On Working Clinically with Sexual Offenders: An Interview with Dr James Cates

When I was first introduced to Dr James Cates about five years ago, it was in a lecture in which he talked about the unique challenges of doing clinical work with the abundant Amish population (third largest in the country) in northern Indiana. I was fascinated by this work in part because it focused on sexual abuse inside a religious community, and I had myself just finished a book on sexual abuse inside the Catholic Church. 

About a year later, I had the great good fortune to read his elegantly written and fascinating book, Serpent in the Garden: Amish Sexuality in a Changing World, about which I interviewed him here. 

I brought him to one of my classes this past semester to lecture on working with the Amish and it was then I learned his newest book was about to make its appearance in print. I eagerly ordered and read Offenders and the Sexual Abuse of Children (Routledge, 2024), and then asked him for an interview about it. His thoughts are below.  

AD: Tell us about your background

James Cates: I graduated with a master’s degree in clinical psychology from George Mason University in Fairfax, Virginia. Jobs were sparse, so I did a nationwide search, and wound up employed in Fort Wayne, Indiana. I planned to stay a couple of years and move back to Virginia.

That was 1982. I’m still in Fort Wayne, looking for the right job to move back. 

Meanwhile, I received my doctorate in clinical rehabilitation psychology in 1993, became a board-certified clinical psychologist, and moved into private practice. Somewhere along the line I began teaching part-time at Purdue University-Fort Wayne, first undergraduate, and more recently in the mental health counseling program. I became involved with the Amish, a culture that I love dearly and respect deeply. I am now semi-retired, and continue to write and to do psychological testing and consultation. 

AD: Your previous books marked you out as the leading scholar-clinician on Amish psychology, so a book on sexual offenders might seem a significant new direction to move in. Are there any connections between these worlds?

JC: Sadly, more connections exist between the Amish and sexual offending than would be preferred. All three of my books on their culture include chapters that address sexual abuse: Serving the Amish: A Cultural Guide for Professionals; Serpent in the Garden: Amish Sexuality in a Changing World; and Dancing on the Devil’s Playground: The Amish Negotiate with Modernity. And mainstream media has picked up the storyline of hidden sexual abuse among the Amish, as among so many groups today, as a social ill in desperate need of change. 

I credit my work with the Amish for helping to broaden my perspective on sexual offending. Their culture is collective, emphasizing a communal and cooperative lifestyle, so that very few actions occur outside public awareness. Their culture also emphasizes forgiveness as a Christ-like virtue, so that sins are to be forgiven and forgotten. Consulting with both social service personnel and Amish ministers on how to handle issues of sexual abuse within the church, and counseling with Amish victims of sexual abuse and those who have sexually offended has given me an appreciation for the interwoven complexities of this behavior, and its impact on the family and community. This fallout is too often obscured as the justice system grinds into gear in mainstream culture.  

AD: The first part of your book helpfully situates what is to come in its social and historical context, especially in the anglophone world. As you survey this history, are there 2 or 3 outstanding factors you unearthed to help explain shifting perspectives on sexual offenses? 

JC: The idea that history is written by the victors is most recently attributed to Winston Churchill. That is so true when considering perspective on sexual offenses. With the caveat that I am neither a historian by training, nor am I an amateur historian, these are my thoughts.

The anglophone response to sexual abuse through the 19th and earlier 20th centuries was dictated by class and caste systems far more than an advocacy to protect all children. As horrible an indictment as that sounds, it fits within the broader disinterest in the rights and well-being of those of lower socioeconomic status. In this country, the status of African-Americans is the most obvious example. As the Civil War became a cause to end slavery, even many who were fervent abolitionists failed to perceive people of color as equal to whites. And these attitudes continued to be codified in law well into the mid-20th century. The backlash to these prejudices became an embrace of equality, and demand that the rights of all people be respected. One of the lasting legacies of this principled backlash has been a strong advocacy for the safety of children. Unfortunately, those who sexually offend then become pariahs in their own right. 

Another rarely considered historical factor was political necessity in the early years of gay rights. That portion of the nascent movement driven by gay men was enmeshed with men attracted to young boys. This uneasy truce lasted until it became clear that an alliance between men attracted to men and men attracted to boys was a detriment to social and political ambitions for the former, who acted to distance themselves from those who would now be termed minor-attracted. While the gay movement did not actively denigrate those who were minor-attracted, the implication was clear: we do not support that type of sexual activity. In that implication, one denigrated sexual minority made a case for its own worth by keeping its distance from another. (And in fairness, at the time those advocating same-sex attraction to boys were also advocating for the freedom to act on their sexual desires, a much different social and political agenda than those currently seeking status as minor-attracted.)   

