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The Thought Change System: an empirically based cognitive behavioral therapy for male juvenile sex offenders: a pilot study.

Recent research in treatment of sexual offenders suggests that comprehensive cognitive -behavioral approaches may yield significant decreases in deviant acting-out behaviors. The current pilot study examined such a treatment called the Thought Change System, which is an empirically based cognitive -behavioral therapy, in a residential treatment center, existing in Portsmouth, Virginia. This system includes the identification of the functions of the negative thoughts, feelings, behaviors, and beliefs, and replacing them with transitional thoughts, feelings, behaviors, and beliefs, and finally alternative beliefs. The Thought Change System also implements the Case Conceptualization Method based an adaptation of the Beck (1998) suggested methodology of mode deactivation. The offenders were adolescent males, age's 11-18, who have a history of failed treatment at prior placements or outpatient treatment centers. The results of this study indicate that a cognitive -behavioral methodology that addresses the underlying personality traits may be effective for severely disturbed sexual offending adolescents; evident by reduced psychological distress, reduced sex offending risk, and reduced aggressive beliefs.

KEY WORDS: cognitive/behavioral treatment; juvenile sexual offenders; cognitive distortions; case conceptualization; sexual offender treatment


The following description proposes the type of treatment for juvenile sex offenders as treated by the Behavioral Studies Program (BSP) at The Pines Residential Treatment Center (The Pines) in Portsmouth, Virginia. The proposed typology is based on the collected works of Richardson, Kelly, Bhante, and Graham (1997); Awad and Saunders (1991); Monto, Agourides, and Harris (1998); Becker and Kaplin (1991); Becker & Hunter (1998); and Hunter (1989). The Pines offers residential treatment for male and female sex offenders. Ninety-eight percent of residents report a prior history of victimization, including sexual, physical, emotional, and/or environmental abuse(s). In support of Hunter and Becker's (1997) review, these residents report their own victimization to have occurred during an early developmental ages (2-5 years). In addition, few residents talked about or acknowledged their abuse(s) until years after the abuse occurred. A prior history of victimization at a young age, and few disclosures appear to be consistent in the histories of those that sexually offend and victimize. Statistical support for this premise is evident in the male population at The Pines. Up to 93% of male BSP residents have been victimized in all four of the above abuse parameters. The juvenile sex offender falls primarily into two major types: those who target children and those who offend against peers or adults (Hunter, 1989). The major difference present in these two groups is based on the age difference between the victim and the offender. Child offenders have been defined as those who target children five or more years younger than themselves (Hunter & Mathews, 1997).

The presence of deviant arousal is often found in juvenile male child molesters who offend against young males, and may be indicative of early onset pedophilia. Indications of non-sexual delinquency and generalized antisocial tendencies have been found most frequently in backgrounds of juveniles who have engaged in aggressive sexual offending. Specific psychological diagnoses are associated for those with a history of prior abuse. For example, a child with numerous early childhood traumas may cause a later diagnosis of Posttraumatic Stress Disorder (PTSD). Johnson, Cohen, Brown, S., and Bernstein (1999) suggest in their longitudinal study that early childhood trauma victims are considerably more likely than those who were not abused or neglected to have Personality Disorders (PD) and elevated PD symptoms, particularly those PD within the Cluster B spectrum as outlined within DSM-IV-TR (APA, 2000). The Cluster B PD spectrum includes those with an underlying commonality of emotion, or some difficulty with regulating emotion. Cluster B includes the Borderline, Narcissistic, Antisocial, and Histrionic Personality Disorder. However, for those with prior history of abuse, The Pines residents traditionally demonstrate symptoms in the Cluster B spectrum, in addition to symptoms from other clusters, including severe distortions and heightened anxiety. The core curriculum at BSP is based on a unique model of cognitive behavior therapy. The concept is predicated on changing the clusters of dysfunctional beliefs that are prevalent in adolescent sex offenders; this concept is accomplished through BSP's Thought Change Book (Apsche, 1999). The Thought Change concept requires each resident to carry a manual and record all negative thoughts. The milieu, the individual therapy, and groups revolve around the record of negative thinking and the associated behaviors as a result of their cognition that propels the resident into his sexual offense system. For those residents who have learning disabilities and reading problems, the entire curriculum is available on audiotape.

