ERIC EJ1017918: Effectively Utilizing the "Behavioral" in Cognitive-Behavioral Group Therapy of Sex Offenders

2013·0.34 MB·English

by  ERIC

INTERNATIONAL JOURNAL OF BEHAVIORAL CONSULTATION AND THERAPY ©2013, ALL RIGHTS RESERVED
2013, VOL. 8, NO. 2 ISSN: 1555–7855
Effectively Utilizing the “Behavioral” in Cognitive-Behavioral explanation for “the decline of behavior therapy” in
SOS treatment.
Group Therapy of Sex Offenders
“Aversive conditioning is messy, expensive, cum-
bersome and unattractive. Worse, it is hard work,
Jerry L. Jennings1 and Adam Deming2
with the therapist doing most of it – a tough sell to
1Liberty Healthcare Corporation and 2Liberty Behavioral Health Corporation most of us who have been trained, and may prefer,
simply to sit and chat… Cognitive therapy gives the
appearance of being more thorough: it can teach
Abstract
methods of self-monitoring and extend treatment
Although cognitive-behavioral therapy (CBT) is touted as the predominant approach in sex offender-specific group well beyond the end of formal visits…”
treatment, a review of the field shows that the “behavioral” part of CBT has become minimal in relation to that
Not surprisingly, the popular dominance of cog-
which is cognitive. The authors show how a revitalized “behavioral sensibility” may help to enhance group treat-
nitive interventions in so-called “cognitive-behav-
ment by focusing greater attention on directly observable behaviors. This clinical practice article presents an
ioral” SOS treatment continued unperturbed by
array of behaviorally-oriented techniques for conducting groups, beginning with the establishment of an operant
Maletzky’s concern. Fifteen years later, behavior
group environment that supports behavior change; expanding empirical awareness of events occurring in group;
therapy remains resigned to an important, but small
streamlining interventions with non-verbal signals; targeted reinforcement of social interaction and bonding; and
and circumscribed role that focuses on condition-
more. The article also describes several behavioral techniques designed specifically for sex offender-specific
ing procedures and phallometry.
groups, which can enhance self-disclosure, social awareness, self-esteem, empathy, and management of deviant
thoughts. „ Current Sex Offender Treatment Models
It is interesting that the first serious challenge to
the dominance of cognitive SOS therapy arose in-
For better or worse, the bulk of today’s sex offend- prehensive in scope. In the 1980s, the new cognitive directly through more recent attacks on its mar-
er-specific (SOS) treatment for adults is delivered therapy of Beck exploded onto the scene and swept riage partner, relapse prevention (RP). Both the
in group formats and most interventions tend to be over the sex offender-specific field along with the Self-Regulation Model (Ward & Hudson, 1998) and
cognitive in nature. Although most SOS clinicians rest of the treatment world (Beck, Rush, Shaw & the Good Lives Model (Ward & Stewart, 2003) have
and programs would describe their primary ori- Emery, 1979; Burns, 1980). The new cognitive ther- attacked Relapse Prevention for its narrow empha-
entation as cognitive-behavioral (McGrath, Cum- apy offered a treatment that appeared capable of sis on offense abstinence, avoidance goals and faulty
ming, Burchard, Zeoli & Ellerby, 2010), the actual fixing serious psychological problems through the presumption of a motivation to change (Yates &
amount of SOS treatment that is explicitly “behav- straightforward process of showing clients how to Ward, 2009). The Self-Regulation Model exploded
ioral” appears minimal in relation to that which is apply clear thinking and eliminate thinking errors. the traditional RP notion of a singular offense cycle
“cognitive.” For SOS clinicians, in particular, cognitive therapy by showing multiple offense pathways with corre-
Forty years ago, the opposite was true. In the 1960s, was much easier to use than behavioral condition- sponding self-regulation styles, while the Good
SOS treatment was explicitly behavioral and large- ing and easy to adapt to psychoeducational group Lives Model expanded the focus of treatment to
ly took place in individual formats. As reflected in formats. Moreover, at a personal level, cognitive encompass areas of life beyond offending behavior,
the name “Association for the Behavioral Treatment therapy offered an optimistic and empowering such as friendship, relatedness, spirituality, self-ef-
of Sexual Abusers,” the SOS practitioners and re- sense of efficacy for SOS clinicians, who had the ficacy, intimacy, purpose and personal meaning.
searchers who formed the first professional guild in added responsibility of protecting society from a Together, these two complimentary models have
1984 were grounded in traditional behavior therapy clinical population for whom treatment effective- gained rapidly in opening the SOS field to a broad-
and guided by the presumption that deviant sexual ness was still an open question (Furby, Weinrott & er, more holistic understanding of the complex dy-
preferences and paraphilias resulted from condi- Blackshaw, 1989). namics of sexual offending and the importance of
tioned behavior. For this reason, their early work By the late 1980s, relapse prevention principles fostering the individual’s intrinsic motivation. The
focused almost exclusively on decreasing deviant from the field of addictions were being applied Motivational Interviewing Model has also grown
sexual responses through the use of counter-con- to domestic and sexual violence – and cognitive in popularity, including SOS groups, because it can
ditioning techniques, often using aversion thera- therapy found a compelling and powerful new ally accommodate RP’s problematic presumption that
py. They emphasized the development of accurate, (Laws, 1989; Jennings, 1990). With this marriage, offenders are motivated to change (Prescott, 2008).
