Strategies in the Treatment of

Paraphilias: A Critical Review

W. L. Marshall, L. E. Marshall, & G. A. Serran
Rockwood Psychological Services
Kingston, Ontario, Canada

We describe approaches to treatment of persons with paraphihas, although

the majority of treatment programs described in the literature target just
sexual offenders. We identify several issues of ongoing disagreement within
the field and provide data on long-term treatment outcome.
Key Words: cognitive therapy, relapse prevention, sexual offenders, thera-
peutic processes, treatment effectiveness.

The paraphilias, as described in the current edition of the Diagnostic

and Statistical Manual of Mental Disorders (DSM-IV-TR, American
Psychiatric Association, 2000), embrace rather disparate problems, such
as transvestic fetishism, pedophilia, and sexual sadism. These appear to
have little in common other than that the DSM implies that all are sex-
ually motivated. In fact, the past 20 years has seen a proliferation of
both research and well-defined treatment programs for sexual offenders
(some, but certainly not all, of whom meet DSM criteria for a para-
philia); very few investigators have described the nonoffending para-
philias. Nor have any broadly accepted treatment programs for these
nonoffending paraphilias been described in the literature. As a result,
we will focus on sexual offenders. This choice does not, apparently, do a
disservice to the treatment of the other paraphilias because they are
typically thought to share enough features with sexual offending to
warrant quite similar treatment (see Laws & O'Donohue [1997] for
descriptions of treatment approaches for the nonoffending paraphilias).
What is needed, however, are more systematic studies of the nonoffend-
ing paraphilias so that treatment programs can be designed on more
empirical bases.
Focusing this article on sexual offenders avoids a further problem:
the poor reliability evident in the DSM diagnoses of paraphilias. In five

William L. Marshall, PhD, is Director of Rockwood Psychological Services. Liam E.

Marshall, MA, is a Senior Therapist at Rockwood Psychological Services, and Geris A.
Serran, PhD, is Clinical Director at Rockwood Psychological Services. Correspondence
concerning this article should be directed to W. L. Marshall, Rockwood Psychological Ser-
vices, 303 Bagot Street, Suite 403, Kingston, ON, Canada, K7K 5W7.
(bill@rockwoodpsyc.com)

162
 STRATEGIES IN THE TREATMENT OF PARAPHILIAS 163

reviews the clarity of the DSM diagnostic criteria for the paraphilias
have been called into question and evidence suggesting that these diag-
noses are unreliable has been presented (Marshall, 1997, 2006c; in
press-b; Marshall & Kennedy, 2003; O'Donohue, Regev, & Hagstrom,
2000). In particular, the diagnosis of sexual sadism has been shown not
to meet satisfactory levels of validity and interdiagnostician reliability
in both actual clinical practice (Levenson, 2004; Marshall, Kennedy, &
Yates, 2002) and in a quasi-field trial (Marshall, Kennedy, Yates, & Ser-
ran, 2002). Furthermore, Levenson (2004) produced data that revealed
the specific unreliability of diagnoses for pedophilia and exhibitionism,
and even for the more general category of any paraphilia.
Contentious Issues in Treatment
The first step in designing treatment programs for paraphilics is to
determine what, in fact, needs to be addressed. The content of programs
for these disorders derives from two sources: research identifying prob-
lematic features of these clients in general and an assessment of the
individual client.^ The latter evaluation typically is an attempt to deter-
mine which of the features identified in the research literature charac-
terize the specific client and to what degree these features are evident,
as well as any possible idiosyncratic problems the client has. In fact,
although clinicians typically make routine assessments in programs
that provide treatment for sexual offenders, most of these programs
have well-defined manuals that guide treatment but allow little fiexibil-
ity for individual differences evident at assessment. The traditional cog-
nitive behavioral/relapse prevention approach has, in fact, been roundly
criticized for this failing (Laws & Ward, 2006), although to date these
criticisms appear to have had little impact on practice.
This tendency to design "one-size-fits-all" treatment programs guided
by excessively detailed treatment manuals is aided and abetted by
research-funding agencies and by the administrators of institutional ser-
vices that provide treatment in several settings. Funding agencies typi-
cally insist on ensuring the integrity of treatment delivery by requiring
the production of an excessively detailed treatment manual to which
clinicians must rigorously adhere. This practice causes the funding
agency to insist on scientific rigor while neglecting a concern for best
clinical practice. Similarly, those who administer programs in several
settings want them all to conform to the same approach. This felt need is
likewise understandable and even desirable, but the consequence has

^ Although there are women who commit sexual offences, few have been officially iden-
tified, so we will focus exclusively on male sexual offenders.
164 W. L. MARSHALL, L. E. MARSHALL, & G. A. SERRAN

typically been to over prescribe treatment protocols. These demands

have resulted in the use of manuals that define procedures in such fine
detail as to be infiexible, thus addressing neither the xmique needs of indi-
vidual clients nor the day-to-day fiuctuations in each client. Such require-
ments persist despite the extensive research supporting the need for more
responsive offender programs (Andrews & Bonta, 2001; Grendreau, 1996;
McGuire, 1995). More specifically, examination of any research study with
sexual offenders clearly demonstrates the variety inherent in all features
typically targeted in treatment programs (see Marshall, Anderson, & Fer-
nandez [1999], Marshall, Marshall, Serran, & Fernandez [2006] for simi-
maries of much of this extensive research literature).
Not only are sexual offenders heterogeneous on the typical treatment
targets, thereby demanding fiexibility in the delivery of treatment, but
researchers have recently demonstrated an important role for the
processes of treatment delivery. Marshall and his colleagues (Marshall,
2005; Marshall, Fernandez, et al., 2003; Marshall & Serran, 2004; Mar-
shall, Serran, Fernandez, et al., 2003; Marshall, Serran, Moulden, et al.,
2002) have shown that the therapist's display of features such as empa-
thy, warmth, directiveness, and encouragement is predictive of the
clients' attainment of the goals of sexual offender treatment. Drapeau
(2005) demonstrated that when sexual offender clients perceived these
features in the therapist they successfully achieved the treatment goals.
In both Marshall's and Drapeau's studies, the failure of the therapist
either to display these features or to convince clients that the features
were genuine resulted in unsuccessful treatment. Similarly, Beech and
his colleagues (Beech & Fordham, 1997; Beech & Hamilton-Giachritsis,
2005) showed that a group climate characterized by cohesion and
expressiveness (both verbal and emotional) resulted in treatment gains
with sexual offenders and that when these features were absent, gains
were few, if any.
These studies are part of a growing body of evidence that attainment
of treatment goals with sexual offenders is highly dependent on process
issues (Burton & Cerar, 2005; Simons, Tyler, & Lins, 2005). In fact, the
amount of variance on indices of change accounted for by the four thera-
pist features of empathy, warmth, directiveness, and encouragement
ranged between 40% and 60%, leaving very little for procedural aspects
to account for (Marshall, Kennedy, Yates, & Serran, 2002).
Studies of nonsex offenders have also demonstrated powerful effects
for therapist characteristics. Alexander, Barton, Schiavo, and Parsons
(1976) reported that positive therapist features explained 60% of the
variance on treatment outcome measures with juvenile delinquents.
The magnitude of this variance accounted for, in studies by Marshall,
 STRATEGIES IN THE TREATMENT OF PARAPHILIAS 165

