Therapist Guide for Maintaining Change: Relapse Prevention for Adult Male Perpetrators of Child Sexual Abuse

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Hilary Eldridge

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  • Part I: Using Maintaining Change

    Part II: The Change Process

    Part III: The Phases of Change Linked to the Exercises in Maintaining Change: A Personal Relapse Prevention Manual

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    Dedication

    For Lucy Faithfull, who spent her life campaigning for children and believed that the best way to protect them is to change offenders

    Foreword

    In the earlier version of this text Hilary Eldridge was kind enough to acknowledge the influence of some of my earlier work in the area of relapse prevention. Thus it seems appropriate that I return the favor by contributing a few prefatory comments to the commercial version of the manual.

    When this manuscript was submitted to Sage Publications I was asked to review it. I recall saying that Hilary was not only a colleague but a personal friend, so I was prepared to like the text. What I was not prepared for; I said, was that I was going to like it as much as I did. I then went on to make some suggestions for improving the manuals, primarily by providing better linkage between the Therapist Guide and the Perpetrator Manual. These changes are reflected in the text you have before you.

    My first knowledge of relapse prevention (RP) came to me in 1978. It was in the form of a manual given to me by Janice Marques, then a graduate student at the University of Washington, supervised by Alan Marlatt, the developer of the original model of RP. This was the alcohol/drug abuse version. She said, “I think there's something here that could be applied to sex offenders.” Five years later the first paper by Pithers, Marques, Gibat, and Marlatt (1983) described the possible application to sex offenders. In the earlier version of Maintaining Change (1995) Bill Pithers quoted the late Fay Honey Knopp as saying that the introduction of relapse prevention was “a quiet revolution within the field.” It may have been quiet at the start but it has been anything but quiet in the past 10 years. Karl Hanson (1996) has evaluated the professional and social impact of RP on the sex offender treatment field:

    the introduction of RP theory was highly motivating to sexual offender therapists. RP validated their perception that many sexual offenders were at ongoing risk and, more importantly, explicitly defined the therapists’ role as addressing these anticipated lapses. Instead of interpreting recidivism as evidence that sexual offenders were untreatable, RP viewed posttreatment behavioral deterioration as an expected and workable problem, (p. 203)

    Hanson (1996) sums up his evaluation:

    RP has provided direction and focus for a generation of sexual offender therapists, (p. 206)

    That, I would submit, is no mean accomplishment.

    Hilary Eldridge's Maintaining Change is directly in the mainstream of RP theory and practice and, to my mind, advances practice through its user friendliness. She states that the manuals may be introduced into existing programs. Here she is talking about the original RP model advanced by Marlatt and Gordon (1985) where the approach is used as a maintenance program following an existing cessation-oriented treatment program. In Hilary's scheme, treatment falls into three phases. Phase 1 has as its goal stimulating the client to recognize the need to change. Hilary's approach weaves RP into the treatment from the beginning although there is the flavor here of some of the more traditional approaches to sex offender treatment. Phase 2 is where RP strategies are introduced, the nuts and bolts of self-control and offense- free lifestyle maintenance. Phase 3 is the community follow-up portion using call-back sessions and the perpetrator's support network.

    It is important to emphasize that RP was designed for people who want to change their behavior Hilary notes that the Maintaining Change program is specifically designed for offenders who clearly show repetitive offense patterns. Not surprisingly, it uses a combination of traditional cognitive-behavioral approaches with the specific interventions characteristic of RP. It has been noted repeatedly in the literature that this is the combination that works best with sex offenders. In this interest I should mention that the 20 points expressed as the underlying philosophy of the program (pp. v-vi, this guide) represent an excellent list of requirements for development of a treatment program for sex offenders.

    I mentioned earlier that these manuals are very user friendly. I should also state that this applies to both therapists and clients. We have used portions of Maintaining Change in our adult outpatient sex offender program with great success. The guidelines for therapists are clear and easy to implement. The information given to our clients, particularly homework assignments, is easy to understand and work with.

    I believe that this is an excellent addition to the sex offender literature and I can personally endorse it and commend it to you. With materials like these, perhaps we can inspire a second generation of sex offender therapists.

    RichardD.Laws, Ph.D. Victoria, British Columbia

    Acknowledgments

    The thrapist guide and the accompanying personal relapse prevention manual for perpetrators are based on principles described by D. Richard Laws, Ph.D., and William D. Pithers, Ph.D., in their work in the area of relapse prevention with sex offenders, and I would like to thank them both for their inspiration. I am especially grateful for the time Richard has taken to review this therapist guide at its different stages of development and to pilot the personal relapse prevention manual for perpetrators in his own program.

    I am also indebted to Anna Salter, Ph.D., who persuaded me to publish these books, and to Barrie Bridgeman from the West Midlands Probation Service and Derek Perkins, Ph.D., from Broadmoor Hospital, who have given me their time, help, and support. I am grateful to everyone who contributed ideas to the project, to James McGuire, Ph.D., for his help regarding source material, and to David Thornton, Ph.D., who helped ensure that the manual can provide continuity between the British Prison Core Sex Offender Treatment Programme and community-based programs.

    Many thanks go to the staff who piloted Maintaining Change in the STOP Programme at Peterhead Prison, in the West Midlands Probation Service's specialist unit, in the Somerset Probation Service, and in Broadmoor Hospital.

    Special thanks are due to colleagues at the Gracewell Clinic and Lucy Faithfull Foundation, without whose cooperation and support Maintaining Change would not have been possible. I would also like to thank the offenders who were committed to an offense-free lifestyle, gave feedback on what worked for them, and contributed parts of their relapse prevention plans to help others avoid reoffending. The names used here have been changed in order to protect the identities of individual offenders, their victims, and families.

