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consists of the identification and challenging of a variety of automatic thoughts, and includes periods of experiment and consolidation of change.

Case example

Presentation

The client was a 36-year-old man, who had referred himself via his wife to the general practitioner, and thence to the consultant psychiatrist, who had referred him to the psychological service asking about his suitability for treatment. His problem was one of recidivist exhibitionism, which had begun 20 years before at the age of 16 years.

At the time of referral to his GP, he had been exposing himself on a regular basis as often as three times a week, with some periods of up to 1 month without an incident, for about 14 months. He had not been caught during this time. When I saw him, he had not exposed himself for the 2½ months since he had made contact with the GP, but was experiencing urges to expose two or three times a week.

He presented as a reserved, reasonably articulate man who did not show undue signs of nervousness.

He was seen on three occasions, to complete an assessment of his problems and conduct a functional analysis. Material of interest from these sessions is as follows.

Sessions one to three

Background

The client was born in the West Midlands, and had a sister seven years older than himself. He said he always felt second best to her, and felt he was an unwanted child. He described his mother as irresponsible. She was often not in when he returned from school, and would leave her cigarettes burning, and not pay the bills. He thought she may have been in hospital, and got the impression she may have had an illness through him. He said he thought a lot of his father who was away in the army a good deal. He remembered his parents arguing and said he was not particularly happy at home. He said he was a difficult child. He was weak, and spent some periods of time in hospital. His ill-health included hearing problems which led to some difficulties at school. He used to feign illness in order to avoid school. Although naughty, he could not recall being punished by either parent. He was teased at school and did not have many friends.

He left school at 15 years, and worked for a local builder. He had three girlfriends from the ages of 17 to 21 years, and married the third as she became pregnant. There were two children from this marriage. The client began having affairs at age 26 years, and was sometimes violent towards his wife. The couple began to be involved in partner swapping with other couples, and a decision was made to swap permanently with one couple. He was remarried at age 30 years, his own children staying with his first wife, his second wife bringing with her the two children from her first marriage.

Exposure history

The client began masturbating at 13 years old. At 16 years he says he was trying to find some way to increase his arousal levels. He was not having much luck with girls and was shy. The idea came to him to expose himself through his bedroom window to passing females. This became a regular pattern.

At 17 years old he was reported and convicted. He was fined. He says his family’s reaction was to feel sorry for him, and to want to help him. The exposures stopped for a short time when he got his first girlfriend. He failed a get an erection with her, or with his second girlfriend, during sexual activity. His second conviction was at age 18½ years, when he was given a probation order. At 19 years, he met his future wife and experienced his first successful and enjoyable sexual intercourse. At 20 years, he was convicted again, and given a fine and probation order with conditional psychiatric treatment. He was prescribed stilboestrol which removed his sexual feelings, but had a distressing side-effect in that he developed breasts. He stopped seeing his girlfriend. After stopping the treatment, he began seeing her again, and was married at 21 years. After this time he began exposing himself from his works van, rather than the house. He still masturbated to fantasies of exposure, though having regular intercourse with his wife. His fourth and fifth convictions resulted in fines and probation orders, with further psychiatric treatment.

The therapy this time consisted of electrical aversion therapy. He described himself as having ‘a confused mind’ as a result of this treatment. He said he wanted to expose himself, but did not actually do it. He recalls thinking he ought to try to make the treatment work, but although it felt unpleasant to think about exposure, he was still experiencing urges.

110 COGNITIVE THERAPY IN CLINICAL PRACTICE

His sixth conviction, at age 25 years, resulted in him being required to have treatment at the Maudsley Hospital in London. Again it consisted of psychotherapy, medication, and aversion therapy. When the behaviour recommenced, he began exposing himself outside, in parks and woods. He says he was afraid of the van being identified. After his seventh conviction, he was given a probation order and fine, without treatment.

At age 29 years, he had begun his relationship with his second wife and for twelve months experienced complete relief from the problem or urges to expose. The problem gradually started again, to women in an age group of approximately 15 to 30 years, and he was convicted again at age 32 years, being given a probation order. He began at this time to indulge in alternative sexual activities, such as displaying pornographic pictures at his car window to passing women. He was hoping to avoid further convictions by these variations, but became conscious that it was not really substituting for exposure, rather that it was keeping him highly sexually aware. He was convicted for a ninth time at age 34 years and fined, this time for his use of pornographic pictures.

A consistent pattern throughout this history was that the client never exposed himself while on a probation order or receiving treatment. The only time he was without urges to expose, apart from when taking stilboestrol, was for the twelve months after his second marriage.

Analysis

A number of hypotheses emerged from material gained from the first three sessions. These will be listed with examples of quotes on which the hypotheses were based. The quotes emerged in the course of the assessment sessions, either in response to direct interviewing questions or through use of automatic thought identification techniques described earlier in the chapter.

1.The client was demonstrating a pattern of destructive dependency. His history showed that the only reliable periods of no offending were while professionals were involved, whether or not they were actively helping, and whatever the nature of the help.

When asked why he was seeking help even though previous therapy had had no lasting effect:

‘I’ve always gone to the doctor after I’ve started doing it again.’ ‘I need something new to stop me doing it.’

‘I know if I keep doing it I’ll get caught. If I get caught I’ll always stop doing it.’

2.There was inconsistency between the client’s belief about his ability to control his exhibitionism, and his control of the behaviour itself, which had been for periods as long as 2 years.

‘I know I’ll do it again.’

‘I haven’t got the willpower.’

3.The client appeared to use no deterrents to recommencing the behaviour once there were no professionals involved. The consequences of starting to expose himself again were to tell his wife, to seek professional involvement, or to gain this through getting caught.

‘My wife stood by me. I couldn’t have a better one. I don’t tell her until it’s all come to light. I don’t want to worry her. Then I tell her everything eventually. When I’m exposing, we don’t communicate as well. I’m more selfish.’

The treatment decision

Although the client had a history of failed therapies, and the exposure behaviour ceased when he was in therapy, there was no indication that any of the therapies had been successful in reducing urges to expose, other than the stilboestrol which had had distressing side-effects. The incidence of urges to expose had remained undetected during some of the therapies.

Importantly, although no lasting effect had ever been achieved, the client was dependent on therapy, as he saw it, to stop the behaviour in the short term.

‘If you can’t help, I’ll take the tablets again.’

It is significant, however, that when asked about his goals for therapy, he was not aiming at a temporary cessation of the exhibitionist behaviour.

‘I want to get rid of the urge and all elements of the problem.’

‘I know what it’s like not to have the problem at all—for that 12 months.’

‘It’s the pressure of having it on my mind. It makes me moody and confused. I just want a peaceful mind.’

It was decided to offer the man treatment, while remaining closely aware of the role of his dependency in this.