The Virtuous Circle: A Grounded Theory Exploration of the Good Lives Model

Abstract

Sexual offenses evoke strong emotional responses and frequently elicit demands from society that offenders be indefinitely incarcerated or treated until they are deemed safe, which may impact the provision of therapeutic treatment for offenders. However, in recent years, there has been a proposal to move toward a positive, strengths-based treatment approach, namely the Good Lives Model (GLM). The present study used semi-structured interviews and a constructivist grounded theory approach to examine the experience of 13 men who were voluntarily engaging in or had completed a GLM community-based treatment program. A conceptual model emerged which outlines the process the men underwent, the factors they identified as crucial for change, and the perceived gains. The model extends previous work by exploring the process from the clients’ perspective. Implications for future research, prevention, and treatment are discussed.

Keywords

sexual offender treatment Good Lives Model therapeutic process

Introduction

Treatment of Sexual Offenders

Sexual offending is a worldwide issue, impacting people across all social and cultural strata and causing great distress for victims. Few offenses evoke such strong public opinion, and society demands that offenders are both punished and rehabilitated (Kim, Benekos, & Merlo, 2016). Many interventions have been used with offenders, with cognitive behavioral therapy (CBT) as the primary method of intervention for the past 40 years and most treatment incorporating a relapse prevention (RP) component (Polaschek, 2003), adapted from addiction treatment (Marlatt, 1982; Pithers, Marques, Gibat, & Marlatt, 1983). The efficacy of interventions with this population is debatable, with meta-analyses restricted to randomized control trials finding no treatment effect (Dennis et al., 2012; Khan et al., 2015). Meta-analyses using less stringent criteria suggest a reduction in recidivism ranging from 22% to 26.3% (Kim et al., 2016; Schmucker & Losel, 2015). However, several factors impinge on conducting ideal research on this population, such as limited information on recidivism, and ethical implications of not providing treatment to control groups, difficulty in matching control groups and the potential difference in motivation levels between those who accept and decline treatment (Langstrom, Enebrink, Lauren, Lindblom, & Hanson, 2013; Marshall & Marshall, 2007). However, it must be noted that Seto et al. (2008) argue that randomized control trials are necessary to ensure treatment given is effective and that using strategies such as offering alternative treatment and aggregating data from smaller studies, the above obstacles can be addressed.

Good Lives Model (GLM)

Two main overarching rehabilitation theories have been proposed when working with sex offenders, namely the Risk Need Responsivity (RNR) principles (Andrews & Bonta, 1998; Andrews, Bonta, & Hoge, 1990) and the GLM (Ward, 2002; Ward & Brown, 2004; Ward & Gannon, 2006; Ward & Stewart, 2003). The RNR principles propose that the highest intensity treatment should be offered to the highest risk offenders, treatment should target criminogenic needs, and that treatment be offered in a manner that maximizes the individual’s ability to benefit (Andrews et al., 1990). The GLM is grounded in a philosophy of universal human rights and holistic treatment. The GLM assumes that offenders, like all humans, seek certain goods which contribute to a happy life but are intrinsically valued for their own purpose. It proposes that offending behavior is the product of a desire for something that is inherently human, but that this desire manifests itself in harmful behavior due to deficits within the offender and their environment, and criminality ensues when people attempt to reach primary goods inappropriately, where there is a lack of skills to achieve a good life, or too much emphasis is placed on one good (Fortune, Ward, & Mann, 2015). The GLM aims to provide offenders with the resources to live a life where their goals are met without harming others and views psychological well-being as equally important to risk management (Ward, 2002). The GLM argues that treatment based solely on eliminating risk factors is unlikely to sufficiently motivate offenders and therefore an approach goal focused program should be used (Fortune et al., 2015). In addition to identifying goals that are necessary for a “good life,” it helps individuals identify and address factors that contributed to offending behavior. Increasingly, literature suggests that treatment should adhere to the RNR principles and incorporate the GLM (Harkins, Flak, Beech, & Woodhams, 2012; Marshall & Marshall, 2014). While the GLM was challenged in relation to a limited empirical evidence base (Bonta & Andrews, 2003; Harkins et al., 2012), empirical evidence takes time to accumulate, particularly when lengthy periods are required to assess recidivism.

Offenders’ Perspectives on Treatment

Parhar, Wormith, Derkzen, and Beauregard (2008) conducted a meta-analysis of 129 studies with offenders, which found voluntary treatment had significant effect sizes, regardless of modality, but that mandated therapy was ineffective. This might indicate efficacy in shifting interventions toward the enhancement of motivation and engagement, something stressed by the GLM. This is a theoretically sound proposition, given the findings of a literature review by Marshall and Burton (2010), which concluded that similar to general therapy, process variables account for twice the amount of variance in treatment-induced changes with this client population compared with the effects of specific techniques (Lambert, 1992). Frost (2004) concluded that the process of engagement in sex offender therapy is not well understood, although extrapolating from more general literature, he concluded that therapist qualities, clients’ perceptions of those qualities, and therapeutic alliance are key variables that predict positive treatment outcomes. Studies that examine offenders’ opinions can help ensure that treatment is relevant to their needs, which is particularly important when attendance may not be experienced as voluntary (Levenson, MacGowan, Morin, & Cotter, 2009; Mandikate & Ackerman, 2012). Garrett, Oliver, Wilcox, and Middleton (2003) suggested that offenders’ perspectives may be ignored or even dismissed due to stigma. However, some survey-based studies found that offenders identified the therapeutic alliance and RP and GLM concepts as useful (Grady & Brodersen, 2008; Levenson et al., 2009; Levenson & Prescott, 2009; Levenson, Prescott, & D’Amora, 2010). Interviews have also been used to elicit information from offenders, in which the men identified learning skills to avoid reoffending and enhanced victim empathy as key (Barthel, 2014; Collins, Brown, & Lennings, 2010; Connor, Copes, & Tewksbury, 2011).

Muldoon’s (2007) study with offenders receiving community-based treatment also highlighted the importance of the therapeutic alliance. This was similar to Drapeau’s (2005) prison-based study, which concluded that offenders sought therapists who were honest, respectful, nonjudgmental, and who encouraged discussion. Safety and containment of the group were considered essential, and it concluded that an offender’s perception of the therapist may directly lead to engagement or avoidance of therapy. Offenders reported that an overtly confrontational approach by therapists led to offenders being less likely to engage, but that it was important that therapists demonstrated their ability to challenge offenders. It may be that the manner in which the therapist explores defense mechanisms is important and that choosing the correct moments to support and challenge could be vital. Therapists were frequently compared with parental figures, and therapist empathy was significant for offenders, as it appeared to counter a history of a lack of care. As a result, the literature on this population suggests that several factors may be associated with treatment efficacy and utility.

