Friday, January 23, 2015

Preventing sexual abuse in the UK: A conversation with Donald Findlater by Jon Brown

As part of the new prevention series I had a conversation with Donald Findlater, Director of Stop it Now UK. (www.stopitnow.org.uk)   Stop it Now UK was established in 2002 by the Lucy Faithful Foundation ( www.lucyfaithful.org.uk) as a result of the inspirational work of Fran Henry, Joan Tabachnick, Alisa Klein and others who of course set up Stop it Now in the U.S.  The Lucy Faithful Foundation is the only UK wide charity dedicated solely to reducing the risk of children being sexually abused. Stop it Now UK was advocating for the primary prevention of sexual abuse before it was really on the social or political agenda in the UK. Under Donald’s leadership, Stop It Now UK has played a pivotal role in raising the profile and importance of preventing sexual abuse and violence.

Stop it Now UK provides a helpline for people who are concerned about their sexual thoughts and behaviour as well as for other family members and for professionals wanting to know more about sexual abuse prevention. It also provides a range of prevention and treatment services.

Before taking on the leadership of Stop it Now UK Donald, who originally trained and worked as a Probation Officer and manager and then  Director of the Wolvercote Clinic, , another initiative ahead of its time in many ways. The clinic provided residential treatment for men who had sexually offended and was the only one of its kind in the UK. The clinic was forced to close due to funding difficulties and to this day the UK still does not have a specialist residential treatment centre for sexual offenders outside the Criminal Justice System.  Funding challenges have also been an issue at Stop it NowUK. Not surprisingly, Donald talks with frustration about the way in which support for prevention activity has been reduced at a time when there is finally a greater recognition of the need to intervene earlier and more proactively to stop sexual abuse and violence occurring in the first place. Donald’s persistence and optimism has been really important in ensuring a continued  focus on sexual abuse prevention in the UK.

Other prevention services provided by Stop it Now UK include Inform, a programme for family members of internet offenders with the aim of helping them to understand the offenders’ motivations and how they can best support the family member to help them remain offence free in the future.  Inform is an individually treatment programme for online offenders that aims to ensure the recipient understands their motivation to offend online and what they need to do to remain offence free in the future. An adapted Inform programme has also been developed for young people; this is also delivered individually.  

All Stop it Now interventions address healthy sexual development through offering information and education; they are based on the premise that sexual abuse and violence is a public health problem that can and should be prevented and this belief has been central to Donald’s motivation to develop Stop it Now. Donald is clear that if we are to make progress in reducing levels of sexual abuse we need to have better informed and aware individuals, families and communities. The work of ATSA member, Stephen Smallbone in Australia has been particularly influential for Donald in developing a prevention framework.

When considering the future, Donald speaks eloquently about the need for more outcome data in the UK to measure the effectiveness of prevention interventions.   Under Donald’s leadership, Stop It Now UK is playing its part with the evaluation of the Helpline (for more information go to www.stopitnow.org.uk).  In fact, in June 2014 an independent evaluation of the Stop it Now! Helpline, conducted by specialist researchers from NatCen Social Research, was published. The report has been described as 'overwhelmingly positive' with findings showing that the Helpline provides a valuable contribution to tackling child sexual abuse by helping people who have sexual thoughts, feelings and behaviour towards children manage their behaviour, and by assisting all callers to be informed about how to protect children and young people from risk of harm. Study participants who had offended could report feeling more in control of their sexual thoughts and behaviour after using the helpline. Positive change was also reported in areas identified as protecting against re-offending, such as:- improving emotional and psychological well-being; addressing beliefs that can facilitate and maintain sexually abusive behaviour; strengthening motivation to desist; reducing the risk of social isolation; and increasing engagement in fulfilling and productive activities. The findings from the research were synthesised and used to develop a toolkit outlining how similar programmes could be implemented elsewhere in the UK. The toolkit was also tested with other project partners in Germany and Finland. More information can be foundhttp://www.stopitnow-evaluation.co.ukStop it Now continues to grow and now has a presence in a number of other European nations.    