objective measures of change; most notably, phal- the cognitive transformation of SOS treatment was The recent emergence of integrated models of SOS
lometry (Laws & Marshall, 2003; Marshall & Laws, decisive. Although the foundational principles of treatment (Bauman & Kopp, 2004; Longo, 2004;
2003). behavior therapy continued to be acknowledged Marshall, Marshall, Serran & Fernandez, 2006; Yates
Almost by definition, the early behaviorally-ori- with the term “cognitive-behavioral,” the practical & Ward, 2008) serves as another indication that
ented proponents were determined to disavow any reality was that cognitive therapy ruled supreme the field is moving away from a generic cognitive
psychoanalytic and psychodynamic “insight-ori- in day-to-day sex offender-specific treatment. The model and toward multi-modal, evidence-based
ented” approaches to either explaining or treating decidedly cognitive character of cognitive-behav- treatment approaches. For example, Marshall and
sexually deviant behavior. By extension, anything ioral SOS treatment continued to gain in popular- his colleagues describe an integrated sex offender
“cognitive” was also avoided as weak science and, ity and achieved widespread acceptance through treatment program in which the diverse targets of
if allowed, was subject to careful grounding in be- the 1990s. By 1995, one national survey found that treatment include self-esteem, acceptance of re-
havioral principles. By its very nature, behavioral only two of 1,784 sex offender treatment programs sponsibility, coping and social skills, offense path-
conditioning techniques entailed hours of intensive identified themselves as behavioral (Freeman-Lon- ways and sexual interests (Marshall et. al, 2006). The
individual work, which meant that group-based go, Bird, Stevenson & Fiske, 1995). In fact, the em- treatment interventions used in Marshall’s program
treatment was more limited in its application to phasis on cognition threatened to become so total are explicitly multi-modal and include an array of
treating sexual deviance. that Maletzky (1996) used the editorial bullhorn of cognitive, behavioral, and supportive psychother-
In the 1970s, however, the field began to broaden ATSA’s own journal to bemoan how “cognitive-be- apeutic techniques, such as role playing, model-
behavioral interventions to include cognitive pro- havioral” therapy had become “cognitive-cognitive” ing, group discussion, written exercises, shaping,
cesses and treatment programs became more com- therapy. Maletzky (1996, p. 263) posed a practical over-learning, rehearsal and self-monitoring. Simi-
7
8 JENNINGS & DEMING
larly, Deming (2009) proposed an Integrated Mod- tive that can fully utilize the crucial interpersonal inative stimulus that signals the opportunity for
el of Sex Offender Treatment (IMSOT), in which processes that are unique to the group modality. positive reinforcement—or its opposite. Members
treatment intensity and duration are largely based There are many ways that clinicians can, in faithful may be more alert and attuned for learning in a
on actuarial risk for recidivism, while treatment accordance with behaviorism’s insistence on ob- pleasant room. Room privacy and freedom from
targets are individualized and based on assessed servable events, enhance their observational skills distraction is also vital. Interruptions disrupt pro-
dynamic risk factors such as those identified in in group treatment to better identify and target cess. They convey disdain, disrespect and devaluing
the Stable 2007 (Hanson, Harris, Scott & Helmus, individual and interpersonal behavior for positive of the group and its members, whether intentional
2007). The emphasis is on using treatment inter- change. or not. Most group therapists can control whether
ventions that have shown efficacy, either with sex This article will present an array of behavioral- they can be interrupted by intercoms and phone
offenders or other populations, in changing spe- ly-oriented techniques across several dimensions, calls and set conditions that prevent people from
cific maladaptive behavioral, emotional and/or beginning with the establishment of an operant entering and leaving during group.
cognitive problems. Group therapy remains the group environment that supports behavior change, Of course, in the real world of SOS treatment, ther-
preferred and primary treatment modality in the expanding empirical awareness of events occurring apists often have to conduct groups in less-than-op-
IMSOT, but individual, couples and family therapy in group, streamlining interventions with non-ver- timal spaces within prisons, jails, secure forensic
modalities are also encouraged when appropriate. bal signals, and more. In all cases, our emphasis is units, parole offices and outpatient practices. To
In particular, relapse prevention is not used as a on practical utility, illuminating how clinicians can illustrate this point, the authors have conducted
core component of treatment. RP is used as an ad- use a behavioral sensibility to improve group treat- groups in an outdoor pavilion in a Florida prison
junct to the therapy process, only to be applied as ment for sex offenders. Although this article will in soaring 100° heat and in a New Jersey church
appropriate after the individual has made relevant describe behavioral techniques designed specifi- basement so cold that we puffed clouds of steam.
gains in treatment. cally for sex offender group treatment, it does not Undoubtedly, we accomplished little under such
A similar revolt against relapse prevention has oc- address the many behavioral techniques that are brutal conditions except perhaps to “extinguish”
curred in the field of juvenile SOS treatment, where currently used in individual therapy, most of which the desired behavior of attendance. But a group
clinicians and researchers have had to reassess and focus on modifying deviant or unhealthy sexual therapist is ethically responsible for trying to rem-
modify traditional adult SOS cognitive-behavioral arousal (e.g., minimal arousal conditioning, olfac- edy such conditions. Perhaps it may entail a more
relapse prevention to accommodate the differing tory aversive conditioning, covert sensitization). At creative response (arriving one hour early to turn
developmental complexities of youth. Here, too, a the same time, the group-specific techniques pre- the furnace on) or require going to a higher rank-
holistic appreciation for the broader importance sented here would meet the following definition of ing authority (prioritizing the need for air condi-
of family, school, peers, physical fun, neurological “behavioral”: tioning).
