One size fits all treatment programs are not effective and programs should be offender specific according to offender typology and paraphilia. They should incorporate relapse prevention (NCMEC, 1998). Treatment method of choice for sex offenders is based on the cognitive/ behavioral model of group therapy with the inclusion of relapse prevention. There are five elements that need to be covered within this model: accepting responsibility, modifying thinking errors that lead to the offense, developing victim empathy, developing social skills and developing relapse prevention skills.

Levels of denial vary from one offender to another and in varying degrees as the offender works through his treatment program. Depending of the level of resistance to the various components of the program the offender in treatment may repeat certain treatment assignments until they are mastered.

Each offender within the program needs to accept responsibility by completing various assignments. During beginning stages of treatment the offender must take responsibility for his sexually deviant behaviors in front of the group. This is accomplished by reading the affidavit that is part of their court records. The affidavit often also contains statements made by the victim that the offender will take issue with. This procedure opens up a dialog within the group dynamic that makes clear the coping strategies of the offender which is to avoid, minimize, intellectualize and/or deny the seriousness of his offense (English, Pullen, Jones, 1996) (Blanchard, 1995). He/she will receive group support and confrontation. This exercise is not only the first step within the group process to take responsibility but also one where the offender can begin to address and understand his thinking errors. As a result of the group confrontation and support, the offender can then move toward an exercise where he/she personally will write and present an appropriate introduction to the group.

While the reading of the affidavit is relatively brief, it acts as a catalyst toward seeing the offense in the context of a gestalt. When writing an introduction that will be read to the group, the offender begins to look at past life patterns that may have culminated in the offense for which he was convicted. Within the introduction the offender needs to disclose at what age he/she began to sexually offend, the time frame that the abuse continued, total number of victims and total number of abuse incidents. This exercise also includes the name of the victim (first name only), age and relationship to the offender. The offender therefore begins the first steps toward no longer objectifying the victim.

A part of sexually deviant behavior is to minimize or deny accountability for the events that led up to the offense. During the writing exercise the offender must also detail any deviant behaviors that lead to the culmination of the offense. This would include the beginning and progression of fantasies, planning, grooming or method of influence. The offender's cognitive understanding of the degree to which he/she manipulated events that lead to the offense is generally somewhat limited during the beginning of treatment. Subsequent assignments address those issues, as does his/her understanding of victim empathy. Within the introduction, the offender must detail the effects his/her abuse had on the victim, should he/she state that he/she is unaware of the effects, than it is sometimes helpful to suggest that he/she describe the potential impact to other persons within that age category. In the event that the offender's actions did not culminate in penetration of the victim, the offender should be encouraged to state to what degree they would have gone with their sexually deviant behavior had it not been stopped. This is particularly beneficial to those offenders within the categories of lewd and lascivious behavior or sexually deviant behaviors such as exposure of genitals in public. These offenders tend to minimize their behavior in the group setting where there are also members whose offenses included incest, sexual molestation of a minor and/or rape. Other components within the Introduction written exercise would include identification of how they have taken responsibility so far, i.e. restitution to the victim or victim's fund, motivation to treatment, current understanding of potential future risk situations, and current support systems they now have in place.

Another early form of accountability is for the offender to appropriately disclose that he/she is in fact a sex offender to family, employers, landlords and others as appropriate. It is not appropriate for the offender when giving information regarding his/her offense(s) to do so in graphic terms. Contact within the community generally exclude all contacts with minors, under the age of 18, regardless of the age of the victim in the offense until such time as is approved by the probation officer and/or treatment provider. Hence, an offender whose victim was age 16 would also be excluded from contract with children of a younger age or different sex of the victims, at the discretion of the treatment provider and probation officer. Future contacts, where the offender's cycle of offense does not include categories of victims, can be addressed through the Safe Guard Program.

Accountability also takes the form completing an Offense Cycle which demonstrates that such deviant acts do not occur suddenly and without prior thought or actions. The offender needs to understand his/her own patterns of behavior and thoughts that lead to his/her decision to offend. Each offender begins his cycle by experiencing sensory feelings or emotions that trigger his/her deviant thought patterns or he may have thoughts (ideas, plans, memories, wonderings) that generate a feeling.. This is the initial part of the cycle and will vary from offender to offender in regard to what that trigger is. Since the offender's mode of coping with those stress factors ultimately is sexual release by use of a victim, this second stage moves the sex offender to increasing levels of thought patterns that reinforce sexually deviant behavior. During the third stage the offender begins to select a target. His/her actions will begin a process of manipulating his environment in such a way as to have access to a random or already accessible victim. This will occur either through the active process of grooming his/her victim or setting up the offense scenario (Ross, 1996).

