Sex Offender and Substance Abuse

John is a 30-year-old, single, Caucasian male. He was convicted seven years ago of enticement and online solicitation of a minor younger than 14, as well as possession of child pornography, second-degree felony charges. Upon his conviction, he served six years and seven months, paid a $10,000 fine, must register for life on the sex offender registry, and is forbidden from using a computer or smart phone. Upon his release from prison he moved in with his mother and father and is currently working for a construction company for minimum wage. He reports really hating his job but feels that his registry status and inability to use a computer has limited him in finding a different career. John has a high school diploma and 18 credits towards an associate degree in general studies.

John reports that the shame and guilt he feels about his offense has driven him to self-medicate with alcohol. He says that most nights he can't sleep and drinks to forget what he did so that he can have a peaceful night. He states that his hatred of his job, his feelings of being stuck and unable to get a better job, and feelings of inadequacy have compounded this problem. John would like to eventually have a healthy relationship but his lack of self-esteem, as well as his offender status and alcoholism, has impeded any attempt he has made on this front.

For John, the first thing to do is to work on his alcoholism. I would implement the Self-Management and Recovery Training (SMART) program with him. This four-point, non-sequential treatment program involves building and maintaining motivation, coping with urges to drink, managing his thoughts, feelings, and behaviors, learning to live a balanced life, and learning goal setting and planning for the future. I anticipate six sessions with John, after his release from detox, that are mostly focused on his substance use disorder. John is at moderate risk of reoffending and has many criminogenic needs. According to the Risk-Needs-Responsivity model, John would need at least 200 contact hours. This would be done through twice weekly individual sessions and twice weekly group sessions over the course of approximately four years.  Over these four years we will work through the sex offender workbook together.

During our first session, I would ask him to fill out the Assessing Your Stages of Change Worksheet that was provided to us during class to see where in the process he is so that I can meet him there and learn where we need to go. I would focus on psychoeducation about substance abuse and discuss his pattern of use. Together, we would go through the pros and cons of his substance use and how important it is to change. It is at this point that I would discuss going to a rehabilitation center to detox from alcohol and make sure he understood my worries and hesitation about him trying to do this alone.

Our next session would happen after he is released from rehab and has fully detoxed. At this point, I would assume John is in the Preparation or Action phase of the stages of change model as he has either started a plan for change or is implementing steps toward change. During the next session, I would work with John on the seven main areas of potential psychological vulnerability identified by Beck, Wright, Newman, and Liese (1993) that represent factors that contributes to his risk of alcohol. Together, we would work on identifying high-risk internal and external situations, such as people, places, things, and moods, that encourage him to participate in drinking. At this point we would role play what to do when he encounters any of these situations and I would reinforce why it is important to stay sober and have a plan when he does enter a high-risk situation. We will work together on maintaining his motivation to stay sober and how he can live a balanced life. We will start to discuss what his plans are for the future and what he would like his life to look like.

It is at this point that I would also ask John for his commitment to abstinence. I would ask him to sign an abstinence agreement and let him know that this is a non-negotiable part of therapy. We would go over what is keeping him from reoffending, how he has set up his life to stop him from reoffending, and who he can talk with now about both positive and negative things in his life. We will write out what his rules are for staying away from potential victims, plans for leisure time, and who he can contact when he has urges and deviant thoughts.

In our third, fourth, and fifth sessions I would help John identify and confront his dysfunctional beliefs about alcohol and his relationship with alcohol. I would really focus on his justification attempts and permission-giving beliefs that he uses to continue to drink. When we start to challenge his cognitive distortions regarding alcohol, we will also start to address those attitudes and beliefs that minimize and justify offending behaviors. These beliefs that John hold include that he didn't really hurt anyone because his victims were all online, that if they didn't want to talk to him that way and send him those pictures that they could have stopped at any time, and if women his own age had talked to him he wouldn't have had to turn online to meet someone, therefore he never would have offended.

John must, at this point, begin working on his offense chain. He must begin by detailing all of his offenses, one at a time, in great detail. This description should include the thoughts, feelings, and beliefs that he felt before, during, and after the offense. This is also the beginning of working on John's relapse prevention plan. By detailing his offense cycle, John will begin to recognize his triggers and risk factors. We will also continue to discuss his triggers and risk factors that relate to his drinking.

To confront his cognitive distortions, I would first explain the role of these thoughts in his offending behavior and how they are continuing to enable him to justify his actions. Then, I would provide him information on correcting these thoughts and how to challenge them when they come to his mind. I would also encourage him to share these thoughts in his sex offender treatment group so that his fellow group members can help him challenge these distortions. He should practice challenging beliefs by evaluating other members of the group's distortions.

