Comparative Criminology International Journal of

International Journal of Offender Therapy and Comparative Criminology http://ijo.sagepub.com/

A Plan Analysis of Pedophile Sexual Abusers' Motivations for Treatment: A Qualitative Pilot Study Martin Drapeau, Annett Körner, Luc Granger, Louis Brunet and Franz Caspar Int J Offender Ther Comp Criminol 2005 49: 308 DOI: 10.1177/0306624X04272853 The online version of this article can be found at: http://ijo.sagepub.com/content/49/3/308

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A Plan Analysis of Pedophile Sexual Abusers’ Motivations for Treatment: A Qualitative Pilot Study Martin Drapeau Annett Körner Luc Granger Louis Brunet Franz Caspar Abstract: Many authors have suggested adapting treatment programs to the specific needs of sexual abusers. However, little research has been conducted to understand what these patients seek in therapy or what elements play a key role in keeping them in treatment. In this pilot study, fifteen (N = 15) pedophile sexual abusers from La Macaza clinic for sexual abusers were interviewed. Plan analysis was used to investigate the most prevalent components involved in staying in or leaving therapy. Results suggest that many components involved in the plans leading to doing and to avoiding treatment were similar. Differences were found in regards to the outcome of confrontations with the therapists, a tendency to isolate and overcomply, guilt related to the abuse, a need for a stable environment, and a need to be accepted. These results are discussed along with possible ways to improve the patients’ involvement in treatment. Keywords: pedophilia; sex abusers; child molesters; sexual offenders; treatment motivation; plan analysis

Researchers and clinicians have taken up the challenge of studying and treating sex abusers and have elaborated treatment programs in different environments. The assessment of these programs generally suggests that cognitive-behavioral treatments are efficient in reducing recidivism. However, the effects of these treatments are limited by a number of factors, including treatment dropout and noncompliance. Relative to treatment completers, dropouts have been shown to have higher recidivism rates, regardless of the type of treatment provided (Hanson et al.,

NOTE: This project was supported by a Quebec Government Fonds pour la Formation de Chercheurs et l’Aide à la Recherche (FCAR) Doctoral Grant and by a FCAR Foreign Exchange Research Grant to the first author. It was approved by the Correctional Service of Canada (Project 1440-1 R71) and by La Macaza Federal Penitentiary. The position expressed in this article does not necessarily reflect the Correctional Service of Canada’s policies. Correspondence concerning this article should be addressed to Dr. Martin Drapeau, ECP - McGill University, 3700 McTavish Street, Montreal, Quebec, H3A 1Y2, Canada; e-mail: [email protected]. International Journal of Offender Therapy and Comparative Criminology, 49(3), 2005 308-324 DOI: 10.1177/0306624X04272853  2005 Sage Publications

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Treatment Motivation for Pedophiles

