Southern Illinois University Carbondale

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Research Papers Graduate School

Fall 9-28-2017

Behavioral Interventions for Sexual Deviancy in

Individuals with Developmental Disorders
Samuel Krus
samkrus@siu.edu

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Krus, Samuel. "Behavioral Interventions for Sexual Deviancy in Individuals with Developmental Disorders." (Fall 2017).

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BEHAVIORAL INTERVENTIONS FOR SEXUAL DEVIANCY IN INDIVIDUALS WITH
DEVELOPMENTAL DISORDERS

by

Samuel Krus
B.A., Southern Illinois University, 2014

A Research Paper
Submitted in Partial Fulfillment of the Requirements for the
Master of Science

Department of Rehabilitation
in the Graduate School
Southern Illinois University Carbondale
December, 2017
 RESEARCH PAPER APPROVAL

BEHAVIORAL INTERVENTIONS FOR SEXUAL DEVIANCY IN INDIVIDUALS WITH

DEVELOPMENTAL DISORDERS

By

Samuel N. Krus

A Research Paper Submitted in Partial

Fulfillment of the Requirements

for the Degree of

Master of Science

in the field of Behavior Analysis and Therapy

Approved by:

Ruth Anne Rehfeldt, Chair

Graduate School
Southern Illinois University Carbondale
September 14th, 2017
 AN ABSTRACT OF THE RESEARCH PAPER OF

SAMUEL NATHAN KRUS, for the Master of Science degree in BEHAVIOR ANALYSIS
AND THERAPY, presented on SEPTEMBER 14th 2017, at Southern Illinois University
Carbondale.

TITLE: BEHAVIORAL INTERVENTIONS FOR SEXUAL DEVIANCY IN INDIVIDUALS

WITH DEVELOPMENTAL DISORDERS

MAJOR PROFESSOR: Dr. Ruth Anne Rehfeldt

Statistical analyses have found a significant proportion of crime is of a sexual nature and

that reducing its occurrence is a complex problem that has had various solutions proposed.

Therapy programs that focus on the reduction of sexually deviant behavior have been proposed

by many clinicians and researchers in the psychological and rehabilitative fields which have

shown varying degrees of success. As treatments have been developed across multiple

disciplines there have been many paradigms developed around the development and

corresponding treatment of sexually deviant behavior. Along with addressing the behavior itself,

many programs have sought to address sexual deviancy based on the interaction it produces

between the individual and the multiple social systems they are a part of with the goal of

understanding development of such behavior from a broader scale outside the individual and

preserving individual liberties while treating such individuals. The goal of this review is to

summarize the methods of several programs based on a massive online search and to examine

the trends among successful treatments as well as propose future directions for the treatment of

individuals that engage in sexually deviant behavior.

Keywords: sexual behavior, sexual assault, cognitive behavioral therapy, mode

deactivation therapy, problem solving therapy, sexual education, functional analysis

i
 TABLE OF CONTENTS

CHAPTER PAGE

ABSTRACT ..................................................................................................................................... i

MAJOR HEADINGS

SEXUAL DEVIANCY AS A CRIME – Introduction ........................................................1

TREATMENT AND REDUCTION OF SEXUAL DEVIANCY– Review........................7

CONCLUSION – Summary ..............................................................................................48

IMPLICATIONS FOR PRACTICE –discussion, Recommendation ................................49

REFERENCES ..............................................................................................................................52

VITA ............................................................................................................................................67

ii
 1

SEXUAL DEVIANCY AS A CRIME

Over the past 2 decades, there has been a noted increase in attention paid to the problem

of sexual deviance as a crime and the methods of reducing the occurrence of such crimes.

Accompanying this attention is also a noted increase in the proportion of prison populations that

are composed of individuals incarcerated for sexual crimes (Becker, 1994; Becker & Murphy,

1998; Fisher & Beech, 1999; Gordon & Porporino, 1990; McGrath, Cumming, Livingston, &

Hoke, 2003; McGrath, Hoke, & Vojtisek, 1998; Prentky, Knight, & Lee, 1997). As of July 2017,

individuals incarcerated for sexual offense make up the third largest proportion of incarcerated

Americans after those incarcerated for drug offenses and those incarcerated for unlawful weapon

use and possession (Federal Bureau of Prisons, 2007). This increased rate of incarceration is not

unique to individuals of sex based crime as changes in sentencing policies have led to increased

convictions for many forms of crime as well as a general increase in sentence terms for

imprisoned individuals (Neal & Rick, 2016). This in turn has contributed to the high rate of

prison overpopulation found across the country and calls for alternatives to incarceration

(Hamilton, 2014).

Targeting sex offenders as a population to treat outside of prison to reduce overcrowding

and strain on penal institutions seems to have great promise given the unique characteristics

individuals that commit sexual offences possess compared to other imprisoned individuals.

Statistical evidence has found that a significant proportion of registered sex offenders possess

any combination of the following characteristics which are considered contributing factors to

their sexually deviant behavior: developmental disability (Marotta, 2015); impulse control issues

(Mathesius & Lussier, 2014); and a previous history as the victim of sexual, emotional, or

physical abuse (Apsche & Ward Bailey, 2003; Mathesius & Lussier, 2014). These characteristics
 2

of sex offenders indicates that behavioral analytic and psychological methods may prove very

successful in the reduction of criminal sexual behavior as such procedures have been used to

successfully treat individual issues of impulse control (Gavriel-Fried & Ronen, 2015; McKeel &

Dixon, 2014), alteration of behavior in individuals with developmental disability (Campbell-

Fuller & Craig, 2009; Dufrene, Watson, & Weaver, 2005) and management of emotional

responses to previous abuse (Gallegos, Cross, & Pigeon, 2015; Hinton, Pich, Hofmann, Otto,

2013). In addition to possessing characteristics that indicate a high likelihood of reformation if

exposed to behavior modification, individuals labeled as sex offenders face greater violation of

personal liberties and greater danger in prison settings than many other individuals. Studies have

found that individuals incarcerated for sexual offenses are viewed with greater stigma from both

prison staff and fellow inmates which produces additional aversive conditions not faced by other

prisoners (Ricciardelli & Moir, 2013; Webb, 2013). Prisoners labeled as sex offenders also face a

greater risk of violence against them and have been found to be the most victimized group of

adult male prisoners in prison populations (Ricciardelli & Spencer, 2014). Often the social

structures of the prison environment promote a belief that such individuals are deserving of

punishment and thus acts of violence against such individuals is legitimate and acceptable

(Stevens, 2013).

Given this greater risk to such individuals in the prison system, prison cannot adequately

be deemed a humane punishment and provides further support for a rehabilitative solution rather

than a penal one. The issue of the identification and treatment of undesired sexual behavior

proves to be one of great complexity across many aspects however. The topic faces not only

polarizing opinion but also ambiguity of meaning which greatly muddles objective interactions
 3

with both the individuals themselves and the behaviors they engage in. The following section

seeks to clarify some of the terms used in cases of sexual deviancy.

What Is a Sexual Offender? What Is Sexual Deviance?

A wide variety of terms are used to label undesired sexual behavior and these terms fall

under several different domains of interest (e.g. legal, psychological, communal) and are often

used inconsistently and thus warrant an explanation. A sexual offender is defined as a person that

has committed a sexual offense as legally defined by the state (Lanyon, 2001; Nezu, Nezu, Klien

& Johnson, 2007). For example, Arizona lists sexual conduct with a minor as defined by

“intentionally or knowingly engaging in sexual intercourse or oral sexual contact with any

person who is under eighteen years of age” (Arizona Revised Statute 13-1405, 1999). Sexual

deviance or sexually deviant interest is a nontechnical term that states interest in sex offending

behavior and may be defined by specific behavior such as pedophilia but does not imply a sex

offense unless the law is broken (Lanyon, 2001; Nezu et al., 2007). Sexual abuse is generally

considered by behaviors that are non-consensual and not mutual. Sexual abuse can involve

behaviors that don’t require contact between the perpetrator and the victim such as sexual

harassment or indecent exposure or acts that involve physical contact such as sexual assault and

rape (Brown & Turk, 1994; Lofthouse et al., 2013).

Factors That Contribute to Sexual Misconduct

Sexual behavior and sexuality as a concept is tied to several arenas of human interaction

and the underlying causes of sexual behavior undesired by the surrounding community is greatly

debated. Depending on the school of logic the cause of sexually deviant behavior can be

anything from a lack of education (Michie, Lindsay, Martin, & Grieve, 2006) to expression of an

underlying mental illness (Bass & Apsche, 2013). Despite the different beliefs about how
 4

sexually deviant behavior develops, statistical analyses have found a few similarities across

individuals that have engaged in sexual offences that often occur with incidence of deviant

sexual behavior. Several studies have found that victims of abuse are more likely to commit

sexual abuse. This is especially the case with individuals with an intellectual disability (ID)

(Lindblad & Lainpelto, 2011; Swango-Wilson, 2011; Bleil Walters et al., 2013). A lack of

opportunity to receive education about healthy sexual behavior and healthy sexual identity

development has also been seen in many individuals that engage in sexually deviant behavior.

Again, this has also been seen to occur in greater frequency with individuals with ID but it has

also been a characteristic found more often in LGBT individuals that have engaged in sexual

deviancy (Price, 2003). In terms of personality, individuals that have engaged in sexually abusive

behaviors have often displayed impulsivity and an inability to delay sexual gratification (Price,

2003). Studies have also found that most reported individuals that engage in sexual deviancy are

males that know their victim (Brown, Stein, & Turk, 1995; Gilby, Wolf, & Goldberg, 1989;

McCarthy & Thompson 1997; Brown & Turk, 1993).

