Sexual Abuse: A Journal of Research and Treatment, Vol. 17, No. 4, October 2005 (
Relapse Prevention with Intellectually Disabled
Jenny A. Keeling
and John L. Rose
The adaptation of relapse prevention theory to sexual offending (W. D. Pithers,
J. K. Marques, C. C. Gibat, & G. A. Marlatt, 1983) has represented an important
movement in cognitive-behavioural treatment for sexual offenders. However, this
model of relapse prevention has been criticised for its limited view and over-
simpliﬁcation of the relapse prevention process (R. K. Hanson, 2000; T. Ward
& S. M. Hudson, 1996). As a result, T. Ward and S. M. Hudson (2000a) have
developed a multiple pathway model of the relapse prevention process based on
self-regulation theory. Although this model continues to be empirically validated
on sexual offenders (J. A. Bickley & A. R. Beech, 2002; T. Ward, S. M. Hudson,
& J. C. McCormick, 1999), there has been no empirical research regarding the
application of this theory to intellectually disabled sexual offenders. This paper
discusses whether the characteristics of offenders in each of the relapse offence
pathways, as described by T. Ward and S. M. Hudson (2000a), may be similar
to the characteristics of intellectually disabled sexual offenders. From a review
of the literature, it appears that the intellectually disabled sexual offender may
be most likely to offend via the approach—automatic pathway or the avoidant-
passive pathway. The potential treatment implications of the self-regulation model
for intellectually disabled sexual offenders is discussed, as well as the need for em-
pirical evaluation with regards to the application of this model to the intellectually
disabled sexual offender population.
KEY WORDS: intellectual disability; relapse prevention; sexual offenders.
Research into sexual offending behaviour has more recently focused on
the application of treatment to distinct populations of sexual offenders, such
as intellectually disabled sexual offenders (Lindsay, 2002). This research has
Department of Psychology, University of Birmingham, Birmingham, United Kingdom.
To whom correspondence should be addressed at Department of Psychology, University of
Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom; e-mail:email@example.com.
2005 Springer Science+Business Media, Inc.
408 Keeling and Rose
stemmed from the recognition that, in order for treatment to be effective, sexual
offender treatment cannot be generic. The principle that underlies this notion is
the responsivity principle, which states that treatment must target the risk of the
individual, the needs of the individual, and it must be delivered in a manner that is
appropriate for the individual (Andrews, 1996). Programs that are sensitive to the
responsivity principle are considered best practice in addressing sexual offending
Whilst programs aim for best practice guided by the responsivity principle, it
is imperative that theory should guide research, which in turn guides therapeutic
interventions, in order to provide appropriate and effective treatment. Although
there has been an increase in research for intellectually disabled sexual offenders
(Lindsay, 2002), there has been very limited theoretical development in this area.
It is important that we do not just accept existing theories of sexual offending
as applicable to the intellectually disabled population, but instead investigate the
utility and applicability of general sexual offender theories to an intellectually
disabled sexual offender population.
Relapse Prevention with Sexual Offenders
Relapse prevention was developed by Marlatt and colleagues (Chaney,
O’Leary, & Marlatt, 1978; Marlatt & Gordon, 1980, 1985) as a method to maintain
change in substance abusers. It is based on the principles of social learning theory
(Bandura, 1986) and describes both the causal and maintaining factors that sustain
the addictive behaviour. The relapse prevention model details both cognitive and
behavioural interventions as well as lifestyle changes and, as such, is very sim-
ilar to current cognitive-behavioural approaches. The relapse prevention model
of addictive behaviours has been innovative in approaching the treatment of such
behaviours and it has proved useful in the development of models of the relapse
process in other problematic behaviours.
The original model of relapse prevention was adapted and developed for
addressing sexual offending behaviour by Pithers (e.g. Pithers et al., 1983) and
Marques (e.g. Marques & Nelson, 1989), and since this time has been incorporated
into many treatment approaches for sexual offenders (Marques, Day, Nelson, &
Miner, 1989; Mann & Thornton, 2000). The goal in relapse prevention is for the
sexual offender to develop self-management skills in order to avoid offending
(similar to avoiding a return to substance abuse).