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2002; Marques, Day, Nelson, & West, 1994). Furthermore, according to Hanson and colleagues (2002), an interrupted treatment may make offenders worse. Rates of attrition vary according to offender characteristics such as youth, impulsivity, and self-control (Marques et al., 1994), motivation (Murphy & Baxter, 1997), social and sexual skills (Chaffin, 1994), and antisocial traits (Wierzbicki & Pekarik, 1993) but also according to treatment settings and types of program. For the Correctional Service of Canada, the dropout rate has been estimated at 18% across all programs (Serin, 2001). Although some programs for highly resistant offenders report attrition rates of 20% (Serin, 2001), other studies suggest dropout rates may be higher. For example, in Abel, Mittelman, Becker, and Rathner’s report (1988) on a voluntary 30-week outpatient treatment, attrition was close to 35%. For juvenile sexual offenders, treatment interruption seems more prevalent, with attrition occasionally reaching 50% (Hunter & Figueredo, 1999). To reduce attrition and maximise the positive effects of therapy programs, clinicians have suggested to take into consideration the different psychological characteristics of sexual abusers (Aubut, Proulx, Lamoureux, & McKibben, 1998) and to adapt treatment programs to the abusers’ needs (Lee et al., 1996). As such, adapting the therapy to the abuser may represent an additional step toward greater efficacy of interventions. Despite this, few studies have been conducted to better understand why sex abusers seek treatment or what elements play a key role in keeping them in or out of therapy. The current study attempted to address these issues. It is a small-sample pilot study aiming at understanding what keeps pedophile sex abusers in treatment. METHOD PARTICIPANTS Fifteen (N = 15) male pedophile sexual abusers between age 33 and 55 years (M = 44.13, SD = 7.79) participated in the current study. The participants were selected according to the following criteria: (a) meeting DSM-IV criteria for pedophilia, (b) having been sentenced to a federal penitentiary term following the sexual abuse of children, (c) absence of psychosis, and (d) having completed the first phase of the specialized treatment program offered at La Macaza (see below for details on the treatment program). These 15 participants were not the only patients in treatment at La Macaza at the time of the study. Unlike the other 10 patients in treatment, the participants included in the current study had (a) exclusively molested victims outside their family (extrafamilial abuse), (b) had never abused female victims (or male and female), (c) had never committed murder, and (d) had never abused teenagers between age 12 and 17 years (hebephilia). These


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last inclusion criteria were selected to increase homogeneity within the sample while providing us with the opportunity to keep as many participants as possible in the current study. This decision was based on the expectation that sexual murderers and sadistic child rapists, offenders who abused within and outside the family or abused girls and boys, could potentially present different dynamics and motives for treatment. All participants had exclusively sexually abused extrafamilial male children younger than age 11 years. Only three participants had at any given time in their life maintained an intimate relationship with a partner their age for a period of at least 6 months. They all had more than four victims, and six participants had already participated in at least one form or another of therapy as a result of their sexual deviance prior to their admission at the penitentiary. All offences involved touching the genitals of the victim, oral sex, or a complete intercourse. The participants were incarcerated for a pedophile offence at the time of the current study and had undertaken a treatment program at La Macaza clinic. THE TREATMENT The treatment clinic of La Macaza’s federal penitentiary offers, since 1992, an intensive treatment program for all types of sexual abusers excluding those presenting an active psychosis. The program is based on cognitive-behavioral therapy and relapse prevention (see Earls, 1997). It includes group sessions, individual sessions and regular assessment meetings. Group therapy includes a dozen participants and is led by two therapists on a daily basis for 3 hours, excluding weekends. The program is divided into two phases, each phase lasting 4 months. The first phase involves discussing motivation for change, analyzing the patient’s offence cycle, increasing personal responsibility, and cognitive restructuring. These four steps generally aim at helping the patient develop greater motivation for change and determine which factors could keep him from truly investing in therapeutic work. Furthermore, possible benefits from behavior change and crime precipitating factors are discussed in detail. The first phase finally involves conditioning using aversive techniques such as ammonia. The second phase of treatment includes social skills training, anger management, sexual education, empathy training, and relapse prevention. It aims at helping the patient find solutions to crime-precipitating problems and conflicts, and developing positive social skills as well as self-assertion techniques. It also aims at helping the patient manage his anger and develop problem-solving skills. Through this second phase, the patient is expected to develop empathy for his victims and to acquire more knowledge about sexuality. Finally, the patient is expected to learn about his offence cycle and to be able to identify positive alternatives to avoid relapse.