Ethical Considerations for Alteration Of Sexual Behavior

The ultimate goal of psychological and behavioral programs are to alter an individual’s

behavior. Since the nature of such programs require the individual to have power exerted over

them by an external force care must be taken not to infringe upon the rights and liberties of the

individuals in a programs care. This is especially true for cases such as those described in this

review as such individuals are more often placed into such programs by an external force, such

as by caregivers or a legal institution, rather than choosing to join such programs of their own

accord. Even in cases where individuals possess the ability to opt out of such programs, there

may be pressure to engage as a means to avoid more aversive situations such as individuals that
 5

can avoid incarceration by being placed on parole or probation but are required to participant in a

community based treatment as part of their sentence (FindLaw, 2017, JRank, 2017). This

decreased ability to exert free will can place such individuals under the umbrella term of a

vulnerable population which require additional considerations and alterations to treatments and

research to ensure the individuals protection. In addition to prisoners or individuals facing

imprisonment charges, minors and individuals with ID are also considered to be vulnerable

populations based on conditions of being wards of others and inhibited ability to make informed

choices (Shivayogi, 2013). In an effort to minimize the risk of exploitation, the governing bodies

of therapeutic organizations such as the American Psychological Association (APA) and

Behavior Analysis Certification Board (BACB) have established a code of ethics with sections

focused on the proper conduct for interactions with such individuals. For example, the BACB

compliance code requires behavior analysts to engage in additional procedures before and during

treatment of vulnerable individuals that are to receive treatment at the request of a third party

(e.g. the court). In such cases the client or their surrogate must be informed of the nature of a

treatment and the care of the ultimate client (the individual receiving treatment) is placed above

all others regardless of the wishes of a third party (Behavior Analysis Certification Board, 2017).

Additional Considerations for Individuals with Id

The condition of possessing an ID creates additional complications and factors that must

be accounted for when addressing the issue of sexual deviance and its treatment. Several studies

have found that individuals with IDs are at greater risk of becoming victims of sexual abuse then

their typically developing peers (Aderemi & Pillay, 2013; Fyson, 2007; Gürol, Polat, & Oran,

2014; Lumley, Miltenberger, Long, Rapp, & Roberts, 1998; Mahoney & Polling, 2011; Swango-

Wilson, 2011). Despite this greater risk of victimization one cannot simply focus on protecting
 6

this population from victimization as individuals with IDs also make up a significant portion of

individuals that engage in sexual deviancy with surveys finding between 4% and 40% of

individuals with ID have engaged in some form of sexually deviant behavior (Miltenberger et al.,

1999; Sex Offender Treatment Services Collaborative- Intellectual disabilities, 2010; Shenk &

Brown, 2007) and between 10% and 15% of individuals that engaged in sexual abuse had some

form of ID(Wilcox, 2004). Further complicating matters is that one of the most frequently cited

perpetrators that individuals with ID find themselves the victims of sexual abuse to are other

individuals with ID (Martinello, 2015; Thompson & Brown, 1997). Some studies have also

proposed that individuals with ID possess additional factors that can contribute to engaging in

sexual deviancy (Lindsay, Steptoe, & Haut, 2011; Phenix & Sreenivasan, 2009; Ward & Mann,

2004). This greater risk of being both victim and perpetrator, along with the greater chance of

being denied liberties that their typically developing peers have access to, has placed a special

interest on developing and adapting effective strategies for reducing sexually deviant behavior in

individuals with ID while still affording them opportunities to express sexuality.

 7

TREATMENT AND REDUCTION OF SEXUAL DEVIANCY

Sexual behavior is expressed in a multitude of ways and the programs developed to alter

sexual behavior when it is expressed in undesired ways can be just as numerous. Views of

sexuality and sexual behavior shape the form that programs take to treat individuals. Practices

that are based strongly in behavioral principles view sexual behavior as a part of a relatively

simple system of interaction with the environment and apply general methods used to treat a

variety of behavior disorders to such cases (Reyes et al., 2006). Practices that view sexual

behavior as the result of one or more complex systems may develop very complex systems of

treatment that seek to address both the behavior itself and other factors of the individual’s life

that are believed to contribute to such behavior (Apsche & Bailey, 2004). The following sections

will describe some commonly used programs for the identification and treatment of sexually

deviant behavior along with the underlying beliefs of why they work.

Functional Analysis

A functional analysis (FA) is a form of functional behavior assessment in which a subject

is systematically presented with antecedents and consequences that mirror what one experiences

in one’s natural environment but arrangements are made so behavior and its antecedents and

consequences are more easily observed. When using this assessment multiple conditions are

generally presented to the subject wherein they come in contact with a specific stimulus and are

observed for the occurrence of the targeted behavior. Through this assessment the events that

precede a targeted behavior, and the result that reinforces the behavior are usually discovered

and a program can be developed to modify the behavior based on its function (Cooper, Heron, &

Heward, 2006).
 8

A modified form of the FA has been developed for when it has been found that a subject

engages in a behavior, such as sexual behavior, because it is in itself reinforcing rather than

because it leads to a reinforcing external consequence. The function of this modified FA is to

find what antecedent stimuli are most likely to precede the subject engaging in the targeted

behavior. As with the original form of the FA, the subject is presented with an antecedent

stimulus under different conditions. How this FA differs is that only the antecedent stimuli are

altered in each condition (e.g. the subject may be presented with people of different genders or

ages in different conditions) and the subject is allowed to engage in the behavior with no external

consequence. The different antecedent stimuli are presented multiple times across individual

trials and the occurrence stimuli is recorded to determine which stimuli is likely to evoke the

target behavior (Dozier, Iwata, & Worsdell, 2011).

Though the use of an FA has been found to accurately determine what stimuli are likely

to lead to the targeted sexual behavior of an individual with disabilities it is not in and of itself a

form of treatment but rather a tool to facilitate the development of a behavior modification

therapy for a subject and evaluate a treatment’s effectiveness (Reyes et al., 2006). This form of

FA has been successfully used to determine what stimuli evoke such behavior as penile arousal

(Reyes et al., 2006), public masturbation (Dozier, Iwata, & Worsdell, 2011), and inappropriate

physical and social interactions of a sexual nature (Pritchard et al., 2012). In addition, the latter

two studies were able to successfully develop behavioral modification programs to eliminate the

targeted sexual behavior in multiple settings (Dozier, Iwata, & Worsdell, 2011; Pritchard et al.,

2012)

While providing a useful tool to facilitate behavior modification programs the use of an

FA has limitations. In the study conducted by Reyes et al. (2006) 10 adult men with mental
 9

disabilities that were receiving treatment as sex offenders had their penile circumference

measured when exposed to appropriate (pictures of adult men and women) and inappropriate

(pictures of children) stimuli to determine their arousal to the stimuli. The results of this study

found some participants showed decreased change in penile circumference when exposed to the

same stimuli over time which indicates a decreased level of arousal with the stimuli and subjects

that showed no arousal to any presented stimuli (which was inconsistent with their history has a

sex offender). These results indicate that the FA was unable to consistently determine what

stimuli would be likely to precede change in penile circumference and determine arousal for said

individuals. Additionally, the subjects of all these listed FA studies were males with

developmental disabilities so it is unknown what external validity this method would have to

women and individuals without disabilities.

Sexual Education Programs

Many have suggested that a lack of accurate sexual knowledge contributes to sexually

deviant behaviors and that this is especially the case among individuals with ID (Cantor,

Blanchard, Robichaud, & Christensen, 2005; Michie et al., 2006). Based on this view, it is

believed that individuals with a lack of knowledge of appropriate sexual and social behavior are

more likely to engage in behavior that is sexually deviant as they discover and gain

reinforcement from such behavior and are not taught an alternate behavior (appropriate sexual

behavior) that can replace the sexually deviant behavior while providing a similar form of

reinforcement. In addition to this lack of knowledge is a lack of opportunity to engage in

appropriate sexual behavior which is believed to contribute to sexually deviant behavior as the

only opportunities to receive reinforcement from sexual gratification are sexually deviant. For

example, an individual that does not have access to an environment where they can form
 10

social/sexual relationships with peers of a similar functioning level may develop deviant

behaviors such as voyeurism or relations with children of a similar functioning level as these are

the only opportunities to engage in and receive reinforcement for sexual behavior that their

environment provides for them. As such individuals are not motivated to specifically engage in

sexually deviant behavior but instead engage in sexually deviant behavior due to a lack of

available alternative behavior this phenomenon has been termed “counterfeit deviance”

(Griffiths, Hingsburger, Hoath, & Loannou, 2013). This theory has not received much support

from research as many studies have found that rather than possessing less knowledge, many

sexual offenders display greater sexual knowledge than their non-offending counterparts

(Lindsay, 2004; Lunsky, Frijters, Griffiths, Watson, & Williston, 2007; Michie et al., 2006;

Murphy, Coleman, & Haynes, 1983; Talbot & Langdon, 2006).

Despite this, many Authors suggest that juvenile sexual offenders often lack or possess

erroneous information about sexual topics and proper social interaction (Becker & Kaplan, 1993;

Bourke & Donohue, 1996; Kaplan & Krueger, 2003; Martin & Pruett, 1998; Ryan et al., 1996;

Shaw, 2002) and it is often requested that juvenile sex offenders receive some form of sexual

education or social skills training as part of their treatment in a rehabilitation program(Brown &

Schwartz, 2006; Center for Sex Offender Management, 1999; Hunter et al., 2003; Kaplan &

Krueger, 2003; Rich, 2003; Shaw et al., 1999; Worling & Curwen, 2000). Additionally, many

studies have found evidence that sexual offender programs that include a sexual education

component show a positive effect in decreasing recidivism among its subjects (Alexander, 1999;

Craig, Browne, & Stringer, 2003; Gallagher, Wilson, Hirschfield, Coggeshall, & MacKenzie,

1999; Hall, 1995; Hanson et al., 2002). Because of this, many programs have been developed to

provide sexual education for juvenile offenders and offenders with ID.
 11

Most institutions develop their own programs for sexual education so there can be a lot of

variation between sex education programs. Sexual education programs cover a wide scope of

topics. Programs usually focus on teaching appropriate social interaction, accurate understanding

of physiology and anatomy, and age appropriate relationships but topics may also include human

development, sexual health, different forms of sexual behavior, and societal and cultural views of

sex depending on the program (Dwyer & Boyd, 2009).

In addition, multiple teaching formats for sex education have been developed including

group, (Dwyer & Boyd, 2009), and one on one between 1 participant and a facilitator (Goodman,

Leggett, Weston, Phillips, & Steward, 2008). The group method of sex education is utilized to

provide the opportunity for critique and input from peers. This allows participants to explore

issues of sexuality and sexual behavior in a safe area that corrects incorrect ideas and prevents

the individual from excusing their behavior (Bourke & Donohue, 1996; Goodman et al., 2008).

