Exploring Client and Therapist Experiences of Sexual Offender Intervention

Abstract

This research explored the therapeutic events both clients and therapists from community-based treatment interventions for perpetrators of sexual abuse identify as significant in their experience of psychological therapy. A qualitative design was utilized to address this research objective. The sample for the present research is comprised of three different treatment programs for sexual offending. Twenty-five clients and nine therapists participated in the study. Two qualitative measures were used to elicit client and therapist responses. Significant Aspects of Therapy Form was administered every second treatment session during each intervention program. The Significant Aspects Follow-Up Interview was conducted with a sub-sample of participants at the conclusion of each treatment module. Thematic analysis was used to identify significant themes noted by clients and therapists from forms and interviews. Thematic analysis resulted in a model of significant events in therapy. In this model, significant events were categorized into six domains. The six domains were as follows: (a) the process of therapy, (b) making changes and progress in therapy, (c) content and structure of therapy, (d) therapist contributions, (e) negative contributions to therapy, and (f) other factors. Each domain further contained between 6 and 18 themes, which are also reported. This study found much overlap and similarity in the experiences of therapy between clients of sexual offender therapy and general psychotherapy. Furthermore, there is overlap between therapists and clients in the aspects of therapy they identify as significant. The implications of these findings on effective service development and comprehensive service evaluations are discussed.

Keywords

treatment progress treatment outcome sexual offender treatment evaluation

Introduction

During the past 20 years, there has been extensive effort to develop a theoretical basis for sexual offending as well as research into the effectiveness of intervention with those who commit sexual offenses (Finkelhor, 1984; Hanson & Morton-Bourgon, 2009; Marshall & Barbaree, 1990; Ward & Beech, 2006; Ward, Day, Howells, & Birgden, 2004; Ward & Gannon, 2006; Ward & Siegert, 2002). This theoretical literature suggests that (a) sexual offending has multiple causes and origins, and (b) intervention programs should target these multiple origins through risk reduction and skills promotion (Ward & Gannon, 2006).

A key question in the research of sexual offender intervention is whether it is effective in reducing recidivism. Consequently, the methods used in intervention evaluation have received much attention and best practice research guidelines proposed (Collaborative Outcome Data Committee (CODC), 2007a, 2007b; Harkins & Beech, 2007). These guidelines suggest that researchers and clinicians need to explore multiple ways of evaluating intervention, while accepting that there are strengths and weaknesses to all methods. A related focus of sexual offender intervention research is the exploration of therapeutic processes and their impact on outcome (Beech & Fordham, 1997; Marshall et al., 2003).

The importance of therapeutic processes such as group cohesion, therapeutic relationship and the benefits of a warm, empathic therapist have been widely established in the general psychotherapeutic literature (Norcross, 2002, 2011; Rogers, 1961; Yalom & Leszcz, 2005). These concepts are also proposed as essential elements within effective sexual offender intervention programs (Beech & Fordham, 1997; Marshall et al., 2003). In recent years, in the broader psychotherapy literature there is increasing focus on client centered research methods (Hannan et al., 2005; Lambert & Shimokawa, 2011; Miller, Duncan, Sorrell, & Brown, 2005). In particular, this research has focused on patient reported outcome systems. This is a promising area for helping therapists understand the process of therapy, and to explore outcomes central to the client’s needs, thereby improving effectiveness. Indeed, Levenson, Macgowan, Morin, and Cotter (2009) highlighted how the client’s experiences of therapy can make a useful contribution to sexual offender intervention evaluation and planning. A series of studies by Martin Drapeau (Drapeau, 2005; Drapeau, Körner, Granger, Brunet, & Casper, 2005) explored client views of sexual offender interventions and found therapist characteristics and the clients’ sense of support in their group as important to their treatment This study is a further attempt to apply therapist and client centered research to sexual offender intervention. It is hoped that this study will highlight the events, experiences, and contributions to sexual offender interventions significant to and valued by clients and therapists. Furthermore, it is hoped that identifying significant events from sexual offender interventions will inform further service development and refinements in interventions. The methodology employed asks therapists and clients to identify “significant events” throughout their therapy sessions during intervention and then uses semi-structured interviews to explore these significant therapeutic events in more detail with participants. The aim is to better understand the “what” of what therapists and clients identify as effective during intervention, so we can better evaluate its outcome in reducing recidivism and building better lives.

Method

Research Design

The present study utilized a qualitative research design to explore the significant events of sexual offender therapy. Data collection occurred in two stages. Participating therapists and clients regularly completed a questionnaire identifying their significant events during therapy. A sub-sample was then asked to elaborate on their experience in semi-structured interviews. Thematic analysis (Braun & Clarke, 2006) was chosen as the most suitable approach to explore the therapeutic events that clients and therapists identified as significant in their experience of psychological therapy.

Intervention Services

Participants were recruited from three community-based sexual offender intervention programs: two from the Republic of Ireland (RoI 1 and RoI 2) and one from Northern Ireland (NI). These services offered group-based sexual offender treatment to perpetrators of sexual abuse. Some individuals were convicted of a sexual offense, while others were unconvicted (but admitted the offense). All clients of these services were males above the age of 18. Treatment in each center was delivered in a modular format. However, each treatment program differed in the content and duration of each module. Table 1 provides a list of modules provided in each service.

Table 1.

List of Intervention Modules Provided by Each Service.