development and personal strengths has tempered Behavioral interventions [are] classified as strate- b. Using Equidistance to Avoid “Seats of Power.” To the
the heavily cognitive, heavily group-based, heavily gies that focused on changing behaviors by setting degree possible, all participants in a group, includ-
offense-focused SOS treatment methods for adults. behavioral goals and using positive and negative ing the group leader(s), should be seated in an even-
Examples include the application of the Good reinforcement to encourage or discourage clearly ly spaced circle in the same kind of chairs where
Lives model (Thakker, Ward & Tidmarsh, 2006), identified behaviors” (Cautilli & Weinberg, 2007, everyone can see everyone else. There are dozens of
Multisystemic Treatment (Borduin, Schaeffer & p. 256) ways that seating may facilitate negative power and
Heiblum, 2009) and social-ecological models that undermine open, respectful communication. Par-
emphasize community-based rather than residen- „ Six Ways to Apply a “Behavioral ticipants may claim the most comfortable uphol-
tial treatment of youth (Hunter, Gilbertson, Vedros Sensibility” to Improve SOS Group stered chairs in accordance with perceived peck-
& Morton, 2004). Treatment ing order. The newer and less powerful members
Given these trends toward more holistic treatment, may get the hard plastic, or folding wooden chairs,
the field of SOS treatment may have never been as 1. Pre-organization of the Physical Space while the least powerful may, at worst, squat on the
open as it is now for innovations that go beyond the A behaviorist or behavior therapist attends careful- floor because there is no chair at all. Some group
generic cognitive-behavioral RP paradigm. So why, ly to the details of the operant environment before members may choose to sit in the corner and/or
at a time when the horizon is at its widest, would starting the experiment or treatment process. This outside the circle, or they may remove themselves
it be a good time to propose a revival of behav- enables him/her to control for variation and reduce from the circle by pushing their chairs backward
ioral approaches? Wouldn’t that be moving in the the number of potential impacting stimuli in order to gain a vantage point from which they can ob-
opposite direction? On the contrary, this article is to optimize the opportunities for reinforcement of serve others without being readily seen themselves.
dedicated to a reawakening of the behavioral per- the desired behavior. Likewise every group thera- A cushy chair or chair outside the circle often
spective because of its unique value in grounding pist needs to be rigorously attentive to the physical provides a “seat of power,” conveying that mem-
sex offender-specific group practice in directly ob- environment of the group treatment room prior to ber’s superiority or specialness and/or providing
servable, and perhaps more reliable, terms. conducting the group. There are dozens of physical a convenient way to avoid group participation and
variables that can diminish or enhance the thera- escape the vulnerability of being on equal ground
„ “Behavioral Sensibility” vs. Behavior
peutic environment of the group room and, there- with peers. Moreover, group members may seize
Therapy by, increase opportunities for reinforcing desired upon the same chairs, week after week, recreating
In truth, there have been almost no explicitly be- prosocial behavior. and cementing the same power ordering, and re-
havioral techniques designed specifically for SOS a. Physical Comfort. To begin with, the group room ducing flexibility.
groups as distinguished from individual treat- should be as comfortable as possible. The group To combat the problem of seats of power, the group
ment. Rather than pushing for the renewed use therapist should systematically assess each of the leader must do everything possible to arrange the
of prescriptive behavior therapy techniques like following factors and do everything in his/her available chairs in the most even and equidistant
conditioning, this article endeavors to show clini- power to maintain a comfortable group room. The fashion possible. This can be done before group
cians how to capitalize on a “behavioral sensibili- temperature should be acceptable; not too hot, not begins, or can even be incorporated into a ritual
ty” to enhance their SOS group treatment. In other too cold. When the group room is clean, odor-free, performed by the members themselves. The con-
words, “behavioral” can be redefined as the practi- quiet and neat, it embodies dignity, respect and tinuous message must be that all members are
cal, naturalistic application of a behavioral perspec- concern. The room can literally serve as a discrim- equal—in importance, value, respect and basic
EFFECTIVELY UTILIZING THE “BEHAVIORAL” IN COGNITIVE-BEHAVIORAL GROUP THERAPY OF SEX OFFENDERS 9
rights—and are equally challenged to face their
own issues and strive for betterment, whether vet-
eran or newcomer, rapist or pedophile. The key dis-
Denial and Blaming
criminative stimulus is the equidistant circle.
c. Visual Reminders of Treatment Themes/Goals. In the
same way that a light is the discriminative stimu-
lus that signals the availability of reinforcement in
a Skinner box, the group room can use visual cues
Partial
related to the purpose of treatment. The possibili-
Self-Responsibility
ties can include all sorts of images and words that
capture a vital theme in treatment, such as self-dis-
closure, honesty, responsibility and empathy. The
visual cue could be a poster, picture, painting, pho-
Full
tograph, flip chart, special motto or quote, or even
Self-Responsibility
a mural. These visual cues can have even great-
er impact if they have been chosen or created by
members of the group themselves, such as a phrase
that occurred one day in group and holds special
meaning to the members.