The one on one format, on the other hand, has been found to be useful for applying lessons to a

participant’s personal experiences. This method allows a participant to talk openly about their

own history of sexually offensive behavior one would rather avoid talking about for risk of being

punished for it and allows the facilitator to guide the participant in specific aspects of their

behavior and the lessons being taught and how the two can be applied to each other. Sexual

education programs may use either format or may alternate between formats for different

components of the program (Goodman et al., 2008).

A sex education program used by a southern medical university was studied to observe its

effects on adolescent males that were incarcerated in a state department of mental health’s

inpatient facility for children and adolescents. The sex education program was conducted in a

group format and focused on six “Key concepts” as described by the Guidelines for
 12

Comprehensive Sexuality Education in Kindergarten through 12th grade, 2nd edition (National

Guidelines Task Force, 1996). The six concepts in order of group presentation were Human

Development; Relationships; Personal Skills, Sexuality, and Society; Sexual Behavior; Sexual

Health; and Society and Culture. Each concept and its subtopics were learnt about through

weekly sessions with interactive group activities, lectures, and roleplaying. Before and after the

training program participants were tested on their knowledge of sexual topics. It was found that

of 5 participants, 2 participants had a significantly increased score, 2 participants had scores that

were comparable to their original scores, and one person had a lower score than their initial

score. Aside from these results no assessments were conducted to measure practical application

of skills and appropriate behavior was conducted. The results of this study may indicate that sex

education program can increase knowledge of appropriate sexual behavior but further research is

needed to assess whether a change in behavior has occurred (Dwyer & Boyd, 2009).

A research study conducted by Craig, Stringer, & Moss (2006) was conducted to assess a

program they developed to specifically treat individuals with ID. This program included sexual

education as part of a weekly cognitive therapy program. Like Dwyer & Boyd (2009), the sexual

education lessons were conducted in a group session and individuals were given specific jobs at

each session to make sure all individuals received adequate food and drink to further encourage

the development of social skills. In addition to the standard lessons taught in sexual education,

subjects were taught about the laws surrounding sexual behavior. Various methods were used to

adapt the lessons to suit the needs of individuals with ID such as providing information through

various mediums including pictures, drawings, interactive exercises, videos, quizzes, and

structured group discussions to emphasize key concepts. Additionally, sessions were kept

deliberately flexible and delivered to suit the pace of the subjects and learned information was
 13

reviewed by presenting recaps of information learned in a previous session at the start of the

session and summarizing new information presented at the end of the session. After the program

ended little change was found in the subjects with only one of 6 displaying some new sexually

appropriate interests while the rest continued to show sexually deviant interests. Little change

was reported in behavior following the study and while no participants were reconvicted

following a 12 month follow up all participants were under 24-hour supervision so it cannot be

determined if this lack of conviction was due to alteration of behavior or a lack of opportunity to

engage in sexually deviant behavior.

In study conducted by Goodman et al. (2008), a unique topic that participants were taught

about were the stages of sexual offending based on programs developed by the Sex Offender

Treatment Services Collaborative (SOTSEC-ID) and the four-stage model of offending

developed by Finkelhor (1984). This model proposes that there are 4 conditions that must be met

that contribute to the engagement of sexually offensive behavior in individuals and specifically

focus on the behavior of child sexual abuse and the factors that contribute to it. In the SOTSEC-

ID’s programs that incorporate this model as part of the sexual education component,

participants are taught to understand these factors that contribute to engaging in sexually

offensive and abusive behaviors and recognizing when these factors occur in their own lives so

they can take responsibility for their actions and behave appropriately.

The first stage of the sexual offending model is called motivation to abuse. In this stage,

there must be an establishment of motivation operations (MO’s) that increase the likelihood of

abusive behavior in the individuals as well as affecting who the target of the abuse will be. If one

can assume that sexual gratification is automatically reinforcing then it would make sense that an

individual would engage in behaviors and engage with stimuli that maximize the reinforcement
 14

of the sexual gratification. Based on this model it is proposed that characteristics of a child may

make them stronger reinforcers than an adult. These characteristics may include similar level of

intellectual and emotional development as it allows the ability to more easily form an intimate

relationship and connect with such a target and the smaller size of a child compared to the

individual as it allows greater control over the target. On the other end of the spectrum, while a

child’s characteristics may make them highly valuable as a stimulus to gain reinforcement from

in the form of sexual interaction and gratification, an adult may have characteristics that act as

low-quality MO’s to engage in sexual interaction with or the adult may not provide any MO at

all for sexual interaction. The characteristics of an adult or the factors of the environment may

create ‘blockage’ that prevents the individual from getting reinforcement from a consensual adult

relationship (Finkelhor 1984). Characteristics of an adult such as having a higher degree of

emotional and intellectual functioning could require an individual to engage in prerequisite

behaviors (courtship, dating, solicitation) that the individual lacks the skill and knowledge to

perform to reach the point where they could appropriately engage in sexual behavior with them

which then blocks the individual from what would otherwise be an appropriate target for

engaging in sexual behavior with. The larger size of an adult also provides the individual with

less physical control over an interaction than they would be granted with a child. An additional

factor that may particularly affect individuals with ID is their access to appropriate individuals

with which to engage in sexual behavior with as such individuals may be at increased risk of

isolation and lack opportunities to develop relationships with appropriate targets (Department of

Health, 2001). It is characteristics such as these that may increase the likelihood that an

individual will engage in sexual behavior with one stimulus (a child) over another (an adult) as

the individual has greater access to children to form relationships, requires less prerequisite
 15

behaviors to engage in sexual behavior, and can more easily over power a child than an adult if it

comes to that.

Overcoming internal inhibitors is the second condition to be met that contributes to

sexually offensive behavior. While an individual may have the motivation to engage in a

sexually offensive behavior, it is unlikely to occur if the individual is inhibited by a history of

rule governed behavior for alternatives to the sexually offensive behavior as well as a history of

punishment for engaging in the sexually offensive behavior and covert behaviors such as

emotions and thoughts. As the act of sexually offensive behavior leads to reinforcement from

sexual gratification despite also leading to potential punishment in internal forms such as guilt

and external forms such as legal action there is potential to engage in the behavior that is

strengthened by reinforcement and weakened by punishment and factors that overcome the

punishing effect of covert behaviors such as feelings of guilt or rules that lead to rule governed

behavior the second condition that contributes to sexual offending is met. Lack of knowledge of

a rule that contributes to rule governed behavior such as the law and lack of understanding of the

consequences of offending or the perspectives of another can lead to the internal factors such as

empathy and guilt being overcome and preventing the internal inhibition of sexually offensive

behavior. Lack of knowledge and understanding of such rules may contribute to the overcoming

of internal inhibitors for adults with ID (O’Callaghan & Murphy, 2007) but it is considered

unlikely that this lack of knowledge is a factor for most men with ID that sexually offend

(Thompson & Brown). In addition to failing to follow rules about appropriate sexual behavior,

offenders often develop cognitive distortions about their offending or minimize their

responsibility for their behavior and the consequences of their offending (Marshall, Anderson, &

Fernandez. 1999). These distorted views may allow a subject to ‘bend’ the rule that governs their
 16

behavior by altering the definition of what the rule is so they can continue to offend without

feeling guilt from breaking a rule. This further may undermine their ability to resist engaging in

offending behaviors (Salter, 1988) Thus, by weakening internal punishers for behavior the

reinforcers for the behavior remain and the likelihood of engaging in the behavior is strengthened

and increased.

As mentioned in the previous step there are internal and external inhibitors to engaging in

sexually offensive behavior. While internal inhibitors include rules and histories of behavior, the

third step consists of overcoming external inhibitors. External inhibitors are environmental

factors that allow or prevent the opportunity to engage in sexually offensive behaviors. These

factors heavily focus on the target of the sexually offensive behavior and how they are protected

from the individual. These include the access the individual has to a target (can the individual

come into contact with a target?) and factors that would signal to the individual that they would

likely be unable to receive sexual gratification were they to engage in the behavior (is there a

supervisor or other person that would prevent the individual from engaging in the behavior?). By

encountering or setting up situations where the individual can engage in sexually offensive

behavior with a target the individual is able to overcome the external inhibitors.

The final step in the model is known as overcoming victim resistance. This step focuses

on the behavior of sexually offending itself and the individual’s success in engaging in the

behavior with the target. The target’s behaviors and characteristics now act as factors that lead to

a successful sexual encounter from the individual and in turn the engagement of a sexually

offensive behavior. Many factors may affect the targets ability to resist becoming the victim of

abuse such as their susceptibility to the reinforcers the individual provides them for interaction

such as attention and physical objects. The target’s knowledge of abuse prevention behaviors and
 17

the pre-existing power the individual has over the target due to their relationship are also factors.

Children that have been taught abduction or abuse prevention strategies are less likely to be the

victims of abuse and individuals that are not in control of the target’s access to reinforcers and

punishment are less likely to be able to elicit desired behavior from the target. It is because of

their relative lack of power and access to a repertoire of target preventing behaviors that children

and people with ID are at greater risk of becoming targets for sexual abuse (Finkelhor, 1984).

While this model was initially designed to explain the process of sexual abuse of

children, the previously mentioned study by Leggett et al. (2008) only had two of their six

participants that exhibited sexual behavior towards children. Furthermore, all participants in this

study had ID which further separated them from the original population the model was based on.

This was done to observe the effectiveness of this form of education when applied to individuals

with ID. The education course consisted of 50 education sessions that were conducted weekly

and 5 maintenance sessions that were conducted monthly after the education sessions had ended.

Each session was 2 hours and began with the participants working to prepare the room by

arranging chairs and going over the rules that the group developed which were to be followed

during sessions. Following this, participants gave a short description of important events they

had experienced the previous week with a focus on interpersonal behaviors and risky situations.

Facilitators might also bring up events for discussion that they had heard about from a

participant’s care workers and probation officers if the participants did not bring them up

themselves. Participants were then given time to discuss and explore the events and how they

related to the participants sexual offending in a supportive manner while still challenging each

other’s undesired behaviors. Past behaviors that were discussed were examined by the group in

regard to how they related to the stage(s) of sexual offending that they had previously learned
 18

and then participants were introduced to new materials that focused on teaching a new stage of

sexual offending or continued to teach about a stage that was being taught in the previous

session. As with other programs designed for individuals with ID, information and lessons were

presented in a variety of ways such as videos, role-play, picture-prompts, small group discussion,

drawings, quizzes and games. Some individuals had trouble staying on task so to further adapt

sessions to their needs multiple activities were presented each session which lasted no more than

20 minutes each and a 15-minute break followed by a short period of physical exercise was

presented approximately half way through each session. These breaks and exercise sessions were

intended to increase a sense of team work and group bonding in addition to ensuring participants

could stay on task. An added measure used to adapt lessons to the participants was to simplify

language through methods such as changing the names of the stages from 1. motivation to abuse,

2. overcoming internal inhibitors, 3. overcoming external inhibitors, and 4. overcoming victim

resistance to 1. Thinking about it, 2. Making excuses, 3. Getting the chance, and 4. Doing it.