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DATA COLLECTION Nondirective semistructured interviews (Kandel, 1972) were used to gather enough information to be able to elaborate a plan analysis. Previous studies have already demonstrated the advantages of such a procedure with sexual abusers (Chorn & Parekh, 1997). Three preliminary interviews were conducted to explore general themes that could be addressed during the interview (these three preliminary interviews were later on not included in the study, hence yielding a final sample of N = 15) and to give the interviewer some time to feel comfortable with this population. The interviews were conducted by a Ph.D. candidate in psychology who was not affiliated with the penitentiary or the clinic. This was made very clear to the participants when explaining the purpose of the current study. The participants were invited to talk about their experience of the treatment. More specifically, the interviewer was requested to address the following general themes: what the participant thinks of the treatment and how he experiences it on a daily basis; what he had expected and hoped for before starting the program; what he thinks of the therapists; what he likes and dislikes in the program and would like to see change; what his past experiences of therapy have been and; what he expects from further treatment. In many cases, these themes were naturally brought up by the participants and did not require the interviewer’s intervention. The interviews lasted between 75 minutes and 90 minutes. All interviews were audiorecorded, transcribed, and reread to control for transcription errors. DATA ANALYSIS Plan Analysis serves as a basis for clinical case conceptualizations and therapy planning. Clinically relevant information about an individual’s behavior and experience is gathered through careful observation and synthesized into a meaningful whole. The fundamental question that guides Plan Analysis is as follows: which purpose, conscious or unconscious, underlies an individual’s behaviors and experiences? The focus of Plan Analysis is instrumental, that is, on how patients’ behaviors serve their basic goals. (Caspar, 1997, p. 260)

The choice of the method used, Plan analysis (Caspar, 1995, 1997), was based on a desire to (a) be as idiosyncratic as possible; (b) provide an organized, dynamic, and integrated presentation of the themes discussed by the participants; (c) use a method that is pragmatic and relies on concrete methodology; and (d) take into consideration wishes, goals, or desires, and the means used to achieve them. Plan analysis draws largely from information-processing theories and incorporates concepts from goal-oriented, interactionist, interpersonal, systemic, cognitive, behavior, change and self-organization, and emotion theories. Psycho-


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dynamic theories about countertransference, defences, and unconscious functioning are also somewhat integrated (for a review, see Caspar, 1995). In summary, the different components of a plan analysis are interrelated and hierarchically organized. They include a patient’s goals or desires but also the means by which these goals are attained. The goal is a “statement of the patient’s intention, hope, wish, or some other ‘end state’ that the individual . . . strives to achieve” (Caspar, 1997, p. 262) 1. Plan structures were elaborated for each participant based on the verbatim transcripts. This was done by conducting content analysis to highlight themes emerging from each given interview (Deslauriers, 1987). Using comparative analysis (Maykut & Morehouse, 1994), the interviews were individually organized by means of within-case analysis. For each participant, efforts were then made to establish a dynamic relation between the different themes. For example, if a participant mentioned confronting the therapist because or to determine if he is trustworthy, this was considered to be a causal relation (or an example of a motive and the mean used to achieve it) and was included in this participant’s plan structure. As such, components found in a plan structure (see Figures 1 and 2) are hierarchically organized, with items at the higher end of the figures representing general motives. Items found below another item are then considered as a mean used to achieve a wish or goal.2 The following step of the current study was to compare the plans of each participant and emphasize similarities and differences between the participants. To make comparison possible, between-participant (or horizontal; Van der Maren, 1997) comparative analysis was undertaken. After an initial review of the different components or themes mentioned in all 15 plan analyses, efforts were made to reduce the number of these initial themes (L’Écuyer, 1987; Schneider, 1999). For example, specific behaviors could be folded into more comprehensive or global behaviors. Such efforts were made to regroup other components presenting important similarities. The resulting components had to be found in at least two participants to be included in the final plan analyses. This led to a total of 21 components or themes (see Table 1 for definition and overall prevalence of each component). All 15 plan analyses were then reviewed using those 21 themes, and the original components were replaced by the newly developed themes. Finally, the different interrelations between the components were examined horizontally. To do this, Participant 1 and 2 were compared. The new plan structure resulting from this comparison was then compared with Participant 3, and so on. This procedure led to a very complicated diagram. Hence, the diagram was divided in two to make its understanding easier: The first figure (Figure 1) presents the components related to the participants’ participation in treatment; the second figure (Figure 2) presents the components related to the participants’ avoidance of treatment.



