve paid the price. She cracked down on him and told him in no uncertain terms that she believed he had manipulated me. I chastised myself for being so naive as to mistake my agenda as a mental health clinician advocating on behalf of my client for the parole officer’s agenda. Her job was to safeguard citizens from someone who was perceived as a dangerous criminal. Steve’s feelings were irrelevant to her. In retrospect, I see now that this situation was a parallel process where I experienced the parole officer’s stringency alongside my client. In my zeal for and identification with Steve’s plight, I did not think to put myself in the parole officer’s shoes and see how she might feel when confronted with three mental health practitioners petitioning for leniency.

I apologized to Steve saying, “I thought I was helping but instead I made things worse for you. I am so sorry! I was naive. Let’s try to repair this situation.” Acknowledging my mistake was crucial for the repair, and from Steve’s perspective, it vindicated his own experience by having me come up against the restrictions he faced. By the end of my internship, we had recovered from my mistake and our alliance was stronger because of it. Saying goodbye was emotional for both of us. We had forged a relationship in which, I believe, Steve felt seen in a way he never had been, and I was moved that he allowed me into his confidence to the extent that he did.

It’s important to note that Steve successfully navigated another nine months of parole without reoffending. He recently wrote to me and said, “Our trust didn’t begin because you left your purse at Starbucks — it happened because I connected with you and your willingness to step out from behind a desk and meet me where I was comfortable.”

Lessons learned

At the end of my time working with Steve, I asked him what he gotten out of therapy with me, besides having someone to vent to and meet with once a week. He said he had learned to trust more because of our relationship. In particular, he mentioned our first meeting at Starbucks as being pivotal in building this trust because I took the time to meet him in person and help him with his technology. He also said he felt I cared for and understood him, and that made him feel like a human being.

This experience working with Steve taught me a few lessons as well. I learned how being curious and willing to take risks are essential components of this profession. If I had allowed Steve’s status as a “sex offender” to prejudice me, I would not have been able to engage with him with as much spontaneity and enthusiasm as I did.

I learned that motivational interviewing and asking for permission before using a clinical intervention helps empower the client. Steve appreciated every opportunity to feel that therapy was his choice rather than an imposition, and this empowerment helped disarm his defenses and enabled his trust to grow.

I learned the critical importance of consultation. I not only received essential guidance and support but also gained confidence through clinical consultation. It took a village. I would like to thank my colleagues Sarah Williams, Casey VanHoutan, Krista Fuqua, Marisa Monahan, Marie Mellberg and the other colleagues who provided advice, consultation and guidance while I worked with this client.

I learned the importance of doing no harm and how easy it is to lose my perspective in countertransference. Even the best of intentions can hurt in situations with conflicting agendas.

Finally, I learned how leaning into the therapeutic alliance is both challenging and rewarding. It enabled me to care deeply about someone whom our society judges and condemns. Ultimately, recognizing that Steve has a love of beauty was the linchpin that evoked his humanity, strengthened our connection and was profoundly moving for both of us. At our last session together, Steve wept because we would not be able to continue working together; I think he felt truly seen by me. I was also moved to tears by his willingness to come on the journey with me, a new counselor. He trusted me in spite of my inexperience and offered me the opportunity to deepen my own humanity.

Lavinia Magliocco is a clinical rehabilitation counselor and licensed professional counselor associate at Three Firs Counseling LLC. The practice specializes in working with chronic illness/disability and complex trauma. Prior to becoming a counselor, she was a professional ballet dancer in New York City, a professional writer and therapeutic Pilates teacher at her studio Equipoise — Enlightened Exercise LLC. Contact her at lavinia@threefirs.com.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Working with perpetrators of child sexual abuse

By Lisa R. Rhodes September 16, 2022

Perpetrators of child sexual abuse are a clientele that some counselors may find challenging to treat. According to the Department of Justice Office of Justice Programs, the term “sex offender” refers to a person who is convicted of a sex offense, which is defined as “a criminal offense that has an element involving a sexual act or sexual contact with another” as well as one that is an offense against a minor.

As of April, 767,023 people were listed in the sex offender registries in the United States, according to SafeHome.org. This number, however, may not reflect the total number of people who have sexually abused children. The Rape, Abuse and Incest National Network (RAINN) reports that the majority of sexual assaults are never reported to law enforcement.

Courtney T. Evans, a licensed clinical mental health counselor with a private practice, Purpose in Grace Counseling, in Eden, North Carolina, says mental health treatment, specifically sex offender therapy, is a recommended form of counseling to reduce recidivism rates among perpetrators of sexual assault.

“While traditional therapy seeks to reduce feelings of anxiety and inadequacy, sex offender therapy seeks to confront the offender with thinking errors, promoting accountability and acceptance for actions,” notes Evans, a member of the American Counseling Association who specializes in treating people with trauma-related disorders, specifically children who have been sexually abused. “Sex offenders are given tools in counseling, but just like someone who attends Alcoholics Anonymous meetings long term, sexual offenders should engage in lifelong support.”

Risk factors

Community safety is the first goal of sex offender therapy, says Pablo Serna, a licensed professional counselor and independent contractor at Henger Enterprises, a therapeutic practice specializing in sexual offender risk assessment and evaluation and sex offender programming in Wisconsin.

Serna has counseled adult male sex offenders, including those who have abused children, for eight years. Most of his clients are mandated by the court to undergo sexual offense treatment or their probation officer may refer them to the practice where he works.

Serna treats perpetrators using group therapy, and he says group members can range from those who fully admit to an offense to those who admit they’ve done something wrong but are not willing to accept full responsibility for their actions.

