Thursday, September 13, 2018

Good Things Happening in Poland and Italy

By David S. Prescott, LICSW

I had the honor of spending several days training in Wroclaw, Poland, last week. Two days went into a Master Class series training trainers and supervisors in their various areas related to Motivational Interviewing (MI), two days at a conference on MI and trauma, and three other days providing consultation on the use of the Good Lives Model (GLM) and MI for private organizations interested in implementing these approaches in Poland and Italy.

The real heroes of the story are people who work days, nights, and weekends to ensure the best possible services in the areas of trauma and addictions in their various countries. Iga Jaraczewska is a clinician who has worked diligently for over ten years to bring MI into Poland to replace older status-quo approaches to addictions. This has brought an increase in understanding how clinicians and other professionals can best respond to trauma. Iga has organized trainings all over Poland, as well as international conferences in Krakow, Warsaw, Torun, and other locations to bring in outside voices. These often involve a progression of introductory and advanced trainings with consult and supervision. Similar efforts are rising in Estonia, with the work of Inga Karton. Following along the same basic path as Iga Jaraczewska in Warsaw, is Domink Meinhart, located in the area surrounding Wroclaw. He has worked to ensure training, master classes, and supervision circles to put these methods into place with fidelity.

Their efforts are remarkable. Around the world, an ongoing phenomenon shows people like these working incredibly hard, often with little reward, to ensure that treatment services to marginalized people are as effective as can be. Among other areas of focus, Iga and Dominik have each taken a great interest in how MI and the GLM can be used to treat people with a variety of problematic sexual behaviors. Both approaches are inherently collaborative and strengths-based, an important consideration in light of research finding that the more coercive the treatment experience the less effective it likely it is to be and that low therapist empathy can be toxic. Iga produced an edited volume focusing in these areas, while Dominik has recently collected articles for the Polish Terapia. Each have built well-received organizations that focus on disseminating these methods with fidelity across a spectrum of professional disciplines.

Equally encouraging are the efforts of the students and other participants in these trainings. People routinely travel from around the country in order to attend various trainings and supervision sessions, often with little incentive beyond becoming a better therapist. As in the implementation of various models and methods in North America, these therapists submit recordings of their sessions to be reviewed by a supervisor, transcribed, and discussed in a group session with other therapists. I had the opportunity to sit in on a day of feedback sessions and felt fortunate to see just how supportive these groups can be.

Similar efforts are bringing these approaches into more areas of the criminal justice system in Italy. Previously, this blog focused on a group in Milan ( including pioneers Carla Xella and Paolo Giulini. Now, a group led by Giacomo Salvanelli is working to expand these methods into other areas within Italy.

Most impressive of all is how all these people work to secure funding for their efforts. Very few people enter the human services with an eye on developing expertise in fundraising in challenging times. And yet, this is often what makes or breaks their efforts to ensure high-quality services for people who often have no voice in the systems that order their lives. Of course, much of the same happens around North America.  There are any number of people doing amazing things with unreasonably scant resources. Having had the great privilege of visiting many programs, it is always an honor to witness the efforts of people working behind the scenes to make trainings, conferences, and other forms of professional development happen.

Taken together, the efforts of these professionals show that therapeutic services improve when like-minded professionals get together with a common goal and purpose to exchange resources and ideas.

Friday, September 7, 2018

Integration into the community of people who have committed sexual abuse

By Kieran McCartan, PhD, David Prescott, LICSW, & Alissa Ackerman, PhD.
Over the years, our field has talked a lot about the use of language and the power of narratives in the field of sexual abuse. Words have impact. Words matter.  We often discuss whether we should use “victim” or “survivor” to discuss people whom have been directly impacted by sexual abuse and whether we should use labels at all. We have also discussed terms such as “sex offender” or the broad array of first person language that has emerged over recent years to describe the individuals that have committed sexual abuse. Likewise, there is the question of whether therapeutic activities should be called “treatment” or “management”. However, the one thing that we have not really discussed (and possibly one of the most important) is “reintegration” vs “integration”. This may seem like a minor semantic difference, but it’s more than that. It is an important debate, especially in terms of the experience of those who have victimized and those who have experienced sexual violence. This language can affect society’s view of each as well as the work that professionals do in the field. It is a conversation about transition and desistence.