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Mastery

Acceptance Pride & respect

Freedom

Autonomy & independence Place of your own Understand

Behave Intimacy

Self-control

Open up Sense of belonging

Safe & predictable environment Constraint Strong & authoritarian therapist Routine Oppose others Guilt

Participates in therapy

Figure 1

Plan Analysis for Participation in Therapy

Mastery

Pride & respect

Acceptance

Freedom Autonomy & independence

Place of your own Behave

Self-control

Understand

Isolation Submission Open up Intimacy

Safe & predictable environment Constraint Strong & authoritarian therapist Oppose others

Respects others

Does not participate in therapy

Figure 2

Plan Analysis for Avoidance of Therapy


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Participant

1. Autonomy and independence: be autonomous, be independent, take his own decisions, have his own ideas, have his own principles, have a personal and distinct identity 2. Safe and predictable environment: be in a safe and predictable environment, be protected, be secure, ask for help and trust it will be given, be contained, be taken care of 3. Strong and authoritarian therapist: have a strong therapist, find a parental figure, find a paternal figure, have a reliable therapist, have an authoritarian therapist, have a trustworthy therapist 4. Acceptance: be accepted, be taken as he is, not be criticized, not be rejected 5. Sense of belonging: belong to a group, be with people sharing similarities, be in a group of peers 6. Pride and respect: prove and demonstrate his capabilities, surprise others by his achievements, demonstrate he is reliable or trustworthy, be proud, be respected, take his responsibilities 7. Constraint: be controlled, be forced to do something, seek to be constrained

Theme

x

x

x

1

2

x

x

x

3

x

4

x

x

x x

x

x

x

6

x

x

5

x

x

x

x

x

7

x

x

x

x

x

8

x

x

x

x

x

x

9

x

x

x

x

x

10

x

x

x

x

11

x

x

x

x

x

x

12

x

x

x

x

x

13

x

x

x

x

14

x

x

x

x

x

x

15

TABLE 1 DEFINITION AND PREVALENCE OF THE COMPONENTS USED FOR THE PLAN ANALYSES (N = 15)

7

8

8

8

10

10

11

Number of Participants

315


8. Isolation: be distant, isolate himself or herself, have peace and quiet, be anonymous, be discrete, be alone 9. Rules: behave, follow the rules, do well 10. Mastery: have a sense of mastery, control his life, be his own person or boss 11. Understand: understand, learn about himself or herself, learn in general 12. Submission: be submissive 13. Oppose: oppose, confront, provoke, or attack therapist and staff 14. Guilt: seek relief from guilt feelings, make amends 15. Freedom: be free, leave jail 16. Open up: open up, talk, express himself or herself, reveal himself or herself 17. Place of one’s own: have a place of his own, take the place he is given, be given a place 18. Self-control: control himself or herself, not recidivate, control his impulses 19. Routine: keep busy, have a routine, avoid boredom 20. Intimacy: seduce therapist, be intimate with therapist or other person 21. Respect others: respect therapist and staff x