“As a facilitator, I will introduce concepts in a general way prior to moving to [the topic of] offenses so members will grasp the idea before applying it to their offense,” Serna explains.

If a group member is reluctant to participate, Serna says he applies ideas from motivational interviewing. For example, he may empathize with the member about how group therapy can be uncomfortable or how the member does not want to be in the group. “I will admit I cannot make him participate and ultimately, he has the choice to participate,” Serna says. “Yet I point out discrepancies like ‘If you want your probation agent off your back, is not participating [going] to help with that?’”

The end goal for clients, Serna says, is to “prevent further victimizations by demonstrating an understanding of their [clients’] thinking and the risk factors that contributed to their offense and [having them] assist in developing interventions.”

Serna and his colleagues use a sex offender treatment curriculum that was developed by Joseph Henger, the president and clinical director of Henger Enterprises. The curriculum involves the perpetrator understanding the cycle of sexual abuse and relapse prevention to help them develop positive lifestyle changes. The curriculum’s main focus is to diminish deviant arousal and overcome pro-offending beliefs and behaviors, Serna says.

Serna and his colleagues also use Static 99R, an actuarial risk assessment tool developed by Karl Hanson and David Thorton. The Static 99R has 10 risk factors for assessing people who have been convicted of a sexual offense. The score of the risk factors characterizes a person’s relative recidivism as below average, average, above average and well above average.

The risk factors are divided into three categories: static, dynamic and acute. The static category refers to risk factors that do not change; the dynamic category notes personality traits or learning deficits that can change with an outside intervention, such as counseling; and the acute category refers to factors that are temporary or that can easily change because of the person’s environment or relationship with others.

According to Serna, static risk factors can include a person’s age, their prior criminal record, their gender and the relationship of the perpetrator to the victim. Dynamic risk factors are ones that can change over time, such as whether the person has any positive life influences, displays impulsivity, has problem solving skills, has an increased sex drive or any deviant sexual interests (such as voyeurism or exhibitionism) or if the person has cooperated with the probation, parole or correctional authorities involved in the assessment and management of their sexual offending behavior.

Dynamic factors, Serna says, can shed light on the person’s motivations to commit a sexual offense. He’s noticed that several of his clients who have perpetrated a childhood sexual offense have a few risk factors in common: a deviant sexual interest or attraction to children, an emotional connection to children or a hypersexual nature.

Clients often tell Serna that they feel they don’t fit in with their peers and that they feel more comfortable doing things that children do, such as playing video games. And a deviant sexual interest in children, he says, is often what allows perpetrators of sexual abuse to give themselves permission to cross social boundaries in order to have sexual contact with someone they know is a minor.

For others, a hypersexual nature plays a part in their motivations. “Some people are pretty indiscriminate” when it comes to sex, Serna notes. They want to have sex with whomever says yes or whomever is available. These clients define themselves by their sexual acts, he says, because it gives their ego a boost and helps them to feel better about themselves.

Although the assessment tool does not consider if the person was sexually abused in childhood or if it is even a risk factor for their behavior, Serna has found that the client’s own childhood sexual abuse can play a role. He has worked with clients who have abused children and tried to justify their actions by saying, “I was abused as a child. I learned to live with it, so I figured my victim would” or “The person is too young; they won’t remember it.”

Serna says other examples of distorted thinking include:

“She’s attracted to me; she’s older than her age.”
“I needed my sexual needs met. The person was there at the time.”
“I’m not going to take the time to find out how old this person is.”
“If a girl is able to have her period, she’s good for sex.”

Serna establishes some ground rules with his clients, including having mutual respect, not using objectified language (e.g., sexist or racist slurs), displaying respectful behavior (e.g., not falling asleep during group sessions), respecting the privacy of other group members and completing assigned therapeutic work.

Taking responsibility

Evans, an assistant professor of counseling at Liberty University, says the current treatment for perpetrators of sexual abuse focuses on the management of the offender. “Most programs are victim-centered approaches,” she explains. “The goal of counseling sex offenders is to prevent recidivism, while different acts and regulations pave the way for enhancing public safety and protecting victims through supervision, re-entry, registration and community notification.”

Evans says that sexual deviance (e.g., sexual interests for children over adults, abnormal preoccupation with sex) among people who sexually abuse children is often associated with an increased likelihood of sexual reoffending. “Child sexual offending may be part of a broader pattern of criminal behavior, underpinned by antisocial, impulsive and aggressive tendencies and a lack of empathy,” she notes. “This is why sexual offender counseling focuses on building empathy and taking responsibility.”

A cognitive behavioral technique that Serna uses in counseling is covert conditioning, a therapeutic approach created by John Morin and Jill Levenson. In their book Road to Freedom: A Comprehensive Competency-Based Workbook for Sexual Offenders in Treatment, Morin and Levenson note that covert conditioning helps perpetrators of sexual abuse control their arousal by linking “deviant sexual thoughts with images (pictures in your mind) of some of the terrible consequences of sex offending.”

Serna often asks clients to write a script about the distorted thinking or triggers that might occur before they decide to engage in a risky situation. Then, they write a second script that includes the negative consequences they will experience if they move forward with their desires.

The purpose of this exercise, Serna says, is for clients to attach the triggers for their behavior in risky situations to a realistic consequence, such as being incarcerated or dealing with feelings of shame or embarrassment.