RoI Service 1	RoI Service 2	NI Service
Motivation and change	Life history/life map	Induction
Choices	Offending behavior	Cycles and cognitive distortions
Cognitive distortions	Relapse prevention	Relationships and attachment style
Pre-offense cycle		Self-management and interpersonal skills
Offense cycle		The role of fantasy in offending
Re-offense cycle		Victim empathy
Role of fantasy in offendingVictim empathy Self-management Values clarification Relationship skillsAttachmentSexuality		Relapse prevention and lifestyle change

Note. Modules in bold were sampled during data collection. RoI = Republic of Ireland; NI = Northern Ireland.

RoI 1

This service provided a group-based treatment program for perpetrators of sexual abuse. The overall ethos and philosophy of the RoI service is one of Cognitive-Behavioral Therapy (CBT), adopting the principles of the Good Lives Approach (Ward & Gannon, 2006) and drawing heavily on the “attachment informed approach” to treatment described by Rich (2006).

RoI 2

This treatment service provided group treatment for perpetrators of sexual abuse. In addition, they provided services for victims of abuse. Only the perpetrator treatment program was sampled. The ethos and philosophy of the treatment service is a combination of CBT psychotherapy and psychoeducational approaches. The program placed an emphasis on motivating the individual to construct a better way of living that does not cause harm to children.

NI

The NI service provides treatment services in a number of distinct areas: psychosexual dysfunction, adult survivors of sexual abuse, and interventions with perpetrators of sexual abuse. The intervention with perpetrators of sexual abuse was the service sampled in this study. The ethos and ethics of this intervention with perpetrators of sexual abuse was to prevent further abuse, break cycles of abuse within families, and prevent future mental health difficulties. The program provided a comprehensive and multi-factorial approach to the origins and difficulties in sexual functioning and sexually abusive experiences through a CBT bio-psychosocial approach. This treatment service provided individual treatment and group treatment for perpetrators of sexual abuse.

Participants

Nine therapists and 25 clients participated in this study. All clients and therapists within each service were eligible to participate in the study. Participation was voluntary. Clients and therapists were briefed prior to commencement of the study and asked to give their informed consent. Ethical approval was received from University College Dublin, the Health Service Executive of Ireland, and the Office of Research Ethics Committee of NI. Figure 1 provides a flowchart of the sample with associated data collection points. Tables 2 and 3 provide demographic details about therapists and clients.

Figure 1.

Study flowchart (RoI = Republic of Ireland; NI = Northern Ireland).

Table 2.

Client Demographic Information.

Client characteristic	RoI 1 (n = 14)	RoI 2 (n = 4)	NI (n = 7)	Total (n = 25)
Age
M	46.21	63.0	42.28	46.44
SD	6.96	12.72	9.77	10.13
Marital status
Single	4	—	—	4
Married	8	1	—	9
Married but separated	2	1	—	3
Married but divorced	—	1	—	1
Widowed	—	1	—	1
Missing	—	—	7	7
Employment status
Employed (full-time)	5	1	—	6
Employed (part-time)	—	—	—	—
Self-employed	3	—	—	3
Unemployed	4	2	—	6
Retired	—	1	—	1
Other (suspended)	2	—	—	2
Missing	—	—	7	7
Living status
In family home	6	—	—	6
Out of family home	5	—	—	5
Not applicable	3	—	—	3
Missing	—	4	7	11
Offense/abuse
Sexual assault (girls)	11	2	—	12
Sexual assault (boys)	1	1	—	2
Sexual assault (mixed gender)	—	—	—	—
Internet	2	1	2	5
Multiple (contact and Internet)	—	—	—	1
Missing	—	—	5	5
Familial or non-familial
Familial	10	3	—	13
Non-familial	2	—	—	2
Both	—	—	—	1
Internet	2	1	2	5
Missing	—	—	5	5
Number of victims
Internet	2	1	2	5
1	10	2	—	12
2	1	1	—	2
10	1	—	—	1
Missing	—	—	5	5
Conviction
No prior	10	4	1	15
Prior sexual	3	—	—	4
Prior violent-nonsexual	1	—	—	1
Missing	—	—	6	6

Note. RoI = Republic of Ireland; NI = Northern Ireland.

Table 3.

Therapist Demographic Information.

Therapist characteristic	RoI 1 (n = 5)	RoI 2 (n = 2)	NI (n = 2)	Total (n = 9)
Age
M	48.80	49.0	43.5	47.11
SD	3.70	4.24	13.44	6.61
Gender
Male	2	1	1	4
Female	3	1	1	5
Profession
Psychology	2	—	—	2
Social work	3	2	1	6
Nursing	—	—	1	1
Years experience in current job
M	6.60	4.5	9.0	6.67
SD	3.91	2.12	4.24	3.6
Total years experience
M	15.60	10.5	9.0	13.0
SD	7.70	2.12	4.24	6.5

Note. RoI = Republic of Ireland; NI = Northern Ireland.

Measures

The Significant Aspects of Therapy Form

Twenty-five clients and nine therapists regularly completed a qualitative questionnaire adapted from the Helpful Aspects of Therapy Form (HAT; Elliott, n.d.; Elliott, 2010; Llewelyn, 1988). The HAT is a brief, open-ended questionnaire completed at the end of a therapy session and elicits the experience of helpful aspects of a specific therapy session in the participant’s own words. This measure was adapted for the present study by reframing the elicited events as significant aspects of therapy (SAT) and allowing participants to also identify negative events. The wording was also simplified. The changes are summarized below in Table 4. The HAT is a good measure of experiences. Llewelyn (1988) successfully utilized the HAT to elicit client and therapist experiences of helpful therapeutic events.

Table 4.

Helpful Aspects of Therapy (HAT) Form.