Research Rationale

The importance of treatment efficacy with a sex offender population cannot be overstated. Simply put, effective treatment prevents future victims. Effective treatment requires full and open engagement. Identifying what promotes optimum engagement and by extension facilitates effective treatment is essential. In other areas of psychological intervention, we ask clients to identify what aspects of the intervention were most helpful in facilitating them to make changes. Based on their responses, we have shaped treatment approaches. It stands to reason that we do the same with this population. If our aim is to prevent future victims, we cannot allow our abhorrence of the behavior and its impact on how we view this client group to prevent us from asking essential questions. This study asks such questions and sought to establish a model of the treatment process and mechanisms of change based on the perspectives of the men involved in a group based on GLM. This research sought to elucidate the processes involved in a therapeutic program, to identify the significant features contributing to change, and to explore the factors impacting the offenders’ ability to engage and their perceived benefits to attending therapy.

Method

Design

A constructivist grounded theory research design was implemented (Charmaz, 2000, 2002, 2014, 2015). Grounded theory is a systematic and inductive method of conducting an inquiry for the expressed purpose of generating theory (Glaser & Strauss, 1967; Strauss & Corbin, 1990). It aims to interpret complex socially constructed experiences, and the systematic process allows for the emergence of categories from the data without a predetermined hypothesis (Jones & Alony, 2011). This study used the constructivist approach to grounded theory (Charmaz, 2014). The researcher aims to develop an understanding of the process and content of the participants’ experiences, with the acknowledgment that this construction is located in time, place, culture, and context. This view asserts that individuals construct their reality as they interact with the world around them and that multiple interpretations of social constructs exist (Appleton & King, 2002). In addition, it posits that researchers’ values and ideas and the research settings can influence the research process and are reflected upon rather than searching for a neutral objective stance (Glaser & Strauss, 1967). This approach was considered the most appropriate as the inherent value of the experience of the person was considered pertinent, given the marginalized nature of the population.

Recruitment

Recruitment took place over an 8-month period from two Irish community-based GLM programs for male offenders. Clients were approached by group therapists to ascertain their interest in participation. Out of 16 men in treatment, eight agreed to participate. In total, 30 men had previously completed treatment, but nine of these individuals could not be contacted due to lack of contact details or incarceration. Another eight men were not contacted as they had prior therapeutic contact with the researcher. Therefore, 13 men who had completed treatment were invited to participate and five agreed. Accordingly, a total of 13 participants were recruited, eight men currently in treatment and five men who had completed treatment.

Program

The program accepts men who have committed any type of sexual offense. Some men are mandated to attend by the judicial system, but others attend voluntarily, with average treatment length of 2 years. Groups generally contain eight men and are facilitated by psychotherapists and psychologists, with each group having a female and male therapist. Groups take place weekly for 3 hrs, and clients complete the following six central tasks: (a) Life Story, where men detail their life history, which is augmented by therapeutic work focusing on early relationships and developmental stages, (b) Chartwork 1, where men disclose their offending behavior from contemplation of offending, to offending, to being arrested, (c) Chartwork 2, where men establish connections between their offending behavior and aspects of how they were living their lives, essentially identifying their offense cycle, (d) Victim empathy tasks, (e) Relationships and sexuality tasks, and (f) Developing a Good Life Plan, where men identify and practise the changes required to ensure they can live a meaningful and pro-social life. Throughout the therapeutic process, other tasks such as developing emotional regulation skills or attending to mental health issues are addressed as required.

Study Participants

All participants attended psychotherapy voluntarily, although one participant had been sentenced mid-treatment to probation, which included completing therapy. Participants ranged in age from 21 to 71 years (M = 53 years, SD = 15 years). Six were married and seven were single. Offenses were as follows: viewing child pornography (8), videoing adults without consent (1), sexual harassment (2), statutory rape (1), sexual abuse (1), and obscene phone calls (1). Some men had committed more than one offense. For the participants attending treatment, the average time spent in psychotherapy to date ranged from 5 to 24 months (M = 15 months, SD = 5.6 months). For those who had completed group, time spent in psychotherapy ranged from 18 to 40 months (M = 29 months, SD = 9 months). The legal status of participants was as follows: post-arrest, waiting to be charged with offense (7), post-sentence (4), and charges dropped (2).

Data Collection and Procedure

Data collection was conducted using the constructivist grounded theory approach (Charmaz, 2014). Interviews used open-ended questions such as, “What was your experience of group?” to allow data emerge without being restricted by preconceived ideas. A broad interview schedule was generated using sensitizing concepts (i.e., tentative concepts based on previous knowledge), to explore themes such as “interaction with therapists.” This was refined after each interview to explore emerging themes and to compare with previously identified concepts. Reflecting and encouraging elaboration was used to gain a full understanding of each participant’s experience. Approval for this study was granted by the appropriate ethics committee. Each participant received an information letter and was given an opportunity to ask questions before signing a consent form. Interviews were conducted by the author and ranged from 61 to 118 min, totaling 1053 min overall (M = 81 min, SD = 20 min). Group therapists and a clinical psychologist were available to provide support should any participant become distressed. Confidentiality was assured throughout interviews with usual limits applying. Participants received a debriefing sheet, which included appropriate contact details.

Analysis

Interviews were recorded and transcribed verbatim, removing identifying information. Data were analyzed as collected, and this informed the subsequent stages of information gathering (Charmaz, 2002, 2014). Data were initially examined and coded line by line by the first author, using brief descriptors that captured the social and psychological processes discussed by the participants. These emerging concepts were systemically compared with new information to ensure the analysis remained grounded in the data. Reviewing and grouping codes allowed for abstract concepts to develop. Memos were used to outline properties and characteristics of concepts. Finally, concepts were examined for links, and emerging theoretical ideas were checked by collecting more focused data using a refined interview schedule. Memos and diagrams were used to make comparisons within individuals’ data and between other individuals’ experiences. Linking the concepts led to the development of themes and subsequently, a model.

External validation was sought by summarizing the information and discussing this with participants at the end of interviews. Supervision, consultation with clinicians in this area, and an external review of the coding process was also used. Four interview transcripts were separately coded by the third author to ensure similar codes were being identified. Memo writing was conducted to capture the researcher’s thought processes in a transparent manner, to provide a link between the data and the analysis to ensure credibility, and to be reflexive within the analytic process and to aid awareness of external influences (Charmaz, 2014). Charmaz (2015) noted that we all come to data with a gender, race, privilege, social class and a moral judgment, and rather than seeking objectivity, subjectivity was acknowledged and supervision was used to reflect on how (a) my experience as a group therapist in this area, (b) my work as a psychologist, (c) my gender, and (d) my personal reaction to details of sexual offenses may have impacted my interpretation of the data.