After being taught about a step, participants were given examples over several sessions of non-

sexual behaviors that the 4 stages could also be applied to such as smoking (step one is thinking

about smoking, step two is making the excuse that ‘one cigarette won’t hurt’ etc.). Eventually

participants were instructed to apply the steps to examples of sexual offending and, following

this, were given individual work with a facilitator where they applied the steps to their own most

recent instance of sexually offensive behavior which they eventually presented to the rest of the

group.

Frequency of sexually offensive behavior before and after the study was not recorded but

participant statements of their incidences of sexual offending in regard to the 4 steps were

observed. Before the program participants made statements that indicated they were not at fault
 19

for the sexual assault, statements that they would not get in trouble for the assault, or statements

that minimized the harm they had caused to their victims. Participants also denied any significant

planning to offend despite evidence to the contrary based on their statements. Following the

program participants made statements regarding the incidences that indicated that they were

responsible for their behavior, statements that they could face consequences for sexually

offending, and statements that acknowledged the victim’s innocence in the situation and the

negative impact the sexually offending behavior had on them. Despite these statements the

researchers acknowledged that it is uncertain if the statements made during sessions reflected

behavior that occurred outside sessions as they were punished and challenged by the group for

making statements that indicated they had done nothing wrong and reinforced and praised for

making statements of responsibility for the incident and that these contingencies did not exist

outside the program setting. To assist in a change of behavior a relapse prevention plan was

developed for each participant that contained goals the participant wanted to achieve, risky

situations and beliefs that facilitated sexual offending, and the new beliefs that had been

discussed in class. These plans were shared with key workers in the participants life that were

then instructed to review them with the participants on a regular basis and at times of great risk.

It was discovered that one participant that had shown great progress in altering his statements

and beliefs of sexually offending had broken the conditions of his sex offender order by forming

a relationship with a mother of young children. Though the participant had not been found to

commit any sexual offence this behavior corresponded to the third step of sexual offending by

providing himself with access to potential victims. Despite this the results of this study have

found that thoughts and beliefs regarding sexually offensive behavior in individuals with ID that

offend are broadly similar to those of individuals without ID that also offend. The same can be
 20

said of the factors that contribute to offending. The results of this study also report that, for

individuals with ID, there are factors that act more prominently or in addition to the factors faced

by individuals without ID such as greater risk of isolation from sexually appropriate partners and

lack of skill or knowledge of prerequisite skills required before one can appropriately engage in

sexual behavior (Goodman, et al. 2008).

Overall, sexual education as a method of reducing sexually deviant behaviors is

inconclusive. This method has predominantly focused on individuals with ID and juveniles that

have committed sexual offenses but little research has been conducted on the change of

frequency of sexually deviant behavior. The effectiveness of such methods is further obscured by

the fact that often times the participants enrolled in such programs are held in highly controlled

environments where the opportunity to engage in sexual deviancy is limited. Despite the lack of

conclusive evidence on the effectiveness of sex education the format and topics addressed in

such programs do have their merits. The component of teaching appropriate sexual behavior to

participants does provide alternative behaviors that can replace sexual deviancy and allow for

individuals to still gain access to sexual gratification. Finally, the focus on individual

responsibility and behavior rather than the manipulation and control of the individual’s

environment from outside forces also allows participants with ID a greater opportunity to access

the liberties of their typically developing peers and brings attention to the unintentional adverse

effects that such populations are at risk of from the individuals and organizations that seek to

keep them safe. While sexual education has not been determined to be a successful program on

its own, it may yet act as a useful component when combined with other programs and the fact

that some studies indicate that increased knowledge of sex and its related behaviors do correlate
 21

with a decrease in statements and beliefs that support sexually deviant acts (Pascal & Herbé,

2011) warrants further research of sexual education’s use on populations with ID and without.

Cognitive Behavioral Therapy

Cognitive Behavioral Therapy (CBT) is one of the commonly used forms of treatment for

typically developing individuals that commit sexual offences (Aos et al. 2006; Hanson et al.

2002; Marshal, 1996; Nicholaichuk, Gordan, Gu, & Wong, 2000; Yates, 2002) and it is used as

part of probation programs in many parts of the U.S. and U.K. (Beckett, Beech, Fisher, &

Fordham, 1994).

CBT as a general practice is based on social learning theory (Bandura, 1986) and is based

on the belief that external and covert behaviors (thoughts, feelings, and cognitive processes) are

linked and that external behavior is influenced by covert behavior. The function of CBT is to

replace undesired covert behaviors with desired behaviors by assessing the individual’s

perceptions and skill deficits. CBT also focuses on the development of external behaviors

through acquisition of skills such as observation of distorted thoughts, problem solving,

perspective taking, skills for appropriate social and sexual behavior and improving relationships,

and developing adaptive behaviors for the management of emotions and urges. Other behaviors

such as sexual arousal to inappropriate stimuli may also be reduced or extinguished as a

component of CBT (Marshall, Anderson, & Fernandez, 1999; Yates, Goguen, Nicholaichuk,

Williams, & Long, 2000). Repetition of skills is a strong focus to establish desired behaviors as

part of the individual’s behavior repertoire and procedures often provide many opportunities for

the individual to engage in the desired behavior (Hanson, 1999).

Similar to sexual education programs, CBT programs are designed with the individuals

own agency in mind. The skills taught are chosen based on a great deal of research on the factors
 22

that can contribute to sexually deviant behavior and how the individual may receive

reinforcement for the new behaviors learned from these skills which may compete with previous

undesired behaviors (Yates, 2003). As CBT places a heavy focus on cognitive distortions as a

contributor to undesired behavior several models and theories based on covert behavior and

cognition have been developed to measure, identify, and alter these covert behaviors in addition

to the more easily detected genetic and historical factors (Langdon, Maxted, Murphy, &

SOTSEC-ID Group, 2007). Using these cognitive-behavioral models, CBT therapies have

targeted cognitive constructs when seeking to alter an individual’s sexually deviant behavior

such as one’s value system (Herman, 1990), affect control, and empathy (Ward, Keenan, &

Hudson, 2000). As the focus centers on the abstract and conceptual rather than concrete and

physical, very few of the models developed have been able to adequately identify and address all

the factors that legitimately contribute to an increased risk of sexual deviance. Despite this, there

has been evidence to the credibility of cognitive and covertly behavioral factors contributing to

overt sexual deviance with studies finding that models like the Ward and Hudson Offending

Pathways model do show a correlation between an individual’s goals and strategies (defined as

the desires of the individual to either access or avoid the opportunity to commit a sexually

deviant act and the form their behavior to carry out this behavior takes) and the frequency of

sexually deviant behavior (Langdon et al., 2007).

Dissimilar to other sexual offender treatments, CBT often seeks to address the tendency

for some treated individuals to be at greater risk of reoffending as time goes on (Hanson, Steffy,

& Gauthier, 1993). To this end, CBT employs the use of follow up programming which is

introduced at some point after the initial treatment is completed. Once the goals of the initial

treatment have been met and the individual has demonstrated the ability to engage in the desired
 23

skills and behaviors the treatment programs that have previously been utilized will end and a

second phase of less involved treatment programs are introduced. This second phase often

involves some form of assessment of skills or refresher programming that ensures the individual

is still capable of engaging in the desired target behaviors along with some form of supervision

in which the individual is monitored to ensure they do not engage in the undesired behavior

(Yates, 2003). An additional effect of these follow up programs is that they provide behavioral

contingencies that are similar to those that were provided in treatment and provide an avenue in

which the desired skills are generalized to a non-treatment setting (Cumming & McGrath, 2000).

The large amount of growth in CBT practitioners and its nature as an interdisciplinary

program that facilitates collaboration from a wide variety of backgrounds has proved to be a

great boon to CBT as an adaptable and effective vehicle for treatment (Levenson, 2014). Not

only has CBT demonstrated itself to be a successful form of therapy for the most apparent

aspects of sexual deviancy, that is the reduction of sexually deviant behavior in the individual

and the immediate stimuli in the environment that act as motivation for such behaviors, but

researchers have also CBT to address less apparent factors and concerns for sexual deviancy that

occur on the sociological, psychological, ethical, and legal levels (Beech & Hamilton-

Giachritsis, 2005; Glaser, 2010; Prescott & Levenson, 2010; Ward, 2010). With this the

conceptions of sexual deviancy and the individuals that commit such acts have been expanded to

incorporate the individual as a victim to be treated as well as a perpetrator to be altered. With a

greater understanding of how trauma inflicted on some individuals effects their own emitted

behavior, CBT has been able to develop and incorporate treatment models such as Trauma

Informed Care (TIC) and the modification of group climate in treatment to maximize treatment

effectiveness. These changes in conception have allowed for CBT to gain greater success in use
 24

for special populations that require special protection as well as treatment. In turn, CBT has been

able to develop programs to treat men with ID (Murphy, Powell, Guzman, & Hays, 2007) and

preadolescent children (Carpentier, Silovsky, & Chaffin, 2006).

In a pilot study conducted in the south-east of England (Murphy et al., 2007), participants

with ID had been admitted to the study for engaging ins sexually abusive behavior were placed

in 1 of 2 treatment groups. Participants entered into the first treatment group were measured on

various scales of knowledge and attitudes towards sex and sexually deviant behavior and any

instance of sexually abusive behavior that occurred prior to the program, during the program, and

the 6 months following the program was logged. During the program sessions participants were

taught basic information about sex and appropriate sexual behavior as part of a sexual education

component of the program. After completing the topics taught as part of the sex education

component, participants were encouraged to self-disclose about their own sexually abusive

behavior and the factors that surrounded them. Topics that were discussed included descriptions

of participants illegal sexual behavior, the distress they felt when talking about their illegal

sexual behavior and cognitive distortions participants used to cope this the distress, their own

experiences of being victims, perspective taking of their victims, and cause of the participants

own sexual behavior. The methods of the second group were conducted in a similar manner with

similar topics being discussed. All topics of sexual education and self-disclosure of past sexual

behavior were adapted to allow for as many sessions as participants needed to fully understand

them.