Serran, et al. (2002) and Alexander et al. (1976) is far larger than typi-
cally observed in the psychological treatment of other disorders. For
example, in reviews (Martin, Graske, & Davis, 2000; Morgan,
Luborsky, Crits-Christoph, Curtis, & Solomon, 1982) of general psycho-
logical treatments (primarily for Axis 1 disorders), only 25% of the
variance in change scores was accounted for by therapist features. Why
would therapist characteristics and other process features be so much
more important in the treatment of offenders (including sexual offend-
ers) than in the treatment of typical Axis 1 disorders? Clients with
anxiety or depression, for example, more often than not seek treatment
themselves and are usually well motivated for, and cooperative within,
treatment. Sexual offenders are typically resistant (Mann & Webster,
2002), unmotivated (Marshall & Moulden, 2006), and defensive
(Rogers & Dickey, 1991). Thus, because therapist skills are fully taxed
in treating sexual offenders, it is no surprise that such skills have a
stronger infiuence on the achievement of treatment benefits than is the
case for other disorders.
Given these observations on the invaluable role of therapeutic
processes in the treatment of sexual offenders, it seems in retrospect
that the rush in the 1980s and early 1990s to over specify procedures
was misguided and has done the field a disservice. It seems to us neces-
sary to generate more flexible treatment manuals, particularly in
research projects or multisetting treatments. Optimal treatment manu-
als would specify the necessary process conditions (therapist style and
skills, group climate) and also would allow therapists to determine nec-
essary fiexibility for successful treatment. We have attempted this in
treatment manuals for our full-treatment program (Marshall, Serran, &
Marshall, 2006) and for our preparatory program (W L. Marshall & L.
E. Marshall, 2006), with more extensive details published elsewhere
(Marshall, Anderson, & Fernandez, 1999; Marshall, Marshall, et al.,
2006; L. E. Marshall & W L. Marshall, 2006).
Risk/Needs Model
Another contentious issue concerns the targets of treatment with sex-
ual offenders. The so-called "risk/needs" model is most clearly articu-
lated by Andrews and Bonta (2001) but has many other adherents or
sympathizers (e.g., Blackburn, 1993; McGuire, 2001). Four general prin-
ciples are contained in this model, each derived from an extensive body
of research with various types of nonsexual and sexual offenders: the
risk principle, the need principle, the responsivity principle, and the
principle of professional discretion. The risk principle is simply that
treatment and management resources should be allocated according to
166 W. L. MARSHALL, L. E. MARSHALL, & G. A. SERRAN

actuarial risk: That is, more extensive and intensive treatment should
be provided for the higher risk offenders. The risk levels referred to
here are derived from actuarial measures based on static risk factors
that are essentially unchangeable. DjTiamic risk factors, those features
of offenders that can be changed, appear in recent risk prediction mea-
sures, such as the STABLE-2000 (Hanson & Harris, 2000). The need
principle is the critical issue for this discussion: that treatment should
focus on (and in some interpretations, only on) modifying those dynamic
features shown to be criminogenic, to predict future risk. The responsiv-
ity principle is that treatment providers should adjust their approach
(and possibly the treatment content) according to the characteristics of
each client (e.g., intellectual level, learning style, cultural features, and
day-to-day fluctuations in motivation and accessibility). This principle
fits with what we now know about the importance of fiexibility in the
application of treatment. The notion of professional discretion gives the
clinician the option to override the other three principles, in war-
rantable circumstances. However, the firmness with which Andrews
and Bonta, and the other adherents, state the necessity of the first
three principles seems at odds with this fourth recommendation.
Good Lives Model
Andrews and Bonta (2001) insisted that the targets of treatment be
restricted to criminogenic factors, but Ward and Stewart (2003a, 2003c)
have offered cogent criticism of this view. They argue that enhancing
sexual offenders' overall functioning will lead them to attain the goals
of a "good life" which, in turn, will reduce their need to offend. The
"good lives" model has emerged from extensive research, summarized
by Deci and Ryan (2000), Emmons (1996, 1999) and Schmuck and Shel-
don (2001). It is consistent with, and incorporated into, the recent move-
ment referred to as "positive psychology" (see Linley & Joseph, 2004),
which emphasizes developing the skills, attitudes, and self-beliefs
essential to achieving those primary goods sought by all people. These
ideas are not unlike Maslow's (1954) earlier notion that people strive for
self-actualization and that achieving this state (or the primary goods of
life) will result in a fulfilled and happy person. Ward and Stewart
(2003a, 2003c) advocated treatment focused toward the good life gOials
based on the belief that the source of sexual offending is an inability to
achieve these goals by prosocial processes. As a corollary. Ward and
Stewart claimed that achieving a good life (i.e., the capacity to meet pri-
mary needs) will eliminate the person's need to offend.
Ward and Stewart (2003b) and Ward and Marshall (2004) provided a
detailed account of how a therapist can implement a good lives
 STRATEGIES IN THE TREATMENT OF PARAPHILIAS 167

approach with sexual offenders. In all aspects of this approach, the ther-
apist works collaboratively with the client. First, it is necessary to
assist the client in identifying an individualized set of goals that is con-
sistent with his interests and abilities and that would lead to the
attainment of a more satisfying life. Next, the therapist helps the client
identify both the skills that need to be enhanced and the attitudes that
need to be modified in order to achieve these goals. Then, specific treat-
ment implements the necessary skills and attitude training. As these
stages evolve, therapist and client together re-examine and possibly
modify these goals.
Combining Treatment Models
Until quite recently, published descriptions of sexual offender treat-
ment programs identified targets for treatment not necessarily consis-
tent with either the risk/needs or good lives models. Most had targets
that represented some elements of both models but not a clear applica-
tion of either model. For example, these programs typically targeted
established risk factors (i.e., criminogenic needs), such as deviant sex-
ual arousal, anger, and substance abuse; however, they also characteris-
tically targeted good lives features, such as intimacy skills and effective
coping, long before these features were shown to be dynamic risk fac-
tors. In fact, as various recent investigators have identified certain fea-
tures as dynamic risks (see Hanson & Harris, 2000; Hudson, Wales,
Bakker, & Ward, 2002; Proulx et al., 1997), they have incorporated
these into treatment, thus approximating the good lives approach with-
out explicit acknowledgment. Those programs, on the other hand, that
do explicitly incorporate the good lives model (e.g., Marshall, Marshall,
et al., 2006), at least in terms of defining the targets of treatment, have
targets that match what is now known about dynamic risk factors.
When static risk factors are combined with these in treatment, the dif-
ferences in practice between appljdng the risk/needs model and the good
lives model are markedly reduced. Ward and Stewart's (2003a, 2003c)
criticism of the risk/needs model is appropriate when treatment goals
rest only on evidence from those static factors identified by actuarial
risk assessment approaches; that is, most published reports of sexual
offender treatment. But as exploration of dynamic risk factors contin-
ues, and these are incorporated into treatment, the major differences
between the application of the risk/needs model and the good lives
model disappear. Glaring differences remain, however.
For example, the risk/needs model continues to demand that treat-
ment focus on modifying deviant sexual interests, because this is an
identified criminogenic need. The good lives model would, on the other
168 W. L. MARSHALL, L. E. MARSHALL, & G. A. SERRAN