In applying the relapse model to sexual offending, one of the main assump-
tions is that the problematic behaviour cannot be an impulsive act for which the
individual has no control (Pithers, 1990). It is imperative to the success of the re-
lapse model that affective, cognitive, and behavioural components are recognised
in order to provide a system of intervention. Should this not be recognised and
Relapse Prevention and Intellectually Disabled Sex Offenders 409
the offence viewed as something the offender has no control over, there would be
very little chance of intervention at any stage.
Using the model of relapse prevention in sexual offenders, Pithers (1990)
went on to describe a common pathway to offending that has been identiﬁed by
examining precursors to sexual aggression (Pithers, Cumming, Beal, Young, &
Turner, 1989). Pithers (1990) described the antecedent to relapse as a negative
change in affect, followed by poor emotional management. The second phase
involves engaging in deviant sexual fantasies, leading to cognitive distortions
about sexual abuse. Pithers proposed that these justiﬁcations lead to the cognitive
planning of an offence in order for the offender to enact their deviant sexual
fantasies and this may be accompanied by masturbation. The ﬁnal stage of the
relapse prevention pathway is to commit a sexual offence. From this pathway, it
can be seen that there are a number of stages in which lapses could occur, and thus
intervention at these times would be appropriate, and may reduce the likelihood
of a return to sexual offending.
The work of Pithers, Marques, and colleagues presents an important de-
velopment in the treatment of sexual offenders. However, there are considerable
difﬁculties with the application of this model, many of which have arisen out of the
considerable wealth of research that now exists about sexual offending behaviour.
Laws (1999) highlights that Pithers’ original model has changed very little over
the years and has been accepted with little evaluation, whilst Hanson (2000) crit-
icises the model for its limited application to sexual offending behaviour. Other
criticisms of the relapse prevention model focus on the utility within treatment,
including poor treatment outcome (Marshall & Anderson, 1996) and the difﬁcul-
ties associated with focusing on identifying risk and coping strategies rather than
developing coping skills (Thornton, 1997). A number of authors have criticised
Pithers et al.’s (1983) model for its focus on a singular pathway. Hanson (2000)
states that a problem exists when an offenders pattern of offending does not ﬁt
the singular pathway of the model. This notion of the need for a multiple pathway
model has been identiﬁed by a number of authors (Laws, 2003; Ward & Hudson,
1998; Ward & Hudson, 2000a). Ward and Hudson (1996) have critically examined
Pithers’ work and outlined a number of oversimpliﬁcations and conceptual weak-
nesses. For example, they question whether the mechanisms of the abstinence
violation effect and problem of immediate gratiﬁcation can be both positioned
between the lapse and relapse as conceptually these two mechanisms contradict
The Self-Regulation Model of Relapse Prevention
It has been recognised that although relapse prevention has helped develop
comprehensive treatment programs, the theoretical development of relapse pre-
vention has been slow (Laws, 1999; Ward & Hudson, 1996). The concept of a
410 Keeling and Rose
single pathway to offending has been criticised in the development of different
models of sexual offending behaviour (Marshall, 1996; Ward & Siegert, 2002)
and in response to this and other difﬁculties in the application of Pithers’ model
of the relapse process for sexual offenders there have been a number of key
developments in the area of relapse prevention over the past decade. Polascek
(2003) describes this research movement as the offence process models. These
models describe offence processes as a result of examining data from sexual of-
fenders (e.g. Polascek, Hudson, Ward, & Siegert, 2001; Ward, Louden, Hudson,
& Marshall, 1995; Ward & Hudson, 2000a). This paper focuses on one of these
multiple offence pathway models of the relapse process called the Self-Regulation
Model of Relapse Prevention (Ward & Hudson, 2000a).