	Original Form	Adapted Form
	Helpful Aspects of Therapy	Significant Aspects of Therapy
Question 1	Of the events which occurred in this session, which one do you feel was the most helpful or important for you personally?(By “event” we mean something that happened in the session. It might be something you said or did, or something your therapist said or did.)	Of the events which occurred in this session, which one do you feel was the most important for you personally?(By “event” we mean something that happened in the session. It might be a helpful event or it may be unhelpful. For example, it might be something someone said or did.)
Question 2	Please describe what made this event helpful/important and what you got out of it.	Please describe what made this event important to you, and what you got out of it.
Question 3	Did anything else particularly helpful happen during this session?b) Please describe the event briefly	Did anything else happen during this session you found particularly helpful?(b). Please describe the additional helpful event briefly:
Question 4	Did anything happen during the session which might have been hindering?b) Please describe the event briefly	Did anything else happen during this session you found particularly unhelpful?(b). Please describe the additional unhelpful event briefly

Note. Changes to original HAT are in bold. HAT = Helpful Aspects of Therapy Form.

The significant aspects follow-up interview

At the end of each therapy module in each service, one therapist and one client were invited to undertake a follow-up interview of their experience of that module. This interview was based on the therapist or clients own SAT forms and sought to expand on their reflections and experiences of therapy. The interview schedule was based on and adapted from the Brief Structured Recall (BSR) protocol on Robert Elliott’s website (http://www.experimental-researchers.org). BSR is a form of tape-assisted recall (Elliott, 1993; Elliott & Shapiro, 1988). Participant’s memory and recall of previously identified events is cued through the playing of audio or video recordings of sessions. Topics covered included initial experience of event, later reflection, and any new thoughts, client’s response and actions, therapist’s responses and actions, and the wider context.

Procedure

Ethical approval

Clients and therapists were asked to give written informed consent to participate in this study. The researcher approached clients and therapists during the first session of a new group or therapy module. The researcher gave a brief presentation of the aims and procedures of the study. They were also given a participant information sheet containing details of the costs and benefits of participation, procedures for withdrawal from the study and how to contact the researcher if they had further questions. Potential participants had 7 days to decide whether to consent. The researcher returned to the next therapy session to collect completed written informed consent forms and to answer any questions that may have arisen. Clients and therapists who did not participate were not affected in any adverse way.

Data collection

There were two stages in data collection. The first stage involved 25 clients and 9 therapists completing a SAT Form at the end of agreed therapy sessions. As each intervention program varied in the length and duration of their module, the frequency differed slightly. However, participants completed these forms roughly every third session (see Figures 2 and 3 for illustrations).

Figure 2.

Participants journey through research (6-week module).

Figure 3.

Participant journey through research (10-week module example).

The second stage of data collection occurred at the end of each intervention module. One therapist and one client from each service were randomly selected and invited to attend a follow-up interview. Therapists and clients were interviewed separately. This interview focused on the participant’s experience and reflections on their SAT forms completed during the previous module. The RoI 1 service video recorded all therapy sessions, and these recordings were used during the interview to assist the participant’s memory of events. In the remaining two services, events were cued by the participant re-reading their completed SAT forms, as video recordings of sessions were not routinely made by these services. Each interview lasted roughly 1 hr and was audio recorded on a digital Dictaphone. The researcher transcribed these interviews at a later date. During transcription, all identifying features and names were removed. All interviews took place at the therapy office of the respective service.

Analysis

There were a number of distinct stages in the analysis procedure. Services were recruited and data collected in two stages. The RoI 1 and NI service were recruited and analyzed at the same time, and RoI 2 was recruited and analyzed subsequently. The analysis procedure for each service was identical. SAT and Interview analysis were kept separate, until all data had been collected and initially analyzed. At advanced stages of analysis, the SAT and interview analysis were integrated.

All data were analyzed using thematic analysis (Braun & Clarke, 2006). Using these authors as a template to guide analysis, the following conventions were followed. First, a “theme” was defined as “an event identified by at least one participant twice or two participants once.” Second, the aim of analysis was to provide a rich description of the entire data set. Third, an inductive analysis approach was taken to the data. This meant that themes were closely linked to the data and not derived from a theoretical interest in the area. Finally, themes were identified semantically, meaning that only the surface or surface meaning was taken from the data.

Analysis was structured into a number of phases. Phase 1: The researcher (D.O.H.) became familiar with the data. This occurred through transcription, reading, and re-reading the interview transcripts and SAT forms. Phase 2: The researcher generated initial codes. SAT forms and interview transcripts were treated separately at this stage. Phase 3: The researcher searched for themes among the codes generated earlier. Themes were sorted and organized into a coherent structure. Phase 4: The researcher reviewed the themes and the emerging thematic map. The researcher sought to develop an overarching model of significant events from the SAT forms and also from the in-depth interview transcripts. Phase 5: The researcher defined and named each theme and produced a hierarchy of themes. Phase 6: The researcher finalized the thematic map.

Two hundred thirty-five SAT forms were analyzed from 25 clients and 9 therapists. In addition, 23 interviews were conducted with 12 clients and 11 therapists. Some participants were interviewed twice, and thus 16 separate participants were interviewed (9 clients, 7 therapists). Analysis of these data sets produced a model of significant events in therapy. An independent coder provided inter-rater reliability for the coding frame developed for SAT form and interview analyses. Thirty SAT forms and 3 interviews were rated according to the coding frame by the independent coder along a 5-point Likert-type scale ranging from strongly disagree to strongly agree. The level of agreement was calculated according to the number of times the second rater “strongly agreed” with the original coding. Agreement levels and Kappa values are presented in Table 5.

Table 5.

Inter-Rater Agreement on Coding Frames for the Significant Aspects of Therapy (SAT) Form and for the SAT Follow-Up Interview.