One author uses a behavioral technique that com-
bines the principle of successive approximations
with program treatment goals. The wall post-
er depicts a dart-board like “target” in which the
bulls-eye is the ideal goal, the next ring is closer to
the ideal and the outside ring is far from the ide-
al. The sample given uses Full Self-responsibility,
Partial Self-responsibility, Denial and Blaming (see
Figure 1). Other target charts could use concepts
that center around reinforcing honesty (e.g., Hon-
esty, Evasiveness, Deception), self-awareness (e.g.,
Self-awareness, Blind spots, Lying to oneself), or
self-disclosure (e.g., Full self-disclosure, Selective
disclosure, and Closed off). When group members
engage in discussion relating to these treatment
targets, therapists can use verbal and non-verbal
Figure 1.
reinforcement of the client’s behavior by looking
at, gesturing toward, or making comments specif- of the group and opportunities for reinforcement. tions; or even paying fees on time. Group rules
ically related to the visual cues in the group room. Cancelling groups can be a negative signal that the are probably most effective when they are simple
Performed in the correct manner, the therapist’s group is not a prized opportunity. and few, stated as positive do’s rather than negative
actions can be a powerful reinforcement of the cli- b. Empty Hands. Any eating, drinking and smoking don’ts and, if possible, have been developed by or
ent’s attention to and discussion of these treatment by the therapist or the members should be forbid- amended by the group members themselves. For
targets. Particular reinforcement and comment
den as distractions to group process, as competing example, different groups may have different rules
should be made when the client shows movement
sources of reinforcement and as potential symbols about whether and how much profanity is accept-
in their behavior toward the center of the target for
of status or power. Some group members may able.
any given treatment goal.
avoid engagement and manage their anxiety in the
3. Roving Eye Contact as the Foundation Stone of
2. Establish Basic Structural Rules that Support/ group by handling their coffee cups, sipping wa-
Group Therapy
Reinforce Pro-social Behavior ter, nibbling on candy, chewing gum and fiddling
Roving eye contact (REC) is an absolutely crucial
a. Timeliness. In addition to managing the physi- with objects like pencils and swizzle sticks. If some
cal features of the operant environment, the group members have coffee or water and others don’t, it foundation for effective observation and interven-
therapist can establish expectations and group may convey that members do not have equal status tion in group therapy (Jennings & Sawyer, 2005).
rules that facilitate conditions for learning. The in the group. Moreover, the group leader may need By continually attending to one group member
first is the often forgotten importance of time as to keep his or her hands completely free in order after another, the group therapist can greatly en-
a discriminative stimulus. Group sessions should to direct communications within the group (see #4 hance the range, depth and utility of behavioral
occur on time, every time, as scheduled, and with on page 10). data about the group, which improves assessment
and intervention, while also role-modeling and re-
consistent starting and ending times. It is fine if a c. Ground Rules. Most treatment programs have
inforcing pro-social interaction for the clients.
group starts or runs five minutes late, as long as some basic ground rules for participating in a
it is consistently so. Strict adherence to timeliness group. These can be verbal and/or written, or even a. REC as Reinforcement. Roving eye contact may be
has multiple importance in protecting the privacy posted on the wall or signed like a behavioral con- the simplest and easiest reinforcement that can be
and respectfulness of the group room (see #1a on tract. The content can vary from group to group, delivered by the group therapist. Although fleeting,
page 8), signaling the value of the group and its but should reflect core values that are vital to the a moment of eye contact can be a very potent, pos-
limited time, establishing a normative behavioral group, such as being respectful; honoring the con- itive acknowledgement of each member as a per-
cue of commitment among group members, and fidentiality of others; timely attendance; refraining son. Through REC, every group member gets re-
strengthening the association between the time from yelling, threats, interruptions and disrup- peated, tangible attention regardless of his/her level
10 JENNINGS & DEMING
of verbal engagement in the group. Knowing that For example, one author led a group in which one gestures that can effectively communicate degrees
one cannot escape attention and is being observed tearful member dominated the group’s attention of intervention. such as raising one finger as a cue
by someone else, particularly an authority figure, with his suicidal drama. By using REC, however, it to “wait a second before you speak,” or raising two
helps to encourage participation because group was quickly apparent that the group was not only fingers to say “wait a bit longer to speak,” or using
members tend to be more alert, reminded of the unsympathetic; they were annoyed to the point full erect palm to indicate that this is no time to
expectation of participation and aware of their cur- of hostility because they viewed his behavior as a interrupt.
