Friday, September 16, 2016

Returning to What’s Real

The elephant in the closet in the treatment and supervision of people who have sexually abused is the voice of the clients themselves. The service user (or in this instance the person who has sexually abused) is at the center of the work that we do, but there perspectives and views of the services that they are subject to are not always present. We need to hear the views, attitudes and perspectives of the service user regarding the work that they are part of (that is listening to the service user voice); we do it in health, business, marketing and other areas of life, but why not sex offender treatment and management? There is an inherent view in some sectors of our field that people who have sexually abused are manipulative, deceptive, and therefore not trustworthy; which means that their views of the service they are part of is unreliable at best and suspect at worst. This is a real issue when one considers that people who have sexually abused are the users of multiple services including counseling, psychology, health, social services, and the criminal justice system. Other users of these services often have mechanisms through which to have their voices heard and participate in the processes that have an impact on their lives. This might take the form of client advisory councils, satisfaction surveys, or feedback-informed treatment.

One has to wonder why a lack of a coherent client/service-user voice is uncommon for one population (e.g., people who have abused) and not another (e.g., people in substance abuse treatment). Perhaps more importantly, do professionals all too often come to think of treatment of people who have sexually abused as something we do to and on our clients rather than with and for them (Miller & Rollnick, 2013)? Do we dictate that treatment must take place in the fashion that we want or one that is most effective for the client? How do we know when we are meeting both the need and responsivity principles in a way that is meaningful for the client? Or is it that we are just as susceptible to bias, misperception, stereotypes and misunderstandings as the public and politicians? Do you “fall in line” with biases that we argue against?  This is an international dilemma, as this problematic approach to the person who has abused as a disenfranchised and unrecognized service user is not just a western problem. Let’s explore this further.

A discussion of the role of Volunteer Probation Officers (VPOs) recently took place at the United Nations Asia and Far East Institute in Tokyo. VPO’s are typically older and well-established citizens who mentor young offenders, from around Japan.  The role of the VPO’s is to assist the young offenders with their behavior, actions, and plans for the future. It is a system designed to provide support and bring about hope and accountability, even as the young offenders can be at risk for disengaging and participating minimally. During the panel discussion, one attendee asked what regrets the VPOs had about their work. The answers were as heart-rending as they were similar; each participant described a time when they had listened more effectively, worked harder to understand the young person, or helped them to achieve the goals that were meaningful to them and not just the legal system.

On their own, these responses are unsurprising, and resemble other human situations where desired outcomes aren’t achieved, such as parents whose children haven’t lived to their full potential or whose lives have ended early. What was striking among the VPOs was what was not said. Reflecting on their failures, no VPO regretted that their young charges had not gotten the diagnostic clarity, effective medication regimes, or the correct empirically supported protocols they needed. In further discussion of this fact, the VPOs acknowledged, as do all professionals, that diagnostic and treatment considerations are vital to success, but that the prevention of failure can reside in the moment-by-moment interactions that all professionals have with their clients.

Likewise, as we go to press with this blog, the Australian Psychological Society has just issued an apology to the indigenous peoples of that country. They state:

To demonstrate our genuine commitment to this apology, we intend to pursue a different way of working with Aboriginal and Torres Strait Islander people that will be characterized by diligently:

·         Listening more and talking less
·         Following more and steering less
·         Advocating more and complying less
·         Including more and ignoring less
·         Collaborating more and commanding less

This sounds like good, old-fashioned therapy to us.

Underneath all of our clinical practices – indeed all helpful interactions – lies a particular kind of conversation. Our field is replete with examples of how professionals should speak with and be with clients. This can be a source of great fascination, from the earliest authors, through Carl Rogers’ core conditions, Berg and de Shazer’s focus on the seemingly simple search for solutions, and beyond. Wampold and Imel (2015) referred to the conversation as “perhaps the ultimate in low technology” (p. ix).

Obviously, not all conversations are helpful, even as they are central to all bona fide forms of psychotherapy (Wampold & Imel, 2015). Indeed, Lilienfeld (2007) has highlighted how some treatments can cause harm. What was central to the Japanese VPOs’ assessment of their failures reflects what has been found in research into the therapeutic alliance (Hubble, Duncan, & Miller, 1999; Duncan, Miller, Wampold, & Hubble, 2010). That is, that the most helpful clinical practice takes place when there is agreement, from the client’s perspective, on the nature of their relationship, the goals of their work, and the means by which they go about it. This view of the working alliance dates back decades (Bordin, 1979), although research has also emphasized the importance of delivering treatment in accordance with strong client values and preferences (e.g., Norcross, 2010). Indeed, importance of the alliance has long been recognized (Orlinsky & Rønnestad, 2005).

These points seem worthwhile in the wake of recent discussions on ATSA’s listserv regarding whether treatment “works” and with whom it is most likely to be effective. It often seems odd that professionals in our field rarely ask their clients about their beliefs as to whether the services they receive are helpful. Perhaps this is due to many professional’s beliefs that asking about what does and doesn’t work in treatment would open the door to discord or attempts at manipulation.  Perhaps it’s because many of us couldn’t handle what our clients really think.

