New Ideas, Roles, and Models for Treatment

S. Margretta Dwyer

Faculty Emerita, University of Minesota

5115 Excelsior Blvd. #449

Mpls. MN. 55416


Phone: 001 612 920 5351

Fax:     001 612 920 4485

When I was a child my mother taught me: „Sticks and stones may break your bones, but words can never hurt you.“ I believed that, and held my head high. When I grew up, I learned that words can hurt you. I found this out especially when I treated persons with sexual offending problems. I found that words like: molester, monster, pervert, sexual deviant, and even a normal diagnostic word like Paedophile can really hurt.

I maintain, today, that not only are these words important, but harmful. They can hinder therapy, they can stop progress totally, lower self-esteem, and they can send wrong messages to the patient even in a so called „right“ treatment program. First of all, since the word Sex Offender has come to mean something so awful, I will refrain from using this term today and instead speak of persons with sexual problems. Hopefully, your mind's eye can follow this, along with they other new terminology and new ideas I want to present today.

My years of observing therapy, applying therapy techniques, using deep soul searching, reading research articles and trying to be creative in facing a world negative about sexuality have brought me here today to speak about these things. These are my observations and thoughts, based on others limited research, my anedotal learnings, my own research and my clinical experiences.


Although research shows that subjective distress, producing low self-esteem, does not predict re-offending (Hanson & Bussiere, 1998), yet the patients themselves have said that when they were upset they were likely to take comfort in offending fantasies and behaviours (Pithers, Beals, Armstrong, & Petty, 1989; Pithers, Kashima, Cumming, Beal, & Buell, 1988; McKibben, Proulx, & Lusignan, 1994 Proulx, Mckibben, & Lusignan, 1996; Cotoni, Heil, & Marshall, 1996). Low self esteem means I am upset with myself We treatment specialists lower patient's self esteem when we allow negative wording in our treatment plans, or promote negative activities such as shock treatment. We lower their self esteem when we call their fantasies deviant. What is a deviant fantasy? Deviant by whose standards? What is deviant, is frequently in the mind of others who make the judgment. We used to say if a man fantasied about another man, that was deviant. Fortunately, we now call this a sexual attraction or a sexual orientation. What is there to say that in the future that Pedophilia will not also be called an orientation, instead of deviant and the fantasies as well. Are we maybe just behind the times in our understandings of how some people's sexuality works? Even though they can not act on these child fantasies, I maintain that we have no right to call the fantasies deviant. Using negative words like deviant only serves to lower a man or woman's self esteem. This idea goes on to affect many other parts of treatment, such as the issue of cognitive distortions.

Cognitive Distortions:

What we call Cognitive Distortions may not be that at all. Just what is a cognitive distortion? Many researchers talk about it, using this same general term but using it in vastly different ways. (Geer, Estupinan, & Manguno-Mire, 2000). Not only does this affect research endeavors, but not being clear on the terminology bodes badly for treatment. How can therapists treat if they are not clear on the meaning ofthe words? Maybe we think we are, but let me ask you: Who determines what is a cognitive distortion or as some therapists call it, „a thinking error“. Who decides that you or I have a thinking error. If you do not believe in God and I do, I could say you have a thinking error; or you could say I have a thinking error. And who is right? Many times in the treatment process, these terms are subjective in meaning, according to whom ever is doing the treating. I agree with some researchers who assert that what is called cognitive distortions may indeed be a thinking process that is only a protective coat or armour wom by the man for protection; just that: for protection. But let's look at another more positive name for this thinking process, such as Congruent Theory Thinking Process.


I prefer to take the patient on a different pathway. I prefer to ask this person to seek to be congruent. When you are congruent, I tell them, in thoughts, behaviours, and feelings, then and only then, will you graduate from the treatment program. Congruent means they will be true to themselves on all levels of living even though it may not be what I believe. So I speak of the Congruent Theory oftreatment.

If instead I speak of cognitive distortions and thinking errors, I am making the judgement of what is right for someone else and that may not be right for them. I believe „cognitive distortion“ and „thinking errors“ terminology can get you into a stand-off position with a patient and then no treatment progress can be made. I have seen it happen in many treatment places. Instead, I believe, we need to tease apart their thinking processes, which are different for different persons, rather than label their ideas with negative terminology which only fürther increases their low self esteem. These ideas fit very weil with the theory of Cognitive de-construction, which I will not discuss here. (Baumeister, 1989, 1990, 1991). Only I prefer to call it the Congruent Theory. Let us examine another aspect of treatment called empathy.



Emphasizing the positive can help us develop empathy for our clients. Teaching empathy skills to clients has always been elusive to many therapists. How do you do this? Well, so far today I have said that negative terminology, and negative treatment behaviours do not inerease self-esteem. I purpose to you today, that if a client has low self-esteem, this will stop him from developing Empathy. I maintain that a patient with low self-esteem, can only feel empathy for himself, not for others. I purpose that a patient's state of Empathy toward others is only in proportion to his own level of self-esteem. In other words: no self-esteem for self no Empathy for others. By trying to avoid further negative self-appraisal, they have empathy only for themselves and they fail to have empathy for their victims. The client becomes egocentric rather than altruistic (Moore, 1990). Some think lack of Empathy has to do with Cognitive distortions; I believe it has nothing to do with distortions, but rather with low self-esteem.

