Treatment at La Macaza Clinic: a qualitative study of the sexual offenders' perspective.

• Author: Drapeau, Martin

Introduction

Most treatment programs for sexual abusers require that the abuser demonstrate a clear motivation for change before being admitted to treatment. According to McGrath (1991), this motivation is most often assessed according to the following criteria: (1) the abuser must admit to his crime and accept responsibility for his actions; (2) he must also recognize that his behaviour is problematic and must be ended; and (3) he must be willing to follow a treatment program. As a result, a patient's desire for change is often considered to be one of the most important factors involved in his admission to a therapy program (Borzecki and Wormith 1987; Hanson and Buissiere 1998). This requirement is justified because motivation for change is often associated with success of a treatment program and with reduced likelihood of recidivism (Chaffin 1994; Hanson and Buissiere 1998; Lee, Proeve, Lancaster, Jackson, Pattison, and Mullen 1996; Maletzky 1993); however, this raises the possibility of coerced treatment. Although most studies suggest that an abuser's initial motivation for therapy is the result of pressure and constraints from the environment (Marshall and Barbaree 1988a, 1988b), the question of whether or not to force a patient into treatment still remains problematic.

According to Marshall, Eccles, and Barbaree (1993), treatment must include some coercion to increase motivation for change in a population making much use of denial. Lee et al. (1996) recommend the use of individual psychotherapy with abusers prior to admission to a treatment program in order to help them realize that their behaviour is problematic. However, not all researchers and clinicians agree with this because it raises many ethical questions (Chaffin 1994) and because some studies suggest that forced treatment may increase dropout (Simkins, Ward, Bowman, Rinck, and DeSouza 1990). Although fear may keep an abuser in treatment (Hanson and Buissiere 1998), it may also have effects opposite to those desired. For example, fear may motivate the abuser to avoid any confrontation with the therapist and to blindly follow staff recommendations. It would therefore be better to ensure the abuser's cooperation without using force (Marshall and Barbaree 1988b). But low motivation for treatment is often considered to be synonymous with resistance and overt opposition to treatment (Wormith 1983), and the assessment of an abuser's motivation often relies on whether or not he accepts the therapist's point of view. According to Miller (1985), patients who appear to show more suffering or to be more dependent on the institution are perceived by therapists as more motivated to change. Some programs assess motivation for change using Likert scales. This may also be a problem because these scales rarely address the nature of the motivation for change or for treatment, and their use with sexual offenders has often been criticized (Wormith 1983).

Although recent studies have demonstrated that there is a strong relation between motivation for change and external benefits (such as a shorter sentence or a more positive report by release officers; see Marshall et al. 1993), it is often suggested that other elements play a key role in motivation for treatment. Hudson, Ward, and France (1992) suggest that guilt may be an important motivator. Polson and Mc'Cullom (1995) found that incarcerated sex abusers often feel a need to talk to a therapist about their difficulties. It may even be important for the abuser to feel accepted and loved by the therapist (Aubut, Proulx, Lamoureux, and McKibben 1998; Drapeau, Korner, and Brunet forthcoming). According to Hanson and Buissiere (1998), the true motivation for treatment would be to satisfy emotional needs. Some abusers feel that the therapist must be confrontational in order to help them realize the harm they have done. This suggestion seems to be supported by Borzecki and Wormith (1987), who found that pedophile sexual abusers often ask for the treatment program to be more strictly organized (Drapeau et al. forthcoming). Occasionally, abusers even lie about their crimes in order to be admitted to therapy. Fedoroff and Moran (1997) and Fedoroff, Hanson, McGuire, and Malin (1992) suggest that up to 20% of sex abusers in therapy have exaggerated their deviant behaviour or imitated other paraphilic symptoms in order to enter and remain in treatment.

Nonetheless, no study has investigated what motivates pedophile sex abusers to enter treatment. With the exception of brief descriptions of the reactions of sex abusers in treatment (Aubut et al. 1998), few if any studies have investigated how pedophile sex abusers consider treatment to be helpful. This study is an attempt to address these two questions.

Method

Participants

Two treatment groups who had recently started treatment at La Macaza Clinic of the La Macaza federal penitentiary were invited to participate in the study. Of these 28 offenders, four declined. The 24 participants who entered the study were between 25 and 69 years of age (M = 46 years; SD = 11 years) and had been convicted of sexual abuse against children. All participants had a sentence of at least two years to serve. Although some of these sentences were particularly long (e.g., seven years), the average length of the sentences was 47 months (SD = 16 months). The participants had been sentenced for various offences: sexual exploitation or children, indecent proposal to minors, sexual abuse, and distribution of pedophile pornographic material. All participants had had repeated sexual contacts with minors involving complete intercourse, with vaginal or anal penetration in 45% of the cases. Although it is difficult to determine the true number of victims an offender may have assaulted, it seems certain that all abusers in this sample had a minimum of four victims. Finally, only two participants were presently undergoing therapy for the first time.

Six participants had abused only boys, while 12 others had abused only girls. The remaining six participants had abused both boys and girls. Most victims were between two and 13 years of age at the time of the assault. One participant had victims of up to 14 years of age. Furthermore, only one participant had exclusively abused children to whom he was related (uncle-niece), while one participant had abused both inside and outside the family.

The treatment program at the La Macaza Clinic

Since 1992 the La Macaza Clinic has offered an intensive treatment program for all types of sex abusers, excluding those presenting an active psychosis (see Earls 1997). The program is based on principles from both cognitive behavioural therapy and relapse prevention. It resembles most treatment programs offered elsewhere for sex abusers in that it is made up of group sessions, individual sessions, and regular assessment meetings. A therapy group includes a dozen participants, with two to three senior participants having already completed the treatment program. The three-hour group sessions are led by two therapists and are held every weekday.

The complete program is divided into two phases, each lasting four months. The first phase involves establishing an initial contact with the patient, discussing motivation for change, analysing his offence cycle, increasing personal responsibility, and cognitive restructuring. These five steps are mainly aimed at helping the patient develop greater motivation for change, as well as helping him determine which factors could keep him from truly investing in therapeutic work. Furthermore, possible benefits from behaviour change and reducing recidivism are discussed in detail. The first phase concludes with conditioning using aversive techniques.

The second phase of treatment includes social skills training, anger management, sexual education, empathy training, and relapse prevention. It aims at helping the patient find solutions to crime-precipitating problems and conflicts and develop positive social skills, as well as self-assertion techniques with significant others. It also aims at helping the patient better manage his anger and develop problem-solving skills...