Wednesday, December 16, 2015

Talking about individuals with learning difficulties who commit sexual harm in 500 words or less

Most programs for people who have sexually abused say they follow Risk, Need, and Responsivity. This is a good thing, but do they really do that? We know that some programs ignore risk, while others don’t really focus on specific client needs. In my opinion, however, the biggest problem with RNR is that we still don’t know what to make of responsivity.

I work with a lot of clients with intellectual disabilities or other cognitive problems. I try to make sure that clients get assessed, treated, and managed in a way that fits their special needs, but what do I mean by special needs? Is it just low IQ or some kind of brain injury, or do we need to think about other problems? What about fetal alcohol effects? What about mental illness? Also, what about clients who were in prison for a very long time who can’t think so well anymore because prison didn’t give them much practice? This definition may be a bit broad, but the point I really want to make is that clients with special needs require special treatment – with specialized tools and procedures. Sometimes, this means we have to be creative.

Now that we know who the special needs people are, how we help them with their problems? A real problem with many programs is that they don’t have books or exercises that were made for special needs clients. Can we use those programs as they were originally written? Do we just talk slower? Do we make the program longer and give it in smaller bits? Research and experience tell us that slower and longer may help some clients, but no special changes at all doesn’t really work. Slower and longer may also lead to problems. My good friend tells a story of his early career when he was trying to explain something to an intellectually disabled client – slower and longer. After getting frustrated, the client said, “Man, I’m retarded. I’m not stupid!” Easier language, with more pictures, repetition, and social stories helps. We also need to remember that nobody likes to have their nose rubbed in their problems, so respect is also really important. What we work on may end up being pretty much the same, but we need to remember that special needs requires special attention.

Managing risk also requires a different approach. Sadly, many special needs clients will never enjoy the same quality of life as their friends without difficulties. A lot of staff are now focused on the idea that special needs clients have the same rights as people without disabilities or cognitive problems. I’m not totally sure about this. I agree that all special needs clients should be able to live as normal a life as possible, but I think we need to be realistic. Do our special needs clients also have the right to good service? What if getting good service means that some clients won’t get to do what they want to? Is that fair? I understand the need to ensure equal opportunity, but being kind and caring enough not to let clients fail is also important. Bill Marshall says Warm, Empathic, Rewarding, and Directive – I agree.

So, that’s 529 words…but they’re 529 words with an average character length of 4.5 and an overall Grade level of 7.2. Still too high for most of our special needs clients, but keep in mind, I’m a psychologist.