Jon Brown, MSc

References

Smallbone, S., Marshall, W.L. and Wortley, R. (2008) Preventing child sexual abuse: evidence, policy and practice, Cullompton, Devon: Willan Publishing.

Friday, January 16, 2015

You Can’t Always Get What You Want: Research and Policymaking


In October 2013, Bill Miller (the primary developer of motivational interviewing [MI]) addressed a group of MI trainers in Krakow, Poland. He took note of the fact that despite its nearly mythical status, randomized clinical trials of MI have only shown treatment effects 58% of the time; 42% of studies have found little or no effect. Make no mistake about it: MI has produced significant effects across diverse areas of psychotherapy, including within prison-based treatment settings. Just the same, the wisdom and courage of Miller’s statement belies the understated tone in which he made it. As our field patiently awaits the results of gold-standard studies proving that what we do works, some researchers, like Bill Miller, have gone beyond the has-it-been-effective-in-a-randomized-clinical-trial question and are taking note of an emerging but often unrecognized trend: treatments competently implemented in many areas are not necessarily effective in all of them.

 

A few years ago, this was the case with an implementation of multi-systemic therapy in Ontario (for a more complete description of these findings, click here). More recently, another examination of MST in Canada appears to have produced beneficial preliminary effects, but is not without acknowledged methodological problems such as a small sample size and process issues (e.g., 65% of participants who provided scores on the Therapist Adherence Measure –Revised rated their therapists as being sufficiently consistent with MST principles. This is below the recommended target of 80%). Between the experiences of multi-systemic therapy and motivational interviewing, professionals should always keep in mind the bigger picture of their efforts and bear in mind that in program implementation (as in life) we don’t always get what we want.

 

In 2012, a review of studies examining a parenting-skills program appeared, and did not get the level of attention that it deserved. Philip Wilson and his colleagues conducted a systematic review and meta-analysis of 33 studies of the Triple P parenting program. Although this may seem unrelated to the treatment of people who have sexually abused, their findings are valuable to all policymakers. At first glance, the Triple P parenting program boasts numerous successful randomized-clinical trials and meta-analyses; numerous jurisdictions have promulgated and paid for its implementation. While these accomplishments have been praiseworthy, Wilson and his colleagues found numerous problems with the research and question basing public policy on flawed research. Among the authors’ conclusions:

 

In volunteer populations over the short term, mothers generally report that Triple P group interventions are better than no intervention, but there is concern about these results given the high risk of bias, poor reporting and potential conflicts of interest. We found no convincing evidence that Triple P interventions work across the whole population or that any benefits are long-term. Given the substantial cost implications, commissioners should apply to parenting programs the standards used in assessing pharmaceutical interventions (p. 1).

 

The examined bias across studies as well as bias within studies, blinding of assessors, percentage of clients who dropped out, etc. In one instance, the authors noted that:

 

Although it claimed to have achieved a reduction in the incidence of episodes of child maltreatment [5], it actually demonstrated an unexplained rise in reports in control areas rather than a drop in Triple P intervention sites. The description of the random allocation was poor, and the analysis was simplistic, being a two-sample t-test of county-wide measures. In particular, although some form of stratification or matching was used (it was not clear exactly how this had been done), there was no evidence that this had been accounted for in the analysis. For example, if counties were randomized within pairs, then the within-pair differences in the changes from baseline would have been of interest, but these were not reported. Therefore, although there are positive conclusions from this study, some doubt remains as to their validity (P. 8).

 

In this author’s estimation, Triple P appears to have produced very good results and has doubtless improved many lives. Just the same, Wilson et al.’s points are well taken: where large-scale public policy is concerned, we should be very careful how we place stock in single studies or even groups of studies, and ask more questions than simply “does it work.” Likewise, there is a body of research finding that bona fide treatments often produce equivalent results (Wampold, 2001), returning us to the question “what works with what client under what circumstances.” Ultimately, professionals and policymakers should be data driven.

