In particular, question is ... that the client's problems included anxiety in approaching male adults. It does not .... presenting problem; that is, what were the key.
Journal of Abnormal Psychology 1974, Vol. 83, No. 2, 196—198
GOALS AND STRATEGIES IN BEHAVIORAL TREATMENT : OF HOMOSEXUAL PEDOPHILIA COMMENTS ON A CASE STUDY GERALD C. DAVISON 1 State University of Yew Pork
G. TERRACE WILSON
at Stony Brook
Rutgers—The State University
Offered here is a critical evaluation of a case report by Kohlenberg in which a homosexual adult pedophile male learned to respond sexually to other adult males and less so to male children. The therapeutic program combined aversive "conditioning" and a modified Masters-Johnson graduated in vivo exposure regimen. The present authors support Kohlenberg's ethical decision to work toward a homosexual adjustment for his client, pointing out that. the theoretical bases of behavior therapy do not include a pathology view of homosexuality as can he found in most other orientations to human behavior. However, the strategies adopted in the case report reflect an inadequate behavioral analysis of the client's problem. In particular, question is raised concerning the initial decision to employ aversive procedures, given that the client's problems included anxiety in approaching male adults. It does not seem necessary to interrupt a prepotent pattern of sexual behavior before attempting more positively to instate another set of feelings and responses, and the apparently favorable outcome of the in vivo exposure regimen lends support to this view. Publication of this unconventional case study will hopefully contribute to open debate of the social values that underlie decisions by clinicians as to their goals in therapy. conversion, deriving from the assumption that heterosexuality is a biological–psychological norm and that homosexual attachments are the result of some pathological deviation from the normal psychosexual developmental process (e.g., Bieber, 1962; Hatterer, 1970; Socarides, 1970). In the case of behavior modification, however, there is no theoretical justification for this bias inasmuch as the social learning viewpoint is consistent with Kinsey ' s contention that man is inherently only sexual, the direction of that biologically based potential being a function of critical social learning experiences (Kinsey, Pomeroy, Martin, & Gebhard , 1953). As with other forms of unconventional sexual behaviors, homosexual responsiveness is assumed to be acquired, maintained, and modified in the same manner as heterosexual behavior (Simon & Gag" " non, 1970). "Normal and "abnormal are seen as labels that reflect the prevailing value judgments of society's labelers, and it is worthwhile to recall that at different periods in Western culture, and presently in many nonWestern societies, homosexual behavior is often expected and even encouraged (Churchill, 1967; West, 1967). The recent proposal by the nomenclature committee of the American Psychiatric Association " to remove the category of "homosexuality from the next revision of the Diagnostic and Statistical Manual illustrates how the psychiatric
We are grateful for the invitation to comment on the case report by Kohlenberg (1974) in which a male homosexual pedophile learned to respond sexually to adult males and less to male children via a modified Masters-Johnson (1970) graduated in vivo exposure regimen. We shall make some observations first on the choice of therapeutic goal, then on the strategies employed. GOALS OF THERAPY The selection of therapeutic goals is closely linked to theories of normal behavior development and with values about what appropriate Kohlenbrg's behavior should he. Accordingly, adoption of increased sexual responsiveness to adult males as a therapeutic objective for a homosexual pedophile may he unacceptable to many readers of this Journal. The psychotherapy literature—including behavior therapy—shows little serious consideration given to improved homosexual functioning as a legitimate and meaningful goal of therapy for a homosexually oriented client. In most instances this reluctance to facilitate homosexual adjustment is part and parcel of attempts at therapeutic heterosexual 1
Requests for reprints should be sent to Gerald C. Davison, Department of Psychology, State University of New York at Stony Brook, Stony Brook, New York 11790. 196
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COMMENTS
nosology is more a product of socio-historical clinical application of behavior therapy, discussed pressures than of scientifically justified generali- elsewhere in greater detail (Wilson & Davison, zations (Szasz, 1961). 1974). Of major concern is the apparent lack of As Bandura. (1969) has tellingly indicated, an adequate behavioral analysis of Mr. M's " behavioral therapy is a system of principles and presenting problem; that is, what were the key procedures and not a system of ethics [p. 87]." variables maintaining his child molesting actions, The client has decision-making primacy in set- and how did these determine the behavior change ting the goals of therapy, the therapist's role in techniques which were selected for use? Like this process being to explore alternative courses most behavior therapists, Kohlenberg assumed at of action and assess their likely consequences so the outset that the prepotent but unwanted bethat the client may make an informed choice havior pattern must he directly interrupted (for a more extended discussion of these issues before an alternative heterosexual repertoire see Bandura. 1969, pp. 102-112). could emerge and that aversive stimulation was It is of interest, however, that despite this the method of choice. Yet there is still no definivalue-free social learning model, and despite tive evidence to support such an assumption. If survey results which showed that the vast ma- in fact the lack of arousal toward adult males jority of behavior therapists would help clients and associated apprehension and tension were i mprove homosexual functioning (cf. Davison & responsible for the absence of adult sexual activWilson, 1973), there has been a dearth of pub- ity, then we wonder why techniques designed to lished reports describing behavioral programs modify these variables were reserved for the directed toward helping homosexuals adjust second phase of treatment and not accorded more satisfactorily to a permanent homosexual priority. Barlow (1973) made the same point in identity. To this end Kohlenberg's case report summarizing a good deal of clinical evidence represents an important contribution. showing that techniques directed at increasing As practicing behavioral clinicians and re- alternative sexual repertoires are frequently searchers we have elsewhere urged the serious effective even in the absence of any attempt to reevaluation of heterosexual orientation as the reduce directly current patterns of prepotent, commonly preferred therapeutic goal (Wilson & undesirable behavior. At the very least, efforts Davison. 