Treatment to adult perpetrators of intrafamilial sexual abuse in Brazil : psychodrama as strategy

The Brazilian policy to combat sexual violence emphasizes the importance of protecting victims, as well as accounting for and taking care of the perpetrator. The aim of this paper is to describe one strategy that is being used to address difficult issues – such as the processes of offenders’ own victimization itself, the expression of sexuality and sexual desire for children – in the context of psychosocial interventions for adult sexual offenders against children and adolescents. The strategies adopted are based on psychodrama techniques, which facilitate the overcoming of emotional obstacles to these issues, creating a playful environment during the intervention, providing conditions for reflection, expression of feelings, decreased tension, and which contribute to integration and group engagement in the tasks. This option avoids a confrontational position and favours the development of empathy.


INTRODUCTION
The purpose of this paper is to describe group psychosocial interventions aimed at supporting male adult perpetrators of sexual violence against family members. The interventions place their emphasis on three topics, considered by Marshall (2001), Manderville-Norden and Beech (2006) and Winder (2017) to be essential for inclusion in any therapeutic action with regard to this demographic, especially intrafamilial sexual offenders. These three topics are: violence suffered and practiced by the sexual offenders themselves; the expression of sexuality; and the recognition that sexual violence is a crime.
Coping with sexual violence against children and adolescents demands action on two fronts: accountability for justice and specific health interventions directed at perpetrators of violence (Marshall, 2007). It is important to note that these men are considered to be human beings and, therefore, violent action is only a part of their subjective constitution. Thus, intervention for cases of sexual violence demands legal prosecution, accountability, and therapeutic care (Passarela et al., 2017).
In this sense, the Brazilian National Plan to Combat Sexual Violence (Plano Nacional de Enfrentamento da Violência Sexual -Brazil, 2013) reaffirms the commitment of the Brazilian government to defend children and adolescents from sexual crimes and to hold the perpetrators responsible for these acts of violence. In addition, the document also attests to the state's commitment to ensuring special care for perpetrators of sexual violence. Regarding adult males, Brazil elaborated a national policy pledging attention to men's health (Política Nacional de Atenção à Saúde do Homem -Brazil, 2008), which certifies health as a basic social and citizenship right for all Brazilian men. It is important to highlight that sexual violence toward children and adolescents occurs in the midst of a strongly patriarchal and adult-centric Brazilian society (Passarela et al., 2017). However, policies developed actions aimed at men are still incipient, and Brazil is very much in a deficit situation with the issue of sexual violence against children, adolescents, and women.
(Disque 100) (Brazil, 2018) presented data on the complaints that occurred in 2017. There were 20,330 occurrences of sexual violence, most of which occurred intrafamilial. Therefore, the most common place of occurrence was the victim's residence, which in many cases was also the perpetrator's residence.
In spite of several efforts made by different segments of society in the struggle to establish less sexist and disrespectful parameters in relation to women, children, and adolescents, it is important to point out some cultural issues that remain in Brazilian society. The parameters still in force dictate a superior hierarchical position occupied by men in relation to women; the value of masculine virility is generally accepted and positively expressed socially, within the family and within intimate relationships; as well as behaviours that signal and maintain domination, including the normalized use of violence by men as a way to obtain submission of women, and of children and adolescents by adults (Zanello, 2018).
Thus, any comment on the subject of sexual violence -or on submissive/dominant relations within or outside the family environment -should consider the inclusion of gender as a necessary bias to build knowledge, dissemination and technical guidance (Beiras & Nascimento, 2017;Meneses et al., 2016;Wolff et al., 2016).
With the 1988 Federal Constitution of Brazil (Brazil, 1988) there was a paradigm shift from the view of the child as an object to the child as a subject with rights. Before, sexual violence against them was veiled and little on the topic was discussed or addressed by public policies. Thus, the Child and Adolescent Statute (Estatuto da Criança e do Adolescente -ECA, Brazil, 1990) affirmed the sexual and fundamental rights of children and adolescents and recognised that this population is particularly vulnerable regarding the stage of development, therefore, an absolute priority. The ECA also affirmed the shared responsibility of government, society, and family to guarantee a dignified, healthy, and protected childhood and adolescence. Brazil was the first country to declare a legal framework to guarantee these rights, which resulted in the creation of a specific justice and security system for this group: the Childhood and Youth Court (Juizado da Infância e Juventude), alongside specialized police stations and centres both to assist victims and to charge perpetrators of violence (Brazil, 2013).
Since 2000, Brazil has been consolidating public policies to protect children and adolescents through the National Council on the Rights of Children and Adolescents. Thus, in 2007, Brazil committed to prioritizing the fight against childhood and adolescent sexual abuse through the Inter-sectoral Commission to Combat Sexual Violence against Children and Adolescents (Comissão Intersetorial de Enfrentamento da Violência Sexual contra Crianças e Adolescentes) by means of public policies and actions. Moreover, the National Plan for Combating Sexual Violence against Children and Adolescents (Brazil, 2013) was elaborated, whose strategic axes are: situational analysis, mobilization and articulation, defence and accountability, attendance, prevention and children and adolescents as protagonists.
The Brazilian Penal Code, Decree-Law No. 2,848/40 (Brazil, 1940) defines, under the chapter on crimes against sexual dignity, the crime of rape as the practice of carnal conjunction or other libidinous acts, by means of violence or threat, in a manner that causes embarrassment. The sentence for this type of crime is imprisonment for 6 to 10 years.
The law includes the category of the rape of vulnerable persons, which occurs when the victim is a person under 14 years of age. In this case, the severity of the sentence is greater -imprisonment for 8 to 15 years. With an aggravating factor, such as personal injury, the sentence increases to imprisonment for 10 to 20 years and, if the act results in death, the perpetrator could face up to 30 years in prison. Other crimes are also categorized, such as crimes against sexual freedom, the corruption of minors, facilitation of prostitution, and sexual exploitation.