The current pilot study examined the effect of the Thought Change System on 10 adolescent inmate sex offenders' beliefs system. This includes the identification of the functions of the negative thoughts, feelings, behaviors and beliefs, and replacing them with transitional thoughts, feelings, behaviors, and beliefs, and finally alternative beliefs. These residents have a history of failed treatment at prior placements or outpatient treatment centers. The results of this study indicate that a cognitive-behavioral methodology that addresses the underlying personality traits may be effective for severely disturbed sexual offending adolescents.


Description of Program

Typology and the Thought Change System

The Thought Change Process is designed to treat a conglomerate of personality disorders. The treatment of the higher risk, aggressive sex offender focuses on specific deviant sexual arousal and antisocial sub-structure. For the same-sex offender of young children who continues to show deviant interest in young victims, the Thought Change Process addresses the specific indices of this sub-group. The Thought Change Process explores deficits in self-esteem, social competency, and frequent depression. Many of these youths display severe personality disorders with psychosexual disturbances and high levels of aggression and violence; therefore, the Thought Change Process also focuses on the specific individual indices of these issues by identifying and modifying the complex system of beliefs.

The Thought Change and Belief Change curriculum consists of a structured treatment program, which addresses the dysfunctional beliefs that, endorse sex offending behaviors. Topics in the Thought Change curriculum include the following: Daily Record of Negative Thoughts, Cognitive Distortions, Changing Your Thoughts, Sexual Offense System, System of Aggression and Violence for Sex Offenders, Moods (how to change them), Beliefs (how it all fits together), Responsibility, Healthy Behavior Continuum, Beliefs and Substance Abuse, Beliefs and Empathy, The Beliefs of the Victim/Offender, The Victim/Victimizer, and the Mental Health Medication System. The sections of the Thought Change Book are designed to progress sequentially through therapy. It is a record of dysfunctional beliefs prior to, during, and following the sexual offense.

The offense belief change system is unique to BSP. The Thought Change System also addresses the psychological underpinnings of the prevalent diagnoses of PTSD within sex offender population. The symptomatology of PTSD has been found in varying presentations among juvenile sex offenders, including dysthymia, anxiety reactions, and some sexual and aggressive acting out. The intrusive images and heightened arousal associated with PTSD may be associated with repetition compulsion and reenactment phenomena. Within The Pines program, the cognitive behavior methodology, especially the Thought Change System in conjunction with antidepressant medication, has been found to be effective in treatment of PTSD.

The Thought Change System includes imagery and relaxation to facilitate cognitive thinking and then balance training. Balance training includes teaching the individual to balance perception and interpretation of information and internal stimuli. This is based on Linehan's (1993) Dialectical Behavior Therapy methodology. The individual first radically accepts that he endorses multiple dysfunctional beliefs. These beliefs are then paired with the behaviors, as the reactive process of the emotional dysregulation of the individual. The individual is taught through collaboration how to address their triggers and to understand how they activate their beliefs and how these beliefs result in problem behavior. By accepting and understanding these beliefs, the individual is able to regulate the emotion and balance their beliefs. The Imagery exercises are implemented to reduce the externalization of the emotional dysregulation.

The program has also been specialized for individuals who are intellectually limited and psychosexually disturbed. All clinical, educational, and vocational programming is presented in a manner consistent with the level of intellectual and psychosocial functioning of these individuals. The curriculum has been tailored to their level of functioning, yet remains consistent with the defined treatment domains within the Thought Change and Belief Change systems.

Case Conceptualization

The Case Conceptualization Method is based on an adaptation of the Beck (1996) suggested methodology of mode deactivation. The purpose of this specific type of cognitive case conceptualization is to holistically and comprehensively identify the multisystem components for each resident, and to specifically identify those personality issues that are impediments to treatment.

