Treatment Model

The first part of the treatment seeks to establish the social and therapeutic framework within which the group treatment will proceed. Components include: establishing group rules, addressing initial denial and developing group social skills.

The purpose of sex education for men with intellectual disabilities and sexually abusive behaviour is to provide:

• A common knowledge base and understanding for human sexuality and relationships, including consent and legal issues
• ‘Permission’ to talk about sexuality and sexually abusive behaviour
• Opportunities to challenge any myths/beliefs/attitudes/cognitive distortions regarding relationships, behaviour or gender roles, which may contribute to sexually abusive behaviour

The content is broadly based around two main components: general sex education aimed at those with an intellectual disability and specific education/discussion on areas that are hypothesized to be less understood or known by men with an intellectual disability who engage in sexually abusive behaviours, eg legal and illegal behaviours, consequences of such behaviours and consent.

The treatment takes a cognitive approach to changing sexually abusive behaviour, through changing the men’s cognitive distortions.

This phase of the treatment introduces men to the cognitive model, ie to the idea that there are emotional and cognitive aspects to behaviour. This is approached within a structured but flexible framework and begins with non-offending examples (eg someone being upset because a promised visit from a friend did not take place) and gradually moves on to challenging behaviour/offending (eg wanting some chocolate in the shop, not having the money and taking it anyway) and finally to sexually offending (including the men’s own offences).

Finklehor’s 4 step model of sex offending provides the framework within which facilitators and participants can discuss the offending behaviour and come to understand it better, especially the various stages or steps involved in the offending process. This part of the programme is intended to help the men to understand that their previous abusive sexual behaviour did not occur in a random or unexplained fashion but that they planned to offend (and therefore that they can plan not to offend). The model provides a relatively simple framework for understanding sexual offending and forms a basis for the later development of relapse prevention. It proposes 4 steps to sexually abusive behaviour:

• thinking about sexually abusive behaviour (having ‘not OK’ sexy thoughts)
• making excuses about why this is OK
• planning how to get access to a victim
• overcoming the victim’s resistance and engaging in sexually abusive behaviour

Each man is required to consider these steps in relation to his own past behaviour. In the process of discussion with the men, it usually transpires that they hold a variety of cognitive distortions (eg the belief that they didn’t plan their offences, they just ‘happened’). These cognitive distortions are then challenged, with the help of other men in the group and each man is helped to develop a more honest account of how his sexually abusive behaviour occurred.

Empathy has long been considered important for regulating and/or mediating pro-social behaviour, motivating altruism and inhibiting aggression. It appears that low victim empathy may be related to some of the cognitive distortions that sex offenders hold, in that both minimization of harm and victim blaming may be the result of low victim empathy.

Various methods are used in the treatment to try to increase victim empathy. Initially the men are supported to talk about times when they were victims of something unpleasant or upsetting. They consider how they felt. The group then works towards getting the men to think about how victims of sexual abuse, generally, might feel. Finally they are helped to face up to how their own victims felt, something which most men find very hard.

Relapse prevention is designed to address the difficulty encountered in most sex offender treatment programmes, that of recidivism or failure of maintenance.

The purpose of relapse prevention strategies is to provide the client with a range of strategies and tactics that will reduce the probability of encountering situations in which a lapse is likely and reduce the likelihood of lapses becoming relapses.

Such strategies are needed because regardless of how powerful the initial treatment effect is, maintenance relies on self-administration of strategies and tactics to avoid relapse, and if such strategies are not explicitly addressed in treatment, the client is less likely to have the appropriate skills and knowledge to apply them.
Towards the end of the treatment, a number of sessions are spent developing detailed relapse prevention plans for each client. These serve as a summary of relevant points of the group treatment programme and are designed to be portable relapse prevention plans that the man can use at any time and that can also be shown to relevant parties such as the residential service and Care Manager.

The serious consequences of the men’s offending behaviour on their victim’s means that steps must be taken following the treatment to help reduce the chance of recidivism:

• At a minimal level, the relapse prevention plan developed for each client should be used as a basis for risk management with services responsible for monitoring the individual. Services are encouraged to re-refer to psychology services if circumstances arise that potentially increase the risk of re -offending
• Maintenance groups are held on a regular basis to monitor the relapse prevention plan as well as assisting the client to deal with other issues and problems which may otherwise increase the possibility of offending
• Inclusion in a further year long treatment group may be possible

Groups will differ in the extent to which it is possible to involve carers, but most will run at least a few sessions of carers groups (often in parallel with the men’s group sessions).