rent level of participation (or lack of). REC com- repeated display to gain the spotlight. The group
5. Use of Selective Verbal Reinforcement by Therapist
municates that something important is happening therapist was able to redirect the crying member
in group right now and it is worth attending to. and open a discussion with the entire group about Although non-verbal gestures offer a very effec-
REC is also a continuous reminder to each group the need for social acceptance and exploration of tive short-hand for delivering reinforcements and
member that he/she is not alone, that this is a social more appropriate and satisfying ways of finding ac- channeling communications within the group,
group and that he/she is connected to others in the ceptance (e.g. not manipulative). Roving eye con- there may be times where it might be preferable for
group, like it or not. tact provides reassurance to group members that the therapist to verbalize reinforcement of behav-
the group leader is alert and aware of their indi- ior. Whereas a private nod or smile may limit rein-
b. REC as Competing Response to Egotism. It is fasci-
vidual welfare as well as his/her concern with the forcement to one group member, the therapist can
nating to watch how group members become ac-
group as a whole. In addition, REC can be used to use simple words such as “yes,” “very good,” “well
culturated to roving eye contact. Through simple
counteract the use of “fixed stare” tactics by some said,” and “thank you” to make the reinforcement
observational learning, group members may begin
offenders who wish to unnerve or intimidate the public to the entire group. Another useful instance
to use roving eye contact themselves. Acquisition group therapist. of verbal reinforcement is to bring extra attention
of this skill should be a desired goal in group treat- of the group to a particularly important event in
ment because it heightens each offender’s own 4. Use of Non-intrusive, Non-verbal Reinforcement by group. The group therapist might draw attention to
social awareness. Use of REC literally opens the Therapist one client’s use of “I statements” and taking respon-
offender’s eyes to the presence and individuality of A group therapist can make many effective inter- sibility, or to verbally commend group members
the other people in the group and the relatedness ventions without speaking. All too often, group for disclosing offense-related behaviors or beliefs,
within the group. In behavior therapy terms, REC therapists make unnecessary verbal interventions or to praise someone’s efforts to offer constructive
is a “competing response” to self-absorbed cogni- that can disrupt the natural flow of interactions in criticism or provide supportive feedback to another
tion. An offender cannot engage in both behaviors group. For example, it is much easier and less in- client. One example of such praise might be, “Your
at the same time. Thus REC naturally counteracts trusive for a group therapist to touch a finger to his ability to talk openly about your offense history
egocentric behavior and thinking, and can, in con- lip than to interrupt group process to say “Please takes a lot of courage and it will help you become a
junction with other interventions, promote empa- don’t interrupt” or “please let Jack finish what he healthier person.” Verbal praise can also be valuable
thy, listening skills and relatedness. was saying.” A verbal intervention takes more time for modeling social communication skills, such as
c. REC for Expanded and Enriched Observational Data. and may cause the whole group to stop and redirect assertiveness and giving and receiving criticism.
their attention to the verbal communication from
It is crucial that the group therapist is continual-
6. Facilitating (= Reinforcing) Healthy, Meaningful
the therapist. In the same way that a traffic cop can
ly observing every member of the group, which is Social Interaction and Bonds
direct drivers without words, the group therapist
another reason for maintaining an equidistant cir-
can direct communication in the group. A simple In an article on group therapy with sex offenders,
cle of seats (see #1b on page 8). Through REC,
nod or smile or open palm can encourage a given Jennings and Sawyer (2003) asserted that all group
the group therapist can gain more behavioral data
group member to speak, or to continue speaking. A therapy gains its therapeutic potency from the in-
about each member and the interactions among
“thumbs up” or nod can instantly say “well done” to teractions and relationships that emerge during the
them. Much of this information may be non-ver-
reinforce an offender’s behavior. Eye contact and a group process (Yalom, 1995; Rutan & Stone, 1993).
bal body language–posture, attentiveness, facial
nod can let a group member know that what is be- Jennings and Sawyer (2003) urged SOS group ther-
reactions, emotional tone, mood, energy level and
ing said in group right now is especially pertinent apists to capitalize on the power of group therapy
other visible responses to the immediate topic of
to him, or that the group therapist is aware that by explicitly using the group medium. They criti-
discussion—but it may be informative of progress
the member desires to speak and “can’t get a word cized the all-too-common practice of “spokes-of-
toward key treatment objectives and skill develop-
in edgewise” at this moment. By leaning forward the-wheel” group therapy in which attention is
ment in such areas as empathy, moral conscience,
and/or raising eyebrows, a group therapist can in- focused on one group member at a time. In effect,
emotional self-regulation, friendship, intimacy, co-
dicate that something important is happening that this can produce a series of one-to-one therapy
operation and much more. deserves the group’s full attention. Or, by leaning encounters between the therapist and individuals
d. REC for Interpersonal Data. At the same time, REC back or rubbing his/her chin, a group therapist can within the group, which inadvertently stifles group
helps to shift the group therapist’s observational indicate that he/she has some concerns, doubts or interaction and bonding. The members attend to
focus from individual behavior to social relations confusion about what is being said or that it calls their singular relationship with the therapist rather
and interactions within the group, which may fur- for some more careful thought by the group. A than their important relationships with others.
ther expand the range of useful observational data. head scratch or chin-rub can be used as a cue for The point is that healthy, vigorous, egalitarian group
In a traditional group, it would be typical for the group members to think or ponder an issue. process is inherently loaded with positive reinforc-
group therapist and everyone in group to focus in- Hand motions can redirect and channel commu- ers for everyone in group. Any given group can be
tently on a group member who is showing intense nications within the group, including redirect- a safe learning laboratory (i.e., operant environ-
emotions during a critical therapeutic moment. By ing questions for the group therapist back to the ment) where members can engage in observational
using REC, the group therapist will also be looking group, or steering communications between spe- learning, gain awareness, practice communication
at each and every member of the group and observ- cific members of the group. For example, an easy and social skills, and build and experience relation-
ing his/her response to that event. Group members hand motion can cue a group member to address ships—all while enjoying the natural reinforce-
may show concern, skepticism, hostility, caring, his response, not to the therapist, but to the group ments of praise, acceptance, friendship, support,
apathy, confusion, fear, or any number of responses member for whom the feedback is intended, or belongingness and much more. Group members
that can provide important information about each to someone for whom that response would have (and group therapists) like to come to a well-run
individual and relations within the group. special meaning. There are also a variety of hand group. Conversely, “poor” group process could po-
EFFECTIVELY UTILIZING THE “BEHAVIORAL” IN COGNITIVE-BEHAVIORAL GROUP THERAPY OF SEX OFFENDERS 11
tentially become a “punishment” for group mem- be useful for breaking out of unproductive habit- should not expect the same quantity or quality of
bers that can stifle learning, openness, alertness, ual patterns of responding. Benefits may include journaling from all group members. Rather, com-
receptivity and sensitivity to others. stirring up a dull and lethargic group, disrupting pletion of the task and successive approximations
Sexual abuse and offending, at least in part, en- unhealthy use of “seats of power,” increasing par- toward more detailed or relevant journaling is rein-
tails social behavior problems and many sex of- ticipation by typically quiet or avoidant members forced. Thus, the group is reinforced as a group, but
fenders suffer pervasive deficits and distortions in and bringing awareness to defensive postures in the the targets can be individualized to suit individual
the realm of social relations. Many are isolated, group. needs and abilities.