Domain	SAT Comparisons	SAT % Agreement	SAT Kappa Coefficient	Interview Comparisons	Interview SAT % Agreement	Interview Kappa Coefficient
Domain 1: Process of therapy	32	87.5	.87	83	95.2	.95
Domain 2: Making changes and progress in therapy	15	80	.79	43	90.7	.9
Domain 3: Content and structure of therapy	23	89.8	.9	21	90.4	.89
Domain 4: Therapist contributions	4	75	.72	20	95	.94
Domain 5: Negative contributions to therapy	3	100	1	10	90	.88
Domain 6: Other factors	—	—	—	15	100	1

Results

This research aimed to address the following question: What do clients and therapists identify as significant therapeutic events in community-based treatment interventions for perpetrators of sexual abuse? To answer this question, an inductive approach to analyzing the SAT forms and interview transcripts was utilized, and guidelines were followed as in Braun and Clarke (2006). Thematic analysis produced a model of significant events in therapy.

The Model of Significant Events in Therapy

In each intervention center, thematic analysis of the participant responses on the SAT form and follow-up interview were combined to produce a model of significant events in therapy. Individual themes identified in the data were categorized and sorted by the first author (D.O.H.) based on similarity into six domains. These were as follows: (a) “The Process of Therapy,” (b) “Making Changes and Progress in Therapy,” (c) “Content and Structure of Therapy,” (d) “Therapist Contributions,” (e) “Negative Contributions to Therapy,” and (f) “Other Factors.” Figure 4 presents a graphical representation of the amalgamated client and therapist model of significant events in therapy. Each domain represents a distinct aspect of significant therapeutic events. Table 6 presents the number of themes contained within each domain and the operational definition used for each domain. The text that follows here gives some illustrative quotes from themes in each domain. Client and therapist responses will be presented separately. Table 7 presents the themes most frequently identified within each domain for both clients and therapists.

Figure 4.

Model generated of significant events in therapy based on factors identified by therapists and clients.

Table 6.

Significant Events in Therapy Domain Definitions.

Domain	Number of Themes Within Domain	Definition
1. The process of therapy	18	The aspects and elements of the therapy session that express how the members in group contribute to each others experience of therapy, especially in emotional and psychological support for each other.
2. Making changes and progress in therapy	15	Identified events that highlight areas where clients have made progress in tackling their presenting problem, or have made changes in their life as a result of their engagement with the therapy service.
3. Content and structure of therapy	10	Events that relate to how the therapy session is structured, how the day is timetabled, and what takes place in the session and how these factors may contribute to a client’s therapy.
4. Therapist contributions	10	What the therapist brings to the therapy session and to the clients experience of the therapist.
5. Negative contributions to therapy	6	Events that are identified as being unhelpful or had a negative effect on the participant or the group
6. Other factors	7	Any other factors or events identified by participants that do not fit into the previous five domains.

Table 7.

Frequency of Identified Themes Organized by SAT and Interview for Each Domain Within the Model of Significant Events in Therapy (Most to Least).

	Client Identification				Therapist Identification
	SAT		Interview		SAT		Interview
Domain and Theme	Freq. of Theme	Px.(n)	Freq. of Theme	Px.(n)	Freq. of Theme	Px.(n)	Freq. of Theme	Px.(n)
(a) The Process of therapy	(173)	(25)	(275)	(9)	(77)	(9)	(183)	(7)
Sharing experiences	59	15	48	7	29	7	30	6
Advice, support, and feedback	32	10	49	7	14	7	28	6
Group atmosphere	2	2	43	7	3	3	47	6
Learning from others	15	7	19	5	5	4	18	7
Role model	11	6	19	6	6	2	17	3
Hope, positive effect of group	8	3	33	6	2	2	8	4
Universality of experience	16	9	19	4	2	2	—	—
Listening to others	9	4	10	5	2	2	10	5
Welcoming new member	6	4	10	5	5	4	7	6
Participation by all	8	5	4	3	3	3	4	3
Positive regard	4	2	9	5	1	1	2	2
Safety in group	—	—	2	1	1	1	4	3
Group autonomy	2	2	3	2	—	—	1	1
Group flexibility	—	—	4	2	—	—	2	1
Acceptance and non-judgement	1	1	—	—	2	2	2	2
Use of humor	—	—	3	2	—	—	1	1
Attempting to break cycle of abuse	—	—	—	—	1	1	1	1
Separating Own victimization from offense	—	—	—	—	1	1	1	1
Making changes and progress in therapy	(106)	(25)	(191)	(9)	(73)	(9)	(145)	(7)
Evidence of change	6	4	21	7	18	6	34	7
Applying learning and making connections	20	13	20	7	14	6	18	6
Desire for change	8	4	16	6	11	4	35	6
Showing empathy	22	11	30	6	5	3	5	2
Taking control of cognitions	16	10	13	3	10	4	7	3
Expressing emotions	6	5	20	5	3	3	14	4
Taking responsibility for offense	5	4	15	7	6	3	8	4
Making changes in life	1	1	28	7	—	—	2	2
Recognizing risks and triggers	15	6	5	2	4	3	5	3
Completing group	5	4	2	2	1	1	3	1
Motivations for attending	—	—	3	3	—	—	7	3
Need for understanding	—	—	4	3	—	—	6	3
External support network	2	1	6	3	1	1	—	—
Acceptance of consequences	—	—	4	2	—	—	1	1
Admitting mistakes	—	—	4	2	—	—	—	—
Content and structure of therapy	(132)	(25)	(89)	(9)	(59)	(9)	(65)	(7)
Content/structure	48	16	13	6	17	7	22	7
Acquiring skills	21	9	9	4	12	6	13	6
Thinking back	17	11	22	8	4	4	2	1
Challenging client’s behavior	10	5	13	5	8	3	12	4
Implication or outcome	12	5	13	6	9	5	4	3
Difficult work of group	6	5	9	4	4	2	2	2
Identifying goals in life	8	5	5	3	3	2	3	1
Leaving session stronger	10	6	2	2	—	—	—	—
Power and control	—	—	1	1	—	—	6	1
Focused attention	—	—	2	2	2	2	1	1
Therapist contributions	(20)	(25)	(63)	(9)	(23)	(9)	(155)	(7)
Therapist management of group	6	7	14	7	15	7	58	6
Therapist guidance	6	5	12	4	—	—	19	7
Help and support provided by therapists	7	4	18	8	1	1	4	3
Therapist style	1	1	18	5	—	—	11	4
Co-facilitation and support for therapist	—	—	—	—	3	2	18	4
Therapist reflection	—	—	—	—	1	1	13	4
Implications for risk	—	—	—	—	2	1	9	3
Therapist emotion	—	—	1	1	—	—	10	3
Maintaining hope for change	—	—	—	—	1	1	8	5
Therapist self-care	—	—	—	—	—	—	5	1
Negative contributions to therapy	(23)	(25)	(33)	(9)	(28)	(9)	(36)	(7)
Negative client contributions	12	10	13	5	5	3	14	5
Not taking responsibility for offense	5	4	5	2	10	6	9	3
Attendance issues	3	1	6	2	12	5	2	2
Negative thoughts	1	1	8	5	1	1	1	1
Not maintaining changes	—	—	—	—	—	—	8	5
Reluctance to challenge	2	2	1	1	—	—	2	1
Other factors	(3)	(25)	(38)	(9)	(4)	(9)	(31)	(7)
Family dynamics/external factors	1	1	17	3	1	1	5	1
Comments about research	1	1	8	4	1	1	6	3
All other comments	1	1	5	4	2	2	5	2
Individual therapy	—	—	6	2	—	—	7	3
Group therapy	—	—	1	1	—	—	6	4
Unique situations	—	—	1	1	—	—	1	1
Client learning style	—	—	—	—	—	—	1	1

