Case Study #1: FJ

Please read over the following information and submit a reaction paper/essay in response to the

prompts that follow the case discussion.

Patient Information and Reason for Treatment:

FJ is a 58-year-old male serving 16 years for sexual battery on a minor (victim under 12). This was

his second conviction and second incarceration for the same crime. When he was 42, he was

convicted of sexual battery on a different minor but pled this down to five years. Such pleas are,

unfortunately, very common in the legal system because of evidentiary problems on getting

proper testimony from victims. Sometimes, the state would rather lock them up for a shorter

period – get them off the streets – instead of taking it to trial and risking that they would be

acquitted and just walk. He served four of the five years and was released back into the

community. He reoffended less than two years after release.

This crime obviously carries much more of a sentence, but he pled it down to 15 years. When we

began our work several years ago, he had already been incarcerated for 10 years at many

different prisons in Florida. He was made a “permanent” at our prison several years ago and had

been on our compound for almost five years. He was in and out of psychological treatment during

that time, mostly for depressive symptoms. He had been on the waiting list for sex offender

treatment for some time, but there were no ongoing sex offender groups at the prison for several

years and his sexual problems had not been a focus of treatment.

I came to the prison when the prison I had been working at was closed. When I joined the staff

as Psychological Services Director, I wanted to pick up a few cases so I could stay active in clinical

work to augment my administrative duties. FJ had been with several different therapists over the

years, but, as is unfortunately the case in prison, they had left or the structure of the department

had changed. He had never spent more than a few months in therapy with anyone.

I took the case because of my experience working with incarcerated sex offenders both in group

and individual therapy.

Therapeutic Approach:

I am a psychodynamically oriented therapist. After reading through the psychological record and

looking at the notes from previous treatment, it was evident that no one had ever tried to tackle

the sexual issues. As is often the case, his depressive diagnosis and the subsequent medication

(Celexa) dominated his treatment. The primary goal and objective of treatment had been control

and management of depression.

I wanted to preserve this goal and help him and psychiatry keep his depression under control.

However, I really wanted to see if he was willing to look at his sexual pathology, understand it,

and develop some goals that centered on not reoffending when he left prison. It turned out that

he was quite committed to doing this, and when we began our work he had but three years left

on his sentence. I ended up working with him for three years, and we did weekly therapy until

the day before he was released into the community.

He ended up serving the legally mandated percentage of his sentence, which was about 13-and-

a-half years of the total 16.

Psychological Testing Data:

He had a great deal of psychological testing during his incarceration, though most was done at

the time he was received, which was many years before our therapy began. This is a summary of

the tests and their results.

Beta-II: this is a standardized IQ measure, with 100 being the average score. He scored 138, and

then, four years later, 141. These IQ measures fall into the very superior range of intellectual

functioning and show higher level cognitive functioning. Thus, he is very smart.

Beck Hopelessness Scale (BHS): this is 20 T/F questions that ask about a person’s outlook on the

future, as well as their optimism about their life being happy and fulfilling. Each response is

scored according to whether the patient endorses the “depressed” view, and if this is so, they

get one point. Scores range from 0 to 20, and the higher the score, the more depressed and

hopeless the individual seems to be. The typical score we see at the prison is between 5 and 10.

Anything over 12 is considered a red flag for diagnostic depression, so the person should be

evaluated further. We do not diagnose depression based on a BECK score, but it becomes a

guidepost for follow-up interview and evaluation.

FJ scored a 12 during reception. He was retested at three other prisons and got scores of 9, 14,

and 12. These are all moderately elevated scores and are associated with depressive feelings and

a negative outlook on life.

MMPI-2: this is the gold standard of objective assessment. The MMPI yields diagnostic

information and compares the patient’s responses to those of other individuals who have been

diagnosed and treated for various psychological disorders and conditions.

