Thursday, March 14, 2019

Author Q&A with Sharon Kelley discussing “How Do Professionals Assess Sexual Recidivism Risk? An Updated Survey of Practices.”

Kelley, S. M., Ambroziak, G., Thornton, D., & Barahal, R. M. (2019). How Do Professionals Assess Sexual Recidivism Risk? An Updated Survey of Practices. Sexual Abuse. Online First
 
Abstract
 
Forensic evaluators may be assisted by comparing their use of instruments with that of their peers. This article reports the results of a 2017 survey of instrument use by forensic evaluators carrying out sexual recidivism risk assessments. Results are compared with a similar survey carried out in 2013. Analysis focuses primarily on adoption of more recently developed instruments and norms, and on assessment of criminogenic needs and protective factors, and secondarily, on exploring factors related to differences in evaluator practice. Findings indicate that most evaluators have now adopted modern actuarial instruments, with the Static-99R and Static-2002R being the most commonly used. Assessment of criminogenic needs is now common, with the STABLE-2007 being the most frequently used instrument. Evaluators are also increasingly likely to consider protective factors. While a majority of evaluators uses actuarial instruments, a substantial minority employs Structured Professional Judgment (SPJ) instruments. Few factors discriminated patterns of instrument use.
 
Could you talk us through where the idea for the research came from?
 
Contemporary surveys of practitioners who complete sexual risk assessments are important for researchers, evaluators, and decision-makers. Researchers benefit from staying informed of what methodologies are actually being implemented in practice in order to consider whether additional research or more effective strategies of communicating research results are needed. Decision-makers such as courts need to have objective data to help guide their understanding of what results should be taken under consideration and how much weight it should be given (e.g., admissibility issues). My colleagues and I also noticed that evaluators in different settings/jurisdictions tended to develop their own norms and culture regarding what is considered common risk assessment methodology, but we wondered how that might translate into the larger field. We also found that while other surveys provided useful information, we were interested in factors that had not yet been examined such as use of old versus new static instruments, use of criminogenic needs instruments, and how evaluators chose to communicate the results of such instruments. 
 
What kinds of challenges did you face throughout the process?
 
We initially had the idea to conduct a survey in 2013, but we chose to add a few survey questions to a larger study on evaluator decision-making that we were conducting at the time. As a result, the information we obtained was fairly limited. However, the process allowed us to better consider the questions we wanted to know, and we set to work designing an independent research project. Designing survey questions is actually more difficult than it appears. In 2017, we spent a considerable amount of time designing the survey and deliberating on the wording of the questions. Even so, after the data was collected and analyzed we recognized the need for additional questions or how existing questions could have been re-worded to better understand the results. Obtaining participation is also a challenge with online surveys. Getting formal approval to utilize the ATSA-listserv and American Psychology – Law Society (AP-LS) email distribution list was important in achieving our results. However, future surveys will need to get formal approval to reach international forensic professional groups as well.

What do you believe to be the main things that you have learnt about the professional practices in assessing Sexual Recidivism Risk?
 
Overall, most practitioners are modifying their methodology to keep up with research advances including using newer static and criminogenic needs instruments as well as communicating risk results based on current norms. However, there continues to be practitioners using older static instruments (e.g., RRASOR) as well as outdated norms associated with these instruments. Divergence was notable in how evaluators appear to be choosing the Static-99R normative group (i.e., Routine/Complete vs. High Risk/Needs groups) and their use of a criminogenic needs measure to assess for dynamic risk factors and treatment change. Within the sample, about 22% reported not using a criminogenic needs instrument due to concerns that the research was insufficient to support its use and concerns about the adequacy of the norms. Similarly, of those who reported that measuring treatment gains was relevant to their work, a third did not use a formal instrument to assess for treatment progress. This divergence did not appear clearly related to educational activities, years of experience, and freedom in selecting their own instruments. However, the tendency to only use the Routine/Complete Static-99R norms was associated with evaluators working in private practice regardless of the setting in which they worked (e.g., outpatient vs. forensic commitment).
 
Now that you’ve published the article, what are some implications for practitioners?
 
 While we were unable to ascertain why some practitioners continue to use older measures and norms, we did identify concerns related to new measures of dynamic risk and treatment need. Frequent concerns were related to a lack of research demonstrating their validity and reliability, concerns about the instruments’ norms, and the belief that no existing measure can predict a reduction of sexual recidivism due to treatment change. Ultimately, the decision to adopt measures and make changes to one’s methodology will be based on demands of the environment and evaluator standards, and this will be different between jurisdictions and practitioners. Our concern is the possible tendency of overlooking or discounting new research findings and becoming comfortably “stuck” in old practices. As such, we emphasize that a good standard of practice would involve making a priori determinations of what one would need (e.g., research or norms), staying informed of research advances, and then changing methodology once the predetermined criteria are met. Such determinations should also be consistent with professional guidelines (i.e., Section 6.08 of the 2014 ATSA Adult Practice Guidelines). Use of forensic checklists can be important in determining when to start or stop using an instrument. I strongly suggest utilizing a checklist or table to track the pros and cons for each instrument under consideration, and to modify this document over time as research advances. I have provided an example of what I termed an Informed Decision-Making Table, which readers will be able to retrieve by contacting me at SharonM.Kelley@dhs.wi.gov. 

Thursday, March 7, 2019

Good Intentions or The Proverbial “Road to Hell?”: Trying to Understand the APA guidelines for Men and Boys.


By David S. Prescott, LICSW & Scott D. Miller, Ph.D.
 
Note: This will also be reposted on Scott’s own blog site as well. Kieran
 
Several weeks ago, the American Psychological Association (APA) released its latest in a series of practice guidelines for psychologists – this time for “Psychological Practice with Boys and Men.”   Prior years had seen guidelines focused on ethnicity, older adults, girls and women, LGBT, and “transgender and gender-non-conforming” persons.
 
Curiously, despite claiming to be based on 40 years of research, and the product of 12 years of intensive study, the latest release attracted little attention.  More, the responses that have appeared in print and other media have largely been negative (1, 2, 3, 4, 5). 
 
What happened?

At first blush, the development and dissemination practice guidelines for psychologists would seem a failsafe proposition.  What possibly could go wrong with providing evidence-based information for improving clinical work?  And yet, time and again, guidelines released by APA end up not just attracting criticism, but deep concern.   Already, for example, a Title IX complaint has been filed against the new guidelines at Harvard.

Consider others released in late 2017 for the treatment of trauma.  Coming in at just over 700 pages ensured few, if any, actual working professionals would read the complete document and supportive appendices.  Beyond length, the way the information was presented–especially the lack of hypertext for cross referencing of the studies cited–seriously compromised any straightforward effort to review and verify evidentiary claims.  Nevertheless, digging into the details revealed a serious problem:  none of the specific approaches “strongly recommended” in the guidelines had been shown by research to be more effective than any other. 

 
Guidelines are far from benign.  They are meant to shape practice, establishing a “standard of care” -- one that will be used, as the name implies to guide training and treatment.  As such, the stakes are high, potentially life altering for both practitioners and those they serve. 
 
And so, on reading the latest release from the APA, we wonder about the consequences for men and boys.  Even a superficial reading leaves little to recommend “being male.”  Gone are any references to the historical or current contributions of men -- to their families, communities, marginalized peoples, culture, or civilization.  In their place, are a host of sweeping generalizations often wrapped in copious amounts of politically, progressive jargon on a wide variety of subjects, many of which are the focus of research and debate by serious scientists (e.g., the connection between media violence and male aggression, socialization as a primary cause of gender and behavior, the existence of a singular versus multiple masculine ideal, etc.). 
 
Cutting to the chase, when viewed in this way, is it any wonder really, that many men – as the document accurately points out – “do not seek help from mental health professionals when they need it?” (p. 1). 
 
And lest there be any doubt, men as a group, are in need help. 
 
You’ve likely read the statistics, seen examples in your practice, perhaps in the life of your family or friends.   It starts young, with boys accounting for 90% of discipline problems in schools, and continues to the end of life, with women living 5 to 10 years longer on average.  The “in between” years are not any better, with men significantly more likely to be incarcerated, addicted to drugs, drop and fail out of school, and end their lives by suicide.    
 
To be clear, the document is not overarchingly negative.  At the same time, if our goal, as a profession, is to reduce stigma -- which previous, and even the present, guidelines do for other groups and non-traditional males -- then the latest release risks perpetuating stereotypes and prejudices of “traditional” men and the people in their orbit.
 

Sticking to the science of helping, instead of conforming to popular standards of public discourse, would have lead to a very different document – one containing a more nuanced and appreciative understanding of the boys and men who are reluctant to seek our care.  In the fractious times in which we find ourselves, perhaps it’s time for guidelines on how to live and work together, as individuals and as a species.

Thursday, February 28, 2019

Supporting foster parents for positive outcomes for youth with sexual behavior problems

A ATSA Prevention committee blog by Rene McCreary with MOCSA at rmccreary@mocsa.org and Julie Patrick with RALIANCE jpatrick@raliance.org

In 2017, the Metropolitan Organization to Counter Sexual Assault (MOCSA) collaborated with RALIANCE via an impact grant to provide therapy for youth with problematic sexual behaviors (YPSB). Despite research showing this at-risk population benefits from counseling (Amand, Bard & Silovsky, 2008), far too often families, caregivers, and service providers lack information and access to help – this includes foster families.

According to the National Center on the Sexual Behavior of Youth, significant risk factors for youth to exhibit sexual behavior problems include many of the experiences foster youth know all too well—parental loss, disruptions or inconsistent care, unsafe environments, witnessing violence, neglect and abuse. Traumatic events are found to be one cause of sexual behavior problems in children (NCTSN, 2009). While little research exists on the percentage of foster children exhibiting sexual behavior problems, foster children experience high levels of trauma, a significant risk factor for sexual behavior problems in children (NCTSN, 2009).

MOCSA’s project appealed to 4,000 case managers, social workers, and caregivers who support nearly 1700 foster care youth in Kansas City, with an open invitation to attend either an in-person workshop or webinar on YSBPs. These trainings resulted in numerous referrals to MOCSA, families who might not have otherwise received effective, evidence-based counseling free of charge. As a result, twenty-five foster families participated in MOCSA’s program for YPSB. Ninety-six percent of youth participating in this program reported an increased knowledge in making good choices about sexual behavior, and 100% of caregivers in treatment via the program increased knowledge in responding to sexual behaviors of children. Ninety five percent of caregivers reported a significant decrease in difficulties experienced in the school setting and increased academic achievement.

While this met the needs and the stipulations of the initial project design, MOCSA and RALIANCE worked together to design a new direction for the project.

Lesson 1: Listening to caregivers

MOCSA’s Youth with Sexual Behavior Problems Program is well established. Formally initiated in 2006 and enhanced in 2014 through a federal grant from the Office on Juvenile Justice and Delinquency, this nationally recognized program provides children and caregivers 12 to 27 weeks of counseling, with each session lasting 60 to 90 minutes.

At the same time, MOCSA also emphasized the importance of  listening to the unique needs of caregivers living with and helping foster youth manage their behavior effectively—recognizing these foster parents as the experts on practical methods to work with these specific youth.  

A series of four one minute videos was developed to support and empower caregivers. The material for these videos was gleaned from recording a structured conversation of focus groups with foster parents as well as case managers. The following themes emerged: understanding the issue, first reactions, building a network of support, and the resiliency powered by the difference they are making. Between Facebook, Instagram, YouTube, and LinkedIn, these videos achieved 254,952 impressions and 718 clicks.

Lesson 2: Kids in the system

MOCSA also worked with partner agencies that were experiencing high demand for services for this population but who lacked knowledge on how to address these issues for system-involved youth. MOCSA conducted additional trainings and produced two six-page Resource Guides — one for foster families and one for professionals.

Additionally, the focus group generated two critical insights about the barriers caregivers face when deciding when/how to reach out for help: 1) foster caregivers are hesitant to seek services for PSBs out of fear of losing their licenses as foster parents, and 2) It is difficult to locate mental health professionals who are trained to provide high quality treatment to these youth and their families. Both these insights have shaped how MOCSA conducts outreach to parents in the system as well as therapy for clients and their families.

Overall, the additional outreach, training, and collaborative efforts allowed MOCSA to reach vastly more people than originally intended. But it also availed the opportunity to develop the internal resources and tools—as well as the research—to expand our outreach and improve clinical practices with children and their caregivers. Along the way, the support of RALIANCE was crucial. As a partner invested not just in the stewardship of funding but in the lives of people “on the ground,” RALIANCE offered a rare collaboration that aligned with the ambition MOCSA embodies for those we serve.  This project was a testament to the success of going further, and the difference MOCSA and other agencies can have in healing children and families when we work together.

RALIANCE’s impact grant program seeks to advance three core strategies to end sexual violence in one generation: Improve the response to victims of sexual violence; reduce the likelihood of perpetration of sexual violence; and strengthen communities’ capacity to create safe environments. This project succeeded on all fronts. To learn more about the project and resources produced, visit us online.

References

St. Amand, A., Bard, D.E & Silovsky, J.F. (2008). Meta-Analysis of Treatment for Child Sexual Behavior Problems: Practice Elements and Outcomes, Child Maltreatment

(13) 145-166. DOI: 10.1177/1077559508315353

Thursday, February 21, 2019

A plea for compassionate self-care

By David S. Prescott, LICSW

Several years ago, I confided to a colleague that I had no history of sexual victimization. Although many of my closest friends have survived sexual abuse and only some discuss it publicly, I have not experienced it personally. I told my friend that this has sometimes posed a dilemma for me: so many people have experienced so many kinds of abuse that I almost never share the fact that I haven’t. I commented to this person that it sometimes seems strange that I keep my own lack of an abuse history private. “I haven’t been traumatized”, I said. “Wait a minute, David”, she said, smiling. You want to tell me that you’ve worked in the field of sexual violence prevention for over 30 years and you haven’t been traumatized?”

Silence followed. I remembered a nightmare from the early 1990s when I dreamed about a client approaching me in the dark, arms bleeding from self-harm, begging me to help him. I thought about all the times I’ve heard arguments in public places and briefly wondered about my status as a mandated reporter of abuse. I thought about all the times I hoped and prayed that my own children would not be abused and all the (likely unnecessary) steps I had taken to prevent it from happening. Then I thought about how unfair it seemed to think of myself as having paid a significant price for working in this field when so many of my colleagues had experienced much worse. It was a long time before I realized that this kind of “others have it worse” thinking actually facilitates the secondary trauma (also known as vicarious trauma) of doing this work.

I offer the above, not because it’s particularly special, but because this response to our work is so commonplace. Yes, I’ve had it lucky, but never easy. The simple fact is that this work has a cumulative effect; a kind of second-hand smoke of the soul. Others haven’t done so well.  In one famous case, a charismatic forensic psychiatrist went public about the PTSD he had acquired from doing his work. In a much sadder situation, a highly respected forensic psychologist committed suicide after revelations that he had placed a webcam in the staff’s bathroom in his office. Other cases abound.

A major problem is that professionals rarely talk openly about the effect that this work has on us. If we’re honest, all too often we can resort to our own bad habits related to anything from poor nutritional choices to what leadership guru John C. Maxwell has called the “3 A’s” of alcohol, arrogance, and adultery. Many a good career has gone bad not because of a specific incident, but because of the slow build-up of doing the work without an explicit regimen of self-care.

Another problem is that it is easy to grasp the idea of secondary traumatization when reading an article or blog post, but not so easy to recognize its role in our lives. It can be harder still to take action, establish a plan for deliberate self-care, and maintain it across time. And again, we need to talk about it more, and I will again offer myself up as a case in point. This is our 302nd blog post since 2010, and yet it is the first time this topic has received direct attention.

Adding to the confusion are all of the positive effects of doing this work. Like many others, I’ve become a better citizen, neighbor, father, husband, and man as a result of working in the fields of trauma and abuse; it’s difficult to imagine doing anything else. Yet I am quite certain I couldn’t keep going if it weren’t for an explicit focus on daily exercise, yoga, and meditation. Yes, these aren’t for everyone; for others, it can be anything from artwork to cooking to bird watching to the right vacations.

For a brief period of my life, I lived in Minnesota and worked closely with former employees of the Department of Corrections. They had a saying: “If you don’t get a break from working on the farm, you’ll start to smell like the barn.” It was a lovely way of saying that we can easily become influenced – and not in a good way – by the settings in which we work. In the spirit of camaraderie, they would remind each other, “Don’t you start smelling like the barn.”

In the end, those of us who are in this work for the long haul should remember three things about secondary trauma:

  1. The effects of secondary trauma are almost certainly inevitable. No one is beyond its reach.
  2. The effects of secondary trauma are different for everyone.
  3. Everything you need to grow beyond secondary trauma and prevent its effects already exists within you.

This last point is the most important. Self-awareness and self-observation, combined with the right intention, combined with the right action, can accomplish wonders. Please be careful out there!

Friday, February 15, 2019

The importance of the life course in understanding why people commit sexual offences


By Kieran McCartan, PhD & David Prescott, LICSW

We have been spending a lot of time over recent years discussing with professionals, practitioners, and policymakers the importance – as well as impact – of adverse experiences and trauma in the lives of people who go on to commit offences. These discussions have often returned the importance of the life course on offending behaviour. People who commit sexual abuse have often been exposed to adverse experiences, trauma, and problematic life course issues are not that different from the rest of the general offending population. It calls to mind the saying, “What unites us is greater than what divides us.” The implications of these findings include that we need to start thinking, across the board, about the role of trauma and adversity in people’s lives (see Levenson, Willis, & Prescott [2018] for example). Just as importantly, we have an opportunity to focus on how a trauma-informed approach can help us prevent, as well as respond, to sexual abuse.

One of the most significant criminological research in the last 40 years has been Professor David Farrington’s “Cambridge study”, a longitudinal study which looked at the impact of environment and development on criminogenic behaviour. In a nutshell, Farrington found that life course, environment, adverse experiences had an impact on an individual’s behaviour; especially in terms of anti-social or illegal activities. Farrington was talking about prevention, multi-agency collaboration, adverse childhood experiences, and trauma before any of these became buzzwords. Research into human development across the lifespan highlights the importance of understanding what happened to people to get them to the point where they have committed an offence. Commonly, professionals in our field often think about preventing re-offending rather than preventing first time offending. If we are to change our prevention paradigm, we need to re-conceptualise the way that we frame these dialogues. The reality of using life course approaches in the prevention of sexual abuse means that we must use more individual, institutional, and community-based multi-agency approaches; we must move our focus to the front end. One way to change our outlook and practice is to frame it within the model of trauma-informed practice.

Trauma-informed practices emphasise the need for practitioners, institutions, and organisations to be aware of the traumatic events, or experiences, that the people that they work with have gone through. Being trauma-informed means asking, “what happened to you?” as well as “what motivated you to do that?” It also involves exploring what’s right with someone and not simply what’s wrong with them; What strengths, positive goals, and protective factors (or “promotive” factors, as Farrington has called them) do this client have that can help them to prevent offending?

Having a trauma-informed approach further involves looking at the life course of the individual and how it has shaped them so that professionals can identify how to help them in moving forward with their lives, building an overarching sense of wellbeing and developing a lifestyle in which offending would be unwanted and unnecessary. It might also involve helping others in similar situations to prevent offending.  As trauma and adversity are central to the lives of people who commit offences, particularly sexual offences, being trauma-informed is a critical part of the foundation to our work with these populations; the correlation between victimization and perpetration is closer than we recognize or, sometimes, that like to consider. Therefore, we need to consider where trauma-informed practice fits in the training of professionals, in media coverage of, and the way that we engage with the public around sexual abuse. 



Friday, February 8, 2019

The collateral consequences of sexual abuse


By Kieran McCartan, PhD, & David Prescott, LICSW

With this post, we have hit a milestone. This is our 300th posting, and the blog has had 375,000 individual “hits” since the blog’s inception eight years ago in February 2010. Over the past eight years, the blog has had several contributors outside of the main blogging team (which has included Alissa Ackerman, Jon Brandt and original blogger/founder Robin Wilson) some infrequent and others more sustained (like the ATSA Prevention committee). All of this has happened with the support of ATSA and its Journal, Sexual Abuse. We are grateful to everyone who has been involved as well as to all of you who read the blog and keep coming back each week!

This blog has addressed diverse issues throughout its existence, so with this post, we focus on the idea of “collateral consequences” in the area of sexual abuse. Primarily an American term, collateral consequences are the unintended outcomes – generally negative – of certain policies and practices. The field of sexual abuse is littered with policies and practices that have negative unintended outcomes. Either separately or in combination, these collateral consequences include barriers to community reintegration of people who have committed sexual offences, horrific experiences for those who have been abused, and the capability of professionals to provide a meaningful service.

For example, in the time that this blog has existed, we question whether there has been any improvement in the collateral consequences, particularly in the USA, in four over-arching areas:

People who have committed sexual offences: Despite strong evidence that measures such as public registries and residency restrictions don’t work to reduce risk or prevent re-offence and can easily make matters worse, they remain in effect. There is little indication that these measures will be re-examined at any time in the future, except for the registration and notification policies linked to juveniles which are being examined. Interestingly, other countries have learnt from the USA’S experience and not replicated the registration and/or community notification policies in the same way; the American version has acted as a cautionary tale in other contexts. Sadly, it seems that in society’s rush to punish, the extant research into what works has gone largely ignored.

Those who have been victimized: For all of the recent media attention on survivors of sexual abuse, including in the #metoo movement, it is difficult to discern whether any lasting changes are being made that will actually improve the lives of those who have survived abuse. On one hand, the international dialogue is welcome and timely. Indeed, rates of reported sexual abuse have gone down across the past few decades. On the other hand, we can find no broad evidence that the experience of survivors has improved across the board in recent years and in some instances, there has been a greater societal backlash as a consequence of the increased societal awareness of sexual abuse.

Friends, families and colleagues: The silent anguish of the family, friends, and colleagues of those who have abused remains an under-acknowledged area of harm. These people have few places to turn for support, particularly when the person who has abused returns to the community. We generally think about the collateral consequences of criminal justice sanctions on families and networks, but we are starting to see and hear of the collateral consequences of supporting non-offending or at-risk individuals too.

Professionals who work in the field of sexual abuse: Finally, although anecdotal, the stories of those who research and treat people who have abused often illustrate that there can be little gratitude for the work they do in building healthier lives and safer communities. Indeed, the work itself can have cumulative effects and can often result in secondary traumatization, which reinforces the need for effective and ongoing staff development. This is particularly important in developing resilience and preventing burn out.