AD: One of the themes in the background of your book seems to be how much we like to paint sexual offenders as bright red grotesques, whose features and causes we confidently feel we can immediately identify, but you note "there appear to be too many variables that contribute to the ultimate behavior to reliably predict patterns of sexual offending" (p.23). Later you note that when it comes to the risk of recidivism for sexual offenses "nothing even approaching a definitive response exists" (p36). Given the enormous publicity that attends sexual offenses, one might expect this to be a heavily researched area. What helps to explain the many lacunae in the clinical literature on these topics? 

JC: The problems in predicting the behavior that leads to sexual offending are myriad. A parallel example from several years ago in the area of substance use exemplifies the dilemma. At that time, studies repeatedly found that among 18–25-year-olds, over 50% were binge drinking on a regular basis. The first problem with this statistic is that by definition, if an 18–25-year-old was not binge drinking, they were abnormal, since they were in the minority. The second problem with this definition became the criteria for binge drinking. As studies began refining the definition of “binge drinking,” using differing criteria for the number of drinks consumed at one time, or within a certain time period, the percentage of those identified as binge drinkers began to vary too. Alcohol use was not significantly changing. The way research defined it was. 

When research looks at sexual offending, the same problem with definitions applies. What is the age of the victim? Legally, a “sex offender” label applies to someone who has sex with a five-year-old, or someone a week younger than the legal age of consent. Do the same dynamics of sexual, emotional, and romantic interest apply to these two individuals? What is the age range of interest for someone who has sexually offended? How often, or under what circumstances do the sexual offenses occur? Do we apply the same criteria to the uncle who molests his niece on two occasions, and the serial offender who has sexually offended against both genders multiple times?  Is there an element of power and control, or do they exhibit a romantic or regressive emotional interest in the younger partner? Not only is this a complex topic, but we do little to encourage those who have sexually offended to be open and honest about their sexual and psychological experiences. 

Research on recidivism in sexual offending is hampered by the shame, guilt, and risks that attend honesty. Consider a standard field research protocol. Participants must be known to have sexually offended. There is no potential to circulate a call for participants, such as can occur at a local 12-step meeting for those struggling with substance abuse who might like to give back to the community. There is no potential to ask counselors to share with clients who would qualify as participants. No, the only participants available are those who have been charged and convicted of a sexual offense. And the majority of these (now) criminals have no incentive to be honest about their behavior, beyond the behaviors for which they have been convicted. If they are, they run the risk of having even more charges added, and facing lengthier sentences. The individual struggling with alcohol or drug abuse, including illicit drugs, can share stories of past use with impunity. Not so the individual who has sexually offended.

The most accessible participants then, are those who have served a period of incarceration and are released. And the most easily obtained outcome measure is recidivism. Have they been arrested post-release for a sexual offense? And again, there is no incentive to be honest if they have not been caught. For the probationer who relapses and watches child pornography but escapes detection, there is no incentive to share that fact. We are then left with no understanding of the emotional and psychological forces that become overwhelming and lead to the decision to risk prison once again in order to fulfill this sexual need. The probationer who shares with a counselor that they have used alcohol, violating the rules of their release, faces minimal expectation that the counselor will report them. But the probationer who shares with a counselor that they have sexually offended, violating the rules of their release? A report is almost inevitable. 

And there is a need – clearly, there is a need – to protect potential victims of sexual offending. But in acknowledging that need, we fail to take into consideration the vague definition that the outcome measure “recidivism” must inevitably become. As another example, studies vary in the types of crimes they define as recidivism. Any violent crime? Or only a sexual crime? If a defendant is initially charged with a sexual crime, but it is reduced by plea bargain to a misdemeanor battery with no sexual component, is that recidivism? These are the types of decisions about definitions that vary from study to study, and complicate meta-analyses.  

AD: One of the (to my mind) peculiarities in treatment of adolescent vs. adult offenders is, as you note, offering the former a "rehabilitative model rather than a punitive one" (p.38). The latter model, when applied to adults (who are often related to their victims), often causes even further unintended hardship (as you note on p.78) and suffering by imprisoning the offender, causing a loss of income to the family and other problems. Is there any argument to be made about adopting a more rehabilitative model across the board for all offenders? What is the evidence we have about rehabilitation and its efficacy? 

The question goes to the broader issue of American attitudes toward rehabilitation. The statistic is hard to pin down, but we rank among the highest per capita incarceration rates among developed countries. We are more comfortable locking away those who offend than finding ways to manage them within the community. 

Restorative justice, the concept that accountability and reparation are more important than retribution and punishment, is beginning to make inroads into the justice system. We see it in the formation of drug courts and mental health courts, designed to treat substance abuse and mental illness primarily as disorders, rather than crimes to be adjudicated. Still, the emphasis on protection for the community means that rehabilitative models for those who sexually offend are slower to develop and slower to be implemented than for other populations. 

