As earlier research has demonstrated, medication may modify target symptoms such as anxiety, depression, obsessionality, or hypersexual drive, but cannot "cure" the paraphilia or interpersonal problems (166). Psychotherapy is essential to foster compliance with medication, ameliorate attitudinal problems, and to develop cognitive skills in resisting and managing paraphilic fantasies and urges. Because concurrent treatment modalities may demand the involvement of multiple clincians, issues of communication, transference and countertransfer-ence, legal risks, and ethical challenges should be familiar to clinicians before embarking on the multimodal treatment of paraphilias (167).
The empirical evidence regarding outcomes of psychological treatment of the paraphilias is limited. To date, most studies have been conducted with heterogeneous sex offender populations that include but are not limited to para-philic offenders. The extent to which paraphilic offenders, nonparaphilic offenders, and non-offending paraphilics are the same or different in terms of etiological factors or treatment needs is unknown. Further, while there are no studies convincingly demonstrating the superiority of one psychotherapeutic methodology to another, there is growing evidence that cognitive-behavioral and relapse prevention models are effective in reducing recidivism of sexual offending behaviors (168). These models, with their focus on behavior, related cognitions, and development of self-regulatory skills, demonstrate the greatest promise for the psychological treatment of the paraphilias.
From a cognitive-behavioral perspective, the paraphilias are primary and chronic. Although fundamentally altering a sexual interest is not viewed as possible, managing the interest is. Therefore, treatment does not focus on cure, but on management of associated thoughts, fantasies, and urges, reduction of associated distress, and conscious choices about behavior. In this framework, exploration of underlying life history themes takes place after behavioral goals have been achieved and relapse prevention strategies learned, and is conceptualized as of secondary importance relative to the need for behavioral control.
The current classification system, the multitude of etiological theories and their inferred treatment approaches, and the tendency for outcome studies to focus on specific paraphilias imply that specific paraphilias require specific treatments. To the contrary, a general rule of thumb is that the paraphilias are more alike than different and, regardless of the specific manifestation, reflect common underlying mechanisms, such as disordered capacity to regulate affect and impulses, that become the target of treatment.
Assessment informs the clinician regarding necessary intensity of treatment and which psychotherapeutic modalities—individual, group, or conjoint couple—are called for. It is beyond the scope of this chapter to detail the components of the full psychiatric-psychosexual evaluation. Rather, those assessment components uniquely related to the paraphilias are highlighted.
Defining the impairment: Because psychological treatment focuses on those aspects of the disorder most related to functional impairment, identification of the specific nature of impairment is essential. The following impairment-related variables, summarized in Figure 12.2, are crucial aspects of assessment.
Cognitive impairment. Sexual thoughts may be as or more distressing than urges or cravings. An individual can have low or average biological drive and still experience frequent distressing and intrusive sexual cognitions. He may be distressed by the content of the fantasies and/or by their intrusive effects, including, for example, guilt, despair, or distraction during efforts at partnered sexual activity. Distorted cognitions that promote denial or minimization or blame others for the problematic behavior contribute to impaired judgment and increase the risk of behavior, particularly in the offending paraphilias. As along as distortions are present, internal motivation to control behavior is minimal and the risk of paraphilic behavior remains significant.
Drive impairment. High biological drive may fuel sexual urges or cravings that are preoccupying, distressing, and difficult to control, increasing the risk of behavioral escalation. Drive assessment inquires about an individual's ability to control his urges, his subjective experience of his drive, frequency of masturbation, and amount of time spent feeling sexually preoccupied. The presence of high drive and/or preoccupying urges and cravings demands consideration of a pharmacological intervention early in treatment. In the
authors' clinic, excessively high drive has been identified as a significant component of the disorder in 10% of patients diagnosed with a paraphilia or nonpar-aphilic problematic sexuality. Although most patients describe themselves as sexually obsessed and preoccupied, and most endorse impairment in controlling their urges, only a fraction experiences difficulty in the form of high drive or genital hyperarousability. This highlights the importance of assessing the nature and intensity of sexual cravings from a psychological as well as biological perspective.
Behavioral impairment. In some individuals, the problem is limited to urges and fantasies. In others, the urges and fantasies have escalated to paraphilic behavior. Problematic behaviors may include frequent masturbation, masturbation in inappropriate contexts, excessive use of or preoccupation with paraphilic pornography, placing undue sexual demands on a partner, seeking inappropriate partners with whom to act out a paraphilic interest, unsafe sexual practices, and deceitfulness. As a paraphilia escalates behaviorally, partnered sex may become impaired. Some individuals suffer extreme financial consequences due to purchasing online sexual services, phone sex activities, or hiring sex workers. Most significantly, some paraphilias lead to severe legal consequences and harm to others.
Exclusivity vs. nonexclusivity. Exclusivity is associated with poorer treatment outcomes. The more exclusive the paraphilia, the more likely it precludes sexual intimacy with an appropriate partner. Treatment then focuses on management of urges and fantasies, behavioral control, minimizing the risk of harm to others, acceptance of one's sexual differences and grieving related losses rather than return to a previous level of nonparaphilic functioning. Although the DSM-IV-TR includes a specifier for exclusive/nonexclusive types only for pedophilia, identifying how this variable contributes to impairment is important in any paraphilia.
Egodystonic vs. egosyntonic attitude. Some individuals seek help because they have been discovered engaging in paraphilic behavior by a spouse, partner, or employer. This individual may have an egosyntonic relationship to the paraphilia, in that he experienced no apparent distress other than that associated with being discovered. Although this may reflect an underlying antisocial or narcissistic personality component that will contribute to poor treatment outcome, this conclusion should be resisted until objective evidence is presented. Distorted cognitions that enable an egosyntonic attitude are common in paraphi-lias that have been enacted secretly over time and may resolve with successful treatment. However, the real presence of underlying sociopathy results in a rigidly egosyntonic attitude and carries significant negative implications for treatment outcome. Without rigorous assessment, the degree to which personality factors are contributing to disordered attitude will remain unclear.
