BEHAVIORAL TREATMENTS FOR MANAGEMENT OF DEVIANT SEXUAL AROUSAL

1. BEHAVIORAL TREATMENTSFOR MANAGEMENT OF DEVIANT SEXUAL AROUSAL Tricia Busby, PhD Daniel Edwards, MA Maria Piccillo, PsyD

2. INTRODUCTIONS • Maria: “Do I Dare Go There?”; “I Went There…Now What?!?” • Dan: “Getting to the Root of the Problem.” • Tricia: “If I Keep Recommending It, Maybe I Should Learn a Thing or Two About It.”

3. LEARNING OBJECTIVES • Participants will become familiar with selection criteria used to identify patients/clients that may benefit from the implementation of Behavioral Treatments. • Participants will be able to determine best treatment modality based on patients/clients individualized needs. • Participants will learn basic skills to implement and monitor three behavioral treatment interventions (i.e. Covert Association, Masturbatory Reconditioning, and Olfactory Association). • Participants will read vignettes and work in small groups to plan behavioral intervention. • Participants will gain information about how the behavioral treatment for deviant sexual arousal program is constructed at Coalinga State Hospital. • Presenters’ Objective: To remain open to feedback and learn new information that can help make our program more effective.

4. OVERVIEW • General Information on Behavioral Treatment Interventions • Olfactory Association • Covert Association • Masturbatory Reconditioning/Satiation Therapy • Case Vignettes (Group Activity) • Management Skills at CSH • Challenges and Limitations • Wrap-Up

5. BEHAVIORAL THERAPY • Learning Theory: a model of psychology that explains human responses through the concept of learning. Learning theory includes behaviorism, cognitive theory, cognitive-behavioral approaches • Thorndike empirically demonstrated the Law of Effect, which simply stated that a response followed by pleasant consequences will be repeated. • Behavior Therapy: a type of psychotherapy that focuses on changing undesirable behaviors. It involves identifying objectionable, maladaptive behaviors and replacing them with healthier types of behavior. • Also referred to a behavioral modification. • Internal vs External

6. Pavlovian Conditioning • Classical Conditioning • Repeated pairings of stimuli with known responses can condition behavior • Contiguity = closeness of the pairings • Contingency = presentation of the US depends on the presentation of the CS • Group Experiment: Hershey Kisses • Counterconditioning • Treatment pairs a maladaptive behavior with an incompatible behavior in order to eliminate the former • Example: Systematic Desensitization • Aversive Counterconditioning • Treatment pairs a target behavior with a stimulus that will evoke an unpleasant response • As a result, the target behavior and stimulus related to it will elicit an undesirable response and will be avoided • Example: Covert Sensitization

7. Operant Conditioning • Furthered the theory of classical conditioning by positing that complex behaviors are voluntarily emitted based on how they “operate” in the environment. • Basically, this theory states learning is based on the consequences of behavior. • Reinforcers can be positive or negative and lead to an increase in a targeted behaviors • Punishments can also be positive or negative and lead to a decrease in a targeted behavior.

8. We Are Almost Through It!

9. EVOLUTION OF BEHAVIORAL THERAPY IN SEX-OFFENSE SPECIFIC TREATMENT • Freund (1957), developed the first “phallometric assessment”; furthered by Bancroft, Jones, and Pullan (1966); later developed into today’s variation by Barlow, Becker, Leitenberg, and Agras (1970) • Earliest treatment of sexual offenders stemmed from the idea that deviant sexual preferences formed the motivation for sexual assaults. As a consequence of this view, early treatment of offenders targeted only their deviant arousal. • Electric Aversion (Evans,1968; Bancroft & Marks,1968; Fookes, 1969) • Behavioral programs of the 1960s, focused primarily on behavioral techniques aimed at reducing deviant sexual arousal (eg. Olfactory Aversion, Covert Sensitization, Masturbatory Satiation, Verbal Satiation) • Although there were notable short-term effects, something was missing. By the 1970s, treatment programs began to focus on also enhancing appropriate sexual arousal and incorporate pieces of a much larger picture (eg. Social Skills, Empathy Development, Relationship Skills, Perceptions and Cognitions, etc)

10. Goals of Behavioral Treatments with Sex Offending Populations • The goal of any behavioral modification intervention is to either reduce or increase a target behavior. • To reduce deviant sexual thoughts, fantasies, and behaviors • To sustain and/or increase arousal to consensual and healthy sexual interactions. • Hanson and Bourgon, 2004 • Study confirmed that deviant sexual interests and antisocial orientation continue to be the most significantly correlated risk factors to sexual recidivism • Marshall et al., 2006 • Sexual Interests is one of seven identified foci of treatment