  • Conclusion: A Broader Perspective on Relapse Prevention

    In order to be effective, relapse prevention programs must provide much more than knowledge of effective coping strategies. The offender must want to give up offending, and must have things in his life that matter more to him, and that he risks losing if he reoffends. For most offenders, the primary key to relapse prevention is the development of a rewarding offense-free lifestyle containing elements that motivate them to make use of the relapse prevention techniques they have learned. Even some habitual offenders are able to make this shift. However, many have built their lives around abusing others, struggle to develop the motivation to make real change, and may find the reality of an offense-free lifestyle very difficult indeed. Given this, we should perhaps be cautious about our expectations. Although some offenders will not reoffend, in high- risk, high-deviancy cases, we can only attempt to reduce the risk of reoffending. In some instances, reoffending is delayed; in others, the level of offending is reduced. Some men may reoffend, but the empathy they have developed and the coping mechanisms they have learned during intervention may work to allow them to reaffirm control and prevent further offending. This is not negative thinking—it is realism and recognizes the value of intervention. However, in the light of it, we should perhaps be even more cautious about making decisions that place offenders in close proximity to children they have abused already or might abuse in the future.

    Many perpetrators of sexual abuse do need long-term external monitoring. However, as Marshall and Anderson (1996) ask, “How extensive does treatment have to be to keep recidivism rates at levels low enough to be acceptable, whatever they may be?” (p. 219). Marshall, Eccles, and Barbaree (1993) suggest that offenders might be stratified into risk categories and treated accordingly. In my view, although it may not be realistic to propose close monitoring of all offenders for the rest of their lives, priority should be given to three groups:

    • Those who have a long history of persistent offending and are at high risk of reoffending according to a risk-of-reconviction algorithm (Fisher & Thornton, 1993; Thornton & Travers, 1991)
    • Those whose offending is directly life threatening
    • Those who are likely to be living with vulnerable children

    Priority for this third group may appear surprising, as it includes incest offenders, whose incidence of reconviction is generally low. However, the opportunity to manipulate and control in a family setting cannot be underestimated. If external monitoring is poor, and the perpetrator starts sliding into old patterns undetected, can we seriously expect children to tell a second time? The memory of what happened after the first disclosure is hardly likely to encourage them.

    It should be possible to manage a low level of monitoring for all known perpetrators of sexual abuse. This could be done through national registers and authorities’ sharing of information regarding the movement of offenders from one area to another.

    We already have good-quality information about offenders who have attended intervention programs, but we are less good at using it. This could be done through the development of a database for the sharing of information about patterns and relapse prevention plans on an areawide, statewide, or, ideally, national basis. The database could be shared by law enforcement agencies, offender program delivering agencies, and the main child protection agencies, and could include information on all offenders who have engaged in programs, not just those who have done prison sentences—many offenders are never charged with their most serious crimes; they're caught on more minor offenses and are never sent to prison. The database could also include unconvicted abusers who have taken part in programs—agreement to be listed in the database could be made a condition of program attendance. The database could include the following details on each offender:

    • Type of offender
    • Previous convictions (and possibly alleged offenses)
    • Target group
    • Grooming tactics
    • Risk factors
    • Relapse prevention plan, including details of any external monitoring network

    We also need to involve the community in offender monitoring in a way that empowers rather than panics people. Community notification without consciousness-raising about who offenders are and the relationship-based nature of much sex offending simply perpetuates the monster image portrayed in the media. Almost every offender is someone's relative, friend, neighbor, church minister, or youth leader, and no one, least of all the offender, recognizes him in the media image. Responsible public education can do much to create a safer, more aware society and reduce the risk of children being sexually abused.

    Appendix A: Weaving Relapse Prevention Philosophy into Intervention: A Sample Program

    Sample Therapy Program

    This sample program is based on my own experience in different contexts for intervention, and should be suitable for running in secure as well as community-based projects. It is aims led and provides a framework that can be used for running programs of differing intensity; hence it is adaptable for low-, medium-, and high-deviance offenders.

    Assessment

    Individual interview can be combined with psychological and psycho- physiological testing and group assessment work. The psychological tests used can inform intervention while acting as a benchmark against which to measure progress. The following battery of personality and offense-related measures used at the Wolvercote Residential Clinic, including the measures used by Beckett, Beech, Fisher, and Fordham (1994), can be used pre- and post-intervention.