THE ADULT PERPETRATOR OF SEXUAL INTRAFAMILIAL VIOLENCE
The perpetrator of sexual violence against children and adolescents is not necessarily a paedophile (Seto, 2009). For this reason, it is currently recommended that, among adult sexual offenders, those who possess indicators of paedophilic interest are identified (Seto, 2012). Paedophilic interest is the expression of a preferential interest in children, for the intention or purpose of achieving or maintaining sexual contact, which may turn into action or persist in recurring fantasies (Gee et al., 2004;Marshall, 2007;Seto, 2012). Extrafamilial and intrafamilial sexual violence are equally intrusive and injurious to the physical and mental health status of their victims. Intrafamilial sexual violence can inflict more severe damage to the victims because it is restricted to the home and the family, and because it can continue for longer periods without interruption (Bogaerts et al., 2010;Finkelhor et al., 2009). Many myths and secrets that enable sexual violence within the family remain long hidden, offering possibilities for sexual revictimization and causing greater harm to their victims (Moyano & Sierra, 2015).
The occurrence of intrafamilial sexual abuse indicates a higher probability that the family will maintain a more closed interactive dynamic, and that its members will be more elusive and isolated. Perpetrators of intrafamilial sexual abuse may have a more aggressive or more seductive approach, but the more problematic issue is that they are within the family's borders, making the environment highly insecure. Family relations involve the maintenance of trust relationships between caretaking adults and children/adolescents taken care of. Thus, the presence of a perpetrator of sexual abuse in the family environment constitutes an opportunity for victim domination and submission and the continuity of abusive practices. (Bogaerts et al., 2010;Worley et al., 2011).
In the Federal District of Brazil -more specifically, in Brasilia (the capital of Brazil) - Penso et al. (2016) profiled the adult perpetrator of sexual violence who was served in the violence care program PAV (Programa de Pesquisa, Assistência e Vigilância à Violência). The perpetrators covered by this program were summarized as follows: brown or black majority; aged between 20-60 years; belonging to a low-income socioeconomic group; with low levels of schooling; self-employed or engaged in informal activities. Most lived on the outskirts of the city. These data mirror the general conditions of the prison population in the Brazilian national context described by InfoPen, although a larger contingent of prisoners belong to the low-income class. Most convicts who are referred to the program have received a penalty of eight years, in cases where no aggravating circumstance or other type of violence is found to be present during the sexual abuse. If these convicts maintain good behaviour while imprisoned, they are given a sentence reduction. Thus, after serving the sentence, perpetrators of sexual violence return to their residences and families, or establish new family ties, returning to live with the victims or with other children and adolescents. The situation of vulnerability of this family reorganization is recognized.