This model bases itself on the theory of self-regulation, which states that self-
regulation is a process whereby internal and external processes allow and motivate
the individual to engage in goal-orientated behaviours (Baumeister & Heatherton,
1996). Goals are described as cognitive structures that are stored as behavioural
scripts (Carver & Scheier, 1981), which allow the individual to interpret their own
or others’ actions, and are ultimately associated with positive and negative emo-
tions. The goals of self-regulation can either be states that an individual wishes to
avoid, or states they wish to achieve (Cochran & Tesser, 1981). Self-regulation not
only involves the suppression of problematic behaviour, but also the enhancement
and maintenance of positive emotional states and behaviour. It is the goal that
is the most important concept and it is the goal that directs the self-regulatory
This model postulates that problems with self-regulation may lead to an in-
creased likelihood of reoffending for sexual offenders. Three styles of problematic
self-regulation have been identiﬁed (Carver & Scheier, 1990) that are important in
sexual offending behaviour. The ﬁrst style of problematic self-regulation is when
individuals fail to control their thoughts, feelings, and behaviour, leading to sexual
offending. Secondly, an individual can aim to control their behaviour but uses
ineffective or inadequate strategies and thus does not effectively manage their
behaviour. Lastly, the offender is able to self-regulate effectively, but it is dys-
functional regulation because their goals are associated with acting in a sexually
Ward and Hudson (2000a) describe in detail the self-regulation model of the
relapse process. This process involves nine phases (see Fig. 1), which are ﬂuid
and provide different stages at which point an offender may intervene and exit the
relapse process using appropriate coping strategies. The relapse process has no
time frame and offenders may move back and forth through the process. Ward and
Hudson (2000a) describe the process for each type of offender and in doing so,
detail differing characteristics for offenders who follow each of the four pathways
to offending. These distinguishing characteristics are useful in identifying the
types of offenders who relapse via the different pathways.
Relapse Prevention and Intellectually Disabled Sex Offenders 411
Fig. 1. The nine phases of the self-regulation model of the relapse
412 Keeling and Rose
Empirical Evidence for the Self-Regulation Model of Relapse Prevention
One of the criticisms of Pithers et al.’s (1983) work is that it was accepted
without evaluation (Laws, 2003). Thus, current theoretical developments are often
subject to empirical validation to avoid past problems. One of the ﬁrst investi-
gations for testing the efﬁcacy of this model and providing cross-validation for
this relapse prevention model investigated different types of offence processes of
male incarcerated sexual offenders and identiﬁed three main pathways and ﬁve
minor pathways (Hudson, Ward, & McCormack, 1999). The results indicated sup-
port for the existence of the approach–explicit and avoidant–passive pathways but
found that the other major pathway was not accounted for by the self-regulation
model. They proposed that this was either a different pathway or was found as a
result of methodological shortcomings, whilst the ﬁve minor pathways appeared
to represent variations of the major pathways. This research provided support
for the utility of the model across all offence types, with the frequency of child
molesters and adult offenders similar in each of the pathways. Importantly, this
research provided evidence for the shortcomings of Pithers’ model (Pithers et al.,
1983; Pithers, 1990), in that a large proportion of offenders exhibited an appetitive
process. Thus, offenders demonstrated that they were motivated to offend and
experienced positive affect during the relapse process.
Bickley and Beech (2002) evaluated the self-regulation model of relapse
prevention for child molesters by investigating the differences between avoidant
and approach offenders and active and passive offenders. This research concluded
that child molesters could be reliably categorised into the four offence pathways
and that there were discrete differences in demographics and questionnaire results
between the two groups (avoidant versus approach; passive versus active). Bickley
and Beech (2002) concluded that their results provided empirical support for
the validity of the self-regulation framework of the relapse process, as well as
identifying considerable treatment implications for the differing self-regulation
There has been some empirical support for the self-regulation model for
non-disabled sexual offenders. It is evident that a multiple-pathway approach to
relapse prevention seems to be validated amongst the general sexual offender
population and this should direct questions as to whether there is any support for
this self-regulation model with intellectually disabled sexual offenders.
