Question

Describe the type and the effectiveness of different treatments for paraphilias. What are the ethical problems associated with the treatment of people with paraphilias

Answer 1

Cognitive-behavioral therapy - Cognitive-behavioral therapy (CBT) involves applying behavioral therapy techniques to modify sexual deviations by altering patients’ distorted thinking patterns and making them cognizant of the irrational justifications that lead to their undesirable sexual behaviors. It may be employed in accordance with a 7-step approach, as follows:

Aversive conditioning with ammonia or (masturbatory) satiation
Confrontation of cognitive distortions (especially effective in groups)
Victim empathy (showing videos of victims and the consequences they experience from the patient’s act)
Assertiveness training (including social skills training, time management, and structuring)
Relapse prevention (identifying antecedents to the behavior [high-risk situations] and ways of disrupting these antecedents)
Surveillance systems (family associates who help monitor patient behavior)
Lifelong maintenance
The incorporation of relapse prevention techniques helps the patient control the undesirable behaviors by avoiding situations that may generate initial desires. The commonly employed technique of covert sensitization pairs a patient’s harmful sexual variation with an unpleasant stimulus in order to discourage repetition of the act. This approach has proved effective in many cases of pedophilia and sadism.

Orgasmic reconditioning - In orgasmic reconditioning, a patient is reconditioned to a more appropriate sexual stimulus. First, the patient is instructed to masturbate to his or her typical, less socially acceptable stimulus. Then, just before orgasm, the patient is told to concentrate on a more acceptable fantasy. This process is repeated at progressively earlier points before orgasm until, eventually, the patient begins his or her masturbation fantasies with an appropriate stimulus.

Social skills training - Because of the widespread view that paraphilic disorders develop in patients who lack the ability to develop relationships, many therapists and physicians use social skills training to treat patients with these types of disorders. They may work on such issues as developing intimacy, carrying on conversations with others, and assertive skills training. Many social skills training groups also teach basic sexual education, which is very helpful to this patient population.

Twelve-step programs - Many physicians and therapists refer patients with paraphilias to 12-step programs designed for sexual addicts. Like Alcoholics Anonymous, these programs are designed to give control to group members, who lead most of the sessions. To increase awareness of the problem, the programs incorporate cognitive restructuring with social support. The group also focuses on the sense of a “higher power” and each individual’s reliance upon his or her spirituality.

Group therapy - Group therapy in this setting is designed to help paraphilic individuals break through the denial they so commonly exhibit by surrounding them with other patients who share their condition. Once these individuals begin to admit that they have a sexual divergence, the therapist can begin to address individual issues (eg, past sexual abuse) that may have led to the sexual disorder.When these individual issues have been identified, initiation of gestalt-type therapy (with the victim, if any) may be desirable to help patients get past the guilt and shame associated with their particular paraphilia. The goal of this type of therapy is to lead the patient to a “healthy remorse.” These patients require lifetime therapy to reduce the likelihood of relapse.

Individual expressive-supportive psychotherapy - Individual expressive-supportive therapy requires a psychologically minded patient who is willing to focus on the paraphilia. The therapist should not set unrealistically high goals but must break through the denial. Patient countertransference and avoidance can be particular problems with this form of therapy. If the therapy enables the patient to break through the denial, he or she can then work on the unconscious meaning behind the particular paraphilia.