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Comparison with treatment
for Conduct Disorder

Ethical Treatment for All Youth
Email: etay@ethicaltreatment.org

About the author

By Timothy J. Kahn
Brandon, VT:  Safer Society Press, 1999.
For ages 11-21

[This portion describes treatment for altering sexual fantasies and measuring arousal]

(p. 144)
Masturbatory Reconditioning.  This method involves making up (with your counselor's help) age-appropriate, nonviolent, consenting fantasies you can masturbate to when you are alone.  You either keep a journal of your masturbation sessions, or you might be asked to make a tape of an appropriate fantasy to make sure that you are including all the healthy elements.  This might sound like an embarrassing activity, but remember that all human beings have sexual feelings.  Masturbatory reconditioning increases your arousal to appropriate sexual behavior.

Covert Sensitization (CS).  In covert sensitization (CS), you cancel out your offending fantasies by pairing them and connecting them with a thought, image, or smell that is scary, unpleasant, or disgusting.  You make tapes of your acting-out urges, then add a scene that upsets you, like being arrested.  Then you think of a scene that rewards you with something pleasant for not acting out sexually.  This method can work well when you also use masturbatory reconditioning to help you find appropriate images to replace your deviant sexual fantasies.

(p. 146)
Note: Covert sensitization is recommended for most young persons with sexual bheavior problems.  One the next page you will find a blank form for a written version of CS, or covert sensitization.  Your counselor may want you to make copies of the blank form, and then you will use the copies to fill out on a daily basis.  You may want to do regular CS, or Empathy CS.  The more CS forms you fill out, the more control you will develop over your unhealthy sexual fantasies.  It is recommended that you work on this assignment for a long period of time.

(p. 148)
One way of measuring boys' progress is to complete a "phallometric assessment" using an instrument called a "penile plethysmograph" before and after you use these techniques.  During a penile plethysmograph evaluation you sit in a private room listening to tapes through headphones, or maybe looking at slides.  The boy's arousal is measured by an instrument resembling a thick rubber or metal band that can sense changes in penis size during the tapes or slides.

(p. 149-150)
Remember:  these methods have been used successfully with many teenagers and adults to control their sexual behavior.  Again, they must be taught to you by a trained counselor, and they may have some emotional side effects that should be explained to you.

On the next page is a sheet called a "Fantasy Tracking Form"...You should fill out the form every time you masturbate, as well as every time you have an inappropriate sexual thought (deviant sexual fantasy)...

Fantasy Tracking
Name: ______________________________________     Date: _____________
Use this form to keep track of your sexual fantasies and/or masturbation patterns.  Check with your counselor for other instructions begore using this form.

Other Person's Name & Age
Type of Behavior
Masturbation Yes/No

[space for 24 entries]

(p. 154)
Healthy Sexual Fantasy.  In this assignment you will develop a healthy sexual fantasy that you can use in place of your deviant sexual fantasies.  Before starting the fantasy, review all of the requirements listed below.  This will help your fantasy be healthy and appropriate.

Your healthy fantasy should include all of the following parts:
1.  Feelings of love.
2.  Caring feelings.
3.  Your partner's name and age (should be close to same age).
4.  Demonstration of respect for partner.
5.  General friendship with partner.
6.  Displays of nonsexual affection.
7.  Verbal consent and discussion of sexual desires.
8.  Straightforward talk about birth control.
9.  Concern for your partner's feelings and orgasm (feeling of satisfaction).
10.  Some degree of privacy.

Here is how it might be organized:
  • Set scene.  Get to know partner.  Show affection.  Treat partner with respect.  Develop friendship.  Share feelings of love and care.
  • Talk!  Discuss sexual attraction.
  • Listen.  Make sure partner wants to have sex as much as you do.
  • Act.  Don't just think about yourself.  Show concern for partner's feelings.  Remember to include birth control
  • After.  Show affection.
Note:  This can be an embarrassing assignment.  Your counselor can provide guidance about how much detail to provide.  For anyone without much sexual experience, there might not be much detail about the sexual behavior, but all the other requirements should be included.  For experienced persons, the fantasy may be more sexually explicit or detailed.

On the next two pages or on additional paper write a healthy sexual fantasy.  Please be thorough, and include all of the ten requirements listed above.  The fantasy should be at least two pages long.

[Permanent defectiveness]

(p. viii)
Many programs using addiction or medical models to address sexual offending behavior adopt AA-type language regarding the "recovery" process.  Because "recovery" seems to conflict with the message that sexual acting out has no "cure"--only control--in Pathways young persons are encouraged to adopt a "sexual abuse prevention and safety lifestyle," and to become a member of the "prevention and safety team."