Relapse Prevention for Intellectually Disabled Sexual Offenders
Relapse prevention models have been introduced into treatment programs for
intellectually disabled sexual offenders (Boer, Gauthier, Watson, & Kolton, 1995;
Haaven & Coleman, 2000). Haaven and Coleman (2000) describe the applicabil-
ity of Pithers et al. (1983) model of relapse prevention model for intellectually
Relapse Prevention and Intellectually Disabled Sex Offenders 413
disabled sexual offenders. However, they have focused on the applicability of
the method of implementing relapse prevention rather than on the applicabil-
ity of the actual model to intellectually disabled sexual offenders. Haaven and
Coleman (2000) noted that relapse prevention continues to evolve and recognised
the self-regulation theory as a new development. From the literature, it appears
that treatment providers for the intellectually disabled sexual offender population
are not yet adopting the idea of different offence pathways to relapse as a model
for treatment. However, this is not surprising given that the offence pathways
model has not yet been empirically validated with intellectually disabled sexual
It is very important to adapt psychological practices in response to current
theory in order to provide the most appropriate and effective treatment, however,
any potential advance in psychological theory must be empirically validated.
Therefore, future research should aim to investigate the applicability of this model
to these populations.
The Self-Regulation Model and Intellectually Disabled Sexual Offenders
The self-regulation model has signiﬁcant implications for the treatment of
sexual offenders and raises questions about the efﬁcacy of treatment that uses a
generic relapse prevention program for all sexual offenders. In order to empirically
evaluate the self-regulation model of relapse prevention for intellectually disabled
offenders, we must investigate whether these offenders can be categorised into the
pathways to offending of the self-regulation model. If this can be achieved, then
we need to investigate how this model of relapse will inﬂuence the focus of, and
the provision of, relapse prevention in the context of sexual offender treatment.
There now exists an extensive literature about differing aspects of sexual
offending by individuals with an intellectual disability (e.g. Lindsay, 2004) and
research has provided a wealth of literature about the characteristics of this spe-
ciﬁc population, which is particularly useful in considering whether Ward and
Hudson’s (2000a) self-regulation model is applicable to an intellectually disabled
sexual offender population. The self-regulation model and the associated empiri-
cal work (e.g. Bickley & Beech, 2002, 2003) have provided a description of the
characteristics of offenders who offend through each different offence pathway.
Some of the characteristics of different pathway offenders have signiﬁcant simi-
larities to identiﬁed characteristics of intellectually disabled sexual offenders and,
therefore, may have implications for the relapse process for this population.
Offenders who follow the avoidant-passive pathway are characterised by
denial or the use of highly ineffective strategies in order to attempt to deal
with deviant sexual interests. Polascek (2003) likens this pathway to the origi-
nal Pithers–Marques pathway to relapse. These offenders are described as having
an underregulation style that leads to an inability to control their sexually abusive
414 Keeling and Rose
behaviour and are more likely to lack coping skills, be more impulsive, have low
efﬁcacy expectations, and engage in apparently irrelevant decisions. These fea-
tures of the avoidant-passive pathway have been identiﬁed as characteristics of
the intellectually disabled population. Nezu, Nezu, and Dudek (1998) identiﬁed
poor self-regulation skills as a characteristic of some intellectual disabled sexual
offenders, as well as deﬁcits in social problem solving skills. The avoidant-passive
individual is also more likely to have low efﬁcacy expectations and this is often
a characteristic of intellectually disabled sexual offenders, which may be linked
to the presence of low self-esteem, low self-worth, and unassertiveness (Boer,
Gauthier, Watson, Dorward, & Kolton, 2001). Another similarity between the
avoidant-passive individual and the intellectually disabled offender is the absence
of adequate coping skills as well as impulsivity.
Glaser and Deane (1999), in studying the differences between intellectu-
ally disabled sexual offenders and intellectually disabled non-offenders, found
that the pattern of sexual offending was often characterised by impulsivity and
poorly planned behaviour rather than an inherent sexual deviancy. Lindsay (2002)
identiﬁed the intellectually disabled sexual offender may be more likely to com-
mit offences across categories and be less discriminatory in who they offend
against, which appears to be indicative of impulsive behaviour. In contrast, Parry
and Lindsay (2003), in a study examining trait impulsiveness, found that sex-
ual offenders with an intellectual disability were less impulsive than non-sexual
offenders with an intellectual disability. Parry and Lindsay discuss that state im-
pulsiveness was not measured and concede that this could lead to sexual offending.