Robin J. Wilson, Ph.D., ABPP
Sarasota, FL

Thursday, December 10, 2015

The “Who Works” Doctrine

In 1974, Robert Martinson published a now-classic text concluding that he was unable to find evidence of the effectiveness of rehabilitative efforts for people involved in the criminal-justice system. Although a section of his essay was titled, “Does nothing work?” it became known as the “nothing works” doctrine. Despite the fact that Martinson himself essentially admitted he had been wrong (Martinson, 1979), the nothing works doctrine held sway for many years until Canadian criminologists such as Paul Gendreau introduced the “something works” doctrine (meaning that it was clear that rehabilitative efforts could work, even if the exact mechanisms remained unclear), and eventually the “what works” doctrine that followed (e.g., Gendreau & Ross, 1987).
What works in treatment seems clear enough, but is it really? The principles of effective correctional rehabilitation (i.e. risk, need, and responsivity) state that we should provide more intensive treatments to those who pose the highest risk, focus on empirically supported treatment goals, and use empirically supported techniques (e.g., CBT).  The responsivity principle further states that we should match treatment to the individual characteristics of each client (e.g., cognitive ability, culture, mental health needs, motivation).
From such simple principles many controversies can emerge and great minds can disagree.   For example, one client who has sexually offended against children might benefit from treatment addressing interpersonal skills in such a way that sex with children is unnecessary and undesirable because of the client’s ability to form intimate relationships with adults. Another client might reap minimal benefits from such treatment, because it is the combination of sexual interest in children and a suite of beliefs supporting abuse that contributes more to his risk. As Tony Ward recently pointed out (Yates, Prescott, & Ward, 2010), absent an explanatory means for understanding risk factors, they may simply be markers for further investigation and understanding in programs that seek to reduce risk and build capacities.
There is no question that the principles of risk, need, and responsivity are vital contributors to “what works” in treatment. However, a robust research literature both inside and outside our field points to the fact that who the professional is can be a vital contributor to building responsivity and beyond. As a result, we are proposing a “who works doctrine” alongside the what works doctrine. The name is intended to be provocative and only slightly tongue-in-cheek, and intended as a homage to those brilliant researchers who came before us. To illustrate the importance of thinking in terms of “who works” in addition to what works, it may be helpful to review influential developments of the past.
In 1979, Edward Bordin proposed a model of the therapeutic alliance that involved agreement on the nature of the therapeutic relationship, and agreement on the goals and tasks of treatment. Subsequent research by Jon Norcross and others would also highlight the importance of having therapy take place in the context of strong client preferences (Norcross, 2011). These four areas: agreement on the nature of the relationship, goals, tasks, and values form the basis of a critical element of treatment. Over a thousand studies have pointed to the contribution of the alliance to successful therapy outcomes. Recent research has highlighted the importance of clinicians getting feedback from their clients in these areas (e.g., Lambert, 2010; Prescott & Miller, 2015). In fact, one can argue that attention to the alliance is amongst the most evidence-based therapeutic activities there is. Without it, targeting criminogenic needs is useless, and a greater waste of resources for those at highest risk (since they presumably receive the most treatment).
Likewise, Bill Marshall’s classic 2005 summary of research that he conducted with others points to the qualities of the most effective professionals (Marshall, 2005). They are warm, empathic, rewarding, and directive (in the sense of being able to guide people and processes. However, much of our field remains influenced by early texts and professionals who advocated a more overtly confrontational approach (e.g., Salter, 1988). Indeed, a 2008 meta-analysis by Karen Parhar and her colleagues found that the more coercive the treatment experience, the less likely it is to be effective (Parhar, Wormith, Derzken, & Beauregard, 2008). Most recently, Theresa Gannon and Tony Ward published an important paper titled, “Where has all the psychology gone?” that illustrated how far correctional programs can stray from what – and who – works in helping people in the legal system to rebuild their lives (Gannon & Ward, 2014).
Elsewhere in the psychotherapy literature, there is evidence that there is a greater difference in success between therapists practicing within a model than there is between models themselves (Wampold & Imel, 2015). Likewise, there is considerable evidence that the most effective practitioners in any endeavor tend to spend more time engaging in activities meant to improve their skills and outcomes (Ericsson, XXX). It is important to separate deliberate practice aimed at improvement from simply practicing a lot. More hours doing the same thing can be just that – doing more of the same. This is particularly crucial when one considers research finding that therapists often overestimate their effectiveness (e.g., Beech & Fordham, 1997; Walfish, McAlister, O’Donnell, & Lambert, 2012).
However, in some quarters, our field is paying less attention to therapeutic variables and focusing on cutting costs by engaging in a very high level of manualization at the expense of a deeper and more meaningful treatment experience (Albright, 2015). There is no reason to believe this will work. For example, Janice Marques and her colleagues found in a randomized clinical trial that there was no difference in re-offense rates between those who did and didn’t complete abuse-specific treatment, although those who “got it” and meaningfully completed their treatment goals really did re-offend at lower rates, although these individuals received no further study. It is therefore not difficult to see how over-manualization (e.g., highly scripted rather than individualized) can easily result in problems adhering to the responsivity principle.
What works in treatment? We propose it is time for a return to a greater attention to factors related to specific responsivity and to draw on the existing psychotherapy research. Areas of focus can include:
·         A return to thinking of our programs as delivering therapy and not simply treatment
·         Greater attention to the professional self-development of therapists
·         Increased recognition that society’s attempts to use punishment-only approaches are almost entirely ineffective, while the right therapy and right supervision can make an impact on re-offense rates, community safety, and client well-being.
·         A greater awareness of the role of adverse experiences in the lives of clients and a greater fine-tuning of therapy in order to help clients understand how adverse events have shaped their lives and provide avenues for growing beyond the effects of these experiences.
·         Greater attention to what is important in clients’ lives (e.g., drawing on the Good Lives Model; Ward citation).
In many environments, this will involve a return to viewing therapists as the professionals and experts that they are. After all, the very definition of evidence-based practice includes clinical expertise as well as best available research and in accordance with client characteristics.  
David S. Prescott, LISCW & Gwenda M. Willis, PhD