11. Clinically Relevant Assessments • Phallometric Measures • Penile Plethysmograph (PPG) • Abel Assessment for Sexual Interest (AASI) • Affinity Assessment • Polygraphs • Sexual History Disclosure • Sexual Thoughts and Fantasy • Multiphasic Sexual Inventory – II (MSI-II) • Psychosexual Life History Inventory (PLHI) • MMPI-II • Implicit Association Test • Attachment Measures; Self-Esteem Measures • Clinical Interview and detailed Case History

12. Selection Criteria for Implementing Behavioral Procedures • Sexual History reveals high rates of deviant sexual acts that are persistent over time • Phallometric evaluations reveal either: • a). Equal or greater arousal to deviant than to normative sexual acts; or • b). Arousal to deviant acts > 30% full erection (i.e., approximately 9-10 mm of increase in penile circumference). • Client self-reports persistent deviant sexual fantasies, or rapid unwanted arousal to staff or persons depicted in media • Client’s behavior reveals he is collecting inappropriate images from magazines and newspapers, or that he is persistently watching television shows depicting his preferred class of victims. • Client’s institutional records show he has attempted to sexually assault staff or other inmates. • Hormonal assessment reveals high levels of testosterone.

13. Behavioral Treatments Most Commonly Used • Olfactory Aversion • Covert Sensitization/Association • Masturbatory Reconditioning/Verbal Satiation

14. OLFACTORY AVERSION • http://www.youtube.com/watch?v=O17g1vr2uTU • Olfactory: refers to the ability to perceive and distinguish odors. • Aversion: the tendency to avoid or cause avoidance of a noxious or punishing stimulus. • Olfactory Aversion: the temporal pairing of deviant sexual thoughts with an unpleasant odor will break the link between these deviant sexual thoughts and pleasure.

16. Olfactory Aversion • When an individual inhales ammonia, or a nauseous odor, it effectively removes all current thoughts and feelings, and gives an individual an opportunity to replace the inappropriate urges with non-offense related thoughts and actions (Laws, 2001; Marshall, 2006).

17. Widely Reported for Over 30 Years • First used to suppress the desire for food in obese persons (Kennedy & Foreyt, 1968) • Earliest application for sexual behavior in 1972 • Colson had a homosexual client smell various noxious odors while imagining sexual scenes • Later used to augment covert sensitization (Maletzky, 1973) • By pairing Valeric acid and placental culture with negative scenes • First with homosexuals (Maletzky & George, 1973) • With exhibitionists (Maletzky, 1973, 1980, 1991) • First used with pedophiles in 1977; using the “assisted” covert sensitization procedure (Levin, Barry, Gambaro, Wolfinsohn, & Smith, 1977) • Most of these studies used penile erection measures to index progress

18. The Basic Procedure Hasn’t Changed • Olfactory Aversion procedures used today closely resemble the procedure described by Colson (1972). • Repeatedly pair the presentation of an inherently noxious odor with the presentation of deviant sexual stimuli (slides, audiotapes, free fantasy)

19. Theories on Olfactory Aversion • Neurological Effect • The inhalation of ammonia fumes ignites a pain-mediated response, as opposed to an olfactory one, thereby, triggering a response in the pain system via the trigeminal nerve to the thalamus. The association of the felt relief, from the termination of the aversive response to the inhalation, while viewing or listening to depictions of deviant scenes, is believed to strengthen the likelihood that such thoughts will occur in the future in contexts that previously elicited deviant sexual fantasies or thoughts. Thus, the procedure is construed as a combination of punishment and aversive relief. • Conditioning Effect • A noxious stimulus paired with the performance of an undesired behavior has an effect on that behavior just because it hurts or otherwise causes extreme discomfort. Thus, future instances of that response decrease (Laws,2001) • Cognitive Mediation • Aversive reactions are, in large part, self-induced rather than automatically invoked. If the aversive self-stimulation established through counter condition is potent, a person may be able to counteract the disposition to engage in deviant behavior by symbolically reinstating…(aversive)…reactions whenever the need arise (Bandura, 1969)