    Pre and Post Measures
    • Offense-focused measures
      • Children and sex
      • Beckett, R. C. (1987). Children and Sex Questionnaire: Cognitive distortions, emotional congruence. Unpublished. (Available from Richard Beckett, Department of Forensic Psychology, Oxford Regional Forensic Service, Wallingford Clinic, Fairmile Hospital, Wallingford, Oxon. OX10 9HH, England. Description in Beckett, R. C., Beech, A., Fisher, D., & Fordham, A. S. [1994], Community-based treatment for sex offenders: An evaluation of seven treatment programmes. London: Home Office Publications Unit. See pp. 155, 163.)
      • Sexual offense attitudes
      • Procter, E. (1994). Sexual Offence Attitudes Questionnaire. Unpublished. (Available from Oxfordshire Probation Service Research and Information Unit, 42 Park End St., Oxford OX1 1JN, England.)
      • Relapse prevention
      • Beckett, R. C., & Fisher, D. (1994). Relapse Prevention Questionnaire. Unpublished. (Description in Beckett, R. C., Beech, A., Fisher, D., & Fordham, A. S. [1994]. Community-based treatment for sex offenders: An evaluation of seven treatment programmes. London: Home Office Publications Unit. See p. 167.)
      • Beckett, R. C., Fisher, D., Mann, R. E., & Thornton, D. (1996). Relapse Prevention Interview. Unpublished. (Description in Mann, R. E. [1996, November], Measuring the effectiveness of relapse prevention intervention with sex offenders. Paper presented at the 15th Annual Research and Treatment Conference of the Association for the Treatment of Sexual Abusers, Chicago; available from R. E. Mann, Programme Development Section, H.M. Prison Service, Abell House, John Islip St., London SW1P 4LH, England.)
      • Personal history
      • NOTA Database (1994). (Database of the National Association for the Development of Work With Sex Offenders. Available from Richard Beckett, Department of Forensic Psychology, Oxford Regional Forensic Service, Wallingford Clinic, Fairmile Hospital, Wallingford, Oxon. 0X10 9HH, England.)
    • Measure of intelligence
      • Ammons, R. B., & Ammons, C. H. (1962). Ammons Quick Test. Missoula, MT Psychological Test Specialists.
    • Measures of self-image
      • Self-esteem
      • Thornton, D. (1994). Self-Esteem Questionnaire. Unpublished. (Available from David Thornton, Programme Development Section, H.M. Prison Service, Abell House, John Islip St., London SW1P 4LH, England. Description in Beckett, R. C., Beech, A., Fisher, D., & Fordham, A. S. [1994]. Community-based treatment for sex offenders: An evaluation of seven treatment programmes. London: Home Office Publications Unit. See p. 146.)
      • Personality
      • Blackburn, R. (1982). Special Hospitals Assessment of Personality and Socialisation. Unpublished, Ashworth Hospital, Liverpool.
      • Emotional loneliness
      • Russell, D., Peplau, L. A., & Cutrona, C. A. (1980). The Revised UCLA Loneliness Scale: Concurrent and discriminant validity evidence. Journal of Personality and Social Psychology, 39, 472–480.
      • Fear of negative evaluation
      • Watson, D., &. Friend, R. (1969). Measurement of social-evaluative anxiety. Journal of Consulting and Clinical Psychology, 33, 4, 448–457.
      • Interpersonal problems
      • Horowitz, L. M., Rosenberg, S. E., Baer, B. A., Ureno, G., &. Villasenor, V S. (1988). Inventory of Personal Problems: Psychometric properties and clinical applications. Journal of Consulting and Clinical Psychology, 56, 885–892.
    • Measures of victim empathy
      • Victim Empathy Scale
      • Beckett, R. C., & Fisher, D. (1994). Victim Empathy Scale. Unpublished. (Description in Beckett, R. C., Beech, A., Fisher, D., & Fordham, A. S. [1994], Community-based treatment for sex offenders: An evaluation of seven treatment programmes. London: Home Office Publications Unit. See p. 136.)
      • Victim empathy vignettes
      • Hanson, R. K., &. Scott, H. (1995). Assessing perspective taking among sexual offenders, non-sexual criminals and non-offenders. Sexual Abuse: A Journal of Research and Treatment, 7, 259–277.
    • Measures of perspective taking
      • Interpersonal reactivity
      • Davis, M. H. (1988). A multidimensional approach to individual differences in empathy. In A. C. Salter, Treating child sex offenders and their victims: A practical guide (pp. 291–293). Newbury Park, CA: Sage. (Original work published in 1980)
      • Social desirability
      • Greenwald, H. J., & Satow, Y. (1970). A short social desirability scale. Psychological Reports, 27, 131–135.
      • Impulsivity
      • Eysenck, S. B. G., & Eysenck, H. J. (1978). Impulsiveness and venturesomeness: Their position in a dimensional system of personality description. Psychological Reports, 43, 1247–1255.
    • Measures of sexual attitudes and arousal patterns
      • Multiphasic sex inventory
      • Nichols, H. R., & Molinder, I. (1984). Multiphasic Sex Inventory manual. Unpublished. (Available from H. R. Nichols and I. Molinder, 437 Bowes Dr., Tacoma, WA 98466-7047)
    • Measures of self-control
      • Alcoholism screening
      • Selzer, M. L. (1971). The quest for a new diagnostic instrument. American Journal of Psychiatry, 127, 1653–1658.
      • Locus of control
      • Nowicki, S. N., Jr. (1976). Adult Nowicki-Strickland Internal-External Locus of Control Scale. Unpublished. (Available from S. N. Nowicki, Jr., Department of Psychology, Emory University, Atlanta, GA 30322)
      • Aggression
      • Buss, A. H., &. Perry, M. (1992). The Aggression Questionnaire. Journal of Personality and Social Psychology, 63, 3, 452–459.
      • Caprara, G. V (1986). Indicators of aggression: The Dissipation-Rumination Scale. Personality and Individual Differences, 7, 763–769.
      • Social Response Inventory
      • Keltner, A., Marshall, P. G., & Marshall, W L. (1981). Measurement and correlation of assertiveness and social fear in a prison population. Corrective and Social Psychiatry, 27, 41–47.
      • Impulsivity
      • Eysenck, S. B. G., & Eysenck, H. J. (1978). Impulsiveness and venturesomeness: Their position in a dimensional system of personality description. Psychological Reports, 43, 1247–1255.
    Measures and Exercises that can be used at Intervals throughout the Program

    Group environment

    Moos, R. H. (1986). Group Environment Scale manual (2nd ed.). Palo Alto, CA: Consulting Psychologists Press.

    Individual clinical ratings

    Hogue, T. (1992). Individual Clinical Rating Form. Unpublished. (Available from T Hogue, H.M. Prison Service, Abell House, John Islip St., London SW1P 4LH, England.)

    Exercises

    Eldridge, H. J. (1991). Breaking the cycle: Offence description and matching relapse prevention plan: Videotaped exercise. (Described in Part II of this guide, pp. 16–17, in the section headed “Monitoring the Offender's Progress.”)

    Eldridge, H. J., Findlater, D., & Wyre, R. (1991). Offences, effects and who is to blame: Videotaped exercise. Unpublished.

    Motivating Offenders

    Depending on individual need, this work may be undertaken prior to or in tandem with the early stages of the program. Common blocks and ways of overcoming them are noted in this guide in Part III, Phase 1, “Motivating Offenders: Working With Blocks to Receptivity (pp. 22–27, this guide).”

    Monitoring Networks

    Good practice for networking linked to a regular progress review system is described in Part III of this volume, in the “Building Networks” sections in Phases 1 and 2 (pp. 43–54, 101–107, this guide), and in the “Working With a Network” section in Phase 3 (pp. 117–118, this guide).