When clients review the scripts repeatedly in group therapy, the recognition of their unhealthy thought patterns and the negative consequences “becomes automatic,” Serna notes. The scripts also include a part that allows clients to create a way to escape risky situations or distorted thinking patterns so they can apply and reinforce interventions with alternative thinking and behaviors, he adds.

People who sexually abuse children need to be aware of triggers, Serna stresses, but it is even more important for them to understand the problematic thinking and choices of their behavior and identify appropriate interventions.

“If they stick with me, they’re going to have a level of responsibility,” he says.

The importance of self-care

Although sexual offense therapy is an important tool in helping to reduce crimes of a sexual nature, it can also take a toll on the counselors themselves. In fact, research has found that mental health professionals who treat perpetrators of sexual assault often need psychological support themselves.

In an article on counseling sex offenders and self-care, which was published in Cogent Social Services in 2019, Evans, along with Courtney Ward, explored the impact of burnout and secondary/vicarious trauma on counselors who work with people who commit sexual abuse, and they found that mental health professionals who do this kind of work often “have a high rate of burnout and stress.”

Thus, “understanding self-care factors that influence well-being is essential,” Evans says.

In the study, Evans and Ward acknowledged that this kind of work can be difficult for some counselors because they are required “to engage in traumatic material in graphic detail while maintaining an empathic relationship with the client.” In addition, they noted that “perpetrators/offenders of sexual abuse are [often] in denial or demonstrate little or no remorse for their abusive behavior, which may exacerbate the impact on the counselor.”

Evans says the detrimental effects on counselors who work with this population can include changes in their self-perception, changes in their thoughts about other people and their environment, problems in personal and romantic relationships, changes in their sexual performance, and depression.

“Personal factors can make a counselor more prone to countertransference,” Evans adds. For example, a counselor who works with this clientele could become more protective of their own children because of the material they deal with in session. If this happens, Evans recommends clinicians seek supervision and feedback on ways to distance their own lives from their clients’ lives, which can also help counselors become more sensitive to the ways countertransference can occur.

Serna says he has managed to remain largely unaffected by the content of his therapeutic sessions with clients who have sexually abused others. He currently leads about 14 to 15 two-hour group therapy sessions per week with clients who have sexually abused children, enticed children, have downloaded/distributed materials online in which children are sexually exploited or have sexually abused adults. Some group members have also abused adults.

Yurta/Shutterstock.com

“If it came to that point [being emotionally affected], then I would know that I can’t do this anymore,” he admits.

Serna says he remains objective and requires clients to reflect on their distorted thinking and feelings because they impact their own lives — not his. “It’s up to the offender to evaluate their own thoughts, rather than me making a judgment about it,” he explains.

With a career that spans 15 to 20 years in the field, Serna has counseled a diverse clientele from the chronically mentally ill to families and adolescents. And he says these experiences have helped him to recognize his own biases and the necessity to lean on his training to maintain a professional distance from difficult clients.

“I’ve learned how to take a step back and be objective,” he says. “I feel like, as a therapist, my role is to be objective. So, when I hear these things, the only way to help them [clients] is to be objective.”

Serna says he maintains boundaries with his clients by not disclosing any personal information, such as his relationship status or if he has children. And he practices self-care by running three miles a day, playing piano and guitar, drawing and taking art classes in his spare time.

“I think keeping these boundaries permits me to separate my personal and professional life,” Serna explains. “When I am frustrated at work, I know it’s a professional issue and will look [to] the resources I have.”

Serna says if he ever gets emotional because he’s feeling frustrated, he’s trained himself to say, “OK, Pablo, this is becoming your issue now.”

Evans suggests that counselors who want to work with this population be “self-reflective regarding signs and symptoms of burnout and engage in self-care activities for prevention and alleviation.” Some self-care strategies include meditation, mindfulness, journaling and personal counseling — anything that promotes emotional well-being.

Overcoming barriers

Most of Evans’ students have not expressed an interest in treating perpetrators of child sexual abuse, largely due to preconceived notions that most people who commit sexual abuse are predators and highly resistant to treatment, she says. Personal morals and beliefs may also prevent students from choosing to work with this population, Evans adds.

But for counselors who are interested in working with this clientele, Evans recommends they seek training and certifications (such as the National Association of Forensic Counselors’ Certified Sex Offender Treatment Specialists and the Certified Juvenile Sex Offender Treatment Specialists certificates) so they can better help this population. It is also important for counselor educators to prepare students to work with difficult clients, particularly those who abuse children, Evans says.

“I think that most counselors have so much empathy for children, as we all should, and this influences feelings and thoughts related to harm to children,” she says. “This is a positive attribute in counseling, [but] it also greatly impacts services to sexual offenders.”

Perpetrators of sexual assault are often victims of sexual offenses themselves, Evans continues, so she advises counselors to take preventative action by “working with those who have experienced trauma and doing trauma screenings and, if warranted, assessments on each client.” Evans says understanding the client’s lifestyle and private logic is essential in understanding their current behavior and preventing future maladaptive behavior.

“I hope that counselor education can instill [an] understanding of sexual abuse, … not only for the victims [but also for] the motives and proper treatment for offenders,” she says. “This is … the best way to treat the problem [and] to work preventatively.”

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Lisa R. Rhodes is a senior writer for Counseling Today. Contact her at lrhodes@counseling.org.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

No, I didn’t! Denial revisited

By Michael Hubbard July 7, 2014

Given that I thought I’d cultivated my listening skills, it was uncharacteristic of me to so abruptly interrupt a patient who felt compelled to plead his court case of a criminal charge in group therapy. We in group, of course, were experiencing the very common occurrence of denial.