Other researchers have consistently identiﬁed impulsivity and poor coping skills as
characteristics of the intellectually disabled population (Ashman & Conway, 1989;
Lane, 1991). Lastly, intellectually disabled sexual offenders have been identiﬁed as
lacking insight (Boer et al., 2001) and this is characteristic of the avoidant-passive
individual, which may also make them more susceptible to engaging in covert
planning via apparently irrelevant decisions. These two characteristics are inex-
tricably linked in the offence process and a lack of insight can leave an individual
unable to foresee the consequences of a chosen course of action.
Avoidant-active offenders are similar in many respects to the avoidant-passive
offenders but they differ in their attempt to utilise coping strategies to attempt to
deal with their deviant sexual interest. However, these coping strategies are inap-
propriate and ineffective (for example, using masturbation or drugs), which can
lead to an increased likelihood of sexual offending. The avoidant-active offender
is similar to the intellectually disabled sexual offender in terms of the poor reg-
ulation and use of inappropriate coping skills (Ashman & Conway, 1989; Nezu
et al., 1998). However, this offence pathway also requires some insight into the
offender’s behaviours in order to recognise the need to control deviant sexual
thoughts or negative emotional states by implementing coping strategies (whether
effective or ineffective). A lack of insight has been identiﬁed as a characteristic
Relapse Prevention and Intellectually Disabled Sex Offenders 415
of the intellectually disabled sexual offender (Boer et al., 2001) and therefore
the ability to recognise the need for strategies may be beyond the capabilities
of some intellectually disabled offenders. However, if an offender did possess
the level of insight reqsuired to identify the need for intervention, it does seem
plausible that an intellectually disabled offender may use ineffective and inap-
propriate strategies, as it has been well identiﬁed that these offenders can have
poor social problem solving skills (Nezu et al., 1998), limited social skills (Boer
et al., 2001), adaptive skills deﬁcits (Haaven, Little, & Petre-Miller, 1990), and
poor coping skills (Ashman & Conway, 1989). This pathway may represent an
intellectually disabled sexual offender who has experienced intervention for their
sexual offending behaviour and therefore has developed some skills to recognise
high-risk situations and the need for intervention, but has not yet developed an
understanding and grasp of appropriate coping strategies.
Offenders who follow the approach-automatic pathway follow overlearned
behavioural scripts in order to offend, behave in an impulsive manner that involves
minimal planning, and may be characterised by offending in a relatively short
amount of time. Ward and Hudson (2000a) identify this pathway as a mirror
image of the avoidant-passive pathway, which only differs by its association
with the approach goal to sexually offend. Therefore, it is not surprising that
the characteristics of offenders following this pathway also share many common
characteristics of the intellectually disabled offender, such as, impulsivity and
rudimentary planning. Of interest is that approach-automatic offenders follow
over-learned behavioural scripts in order to sexually offend, which are unlikely to
be under attentional control and may be activated by situational or environmental
cues. Behavioural scripts are cognitive frameworks within the long-term memory,
which guide behaviour in line with the goals of the individual. Ward and Hudson
(2000b) identify offence scripts as cognitive frameworks that develop over time as
a result of committing sexual offences. These scripts serve to guide an individual
towards offending and are activated, without conscious intention, by relevant cues
that may be unknown to the offender. They describe the importance of this concept
as helping to understand the possible processes with which an offender will make
apparently irrelevant decisions.
Sexual offending scripts develop over time and become more extensive and
coherent as sexual offending behaviour continues. Responses to sexual offend-
ing by individuals with an intellectual disability are often inconsistent (Clare &
Murphy, 1998; Nankervis, Hudson, Smith, & Phillips, 2000) and sexual offending
may often go unreported, as carers or relatives may be reluctant to involve the
police or the allegations are not taken seriously by the police (Clare & Murphy,
1998). Given this, it is possible that offenders with an intellectual disability may
have a more extensive record of sexual offending than their criminal record sug-
gests. Thus, it is also possible that intellectually disabled sexual offenders may
have more extensive and coherent offence scripts, which have developed over
416 Keeling and Rose
time as a result of previous sexual offences. Should this be the case, intellectually
disabled sexual offenders may be likely to follow the approach-automatic pathway
if the goal is to sexually offend.