One of the main ways that we can combat the collateral consequences linked to sexual abuse is through better joined up, multiagency and long-term policy and practice. It’s important to recognise all the potential outcomes from sentencing, treatment, management, integration and support services related to sexual abuse to make sure that problems are not compounded or result in adverse (problematic) outcomes.

In the end, we continue to know what does and doesn’t work to reduce the harm of sexual abuse. The question remains as to whether society and its policymakers are willing to examine our practices and their many consequences.

Thursday, January 31, 2019

Hearing the narrative, seeing the person: Considering the appropriate research methodology

By Kieran McCartan, PhD, and David Prescott, LICSW

A memorable case discussion attended by the second author featured a consultant recommending multi-systemic treatment (MST) for an adolescent who had been acting out aggressively ever since his father’s death. The case manager was concerned about his behaviour and had just overseen an unsuccessful course of MST with this client. Despite the fact that MST hadn’t worked, the consultant recommended that it be repeated, not because it was the correct intervention for that particular individual (for whom grief counselling might also have been appropriate), but because of the strength and quality of the MST research. The situation calls to mind words from a UK practitioner during a conference in 2012: Are we personalizing our manuals or manualizing our persons?

It often seems that our field is governed by large-scale studies and quantitative evidence indicating that a particular treatment, intervention, or process either works or doesn’t work. Understandably, we look at the broader outcomes of re-offense and risk reduction to drive future processes. We (the authors) are not saying that this is wrong, but rather that practitioners should remember the individual in the process, as well as the greater cohort. Sexual abuse (and treatment for sexual abuse) is as much about personal narratives and context as it is about processes and outcomes. Sadly, our most sacred studies don’t always take into account the experiences of those who have lived through the interventions.

The prevention, treatment, and management of people who have committed, or may commit, sexual offences include features that range from the individual through to the social and cultural. One implication is that we must use multiple research methodologies to answer a range of questions that include the “service user”, the “service provider” and the facilitating institution; their “voices”. A single research methodology, epistemology, ontology, or form of data analysis will not work in all circumstances; especially given that research and practice linked to sexual abuse cross many social (politics, law, policy, sociology, criminology, psychology) and physical (chemistry, biology, psychology) disciplines, and everything in between (public health). We need quantitative studies to look at large cross-population samples and answer broad-based questions. However, is a quantitative approach the best one for small-scale, small-cohort, individualised, practice-based, policy-based or process-driven questions? No, it isn’t. We often need to consider case studies or qualitative research methods to answer these more personalised, individualized, and small cohort questions. The research question, who is asking it and why they are asking it are central drivers as different disciplines and different groups have different agendas; which is fine, as long as its transparent and clear!

We need to use the research (and treatment) method that enables us to answer the question that we are asking. We can’t fit a particular research question into a certain methodology for artificial reasons because, in reality, it will fail and jeopardise the outcome.  Certain research questions linked to prevention, treatment, management, and community integration need to be qualitative so that we can capture the appropriate narrative and understand whether the process or intervention is working at a ground level. We need a qualitative, or case-focused, approach to hear and understand the “service user” experience, or the expert voice, within the cohort sample and larger outcome. This is essential, because we need to connect research and treatment in a coherent way that does not create paradigm extremes (quantitative being the choice of “research” and qualitative being the choice of “treatment”). This happy medium incorporates multi-stage, multi-methodology, and multi-disciplinary studies in order to focus on the larger research questions as well as capturing the personal narrative. A multi-methodology approach enables us to explore treatment, research, and policy questions and facilitates a more holistic response.

Working in a politically, socially, and personally sensitive area demands that we think ethically about the research that we do and the way that we do it. Often times we need to do the complex, expensive research study that allows us to understand the reality of the situation. Unfortunately, this type of research does not happen as much, or in as much of a nuanced way, as it should.