As part of a program in a largely forensic mental institution, our clinicians are primarily working with individuals convicted of some offense and admitted under the “guilty except for insanity” (GEI) determination. More specifically, my team’s sex offender treatment program works with those who have a sex offense conviction in their history and/or have been sexually assaultive or otherwise sexually inappropriate in the hospital.

Yet to take it out of the forensic arena, most counselors will have any number of client cases in which some form of denial may also play a central role. We see denial and so-called “resistance” in couples counseling, in family counseling and when working with any age and circumstance. We witness denial in issues of death and dying or with clients and families dealing with serious or terminal illness. And what counselor working in the drug and alcohol, gambling and other addictions field wouldn’t agree that denial is a hallmark in that client population? Ultimately, whatever level of denial we experience may be perceived as resistance and a barrier to treatment.

There are all kinds

While there are multiple types and levels of denial, most are ultimately rooted in avoiding or mitigating responsibility and accountability, generally more along the lines of minimizing or redefining behavior. Yet I have worked with some clients who engage in denial of facts, especially in the initial sessions. This is the classic denial of their offense or some other behavior. It’s also the very common default or impulsive defense mechanism among many of us, especially at a young age (“No, I didn’t break that window”).

In the case of the patient I interrupted, he not only denied the offense (a rape charge), he also denied any transgression in his entire life. Further, he was more focused on pleading his case with the group members and clinicians than on his treatment.

More common, however, are all the other types of denial. Many sex offenders with whom I have worked will engage in denial of impact or harm (“I only fondled her”), even if they admit to their offense. I see this often in cases of attempted rape, wherein the prevailing, and mistaken, attitude is often that there is less trauma if there was no penetration.

Yet we see that same perspective in other forms of rationalization (“Children are resilient; he’ll forget it”), in couples and family disagreements (“It’s always drama with her, so we don’t take her threats of suicide seriously”) and with other situations. Those who work with grief and bereavement will very likely identify with the upset client whose friends, family members or other acquaintances deliver minimizing and rather dismissive statements such as “time to move on,” “don’t dwell on it,” “get over it” and, of course, the trite “time will heal.”

Denial of intent is another common excuse (“It got out of control”). In my work, I’m often subjected to a curious phrase regarding date rape: “There we were … and it just happened,” thus jettisoning the fantasizing, the grooming and all the other behaviors that led up to a life-altering result.

Denial of responsibility, which is related to denial of intent, does not necessarily deny behavior, but is more along the lines of shifting blame. An example most of us have heard, particularly in working with children, is “He started it first.” In a more bizarre example, however, I had a client who was talking about a college female who was raped. His comment was, “Well, it happened in a fraternity. She should have known what was going to happen because that’s what happens at frat houses.”

There are many other types of denial, of course, including a minimizing form — denial of frequency (“It only happened once”) — and denial of fantasy (“I only fantasize about my girlfriend in a healthy way”). That fantasy example was voiced by a hypersexual patient who had molested many young boys over the years. He was engaging in impression management to impart an image of his engaging only in appropriate fantasies.

Do I really need this?

One important form of denial affects almost all counselors and other clinicians: denial of treatment need. Many clients with whom I’ve worked say, “I’ve learned my lesson. I’ll never do that again.” While they may genuinely believe that, what they’re overlooking is that they may not have examined the circumstances that led to their offenses, their triggers and risk factors and, thus, what interventions to use. Yet this type of denial isn’t the sole property of those who have engaged in some form of criminal activity.

Many counselors in various settings deal with individuals who have been “coerced” into making appointments. It may be someone with gambling, alcohol or other addictions forced into treatment by families, friends or even a workplace supervisor. It may be someone who had a “dirty” urinalysis at work and was suspended until he or she engaged in some mandatory employee assistance program (EAP) sessions. Few of these individuals show up feeling the need for treatment, especially if it was not their choice.

Often, resistant clients show up in family counseling. These may be teenagers or others with behavioral issues, or a spouse with relationship problems, depression, sexual dysfunction or other presentations. Many of these clients feel that they don’t need counseling, or even if they agree to the need, they are embarrassed to be seeking mental health counseling. Stigma exacerbates a natural tendency to deny.

Many of the individuals pushed into counseling may feel that the problem is with their partner, their parents or with other relatives or friends. Even among those who admit to some level of treatment need or recognize a problem, many prefer to participate in the multibillion-dollar self-help industry of books and videos. Yet is that so very different from those who deny a disease or who think that they can lose weight or otherwise regain some level of health on their own through use of a book or video? The question remains whether an individual who feels confident in self-healing is still engaging in a form of denial. Perhaps so, but with placebo or other effect in place, does it matter if the outcomes are positive?

It may be important to explore why denial occurs in our clients, but a key question is whether denial is a deal killer in treatment. It may seem, for instance, that working with an offender who denies his or her crime is a barrier, but there are many who would disagree with that premise.

Does it matter?

In the world of sex offender treatment, most community-based and residential programs in the United States consider taking responsibility for offenses a key component of treatment. That would be defined as a disclosure or admission at least approximating police and victim reports, even if the offender minimizes or engages in other forms of denial. Use of polygraphs is also a common practice. In fact, it is generally a condition of parole.

By comparison, no Canadian sex offender programs require full admission of guilt, and one report indicates that only approximately 26 percent of Canadian community-based programs require any offense disclosure at all (McGrath, Cumming, Burchard, Zeoli, & Ellerby, 2010). That may seem counterintuitive. After all, how can one deal with any situation — whether offense-related or not — if the client denies its occurrence? The answer may rest in what we as clinicians are seeking, both in mining for information helpful in therapy and as an outcome.