The results of this study showed initial promise as only 1 of 8 engaged in sexually

abusive behavior during both groups. The behaviors this participant engaged in were non-contact

behavior including public masturbation and indecent exposure. In the 6 months following the
 25

program no participants had been convicted of committing a sexual offense but 3 participants,

including the participant that had engaged in sexually abusive behavior during the programs, had

engaged in sexually abusive behavior in the form of nonconsensual sexual touching through

clothing, public masturbation, and verbal sexual harassment. It is of note that all participants that

had continued to engage in sexually abusive behavior during and after the program had had

diagnoses that placed them on the autistic spectrum which indicates that the program received

may need further adaptation to achieve greater effectiveness with this population or an

alternative treatment may need to be developed all together. Additionally, assessment of

participants found that participants showed greater sexual knowledge and empathy for victims

following the program.

To assess the impact CBT had on some individuals that went through CBT to modify

sexually abusive behavior, a follow up interview was conducted with 16 men with intellectual

disabilities after 2 months of completing a CBT program (Hays, Murphy, Langdon, Rose, &

Reed 2007). The majority of the subjects reported that they would like to attend additional

sessions but, with the exception of the rule of confidentiality, when asked about any individual

lesson or rule less than half of the individuals were able to recall the rule asked about.

CBT and Its Use with Teen and Child Populations

CBT programs have also been uniquely adapted to treat the population of preadolescent

individuals that engage in sexual deviance as it is commonly believed that sexually deviant

behavior in childhood becomes increasingly difficult to alter as they age and some studies

indicate that individuals that display Sexual Behavior Problems (SBP) in childhood may have an

increased chance of engaging in sexual offenses in adulthood (Burton, 2000; Carpentier et al.,

2006; Zolondek, Abel, Northey, & Jordan, 2001). Although current studies to not accurately
 26

portray the risk of childhood SPD leading to adult sexual offense, this problem has been deemed

important enough for some state child welfare systems to have developed tracking systems for

registering and handling such children and some states include such children in sex offender

registries (children Safety Act, 2005)

A comparison study by Carpentier et al. (2006) of the individual effectiveness of CBT

and Play Therapy (PT) on children that displayed SBP showed highly promising results in favor

of CBT. The participants for the study were selected from various child health and care and law

enforcement centers and admitted into the program upon meeting criteria such as displaying

clinically significant SBP. Upon being admitted into the program, participants were placed at

random within a CBT or PT treatment group.

The CBT condition focused on behavior modification and psychoeducational principles.

Participants were engaged in 12 highly structured sessions where they were educated in topics

such as learning concrete sexual behavior rules, behavior self-control techniques, sex education,

and identifying inappropriate sexual behavior. This program was specifically developed for

children rather than being adapted from programs designed for adult sex offenders that have been

used in previous treatment programs (Araji, 1997). Additionally, the caregivers of the

participants were educated in appropriate and inappropriate childhood sexual behavior and

techniques to manage inappropriate sexual behavior such as minimizing opportunities for SBP to

occur. A third group that did not display SBP but instead other behavioral problems such as

ADHD and oppositional defiant disorder also engaged in this form of CBT therapy

The comparative PT program was less structured than the CBT program and instead focused on

client-centered and psychodynamic play therapy principles. In this condition participants

engaged in 12 sessions that had a different form of play activity for each. While the CBT
 27

program was directly lead by therapist the PT was minimally directed, instead therapists focused

on giving reflections of what participants said, probing into feelings, and interpreting patterns of

play. During play, a theme that was similar to a lesson taught in the CBT program was

introduced for discussion which the participant would engage in with their care giver as the

therapist observed and assisted the care giver. Participants from all groups had reports given

following 1 and 2 years of treatment to provide information on whether participants had engaged

in any sexual offenses.

The results of the study found that 2% of participants in the CBT had been reported for

committing a sexual offense in a 2-year span following treatment which was significantly lower

than the 10% of participants in the PT group reported to have committed a sexual offence. The

incidences of sexual offense by the third behavioral disorder group closely matched that of the

SBP-CBT group which indicated that the CBT program may be effective in reducing sexual

offences in individuals with non-sexual behavior disorders as well. Overall participants that

engaged in this short-term form of CBT displayed very low incidence of sexual offence

following a 2- year period after treatment thus supporting both this form of CBT and the use of

caregiver education and involvement as a part of treatment.

The results of this study mirror those of previous studies focused on CBT programs for

children with SBP (Araji, 1997; Cohen & Mannarino, 1996; Cohen & Mannarino, 1997; Pithers,

Gray, Busconi, & Houchens, 1998) with children that go under various forms of CBT displaying

a marked decrease in SBP post treatment which some studies found were maintained in follow

up studies (Bonner & Fahey, 1998; Bonner, Walker, & Berliner 1993; Bonner, Walker, &

Berliner, 1999). An additional unique aspect of this study was that the gender of the sampled

participants was relatively even with just over 60% of participants being male. Analysis of
 28

correlation between demographics found that gender had no significant effect on SBP or risk of

engaging in sexual offense. These results indicate that females may be a risk population for

sexual offending that currently has received relatively little focus and may warrant further study

on rates of sexual offense committed and unique challenges to treatment faced by such a

population. Based on the results of this study and previous, it appears that CBT programs are

generally effective in reducing SBP and usually showed a greater effect than comparative

programs.

While several studies have found that CBT in its multiple form have generally shown

success as treatments for reduction and removal of sexually deviant behaviors in teens and

children, little research has been conducted on CBT effectiveness on specific behaviors as

opposed to sexually deviant behaviors as a whole (Anstiss, 2003; Eastman, 2004; Friendship,

Mann, & Beech, 2003; Geer, Becker, Gray, & Krauss, 2001; Looman, Dickie, & Abracen, 2005;

Marin & Bell, 2003; McGrath, Cumming, Hoke, & Bonn-Miller, 2007; Newbauer & Blanks,

2001; Reitzel & Carbonell, 2006; Righthand & Welch, 2004; Schweitzer & Dwyer, 2003;

Sullivan, Sullivan, & Hopkins, 2006; Webster, 2005). Additionally, there has been little

determination of which model of CBT and accompanying secondary components works most

effectively for which targeted behavior (Print & O’Callaghan, 2004; Worling, 2004). In an

attempt to assess the individual effectiveness of individual models of CBT and the specific

behaviors they are used to treat, Ikomi, Harris-Wyatt, Doucet, & Rodney (2009) had conducted a

state-wide survey of treatments used by providers across the Southwest. The result of the study

confirmed that CBT of some form was by far the most popularly used treatment with 133 of 223

appropriate responses citing CBT as the form of therapy used. CBT with no additional

component listed (e.g. relapse prevention, social skills) was reported as having an average
 29

success rate of 87.31% based on 16 reports while CBT with relapse prevention had a rate of

84.53% across 15 reports and CBT with social skills had a rate of 76.75% across 2 reports. Of

the cases reported the most commonly targeted behaviors in descending proportions were

indecency with a child involving sexual contact (39%), indecency with a child involving no

contact (31%), aggravated sexual assault (14%), sexual assault (14%); and incest (1%).

It should be noted that while the reported answers of the survey indicate that CBT is most

commonly used the exact proportion of treatment providers that use CBT could not be

determined due to significant number of providers stating they used group therapy which is not a

specific therapy program but a way to administer a therapy program. As such it is unknown if

these providers used CBT or some other form of therapy that was administered to individuals as

a group rather than individually. Additional confusion about CBT components is that Group

CBT programs reported an average success rate of 86.67% but no CBT programs were

specifically reported to use individual therapy so comparisons of the effectiveness of group

versus individual therapy could not be drawn. Other reports indicated that group based CBT with

experiential therapy and CBT with family therapy were highly successful based on an average

success rate of 90% and 95% but these results were drawn from a single report each so the

generalizability of the results is highly suspect. Given the methods used for collection of data,

definitive recidivism rates could not be determined. The general results of this study align with

the view that CBT is overall a highly successful treatment but there are indications that there is a

component of ‘best fit’ for treatment and individual matching that is not currently being

addressed.

CBT Derived Programs

 30

CBT as a therapy has proven to have a treatment process that is highly flexible and easily

altered while still maintaining its core characteristics. When this is paired with its status as the

most commonly used form of treatment for sexually deviant behavior it is easy to understand

how the base ideas of CBT have branched into several adaptations and modified treatment

programs that may be found today in any number of treatment facilities or organizations one may

encounter. As the need for effective treatment for none typical populations and the desire to see

larger changes increases so too does the forms that CBT takes to fill these niches. As a result of

this CBT principles can be found in highly specialized programs that address issues of

population and environment that rarely occur but are none the less important, in newly

established therapies branched away from CBT and developed their own principles, and even as

components of hybrid therapies based on the principles of several underlying disciplines.

While there have been several fully established therapies that have been derived from

CBT that there are still several more that are being developed and being piloted. One such

therapy is the Thought Change System (TCS) that expands upon standard CBT and incorporates

components of the Case Conceptualization Method (Apsche, Evile, & Murphy, 2004). TCS was

developed for use in treating sexually deviant arousal and anti-social behavior in aggressive

offenders that also possess a personality disorder. To this end, TCS takes the aspects of detecting

and altering cognition and cognitive distortions from CBT and expands upon that premise

through the addition of developing transitional cognitions to replace undesired cognitions before

replacing those with desired cognitions in turn and providing education and training in altering

cognitions that contribute to other non-sexual behavior.

The program uses a structured system to identify and analyze undesired cognitions in an

in-depth manner such as requiring a daily record of negative thoughts and teaching how
 31

cognitions contribute to several systems of behavior outside of sexual offenses such as violence

and drug abuse. The program also teaches about healthy behavior as being on a continuum that

changes with the situation and the system of mental health and psychiatric medication during

treatment. The issue of accompanying personality disorders that individuals undergoing this

treatment are also addressed in several ways. In addition to exploring and treating deficits in

skills such as social competency, TCS seeks to identify and treat deficits in self-esteem and the

effects of frequent depression. TCS also addresses the effects of PTSD within the population of

individuals that offend and how they contribute of undesired cognitions and behaviors. The case

conception method incorporated into TCS is designed to identify the multisystem components of

each participant that contribute to their behavior and identify how accompanying personality

issues may impede treatment (Beck, 1996).