Aside from developing offence scripts as a result of previous sexual offending
(Ward & Hudson, 2000b), the authors also report that the application of script
theory to sexual behaviour has identiﬁed that sexual scripts are inﬂuenced by
the knowledge of norms, values, rules, and beliefs by the individual. That is, the
knowledge of the individual is incorporated into the sexual scripts that guide the
individual to interpret and engage in sexual behaviours.
It is well established that intellectually disabled individuals are more vulner-
able to abuse (Vizard, 1989; Sobsey, 1994), and that intellectually disabled sexual
offenders may have experienced a high incidence of sexual (Lindsay, Law, Quinn,
Smart, & Smith, 2001) and physical abuse (Hayes, 2002). Not all sexual offenders
have been abused, however, Lindsay (2002) states that there may be an association
between sexual offending and past sexual abuse for people with an intellectual
disability. It is reasonable to assume that the experience of abuse, and speciﬁcally
that of sexual abuse, may inﬂuence the development of cognitive scripts relating to
sexually offensive behaviour. This may occur as a result of dysfunctional norms,
values, rules and beliefs that may develop as a result of being the victim of abuse.
Therefore, if the intellectually disabled population is more vulnerable to abuse, it
may be likely that they will develop these abusive offence scripts and thus follow
the approach-automatic pathway should they have the desire to offend.
Approach-explicit pathway offenders engage in explicit and lengthy planning
and use comprehensive strategies in order to offend. These individuals can self-
regulate appropriately, however, they have selected sexually harmful goals. These
features of intact regulation, control, and conscious explicit planning seem to have
little in common with the intellectually disabled sexual offender. The approach-
explicit offender sees sexually abusive behaviour as an acceptable means to and
end, which Ward and Hudson (2000a) suggest may be a result of early learning ex-
periences, such as childhood sexual abuse. As discussed previously, intellectually
disabled sexual offenders are certainly more vulnerable to abuse and the incidence
of historical sexual abuse is high in this population. However, the other character-
istics of the approach-explicit offender are at odds with the knowledge we have
of intellectually disabled sexual offenders. For example, intellectually disabled
offenders have been identiﬁed as being impulsive (Glaser & Deane, 1999) and
the offending features impulsive characteristics such as, indiscriminatory victim
selection and type of offending (Lindsay, 2002). These features seem to suggest
that the intellectually disabled offender would be more likely to act impulsively
rather than in a controlled manner. Glaser and Deane (1999) also identiﬁed that
this population appear to engage in poorly planned behaviour, whilst Boer et al.
(2001) identiﬁed this population as lacking insight. Insight is required to see the
consequences of ones actions and to make decisions about action. Without insight,
Relapse Prevention and Intellectually Disabled Sex Offenders 417
and in combination with impulsive behaviour, it seems very unlikely that an in-
tellectually disabled individual would engage in conscious explicit planning. As
discussed previously, the characteristics of the intellectually disabled population
seem to be more associated with a passive self-regulation style (e.g. Nezu et al.,
1998) and it may be unlikely that an active regulation style is common amongst
intellectually disabled sexual offenders. In light of current literature, it seems
unlikely that many of this population would follow this pathway to relapsing.
From the research into the characteristics of intellectually disabled sexual
offenders, it seems that they may be more aligned with a passive, rather than
active, style of self-regulation. Thus, it would be expected that these individuals
would be more likely to follow either the avoidant-passive or approach-automatic
pathways to relapse. In terms of goal selection, it is more difﬁcult to align this
group with either the approach or avoidant goal. It appears that the characteristics
of each goal type relate more to offence-related factors than to the skills, abilities
and level of functioning of an individual.