Rehabilitation for a particular population will relate to that population’s standing. Those who engage in criminal behavior are placed at the intersection of politics and science. There is a grim reality to the frequency with which Americans incarcerate those who commit crimes. Reducing the number of people likely to commit crimes who are on the streets does indeed contribute to a lower crime rate. So, at some point the issue becomes philosophical: to what extent is the drug dealer/drug user/burglar/child pornographer/etc. deserving of rehabilitation and a return to mainstream society? Only the to extent that we believe that a given population deserves rehabilitation do we begin to emphasize rehabilitation for them. And only to the extent we emphasize rehabilitation is it funded, analyzed, refined, and measured for its efficacy. 

An argument for extending rehabilitation? For those of us who argue for the worth of the individual over the erosion of civil rights and the staggering costs of incarceration, it is well worth it. For those of us who argue for the safety of the community over the worth of the individual? Rehabilitation is secondary to confinement.  And the argument is obviously not that black-and-white. Argue within the shades of gray and it becomes a tumultuous argument, indeed. 

AD: I thought my cynicism about the legal system was approaching bedrock level, but I confess it fell still further as I watched you judiciously sift and sort through the evidence for geographical restrictions on offenders, state-mandated offender registries, and similar tools of social control. Given that, as you show, we have virtually no empirical evidence for their utility, how are we to explain their ubiquity today--are they simply the perverse fruits of moral panic, a kind of "quarantining" or ghettoization of undesirables we see throughout human history going back to biblical leper colonies? 

JC: The high-profile kidnapping, sexual assault, and murder of several children resulted in federal laws that have shaped social control of those convicted of sexual offending. To some extent, it was a perfect storm of events: the public was clamoring for a sense of safety due to multiple events on the world stage that led to unrest and feelings of unease; the media hyped stories of child abduction and murder in an endless loop as the public became increasingly interested, and the media fed that interest; and social science had little or nothing in the way of evidence to support or refute proposed legislation. 

Once legislation was in place, research was playing catch-up to determine how effective it might be. Laws continued to be modified, expectations for registries continued to evolve, and research needed to change to match current expectations. By the time research was demonstrating that registries had no deterrent effect and geographic limitations were ineffective, both of these safeguards were entrenched in the public psyche as “deterrent measures.” For legislators it was no longer a matter of what might be effective. It was a matter of public demand. 

A demonstration of just how little evidence-based practice impacts social policy can be seen by placing gun ownership and sexual offending side by side. Mass shootings have become a norm in the United States – including in schools - but no one is seriously considering gun control, despite the evidence that gun control would work to reduce senseless deaths. Meanwhile, registries and geographic limitations on habitation do nothing to reduce sex offending, but we cling to them like a drowning man to a life preserver.

AD: At the end of ch.9 you note that "the necessary, fundamental change is a better understanding of a person who sexually offends." This seems so simple as to be almost startling, but I think it true. And yet I know from my students that the one population they all say they would struggle the most to work with, some of them expressing horror at the very thought, is that of sexual offenders. What are some of the most startling or surprising insights for you working with sexual offenders--what have you learned from them?

JC: Let me start the answer to this question indirectly, and wind my way back. It strikes me as a political rather than a clinical statement that as a 68-year-old male, in my state of residence I can carry on a romantic/sexual affair with a 16-year-old, and not only be within the boundaries of the law, but there is no preponderance of research explaining what might be the hell wrong with me. And yet social science churns out article after article detailing the problems of a 20-year-old who deigns to fall madly in love with a 15-year-old. 

Now, a couple of quick clarifications to the paragraph above. I have no interest in a romantic or sexual liaison with a 16-year-old. Rather, my point is that empirical research does not bother to extensively study age differences in romantic interest across the lifespan; only between adults and children. And the example I use is one of the narrower age gaps that can occur that result in arrest, charge, and conviction leading to the label of “sex offender.” Obviously, 20-year-olds (and older) are also sexually abusing much younger children, a clinical problem in desperate need of research. 

The point however, is that between the black-and-white of inappropriate sexual acting out and sexually permissible behavior there is a wide, gray area that becomes codified in laws that may not be an accurate representation of how clinically disordered a person is. 

I give two brief examples in the book. Fleshing these out a bit gives a better sense of just how different the dynamics between two people who become “sex offenders” can be. 

One was a case in which I testified for the prosecution. This was an approximately 40-year-old man who had a history of arrests for various offenses. His apartment was filled with toys and games he used to entice children from the neighborhood. By the time he was arrested he had multiple victims, and from all potential observation, no remorse for his behavior. He appeared to exhibit an Antisocial Personality Disorder – that is, a lack of conscience or ability to empathize with others, and a willingness to disregard their rights. In his case, rehabilitation was far less of a concern than safety for the community. His is one extreme of those who sexually offend. He also had charges for various non-sexual felonies. His sexual offending was part of a larger pattern of disregarding the rights of others. 

