A Four-Phase Treatment Design for Juvenile Sex Offenders

Presented by: Nori J. Muster,
a candidate for the degree of
Masters of Science in Interdisciplinary Studies, 1991

Determining Content Validity

Examining case vignettes, while interesting, yields limited information-especially when attrition is high and group membership is in constant flux. In an ideal research situation, there would be a control group that would not be exposed to art therapy, but would receive similar treatment in all other areas. To best test the treatment design, several treatment groups could be conducted simultaneously over a six month period. Groups would be closed and limited to five members each. There could be a follow-up study after three years, which would be long enough to assess recidivism among the participants. This could then be compared to the general population of juvenile sex offenders.

Since no such studies are planned for the near future, and no similar studies have been done in the past, it is necessary to find another means of evaluating the four-phase treatment design. One method to test the design's validity would be to ask therapists in the field for direct feedback. Expert judgment could lend content or face validity, or proof that the treatment design appears to achieve what it purports to achieve (Gay, 1987). While face validity is not conclusive, it would provide additional support for treatment design.

It is possible that the many experts will not support the design, since virtually all scholarly literature on juvenile sex offender treatment promotes confrontational, adult treatment models (see French, 1988; Lombardo & DiGiorgio-Miller, 1988; Margolin, 1983; and Stevenson, Castillo, & Sefarbi, 1989). Some researchers support a psychoeducational model (Hains, Herrman, Baker, & Graber, 1986), but few if any support a sympathetic approach as proposed in this study. A simple survey of experts will gather valuable feedback to determine if a more substantial pilot study should be undertaken.


A questionnaire was mailed to 50 counselors and psychologists who work in the field of sexual abuse and sex offender treatment. The instrument was meant to test the content validity of the treatment design by asking questions about sexual abuse treatment in general, attitudes toward art therapy, attitudes toward leniency, and so on. The survey packet contained a letter of introduction, a diagram and brief explanation of the four-phase treatment design, and a two page questionnaire (see Appendix D for complete survey packet).

The Sample

Of the 50 subjects in the sample, 35 were chosen because they specifically advertised themselves as sexual abuse and/or sex offender counselors in Oregon telephone books and service directories. An additional nine subjects were people the researcher met in the course of doing this study. These individuals also work directly with sexual abuse victims and/or sex offenders. The remaining six subjects were employees at the juvenile facility where the pilot study took place. Of those six employees, four worked as line staff in the cottage where the design was tested. These four employees were asked to answer additional questions, since they were in direct contact with the boys who took part in the pilot group.

Subjects were asked for short answers in some questions, or asked to "check all that apply" in multiple choice questions. There were some open-ended questions that asked for comments. Although these were optional, many respondents wrote comments.

Forty-four surveys were mailed on March 15, 1991; six were dropped of at the juvenile facility on March 15 to be distributed through the internal mail system. All packets contained a self-addressed, stamped envelope for convenience. The letter of introduction specified a deadline of April 26 to return the survey. The deadline was also written on the return envelopes. On April 15 a follow-up post card was mailed to encourage individuals to complete the survey. A total of 21 surveys were received by the deadline. One packet was returned with no forwarding address; two surveys were incomplete, and thus unusable; 29 subjects made no response. It is probable that more people would have responded to a shorter, simpler survey.

Future studies of this kind would yield more reliable data with a larger sample. But even with a small sample, the data shows strong trends in certain areas that are statistically significant.

The Instrument

The first section of the instrument asked for demographic information. The second section dealt with sex offender/sexual abuse treatment in general. The main body of the survey compared treatment attitudes toward three age groups: child, adolescent, and adult sex offenders. The last section, multiple-choice, asked for an evaluation of the treatment design (see Appendix D for complete survey instrument).


Of the 18 respondents, three were psychologists (17%), eight had master's degrees (44%), five had master's of social work degrees (28%), one had a bachelor's degree only, and one had M.E.D. certification only. Ten of the respondents (60%) worked in private practice, while the others reported working for public and private agencies. Eleven worked with child sexual abuse victims; 13 with adults molested as children; nine with juvenile sex offenders; and five with adult sex offenders. Ten of the 18 (60%) reported working with both victims and offenders. Thus, the sample is a good mix of private and agency therapists who work with both offenders and victims.

When asked to give a subjective estimate of how many sex offenders were once victims of sexual abuse, nine said 80% or more were once victims. Six estimated that 50% to 75% of sex offenders were once victims. The remaining two gave no answer. Although subjective, this data gives insight into the opinions of therapists in this study. From these replies, it is clear that the majority of the respondents felt sexual abuse is an issue for most sex offenders.