Note. — = not identified by participants; freq. of theme = frequency of theme; Px. = participant.

Domain 1: The Process of Therapy

The process of therapy was the most frequently identified domain by clients and therapists. Themes were collected under this domain that related to the therapeutic process; what clients felt they received, or therapists felt they provided. The sense that therapy provides a safe place where experiences can be shared was the most frequently identified theme in this research.

Client responses

Clients identified a number of ways in which they “shared experiences” within the group sessions. One significant aspect of “sharing experiences” was the ability to share personal stories and “get things off your chest.” The group/therapy is seen as a place where clients can come and share anything that is occurring in their lives currently. One client expressed how “during my ‘check-in,’ I informed the group that my partner was considering reducing my access at the weekend . . . this bothered me a little and I felt some relief sharing with the group” [Client 3; RoI 1]. Another client recognized the honesty in others, and how he felt able to open up and share his experiences with them:

Looking back on it, the bravery, the rest of the group, cause I was a stranger to them, and they were very open even in the way they told a bit about themselves other than just the offending, . . . And in my case . . . I was able to open up. (Client 4; RoI 1)

This client also reported that this was the first time he could be honest with others and share his experiences; “I was amazed by it [the sharing], for such, the offending and even in my own case to be able to for the first time ever to be able to speak and feel comfortable within that group” (Client 4; RoI 1).

Therapist responses

Therapists identified the level of honesty and depth of sharing that took place in sessions. One therapist stated,

When [client] talked about his childhood and how his sexual abuse [his victimization] has impacted on his own sexuality . . . the degree of honesty [client] displayed—he was enormously courageous which puts the bar high for the other men, [it is] also a measure of the degree of safety in the group. (Therapist 2; RoI 1)

Setting the bar for others, encouraged members to share their experiences honestly, and demonstrated the level of trust and safety in the group.

Other themes frequently cited were experience of receiving support and feedback from other group members (clients) and therapists in the course of the therapy group. One client highlighted how receiving group support helps clients cope: “after going through and talking about my childhood, all the other members showed their appreciation, by each commending me, and showing their sympathy” (Client 3; RoI 1). Therapists also identified how providing support and feedback can help clients in therapy. One therapist reported feedback and support “set the tone for the new member and challenged him to see group as important and an opportunity for him. It was much more powerful coming from group members than facilitators” (Therapist 2; RoI 1).

Domain 2: Making Changes and Progress in Therapy

The second most frequently cited domain was “making changes and progress in therapy.” This domain contained themes relating to how therapy sessions helped clients to make changes in their life and to make progress in therapy. Examples included how the therapy group helped clients to make changes, that group members and therapists increased client motivation to change, and that clients felt they had evidence of changes being made. Both clients and therapists recognized the importance of making links between the group work and the clients own offending or current situation. An important theme in this domain was applying learning/making connections.

Client responses

Equally, clients identified how they apply group learning to their life and how they have made connections between exercises and their offenses or their early childhood. One client identified how “seeing the torment victims suffer from sexual abuse in the video. I realized the torment I have caused to my daughter . . . also to my wife and other children because of my actions towards my daughter” (Client 6; NI).