Beech, A. R. & Fordham, A. S. 1997. Therapeutic climate of sexual offender treatment programs. Sexual Abuse:  A Journal of Research and Treatment 9: 219–237.
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16, 252-260.
Gannon, T. A., & Ward, T. (2014). Where has all the psychology gone? A critical review of evidence-based psychological practice in correctional settings. Aggression And Violent Behavior., 19, 435-446.
Gendreau, P., & Ross, R.R. (1987). Revivification of rehabilitation: Evidence from the 1980s, Justice Quarterly, 4(3), 349-407.
Lipton, D.S., Martinson, R., & Wilks, J. (1975). The effectiveness of correctional treatment: A survey of treatment valuation studies. New York: Praeger Press.
Marshall, W. L. (2005). Therapist style in sexual offender treatment: Influence on indices of change. Sexual Abuse: Journal of Research and Treatment, 17, 109-116. doi: 10.1177/107906320501700202
Martinson, R. (1974). "What Works? - Questions and Answers About Prison Reform," The Public Interest, 35, 22-45.
Martinson, R. (1979). "New Findings, New Views: A Note of Caution Regarding Sentencing Reform". Hofstra Law Review, 7, 242-258.
Norcross, J. (2011). Psychotherapy relationships that work, 2nd ed. New York: Oxford University Press.
Parhar, K. K., Wormith, J. S., Derkzen, D. M., & Beauregard, A. M. (2008). Offender coercion in treatment: A meta-analysis of effectiveness. Criminal Justice and Behavior, 35, 1109 – 1135.
Prescott, D.S., & Miller, S.D. (2015). Feedback-Informed Treatment (FIT) with people who have sexually abused. In B. Schwartz (Ed.), The sex offender, volume 8 (pp. 17-1 – 17-xxx). Kingston, NJ: Civic Research Press.
Salter, A. (1988). Treating child sex offenders and victims. Thousand Oaks, CA: Sage Publishing.
Walfish, S., McAlister, B., O’Donnell, P., & Lambert, M. J. (2012). An investigation of self-assessment bias in mental health providers. Psychological Reports, 110, 639–644.

Friday, December 4, 2015

“Dancing through the puddles to eradicate sexual harm” talking prevention with Cordelia Anderson.

Cordelia has been working in the field of sexual harm for nearly 40 years traversing the landscapes of research, treatment and victim advocacy with a focus on prevention, reduction and support. Cordelia believes that the best way to prevent sexual harm is to fully understand its causes, the perpetrators and its victims; we need a holistic, informed and multi-dimensional approach. In order to develop a shared, systematic approach to preventing sexual harm we need to recognise that that what are often seen as different [opposing] sides of the sexual harm field [treatment providers vs. victim advocates vs. criminal justice professionals vs. the ‘public’] are not actually opposed, instead they are actually complementary and we need to get better at drawing them together through language as well as action. Which means that in order to prevent sexual harm we need to be able to see the being picture, we have to be able to dance between the disciplinary ‘puddles’ [like Cordelia has across her career], or get out of our silos, of sexual harm.

At the core of Cordelias’ work is the belief that sexual harm is preventable, that we should be working towards eradicating it rather than just simply reducing it. The language of public health and health care was used a lot in the interview with Cordelia pointing out that sexual harm is not a distinct and separate [a one-off occurrence], but rather connected to a range of social, psychological, cultural and developmental issues [so part of an eco-system or constellation of issues]. Preventing sexual harm is tied to public health, criminal justice and social justice; we need to understand why and how it happens before we can stop it.

Interestingly, using the health analogy I asked Cordelia if sexual harm could be considered as part of a disease model like cancer or HIV to which she responded “sexual harm is endemic, not an epidemic”. She expanded upon this answer by asking me to consider why society has not responded to sexual harm fully in the past? Why society is willing to accept that some people will be the victims of sexual harm? Who controls and directs the conversations about sexual harm? Are we willing to challenge these individuals, organisations or platforms on the messages that they convey? We need to examine the social attitudes to sexual harm and its ‘acceptability’ before we can eradicate it; therefore it seems that it is both endemic and an epidemic. Although, the eradication of something so prevalent in society seems like a tall order, or even impossible, she believes that it is possible if we all work systematically and collectively on the issue.

In discussing her career Cordelia points out how far we have come since the 1970’s when sexual harm was not really discussed [especially in respect to children] to the stage where we are at now where it is more widely discussed and more fully accepted. She points out that we know more about the causes of sexual harm and its impact than ever before, with on-going research and treatment solidifying the base [i.e., the importance of attachment, the impact of child abuse and neglect on development across the lifespan, the importance of family dysfunction] as well as revealing new fields [i.e., attachment, desistence, trauma informed care]. We still have a way to go to completely eradicate sexual harm; but we are moving in the right direction and will continue to do so the more that we share information across our silos.