At the other extreme was a young man with a severe addiction to marijuana. He began sexually abusing his young daughter. He hated himself for doing so, and after one incident said to her, “If I do this again, tell mommy.” He sexually abused her again, and in turn, his daughter told her mother. He did not contest the charges. While he waited for the justice system to proceed (it took 14 months for his sentencing hearing), he lived on house arrest with his parents. He found a job, and made voluntary child support payments on a biweekly basis. Despite his cooperation and behavior, he was given a sentence of 12 years. In counseling him as he waited for sentencing, and staying in touch with him during the time he has been in prison, it is clear to me that he is not attracted to children. The incidents with his daughter arose from a combination of reduced inhibitions due to drug use, tensions with his wife (the girl’s mother), and feelings of helplessness in his larger environment. 

In these two vignettes, from a legal perspective, the behavior is the same. A child under the age of 14 was touched for the purpose of sexual gratification. From a clinical perspective, they could not be more disparate. Regardless of the presenting problem, it is a profound reminder for those of us in the mental health field: there are multiple reasons for a behavior to occur. 

And the most surprising observations? Very few of my clients fail to offer me insights in some way. Sometimes, they are insights that leave me grieving the human condition. Sometimes, they are insights that leave me breathless with what the human condition can overcome. The most startling among those who sexually offend has been the integrity they can demonstrate. Knowing full well that they are now pariahs, despised by so many, relegated to wear the scarlet letter of the registry upon their release from incarceration, they carry on with a dignity and purpose that belies their pariah status. There are several that I am proud to call my friends.  

AD: Your historicizing tendencies in this book are never so powerful and disturbing as when you show that many of the treatments previously used to "treat" today's offenders were the self-same ones used not so long ago to try to "convert" mostly gay men into heterosexuality. Are there, in fact, any treatments we have today that are (a) not connected to those abuses and (b) effective? 

JC: Visualize a map of empirical study of effective treatments for sexual offending. There is a broad, well-traveled road that runs through the middle of the map. That is the history of Sexual Orientation Change Efforts (SOCE), as they are now called, the historical efforts to convert sexual minorities to heterosexuality. At some point, that road begins to narrow, and eventually becomes a minor path. But branching away from it is a path that broadens into its own road. And these are the efforts to create change among those who sexually offend. Same journey; different destination. 

Now, staying with that visual, imagine side trails leaving the main road, both from the original highway and the new branch. These are much narrower, and almost all of them dead-end. That is the history of alternative treatment efforts, for both SOCE and for sexual offending. Without sufficient funding or willingness on the part of the larger mental health community to explore them, they may hold potential, but the destination is a therapeutic dead end. 

In brief answer to your questions then, (a) no, nearly all of the interventions in use today have their genesis in SOCE approaches, and (b) their efficacy is based on outcome measures, and the inefficacy of those measures is discussed above.  

I devote a single chapter to the evolution of mental health treatment. The topic is worthy of an entire book itself. My hope is that the chapter spurs a healthy debate on the efficacy of treatment, and that the community of current mental health practitioners implementing and researching these treatments are called to critically analyze their approaches.   

AD: Your chapter on minor-attracted persons is perhaps the one where we see most acutely the limitations and short-comings of our research, knowledge, and clinical practice. Where would you like to see the research go? What future directions and changes do we need to investigate? 

Minor-Attracted People (MAPs) are a paradox. They again demonstrate the intersection of the clinical and political. Allyn Walker wrote extensively about MAPs in their book A Long, Dark Shadow: Minor-Attracted People and Their Pursuit of Dignity, only to be pressured to resign from their position as faculty at Old Dominion University because of it. On the one hand, there is increasing urgency to recognize the right of MAPs to express themselves as romantic and sexual human beings. On the other hand, there is the ongoing urgency to protect vulnerable children from any more exposure to adult romantic and sexual encounters than a socially toxic environment already allows. 

The fear is the “slippery slope” of acceptance. It took time, but from riots by street people outside the Stonewall Inn in 1969, gay liberation brought us to Obergefell vs. Hodges in 2015, the Supreme Court decision legalizing same-sex marriage. Some fear that embracing MAPs as a legitimate sexual orientation is an ultimate invitation to act on that desire, protests to the contrary notwithstanding. They point to the slow history of acceptance of same-sex couples as an example of how that can occur. 

It is here that social scientific research can be most helpful. Is minor-attraction a sexual orientation? Are there different manifestations of minor attraction? How often does minor-attraction as a sexual orientation coexist with other sexual orientations? If minor-attraction is only one of many reasons that individuals may desire to become sexually involved with a child, what clinical/emotional/psychological factors and traits contribute to minor-attraction as opposed to other reasons for focusing on children? And if a MAP chooses to embrace that attraction but remain abstinent from acting on the desires, what are the most effective means of assisting them in doing so?  

AD: Sum up your hopes for this book? Who should read it? 