Likewise, as professionals we seem hesitant to get into debates about the service user voice evidence-based practices. In a recent conversation on the ATSA listserv a member noted the differences between the American Psychological Association’s definition (“the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences”) and the more stringent standards for empirically supported protocols such as EMDR and DBT. In the end, understanding the treatment experience from the perspective of the client and working to ensure agreement on the goals and tasks of treatment as well as the nature of the working relationship may have as strong an evidence base as any other approach in the helping professions.

The need to understand, process and reflect upon the service user raises the important question - what is an appropriate evidence base? We spend a lot of time discussing the merits of psychometrics, clinical trials, Randomized Control Trails and downplay the importance of qualitative research. The common narrative in the field is about levels of significance and outcome measures, not necessarily about what was said in and about the treatment. Maybe the first think that we need to do, before listening to and acting, is to recognize the service user voice.

David S. Prescott, LICSW
Kieran McCartan, PhD


Goldberg, S.B., Miller, S.D., Nielsen, S.L., Rousmaniere, T., Whipple, J., & Hoyt, W.T. (2016). Do Psychotherapists Improve with Time and Experience? Journal of Counseling Psychology, 63, 1-11.

Lilienfeld, S.O. (2007). Psychological treatments that cause harm. Perspectives on Psychological Science, 2, 53-70. Retrieved September 16, 2016 from 

Norcross, J. C. (2010). The therapeutic relationship. In B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A. Hubble (Eds.), The heart and soul of change: Delivering what works in therapy (2nd ed.)(pp. 113- 141). Washington, DC: American Psychological Association.

Orlinsky. D.E., Rønnestad. M.H. (2005). How Psychotherapists Develop. A Study of Therapeutic Work and Professional Growth. Washington D.C.: American Psychological Association.

Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: Research evidence for what works in psychotherapy (2nd ed.). New York, US: Routledge.

Friday, September 9, 2016

Balancing the books? Starting to understand the reality of sexual harm in the UK

A recent report from the Crown Prosecution Service [CPS] for England and Wales shows an upturn in reporting, recording, prosecutions and convictions in sexual harm [including, Rape, Child Sexual Abuse, Prostitution, Honour based offences, etc.] for the year 14/15 for women and girls. Although the report indicated that the largest increases were for women and girls as victims of sexual harm and for males as perpetrators, it does also show that there was an increase for men and boys as victims as well as for females as perpetrators too. The data came from the CPS case management system, which means that the results and analysis were based upon what was recorded by CPS staff via the existing databases and systems.

The report signals that:
- The volume of referral’s to the CPS for Sexual Abuse, Domestic Violence and Rape decreased by 3.3% to 124,737 compared to 14/15;
 The volume of individuals charged with Sexual Abuse, Domestic Violence and Rape by the CPS increased by 0.5% to 86,067 compared to 14/15;
- The volume of individuals prosecuted by the CPS for Sexual Abuse, Domestic Violence and Rape increased by 9.8%, to 117,568 defendant’s, from 14/15 to the highest level ever recorded; and
- The volume of individuals convicted of Sexual Abuse, Domestic Violence and Rape also rose by 10.8%, to 87,275, from 14/15 to 87,275 in 15/16, to the highest level ever recorded.

The main take-home message from the report is that the volume of prosecutions and convictions across the violence against women and children spectrum is the highest that they have been over the last nine years that the CPS has been recording them in this fashion and that new, as well as relatively new, offences (e.g., Female Genital Mutilation, Honour Based crimes and revenge porn offences) have shown increasing referral’s, charges, prosecutions and convictions. The report highlights, what we have often suspected, that the rates of sexual harm and violence against women and children do not match the reality of sexual harm in society. However, it’s important to put these findings into context as we need to recognise that 15/16 was not necessarily a peak year for sexual harm, but rather that it is an indication of a turning tide in society;

- There seems to be a growing trust in the Criminal Justice System epically the police; the public seems to be more willing to report crime and seek prosecutions.
- An increased awareness of violence against women and children in society because of high profile media cases, the IICSA investigation and a series government reviews (inc, prostitution, hate crime, etc).
Updates and changes to crime recording (including, the recording of new crimes and a change in terminology in existing ones) means that some offences may have not been recorded previously, or if they had been recorded they may have been recorded in a different category.
- A review of sentencing guidelines for sexual offences.
- The increase in historical sexual harm offences being reported and processed by the police, CPS and Courts.
- A commitment from the CPS to offer more support to victims of sexual harm, with the former Prime Minister calling  sexual abuse a national threat.
- An increase in funding to understand, prevent and respond to FMG, honour-based violence and trafficking from the UK government.

This highlights a commitment from the Criminal Justice System in England & Wales and UK government to respond to sexual harm, and related offences, resulting in increased reporting, recording, prosecutions and convictions. The increase revealed by the CPS report is not surprising given the under-reported nature of sexual harm and starts to help us understand the nature of these offences in society; the take-home message seems to be the more we talk, the more we see and the clearer picture we get. Therefore it’s not so much an increase, potentially, but rather a reality check and call for more preventive work and public/societal engagement work to be done.

Kieran McCartan, PhD

Friday, September 2, 2016

Mitigating Sexual Recidivism: ‘Treatment’ or ‘Intervention’?