Cordelia believes that in order to eradicate sexual harm there are certain actions that we should be carrying out, or should be happening more often, including, [1.] continuing to breakdown disciplinary silos so that we can see the big picture; [2.] that victim advocates and other professionals who work in the field of sexual harm recognize that they are more effective when they
work together; [3.] that society has to own the problem of sexual harm, not passing it off to professionals, as that is the only way that we will eradicate it; and  [4.] we have to be critical, constantly critical, of current approaches to eradicating sexual harm asking whether they are suitable and/or fit for purpose.

Talking with Cordelia was interesting and refreshing, especially given that the sexual harm field has finally caught up to the multi-disciplinary approach to prevention that she has been advocating for the last 40 years.

Kieran McCartan, PhD

Wednesday, November 25, 2015

Polygraph Testing and Sex Offenders

We recently had a blog post on the polygraph by David Prescott which readers may want to look at in relationship to this new one.
Polygraph testing of sex offenders has come in for a good deal of recent criticism.  While polygraphy in general, and post-conviction sex offender testing (PCSOT) in particular, is not without its problems, many of the negative comments are based on misunderstandings, misconceptions, and sometimes just plain mischievousness.  Other criticisms, however, are based on genuine concerns, a number of which are eloquently described in a recent blog by David Prescott (2015).  But what is often unclear is the extent to which these objections are fundamental to polygraph testing and PCSOT, or whether they relate to poor or outright bad practice in delivery.
Supporters of PCSOT argue that it makes an important contribution to sex offender treatment and management by facilitating disclosure, bringing to attention changes in risk (both increases and decreases), and encouraging offenders to modify their behaviour.  As these outcomes are also sought by treatment providers and offender supervisors in their work with sex offenders, it would seem that it is not the ends of PCSOT that critics don’t like, but the way in which it gets there. 
Objections to PCSOT are of two types, ethical and practical.  As Mark Chaffin astutely observed (Chaffin, 2011), good practice standards are not the same as ethical principles – even where the delivery of PCSOT is well managed, potential ethical objections don’t disappear.  If PCSOT falls at the first, ethical hurdle then there is little point in carrying on, so it makes sense to start there. 
Ethical objections are not hard to find.  Terms commonly used in critical commentaries are ‘coercion’, ‘intrusion’, ‘psychological manipulation’, ‘intimidation’, ‘self-incrimination’, and ‘overriding autonomy’.   Many of this frightening terminology arises from the notion that polygraphy is primarily about interrogation, stated explicitly by Chaffin (2011) who described it as “fundamentally a coercive interrogation tool for extracting involuntary confessions” (p. 320).  But PCSOT need not, and should not, be about interrogation and confession.  Instead, it should be seen as an interview process in which lying is explicitly discouraged but which otherwise mirrors ordinary interviewing practice.  The questions asked during PCSOT are asked by supervisors and treatment providers already, and if they’re not then they shouldn’t be asked by the polygraph examiner.  Offenders have an opportunity to explain deceptive outcomes, but they are not intimidated into doing so. 
Provided that the questions asked during the polygraph test are directly relevant to treatment or supervision, how is it coercive, or morally problematic, to expect the offender to answer honestly?  The problem comes not with the answers, but when an offender who is judged to be deceptive in the absence of disclosures is whisked back to jail, thrown off a treatment programme, or has his progress impeded in some other way on that basis alone.  This is rightly troubling given the procedure’s error rate, which is probably in the region of 10-20%.  It is not, however, a moral issue for polygraphy, but for how its results are used.  A ‘deceptive’ test in the absence of disclosure should be seen as a warning sign, an indication that something requires further investigation or attention, but it should not on its own trigger definitive action.  While that may seem a flimsy use of a muscular outcome, PCSOT is meant to contribute information to treatment and supervision, not drive it.  To that end, it would be a great help if we moved away from talking about ‘passed’ and ‘failed’ tests altogether.
Mandatory PCSOT is of course coercive in that there are penalties for non-cooperation.  But we’re talking about convicted and usually high risk offenders, who by virtue of their criminal convictions are required to accept a range of restrictive and coercive measures such as conditions on where they live, limitations on employment, curfews, and treatment requirements. 
There is, however, a belief that the way in which information from polygraph testing is obtained is inherently hypocritical, with examiners deceiving offenders by telling them that the procedure is error free while at the same time demanding that the offender should always tell the truth.  While this may occur, it is certainly not good practice, nor is it necessary.  Indeed, the British Psychological Society (2004) stressed that participants should be informed of known error rates, a sentiment with which it is hard to disagree.  There is no reason to believe that PCSOT would cease to be effective in these circumstances, and indeed in our experience it has not happened in the UK where we are honest about error rates.
Keeping with the hypocritical theme is another objection that one of the most commonly used polygraph formats, the ‘probable lie technique’, requires the examiner to force the offender to lie to some questions in order to compare the response to answers to so-called relevant questions.  But though this is what tends to be taught, it is not the lie but the uncertainty of the answer that is probably the basis of the effect.  Regardless, those with qualms about ‘probable lies’ can make use of an aligned technique in which the offender is told to lie to certain questions, removing any subterfuge and also avoiding the risk of the examinee admitting to transgressions that have nothing to do with sexual risk.