JC: Bear with me for a moment – my dad was a Baptist minister, and some of those lessons linger. One of those lessons was the story of Elijah the prophet on the mountainside. God sent a message, but first he sent an earthquake, a huge wind, and a fire. The message wasn’t in any of these. And then, God sent the soft whisper of a voice. That has been an important lesson for me.

So much of what is written about sexual offending advocates for the victim and rails against those who offend. Less often, but still in print are those writings that advocate for those who offend and rail against the system. Offenders and the Sexual Abuse of Children is, unapologetically, an indictment of the mental health, social service, and justice systems as they attempt to protect victims and treat those who offend. But I strive to maintain a balanced perspective. The system is not in need of repair because of indifference. On the contrary, there is a desperate desire to protect the community and potential victims. My voice may rise above a whisper in these pages, but I strive to avoid the drama of frustration and anger that so often pervades these emotional arguments. 

I encourage anyone in the fields of mental health, social services, or criminal justice who work with those who sexually offend or their victims to read this book. I also encourage those who volunteer with organizations that support those who offend, their victims, or their families to read this book. And for those who have offended and their families, some may find this book of interest as well. As much as possible, I have stayed away from jargon, and maintain a readable style. 

AD: What are you at work on next? 

Back to the Amish, at least for a time! Several years ago, I was part of a program that offered psychoeducational classes for Amish youth arrested for drug and alcohol offenses in the Elkhart-LaGrange settlement of northern Indiana (the third largest Amish settlement). Over the 14 years the program ran, we collected data on almost 1000 participants. That data is ready for analysis, and I am working with several other professionals to begin that process.

I am also co-authoring another book on the Amish. This book examines the strengths and weaknesses of Amish culture, particularly as their social fabric comes under criticism from ex-Amish, the media, and the larger culture.  

And the response to Offenders and the Sexual Abuse of Children will guide my decisions about further work (article, book, etc.) in this area.  

Thank you so much, Dr. DeVille, for the opportunity to share on this blog! Always fulfilling to work with you as a colleague and a friend.

Working with Violent and Sexually Harmful Children and Adolescents

This book is so new that it bears, on my copy, a copyright date of 2022 even though I have had it in my hands since late August 2021. (One might reflect that perhaps this confusion over dates reflects a rush to get into print a book that, alas, has not been copy-edited very well: I've found several typos and solecisms, which is not a thing one typically expects or encounters in Routledge books.)

In any event, it is a rich collection of articles from numerous clinicians in England associated there with the prestigious Portman and Tavistock clinics: A. Nathanson et al., eds., From Trauma to Harming Others: Therapeutic Work with Delinquent, Violent, and Sexually Harmful Children and Young People (Routledge), xxiii+172pp. In what follows, I simply put together some insights pulled from several (but not all) chapters. I do so in part because about half my current clinical work is with adolescents court-ordered into individual and group psychotherapy for various sexual offenses. This is not work I ever expected to find myself doing at this stage of my life. It was, to be frank, work I was faintly horrified by when I first learned of it. But now that I have been immersed in it for nearly a year, I have come very much to enjoy it in that Winnicottian sense I wrote about here. 

The introduction takes us into some of the theoretical underpinnings of the essays in the collection, and explicitly makes mention of someone whom I was introduced to through reading Adam Phillips: the late American psychiatrist and psychoanalyst Robert Stoller. His book Perversion: the Erotic Form of Hatred gets cited by the editors as a useful text, which I have also found it to be. Stoller has argued--in my view correctly--that often what is sought in sadomasochistic fantasies and enactments as an adolescent or adult is a triumph over childhood traumas. The authors and editors in this new book would also seem to share that view.

The other author they cite, unfamiliar to me, is Ismond Rosen, editor of a collection of articles, published by Oxford UP in its third edition (original: 1979) in 1995 as Sexual Deviation. 

The editors go on to be clear about things that in the popular imagination are often obscure, noting that "only a minority of adolescents who sexually harm others turn into habitual sex offenders" (xiv). This is confirmed in some of the case studies later in the book of adolescents who sexually harmed children not because of an attraction per se to children as such, but because in each case the child represented something the offender hated and sought to strike at to hurt someone else--chiefly a parent. 

The editors in the introduction, and many of the other authors in this collection, acknowledge that what has changed in their work over the years with this population is the Internet and the widespread and rampant access to pornography (and the related problem of other images on social media). 

Mariane Parsons has a brief chapter, "Key Concepts Developed at the Portman Clinic," whose conclusion is simply stated but, in my view, absolutely crucial for this kind of work: "to foster...and enhance the youngster's self-esteem and capacity to be curious about himself it is of vital importance to help him to feel seen by the therapist as a whole person with strengths that can be valued (as well as weaknesses that need help). This offers hope to the patient and is essential for a move towards a healthier future" (p.7). I have written at length elsewhere (in press) about trying to do exactly this and why it is so vital for clinician and patient alike, so I will say no more about that here. (The last chapter in the book, "The History of the Portman Clinic," brings us back to the introduction, but with more particular detail and less clinical material.)