Trending research demonstrates low rates of sexual recidivism for nearly all juveniles and most adult sexual offenders.  Many studies have been aimed at trying to determine whether ‘sex offender’ treatment is effective at reducing recidivism.  But there is growing evidence that most sexual offenders will not reoffend, regardless of treatment, and moreover, that treatment has only a small or moderate effect on recidivism.  If treatment isn’t as effective as we want it to be, what do we do with such ‘inconvenient’ data?  We can consider elements of an effective intervention, and uniquely tailor individual pathways for clients to recover.  When indicated, it should include sex-specific treatment.

A recent, large meta-analysis by Schmucker and Lösel (2015) reports sexual recidivism of 13.7% for untreated offenders, and 10.1% for clients who completed treatment - an absolute reduction in recidivism of 3.6%, and a relative reduction of 26.3%.  Previous studies by Lösel and Schmucker (2005), (2008) showed a slightly stronger, but still low-moderate treatment effect.  Duwe and Goldman (2009) found a 13.4% sexual reoffense rate for treated clients versus 19.5% sexual recidivism for offenders who did not participate in treatment.  Many other studies have found similar results.

Karl Hanson and colleagues (2014) confirmed a low rate of reoffending (1%-5%) for low risk sexual offenders, and a 22% rate of reoffending for high-risk offenders after five years, but then discovered that after ten years offense-free in the community, high-risk offenders effectively became low recidivism offenders.  Michael Caldwell (2016) completed the largest meta-analysis to date, which revealed current sexual recidivism rates for juveniles is likely to be less than 3%.  In both studies, if clients reoffended, it was likely to occur within the first few years after intervention.  Authors in both studies were unable to determine WHY recidivism was low and desistance was stronger over time; yet it seems that effective treatment might enhance outcomes. 

Risk for reoffending, as part of a psychosexual assessment, seems to have become overly simplified into essentially three categories: low, medium, and high risk, which then often determines outcomes: everything from plea agreements, to incarceration, treatment, and perhaps conditions of supervision or imposition of civil regulations. So how can we analyze the cost-benefit of interventions to clients, and to public interests? 

Gregory DeClue has suggested an empirical process from the world of medical treatment might be helpful to determine the cost-benefit of treatment.  Dr. DeClue points to statistical concepts known as “Number Needed to Treat” (NNT), and “Number Needed to Harm” (NNH). Together, NNT and NNH provide an empirical way to consider, in an aggregate manner, the cost-benefit to “treat” or “not to treat.”  According to DeClue, using data from Schmucker and Lösel (2015), NNT reveals that only about one person in 28 is likely to not reoffend as the direct result of treatment.  That seems like a weak return on the investment, but more troubling is the counterbalance:  to what extent is treatment actually unwarranted, counterproductive, or indeed harmful to individuals and their families – known as iatrogenic consequences?

A meta-analysis by Kim, Benekos, & Merlo (2016) found “that sex offender treatments can be considered proven or at least promising.” They also determined that ages of clients and types of interventions influence the success of treatment.  This study also suggests that outpatient treatment may be more effective than treatment in prison, “If community treatment is more effective than institutional treatment, then a review of existing sentencing statutes and policies might be appropriate.”  So if treatment is not the primary change agent, what is?  It might be, broadly, the intervention.

Most individuals arrested for sexual offending do not sexually reoffend, and treatment effect alone doesn’t account for low recidivism rates; so what else might broadly mitigate reoffending?  Research indicates that civil regulations (the registry, residency restrictions, etc.) are not only ineffective, they might be counterproductive.  More and more, civil regulations are being challenged by the judiciary in state and federal courts as not only being ineffective, but unconstitutional.   Caldwell wrote, “The bulk of available evidence indicates that the decline in adult and juvenile sexual recidivism rates has occurred, unrelated to, and perhaps despite, these recent policy trends.”  The sex offender registry is especially harmful to juvenilesBirgden and Cucolo (2011) argue that treatment as management, rather than treatment as rehabilitation, panders to public policy and puts unwarranted concerns about public safety ahead of effective treatment.  CSOM promotes a systems approach to interventions, including effective supervision, and that recovery is not all about ‘treatment.’

We should be mindful that reducing risk is not the only aim of treatment, and only tells part of the story about an effective intervention.  And how do we determine what kind of treatment experiences we should offer?  For example, Levenson and Prescott (2013), discuss many benefits that may be derived from treatment, resulting in improved outcomes for clients, victims, and their families - better lives AND safer communities.  Indeed, the same authors have published three studies indicating that people who have sexually abused typically believe their treatment experiences to be worthwhile (e.g., Levenson & Prescott, 2009).  Perhaps one avenue for professionals to consider is moving beyond treatment interventions that focus on reducing risk and help people remain at low risk.  Another treatment target might be helping clients adjust to the social consequences of being publically labeled a “sex offender.” Still another focus of treatment might be “cognitive transformation” – promoting desistance by helping clients view themselves as having become a different (better) person.