    Preparation for the Main Program: Detailed Analysis of the Offending Cycle

    At this point, the offender is asked to complete exercises from Phase 1 of Maintaining Change: A Personal Relapse Prevention Manual. This provides homework to support individual and group work. An in-depth analysis of the offending cycle begins. Ideas for identifying the thinking, feeling, and senses cycles are described in this guide in Part III, Phase 1, “Working With Multidimensional Cycles of Sex Offending (pp. 27–43).”

    To understand his cycle thoroughly, the offender will have to challenge his own thinking errors. Groups can be used very effectively to facilitate this process, and the therapist can set group members individual tasks to help them argue against their own distorted logic. The personal relapse prevention manual helps here, too.

    In summary, each offender identifies the attitudes, beliefs, feelings, and behaviors that have led him toward offending as well as those that can help him resist the desire to offend. He relates these to his cycle, its active phases and phases of inhibition, and makes his first self-awareness and “breaking the cycle” videotapes. Provided the offender gains a real understanding of his own cycle at the beginning of therapy, he will be able to apply what he learns in future therapy to that cycle and the breaking of it. “Weaving” is about constantly making links between what is learned and relapse prevention.

    The Main Program

    Exercises from Phases 1 and 2 of the personal relapse prevention manual are set at intervals during the program. The therapist can give offenders whole sections en bloc or separate exercises, whichever integrates best with a given program and with the progress of individuals. Some men prefer having the freedom to use the entire manual in their own ways, whereas others are daunted by seeing all the exercises at once and feel pressured to complete them all quickly.

    Most therapy programs include cognitive, behavioral, and psychotherapeutic components aimed at intervening in the offending process and breaking the cycle. Work can take place individually, in group, or a combination of both. Relapse prevention can form an integral part of either.

    Individual Work

    Although intervention often takes place on an individual basis, without accompanying group work, it is rare for the opposite arrangement to form part of good practice. Hence the sample group work program is backed by ongoing individual work (see Table A.1). Some work is done more effectively and appropriately in individual sessions, for example, behavioral work for sexual fantasy control, individually structured work on changing negative thinking patterns, and personal survivor and family-related work. This guide includes information on the last of these areas in the sections on building networks. The fine-tuning of an individualized relapse prevention plan is an appropriate task for individual work. Group discussion and review of the relapse prevention plan is invaluable, but if group is the only setting for such work, there is a danger that a “group plan” may be devised that is of little real value to each individual.

    Table A.1. Sample Combined Individual/Group Work Program

    Therapeutic Approaches

    The program is primarily aims led, so although the specific exercises and techniques recommended have intrinsic value, in essence they are devices to achieve certain objectives, rather than ends in themselves.

    A range of therapeutic approaches, techniques, exercises, and devices may be employed to achieve the desired objectives. These will vary depending on the needs of individual offenders and the repertoire of the therapists. Care should be taken to ensure that the approaches used are enabling, not humiliating, and that the instructions given are clear and well understood.

    Cognitive approaches that stimulate offenders to use rational thought processes to challenge their own distorted thinking often constitute a useful starting point for therapy. Offenders may find this method less threatening than, for example, acting out offending scenarios in role play. As work progresses, more dramatic interactive approaches may be necessary to facilitate the development of real empathy rather than just intellectual awareness.

    Group Work Program

    The offender enters a core group work program that operates on a modular basis and has as a constant theme the offender's need to relate all that he learns to developing relapse prevention strategies suited to his own pattern of inhibitors and activators.

    The modular program consists of four core elements, each of which is divided into modules that are different from but not necessarily more advanced than each other. This idea was originally conceived by Ray Wyre (Eldridge & Wyre, in press) for Gracewell Clinic's residential program and is used at Wolvercote Residential Clinic, in which setting each module includes ten sessions, each of three hours duration. However, the modular program can be adapted for less intensive programs (See sample program in Tables A.2 and A.3). In the sample program there are six sessions within each module, two of which focus specifically on relating new learning to relapse prevention. This program can be modified for closed or open groups to be run as a rolling or progressive program. At the end of each block of sessions, the offender completes a “breaking the cycle” video and another “self awareness” videotaped exercise. These are described in Part II of this guide, in the section headed “Monitoring the Offender's Progress” (pp. 15–20).

    Offenders may attend other groups in addition, depending on their particular needs—for example, groups on improving reasoning ability and positive thinking or personal survivor groups.

    Overall Aims of the Program

    The overall aims of the program are to reduce the offender's risk of reoffending by doing the following:

    • Challenging the offender's cognitive distortions, including generalized distortions, and those specific to offending scenarios
    • Increasing the offender's empathy for his victims
    • Increasing the offender's awareness of his pattern, with a view to interrupting it
    • Increasing the offender's control over his sexuality
    • Increasing the offender's ability to develop an offense-free lifestyle, in which he meets the emotional needs previously met by offending are met in other ways

    Table A.2. Sample Group Work Program

    Table A.3 Typical Six-Session Module (Example: Victim Awareness/Empathy)
    Session 1Victim awareness/empathy
    Session 2Victim awareness/empathy
    Session 3Victim awareness/empathy
    Session 4Victim awareness/empathy
    Session 5Relapse prevention ← victim awareness/empathy linked
    Session 6Relapse prevention ← victim awareness/empathy linked
    Objectives for Participants

    By the end of the program, each offender should be able to do the following:

    • Challenge his own thinking errors
    • Relate what he has learned in each module to his past offending
    • Identify ways in which he can use new learning to break his cycle in the future
    • Describe and act on a realistic relapse prevention plan that involves other people but does not rely on them
    Arrangement and Length of Modules

    Each of the modules within the four core elements may be run in blocks of varying length to suit the duration and intensity of the program. In the sample program shown, modules on victim awareness/empathy, sexuality and relationships, and assertiveness/anger management are run in blocks of 6 weeks, with one session run each week. Wherever possible, however, sessions should be run at least twice weekly to ensure that all group members can participate fully and to increase the impact of the therapy. In our own residential program, sessions are run each weekday for 12 months. Where the only available option is to meet once a week, the size of the group should be kept to a small number, perhaps a maximum of five participants, to ensure the regular meaningful involvement of everyone in the group.