In the pilot study of TCS all 10 participants were selected from the participant population

of the Behavior Study Program (BSP) at the Pines Residential Treatment Center in which TCS

was developed. The participants were of various ages and ethnic backgrounds and were admitted

into the center for displaying behavior such as flashing, fondling, vaginal penetration, and anal

penetration. Participants underwent an approximately 16-week TCS program along with ongoing

Individual and family therapy. Additional therapeutic services were also provided as needed.

The results of the study found that after 12 months of treatment, participant assessments

indicated a lower prevalence of negative overt behaviors, negative internal cognitions and

behaviors, and undesired behaviors that characterized the participants accompanying personality

disorders. Participants also showed a decrease in beliefs that supported aggression and the

victimization of others as well as beliefs that supported the desire to engage in an appropriate

intimate relationship in which individuals hold equal amounts of power. The findings of this
 32

study do show promise for this therapy as participants showed observed decreases of overt

undesired behavior reported increases of desired cognitions and covert behavior. Additionally,

participants that found desired changes in this therapy had previously failed to achieve those

changes when administered treatments at other facilities that had not used this method.

Additional research is still required as the sample size for the study was small and details of

participants history with previous treatment was limited. Despite this, the methods and results of

this study provide further evidence in the link between issues in non-sexual arenas of an

individual’s life and the prevalence of sexually deviant behavior. This focus on treatment outside

the sole issue of sexual behavior will explored further in the following CBT derived therapies.

Problem Solving Therapy

Problem solving therapy (PST) is a modified form of cognitive behavior therapy (CBT)

focuses on teaching problem solving skills to the subject to modify behavior. There are two

major processes that PST focuses on in treatment known as problem orientation and problem

solving. Proper problem orientation is a process of motivation in the subject that involves the

factors that affect an individual’s behavior when confronted with a problem. The cognitive

component of this problem orientation addresses factors such as the individuals thought about

the problems such as their assumptions and expectations about the problem faced and the

individuals own ability to behave in an effective manner to solve the problem. This orientation

can be positive or negative which respectively facilitate or inhibit problem solving behavior.

With a positive problem orientation, an individual is able to effectively analyze a problem and

their own thoughts about it; e.g. what is the problem, what caused the problem, can the subject

solve the problem, etc.; while an individual with a negative problem orientation would
 33

ineffectively analyze a problem due to inaccurately identifying or failing to observe details of the

problem that lead to effective analysis and solving of the problem (Nezu & Nezu, 2001).

The behavioral component of problem orientation addresses behavioral styles of the

subject and identifies 2 patterns of maladaptive behavior that inhibit effective problem solving.

The first style is known as avoidance and consist of procrastination, passivity, and inaction with

the individual engaging in behavior to avoid interacting with the problem. The second

maladaptive pattern of behavior is known as impulsiveness or carelessness and is characterized

by ineffective interaction with the problem that seeks to solve it but results in failure. This results

in many unsuccessful attempts to solve the problem and is associated with subjects that have a

lower tolerance to aversive thoughts and feelings (Nezu & Nezu, 2001).

The second major process addressed in PST is known as “problem solving proper” and

involves effective application of 4 tasks and their corresponding goals for effectively resolving

problems. The 4 tasks of “problem solving proper” are problem definition and formulation,

generation of alternatives, decision making, and solution implementation. The goal of problem

definition and formulation is to accurately understand the nature of the problem and develop

realistic objectives in solving it. To succeed in generating alternatives the subject must develop a

wide array of possible solutions to the problem without becoming too focused solving the

problem a specific way or specific details of the problem. Decision making involves analysis of

the potential solution developed with the previous goal in order to determine which solutions are

most effective and likely to solve the problem. Finally, solution implementation and verification

is achieved by and carrying out a chosen solution and analyzing it afterwards to determine its

effects on the problem if it was effective or how it could be altered to be more effective (Nezu &

Nezu 2001).
 34

While no studies have been currently conducted as of yet to use PST solely to reduce

unwanted sexual behavior, survey data of 124 incarcerated child molesters has found that they

scored lower in positive problem orientation and rational problem solving and higher in negative

problem orientation, avoidance and impulsive carelessness when compared to non-sex offenders

of a matching age. Additionally, scores of avoidance problem solving strategies positively

correlated with sexual aggression and scores of negative problem orientation and

impulsivity/carelessness positively correlated with sexual deviancy. These scores indicate that a

lack of problem solving skills may contribute to the engagement of sexually deviant behavior

(Nezu, Nezu, Dudek, Peacock, & Stoll, 2005)

A modified form of PST adapted to treat sex offenders with ID has been proposed by

researchers for the use in various rehabilitation programs (Nezu, Greenberg, & Nezu, 2006;

Nezu, Fiore, & Nezu, 2006). In order to adapt PST to be used with individuals with ID that have

sexually offended, individuals would be taught to use the 4 “problem solving proper” skills when

they encounter problems such as finding themselves in situations in which they would likely

commit a sexual offense so one could engage in effective behavior without avoiding situations

that would be beneficial and avoid engaging in impulsive action that lead to committing a sexual

offense (Nezu, Fiore, & Nezu, 2006).

One such program is Project STOP. This program multiple component, cognitive model

to provide assessment and treatment for sex offenders with ID. participants are provided with a

variety of ABA/behavioral therapy based treatments such as masturbatory conditioning and CBT

based programs such as PST that they are given based on a personalized plan developed for their

individual behavior and functioning level. Data was collected from the records of 25 participants

that were actively engaged in treatment and were referred for various forms of sexually deviancy
 35

including exhibitionism, stalking, sexual threat, child molestation, child rape, adult rape, and

other sexual assault. The observed participants were also found to have a wide range of

diagnoses in addition to ID among them including dysthymia, voyeurism, generalized anxiety

disorder, oppositional disorder, paraphilia, schizophrenia, pedophilia, and various personality

disorders including dependent, antisocial, passive, narcissistic, and nonspecific. These

participants were found to have an increase in motivation and frequency of engagement in

adaptive behavior. Most of the participants showed strong trends in improvement for clinical

target behaviors but the reported changes were not statistically significant for the group as a

whole. Recidivism rates for the participants of Project stop were low as only 1 participant

committed another sexual offense between the years of 2002-2005 and 3 participants being re-

incarcerated for probation violations over a 12-year span between 1993-2005 (Nezu, Greenberg,

& Nezu, 2006). These results indicate that the methods used by Project Stop are effective in

reducing targeted sexually deviant behavior but it is uncertain the effects of individuals

treatments as participants are treated using a multi-component program.

Mode Deactivation Therapy

Mode deactivation therapy is a multi-disciplinary program derived from the principles of

cognitive behavior therapy (CBT), functional analytic behavioral therapy (FAP), acceptance and

commitment therapy (ACT), mindfulness, and dialectical behavior therapy (DBT) (Apsche,

Bass, & Backlund 2012). The main goal of MDT is to restructure the beliefs of an individual

having them examine their perceptions of their environment and analyzing how the results of

their behaviors either increase or decrease the likelihood of them occurring in the future (Beck,

1996) While this program had initially been developed for theoretical studies of how the mind

works(Alford & Beck 1997; Beck, 1996), there has been recent research to use MDT as a
 36

method to decrease sexual aggressive behavior in individuals who’s cases are made complicated

by accompanying multi-axial diagnoses and/or a history of abuse (Apsche & Bailey, 2004;

Apsche, Bass, & Backlund, 2012; Apsche, Bass, & Houston, 2008; Apsche, Bass, & Murphy,

2004; Apsche & Ward, 2003; Apsche & Ward Bailey 2004; Apsche, Ward, & Evile, 2003a;

Apsche, Ward, & Evile, 2003b).

The process and rational of MDT is demonstrated in the 3-part theoretical case analysis

of Apsche and Ward Bailey (2003; 2004a; 2004b). Based on the experience of Apsche & Bailey

(2003), many adolescents that have a history of abuse develop survival coping strategies that

take the form of personality traits and/or patterns of behaviors. From this display of personality

traits and behaviors is where an individual receives a diagnosis of having a variety disorders such

as anti-social personality disorder and obsessive-compulsive disorder. As with CBT, it is

believed that these overt traits and behaviors are caused by covert thoughts but these thoughts are

not linked any specific mental disorder, that is, the great variety of mental disorders and

maladaptive behavior of various individuals could be caused by the same thought (Bass &

Apsche, 2013). Based on this belief, MDT proposes to focus an individual’s thoughts rather than

one’s disorder or behavior because when the thoughts are altered so too are an individual’s

expression of a disorder and behavior.

MDT also contends that an individual’s behavior is based on reinforcement contingencies

which is borrowed from the principles of FAP (Kohlenberg & Tsai, 1993). Based on this belief

an individual’s thoughts and perceptions are based on reinforcement for past contingencies. For

an individual with a history of abuse this would mean that beliefs and the accompanying

behaviors that proved successful in an abusive environment would have developed a strong

history of reinforcement even if they are considered maladaptive and undesired by society. From
 37

this, behaviors such as aggression and beliefs that others are to blame for one’s actions are

developed and persist outside of the abusive environment which then require action and

alteration by legal and rehabilitative entities.

These beliefs that develop from a history of reinforcement do not exist independently of

each other but are instead believed to form an interconnected series of beliefs and perceptions

that lead to corresponding thoughts and behaviors. This system of interconnected beliefs,

motivations, and accompanying behaviors are known as modes (Beck, 1996) which forms the

bases for an individual’s characteristics such as their common patterns of behavior, their

motivations, their emotional responses to stimuli and accompanying behavior in reaction to said

emotions, and other aspects that would be considered the makeup of one’s personality. Modes

develop in response to an individual’s environment and the problem that can arise with a mode is

it can generalize to environments and contingencies outside the one in which it developed

leading to the thoughts and accompanying behaviors to occur in situations in which they are

maladaptive rather than adaptive. From this perspective, the problem of abused individuals that

have engage in undesired behavior is three-fold: a series of perceptions and beliefs have

developed that has led to a pattern of thoughts and behavior which prove highly adaptive in one

series of contingencies and then generalized to contingencies in which the behavior is

maladaptive; The beliefs and perceptions both act as reinforcement for the pattern of behavior

and block external stimuli from acting as a punisher for said behaviors and they are maintained;

and as the present behavior is reinforced and outside stimuli are block the ability to develop new

behaviors is inhibited. MDT seeks alter this undesired overt behavior by disrupting the process

of an undesired mode that contribute to them and are triggered by the environment. MDT also
 38

remedies the nature of these modes which make them resistant to change through a process of

Validation-Clarification-Redirection (VCR) (Apsche, Bass, & Backlund, 2012).