The loudest and most forceful ethical objections seem to come from those in the adolescent treatment world.  The increased vulnerability of juveniles and adolescents, the worry that more harm than benefit may result from their perception of the process, and the focus on developmental rather than offending issues per se changes the tone of PCSOT from what it is when used with adults.  Indeed, it is not even clear that polygraphy works in the same way as it does in adults given differences in brain maturity and psychological development.  Whereas PCSOT in adult offenders has a steadily thickening evidence base, the same cannot be said for adolescent testing.  But while even critics like Chaffin (2011), who consider the ethical concerns relating to adolescent testing to be “substantial”, don’t go so far to say that it is unethical, they rightly argue for more evidence about the impact of its use in young people.  Until this evidence is produced it is almost certainly right that PCSOT should be used with great caution in young people, with decisions made on a case by case basis (in the UK we do not test those under 18 years of age at all), but care must be taken not to entangle the specific issues associated with testing young people with polygraph testing more generally.
None of the ethical objections referred to above would appear to be fundamental to PCSOT but to how it is delivered.  Which brings us to the more practical aspects of the process. 
In the US the prevailing approach to PCSOT is the Containment Model based on a triangle formed by treatment provider, offender supervisor and polygraph examiner.  While it has clear attractions from a public protection perspective, and helpfully stresses the need for communication between those working with offenders, it implies that all sex offenders require high levels of external control to keep them from reoffending.   Some offenders, however, genuinely seek to improve their internal controls and engage with treatment and supervision, and for them the emphasis on containment risks impairing internal longer term change.  For them the containment model may not be right, but nor is it the only show in town.  PCSOT can have a different focus.  Remembering that test outcome and disclosure are complementary, in those who are working with us polygraphy can function as a truth facilitator, encouraging them to discuss problematic thoughts and behaviors and provide reassurance that their risk is stable.  And though some argue that disclosures simply represent a ‘bogus pipeline’ effect resulting from the false belief that the polygraph is a 100% lie detector and is lost once an offender learns otherwise, all the evidence shows that disclosures continue regardless.  Indeed, rather than denigrating the increase in disclosure obtained in PCSOT we should be looking for ways to enhance the effect. 
There are associated concerns that the largely controlling approach of the Containment Model, and by implication PCSOT more generally, may impact negatively on both therapeutic and supervisory relationships. Arguments to this effect, however, are based on theoretical rather than empirical grounds.  What evidence there is suggests that PCSOT can in fact improve relationships.  It does not have to carry with it the implication that sex offenders are not to be trusted.  It should be remembered that polygraphy also catches offenders telling the truth; one should not underestimate the benefits for an offender who is able to demonstrate that he is being honest in his dealings with those working with him, and the positive impact this can have on his relationship with them. 
David Prescott stresses the importance of establishing a treatment culture “in which honesty and commitment are valued more than the appearance of compliance with expectations”.  There is no reason why PCSOT, when used properly, cannot contribute to this.  He asks, “What level of disclosure is good enough for treatment to be effective?” (which can just as well be asked about supervision).  This is not just a question for PCSOT, but whatever the answer is it should be the level of disclosure sought by therapists, supervisors, and PCSOT examiners alike.  The need for ‘complete confession’ or ‘full disclosure’, while perhaps a feature of some PCSOT programs, does not have to be what PCSOT is about.
Then there are those who argue that there is little evidence for the efficacy of PCSOT, noting few studies into reconviction rates.  Is recidivism, however, the right outcome with which to judge PCSOT.  PCSOT is about providing information, the nature of which is determined by therapists and supervisors and which they believe is important for supervision and treatment generally.  If this information does not contribute to treatment or supervision, and ultimately a reduction in recidivism, then either the wrong questions are being asked, or the answers are not being employed effectively.  The blame should not be placed at PCSOT’s door.  It seems odd to want it both ways – to argue that the information provided by PCSOT lacks value and does not reduce recidivism, but nonetheless we seek it in other ways. 
If PCSOT is not to be judged by recidivism rates, how should it be evaluated?  As it is about information gain surely attention should be focused instead on the value of the information provided – the frequency and content of disclosures, the impact of test outcome on decision making, and actions taken after a polygraph test can all form part of a cost-value analysis to determine the value added by PCSOT compared with the cost of administering it.  In other words, to what extent does PCSOT better enable probation officers to monitor risk and initiate timely interventions, and allow therapists to more accurately identify and address treatment targets?
Where the critics have it right is their observation that the process depends on competent polygraph examiners and well-designed and governed PCSOT programs.  Examiners must be properly trained and supervised, the protocols they work to sound, and their work subject to rigorous quality control.  The tendency to go for those with the cheapest rates or the flashiest websites needs to be resisted, and there lies the basis of potential problems.
In the end, one might ask whether it is unethical not to use PCSOT in the treatment and supervision of sex offenders.  If the information obtained during a polygraph examination adds significantly to what is otherwise known about treatment need and risk, is it right to deny the potential benefits of PCSOT to an offender?  If PCSOT does reduce risk, how can one explain to a future victim why it did not form part of the offender’s treatment and supervision package?  While the evidence for PCSOT is supportive rather than conclusive, objections tend to rely on opinion rather than fact. 
Those who make use of PCSOT must know the right questions to ask of it, how much weight to give its results, and how to integrate it with everything else they do with an offender.  More thought needs to be directed to which offenders are most likely to benefit, the needs that can best be targeted in those offenders, and whether modifications are necessary depending on the characteristics of the individual taking part (sounds a bit like the ‘risk-needs-responsivity’ principle).  In the end, that is an argument for enhancement, not abandonment. 
Don Grubin MD FRCPsych