20. Ammonia versus Vomit Who would win this epic battle? • Maletzky (1980, 1991,1997) argued that nauseating smells (i.e., vomit, feces, rotting flesh) are more effective than chemically noxious ones. • While chemical smells (i.e., ammonia, smelling salts) produce a burning sensation that travels via the cranial nerve to the thalamus (relaying sensation, special sense and motor signals to the cerebral cortex, along with the regulation of consciousness, sleep and alertness)

21. ….and the winner is…… • Putrid odors travel via the olfactory cranial nerve, olfactory bulbs, and the limbic system of the brain (a set of brain structures including the hippocampus, amygdala, anterior thalamic nuclei, and limbic cortex, which support a variety of functions including emotion, behavior, long term memory, and olfaction) • Maletzky argues this neural connection could possibly directly unlink sexual arousal from previously bonded to deviant or non-deviant stimuli - basically the smell of rotting flesh is a sexual turn-off.

22. …however • According to Laws (2001), Maletsky’s claim that nauseating smells are more effective than chemically noxious ones is not empirically substantiated. • Studies show that in dealing with sexually deviant problems, a nausea-eliciting agent and one that simply results in a burning sensation in the throat and nose produce virtually identical results.

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26. Implementing Treatment • STEP 1: Participant is asked to go to a private place and begin describing a deviant sexual fantasy. At initial point of arousal, an ammonia capsule is broken and the participant inhales the fumes (It should be noted that arousal preferable but not required). • STEP 2: As soon as possible, describe three (3) unpleasant ammonia effects and the reason why you are experiencing each (e.g., “my nose is running because I’m fantasizing about fondling my 10-year-old daughter's breasts." "my eyes are burning because . . ." "I am coughing because . . .") • STEP 3: Participant will start over again talking about your deviant sexual fantasy. As soon the participant progresses to the next element of the deviant sexual fantasy (or upon noticing sexual arousal), another whiff of the ammonia is taken. • STEP 4: Participant continues talking out the deviant fantasy, smelling the ammonia during each element of your sexual fantasy and/or sexual arousal for approximately 10 minutes. Participant may never get past that first deviant aspect of the fantasy and that's okay – the idea is to pair the noxious odor with the deviant elements. Participant does at least 8 pairings in one weekly session for approximately 10 weeks.

27. Olfactory Aversion Selection Criteria • This technique should be utilized in rare cases, when client has not responded effectively to other treatment courses. • This technique should be considered for clients/patients who have sexual preoccupation, a high arousal to offense-related themes, and when fast treatment is necessary. • This technique should be considered when clients/patients report a high frequency of deviant thoughts that are viewed by the client as intrusive and interfering with daily functioning. • This treatment is generally to be used for those clients/patients whose deviant thoughts/urges are triggered by a variety of stimuli throughout each day. • This technique is one of the most anecdotally successful interventions for exhibitionists. • Should not be used with: • Clients/patients who have sensitive nasal passages or respiratory medical conditions • Clients/patients who have urine fixations • Fragile therapeutic alliance

28. Covert Sensitization • Covert: The word “covert” refers to something that is not directly observable. In this case, it is something that is going on in your thoughts and in your mind, hence others can not see it. • Sensitization: the process of becoming more aware • Covert Sensitization: a procedure in which a person conditions themselves to become more aware of the negative effects and consequences of a stimulus • In this case, connecting negative consequences of sexual abuse to the otherwise pleasurable aspects of a deviant sexual fantasy

29. What is Covert Sensitization? • Covert sensitization is one of a group of behavior therapy procedures classified as covert conditioning, in which an aversive stimulus in the form of a nausea- or anxiety-producing image is paired with an undesirable behavior in order to change that behavior. • Assisted Covert Sensitization is a procedure where foul odors are added to the aversive images. • Based on research begun in the 1960s, psychologists Joseph Cautela and Albert Kearney published the 1986 classic The Covert Conditioning Handbook.

30. Example of Covert Sensitization Procedure* • Covert sensitization is described to the individual as an aversive conditioning technique in which he, in imagination, pairs the pleasurable object within a noxious setting with the image of himself vomiting on himself, the person of his sexual desires, and every aspect of the stimulus situation. • By imagining this disgusting scene over and over again, the person starts associating the person of his sexual desires with vomit, and the sexual object becomes much less appealing. • Finally, a therapist would instruct the person to imagine the person of his sexual desires, becoming nauseous again, and then deciding to refuse to think about the person. In the imagined scene, the nausea (which is an unpleasant stimulus for almost everyone) goes away as a consequence of the person's choice not to think of the person he sexually desires. *Based on Cautela, J. & Wisocki, P. (1971b)

31. Efficacy of Covert Sensitization • (Levin et al, 1977) In this case study a 39 year-old male manifesting pedophilic behaviors for approximately 20 years was treated with variations of Covert Sensitization. One phase of treatment used the pairing of sexual imagery to two young females with psychologically aversive imagery. At baseline, the patient measured a 72% erection to the girls. By the end of treatment administration (8 sessions; two per week; four scenes per session), penile response on PPG was down to 5%.