Methods of offenses vary from offender to offender, some are at one end of a spectrum and will remain there and others will increase the level of offense over time prior to being exposed for the sexually deviant behaviors that they in fact are. Jonathan Ross (Ross, 1996) identifies 10 levels of sexual aggression. The sex offenders in treatment need to address and identify their own continuum of sexual aggression. This would include previous initial stages, the indexed offense and their projection as to where on the continuum their deviant behavior would have eventually led had disclosure not occurred.

The continuum of aggression begins where an offender objectifies or exploits a person in an effort to obtain sex through words or status. The second level includes behaviors that are seen as acts of non-contact sexualization. This is accomplished in the form of obscene phone calls, voyeurism, exposure of genitals and theft of items used for sexual deviant fantasies. The next part of the continuum varies slightly from the first behavior listed above in that the offender moves from sexual exploitation into a more active form of sexual harassment. His/her remarks to his/her target will be more aggressive and the objectification of the victim becomes more based on "quid pro quo" to attempt to gain sexual gratification (Ross, 1994). The fourth item on the continuum is minimal contact that includes stalking a potential victim, frottage and physical contact with the victim via means that can be excused as accidental. Fifth on the continuum is tactile or oral contact with the victim including masturbation or kissing the genital area of the victim. Midway in the continuum, aggressive contact includes victimization where the breasts or buttocks of the victim are grabbed or physical restraint is used to accomplish the sexually deviant behavior. Further left on the spectrum in severity of offense there is genital penetration whether that is accomplished orally, anally or vaginally. This would also include the use of force for rape and penetration of the victim with objects. The more severe form of sexual aggression is the forcible penetration offenses that perpetrate the use of weapons, bondage, forcibly restraining the victim during the act and all forms of rage rape. To the very extreme end of the continuum we have the sadistic and/or ritualistic abuse that often will include infliction of pain, kidnapping and torture and finally, those cases that include sexual homicide, victim mutilation, or dismemberment as one might also see with serial killers (Ross, 1994).

It is interesting to point out that in a study by Briere and Runtz (1989) non-sex offending college students were asked to fill out a questionnaire regarding their sexual attraction to children. Within this study "21% of the students admitted to sexual attraction to some children, 9% described sexual fantasies involving children, 5% admitted to having masturbated to those fantasies and 7% stated there was some likelihood of having sex with a child if detection and punishment were unlikely" (Briere, Runtz, 1989, p. 65). The study maintained however, that the survey data did not support theories of sexual repression or impulse-control problems among potential pedophiles. It did support "child sexual interests with negative early sexual experiences, masturbation to pornography, self-reported likelihood of raping a woman, frequent sex partners, sexual conflicts and attitudes of sexual dominance over women" (Briere, Runtz, 1989, p. 65).

Identifying the cycle of offense does not end with the offense itself. The offender must also reflect and identify the period after the offense that is often distinguished by active thought processes of denying, minimizing, rationalizing and avoiding detection. This can be due to internal conflict within the offender characterized by depression, shame or self-pity.

As the offender progresses though treatment they will again repeat the re-offense cycle exercise, along with sharing learned insights with the newer member(s) of the group by giving feedback, support and empathetic confrontation when appropriate.

In order to begin to control the thought processes the offender needs to first recognize the way in which these thought processes take place. They need to modify their thinking errors. Early in the treatment program, other members of the group will actively participate in confronting the new offender's comments and thought distortions that lead to subsequent denial, minimization and rationalization of the process that the offender uses to justify his/her acting out behaviors. See list of defense mechanisms in Appendix E. The offender learns that the act of offending did not occur in a vacuum but was the result of subtle and not so subtle decisions based on thought processes. To this end the offender is required to keep a daily mood log, anger log, a trigger log and a log that includes entry of all sexual impulses. They must also do an exercise that demonstrates the chain of events that occurred up to and including the identification of high-risk situations.

The sex offender often comes into treatment unable to identify a full range of moods and emotions. The daily mood log helps them to identify feelings of anger, happiness, sadness, fear, nervousness, ambivalence, guilt, confusion and trapped feelings. It also requires that the offender rank the degree or intensity of the emotion. Variations of an emotion are also explored in varying terminology such as anger-mad-pissed off; sad-depressed-gloomy, nervous-anxious-tense; guilty-blaming; afraid-scared-frightened, etc. Once the offender can narrow down the exact degree of emotion he/she is observing, they log the immediate thoughts and attitudes that surrounded the emotion. They later list any thinking errors such as blame, justifications, avoidance or resistance, and then follow through by logging what a rational response to the feeling/emotion would be. These exercises are later shared with the group for feedback (Hammond, 1999).