(p. 4)
Completing Pathways will not "cure" you of your problem--there is no cure--but it will teach you how to recognize and control your problem behaviors.

(p. 27)
Remember:  sexual behavior problems are not caused by a disease that can be cured.  So, the bad news is that you can not be cured.  The good news, though, is that you do not have any disease. 

[Editorial comment:  If there is no disease, why is there diagnosis and treatment?  And why must the youth be afraid of offending for the rest of his life?]

(p. 48)
To get over your denial you must admit that you acted out sexually, that it was a choice you made and that you may have sexual feelings that are hard to control even after treatment.  If you can make it to this point, you will be well on your way toward beginning the treatment process.

Denial is one type of thinking error--a mistaken belief that influences your behavior.  Thinking errors are the little messages running through the back of your mind that make it seem okay to commit your offenses.  Any time you make excuses for your behavior, blame someone else, or suggest that what you did wasn't wrong, you're using a thinking error.*

*"Thinking errors" were first described by Samuel Yochelson and Stanton Samenow, The Criminal Personality, Vol. I & II, Dunmore, Penn.:  Jason Aronson, Inc., 1976, 1977.

(p. 209)
Explain how it might be possible under certain conditions for you to have further sexual behavior problems.  Describe what those conditions might be, and what sexual behavior problems you are capable of having in the future.

(pp. 282, near end of book)
Personal FFO (Freedom From Offending) Contract

5.  Long-Term Environmental Restrictions
Your long-term success will depend to a large extent on the long-term personal boundaries and barriers you build into your life after treatment.  List your plan for keeping up your barriers after you leave treatment.  Be realistic.

A.  Contact with children:  under what circumstances will you let yourself have contact with children more than three years younger than yourself?

B.  Drugs or alcohol:  under what circumstances will you let yourself engage in drug or alcohol use?  How do you intend to keep it from being a problem?

C.  Knowledge of your history of offending:  who will you tell in the future about your history of sexual offenses?  Why or why not?

D.  Sex life:  what role will sex play in your future relationships?  How do you intend to keep the sexual element of your relationships healthy and responsible?

E.  Work:  what jobs do you hope to pursue in the future?  What jobs will you put off-limits for yourself based on your history?

6.  Alternatives to Offending
What will you do, who will you call to prevent yourself from reoffending when you find yourself in your offense cycle or in a high risk situation?

(p. 289)
Final Exam
Open Book:  Typed Report Encouraged.  In order to successfully complete Pathways, each young person must thoroughly answer the following questions.  A written paper is required, documenting the responses to each question.  Please list each question on a separate piece of paper, and then answer the question.  This assignment usually takes more than four pages.  Each answer should be a paragraph long.
1.  What have you learned about your potential risk of sexual reoffense or future sexual behavior problems?
2.  What are some risk factors which could increase your potential risk of reoffense or future sexual behavior problems?
5.  What have you learned about your sexual urges, and how have you learned to control your deviant sexual fantasies?
6.  How do your thinking patterns contribute to your victimizing other people, either in a sexual way or a non-sexual way?
7.  What do you do in your day-to-day life to eliminate thinking errors?
10.  What is it about you (your personality) that allowed you to commit a sex offense in the first place?
12.  Describe how you intend to maintain your treatment gains after completing this treatment program.
13.  What are the factors that might eventually lead you to having sexual behavior problems in the future?
19.  In the future whom do you think you will tell about your history of sexual behavior problems?  Explain why you will tell or not tell.

[Detailed descriptions of all sexual and other unacceptable feelings and behaviors ad infinitum, with self-castigation.]

(p. 32)
The following information should be shared in every treatment group.  It is your responsbility to bring up this information in the group.  Remember, this is yor treatment, don't wait for someone else to do it for you!

Things to bring up in your weekly group session:
1.  Significant positive or negative events in your life.
2.  How often you masturbate (masturbation rate).
3.  Deviant sexual fantasies--sexual thoughts that involve young children, violence, or coercion.
4.  Contacts with children and how you handled them.
5.  Changes in your support system.
6.  Dating plans and interests in girls or boys.
7.  Plans for the next week, to make sure that you are prepared for any situation that might occur.
8.  Progress in your treatment work.

(p. 37)
The daily diary form on the next page is included for you to copy, or for you to duplicate on your computer.  If you don't have a copy of the form, you may use a plain piece of paper for each day's entry.  Make sure that you bring your diary to your counseling session every week.  At the bottom of the form you will notice a section that says M=___.  This is for you to keep track of how many times you masturbated each day.  Check with your counselor to see if you should fill out that section.  The blanks for the fantasy are where you write down what you thought about when you were thinking about sex.

