Case Studies in Sexual Deviance

Toward Evidence Based Practice

William T. O'Donohue

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134502622
• Edition: 1
• Topic: Psychology
• Subtopic: Psychopathology
• Index: Psychology

The assessment and treatment of sexual deviance can be very difficult tasks, and it can be hard to find mentors to provide initial skills training and help in navigating the many complexities of a particular case. This book presents a series of case studies from international experts in the field that depict the evidence-based assessment and treatment of a variety of paraphilias. Intended as learning tools readers can use as models and from which they can gain insight, these case studies are offered as exemplars of clinical problem solving. The authors of each chapter provide research evidence that justifies treatment decisions, explain their assessment strategies and case formulations, and provide information about how to navigate common problems a clinician will encounter, such as denial, poor motivation, and co-morbid problems. A variety of assessment instruments and treatment strategies are also illustrated. Both new and experienced clinicians will find this book to be an invaluable resource in their own work.

1

INTRODUCTION TO CASE STUDIES IN SEXUAL DEVIANCE

Improving the Quality of Services

William T. O'Donohue

The Value of the Case Study Approach

This book presents a series of case studies that depict the evidence based assessment and treatment of a variety of paraphilias. It is not intended to present these case studies as additional evidence for the effectiveness of these treatments. Unfortunately, this has been an all too common mistake in the history of mental health treatment—case studies have been overvalued as evidence for conclusions about treatment efficacy. The reader is cautioned not to make this mistake with the case studies presented in this book. All of the authors of these chapters acknowledge that their case studies ought not to have this function.

However, case studies are valuable—and perhaps even invaluable—for other reasons. First and foremost, they illustrate the concrete application of abstract information usually derived from research studies to a particular clinical situation. One can read the assessment or treatment outcome literature and come to general conclusions that a therapist ought to use, for example, Relapse Prevention in the treatment of some paraphilias, but this still leaves many open questions regarding how exactly to accomplish this. What assessment ought to be conducted first? What intervention steps ought to be conducted and in what sequence; for example, are offense claims targeted before problems of immediate gratification? What ought a therapist to do with common problems that occur in therapy such as problematic client motivation? Case studies can illustrate possible solutions to these sorts of practical and important questions.

Thus, the case studies in this book are presented as exemplars of clinical problem solving in assessing and treating paraphilias. They are presented as learning tools that give readers the opportunity to model their behavior after that of experienced experts. It is important to note that these cases have been disguised to protect client confidentiality—many authors achieved this by blending two cases. However, the chapter authors tried to provide practical and concrete cases that are realistic depictions of how an actual case would unfold.

Another important reason why case studies can be useful is that there is simply much missing information in the field of sexual deviancy. Some key paraphilias have few or no randomly controlled outcome studies (Laws & O'Donohue, 2012). These problems are to some extent “orphaned” and if the clinician decides to treat he or she usually extrapolates what has worked for other similar problems. However, this extrapolation requires some clinical ingenuity and the ability to adapt and translate these principles to a new therapy target. Thus, at times the case studies in this book review this kind of extrapolation.

In addition, case studies can be helpful because the treatment of the paraphilias is very difficult. This will be discussed more fully below but suffice it to say at this juncture that clinicians in this field are often working over a quite prolonged treatment period (treatment can last for several years), with complicated clients (legally and clinically). Clinicians will be using assessment devices with unknown or problematic error terms, with clients who display various levels of treatment motivation and various and often unknown levels of accurate disclosure. Clinicians will be battling powerful motivating forces (deviant sexual urges), with treatment targets such as sexual self-control and sexual orientations that are, at best, highly resistant to change, with a host of comorbid problems (e.g., alcohol abuse, misogyny, or even Anti-Social Personality Disorder). In addition, clinicians will be dealing with problems that have a high relapse rate, in domains that have a number of legal consequences and that are some of the most socially stigmatized problems, and with treatments that are not all that powerful (Marques, Wideranders, Day, Nelson, & Ommeren, 2005).

Finally, case studies can assist in the problem of training—they can be a part of how students can learn to skillfully and faithfully implement evidence based techniques. It appears that we have a bit of a workforce problem in this area—there are too few therapists trained to provide high quality treatment given the unfortunate need revealed by the epidemiology of sexual victimization. Reading case studies is a method that can partially help with this problem because it provides a concrete illustration by these experts of the methods that have been shown to work. Clinicians seem to like to read case studies: perhaps because it so clearly mirrors their day-to-day experience and perhaps because if a case study is well written it unfolds as an interesting and even compelling narrative.

The chapter authors were asked to write their chapters to have some sort of similar structure. They were asked to include these elements in their chapters:

1. Provide a brief background/description of the case.

2. Present a clinical assessment (include a rationale for the psychometrics of measurement strategies used).

3. Case formulation (demonstrate how they came to conceptualize the case); arrive at conclusions (however preliminary); any diagnoses; rule in or rule out any comorbid issues and how they plan to deal with these.