hand, suggest that enhancing the sexual offender's capacity to meet his
needs prosocially should result in extinction of his deviant sexual inter-
ests. Marshall (1997) produced evidence, albeit hmited, that confirmed
this suggestion. He selected for study only those child molesters who
had long histories of quite vicious and sexually intrusive offending and
who displayed markedly deviant sexual arousal at phallometric testing.
These offenders then completed a comprehensive treatment program
addressing a combination of risk/needs targets and good lives targets,
with one exception: It lacked any attempt to modify deviant sexual
arousal or interests. Results revealed that these offenders attained the
targets of treatment and that, most importantly, posttreatment phallo-
metric assessments revealed normative sexual interests.
Another major difference between approaches remains. Almost all
treatment programs ostensibly adhering to the risk/needs model target
overcoming denial ("I did not commit the alleged crime") and reducing
minimizations ("I did not do harm"; "The victim was willing"; "I was not
responsible"). Yet, a significant body of evidence has failed to demon-
strate a link between denial or minimization and subsequent recidivism
(see, e.g., Hanson & Bussiere, 1998).
These disagreements about the model that should guide treatment
notwithstanding, treatment programs for sexual offenders seem to be
moving toward incorporating many of the features of the good lives
model. Although we do not strictly adhere to all aspects of this model,
we do incorporate many of its features in the most recent description of
our program (see Marshall, Marshall, et al., 2006). Our program differs
in some respects from other cognitive behavioral treatments; however,
many of the targets are common to all programs (see Carricb & Calder
[2003] and also the edited volume by Marshall, Fernandez, Hudson, &
Ward [1998] for descriptions of numerous programs operated in various
countries). The components of our program rest on the extensive body of
available evidence reported by researchers across the world and sum-
marized in review papers (Abracen & Looman, 2004; Fanniff & Becker,
2006; Kirsch & Becker, 2006) and book chapters (Green, 1995;
Schwartz, 1995, 2002).
In the following section we outline the targets in our program and
briefly describes how we address these targets. We also provide evidence
of the effectiveness of these approaches to achieve each of the targets.
Targets of Treatment
In Table 1, we outline the typical targets of sexual offender treatment
programs. We distinguish offense-specific targets (i.e., those relevant to
all clients and that feature in most programs) from offense-related
 STRATEGIES IN THE TREATMENT OF PARAPHILIAS 169

targets. The latter are commonly identified problems (e.g., substance

abuse, poor anger control, poor impulse control) that appear to be func-
tionally related to the clients' offending proclivities. In the settings
where we conduct treatment (Canadian federal prisons), specialized
programs are available for most of the offense-related targets. Because
these programs are operated by experienced practitioners expert in
dealing with these targets, we do not have to include a focus on these
issues in our programs; we simply assist clients to integrate what they
have learned in related programs.
As detailed descriptions of our approach to modifjdng the offense-spe-
cific targets are provided elsewhere (Marshall, Anderson, & Fernandez,
1999; Marshall, Marshall, et al., 2006), we provide only brief descrip-
tions here.
Life History
The client produces a life history that covers his relevant and impor-
tant experiences (both positive and negative) through childhood, adoles-
cence, young adulthood, midlife, and older age, if each is relevant. The
life history will both assist the therapist in developing a deeper under-
standing of the client and help him to identify persistent behavioral,
cognitive and emotional difficulties that can be addressed in treatment.
It also serves to initiate the collaborative process of generating each
client's offense pathways. Identifying these can help to develop an effec-
tive self-management plan that includes relevant aspects of the good
lives model and is aimed at reducing risk to reoffend.
Self-Esteem
The examination of each client's level of self-esteem begins in the
very early sessions of the program, as do treatment procedures for
enhancing self-worth. This early attention to self-esteem serves to

Table 1
Targets of Treatment
Offense-Specific Targets Offense-Related Targets
Generation of a life history Substance abuse
Enhancement of self-esteem Anger management
Acceptance of responsibility Cognitive skills
- Minimizations Other psychiatric problems
- Schemas
- Empathy
Defining offense pathways
Developing coping skills
Modifying sexual interests
Generation of self-management plans
170 W. L. MARSHALL, L. E. MARSHALL, & G. A. SERRAN

convince clients that the therapist is concerned about their welfare

and that the focus of treatment will be on enhancing their lives; it also
engages clients in the treatment processes. Therapists assist clients
with low self-esteem to identify actions they can take within the
domain of functioning where they lack confidence. For example, thera-
pists pose a specific situation for a client lacking in assertiveness. Sev-
eral possible courses of action will then be generated, the likely
costs/benefits of these actions will be discussed, a role-play of the
selected response performed, and the actual behavior enacted in the
real-life situation. Initially therapists select actions likely to lead to
success, and, as clients gain more confidence, increasingly difficult
tasks are set.
In order to increase their belief that they can enact these behaviors
(i.e., to increase their sense of self-efficacy), clients are encouraged to
list several mildly pleasurable activities and then increase the fre-
quency with which they engage in these activities. Further, each client
is helped to generate a list of personal features that reflect his good (but
not necessarily remarkable) qualities, such as being a good worker, a
loyal friend, an interesting conversationalist, or a generous person. The
client then lists these on a pocket-sized card, which he reads several
times each day. We have shown that this combination of procedures,
enacted within the context of a supportive environment involving a
warm and empathic therapist, markedly enhances self-esteem (Mar-
shall, Champagne, Sturgeon, & Bryce, 1997; Marshall & Christie, 1982;
Marshall, Christie, Lanthier, & Cruchley, 1982).
Acceptance of Responsibility
The client's capacity to accept responsibility for his actions (not just
his offenses) develops throughout treatment. Initially, the client
describes the factors that influenced his decision to offend and the
behavioral steps he took to secure a victim and commit the offense.
Then, with the help of his therapist, he explores his associated thoughts
and feelings during these actions and their disclosure. Gradually the
client comes to understand that his way of looking at his offense refiects
no more than his perspective on what happened and is colored by his
need to reduce his culpability. This process challenges the client's belief
about the harm he did (or did not) cause, his remorse for the offense,
and his offense-facilitating schema. Once the client recognizes them, the
therapist challenges these attitudes, beliefs, feelings, and schema in a
firm but supportive manner, and continues to do so throughout treat-
ment whenever inappropriate views are expressed. We have provided
evidence that this approach over the course of treatment, does, indeed.
 STRATEGIES IN THE TREATMENT OF PARAPHILIAS 171

have the desired effects (Marshall, 1994; Marshall, O'SuUivan, & Fer-
nandez, 1996).
Coping and Mood Management
Sexual offenders tend to employ ineffective ways of coping with prob-
lems, and these inadequate coping responses lead to a sense of frustra-
tion (Cortoni & Marshall, 2001; Marshall, Cripps, Anderson, & Cortoni,
1999; Marshall, Serran, & Cortoni, 2000). By outlining effective and
ineffective coping styles (see Parker & Endler [1996] for a detailed
description of coping styles) we help clients recognize their dysfunc-
tional styles and the costs associated with these styles, as well as assist
them in developing more effective responses. In many cases, this
process results in the client's recognition that specific skills training is
necessary. At that point, we quickly move the client to the next compo-
nent, social skills, which addresses the majority of the skill deficits.
However, the most common skill deficit concerns the client's inability to
problem-solve effectively. To train clients in effective problem-solving
strategies, we follow procedures outlined by D'Zurilla (1988).
Our strategies are effective in developing adaptive coping responses
in sexual offenders (Serran, Firestone, Marshall, & Moulden, in press).
When clients develop effective coping styles, they reduce the emotional
turmoil they have experienced in the past as a result of inadequately
dealing with the difficulties of life. In addition, throughout treatment
we encourage clients to recognize and to express their emotions. These
various strategies help clients overcome a common problem among sex-
ual offenders, lack of emotional regulation (Ward & Hudson, 2000).
Social Skills
The primary focus for all clients in this component is on the skills,
attitudes, and self-beliefs that facilitate the formation of effective inter-
personal relationships. Beyond specifically training clients to develop
effective attachment styles in order to increase their future experience
of satisfaction and intimacy, we also train them to deal with anger and
anxiety and to become appropriately assertive.
As a first step in our relationship-training component, we ask each
client to describe one or more relationships he has had in the past. We
assist him in identifying the various behaviors that either enhanced the
relationship or caused problems. The therapist describes different styles
of romantic attachments and asks each client to identify his typical
attachment style. Through group discussion, participants clarify the
nature of intimacy, and the therapist describes what is known about the
benefits of intimacy. Clients receive training in communication skills.
172 W. L. MARSHALL, L. E. MARSHALL, & G. A. SERRAN