(pp. 57-68)
[Each question below provides a half page for responding, followed by the note "If you need more space, use a separate piece of paper."]

Assignment 3F

Who I Hurt.  Fill out the list below with the names of each person you have acted out with sexually.  Describe your relationship with each person, the age of the person, and your age when the sexual behavior started.  Include all of the people you have acted out sexually with, not just the ones you were caught for.

Assignment 3G

What I Did.  In the space below, describe exactly what you did with each victim.  Include the total number of incidents and a description of your sexual behaviors.

Assignment 3H

How I Did It.  In the space below, describe how you got each of your victims to go along with your sexual behavior.  Include all bribes, threats, force, promises, stories, etc.

Assignment 3I

Victim Reactions.  Think about how each of the victims of your sexual behavior reacted to your sexual behavior.  Describe exactly what each of the victims said or did while you were acting out sexually.  Describe how their faces looked and how they held their bodies.

Assignment 3J

Victim's Feelings.  In the last assignment above you described how the persons you abused acted during the abuse.  This assignment is about their feelings.  In the space below, write how you think each of the persons you acted-out sexually with actually felt during the sexual behavior.  Some possible examples are "scared," "confused," "frightened," "loved," or "sad."

Victim's Name           Feelings Before          Feelings During         Feelings After

Assignment 3K

Planning My Offenses.  When people plan and think about their sexual acting out ahead of time (as almost all sex offenders do), it's called "fantasizing."  Sometimes people masturbate while fantasizing; sometimes they don't.  In this assignment, list your plans for your sexual behavior, including all thoughts of offending.  When did you first think of offending?  Where were you?  How often did you have these thoughts before committing your offense:  hourly? daily? weekly? monthly?  How did your fantasies and your palnning thoughts change after your offenses?  Explain how far in advance you planned your offenses.  (If you have many offense, estimate the best you ca.)  This assignment will help you when you work on understanding your cycle in chapter 7.

Assignment 3L

Getting Caught.  Describe how you got caught for your sexual behavior problems.  Where were you and who was with you when you got caught?  Who told?  Who did they tell?  Were the police called?

Assignment 3M

Who Is Responsible?  In the space below, list the names of each of the persons you abused, how much responsibility for your sexual behavior against that victim belongs to you (0 means none, 100% means all), who else is responsible, and why?

Assignment 3N

Future Effects.  List the names of each of the persons you abused and what long-lasting effects your sexual behavior might have on each of them.  Be specific.

Assignment 3O

Friends and Family.  Explain how the important people in your life reacted when they found out about your sexual behavior problems.  List what you think they were feelings as well as what they said or did.

What she felt:
What she said and did:

What he felt:
What he said and did:

Brothers and sisters
What they felt:
What they said and did:

Other relatives
What they felt:
What they said and did:

What they felt:
What they said and did:

Assignment 3P

Getting Honest.  On a scale of 0 to 100%, how honest were you when you were first caught for your sexual beheavior problems?  (0 means you weren't honest about anything, 100% means you were completely honest about everything): _____ %

How honest you are now being about the full extent of your sexual behavior problems: ___ %

List all of the people to shom you have told the whole truth about all of your sexual behavior.

Assignment 3Q

List all sexual and physical abuse of animals you have ever done.  Include your age at the time, the animal's name, type of animal, sex of animal, what you did to the animal, and how many times you abused the animal.

Assignment 3R

Sexual History.  Describe your first sexual experience that you can remember.

Assignment 3S

Describe how and where you learned about sex when you were younger (include X-rated movies, magazines, books, school, watching others, telephone "sex lines," etc.).

Assignment 3T

Describe any and all sexual experiences you have had with anyone older than you, including incidents you consider mutual as well as nonconsenting.

Assignment 3U

List the sexual experience that you are most embarrassed and ashamed about (sex with animals, masturbating with women's underwear, molesting young children, etc.).

Assignment 3V

Who else in your family has been in trouble for their sexual behavior (include grandparents, uncles, etc.)?  Describe what they did that got them into trouble.

Assignment 3W

Who among your friends, relatives, acquaintances do you personally know has been sexually abused (other than your victims)?

Assignment 3X

List everybody with whom you have ever had sexual contact (including the victims).  Start with your first contact and go in order through your most recent sexual encounter.

Name       My Age       His/Her Age        Sexual Activity

(pp. 72-73)
Assignment 4A

In the space below, list the names of the persons you victimized in a direct manner.  (You already did this in chapter 3, but please list them again here.)

Assignment 4B

In the space below, list the names of the persons you victimized in an indirect manner.  List the person's name, the person's relationship to you, and how they have been hurt.