 

  David S. Prescott, LICSW

Wampold, B.E. (2001). The great psychotherapy debate. Mahwah, NJ: Lawrence Erlbaum Associates, Inc.

Sunday, January 11, 2015

Journal Spotlights for 2014

With the start of a new year, we at the SAJRT Blog (Myself, David and Jon) thought that we would devote the first blog to what we thought were three stand-out journal articles of 2014. We have each written about one journal article, which are personal choices by the bloggers, and not based on data regarding  any journal downloads or citations.

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Lewis, Klettke and Day published their paper, entitled “Sentencing in child sexual assault cases: factors influencing judicial decision-making”, in the December edition of the Journal of Sexual Aggression. This article stood out to me as being quite salient as it tackled one of the main issues that often arises in public understandings of sexual abuse, and related punishment, sentencing. The article discussed the factors that involve decision making in CSA cases in terms of sentencing and verdict. The research was based upon 113 cases of CSA in Australia from 1998 – 2009. The results indicated that the main factors that affected judicial decision making where (1) creditability (i.e., if the victim is not seen as credible by the judge this impacts the sentence handed down), (2) behavioral evidence (i.e., the behavior of the child victim before and/or post event, with lower level harmful behaviors being seen as indicative of CSA as well as higher level ones), and (3) offence factors (i.e., young victims and more victims resulted in long sentences). This research is important as it is on an under researched area, talks to the need more multi-profession working, the existence of sexual abuse myths within the system by professionals (who should have a better and more realistice perception) and a need for better education on the reality of CSA, and its impact upon victims, for the legal system.Although this research was based in Australia it speaks to a wider international issue. (KM)

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A study that has garnered less discussion than one might think is by Karl Hanson, Andrew J. R. Harris, Leslie Helmus, & David Thornton, “High-Risk Sex Offenders Might not be High Risk Forever,” published in Journal of Interpersonal Violence.  In brief (and taken from the abstract), the authors followed and aggregated sample (drawn from 21 smaller samples) of 7,740 sexual offenders to examine the risk they posed for sexual recidivism over a 20 year follow-up period. Overall, the risk of sexual recidivism was highest during the first few years after release, and decreased substantially the longer individuals remained sex offence-free in the community. This pattern was particularly strong for the high risk sexual offenders (defined by Static-99R scores). Whereas the 5 year sexual recidivism rate for high risk sex offenders was 22% from the time of release, this rate decreased to 4.2% for the offenders in the same static risk category who remained offence-free in the community for 10 years. The recidivism rates of the low risk offenders were consistently low (1% to 5%) for all time periods. The authors state that these results suggest that offence history is a valid, but time dependent, indicator of the propensity to sexually reoffend.

What can professionals take away from these findings? Perhaps the most important lesson is that risk reduces with the passage of time in the community, and that this must be accounted for in risk assessment. However, professionals and the public alike have heard statements to the effect that “once a sex offender always a sex offender.” While many in our field have long known that this statement is untrue, Hanson, Harris, Helmus, & Thornton’s study challenges all professionals to think differently about persistence in, and desistance from crime.

What lessons can policymakers draw from this study? The current state of our research makes clear that we should consider short-term, high-intensity, cost-effective responses to sexual offending (such as providing opportunities to complete treatment programs) to longer term, cost-ineffective, and low intensity responses that have demonstrated no effect on reducing risk (such as lifetime GPS monitoring; see Smith, Goggin, & Gendreau, 2002). Clearly, even one sexual re-offense is one too many and virtually everyone wants to prevent further sexual harm. This study illustrates the need for empirically supported risk assessment in order to best allocate public resources. Only then can we claim that we are engaging in the most effective ways possible to prevent sexual abuse. (DP)

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Hanson’s 2014 article on desistance, as David reviewed, has implications that are far-reaching and yet to be realized.  If fidelity to evidence-based practices (EBP) is foundational in the treatment and management of those who have sexually offended, Hanson’s research, simply stated, should result in significant adjustments to sex offender policies and practices, both systemically and as applied to individual clients.  It is incumbent on professionals to actually use new research when it reveals outdated practices.  This point is central to a 2014 Aggression and Violent Behavior article by Theresa Gannon and Tony Ward.