and rudimentary sex education focuses on behaviors that enhance sex-

ual satisfaction. Issues such as jealousy, loneliness, living alone, and the
value of mutually enjoyable activities are discussed in detail. These pro-
cedures significantly enhance intimacy skills and reduce loneliness
(Marshall, Bryce, Hudson, Ward, & Moth, 1996).
Sexual Interests
We (Marshall, Marshall, et al., 2006) have developed a protocol for
deciding when it is necessary to introduce procedures to modify sexual
interests. Although some sexual offenders display deviant patterns of
sexual arousal during phallometric testing, not all do (see Marshall &
Fernandez [2003] for both a description of phallometric procedures and
a summary of the evidence on the capacity of the procedure to identify
deviance). Thus, the goal of modifying deviant interests is not applica-
ble to all sexual offenders.
When it is necessary to reduce deviant arousal and enhance arousal to
appropriate sexual scenes, we employ one or more of the following proce-
dures: olfactory aversion, ammonia aversion, and masturbatory recondi-
tioning (which includes procedures for enhancing appropriate interests,
sometimes called thematic shift, and procedures for reducing deviant
arousal called satiation). These procedures are in common use in various
sexual offender treatment programs throughout the world (Abel, Osborn,
Anthony, & Gardos, 1992; Barbaree, Bogaert, & Seto, 1995; Hudson, Mar-
shall, Johnston, Ward, & Jones, 1995; Maletzky, 1991; McConaghy, 1993).
We have generated evidence on the effectiveness of these procedures
(Johnston, Hudson, & Marshall, 1992; Marshall, 2006a, 2006d, in press-
b) as have others (see literature review by Laws & Marshall, 1991).
For some clients, either unresponsive to these behavioral procedures
or so overwhelmed by their deviant thoughts that they cannot focus on
treatment, we employ pharmacological interventions. Still others who
are sexually preoccupied or have dangerous deviant interests (e.g., sex-
ual sadists) also require medical treatments. Such medical interven-
tions are seen as part of the total treatment approach. Commonly used
medications for these purposes include one or another of the so-called
antiandrogens (or hormonal interventions) to dampen libido, or one of
the selective serotonin reuptake inhibitors (SSRIs) to control sexual
preoccupation. Bradford (2000) and Glaser (2003) have described these
interventions and their effects.
Self-Management Plans
Relapse prevention approaches (Marques, 1982; Pithers, Marques,
Gibat, & Marlatt, 1983) to the treatment of sexual offending require
 STRATEGIES IN THE TREATMENT OF PARAPHILIAS 173

clients to develop an extensive set of avoidance plans. These plans are

meant to equip them with strategies to reduce involvement in situa-
tions and avoid internal states that would raise their risk to reofFend.
Clients are required to keep this list of avoidance plans with them at all
times for the foreseeable future after completing treatment. Criticisms
of this relapse prevention approach have heen proffered by several
authors (Laws, 1996, 2003; Laws & Ward, 2006; Marshall & Anderson,
2000; Marshall & Serran, 2000; Thornton, 1997; Ward & Hudson, 1996;
Ward, Hudson, & Siegert, 1995). Mann (2000), for example, pointed out
that avoidance goals are typically not sustainable over time and noted a
considerable body of literature in which approach goals are preferred
(Gollwitzer & Bargh, 1996). Thornton (1997) noted that the focus on
deviance in relapse prevention programs might make these behaviors
too visible and, therefore, too tempting. He also suggested that an
excessive attention to risk factors occurs in the absence of training
clients to cope with these risks. Finally, Marshall and Anderson (2000)
suggested that the Marques and Pithers approaches to relapse preven-
tion place unreasonable demands on clients, all but convincing them of
an inevitable relapse.
In our program only very limited avoidance goals are generated. For
example, a child molester will be required to avoid situations in which he
could be alone with children. We emphasize the development of positive
or approach goals that are exclusive of offending and that are enjoyable
to the client. By incorporating the basic elements of the good lives model
and emphasizing approach goals, we assist clients in developing self-
management plans that are easy to attain and that markedly increase
life satisfaction. Because the goals of these plans are desirable to clients,
they do not need to carry a list of plans with them after treatment. The
fewer actions clients have to take, and the more personally rewarding
are the things they have to do, the more likely they will succeed.
After Care
High-risk sexual offenders need supervision and further treatment
once released to the community. Some moderate risk clients may also
require postrelease supervision and treatment, but most will not; nei-
ther will low risk offenders. Clients do, however, need to identify an
effective group of people (professionals, friends, family, workmates) who
can serve as supports upon their return to the community. The more
adequate these support groups are, the greater the chances the clients
will not reoffend (Wilson & Picheca, in press).
Although some jurisdictions (mostly in the U.S.) have sexual offender
registers and require public notification for released sexual offenders.
174 W. L. MARSHALL, L. E. MARSHALL, & G. A. SERRAN

these strategies seem, in many cases, more likely to increase than to

decrease risk. Marshall, Marshall, et al., (2006) criticized these
approaches. They suggested that public notification is more likely to
increase reoffending because of the stress the offender experiences.
Thus Marshall, Marshall, et al. suggested public notification should be
used only with extremely dangerous cases when alternative contain-
ment strategies are not available. Sexual offender registers could be of
considerable help to police investigating a sexual crime when they have
no suspects. Awareness that known sexual offenders are in the area
where a sexual crime was committed could serve to generate suspects.
However, to ensure the client's right to privacy, restricted access to such
registers must be enforced.
Treatment Effectiveness
Some claim that sexual offender treatment has not yet been shown to
be effective (McConaghy, 1999; Quinsey, Harris, Rice, & Lalumiere,
1993; Rice & Harris, 1997, 2003), while others take a more optimistic
view of the evidence. Some of these differences of opinion result from
differing views about the type of design that should be employed to
appraise treatment.
Rice and Harris (2003) have consistently argued that the only design
providing a basis for inferring unequivocally the effectiveness of treat-
ment is the Random Controlled Trial (RCT). Yet the general clinical lit-
erature contains an ongoing debate about the value of the RCT design
in evaluating effectiveness (see Persons & Silberschatz [1998] for a
summary). Martin Seligman (1995, 1996) most notably opposed the use-
fulness of the RCT design, declaring it to be "the wrong method for
empirically vahdating psychotherapy as it is actually done" (Seligman,
1995, p. 966). He made the point that the crucial elements of effective
clinical practice cannot be reproduced within the RCT design. This
debate is ongoing in the general offender field as well (see Hollin, in
press). Within the sexual offender field, Marshall (1993, 2006b; Mar-
shall & Pithers, 1994) has pointed to practical and ethical problems
with the RCT design. Most institutional systems funding sexual
offender treatment (e.g., prison systems, psychiatric facilities) would
very likely balk at any suggestion that some sexual offenders under
their care be allocated to a no-treatment condition and later released to
the community among potential victims. If anyone has the right to
allow sexual offenders to go untreated in such a study, it should be the
potential victims. Whatever the eventual outcome of this debate over
what constitutes a satisfactory design, there are still available data,
although of varying quality, that lead to grounds for optimism.
 STRATEGIES IN THE TREATMENT OF PARAPHILIAS 175