GROUP PSYCHOSOCIAL INTERVENTION
Studies on therapeutic care show a decreased likelihood of sex crime recidivism when offenders take part in therapeutic activities (Geiger & Fischer, 2017;Leclerc & Cale, 2015;Marshall, 2001Marshall, , 2007SOMAPI, 2015). While one cannot speak of therapeutic care as a deterrent to recurrence of sexual abuse, studies (Howells & Day, 1999;Holland & Pointon, 2007;Marshall, 2007) show that when the sexual offender receives some type of treatment, there is an increased likelihood of non-recidivism in relation to the offender who does not receive treatment. On average, relapse into criminal behaviour can be said to decrease by 10% to 20% compared to the untreated sex offender. This difference may seem small, but it is still a positive outcome and vindicates the strategy of facilitating reflection by the offender on the violent act committed (Marshall, 2018).
Rev. Bras. Psicodrama, São Paulo, v28, n1, p.5-15, Jan.-Abr., 2020 Treatment to adult perpetrators of intrafamilial sexual abuse in Brazil: psychodrama as strategy These activities can be provided individually or in a group (Marshall, 2007). Group service allows a therapeutic reach that must be guided by defined objectives, with previous evaluation of the participants. It is important that group members possess similar characteristics with respect to the violent sexual act practiced in order to avoid under or overtreating different participants (Marshall, 2001(Marshall, , 2007. The contribution that the PAV program offers to the modalities of group therapy consists of a playful facilitated environment, which is fundamental for the engagement of the subjects in the drama. For this, two psychodrama instruments are applied: the "as if" dimension and "intermediary objects" (Moreno, 1993), both of these encourage individual and group transformations through group protagonism, creativity and spontaneity (Moreno, 1972). The use of psychodrama resources allows for change through dramatic performance, without the need for excessive verbalization on the part of the participants , which justifies and corroborates the use of psychodrama techniques in sessions that deal with difficult issues, as they facilitate management and participation by group members (Hollander & Craig, 2013). Marshall (2007) points out that addressing a topic in deeply addressing issues related to the criminal sex behaviour provides an opportunity for reflection on violent behaviour, and that this can be achieved through non-verbal behaviour. Likewise, Bermúdez (1968) understands that speech is not essential, or should not be considered the sole or primary means of expression, and that perception of the meanings present in dialogue can be emphasized by dramatic performance.
The psychodrama resource of the "intermediary object" allows participants to warm up for the activities developed throughout the group process, fostering readiness for reflection (Moreno, 1983). Various props (cushions, toys, workplace materials, scrap material) can be used as intermediary objects to facilitate expression of participants' thoughts and feelings, reducing stress and creating a more relaxed environment. The other psychodrama resource, the "as if" dimension, allows participants to experience situations and participate in activities through bodily representations, taking on social, family, and other roles. It is "as if" they themselves are not speaking or dramatizing, but rather the character they are role playing is doing the speaking; therefore, the emotions and feelings are lived with less embarrassment because it is "just a play session" (Moreno, 1972). The presence of these two resources allows the contacts between team and participants to be permeated by empathy, a fundamental aspect for mediating relationships in this context (Marshall, 2007;Moyano & Sierra, 2015;Mudry et al, 2018).
The following sections of this article provide a report on the psychosocial care that was delivered on behalf of an adult perpetrator of intrafamilial sexual violence, carried out in a public health institution in Brazil. This work presents an initiative providing assistance to this category of offender, that seeks to overcome prejudice and rejection, and that indicates psychodrama as an innovative methodological strategy of great utility.

THE PSYCHOSOCIAL INTERVENTION METHOD
This report is based on the records of the sessions of a psychosocial intervention group that occurred in the second half of 2018 in the institution already mentioned. Participants included adults that committed intrafamilial sexual violence against children and adolescents and who had already served their sentences (closed system), or were still serving their sentences  The flow of care indicates that, first, these subjects are evaluated in interviews with a psychologist, a social worker, and a psychiatrist. The interviews are conducted individually and with the family. It is only after this process that the group service begins. Subjects who are considered unsuitable for the group (due to their pathology) are treated individually. The group service is performed in eight two-hour meetings with about 15 to 18 participants. Each session has a theme, namely: group integration, stigma, personal suffering due to suffered and practiced violence, expression of sexuality, gender relations, risk and protection thoughts, sexual desire for children and adolescents, and reconstruction for the future. The methodological framework and innovative theory behind the program is already available in Meneses et al. (2016), Conceição et al. (2018) and Penso et al. (2018).
The group meeting is a psychosocial intervention based on psychodrama. The psychodrama session is divided into three stages: warm-up, dramatization, and sharing. The purpose of the warm-up stage is to integrate the members of the group and bring them closer to the content to be explored in more depth; dramatization seeks to create a space for the emergence of spontaneity so that identification with social and family roles can be expressed; and the final step provides an opportunity for all participants to exchange their experiences and to develop, it is hoped, an of understanding themselves and their actions (Moreno, 1993). However, the intervention prioritizes group content, interactions and the relational and procedural dynamics of the group. Therefore, it is considered that this intervention follows a general methodological orientation of Sociodrama (Moreno, 1983(Moreno, , 1993.
In the second half of 2018, the group initially had eight adults, who met for eight sessions, from August to November. The group intervention took place in a room where participants could perform activities standing or sitting in a circular arrangement. The team that coordinated the group was composed of a male psychologist, a female psychologist, and two female social workers.
Two female observing psychologists (graduate students) who took notes during all the meetings were also part of the team.
On a bi-weekly basis, the team met with two supervisory psychologists (postgraduate professors from a public university) who were responsible for a research partnership between the program and the academy.