Anne Alvarez, in her chapter "Motiveless Malignity," notes bluntly that clinicians, when working with patients of psychotic and psychopathic tendencies, must "look evil straight in the eye" but then also look at whatever good qualities may be starting to emerge in a patient as well. Sometimes these qualities will be very minimal and must not be overplayed or exaggerated. In some particularly damaged individuals the most we might ever see are "faint beginnings...of trust and faith" which may be remarked upon unsentimentally. Such patients also generally cannot handle symbolic interpretations ("in attacking me you are seeking to strike at your mother") so these must be used with great caution.

Donald Campbell's chapter, "Considering Perversion from a Portman Clinic Perspective," engages with Stoller and other recent clinicians after returning to Freud's 1905 Three Essays on the Theory of Sexuality. Campbell's chapter inspired me to return to that 1905 work also, and find in it some refreshingly blunt and straightforward claims, including that "sadism is the most common and the most significant of all the perversions." 

Campbell agrees with this, and notes that none of us should recoil from this because "all of us in one way or another are neurotic and have entertained perverse fantasies" (22). Much of the rest of the chapter is taken up with case studies and other clinical material. 

Toward the end he offers a welcome note of caution which it seems to me those running CBT-type treatments for sexual offenders might need to take deeper note of: whether in individual or group treatment, authoritarian and "macho" tendencies must be avoided in leaders who must also avoid focusing "exclusively on behavioral change without understanding the individual's internal conflicts and anxieties." Merely focusing on externals overlooks "the abuser's capacity to adopt language, concepts, and whatever is suggested as normative behavior," offering "simulated attitudes and behaviour" and a mere appearance of change (33). 

Graham Music and Heather Wood author the next chapter, which focuses on porn on the 'net. They begin by quoting a 2017 UK study to the effect that 65% of adolescent boys had not just seen porn on-line but "thought such images were realistic." Those who are emotionally fragile may gravitate towards porn and become fixated on it in part because of a pre-existing lack of connection to their own "bodily experiences and desires" (38). Continued use of it may be a defense mechanism against "core complex anxieties." One way to combat this, they aver later in the chapter, may come through developing greater capacity to mentalize, here drawing on Peter Fonagy's well-known work in this regard. 

The authors are commendably straightforward about what is offered by life in comparison to the endless fantasies of porn: compared to those images, reality must seem "very grey and dull" and it requires a perhaps unlovely "acceptance of ambivalence and imperfection" (39). Here I am put in mind of Adam Phillips again and his rather bald assertion that "reality matters because it is the only thing that can satisfy us." 

The ending of this chapter leads into the next, for both talk about porn in Winnicottian terms: as an object over-invested with meaning for some; as an object that attempts to replace human and fleshly contact because of past trauma; as an object to which one relates precisely to escape from the problem of relating to flesh-and-blood human beings. Thus do we come to John Woods' chapter on porn, "Seeing and Being Seen," which draws on Winnicott at length.  

Woods begins by commendably acknowledging the "contradictory messages from adult society" that children and adolescents get around sex and porn. On the one hand, we live in a libertarian world where "freedom of expression" is strongly encouraged and the right to sex, to sexual and gender identity, and to explorations of the same are all held up as goods that rights-bearing autonomous citizens have and which must not be impeded by censorious governments or others. But on the other hand, those of us who are working with adolescents and children, especially those court-ordered into treatment, operate with an inescapable and relatively clear moral imperative: certain forms of sexual exploration and expression are totally prohibited by the law, which punishes those who disobey, and our adolescent patients must be brought into compliance with this. 

Woods introduces another element here between competing moral and legal philosophies: the question of development. He believes that "unrestricted access to internet pornography undermines normal development" (56) and can contribute to the problem of voyeurism. On this topic, he draws on Winnicott's erstwhile analysand, the problematic Masud Khan (himself guilty of sexual boundary violations--inter alia--with patients), who notes that the intensity of pornographic arousal may be closely tied to how much of a need for "object relating" it provides. Additionally, the power of voyeurism may come from the fact that one believes one to be able to see anything and everything without consent.

Later in the chapter, Woods returns again to the moral problem of pornography, and is refreshingly candid in asking why "we are turning a blind eye to the very damaging effects of internet pornography in our society" (60) which he says should be regarded as a "Public Health issue" (61). He says clinicians should give support to parents who are fighting to maintain some control over what their children are exposed to, and that "the ideal of free expression and no censorship has to be questioned." Based on my own clinical experience watching how badly distorted some adolescents' views of sex are based on exposure to porn, and how many problems it has created in their life, I am firmly in agreement with Woods in all this.