Hanson et al. (2002) gathered studies (some published, some not)

from around the world, including in their analyses only those studies
that met both of these criteria: They relied on official recidivism as the
index of success or failure, and they included a comparison group of
matched untreated offenders. Some, but few, of these used the RCT
design. Other programs, unable to treat all available offenders due to
lack of resources or to high refusal rates, obtained an available pool of
untreated offenders as a comparison group. These employed an "inci-
dental design." Hanson et al. identified 42 studies of sufficient method-
ological status from which to infer treatment effectiveness. These
involved over 9,000 sexual offenders, approximately half of whom had
received treatment. In their meta-analysis, they found that programs
which did not employ a cognitive behavioral (CBT) approach to treat-
ment were ineffective. Graduates of CBT programs recidivated at a rate
of 9.9%, whereas the untreated comparison subjects reoffended at a rate
of 17.3%, a statistically significant difference. CBT also reduced general
recidivism: Treated subjects had a nonsexual reoffending rate of 28.7%,
whereas untreated offenders had a recidivism rate of 41.7%.
A more recent, and more comprehensive, meta-analysis of treatment
outcome studies with sexual offenders has been reported by Losel and
Schmucker (2005). Going beyond the English language literature, they
identified 69 studies, involving 22,181 sexual offenders, in which
treated subjects were compared with an untreated group. Losel and
Schmucker's findings were quite similar to the observations of Hanson
et al. (2002). They found that treated sexual offenders had a sexual
recidivism rate of 11.1%, whereas the untreated subjects recidivated at
17.5%. Similar effects were found with any reoffense (treated = 22.4%,
untreated = 32.5%). In addition, Losel and Schmucker found, as did
Hanson et al., that only cognitive behavioral programs produced signifi-
cant reductions in recidivism. Nonbehavioral approaches failed to
demonstrate any treatment benefits.
Losel and Schmucker (2002) reported almost equivalent effects for
prison-based and community-based treatment programs, a result which
again matches what Hanson et al. (2002) reported. Three additional
sets of analyses are reported by Losel and Schmucker. They found a
lower effect for group treatment (odds ratio = 1.71) than for individual
treatment (odds ratio = 2.88), which may be particularly surprising to
North American treatment providers, the majority of which employ
group therapy (McGrath, Cumming, & Burchard, 2003). Losel and
Schmucker also reported differential effect sizes for different types of
sexual offenders: rapists showing the best response to treatment (odds
ratio = 4.91), nonfamilial child molesters the next best response (odds
176 W. L. MARSHALL, L. E. MARSHALL, & G. A. SERRAN

ratio - 2.15), and incest offenders the lowest, but still a significantly
positive, response (odds ratio = 1.02). Finally, these authors found that
only those sexual offenders who successfully completed treatment
showed a significant benefit. This latter observation is consistent with a
report by Marques, Weideranders, Day, Nelson and van Ommeren
(2005) that summarized their final findings of California's Sex Offender
Treatment and Evaluation study of sexual offender treatment. Measur-
ing the degree to which sexual offenders achieved the goals of treat-
ment. Marques et al. found that those who "got it" achieved
significantly and dramatically lower rates of postrelease recidivism
than did those who did not successfully complete treatment.
We (Marshall, Marshall, et al., 2006) recently reported some details
of our examination of the overall reoffense rates for our treated sexual
offenders. We followed 534 treated sexual offenders for an average of 5.4
years, 48% of whom were at risk for over 6 years. Because we are able
to recruit over 94% of available sexual offenders into our treatment pro-
gram, we have an insufficient number of untreated clients to form a
comparison group; however, we do have data on the actuarial risk levels
of our treated clients calculated prior to their entering treatment. The
actuarial instruments employed in this study were developed after
extensive examination of many hundreds of offenders followed for sev-
eral years after release (see Doren [2006], Hanson & Thornton [2000]
and Andrews & Bonta [2001] for a description of these instruments).
Based on these risk assessment instruments, the expected reoffense
rates for our treated subjects were 16.8% for sexual offenses and 40%
for nonsexual crimes. What we actually found was that only 3.2% of our
treated clients committed a subsequent sexual offense and that 13.6%
reoffended in a nonsexual way.
On the basis of these and other studies, we believe the evidence indi-
cates that sexual offenders can be effectively treated. Of course, not all
treatment programs for sexual offenders are effective, but given the dif-
ficult nature of these clients and their usual resistance to treatment, we
would not expect all programs to be effective. We think it is quite inap-
propriate to conclude, when any particular program is shown to be inef-
fective, that sexual offenders in general, or even the ones treated in this
program failure, are intractable to treatment. Such a conclusion essen-
tially blames the client. Instead, the correct response should examine
what might have caused the failure and attempt to redesign treatment.
Only through the sound application of therapeutic principles accom-
panied by continuous examination of the effectiveness of procedures,
and holding ourselves (i.e., the treatment providers) responsible for
improving our treatment approach, will treatment for sexual offenders
 STRATEGIES IN THE TREATMENT OF PARAPHILIAS 177