In Bickley and Beech’s (2002) classiﬁcation of goal characteristics, they
identiﬁed avoidant offenders as having an awareness of harm of offending, having
few cognitive distortions, having extreme guilt and shame following the offence,
and having no explicit engagement in offence type activities. In contrast, approach
goal offenders demonstrate limited awareness of harm, many cognitive distortions,
no negative self-evaluation following the offence, and engage in explicit offence
supportive activities. From the literature, it appears that intellectually disabled
sexual offenders often engage in those characteristics associated with the approach
offender. Intellectually disabled sexual offenders have been identiﬁed as having
difﬁculties in perspective taking (Haaven et al., 1990), and therefore this may
inﬂuence their ability to be aware of the harm to others of their behaviour. They
have also been found to engage in cognitive distortions that do not differ in
sophistication from the non-disabled sexual offender (Haaven et al., 1990; Lindsay,
Neilson, Morrison, & Smith, 1998).
The literature indicates that the intellectually disabled sexual offender may
be most likely to offend via either the avoidant-passive or approach-automatic
pathways. Given that they may also be more likely to share more characteristics
with the approach offender than the avoidant offender, it is proposed that the
most likely route for the intellectually disabled sexual offender is through the
Treatment Implications of the Model of Self-Regulation
It is imperative that, for treatment to be effective, it abides by the responsivity
principle (Andrews, 1996). The responsivity principle model of best practice was
developed after the original relapse prevention work (e.g. Pithers et al., 1983) and
418 Keeling and Rose
therefore the principle does not feature in the model. As such, using the original
relapse approach as a current treatment model has been a subject to criticism
and recent research has shown that different approaches to relapse prevention
can be more successful (Mann, Webster, Schoﬁeld, & Marshall, 2004). The self-
regulation model provides a basis for responsive relapse prevention, in that, it
provides an opportunity to identify speciﬁc individual treatment needs and allows
for the provision of responsive treatment, which is essential in the treatment of
intellectually disabled sexual offenders. This paper will discuss the implications of
the self-regulation model on treatment needs. However, it should be highlighted
that in developing programs for intellectually disabled sexual offenders, there
needs to be a particular focus on the manner of treatment delivery. That is, for this
group who present with a vast range of difﬁculties and needs, there needs to be
speciﬁc attention to the individual characteristics, especially in consideration of
the most effective way to deliver treatment.
The development of the self-regulation model of the relapse process has a
number of potential treatment implications. The ﬁrst is that it questions the utility,
effectiveness, and appropriateness of a generic relapse prevention intervention for
all offenders. The second is that it provides a theoretical basis for the assessment
of self-regulatory deﬁcits and offence-related goals. Thirdly, it provides a theoret-
ical basis for focusing on self-regulation and management in relapse prevention
intervention (Ward, Hudson, & Keenan, 1998).
In recognising the utility of the self-regulation model of relapse we are
moving away from a single pathway approach to a multiple pathway approach
to offending. In doing so, we are recognising that offenders are a heterogeneous
group with a variety of difﬁculties and a variety of treatment needs. If we assume
that individuals offend via different pathways, inherent to this is the assumption
that the focus of intervention should vary. As a result, we must ask whether a
generic relapse prevention intervention will be the most useful and effective for
all these different kinds of offenders. If the self-regulation model continues to
be empirically validated through research, it is unlikely that we can continue to
uphold the use of a non-speciﬁc relapse prevention intervention.
The self-regulation model has provided a theoretical basis for assessment
that, in turn, can be used to direct the appropriate treatment to offenders. One
method for achieving this has been practically demonstrated and empirically val-
idated by Bickley and Beech (2002), who developed a classiﬁcation system for
self-regulation style and offence-related goal type. The model has identiﬁed a
number of characteristics of offenders from each pathway that can be used in as-
sessing offenders. This method of assessment is useful in identifying criminogenic
treatment needs and focus for different pathway offenders in treatment planning
(Polascek & Hudson, 2004).
The major beneﬁt of this model is that it has provided a theoretical basis for the
reﬁnement of relapse prevention techniques in order to increase the effectiveness
Relapse Prevention and Intellectually Disabled Sex Offenders 419
of relapse prevention. It has allowed for a more comprehensive understanding of
the relapse process in sexual offenders and provided a focus on self-regulation
and the associated deﬁcits. The identiﬁcation of speciﬁc characteristics to each
pathway has provided very speciﬁc treatment targets that can be used to adapt
treatment for individual offenders. Ward and Hudson (2000a) identiﬁed examples
of what treatment targets may be useful for different offence pathways offenders.