32. Evolution of Covert Sensitization to Covert Association • Most behavioral interventions aimed at modifying sexual fantasies met the criteria for designation as cognitive behavioral. However, in the 1970s, the focus of treatment moved away from strictly behavioral approaches to cognitive behavioral approaches. • Marshall et al. 2006 changed the name of the procedure to Covert Association for two reasons: • To distinguish it from Cautela’s (1967) procedure. • It became evident that imagining covert aversive consequence did not have as lasting effects as real-life events (such as sniffing ammonia or verbally satiating). Marshall theorized (and later tested) that crux of the covert procedure was simply the association between imagining the sequence of deviant thoughts/behaviors and thoughts about the imagined possible consequences, rather than experiencing aversive effects of the pairings.

33. What is Covert Association? • As stated previously, the word “covert” refers to something that is not directly observable. In this case, it is something that is going on in your thoughts and in your mind, hence others can not see it. The word “association” is a mental connection of ideas or feelings. • Efficacy: Marshall (2007) • Covert Association was applied to a child molester who abusedboys. Results indicate that treatment produced a significantreduction in urges and fantasies relating to boys and reducedsexual responding to boys.

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36. Underlying Theories of Covert Association • Contiguity Theory (Guthrie, 1935) • Association by contiguity is the principle that ideas, memories, and experiences are linked when one is frequently experienced with the other. The more two items (stimuli) are perceived together the stronger the link between them. • In conditioning, contiguity refers to how associated a reinforcer is with behavior. The higher the contiguity between events the greater the strength of the behavioral relationship. • Contingency Theory (Colwill & Rescorla, 1986) • Although for many years instrumental learning wascharacterized solely in stimulus-response (S-R) terms, recentevidence from outcome devaluation studies has made it clear that,in instrumental conditioning, rats are able to encode the specificconsequences of their actions and that the encoded action-outcome(A-O) relationship plays a critical role in the initial acquisitionand performance of an instrumental action (for a review, see Colwilland Rescorla, 1986).

37. Associationism • Contiguity and Contingency Theory, when combined together, create a modern version of Associationism (see Hall, 1991) • Learning develops from repeatedly pairing two stimuli, or a stimulus and a response, the first stimulus will come to automatically elicit the second stimulus or response (Pavlovian conditioning). • Thus, the consequences do not have to be aversive. • The goal of Marshall et al.’s (2006) revised version is that with repeated pairings, the early steps of the deviant sequence will elicit automatic thoughts of the consequences thus aborting the thoughts/behaviors early in the sequence. • Most individuals who have committed sexual offenses try to suppress thoughts about the negative consequences of their acts because they are upsetting. They are unpleasant to think about. However, if used in a careful and planned way, these unpleasant thoughts when paired with the deviant thoughts can be powerful in “turning off” deviant sexual thoughts.

38. NEGATIVE Consequence DEVIANT THOUGHT

39. Treatment Implementation • STEP 1: Participant develops event chains that correspond to typical deviant sexual fantasies or offense patterns • This sequence of events is written on the front of a pocket-sized index card and the events are to stop prior to a sexual act • STEP 2: Participant develops a list of consequences perceived as highly unpleasant and likely to happen upon reoffense • At least 2 are written on the back of each index card • STEP 3: Cards are taken out and read several times a day for several weeks. Event chain is read first and then card is flipped over to consequences. As individual progresses through process, he or she will gradually introduce the consequences earlier in the sequence (more detail provided below) ☺There are variations of the Covert Sensitization technique. This particular variation was developed by Marshall, 2006.

40. STEP 1: Deviant Scenes The first step is to develop at least six sequences that incorporate both aspects of an individual’s offense patterns and aspects of his deviant fantasies. Remember, for purposes of this treatment, we define “deviant sex” as when someone does not or cannot give their consent or permission. These may be deviant fantasies an individual had in the past or ones that he is currently having. Remember, sexual offending does not just happen. It is the endpoint of a series or chain of events. In writing these chains, an individual will want to capture the major steps in his offense patterns that led up to offending. A good technique is to model these scenarios from completed Behavior Chains, if that is an aspect of the treatment program. An individual can work with his treatment provider to best align the two.