Ariel Nathanson's chapter "Working with Mental Hackers and Backroom Thinkers" introduces the useful concept of having a mental backroom "as both a hiding place and a control centre" from which to exercise one's wishes for "omnipotence" (67). This chapter could have withstood some further development and elaboration, not least by drawing on what seems to me an obviously relevant body of literature: that of schizoid personality theory from Fairbairn, Guntrip, Winnicott, and most recently Nancy McWilliams. 

She reports confronting one patient with the rather colourful question: "are you making direct in-the-moment contact with me or do you use the sessions as a takeaway service, store my comments, and feed yourself elsewhere?" (76). If progress is made with such patients, then they may come to realize how much of life they are missing out from and thus they may come to leave their backroom, regarding it no longer as a "glorified control centre" but instead a "bleak addict's den" (77). 

In his chapter "Angels and Devils: Sadism and Violence in Children," Graham Music echoes several themes noted earlier about sadomasochism supplying unmet needs, or being a way to triumph over earlier traumas as well as various forms of "anxiety, stress," or "feelings of inadequacy" (86). Sometimes, however, the intensity of sadistic fantasies or enactments is precisely due to the patient having an internal world that is "empty and flat" with much deadening of feeling.

As we move into the later chapters in the book, some of the clinical material becomes darker and we see more severe cases of violent sexual acting out. This leads one of the authors in this section, Tim Baker, to reflect on the connection between aggression and the counter-transference. This becomes especially tricky to manage if one is working with an adolescent offender who was also himself victimized at some point. Baker's chapter on self-harm in adolescents offers some helpful vignettes to those struggling to understand such things as adolescents exposing themselves on-line or in school settings, or in public places, or those who admit to, but never carry out, sexual attacks on siblings. Much of this is discussed under the heading of Winnicott's aphorism that "it is joy to be hidden, but disaster not to be found." 

Patricia Allan's chapter, "Securing the Disaster Zone," offers some useful ways to think about initial contact, early assessment, and decisions for treatment with adolescents. She worked with a badly traumatized 8-year-old boy whose clinical presentation was of very considerable complexity and difficulty.

Ariel Nathanson's chapter closes out the book. She begins by presenting a case of a young man who admitted to using sadomasochistic pornography (of violent cuckolding) to masturbate to as a way of handling fights with and rejection from his girlfriend. He explicitly felt that this was a better way of handling things than giving in to his aggression towards her. The problem with such an approach, Nathanson says (here drawing, as numerous authors before her have, on the work of M. Glasser in the Rosen volume, Sexual Deviation, noted above) is that it rapidly becomes "both perverse and highly addictive" (139).

Nathanson's chapter is an attempt to synthesize "common themes and dynamics" across her many years of work with adolescent and young adult males presenting with sexual difficulties and offenses. Most of them wound up in long-term psychotherapy. All of them presented as "suffering, highly addicted to their destructive activities and feeling at the mercy of those, unable to free themselves, as they would desperately like to do in order to lead a normal life" (140). 

Central to every story, she says, is a theme of descending into a dark world. For many, this is a comforting and familiar world, a world where they can feel alive, where they feel their "real self" may be discovered, where their "real attachment" and "first love" abide (140). Such a world elides the problem of abandonment. It creates and welcomes plenty of bad objects which become perversely salvific.

Nathanson talks of how all her patients come sooner or later to a moment of realizing how and when their "fuck-it" button functions in life--that rapid moment of transition from one self-state to another which has previously been so rapid for them and so out of control that they find themselves back in addictive behaviors before they realize it, let alone attempt to control them or resist them. As one increasingly recognizes the dynamics of this process, she reports that patients notice things slowing down. The fuck-it button might still get pressed, but this time with a little more room for noticing, and perhaps very briefly tolerating, the anxieties that precede it.  

As this increases, patients realize how much they have ritualized, via negative behaviors, unintegrated anxieties, memories, feelings. Over time much of this can actually decrease: enactments may still happen, but with less intensity and frequency, and with greater realization and control: this is what she calls "emerging potency" (148). One patient noted "how not enacting sexually made him feel more potent, creative, and able to use his aggression to assert himself at work." 

Central to success in this work is an increasing "integration between the physiological and psychological, often reconfiguring the relationship between their bodies and their minds after many years of addiction and abuse" (149). 

In her conclusion, Nathanson affirms a practice that is central to the program I work in with adolescent sexual offenders: not just building a general relationship with each patient, but having each patient narrate in close and concrete and unsparing details the nature of their enactments and abuse. These are then "looked at carefully, under a microscope." 

Each of my patients struggles to do this, but it is key to all future progress. Such enactments, she says--echoing, of course, Bion--constitute "attacks on linking." The moment when the fuck-it button is identified is the beginning of the end of attacks on linking, the beginning of the restoration, in fact, of the capacity to see, and gradually to accept and tolerate, linking (between, that is, maladaptive behavior in the present along with anxieties and feelings from a traumatic past, which are now noticed and increasingly tolerated before being changed). 