When recidivism rates are low, and treatment effect is weak, it raises questions about when sex offender ‘treatment’ is indicated – effectively begging the question: “to treat” or “not to treat.”  The answers are only partially informed by risk/recidivism studies. Many questions abound, including the influence of treatment on the nature, severity, imminence, and frequency of re-offense, if it does occur. Further, while it makes sense to ask whether treatment works, we are still in need of research into the effective components of both treatment and treatment providers. In addition to psychological factors, we should consider situational factors that might contribute to re-offending after treatment completion.

How should new data on the weak effectiveness of ‘treatment’ guide interventions with individual clients?  How should public policies be reviewed in light of new research?   Collectively, new data, and anecdotal evidence, provides strong evidence that the “sex offender system” might be mired not just in ‘old research’ about what works in the treatment and management of sexual offenders, but that public policies are straining valid concerns for public safety.   As a result, systems are overreaching and over-treating individuals, in large numbers, from juveniles to the civilly committed.  The consequences to individuals and families, and the costs to public interests, are incalculable.

Why are so many people ending up in the “sex offender system”?  Perhaps one reason is a tendency to conflate “seriousness” of a sexual offense with “dangerousness.”  This results in catching too many individuals in the “sex offender net,” regardless of “dangerousness” and, out of fear of any risk of reoffending, the system is reluctant to let them go.  In order to avoid any true positives (predicted to reoffend and does), or false negatives (predicted to NOT reoffend but does), the system is willing to tolerate a high percentage of false positives (predicted to reoffend but doesn’t).  Or simply stated, “Better to lock up ten sex offenders than one might reoffend.”  The fallacy is that about nine out of ten offenders are not likely to sexually reoffend, yet we commit vast, unwarranted public resources to nine out of ten sexual offenders, as an unwarranted hedge against possible recidivism.

In the UK, with the introduction of the transforming rehabilitation agenda, distinguishing between low and high risk offenders is becoming more salient in community management.  It distinguishes between sex offenders and non sex offenders, by risk categories and management.  All sex offenders are now managed by a streamlined probation services, while low/medium risk non sex offenders are managed by private Community Rehabilitation Companies (on a payment-by-results scheme).  All high/very high risk offenders are managed by traditional probation.  This suggests that the UK government perceives low risk sex offenders as generally more dangerous than low-risk non sex offenders.

Interestingly, in the UK (and elsewhere outside the USA) not all sex offenders receive treatment – it is based on their level of risk and whether or not clients deny their offence.  In the UK, it is usually medium, high and very high risk sex offenders that receive Sex Offender Treatment Programmes (SOTP); with low risk offenders receiving a form of cognitive skills program.  Putting low-risk sex offender in SOTP could actually make clients worse and increase their likelihood of offending. Practitioners and policymakers suggest that we look at alternatives to traditional SOTP, and Ruth Mann points to a wide-range of psycho-social treatment interventions.  With skepticism about whether sex offender treatment works, in the UK, treatment must be evidence-based.  

So what are the takeaways here?   One is to avoid the tendency to measure the success of ‘treatment’ in a dichotomous manner - whether or not clients reoffend.   There is much more to consider in decisions about treatment, e.g. when is treatment indicated?  Should treatment be compulsory?  If so, where should treatment take place (institution or in the community)?  What are the specific treatment targets to measure progress and determine completion?   What kind of treatment is effective for a particular client?   How much treatment is enough?  Principles of Risk-Need-Responsivity and Good Lives are able to empirically guide the application of aggregate data and other research to individual clients.  Sometimes, when empirical evidence suggests treatment is not indicated, we still need to intervene, but find the courage to not put clients through unwarranted or lengthy ‘treatment.’ 

By all indications, a wide-range of interventions seems to effectively mitigate recidivism, so perhaps rather than focusing on “does treatment work,” what might be needed is to fine-tune characteristics of interventions that are demonstrated to be effective with specific types of clients, e.g. juveniles, low risk, non-contact, females, repeat offenders, etc.  Not all sexual offending is rooted in sexual deviancy, sexual compulsion, or sexual violence.  Sometimes people simply lose their sexual boundaries, and it’s not likely to happen again.  While it may be useful to trace pathways to sexual offending, not every sexual offender has a sexual offense “cycle.”  With half of all sexual assaults occurring under the influence of alcohol, treatment for chemical abuse or addiction might be primary.  Not everyone who sexually offends needs sex-specific treatment.  A large percentage of adolescent offenders, and their families, might be well-served by participation in a time-limited psycho-sexual education program.

Because sexual offending is often more about relationship violations than sexual violence, interventions might focus much more on managing social damage, repairing relationships, and restoring families.  When there is so much that can be accomplished by creating a recovery plan that is unique to individuals and their families, it’s unfortunate that there is so much emphasis placed on “relapse prevention,” strict compliance with supervision, or criminal enforcement of civil regulations. Effective interventions can build on the optimism of protective factors, use positive psychology to build social skills, competency, and resiliency, and embrace strength-based principles of Good Lives.

When sexual misconduct occurs, intervention is almost always warranted – ‘treatment’ might not be.  Interventions can be empirically guided by a client’s Risk-Need-Responsivity and principles of Good Lives, and perhaps by uniquely tailoring interventions to individual clients, with consideration of the five “W’s”: who, what, when, where, and why.