THREE PSYCHOSOCIAL INTERVENTION MEETINGS AND THEIR FAMILY-RELATED THEMES
The criterion adopted for choosing the description of the themes that are developed in the sessions described in this text is the "dreaded scene" concept. This concept was created by the Argentine School of Psychodrama and is defined by the formal expression of the psychic aspect that is most feared by the participant of a psychodrama, which supplies content that can provide an advance in the understanding of the conflicts. The "dreaded scenes" need to be clarified or revisited because they are situations, facts or feelings that interfere with the participants' reflection process (Bermúdez, 1968;Menegazzo et al., 1995).
For this reason and to exemplify how these contents can be developed, three sessions from the intervention being discussed were chosen, whose themes address dreaded scenes: the violence suffered and perpetrated in the offender's own lifetime; reflection on one's own sexuality; and sexual desire for children and/or adolescents. The content of these three sessions was directly linked to the family relationship of the adult perpetrator of sexual violence and his return home after serving his sentence.

VIOLENCE SUFFERED AND PERPETRATED IN THEIR OWN LIVES
The object of the development of this content was to enable participants to come into contact with the suffering coming from the various forms of violence suffered during their lifetime (physical, emotional, psychological, sexual), recognizing their → → suffering and the suffering of others (especially their victims). Session planning was as follows. 1) Non-specific warm-up: the group participants did a self-massage. Then, participants were asked to walk around the room, looking at each other, feeling their own breath, noticing whether or not they felt any pain. 2) Specific warm-up: while participants were still walking, they were asked to choose a person and to form a pair, and then were asked to follow the coordinator's directions to role-playing. Each which story was most impactful, which story evoked more emotion? The next step was to choose a single story, which would be the story of the group, and from which a scene would be created, which would bring together all the stories and represent the overall story of the group.
Then the participants chose which roles they wanted to play in the scene. To facilitate the expression of the chosen role, each participant received a label indicating their choices. We sought to compose the scene so that victimizers and victims were represented. The question at this point was not the performance requirements of the actors, but rather to create conditions so that spontaneity could arise, and participants could perceive their identification with certain attitudes and characteristics of violence. 4) Closing session: At the end of the scene, participants were asked how they felt about playing the chosen roles. "Did I suffer or cause suffering?" "Did I injure someone or was I injured?" "How about the power relations between the adult and the child?
How does the child feel when suffering violence?" "What was the failure to prevent the violence from happening?" "Who could the child have asked for help?" These were some of the guiding questions of the final phase of the discussion for the closure of the session. 5) After the closing, everyone participated in a ritual that sought to concretize (and to give a symbolic experience to) the theme of the day. In this session, all participants received a piece of blank paper on which they could write the violence they had suffered, crumple these pieces of paper, and throw them away in the trash.
Treatment to adult perpetrators of intrafamilial sexual abuse in Brazil: psychodrama as strategy attraction to children or adolescents, who can you ask for help? Or, do you believe it is not possible to get help for this kind of problem? How can PAV become a source of support in this regard? 4) Closure of the session: this topic required a psycho-educational closure regarding the inclusion of objective information on legislative changes (indicated in the initial part of the text), recognizing that most participants do not have correct or current knowledge.

FINAL CONSIDERATIONS
Although there are other initiatives of this nature in Brazil, we must recognize the efforts made by the group of professionals dedicated to consolidating this experiment. The choice of the methodological strategy of psychodrama constitutes a resource and, at the same time, a strategy that may be effective in the face of the impasse that exists regarding the question of how to structure a proposed intervention designed for recipients that come from a very sexist and prejudiced society, with little or no schooling. In this sense, psychodrama also offers a possibility for facilitating group construction. As a methodological approach, there is still a need for specific training and team training. We found a possible and extremely fruitful academic partnership for permanent reflection on the topic, for research in partnership and for dissemination of the results achieved. Finally, we would like to highlight that developing a structured system of care for the adult sexual offender who committed violence against children and adolescents in an intrafamilial scenario is part of the circuit of protection for children and youth and is of great interest to family therapists.

AUTHORS' CONTRIBUTION
All the authors contributed equally for this paper.