Results

Model of Therapeutic Change Using GLM Principles

The model developed sought to capture the participants’ experience of attending a GLM treatment program, and Figure 1 visually depicts the process of psychotherapy identified from the data. The model will subsequently be discussed using participants’ words to illustrate points, using pseudonyms for ease of reading. The model describes the emotional and psychological state of the men as they enter therapy and the core conditions that appear necessary for therapeutic work to commence and indeed, these conditions remained a fulcrum throughout the process. The model then portrays a circle of therapeutic change, with other aspects fundamental for change portrayed in the middle circle, namely the therapeutic and group alliance, engagement and using the group as a microcosm of society. Therapeutic techniques, which loosely correlated to the program structure were depicted as being the spine of the process. The facets were interconnected and happened in partnership with each other (e.g., having a corrective experience was a therapeutic technique, which would not happen without a solid therapeutic alliance). The model is circular, as the process of therapeutic change did not occur in a linear manner. Instead, the men described engaging in the process, experiencing surges of psychological growth that led to some gains, which allowed the men to engage more effectively in the process and thus lead to further gains. The perceived gains that the men noted are outlined in the outside circle. Three potential outcomes are shown: adherence, relapse, or interruption of the process due to external influences (e.g., prison).

Figure 1.

Model of therapeutic change.

Explanation of Individual Factors Within the Model

Entering therapy

Men described experiencing shame, fear, and desperation post-arrest, and thoughts of suicide indicated that some men felt they had irrevocably tainted their lives by their behavior. The sense of despair was heightened by recognition from the men that their behavior was responsible for their current position. Many of the men were experiencing or fearing significant loss and isolation, with anxiety expressed regarding career repercussions, damaged relationships, or social status. For some men, the loss of their own identity was a factor, as they believed they would be viewed by the rest of the world through the prism of their offending behavior. “It’s gonna contaminate my whole life . . . I won’t be a nephew anymore . . . I’ll just be an offender” (Max). Seeking help was a process which in itself proved difficult given the stigma around sexual offending. It meant becoming part of something undesirable, “a bunch of people that . . . that in another life you would consider monsters” (Edward). However, there also appeared to be a sense of hope, in that their current life was deeply unsatisfactory. “I wanted to change my life . . . because my life was . . . a place that I didn’t want it to be” (Ethan).

Core conditions for therapy

Some characteristics of the therapeutic process were identified as vital to enable the men to engage in the process and to experience meaningful therapeutic change. The term “core conditions” was used as they were consistent with the core conditions espoused by Rogers (1957). Fred described authenticity and genuineness of the therapists as vital for him to engage in therapy:

I was at my lowest point when I came here . . . and she . . . her . . . Glow of loveliness . . . was just immense . . . and I knew she cared about me . . . I wasn’t just another client . . . and people can fake it . . . and I’m great at faking . . . but I knew this was genuine. (Fred)

The sense of unconditional positive regard was also described as significant, as men who were anticipating judgment and rejection were treated like a “normal person” (Max). This nonjudgmental and empathic atmosphere appeared to be conducive to disclosing offending behavior. The men appeared clear that they could be held accountable for their behavior but that it could be accomplished in a respectful manner. This made men more likely to disclose behavior that they were ashamed of, as instead of experiencing rejection, they encountered acceptance, empathy, and an offer of assistance. Although making the decision that it was safe to open up to the group took varying lengths of time for each man, it was noted that without honesty, the process was destined to fail, “everything almost flows from there . . . it wouldn’t without . . . the honesty . . . the support for each other; they would be difficult or impossible if people didn’t trust each other” (Noah). These core conditions were essential in allowing the men to begin to participate in psychotherapy and remained vital the whole way through the process.

Virtuous circle of change

Therapeutic change was described as a virtuous circle, where skills learned at group were used to effect change in life, which in turn enhanced their ability to gain more from the group process. Progress was not linear, despite the loose structure of having six main therapeutic tasks to complete:

I would’ve been very poor at second-guessing or working out the way people felt or why they felt a certain way so I’m much better at that now because of the tools I gained at group . . . em . . . and that then becomes symbiotic; I am able to be better connected with people and people feel better connected to me . . . and there is a virtuous circle. (Zach)

The circle of change and the mechanisms involved were broken down into five themes, all of which were interconnected, with the core conditions remaining at the center.

Therapeutic alliance

The therapeutic alliance was viewed by the men as essential to the process. When the relationship was valued and the client felt supported, the underlying values of respect and unconditional positive regard allowed for challenges to the men’s way of thinking or behaving to be received in an acceptable manner. Belief in the therapists’ expertise and knowledge was viewed as essential and the therapists were perceived as shrewd enough to notice if attempts were made to hide or downplay aspects of behavior. The value placed on the therapeutic relationship often led the men to seek approval from therapists by engaging fully. “You are kinda complimented a little bit . . . if you spot something like that . . . not that you are fishing for compliments . . . but eh . . . yeah it’s still nice” (Daniel). Therapists were often viewed in a parental role, which accentuated the men’s need for therapists to view them favorably. In this respect, being challenged by therapists could be a difficult process for the men:

I was using humour and sarcasm as . . . a defence mechanism . . . I got challenged on that from one of the facilitators . . . and that’s actually the hardest . . . it was always the thing . . . facilitators were often viewed as being the mammy and daddy. (Edward)

However, they were generally open to being challenged if it was perceived as coming from an empathic place, “he wouldn’t run away from a challenge . . . but he only has your best interests at heart . . . and you know that he is bloody well right as well” (Fred). This could also lead to healing moments for the men. For Fred, who perceived his older siblings as abandoning him to abusive parents, the facilitators were viewed as older siblings, who provided him with a corrective experience: “To me they were my big brother and sister who love me . . . and want me to get better and they don’t judge me” (Fred).

Conflict within group was also used as a therapeutic opportunity, and many of the men learned that disagreements were not the end of the relationship but that the rupture could be repaired and the relationship sustained. Edward reflected that he developed psychologically during his time in group, perceiving himself as initially behaving in a childlike manner when he was annoyed with the therapists, but over time, developing adaptive coping strategies and being able to communicate distress and frustration by talking to the therapists. In addition, the balance of a male and female therapist was noted as important by most men, despite many men in the earlier stages of the therapeutic process being unable to clarify why. Those who had been in therapy for longer articulated that a female presence provided them with an opportunity to witness healthy interaction between genders. In addition, many of the men had a history of difficult interactions with females, and engaging with a female therapist was useful to explore the root causes of this. For others, positive interaction with a female demonstrated that it was possible to have a healthy relationship with a woman.

Group alliance

The importance of peer support, encouragement, and challenges could not be overstated. The rolling group, where men commenced psychotherapy with others who had been attending for a longer period, appeared to instill hope, provide an objective to aim for, and reassurance that progress, although difficult, was possible. Lucas spoke about one of his first nights at therapy where another client spoke: “He was very very open and honest . . . Brought me to tears actually, to be honest with you. And that changed my mind . . . I knew . . . well if he can do it, I can do this” (Lucas).

