Outpatient treatment

There are relatively few dedicated outpatient resources for the treatment of sex offenders. Within the general psychiatric services the majority of sex offenders are treated by psychologists, usually working with a cognitive-behavioural model. General psychiatrists may be asked to provide psychiatric cover and may rarely be requested to prescribe antilibidinal medication under the strict informed consent regulations.

Within the specialist centres patients are usually referred for treatment by courts—usually on a probation order with a condition of treatment—or by probation officers, psychiatrists, social workers, or occasionally general practitioners. Before embarking on assessment and treatment it is crucial to identify the following.

• The responsible clinician with regard to the patient's overall psychiatric care who, for example, could admit the patient should this be required in the course of outpatient treatment. In the United Kingdom this psychiatrist will usually also be the nominated keyworker under the care programme approach.

• The professional responsible for assessing risk to potential victims and the circumstances under which this information will be transmitted to other agencies such as social services, probation services, or police. Usually this will not be the professional offering direct treatment. Ideally it is a psychiatrist specifically trained in risk assessment and risk management.

• The person who will provide the treatment, whether psychodynamic, cognitive-behavioural, or pharmacological.

• The allocated case manager within the specialist centre who will liaise with the different professionals and agencies involved but not necessarily offer direct treatment. This might involve writing interim reports on the progress of treatment to be co-ordinated for risk assessment purposes; this also protects the role of the therapist.

Once these professional roles are established, they should be explained as clearly as possible to the patient. Assessment and treatment

The single most important factor predicting a successful outcome of treatment is the patient's motivation and willingness to enter into a therapeutic contract. Motivation is always a complex mixture of the threat of external sanction from the law, the wish not to return to prison, a wish to placate a spouse or partner, an insurance policy should re-offending occur, and a genuine wish to change, both to control the fantasies and, rarely, to relinquish the fantasies in favour of a more socially acceptable sexual structure.

Cognitive-behavioural treatment aims to challenge the cognitive distortions which exist in the mind of the sex offender such as the self-justification that the victim encouraged and enjoyed the abuse and more centrally that the abuse did not harm the offender. It also aims to teach the offender to recognize the psychological circumstances in which an offence is likely to take place. Such treatment follows the principles employed in other cognitive-behaviour therapies (see Ch.a,P.t§I.,§,.3.2.:l1, Chapter6.3.2..2, Chapter,6.3.2.3 and Chapter.6.3.2.4).

For psychodynamic treatment an element of 'psychological mindedness' is necessary in the offender—an ability to recognize their own affective states, a willingness to acknowledge internal conflict, a flexibility in thinking, and a spontaneous ability to link current events with the experiences of childhood. The propensity to externalize responsibility and place the locus of control in external individuals or agencies does not augur well for treatment. Although some of these capacities can be established from the previous history (including the history of previous attempts at treatment) and from the initial interviews, it is likely that much will only be revealed in the course of treatment; indeed treatment itself is regarded by some as an extended diagnostic process. It is generally accepted that dynamic psychotherapy is effective only when the patient voluntarily seeks treatment (this is equally true in outpatient treatment as in secure settings). Regularity and reliability—important factors in any therapy—are of particular significance for the sex offender whose childhood experiences are so often characterized by inconsistency and deception. Danger times are the breaks in therapy: the patient may make a pre-emptive strike and miss the sessions leading up to the break, exerting the control which has been so lacking in his or her life.

Whether the treatment is individual or in groups the purpose is for the patient to discover the conflicts, anxieties, and affects which are defended against by the deviant sexual act, and through the 'second chance' of therapy to establish less pathological forms of defence, or at least control so that the deviant fantasies do not have to be 'acted out'.

The importance of transference and countertransference issues are stressed in psychodynamic approaches and concern the way the sex offender relates to the therapist and the responses that he or she elicits in the therapist. Throughout the treatment the therapist must permanently be alert to the possibility—even likelihood—of further deception within the transference and false compliance.

The length of treatment will vary according to the modality being employed. Cognitive and behavioural treatments are intensive, circumscribed, and of relatively short duration (6 months to 1 year). Dynamic treatments last longer, often 2 to 3 years of weekly sessions. There is an increasing body of professional opinion that the underlying fantasies never disappear and that when the regular formal treatment has finished recidivism is only reduced if the patient maintains a less formal supportive link with the therapeutic agency over many years.

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