alienated, lonely, defensive and avoidant; many 3. The “Why the Prize?” Technique Often, in secure treatment settings, such as prisons,
others are threatening, antagonistic, manipulative detention centers and civil commitment facilities,
In this technique, one group member is chosen (at
and demanding; many more are distrustful and the range of choices for such rewards can be more
random or by plan) to be the Token-Giver, who
self-absorbed. A safe and well-run therapy group limited. Nonetheless, even rather simple rewards,
gives “tokens” to other members as “prizes” for
can be an ideal operant environment for testing out such as new pens, pencils, or notebooks can be
having done something “good” during the group
new, pro-social behaviors and developing attach- powerful motivators. Further, this technique often
process. If desired, the Token Giver can give one to-
ments—gradually, of course, through successive has its greatest impact, not on individual group
ken for something good, or can give two for some-
approximations and reinforcement by social praise members, but in facilitating cohesion and cooper-
thing exceptional. The group therapist provides
and acceptance. Readers are referred to Jennings ation within and amongst group members as they
no instruction or guidelines to the Token Giver
and Sawyer (2003) for a number of additional work toward a common goal(s).
regarding what is “good.” The group member must
practical tips for “maximizing” group process for
decide, but cannot speak out loud. As the group 5. Functional Analysis for Process Groups
sex offenders.
session proceeds, the members are usually curious
As described by Hoekstra (2008), functional anal-
„ Specific Behavioral Techniques for Sex as to why some members receive tokens. They may
ysis can be applied to process groups using the be-
Offender Group Therapy wonder if the reward was given for showing insight, havior therapy principles of Functional Analytic
being supportive, demonstrating empathy, giving
This section of the article is devoted to six behav- Psychotherapy (Kohlenberg & Tsai, 1991). It entails
constructive criticism, or some other prosocial be-
ioral techniques or exercises that have been de- a thoughtful, detailed analysis of the operant con-
havior. The reward contingency of the token-giving
signed or used specifically for sex offender-specific tingencies occurring in the group in order to target
may also motivate members to be more active in
treatment groups. particularly desired and undesired behaviors for
group and to be more thoughtful about what they
reinforcement or extinction. It can be used to focus
1. Problem Cards Technique to Encourage Disclosure say and do in order to earn a token.
on a single group member or the group as a whole.
In this technique, the group therapist instructs the Subsequently, the group leader might ask vari- The procedure begins with the identification of
group members to write down two current person- ous recipients of tokens, “What do you think that
the Clinically Relevant Behaviors (CRBs) of tar-
al problems on index cards in preparation for the you did well that earned that token?” This inqui-
geted concern. “CRB1s” are problem behaviors
next group session. One problem should be more ry process may stimulate a thoughtful discussion
that interfere with the member’s ability to make
immediate and difficult, while the other problem that heightens everyone’s attention to the “how” of
meaningful connections in the group. For example,
can be less so. Subsequently, at the next group ses- healthy pro-social behavior and relatedness. It can
Henry’s problem behaviors include talking con-
sion, the group therapist does nothing more than also illuminate caring relationships between group
stantly, talking loudly, refusing to be interrupted,
ask if members have brought their problem cards. members. If needed or useful, the group therapist
and boring the group with excessive, unimportant
The group therapist does not ask to see the cards can also query the Token-Giver to explain what
details. “CRB2s” are improvements in desired be-
and starts the group session. If a group member each member did that deserved a reward of recog-
havior. They entail successive approximations of
asks about the problem cards, the therapist offers nition. The “Why Prize” technique can be useful for
the desired adaptive responses. In Henry’s case,
the choice to disclose either problem or disclose empowering a particularly shy or non-participat-
positive behavior changes might include pausing,
neither and talk about something else. The purpose ing member. It can also be useful to counteract a
allowing others to speak, remaining silent and lis-
of this technique is to stimulate more self-disclo- overly domineering or talkative member because
tening, using less detail, lowering his voice volume
sure. Research has shown that groups who were he/she is forbidden to talk and is forced to be atten-
and speaking less rapidly. Finally, CRB3s are ver-
instructed to write two problems had the highest tive to others rather than him/herself.