Therapeutic Phase System

The treatment of all residents in the program is organized into phases of approximately sixteen weeks duration. All residents must complete three major phases of treatment, with some youths then entering a more prolonged phase of transitional living. Each phase of treatment provides a series of specialty groups (typically 3 to 4), that run concurrently with one another. Residents also participate in on-going individual and family therapies. In addition, adjunctive psychiatric, educational, vocational, and recreational therapeutic services are provided. The program utilizes objective assessment in addition to staff observation to determine resident mastery of therapeutic goals, and readiness to progress to a subsequent phase of treatment.


Ten male sexual offenders from the Behavioral Studies Program (BSP) at the Pines Residential Treatment Center (6 African-Americans, 2 Eskimo-American, 1 European-American, and 1 Hispanic American) between ages 11 and 18 years (x=13.5) participated in the Thought Change Program. Accumulated data from prior positive treatment outcomes at The Pines has demonstrated that the Thought Change Program is an empirically supported cognitive-behavioral based treatment. All participants were first-time admissions to BSP and had never participated in a cognitive-behavioral based sexual offending treatment program before. Informed consent including the tasks involved, and participants' rights were reviewed. Both verbal and written consent was obtained from the participants. Their mean estimated length of stay was 18.3 months (SD= 3.53, range 12-23), mean estimated number of victims was 2.4 (SD=3.4, range 1-12). Types of offenses included flashing, fondling, vaginal and anal penetration, or a combination.


Social History Information--BSP Youth Version is a self-report survey administered during the admission process to acquire background information regarding the resident. Youth Self-Report (YSR; Achenbach, 1991) is a multiaxial assessment designed to obtain 11- to 18-year-olds' reports of their own competencies and problems in a standardized format. The means and standards are divided into three categories: internalizing (which measures withdrawn, somatic complaints, anxiety and depression), externalizing (which measures delinquent behavior and aggressive behavior), and total problems (which represent the conglomerate of total problems and symptoms, both internal and external).

Beliefs Assessments (Apsche, 2000)--includes four assessments:

The Beliefs About Intimacy assessment measures specific idiosyncratic means expressing beliefs about close relationships. The factors that are analyzed consist of (a) how our attitudes are related to the attitudes of others (b) what specific elements are included in positive, negative, and overall attitudes.

The Beliefs About Control includes 31 statements which reflect feelings and attitudes toward power, control, and authority.

The Beliefs About Victims includes 20 statements based on faulty beliefs about victims of sexual offenses. It represents a measure of cognitive distortions that sex offenders endorse.

The Beliefs About Aggression consist of 25 statements, which measures dysfunctional beliefs/cognitive distortions about aggression.

Child Behavior Checklist (CBCL; Achenbach, 1991)- The CBCL means and standards are divided in the same format as the YSR. The therapist completed this form.

Fear Assessment (Apsche, 2000) is a 60-question assessment that measures fear and anxiety reactions that are related to or are associated with the symptoms of Posttraumatic Stress Disorder. Mean scores are divided into five sections, which include personal reactive/internal, personal reactive/external, environmental, physical, and abuse. Any mean score above 2 is considered significant. This form was simultaneously completed by both the therapists and the residents

Devereux Scales of Mental Disorder (DSMD; The Devereux Foundation, 1994) illustrates level of functioning in comparison to a normal group, via behavioral ratings. T scores have a mean of 50 and a standard deviation of 10; a score of 60 or higher indicates an area of concern. The therapists completed this form.

Juvenile Sex Offender Assessment Protocol (J-SOAP; Prentky, Harris, Frizzell, Righthand, 2000) is an actuarial risk assessment protocol for juvenile sex offenders.