Jon Brandt, David Prescott, and Kieran McCartan

Appreciation to Greg DeClue, Ph.D. and Michael D. Thompson, Psy.D. for contributions to this blog.

Alexander, M. (1999) Sex offender treatment efficacy revisited. Sexual Abuse: A Journal of Research and Treatment, 11, 101-116.

Birdgen, A., Cucolo, H., (2011) The Treatment of Sex Offenders: Evidence, Ethics, and Human Rights,  Sexual Abuse: A Journal of Research and Treatment 23(3) 295 –313.

Duwe, G., & Goldman, R. (2009) The impact of prison-based treatment on sex offender recidivism: Evidence from Minnesota. Sexual Abuse: A Journal of Research and Treatment, 21, 279–307.

Hanson, R.K., Harris, A.J.R., Helmus, L., and Thornton, D. (2014) High-Risk Sex Offenders May Not Be High Risk Forever, Journal of Interpersonal Violence, 29, 15, 2792-2813.

Kim, B., Benekos, P., Merlo, A. (2016) Sex offender recidivism revisited: Review of recent meta-analyses on the effects of sex offender treatment. Trauma, Violence, & Abuse, 17: 105-117.

Levenson, J. (in press), Hidden challenges: Sex offenders legislated into homelessness. Journal of Social Work. Published online: June 22, 1016.

Levenson, J. & Prescott, D.S. (2013) Déjà vu: From Furby to Langstrom and the evaluation of treatment effectiveness, Journal of Sexual Aggression.

Lösel, F., & Schmucker, M. (2005) The effectiveness of treatment for sex offenders: A comprehensive meta-analysis. Journal of Experimental Criminology, 1, 117–146

Lösel, F., & Schmucker, M. (2008) Does sex offender treatment work? A systemic review of outcome evaluations. Psicothema, 20, no. 1, p. 10-19.

Sandler, J.C., Freeman, N.J., and Socia, K.M. (2008) Does a watched pot boil? A time-series analysis of New York State's sex offender registration and notification law. Psychology, Public Policy, and Law, 14(4), 284-302.

Schmucker, M., & Lösel, F. (2015) The effects of sexual offender treatment on recidivism:  An international meta-analysis of sound quality evaluations.  Journal of Experimental Criminology, 11.

Friday, August 26, 2016

Denial, Risk, and Good Lives:The Need for Protective Processes

At a recent training on treating adolescents who have sexually abused, the discussion of polygraph came up, as it often does. My standard approach is to inquire whether professionals have truly asked all the questions they need before resorting to this measure. I explained that in the programs where I work, I have little reason to use it and outlined some reasons why. This led to a familiar case example: “Mr. Prescott, what if you are returning a young person who abused a sibling to his home where there are even younger siblings. Wouldn’t you want to know whether the younger siblings have been abused?” On its face, this is a fair question. My answer is almost always the same: That I typically assume that the the younger siblings have either been harmed, exposed to harm, or have otherwise been through bad experiences. This calls for diligent family interventions in order to restore safety and balance (and often to create it for the first time). The polygraph would only provide limited information about past events, while my sights are set on building better futures and preventing further harm.   

At the same time, I do not want to “out” anyone who has been abused and has not reported it. Decades of work with people who have been victimized has made clear that people who have been abused need to disclose this information in their own time and in their own way. It’s one thing when family members disclose their actions or those of others; it’s another matter to go in and coerce this information, no matter how good the intentions. In the meantime, it is the responsibility of adults to keep all young people safe and provide access to rehabilitation and growth. A final consideration is in resource allocation: with scant resources, is it wiser to put money into a polygraph exam or family therapy?

The training organizers told me afterward that the person asking the polygraph questions was likely a proxy for someone seated next to her. This person is apparently known for adopting a stance of, “I don’t care if it lacks research, I’m still using it.” In the end, I found myself wondering if, as a field, we only endorse evidence-based practice up to the point where it challenges our beliefs, many of which have little grounding in evidence. It’s not just an academic question; how many of us have seen actuarial risk estimates in adults revised upwards versus downwards?

A couple of days after this experience, an interested person asked whether the Good Lives Model (GLM) might be useful with people who categorically deny crimes for which they received convictions. This was another very good question and my answer here was that at a broad level, its collaborative and strength-based nature might help to elicit disclosures of past wrongdoing, but that there are other approaches in the literature that are also positive in nature (e.g., Serran & O’Brien, 2009). The GLM might help clients build on existing capacities, although without examining how one’s “good life plan” had gone awry in the past, its usefulness would be limited.

Together, these situations brought home the point that as professionals, we can often focus on managing risk to the detriment of building strengths. As others have observed, we tend to focus on having clients accept responsibility for the past when we may want to expend more energy on their taking more responsibility for their future.

Obviously, an understanding of past behavior and its connection to future risk is important. In some cases, however, one wonders if the cultural value we place on “confession” can actually impede conversations that build the trust and honesty that result in meaningful disclosure and further dialog. At a time in our profession when we have an increased focus on protective factors (those factors that protect against future recidivism), perhaps it is also important to think in terms of “protective processes” – those conversations and therapeutic intervention that actually build the capacities for accountability and honesty. While our field often finds itself looking for the newest technology for aiding assessment and treatment, it can be easy to overlook the role of skillful conversation.