Level of risk. Paraphilic expression may be limited to fantasies, with little immediate risk of behavioral escalation. On the other hand, there may be an immediate danger, as in the offending paraphilias, autoerotic asphyxiation, and some cases of sexual sadism or masochism. Danger may be symbolic and benign or real and potentially lethal, as in cases reflecting loss of control or confusion regarding the boundary between consent and coercion. Assessment of self-mutilating behaviors is particularly critical in transvestic fetishism, where gender dysphoric transvestites may report attempts at auto-castration.
In pedophilia, the number and variety of prior offenses, relationship to victim, age, and gender of victim have been shown to be strong predictors of reoffense (169). Therefore, these variables comprise a critical aspect of risk assessment in pedophilia. Hanson and colleagues, in their excellent reviews, have pointed out that structured assessment of these specific risk factors is more effective than unstructured clinical assessment.
Comorbidity. Comorbid multiple paraphilias, depressive, anxiety, and substance abuse disorders are common. Although there is no empirical evidence that paraphilias are commonly associated with particular personality disorders, personality disorders may co-occur. Comorbidity assessment clarifies the nature and extent of functional impairment, identifies potential obstacles to treatment success, and informs pharmacological decisions and decisions about initial treatment focus.
Cognitive-behavioral treatment integrates cognitive and behavioral interventions to assist individuals in gaining control of the paraphilic cognitions, urges, and behaviors. Group psychotherapy is often the modality of choice, particularly in severe or offending paraphilias. Although individual treatment can target para-philia related impairments, the potency of group therapy to do so, through both therapeutic support and therapeutic confrontation, is greater. Recent outcome studies, using rates of recidivism, suggest that treatment outcomes in pedophilia are relatively positive (169-171). This is contrary to common myth that sexual offenders are untreatable and has positive implications for the application of similar treatments to other paraphilias (172).
The development of insight is not central to the cognitive-behavioral model, but insight oriented strategies may be integrated in order to achieve particular goals. Because the paraphilias represent a heterogeneous group, treatment must be individualized and the basic framework adjusted in order to accommodate individual presentations. It is beyond the scope of this chapter to detail cognitive-behavioral treatment protocols. Rather, a skeleton of treatment guidelines is presented. Overall treatment objectives include the following.
Control and management of problematic thoughts, affects, urges, impulses, and behaviors Modification of paraphilic arousal Amelioration or management of comorbid conditions Resolution of other life issues Relapse prevention
Strategies commonly used to promote the development of self-control in thoughts, feelings, urges, and behavior include thought substitution, redirection, distraction, affect and urge tolerance, behavioral rehearsal, behavioral abstinence, and positive conditioning. Treatment addresses the cognitions, feelings, urges, and behaviors that are related to the cycle of paraphilic regression. Any factor that increases the odds of paraphilic behavior occurring is conceptualized as a "trigger" or high risk association. The identification of triggers, an understanding of the relative risk associated with each, and the development of concrete strategies to manage them are central components of early treatment. Making decisions about complete or partial avoidance of triggers is a critical aspect of treatment and, later, relapse prevention.
Cognitive distortions provide justification for inappropriate behavior and allow the individual to minimize or deny the negative effects on self and others. Facilitated by cognitive interventions such as thought substitution, redirection, and distraction, the individual learns to replace problematic cognitions with rational thought and to redirect his thinking in alternative directions. Similarly, after identifying those feeling states and sexual urges that serve as triggers, the individual learns to use redirection, distraction, and affect and urge tolerance. This includes the skill of tolerating feelings without acting on them, and learning to trust that feelings, including sexual feelings, pass if not enacted. Whether particularly high or not, sexual drive must be managed in the treatment of paraphilias. Treatment promotes concrete strategies for mediating sexual feelings and for learning behavioral alternatives to indulgence in paraphi-lic behaviors.
Modifying paraphilic sexual arousal: As noted in the discussion on etiology, treatment regarding paraphilic arousal generally emphasizes behavioral control as opposed to unlearning or relearning. There is considerable disagreement about the effectiveness and ethical basis of such techniques, and little empirical evidence that deconditioning strategies are effective in modifying a core paraphilic pattern. However, many individuals enter treatment in the hope that such a possibility exists. Behavior modification strategies are used to challenge the paraphilic fixedness or rigidity. Behavioral rehearsal uses mental imagery of paraphilic scenes reported by the patient, but with alternative, nonpar-aphilic outcomes. Positive conditioning is the use of nonparaphilic sexual fantasy during masturbation. The more exclusive the paraphilic arousal, the more difficult is modification. However, if used as one among many strategies, and if neither the patient nor the clinician holds unrealistic expectations, it may have benefits in controlling, not eradicating, sexual arousal.
Relapse prevention: The risk of relapse in chronic behavioral disorders is high. The core of relapse prevention is the use of cognitive-behavioral strategies learned in treatment to manage triggers and high risk situations with competence. An individual is ready for this stage of treatment when he has achieved behavioral control, demonstrated capacity to function without cognitive distortions, demonstrated capacity to manage his own affect and impulses, and shown consistent motivation to maintain abstinence from paraphilic behaviors. He has become exquisitely familiar with the repeating sequences of thoughts, urges, and behaviors associated with his own paraphilic regressive cycle. In relapse prevention, he develops a clear personal plan for self-management and for management of high risk situations.
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