In “Where has all the Psychology Gone?  A Critical Review of Evidence-Based Psychological Practice in Correctional Settings,” Gannon & Ward wrote, “The correctional psychology discipline is facing a crisis - [the] correctional psychologists’ mounting neglect of evidence-based practice… [that] stems from psychologists’ acquiescence to the risk and security oriented policies of correctional systems.” 

Gannon & Ward discuss the “immense tension between punishment and rehabilitation proponents,” which has existed for more than 100 years.  They describe the “dual relationship” that therapists must straddle when institutional security imposes constraints on privileged communication and therapeutic relationships.  Because security concerns are legitimate, the therapeutic alliance, which is vital to positive therapeutic outcomes, is continuously under pressure.  The therapeutic alliance is further compromised by institutional considerations masquerading as therapeutic concerns.  Sometimes, psychotherapists are forced into managing security issues, while correctional officers and undertrained paraprofessionals are often required to exercise roles that should be in the domain of experienced clinical staff.

Gannon & Ward are not na├»ve to the gap between the ideals of efficacious psychotherapy and the realities of providing services to a large number of clients, within institutions that operate under politically-imposed constraints.  Indeed, they argue that these are reasons why licensed psychotherapists should assert professional and ethical responsibilities to EBP, rather than simply capitulate to competing concerns.  Gannon & Ward don’t specifically refer to SVP or civil commitment programs, but their arguments would seem to be even more applicable in settings where there is a clear mandate to provide efficacious psychotherapy to involuntary clients.

It would be wrong to conclude that “Where has all the Psychology Gone” is a scolding of psychologists, or that the authors’ arguments don’t apply to all licensed psychotherapists.   Gannon and Ward have painstakingly reinforced every paragraph with links to sources that will support professionals who recognize both the efficacious benefits and professional responsibilities to maintain EBP in institutionalized treatment.  Clinical and administrative professionals who want to “put the psychology back” into institutional settings, will find a compelling case that evidence-based psychological practices do not have to take a backseat to institutional security.   (JB)
 
(Please note: The authors Professor Tony ward [Tony.Ward@vuw.ac.nz] and Professor Teresa Gannon [T.A.Gannon@kent.ac.uk] are happy to be directly contacted by any readers who would like a copy of their article.)

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We hope you enjoyed these snippets, that you will go  read the full articles and that they will give you food for thought. These three articles indicate that there is still educational and supportive work to be done in respect to sexual offending  with professionals (in all guises) across the Criminal Justice System, as well as outside of it.

Kieran McCartan, Ph.D, David Prescott, LICSW, & Jon Brandt, MSW LICSW.

References

Gannon, T. A., & Ward, T. (2014) Where has all the Psychology Gone?  A Critical Review of Evidence-Based Psychological Practice in Correctional Settings, Aggression and Violent Behavior, 19, 435-446.

Hanson, K.,  Harris, A. J. R., Helmus, l., & Thornton, D. (published online).High-Risk Sex Offenders Might not be High Risk Forever.  Journal of Interpersonal Violence.#

Lewis, T., Klettke, K.,  & Day, A. (2014). Sentencing in child sexual assault cases: factors influencing judicial decision-making.  Journal of Sexual Aggression, 20, 281 – 295.


Smith, P., Goggin, C., & Gendreau, P. (2002). The effects of prison sentences and intermediate sanctions on recidivism: General effects and individual differences. (User Report 2002-01). Ottawa: Solicitor General Canada.