OFFENDERS 113

C: Yes, I’ve been trying to think of the law, and what people would think of me if they found out, and how I’d feel. T: How do you feel about a gap now? Trying for a longer time with these reminders?

C:It’s given me a lot of confidence. I hope I’ll cope better. In a way I was expecting something like this. It’s very clear to me now what’s been happening. You’ve been very straight with me.

Therapist and client collaborated over the length of time to extend the behavioural experiment. It was important that the client experienced long enough away from professional contact not only to control urges, but to test his strategies when he faced actual temptation to expose. A period of three months was agreed, and the rationale for this made fully explicit. The time allowed was for experimentation, not necessarily for success.

Session six

The three-month behavioural experiment was reviewed. What transpired will be illustrated with quotes and thoughts identified from the session.

The client had experienced urges about two or three times a week for the first month and resisted the temptation to expose, using the card and cognitive methods to help him.

‘The first month was OK. There were lots of triggers and opportunities and I thought of things to put me off.’

He had then started exposing himself for a period of two weeks, beginning by masturbating while able to see women but without being seen, the behaviour gradually becoming more visible and more frequent until exposure was happening daily at work.

‘I decided to expose myself. I was still thinking of the card but I put it to the back of my mind.’

The exposure period stopped again and, along with this, urges to expose ceased. The client was aware that over this ensuing six-week period, urges to expose were gradually coming back, about once a week for the previous two weeks.

‘I woke up to what I was doing and stopped. I thought of the consequences again, and this set me off on the right track again.’

In discussion over what he felt had happened over the 3 months, what his opinion was about how he had managed, what his views were about what had gone wrong and why, the following quotes emerged:

‘It’s difficult to overcome what you really want. I’m not sleeping, I’m worrying about work. It’s putting pressure on me again—it’s not fair. All I want is peace of mind.’

‘I’ve let people down: you for your help, myself, my family.’

‘I don’t think I can cope on my own. I’m not trying hard enough. I need to see you more often. I could get my wife to help me—she’s around. If I was to tell her, she’d ask me to stop and I’d stick to it.’

‘I thought I could cope on my own. I’m not normal. This is a stupid thing that normal people don’t have. I can’t control it over a long period.’

Re-analysis

As a result of this review, three main points emerged, to be considered at the next session.

1.The dependency issue. There was some evidence that the client had changed his belief about his self-reliance, his ability to help himself. He had utilised the strategies but they had not proved sufficient to maintain lasting control. He had returned to the session indicating renewed dependency on the therapist as a result, but still somewhat altered in his attitude in that he was taking responsibility for his failure to cope over an extended period. This latter was clearly not a good thing on the surface, since he was showing signs of being more depressed than before. However, one hypothesis was that this may have been a reflection of some enduring change in his thoughts about his responsibility for the problem.

2.The automatic thoughts ‘I need to do it’ and ‘I really want it’ appeared not to have changed as a consequence of challenging thoughts about control in session four. Indeed the client had identified the issue of pleasure and ‘liking it’ as being a problem in session five.

3.A new group of thoughts concerning dissatisfactions the client had about his wife, and a resulting sense of life being dull, had not been confirmed and challenged. The client had suggested in earlier sessions that his need for excitement was met by his exposure behaviour. Thoughts which had been identified were as follows.

Why he had begun exposing after a twelve-month gap following his second marriage? ‘Things got dull again. Just the general way of life. I felt I wanted to do it.’

And what did he feel about his wife?