The issue with reintegration is the addition of the prefix “re”. It indicates a return or a re-entry—this poses a problem? It assumes that they have been integrated into the community to begin with. In talking with anyone who works in the field of sexual abuse, it is common to hear them discussing their work in terms of changing people, changing attitudes and, most importantly, changing behaviors. The common thread that winds through discussion among police, probation, parole, treatment providers, and counsellors who work in the field of sexual abuse is that the person who has committed the abuse comes out of their service (i.e., prison, counselling, treatment, etc.) different, that they are a changed person. Herein lays the problem with the “re” in reintegration: We are not returning the person to the point that they were at pre-offence or pre-sentence, because that is a problematic and potentially harmful place. We are trying to integrate people who have committed sexual abuse into society, to successfully integrate many of them for the first time. What we see with these men (it’s mostly men that we are talking about) is that their lack of integration (whether socially, culturally, personally, psychologically or emotionally) contributed to their sexually abusive behavior in the first place. We are trying to help them move forward into a positive, productive, and engaging life, not back to the lifestyle that they had before.  

Thinking about integration versus reintegration enables us to view integration as being about the society, community, and individual’s social network working together to support the person. In contrast, reintegration too rarely looks beyond a return managed by professionals to similar circumstances. Therefore, we propose a view of integration that includes professionals playing a role, but that they are not alone in doing it. Integration is everyone’s responsibility, were as reintegration is often seen as the responsibility professional services. Past blogs have focused on the language that we use, what it means, and what its outcomes are. If we want people to take responsibility for their behavior and change we need to use language that reflects this goal.

Wednesday, August 22, 2018

The polygraph as applied: Are we focusing on technology at the expense of everything else that works?

By David S. Prescott, LICSW, Kieran McCartan, Ph.D., & Alissa Ackerman, Ph.D.

Nothing divides the professional and academic community who work in the field of sexual abuse quite like the polygraph. It is a debate that has gone on internationally for decades. A fascinating wrinkle in policy and the law recently came to the authors’ attention. In at least one state in the USA, there is a policy holding that people on probation cannot be sent back to prison for failing a polygraph examination; which makes sense given the status of the research around the polygraph and its admissibility in court. However, in this state, the same people can be sent back to prison if the examiner believes they have deliberately manipulated the results of the test. This has resulted in at least one examiner expressing certainty that many of his examinees have tried to influence the results, with many of them becoming incarcerated because of the examiner’s belief. Which highlights the main issue that the polygraph faces, that there are a multitude of different audiences (public, judiciary, professionals, academics, etc) all with different attitudes, experiences, evidence bases and strongly held views around it.

We want to be clear that this is more a problem of how professionals use or even abuse the power that they have over clients/examinees than it is about the polygraph itself, although empirically separating the effects of the polygraph from the examiner may be more complicated than many would think. The good news is that the Department of Corrections in that state is having a fresh look at its policies. The bad news is the context of professionals believing in their approach to the detriment of their clients. In some cases, one wonders how much deception by the examiner in the process is acceptable given the potential costs and lack of truly informed consent. These kinds of ethical questions certainly exist elsewhere, but rarely get the attention they deserve with vulnerable populations such as those for whom basic liberties are in the balance.

To put all of this into perspective, it can be useful to review what research has shown time and again: Punishment on its own neither reduces risk nor deters crime. While many questions about treatment remain debatable, people who complete treatment programs emerge at lower risk. Community supervision can also further reduce risk, and yet there is still no credible evidence that the polygraph, as currently applied, is improving outcomes, except in the opinions of its adherents.

This, in turn leads to further questions. When we apply the polygraph as described above, with examiners being able to send people to prison so easily, at what point are we not only interfering with methods that would promote community safety, but also denying justice? (as a side note, it is important to note that others in our field, including therapists, can also wield undue negative influence under the wrong conditions).