bal statements that show awareness of the problem
rate of self-disclosure; while groups who wrote one
4. Group Reinforcement Response Contingency behavior. Thus, Henry might say things like, “I’m
problem had the second highest; and groups with-
afraid no one wants to hear me...”, “I don’t know
out problem cards had the lowest rate of self-dis- A group reinforcement response contingency is a
when to shut up…”, “I’m a leaky faucet...”, “I want
closure (Flowers, 1975; Upper & Flowers, 1994). behavioral technique that can be used broadly to
others to like me…”, “When it’s quiet, I’m anx-
It is hypothesized that this technique may prompt reinforce a wide variety of desired behaviors. In
ious…”
members to prepare for upcoming group sessions this technique, all members are reinforced, rath-
by giving active thought to their private issues and er than individual members. A typical example By clarifying the behavioral specifics of the target
the potential consequences of self-disclosure. Also, would involve setting a task for the whole group, behavior and its improvement, the group therapist
by listing one’s problems, the offender may be tak- such as a homework assignment like journaling or can more directly reward the improvements—
ing a step toward acknowledging and operational- tracking the occurrence of an adaptive, healthy or spontaneously within the group and in private con-
izing his/her problem. targeted behavior goal. If all members of the group sultation. The therapist can now be alert to oppor-
complete the task on time and with an appropriate tunities to reinforce CRB2s and CRB3s when they
2. Seat Rotation Technique to Stimulate Activity level of effort and quality, the group therapist gives occur. Thus, in this example, the group therapist
This simple technique is designed to reinvigorate a small tangible reward to everyone. Journaling can might smile and nod at Henry when Henry allows
group process by altering established discrimina- be particularly useful as a response contingency himself to be interrupted (reinforcing a CRB2). Or
tive stimuli and response contingencies. The group given its wide use in most sex offender treatment the therapist might take a moment to publicly com-
leader asks the members to stand up and shift over programs. Given the diversity in treatment needs pliment Henry for making an important insight for
one or two seats. If desired, the therapist can direct- among group members at any given time, it is not the group. “It’s interesting. Some people have an
ly solicit their reactions to the change of position necessary for all members to journal or track the urge to talk when they feel anxious, while others
and perspective. The seat rotation technique can same targeted behavior. Additionally, therapists get very quiet. It’s great that Henry says he can rec-
12 JENNINGS & DEMING
ognize that feeling because now he can control his examples of behavioral approaches that can be used (2006) are explicit in indicating that techniques like
urge to talk when he feels anxious.” to enhance behavioral deficits or eliminate behav- odor aversion, covert association, masturbatory
ior excesses: reconditioning, and verbal satiation are conduct-
6. Objective Behavioral Definitions (Measures) of
Group Process a. Enhancing Self-Esteem. As developed by Marshall, ed in individual sessions. Laws (2001) provides a
Marshall, Serran and Fernandez (2006), this behav- very detailed discussion of olfactory aversion with
Some may find it helpful to apply a behavior-
ioral technique asks each group member to create a sexual offenders, but does not mention the role of
al sensibility to SOS groups by finding objective
reminder card that lists eight to ten positive state- the therapy group in that process. In their review
measures or correlates of desired behaviors that
ments about him/herself and another list of healthy of CBT with sex offenders, Moster, Wnuk & Jeglic
are more readily, though perhaps less reliably, ex-
and appropriate social activities that he/she would (2008) also say nothing about the role of the ther-
pressed verbally and cognitively. Group therapists
personally find pleasurable. Group members are apy group in CBT interventions for deviant sexual
often complain of particular group members who
encouraged to pursue such social activities, paus- arousal.
“talk the talk,” but don’t “walk the walk.” They may
ing to review the positive self-statements prior to, Clearly, many of the therapeutic interventions used
use the right concepts and terms, they may show
and if possible, during the activity. The treatment to change unhealthy sexual arousal patterns are
mastery of thinking errors, they may be polite and
group can provide support and reinforcement as private in nature (e.g., masturbation) and should
attentive—but it is not consistent with other behav-
group members help each other to develop real- not be introduced or practiced in a group format.
ior that may be aloof, exploitative, self-serving or
istic, positive self-statements and find pleasurable However, there are aspects of this process that are
even belligerent (especially in peer relations out-
outlets where they can express their positive traits well suited for a group format, and for which be-
side of group).
and talents. Group sessions can provide opportu- havioral group interventions can be used effective-
As one example, group concepts as abstract as
nities to share and reinforce successful experiences ly. For example, one of the authors uses an “Arousal
“cohesiveness” can be grounded in observable
and to problem-solve and refine behaviors based Management Orientation Group” for sexual abus-
behavior. “Cohesiveness” is one of the classic “cu-
on less successful experiences. ers prior to their involvement in an individual
rative factors” in group treatment defined by Ya-
b. Enhancing Empathy. This technique is heavily modification program. This time limited group
lom (1995) and has been identified for its value
reliant upon the group therapist to identify and provides basic information regarding classical and
in group therapy with sex offenders (Jennings &
reinforce empathy-related emotional experiences operant conditioning principles and the mecha-
Sawyer, 2003; Marshall & Burton, 2009; Beech &
occurring in the group with verbal or non-verbal nisms through which the client may learn to alter
Hamilton-Giachritsis, 2005). In fact, cohesiveness
praise. This could include redirecting an individual their sexual arousal. The group modality enables
is considered the primary therapeutic factor from
to recognize and label his/her own internal emo- offenders to ask questions and see how other men
which all others flow. Humans are social animals
tions; or praising a group member for accurately manage the process, which can diffuse anxiety and
with an instinctive need to belong to groups and
recognizing emotion in others; or reinforcing a reinforce continued efforts to practice the condi-
personal development can only take place in an
group member for showing compassion and active tioning procedures.