They stated that avoidant-passive individuals would beneﬁt from focusing on the
development of relationship skills, problem solving skills, and emotional and be-
haviour management skills. Polascek (2003) described treatment approaches for
this group should focus on challenging beliefs about helplessness and increasing
personal efﬁcacy. For avoidant-active offenders, Ward and Hudson (2000a) recom-
mended a focus on skill acquisition and developing appropriate coping strategies,
whilst Polascek (2003) expands and states that treatment should focus on ensuring
that the offender can identify and be responsible for his actions in his offending.
Ward and Hudson (2000a) stated that the approach-automatic offenders
should focus on an increased awareness of offence scripts whilst also strengthen-
ing metacognitive control. Polascek (2003) reinforces this idea and identiﬁed that,
within this group, there may be a range of cognitive deﬁcits which could provide
appropriate treatment targets. For those offenders who offend via the approach-
explicit pathway, Ward and Hudson (2000a) recommended that treatment focus
on perspective taking and cognitive restructuring, as well as focusing on core
schema in order to address goal selection issues. It is proposed that the behaviour
of these individuals does not ﬁt into the current therapeutic practices from sexual
offenders (Polascek, 2003) and, although cognitive restructuring is suggested, it
is questionable whether it is helpful or detrimental to attempt to achieve this in a
group with men who do not share these beliefs.
Thus, in identifying whether this model is applicable to intellectually dis-
abled sexual offenders, it will enable us to have the opportunity to adopt speciﬁc
treatment targets on the basis of theoretical developments rather than assuming
general sexual offender models and theories are applicable to this population. It
is hoped that this will lead to more comprehensive and effective sexual offender
treatment for intellectually disabled offenders.
From a review of the literature of intellectually disabled sexual offenders, in
light of the self-regulation model of the relapse process, there is certainly some
evidence for the application of this model to the intellectually disabled popu-
lation. From the descriptions of each pathway to offending, it seems that the
most likely route for the intellectually disabled sexual offender to relapse would
be through the approach-automatic pathway, followed by the avoidant-passive
420 Keeling and Rose
pathway. However, the avoidant-active pathway also shares certain characteristics
in common with the intellectually disabled offender, such as poor self-regulation
and the use of poor coping strategies. What does seem clear from the literature is
that intellectually disabled sexual offenders seem to have very little in common
with the offender who relapses via the approach-explicit pathway. The goal selec-
tion is based on individual preference and motivation, rather than being inherent
to the functioning of the individual. Therefore, although the literature has high-
lighted that the intellectually disabled sexual offender shares many characteristics
with the approach goal offender, these characteristics are often treatment targets
(e.g. addressing cognitive distortions and victim harm). Therefore, it would be
interesting to examine whether these characteristic remain in a sample of intellec-
tually disabled sexual offenders who have successfully completed treatment. At
present, it remains unclear whether there is any relationship between the charac-
teristics of individuals with an intellectual disability and goal-selection.
The treatment implications of this model are important for the intellectually
disabled population. This work may provide a theoretical basis for the treatment of
intellectually disabled sexual offenders, and thus will enable us to select and direct
appropriate treatment. It seems quite plausible that this model of self-regulation
would be applicable to intellectually disabled sexual offenders, however this must
be empirically validated. Results of such empirical investigations may have fu-
ture implications for the treatment of intellectually disabled sexual offenders. The
self-regulation model, although not being concerned with the etiology of sexually
abusive behaviour, does describe the process of offending and therefore is inter-
connected with theories of sexual offending behaviour (Ward & Hudson, 2000a;
Ward, Hudson, & Keenan, 1998). There is a distinct lack of models and theories
of sexual offending for intellectually disabled individuals and an empirical inves-
tigation into the applicability of this model for this population would be extremely
important in itself, as well as providing a theoretical backdrop for applying other
general theories of sexual offending to an intellectually disabled population.
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