When asked to respond to the statement, "There are a great many people who block out memories of sexual abuse. Therefore, we see only the tip of the sexual abuse 'iceberg,' " the majority (89%) agreed. (See Figure 2.) This response indicates that a clear majority of the therapists in this sample felt sexual abuse was more pervasive a social problem that what is generally acknowledged.

[Editor's Note: The graphs on these thesis web pages were lifted from old Pagemaker files, therefore the quality of the type is not perfect.]

Figure 3 compares respondents' willingness to use sympathetic methods with each of three groups: child victims of sexual abuse who act out sexually, juvenile sex offenders who were victims of sexual child abuse, and adult sex offenders who were victims of sexual abuse. The specific statements compared in this chart are, "I would use sympathetic methods that are normally used with sexual abuse victims" and "Sympathetic forms of therapy tend to reinforce minimization and denial."

As expected, therapists said they would choose sympathetic methods most frequently with children (39% pro-sympathetic, compared to 17% anti-sympathetic). Juveniles ranked equally for pro-sympathetic and anti-sympathetic (33% to 33%), while adults ranked slightly less likely to have anti-sympathetic treatment (only 28% said they were anti-sympathetic).

Figure 4 addresses the controversy, "What should the therapist address first, abuse issues or offender issues?" Respondents marked answers they agreed with for each of the three groups (children, juveniles, and adults). The specific statements analyzed in this figure are: "Offender issues should be dealt with first," "Offender's own sexual abuse issues should be dealt with first," "Abuse and offender issues should be dealt with simultaneously," "The therapist should be flexible about what to work on first," and "Since offenders are criminals, only the criminal behavior need be addressed."

Overall, the categories "simultaneous" and "flexible" scored highest. No one responded that only criminal issues should be addressed in any of the age categories. The majority thought it best to address the victimization issues of children and juveniles before moving on to offender issues. In the case of adults, there was more support for beginning with offender issues (28% compared to 11% for victimization issues). However, the greatest majority (72%) felt the therapist should be flexible when dealing with adult sex offenders.

Figure 5 charts respondents' approval of the more severe forms of therapy with sex offenders: confrontational group therapy, aversion therapy with penile plethysmograph assessment, and castration.

While the questionnaire did not ask about using aversion therapy or castration with children, three respondents (17%) said they approve of confrontational group therapy. The preference for these three techniques was greatest with adults, but also high for juveniles. For example, 17% said they approve of castration for juvenile sex offenders.

In Figure 6, respondents were asked to specify when a sexual abuse victim becomes a victim-turned-perpetrator. The question asked, "At what age should a sexually abused child be held responsible for aggressive sexual behavior?" Of the 18 respondents, one third gave no answer, one third said "any age," "all life," "all ages," and so on. Another 28% named a figure between three and six years of age. Only one person said anything beyond kindergarten. Thus 61% thought children should be held responsible beginning at an age younger than six. This contradicts a study cited earlier, wherein the author said children should not be held responsible for aggressive sexual acts until they reach 16 years of age.

Figure 7 gives an overview of attitudes toward using art therapy with sexual abuse victims and sex offenders. Nearly all respondents had heard of using art therapy with victims (94%) and a high percentage (89%) had heard of using it with juvenile sex offenders. Many said they use art therapy in their own practice (61%) and stated that they thought it could be useful for children and juveniles (83% and 72%, respectively). The lowest ranking was in conjunction with adult sex offenders, but still, half of the respondents said art therapy could be useful.

Evaluating the Four-Phase Treatment Design

Respondents were asked to rate the four-phase treatment design by checking items from a multiple choice list. Four items characterize the design as inadequate or ineffective and four items characterize it as adequate or beneficial (see Figure 8). The highest percentage of respondents (50%) chose the favorable statement, "The four-phase treatment design appears suitable for juvenile sex offenders, if used in conjunction with the therapeutic milieu described." Half of the respondents chose this response, while 33% said it would be "useful in other situations as well."

The most common criticism was the statement, "Juvenile sex offenders would take advantage of a treatment plan like this to avoid responsibility for their sex crimes." Five respondents (28%) chose this answer, but three qualified their answer by writing in comments like, "Might take advantage-therapist would have to be alert to this," or "It is possible they could [take advantage] with an inexperienced therapist." In other words, three of five respondents felt juveniles could take advantage, while only two (11%) chose this answer without qualifying it.

The second most common criticism (22%, or four respondents) was the statement, "I'm not against leniency, but I would make many changes in the treatment plan, as it is described herein."

See Figure 8 for respondents' ratings of the four-phase treatment design.