At this point in therapy, we be switching our focus from his drinking problem to focusing on his offender status and only briefly checking in from time to time about it. To do this, we will put together a relapse prevention plan specifically for his substance use. He will fill out a card to carry with him that lists his top three high risk situations and triggers, three protective factors, his three sober coping strategies for stress, and three emergency contacts. He will also write out his action plan about what he will do if he has a craving or if he is concerned about a relapse. It will be important that he learns not to view slips of sobriety as a failure but instead as an opportunity to grow.

To continue working on his relapse prevention plan, we will go over his specific internal and external barriers. To address his internal barriers, I will have him write down what thinking errors and misinterpretations he has solved as well as which ones he still has trouble with that might contribute to his problems and put him at risk of reoffending. We will go over what his triggers and warning signs are before he starts to have deviant fantasies and what he can do to stop them from becoming too strong. To address the external barriers, we will go over which events, feelings, and thoughts are still high-risk elements for him and I will ask for his interpretations of how he would understand those events feelings, and thoughts to be high-risk. To encourage him, we will go over some examples of how he managed to overcome some high-risk elements or situations in the past.

John is displaying three different types of denial, denial of impact, denial of responsibility, and denial of denial. His parents are enabling this denial by participating in it themselves. Once John begins working through his own denial, with his permission, I would ask him to invite his parents to attend a few sessions with him. I would ask John to give his parents psychoeducation about the different types of denial and how it is an understandable form of self-preservation. All three of them should work together to give up these distortions and John must allow himself to be responsible for his abusive actions. He should also open up in group about his denial and confront with empathy other offenders' denial of their actions.

Some emotions that John endorsed feeling before he offended were isolation, feeling rejected, guilt, shame, and sadness. He must learn to cope with his negative affect and identify when these emotions begin to overwhelm him. He needs to learn the intensity, expression, and appropriateness of all emotions so that he can properly cope with them. I will provide him with psychoeducation about these experiences and the purpose of emotions. We will work together on emotional labeling so that he can identify them and is better equipped to deal with these emotions as they come up.

John repeatedly states that he wants to have a healthy and consensual relationship but is severely lacking in interpersonal skills. Together we will work on assertiveness training and improving his communication. These skills will be practiced, assessed, and reinforced through group meetings, in role play, and as homework assignments. We will also work on building John's self-esteem and building more social support. It will be very important for John to realize that sex does not equal intimacy and he needs to learn how to build and maintain friendships before he can attempt to have a successful, intimate relationship.

Empathy is defined as the ability to cognitively identify someone else's perspective, to recognize emotions within oneself, and to apply these emotions by behaving compassionately as a result of another's feelings. John experiences empathy deficits when it comes to his victims and his victims' families. This will mostly be undertaken in group therapy where he will discuss with the group his offense and how he believes his victims and their families feel. He will also listen and participate in discussions about the other offender's victims and their families. For homework, John will write a letter of genuine remorse for his actions to his victims where he accepts full responsibility for his actions and will then read the letter to the group for them to give him feedback on it. We will come up with ideas, in detail, of how he plans to provide restitution to his victim.

At this point, we will continue to form his relapse prevention plan and turn it into a concreate plan that he can follow. We will go over where he still feels vulnerable to victimizing again. We will discuss what thinking errors still make him vulnerable to offending again and he will write down alternate understanding and his plans to escape or avoid these. He will detail what reoffending means to him and what the consequences would be to him, his victim, his family, and his friends if he were to reoffend. He will fill out the Urge Control Contract and have it signed by me, his group leaders, his parole officer, his parents, and himself. On it will be my number, his parole officer's number, and an emergency contact that he can call if he has trouble handling an urge, thought, or feeling.

The first challenge I anticipate facing with John is that his alcoholism must be dealt with first and foremost. John suffers from withdrawal symptoms of anxiety, insomnia, nausea, and abdominal pain as soon as eight hours after his last drink which leads him to either being under the influence or going through withdrawal at any point during the day. This is extremely dangerous since he deals with heavy machinery at his construction job. It also inhibits any type of therapeutic interventions since he is not cognitively present. Ideally, this would be handled in an inpatient facility where he could detox safely. My fear would be, if he tried to do this on his own or with his parents, that his detox symptoms would be severe enough that he would suffer hallucinations and seizures.

The second challenge would be helping John overcome some of his other issues that are not the primary targets of treatment. These would include his very low self esteem and assisting in career counseling. Some of his self esteem issues may be resolved throughout the course of treatment but my prediction is that more would need to be done after or in conjunction with therapy for his alcoholism and offender status. With all of the many other issues to be addressed, he may be better suited seeking career or education counseling from another source who has more specialization in this area, possibly through a local college.

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