But does it matter? While it would seem logical that issues are difficult to address if denied, in the sex offender world at least, data are indicating very little correlation between denial and recidivism. Some, in fact, would point out that denial is an indicator that the offender is well aware, and ashamed, that the act was inappropriate or deviant, in addition to being illegal. In such cases, perhaps our clinical attention is distracted by their denial and should be emphasized elsewhere (e.g., social skills, healthy relationships, etc.).

For those clinicians who believe that client denial does matter, some point to other contributing factors to denial, including the milieu. For instance, in group therapy, it’s reasonable to believe that initial denial would be both common and understandable, particularly with an individual newly introduced to the group. Safety and trust must generally be established. It’s the rare client who is willing to share his or her failures in front of strangers.

Yet one source of help is when the newer clients in group realize that there are others in the same boat, that they’re not alone and that there is support. While this is one of the many advantages of group therapy, a step-up approach with motivational interviewing and alliance-building in individual sessions may be required.

Even in smaller situations such as couples counseling, the sharing may be difficult at first. Yet there are also other dynamics involved in couples and family counseling, such as clients seeking support for “their side,” the fight over “right and wrong,” couples utilizing other techniques (e.g., manipulation) and the perceived or actual issues (even if they aren’t obvious to the clients).

Who’s responsible?

It’s far too easy for many of us to say that a client is “in denial” or “resistant.” As stated earlier, many U.S.-based sex offender programs require accountability, including reasonable admission of offenses, with the implication that treatment could be withheld if the offender refuses or resists.

Whether or not it matters may be determined on an individual basis. If it is deemed important, and if there is resistance, might this not be a responsivity issue? And if so, should we not be responsible ourselves as the clinicians?

Our program here is on a risk/needs/responsivity model. Simply put, higher-risk patients receive more intense treatment than those assessed at lower risk. Patient needs, including dynamic risk factors, are addressed as important factors in treatment. Responsivity is an indication of the patient’s response to and/or acceptance and digestion of the treatment approach, as well as a measure of the clinician’s ability to provide the service that will be most accepted.

So while we may feel justified in indicating that a patient’s intransigence is a barrier to treatment, are we not responsible on some level for treatment failure if we are not experiencing a response? And if we assume that responsibility, is it not our task to continue the search for treatment to which the patient may respond? Can we achieve a measurable outcome even in the face of denial? Obviously, some programs believe so. But how?

In a forensic setting, we’re seeking risk mitigation — simply put, to achieve a goal of returning the patient to the community without that individual committing another offense. But can risk mitigation be achieved even if the patient refuses to take responsibility for his offenses? Perhaps so if we’re able to work with the patient to discuss all the circumstances and other factors surrounding the offense. I call this the “backdoor approach.”

For instance, if a patient is willing to discuss what was going on in his or her life prior to, during and even after an offense — even without admitting to an offense — we may be able to identify and point out behavioral patterns and/or circumstances that would be considered potentially contributory to an offense. For example, while not necessarily an excuse for offending, if the patient states that he or she was on methamphetamine or other substances, a risk factor emerges.

I have had patients indicate that their offenses occurred after a break-up or during a rough period in a relationship. Regardless of whether one believes that watching pornography is pre-offense behavior, many have indicated that they turned more and more to porn after a break-up or during a period of no sexual activity, and sought other outlets. Alcohol and drug use has been cited as one of the more common outlets.

Of course, in our setting in a mental institution, there are also contributory situations of a patient going off medication or otherwise decompensating, leading to offense-related behavior. Stress and other situations can be explored, patterns noted and, thus, risk factors identified. Even in cases in which the offense is denied, the patient is often able to see what situations set up as being more risk-related scenarios — and thus their vulnerabilities. Risk mitigation can then be effected on some level by addressing the vulnerabilities through appropriate interventions.

This same approach would be viable in couples counseling, family counseling and other similar forms of counseling. In short, we can examine environmental and other issues that trigger emotions, thoughts and consequential behavior in our clients. This approach relates to a form of mindfulness in which clients can step away and look at external influences, perhaps setting aside blame and personalized issues in the process.

Ethical issues

While considering the reasons for denial, and strategies to achieve some outcome, the topic is not without some ethical issues. The preamble of the 2014 ACA Code of Ethics reads in part:

“These professional values provide a conceptual basis for the ethical principles enumerated below. These principles are the foundation for ethical behavior and decision making. The fundamental principles of professional ethical behavior are

• autonomy, or fostering the right to control the direction of one’s life;

• nonmaleficence, or avoiding actions that cause harm;

• beneficence, or working for the good of the individual and society by promoting mental health and well-being;

• justice, or treating individuals equitably and fostering fairness and equality;

• fidelity, or honoring commitments and keeping promises, including fulfilling one’s responsibilities of trust in professional relationships; and

• veracity, or dealing truthfully with individuals with whom counselors come into professional contact.”

In attempts to deal with denial, are there iatrogenic factors present in our demand for disclosure that would constitute maleficence? And where do we stand, and how would we know, if the person indeed did not commit an offense? If, in our cases, a denier passes a polygraph, does that carry any weight, notwithstanding admissibility (or not) in court, police reports or other materials?

Would it be ethical to “treat” someone for something they did not do; or do we treat based upon all the other findings, regardless of the client’s adamant stance? Are we out of our scope of practice if drawn into the legal questions? We must be mindful of these ACA ethics standards:

B.1.b. Respect for Privacy

Counselors respect the privacy of prospective and current clients. Counselors request private information from clients only when it is beneficial to the counseling process.

