Treating Abuse Before It Happens: Getting the Balance Right

By David S. Prescott, LICSW

Past posts to this blog have shown how providing the right treatment to people who have a sexual interest in children can help prevent abuse. There is a small but growing number of people reaching out for help, often saying, in essence, “Help! I have this interest and I never want to act on it. Can you help me to live a better life?” Often, this interest is accompanied by any number of other conditions, such as anxiety, depression, backgrounds of trauma, substance use disorders, and others.

Treating people who ask for help and are not known to have abused need not be a controversial topic, but it is in many quarters where people have not studied the issues involved. Our field understands the treatment needs of people convicted of sex crimes and has shown that the right interventions have the potential to prevent abuse and other harms. Our track record demonstrates better outcomes than simply punishing people. Likewise, psychotherapy has a long history of efficacy with the other conditions above. We have every reason to believe that the right treatment with the right client can help them to prevent acting on their interests. The evidence for optimism is there, even as much more research and treatment innovation are needed.

Where providing therapy to these individuals becomes controversial, of course, is in the actual context of treatment. Proper balancing of individual rights and mandatory reporting laws, for example, can be complicated. Much has been written in this area, including misconceptions around language. For example, Allyn Walker, Robert P. Butters, and Erin Nichols surveyed 200 students preparing for entry into social service professions at a public university. From the abstract of their paper:

Survey results show that more than half of the students believe clients who identify themselves as pedophiles must be automatically reported to the police, which has implications for providers’ understandings about the term “pedophile,” as well as their knowledge of guidelines for when clinicians may break client confidentiality. This belief was not significantly affected by taking ethics courses, nor courses that discussed mandated reporting guidelines. Despite this finding, 91% of students did not believe that they would need to report a client who had attractions to children, but who had never committed a sexual offense against a child. The majority of students indicated a willingness to work with minor-attracted clients, and commonly indicated in comments that they wanted more information about MAPs and when to break client confidentiality in their programs of study. Study results indicate a need for education among social service students about these issues.

To be clear, “person with a sexual interest in children but who has never committed a sexual offense” and “pedophile” can be the same thing. This study illustrates that words matter. The paper’s title further illustrates the problems that clients and clinicians alike can have: “‘I would report it even if they have not committed anything’: Social service students’ attitudes toward minor-attracted people.” One can rightly wonder if the status quo could possibly make it more difficult to get help.

More recently, a study by Agatha Chronos, Sara Jahnke, and Nicholas Blagden explored the treatment needs and experiences of people with pedohebephilic interests. According to their paper, the authors examined “findings from 22 qualitative, 15 quantitative, and 3 mixed-method studies on the treatment needs and experiences of pedohebephiles.”  From the abstract:

Research suggests that this population experiences significant levels of distress, depression, and anxiety related to their sexual interest. Many individuals belonging to this population would seek (median = 42.3%), or have sought (median = 46.5%), treatment to cope with their sexual interest or with potential related mental health repercussions. Their experiences in treatment have been mixed, with some reporting positive experiences with empathic therapists and others reporting rejection. Most frequently, pedohebephiles report fear of exposure and rejection as barriers to seeking treatment, in addition to fear of the legal repercussions. The current study is the first to summarize and discuss previous findings on the treatment needs and experiences of pedohebephiles. The findings indicate that the treatment needs of pedohebephiles often remain unaddressed. Suggestions to increase the fit between treatment services and the needs of pedohebephiles are put forward.

It is not surprising that so many people would not want to enter treatment under these conditions. Nonetheless, one finding in particular offers implications for the way forward: some clients reported having positive experiences with empathic therapists and others reporting rejection. The idea that therapist empathy is critical to successful treatment goes back to Carl Rogers and earlier. Moyers and Miller (2013) reviewed the evidence and concluded that low therapist empathy can be “toxic.”

In the author’s experience, one of the best ways forward can be to use the components of the therapeutic alliance to ensure that one isn’t tacitly rejecting their client while working to remain empathic and compassionate. This is not easy. Many therapists enter treatment assuming that their number one goal at each step is to prevent offending. At the same time, clients can have other needs that go addressed. For example, one client in a discussion group described a situation along the lines of, “I told my therapist about how I went to see the new superhero movie. They asked if that was a good idea given that there would undoubtedly be children present. They went straight to, “What are your triggers there?” That wasn’t the point. I needed to talk about the cravings for alcohol I was having at the time and what I did to keep myself sober. But my therapist kept coming back to prevention, prevention. I’m not a ticking time bomb, at least not all the time. I wish I could get help for my other issues.” It is entirely likely that attention to elements such as alcohol use and cravings can be as effective in the prevention of abuse as well as other undesirable outcomes.

It often seems that in our rush to prevent abuse quickly, we can easily overlook the crucial foundations of our interventions, including the working alliance, as defined by Edward Bordin in 1979. Practitioners and programs might work to create a culture of feedback and get feedback from their clients, asking in essence:

— Are we working on all the goals that are important to you?

— Do we have agreement on how I fit into your life and how we work together?

— Is my approach a good fit for you?

These may seem like obvious questions, but it is amazing how rarely clinicians actually ask them. From there, it can be possible to have discussions about what is and isn’t working. There is certainly a time and a place to suggest that going to a particular movie likely doesn’t serve a client’s long-term interests. However, there is no reason this can’t take place in a context in which the client’s other needs are met. Given the current state of trust between clients and their therapists at present, and the often challenging context of treatment, returning to the basics of the working alliance has never seemed more important.

Preventing abuse by offering help is critical to healthy communities. For all of our knowledge about what works in treatment, the question for practitioners is how best to be the therapist that each client can respond to.