The process begins with validation as a method to ease participants into the therapeutic

process and borrows many techniques adapted from DBT such as radical acceptance and

relaxation. A stance of radical acceptance for the individual’s behavior eases the initial process

as it avoids setting the therapist into a position of opposition with the individual they are

attempting to treat. Based on the tenants of MDT an individual that has developed maladaptive

mode has developed it in response to an environment of consistent opposition (e.g. from the

abuse they consistently faced and adapted to in the past) and the behavior of said mode has

generalized to several environments, including the therapeutic environment that the therapist

tries to establish. To create a dynamic of rapport between the therapist and client an attitude of

radical acceptance is adopted in which an individual’s beliefs are not challenged but instead

examined. Participants are even encouraged to examine the ways in which their perceptions are

true and adaptive. Through this method an individual that had developed obsessive or addictive

behaviors can look at their history of previously being in an environment where danger could

appear suddenly and unexpectedly and identify and receive validation for the ways in which such

beliefs and behaviors actually allowed them to react quickly to sudden danger or how drug use

helped to alleviate emotional distress in that environment so the individual could do what they

needed to in order to succeed. By avoiding a stance of opposition, a therapist is less likely to act

as a stimulus that encourage the undesired behavior which was itself designed to react in

response to opposition (Apsche & Bailey, 2003).

The next step after validation is clarification which occurs in during belief examination.

While the therapist provides feedback that confirms the participant’s views were reasonable
 39

given the context, the therapist also suggests that these perceptions may not hold true in every

context and how past events may have skewed the perceptions of present events. Imagery and

relaxation exercises are to reduce the stimulus control that external stimuli have on undesired

covert behavior (the symptoms of the individuals’ disorder and emotional responses). Individuals

are taught to examine their perceptions of external stimuli and identify internal stimuli through

that can influence perceptions and behavior through a method called balance training that

facilitate the phase of redirection.

By reducing the control that internal stimuli have over behavior and teaching participants

to recognized their emotions an individual is now able to think critically about their internal and

external environments. The participant is able to manage emotions and focus on the idea that

their perceptions may not match their environment. With this in mind, the participant is now able

to identify inconsistencies between the perceptions they hold and the environment they currently

face. From this point the external stimuli in the environment can now be accurately perceived

and new behaviors can be established that are adaptive to the contingencies faced.

The format that therapy takes for an individual is uniquely designed for them based on

around the Cases conceptualization method and mastery system (Apsche & Ward, 2003).

Participants in a program have a workbook developed for them that takes into account the

individuals history and beliefs and teaches them at a rate that accommodates them. Participants

are also introduced to easy challenges that initially provide success easily and frequently to

quickly develop a history of reinforcement before facing a more difficult task. Through this

method an individual is taught to recognize the external stimuli of the environment and the

internal stimuli of their modes and how to understand how these factors provide motivation that

act as the function of their behavior as well as the form that their behavior takes.
 40

MDT was developed as a melding of components from multiple therapies across multiple

disciplines designed to address complex problems that accompany the treatment of some

individuals. The complex nature of MDT can make it difficult to validate as it has several

components that work independently and in conjunction which inhibits the ability to measure

and determine what causes behavior change, to what do degree, and why behavior change

occurred. In addition, the cross-discipline components from which MDT is derived were

themselves developed based on different, and sometimes conflicting, paradigms of how and why

behavior occurs. This raises questions such as whether behavior comes from and is separate from

the thoughts that compose our “mind” and behavior changes as we “think” of ways to be more

successful in our environment or whether thoughts themselves a form of behavior shaped by the

environment as well as the relationship between behavior influencing other behavior (thoughts

influencing overt behavior). Regardless of the debates and conflicts of ideologies, studies of

MDT as a whole and as a series of components have found success as a complicated program to

achieve desired changes in complicated issues of anxiety (Apsche & Bass, 2006; Apsche, Bass,

& Siv, 2006), physical aggression (Apsche, Bass, & Houston, 2007), and sexual deviance

(Apsche, Bass, Jennings, Murphy, Hunter, & Siv, 2005).

Over its course of research and development, several comparison studies have been

conducted between MDT and its forerunner CBT as a treatment for specialized populations. The

reasoning behind such comparison studies has been to determine if the widely used CBT is the

most effective method for treatment in all contexts and such comparisons demonstrate the

importance of continued research and development even after the success of a method has been

supported by research. As MDT was developed as an extension of CBT both programs share

many similarities in the method and goals of treatment, especially in forms of CBT adapted for
 41

clients with histories that complicated their treatment (Apsche, Bass, & Murphy, 2004). Both

programs focus on establishing a good client-therapist relationship that works to empower clients

to manage their own behavior but the difference occurs in the view of client perspective. While

CBT seeks to change thinking on the basis that undesired thoughts are distortions that are not

accurate MDT views these thoughts as being not only true but essential to the clients previous

health and safety. With this belief, the goal of MDT is not to change the way one thinks but to

examine and understand the context of their environment and determine which thoughts and

behaviors will be most successful in that context. The importance placed on the individual

perspective in MDT in turn places importance on things not addressed in CBT such as learning

what stimuli triggers undesired thoughts and behaviors, anxiety reduction, addressing trauma

from the past. It is based on this view that MDT incorporates additional components not found in

CBT to address issues such as how to treat a noncompliant client that resists treatment (Apsche,

Bass, & Murphy, 2004).

Studies between MDT and CBT found indication that participants received greater

benefit from MDT than CBT in reduction of elicited undesired sexual behavior and recidivism

(Apsche et al. 2005). Several additional benefits for MDT over CBT have been reported for this

specialized populations such as participant reports of MDT being less aversive than CBT and the

effectiveness of MDT as a general method for treating and addressing individual factors of

multiple different accompanying disorders which in the past had required the development of

individual treatments to address (Apsche, Bass, & Murphy, 2004; Apsche & Ward, 2003).

In an early comparison between MDT and CBT (Apsche & Ward, 2003), 14 adolescent

participants who were admitted to a residental treatment center for sexual offences were selected

for the study based on their lack of history with CBT or MDT Treatment. The offenses that
 42

participants had been reported for included flashing, fondling, vaginal and anal penetration, or a

combination of the previous and the number pf victims reported varied from 1-13 per participant

(Apsche & Ward, 2003). Results of the study found that participants that had taken part in the

MDT scored as posing a low risk to community safety after treatment in comparison to the CBT

group which posed a moderately high level of risk to the community after treatment. Participants

also showed characteristics that indicated they were less likely to offend such as lower internal

motivations to offend, a greater understanding of the impact of sexual assault, and increased

empathy. Participant behavior reflected these assements as the MDT group showed greater

adherence to the rules of the treatment center and had fewer occurences of aggressive and

destructive behavior. Additionally, Participants in the MDT group participanted and behaved

appropriately during therapy sessions on a higher average than the CBT group.

Participants in the MDT also displayed a greater desired change in various other aspects

outside the focus of sexually deviant behavior. Reports for non sexual undesired behavior and

symptoms of disorder such as physical aggression, withdrawn behaviors, and depressive attitudes

were noted to be lower in the MDT in comparision to the CBT by a small but statistically

significant amount. Finally behaviors and characteristics associated with a history as victims of

trauma and symptoms of the participant’s individual disorders showed a significantly larger

desired change in MDT compared to CBT. Both groups were assessed to have similar levels of

fear and anxiety reactions that are symptomatic of Posttraumatic Stress Disorder (PTSD).

Despite this, MDT participants displayed fewer overt symptoms of PTSD and/or other disorders

and demonstrated coping skills of greater effectiveness and functional behavior of greater

frequency than those displayed by the CBT participants.

 43

In a more recent comparison study (Apsche et al. 2005), a three-way comparison study

was conducted to assess the effects of MDT, CBT, and Social Skills Training (SST) on Teens

with psychiatric disorders. This study was conducted using a much larger population selected

from the residential treatment facility where the study took place. All participants were children

and young adults admitted for treatment of aggression and/or sexual aggression and displaced

various disorders including PTSD, Conduct Disorder, Oppositional Defiant Disorder (ODD),

Mixed Personality disorder, Borderline Personality Disorder, Narcissistic Personality Disorder,

and Dependent Personality Disorder. After admittance into the study, participants were randomly

placed in one of 3 conditions. These groups were the previously described MDT program, a

modified CBT program, and an SST program

The CBT condition used a form of CBT specifically designed for youth with personality

disorders and psychosexual disturbance that displayed high levels of violence or aggression. The

program consisted of a previously published treatment curriculum and included a workbook

called “Thought Change” (Apsche, 1999; Apsche, Evile, & Murphy, 2004). The curriculum

required participants record negative thoughts on a daily basis. Participants were also required to

learn about cognitive distortions, the link between beliefs and patterns of aggressive behavior

and sexual offenses, and mental health and substance abuse issues. Finally, participants were

trained in skills for taking responsibility for actions, developing victim empathy, cognitive

restructuring, mood management, and proper mental health maintenance.

The SST program focused on identifying, developing, and reinforcing desired behaviors

using many behavioral analytic techniques (Henggeler, Schoenwald, Borduin, Rowland and

Cunningham, 1998). Participants in this group were taught alternative behavior to engage in and

to identify contingencies in the environment which were practiced through methods such as
 44

modeling and roleplaying. Reinforcement desired behaviors was provided through shaping and

fading procedures and participants were individually evaluated based on their performance.

Measurements of success were based on the frequency of reports of physical and sexual

Aggression found in daily behavior reports and behavior incident reports conducted by the

treatment facility. Based on these parameters it was found that all participants benefited from

their therapy programs but the greatest desired results came from participants in the MDT group.