Another aspect of “making changes and progress in therapy” was in “showing empathy” toward group members, families, and their victims. One client reflected on how a group member challenged a fellow member on a negative comment about his wife. For this client, it showed how family members are victims by proxy and should be treated with as much respect as victims:

I think it shows a general stance of empathy towards victims, towards family members who are involved and who are also victims, and it’s just being careful of the importance of being . . . careful in what you say, in what you do, the perceptions that may be, how things are perceived in other people as well. (Client 5; RoI 1)

Therapist responses

One therapist identified how clients made connections between the learning in sessions and their lives outside of group. In particular, how “making links with past responses . . . feelings of shame and current behavior are important for future change” (Therapist 11; RoI 1).

Another aspect for therapists was the “evidence of change” in clients attending the programs. One therapist described how a client initially “was not sure of the benefits of understanding the impact, the victim’s impact” (Therapist 1; NI), but then showed he was “trying to understand how his behavior did affect his victims” (Therapist 1; NI). On a general level, therapists identified how clients were making progress in therapy and displayed evidence of change. Another therapist expressed,

When [client] came into group first, that he was very dismissive of the impact, and with this particular daughter he had denied it to her, and he had also tried to get her to sign something to say that it did not happen, . . . so that was a massive shift for [client] to own it like that, and then to be actually interested in what he has done, to his daughters. (Therapist 2; RoI 1)

Domain 3: Content and Structure of Therapy

The third domain identified by clients and therapists brought together themes related to the content of sessions and how they were structured. This domain differed from the two domains described above in how concrete the themes were. Examples include content being useful, how the exercises and work of the session helped clients think back or to acquire new skills.

Client responses

Clients reflected on the structure and content of therapy. One client reflected on how the group helped him identify goals in his life. “I had never stopped to look at the goals or obstacles in life: I have spent my time racing” (Client 14; RoI 1). Another client identified the benefits of telling his life story in the group: “The thing about this particular module was how draining and sometimes difficult to understand it was, and trying to find answers as to why it [abuse] happened to me” (Client 6; RoI 1).

Therapist responses

One therapist identified how their program had an induction group prior to their offender intervention program:

That made a huge difference I think, by the time we got down to some heavy exercises or some real work. There was a good cohesion there, and people were willing and open to talk about their life histories, talk about their life stories, in a pretty open way. And open to being questioned on it by other members of the group in a frank and honest group. So I think the induction did make a difference. (Therapist 2; RoI 2)

Domain 4: Therapist Contributions

The fourth domain brought together themes relating to the contribution made by therapists to the clients’ experience of therapy.

Client responses

Clients identified a number of ways in which they felt supported. First, in how therapists recognized a client’s effort and changes made: “It was the fact that [therapist] noticed the change in me. That I was more relaxed, because I got it off my chest” (Client 4; RoI 1). Second, in how therapists supported clients when they felt vulnerable, and finally, in recognizing that co-therapists hold the complexity of roles and experiences of survivors and perpetrators of child sexual abuse:

I suppose from [therapist 1] who works primarily with perpetrators] point of view he would have known from an offender’s point of view, and [therapist 2] who also works with survivors] would have been dealing with kids who would have been in similar situations, so that had a great mix there as well. (Client 3; RoI 1)

Therapist responses

One theme identified was the modeling of appropriate behaviors to group members provided by therapists:

So if you want to model how to be respectful, to get external people to be respectful, . . . we have to do that in here as much as what an individual says is very difficult to take on board, our response is so important. (Therapist 11; RoI 2)

Domain 5: Negative Contributions to Therapy

Negative contributions to therapy were not frequently identified. Perhaps clients were reluctant to criticize the therapists and service provided, and therapists were reluctant to criticize their own skills and effectiveness. Nonetheless, some participants described negative events and contributions to therapy. This domain captured the significant negative events identified by clients and therapists.

Client responses

Clients were also aware of times when therapists made negative contributions. For example, one client stated,

I felt it was wrong of one of the facilitators to kind of, more or less silence him, and say no more. . . . he was a bit angry about the thing. Once he had discussed what he had to say, then he should have spoke to him and got it out into the group. (Client 3; RoI 1)

Therapist responses

“Negative client contributions to therapy” was the most frequently identified theme. Negative contributions from clients were often the focus of this theme. Both clients and therapists identified experiencing a client’s defensiveness, their reluctance to engage in a session or rejection of support as negative to therapy. One therapist described how “[a client was] very defensive in the first couple of sessions. . . . Didn’t really participate in the exercise, just the bare minimum” (Therapist 2; RoI 2).

Other important themes to emerge under this domain were “not taking responsibility for offense” and “attendance issues.” Not taking responsibility for offense was identified when clients refused to accept their offense and minimized their responsibility. Therapists and clients often challenged these contributions. Attendance issues were identified when clients arrived late, left early, or missed sessions. It was clear that clients who had poor attendance were not engaging with the therapy program.

Domain 6: Other Factors

The final and smallest domain within the model is “other factors.” Clients and therapists reflected on their experiences of therapy such as the role of external factors and family dynamics, and learning styles. The most frequently identified theme was family dynamics/external factors. Participants described how events outside of therapy or external agencies might affect therapy.

Client responses

One client identified how child protection officers have a role to play in their life and clients should be accepting this. “That is part of it, and you have to realize, each and every part of the service have to do their work, down to child protection. We may not like it, but we survive it, we get through it” (Client 7; RoI 1).

Therapist responses

Another theme identified was individual therapy. Participants described how individual therapy might also contribute to someone’s therapy. One therapist identified how victim issues or experiences of abuse are more appropriately dealt with through one-to-one work:

If you put him in another group to deal with these other issues, he would have all the issues of building up trust, confidentiality, all the stuff that are so surface for him, so prevalent for him. I think we would have been putting him under a lot of pressure, we would have been asking I feel too much of him. (Therapist 17; RoI 1).