evolve to the point where all will agree that it is effective. Only when we
treatment providers apply sound therapeutic principles and continu-
ously examine the effectiveness of our procedures, and also welcome
responsibility for improving our treatment approaches, will treatment
for sexual offenders prove truly effective.
review befor
References submission
Abel, G. G., Osborn, C. A., Anthony, D., & Gardos, P. (1992). Current treatments of para-
philiacs. Annual Review of Sex Research, 3, 255-290.
Abracen, J., & Looman, J. (2004). Issues in the treatment of sexual offenders: Recent
developments and directions for future research. Aggression and Violent Behavior: A
Review Journal, 9, 229-246.
Alexander, J. R, Barton, C, Schiavo, S., & Parsons, B. V. (1976). Systems-behavioral inter-
vention with families of delinquents: Therapists characteristics, family behavior and
outcome. Journal of Consulting and Clinical Psychology, 44, 656-644.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental dis-
orders (4th ed., text rev.). Washington, DC: Author.
Andrews, D. A., & Bonta, J. (2001). The psychology of criminal conduct (3rd ed.). Cincin-
nati, OH: Anderson.
Barbaree, H. E., Bogaert, A. F., & Seto, M. C. (1995). Sexual reorientation therapy: Prac-
tices and controversies. In L. Diamant & R. D. McNulty (Eds.), The psychology of sex-
ual orientation, behavior, and identity: A handbook (pp. 357-383). Westport, CT:
Greenwood.
Beech, A. R., & Fordham, A. S. (1997). Therapeutic climate of sexual offender treatment
programs. Sexual Abuse: A Journal of Research and Treatment, 9, 219-237.
Beech, A. R., & Hamilton-Giachritsis, C. E. (2005). Relationship between therapeutic cli-
mate and treatment outcome in group-based sexual offender treatment programs. Sex-
ual Abuse: A Journal of Research and Treatment, 17, 127-140.
Blackburn, R. (1993). The psychology of criminal conduct: Theory, research and practice.
Chichester, UK: Wiley
Bradford, J. M. W. (2000). The treatment of sexual deviation using a pharmacological
approach. The Journal of Sex Research, 37, 248-257.
Burton, D., & Cerar, K. (2005, November). Therapeutic alliance. Paper presented at the
24th Annual Research and Treatment Conference of the Association for the Treat-
ments of Sexual Abusers, Salt Lake City, UT.
Carich, M. S., & Calder, M. C. (2003). Contemporary treatment of adult male sex offenders.
PljTnouth, UK: Russell House Publishing.
Cortoni, F. A., & Marshall, W. L. (2001). Sex as a coping strategy and its relationship to
juvenile sexual history and intimacy in sexual offenders. Sexual Abuse: A Journal of
Research and Treatment, 13, 27-43.
Deci, E. L., & Ryan, R. M. (2000). The "what" and "whjf" of goal pursuits: Human needs
and the self-determination of behavior. Psychological Inquiry, 11, 227-268.
Doren, D. M. (2006). Recidivsm risk assessments: Making sense of controversies. In W. L.
Marshall, Y. M. Fernandez, L. E. Marshall, & G. A. Serran (Eds.), Sexual offender
treatment: Controversial issues (pp. 3-15). Chichester, UK: Wiley.
Drapeau, M. (2005). Research on the processes involved in treating sexual offenders. Sex-
ual Abuse: A Journal of Research and Treatment, 17, 117-125.
D'Zurilla, T. J. (1988). Problem-solving therapies. In K. S. Dobson (Ed.), Handbook of cog-
nitive-behavioral therapies (pp. 85-135). New York: Pergamon Press.
Emmons, R. A. (1996). Striving and feeling: Personal goals and subjective well-being. In P.
M. Gollwitzer & J. A. Bargh (Eds.), The psychology of action: Linking cognition and
motivation to behavior (pp. 313-337). New York: Guilford.Press
178 W. L. MARSHALL, L. E. MARSHALL, & G. A. SERRAN

Emmons, R. A. (1999). The psychology of ultimate concerns. New York: Guilford Press.
Fanniff, A. M., & Becker, J. V. (2006). Specialized assessment and treatment of adolescent
sex offenders. Aggression and Violent Behavior: A Review Journal, 11, 265-282.
Gendreau, P. (1996). Offender rehabilitation: What we know and what needs to be done.
Criminal Justice and Behavior, 23, 144-161.
Glaser, W (2003). Integrating pharmacological treatments. In T Ward, D. R. Laws, & S.
M. Hudson (Eds.), Sexual deviance: Issues and controversies (pp. 262-279). Thousand
Oaks, CA: Sage.
Gollwitzer, P. M., & Bargh, J. A. (Eds.). (1996). The psychology of action: Linking cognition
and motivation to behavior. New York: Guilford Press.
Green, R. (1995). Comprehensive treatment planning for sex offenders. In B. K. Schwartz
& H. R. Cellini (Eds.), The sex offender: Corrections, treatment and legal practice (Vol.
1, pp. 10.1-10.9). Kingston, NJ: Civic Research Publications.
Hanson, R. K., & Bussiere, M. T. (1998). Predicting relapse: A meta-analysis of sexual
offender recidivism. Journal of Consulting and Clinical Psychology, 66, 348-362.
Hanson, R. K., Gordon, A., Harris, A. J. R., Marques, J. K., Murphy, W. D., Quinsey, V. L.,
& Seto, M. C. (2002). First report of the Collaborative Outcome Data Project on the
Effectiveness of Psychological Treatment of Sex Offenders. Sexual Abuse: A Journal of
Research and Treatment, 14, 169-195.
Hanson, R. K., & Harris, A. J. R. (2000). Where should we intervene? Dynamic predictors
of sex offender recidivism. Criminal Justice and Behavior, 27, 6-35.
Hanson, R. K., & Thornton, D. (2000). Improving risk assessments for sex offenders: A
comparison of three actuarial scales. Law and Human Behavior, 24, 119-136.
Hollin, C. R. (in press). Offending behaviour programmes and contention: Evidence-based
practice, manuals, and programme evaluation. In C. R. Hollin & E. J. Palmer (Eds.),
Offending behaviour programmes: Development, application, and controversies. Chich-
ester, U.K.: Wiley.
Hudson, S. M., Marshall, W. L., Johnston, P., Ward, T, & Jones, R. L. (1995). Kia Marama:
New Zealand Justice Department's programme for incarcerated child molesters.
Behaviour Change, 12, 69-80.
Hudson, S. M., Wales, D. S., Bakker, L. W, & Ward, T (2002). Dynamic risk factors: The Kia
Marama evaluation. Sexual Abuse: A Journal of Research and Treatment, 14, 103-119.
Johnston, P., Hudson, S. M., & Marshall, W L. (1992). The effects of masturbatory recon-
ditioning with nonfamilial child molesters. Behaviour Research and Therapy, 30, 559-
561.
Kirsch, L. G., & Becker, J. V. (2006). Sexual offending: Theory of problem, theory of
change, and implications for treatment effectiveness. Aggression and Violent Behavior:
A Review Journal, 11, 208-224.
Laws, D. R. (1996). Relapse prevention or harm reduction? Sexual Abuse: A Journal of
Research and Treatment, 8, 243-247.
Laws, D. R. (2003). Harm reduction and sexual offending: Is an intraparadigmatic shift
possible? In T. Ward, D. R. Laws, & S. M. Hudson (Eds.), Sexual deviance: Issues and
controversies (pp. 280-296). Thousand Oaks, CA: Sage.
Laws, D. R., & Marshall, W. L. (1991). Masturbatory reconditioning with sexual deviates:
An evaluative review. Advances in Behaviour Research and Therapy, 13, 13-25.
Laws, D. R., & O'Donohue, W (Eds.). (1997). Sexual deviance: Theory, assessment, and
treatment. New York: Guilford Press.
Laws, D. R., & Ward, T (2006). When one size doesn't fit all: The reformulation of relapse
prevention. In W L. Marshall, Y. M. Fernandez, L. E. Marshall, & G. A. Serran (Eds.),
Sexual offender treatment: Controversial issues (pp. 241-254). Chichester, UK: Wiley.
Levenson, J. S. (2004). Reliability of sexually violent predator civil commitment criteria.
Law & Human Behavior, 28, 357-368.
Linley, P. A., & Joseph, S. (Eds.). (2004). Positive psychology in practice. Hoboken, NJ:
Wiley
 STRATEGIES IN THE TREATMENT OF PARAPHILIAS 179