    In the sample program, the module concerning the role of sexual fantasy in the offending cycle runs in blocks of 4 weeks, as additional individual work is done using behavioral techniques for sexual fantasy control.

    Objectives for Each Module

    In addition to the objectives outlined below, it may be helpful for each offender to identify his own set of objectives, related to relapse prevention, to be achieved by the end of each module.

    Victim Awareness/Empathy Objectives

    By the end of the program, the offender should be able to do the following:

    • Recognize the impact of his whole offending cycle on his victims
    • Describe how he controlled his victims and interpreted their behavior to legitimize his own
    • Demonstrate empathy with victims of sexual abuse and his own past victims in particular
    • Describe the ripple effect of his offending on others
    • Identify how he will use victim empathy to avoid reoffending in the future, even if he is approached by a child who is acting out sexually
    • Explain how he will use his greater understanding of victim issues to block arousal, pro-offending thinking, and targeting behaviors
    The Role of Sexual Fantasy in the Offending Cycle Objectives

    This module is used to complement behavioral techniques for fantasy control. By the end of the program, the offender should be able to do the following:

    • Describe the part played by sexual fantasy in his cycle
    • Describe how fantasy reinforces the desire to offend and acts as a rehearsal of offending
    • Describe the distorted pro-offending thinking inherent in fantasy, and its desensitizing effect
    • Use behavioral techniques to restructure his arousal to adult consenting behaviors
    • Expect brief, “flitting” thoughts of illegal behavior and to learn effective ways of coping with such thoughts
    • Recognize that masturbating to thoughts of sexual abuse is a lapse and describe ways of coping effectively with such lapses
    • Relate what he has learned to his own offending pattern and to relapse prevention
    Sexuality and Relationships Objectives

    By the end of the program, the offender should be able to do the following:

    • Identify the ways his attitudes toward sex and sexuality have helped him legitimize his offending
    • Restructure his thinking patterns that objectify people, especially women and children
    • Plan how he will use new thinking patterns about sex and sexuality to prevent a repetition of previous routes to relapse and to block thoughts that promote “I want, therefore I take”
    • Demonstrate nonabusive attitudes toward sex and sexuality
    • Understand the meanings of responsibility and intimacy in relationships
    • Demonstrate knowledge of sex and sexuality in the context of positive consenting relationships
    • Describe the differences between consent, compliance, and coercion
    • Describe how he can use his greater understanding of these issues to change pro-offending thinking and behavior patterns and to replace abusive with nonabusive sexual relationships
    • Relate what he has learned to his own offending pattern and to relapse prevention
    Assertiveness Training and Anger Management Objectives

    By the end of the program, the offender should be able to do the following:

    • Identify whether anger plays a part in his cycle and, if so, the ways in which he has used anger to provide himself with excuses to offend
    • Identify the links between lack of assertiveness (whether expressed through withdrawal or aggression) and his sex offending cycle, especially his excuses to offend
    • Demonstrate appropriate anger management and assertiveness skills
    • Demonstrate positive, realistic thinking patterns
    • Identify scenarios in which he will use these skills as effective coping mechanisms to break out of old routes to reoffending
    • Practice positive thinking and assertive behavior
    • Relate what he has learned to his own offending pattern and to relapse prevention
    Callback

    A useful format for callback interviews is described in this guide in Phase III, “Post-Intervention Monitoring and Callback (pp. 109–115).”

    Appendix B: The Relapse Prevention Questionnaire and Interview

    The Relapse Prevention Questionnaire was originally developed for use in the Sex Offender Treatment Evaluation Project (Beckett, Beech, Fisher, & Fordham, 1994) as a research tool to measure to what extent individuals participating in treatment programs were aware of their risk factors and risk situations or scenarios and whether they had developed strategies to prevent reoffending. It is divided into questions that focus on awareness of risk factors and questions that focus on the use of appropriate strategies to avoid risky scenarios/situations, escape from them, or, if necessary, cope safely with them.

    One of the authors, Dawn Fisher, comments, “In addition to being used as a research measure, the Relapse Prevention Questionnaire is of value clinically in that it can be used to gather information about individuals’ awareness of their risk factors and situations and the strategies they have developed to avoid risk situations in the future and prevent reoffending.”

    Using the scoring guide enables a score to be derived for each individual, but it should be noted that the method of scoring is somewhat subjective, and the subscales are not statistically derived. Scorers should be trained in the use of the interview, and, where possible, interrater reliability checks should be carried out. The estimated level of risk simply reflects an individual's willingness to admit to the possibility of future risk. It is not a score of actual level of risk.

    The questionnaire has been adapted for use in the Lucy Faithfull Foundation's residential offender program, and has been further developed as an interview for use in the Sex Offender Treatment Programme running in prisons in England and Wales. Ruth Mann describes the interview in a paper she presented at the 1996 meeting of the Association for the Treatment of Sexual Abusers; she has commented that it is able to distinguish quite subtly between different areas of relapse knowledge and can inform on the effectiveness of a relapse prevention intervention. The version used in the prison program as an interview (Beckett, Fisher, Mann, & Thornton, 1996) is presented here.

    Relapse Prevention Interview
    by RichardBeckett
    DawnFisher
    RuthMann
    DavidThornton

    Surname: ___________________________________________

    Forenames: ___________________________________________

    Date of Birth: ___________________________________________

    Interviewer: ___________________________________________

    Instructions to Interviewer

    Introduce this interview with the following words:

    From the work that has been done with people who commit sexual offenses, it is known that they go through several stages before an offense can happen. It will be easier for you to avoid offending in the future if you are aware of these stages, and the factors that put you at risk, and if you have worked out ways of controlling them. This interview is to see how good you are at doing that.