Discussion

This study proposes a model of “significant events” during intervention with men who sexually offend. Events were grouped according to six domains: (a) the process of therapy, (b) making changes and progress in therapy, (c) content and structure in therapy, (d) therapist contributions, (e) negative contributions to therapy, and (f) other factors. This model provides a unique insight into sexual offender intervention and practice. Both clients and therapists identified events in therapy that shed light onto how community-based sexual offender intervention is routinely provided. Furthermore, significant events identified by therapists and clients in this study are consistent with those identified in both the general psychotherapeutic literature (Yalom & Leszcz, 2005) and sexual offender intervention literature (Drapeau, 2005; Marshall, 2005; Marshall et al., 2003).

The findings from the present study add to our understanding of the process and content of therapy. Across the three services, there is strong evidence of the presence of “common therapeutic factors.” The most frequently identified themes common to all services were from the process of therapy and making changes and progress in therapy domains. This suggests that clients of sexual offender intervention value (a) sharing, support, and a positive atmosphere; (b) acquiring skills; and (c) a therapist who will manage the environment, the client’s emotional needs, and offer guidance. This builds on the large evidence base from psychotherapy research, supporting the significant impact of the process, the content, the structure, and the therapist on a client’s experience and outcome from therapy (Norcross, 2002, 2011; Yalom & Leszcz, 2005). While it has been shown that sexual offender intervention reduces recidivism, there has been less attention on what clients and therapists experience as significant in their therapy. Clients in the present study described the role of “universality” (Yalom & Leszcz, 2005) and providing a “corrective emotional experience” (Yalom & Leszcz, 2005) as significant to their therapy. The present research adds to our understanding of what clients identify as significant in their intervention. A second contribution made by this research is to our understanding of therapists’ experiences of sexual offender programs. Therapists also identified themes previously identified in psychotherapeutic literature. Of particular significance is the overlap with previous sexual offender research. Marshall (2005) identified 17 therapist characteristics that contribute to positive outcomes and reduced recidivism; therapists and clients in the present study identified many of these factors.

The present study also builds on the theoretical and empirical research on sexual offender treatment theory. The model of SAT adds support to the concept of offender readiness (Ward et al., 2004), the Good Lives Model (Ward & Gannon, 2006), and empirically supported treatments (Beech, Fisher, & Beckett, 1998; Marshall, Marshall, Serran, & Fernandez, 2006). In regard to the offender readiness model (Ward et al., 2004), clients in the present study supported the importance of treatment readiness as a factor of change through their identification of a “desire for change” as a significant event in their therapy. Furthermore, Ward et al. (2004) identified that treatment readiness is a function of both internal and external factors. Again, clients identified this in the present study. Internal “cognitive” factors were reported as follows:

I remember [client] saying “sometimes I kind of sit and I wonder what the impact of this was on my victims, and I would like to understand that a wee bit more” you know “what exactly I did to them.” (Therapist 2; RoI 1)

External factors were reported as follows:

[Therapist] said to me “come in the first 6 weeks, just sit and observe” and then you were right in and observing and you were taking part . . . [therapist] made that easy, no doubt about it and indeed [service manager] and [therapist 2], they all made me feel very comfortable. (Client 4; RoI 1).

Participants also identified the importance of sessions that are strength based with skill and knowledge building as significant to their intervention. This is consistent with the Good Lives Model of treatment, where the goals of intervention are to help offenders identify their primary goods and to provide ways in which they can develop skills to achieve these in more appropriate ways. Clients identified at least three goods: knowledge, inner peace, and relatedness. One client reported on his goal of relatedness:

[the goal] of me trying to, the importance of trying to reconnect, or to . . . communicate with her [his sister] is. . . it serves a lot of different purposes. It is . . . trying to forgive, . . . and in some way put the past behind me. (Client 15; RoI 1)

Limitations of the Study

There are a number of limitations within this study which affect the generalizability and strength of the conclusions drawn from the results. First, no measure of outcome was used to evaluate the effectiveness of the interventions sampled. Furthermore, this study does not cover a full range of therapy modules. Both these factors reduce the impact of the resulting model of significant events. Furthermore, it cannot be claimed that the events identified as significant are responsible for reducing recidivism or being components of effective interventions. In addition, it should be noted that the sample size, while large for a qualitative study, is perhaps too small to generalize to other populations, and different samples may generate alternative examples and produce a different model of significant events. Second, there is a possibility of positive bias in participant responses. This may give the impression of an overly positive experience of the interventions sampled. Previous studies have highlighted this as a limitation (Levenson et al., 2009; Levenson, Prescott, & D’Amora, 2010). A further difficulty attributed to positive bias is the possible perception that participants are being evaluated. Therapists may have felt that their skills or performance were being evaluated and as a result, would be less likely to report negative events. Related to this limitation is that participants were aware of the aims and objectives of this study, and therefore there may be some form of expectancy effect in their responses. Positive response bias is difficult to eliminate, and attempts were made to elicit significant negative experiences from participants.

Implication for Practice

Exploring the client and therapist views of therapy has significant implications for the provision of therapy services. Client responses should be used to identify aspects of therapy deemed significant and positive for therapy; the three most significant themes identified in the present research were as follows: (a) sharing experiences; (b) advice, support and feedback (from other clients); and (c) group atmosphere. Likewise, client and therapist responses should be used to guide service provision through the development of therapist characteristics; aspects such as offering (a) support, (b) guidance, and (c) specific therapist styles. The particular utility of the findings from the present study shows the importance clients place in the process of sharing with others in the group and the support provided by other group members. The contribution of therapists is a key element in how the bonds grow within the group. Therapists should take note of these factors to develop and enhance the client’s experience of sharing by ensuring that the group is safe, and that there is a good group atmosphere and bond.