Participants in the MDT condition showed the greatest decrease in physical and sexual

aggression between baseline and post-treatment measurements. Statistical analysis also found

that MDT was the only treatment that showed statistically significant reduction in rates of sexual

aggression from baseline to post-treatment. Additionally, statistical comparison of the change in

all three conditions found that while CBT had Greater reduction in aggression than SST the

difference was not statistically significant which indicated that both CBT and SST had roughly

the same level of effectiveness while the results indicate that MDT is the most effective method.

The results of this study indicate that MDT may be better at treating teens with psychological

disorders for a variety of issues including sexual deviancy.

MDT has also seen its own forms of modification from the standard through

experimentation in the format of the therapy program. An example of this is Mode Deactivation

Family Therapy which tries to examine family interactions and understand them as a process that

influence the behavior of all members (Apsche & Bass, 2006; Apsche & Ward, 2003). With this

view, not only is the child treated for behavior change as a client but the whole family is treated

for change as the client’s environment. As MDT proposes that an individual’s modes develop

based on the environment it is common that an individual’s family and home life provide the

greatest basis on which an individual develops their modes. People treated with MDT are often
 45

victims of an unsafe environment that necessitated the need to develop aggressive modes for

success and if this environment is one’s home life then special considerations must be taken in

order to effectively treat the client as both they and their environment need changing. MDT

Family Therapy addresses this through a multistep process similar to single client MDT (Apsche,

Bass, & Houston, 2007). The process begins by assessing the basic struggles the family faces

that cause them fear and anxiety. After this, the therapist seeks to understand the individual

modes and beliefs of each family member and their collective beliefs and mode to understand

how each individual’s modes and beliefs interacts with those of their family members as a

process. The family based format of MDT also uses the Validation-Clarification-Redirection

method of the standard except that the family members do not only have their individual beliefs

validated as having truths within them but are also shown how the beliefs of others within the

family have truths within them as well. From this understanding family members are taught to

find compromise between their beliefs and develop new beliefs based on this compromise. The

same process is conducted with collective family beliefs and family members are taught to

recognize how some family beliefs come into direct conflict with others and develop new family

beliefs that cohesively integrate these conflicting beliefs. It is through this method that the family

is treated both as individual clients and with the family dynamic as a whole as a client to change

both the individual’s interaction with their environment and the environment as a whole.

This alternative take on MDT is also finding success as a treatment based on the results

of research studies (Apsche, Bass, & Houston, 2008). In comparison treatments between Family

MDT and a standard treatment procedure in an outpatient setting it was suggested by the data

that MDT was more effective in reducing various undesired behaviors than TAU and had a lower

recidivism rate over a 2-year period following pose treatment. The reports of sexually deviant
 46

behavior in the Family MDT treated adolescents was reduced to 0 reports following treatment

and was maintained over a 2 year follow up period while the TAU group was had a recidivism

rate of 50% in the 2-year follow up. Reports of out of referrals for out of home placement, family

arguments, and physical and verbal aggression in the treated adolescent was also reduced and

maintained to a much greater degree than the TAU group. No reports of aggression committed

by family members of the adolescent were recorded so the effectiveness of family MDT in

altering the behavior of individual family members is not as well understood. As MDT achieves

further modifications and diversity of forms new issues such as the treatment for incestuous

behavior without splitting up a family may be addressed.

While CBT was shown to produce desired results in all of these comparisons, MDT was

consistently found to be more effective in achieve desired change. The additional results of some

studies (Apsche et al. 2005; Apsche & Ward, 2003) also indicate that participants may find

greater appeal and validity from MDT treatments as evidenced by their behavior during

treatment sessions. The ideology of this form of therapy holds that undesired behaviors like

sexually deviant behaviors may not be something to be treated directly but rather part of a group

off behaviors t that are symptoms of an underlying set established contingencies which instead

must be examined and treated. This belief creates a less individual focused view of the problem

and expands the area of examination to the environment and history of a client unlike the views

used by BAT and sexual education.

It is worth noting that MDT was developed specifically to treat a special population, that

being teens and adults with one or more diagnoses of personality and anxiety disorders (Apsche,

Ward, & Evile, 2003b). This sets this program apart from many other therapies which are

commonly designed to treat a more general population and then adapted to better suit a special
 47

population. This unique history of development may be why MDT is found to be so effective

with its targeted population as it’s paradigms were developed directly based on the issues faced

by this population while adapted programs are based on paradigms that are not focused on a

special population and thus as not as readily equipped to address such issues.

What is certain is that this greater appeal and effectiveness of treatment can prove to be

very important in terms of finding a practical treatment method. With issues of conduct disorder

having a prevalence of 6% to 16% in males under the age of 18 and being one of the most

frequently reported problems in mental health programs (Kazdin & Weisz, 2003) there is a need

for programs designed for clients that engage in uncooperative behavior resist treatment

protocol. The need for addressing conduct disorder is further illustrated by the its high

prevalence in incarcerated youth where rates as high as 91% of the population (Boesky, 2002).

Further problems may lie ahead for such individuals as studies indicate that 80% of youths with

conduct disorder are likely to meet criteria for psychiatric disorders in the future (Kazdin &

Weisz, 2003). The development of factors that both complicate and cause resistance to treatment

certainly pose a problem to be addressed within the rehabilitative communities. Overall studies

indicate that CBT proves a generally effective method but by no means acts as a panacea, instead

it may act as a base to which effective treatment can be developed from for the treatment of

individuals with behavioral systems made complicated by uncommon history and biology.
 48

CONCLUSION

When seeking to develop a program for reducing sexually deviant behavior, there are

many factors to be taken into account in order to lead the development. Sex-offending behavior

is generally believed not to have a single cause but is the result of a combination of risk factors

(marshal, Anderson, & Fernandez, 1999). These factors include both overt and covert behavioral

factors and environmental factors of both the present and the past that have led to the

development of a behavioral pattern that is now problematic (Marques, Day, Nelson, & West,

1994; Prentky, Knight, & Lee, 1997; Seghorn, Prentky, & Boucher, 1987).

Individual characteristic such as developmental and intellectual ability and personal

environment must also be taken into account when developing a program as some cases may

require only relatively simple methods such as those used by Dozier, Iwata, & Worsdell (2011)

to reduce sexual behavior and in an individual with little autonomy and a highly controlled

environment. On the other hand, typically developing individuals or those that live in

environments that have little control may require more complex treatments as there are

additional factors that contribute to sexual deviancy not found other cases (Aos et al. 2006;

Apsche & Ward, 2003). Given the success of multidisciplinary programs such as CBT and its

derivatives, it is likely that an effective intervention would require multiple components from

multiple disciplines
 49

IMPLICATIONS FOR PRACTICE

Through the analysis and translation of multiple treatments and ideologies, this

review brings to light many proposals for clinicians to interact with their clients, with their fields,

and with the fields of others. The best form of treatment is generally one that is conducted on

multiple levels and as practitioners, the acumen of treatment synthesis must be recognized. As

multiple professionals seek to find the best treatment for individuals their goal to each other

should be understanding and cooperation as their goal to the individual should be the end of

sexual deviancy. In the analysis of more mentalistic practices, many of the cognitive aspects of

therapies like CBT and MDT could be translated into behavioral language. For example,

thoughts are already described as a form of covert verbal behavior in behavior analysis and

beliefs could be considered to be thoughts with a history of reinforcement. Verbal behavior can

also act as a stimulus for an individual where it appears in the form of another person speaking or

the individuals own thoughts. As with any stimulus, the introduced stimulus of a thought can act

as a motivating operation for behavior so in this way it can be argue that the CBT believe that

behavior can be caused by thoughts is true. Based on this, one could in theory study how the

reinforcement/punishment process of thoughts occur in an individual and develop a method to

alter the occurrence of stimulus in an individual’s internal environment (thoughts in their mind)

and the interaction the individual has to these stimuli. Similar methods are already being used in

programs such as Acceptance and Commitment therapy in which an individual it trained to

examine and recognize one’s thoughts as being merely thoughts which do not need to influence

behavior (Hayes, 1999). Such methods could be viewed as decreasing the stimulus control a

thought has on a specific behavior. Integration of programs from differing ideologies can be

conducted with the translation of term and may lead to the development of new programs and
 50

ideologies that ask questions and find solutions to a problem that were previously unable to be

examined due to limitations in the ideologies found in the component fields of study.

Successful programs must also acknowledge the lower quality of life that individuals

with ID are at risk of and provided opportunity to engage in appropriate sexual behavior (Ward

& Mann, 2004). Programs that focus solely on the reduction of sexually deviant behavior without

providing opportunities to engage in alternative sexual behavior are unlikely to be successful as

sexual gratification is innately reinforcing to humans so it is likely to be sought by individuals

through whatever means are available to them when the appropriate MO’s are presented

(Cooper, Heron, & Heward, 2006). Furthermore, programs to at seek to be an advocate for

individuals with ID must work to provide them with opportunities they would be warranted if

they did not have ID including the opportunity to express themselves in a healthy sexual manner.

To this end, some individuals seek to promote programs developed around instilling choice in

participants. Such programs have found that allowing choice in programs has led to increased

participation in programs, better performance in emitting desired behaviors, and less reported

discomfort when exposed to aversive situations, e.g. participants found therapy less aversive

when allowed to choose some aspect of its administration (Bannerman, Sheldon, Sherman, &

Harchik, 1990). Such results correspond to some aspects of the mores successful programs such

as CBT and supports the idea of successful program development as being a collaborative

process with the participant.

Along with the instillation of choice comes the promotion of self-advocacy and

preservation of liberties. As stated by the Developmental Disabilities Assistance and Bill of

Rights Act 2000 (200, individuals with ID are guaranteed the same basic rights as their typically

developing peers. This includes the rights to sexual expression and in order to maintain these
 51

rights, behavior alteration should be sought in lieu of elimination. The ultimate goal of treatment

should be the individual engaging in appropriate sexual behavior and considerations to the

individual’s desires and their environment should be made. It must always be remembered that

when addressing an issue of behavioral correction, especially a taboo topic like sexual behavior,

that the individual is not a problem to be fixed but a person that has a problem to be assisted

with.
 52

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VITA

Graduate School
Southern Illinois University

Samuel N. Krus

Sam_krus@comcast.net

Southern Illinois University Carbondale

Bachelor of Arts, Psychology , May 2014

Special Honors and Awards

Magna cum Laude

Research Paper Title:

Behavioral Interventions for Sexual Deviancy in Individuals with Developmental
Disorders

Major Professor: Ruth Anne Rehfeldt