Thursday, May 16, 2019

Learning to Take a Mindful Pause

By Janet DiGiorgio-Miller, Ph.D. & David Prescott, LICSW

Dr. Jon Kabat-Zinn describes mindfulness as a “process of being present in the moment without judgment and with care, concern, and compassion for self and others.” Teachings related to mindfulness have been around for thousands of years and are found in many religions. There have been numerous studies and meta-analyses showing mindfulness meditation to be a helpful adjunct to treatment for many types of physical and psychological issues. Neuroscience has also shown that regular meditation changes the composition of the brain and gives individuals techniques to manage their reactivity to stressful events.

There is emerging research regarding using mindfulness and meditation as a technique to enhance coping skills and reducing impulsivity with individuals involved in the criminal justice system. Gillespie, et. al (2012) found that controlled breathing techniques, which are the foundation to mindful based approaches and mediation could potentially increase prefrontal control over the amygdala thus leading to improved emotional control and sexual self-regulation.  Borders, et al (2009) determined that mindfulness decreased anger, hostility and aggression by decreasing rumination. Samuelson, et al (2007) found that mindful-based stress reduction courses offered in a correctional facility assisted the inmates with a decrease of hostility and an increase of self-esteem. Although this research has been criticized for methodological flaws, Van Dam, et. al. (2018), in self-report measures subjects report a difference in their reactivity to experiences after regular mediation.  

Why should professionals working with people who have abused care? The direct contributions of mindfulness and other forms of meditation described above can also assist clients in being more amenable to participating in treatment and supervision. Improved self-control can further boost client capacity in responding to the services once involved. Each of these aspects aids in programming adhering to the responsivity principle. Finally, there is one point that is often overlooked: Before a person can use cognitive-behavioral interventions to change their thought patterns and behaviors, they must first be able to more fully observe these patterns.  

Inasmuch as they include an explicit focus on examining – even contemplating – internal states and ultimate concerns, approaches such as the Good Lives Model and Motivational Interviewing can dovetail effectively with mindfulness. Likewise, it is not difficult to see how mindfulness can help people who have abused become more empathic. Further, clients practicing mindfulness are better poised to recognize that the tools they need for change exist within them and that they have better control over their thoughts and emotions than they realize. Eventually with practice, clients learn to better regulate themselves and to come to more thoughtful responses to the situations which present themselves. 

Kabat-Zinn, et al (2009) introduced the attitudinal foundations of mindfulness. 
He outlined 9 Principles of Mindfulness:

 Non-Judging
 Patience
 Beginner’s Mind
 Non-Striving
 Acceptance
 Letting Go
 Commitment
 Recently two principals were added: Generosity and Gratitude

How can we learn to take a mindful pause ourselves and allow our clients to do the same? There are any number of ways. An excellent first step is simply to take a meditative breath to a count of four in and a count of four out (sighing doesn’t count). In moments of stress, slowing your breath allows the prefrontal cortex to signal the amygdala to relax and in turn slow the body’s response to stress. This breath repeated over time allows the body to relax and thus a mindful space is created. In this mindful space, you can think more clearly about the events occurring and allow alternative explanations for the event, in turn allowing you to respond in a calmer, more deliberate way. While you are in the mindful space it is helpful to remember Dr. Kabat-Zinn’s foundational attitudes. 

As therapists, if we practice the tenets of mindfulness in our own lives, we are more likely to instill hope in our clients’ outlook. When we practice nonjudgement, we can convey to our client a sense of safety in therapy. We can be patient and allow clients to fully discuss their issues in a more reflective way. We can have a beginner’s mind and not expect the same results. We can learn to pause, which is also being patient and give ourselves a “mindful space” to fully examine all of the variables in the therapy not just one theory. We can be kind to ourselves and model this behavior to our clients as they learn to change. We can be generous with our time and thoughts as our clients navigate the road to change. Most importantly we can be grateful and teach our clients the value of gratitude. 

If we practice self-compassion and care for ourselves, we are more able to do this difficult work. As we become more focused on the good around us, we become more optimistic about positive change for our clients. At the same time, we become less attached to the outcomes, knowing we have done our best to facilitate change.

“The stiller you are the calmer life is.” – Rasheed Ogunlaru 
 
References:

Borders, A., Earleywine, M., & Jajodia, A., (2009) Could Mindfulness Decrease Anger, Hostility, and Aggression by Decreasing Rumination? Aggressive Behavior, 36, 28-44

Gillespie, S., Mitchell, I., Fisher, D., Beech, A. (2012) Treating Disturbed Emotional Regulation in Sexual Offenders: The Potential Applications of Mindful Self-Regulation and Controlled Breathing Techniques. Aggression and Violent Behavior 17, 333-343

Kabat-Zinn, J., & Hanh, T. N. (2009). Full Catastrophe Living: Using the Wisdom of your Body and Mind to Face Stress, Pain, and Illness. Delta.

Van Dam, N. T., van Vugt, M. K., Vago, D. R., Schmalzl, L., Saron, C. D., Olendzki, A., ... & Fox, K. C. (2018). Mind the hype: A critical evaluation and prescriptive agenda for research on mindfulness and meditation. Perspectives on Psychological Science, 13, 36-61.

Thursday, May 9, 2019

Good things are happening in Italy

By Carla Maria Xella, PhD  (CIPM & President of the Scientific Committee of CoNTRAS-TI)

Among European countries, Italy is one of the few lacking any public action regarding the treatment of people who committed or are at risk of committing sexual abuse. In Italy, projects for the treatment of sexual offenders, both in detention and in the community, do exist, but currently, depend on uncoordinated personal initiatives. Consequently, treatment programs are aleatory and insufficient. 

The Public institutions’ approach to the issue of sexual abuse is focused only on punishment. Approximately one month ago, the new Italian Government issued a new so-called Security Bill, increasing the length of sentences for sexual abuse against children from 5-10 years to 6-12 years, and to 14 years for gang rape. Not a word about risk assessment! The translating and validating STATIC-99-R and STABLE plan, approved by the former Government, has been canceled. The new Security Bill does mention “treatment programs for sexual offenders”, but… with no funds established to carry them out!

So, indeed, no treatment is currently provided by law to sex offenders, either in prison or in the community. Sex offenders serve their long sentences restricted in special wards, they are rarely admitted to probation or parole for community management/reintegration. Post-release they have no registry, no treatment, no follow-up. In Italy sexual offense prevention, not to mention recidivism prevention, is non-existent in policy and practice.

If you are wondering what the good news is, the answer is that professional practice is starting to change in Italy, slowly but surely. Several treatment programs are now in place, often with European or private funds, and they follow or try to follow, the best international practices. The common need of the providers of these programs is, anyway, sharing common experiences and practices. In October 2017, a national association, named CoNTRAS-TI (in English: National Coordination of Treatment and Research about Sexual Offending – Italian Experiences, and the acronym can be translated in Pathways to stop it) has been founded. The aim of CoNTRAS-TI is to share research data and best practices among its members and with members of other similar international associations, and to foster collaboration with public Institutions, to promote a climate of sensitivity towards sex offender treatment and reintegration in the community.

Last year CoNTRAS-TI and ATSA have signed their affiliation and I, as the President of the Scientific Committee, had the chance to attend the Board of Directors and the Conference in Vancouver. A precious collaboration has been established, with our ‘elder siblings’ offering us their help to spread scientific evidence about sex offender assessment and treatment.

Building upon the development of CoNSTRAS-TI on May 20th  our first National Conference is taking place in Milan, Italy. The main aim of this first Conference is to promote exchange among those who are concerned with sexual abuse at various levels. The conference will be opened by Fabian M. Saleh, from Harvard University, who will discuss the assessment and treatment of paraphilic disorders in sexual offenders. Col. Antonio Manzi, Carabinieri Force, will speak about the importance of training in scientific risk assessment for those concerned with the safety of the community; Judge Annamaria Gatto (Surveillance Court) will speak about the lack of any system of monitoring and control for high-risk sexual offenders in Italy currently. Most importantly, we will have Gloria Soavi, president of CISMAI (the network of Italian association and stakeholders concerned with child protection against abuse and neglect) speaking as well. Her presence at the Conference can be hardly underestimated: she will highlight the importance of a strong collaboration between professionals who deal with victims and those who deal with perpetrators in the prevention of sexual abuse. Unfortunately, often the services dealing with victims are unwilling to share information and to build a net for taking charge together of complex cases, like family sexual abuses. As a member of the International Committee of ATSA, I will close the morning conference with a review of international approaches to sexual offending.

In the afternoon, two roundtables are planned. The first roundtable will propose some Italian Experience of Research and Treatment regarding Sexual Offending with (1) Andrea Scotti speaking about the C.I.P.M. model of treatment (now ongoing in Milan and in Rome Region); (2) Maura Garombo speaking about the Vercelli Program; Dante Ghezzi (TIAMA) will discuss the issues of youths who sexually abuse; (3) Davide Dettore will explain his model for the treatment of people who sexually offend online; (4) Georgia Zara will speak about the Italian validation and translation of the CID-SO, a tool for denial assessment in sexual offenders developed by Sandy Jung; & (5) Amelia Ciompi (Prison Administration Department) will speak about the need of a review of recidivism rate in Italian sexual offenders, which is lacking at present. The theme of the second roundtable is the public perception of sexual offending, and the participants will be journalists of various Italian newspapers. The roundtable will be moderated by Paolo Giulini, Secretary of CoNTRAS-TI.

The Conference is the first attempt to publically share experiences and research results about sexual offender assessment and treatment, to prevent new offenses and make the society safer.  We hope that spreading scientific information can hopefully lead Public Institutions to listen!

Thursday, May 2, 2019

What Different Research Methodologies Tell Us


By Jeff Sandler, Research Scientist New York State office of Mental Health & ATSA research committee

This is a blog posting by the ATSA research committee. Kieran
 
A few weeks ago, an entry was posted to the ATSA blog entitled “Hearing the Narrative, Seeing the Person: Considering the Appropriate Research Methodology.” The piece discussed the importance of using various research methodologies to investigate questions surrounding sexual offending and treatments for sexual offending. The central thesis of the piece was that no single research methodology, or style of research, should be used for all studies on topics related to our field. The ATSA Research Committee would like to support the importance of using different research methodologies when studying a topic, but also offers a note of clarification and caution.

The ATSA Research Committee is, not surprisingly, very pro-research. As the blog from a few weeks ago correctly points out, there are many different types of research and research designs: large-sample, small-sample, cross-sectional, longitudinal, experimental, archival, prospective, retrospective, quantitative, qualitative, and many more. Each different type of study allows for different conclusions to be drawn from its results.
 

The blog from a few weeks ago argued that case studies and qualitative research have an important role to play in the study of sexual offending and the treatment of sexual offending. The Research Committee would like to echo that sentiment. There is no question that case studies and qualitative research play an important role in the research process.
 

A note of caution needs to be struck, however, about what the results of case studies and small-sample studies can tell us and how the results of such studies can be used. Specifically, the results of case studies and small-sample studies cannot be assumed to generalize to other people or populations.
 
That is, showing that a particular treatment model or intervention was effective for one, or five, or ten people is just that: A finding that one, or five, or ten people benefitted from a particular treatment model or intervention. It is not an indication that the treatment model or intervention is likely to benefit larger groups of people (particularly groups with different cultural backgrounds or from different geographic settings). To be able to make statements about the likelihood of an intervention being effective with other groups, quantitative, inferential studies are required.
 

Furthermore, the results of case studies and small-sample studies almost never have confirmatory or disconfirmatory value. That is, the data from such studies, as usually conducted in our field, cannot be used by themselves to either validate or refute a particular belief. Not only is it incorrect to cite a single case or a handful of cases as proof that a certain treatment model or intervention works, but it can also actually be dangerous to do so. This is something that we, who work in the field of sexual offending, have seen firsthand and all too often. Time and again, we have seen legislatures draw up and enact well-intentioned, but ultimately failed, laws based on a single case or a handful of cases. This is how we ended up with public policies such as community notification and residence restrictions that likely would never have been enacted had lawmakers consulted and heeded the findings of empirical quantitative studies.
 

With so much research being conducted and published these days, it is important to understand what we can and cannot learn from various types of studies. Case studies and qualitative studies are most important in the context of discovery: exploring a new line of inquiry or further understanding the lived experiences of participants. For those purposes, case studies and qualitative studies are invaluable. For clinicians, they offer possible avenues of treatment to explore once all evidence-based treatment options have been exhausted. For researchers, they offer a hypothetical roadmap, indicating places where further quantitative research is both warranted and needed. Case studies and qualitative studies should not be used, however, to assess either the effectiveness of treatment models or interventions that have been shown by quantitative research to be effective or ineffective, or to test a particular theoretical model.
 
One final cautionary note the Research Committee would like to offer relates to confirmation bias, the tendency to seek out and favorably view research that supports our beliefs and discount research that refutes our beliefs. Confirmation bias is a natural human tendency. We all want to believe that what we believe is correct, that what we are doing is good. As such, it is easy to look for findings that support our convictions and to search for reasons to discount the findings of studies that do not support our beliefs or actions. It is problematic, however, to hold up a case or a handful of cases as evidence that a particular empirical finding is wrong or that the finding does not apply to us and our unique circumstances. Case studies are valuable and can stimulate empirical research studies that researchers can and should conduct, but they are a starting point and cannot replace the findings of rigorous empirical research.
 
Being evidence-based means being open to the results of all rigorously-conducted research, even research that contradicts our beliefs or tells us that we should be doing things differently. It means being vigilant and explicit about the certainty and uncertainty of our claims, interpretations, conclusions, and recommendations. It means recognizing that although almost all research methodologies can contribute some insight, that does not mean that all research should be considered equal in quality or in the weight given to it. It means recognizing that informed speculation is valuable and necessary to bridge the gap between what has been demonstrated by available evidence and what has not yet been rigorously tested, but that speculation should not be used to circumvent available evidence.

Being evidence-based is tough and occasionally unpleasant. It means being open to the idea that we are wrong, that what we believe is not accurate, and that we should adjust our actions accordingly.

Friday, April 26, 2019

Treatment Options and Outcomes for the Other Recidivism

By Norbert Ralph, PhD, MPH
 
Please note that this is Part 2 of a 2 part blog, Part 1 can be found here. Kieran
 

In a recent blog posting (Ralph, 2019) I discussed the "Other Recidivism", that is nonsexual recidivism, for juveniles who sexually offended (JwSO). Caldwell's (2016) meta-analytic study of research since 2000, found low base-rates for sexual recidivism (2.75%) but nonsexual recidivism was 27.25%, 10 times higher. Steinberg, Cauffman, and Monahan (2015) studied 1,300 serious juvenile offenders and found that individuals who psychosocially mature are more likely to desist from criminal behavior. Cauffman, Skeem, Dmitrieva, and Cavanagh (2016) in assessing psychopathy found that increased psychosocial maturity was associated with decreased psychopathy scores in juveniles. Férriz Romeral, Sobral Fernández, and Gómez Fraguela (2018) in their recent meta-analytic study found that lower levels of moral reasoning were associated with juvenile recidivism generally, but a higher effect was found for older adolescents and females.
 

Methods to promote psychosocial maturity
 

The above findings are complemented by research providing evidence that specific treatment methods are associated with increasing psychosocial maturity in juvenile probation populations. Moral Reconation Therapy (MRT) promotes moral reasoning for juveniles (Little & Robinson, 1988). Two studies (Burnette, et al., 2003; Burnette, et al., 2004) showed positive changes with youth on probation using MRT, including increases in the level of moral reasoning. Brown (2016) in a more recent study using a sample of 86 offenders in Colorado found that juveniles who completed MRT treatment were 3.89 times less likely to re-offend compared to non-completers. Aggression Replacement Training (ART) (Goldstein, Glick, & Gibbs, 1998) is another treatment method with significant research which promotes prosocial maturity in probation youth. It has modules promoting social skills, moral reasoning, and anger control. Its effectiveness with juveniles on probation has been described in research studies (Goldstein, Nensén, Daleflod, & Kalt, 2005). Amendola and Oliver (2010) note that ART is a "Model Program" for the United States Office of Juvenile Justice and Delinquency Prevention and the United Kingdom Home Office. Also, Ralph (2015a; 2015b) in three studies with ART with JwSO found beneficial outcomes on psychological measures.
 

A meta-analysis and review of effective practices for juveniles on probation was done by Lipsey (2009). He notes that the most effective methods associated with reduced recidivism for probation youth in rank order are approaches which utilize: 1. Counseling, 2. Skill building, 3. Multiple wrap-around services, 4. Restorative justice methods, and 5. Surveillance (structured probation supervision). The approaches that used counseling and skill building can be characterized as promoting psychosocial maturity. Kettrey & Lipsey (2018) suggested that best practices for treatment of JwSO should include interventions for the general probation population. While treatment in the eight studies reviewed was associated with reduced sexual recidivism, the effect was not statistically significant, although there was a significant treatment effect for decreased general recidivism.
 
Two studies by the author using a prosocial skills training workbook (Ralph, 2016; Ralph, 2019a) used outcome measures of psychosocial maturity. In both studies, an instrument rating prosocial behaviors of adolescents completed by counselors was used before and after treatment. Total scores for the instrument showed statistically significant gains in prosocial characteristics in both studies. An item analysis showed statistically significant changes in the following areas: 1. Cooperation with adults and rules, 2. Improved emotional control and regulation, 3. Resisting peer pressure, and 4. Planning and thinking ahead.
 
Discussion
 

This brief literature review describes that interventions to promote psychosocial maturity and moral reasoning are associated with desistance from criminal behaviors in juveniles. These treatment methods have been used with JwSO. Interventions to promote psychosocial maturity are cost-effective and can be readily implemented in most programs (Ralph, 2017). These approaches, along with supportive family, school, and neighborhood environments, can likely promote prosocial functioning not only in probation youth generally but JwSO.
References

 
Amendola, M., & Oliver, R. (2010). Aggression replacement training stands the test of time. Reclaiming Children and Youth, 19, 47-50.

Brown, B. L. (2016). The Efficacy of Juvenile Moral Reconation Therapy in Gunnison, Colorado. (Doctoral dissertation). Retrieved from , ProQuest Dissertations Publishing, number 10253255.
 

Burnette, K. D., Swan, E. S., Robinson, K. D., Woods-Robinson, M., & Little, G. L. (2003). Effects of MRT on male juvenile offenders participating in a therapeutic community program. Cognitive-Behavioral Treatment Review,12(2), 2-5.
 
Burnette, K. D., Swan, E. S., Robinson, K., Woods-Robinson, M., & Little, G. L. (2004). Treating youthful offenders with moral reconation therapy: A recidivism and pre-posttest analysis. Cognitive-Behavioral Treatment Review, 3(4), 14-15.
 
Caldwell, M. F. (2016). Quantifying the Decline in Juvenile Sexual Recidivism Rates. Psychology, Public Policy, and Law. Advance online publication. http://dx.doi.org/10.1037/law0000094
 
Cauffman, E., Skeem, J., Dmitrieva, J., & Cavanagh, C. (2016). Comparing the stability of psychopathy scores in adolescents versus adults: How often is “fledgling psychopathy” misdiagnosed? Psychology, Public Policy, and Law, 22(1), 77-91. doi:10.1037/law0000078
 
Férriz Romeral, L., Sobral Fernández, J., & Gómez Fraguela, J. (2018). Moral reasoning in adolescent offenders: A meta-analytic review. Psicothema777, 30(3), 289-294.
 
Goldstein, A. P., Nensén, R., Daleflod, B., & Kalt, M. (Eds.). (2005). New perspectives on aggression replacement training: Practice, research and application. John Wiley & Sons.
 
Goldstein, A., Glick, B., & Gibbs, J. (1998). Aggressions replacement training (Rev. Ed.), Champaign, IL: Research Press.
 
Kettrey, H., & Lipsey, M. (2018). The effects of specialized treatment on the recidivism of juvenile sex offenders: a systematic review and meta-analysis. Journal of Experimental Criminology, 14(3), 1-27.
 
Lipsey, M. W. (2009). The primary factors that characterize effective interventions with juvenile offenders: A meta-analytic overview. Victims and Offenders, 4, 124-147.
 
Little, G. L., & Robinson, K. D. (1988). Moral reconation therapy: A systematic step-by-step treatment system for treatment resistant clients. Psychological Reports, 62(1), 135-151.
 
Ralph, N. (2015a). A follow up study of a prosocial intervention for juveniles who sexually offend. Sex Offender Treatment, 10(1).
 
Ralph, N. (2015b). A longitudinal study of factors predicting outcomes in a residential program for treating juveniles who sexually offend. Sex Offender Treatment. 10(2).
 
Ralph, N. (2016). A validation study of a prosocial reasoning intervention for juveniles under probation supervision. Sex Offender Treatment. 11(2).
 
Ralph, N. (2017). Prosocial Treatment Methods for Juveniles Who Sexually Offended. ATSA Forum, IX (3).
 
Ralph, N. (2019a). A Replication of a Prosocial Reasoning Intervention for Juveniles. Manuscript submitted for publication.
 
Ralph, N. (2019b). The Other Recidivism. Manuscript submitted for publication.
 
Steinberg, L. (2015). Age of opportunity: Lessons from the new science of adolescence. Boston: Mariner Books, Houghton Mifflin Harcourt.
 
Steinberg, L., Cauffman, E., & Monahan, K. (2015). Psychosocial Maturity and Desistance From Crime in a Sample of Serious Juvenile Offenders. Retrieved February 4, 2019, from https://www.ojjdp.gov/pubs/248391.pdf

Wednesday, April 17, 2019

The impact of working with sex offenders: how to take care of yourself as a professional working with (sex) offenders?

By Marije Keulen-de Vos, Minne De Boeck & Kasia Uzieblo (Dutch Chapter of ATSA, NL-ATSA)

On March 26th NL-ATSA, the Dutch Chapter of ATSA organized a symposium in Utrecht (the Netherlands) on the impact of working with sex offenders. Colleagues from police and forensic hospital settings addressed the issue of secondary trauma. Secondary or vicarious trauma relates to the behavioral and emotional consequences of exposure to the traumatic events experienced or inflicted by others. These traumatic experiences in professionals may include changes in the professional’s sense of self, interpersonal relationships, and behavior. Individuals working in mental health care are among the occupational groups identified as being at high risk of secondary trauma (Moulden & Firestone, 2007). Nevertheless, there is fairly limited research on this topic, let alone on traumatic experiences in professionals working with sex offenders. 

The first presenter, Henk Sollie (Phd., Twynstra Gudde, the Netherlands), focused on the mental resilience of police offers who investigate cases involving child sexual exploitation material (CSEM). Based on observational studies and semi-structured interviews, he examined what CSEM investigators consider demanding working circumstances and how they cope with these burdens. Henk Sollie’s studies show that many police officers may experience signs and symptoms of vicarious trauma at some point in their career as they often experience great internal and external pressure to cover the overwhelming number of leads that they receive, to substantiate cases, and to save lives. Many of these investigators voice a firm unwillingness to “abandon” the victims by changing work assignments. Also, exposure to disturbing photographs and videos, and intense contact with perpetrators and victims have an enormous impact on their well-being and on their personal life. For example, many remain preoccupied with (old) cases, many experience sexual problems within their own intimate relationship and/or struggle with the enjoyment of physical contact with their children. An important element in being able to deal with the emotional impact of CSEM investigations is mental resilience. Henk Sollie defines resilience as “the outcome of a coping process in which internal and external resources enable a criminal investigator to continue to function throughout stressful situations and to recover from such situations in a sustainable manner while retaining their motivation to carry on with their investigative work”. The stress associated with exposure to such traumatic events as child sexual abuse can be mitigated further by applying adaptive, proactive coping strategies such as compartmentalizing one’s emotional response to the disturbing content, pressure regulation (i.e., workload prioritization), task autonomy and social support. These strategies also depend on organizational resources, for example, joint instead of single case responsibility, classification software and design of the workplace. Henk Sollie concludes that the everyday mental resilience in these officers does not come from rare and special qualities but should be rather considered as the result of the everyday magic of ordinary resources. 

The second presenter, Anneloes Huitema (De Waag, Utrecht, the Netherlands), focused on the prevalence and severity of aggressive incidents in a forensic psychiatric hospital. Her study is part of Nienke Verstegen’s Ph.D. research (Vander Hoevenkliniek, Utrecht, the Netherlands). They have retrospectively analyzed over 3600 aggressive incidents by using the Modified Overt Aggression Scale in both forensic patients who are judged being legally insane and patients who have received forensic mental health care under civil law. Prevalence rates of incidents are substantially higher in the latter group. The latter group is often admitted to the hospital when they experience a crisis situation, which may explain these higher rates. Of all types of incidents (verbal, physical, sexual), verbal transgressions are most common with 2667 reports. Only a minority of incidents, 157 out of 3600 incidents, are characterized by sexual transgressions (e.g., rape, indecent remarks). Also, female patients are responsible for a relatively higher number of incidents than male patients. Remarkably, forensic patients who have committed a sex offense seem to cause less aggressive incidents compared to non-sex offenders. Notwithstanding these interesting findings, it is important to realize that these numbers probably regard an underestimation of the true prevalence of aggressive incidents in the forensic psychiatric hospital. 

In the final two presentations, Nicole Strijbos (de Rooyse Wissel, Venray) and Maarten Hoogslag (Dutch Institute for Psychotrauma) discussed how professionals can stay “healthy” when working with sex offenders. Nicole Strijbos is a member of a peer support and guidance committee in the forensic psychiatric clinic De Rooyse Wissel. This committee offers collegial support when colleagues experience aggressive incidents. In case of an incident, the committee provides immediate care and support and subsequently schedules three meetings with the colleague(s) in question. The first meeting (after 24 to 72 hours after the incident) focuses on structuring information, exploring current symptoms (e.g., poor sleeping, reliving the incident) and providing tools on how to deal with these symptoms. The second meeting is after one to two weeks after the first meeting. The aim of this meeting is to reflect on the situation and to explore possible symptoms of trauma. Four to six weeks after the incident, the third meeting takes place. In this meeting, the processing of and giving meaning to the incident is being addressed. If necessary, colleagues are referred to as a licensed trauma psychologist. The main purpose of this support system is to help those involved regain control and attribute meaning to events. Nicole Strijbos presented real-life case examples and discussed several do’s (e.g., respond to feelings of colleagues, ask open questions) and don’ts (e.g., encourage recovery and try to offer an immediate solution). 

The symposium closed with an interactive workshop. In this workshop, Maarten Hoogslag elaborated on possible self-protective skills for professionals working with (sex) offenders. Two actors were re-enacting real-life therapist-client interactions in which the bounds of the therapist were being overstepped by the client. Throughout the plays, participants were invited to provide input for these reenactments. Hoogslag’s take-home message was to always address the situation at hand, to set clear bounds, and to assess the nature of the aggressive behavior in the patient (i.e., is it personal or not) in order to enable a more efficient and self-protective response to this behavior. 

The fact that this symposium was sold-out, as well as the grateful feedback during and after the event, illustrates that many practitioners are struggling with how to deal with aggressive behavior in (sex) offenders. Opportunities to share best practices and more research to obtain an in-depth understanding of these aggressive behaviors in forensic patients and their impact on the professional’s well-being are clearly highly needed. 

Friday, April 12, 2019

The MASOC/MATSA conference and thoughts on why we do this work



By David S. Prescott, LICSW

The partnership between MASOC and the Massachusetts chapter of ATSA took place last week in Marlborough, MA. Now in its third decade, this conference has become one of the most successful of its kind in the world. This year’s presenters came from as far away as Australia and Sweden. Participants traveled from California and Iceland. Just as significantly, these people were not just coming for the first time; they’re regulars.

It’s hard to describe what makes the MASOC-MATSA experience work so well. Marlborough is not close to Massachusetts’ most desirable destinations. Not only is the hotel not the best in the world; it probably isn’t even the best hotel in Marlborough. Outsiders naturally wonder: what is it that makes the experience so special?

In the end, the MASOC/MATSA conference magic comes down to the people who organize and participate in it. Before his untimely passing a few years ago, MASOC founder and pioneer Steve Bengis was the most outward-facing representative of the conference. He would stand for hours at a spot equidistant from the registration tables, hotel elevators, and walkway to the exhibitors, welcoming one and all. As much as Steve is missed, it is remarkable how the conference organizers, almost all of whom have been around since the beginning, continue to create the same atmosphere. It is one that isn’t just welcoming, but about coming home.

There were numerous offerings this year. Personally, I attended an excellent intensive full-day presentation by Russ Pratt on adolescents and pornography, in which he described his “savvy-consumer” model. It is a framework for how adults can guide youth through the ubiquitous, porn-related dilemmas and controversies that they experience as they grow up. Robert Kinscherff gave an excellent half-day pre-conference workshop on neurobiology, human development, and attachment. Keith Ramsey presented an excellent overview of mindfulness research and application within broader empirically supported frameworks. Perhaps the most dynamic of all was Laurie Guidry’s keynote. Many outside of the Northeastern US don’t know just how highly regarded – and loved – Laurie is. She has been a teacher to many up-and-coming professionals. Her keynote focused on the need for all professionals in our field (as she explained it) to build on the #metoo-movement momentum and break through the reactive noise that pervades efforts to inform public conversation and policy. At her invitation, dozens of people who have survived sexual abuse joined her on stage in solidarity.

In the end, the conference experience always comes down to people. For me, the turning point came in a quiet side conversation with Alissa Ackerman at a large dinner gathering.  We both agreed that after too many months of working at a breakneck pace, we both felt immensely restored simply being together with so many people united in a common cause.

I then returned home only to engage in dialog with others outside of our field. I took part in a social-media discussion about honoring those victimized by abuse and oppression. One person felt that cultivating compassion for those who have caused harm and oppression sends the wrong message to those who have been abused. My point was that the emerging consensus in research is that they are often the same people. In the end, my thinking about our work, refreshed by my colleagues at the MASOC-MATSA conference is that it is time not only to influence the direction of public dialog and policy, but that we can do so by asking the right questions based on our empirical and practical knowledge. For example:

·         Can we reduce oppression and harm by understanding those who cause oppression and harm?
·     To what extent are those who have harmed and oppressed others willing to change? How effectively can we help them if we don’t work to understand and have compassion for them?
·        Are those who harm and oppress ambivalent about their own actions, or at least those actions that are within their awareness?
·         Can we improve our understanding and work by developing compassion for them?
·         How do we reconcile the disparities when those who have harmed and oppressed have themselves experienced harm and oppression?
·   Under what conditions can/should we be compassionate towards those who have harmed or oppressed?
·         Do people who harm and oppress also suffer? 
·       Have those who have harmed and oppressed also experienced harm and oppression as a result of their own actions?
·         Should we not use treatment to (at least partially) address this harm?
·       Are there some types of human being that are simply irredeemable and with whom we shouldn’t use treatment ever? If so, who are they?
·         If we decide that there are some human beings to whom we should not provide treatment, at what point do we begin to throw other humans away or kick the solutions further on down the road into the future?
·        Under what conditions do we begin to view other human beings as unworthy of assistance? Do we then risk creating our own forms of harm and oppression?


Thursday, April 4, 2019

The Other Recidivism.

By Norbert Ralph, PhD, MPH

Please note this is part 1 of a 2-part blog, part 2 will follow over the next couple of weeks. Kieran

In 2001 when I started treating juveniles who sexually offended (JwSO) the focus was on sexual crime and sexual pathologies. This approach was described in publications like Pathways (Kahn, 2001), Steen and Monnette (1989), and Ryan (1999). A paradigm shift was crystallized by Calwell's article (Caldwell, 2016) reporting the average sexual recidivism for JwSO since 2000 as 2.75% and total recidivism as 30%. This implied that for JwSO nonsexual recidivism needed to be addressed, in addition to sexual issues. In this brief blog, I'll address issues related to the "other" recidivism, nonsexual recidivism when treating JwSO, and developmental factors influencing it.