The group format also led to the men feeling supported and less isolated. Committing a sexual offense is one of the most stigmatizing acts that a person can engage in, but this group allowed the men to feel like they could reintegrate with society. “You feel less alienated . . . or less . . . em . . . removed from society” (Max). The support and shared experience seemed to lead to a feeling of belonging to something important, and mutual disclosures meant that trust developed, and thus a sense of allegiance to the group developed. With this loyalty and sense of allegiance, men began to take responsibility for how the group functioned, and a realization emerged that psychotherapy was not being “done unto them” but that they were active participants in their own rehabilitation. “There’s a collective responsibility for how well the group works itself . . . not just the facilitators” (Noah). Taking ownership of the group appeared to evoke an atmosphere of mutual accountability, and if one was perceived to be coasting through group, this would not go unnoticed by fellow group members:

At best you are kidding yourself . . . at worst . . . you’re codding* the group . . . and it’s the group . . . well the group will weed you out if you’re not . . . you know participating . . . if you are just you know . . . just faking it . . . just to try . . . if you’re just doing it to get a favourable report to hand to a judge . . . then . . . you know . . . you shouldn’t be in group . . . the whole point of group is to get better. (Henry)

However, while group members held each other accountable, there was an acceptance that people could make mistakes and that it was their behavior afterwards that was important. For example, Fred spoke about how he returned to gambling halfway through treatment, and his experience of disclosing this to the group. He explained that he had to work hard to regain trust but that he was given that opportunity:

People expressed that disappointment . . . a lot of people felt that I had betrayed the group . . . I betrayed trust . . . that was hard to take . . . but it was said in a respectful tone and an empathetic tone cos (sic) those guys had done things they weren’t proud of either . . . I knew leaving the room that I still had the support . . . I was able to come back the next week and that was the main thing for me . . . I was able to start again. (Fred)

Engagement

It was clear that for this group of men, psychotherapy was an important part of their week. Fear and skepticism about psychotherapy seemed to begin to alleviate once the men realized that the process was beneficial, and this resulted in a stronger commitment to therapy. Instilling hope that change was possible, and that their life was not static, was highly significant for the men as it provided a motivation to pursue the process. The quality of engagement with the therapeutic process appeared to change over time with motivation shifting from extrinsic to intrinsic. Although some men were motivated internally from the outset, in general, earlier motivations seemed to be linked to legal processes or to offer assurances to significant others that they would not reoffend. Motivation became more intrinsic where the men realized that addressing their difficulties could bring about a happier offense-free life:

At first I was just doing everything I could do . . . prepare myself better for court . . . but as I got into it more . . . I realised that I had a lot of unresolved problems . . . a lot of things from my childhood . . . they had definitely affected me. (Max)

Intrinsic motivation was described as a desire to be someone who did not hurt other people and embracing this potential when many people had dismissed the possibility of rehabilitation.

Men communicated that unless they engaged fully in the process, it was unlikely to make a significant impact. None of these men were mandated to attend psychotherapy and this was highlighted, with some perceiving a difference in engagement levels when they chose to attend instead of being coerced. Interestingly, Ethan, who was awaiting a professional inquiry, was perceived by himself and his peers as having made fewer changes and appeared dismissive of therapy at times, “are we going to play a party game?” (Ethan). However, he also desired to be part of the group and was frustrated upon receiving peer feedback that he needed to improve his engagement. This highlighted the complex and tangled mix of motivating and coercive factors.

Therapeutic techniques

Details of the structured tasks are outlined in the section “Method,” and these were sustained in the group tasks within GLM. The important aspect of psychotherapy from the men’s perspective appeared to be the holistic approach, with other issues being addressed concurrent with their sexual offending. The Life Story task and the exploration of aversive childhood incidents produced strong emotions, and the therapeutic process often provided the men with a corrective experience. Fred spoke about being able to express empathy toward himself as a child:

I was actually able to relate to that child . . . and go back to him . . . and put my arms around him and say it’s okay . . . I’m okay now . . . because as a child I was always in fear . . . I was afraid of everything . . . I lived my life through fear and being in here . . . I was able to . . . talk to that child . . . acknowledge that child . . . acknowledge the fears . . . and know . . . finally that it wasn’t my fault . . . and to know that I am worthy of love . . . I am worthy of caring for other people. (Fred)

Then, men were invited to explore their patterns of sexual offending. It appeared they valued the process of figuring out what had contributed to their offending, rather than simply receiving a clinical formulation. Therapists gave guidance by probing and questioning, but the men took time to source answers themselves. Justification, cognitive distortions, and minimization of behavior were challenged. “The group actually mirrors to you . . . so . . . you . . . begin to see . . . yourself . . . performing . . . I mean I can tell myself all kinds of stories to justify . . . whereas . . . the group will hold you accountable” (Andrew). Planning for a happier and pro-social life was a task throughout group and making sustainable changes was important. For example, one man recognized that there was a lack of interpersonal activity in his life, which he addressed by engaging in more sociable activities, which allowed him to meet his need for social interaction in an adaptive manner.

Group as a microcosm of society

One of the striking aspects of the men’s experience of psychotherapy was that the group functioned as a miniature society, where interpersonal style could be explored in a safe environment. When the men discussed their roles in group, some could identify similarities in their behavior both within and outside of group sessions. As Edward stated, figuring out how to manage his interactions with the other men in the group took time, and he recognized the pattern of interaction from other times in his life. “The biggest learning . . . was . . . actually how do I integrate into this group . . . what is the dynamic . . . here . . . why is it happening . . . seeing well . . . there are patterns . . . This wouldn’t be the first time that I’ve had these feelings” (Edward). Another key component noted by the men was that the group setting gave them an opportunity to help others. This was invaluable to their sense of self-worth, which generally was significantly impaired after arrest. Interestingly, this fostered a sense of responsibility, as Charles explained, “I owed a debt to the other guys . . . to the people who came in . . . to have some seniors in the group” (Charles).

Changes observed

The men observed changes within themselves over the course of therapy, including their ability to better understand and manage emotions. Many men indicated that before attending therapy, strong emotions were something to be suppressed, denied, rationalized, or avoided. It appeared that emotional literacy was a skill that had to be learned (or childhood lessons had to be unlearned), and new ways of interacting with emotions cultivated. “So I didn’t really emotionally develop when I was younger . . . so eh, there’s a bit of Junior Infants in me!” (Zach). In addition, by identifying their own emotional state, it seemed to become easier for the men to be attuned to others’ emotions. Improved relationships and enhanced communication were noted by many of the men, in what seemed to be a cycle of learning, positive reinforcement, and increased happiness. Addressing differences of opinions and learning new ways of managing conflict were also noted to improve relationships.

Empathy appeared to develop in three distinct areas: empathy for themselves, for other people, and for their victims. Fred spoke about developing empathy for himself as a child, and his fear that he would be thrown out of the house like his older sibling, “It was a miracle . . . I would never have been able to acknowledge that child’s pain . . . in the outside world . . . I needed a safe secure environment” (Fred). Perhaps due to the men’s increased sense of emotional understanding, there was a growing recognition that others could feel similarly. Interestingly, empathy for victims was not discussed by many of the men, although some acknowledged it as a factor in their learning. Men may have found this difficult to reflect on, perhaps due to shame and guilt.