FJ took the MMPI-2 only once, and this was when he came into prison. The results yielded

elevations on the 2 and 10 scales corresponding to, respectively, high degrees of depression and

social introversion. There is also a slight elevation on 3, which is the anxiety scale. This profile is

associated with a brooding loner, someone who stays to themselves mostly and keeps a great

deal of agitated and anxious depression (probably at diagnostic levels) and emotional pain inside

and hidden from others. The profile suggests sexual conflict and, interesting enough, is somewhat

antithetical to antisocial personality disorder. This man is not a sociopath.

Rorschach: this is the famous “ink blot” test and is the only one of the four instruments that I

administered myself. I gave him a Rorschach prior to our first therapy session (as I usually do

prior to starting therapy) because it is not a good idea for a therapist to give a patient this test

once therapy has started. (The interpersonal dynamics may distort the results.)

FJ’s profile shows a great deal of cognitive energy expended to integrating the entire blot and

relating different parts to one another. This indicates that he is a thinker and perhaps thinks too

much; he overly thinks through issues. He backed away from the colored stimuli and had few

color responses, suggesting that he represses feeling. Taken with the first finding, this suggests

that he “thinks about” the world rather than “feels” the world. There are some indications of

poor self-esteem and distanced or aloof human relations. He has trouble connecting to others.

Diagnosis:

Pedophilia

Persistent Depressive Disorder

The DSM diagnostic criteria for pedophilia are as follows:

A. Over a period of at least six months, the individual has recurrent, intense, sexually

arousing fantasies, sexual urges, or behaviors involving sexual activity with a

prepubescent child or children (generally, 13 years of age or younger).

B. The individual has acted on these sexual urges, or the sexual urges or fantasies cause

marked distress or interpersonal difficulty.

C. The individual is at least 16 years of age and at least five years older than the child or

children in Criterion A.

The DSM diagnostic criteria for persistent depressive disorder are as follows:

A. Depressed mood for most of the day, for more days than not, as indicated by either a

subjective account or an observation by others, for at least two years

Note:

In children and adolescents, mood can be irritable and duration must be at least 1 year.

B. Presence, while depressed, of two (or more) of the following:

1. Poor appetite or overeating

2. Insomnia or hypersomnia

3. Low energy or fatigue

4. Low self-esteem

5. Poor concentration or difficulty making decisions

6. Feelings of hopelessness

C. During the two-year period (one year for children or adolescents) of the disturbance,

the individual has never been without the symptoms in Criteria A and B for more than

two months

Legal History and Crime:

I do not think it is necessary to share the sexual details of his crimes.

In both crimes, the victim was an eight-year-old boy. There were similarities between both

crimes. FJ had met both children through volunteer work he was doing in the community. The

nature of this work was clearly designed to bring him in contact with children. From what I could

piece together from police reports, both of these children came from very trying and

dysfunctional family systems in which their psychological needs were not being met. In other

words, both were extremely vulnerable and had no one who was really bothering to ask why FJ

was taking an interest in their child and spending so much time with him.

The victims did not know each other.

He also spent lots of money on these victims. As is the case with many pedophiles, he “groomed”

his victims by taking them places, buying them toys and gifts, and praising them in order to make

them feel good when they were with him. For me, this “grooming” is a particularly ugly and

unsettling part of pedophilia.

Both of his crimes involved several months of sexual contact between the children and him. He

was arrested each time when the victims eventually told the guidance counselor in their

respective schools.

Childhood:

The following is an overview of his childhood and those aspects of it that are relevant to the

content and direction of therapy.

FJ was raised by his mother and had one sibling, a sister who was five years younger than him.

No father. One of his earliest memories was trying to give a hug to a man his mother was dating.

The man pushed him away and said, “Men don’t hug.” Mom seems to have been a nice, friendly,

nurturing parent who was not dysfunctional in any way. She worked hard in retail sales to provide

for him and his sister, and she had no legal record and did not drink or use drugs excessively. She

did not abuse him in any way.