Another version of the Mood Log is termed Trigger Log and it differs from the above predominantly in ease of use and identification of the components involved in recognizing all aspects of a trigger. Identification of the emotion is in the form a checking the most appropriate box, i.e. happy, nervous, sexual arousal, anger, concern, or other. It requires an intensity level based on the numbers 1 through 10 with 10 being the highest in intensity. It breaks down the focus of the trigger further than the other tool (mood log) does in that the offender must state whether the focus was toward male child, female child, object, man, woman, or other. They must also identify the place the trigger occurred, examples being, at work, at home, in transport, or other. The feelings of the offender are logged (mad, sad, glad, afraid, nervous) as are his/her thoughts at the time (passing observation, considered consequences, fantasy with duration and/or frequency, and other). The offender needs to be reminded that there are always choices when faced with triggers in their life. Subsequently in this tool they must state the choices they had at the time, i.e. escape place or thought, engaged in fantasy of what they would like to do or whether they escalated their behavior and/or acted out on it. They record what action they took as a result of the trigger such as diverting their attention or refocusing, acted on the thought for immediate gratification or delayed satisfaction and/or suppressed the impulse. Thought triggers, always have a result and the offender needs to identify what the result of their response to the trigger was whether they acted out as a result of the thought, whether they responded in a thoughtful manner or whether they chose to dismiss the thought, let it pass with the result of no recurrence of the thought. The final part of that exercise is rank how they felt they handled the triggering thought or moment. In their written response they answer if they handled it very responsibly, somewhat responsibly, whether there could have been an improvement in their response, or if they considered themselves to have handled the event in an irresponsible manner (Hammond, 1999).

Many cases of deviant sexual behavior patterns, although not all, have their roots in initial feelings of anger that is later sexualized as a means to release. Many of the sex offenders are also required to maintain an anger log that will make clear the triggers that precipitated feelings of anger and it's intensity, cause or triggering events. As a tool, the anger log assists the offender in being able to clarify the physical sensations and complex emotions that occur as a result of an anger trigger. Intensity is logged as is his/her responses by active behaviors and whether the offender focused the anger toward a particular person or inanimate object. Some offenders will act out and others will internalize the emotions that then build up over time. If substances were used prior to the anger trigger this also must be logged. The reinforcement of positive behaviors during anger triggers are also included in this exercise as the offender makes a cognitive effort to include periods of positive self-talk, use of exercise to diffuse acting out and whether they took the precautions of "time out" if the anger trigger was intensifying (Cullen, Freeman-Longo, 1994).

The sexual impulses log should be maintained daily to track all sexual responses including what the trigger to the response was, whether the trigger was a result of external events or internal fantasy, the arousal rate on the scale of 1 to 10 with 10 being the highest. Duration and frequency need be recorded also. The offender will log whether the response was of the type that was a passing thought or a physical response to the trigger. They need to state what the end result of the trigger was and action taken, such as use of fantasy to masturbation, consensual sexual relationship with an age appropriate partner or if they redirected the impulse. They need to identify if sexually deviant behavior or healthy sexual behavior resulted.

In conjunction with the offenders abuse cycle exercises, the High Risk Recognition Chain of Events and developing a Relapse Prevention Plan are used. Once again the offender must map out both his thought processes prior to the sexual offense, the behaviors and choices he/she made prior to the acting out behavior. Many offenders come into the program with a strong belief system that supports their contention that their deviant behavior "just happened" or is/was directly, or indirectly, the fault of another person or event (Marshall, Laws, Barbaree, 1990). They have little cognitive insight to all the steps and choices that culminated in the act. The lapse process generally will start with a life event that will cause the offender to feel helpless and/or not in control of his own life. This causes a change in thinking patterns of the offender to actually feel they are victimized. The initial event, for example, could be loss of job, breakup with a partner or fear of such losses. Reactions could be feelings of abandonment, betrayal, depression (anger turned inward), anger projected outward, or a blow to the perceived self-esteem of the individual offender. The action causes a reaction in the offender and sets into place decision processes that at first appear to be unimportant or minor but reinforces the offender's perception that, as a victim, he/she must again regain control of his life. He/she must prove his/her mastery over himself/herself and others in an effort to push aside feelings of being trapped or weak.