Finally, Nathanson notes that responses to enactments are often much more effectively delivered by group therapy than individual. In the latter, responses from the therapist to enactments can seem authoritarian and punitive, shutting down the process of exploration and reinforcing the very habits of flight one is working to heal. A group, by contrast, offers different ways of exploring these enactments that eventually lead to their extinguishment (or at least very dramatically reduced number and nature).

In sum, then, From Trauma to Harming Others is a rich compendium of clinical experience that all those of us working with adolescents and young men struggling with sexual addictions and crimes can profit from with gratitude. 

Healing Sexually Betrayed Boys and Men

Last year I reviewed a manuscript for Routledge and in exchange for my labours took my remuneration in books, including a copy of this book: Richard B. Gartner, Healing Sexually Betrayed Men and Boys: Treatment for Sexual Abuse, Assault, and Trauma (Routledge, 2018). 

It is the second volume, a companion to Understanding the Sexual Betrayal of Boys and Men: The Trauma of Sexual Abuse (Routledge, 2017).

I have not read the 2017 volume, but on the strength of the second, I will be doing so.

Healing Sexually Betrayed Men and Boys is a very rich collection, only some of which I can hope to convey here. It certainly belongs in the hands of every man or boy who has been victimized, but will be equally valuable to their partners and family members, and of course to clinicians of all traditions. There is a great deal of solid research conveyed here as well as some pioneering programs, and reflections of those pioneering clinicians themselves. 

The book is divided into four sections, with a total of fifteen chapters. Most are written by US clinicians, but several are written by clinicians in Canada, including one, Rick Goodwin, based in Ottawa, where I did my initial training in psychology and underwent psychoanalysis. So his chapter was of special interest to me.

The first section looks at general and global issues in treating men who have been abused. The second looks at focused treatments, including a new program, Weekend of Recovery, and a resource-rich website to which it is connected, MaleSurvivor.org. The third section, "Women in the Picture," looks at female therapists working with male survivors as well as female partners of the same; there is also a section on same-sex partners and their unique challenges. In this section also is a chapter on covert seduction, about which more in a moment. 

The fourth and final section is a rare look at perpetrators who are also survivors/victims, and the very great difficulties that arise when trying to find placements for such men to be treated. I will return to this again later. Each section, and nearly every chapter, also contains often harrowing case material of patients the authors have treated over the years. 

Let me just highlight three chapters while, again, encouraging all those with interest in this area to read the whole book. 

The fourth chapter, co-authored by Howard Fradkin and Jim Struve, "Empowering Male Survivors to Heal through Community and Peer Connections," contains a new model that I have found fascinating. Based on their belief that group work is a crucial adjunct to individual psychotherapy, the authors proposed, plan, and have helped host Weekends of Recovery around the world since 2001. "While not considered therapy, the weekends often have therapeutic benefits," the authors say (102). In this regard, A good bit of the underlying philosophy, they say, comes from that landmark book we all know and love, The Theory and Practice of Group Psychotherapy by Irvin Yalom and Molyn Leszcz; their sixth edition was published just a month ago. There is much here, it seems to me, that would lend itself to Catholic churches borrowing and adapting for similar purposes as parishes and victims try to heal from the never-ending abuse in their midst, which I have addressed at length elsewhere. 

Chapter 11, "Covert Seduction and its Effect on Boys and Men," by Kenneth Adams is deeply interesting, raising a concept I have never heard before: covert seduction, where boys are used emotionally and sexually without actual physical sexual contact in most cases: "you can be sexually abused without being sexually touched" (214). One example of this he focuses on later in the chapter is exposure to pornography, especially at an early age. Other examples include bathing and toilet rituals as well as expecting boys to fulfill emotional and sexual needs of their mothers in the absence, or as rivals to, husbands and fathers. 

The damage this can leave is very real, serious, and long-lasting in many cases, resulting in guilt, schizoid-like detachment, shame, ongoing struggles to detach from the covertly incestuous family member, etc. In therapy, Adams cautions several times, these victims will often be the ideal patients--docile, compliant, reporting positive effects and results. All this is in fact a sign of their pathology: they have learned compliance, docility, and the importance of manifesting positive results as a result of their abuse. 

The last section is useful in highlighting some of the challenges that come from men who were themselves victims before going on to be perpetrators. The authors cite research indicating that this number is much lower than is sometimes portrayed, suggesting it is around 12% of abuse victims who go on to become perpetrators (a number borrowed from Anna Salter's very useful groundbreaking book Predators). Additionally this section contains a helpful typology of abusers, and a section of female abusers as well. 

All told, Richard Gartner and his contributors to Healing Sexually Betrayed Men and Boys: Treatment for Sexual Abuse, Assault, and Trauma have given us many insights (each chapter's lengthy bibliography is very valuable indeed) in this rich and helpful book. I know I shall be returning to it regularly.