FJ describes himself as a socially awkward child who had trouble making friends. He excelled in

school, was never suspended or expelled, and his teachers generally liked him. I read some

interesting comments from elementary report cards in which teachers said he was a “pleasure

to have in class” and their only concerns were his social skills and his rather consistent isolation.

He never participated in group sports or extracurricular activities at school.

FJ was molested when he was eight (yes, that age is conspicuous) by a man who lived in the

neighborhood. He recalled much of this period in his life with startling detail. Suffice to say that

he was groomed by the man who molested him in that he was given toys, praised, and hugged

at times.

FJ inmate graduated in the top 10 percent of his high school class, was never arrested as a child

growing up, and attended a prestigious military academy out of high school. He earned a BA in

engineering and served our country for 6 years until he was honorably discharged. During the

time he was in the military, he was married and had two children, both boys. He was married for

six years, and FJ and his wife were divorced shortly after he left the military because “we just

were fighting all the time – about money and sex.” She moved out of state and took the boys

with her. FJ saw the boys “only a few times” over the years.

During the time between his divorce and his first arrest (about ten years) he worked for a

manufacturing firm, made good money, stayed to himself, and dated sporadically. He began

viewing child pornography during those years and also engaged in very risky sexual encounters.

He admitted that “there were a lot of bad things brewing in my mind during those years.” As we

worked, the age at which he admitted to be consumed by fantasies of having sex with children

began to get earlier and earlier. This was clearly a prominent feature of his fantasy life for many

years, but he did not act upon it until around the age of 40.

Our work focused on the rather unpleasant and awful details of this and was punctuated by his

shameful admission (he used the word “ashamed”) that part of him enjoyed this because it was

the first time in his life that a man had been nice and paid attention to him.

Course of Treatment:

When I first met him, I found FJ to be interpersonally inappropriate and socially awkward. He

tried to tell jokes that were not funny, ask personal questions about my belief in God and religious

convictions, and intellectualize everything. FJ did not feel the world; he tried to think it through.

Nevertheless, he told me that he wanted to understand why he had molested these boys. He said

he never really understood it, something which again reflected this rather misguided intellectual

approach to life.

After I talked to him for about an hour in that first session, I was not sure if he felt remorse for

his crimes. Even after three years of therapy, I am not sure if there is “guilt” here. This has always

troubled me, but I do believe that FJ wanted to understand his actions and that he did not want

to offend again. This was clear from the beginning of our therapy, and that was enough for me

to begin working with him in earnest. Despite his oddness at times, he was respectful, motivated

for treatment, and would talk about anything I asked him to. He told me in that first session that

he had been molested as a child, but he did not say this in a tone that would suggest he was using

it as an excuse. He seemed unsure of its meaning and relevance as to why he was sitting across

from me wearing blue.

At the beginning of our therapy, he had been under psychiatric care for over two years because

of depression. He was taking Zoloft (an antidepressant) because he had consistently reported sad

and hopeless feelings, sporadic fatigue, difficulty sleeping, and poor self-esteem. In contrast to

the grandiosity of most inmates, FJ was consistently troubled with feelings that he was a failure,

a “loser,” and a disappointment to his mother and children.

I did not want to talk him out of these self-perceptions, for I felt they were vestiges of the

humanity which he had to abandon in order to commit his crimes. Still, the depression was well

controlled by medication, and it was not to be my primary therapeutic focus. I needed to get at

the sexual pathology.

At the outset, our work involved two tracks that I tried to develop simultaneously. I wanted to

talk about how he had victimized these children and how he was victimized himself. The purpose

of this dialogue, I told him, was to always keep in mind and work toward the ultimate goal:

prevention of re-offense upon being released from prison.

We talked about his crimes. I made him use their names and admit all that he had done. I used

police reports to challenge him on those details that he did not want to remember or talk about.

Gradually, he became more and more open.