Furthermore, this study adds additional weight to the importance of a therapist’s warmth, empathy, and genuineness. It is clear from the present study that therapists need to strive to meet the needs of clients and develop the characteristics highlighted by previous research (Marshall, 2005; Marshall et al., 2003; Rogers, 1961; Yalom & Leszcz, 2005) on therapist’s contribution to change. By acknowledging the significant events of therapy identified in this research and incorporating these into practice, therapists may increase a client’s engagement in therapy and contribute to its positive outcome.

Another key implication of the present study comes from the guidance for programs and therapists to deliver both offense-focused components such as recognizing risks, taking responsibility for the offense in addition to personal development components such as self-esteem and mood regulation in a sexual offender treatment intervention. This concurs with previous literature and research on client satisfaction and engagement in treatment (Levenson et al., 2009; Levenson et al., 2010).

Implications for Treatment Service Evaluation

It is recognized that the model of significant events does not identify efficacious practice, and no claim can be made that the presence of significant events identified in the present study leads to risk reduction or lower recidivism. We believe that the findings of the present study suggest the utility of identifying client experiences of therapy when evaluating the efficacy of therapy. Intervention services may aim to be “non-judgmental” or warm, genuine, and empathic, but it is only when clients identify these factors and therapist features that services can safely claim this therapeutic ethos. Exploring client experiences of therapy is an effective way of validating the provision of specific content or approaches.

There is agreement that therapeutic process research in sexual offender treatment is under-utilized and that the number of studies is limited (Marshall et al., 2003; Marshall & Serran, 2000). Furthermore, Ward, Polashek and Beech (2006) identified that the issues around the process of change within sexual offender intervention are unspecified. These authors suggest that there is potential for therapeutic process research to make a contribution to intervention evaluation in conjunction with other more established outcome methods such as uncompromised random assignment (Marques, Wiederanders, Day, Nelson, & Van Ommeren, 2005) and within-treatment change (Beech, Erikson, Friendship, & Ditchfield, 2001).

Similarly, exploring therapists’ experience of therapy also enhances service evaluation studies. Therapists are in the position of having received training and having knowledge of therapy as it should be delivered. They are, therefore, in the position to compare this knowledge with how therapy actually is delivered. Therapists are able to highlight and explore where delivered therapy deviates from the prescribed model or manual. This is a useful measure of therapy and can add considerable information to an evaluation of a therapy service.

The findings of the present study contribute to the service evaluation literature in two ways. First, clients identified the strong impact that others in the group had on their experience of therapy, and also the impact that content, structure, and exercises had on their therapy. Both clients and therapists identified the change visible in themselves and in others. This has the potential to be a useful measure of intervention outcome and a way to evaluate the efficacy of an intervention program. This method of evaluation may be used in tandem with other more established and objective methods of evaluation. One limitation of exploring the experiences of therapy as a means of intervention evaluation is the danger of positive reporting biases, and this can be balanced by using other methods of evaluation and outcome measurement.

A second contribution and implication to treatment evaluation made by the present study is the model of events identified in this research. In client responses, there was a strong emphasis on the contribution of fellow clients and less emphasis on therapist contributions; this is in contrast to the responses received from therapists. This finding indicates that therapists may overestimate their contribution, whereas clients may underestimate the impact the therapist has on the therapy session.

Implications for Future Research

This research has at least two implications for future research. First, this research explored client and therapist experiences of therapy across three treatment services. The outcome of this exploration was a model of significant events in therapy. Many of the themes within this model were identified as being common across the services. Future research is needed to explore and validate this model further. More specifically, this model was developed through the analysis of open-ended questionnaires and semi-structured interviews. Future research could refine the model with more focused questioning about each of the six domains and the themes within those domains. Furthermore, future research should explore the model of significant events with a broader population. Exploring the significant experience of therapy with prison-based offenders or violent non-sexual offenders might highlight other offense-specific factors of therapy that are significant to individuals engaged in therapy.

A second implication for future research is to link the model of significant events in therapy to intervention outcome. The model developed in the present research was developed through exploring the experiences of clients and therapy while they were still in therapy. Future research should link the model of significant events to intervention outcome. This could be done by recruiting participants prior to commencement of their therapy and following them for the course of their intervention, and also for a significant period post intervention. This research would then be able to evaluate whether the events identified by participants in the present study are linked to effective therapy and positive treatment outcome.

Conclusion

The present research identified a model of significant events in therapy. This model is made up of six domains, each of which presents a unique aspect of the therapeutic experience. The largest domain (“the process of therapy”) highlights the importance of the “common factors” of therapy identified in the previous literature (Marshall et al., 2003; Yalom & Leszcz, 2005). The exploration of client and therapist experiences of therapy can make an important contribution to future service delivery and can aid the evaluation of current therapeutic practice. These findings clearly show that there is value in developing services, and giving direction to therapists and clinicians in developing their skills, in being responsive to client needs, and incorporating client centered research into practice. Furthermore, the areas of therapy identified as significant in the present research can be used to explore the relationship between treatment process and treatment outcome in future research. It is important to note that the model of significant events in therapy was developed using three sexual offender treatment services. The identification of common therapeutic factors across all three services highlights the similarities in all forms of psychological therapy.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded through a grant from Special EU Project Body INTERREG IIIA [Reference: 001846]. This was administered by Co-Operation and Working Together (CAWT), a partnership between the Health and Social Care Services in Northern Ireland and Republic of Ireland, which facilitates cross-border collaborative working in health and social care.

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