We then need to turn to other questions, such as what our goals actually are? Are we using the available methods to reduce risk? Build better lives? Assist those who have been abused? Or continue the punishment? Our belief is that punishment is punishment and rehabilitation is rehabilitation, and that when we confuse the two, neither can be entirely effective.

Finally, there is a real question of the polygraph’s best use. Does a sexual history polygraph really provide as much information as one might hope or is an examination into whether someone is basically following the rules help them – and the community – more. Do other methods, such as polygraphing people on their thoughts and fantasies simply muddy the waters through a belief that one’s fantasies equals their future behavior”?

Additionally, we would also encourage a consideration of how the polygraph is used internationally. While the polygraph is not necessarily an example of American exceptionalism, it might as well be because most other countries internationally do not use the polygraph in the same way, with the same frequency or with it having the same impact in the criminal justice system as in the USA. For example, in the UK the polygraph was only introduced in 2014 for high risk individuals, it is by no means used with all people that have committed a sexual offence, and is not admissible in court. Whereas in other countries, like Australia, Israel, Sweden and New Zealand (to name a few) the polygraph is not used with individuals that have committed a sexual offence.

Unfortunately, recent dialog has focused more on choosing sides – for and against the polygraph – than sorting through the various issues and balancing them against the human rights of each client or examinee. We must keep in mind, in our desire to discover the truth and seek answers from those that commit sexual abuse, that the consequences of false positive (as well as the resulting conviction and related outcomes) can be significant for victims and the accused.

Perhaps before we can answer questions about the polygraph, it is better that we return to the basic questions of why we do this work and what all our science tells us about the way people become safer and grow beyond their traumatic experiences.

Thursday, August 16, 2018

Explicit Issues: Pornography and Morality

By David S. Prescott, LICSW & Kieran McCartan, Ph.D
Some recent social media discussions have returned to the discussion of pornography and its place in the treatment of people who have abused (as well as broader questions of its place in masculinity and society). One case discussion involved an intellectually disabled person while another considered whether it is acceptable for men to look at women’s bodies. Setting aside the complexities of the former and the inevitability of the latter, serious questions remain for practitioners who attempt to balance risk management with client’s rights to engage in behavior deemed legal/not illegal by high courts around the world. Let’s be clear: we are not saying that pornography use is without risks. Author David Ley has written an entire volume dedicated to ethical considerations in pornography usage.
Where to start? A study by Drew Kingston and his colleagues found that pornography use is a risk factor for re-offense primarily among those who are already high risk and use pornography frequently. A new meta-analysis by Joshua Grubbs and his colleagues describes how “pornography-related problems—particularly feelings of addiction to pornography—may be, in many cases, better construed as functions of discrepancies—moral incongruence—between pornography-related beliefs and pornography-related behaviors.” In other words, analysis of the data suggests that so-called pornography addiction may have more to do with morality than with actual addiction. It often seems that the only thing people can agree on is that more research is needed. Sadly, there is no shortage of poorly constructed research seemingly designed to confirm the various authors’ biases and appearing in obscure journals and web sites.
All too often at the front lines of practice, pornography is an inconvenient elephant in the room that invites morality-laden rather than empirically informed responses. In a conversation about the Kingston findings a participant became furious that the subject hadn’t been framed in their preferred light. In another instance involving an adult in group care who requested that he be allowed to possess pornography similar to other clients, an outside consultant took to spreading rumors about those who pointed out there was nothing in the client’s risk profile to prevent his having it. These situations could potentially have had career-altering repercussions. The concern in each instance is that people’s moral beliefs can cloud their judgment about clients in their care, raising questions about who gets to make the decisions about their own life and under what conditions?
Elsewhere, pornography can be more than just the elephant in the room. It can be a source of embarrassment, scorn, rebuke, and debate. Although everyone has an opinion on pornography and very few acknowledge watching it, the viewing figures of “tube” sites like PornHub and YouPorn provide clear evidence to the contrary (Psychology Today piece on pornography viewing). Whatever our moral beliefs, pornography usage is ubiquitous in those parts of the world with Internet access. How this ubiquity will change people over time remains unknown, despite our worst concerns. One wonders about the extent to which professionals in the field of combatting sexual violence are engaged in hypocrisy, and to what extent we cannot study the issues involved more openly or with greater intellectual honesty.
The field of treating sexual abuse has not reached a point, where we can have a detailed, nuanced, and adult conversation about pornography. The debate tends to focus on abuse of power, humiliation, and gender; all of which we agree with. In addition, there is a massive power imbalance in pornography. All pornography is not the same, any more than all other forms of media are the same. Obviously, there are large sections of it that are illegal, highly problematic and have serious cause for concern (child sexual abuse, bestiality, snuff movies to name but a view), but there are other forms of pornography that are normal adult sexual relationships on show (for instance the debate around “ethical” pornography and amateur pornography); however, while important (actually essential) to flag these debates they are not the remit of this discussion (for more information on the reality of Pornography we suggest the work of Maree Crabbe). In many ways, the issues with pornography are the why, where, when and how of its use; its context and need for viewers to engage. The fact that we shy away from talking about sex, sexuality, and healthily relationships in modern society holds us back from further clarity. Professionals and critics can condemn people for watching pornography, but don’t ask why they are viewing it, whether their usage is harmful to themselves or their relationships with others, and if they have considered what is actually happening within it. There is a very real question as to the ethics of condemning the viewer without understanding the context.
These debates come to the fore where we think of certain populations who can’t access sexual expression in the same way as others, either because their primary sexual interest is in children or because their diminished capabilities keep them under the care and/or guardianship of others.
As professionals who work in the field of sexuality and sexual abuse we need to leave our moral issues at the door when engaged in practice with individuals who view pornography, because our role is to help these individuals and not to judge them, especially when we have power and influence over them. We need to help people see what pornography is, what role it serves, and whether its harmful to them (or others) help them stop engaging with it; but this needs to be on a case by case basis and in a neutral way. Again, absent specific empirically based risk considerations whose morality is it?