B.1.c. Respect for Confidentiality

Counselors protect the confidential information of prospective and current clients. Counselors disclose information only with appropriate consent or with sound legal or ethical justification.

B.2.e. Minimal Disclosure

To the extent possible, clients are informed before confidential information is disclosed and are involved in the disclosure decision-making process. When circumstances require the disclosure of confidential information, only essential information is revealed.

These questions may all lead to what boundaries we draw regarding working with denial. It is likely an easier decision when there is no denial of fact, but rather the more often expected “lesser” denials. Yet, as in all cases, we must consider potential iatrogenic effects. When we consider how very much we detest denial in our society, and yet forgive confession, it behooves us to explore our goal as counselors when denial is a key factor.

We might want to examine whether our goal is an outcome we can achieve by other means, or whether we are so outraged at the “lies” that we become committed to “breaking” someone.

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Michael Hubbard is a mental health specialist with the sex offender treatment program at Oregon State Hospital in Salem, Ore. Contact him at Michael.Hubbard@state.or.us.

For related reading, see Hubbard’s article from the April 2014 issue of Counseling Today: Sex offender therapy: A battle on multiple fronts

Sex offender therapy: A battle on multiple fronts

By Michael Hubbard March 31, 2014

Working with individuals with sex offense convictions is a specialized area of counseling. There are also “specialties within the specialty” when factoring in the different venues for treatment, including programs in prison, in private practice (often with those on postprison supervision or probation) and in mental institutions. The individuals within this population are generally quite different, and the dynamics are made even more complex when considering whether the offenders are adult males, adult females (yes, there are female sex offenders) or juveniles. The research on each population varies considerably. There is a paucity of research on female sex offenders, and research is still somewhat lacking (although growing) on the ever-complex juvenile offenders.

Sex offender therapy is challenging regardless of the nature of the clients, and other factors also come into play. There exists the constant issue of resistance to treatment, particularly when treatment is a condition of probation or parole. Criminogenic thinking pervades the scene, and counselors must be on guard for the often subtle signs of that mind-set. For instance, individuals convicted of sex offenses can be highly manipulative, not only with their therapist but also with others in their therapy groups. Power plays, deflection, grooming and lying are a few examples of the criminal thinking that may be evident. Many offenders will also present with a virtual encyclopedia of thinking errors. Often topping the cognitive distortion list are victim stance (“This label is unfair”), minimization (“All I did was grope her”), justification (“We’d had sex before and she didn’t complain”) and entitlement.

In addition to the cognitive distortions and potential for criminogenic behavior, counselors may also have to contend with other factors such as addictions, co-occurring disorders and, of course, shame, guilt and incredibly demeaning self-talk. The ultimate goal of sex offender therapy is relapse prevention, based first upon accountability and assumption of responsibility for offensive behavior. But when all of these factors are thrown into the mix, the counselor is often faced with denial on several levels: denial of facts (“It wasn’t me”); denial of intent (“I was drunk”); denial of impact (“She didn’t seem to mind”); and denial of the need for treatment.

Research supports the best practice of sex offender therapy being conducted in groups whenever possible. The peer support, which includes challenging denial and other thinking errors, is invaluable in treatment and also lends itself to generally better outcomes. Part of the reason for this is that so many sex offenses are based in secrecy. Bringing offenses out into the open is generally conducive to discussion and to the cognitive elements that are so important to reducing recidivism.

Of course, group therapy adds still other elements for the therapist to consider, including properly populating groups (for example, matching risk factors, genders and ages) and building and maintaining effective group dynamics. Sex offenders don’t want to talk about their “stuff” in front of others. Consequently, providing a safe environment and building trust are staples of effective sex offender therapy groups.

While this represents a formidable enough battlefront on its own, sex offender therapists are faced with another perhaps even more challenging front — that of our society, including our lawmakers.

Society’s perception

In this discipline, we understand that risk mitigation is a primary concern. After all, society demands and deserves protection, and we all share the goal of ensuring that there will be no more victims of sex offenses. In fact, that is a primary directive.

Yet our society is also responsible for erecting many of the barriers that stand in the way of the recovery that sex offender therapists and our clients strive to achieve. Understandably, victim advocacy is far more palatable than the thought of treating a population that most would prefer to exile. However, the sad fact is that punitive barriers such as limited jobs, housing restrictions and sex offender registration raise significant risk factors for recidivism. These barriers often negate the efforts of sex offender therapists and those clients who possess legitimate desires to recover and return as productive members of society. In fact, our society may be contributing to future victimization — just the opposite of our primary goal.

As we all know, hopelessness is like a vampire to therapy. As our restrictive policies and biases feed that hopelessness, treatment and recovery are undermined, and relapse can become more likely. The short of it is that society’s efforts are based on a significant amount of misinformation and myths about sex offenders, and politicians and law enforcement officials often respond to the public’s demand for protection with tougher and more restrictive laws. Those laws and policies, even when couched as seemingly more sensible restrictions on living locations (as though all sex offenders are child molesters), send a clear message of “not on our block, in our neighborhood or in our town.”