1974). We have been impressed by the to develop an alternative mode of sexual fulfailure of available research findings to demon- fillment could be concurrently combined with strate either that the psychological difficulties of therapy aimed at eliminating pedophiliac tenhomosexuals are due to factors other than the dencies. prejudices suffered by an oppressed minority The gratifying .results obtained with the modigroup or that homosexuals of either sex are fied Masters and Johnson (1970) treatment (a necessarily more disturbed than comparable clinical innovation for which Kohlenberg is to heterosexual samples (e.g., Kinsey et al., 1953; be commended) suggest that the factors which Loney, 1972; Saghir, Robins, & Walbran, 1969; were maintaining Mr. M's sexual inadequacy Thompson. McCandless, & Strickland, 1971). with adult males were such as to render aversion Accumulating evidence suggests that homosexu- therapy both inappropriate and unnecessary. ality can be a rewarding and viable life style. Curiously enough, however, Kohlenberg attribThis reconsideration of the proper focus for be- uted the failure of the aversive procedure to havior therapy is important for, despite some highly debatable speculation about the particular successes in orienting homosexually inclined parameters of the conditioning method used persons to heterosexuality, the data thus far rather than to a mismatch of problem and techindicate that not all homosexuals have responded nique. We have suggested that this is typical of , the behavioral literature 's overconcern with the to this type of treatment (Birk, Huddleston Miller, & Cohler, 1971; Feldman & MacCulloch, technical details of the " conditioning " methods 1971). Moreover, as Wilson and Davison (1974) employed at the expense of an adequate behavhave proposed and as Kohlenberg's case study ioral analysis of presenting problems. suggests, behavior therapy might be useful in The case report also suffers from the failure to helping homosexuals live more happily and ef- include important additional clinical outcome fectively as homosexuals. details. For example, what was the nature of Mr. M's subsequent adjustment to the adult homoTHERAPEUTIC STRATEGIES sexual world? How did he cope with the probWhile we clearly wish to reinforce positively lems of living—both those peculiar to an unconventional life style and those held in common Kohlenberg' s innovative efforts, his report unfortunately illustrates some problems in the by most adults in contemporary society (cf.
COMMENTS Davison & Neale, 1974)? Was he happy? Had his occupational adjustment improved? CONCLUSION
It would he churlish, however, to overemphasize these objections to Kohlenberg's most interesting approach to a difficult and increasingly controversial area of clinical practice. The thorny decisions concerning social values that therapists, be they behavioral or not, have to make on a daily basis can best be resolved by their open and public airing (Kanfer & Phillips, 1970). After all, abstract principles and technical maneuvers are used by human beings who themselves are children of their culture. This Journal ' s publication of Kohlenberg ' s article should provide a necessary and welcome opportunity to further the debate. REFERENCES BANDURA, A. Principles of behavior modification. New York: Holt , 1969. BARLOW, D. H. Increasing heterosexual responsiveness in the treatment of sexual deviation: A review of the clinical and experimental literature. Behavior Therapy, 1973, 4, 655-671. BIEBER, I. Homosexuality . New York: Basic Books, 1962. BIRK , L., HUDDLESTON, W., MILLER , F.., & COHLER, B. Avoidance conditioning for homosexuality. Archives of General Psychiatry, 1971, 25, 314-323. CHURCHILL, W. Homosexual behavior among males. Englewood Cliffs, N.J.: Prentice-Hall, 1967. DavIsoN, G. C., & NEALE, J. M. Abnormal psycholclinical approach. New ogy: An experimental York : Wiley, 1974. DAvisoN, G. C., & Wi lson , G. T. A survey of the attitudes of behavior therapists towards homosexuality. Behavior Therapy, 1973, 4, 686 696.
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FELDMAN, M. P., & MACCULLOCH, M. J. Homosexual behavior: Therapy and assessment. Oxford: Pergamon, 1971. HATTERER, L. J. Changing homosexuality in the male: Treatment for men troubled by homosexuality. New York: McGraw-Hill, 1970. KANFER, F. H., & PHILLIPS, J. S. Learning foundations of behavior therapy. New York: Wiley, 1970. KINSEY, A. C., POMEROY , W. B., MARTIN, C. E ., & GEBHA RD, P. H. Sexual behavior in the human female. Philadelphia: Saunders, 1953. KOHLENBERG , R. J. Treatment of a homosexual pedophiliac using in vivo desensitization. Journal of Abnormal Psychology, 1974, 83, 192-195. LONEY J. Background factors, sexual experiences, and attitudes toward treatment in two "normal" homosexual samples. Journal of Consulting and Clinical Psychology, 1972, 38, 57-65. MASTERS, W. H., & JOHNSON, V. E. Human sexual inadequacy. Boston: Little, Brown, 1970. SAGHIR, M. T., ROBINS, E., & WALBRAN, B. Homosexuality. II. Sexual behavior of the male homosexual. Archives of General Psychiatry, 1969, 21, 219-229. SIMON , W., & GAGNON, J. H. The sexual scene. New York: Transaction, 1970. SOCARIDES , C. W. Homosexuality and medicine. Journal of the American Medical Association, 1970, 212, 1199-1202. SZASZ , T. S. The myth of mental illness. New York: HHoeber-Harper , 1961. THOMPSON , N. L., McCANDLESS, B. R., & LTARNICDK . R. Personal adjustment of male and feS,B male homosexuals and heterosexuals. Journal of Abnormal Psychology, 1971, 78, 237-240. WEST, D. J. Homosexuality. Chicago: Aldine, 1967. WILSON , G. T., & DAVISON, G. C. Behavior therapy and homosexuality: A critical perspective. Behavior Therapy, 1974, in press. ( Received June 29, 1973)