The residents were administered a test packet (resident packet), which included the Beliefs Assessments and Youth Self Report. The objective assessments were completed upon admission and at six months intervals. The initial administration included a reading exercise to determine the residents' level of reading and comprehension. Within this initial stage of treatment, the assigned therapist was given a clinician's packet (which consisted of the Fear Assessment, DSMD, J-SOAP, and CBCL). The initial assessments within the packet are provided and designed to determine a baseline of behavior. Like the residents' packets, the clinicians' packets were administered at six-month intervals. The following were assessed:

(a) Behavioral and emotional problems, including psychopathology (total scores from DSMD)

(b) Strengths and types of fear (total mean scores on 5 scales from the Fear Assessment)

(c) Level and types of beliefs endorsed; including control, aggression, victim, and intimacy (totals from Beliefs Assessments)

(d) Behaviors and thoughts that are self-reported and observed by residents and therapists (total T scores from YSR and CBCL)

(e) Level of risk to the community (total score from J-SOAP)


Devereux Scales of Mental Disorders

The DSMD has a mean of 50 and a standard deviation of 10. Any score over 60 is considered clinically significant. The following four scales were analyzed: (1) Externalizing, which indicates prevalence of negative overt behaviors or symptoms, (2) Internalizing, which measures negative internal mood, cognitions, and attitudes, (3) Critical Patholo gy, which represents the severe and disturbed behavior in children and adolescents, and (4) Total, which indicates a conglomerate of all scores including general Axis I pathology, delusions, psychotic symptoms, and hallucinations.

After 12 months of the Thought Change System, mean scores that represent overt behaviors, decreased from 54.4 (SD=10, Range=40-75) to 50.6 (Range=41-71). Results from the internalizing scales illustrate a significant decrease in externalizing behaviors from 64.0 (SD=10, Range 43-95) to 52.2 (Range=40-73). Critical Pathology scores demonstrate a significant change from 57.0 (SD=10, Range=43-84) to 47.50 (42-67), which demonstrates a decrease in severe/disturbed behaviors after 12 months of treatment. The total score were reduced from a mean of 59.4 (SD=10, Range=42-89) to 49.9 (Range=42-67) after a 12-month period.

Child Behavior Checklist

The CBCL means and standards deviations are divided into three categories: internalizing, externalizing, and total problems. The internal mean scores, after a 12-month period decreased from 65.5 (SD=8.6, Range=55-83) to 55.7 (SD=10.06, Range=39-70). The external mean scores decreased, from 67.2 (SD=8.90, Range=47-79) at the initial assessment to 56.9 (SD=12.28, Range=32-75) at final assessments. The total scores decreased significantly from 68.5 (SD=11.2, Range=54-93) in the first round to 57.4 (SD=l 1.6, Range=43-77) in the third round.

Youth Self Report

Internalizing means decreased slightly from 55.4 (SD=7.3 1, Range=41-63) to 52.6 (SD=6.46, Range=43-68), after a 12-month period. Externalizing means decreased from 58.1(SD=7.94, Range=45- 67) to 55.6 (SD=6.92, Range=46-66) after the third assessment. The total scores indicate a decrease from 60.5 (SD=8.44, Range=45-70) to 53.6 (SD=6.35, Range=48-68), after a one year period.

Beliefs Assessments

Beliefs About Victims baseline score was 44.2 (SD=10, Range=20-72) and after twelve months in the Thought Change System, the final score was 25.9 (SD=10, Range=20-40). Beliefs About Aggression score decreased significantly from 77.5 (Range=44-119) to 51.3 (SD=10, Range=27- 77) after a one-year period. Beliefs About Intimacy total score increased tremendously from 23 (SD=- 10, Range=-12-66) to 43.3 (Range=O-78); which represents the desire to engage in an appropriate intimate relationship. Beliefs About Control total score increased from 35.8 (SD=10, Range=3-81) to 59.7 (Range=23-106); which indicates an increase in desire to develop egalitarian relationships.

Juvenile Sexual Offender Adolescent Protocol

The total mean scores decreased from 25.9 (SD=1.67, Range=12-41) at the six months point in treatment to 19.9 (SD=1.44, Range=12-31) at 12 months of treatment.


This was a pilot study of treatment of adolescent male sex offenders with a conglomerate of personality disorders. All of the residents had prior unsuccessful treatment outcomes at either another facility or at an outpatient treatment center. The results of this study indicate that a cognitive- behavioral methodology that addresses the underlying personality traits may be effective for severely disturbed, previous treatment failure, sexual offending adolescents.