In the meantime, the question of “Who is a sex offender?” is often overlooked. When I describe a 19-year-old who had consensual sex with his 16-year-old girlfriend of two years, some people will respond, “Well, he’s not a sex offender in that case.” Yet I have worked with a number of individuals convicted in similar situations who are now registered as sex offenders for life and required to complete treatment. In fact, there were so many such cases in Oregon that the state finally passed what is referred to as the “Romeo and Juliet law.” Under this law and similar laws in some other states, there is generally no charge of engaging in unlawful sex even if the “victim” is underage and the “offender” is an adult, as long as the age difference is no more than three years and the sexual act was consensual. My point here is that there is no set “profile” for all individuals labeled as sex offenders, yet society and the media frequently attempt to paint one.

Common myths

This particular battle is not restricted entirely to public sentiment. In the state institution in which our program operates, the public’s general misconceptions about sex offenders are often shared by some staff members. And I should point out that those in our counseling community are not immune. Some of the common myths about sex offenders are as follows.

Most sex offenders are predators. Reality: The most common sex offender is opportunistic, has one victim and is known to the victim.

Most sex offenders are dirty old men, strangers and pedophiles who will grab children off playgrounds. Reality: First, pedophiles (those sexually attracted to children) are not necessarily child molesters, for most do not commit offenses regardless of their attraction. Most sex offenders and child molesters are relatives or otherwise known to the family; only 2-3 percent of such offenses are committed by strangers. An estimated half of all child molestations are committed by teenagers.

Once a sex offender, always a sex offender (most sex offenders will reoffend). Reality: Study results vary considerably depending on the nature of the crime, whether the offender was previously incarcerated, whether the offender received treatment, what kind of support exists and the time after release and/or treatment completion. Yet contrary to popular belief, studies and statistics (including those from the Bureau of Justice) indicate that recidivism rates for sex offenders are lower than those for the general criminal population. A five-year study from the New York State Division of Criminal Justice Services noted a rate of recidivism ranging from 6 to 23 percent, depending on the offense (incest had the lowest recidivism rate, while molestation of boy victims had the highest recidivism rate). The Center for Sex Offender Management cites a recidivism rate of 12-24 percent but adds that many such offenses are underreported.

Treatment for sex offenders does not work. Reality: This statement has been a source of debate for decades. The effectiveness of treatment depends on a number of factors, including the type of offender, the type of treatment and how much management, supervision and support the offender has. Although the risk of recidivism exists even in the best of cases, most offenders can and will lead productive and offense-free lives after treatment.

Most sex offenders were sexually abused when they were children. Reality: Although sex offenders are more likely to have been sexually abused than nonoffenders, the vast majority of individuals who were sexually abused will not go on to commit sex crimes. A 2001 study by Jan Hindman and James Peters found that 67 percent of sex offenders initially reported sexual abuse in their history. Yet, when subjected to a polygraph, that figure dropped to 29 percent, suggesting that reports of sexual abuse were initially exaggerated to justify or rationalize their offenses.

I recall my former graduate school classmates, and even some of my professors, asking me, “How can you do that kind of work?” Most often the question came from those working with victims of sexual and physical abuse. Others in law enforcement and victim advocacy programs often repeated the question. The implication from some is that a counselor who treats the instigators of sexual abuse cannot also identify with the victims of such abuse. That argument could not be more fallacious.

Other obstacles

In our sex offender treatment program at a state hospital, a primarily forensic mental institution, our first challenge is getting patients with sex offenses into our program. We run an evidence-based program, principally using cognitive behavior therapy (CBT), that serves all risk levels and populations that have regular and diminished cognition with a variety of biopsychosocial diagnoses. Most of the patients in our program are in the hospital under a “guilty except for insanity” adjudication and under the jurisdiction of Oregon’s Psychiatric Security Review Board (PSRB). No matter why they are here, any patient with a history of a sexual offense or who engages in inappropriate sexual activity is referred to our sex offender treatment program.

When referred, a sex offender risk assessment is conducted to evaluate risk and appropriateness for sex offender therapy and to provide recommendations. Participating in sex offender treatment at the hospital is not mandatory, although the PSRB — concerned with risk mitigation — may consider nonparticipation a risk factor when contemplating the patient’s release to a less restrictive facility.

The patients often balk at the thought of living with the “sex offender” designation, fearful they will be subjected to harassment and other abuse. Their fear is warranted; many are labeled with terms such as chi mo (child molester), pedophile or predator and become targets for possible physical assault. Staff members are not immune to falling into the judgment trap, sometimes in the form of what we call the “ick factor.” Even if they try not to show it, the patients can read it. Many sex offender patients carry so much shame and guilt that any suggestion of judgment can keep them from engaging in treatment or create a setback. We use a considerable amount of motivational interviewing to facilitate patients’ decisions to engage in the treatment they sorely need to progress through this institution.

Because our team operates in a state institution, we face some challenges not seen as often in private practice or other counseling venues. Our patients have mental illness, with everything from schizophrenia spectrum disorders to various personality disorders. In addition, more than one-third of the members in the groups we facilitate have diminished cognition. This represents another barrier to effective treatment, especially when considering that CBT and adjunct approaches such as dialectical behavior therapy and acceptance and commitment therapy are the most foundational and evidence-based practices when working with sex offenders. Indeed, the dynamic risk factors between the populations vary considerably.

As stated before, therapists in this field often deal with criminogenic thinking. Although we may expect that with many clients on postprison supervision, it is easy to forget in this hospital, where we are working with those who have been diagnosed with some form of mental illness. But the guilty except for insanity plea and accompanying diagnoses do not preclude criminogenic thinking. We witness manipulation, victimization and other criminal activities all too frequently. Given all these factors, providing sex offender therapy in our program is sometimes like looking through a fractured lens and still trying to divine a clear image of each patient and how to work with that patient for engagement and progress.

How might this apply to you?