x x

x

x x

x

x

x

x

x x

x

x

x

x x

x

x x

x

x x

x

x

x

x

x

x

x

x x

x x x

x x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x x

x

x

x x

x

x

x

2 2

2 2

2

4

6 4 4

6 6

7

7 7

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RESULTS DEFINITION AND PREVALENCE OF THE THEMES Horizontal and vertical comparisons suggested a total of 21 themes to be used in the plan analyses. For example, the most-often mentioned theme (see Table 1) was a desire to be autonomous and independent (11 participants). Most participants often expressed a wish or reported behavior related to a desire to be independent and autonomous, to take their own decisions, and to have a personal and distinct identity. The next two most-mentioned motives were a desire to be in a safe and predictable environment (n = 10) and to have strong, reliable, trustworthy, and authoritarian therapists (n = 10). Two of these wishes often appeared to be disharmonious or contradictory for the participants. For example, although they very much wanted to be autonomous and independent, they also sought authoritarian therapists who may oppose their attempts for autonomy. Although less prevalent, the three following components were nonetheless mentioned by 8 participants: (a) to be accepted, not criticized, and avoid rejection; (b) to belong to a group of peers sharing similarities with the participant; and (c) to gain pride and respect by being reliable and trustworthy, by taking their responsibilities, and by achieving. Once again, many of these components seemed to be problematic for the participants. For example, they often hesitated between remaining in a safe situation and making possibly unsuccessful attempts to reach their goals. The remaining themes can be found in Table 1. THE COMPONENTS INVOLVED IN THE PARTICIPANTS’ PARTICIPATION IN THE TREATMENT PROGRAM Overall, qualitative analysis suggested three supraordinate motives for treatment (see top of Figure 1): (a) a desire to recover their freedom (n = 4), a desire to have a sense of mastery (n = 7), and a wish to avoid criticism and rejection and to be accepted (n = 8). The components associated to a desire for freedom. To regain their freedom, the participants made use of two possible means: control themselves, whether it be in regard to anger, sexual fantasies, or prevention of an eventual relapse (n = 2), and participate in the treatment program. At a next level, they seemed to have only one available means to control themselves: They sought a stable and safe environment that could contain them and be predictable (n = 10). The desire for such an environment was achieved by participating in therapy, by putting themselves in a situation of constraint (n = 7) or by searching for trustworthy, reliable, and authoritarian therapists (n = 10). At the next level, the participants wanting to have strong, reliable, and authoritarian therapists (n = 10) only seemed to have one means available to them: attacking and opposing the therapist (n = 6). The participants confronted the therapist on



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various issues to make sure he could contain and control the situation as well as ensure peace and order. If the outcome of this was positive, that is if the therapist could contain the attacks without rejecting the participant from the program or without showing too many weaknesses, the participants reported feeling secure and confident and got more involved in the treatment. The components associated to a desire for mastery. To gain a sense of mastery and of control over their life (n = 7), the participants had six different possibilities: (a) to control themselves (n = 2); (b) to be autonomous and independent (n = 11); (c) to understand and learn (n = 6); (d) to open up, talk freely, and express themselves (n = 3); (e) to have a place of their own (n = 2); and (f) to take their responsibilities and demonstrate they are reliable (n = 8). At the next level, Figure 1 shows that these six means used to achieve a sense of mastery are also goals for which other means are necessary, some of which have been mentioned earlier. For example, to be autonomous and independent (n = 11), the participants may control themselves (n = 2), confront the therapist (n = 6), and/ or look for a stable environment (n = 10). Finally, they may also choose to learn and to better understand their difficulties (n = 6). For this last component, they occasionally looked for a stable environment, sought constraints (n = 7), confronted the therapists and/or talked freely and revealed themselves (n = 3). At this same level, the participants’ desire for a place of one’s own (n = 2) could be achieved by either looking for a stable environment (n = 10) or by behaving and following the rules (n = 7). In addition, to gain respect and take their responsibilities (n = 8), the participants either tried to understand and learn (n = 6), talked freely and revealed themselves (n = 3), or behaved and followed the rules. At the third level, the participants wanting to talk and reveal themselves presented three behaviors: they would participate in therapy, they would seek trustworthy and reliable therapists (n = 10), and/or would look to belong to a group where participants share many similarities with them (n = 8). One last sequence of hierarchically organized goals and operations relates to the wish to behave and follow the rules (n = 7). To achieve this, the participants either participated in therapy and/or searched for strong, reliable, and predictable therapists (n = 10). The components associated to a wish to avoid criticism and rejection and to be accepted. The last superordinate wish mentioned by the participants referred to a desire to avoid criticism and rejection and to be accepted (n = 8). For this purpose, they made use of four possible means: They would behave and follow the rules (n = 7), seek to belong to a group of peers (n = 8), look for trustworthy, strong, and authoritarian therapists (n = 10), and/or try to be intimate whether it be with another inmate or with the therapists (n = 2). For this last component, the most obvious means were to belong to a group of peers and/or to respect the therapists (n = 2). Finally, there were also two other goals or motives (bottom left of Figure


