Let’s talk about emotions: An NL-ATSA webinar

By Minne De Boeck, Rosa Oranje, Cathy van Harten, & Kasia Uzieblo

Emotion regulation in the treatment of people who committed sex offenses (PCSO) is a topic that has long been underexplored in practice and especially in research. Initially, the assumption was that sexual offending behavior originated mainly, if not only, from sexual deviant fantasies. In line with this assumption, the main aim of the early behavioral interventions was to recondition sexual offending behavior through for instance aversion therapy. Treatment programs of PCSO’s gradually started to focus more on cognitions and self-control. Hence, we started to abandon the mere stimulus-response principle by paying more attention to other psychosocial factors such as attitudes, beliefs, and interpersonal relationships, and the way these factors may underly the client’s offending behavior. Today, cognitive-behavioral therapy (CBT) is the most widely used therapy for PCSO’s and has to date received the strongest empirical support compared to other approaches (see for an overview of its history, Moster, Wnuk, & Jeglic, 2008). But CBT is not all about cognitions and behaviors. CBT techniques also help individuals to gain control of emotions. Although this component of CBT seems to have been a bit neglected over the years, there seems to be a recent uptick of interventions that focus on emotion regulation in these clients (e.g. emotion-focused therapy, mindfulness). Given the importance of emotion regulation as a risk factor for sexual recidivism, the Dutch-speaking association of ATSA, NL-ATSA, organized an online conference on emotion regulation. The aim of the conference was to share best practices in emotion regulation interventions. Three therapists were given the opportunity to present their interventions to 100 practitioners from the Netherlands and Flanders (Belgium). 

The first session was presented by Sabine Noom (Msc) and Marc Lexmond (Msc), who work in the Van der Hoeven Clinic, a Dutch inpatient treatment center for offenders with psychiatric problems, including PCSO’s. Their unit provides treatment to medium- and high-risk PCSO’s. The treatment duration usually ranges from 6 months to 2 years. The goal of the treatment is to reduce dynamic risk factors and increase protective factors. Their treatment program focuses on (1) behavior through role-play and psychomotor therapy; (2) the connection between patients and therapists on the one hand, and amongst patients on the other hand; (3) learning how to take care of each other and how to communicate with one another; (4) creating a positive life plan; (5) acknowledging the person behind the perpetrator; and (6) learning how to behave in a prosocial way by the process of trial and error. The therapists also develop a workbook 'My Emotions' with the patients. This methodology is based on schema therapy. They most often start with the so-called ‘side model’, by exploring the healthy side of the patient, his/her fighter and destroyer side, and his/her protector side among others. The client learns how to talk to his/her different sides after identifying which side is claiming a big role in specific situations. This way clients learn to understand their offending and present behavior.

In the second presentation, Ellen Gunst (PhD; FIDES) focused on Emotion-focused therapy (EFT), a therapeutic approach based on the premise that emotions are key to identity and which emphasizes the adaptive nature of emotions. The primary focus of EFT is to promote the client's instantaneous experience. This framework postulates that controlling emotions cannot be learned consciously but can be acquired implicitly (e.g. by experiencing emotions and experiences). Hence, the aims of EFT are to create a genuine empathic valuing relationship and deepening the client’s experiencing in therapy. In order to facilitate intimacy and connectedness in their patients, various EFT techniques can be used. During her presentation, Ellen Gunst illustrated the so-called Two-Chair Task. This task aims to resolve the intra-psychic conflict within by evoking emotional responses in the client. This technique was illustrated with a case example. This patient was initially difficult to motivate for and engage in therapy, but after a year the therapists succeeded in forming a minimal form of connection with the patient. The two-chair technique was applied to help him gain insights into his anger, frustration, and sadness. With this case example, Ellen Gunst demonstrated that it is possible to teach these patients how to acknowledge their feelings and to facilitate their empathic abilities. 

In the final presentation, Martine Ruijter (Msc; Antes) explained how she applies visual techniques of visualization with PCSO’s. According to Martine Ruijter, PCSO’s are more open to discussing their behavior, thoughts and feelings by making them visible. The focus lies on the patient’s story, not the interpretation by the therapist. The advantage of this therapy is that in case a proper therapeutic relationship does not ensue, the client can still focus on the material, which in turn might help to (re)build therapeutic contact. There are four levels on the ‘expressive therapy continuum’, namely: (1) Kinetic to sensory, (2) Perception to affect, (3) Cognition to symbolic, and (4) Creativity. The goal is to get the client to the fourth level and to create balance in his emotional experiences. Martine Ruijter also observes some remarkable differences between different PCSO’s in their artwork: the artwork of patients who have committed rape seems to be more chaotic and often cracks are drawn, whereas patients who have abused minors seem to be more creative but difficult to reach throughout the conversation. According to Martine Ruijter visual therapy should be regarded as complementary to CBT.

Important take-home messages were that in therapy we sometimes need to pay more attention to non-verbal expressions of emotions. Clients need to learn how to regulate their emotions through practice (e.g. visual therapy, role play). Therapists should also dare to slow down, explore the emotional experiences in-depth, and pay attention to physical experiences and traumas. The interventions that focus on emotional expression can be considered as a valuable addition to CBT interventions that focus on cognition and behavior. However, all presenters also emphasized the need for empirical insights into the efficacy of emotion regulation interventions in terms of the well-being of PCSO’s and the risk of recidivism.