Thursday, August 9, 2018

Energy Flows Where Attention Goes:Checking our privilege and Influences

By David S. Prescott, LISCW, Kieran McCartan, PhD, & Alissa Ackerman, PhD.

Recent news media events remind us of the importance of establishing the most helpful directions for research and practice. For example, recent allegations of sexual assault in professional contexts have captured the attention of many professionals. In one instance, a university professor has identified himself as a “survivor of sexual violence” after an alleged incident of public groping in the elevator at a conference of the Society for the Scientific Study of Sexuality.

Likewise, recent legal manoeuvring by Brock Turner (whose light sentence in response to a sexual assault on the campus of Stanford University) sparked outrage has again made the news when his lawyers argued that his conviction should be overturned because his crimes involved sexual “outercourse” and not intercourse. Likewise, Bill Cosby has made the news by challenging his designation as a sexually violent predator in Pennsylvania and a registered sex offender. Likewise, a search of recent media accounts shows more instances of workplace sexual assault than can be described here.

As much as we applaud those who step forward in the wake of abuse and the media attention that keeps this topic alive in public discourse, we also believe it’s vital to keep in mind whose lack of privilege keeps them out of the media. As one example, it’s important to keep in mind that being groped in an elevator at a sexuality conference, while worthy of discussion, is not addressing the problem of more severe sexual violence that happens in many communities and rural areas every day. Brock Turner and Bill Cosby are easy media events; understanding the context of sexual violence for less privileged people is much more of a challenge.

Sadly, privileged and photogenic people often receive our attention more than the truly disadvantaged. This needs to change. Likewise, it is essential that our field actively seek out opportunities to conduct research and provide meaningful help where it is needed most. All too often, media accounts focusing on who did what to who overlook the more important questions of what we can do to stop these events from happening.

Those of us who study and provide treatment in the wake of sexual abuse would be wise to consider our own privilege, and how it focuses the lenses through which we view sexual abuse. Of course, even saying this risks appearances that we (the authors) are saying we are somehow “more enlightened than thou”, when we would include ourselves in this caution. All of our media have an opportunity to participate in dialog and debate these most difficult issues.