David S. Prescott, LICSW


Serran, G., & O’Brien, M. (2009). A treatment approach for sexual offenders in categorical denial. In D.S. Prescott (Ed.), Building motivation to change in sexual offenders (pp. 96-117). Brandon, VT: Safer Society Press.

Ware, J., & Mann, R. (2012). How should “acceptance of responsibility” be addressed in sexual offending treatment programs? Aggression and Violent Behavior, 17, 279-288.

Friday, August 19, 2016

Juveniles who sexually offend: A view from 2016

This blog, like last weeks by Jon Brandt (New Research: Juvenile Sexual Recidivism < 3%), is linked to a recent publication by Michael Caldwell on the declining rates of juvenile sexual recidivism. Kieran
When I first started working with juveniles who sexually offend (JSO) in 2001, the focus was on sexual deviancy and compulsions. Our knowledge about this population has increased since then, and this population has likely changed as well, all of which has implications for practice and policy. The following is a personal view of how things look in 2016.
Knowing the prevalence rates of outcomes is an important starting point for assessment. Caldwell's (2016) article cited a weighted mean sexual recidivism rate of 2.75% for JSO youth, and a nonsexual recidivism rate of 30.00%. Measures of both sexual and nonsexual recidivism should be included in JSO assessment. The latter is a more recent development, and warranted given the high prevalence level noted by Caldwell and others. Nonsexual crimes also cause harm to victims.
Caldwell's study also suggests that the results from sexual risk measures, given a base-rate of 2.75%, may need to be qualified. For example, if a risk measure puts youth in the highest risk level, with say a risk of twice the base-rate of 3%, 94% of these "high risk" would be predicted to not sexually reoffend.[i] One study (Borowsky, Hogan, Ireland, 1997) examined rates of sexual offending behaviours reported in non-forensic, community samples, and found this rate for juveniles to be 4.8%, higher than the base-rate reported for reoffending of 2.75% by Caldwell. These considerations suggest decisions regarding out of home or secure placement, let alone civil commitment, may not be justified based primarily on findings from risk measures of sexual recidivism.
Developmental outcomes are also important to assess. These include psychiatric factors (depression, anxiety, etc.), neuropsychological conditions (ADHD, autistic spectrum, learning and intellectual disabilities, etc.), substance abuse, violence and trauma related conditions. The high prevalence of these conditions in this population, and also the availability of evidence-based treatment approaches to address them, argues for the inclusion of such factors in assessments. Also neighborhood, socio-economic, ethnic, cultural, and family factors are also important.[ii] Prevalence rates of psychiatric conditions in outpatient setting are likely lower than in residential or secure settings.
In 2001, the priority as I recall it for JSO youth was treating what was assumed to be an underlying sexual pathology. For most of these youth, however, I found there wasn't evidence of a pattern of enduring sexual deviancy. While there are such youth, they are rare in my experience. Impulsivity, poor judgment, supervision problems, and sometimes a history of sexual victimization, seemed to be the best explanations, rather than a primary disordered sexual behavior pattern.
This led me to believe that treatment approaches which promoted better social judgment and skills, along with family education, and a psychosexual education component, was optimal for most JSO youth. The theory and techniques of Moral Reconation Therapy and Aggression Replacement Training provided the framework for approaches to promote more mature social judgment and skills. One recent study (Ralph, 2016), documented deficits in prosocial reasoning for JSO youth, and three previous studies (Ralph, 2015a; Ralph, 2015b) documented the effectiveness of these approaches with JSO youth, including reducing sexual misbehavior.
In 2001, evidence-based practice with JSO youth wasn't in widespread use in my experience. Now it is a major consideration in treatment, and in California, some probation departments require evidence-based practices to obtain funding. In my view, evidence-based practice should include an evaluation of outcomes for treatment programs. You should be able to track your therapeutic outcomes so you can see not only if a given client improves, but also whether the program as a whole shows positive outcomes. Every surgery center in the USA has to do outcome studies (mortality and morbidity), and so should JSO treatment settings. In my experience highly committed, but rarely is any program evaluation done in JSO programs to document these admirable efforts. Worling, Littljohn, and Bookalam's (2010) study on a 20-year follow-up from the SAFE-T program in Toronto is probably the best known example of such research. A more modest effort was my own recent follow-up study of 129 youth in a residential JSO program (Ralph, 2015b).
The ultimate outcome to be tracked for JSO interventions had been sexual recidivism. This may not be the best measure to use in an era of recidivism less than 3%. Is a good program now one that reduces recidivism from 2% to 1%? Other outcomes might be tracked including non-sexual recidivism, reduction in psychiatric symptom ratings, and increases in prosocial reasoning and skills. Righthand's (2005) treatment progress scale is a useful tool with some normative information available. Examples of such measures are also found in my recent article (Ralph, 2016).
Norbert Ralph, PhD, MPH
Licensed Clinical Psychologist
Borowsky IW, Hogan M, Ireland M. (1997). Adolescent sexual aggression: risk and protective factors. Pediatrics. 1997 Dec;100(6):E7. 
Caldwell, M. F. (2016). Quantifying the Decline in Juvenile Sexual Recidivism Rates.
Psychology, Public Policy, and Law. Advance online publication.
Epperson, D., Ralston, C., Fowers, D., DeWitt, J., & Gore, K. (2006). Actuarial risk assessment with juveniles who sexually offend: Development of the Juvenile Sexual Offense Recidivism Risk Assessment Tool-II (JSORRAT-II). In D. Prescott (Ed.), Risk Assessment of Youth who have Sexually Abused: Theory, Controversy, and Emerging Strategies. (pp. 118 169). Oklahoma City, OK: Wood & Barnes.
Ralph, N. (2015a). A Follow Up Study of a Prosocial Intervention for Juveniles who Sexually Offend." Sex Offender Treatment. Retrieved from
Ralph, N. (2015b). A longitudinal study of factors predicting outcomes in a residential program for treating juveniles who sexually offend. Sex Offender Treatment. Retrieved from
Ralph, N. (2016). An instrument for assessing prosocial reasoning in probation youth. Sex Offender Treatment. Retrieved from
Righthand, S. (2005). Juvenile Sex Offense Specific Treatment Needs & Progress Scale. Retrieved from
Worling, J. R., Litteljohn, A., & Bookalam, D. (2010). 20-Year Prospective Follow-Up Study of Specialized Treatment for Adolescents Who Offended. Behavioral Sciences and the Law, 28, 46–57.