interpersonal context. A cohesive group is one in
empathy to other group members. The group ther- Once the individual has begun practicing arous-
which all members feel a sense of belonging, ac-
apist might selectively reinforce group members al conditioning techniques privately, the therapy
ceptance and validation. Researchers have created
for recognizing and articulating the harmful effects group can continue to provide a highly reinforc-
objective behavioral definitions to better identify
of sexual abuse on victims, especially their own ing environment in which the participants hear
and measure the occurrence of group cohesion
victims. The group therapist may attempt to extend about how others are having success in changing
such as, increased eye contact with persons speak-
the empathy activity by giving homework assign- their deviant sexual arousal. Reinforcement for be-
ing, increased member to member interaction, in-
ments for members to engage in “active empathy” havior change can also take place when offenders
creased positive verbalizations by group members,
behavior outside of group. Ideally, over time, it is discuss “what’s working” and the importance of
increased disclosure of problems, increased ratings
expected that group members themselves may be- maintaining regular practice of the techniques. In
of trust in other members, and increased satisfac-
gin to imitate the same reinforcement of positive addition, since therapists are not engaged in behav-
tion with sessions and with group itself (Upper &
empathy with their peers. ioral modification themselves, the group modality
Flowers, 1994; Taube-Schiff, Suvak, Antony, Bieling
c. Managing Deviant Thoughts. Research has consis- can increase the power of peer reinforcement as of-
& McCabe, 2007).
tently shown that “thought suppression” is not an fenders share information about their experiences
At the same time, efforts to operationally define a
effective method for managing deviant or unwant- and successes.
concept can be valuable in forcing researchers to
ed thoughts (Wegner, Schneider, Carter & White,
think more clearly about a phenomenon. To use a „ Conclusion
1987; Abramowitz, Tolin & Street, 2001). At worst,
classic example, the field of sex offender-specific
efforts at willful suppression can increase self-ab- The commonly understood and widely accepted
treatment continues to vigorously debate the de-
sorbed thinking, generate irritability and mood- treatment of choice for sexual offenders is cogni-
gree to which empathy deficits are related to sex
iness, or even backfire into exaggerated rebounds tive-behavioral group therapy. But the quantity
offending (e.g., Hennessy, Walter & Vess, 2002).
of more intensive deviant thinking. As applied in of sex offender group treatment that is explicitly
In trying to design effective measures of empathy,
a group therapy context, the group therapist can “behavioral” has become minimal in relation to
researchers have asked if empathy is a multi-com-
explain and demonstrate how to develop specific, that which is overwhelmingly “cognitive.” More-
ponent, contextually-specific trait or a stable gener-
detailed “focused distracters” as an effective alter- over, the emphasis on cognition is virtually syn-
alized characteristic? Is empathy a complex mix of
native to manage deviant thinking and/or using onymous with an emphasis on verbal communi-
perspective taking, emotional responding and be-
“thought” approach goals in conjunction with cog- cation—talking. By renewing our appreciation for
havioral choices related to perspective-taking and
nitive restructuring (Shingler, 2009). The group the behavioral perspective in group therapy, we are
affect? A behavioral sensibility urges more rigor in
then reinforces success through mutual support, also calling for greater appreciation of the valuable
our use of constructs like empathy in group work.
encouragement and problem-solving. non-verbal interpersonal data that is available in
7. Using Behavioral Techniques with Specific d. Managing Deviant Sexual Arousal. Behavioral and group sex offender treatment.
Treatment Targets cognitive-behavioral techniques for reconditioning One training technique that is used by the authors
Provided here are three specific treatment targets, and managing deviant sexual arousal are typically is to present a scenario in which the therapist has
often cited as important areas of behavior change assumed to be interventions to be used privately lost all ability to speak. The therapist is then asked
to be addressed in sexual offender treatment, and in individual therapy. For example, Marshall, et. al. to conduct a group session without words. Typical-
EFFECTIVELY UTILIZING THE “BEHAVIORAL” IN COGNITIVE-BEHAVIORAL GROUP THERAPY OF SEX OFFENDERS 13
ly, this forces the mute group therapist to make a Borduin, C., Schaeffer, C. and Heiblum, N. (2009). A randomized clin- Marshall, W. and Burton, D. (2009). The importance of group process-
dramatic shift in focus and approach. First, as de- ical trial of multisystemic therapy with juvenile sexual offenders: es in offender treatment. Aggression and Violent Behavior, 15,
scribed in this article, the group therapist must use Effects on youth social ecology and criminal activity. Journal of 141-149.
hand signals and body language to direct commu- Consulting and Clinical Psychology, 77, 26-37. McGrath, R., Cumming, G., Burchard, B., Zeoli, S. and Ellerby, L.
nication between and among group members and Burns, D. (1980). Feeling Good: The New Mood Therapy. New York: (2010). Current practices and trends in sexual abuser manage-
also to express approval, confusion, doubt, concern Wm. Morrow & Co. ment: The Safer Society 2009 North American Survey. Brandon,
and other responses (i.e., reinforcement). But more Cautilli, J. and Weinberg, M. (2007). Editorial: Behavior Analysis in VT: Safer Society Press.
importantly, the mute group therapist is forced to Criminal Justice. The Behavior Analyst Today, 8 (3), 256-258. Moster, A., Wnuk, D. and Jeglic, E. (2008). Cognitive behavioral thera-
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Freeman-Longo, R., Bird, S., Stevenson, W. and Fiske, J. (1995). Na-
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