    Think about the sexual offense(s) you have committed and then answer the following questions. Even if you do not believe you would be at risk of offending again, consider the factors that would be important if you were.

    You may wish to allot a time limit for each answer to be produced.

    • 1a. What feelings or moods would put you at risk of sexual offending again? Describe at least two different moods that would put you at risk.
    • 1b. How will you cope with such feelings or moods in the future? Describe at least two ways of coping with them that you could use to reduce the risk of you reoffending.
    • 2a. What thoughts, including sexual thoughts or fantasies, would put you at risk of sexual offending? Describe at least two different thoughts.
    • 2b. How would you cope with such thoughts in the future? Describe at least two different ways of coping with such thoughts that you could use to reduce the risk of their leading to a sexual offense.
    • 3a. What events might make you more likely to have feelings or thoughts that put you at risk of offending? Describe at least two different events.
    • 3b. How would you cope with such events in the future? Describe at least two different ways of coping with each event that you could use to reduce the risk of their leading to a sexual offense.
    • 4a. In what situations are you most likely to offend? What situations or places should you avoid? Describe at least two situations or places.
    • 4b. How would you cope if you were in these situations or places in the future? Describe at least two different ways of coping that you could use to reduce the risk of each situation leading to a sexual offense.
    • 5a. Many offenders go to considerable effort to set up a situation in which they can offend. How did you set up your offense situation(s)? Describe at least two different methods that you have used to set up a situation in which you could offend.
    • 5b. What would be the warning signs for you that you were setting up another situation where you could offend? Describe at least two different warning signs.
    • 6a. What sort of person would be most at risk from you? Describe this person in terms of looks, personality, age, attitudes, and so on.
    • 6b. How would you cope if on meeting someone you began to have thoughts or ideas about offending? Describe at least two different ways of coping that you could use to reduce the risk of your committing a sexual offense.
    • 7a. How might other people know you are at risk? Describe at least two different things that they might see or observe.
    • 7b. What could you do to obtain help if you were at risk of offending again? Describe at least two different things you could do.
    • 8. Who have you told fully about your past offending and enlisted to help you in preventing yourself from reoffending?
    • 9a. Thinking about the excuses or justifications you used to give yourself permission to offend, describe at least two of them.
    • 9b. How would you respond to such thoughts in the future? Describe at least two things you could say to yourself or do to stop this kind of thinking leading to sexual offending.
    • 10a. Indicate on the following scale of 0 to 10 the likelihood of you committing a sexual offense in the future (0 is not likely at all; 10 is extremely likely). Circle the number that best describes you.
    • Not likely 012345678910 Extremely likely
    • 10b. Please explain why you have given yourself this rating.
    Relapse Prevention Interview Scoring Guide
    Basic Principles of Scoring

    Each response is scored from 0 to 2 according to whether the offender's response meets certain conditions. It is obviously not possible for this scoring guide to account for all possible responses. Therefore, if in doubt, please decide which of the following best describes the offender's response:

    • 0 = The offender refuses to recognize risk or the need to develop coping strategies. He shows no understanding of relapse prevention concepts whatsoever.
    • 1 = The offender does not refuse to acknowledge risk and has some understanding of relapse prevention issues, but this is general or unsophisticated and could do with further development.
    • 2 = The offender has a clear and appropriate understanding of his offending behavior, risk factors, and relapse prevention concepts and has developed well-thought-out, realistic, and workable coping strategies.
    Q1aSCOREDESCRIPTION
    0Identified no moods.
    1Answered the question but with reference only to his past offending or gave an answer that is not a mood (e.g., “My mother”). Identified just one distinct mood. Include cases who use different words that describe basically the same emotion (e.g., “anger, rage, frustration”).
    2Identified more than one distinct emotion.
    Q1bSCOREDESCRIPTION
    0Identified no coping strategies. Include those who discount the possibility of the mood recurring or who say that “things are different now.” Also score 0 for strategies that would put the offender at higher risk (e.g., “I would go for a walk along the canal”).
    1Identified only oversimplified or unconvincing strategies that are poorly thoughtout, unlikely to happen, or unlikely to work (e.g., “I'll settle down and meet a nice girl”). Also only score 1 for offenders who mention only avoidance strategies (e.g., “I would keep away from children”) or only escape strategies (e.g., “I would leave right away”).
    2Identified more than one strategy that is well thought-out, realistic, and workable, at least one of which should be a cognitive strategy.
    Q2aSCOREDESCRIPTION
    0Identified no high-risk thoughts.
    1Identified one distinct high-risk thought or gave as an answer a risk factor that is not a thought (e.g., “drunk”). Identified more than one thought but did not acknowledge the role of deviant sexual fantasy in his offending.
    2Identified more than one distinct thought, including deviant sexual fantasy.
    Q2bSCOREDESCRIPTION
    0Identified no coping strategies. Include those who discount the possibility of the thought recurring or who say that “things are different now.” Also score 0 for strategies that would put the offender at higher risk (e.g., “I would go for a walk along the canal”).
    1Identified only oversimplified or unconvincing strategies that are poorly thought-out, unlikely to happen, or unlikely to work (e.g., “I'll settle down and meet a nice girl”). Also only score 1 for offenders who mention only avoidance strategies (e.g., “I would keep away from children”) or only escape strategies (e.g., “I would leave right away”).
    2Identified more than one strategy that is well thoughtout, realistic, and workable, at least one of which should be a cognitive strategy.
    Q3aSCOREDESCRIPTION
    0Identified no events.
    1Gave an answer that is a risk factor but not an event or that relates to his past behavior but not the future (e.g., “If a child is provocative—but this wouldn't affect me now”). Identified just one distinct event or type of event.
    2Identified more than one distinct event or type of event.
    Q3bSCOREDESCRIPTION
    0Identified no coping strategies. Include those who discount the possibility of the event recurring or who say that “things are different now.” Also score 0 for strategies that would put the offender at higher risk (e.g., “I would go for a walk along the canal”).
    1Identified only oversimplified or unconvincing strategies that are poorly thought-out, unlikely to happen, or unlikely to work (e.g., “I'll settle down and meet a nice girl”). Also only score 1 for offenders who mention only avoidance strategies (e.g., “I would keep away from children”) or only escape strategies (e.g., “I would leave right away”).
    2Identified more than one strategy that is well thought-out, realistic, and workable, at least one of which should be a cognitive strategy.
    Q4aSCOREDESCRIPTION
    0Identified no high-risk situations.
    1Cave an answer that is not a situation or that is not well defined (e.g., “stressful situations”). Identified just one distinct situation or type of situation (e.g., baby-sitting). (Note: Alcohol counts as a situation.)
    2Identified more than one distinct situation or type of situation.
    Q4bSCOREDESCRIPTION
    0Identified no coping strategies. Include those who discount the possibility of the situation recurring or who say that “things are different now.” Also score 0 for strategies that would put the offender at higher risk (e.g., “I would go for a walk along the canal”).
    1Identified only oversimplified or unconvincing strategies that are poorly thought-out, unlikely to happen, or unlikely to work (e.g., “I'll settle down and meet a nice girl”). Also only score 1 for offenders who mention only avoidance strategies (e.g., “I would keep away from children”) or only escape strategies (e.g., “I would leave right away”).
    2Identified more than one strategy that is well thought-out, realistic, and workable, at least one of which should be a cognitive strategy.
    Q5aSCOREDESCRIPTION
    0Denied that the offense was set up in any way (“It just happened”) or portrayed the offense as entirely opportunistic.
    1Described one behavior that set up the offense situation.
    2Described at least two separate behaviors that were used to set up the offense situation.
    Q5bSCOREDESCRIPTION
    0Denied that offending is planned or that it is likely to happen again.
    1Identified only completely implausible, unrealistic, or overly inclusive warning signs (e.g., “being alone”) or identified warning signs but denied the likelihood of their occurring or identified only one sign.
    2Identified more than one warning sign.
    Q6aSCOREDESCRIPTION
    0Denied that any person is at risk or could not give any description.
    1Gave a limited or vague description (“a woman”) or a description that does not tie with his offending (e.g., offender against children claims adults are most at risk from him) or the description is reluctant and plays down risk (e.g., “Possibly women in their 20s, but basically I think I am safe with anyone now”).
    2Described at least one specific personal characteristic other than age or gender and in clear detail (e.g., “6- to 8-year-old girls with blonde hair and big eyes”).
    Q6bSCOREDESCRIPTION
    0Identified no coping strategies. Include those who discount the possibility of the situation recurring or who say that “things are different now.” Also score 0 for strategies that would put the offender at higher risk (e.g., “I would go for a walk along the canal”).
    1Identified only oversimplified or unconvincing strategies that are poorly thought-out, unlikely to happen, or unlikely to work (e.g., “I'll settle down and meet a nice girl”). Also only score 1 for offenders who mention only avoidance strategies (e.g., “I would keep away from children”) or only escape strategies (e.g., “I would leave right away”).
    2Identified more than one strategy that is well thought-out, realistic, and workable, at least one of which is a cognitive strategy.
    Q7aSCOREDESCRIPTION
    0Denied any future risk or listed no signs.
    1Did not deny risk but listed no signs or completely implausible signs (e.g., “I would tell the police”) or denied that others would be able to see anything—only he would know.
    2Listed one sign or more.
    Q7bSCOREDESCRIPTION
    0Had no ideas of ways to obtain help or denied any need for help.
    1Identified an unspecified source of help only (e.g., “I'd talk to someone”) or referred to people with whom he has not made contact (e.g., “I'd join a support group”).
    2Listed more than one specific source of help with which he has already established contact.
    Q8SCOREDESCRIPTION
    0Could not identify anyone to tell if worried or denied possibility of risk.
    1Identified only one person or people with whom he has not established contact (e.g., “I would have found a group so I would tell them”).
    2Identified two or more people with whom he has established contact.
    Q9aSCOREDESCRIPTION
    0Identified no distortions or excuses or identified statements that are not distortions or excuses or that he does not understand as being such.
    1Identified one or two distortions or excuses.
    2Identified more than two distortions or excuses for offending.
    Q9bSCOREDESCRIPTION
    0Gave no strategy for responding to distortions or did not identify distortions.
    1Described a vague strategy but without details on how he would put it into practice (e.g., “I'd get it out of my head”; “I'd talk to somebody”) or described one sophisticated strategy only or described strategies that rely exclusively on others. Score 1 for a response of “Remind myself of the consequences” as a sole strategy.
    2Described more than one sophisticated cognitive strategy, such as disputing the thought, reminding himself of the consequences of offending, using an aversive visual image, and repeating a phrase that will motivate him to avoid offending. Strategies are self-reliant and do not depend on others.
    Q10aScore is the number circled. In scoring the answer, it is important to make a distinction between seeing self at no risk (i.e., scoring 0) and seeing self at some risk (i.e., scoring 1–10). It is not possible to make judgments purely on the number given without taking the respondent's explanation into account. See his answer to Question 10b after his rating.
    Relapse Prevention Interview Scoring Sheet

    Name:

    Scorer:

    Pre/Post-treatment:

    Recognition of risk factors = 1a + 2a + 3a + 4a + 5b + 6a + 7a + 9a
    Identification of coping strategies = 1b + 2b + 3b + 4b + 6b + 7b + 8 + 9b
    Acknowledgment of planning = 5a
    Estimated level of risk = 10

    AUTHOR's NOTE: The Relapse Prevention Interview, developed by Beckett, Fisher, Mann, and Thornton (1996), appears in this appendix by permission of its authors.

