The Client No One Wants to Treat

In many ways, Alexandra Roth is an ordinary, albeit skilled, therapist. Over her 40 years as a social worker, she’s been trained in a number of modalities. She works with adults, teens, children, partners, and parents. She’s personable. She offers teletherapy. Her Psychology Today profile describes her style as “client-centered and collaborative.” At first glance, there’s little that raises an eyebrow.

But when she talks about a certain population she works with, scrutiny often follows. Disclosing it, she says, is “a conversation killer.” In addition to her normal caseload, Roth works with people who are attracted to children.

“I know there’s a distaste for what I do,” Roth says preemptively at the start of our interview, “but I’ve always had a high tolerance for things that other people find scary.”

“Scary” might be a bit of an understatement. In the catalog of client behaviors that send even the bravest, most skilled therapists running for the hills, pedophilia ranks high on the list.

Roth says that’s precisely the point.

Nine years ago, she was listening to the radio when an episode of This American Life came on. It was a story about a pedophile who’d been trying desperately—and failing—to get mental health treatment. Providers—whether they felt disgusted, fearful, or ill-equipped to deal with the potential legal ramifications—declined to see him. Moved by his plight, Roth found a list of resources linked to the episode and learned about an organization pairing therapists with pedophiles seeking treatment. She applied to join their directory of providers, and got accepted.

That organization, the Maryland-based B4U-ACT, opened Roth up to the world of pedophile mental health advocacy. Since its founding in 2003, B4U-ACT has paired hundreds of therapists with pedophiles seeking treatment, providing a resource it says is desperately needed, since many pedophiles—including those who have pedophilic thoughts but will never act on them—are too ashamed to seek treatment.

The organization also coordinates workshops co-led by therapists and pedophiles; offers online support groups for pedophiles and their families; hosts discussion groups for therapists, pedophiles, and researchers; and publishes an online journal co-written by therapists and pedophiles. It’s also been leading a campaign to change the language typically used to describe pedophiles and pedophilia, namely by referring to pedophiles as minor-attracted persons, or MAPs.

Does this sound alarming? Why would anyone work to humanize a population struggling with something so appalling and potentially dangerous?

“A lot of people think the more you shame someone, the less likely that person is to do something wrong,” Roth explains, “but shame actually makes it harder for someone to make good choices.” Because most pedophiles struggle with loneliness, fear, self-hatred, and suicidal ideation as a result of their desires, she says, “therapy with them often has to do with addressing problems of identity and how they’ve been affected by stigma.” Many times, she says, the work doesn’t center around the client’s attraction to minors at all. “We’re focused on problems that might bring any other client to therapy, like depression or problematic relationships with parents or partners.”

Are more alarm bells going off? Why wouldn’t Roth focus exclusively on addressing something that seems so crucial to control? Although she tells clients up front that she has a duty to report if she suspects abuse has occurred or is occurring, she says that as far as she knows, her clients (10 in total) have never broken the law, and are part of a silent but sizable group of people who are attracted to minors but have no intention of acting on that attraction. Too often, Roth argues, these people are overlooked in the larger conversation about pedophilia.

“I’ve never had a client who believed acting on their thoughts was a good idea,” she says. “I’ll explain to them that I’m here to help. I’ll say, ‘You have this challenge. You want to avoid breaking the law or hurting anyone. How can we make the rest of your life good enough so it’s worth it for you to not do those things?’”

A Corrective Experience

It’s this kind of curious, nonjudgmental approach that retired social worker Russell Dick says is imperative to doing effective therapy with this population. “Most MAPs who’ve sought therapy have had bad experiences,” he explains. “As soon as they told the clinician that they had feelings of attraction toward minors, they became the problem. Some therapists have refused to treat them or reported them to child protective services. Despite being professionals who’ve been trained not to judge people, many are repulsed by the idea of working with them. I get it. I used to think the same way.”

Dick has a long history of activism. In college, he got involved in local peace and civil rights movements. During the Vietnam War, he filed as a conscientious objector. Years later, he went on to volunteer with his local NAACP branch. But it wasn’t until his late 40s that his thinking about pedophiles began to change. He was working at a psychiatric hospital and encountered a volunteer on the client rights committee named Mike, who’d been jailed for having a relationship with a teenage boy. Dick and Mike would carpool to work, and the two began to develop a close friendship. Over time, Mike told Dick about the shaming messages he’d been living with, the loneliness he felt at having to hide his feelings, and how he felt like he had no advocates in the mental health field.

In 2002, they cofounded B4U-ACT to remedy these kinds of problems, and created a set of guidelines for therapists interested in working with people attracted to minors. The prerequisites, Dick says, aren’t some sort of specialized training, but “a willingness to reconsider one’s cultural and environmental perspectives.” Pedophiles “didn’t choose to have these attractions,” he adds, “just as you and I didn’t choose who we’re attracted to.”

Choice or not, even the most nonjudgmental therapists will likely argue that acting on those attractions to minors, who can’t give legal consent, is indefensible. But Dick says that most of those seeking B4U-ACT’s services haven’t acted—and will never act—on their thoughts and feelings. “The messages from the media are that these people will harm minors,” he explains. “But the majority of sexual offenses are situational and opportunistic, committed by people who are primarily attracted to other adults and by those who might be described as morally indiscriminate. They’re people with social and narcissistic personality disorders. They’re also people who commit sexual offenses broadly.” In other words, Dick says, many pedophiles aren’t at risk of acting on their feelings—and they’re wrongly conflated with those who do.

“They hear messages from the culture that they’re monsters who are doomed to rape minors,” he continues. “They hear that they have uncontrollable, animalistic urges. They think they’ll become the monster they hear about. They become depressed and anxious. They feel hopeless about their future, isolate themselves, and struggle to develop trusting relationships for fear of revealing their secret.”