Losel, F., & Schmucker, M. (2005). The effectiveness of treatment for sexual offenders: A
comprehensive meta-analysis. Journal of Experimental Criminology, 1, 1-29.
Maletzky, B. M. (1991). Treating the sexual offender. Newbury Park, CA: Sage.
Mann, R. E. (2000). Managing resistance and rebellion in relapse prevention intervention.
In D. R. Laws, S. M. Hudson, & T. Ward (Eds.), Remaking relapse prevention with sex
offenders; A sourcebook (pp. 187-200). Thousand Oaks, CA: Sage.
Mann, R. E., & Webster, S. (2002, October). Understanding resistance and denial. Paper
presented at the 21st Annual Research and Treatment Conference of the Association
for the Treatment of Sexual Abusers, Montreal.
Marques, J. K. (1982, March). Relapse prevention: A self-control model for the treatment of
sex offenders. Paper presented at the 7th Annual Forensic Mental Health Conference,
Asilomar, CA.
Marques, J. K., Weideranders, M., Day, D. M., Nelson, C, & van Ommeren, A. (2005).
Effects of a relapse prevention program on sexual recidivism: Final results from Cali-
fornia's Sex Offender Treatment and Evaluation Project (SOTEP). Sexual Abuse: A
Journal of Research and Treatment, 17, 79-107.
Marshall, L. E., & Marshall, W L. (2006). A motivational preparatory program for sexual
offenders. Manuscript in preparation.
Marshall, W L. (1993). The treatment of sex offenders: What does the outcome data tell
us? A reply to Quinsey et al. Journal of Interpersonal Violence, 8, 524-530.
Marshall, W. L. (1994). Treatment effects on denial and minimization in incarcerated sex
offenders. Behaviour Research and Therapy, 32, 559-564.
Marshall, W. L. (1997). Pedophilia: Psychopathology and theory. In D. R. Laws &
W. O'Donohue (Eds.), Handbook of sexual deviance: Theory and application (pp. 152-
174). New York: Guilford Press.
Marshall, W. L. (2005). Therapist style in sexual offender treatment: Influences on indices
of change. Sexual Abuse: A Journal of Research and Treatment, 17, 109-117.
Marshall, W. L. (2006a). Ammonia aversion with an exhibitionist: A case study. Clinical
Case Studies, 5, 15-24.
Marshall, W. L. (2006b). Appraising treatment outcome with sexual offenders. In W L.
Marshall, Y. M. Fernandez, L. E. Marshall, & G. A. Serran (Eds.), Sexual offender
treatment: Controversial issues (pp. 255-273). Chichester, UK: Wiley.
Marshall, W L. (2006c). Diagnostic problems with sexual offenders. In W. L. Marshall, Y.
M. Fernandez, L. E. Marshall, & G. A. Serran (Eds.), Sexual offender treatment: Con-
troversial issues (pp. 33-43). Chichester, UK: Wiley.
Marshall, W L. (2006d). Olfactory aversion and directed masturbation in the modification
of deviant preferences: A case study of a child molesters. Clinical Case Studies, 5, 3-14.
Marshall, W. L. (in press-a). Covert association: A case illustration. Clinical Case Studies.
Marshall, W. L. (in press-b). Diagnostic issues, multiple paraphilias, and comorbid disor-
ders in sexual offenders: Their incidence and treatment. Aggression and Violent Behav-
ior: A Review Journal.
Marshall, W. L., Anderson, D. (2000). Do relapse prevention components enhance treat-
ment effectiveness? In D. R. Laws, S. M. Hudson, & T. Ward (Eds.), Remaking relapse
prevention with sex offenders: A sourcebook (pp. 39-55). Thousand Oaks, CA: Sage.
Marshall, W. L., Anderson, D., & Fernandez, Y. M. (1999). Cognitive behavioural treatment
of sexual offenders. Chichester, UK: Wiley.
Marshall, W L., Bryce, P., Hudson, S. M., Ward, T, & Moth, B. (1996). Enhancement of
intimacy and the reduction of loneliness among child molesters. Journal of Family Vio-
lence, 11, 219-235.
Marshall, W. L., Champagne, F., Sturgeon, C, & Bryce, P. (1997). Increasing the self-
esteem of child molesters. Sexual Abuse: A Journal of Research and Treatment, 9, 321-
333.
Marshall, W. L., & Christie, M. M. (1982). The enhancement of social self-esteem. Cana-
dian Counsellor, 16, 82-89.
180 W. L. MARSHALL, L. E. MARSHALL, & G. A. SERRAN

Marshall, W. L., Christie, M. M., Lanthier, R. D., & Cruchley, J. (1982). The nature of the
reinforcer in the enhancement of social self-esteem. Canadian Counsellor, 16, 90-96.
Marshall, W. L., Cripps, E., Anderson, D., & Cortoni, F. A. (1999). Self-esteem and coping
strategies in child molesters. Journal of Interpersonal Violence, 14, 995-962.
Marshall, W. L., & Fernandez, Y. M. (2003). Phallometric testing with sexual offenders:
Theory, research, and practice. Brandon, VT: Safer Society Press.
Marshall, W. L., Fernandez, Y. M., Hudson, S. M., & Ward, T (Eds.), (1998). Sourcebook of
treatment programs for sexual offenders. New York: Plenum Press.
Marshall, W. L., Fernandez, Y M., Serran, G. A., Mulloy, R., Thornton, D., Mann, R. E., &
Anderson, D. (2003). Process variahles in the treatment of sexual offenders: A review of
the relevant literature. Aggression and Violent Behavior: A Review Journal, 8, 205-234.
Marshall, W. L., & Kennedy, P. (2003). Sexual sadism in sexual offenders: An elusive diag-
nosis. Aggression and Violent Behavior: A Review Journal, 8, 1-22.
Marshall, W. L., Kennedy, P., & Yates, P. (2002). Issues concerning the reliahility and
validity of the diagnosis of sexual sadism applied in prison settings. Sexual Abuse: A
Journal of Research and Treatment, 14, 310-311.
Marshall, W. L., Kennedy, P., Yates, P., & Serran, G. A. (2002). Diagnosing sexual sadism
in sexual offenders: Reliability across diagnosticians. International Journal of Offender
Therapy and Comparative Criminology, 46, 688-676.
Marshall, W. L., & Marshall, L. E. (2006). Manual for the Rockwood Psychological Services
Preparatory Program. (Availahle from Rockwood Psychological Services, Suite 403, 303
Bagot Street, Kingston, ON, K7K 5W7, Canada)
Marshall, W. L., Marshall, L. E., Serran, G. A., & Fernandez, Y. M. (2006). Treating sexual
offenders: An integrated approach. New York: Routledge.
Marshall, L. E., & Moulden, H. M. (2006). Preparatory programs for sexual offenders. In
W. L. Marshall, Y. M. Fernandez, L. E. Marshall, & G. A. Serran (Eds.), Sexual offend-
ers treatment: Controversial issues (199-210). Chichester, UK: Wiley.
Marshall, W. L., O'SuIlivan, C, & Fernandez, Y. M. (1996). The enhancement of victim
empathy among incarcerated child molesters. Legal and Criminological Psychology, 1,
95-102.
Marshall, W. L., & Pithers, W. D. (1994). A reconsideration of treatment outcome with sex
offenders. Criminal Justice and Behavior, 21, 10-27.
Marshall, W. L., & Serran G. A. (2000). Current issues in the assessment and treatment of
sexual offenders. Clinical Psychology and Psychotherapy, 7, 85-96.
Marshall, W. L., & Serran, G. A. (2004). The role of the therapist in offender treatment.
Psychology. Crime and Law, 10, 309-320.
Marshall, W L., Serran, G. A., & Cortoni, F. A. (2000). Childhood attachments, sexual
abuse, and their relationship to adult coping in child molesters. Sexual Abuse: A Jour-
nal of Research and Treatment, 12, 17-26.
Marshall, W. L., Serran, G. A., Fernandez, Y. M., Mulloy, R., Mann, R. E., & Thornton, D.
(2003). Therapist characteristics in the treatment of sexual offenders: Tentative data
on their relationship with indices of behaviour change. Journal of Sexual Aggression,
9, 25-30.
Marshall, W. L., Serran, G. A., & Marshall, L. E. (2006). Manual for the Rockwood Psycho-
logical Services Sexual Offender Treatment Program. (Available from Rockwood Psy-
chological Services, Suite 403, 303 Bagot Street, Kingston, ON, K7K 5W7, Canada)
Marshall, W L., Serran, G. A., Moulden, H., Mulloy, R., Fernandez, Y. M., Mann, R. E., &
Thornton, D., (2002). Therapist features in sexual offender treatment: Their reliable
identification and influence on behaviour change. Clinical Psychology and Psychother-
apy, 9, 395-405.
Martin, D. J., Graske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance
with outcome and other variables: A meta-analytic review. Journal of Consulting and
Clinical Psychology, 68, 438-450.
Maslow, A. H. (1954). Motivation and personality. New York: Harper & Row.
 STRATEGIES IN THE TREATMENT OF PARAPHILIAS 181