[i] When three categories of risk are used for the Iowa validation sample for the Juvenile Sex Offender Assessment Protocol-II (JSORRAT-II), the highest risk category (7 or higher) has about twice the risk of the middle level category which is at about the base-rate.
[ii] Ralph (2015) documents in a JSO residential setting 55.8% had an Individual Education Plan, 43.2% had prior mental health treatment, and 83.1% had used psychiatric medications at any time. Using DSM-IV TR criteria, the rates for various diagnoses are as follows: attention deficit disorder 39.7%, posttraumatic stress disorder 34.9%, depressive disorders 30.2%, conduct disorder 27.8%, anxiety disorders 11.9%, bipolar and mood disorders 8.5%, adjustment disorders 4.8%, and oppositional defiant disorder 1.6%. One youth, 0.8%, had a DSM-IV TR diagnosis of pedophilia, and no other sexual disorders were diagnosed for this sample.

Friday, August 12, 2016

New Research: Juvenile Sexual Recidivism < 3%

It is not often that research in any field is so persuasive that it can propel systemic changes, but that is not an overstatement for the potential of the compelling 2016 meta-analysis conducted by Michael Caldwell at the University of Wisconsin - Madison.  Caldwell provides the strongest evidence to date that the base-rate for sexual recidivism by adolescent offenders is so low that it demands reconsideration of best practices with juvenile offenders, and a course-correction for public policies.

In the Online First Publication of “Quantifying the Decline in Juvenile Sexual Recidivism Rates,” (Psychology, Public Policy, and Law; July 18, 2016), Dr. Caldwell reviews 106 international recidivism studies involving more than 33,000 juveniles who have sexually offended.  After transparently controlling for variations between studies, Caldwell determined that the mean five-year sexual recidivism rate for offenses committed over the last 30 years is less than 5%.  Looking at the most recent 33 studies, since 2000, Caldwell determined “a mean sexual recidivism rate of 2.75%.  This suggests that the most current sexual recidivism rate is likely to be below 3%.”  Longer follow-up periods, up to 36 months, revealed more sexual recidivism; but thereafter, follow-up times did not significantly increase recidivism rates.

Caldwell thoughtfully considered, and methodically dismissed several potential factors that might explain the decline, concluding that civil regulations and incapacitation do not explain such a significant drop in recidivism, but noted, “… improvements in treatment and supervision is one of the few possible explanations for which there is no contradictory evidence,” and that “preliminary evidence suggests that treatment can be moderately effective.”  Caldwell suggests that public discourse might be raising awareness about sexual violence, with a possible mitigating effect.  However, he went on to write, “These results offer no conclusive explanation as to the cause of the decline in juvenile sexual recidivism rates.”

Violent crimes in the US, including sex crimes, have been in steep decline for more than three decades.  Over the same time period, Caldwell found a 73% decrease in sexual recidivism.  Despite the dramatic 30-year decline in both first time and repeat sexual offending, there has been growing public anger about sexual abuse, and a deepening antipathy for those who have sexually offended.  In the US, this led to a dramatic increase in sentencing, and a proliferation of “civil regulations” for ‘sexual offenders,’ including a nationwide sex offender registry, regional residence and zone restrictions, local notification laws, domestic and international travel restrictions, and 21 states now provide for the civil commitment of sex offenders, including juveniles.
In the US, many civil regulations were initiated in reaction to serious, high-profile sex crimes by adults, but ensuing changes in public policies gradually migrated into the juvenile system.  Caldwell writes, “The bulk of available evidence indicates that the decline in adult and juvenile sexual recidivism rates has occurred, unrelated to, and perhaps despite, these recent policy trends.”  He goes on to express his concern that civil regulations “have unintended consequences that harm the adolescent perpetrator, their families, and at times their victims.”  In 2013, The Human Rights Watch published a rebuke of the registry for juveniles.  It is not an overstatement that most juvenile offenders, no matter how low their risk or how great their effort, cannot escape the devastating, lifelong consequences of current public policies.
Public policies and practices for both adults and juveniles with sexual offenses are predicated on the popular misperception that most sex offenders are destined to reoffend.  In 2014, Karl Hanson and colleagues published ground-breaking research which revealed that even men considered at high risk for reoffending were not high-risk forever.  Hanson determined that the longer one remained offense-free in the community, the lower the risk for sexually reoffending (a five-year “half-life”).   Hanson wrote:

The current results suggest that sexual offenders who remain offence-free could eventually cross a “redemption” threshold in terms of recidivism risk, such that their current risk for a sexual crime becomes indistinguishable from the risk presented by non-sexual offenders.  Previous large sample studies have found that the likelihood of an “out of the blue” sexual offence to be committed by offenders with no history of sexual crime is 1% to 3%.*

Now, Caldwell has essentially determined that sexual recidivism data for juvenile offenders yield similar results and conclusions; recidivism is not only much lower than previously believed, but it might be that juveniles who have sexually offended have about the same risk of sexual reoffending as first time offenders - in the range of 1-3%.  One 2008 study determined that about 95% of sexual offenses are first-time offenders.  Collectively, these findings suggest that the base-rate for sexual recidivism might be the same or less than the rate of first-time juvenile sexual offending.  There is mounting research that the basis for civil regulations are largely unfounded, raising significant doubts about not only their efficacy, but whether corresponding public policies for juveniles are both unwarranted and indeed harmful.

Caldwell’s meta-analysis reveals persuasive evidence that many practices currently in place for the treatment and management of juvenile offenders are not really about public safety, but rather about public policy.   Sexual misconduct comes at a high cost to victims, their families and friends.  Interventions with juvenile offenders also come with a high cost – to those juveniles, their families, and to society.   For these reasons, we must commit more resources to reforms, starting with primary prevention.  When sexual abuse occurs, Caldwell’s research should strengthen professional courage to not overreact, to avoid the tendency to pathologize or criminalize offending juveniles, to not conflate serious sexual misconduct with public “dangerousness,” and to thoughtfully apply science to effective interventions.

Going forward, an empirically-derived base-rate of less than 3% should be overarching in sexual risk assessments.  One challenge of rendering meaningful risk assessments has always been to determine what qualitative or quantifiable variables appear to separate those who sexually reoffend from those who remain offense-free.   Unless risk factors or protective factors are determined to be overriding, a 3% base-rate is likely to make it difficult to prove that any specific aggravating or mitigating factor carries enough weight to override such a low base-rate for recidivism.  It seems a bit simplistic to set aside established static and dynamic risk factors that are often integrated into a psychosexual assessment, but if clinicians used only this new base-rate to prognosticate sexual reoffending, they would be accurate 97% of the time.

However, risk is not, and should not be the only consideration in a good psychosexual assessment.  On the cautionary side, Caldwell noted that there is considerable evidence that juveniles with sexual offenses have often engaged in other delinquent behaviors, and that general delinquency for juveniles is a risk factor for sexually offending as adults.  A challenge to using new research that portends exceptionally low detected recidivism rates, will be to strike a better balance between sometimes competing concerns, for victims, offenders, their families, and legitimate public interests.

Researchers typically are neither clinicians nor policymakers, and most are too modest to actively promote their own research.  So it is incumbent on colleagues, and all stakeholders, to recognize credible research and have the professional mettle to actually use it – to light the way to informed public policies, and follow it to logical applications with individual clients.  For too long it seems we have had it backwards – we have been managing nine out of ten teenagers with sexual offenses as if they are likely to sexually reoffend.  In light of Caldwell’s findings, I would like to ask clinicians, social workers, probation agents, prosecutors, judges, law enforcement, and other professionals in the juvenile justice system to consider this question: if you knew, and believed, that 97 out of every 100 young people to whom you are providing services are not destined to sexually reoffend, how would it change, case by case, your treatment and management of those teenagers and their families?

In my experience, once young men come to understand that they have caused harm to another, most feel genuine remorse and profound regret.  They know there are no ‘do-overs’ – there is only ‘never again.’  Every individual who has sexually offended can be held accountable through restorative justice, and by employing principles of Risk, Need, and Responsivity, we can uniquely tailor and target treatment as a pathway to restoration.  We can wrap every youthful offender in the protective factors of Good Lives, and endeavor to help every juvenile offender to quickly, responsibly, and safely return to their families and communities.  Caldwell’s research indicates that they, and we, will succeed 97% of the time.

Jon Brandt, MSW, LICSW

Note: Michael Caldwell has given permission to post his email address, for readers who would like to request a copy of his research:

Caldwell, M.F. (2016, July 18). Quantifying the Decline in Juvenile Sexual Recidivism Rates. Psychology, Public Policy, and Law. Advance online publication.

*Hanson, R.K., Harris, A.J.R., Helmus, L, & Thornton, D;  High-Risk Sex Offenders May Not Be High Risk Forever, Journal of Interpersonal Violence October 2014, 29: 2792-2813, first published March 24, 2014