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1) that brought the participants to therapy. These were a wish to have a routine or to keep busy (n = 2) and a wish to reduce the guilt resulting from their offence (n = 4). THE COMPONENTS INVOLVED IN THE PARTICIPANTS’ NONPARTICIPATION IN THE TREATMENT PROGRAM The plans leading the participants to take part in therapy (Figure 1) very much resemble the plans involved in their avoiding therapy (Figure 2). The three main motives seen in the plans leading to therapy (freedom, mastery, and acceptance) can also be found in those leading to avoid treatment. To satisfy a wish for freedom, the participants used self-control. Unlike in the plan leading to therapy, that was the only option available. As such, a desire for freedom was never directly related to avoiding therapy. On the other hand, selfcontrol, either to gain freedom, be autonomous, or have a sense of mastery, could lead to avoidance of therapy. This was not the case in the plan involved in undergoing treatment. In both plans, self-control could be achieved by being in a safe and predictable environment. However, in the plan leading to therapy, this motive was not per se sufficient to enter and remain in treatment. Other intermediate motives and means, including being constrained or having strong and authoritarian therapists, were involved. For this last component, the participants mentioned two possible means. Unlike in the plan leading to therapy, the one related to the avoidance of treatment involved not only a confrontation of the staff but also efforts to be respectful. Such efforts often appeared to be the result of some participants’ attempts to avoid devaluating the therapists and the treatment. These comments were often made early on in the interviews, that is at a time when some participants were still uncertain about trusting the interviewer. Although they had little difficulty in expressing their desires and motives, these participants were at first reluctant to share means and behaviors that could give the impression they were resisting treatment or unhappy with their situation. As such, comments made in the first few minutes of the interviews occasionally gave the impression that “everything is just fine and perfect.” For example: Interviewer: So you are saying that you really want therapists who are strong and, huh, can you tell me a little bit about that? Participant: Well there is not much to say, really. I just think if you want them to be strong or whatever, you have to respect them. There isn’t really much to say! Hum, everything is fine here. The people are nice and the therapists too. And I respect them.”

As this participant learned to trust the interviewer, he felt more comfortable in sharing thoughts that were not as politically correct. About 20 minutes into the interview, this participant explained,



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No it’s true what I said, I do respect them. But sometimes, and others do this too, we, huh, I also just give them a hard time, you know? It’s not mean or anything it’s just that (pause) . . . well I just want to make sure they can put up with this shit, you know? If not, what the f**k are they doing here?

Unlike in the plan leading to therapy, the one related to nonparticipation included a simple relation between wanting to be understood and accepted and avoidance of treatment. For these participants, it is clear that they felt, or at one point anticipated that the therapists and the staff involved in the treatment would be disrespectful. This was reason enough for them to not seek or participate in therapy. The components reduce guilt, have a routine and keep busy, and belong to a group of peers were not found in the plans leading to avoid therapy. On the other hand, two new components were added. To avoid rejection and criticism and to be accepted, the participants would also isolate themselves (n = 7). This could be achieved by shunning therapy altogether or by submitting to the therapists and to the staff in general (n = 6). This submission directly served the purpose of being left alone, being distant, or being anonymous. Isolation was also used to be autonomous and independent (n = 11) and to behave and follow the rules (n = 7). As for submission, not only did it help in isolating themselves but also was a way to behave and follow the rules. THERAPY: YES OR NO? It is striking to see how the same motives can be involved in either participating in or avoiding therapy. This suggests that many goals or means used to achieve them are of crucial importance in keeping the patient in therapy and can give a good idea of whether he is actively participating in or avoiding therapeutic work. A patient isolating himself or being overcompliant and submissive does not appear to be an active participant who is truly involved in therapy. On the other hand, guilt and a wish to keep busy may at least keep the patient in therapy long enough for him to get truly involved. Many components are crucial in the patients’ decision to participate in or avoid therapy. Among these, the outcome of the patients’ confrontations with the therapist, whether it is to gain autonomy or to make sure the therapist is strong and reliable, may directly lead to an active involvement or avoidance of therapy. This is also the case when the patient has a wish to control himself. Many higher level motives can also influence the patient’s decision. For example, a wish for a stable environment can either bring the patient to therapy or eventually lead him to confront the therapist to determine if he is trustworthy and then—possibly—to avoid therapy. The same situation can also be seen regarding a patient’s wish to avoid criticism and to be accepted. To achieve this, a patient may, for example, isolate himself or avoid therapy altogether thus leading him to not participate in therapy. This same wish can also bring him to seek a group of