McConaghy, N. (1993). Sexual behavior: Problems and management. New York: Plenum
Press.
McConaghy, N. (1999). Methodological issues concerning evaluation of treatment for sex-
ual offenders: Randomization, treatment dropout, untreated controls, and within-
treatment studies. Sexual Abuse: A Journal of Research and Treatment, 11, 183-193.
McGrath, R. J., Cumming, G. F., & Burchard, B. L. (2003). Current practices and trends in
sexual abuser management: The Safer Society 2002 Nationwide Survey. Brandon, VT:
Safer Society Press.
McGuire, J. (Ed.). (1995). What works: Reducing reoffending-guidelines from research and
practice. Chichester, UK: Wiley.
McGuire, J. (2001). What works in correctional intervention? Evidence and practical
implications. In G. A. Bernfeld, D. P. Farrington, & A. W. Leschild (Eds.), Offender
rehabilitation in practice: Implementing and evaluating effective programs (pp. 25-43).
Chichester, UK: Wiley
Morgan, R., Luhorsky, L., Crits-Christoph, P., Curtis, H., & Solomon, J. (1982). Predicting
outcomes of psychotherapy by the Penn Helping Alliance Rating Method. Archives of
General Psychiatry, 39, 397-402.
O'Donohue, W. T., Regev, L. G, & Hagstrom, A. (2000). Problems with the DSM-IV diagno-
sis of pedophilia. Sexual Abuse: A Journal of Research and Treatment, 12, 95-105.
Parker, J. D. A., & Endler, N. S. (1996). Coping and defense: A historical overview. In M.
Zeidner & N. S. Endler (Eds.), Handbook of coping: Theory, research, applications (pp.
3-23). New York: Wiley
Persons, J. B., & Silberschatz, G. (1998). Are the results of randomized controlled trials use-
ful to psychotherapists? Journal of Consulting and Clinical Psychology, 66, 126-135.
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 J. G. Greer & I. R. Stuart (Eds.), The sexual aggressor: Current perspectives on treat-
ment (pp. 214-239). New York: Van Nostrand Reinhold.
Proulx, J., Pelierin, B., Paradis, Y, McKibben, A., Aubut, J., & Ouimet, M. (1997). Static
and djTiamic predictors of recidivism in sexual aggressors. Sexual Abuse: A Journal of
Research and Treatment, 9, 7-28.
Quinsey, V. L., Harris, G. T., Rice, M. E., & Lalumiere, M. L. (1993). Assessing treatment
efficacy in outcome studies of sex offenders. Journal of Interpersonal Violence, 8, 512-
523.
Rice, M. E., & Harris, G. T. (1997). The treatment of adult offenders. In D. M Stoff, J.
Breiling, & J. D. Maser (Eds.), Handbook of antisocial behavior (pp. 425-435). New
York: Wiley
Rice, M. E., & Harris, G. T. (2003). The size and sign of treatment effects in sex offender
therapy. Annals of the New York Academy of Science, 989, 428-440.
Rogers, R., & Dickey, R. (1991). Denial and minimization among sex offenders: A review of
competing models of deception. Annals of Sex Research, 4, 49-63.
Schmuck, P., & Sheldon, K. M. (Eds.). (2001). Life goals and well-being. Toronto: Hogrefe
& Huher.
Schwartz, B. K. (1995). Introduction to the integrative approach. In B. K. Schwartz & H.
R. Cellini (Eds.). The sex offender: Corrections, treatment and legal practice (Vol. I, pp.
1.1-1.13). Kingston, NJ: Civic Research Publications.
Schwartz, B. K. (2002). The JRI model for treating varied populations with inappropriate
sexual behavior. In B. K. Schwartz (Ed.), The sex offender: Current treatment modali-
ties and systems issues (Vol. IV, pp. 1.1-1.30). Kingston, NJ: Civic Research Publica-
tions.
Seligman, M. E. P. (1995). The effectiveness of psychotherapy: The Consumer Reports
Study. American Psychologist, 50, 965-974.
Seligman, M. E. P. (1996). Science as an ally of practice. American Psychologist, 51, 1072-
1079.
182 W. L. MARSHALL, L. E. MARSHALL, & G. A. SERRAN

Serran, G. A., Firestone, P., Marshall, W. L., & Moulden, H. (in press). Changes in coping
following treatment for child molesters. International Journal of Offender Therapy and
Comparative Criminology.
Simons, D., Tyler, C, & Lins, R. (2005, November). Influence of therapist characteristics on
treatment progress. Paper presented at the 24th Annual Research and Treatment Con-
ference of the Association for the Treatments of Sexual Abusers, Salt Lake City, UT.
Thornton, D. (1997, October). 7s relapse prevention really necessary? Paper presented at
the 16th Annual Research and Treatment Conference of the Association for the Treat-
ment of Sexual Abusers, Arlington, VA.
Ward, T, & Hudson, S. M. (1996). Relapse prevention: A critical analysis. Sexual Abuse: A
Journal of Research and Treatment, 8, 177-200.
Ward, T, & Hudson, S. M. (2000). A self-regulation model of relapse prevention. In D. R.
Laws, S. M. Hudson, & T. Ward (Eds.), Remaking relapse prevention with sex offenders:
A sourcebook (pp. 79-101). Thousand Oaks, CA: Sage.
Ward, T, Hudson, S. M., & Siegert, R. J. (1995). A critical comment on Pithers' relapse
prevention model. Sexual Abuse: A Journal of Research and Treatment, 7, 167-175.
Ward, T, & Marshall, W. L. (2004). Good lives, aetiology and the rehabilitation of sex
offenders: Abridging theory. Journal of Sexual Aggression, 10, 153-169.
Ward, T, & Stewart, C. A. (2003a). Criminogenic needs or human needs: A theoretical cri-
tique. Psychology, Crime & Law, 9, 125-143.
Ward, T, & Stewart, C. A. (2003b). Good lives and the rehabilitation of sexual offenders.
In T. Ward, D. R. Laws, & S. M. Hudson (Eds.), Sexual deviance: Issues and controver-
sies (pp. 12-44). Thousand Oaks, CA: Sage.
Ward, T, & Stewart, C. A. (2003c). The treatment of sex offenders: Risk management and
good lives. Professional Psychology: Research and Practice, 34, 353-360.
Wilson, R. J., & Pichea, J. E. (in press). Circles of support and accountability: Engaging
the community of sexual offender risk management. In B. K. Schwartz (Ed.), The sex
offender: Theoretical advances, treating special populations and legal developments
(Vol. V). Kingston, NJ: Civic Research Institute.

how to cite a citation in aquote