In Canadian data, 17 is the age of highest incidence of those accused of property crimes, and age 13 likewise the age of highest incident of those accused of sexual crimes against children (Statistics Canada, 2016). These ages are "humps" in these curves and crime rates decline significantly after these ages. Steinberg, Cauffman, and Monahan (2015) studied 1,300 serious juvenile offenders for seven years after conviction. Less than 10 percent of the sample could be characterized as chronic offenders. Even for juveniles who were high-frequency offenders at the beginning of the study, the majority stopped offending by age 25. They developed a measure of psychosocial maturity which included impulse and aggression control, consideration of others, future orientation, personal responsibility, and resistance to peer influences which increased through all subgroups through age 25, consistent with current research regarding brain maturity and harmful behaviors (Steinberg, 2015). Less mature individuals were more likely to be persistent offenders, and even high-frequency offenders who psychosocially mature were more likely to desist from criminal behaviors.

Cauffman, Skeem, Dmitrieva, and Cavanagh (2016) studied 202 male juvenile offenders and 134 male adult offenders, all in secure detention facilities using versions of the Hare Psychopathy Checklist. A measure of psychosocial maturity was also used. They found that there was a greater risk of exaggerating psychopathic traits with juveniles compared to adults. They noted that 37% of juveniles who met the cut score for psychopathy continued to meet this criterion two years later compared to 53% of adults. False positive errors appeared to be more common among the youngest and least psychosocially mature juveniles. Increased psychosocial maturity, in turn, predicted decreased psychopathy scores in adolescents but not adults. Férriz Romeral, Sobral Fernández, and Gómez Fraguela (2018) conducted a meta-analytic analysis of 72 studies regarding the relationship between moral reasoning and juvenile criminal behavior. They found a moderate positive effect size (d=.662) which was larger for older adolescents and females.

The above review suggests that the "other" recidivism to be targeted for assessment and intervention with JwSO is nonsexual recidivism which in the Caldwell (2016) study was 10 times the rate of sexual recidivism (27.25% vs 2.75%). A variety of instruments exist for the assessing of the nonsexual recidivism with significant research including the Structured Assessment of Violence Risk for Youth and the Youth Level of Service/Case Management Inventory (Vincent, Drawbridge, & Davis, 2019). Also Férriz Romeral, Sobral Fernández, and Gómez Fraguela (2018) reviewed methods for assessing moral development, one component of psychosocial maturity.

References

Caldwell, M. F. (2016). Quantifying the Decline in Juvenile Sexual Recidivism Rates. Psychology, Public Policy, and Law. Advance online publication. http://dx.doi.org/10.1037/law0000094

Cauffman, E., Skeem, J., Dmitrieva, J., & Cavanagh, C. (2016). Comparing the stability of psychopathy scores in adolescents versus adults: How often is “fledgling psychopathy” misdiagnosed? Psychology, Public Policy, and Law, 22(1), 77-91. doi:10.1037/law0000078

Férriz Romeral, L., Sobral Fernández, J., & Gómez Fraguela, J. (2018). Moral reasoning in adolescent offenders: A meta-analytic review. Psicothema777, 30(3), 289-294.

Kahn, T.J. (2001). Pathways: A guided workbook for youth beginning treatment (3rd Ed.). Brandon, VT: Safer Society Press.

Ryan, G. (1999). Treatment Of Sexually Abusive Youth. Journal of Interpersonal Violence, 14(4), 422-436. Doi:10.1177/088626099014004005

Statistics Canada. (2016, May 10). Young adult offenders in Canada, 2014. Retrieved from https://www150.statcan.gc.ca/n1/pub/85-002-x/2016001/article/14561-eng.htm

Steen, C., & Monnette, B. (1989). Treating adolescent sex offenders in the community. Springfield, IL: Charles C. Thomas Publisher.

Steinberg, L. (2015). Age of opportunity: Lessons from the new science of adolescence. Boston: Mariner Books, Houghton Mifflin Harcourt.

Steinberg, L., Cauffman, E., & Monahan, K. (2015). Psychosocial Maturity and Desistance From Crime in a Sample of Serious Juvenile Offenders. Retrieved February 4, 2019, from https://www.ojjdp.gov/pubs/248391.pdf

Vincent, M., Drowbridge, D., & Davis, M. The Validity of Risk Assessment Instruments for Transition-Age Youth. Journal of Consulting and Clinical Psychology, 87, 171-18