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peers that may lead to doing therapeutic work. Higher order wishes are also to be considered for they may, depending on the means used to achieve them, lead to therapy or not. DISCUSSION The finding to the effect that a patient’s wish to have self-control may directly lead to either therapy or avoidance of therapy seems particularly significant. A recent pilot study on the same sample suggests that denial plays a central role in a patient’s wish to control himself by avoiding therapy (Drapeau, Körner, Beretta, & de Roten, 2004). In these cases, not participating in therapy became so-called proof that the patient did not need help and could control himself without therapy. This seems to demonstrate the importance of being able to detect and understand not only the presence but also the purpose of the defense mechanisms used by patients. How the therapists or the institution manage these defenses could potentially have an impact on the patient’s decision to do or not do therapy. In such cases, overt confrontation of the patient’s denial may not be the best answer. The therapists may instead choose to reach the patient by discussing other means he may have to control himself, thus avoiding temporarily (at least until the proper moment) his denial. This example demonstrates how plan analysis can influence therapeutic interventions. It may prove useful to help a patient make use of alternative means or to help him develop new means to have a greater variety of possibilities and to reduce the risk that one operation may be frustrated. Another finding concerns the patients’ tendency to isolate. A patient who isolates himself has a risk of avoiding therapy. Although this may seem obvious, certain further comments must be made. The participants we interviewed very often isolated themselves by submitting or by overcomplying to the therapists or to the treatment program. In such cases, the therapists may actually believe that the patient’s compliance is a positive indication of his involvement in therapy. This is also the case with patients who follow the rules “a little too well.” The truth may be completely opposite to this: The patient’s desire to behave or to comply may eventually lead him to avoid therapy. This seems to indicate the importance for therapists to maintain a critical position toward a patient’s apparent cooperation. Six participants mentioned opposing and confronting the therapists to either make sure they are trustworthy, strong, and reliable, or to gain a sense of autonomy and independence. This moment appeared to be particularly significant as the outcome of these confrontations could be directly related to doing or avoiding therapy. When the therapist definitely rejected the patient from the program or was unable to contain the attacks and confrontations and showed either too much hesitation or weakness, the patient tended to avoid therapy. However, when the therapist was able to handle these attacks, be predictable and trustworthy, and show strength while maintaining order, the patient seemed most often relieved and satisfied and got more involved in the treatment.