Those of us currently in this field, as well as those counselors who may one day work with sex offenders, must realize that our approach to treatment will be negatively affected should we hold on to the same misconceptions and biases that are so prevalent in society. We are already familiar with the more general bias toward mental illness. Consider how much more that can play out in a charged atmosphere of offenses with the prefix sex. If you are a counselor and saying to yourself, “I have no intention of working with sex offenders,” here’s news for you: Most counselors will work with sex offenders, although perhaps without even knowing it.

Consider that a U.S. Department of Justice report from 2005 said studies suggest that sexual assault is one of the most underreported crimes. That same report estimated that 60 percent of rapes go unreported. As a counselor, you may be just as likely to work with a client who has committed a sexual offense, even though the client comes to you for another unrelated reason, as you are to work with a client who eventually discloses that he or she was sexually molested. Given the underreporting of sexual crimes, it is not unthinkable that you may have a client who has offended and is coming to you due in part to the guilt that he or she is experiencing. Or you may have someone well into therapy for a different reason (for example, depression), only to finally have that client confess to sexual offending.

So, how should you prepare? As with any area in counseling, seek out information, research and guidance. There are a number of excellent resources in the field of sex offender therapy, including the Center for Sex Offender Management, the Association for the Treatment of Sexual Abusers (ATSA) and the New England Adolescent Research Institute. All provide forums for research and to improve the work we do, both in treatment and in support for recovery. ATSA has many organizations under its umbrella on a state level that offer workshops on sex offender therapy and related topics. It also hosts an annual conference with a plethora of research and presentations.

For those inclined to explore or promote advocacy, these organizations (as well as others) produce important educational information. Speaking of which, another misconception exists that if a therapist advocates for a recovery-minded approach in treating sex offenders, that person is precluded from advocating for victims. Some people even view us as “offender defenders.” But most of us have treated, and continue to treat, victims of sexual and other abuse. In doing so, we often treat individuals who are both victims and offenders.

Current research indicates that the most evidence-based therapy for sex offenders, with the best outcomes, is CBT. In addition, a person-centered approach has been demonstrated to be most effective. This is understandable given the shame and suspicion felt by many offenders. An interdisciplinary team that communicates well is another key factor for optimal treatment and supervision. When working with clients on postprison supervision in private practice, this team would include the therapist, the parole officer and other professionals such as polygraphers. In our hospital setting, the communication and cooperation between our sex offender treatment program personnel and the unit psychiatrists, psychologists, nurses and other staff such as treatment care plan specialists are essential to crafting and implementing treatment plans, considering and managing outings and other privileges, and working toward the patients’ recovery and eventual transition to other settings such as group homes.

Other programs, such as one begun in Canada called the Circle of Support and Accountability (COSA), have recognized the need to provide ongoing support and guidance as sex offenders leave treatment and attempt to make their way back into society as productive members. Studies involving the original COSA and those established in states such as Minnesota have demonstrated a significant reduction in recidivism — in some cases, in excess of 70 percent. In turn, this has had a positive fiscal impact by reducing prison time due to relapse and reconviction. Most important, that translates to fewer victims.

As stated earlier, group treatment is best practice in the field of sex offender treatment. Of course, many counselors in private practice may not have enough clients to establish a group. When there are enough members, setting up and running sex offender groups presents another level of challenge. First, groups should be set up with homogeneity in risk level, age and gender. In other words, low-risk clients should not be mixed with high-risk clients, genders should not be mixed and juveniles should not be included in groups with adults.

Once established, group dynamics become a focal point. Even though all group members will have committed some form of sex offense, some members will not be above judging others. For instance, a person convicted of raping an adult female may object to being in the same room with someone who molested a child, a relative or a male adult. Although society may not make distinctions between sex offenders, the offenders themselves sometimes have their own hierarchy.

Another challenge, yet to be sorted out by sufficient research, is treatment of offenders who are developmentally delayed. Some therapists have raised valid questions about using CBT with those who have diminished cognition. In addition, there are some risk factor differences between those with regular cognition and those with diminished cognition. Many treatment programs that handle both populations simply modify their regular program for clients who are developmentally delayed. Others have more distinct programs, with the one for developmentally delayed clients focused more on addressing emotional dysregulation and other dynamic risk factors.

Closing thoughts

Sex offender therapy is a controversial topic. No matter your involvement (or lack of involvement) in working with or advocating for the treatment of this population, you may still experience the battlefront I have outlined. The research and dissemination of findings will be limited as long as there is polarization around sex offender issues and as long as those perceived “sides” are not willing to listen to each other.

As counselors, we all know that listening, and especially reflective listening, involves a number of skills, not the least of which is seeing through the issues without allowing our own emotions to get involved. The public needs to receive an education on these issues. In addition, politicians, government agencies and policymakers must be urged to listen rather than simply striving to establish more “tough on offender” laws that sometimes make little sense and may, in fact, ultimately contribute to additional victims.

As counselors, however, we first focus on caring and applying our skills as best we can. We know that we cannot cure, but we can do our best to prevent future victims. In the process, it’s very likely that you will be faced with the task and frequent frustration of educating others who will not care. In fact, many will suggest that you simply throw away the key rather than provide treatment.

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Michael Hubbard is a mental health specialist with the sex offender treatment program at Oregon State Hospital in Salem, Ore. Contact him at Michael.Hubbard@state.or.us.

For related reading, see Hubbard’s July 2014 piece on denial: ct.counseling.org/2014/07/no-i-didnt-denial-revisited/

Letters to the editor: ct@counseling.org

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.