Thursday, August 2, 2018

Author Q & A with Andreas Witt discussing “The Prevalence of Sexual Abuse in Institutions: Results From a Representative Population-Based Sample in Germany”

Witt, A., Rassenhofer, M., Allroggen, M., Brähler, E., Plener, P. L., & Fegert, J. M. (2018). The Prevalence of Sexual Abuse in Institutions: Results From a Representative Population-Based Sample in Germany. Sexual Abuse. iFirst
The lifetime prevalence of sexual abuse in institutional settings in Germany was examined in a sample representative of the general adult population (N = 2,437). Participants completed a survey on whether they had ever experienced such abuse, its nature (contact, noncontact, forced sexual, intercourse), the type of institution (e.g. school, club), and the relationship of perpetrator to victim (peer, caregiver, staff member). Overall, 3.1% of adult respondents (women: 4.8%, men: 0.8%) reported having experienced some type of sexual abuse in institutions. Adult women reported higher rates of all types than did men, with rates of 3.9% versus 0.8% for contact sexual abuse, 1.2% versus 0.3% for noncontact sexual abuse, and 1.7% versus 0.2% for forced sexual intercourse. We conclude that a remarkable proportion of the general population experiences sexual abuse in institutions, underscoring the need for development of protective strategies. Especially, schools seem to represent good starting points for primary prevention strategies.
Could you talk us through where the idea for the research came from?
The idea for this article has a long history. Since the “so called” abuse scandals in 2010, the topic of child sexual abuse has gained a lot more public and political attention in Germany. Until this point there had only been a few studies on the prevalence of sexual abuse and other types of maltreatment in Germany. So there was clearly a need for data. Interestingly, those who came forward in the “so called” abuse scandals in Germany were men who had experienced sexual abuse in institutions. Additionally, one of our colleagues, Dr. Allroggen had conducted a survey with adolescents that were living in institutions and found tremendously high rates for experiences of sexual abuse. We were therefore interested in the prevalence in the general population of sexual abuse institutions but also leisure activities. Luckily, our department had the chance to participate in a large survey, so we took the chance and included questions about sexual abuse in institutions and leisure activities in the survey.
What kinds of challenges did you face throughout the process?
A big challenge in research on sexual abuse is whether it is ok to ask people for such experiences. Institutional review boards are sometimes hesitant to approve such research due to concerns that asking participants about sexual abuse will induce extreme distress. Fortunately, research on reactions of participants exists that helps to adequately address these concerns. For example Jaffe et al. (2015) report in their meta-analysis that trauma-related research can lead to some immediate psychological distress, however this distress is not extreme. In general, individuals find research participation to be a positive experience and do not regret participation, regardless of trauma history or PTSD. To present those findings helped that the IRB approved our research.
The other issue that we were facing was how to ask individuals about their experiences of sexual abuse. There is no questionnaire that especially assesses sexual abuse in institutions. Therefore, we had to be careful in selecting the questions, as we needed the questions to be non-judgmental. Additionally, when we were designing the questions we were interested in a range of related topics and would have liked to include a lot more questions but resources are limited and so we had to narrow our questions to the essential ones.

What do you believe to be the main things that you have learnt about the prevalence of Sexual Abuse in institutions?
One of the most compelling findings is the amount of people that are affected by sexual abuse within institutions. We also find that experiences of child sexual abuse, as with other  types of child maltreatment, is very common in the general population. When we investigate specific populations, such as children living in institutions the rates are even higher. Our findings also suggest that sexual abuse may occur in a wide variety of settings and that adult caregivers or staff, as well as peers have to be considered as potential perpetrators. Clearly, efforts have to be taken to prevent sexual abuse in different settings and also in regards to perpetrators.
Now that you’ve published the article, what are some implications for practitioners?
Sexual abuse in institutions is an issue. The results of our study indicate that a substantial number of people are affected. Therefore asking about such experiences is necessary, to understand peoples behaviors and health, because we know about the negative and lasting potential of such experiences. Additionally, our results suggest that prevention programs should be established. Especially schools seem to be a good setting for such programs. Additionally, such programs should also address peers as potential perpetrators. 