    References

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    Eldridge, H.J., & Still, J. (1995). Apology and forgiveness in the context of the cycles of adult male sex offenders who abuse children. In A.C.Salter, Transforming trauma: A guide to aid survivors of child sexual abuse (pp. 131–158). Thousand Oaks, CA:Sage.
    Eldridge, H.J., & Wyre, R. (in press). The Faithfull Foundation's residential program for sexual offenders. In W.L.Marshall, S.M.Hudson, T.Ward, & Y.M.Fernandes (Eds.), Sourcebook of treatment programs for sexual offenders. New York;Plenum.
    Faller, K.C. (1990). Sexual abuse by paternal caretakers: A comparison of abusers who are biological fathers in intact families, stepfathers and noncustodial fathers. In A.L.Horton, B.L.JohnsonL.M.Roundy, & D.Williams (Eds), The incest perpetrator: A family member no one wants to treat (pp. 65–73). Newbury Park, CA:Sage.
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    Finkelhor, D. (1984). Child sexual abuse: New theory and research. New York:Free Press.
    Fisher, D., & Thornton, D. (1993). Assessing risk of re-offending in sexual offenders. Journal of Mental Health, 2, 105–117. http://dx.doi.org/10.3109/09638239309018395
    Hanson, K.R., Cox, B., & Woszcyna, C. (1991). Sexuality, personality and attitude. Questionnaires for sexual offenders: A review. Ottawa: Solicitor General, Canada.
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    Marlatt, G.A. (1989a). Feeding the PIG: The problem of immediate gratification. In D.R.Laws (Ed.), Relapse prevention with sex offenders (pp. 56–62). New York:Guilford.
    Marlatt, G.A. (1989b). How to handle the PIG. In D.R.Laws (Ed.), Relapse prevention with sex offenders (pp. 227–235). New York:Guilford.
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    Salter, A.C. (1988). Treating child sex offenders and their victims: A practical guide. Newbury Park, CA:Sage.
    Salter, A.C. (1992). Walking the walk, talking the talk: Indicators to effective intervention. Paper presented at the annual meeting of the National Association for the Development of Work With Sex Offenders, Dundee, Scotland.
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    Further Reading

    Eldridge, H.J. (1991). Assessment and treatment of sex offenders. In G.Bradley & D.Lamplugh (Eds.), The sentencing of sex offenders (Report of an interdisciplinary conference) (pp. 61–65). London:Suzy Lamplugh Trust, in conjunction with the Criminal Bar Association.
    Laws, D.R. (Ed.). (1989). Relapse prevention with sex offenders. New York:Guilford.
    Marshall, W.L., Laws, D.R., & Barbaree, H.E. (Eds.). (1990). Handbook of sexual assault: Issues, theories and treatment of the offender. New York:Plenum.
    McKay, M., Davis, M., & Fanning, P. (1981). Thoughts and feelings: The art of cognitive stress intervention. Oakland, CA:New Harbinger.
    Multi-agency Working Group of Forensic Psychologists. (1994, July). Guidelines for PPG usage. Forensic Update (newsletter published by the Division of Criminological and Legal Psychology of the British Psychological Society).
    Thornton, D., & Travers, R. (1991). A longitudinal study of the criminal behavior of convicted sexual offenders. In Proceedings of the Prison Psychologists’ Conference. London:Her Majesty's Prison Service.
    Wanigaratne, S., Wallace, W., Pullin, J., Keaney, F., & Farmer, R. (1990). Relapse prevention for addictive behaviours. Oxford:Blackwell Scientific.

    About the Author

    Hilary Eldridge, B.A. (Honors), Dip. S.W., C.Q.S.W., is Clinical Director of the Lucy Faithfull Foundation, which works with adult and adolescent perpetrators of sex abuse, and runs an adult residential clinic for offenders providing intensive, long term therapy. The clinic also provides therapy for survivors and their families and trains professional groups in work with sexual abuse. Hilary Eldridge has specialized in work with sex offenders for more than 20 years. After completing postgraduate training at Leicester University, she worked as a probation officer and later co-founded the Gracewell Clinic, which ran the first residential program for adult sex offenders in Europe. She was Head of Training and Program Development for Gracewell. She has worked as consultant to a prison program and currently consults to community-based programs, in addition to directing the Lucy Faithfull Foundation's Wolvercote Residential Clinic. She has published book chapters and other materials relating to sexual abuse, including “Apology and Forgiveness in the Context of the Cycles of Adult Male Sex Offenders who Abuse Children” (with Jenny Still), which appeared in Transforming Trauma, by Anna Salter (1995); and “Barbara's Story,” which appeared in Female Sexual Abuse of Children, edited by M. Elliott (1993). She is a member of the National Association for the Development of Work With Sex Offenders (also known as NOTA).

    About the Contributors

    Richard Beckett is a consultant forensic and clinical psychologist and Head of Oxford Forensic Psychology Service. He has held grants for research into adult and adolescent sex offending and is co-recipient of British government grants into the evaluation of community sex offender treatment programs and the treatment of sex offenders in prisons in England and Wales. He is an honorary research fellow at Birhimgham University.

    Dawn Fisher is a consultant forensic and clinical psychologist working in a private secure hospital setting. She has worked in the forensic field since 1979, and has specialized in the assessment and treatment of adult and adolescent sex offenders. She is involved in a British government research project to evaluate the effectiveness of community and prison- based treatment programs for sex offenders.

    Ruth Mann is a principal forensic psychologist who has worked with the Prison Service in England and Wales for ten years. She manages the Prison Service Sex Offender Treatment Programme, which runs in twenty five prisons, making it the largest scale program of its kind in the world.

    Jenny Still, BA, qualified as a social worker in 1974. She has specialized in working with child abuse since 1977 as a practitioner, consultant, and teacher. As Senior Lecturer at the University of London, she set up and ran the government-sponsored national training program on child sexual abuse. She co-founded the Gracewell Clinic and is now Deputy Director of The Lucy Faithfull Foundation.

    David Thornton, PhD, is a senior principal psychologist. He was responsible for introducing the Sex Offender Treatment Programme into prisons in England and Wales. He is Head of the Prison Service's Programme Development Section, which is responsible for the management of all accredited prison-based offending behavior programs, of which the Sex Offender Treatment Programme is one.


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