41. Deviant Scenes Continued The deviant chain should NOT include the actual rape or molest because an individual wants to target the earlier behaviors in his offense chain. An individual should not let his thoughts progress to an actual crime. For example, contact (or “hands-on”) sexual offenses would stop right before the hands-on activity takes place. For non-contact offenses, such as exhibitionism, the scenario would terminate just before exposure. Each chain will be broken down into six separate steps and the individual will then write these out on the front side of a pocket-sized card. The events should be written as if they are occurring in the present time. This will help to stimulate an individual’s imagination and aid him in feeling as if he is presently in the situation.

42. Example of Covert Association Deviant Scenario Scenario One – Offense Against John I am sitting at home feeling irritated because my girlfriend is yelling at me again for not having a job so I decide that I will go to the county fair and go to the beer tent to feel better. After parking my car and as I am walking to the beer tent, I notice that it is “wrist band” night and a lot of kids are around. I am standing at the beer tent next to the Scrambler ride and I hear the carnival worker tell a young boy that he can not get on the ride without an adult. I approach the child and offer to go on the ride with him. We get on the ride and I sit very close to him. I am very excited. Half-way through the ride I reach across to touch his leg. *Each step should be a decision point where an individual has made a choice to move ahead toward offense.

43. STEP 2: Unpleasant Consequence Scenarios The second step of the process is to list out unpleasant consequences. They may include scorn and ridicule from others, being arrested and going to jail, being physically assaulted in jail, family and friends shunning them. As in the deviant chains, each consequence should be written in the present tense, as if it is happening in the here and now. This will help the individual actually picture the scene in his imagination. An individual should write at least two unique unpleasant consequences on the back of each deviant chain card. These consequences will be repeatedly paired with his deviant chains.

44. STEP 3: Treatment Sessions Once an individual has written all six of their deviant chain cards and have at least two negative consequences on the back of each, the sequences should be reviewed by treatment providers and receive final approval to begin the Covert Association procedure. The individual will begin with just three of his six cards. Each day he will read and imagine both the deviant chains and the consequences. He will read these at least three times per day. It is best if the individual can determine what three times throughout their day he is most vulnerable to engage in or be triggered by deviant thoughts or fantasies and read the cards around these times. The individual should find a quiet place where he can reliably spend about 8-10 minutes reviewing the cards each day. The individual will read these three cards, three times a day, for three weeks.

45. Treatment Sessions Continued Initially, the individual will read the deviant chain sequence to the end (steps 1-6) and then flip to the reverse of the card and read the corresponding consequences. By the middle of the first week (on the third day), the individual will move the reading of the consequences up one step in his deviant chain. For example, the individual will be reading his deviant chain up to step five and then flipping over to his consequences. During the second week, the individual will shift to flipping his consequence after reading step 3 or 4 in his deviant chain. By the end of the third week, the individual will routinely be reading the consequences after step one. At the beginning of the fourth week, the second set of three cards replaces the three sequences have been reading. Individuals will then repeat the entire process with the second set: three cards, three times a day, for three weeks. Therapists should check with an individual on a weekly basis to ensure he is continuing the practice.

46. Treatment Timetable

47. Covert Association Selection Criteria • This technique should be considered when the overall goal is to reduce the arousal to deviant sexual thought/fantasy • Can be used on its own or paired with a masturbatory enhancement intervention (i.e. masturbatory reconditioning or directed masturbation)

48. MASTURBATORY RECONDITIONING/ VERBAL SATIATION • CLIP: 99 Bottles of Beer • http://www.youtube.com/watch?v=3KnpZYkTWno

50. MASTURBATORY RECONDITIONING/ SATIATION • Reconditioning: relearning of something that was previously learned. • Example: if you moved to England, you would need to relearn which side of the road to drive on. For awhile all of your automatic responses would need to be kept in check until you are reconditioned to driving on the left side of the road. • Satiation: means you have had enough. It refers to over-indulgence or going past the point of pleasure because of excess. • Example: Eating five-gallons of chocolate ice cream in one sitting. Initially it would be enjoyable, but after the first pint or two, you would become satiated • Johnston, Hudson, and Marshall (1992) first made Masturbatory Reconditioning and Verbal Satiation a two-component process. Note: Laws stated that the results of each by themselves were ambiguous.