With regard to being molested himself, our work focused on the rather unpleasant and awful

details of this. His recollections were punctuated by his shameful admission (he used the word

“ashamed”) that part of him enjoyed this because it was the first time in his life that a man had

been nice and paid attention to him.

The most problematic part of the molestation—and this probably occupied much of our work for

the first year—was that in order to survive it, he had to distort his thinking. He convinced himself

during this experience, and solidified in the years following, that this really wasn’t such a bad

thing after all and that he actually derived some sorely needed attention and affection from it. FJ

concluded—and I know this sounds very troubling—that this taught him something about love

and affection. The distorted nature of this is in the service of survival. In order to survive trauma,

we adopt all kinds of strange ideas, or ideas that sound strange to something lucky enough to sit

outside the trauma.

The danger here is what you might surmise. This kind of thinking makes it easier to victimize, for

it provides the rationalizations necessary to act counter to one’s sense of right and wrong. Later,

as I took FJ again through his crimes, it was difficult for me at times to know if he was talking

about himself, his victims, or himself as a victim and himself as a perpetrator, or even the person

who molested him or himself. What I mean is that it all ran psychologically together – the psychic

and moral lines were blurred, and the roles were almost indistinguishable. I had to help him

separate it all.

We began to pull this all apart and distinguish such concepts as victim and perpetrator, adult and

child, and affection and exploitation. I know it sounds simple and obvious; it was neither.

So, he began to see that his crimes were made possible because he could not empathize with his

victims, and he could not do this because he had never admitted to himself the horror of his own

molestation. He never told anyone, not even his mother. Much of our work began to focus on all

of the bad feelings he had repressed and recognizing the pathological effects of this repression.

An interesting sidelight here is that FJ kept a journal on a daily basis. He learned early in our work

that I like to talk about dreams, and he proceeded to oblige me. He wrote down about one dream

a week for almost two years. They became an unexpected guide for our work. His dreams were

not full of sexual images (he probably withheld those from me), but rather snippets of his mother,

his childhood, days in the service, and countless visuals of walking endlessly in circles, flying

somewhere with no destination in mind, being lost on a derelict bridge, and being lost on a

desolate farm from which he could not leave. The latter images are certainly metaphors for

institutionalization and FJ’s fears of getting back into the real world, possibly of reoffending. We

worked on all these issues.

FJ went home late last year. Before he left, he said to me, “I wish I had worked with you during

my first incarceration. I don’t think I would have molested that second boy.” Of course, this was

nice to hear, even though it is mere speculation. He has called me twice since he was released to

tell me he is doing “fine” and is continuing his therapy in the community. Whether FJ is really

“fine” right now, and if so, how long this will be, is difficult to know. It is also hard to know to

what extent, if any, I helped him.

Case Study #1 Reaction Paper Assignment:

There are many different types of psychological disorders with which therapists attempt to help

their patients. Some are easy to understand; others are not. Depending on the disorder and the

experiences of the patient, therapists can find that certain cases are more difficult for them to

take on and work through.

There are many nuances of this therapeutic relationship and FJ’s presentation that are worth

reflecting on. These issues have to do with how you are going to handle working with individuals

who tell you things or have problems that are difficult to hear about. Remember that this

assignment is not about you analyzing the patient (though I welcome your comments about the

case), but rather to look inside yourself and focus on how you might react in similar situations.

Please provide a 1,000-word (about three pages), double-spaced, typed paper that is your

reaction to the following five prompts:

1. Does he meet the diagnostic criteria for pedophilia? Why or why not?

2. Could you work with a pedophile? Why or why not?

3. Do you think that psychologists or therapists can and should refuse to work with certain

individuals? Under what circumstances or in what instances?

4. What types of problems or disorders do you think you would have the most trouble with

as a therapist?

5. How would you handle working with someone who scared you, repulsed you, or made

you mad? What would you do with these feelings?

Feel free to comment on any other aspects of the case that interest you.