In 2011, B4U-ACT conducted an online survey of people attracted to minors. Nearly 200 people responded. Asked whether they’d ever seriously thought about ending their life over their attraction to minors, almost half said yes. Asked whether they felt they could talk to someone about their thoughts, roughly two-thirds said no.

When it comes to responding to clients who disclose their attraction to minors, Dick says a little patience and compassion goes a long way. “Don’t jump into panic mode and immediately assume that fantasies indicate risk. There’s no mandatory reporting required for people who simply have thoughts and feelings of attraction to minors. The goal is not just prevention. Focus on the well-being of the client in front of you.”

The Trauma Question

Sometimes that’s easier said than done. Jackie Craissati, a London-based clinical and forensic psychologist who specializes in sexual offenders and men with personality disorders—after they’ve offended—says even the most composed therapists can easily be triggered by this work.

“Even pedophiles who are worried about their behavior and seek therapy will minimize what they’re doing or thinking about doing,” she says. “They will lie about what they’ve done and try to justify it, but you can’t jump down their throat and close them down. It’s incredibly difficult. There are times when I’ve found myself gritting my teeth when a child is referred to as seductive or flirtatious, because we’re thinking about potential victims here. But you’ve got to learn to let that wash over you and remain curious and nonjudgmental.” She tries to keep in mind that many pedophiles are also in distress, and “have a right to receive support and explore that with a skilled professional just like anyone else.”

Social worker Mary Jo Barrett agrees that working with pedophiles can be personally difficult. “I try to keep the pedophile’s humanity in my head,” she says. “But how do you hold what they did? The behavior is reprehensible, so you have to be able to separate the human from the behavior. Each therapist has to figure out for themselves how to hold multiple realities—that there’s a survivor and a perpetrator, and the perpetrator has human qualities. It does challenge you.”

Barrett has spent almost five decades working with perpetrators of family violence, including adults who’ve sexually abused minors. At the Center for Contextual Change, which she cofounded in Illinois, therapists are often assigned to work with these individuals. Since these clients are referred by courts, the therapy centers around the abuse. Rather than primarily following the client’s lead, as Roth and Dick do with nonoffenders, the therapists on Barrett’s staff lead clients through a multistep process, which includes assessing risk, taking a social history, and administering tests that gauge sexual attraction. Next comes individual, group, and sometimes family therapy, in which clients develop skills to manage dysregulation. They’re taught to try meditating, journaling, exercising, or calling a sponsor when urges come up. Gradually, the therapist helps them take responsibility for their behavior and develop what Barrett calls “appropriate sexual attraction.”

Like Roth and Dick, Barrett says that empathy is her guiding principle. “Years ago,” she says, “I woke up from a dream asking myself, What kind of person works with sex offenders? And I realized the answer is a really compassionate one. I understand people’s reservations, but the fact is that if we all did a better job of getting to know the named ‘other,’ there’d be a lot more humanity in this world. If you’re going to work with this population, you have to work on your own being. You have to work on what gets in the way for you.”

When it comes to doing your own work, Craissati and Barrett are on the same page as Roth and Dick. But their thinking diverges on a major question informing treatment: whether pedophilia is always a result of trauma. Barrett maintains that it is.

“Most of the people I’ve worked with are survivors of childhood trauma,” she says. “I believe there are severe attachment disorders for all of them, and very severe neglect. I recently worked with a grown man who abused, and when I took his history, I could honestly say that he’d stopped growing at age 14. Part of him was stunted, and that was the part that was attracted to children.”

Craissati says the trauma–pedophilia connection is fuzzier. “Depending on your sample of men who’ve offended, between 30 and 50 percent have been sexually abused as children,” she says. But getting an accurate read is tricky. “Some might exaggerate to elicit sympathy, or hide it because of shame.” We have to think about trauma broadly, she adds. “It’s not just sexual assault: it can be exposure to highly sexualized environments, or having a mother who’s a sex worker, or an early introduction to pornography.”

Roth disagrees. “The research is mixed and unpersuasive,” she counters. “It’s based on those we know have acted, not on those who haven’t. If you’re only talking to a forensic population, your findings will only pertain to that population.”

Lonely Work

Despite their different perspectives, one thing is certain: Roth, Dick, and Barrett have all been criticized or scrutinized for their decision to work with pedophiles, including by therapists. “I sometimes hear that I’m protecting them,” Barrett says. “Or ‘How do you know they’re not just grooming you like they’re grooming everybody else?’ My response is ‘How can I really know anything?’ Can I say without question that this person will never offend again? I can’t. But I can’t say that about any symptom I’m trying to help people manage.”

Dick says the revelation that he works with pedophiles often evokes a visible “ugh” reaction from other clinicians. “When I tell therapists about my work, they frequently say, ‘Oh, good for you for being able to work with them, but I could never do it.’ I’d receive a warmer reception if I told them I worked cleaning public toilets.”

Roth says it’s fine if some therapists don’t want to work with pedophiles. “I wouldn’t want to work with certain clients either,” she explains. “Some therapists don’t want to work with teenagers; others really do. Some therapists enjoy working with polyamorous or kinky people; others say it’s not for them. If you can’t work with certain people without prejudice, for goodness’ sake don’t do it.”

But if you think you can, Barrett says your help is desperately needed. If you’re on the fence and one of your main concerns is protecting children’s safety, Roth has something to add: working with pedophiles makes you part of the solution. “I’m one hundred percent in favor of every law that protects children,” she says. “And I want to help people not break those laws. But you don’t do that by lecturing pedophiles about how terrible they are: you do it by helping them have a good life so they’re more invested in preserving it.”

ILLUSTRATION © JORM SANGSORN