Friday, July 27, 2018

Reflections on registration and its inherent paradoxes

By Kieran McCartan, PhD, David Prescott, LISCW, & Alissa Ackerman, PhD

On its face, registering individuals who have committed sexual offenses seems like common sense. It neatly ties to public perceptions and myths around these individuals, their rates of recidivism, and levels of risk. The creation of a registry reinforces risk management procedures, public protection policies, and an increasing “audit culture” (one in which there is an ever-increasing focus on monitoring and supervision) within the criminal justice system. It can seem that we are all better protected from sexual abuse when we are constantly monitoring our known sex offenders in the community, although the evidence for this is presently lacking.

The notion that focusing on the small number of people who have been brought to the attention of law enforcement, charged, convicted, and then mandated to register, while ignoring the larger community where sexual victimization occurs every day, is a clear indication that, as a society, we are not actually focusing on risk. Rather, we are making the erroneous assumption that reactive focus of registration is a better, more effective, policy that proactive prevention. This is not the only collateral consequence or contradiction of registries.

There are numerous inherent contradictions – paradoxes – that go hand in hand with developing a register. For example, by feeding myths about the inability of people who have sexually abused to change and the importance of prioritizing an audit culture, professionals and lay people alike can overlook what is actually known to reduce risk and harm. We argue that it is vital to examine the collateral damage caused by policies seemingly steeped in common sense. Doing so may force us to ask if the registry (especially in its current form) is actually fit for the combined purpose of public safety and community (re)integration.

The unfortunate and often unintended messages from the registration of people who have sexually abused include those that are:

-          Anti-rehabilitation: The basic premise of the register is that the police and criminal justice system will have information on known offenders so that if, and potentially when, someone reoffends, law enforcement will know where to find them. This suggests that people don’t change; that once someone is labelled an offender that they will always be an offender. This goes against the basic tenants of treatment/rehabilitation and enables the individual to disengage from the process. Even the most stringent studies of rehabilitative efforts find a larger effect of treatment on recidivism than the registry.

-          Anti-desistence: The register reinforces in people that they will always be a risk and always likely to re-offend, which impacts on their motivation to change and to desist. The inherent message is that they can never be more than the sum of their worst behaviors.

-          Impede the (re)integration of individuals convicted of a sexual offence: There are many unknown and unplanned outcomes of registration for the person on the register, from the sharing of their personal data to where they can live, work and how they can access the internet. This disconnects people from their communities, impeded reintegration.

-          Enforces myths about sexual abuse perpetration: The creation of registries enforces the idea that sexual abuse is perpetrated by a small group of individuals who continually reoffend. The reality, however, is that most individuals who sexually offend are not known to the police and do not have a prior offence at time of arrest.

Despite these concerns and the lack of meaningful supportive evidence, registries have been implemented internationally over the past 15-20 years and they are often seen as good practice in sex offender risk management. There has been virtually no mention in the professional literature of how rehabilitation and registration can work together, or if that is possible. Most western and northern hemisphere countries have a sex offender registry. However, there are variants in the structure and function of these registries. For example, some registries are available only to the police, some only target certain sexual offenses, and some target non-sexual offenses. Registration is the only common denominator.

The USA is an extreme example. The country is fast approaching one million people on the public registry. The USA asks for the most information, sharing much of it publicly. Even the penalties for non-compliance are extreme. Interestingly, countries looking to develop their own registers have looked to the USA as an example, though none has directly replicated it.

The policing and risk management function of the register may have merit, but it is time to reconceptualize it and reconsider the underlying premise to make sure that it is a prosocial, positive risk management tool. As for the USA, there is little room to argue that the registry, in its current form, is prosocial or positive.

When asked, most lay people believe that providing rehabilitative services to people who have committed sexual crimes is one of many good ideas. Given that the registry is likely here to stay, it’s time to consider how we can also promote policies that are going to have a demonstrable impact on public safety.