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Few studies have examined this phenomenon. Rare examples can, nonetheless, be found in the clinical literature. For example, Weiss (1993) suggested that a patient tests the therapist from the beginning to the end of therapy. He does so to explore the world and to determine its dangers and opportunities so that he may protect himself from the dangers and take advantage of the opportunities. Testing would be a fundamental human activity aiming at a better adaptation to interpersonal dynamics. As Caspar (1997) noted, the therapeutic relationship, and more specifically the idea of complementary interpersonal dynamics, plays an eminent role in most psychotherapy approaches. Although this may be more obvious for psychodynamic, psychoanalytic, and humanistic therapists, cognitivebehaviorial therapists have also clearly developed their theories to give more importance to the relationship between the therapist and the patient (Caspar, 1997; Safran & Segal, 1996). Such efforts have been validated by empirical findings (Connolly Gibbons et al., 2003; Waddington, 2002). More research has to be done to understand not only what keeps pedophile sexual abusers in or out of treatment but also what they are looking for in therapy. Future work could involve differentiating the plans used by regressed versus fixated abusers, extrafamilial versus intrafamilial offenders, or by homosexual versus heterosexual pedophiles. Certain limitations present in the current pilot study should also be overcome in future studies. The current study involved interviewing participants who were in treatment at the time of the interview (although one participant did quit in the weeks following the interviews), thus bringing them to make more connections between components leading them to stay in therapy. In that sense, all the relations they made between components involving their leaving therapy were either hypothetical or based on the recollection of past treatment failures. As such, our findings must be interpreted with caution. Ideally, future research should involve comparing two groups of patients, one participating in therapy and the other having dropped out. The interviews could also be conducted before treatment begins with a group of patients who accepted a treatment offer and a group who declined this same offer. It is conceivable that motives given by the participants in the current study are the result of therapy itself. To assess this, motives given by the participants could be compared with those favoured by the therapists and the program. Although this question has so far been neglected by researchers, preliminary findings suggest that sex abusers in treatment actually pursue a different therapy agenda then the therapist (Drapeau, Körner, & Brunet, 2004). Another limitation of the current pilot study concerns the sample size (N = 15). This, combined with a lack of cross-validation procedures, precludes drawing strong conclusions from the results. A next step in the study of motivation for treatment using plan analysis should include a quantitative assessment of interrater reliability and a split sample procedure to determine if the models developed independently from the two samples are comparable. Finally, although 15 participants may be a respectable sample size in terms of qualitative research, it may be useful to increase the number of participants to also obtain a more robust quantitative assessment of the presence or absence of the different components.


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In conclusion, although a wish to leave jail and to be free are often mentioned by therapists as motives for treatment in this population, we can only agree with Balier (1996) that these patients eventually become motivated by something more than that. Even if they are often obligated, one way or another, to seek therapy, these patients seemed to come to a point where they made certain attempts to own therapy and gain something through it, whether it fit or not the claimed objectives of the program; not one participant in the current pilot study mentioned “dealing with a sexual problem,” a major objective of any treatment program with this population, as a motive for entering and remaining in treatment. NOTES 1. A patient is assumed to have many independent plans that may be harmonious or contradictory. Plan analysis also includes an operation element that is the means by which the patient tries to reach his goals. All of the participant’s plans are organized and presented in a diagram (referred to as the plan structure). It is important to note that a plan can serve another plan. In such a case, the wish element of the subordinate plan is an operation or mean component of the superordinate plan. Some obvious advantages of plan analysis are that it takes into consideration many different theories, it is idiosyncratic and robust, and it is pragmatic and relies on concrete methodology. 2. Many means were elaborated to ensure greater reliability and validity: (a) plan analysis instructions as suggested by Caspar (1995) were applied: All raters were trained and licensed psychotherapists, all raters had had prior experience of personal therapy, and all cases were discussed between at least two raters; (b) inference had to be maintained at a moderately low level, and each of a rater’s suggestions needed to be supported by a patient’s comment in the interview; and (c) to avoid that the two raters meet in a common bias, a third rater also participated on five randomly selected cases. Once again, agreement had to be reached to suggest a plan. Such a procedure appears to be a worthy compromise to increase the balance between the idiosyncratic properties of plan analysis and the necessities of research.

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International Journal of Offender Therapy and Comparative Criminology Martin Drapeau, Ph.D. McGill University 3700 McTavish Street Montréal, Québec Canada Annett Körner, Ph.D. University of Freiburg, Germany 1825-8 de la Visitation Montréal, Québec Canada Luc Granger, Ph.D. Département de Psychologie Université du Québec à Montréal C.P. 6128, succursale Centre-Ville Montréal, Québec Canada Louis Brunet, Ph.D. Département de psychologie, Université du Québec à Montréal C.P. 8888 succursale Centre-ville, Montréal, Québec Canada Franz Caspar, Ph.D. University of Freiburg, Germany Psychologisches Institut Abteilung Klinische und Entwicklungspsychologie Engelbergerstr. 41 Freiburg Germany
