À l’heure où les mesures d’injonctions de soins deviennent de plus en plus fréquentes en France chez les auteurs d’agressions sexuelles, les professionnels de santé mentale se trouvent souvent très démunis face à ces demandes, et les stratégies thérapeutiques appropriées manquent. Nous présentons ici un modèle thérapeutique de groupe adapté à la prise en charge des auteurs d’agressions sexuelles sur enfants et développé dans le cadre de l’Antenne de Psychiatrie et de Psychologie Légales de La Garenne-Colombes, dirigée par le Docteur Coutanceau. S’inspirant librement d’un modèle nord-américain peu applicable en l’état en France, notre modèle permet d’aborder différents thèmes liés à la prévention de la récidive chez des patients à la pensée généralement concrète, pauvre, disposant de faibles capacités d’introspection. Nous exposons donc dans cet article les principes théoriques sous-jacents au modèle de base, l’application qui en a été faite en Amérique du Nord, et l’adaptation que nous avons effectuée afin de permettre son application à la mentalité française. La technique appliquée est illustrée à l’aide de 2 cas et de leur évolution après 4 à 5 ans de suivi.

Psychotherapy for sex offenders has only very recently started to develop in France. The French law on compulsory treatment for sex offenders was voted in 1998, and many mental health practitioners are not trained to treat such patients yet. In our ambulatory forensic consultation, sex offenders have been treated since 1992 and group psychotherapy has been offered to them since 1994. Our first the­rapeutic models were the North-American behavioural-­cognitive therapy and Pithers" relapse prevention model. Behavioural-cognitive theory describes paedophilia as an acquired sexual preference maintained by positive reinforcement. Pithers (1990) considered that relapse only occurs in high-risk situations, and that high-risk situations always come after offence precursors. In North America, relapse prevention consists in helping paedophiles spot their high-risk ­situations and offence precursors, and enhance their skills to cope with such situations or to prevent them. Therapy programs were developed according to these models, aiming to help offenders develop such skills, ie empathy, social skills, cognitive restructuring, self-esteem, etc.Trying to apply these therapy programs in France, our team quickly realised that we would have to adapt them to French culture. On the one hand, behavioural-cognitive theory did not seem satisfactory enough in explaining paedophilic behaviour and paedophilic preference. On the other hand, behavioural-cognitive therapy made patients into children too much and increased resistance. Therapy based on programs seemed too rigid for French patients and therapists, and we often felt we were working on an issue that would have been much more accurate to work on a few sessions earlier, when this issue was spontaneously brought up by a patient. We believe change occurs all the more as issues are worked on at the right moment for the patient. Moreover, on a cultural point of view, we also realised the use of programs in psychotherapy was difficult to accept in France both by patients and therapists, as our culture is strongly influenced by psychoanalysis, especially free association. The use of a plethysmograph was also impossible in our country. We thus decided to use Pithers" relapse prevention model but to let our patients free to speak, so our therapy was not a program. Offences were analysed according to Pithers" ideas about high-risk situations and offence precursors. Most of the sessions were non-directive, but therapists offered each patient to work on his offence when they believed it was the right moment. Important issues (such as empathy, cognitive distortions, emotional control, etc.), were tackled as they came up, which seemed easier and less rigid as sessions were linked to patients" current preoccupations. Post-group meetings enabled therapists to draw themes that seemed important to work on with each patient (empathy, consequences on victims, anger, cognitive distortions, emotional expression, relational issues, self-esteem, intimacy…). These issues were discussed the next time they were raised by the group. We were interested to notice that all important issues came up spontaneously from the group during the sessions as long as patients were free to share their concerns, without therapists having to set issues beforehand. Two case studies illustrate our method. Bernard was 40 when he first came to our consultation. Ori­ginally a teacher, he was dismissed and became a marketing man after being sentenced to five years of prison for sex offences on two 6-year-old girls. Bernard relapsed a few years after he got out of prison by sexually offending two girls, aged 10 and 13. At our first interview, Bernard had cognitive distortions about sexual education and always avoided sexually explicit words to describe the offences. He did not realise the consequences of his acts on the victims, but said he wanted to be treated because he felt lonely. He first described a ­sexual preference for adult women, but progressively aknoledged feeling attracted to female teenagers. He did not know why the offences occurred at such a moment in his life, and had no idea of his high-risk situations nor of his offence precursors. Bernard often confused his need for sex and his need for affection. After four years" participation to our relapse prevention group therapy, Bernard has clarified his sexual preferences : he has always been mostly attracted to girls from 6 to 10 years old. He has also always been attracted to women younger than him, and now seems to be mostly aroused by female teenagers. Working on his offences has helped him identify his high-risk situations and the strategies he used to get close to his victims and to be trusted by them and their single mothers. Bernard often offended when he was feeling lonely and rejected, after a break-up with a partner. Twice during these four years, Bernard found himself in such high-risk situations, but managed to stop before relap­sing. However, empathy towards victims is still difficult to develop for Bernard. Neither has he yet managed to build a new relationship with a woman, as he still seems to suffer from an unhappy love affair he went through several years ago. This case study shows one of the limits of Pithers" relapse prevention model, if it is used mechanically. Indeed, we should logically have spotted as high-risk situations for Bernard interactions with 6 to 10 year-old girls. Helping him face his past and present sexual fantasies led Bernard realise his high-risk situations were now mainly about teenage girls, even if he had mostly been attracted to younger girls earlier in his life. After 2 to 3 years of therapy, we have quite often noticed this kind of evolution in sexual preferences in paedophiles, their preferences changing towards teenagers or young adults. In France, mental health professionals are often reluctant to follow sex offenders because of negative counter-transference and lack of specific training. However, first changes often occur quite quickly in paedophiles when they are offered group therapy. The group makes it easier to confront paedophiles to the reality of their offence and of their sexual fantasies. These patients often express being very relieved after the first sessions, as the group therapy is ­generally their first opportunity to express their feelings, ­sexual fantasies and thoughts about paedophilia. Pithers" model, used within a group were patients are free to speak in a human, warm and confronting atmosphere, seems cli­nically accurate and effective in helping paedophiles in France. We now need studies to check therapy effectiveness on relapse and to understand which therapy factors are efficient on sex offenders.