So we have tackled negative words, negative treatment issues, SeIf-esteem, Cognitive Distortions, Congruent Thinking Theory' and Empathy. What's next you say? I have long questioned if the Relapse Prevention Model has given us all we really need. Knowing that it came from the alcohol and substance abuse treatment model, I analysed it and wondered if more is needed today. So I speak today of what I call the Hesitation Point Model.

Hesitation Point Model

I do not believe that a return of the sexual fantasy is necessarily an identifiable lapse. To label a „thought“ as a „lapse“ can send a client into a depression. We who have worked with persons with sexual problems, know that always, at some point in time, the fantasy of doing offensive behaviours will return to them. I do not believe we should call this a „lapse“, but rather a „point“ on a continuum. There are many points on the continuum, the most important of which is the „Hesitation Point“. My model looks like this:

Stress/Iow point  Depression/anxiety point  Thought point  Fantasy point  'HESITATION POINT PIan point  Offending point.


Stress/low point  Depression/anxiety point


thought point  fantasy point  HIESITATION POINT    plan point  offending point


                                    External help & a Treat      Continue Internally

At the Hesitation Point they need to turn to someone externally they trust and give themself a „treat“. The „treat“ before, in order to feel good has been re-offending. Now he must lind another treat at this point. Along with this he must find that person he can trust. lt could be a probation officer or a former therapist. If he has no support Systems to turn to, he probably will continue in his internal situation and re-offend. The Patient bears the responsibility for hesitating at the Hesitation Point and what he does with it. However, before the Patient leaves treatment the therapist bears the responsibility to see that the client has had suflicient practice in this behavioural plan.


New wording, new models and incorporating new ideas leads to finding new roles for therapists. We can not do all the same old way without examining new philosophy, new values and new actions. For we are responsible for helping persons with sexual problems. We too bear responsibility for the attitudes the public frequently has, as well as what the media presents. We allow this to happen in subtle ways. We need to speak what we know to be true and not hold back. Our culture fears persons with sexual problems, not because he is deviant, but because he is so ordinary. We fear him because he is us. We need to educate the public and the media. We can not just do and say things that will make us look good. An example of this is: the American Roman Catholic bishops recently set aside a whole day of prayer where they would stay in their churches and pray for all the victims. Sounds good. Sounds nice. But in the long run it projects a condemnation for persons with sexual problems. If you purport to be praying, would not the ideal thing to do, that would send a strong message about healing, be to pray also for the persons with the sexual problems? This is a subtle message of condemnation of a sex offender and an effort to look good in the public eye. These subtle messages make it more difficult for us to do treatment. In closing this presentation about



Congruent Theory Thinking Process and

Hesitation Point Model

I am aware that these ideas fit in weil with the Harm Reduction Theory and the Cognitive Deconstruction concepts so recently talked about. Never before in time have we had so much data and incredible means of sharing it. Sometimes, however, ifwe are not careful wisdom and understanding may be lacking. This conference is about gathering wisdom and definitely about understanding as the conference' s title says.


Baumeister, RF (1989) Masochism und the self Hillsdale, NJ: Lawrence Erlbaum.

Baumeister, RF (1990). Suicide as escape from self Psychological Review, 97,90-113.

Baumeister, RF (1991) Escaping the self New York: Basic Books.

Geer. J.H., Estupinan, L. A.; & Manguno-Mire, G. M. Empathy, social skills, and other relevant cognitive processes in rapists and child molesters, Aggression and Violent Behavior, 5, no. 1, pp. 99-126, 2000

Hanson, RK., & Bussiere, M.T. (1998). Predicting relapse: A meta-analysis ofsexual offender recidivism studies, J. of Consulting und Clinical Psychology, 66, 348-3 62

Levine, J. (2002). Excerpt from book Harmful to Minors. The Perils of Protecting Children from Sex. U of Minnesota Press.

Moore, BS (1990). The origins and development of empathy. Motivation und Emotion 14, 75-80.

McKibben, A., Proulx, J., Lusignan, R. (1994) Relationships between conflict, affect and deviant sexual behaviors in rapists and child molesters. Behavior Research and Therapy, 32, 571-575.

Pithers, WD., Beal, LS, Armstrong, J. & Petty, J. (1989) Identification of risk factors through clinical interviews and analysis ofrecords. In DR. Laws (Ed.), Relapse prevention with sex offenders (pp. 77-87). New York: Guilford Press.

Pithers, WD, Kashima, KM. Cumming, GE. Bea, LS. & Buell, MM. Relapse prevention of sexual aggression. In RA Prentky & VL Quinsey (Edds.), Human Sexual Aggression: Current Perspectives. Annals of the New York Academy of Sciences, 528 (1988).

Pithers, WD. (1997). Relapse prevention with sexual aggressors. Sex Offender Programming 3, No 4. Taken from the Internet.

Proulx, J., McKibben, A., & Lusignan, R. (1996). Relationships between effective components and sexual behaviors in sexual aggressors. Sexual Abuse: A J of Research and Treatment, 8, 279-289.

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