Using the example of a male pedophile attracted to young boys of a certain age, the pedophile might choose to take a walk to offset his frustration after having had an argument with his supervisor at work, he fears the loss of his job as a result. He appears to walk aimlessly, deep in thought. He reargues his position in his mind and he thinks over what he could have, would have, should have said, and his physiological reactions are charged with the autonomic systems flight, flight or freeze mechanisms. He is feeling a combination of abandonment, betrayal and anger. The walk becomes a circular dance where relaxation and logical thinking becomes alien to him. He notices he is coming up upon a park several blocks from his apartment and decides to sit down and take a rest to sort out what is going on inside himself (lapse 1). He realizes he is watching children play in the park not far from an apartment complex and focuses his gaze on a group of 10 year-old boys. He feels isolated as he watches the boy's carefree play. After observing the boys for a while he notices one boy who appears to be separate from the group, playing but not quite part of the group (lapse 2). Suppertime occurs and the boys are called home with the exception of the one boy. The offender strikes up a conversation with the lone boy beginning a "friendship" to fulfill his emotional needs (lapse 3). The boy returns home after several hours and the offender returns home. The next day the offender returns to the park and repeats the process, each time leading the boy into a position of trust and friendship until the lapse behavior turns to a relapse of sexual abuse of his "groomed" victim. He rationalizes that the boy he befriended is interested in changing the relationship to one of sexual consent. The offender has gone through the relapse process of many distinct decisions (lapses) prior to the actual offense (relapse). Other examples of lapses are provided in Appendix F. He responded to a real life stressor by setting up a series of seemingly unimportant events to lead himself into high-risk situations. His maladaptive thought processes are reflected in each choice he made in lapsed behavior until he has manipulated his victim to satisfy his deviant sexual need that is his primary coping mechanism for release of stressors in his life.

Once the offender is able to identify the steps and choices he/she took he/she needs to thoroughly examine the warning signs and triggers of his/her own re-offense cycle. Depending on the type of sexual deviancy of the individual offender, triggers could include television commercials, movie scenes, observing children, women, seeing an opportunity to offend, and situations where vulnerability is apparent. Warning signs that could lead to relapse includes feelings of isolation, boredom, anger, self-pity, depression, confusion, humiliation, rejection and loneliness and fear (Ross, 1992).

Initially the offender can begin to learn problem solving and self-control skills by the use of reminder cards, lapse rehearsals and cognitive restructuring. They will learn escape strategies for each seemingly unimportant decision they are known to make in their re-offense cycle. They learn to redirect their thought processes. Anger management strategies are set into place and interpersonal skills reinforced. Rather than trying to control others when feeling helpless and using victimization as a means of personal power and control, the offender learns to control himself/herself, which is a means of true empowerment. Jonathan E. Ross (1992) suggests the specific ways to restructure behavior when faced with projections of deviant sexual arousal. He suggests exercises in controlling thought processes. When faced with deviant sexual fantasies (DSF) the offender should try to remove himself/herself from the situation, become busy in an alternative activity, or share his/her thoughts with a peer role model. They can write the fantasy in a journal (using appropriate terminology to offset excitement), or attempt to change the DSF into a healthy appropriate fantasy. Another exercise is to imagine the negative consequences, in vivid and meticulous detail, should the offender actually proceed down the path to re-offense. (Appendix D)

The need for victim empathy is a strong component of the sex offender treatment program. Had the offender been able to empathize with his/her victim the act would not likely have occurred. Sex offenders do not have an empathetic understanding of the full scope and range of the victim's reactions to their sexually deviant behaviors. Long term problems will likely occur as the victim tries to regain a safe sense of self, both internally and within their individual environment. As a result of the abuse the victim may typically react in one of two ways. They can express fear, anxiety and anger as displayed by crying, shaking, smiling, restlessness or tenseness (PAVE, 1995). They can also respond by quietly internalizing their reactions as in the case of a state of shock, physical exhaustion and by attempting to deny the abuse or repress it. Victims often carry the burden of feeling guilty for having been abused (i.e. why did this happen to me, what did I do to bring this on). They not only fear the abuser, but in some cases, it includes a sense of guilt that they are responsible for what happens to the abuser as a result of his/her being caught. Most victims will have difficulty due to their new feelings of vulnerability and loss of control over their lives. Boundaries that were safe before now have become questionable and dangerous. They question their abilities of judgment and decision making. They now wonder who they can trust and who is not worthy of their future trust. They are left with a sense of embarrassment and shame. They wonder what their loved ones will think, what their friends or community will now think of them. The victim will often feel ashamed that they are now dirty or disgusting, their self-respect has been shattered (PAVE, 1995).

The sex offender must consider all of the above in an effort to begin to empathize with how the victim felt during the abuse and how it will effect them for years to come. In a victim clarification statement, the offender writes a letter to the victim (not to be sent unless it is in the best interest of the victim) in which he assures the victim that they were not responsible for any of the deviant acts against them. The offender must also write a trauma relationship statement where he/she considers how the victim saw themselves within the community prior to the abuse, during the abuse and after the abuse. Offenders are encouraged, and sometimes mandated, to make retribution in the form of monetary payments to the victim's retribution fund. Contact with the victim can only occur with the consent of the treatment provider and probation office and only with consideration for the welfare of the particular victim. Where contact for the purpose of a sincere clarification statement is deemed to be unhealthy for the victim, no contact is allowed. Violation on the part of the offender results in a Violation of Probation Order and the possibility of being remanded to prison.