While understanding the causes, triggers, and cycle of their offending is a key component of the group program, some men were hesitant to embrace this in case it could be construed as trying to excuse their behavior. However, an understanding was gained by most men who had completed or were near to completing therapy, as to what had likely triggered their behavior and why they had found it emotionally and sexually satisfying. Fred describes his understanding of why he made obscene phone calls:

My brain was constantly screaming at me . . . how stupid I was . . . how pathetic . . . and making those phone calls . . . was a release . . . it turned those voices off for the seconds I was on the phone . . . I was in control . . . there was no one screaming at me . . . I was doing the screaming if you like . . . metaphorically speaking . . . I was being the aggressor. (Fred)

The men conveyed that understanding by itself was not an answer to living an offense-free life, but that it was a starting point in identifying changes required and learning how to manage situations where potential opportunities for recidivism might arise. “Understanding the root causes . . . the emotional and psychological causes . . . I know what my stressors are and I know what the precursors to offending are” (Zach). Taking responsibility for their actions was another significant step with some men disclosing their behavior to important loved ones, and although initially driven by the therapists, was something that they themselves took ownership of. When it came to the therapeutic process, it seemed that, for the most part, men took responsibility for their own progress. “They (therapists) are a tool to the end but they are not going to fix you . . . group is not going to fix you . . . the only person that can fix you . . . is you” (Edward).

Similarly, Andrew began to recognize that his anger at the religious and legal systems was a distraction from his experience of shame and was a way to deflect responsibility. There was a recognition that he may have relied on empathy from the therapists to evade reflecting deeply, “all of us agreeing that this is a lousy organisation . . . doesn’t necessarily help me” (Andrew). With the above seemed to come a state of acceptance of a new reality, and men acknowledging that valuable relationships may be lost, some career pathways were closed and legal repercussions were a reality. The men discussed how therapy facilitated developing coping skills for their new lives. The men appeared to place great value on making plans and regaining hope for the future, which seemed to be a process for the men to give themselves emotional permission to move forward with life and to visualize an offense-free future. Given the above, it was understandable that many men felt they had gained greatly in relation to self-acceptance. “I don’t dislike myself as much as I used to dislike myself . . . I used to get very frustrated with myself . . . having had ten years of an anxiety . . . disorder . . . I’d a lack of self-worth which has certainly improved” (George). As noted earlier, none of the men who participated in this research went to prison, and all had either completed or were planning to complete the treatment program. Therefore, the positivity of the self-described outcomes was unsurprising, with some discussing how it would be difficult to leave the supportive environment of group despite looking forward to a new start in life. For those who had completed the therapeutic process, the experience appeared to have played a significant role in changing their lives. “I’m a totally changed individual . . . in my own head . . . I am . . . My outward appearance may be the same . . . but inside I am far more at peace . . . I got so much . . . I will be eternally grateful” (Fred).

Discussion

This study constructed a model of the therapeutic process of a group of men who were voluntarily engaging in GLM treatment in line with constructivist grounded theory principles. The men commenced psychotherapy at a stage of crisis, and there was a sense that attending was both out of desperation and hope. The core conditions as outlined by Rogers (1957) and which are highly consistent with the GLM philosophy were highly significant in enabling the participants to engage in psychotherapy, and these conditions remained central throughout. The therapeutic alliance allowed for trust to emerge and for transference to be used as an effective therapeutic tool. The group alliance was noted to enhance support, decrease isolation, and increase motivation. Loyalty to the group developed, which enabled the men to hold each other accountable for their participation, work rate, and behavior. The use of group as a tool also developed, with men re-socializing, learning new skills, and experiencing the opportunity to be a productive and valuable member of a process. Essentially, men were assisted to explore their lives, guided toward an understanding of their behavior and supported in developing the skills to make healthier, pro-social choices.

Although the participants in this research were not mandated to attend therapy, it must be noted that all the men commenced therapy post-arrest and in light of legal proceedings. However, despite this, the elicited model suggested that the therapeutic process with this group of men was not unduly dissimilar to other client groups. Brodsky and Lichtenstein (1999) suggested that therapeutic techniques with willing clients may not generalize to unwilling clients. In relation to men who sexually offend, even if attendance in therapy is officially voluntary, external motivation and legal coercion may be unavoidable (Parhar et al., 2008), and this was observed in this study. However, the GLM principles attempt to address this, as they emphasize the importance of developing intrinsic motivation using approach goals and focusing on psychological well-being as well as risk reduction (Ward & Brown, 2004; Ward & Stewart, 2003). It would appear from this study that when men felt that they were engaging in a process which could assist them in living a happier life, they invested more, compared with when they perceived themselves as engaging for more external reasons. Therefore, over time in therapy, the motivation to engage in the process changed from extrinsic motivators to a more internal motivation, where men engaged in the process to make real and substantive changes to their lives.

Core Conditions

The elements identified at the core of therapeutic change fit particularly well with the person-centered framework and GLM principles, which is perhaps more important in this context as the client group is highly marginalized. The use of Rogers’ (1957) term core conditions was chosen as it encompassed his concepts of genuineness, unconditional positive regard, and empathic understanding. The idea of being empathetic and nonjudgmental toward offenders may evoke a fear of collusion by the therapist (Marshall & Serran, 2004). However, GLM assumes that people who have offended were attempting to achieve primary goods, which all humans seek, albeit in a destructive and harmful manner. It would seem that men in this study placed a significant value on being treated as human. The concepts of genuineness, unconditional positive regard, and empathic understanding are inherent to the GLM and were noted by the men in this study as a significant reason why they choose to embrace the therapeutic process.

Therapeutic Alliance

The importance of the therapeutic alliance was evident in this study, with the men indicating that when they valued the relationship with their therapists, they felt supported and were able to receive challenges. Similar to Sandhu and Rose’s (2012) finding that therapist empathy and warmth were the best predictors of reduced minimization and denial, the men in this study were more likely to disclose the behavior that evoked shame in the knowledge that they would receive help to change, rather than condemnation. Indeed, Marshall and Serran’s (2004) review suggested that offenders are more likely to engage effectively in treatment when the therapist creates a supportive and encouraging environment. They proposed that an overly confrontational approach will increase resistance in offenders. This is not dissimilar to general group psychotherapy, where negative outcomes are associated with confrontational therapists, demands for immediate self-disclosure, negative counter-transference, and limited empathy (Roback, 2000). The GLM principles of balancing risk management with promoting psychological well-being fits with Serran, Fernandez, and Marshall’s (2003) study which advocated that an equilibrium between being supportive and challenging must be sought. This was mirrored in the current study with participants seeking therapists who could facilitate disclosure and discussion, and hold the individual accountable in an empathic and caring manner. It appeared that the manner in which the challenge was made is vital, perhaps more so than the actual challenge, which highlights that the GLM position of balancing promoting well-being and managing risk is possible. Serran et al. (2003) postulated that the reluctance of sex offenders to take responsibility for their actions might be an attempt to avoid further damage to their sense of self-worth. They suggest that a safe environment may be more helpful to allow offenders to explore this, rather than a confrontational manner, which would inhibit responses. While the therapeutic alliance has been identified previously as important with this client population (Harkins & Beech, 2007), Marshall and Serran (2004) suggested that the role of the therapist in treating sex offenders often escapes attention because of the emphasis on manualized approaches. However, transference was frequently noted by the men in this research, with therapists often viewed in a parental role of providing a secure base for the men, which allowed them to explore past and current experiences (Bowlby, 1978) and at times to experience a form of limited re-parenting (Martin & Young, 2010). Therapists’ ability to reflect on relationship patterns developed in childhood that are potentially being played out in therapy may be useful for offenders to identify dysfunctional patterns. However, offender characteristics may interplay with this process, with high levels of hostility in offenders associated with a reduced ability to engage and connect with therapists (Watson, Daffern, & Thomas, 2017).

Therapy with men who have sexually offended often tends to be facilitated by a mixed gender pair. Blasko and Jeglic’s (2016) study exploring sex offenders’ perception of the therapeutic alliance found a significant negative relationship between high-risk offenders and bond formation, particularly with female therapists, which may be due to higher levels of cognitive distortions about women. However, Blasko and Jeglic (2016) found that risk of recidivism was negatively correlated to offenders’ perceived bonds with female therapists but not with male therapists, perhaps due to potential room for growth in relation to therapeutic rupture and repair. In addition, Sandhu and Rose (2012) found female therapists potentially played a role in changing offenders’ perceptions of women, by affording them the opportunity to relate to women in a socially appropriate manner. Social learning theory suggests patterns of behavior can be learned through observation and strengthened by immediate consequences (Bandura, 1977). Therefore, if new group members see the therapeutic alliance valued by their peers and observe positive interactions with the female therapist, they may learn new and more adaptive patterns of engaging with women. In this research, men who had been in therapy longer reported that the female therapist was significant because so many group members had difficulties relating to women, and treatment provided an opportunity where interaction was necessary and positive.

Engagement

Instilling hope that change is possible is an essential part of any therapeutic process (Hubble, Duncan, & Miller, 2012). However, it appears magnified with this clientele. If there is a societal perception that sexual offenders are untreatable, it is easy to see why therapy could feel pointless. The GLM is key in this regards as it offers offenders a hopeful way of looking at their problems (Marshall & Marshall, 2014). Ross, Polaschek, and Ward (2008) hypothesized that the GLM may be more appealing to offenders, as it proposes a more collaborative approach, which may increase therapeutic alliance and ultimately increase treatment effectiveness. It may also be that by experiencing some initial tangible positive results, men valued the process more highly, and were therefore more highly motivated to engage, similar to what is suggested by Ryan and Deci (2000). This is an encouraging finding as change resulting from treatment is found to be long lasting when the client can attribute it to their own participation (Lambert & Bergin, 1994).

Group Alliance & Group as a Microcosm of Society

The group alliance and using the group as a microcosm of society were two aspects to treatment that the men identified as valuable, many aspects which fit with Yalom’s (2005) work. For example, his concept of universality, which involves men identifying their experience as not being unique, was noted in this research and appeared to reduce the men’s sense of isolation. Morgan and Winterowd (2002) suggested that universality may also address shame, which can be an inhibitor to exploring offending behavior. Yalom’s (2005) concept of altruism, where the men profited from the act of giving, was salient in this study, where some men felt for the first time in their lives, they were making a valuable contribution. Group cohesiveness was further deemed important in that men saw the openness of others, began to trust and disclose, and were rewarded with empathy and acceptance. For many offenders, this may be their first opportunity to join and function in a healthy group (Morgan & Winterowd, 2002). A strong sense of group cohesiveness allowed the men to challenge each other effectively, and to feel that they, as well as the therapists, were responsible for their progress. Cohesive groups are associated with positive outcomes, whereas highly critical feedback in the absence of group cohesion is related to negative outcomes (Harkins & Beech, 2007; Marshall & Burton, 2010; Roback, 2000). The above outlines the many ways group treatment can support men who have offended in achieving some of the primary goods as outlined by the GLM in a healthy and pro-social manner. In addition, Morgan and Winterowd (2002) suggested that group psychotherapy is a ready-made experiment laboratory, where behavior can be evaluated in the moment by receiving feedback. This was pertinent to the men in this study, where group was experienced as a safe place to discuss behavioral patterns and to try new ways of interacting.

Therapeutic Techniques

The specific therapeutic techniques used, such as the core tasks, will not be discussed here, as while they were deemed important, they were not conversed about in detail. However, one significant factor noted was that, for many of the men, other issues in addition to their offending were addressed. While Serran et al. (2003) stressed the importance of addressing issues as they arise with this client group, it may be that the current model of mental health treatment, where different agencies deal with specific issues, facilitates men dealing with concerns in a “piecemeal” manner. For these men, who may be adept at compartmentalizing aspects of their lives, integration appears vital. Walsh and Nic Coitir (2015) discussed that in general psychotherapy the client’s well-being is the primary focus, but with sex offenders treatment can be overly focused on factors that are perceived to be directly associated with offending. The findings of this research emphasized the importance of an approach that focused on all aspects of the client’s presentation. Again, this fits with the GLM emphasis on holistic treatment, rather than focusing on the offending behavior in isolation.

Limitations

This was a qualitative study with a limited number of participants, all of whom were voluntarily attending community-based treatment. Furthermore, although no formal risk measures were obtained, it could be surmised that the men were more likely to be low-risk offenders, as they had received probation rather than a prison sentence, or were residing in the community while awaiting trial. This may mean that the results are not transferable to prison programs or high-risk offenders. Similarly, the predominance of Internet offenders may make it difficult for findings to be generalized to clients who offended in other ways. It was noted that the men who engaged in this study may be more positively inclined toward psychotherapy, and it is unknown if the men who declined to take part had similar experiences. In addition, the men were aware that the researcher had worked in this area previously. While this may have had a positive impact on participant recruitment, it may have inhibited criticism, particularly as interviews took place in the clinic. Furthermore, in relation to gains made during treatment, this was elicited from the perception of the men with no corroboration. This design was chosen to construct a model purely from the men’s perspectives, but it is acknowledged that their perceptions may be inaccurate, and given the limited confidentiality, men were unlikely to admit to any reoffending.

Clinical Implications and Future Research

These findings have important implications for treatment with men who have sexually offended, as they identify factors that are important to clients. The factors identified by the men as significant in evoking change were the core concepts of the GLM, namely the holistic approach, the importance of enhancing intrinsic motivation, and developing the skills to seek primary goals in a pro-social and adaptive manner. This study thus provides support for GLM as an overarching framework for treatment from a client perspective. It suggests that our existing knowledge about the importance of therapeutic alliance with other client groups is relevant to clients who have sexually offended. It also highlights the important role other group members play in the therapeutic process for each individual, which illustrates the necessity for therapists to protect the group dynamic and assess clients’ suitability for entering the group. Future research could aim to elicit a model from therapists’ perspectives to ascertain if the same factors are considered pertinent. Furthermore, it could be useful to use quantitative measures on a larger scale to investigate if the gains discussed by the men are borne out by psychometric risk measures.

Conclusion

The current study examined factors involved in the therapeutic process of a group of 13 men who were voluntarily engaging in community group psychotherapy, based on GLM principles. Participants identified several factors that were significant contributors to the therapeutic progress, such as core conditions, engagement, the therapeutic and group alliance, using group as a microcosm of society, and the structure of treatment program, all of which fit with the concepts highlighted by the GLM. Understanding the therapeutic process from the perspective of this client group is thus viewed as essential in ensuring that treatment is responsive, effective, and meaningful. This is particularly relevant when the providers of such therapy are tasked to provide treatment which must serve the well-being of two clients, namely the patient and society as a whole.

Footnotes

*

codding is a colloquial term which means fooling

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) received no financial support for the research, authorship, and/or publication of this article.

References

Andrews

D. A.

Bonta

(1998). The psychology of criminal conduct (2nd ed.). Cincinnati, OH: Anderson.

Andrews

D. A.

Bonta

Hoge

R. D.

(1990). Classification for effective rehabilitation: Rediscovering psychology. Criminal Justice and Behavior, 17, 19-52. doi:10.1177/0093854890017001004

Appleton

J. V.

King

(2002). Journeying from the philosophical contemplation of constructivism to the methodological pragmatics of health services research. Journal of Advanced Nursing, 40, 641-648.

Bandura

(1977). Social learning theory. Prentice Hall, NJ: Englewood Cliffs.

Barthel

J. M.

(2014). Treatment of child sex offenders: Examining effectiveness towards reducing recidivism from the offender’s perspective. Texas Christian University. Forth Worth, TX.

Blasko

B.L.

Jeglic

E.L.

(2016). Sexual Offenders’ Perceptions of the Client–Therapist Relationship: The Role of Risk. Sexual Abuse: A Journal of Research and Treatment, 28(4) 271–290. DOI: 10.1177/1079063214529802

Bonta

Andrews

D. A.

(2003). A commentary on Ward and Stewart’s model of human needs. Psychology, Crime & Law, 9, 215-218. doi:10.1080/10683/16031000112115

Bowlby

(1978). Attachment theory and its therapeutic implications. Adolescent Psychiatry, 6, 5-33.

Brodsky

S. L.

Lichtenstein

(1999). Don’t ask questions: A psychotherapeutic strategy for treatment of involuntary clients. American Journal of Psychotherapy, 53, 215-220.

10.

Charmaz

(2000). Grounded theory: Objectivist and constructivist methods. In Denzin

Lincoln

(Eds.), Handbook of qualitative research (2nd ed., pp. 509-536). Thousand Oaks, CA: Sage.

11.

Charmaz

(2002). Qualitative interviewing and grounded theory analysis. In Gubrium

Holstein

(Eds.), Handbook of interview research: Context and method (pp. 675-694). Thousand Oaks, CA: Sage.

12.

Charmaz

(2014). Constructing grounded theory (2nd ed.). London, England: Sage.

13.

Charmaz

(2015, May 5-6). Grounded theory: A constructivist approach. Paper presented at the 8th Qualitative Research Summer School, Dublin City University, Ireland.

14.

Collins

Brown

Lennings

(2010). Qualitative review of community treatment with sex offenders: Perspective of the offender and the expert. Psychiatry, Psychology and Law, 17, 290-303. doi:10.1080/13218710903421282

15.

Connor

D. P.

Copes

Tewksbury

(2011). Incarcerated sex offenders’ perceptions of prison sex offender treatment programs. Justice Policy Journal, 8, 27-50.

16.

Day

(1999). Sexual offender views about treatment: A client survey. Journal of Child Sexual Abuse, 8, 93-103. doi:10.1300/J070v08n02_06

17.

Dennis

J. A.

Khan

Ferriter

Huband

Powney

M. J.

Duggan

(2012). Psychological interventions for adults who have sexually offended or are at risk of offending. Cochrane Database of Systematic Reviews, 12, 1-95. doi:10.1002/14651858.CD007507.pub2

18.

Drapeau

(2005). Research on the processes involved in treating sexual offenders. Sexual Abuse: A Journal of Research and Treatment, 17, 117-125. doi:10.1007/s11194-005-4599-5

19.

Fortune

C. A.

Ward

Mann

(2015). Good lives & the rehabilitation of sex offenders: A positive treatment approach. In Joseph

(Ed.), Positive psychology in practice (2nd ed., pp. 635-658). Hoboken, NJ: John Wiley.

20.

Frost

(2004). Therapeutic engagement styles of child sexual offenders in a group treatment program: A grounded theory study. Sexual Abuse: A Journal of Research and Treatment, 16, 191-208. doi:10.1177/107906320401600302

21.

Garrett

Oliver

Wilcox

D. T.

Middleton

(2003). Who cares? The views of sexual offenders about the group treatment they receive. Sexual Abuse: A Journal of Research and Treatment, 15, 323-338. doi:10.1177/107906320301500408

22.

Glaser

Strauss

A. L.

(1967). The discovery of grounded theory: Strategies for qualitative research. Chicago, IL: Aldine.

23.

Grady

M. D.

Brodersen

(2008). In their voices: Perspectives of incarcerated sex offenders on their treatment experiences. Sexual Addiction & Compulsivity, 15, 320-345. doi:10.1080/10720160802516310

24.

Harkins

Beech

A. R.

(2007). A review of the factors that can influence the effectiveness of sexual offender treatment: Risk, need, responsivity, and process issues. Aggression and Violent Behavior, 12, 615-627. doi:10.1016/j.avb.2006.10.006

25.

Harkins

Flak

V. E.

Beech

A. R.

Woodhams

(2012). Evaluation of a community-based sex offender treatment programme using a Good Lives Model approach. Sexual Abuse: A Journal of Research and Treatment, 24, 519-543. doi:10.1177/1079063211429469

26.

Hubble

M. A.

Duncan

B. L.

Miller

S. D.

(2012). The heart and soil of change: What works in therapy. Washington, DC: American Psychological Association.

27.

Jones

Alony

. (2011). Guiding the Use of Grounded Theory in Doctoral Studies - an example from the Australian Film Industry. International Journal of Doctoral Studies, 6, 95-114.

28.

Khan

Ferriter

Huband

Powney

M. J.

Dennis

Duggan

(2015). Pharmacological interventions for those who have sexually offended or are at risk of offending. Cochrane Database of Systematic Reviews, 2, 1-72. doi:10.1002/25+62969.CD007989.pub2

29.

Kim

Benekos

P. J.

Merlo

A. V.

(2016). Sex offender recidivism revisited: Review of recent meta-analyses on the effects of sex offender treatment. Trauma, Violence, & Abuse, 17, 105-117. doi:10.1177/1524838014566719

30.

Lambert

(1992). Psychotherapy outcome research: Implications for integrative and eclectic therapists. In Norcross

J. C.

Goldfried

M. R.

(Eds.), Handbook of psychotherapy integration (pp. 94-129). New York, NY: Basic Books.

31.

Lambert

Bergin

A. E.

(1994). The effectiveness of psychotherapy. In Bergin

A. E.

Garfield

S. L.

(Eds.), Handbook of psychotherapy and behavior change (pp. 143-189). New York, NY: John Wiley.

32.

Langstrom

Enebrink

Lauren

Lindblom

Hanson

(2013). Preventing sexual abusers of children from reoffending: Systematic review of medical and psychological interventions. British Medical Journal, 347, 1-11.

33.

Levenson

J. S.

MacGowan

M. J.

Morin

J. W.

Cotter

L. P.

(2009). Perceptions of sex offenders about treatment: Satisfaction and engagement in group therapy. Sexual Abuse: A Journal of Research and Treatment, 21, 35-56. doi:10.1177/1079063208326072

34.

Levenson

J. S.

Prescott

D. S.

(2009). Treatment experiences of civilly committed sex offenders: A consumer satisfaction survey. Sexual Abuse: A Journal of Research and Treatment, 21, 6-20.

35.

Levenson

J. S.

Prescott

D. S.

D’Amora

D. A.

(2010). Sex offender treatment consumer satisfaction and engagement in therapy. International Journal of Offender Therapy and Comparative Criminology, 54, 307-326.

36.

Mandikate

Ackerman

(2012). Can convicted offenders be classed as “volunteering” for therapy? Working with men who have committed sexual offences and volunteered for treatment in a prison-based therapeutic community. Paper presented at the 12th Conference of the International Association for the Treatment of Sex Offenders. September 5-8. Berlin.

37.

Marlatt

G. A.

(1982). Relapse prevention: A self-control program for the treatment of addictive behaviours. In Stuart

R. B.

(Ed.), Adherence, compliance, and generalization in behavioural medicine. (pp. 329-378). New York, NY: Brunner/Mazel.

38.

Marshall

W. L.

Burton

D. L.

(2010). The importance of group processes in offender treatment. Aggression and Violent Behaviour, 15, 141-149. doi:10.1016/j.avb.2009.08.008

39.

Marshall

W. L.

Marshall

L. E.

(2007). The utility of the random controlled trial for evaluating sexual offender treatment: The gold standard or an inappropriate strategy? Sexual Abuse: A Journal of Research and Treatment, 19, 175-191. doi:10.1177/107906320701900207

40.

Marshall

W. L.

Marshall

L. E.

(2014). Psychological treatment of sex offenders: Recent innovations. Psychiatric Clinics of North America, 37, 163-171. doi:10.1016/j.psc.2014.03.006

41.

Marshall

W. L.

Serran

G. A.

(2004). The role of the therapist in offender treatment. Psychology, Crime & Law, 10, 309-320. doi:10.1080/10683160410001662799

42.

Martin

Young

(2010). Schema therapy. In Dobson

K. S.

(Ed.), Handbook of cognitive behavioral therapies (3rd ed., pp. 317-346). London, England: Guildford Press.

43.

Morgan

R. D.

Winterowd

C. L.

(2002). Interpersonal process-orientated psychotherapy with offender populations. International Journal of Offender Therapy and Comparative Criminology, 46, 466-482. doi:10.1177/0306624X02464008

44.

Muldoon

(2007). An analysis of the theory and practice of psychotherapy with sexual offenders in an Irish Institute. University College Dublin. Dublin, Ireland.

45.

Parhar

K. K.

Wormith

J. S.

Derkzen

D. M.

Beauregard

A. M.

(2008). Offender coercion in treatment: A meta-analysis of effectiveness. Criminal Justice and Behavior, 35, 1109-1135. doi:10.1177/0093854808320169

46.

Pithers

W. D.

Marques

J. K.

Gibat

C. C.

Marlatt

G. A.

(1983). Relapse prevention with sexual aggressors: A self-control model of treatment and maintenance of change. In Greer

J. G.

Stuart

I. R.

(Eds.), The sexual aggressor: Current perspectives on treatment (pp. 214-239). New York, NY: Van Nostrand Reinhold.

47.

Polaschek

D. L. L.

(2003). Relapse prevention, offense process models, and the treatment of sexual offenders. Professional Psychology: Research and Practice, 34, 361-367. doi:10.1037/0735-7028.34.4.361

48.

Roback

H. B.

(2000). Adverse outcomes in group psychotherapy: Risk factors, prevention, and research directions. Journal of Psychotherapy Practice and Research, 9, 113-122.

49.

Rogers

C. R.

(1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95-103.

50.

Ross

E. C.

Polaschek

D. L. L.

Ward

(2008). The therapeutic alliance: A theoretical revision for offender rehabilitation. Aggression and Violent Behavior, 13, 462-480. doi:10.1016j.avb.2008.07.003

51.

Ryan

R. M.

Deci

E. L.

(2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist, 55, 68-78.

52.

Sandhu

D. K.

Rose

(2012). How do therapists contribute to therapeutic change in sex offender literature: An integration of the literature. Journal of Sexual Aggression, 18, 269-283. doi:10.1080/13552600.2011.566633

53.

Schmucker

Losel

(2015). The effects of sexual offender treatment on recidivism: An international meta-analysis of sound quality evaluations. Journal of Experimental Criminology, 11, 597-630. doi:10.1007/s11292-015-9241-z

54.

Serran

Fernandez

Marshall

W. L.

(2003). Process issues in treatment: Application to sexual offender programs. Professional Psychology: Research and Practice, 34, 368-374. doi:10.1037/0735-7028.34.4.368

55.

Seto

M. C.

Marques

J. K.

Harris

G. T.

Chaffin

Lalumière

M. L.

Miner

M. H.

. . . Quinsey

V. L.

(2008). Good science and progress in sex offender treatment are intertwined: A response to Marshall and Marshall (2007). Sexual Abuse, 20, 247-255. doi:10.1177/1079063208317733

56.

Strauss

Corbin

(1990). Basics of qualitative research: Grounded theory procedures and techniques. New York, NY: Sage.

57.

Walsh

Nic Coitir

(2015, November 11-14). Group therapy for sex offenders: Why bother? Paper presented at the Psychological Society Ireland, Galway.

58.

Ward

(2002). Good lives and the rehabilitation of offenders. Promises and problems. Aggression and Violent Behavior, 7, 513-528. doi:10.1016/S1359-1789(01)00076-3

59.

Ward

Brown

(2004). The Good Lives Model and conceptual issues in offender rehabilitation. Psychology, Crime & Law, 10, 243-257. doi:10.1080/10683160410001662744

60.

Ward

Gannon

(2006). Rehabilitation, etiology, and self-regulation: The comprehensive Good Lives Model of treatment for sexual offenders. Aggression and Violent Behavior, 11, 77-84. doi:10.1016/j.avb.2005.06.001

61.

Ward

Stewart

(2003). The treatment of sex offenders: Risk management and good lives. Professional Psychology: Research and Practice, 34, 353-360. doi:10.1037/0735-7028.34.4.353

62.

Watson

Daffern

Thomas

(2017). The impact of interpersonal style and interpersonal complementarity on the therapeutic alliance between therapists and offenders in sex offender treatment. Sexual Abuse: A Journal of Research and Treatment, 29, 107-127.

63.

Yalom

I. D.

(2005). The theory and practice of group psychotherapy (5th ed.). New York, NY: Basic Books.