The combination of results from the DSMD, CBCL, and YSR suggest that CBT treatment is effective for these typologies in reducing internal distress as a result of varying psychological disorders present. As measures indicated, the critical pathology factor was reduced by more than one standard deviation. It also suggests that this particular CBT methodology has an effect on reducing externalizing aberrant behaviors. The CBT, specifically the Thought Change System, also influenced a reduction in aggressive cognition in the typologies. This suggests that there may be a relationship between aggressive cognition and aggressive behavior. The significant reduction in the victim beliefs implies that the individuals may have developed a sense of empathic responses to understand how their dysfunctional cognition is related to their sexual offending behavior.


The results suggest that the implementation of the Thought Change System reduced internalizing, externalizing, and critical pathology measures across assessments; however, the small sample size of the pilot may limit generalizability. It is important to note that this pilot study also suggests those sexual offending adolescents, in the described typology, have a conglomerate of personality beliefs. Treating sex offending behaviors without addressing the underlying personality beliefs appears to be related to recidivism. This study represents the first successful empirically validated attempt to treat this specific typology.


Achenbach, T.M. (I 99 1). Manual for the Child Behavior Checklist and 1991 Profile. Burlington, VT: University of Vermont Department of Psychiatry.

Achenbach, T.M. (1991). Manual for the Youth Self Report and 1991 Profile. Burlington, VT: University of Vermont Department of Psychiatry.

Amidon, E.J., Amidon, M.G., Apsche, J.A., Silvertnan, M.L., and Stivers, E.H, (1992). The Intimacy Manual: Balancing Control and Intimacy in the Bedroom and

Boardroom. Morrisville, PA: International Information Associates.

Apsche, J.A. (I 999) Thought Change Workbook. Portsmouth, VA: Alternative Behavioral Services,

Awad, G.A. & Saunders, E.B. (1991). Male adolescent sexual assaulters: clinical observations. Journal of Interpersonal Violence, 6, (4), 446-460.

Beck, A.T. (1996). Beyond Belief. A Theory of Modes, Personality, and Psychopathology. In P.M. Salkovskis (Ed.), Frontiers of Cognitive Therapy (pp. 1-25). New York, NY: The Guilford Press.

Becker, J.V. & Hunter, J.A. (1997). Understanding and treating child and adolescent sexual offenders. Advances in Clinical Child Psychology, 19, 177-196.

Hunter, J.A. (I 999). Adolescent sex offenders. Handbook of psychological Approaches with Violent Offenders: Contemporary Strategies and Issues, 117-129,

Hunter, J.A. & Mathews, R. (1997). Sexual deviance in females: psychopathology, theory, assessment, and treatment. Handbook of Sexual Deviance Theory and Application, 465-480

Prentky, R., Harris, B., Frizzell, K. and Righthand, S. (2000). An actuarial procedure for assessing risk with juvenile sex offenders. Sexual Abuse: 4 Journal of Research and Treatment, 12, (2), 71-93

Richardson, G., Kelly, T.P., Bhante, S.R., and Graham, F. (1997). Group differences in abuser and abuse characteristics in a British sample of sexually abusive adolescents. Sexual Abuse: A Journal of research and Treatment, 9, 239-257.

Please address correspondence to:

Jack Apsche, Ed.D., ABPP

The Pines Residential Treatment Center

1801 Portsmouth Boulevard

Portsmouth, Virginia 23704.


Jack A. Apsche (1), Maria M. Evile (2), & Christopher Murphy (3)

(1) The Pines Residential Treatment Center, Behavioral Studies program Portsmouth, Virginia

(2) The Pines Residential Treatment Center, Behavioral Studies Prograrx4 Outcome Studies Department, Portsmouth, Virginia

(3) The Pines Residential Treatment Center, Behavioral Studies Program, Portsmouth, Virginia
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Author:Apsche, Jack A.; Evile, Maria M.; Murphy, Christopher
Publication:The Behavior Analyst Today
Date:Jan 1, 2004
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