4. Treatment plan and implementation (again, with a rationale that this is reasonably evidence based).

5. Deal with complications in treatment (denial, nonattendance, lapses, etc.).

6. Terminating treatment and developing a relapse plan or any other issues for post-treatment.

7. Conclusions and any general advice or perspectives.

8. How nonspecifics were dealt with in this case (e.g., the therapeutic relationship)?

9. What would the clinician have done if therapy wasn't working as it should?

10. What ethical or legal considerations came into play?

11. What common “mistakes” were avoided in treatment?

12. What is the “art” of this case, and how was it (if at all) informed by scientific evidence?

13. What cultural factors did the clinician consider and what difference did these make (if relevant in this case)?

General Problems in the Assessment and
Treatment of Sexual Deviance

There are a variety of factors that contribute to this difficulty. Below is a partial list:

1. Clients can be in (full or partial) denial.

2. Clients can lie (paraphilias are stigmatized and are difficult to admit to).

3. Clients often are not highly motivated to be in treatment or do not stay motivated (perhaps treatment is legally mandated).

4. Clients are often highly heterogeneous—from juveniles to the elderly, with a wide range of status on variables such as SES, intelligence, and general social skills. Kiesler (1966) years ago astutely warned about client uniformity myths.

5. Clients can be entwined in complicated family systems that impact treatment progress.

6. Much rides on the success of treatment because treatment failures can mean that another child is molested or another woman is raped. It can also mean that the client must go back to prison perhaps for decades.

7. Treatment often occurs in a variety of settings and must be adapted for these settings (e.g., prisons, outpatient therapist offices, or special inpatient settings).

8. Assessment often involves domains that force us to rely on problematic self-report such as sexual fantasy. Assessment is often multifaceted and requires the measurement of many domains, and these results must be synthesized. These measurements often have to occur many times if treatment progress is to be measured.

9. The psychometric instruments that we use often have important missing psychometric information or problematic psychometric information— we know too little about the error terms of these instruments. There is often reason to believe that the error terms are large or unacceptable. Some of this is often due to the complex and difficult objective of assessment: it is simply very complex to accurately measure risk of reoffending over a 5-year period.

10. Some psychometric instruments are controversial because of what is involved in their procedures (e.g., the penile plethsymograph requires the presentation of deviant stimuli and requires a strain gauge to be placed on the client's penis; O'Donohue & Letourneau, 1992). This is quite different from usual assessment procedures carried out by mental health professionals.

11. Treatments are provided by a wide variety of professionals from psychiatrists to psychologists to social workers, who have a wide variety of general clinical experience, and a wide variety of personal characteristics. Kiesler (1966) also warned against therapist uniformity myths.

12. Treatment is often very long term, with Relapse Prevention modules it can even been construed as lasting an entire lifetime.

13. Treatments are complicated to implement. They often do not rely on single components such as contingency management or exposure therapy for anxiety but rather are multifaceted. Thus, the therapist must have a wide range of skills.

14. Some treatment targets are just very difficult to change (e.g., sexual orientation). It may be said that it is even unclear what all the practical goals of therapy ought to be. For example, is the goal to change a deviant orientation, or because of practical limitations allow the deviant sexual interest to remain, but work to have the client not act on the deviant orientation?

15. Important controversies exist regarding these treatment goals. Is it permissible, for example, in a Harm Reduction Model, to allow the client to masturbate to deviant fantasies (in the hopes that this will decrease further acting out on these), or is this unacceptable deviance in and of itself?

16. Treatment often takes place in a legal context and these vary across states and nations. Thus, the clinician often has to attend to unique forensic parameters or requirements.

17. Treatment effects are weak (Marques et al., 2005). Some have even claimed that they are so weak that it is wrong to claim that a treatment is evidence based (Laws & O'Donohue, 2012).

18. Relapse is very common. It is possible to think that the only reasonable goal is zero future occurrences (as opposed to say a Harm Reduction Model) and this can be a very hard goal to achieve. If it is not achieved, many would then regard treatment as a failure.

19. There are multiple models of treatment and controversies exist regarding which ought to be implemented (e.g., Relapse Prevention Therapy vs. Good Lives Model of therapy).

20. Clients often present with serious comorbid problems. They may have a long standing substance abuse problem or a personality disorder such as Anti-Social Personality Disorder. They may have other problems such as anger control, problematic attitudes toward women, or poor social skills. These problems complicate treatment and sometimes even obviate it. However, questions remain regarding case formulation: when should comorbid problems be treated: one at a time at the outset of treatment, simultaneously, or should they be ignored for the time being? Should the therapist coordinate treatment with another therapist or try to treat these problems him- or herself?

21. Quality treatment is expensive partly due to its length and partly due to the rarity of high quality therapists given the demand; in these economic times there can be insufficient funds to properly treat individuals. Often taxpayers are involved in this because treatment may be provided in a correctional institute or under the conditions for probation and parole. Taxpayers can ask legitimate questions about the val...

Table of contents

• Cover
• Half Title
• International Perspectives on Forensic Mental Health
• Title Page
• Copyright Page
• Table of Contents
• About the Contributors
• 1 Introduction to Case Studies in Sexual Deviance: Improving the Quality of Services
• 2 Multisystemic Therapy for Youth Problem Sexual Behavior: A Case Example
• 3 Clinical Reflections on the Assessment and Treatment of a Rapist
• 4 The Good Lives Model of Offender Rehabilitation: A Case Study
• 5 Treatment of Sexual Masochism
• 6 Voyeurism: A Case Study
• 7 Exhibitionism: A Case Study
• 8 Telephone Scatologia
• 9 Possession of Child Pornography: A Case Study
• Index