Assignment 4C

Talk with your parents, foster parents, or group home staff and ask for their feedback on the above assignment.  Make sure that you have not left out any persons who may be indirect victims of your sexually inappropriate behavior.  Please describe what the person said in the space below:

(p. 212)

1.  Describe why you think you are accountable for your sexual behavior.  Explain in detail why you think it is your fault, and nobody else's.

2.  List all of the people whom you have hurt in sexual ways.  Describe in detail what you have done to them.  Include all the persons you abused, not just he ones that you were caught for.

Person's Name        # of Incidents of Sexual Behavior      Types of Sexual Behavior

(p. 216-218)
1.  List all of the people whom you have hurt in sexual ways.  Describe in detail what you have done to them.  Include all the persons you have abused, not just the ones you got caught for.

2.  List all of the people whom you have hurt in physical ways during your lifetime.  Describe in detail what you have done to each person.

3.  List all of the people whom you have hurt in verbal or emotional ways.  Describe in detail what you have said or done to hurt each person.  Include all verbal harassment, name-calling, threats, etc.

4.  Not counting the things that you have already listed in this assignment, list all of the people you have hurt or affected as a result of your selfish, hurtful, or criminal behavior.  Include all of the indirect victims that you listed in chapter 4.

5.  In the space below, describe the problems you have had in the past year with behaving in irresponsible, hurtful, or selfish ways.  This is a chance to take a good look at yourself.  Be honest, and remember that it is a good thing to admit problem behaviors.  Admitting is the first step towards making positive changes.

6.  Talk to two adults you know well.  If you live with your parents, they would be good persons to talk with.  If you live in a foster home, then talk with your foster parents.  If you live in a group home, pick the staff or counselors you know the best.  When you talk with the adults, ask them to give you feedback about what you do in your day-to-day life that is irresponsible or hurtful.  Tell them what you wrote in #5, above.  Write down what they tell you in the space below.

(p. 233)
1.  List all of the excuses you have used in the past to explain why you acted out sexually.

2.  Now write, "I chose to act out sexually" 10 times below.

(p. 260)
Truth Story.  Please cover all of the following issues in your own personal truth story.  This assignment should be at least two pages long.

Section 1
1.  Explain who you are (name, age, who you were living with when you got caught).
2.  Describe what offenses you got charged with or what sexual behavior you got caught for.
3.  Describe how you denied your sexual behavior, and list everybody you denied to.
4.  Describe why you think you denied parts or all of your sexual behavior.
5.  Describe your parents' role in your denial.

Section 2
1.  Now explain how many victims you really had, how many incidents total, and how much force and coercion you really used.
2.  Explain when and why you finally decided to tell the truth about all of your sexual behavior.
3.  Describe how your parents reacted when you told them the truth about all of your sexual behavior.
4.  Describe how you felt after telling the whole truth.

Section 3
1.  Summarize what you have learned about denial, and list the main reasons that you did not admit to all your offenses and sexual behavior problems right away.
2.  Give any advice you have for other young people who are charged with or have been caught for sexual acting out.

(p. 265)
Assignment 12B.  Choose someone to share your truth story with.  In many treatment programs you will be asked to share this assignment with your treatment group, as well as someone else.  Your counselor can help you find an appropriate person to share the story with.  If possible, share the story with someone who is fairly new to treatment, who may still be denying parts of their behavior.

(p. 275)
Write a two-page letter to yourself describing what you would like to know, how you would like to feel, and what you want others to think of you.  This letter is a way of thinking about your goals for treatment as well as goals for your life.  You may write down your goals for as far into the future as you would like to go.  If you have a computer, it works well to use it for this letter.  Just print the letter and tape it or staple it in the space below.  Remember:  the letter should contain the following parts:

Dear: _______________________ (put you name on the line),
Describe how you feel about yourself now.  Include five positive things you like about yourself.
Describe how it feels to have sexual behavior problems.
Describe what you think your main problems are.
Explain what you would like to feel like in the future.
Describe personal strengths you would like to build on in the future.
Describe how you would like others to view you in the future.
Describe your support system.  Who are you close to?
Describe what you would like to accomplish in the future (family, relationships, job, etc.)
Describe everything you need to do to accomplilsh your goals.  Focus especially on treatment activities.
_____________________ (you)

(p. 279)
Personal FFO (Freedom From Offending) Contract

1.  Personal information
Name: _____________________________  Date: _____________
Date you started treatment: _____________
Date of planned graduation from treatment:  ______________
Your age now:  _________

2.  Sexual Offense History
A.  Sex and general age range of the people you have admitted abusing:

B.  Specific sexual acts:  what exactly did you do to the people you abused?  You may combine all acts performed with different victims:

C.  Assault process:  describe how you committed your offenses, such as the type of force, bribes, games, etc., you used: