Cognitive Behavioral Therapy (CBT) for Criminal Behaviors

Abstract

Criminal behavior, theft, fraud, violence, manslaughter, etc., are defined as illegal behaviors that cause problems at the social level. In the emergence of criminal behavior, approximately four concepts are functional. These concepts are individual motivation, relevant circumstances, meaning to the individual, and the individual’s reason for committing the crime. These concepts are also considered in crime prevention. In this chapter, information is provided about cognitive behavioral therapy (CBT) and the therapeutic methods derived from this approach. First, Cognitive Behavioral Therapy is explained of how it originated. Then, the therapeutic approaches as third wave derived from the CBT approach such as schema therapy, acceptance and commitment therapy, and metacognitive therapy are discussed. The professionals recognize that thought content is the fundamental step in the development of criminal behavior. For this reason, information is also provided on techniques such as recognizing thought errors, distraction, social skill training, and breathing and relaxation exercises that are effectively used in the rehabilitation of criminal behavior. Studies from the relevant literature address the effectiveness of cognitive therapy techniques in neutralizing criminal behaviors, including anger management, sexual offending, and partner violence. Findings from the literature and suggestions for accelerating future studies in this area are provided.

1. Introduction

Criminal behavior has long been analyzed in both clinical psychology and forensic psychology to prevent crime. Cognitive behavioral therapy provides forensic psychology with useful tools to explain criminal behavior and to prevent it. The interaction among the three components of CBT results in different models for each criminal behavior. The models have the same perceptions of criminal behavior, such as personal variables, individual responsibility, and risk reduction, rather than cultural and social aspects.

1.1 Cognitive behavioral therapy

Cognitive therapy is based on the cognitive model, which states that perceptions related to an event have a mediating role for emotions about that event. The cognitive model provides three different levels for cognitive perspectives. The first level is automatic thoughts about an event. Automatic thoughts arise quickly in the mind, and automatic thoughts are also the cause of sudden emotional reactions to events. In cognitive theory, it is mentioned that people can have different automatic thoughts about the same event based on beliefs underlying automatic thoughts. These beliefs are developed based on childhood experiences about the environment. Childhood experiences influence beliefs about oneself, other people, and the world. These beliefs continue by selectively focusing information that confirms these beliefs. Core beliefs are the most important beliefs that are global, rigid, and overgeneralized. Automatic thoughts are words or images associated with a particular situation. İntermediate beliefs lie between these two levels. Intermediate beliefs arise as rules, attitudes, and assumptions to resolve negative core beliefs. İntermediate beliefs influence the perception of the two events [1].

1.1.1 Case

Sally is an 18-year-old college student who suffers from depression. She strongly believes that she is inadequate because she performed poorly as a child compared to her older brother, and her mother reinforced this belief by saying, “Cannot you do anything right?” “Your brother got a good report card. But you? You’ll never do well.” The core beliefs continued as she selectively focused on poor performance in her school life. Sally developed intermediate beliefs for inadequacy beliefs, such as “I should be good at everything I try” or “I should always do my best.” These intermediate beliefs led to negative automatic thoughts about everyday events, such as Sally not being able to sleep because she felt anxiety, with an automatic thought that said “I’ll probably fail that night” [1]. The middle beliefs led to negative automatic thoughts about daily events, such as Sally could not sleep because she felt anxiety.

1.2 Third-wave therapies

The first wave of therapy is behavior therapy, which is based on classical conditioning, operant conditioning, and behaviorism. The second wave is cognitive therapy, which focuses on both cognition and information processing. The third wave focuses on the contextual approach, which considers the function of behaviors and private events. Some examples of third wave are metacognitive therapy, acceptance and commitment therapy, and schema therapy. Metacognitive theory was developed by Adrian Wells and is based on the self-regulatory executive function model and cognitive attention syndrome. The self-regulatory executive function model states that the interaction between lower-level automatic processing and higher-level automatic processing activates the cognitive attention syndrome (CAS) as a function of metacognitive beliefs. When the metacognitive beliefs mention the effectiveness of the CAS for problem solving, problem avoidance, or the uncontrollability of the CAS, the CAS is activated by the self-regulatory executive model (S-REF). The CAS activates cognitive processes (rumination, worry) that lead to threat monitoring as dysfunctional coping strategies [2]. The Acceptance and Commitment Therapy (ACT) states that words and events match until worlds with events can elicit the same responses. The ACT states that people cannot distance themselves from their thoughts and feelings because their dysfunctional problem-solving strategies are based on experience. The ACT describes that psychological problems are based on inflexibility resulting from both reliance on experience and the conflation of words and events [3]. Schema therapy expresses that toxic childhood experiences lead to early maladaptive schemas, that is, pervasive themes related to relationships with others, memories, and life experiences. Dysfunctional responses lead to continuity of early maladaptive schemas [4].

2. History of CBT

CBT can be understood as an integration of two different schools of psychology (behavioral psychology and cognitive psychology). Behavioral psychology is a perspective that uses experimental methods, falsifiable hypotheses, and operationalization to make psychology a natural science. The goal of behaviorism is to manipulate behavior by understanding the interaction between behavior and environmental variables. Behaviorism began with the discovery of classical conditioning. Russian physiologist İvan Pavlov produced a conditioned adaptive response in dogs by linking a conditioned stimulus (a bell) to an unconditioned stimulus (a food). At the beginning of the experiment, the dogs showed no response to the bells, but after classical conditioning, the dogs also showed a salivary response to the bells when the food appeared. John Watson hypothesized that all human behaviors can be explained by classical conditioning. He tested this hypothesis in the experiment “Little Albert.” Albert was an 11-month-old infant who had no fear of white fur before the experiment. John Watson used a loud voice to elicit an unconditioned fear response when Albert looked at a rat with white fur, and after repeating the same procedure, Albert showed a conditioned fear response to the rat with white fur. Watson reported that little Albert generalized the same fear response to other objects with white fur [5]. Burrhus Skinner, another behaviorist, developed operant conditioning based on Edward Thorndike’s studies of the law of effect, which states that the frequency of behaviors followed by satisfaction increases and the frequency of behaviors followed by dissatisfaction decreases [6]. Skinner noted that organisms change their own behaviors in response to environmental changes. Some environmental changes lead to a decrease in the frequency of behaviors, and this effect is called punishment. Some environmental changes lead to an increase in the frequency of behaviors, which is called reward [7]. Mary Cover Jones used classical conditioning to treat a three-year-old boy who suffered from rabbit phobia. During treatment, she systematically related cookies and rabbits [8]. Albert Bandura contributed to behavior therapy with the social-cognitive process by showing the possibility of a cognitive process from a behavioral perspective. The social-cognitive process states that the organism can learn new behaviors by observing indirect rewards and indirect punishments [9]. Cognitive therapy is based on the cognitive model, which states that people’s emotions and behaviors are influenced by thoughts about events. The cognitive model is based on the Greek philosopher Epictetus’ statement that “people are not disturbed by things, but by the view they have of them.” Aaron T. Beck, the founder of cognitive therapy, attempted to test a psychoanalytic theory about depression. The theory states that depression is a result of inner anger toward others. Beck could not prove the theory of inner anger, but he found extremely negative views about themselves in the group of depressed patients [10]. Beck improved the studies on negative self-images until he found cognitive errors in patient groups. Beck developed cognitive therapy based on scientific studies of patients [11]. The metacognitive therapy (MCT) approach is the result of laboratory findings on attentional biases and observations in clinical patients. Unlike the CBT approach, MCT focuses on maladaptive thinking styles (rumination and worry) rather than cognitive content (beliefs or automatic thoughts) [12]. Acceptance and Commitment Therapy (ACT) was developed by Steven Hayes and his doctoral student Robert D. Zettle based on the role of language in clinical situations. The ACT is based on Relational Frame Theory, which, unlike CBT, emphasizes possible behavioral/behavioral relationships rather than cognitive control of behaviors [13]. Schema therapy was developed by Young and colleagues using various schools of therapy such as cognitive behavioral therapy, Gestalt therapy, object relations, attachment therapy, constructivist therapy, and psychoanalytic therapy. Schema therapy focuses on chronic personality disorders and is based on long-term psychotherapy sessions [4].

3. Techniques of cognitive behavioral therapy

Psychoeducation: Psychoeducation can be used to change patients cognitively. The content of psychoeducation includes the philosophy of CBT based on a cognitive model about the relationship between events and emotions under the mediation effect of cognition, the role of core beliefs and intermediate beliefs, and specific models for certain psychopathologies. Therapists define the nature of beliefs as something learned in the past rather than innate.

Socratic dialog: Therapists can use the Socratic Dialog technique to review overgeneralized thoughts by evaluating them in the context of specific examples.

Behavioral experiments: Behavioral experiments are used to test the validity of assumptions. Behavioral experiments are more effective than verbal techniques.

Role plays: Role plays can be used for social skill training to practice assertiveness and empathetic communication with others during a discussion.

Restructuring early memories: Memories related to core beliefs can be changed through the use of emotional and experiential techniques following the presentation of cognitive techniques. The therapist finds traumatic memories to change the meaning of the event during the imagining process. Memories associated with core beliefs can be altered through the use of emotional and experiential techniques following the presentation of cognitive techniques. The therapist finds traumatic memories to change the meaning of the event during the imagination process. Problem solving: Learning to problem solve involves specifying a problem, planning a solution, designing an experiment to solve the problem, and evaluating its effectiveness. Patients must examine dysfunctional beliefs that prevent the problem-solving process from beginning.

Decision making: The therapist guides the patient in evaluating options based on the pros and cons of the options during the decision-making process. The patient chooses the best option at the end of the dialog.

Refocusing through distraction: The therapist guides the patient to recognize his or her own past strategies as the patient refocuses or distracts his or her attention. This same technique can be used as an imagination of possible strategies for refocusing distraction in the future. Some strategies include memory cards to recall motivating worlds in the past.

Relaxation: Relaxation including systematic muscle contraction relaxation exercises. Relaxation exercises produce a paradoxical arousal effect in some patients. Thinking of relaxation exercises as an experiment to treat anxiety symptoms may be beneficial to patients [14].

4. Research on the effects of cognitive behavioral therapy (CBT) on unlawful acts

A study has shown that a CBT program for law-breaking behavior can reduce recidivism by 29% when the treated group is compared to the non-treated group [15]. The study used cognitive modification for cognitive distortions. A meta-analysis found that CBT programs were effective in reducing recidivism between 1968 and 1996. Programs were found to be most effective when they targeted both cognitive and social skills, rather than just standard behavior modification [16].

4.1 Research on anger management

4.1.1 Statistical studies on the effect of cognitive behavioral therapy on anger management

A meta-analysis based on 50 studies showed that cognitive behavioral therapy is an effective treatment for anger problems [17]. Another meta-analysis showed that CBT-based treatments reduced the risk of general relapse and violent relapse for anger problems by 23 and 28%, respectively [18]. A systematic review study showed that CBT-based group therapies improved anger management skills in different groups such as college students, psychiatric patients, and individuals with personality disorders [19]. One study indicated that CBT-based group therapy was effective for adolescents with anger management problems [20].

4.1.2 Models of anger management

4.1.2.1 Anger episode model

The anger episode model assumes that intense anger occurs in a short period of time. The model states that unhealthy anger results from modeling others. The model defines five contexts of the anger episode: trigger, appraisal, experience, expression, and outcome. The trigger is a stimulus that triggers the anger episode. A trigger can be an external stimulus (e.g., a criticism) or an internal stimulus (e.g., a picture of a problematic situation about a friend). The appraisal phase is about beliefs related to the triggers. Four types of appraisal lead to anger about the trigger. Making demands of the trigger, usually involving a “should” or “should not,” scaring the trigger, believing that unpleasant events will not be tolerated, and explaining events by using general terms for the personalities of others. The next step is experiencing anger, which includes both physiological reactions (high heartbeat or tense stomach) and secondary thoughts about the trigger. Another step is the expression of anger in the form of verbal or physical expressions. Offenders who have a problem managing their anger may be encouraged by their family members or gang members to express their anger physically rather than showing patience with it. The consequences of anger can be classified as positive or negative, with over long or short periods of time. Aggressive behaviors can lead to positive outcomes in the short term, but the same aggressive behaviors can also be triggered for the next anger outbursts [21].

4.1.2.2 Anger management techniques

Using psychoeducational techniques, the anger episode model is presented with patient examples. Offenders learn an emotional vocabulary to identify their anger spectrum using an anger thermometer. The anger management model provides environmental manipulations to reduce triggers. These include moving to a less crowded place. Some techniques target anger experiences, such as barbing. Barbing is an exposure technique used with verbal anger triggers. The offender calls out the verbal trigger until it loses its meaning. Some techniques target the expression of anger, such as assertiveness training. Expressing anger assertively has two parts. The first part is using certain verb patterns such as “if ..., then I feel,” and the second part is asking for help.

4.1.2.3 Case

Terry was a young woman who grew up with her abusive mother. Terry’s sister had schizophrenic episodes. Terry’s father had suicidal thoughts during Terry’s childhood. Terry’s mother’s behavior included yelling, hitting, and being abusive to Terry and Terry’s sister. Terry has been in psychotherapy treatment for 20 years for anger issues. Terry described herself by saying, “I know I am crazy, I need help fighting dangerous thoughts.” Terry described her fears of the harmful effects of her anger on her life. For example, Terry attacked an elderly lady, as a result of which she was arrested. Terry’s anger management problem increased over time [22]. Terry’s anger management problem can be explained using the anger episode model. Her mother’s physical attack on Julia (Terry’s sister) was the trigger for her anger. Terry appraised the triggering event based on these thoughts, “I was mad as hell, God help me, I’d have a baseball bat or something, I’d lunge at her,” indicating the belief of losing control during unpleasant events. The appraisal phase directly impacts the experience phase. Terry stated that she got energy and felt possessed, as if on TV. Terry physically attacked her mother in the expression phase of anger. The result of this action was that her mother did not speak to her for a long time, and Terry learned the attitude of being violent to protect herself, which led to new triggering events as a short-term positive result as a long-term negative result, and her mother stayed away from her little sister Julia after the tantrum.

4.1.2.4 General aggression model (GAM)

The GAM is divided into two parts, distal process causes and proximal process causes. The distal process causes state that personality generates aggression tendencies. Personality is the result of the relationship between biological modifiers and environmental modifiers. Biological modifiers cause the factors for the development of aggressive personality. Biological modifiers include ADHD, impaired executive functions, low arousal, and hormonal imbalances. Environmental modifiers that lead to aggressive personality include cultural norms, violent peer groups, difficult living conditions, and maladaptive families. The immediate process causes can be divided into three stages: Input, Routine, and Outcome. The input stage means that two parts of aggression are the person and the situation. Two factors influence internal variables such as cognition, affect, and arousal related to aggression. The person factor is the trait of aggression, including high self-esteem with narcissism, high self-efficacy for aggression, acceptance, hostile cognitive distortions, moral justification of violence, certain personality disorders, and high neuroticism. Situational factors contributing to aggressive behavior include provocation, exercise, alcohol, anonymity, noise, presence of weapons, and threatening stimuli. Situational factors and biological factors interact to influence internal factors such as cognition, affect, and arousal related to aggression. The second stage is the process of decision making with or without judgment based on internal variables under the influence of situational factors and personal factors. The internal variables, that is, affect, cognition, and arousal, may influence each other. The input variable increases the accessibility of aggressive thoughts, behaviors, and anger. The third stage focuses on both the appraisal process and the decision-making process for aggressive or nonaggressive responses. Immediate appraisals lead to inferences about traits or situations. People respond aggressively to others when they infer a particular trait. Inference from a trait leads to approving goals, plans, and behavioral scripts toward another person. Individuals can make alternative inferences about the behavior of others if they have both sufficient time and cognitive resources to consider negative outcomes [23].

4.1.2.5 Anger management techniques

The techniques refer to the model based on reversing risk factors such as positive attitudes toward aggression, high neuroticism, and low conscientiousness through the use of CBT techniques. Virtual Reality Aggression Prevention Training (VRAP) is an exposure technique that improves both awareness of aggression and control over aggression during social interactions. The technique provides physiological feedback to the therapist for real-time therapeutic intervention and treatment design for the offender. The technique can be used for social skill practice or relaxation exercises in a virtual reality environment [24].

4.1.2.6 Case

This case is about anger management in three individuals who have similar anger management problems, such as verbal, emotional, and physical violence against others in prison. The three cases also have prior convictions related to violent behavior. Demographic information about the cases states the following: The 3 men were 26, 30, and 40 years old. Similar characteristics of the cases are: sexual orientation toward other men, victims of childhood sexual abuse, rejection by the family because of their sexual orientation, and anger toward the family and society. Three psychopathologies were diagnosed: depression, antisocial personality disorder, and generalized anxiety disorder. Some cognitive schemas can be summarized as “I often think that I get angry,” “controlling anger is difficult because there are many instances,” ““I should be reactive because people are bad, “and” if people do not make me angry, I do not feel angry. “Some other examples of cognitive distortions: “people deserve aggressive behavior“—these types of schemas and automatic thoughts lead to aggressive behavior against both self and others. An example of aggressive behavior toward other prisoners: Prisoner G offers prisoner S a dessert, but prisoner S refuses to eat the dessert. Prisoner G yelled at Prisoner S in an angry voice after his refusal. Prisoner O said, “Leave S alone, he is just sitting there.” Prisoner G threw the dessert against the wall. Psychologist applied several CBT techniques in this case; for example, psychologist used Socratic dialogue to recall alternative behaviors, recalled hot automatic thoughts by imagining the problematic situation, and activated and diverted attention, and also psychologist used relaxation exercises during the imagining process to balance both physiological reaction of anger and physiological relaxation [25]. The case can be explained by the General Aggression Model (GAM). Prisoner G. grew up in a negative family environment because he had a different sexual orientation. The interaction between biological modifiers and environmental modifiers causes prisoner G. to react to rejection in his personality. The event of rejection of friendly behavior, such as presenting desserts, leads to negative cognitions, emotions, and arousal during the route phase. Prisoner G. has become accustomed to immediately processing his impulsive actions, such as yelling at or throwing certain objects at the wall, without evaluating the results. Prisoner G.’s action led to a social reaction from Prisoner O., who was subsequently warned, and at the end of the event, Prisoner G. created a negative environment in the prison.

4.2 Research on addiction

4.2.1 Studies on the effect of cognitive behavioral therapy (CBT) on addiction

A literature review shows that CBT interventions for alcohol or other substance abuse disorders are effective under two mediator variables, including self-efficacy and coping skills. Self-efficacy is related to improvement in therapeutic commitment, global symptom severity, and reduction in drinking frequency. Coping skills are related to self-regulatory cognitions and behaviors to reduce substance use risk behaviors in the Litracer study [26].

4.2.2 Models for the disease of addiction

4.2.2.1 Marlatt’s cognitive behavioral model

Martlatt’s cognitive behavioral model is based on social-cognitive psychology. Martlatt’s model aims to prevent relapse in addiction. The model emphasizes that two categories of factors lead to a relapse episode. The immediate determinants include the absence of the injury effect, outcome expectations, the person’s coping skills, and high-risk situations. The second factor includes antecedents such as urges with craving and lifestyle imbalances. High-risk situations are a threat to the person’s perception of self-control over his or her own addictive behavior. High-risk situations include negative emotional states (depression, anxiety), interpersonal conflicts (conflicts with family members), positive emotional states (parties), and testing personal control over addictive behaviors (buying a bottle of wine). Coping skills are important for relapse episodes because responding to trigger situations is critical for relapse episodes. Cognitive behavioral therapy strategies can increase self-efficacy for relapse episodes. Outcome expectations mean that positive expectations of alcohol/drug use for satisfaction also ignore negative outcomes. The effects of the absence violation are the attitudes of the person himself, which decay during the healing process. Attitudes can be global, stable, and internal explanations for one’s failure. Attitudes can reduce self-efficacy, which prevents relapse. Covert antecedent factors lead to “seemingly irrelevant decisions” (AID) that appear to have nothing to do with relapse but actually increase the risk for relapse. Covert antecedent factors include lifestyle factors that represent an unbalanced life between duties and leisure. Lifestyle can lead to rationalizations for addiction. Another covert antecedent factor is craving for immediate gratification; craving has two processes: The first step relates to classical conditioning between stimuli and past gratification, and the next step relates to cognitive processes related to the expectation of a positive effect from alcohol or drugs [27].

4.2.2.2 Techniques for addiction control

Self-observation is a technique based on understanding the triggers for relapse. The technique may involve writing down cognitions, emotions, and behaviors during relapse. The cognitive restructuring technique is a definition of psychoeducation via Martlatt’s cognitive behavioral model. Psychoeducation can mention the myths as well as the Placebo effect of medication during the relapse episode. Downsizing goals to more manageable and smaller goals is a technique based on self-efficacy. Relapse roadmap is a technique based on discovering possible scenarios for relapse. The relapse roadmap can be used to develop coping skills for each scenario.

4.2.2.3 Case

R.P. was a 14-year-old adolescent who lived with her family, including her mother, father, and sister. R.P. was diagnosed with depression and drug addiction. R.P. was caught using drugs at school. R.P. reported using marijuana and other drugs for 2 years. She suffered from depression for 1 year. She took antidepressants and received psychiatric treatment for her suicidal thoughts. She stated that she did not think about the negative consequences of drug use and acknowledged that both her communication and problem-solving skills were problematic. R.P.’s situation can be explained on the basis of Martlatt’s cognitive behavioral model. In high-risk situations, there were both relationship conflicts and problematic episodes regarding her mental health. R.P. applied ineffective solutions, such as taking various drugs. The ineffective solutions increase positive expectations about the outcomes of drug use. The positive expectations lead to relapse. The absence of violence and the thought of the positive effects of the drug increase the likelihood of relapse. R.P. learned to manage her stress without drug use. Instead of using drugs, she found other activities such as talking with her boyfriend, exercising, drawing, and listening to music. She recognized some events as triggers for both her depression and anxious feelings, such as relationship conflicts with her boyfriend or her worries about school. She recognized her automatic thoughts about her grades in school. She changed her high expectations of both her triple scores and her exam scores [28].

4.3 Research on partner violence

4.3.1 Studies on the effect of cognitive behavioral therapy (CBT) on partner violence

Cognitive behavioral group therapy can reduce both physical and psychological abuses in male perpetrators of partner violence when CBT is delivered with a therapeutic alliance that prevents blaming others for their aggressive actions and reduces resistance to the therapist’s efforts [29]. Standard CBT group therapy is an effective treatment for preventing partner violence in men with or without motivational interviewing strategies [30].

4.3.2 Models for partner violence

4.3.2.1 Duluth model with CBT

The Duluth model was developed for men who perpetrate domestic violence against family members or men. The Duluth model is based on feminist theory, which states that domestic violence is a consequence of the power and control paradigm. The Domestic Violence Project is a group psychoeducation program for men who exhibit partner violence. The psychoeducation program follows the Duluth model and lasts 28 weeks. In the first phase of psychoeducation, specific topics are addressed, such as emotional abuse, belittlement, denial, blaming, intimidation, children, male privilege, economic abuse, coercion, and threats. The themes are presented on the power and control wheel. The Duluth model emphasizes non-threatening behavior over the power and control wheel. The themes on the non-threatening behavior wheel are honesty, respect, trust and support, accountability, responsible parenting, economic partnership, shared responsibility, negotiation, and fairness. The Duluth model explains domestic violence as a past learned behavior related to power and control. The Duluth model emphasizes the influence of socialization on behavior rather than psychopathology [31].

Criticism of the Duluth model relate to the therapeutic process, theory, and effectiveness of the model. The first criticism is that the Duluth model neglects data on female violence, such as mothers being one of the violent groups for child abuse. Another criticism is that the Duluth model is presented as a CBT model, but the Duluth model does not fit CBT because of its polarized thinking based on the gender paradigm. Criticism of the effectiveness of the model is that the recidivism rate for domestic violence after intervention treatment was 40% [32].

4.3.2.2 Techniques related to partner violence

The Duluth model uses group psychoeducation based on themes related to power and the wheel of control. The second episode of the treatment cycle provides video exercises on the topic to understand the pathways of violence based on the topic, and the final episode of the treatment cycle focuses on practicing non-violent and non-controlling behaviors in the problem situation using role playing. The treatment cycle is used for each theme of the power and control wheel.

4.3.2.3 Case

Lyn is a 65-year-old white woman who experienced domestic violence at the hands of her father, stepfather, ex-husband, husband, and son. Lyn reported sexual abuse, threats with weapons, and beatings in her past life. Lyn stated she was emotionally abused by her son, a middle-aged adult. Lyn came from a dysfunctional family in which her father used emotional and physical violence against her and her mother. Lyn blamed her mother for not protecting her from her father. Lyn mentioned that her son blamed Lyn because Lyn had not protected her son from his grandfather’s violence in the past [33]. The themes related to power and control can be seen in the case: intimidation by the male relatives, emotional abuse by the son due to blame, children growing up with domestic violence, and threats with guns.

The assumptions of the Duluth model have been heavily criticized because of its feminist bias, which is inconsistent with some of the assumptions of the CBT model. The BIP program is based on both the Duluth model and couple therapy techniques, and the BIP model harmonizes with the therapeutic CBT model. The BIP program is based on the I3 model (instigation—prompting—(dis)inhibition).

4.3.2.4 I3 model

The I3 model was developed based on the analysis of studies containing predictions of violence in couple relationships (İPV). The I3 model identifies three main factors for intimate partner violence, including instigation, drive, and (DİS) inhibition. The core assumption of the I3 model is that intimate partner violence is the result of the interaction between environmental triggers and aggressive drives that overcome individual coping skills. The instigation factor states that direct/indirect instigation contexts are starting points for intimate partner violence. Direct instigations are provocative events such as abusive remarks between partners. Indirect instigations are events that trigger the aggressive urge in both the original source and the intimate partner. Instigations are the situational and dispositional factors that lead to aggressive responses to triggering events. There are four types of impelling factors. Distal factors represent the evolutionary and cultural predisposition to aggressive drives. Dispositional factors represent individual differences for experiencing aggressive drives. For example, hostility tendency, anger outbursts, and testosterone levels. Relational factors are dyadic features of the relationship such as jealousy, insecurity in the relationship, and dissatisfaction with power dynamics in the relationship. Situational factors are representative of immediate variables such as cognitions, affects, and physiological arousal. Situational factors have two subcategories (internal-external). Internal situation can be physical pain, and external situation can be hot room temperature or violent media. The instigating factors must be compatible with the drive factors in order to increase the aggressive urge. The (dis)inhibition factor is a critical factor based on both self-regulation (inhibition) and self-control (disinhibition). Disinhibition factors contain four subfactors: distal, dispositional, relational, and situational. Distal disinhibition states that cultural norms promote intimate partner violence. Dispositional disinhibitor result in the reduction of abilities associated with the prevention of aggressive drives. These include the inability to maintain both high executive function and the prevention of impulsivity. Relationship-related disinhibition factors include lack of empathy for the partner and low commitment to the relationship. Situational disinhibition factors related to external and internal influences, such as alcohol intoxication, impair executive function, which is important for both problem-solving skills and understanding social cues during an argument between partners. Inhibitory factors can provide protection for aggressive urges, but a lack of inhibitory factors can also lead to a decline in coping skills for aggressive urges. Each self-regulatory attempt consumes the resources needed to inhibit the next drive. In this sense, each self-regulation is a situational disinhibition factor for the next impulse [34].

4.3.2.5 Techniques for partner violence

Techniques for instigation include the use of self-observation sheets, relaxation exercises to activate the parasympathetic nervous system to reduce anger, and psychoeducation for social learning experiences about aggression patterns using the offender’s life history. Techniques for facilitation include identifying cognitive errors (arbitrary reasoning, overgeneralization, dichotomous thinking) that lead to aggression, cognitive restructuring through the use of contention questions aimed at both reducing certainty about thoughts and seeking alternative information against hostile thoughts, and social skill training based on role playing. Inhibition techniques include working on problem-solving worksheets, improving self-awareness of negative consequences of violence, and training in the use of empathy based on perspective taking.

4.3.2.6 Case

GM was a 42-year-old white man living in the United States with his 58-year-old partner. GM was supported by his girlfriend’s income, and GM also has a monthly income from Social Security disability İnsurance because of his chronic neck and back pain. His current partner reported a long history of domestic violence by him. The case can be explained by the I3 model. İnstigations: GM reported his direct instigations, for example, verbal and physical aggression by his partner due to his immature behavior. The indirect instigations were intrusive neighbors, holistic calls from his debt collectors, and traffic. GM’s distal instigators were relationally abusive parents, GM had an aggression problem since age 17, such as fights with neighbors, friends, and strangers in bars as dispositional causers, situational causers: GM reported that he had low self-esteem because of both his financial problem and sexual problem, and also, he had physical pain because of his neck. GM had a sensitivity to temperatures, and GM used marijuana as self-medication. (Dis)inhibition: GM could not appreciate the consequences of his partner’s violent acts, such as arrest or loss of financial support. GM had multiple concussions due to his field hockey past. The multiple concussions could result in his inability to properly assess the consequences of his violent behavior. GM reported that he consumed alcohol prior to his aggressive behavior. GM ability to suppress his aggressive urges was limited by poor executive functioning for a variety of reasons. The first session of treatment for GM included psychoeducation for rational treatment as well as identification of the triggers for his aggression. Further sessions addressed the aggression patterns of GM ‘s parents and their impact on GM ‘s social interactions with others. For this reason, GM was given self-observation worksheets. GM learned coping skills for his aggression triggers, such as sleep regulation and relationship disconnection. GM learned relaxation exercises for the physiological symptoms of his aggression. GM learned to modify his cognitive distortions. GM developed his social skills, including empathy, using role playing. GM improved his decision-making ability with the evaluation of partner violence based on both its positive and negative sides [35].

4.4 Research on sexual offenders

4.4.1 Studies on the effect of cognitive behavioral therapy (CBT) on sex offenders

In a literature review study based on 10 different studies, it is mentioned that CBT interventions reduce the recidivism rate of sex offenders. The outcome of the literature review study includes a comparison group, a homogeneous group of medium and high risk sex offenders, and a follow-up period of 1 year. CBT intervention groups have recidivism rates ranging from 0.6 to 21.8% for deviant behavior. For sex offenders compared to the intervention group, recidivism rates for deviant behavior range from 4.5 to 32.2%. In the same study, it was emphasized that CBT intervention reduces the recidivism rates of sex offenders who take responsibility for their criminal behavior. The result of the study also showed that CBT intervention reduced recidivism for other violent behaviors in the sex offender group [36]. Another study used a retrospective risk scale and information from Canadian sentencing practices to control for sex offender offense severity. The same study used records from the Canadian Police Information Center to determine the recidivism rates. The integrated CBT program reduced recidivism rates by 76 to 81% for high-risk sex offenders and 65 to 75% for medium-risk cases [37].

4.4.2 Models on sex offenders

4.4.2.1 Integration of the cognitive behavioral model for sex offenders

The behavioral model explains deviant sexual behavior based on Pavlov’s classical conditioning model. The object of deviant sexual behavior is initially a neutral stimulus that matches a natural stimulus that elicits a sexual arousal response. After the adaptation process, ex-neutral stimuli can also lead to sexual arousal. The continuity of deviant sexual behavior is explained on the basis of Skinner’s model of operant conditioning. The deviant sexual behaviors are usually rewarded with orgasm for sexual objects, for example, children or animals. The cognitive model expresses that deviant sexual behaviors exist under the influence of cognitive biases. Sex offenders typically minimize or justify sexually deviant behaviors. Sex offenders tend to misunderstand victims’ actions and cues. They also deny the criminal behavior to reduce their guilt for the consequences of the criminal behavior.

4.4.2.2 Techniques for sex offenders

The cognitive restructuring method consists of four steps: The first step is psychoeducation about the cognitive model, including the effects of cognitive distortions on sex offender behavior. The second step is about providing offenders with information to change the process of false thinking. The third step is about helping offenders distinguish functional thoughts from non-functional thoughts. The final step is about challenging non-functional thoughts.

4.4.2.2.1 Education to deal with emotions

Sex offenders are educated about their own emotional behaviors and how to cope with negative emotional states. Education about negative emotions include recognizing the different parts of negative emotions such as depression, anger, shame, and guilt. Offenders can use their negative emotions as a clue to their risk of reoffending.

4.4.2.2.2 CBT techniques for empathy deficits

Videos of victims’ reactions can be used to develop empathy. Offenders can write a letter to the victim expressing regret for past sexual assaults. Offenders can read the letters in groups of three to get each other’s feedback. Offenders can write a letter as a victim of sexual assault to develop empathy.

4.4.2.2.3 CBT techniques for deviant sexual arousal

Masturbatory satiation can be used for aversive conditioning. The offender can imagine a healthy sexual seance while masturbating. The offender may verbalize a healthy sexual image while experiencing orgasm. The offender can imagine a deviant sexual seance after orgasm. The second part of the exercise is used to explore both the impotence phase and the deviant sexual seance.

4.4.2.3 Case

The sex offender preyed on 19 women in southern Italy between September 2002 and November 2005. All victims were raped in the evenings in suburbs. The age of the victims varies from 10 to 34 years. The perpetrator looks like a non-violent, good-looking gentleman. The perpetrator was caught by local residents during the last sexual assault. The offender was a 38 year old male who has a family of 2 children and a wife. The perpetrator’s wife and colleagues described him as an accommodating and reasonable person. The psychological assessment revealed that the offender exhibited borderline symptoms (unstable self-image and impulsivity) and narcissistic symptoms (grandiose sense of self-importance, lack of empathy, and fantasies of unlimited success and power). The offender described his family as having a warm mother and a father who was not very empathetic. The offender believed his penis was too small and had a deficient shape. As for the anatomical problems, the perpetrator believed that his partner was not sexually satisfied with him. He also had an erection problem since 2002. The offender admitted to having problematic thoughts about inadequacy. The offender imagined sexually aggressive fantasies when he masturbated to solve his erection problem. When he saw his first victim, he felt sexual arousal due to his predatory actions. The frequency of his sexual assaults increased from one sexual assault every 50 days to one sexual assault every 20 days after his first sexual assault. The perpetrator described his sexual assaults as an “apparent affirmative sexual act” [38]. The case can be explained using the CBT model. Initially, the perpetrator imagined sexually aggressive fantasies when he stood up. The repeated action resulted in sexual aggression being associated with sexual arousal. Classical conditioning produced sexual arousal when the perpetrator performed a predatory act such as his sexual dominance fantasies. The cessation of sexual assault changed his mind so that the offender continued to perform criminal acts because of the operative conditioning. The sex offender became increasingly dissatisfied over time. The offender increased the number of sexual assaults he performed over time. The offender minimized the outcome of his criminal acts by using “seemingly affirmative sexual arousal” words. The minimization leads to a repetition of the criminal acts based on the cognitive model. Also, the lack of empathy leads to reinforcement of the sexual acts without remorse. In addition, by trivializing his criminal acts, the offender may protect his self-image.

4.4.2.4 Self-regulation model with cognitive behavioral therapy

Marlatt’s relapse prevention model or cognitive behavioral model for addiction problems is applied to sex offenders. Marlatt’s cognitive behavioral model explains sex offenders’ actions based on a lack of coping skills for sexual urges. The model is criticized for emphasizing a single pathway for sex offenders. In addition, the model does not include milestones for sex offender behaviors. The self-regulation model was developed to enhance Marlatt’s cognitive behavioral model for sex offenders. Self-regulation is a goal-setting process that is important for monitoring, modifying, selecting, and evaluating actions. Goals can be divided into acquisition goals and inhibitory goals. Acquisition goals are concerned with the development of skills or behaviors. Acquisition goals focus on data associated with achieving the goal. Inhibitory goals are about reducing behaviors. The inhibitory goals placed high demands on performance, which led to a focus of the data on failure. Sustaining the inhibitory goals is more difficult than sustaining the acquiring goals. The model identifies goals as cognitive structures that contain behavioral outlines to guide actions. The model of self-regulation identifies nine phases: Life Events, Desire for Deviant Sex, Establishment of Offense-Related Goals, Choice of Strategy, Entry into a High-Risk Situation, Recidivism, Sexual Offense, Post-Offense Evaluation, and Attitude toward Future Offense. In the life event phase, it is mentioned that a particular life event produces cognitive structures, including goals, beliefs, and needs. These cognitive structures can be automatically activated by similar life events in the past. The second phase is about the desire for deviant sexual activities, that is, sexually aggressive fantasies that increase the possibility of sexual assault. Certain cues may trigger both goals related to sexual desire and maladaptive beliefs related to sexual fantasies. In the third stage, targets are mentioned for both acceptance of maladaptive sexual desires and strategies for deviant sexual desires. Inhibition targets focus on avoidance of sexually deviant behavior as opposed to acquisition targets that lead to sexually aggressive behavior. The fourth stage refers to the choice of strategy. The model of self-regulation describes four pathways based on both different goals and different strategies. The avoidant-passive pathway involves sex offenders who unsuccessfully attempt to prevent their deviant sexual desires. Individuals with poor coping skills, impulsive behavior, and low self-efficacy follow the avoidant-passive pathway for recidivism. Both denial and “seemingly irrelevant choices” (AID) are found in this pathway. The avoidant-active pathway represents the direct attempts to avoid sexual misconduct. The offender uses dysfunctional strategies to control his deviant sexual fantasies. As a result of the dysfunctional coping strategies, deviant sexual desire increases in the fourth stages. The approach automaticity pathway includes behavioral scripts for automatic sexual aggression that may be impulsive or rudimentary. The pathway shows harmony with acquisition goals. The sexually aggressive behaviors are easily activated by environmental stimuli without cognitive resources in a short time. The Approach Explicit pathway represents sex offenders who have high self-regulation for deviant sexual desires but harmful goals for sexual desires. Offenders use deliberate strategies to commit sexual assault. Sexual assault is an acceptable act for a positive emotional state in the pathway group. The fifth phase is about victim contact for sexual offenders. The assessment processes for potential victims may vary depending on the pathway type. Individuals with the avoidant-passive pathway experience sexual arousal, and they may also exhibit automatic behaviors toward the victim. Individuals with the avoidant-active pathway use paradoxical strategies to control sexual deviance, such as drug use, resulting in a sense of loss of control. Individuals with the automatic approach path focus on the immediate gratification of sexual satisfaction. Persons with explicit approach have positive emotions due to their plans for sexual acts. The sixth stage contains lapse episodes for four pathways. Individuals with the avoidant-passive pathway change their goal from avoidant to approaching during the lapse episode. This change is temporary. Individuals with avoidant-active pathway are changed to approaching goal. Individuals evaluate the control attempt as a failure. Individuals with the approach-automatic pathway show impulsive reactions as opposed to the approach-explicit pathway. The seventh stage is sexual assaults that are self-focused or victim-focused. Self-focused sexual assaults are indicated by both short duration and high intrusiveness. The eighth phase is the follow-up to the crime, which can be both protracted and less violent. Individuals with avoidance behaviors may exhibit negative feelings such as guilt or shame as a classic abstinence violation response. If the individual’s evaluation of the sexual offense is based on stable or uncontrollable internal reasons, the individual may attempt to sexually assault a second time in the future. The ninth stage involves attitudes toward future offending. Individuals with avoidance behaviors may reattain their avoidance goal for sexually deviant desires through solutions that do not work, or they may permanently change their goal. Individuals with the approach pathway may have feelings of success after sexual assault. Individuals with the approach pathway develop new strategies based on their past experiences with sexual assault [39].

4.4.2.5 Techniques for sex offenders

Offenders learn a self-regulatory model for analyzing their progression to sexual assault. Offenders use their pattern of sexual assault, including cognitive biases, decision making, pathways, and interpretations of events, to develop new strategies based on CBT techniques for sex offenders. In addition, offenders find prosocial goals related to the risk situation for reoffending [40].

4.4.2.6 Case

Demographic data of the sex offender: The offender is 50 years old, father of five daughters, married, retired soldier, lives in Jordan, and has no mental disorder and he has been diagnosed with diabetes. The perpetrator’s daughters reported that their father tried to sexually assault them several times. The offender used sleeping pills to sexually assault them. The offender sexually assaulted his daughter in his car by performing sexual movements. The offender watched pornographic movies in his room and threatened other family members. The offender sometimes went into his daughters’ rooms without clothes. The perpetrator’s daughters reported that their mother knew everything about her husband but did nothing because she said, “We don’t want to expose ourselves in front of relatives, and no one will believe us” [41]. The case can be explained on the basis of the model of self-regulation. The sex offender’s past experiences led to a cognitive structure for sexually deviant desires toward his daughters. Watching pornographic movies can be a cognitive stimulus for deviant aggressive sexual desires. The offender’s goal setting is based on acceptance of aggressive sexual desire. The offender’s strategy changed from the automatic approach strategy, which is impulsive, to the explicit approach strategy as the offender developed a plan for sexual exploitation using sleeping pills. The offender had high expectations for gratification, which led to impulsive sexual behavior. The offender exhibited self-focused patterns that led to violence against his victim. The offender was able to experience negative emotions due to his unsuccessful attempts.

5. Conclusion

In conclusion, much research has indicated that CBT is an effective therapy for the criminal population. Research has shown that CBT can be useful with new technological tools. Third-wave therapies and CBT offer many techniques for criminal behavior based on different models for different criminal populations. The CBT approach provides opportunities for effective treatment of criminal behaviors such as addiction, sexual assault, aggression, and intimate partner violence. The CBT approach can explain a wide range of criminal patterns using specific models of unlawful acts. CBT-based treatment can be combined with the technological tools. On the other hand, research on the relationship between CBT and criminal behavior, based on paper-and-pencil measures, lacks the subjective views of offender groups about the treatment experience. Another issue is that the treatment setting includes a prison environment that may influence treatment outcomes. New research may be based on the use of virtual reality technology for treatments in the prison setting. In addition, new research can use both scales and interview techniques for the subjective experiences of offenders. The final suggestion is that new research can focus on combining third-wave therapies and CBT models to provide effective treatments for offender groups.