Chaffin, M. (2011). The case of juvenile polygraphy as a clinical ethics dilemma.  Sexual Abuse: A Journal of Research and Treatment, 22:314-328.

Friday, November 20, 2015

Good Things Are Happening in Australia and New Zealand

ATSA has long enjoyed a friendship with the Australia and New Zealand Association for the Treatment of Sexual Abuse (ANZATSA). I had the honor of attending their biannual conference this month, and wanted to share some impressions in the event that it is useful.
There is a saying among historians that “Happy is the nation that has no history.” In other words, it can be painful to reflect on the history of one’s country, and this couldn’t be more true in the case of Australia and New Zealand (and elsewhere). At a time when so much of the world is grappling with problems related to human migration, the ANZATSA conference began with traditional greetings from an Elder of the Wurundjeri people (caretakers of the land on which the conference took place) and a Maori delegate from New Zealand. It is one thing to hear about this kind of opening and another to experience it. It was an important way to open the conference, as in many places in Australia, aboriginal people made up 2-3% of the general population and 70-80% of of incarcerated people. Addressing abuse in this context cannot be meaningful without explicit discussion of the systematic racism that occurs in these and other countries, including the USA and Canada. One ANZATSA attendee related to me that she could only become an Australian citizen at the age of seven because, as an Aboriginal, she had “fallen under the Plants and Animals Act.”
The first keynote addressed more immediate problems facing aboriginal people in that part of the world, before the conference turned to practice matters such as research and practice related to therapeutic engagement. Nicola Gavey, a Professor of Psychology at the University of Auckland, New Zealand, spoke on the topic of rape culture, focusing on the incidents and subsequent media coverage in Steubenville, Ohio, and the Roast Busters scandal of 2013 in New Zealand. The conference program noted that her 2005 book Just Sex? The cultural scaffolding of rape received a Distinguished Publication Award from the Association for Women in Psychology. Her current project ‘Pornography in the Public Eye’, raises questions about the gender and sexual politics of mainstream pornography.
Arguably, the most stunning presentation was by Louise Nicholas, who has established herself as a national treasure in New Zealand. She is a National Sexual Violence Survivor Advocate in New Zealand. She is a survivor of child and adult rape, perpetrated against her by rogue members of the New Zealand Police. While there are many people who have survived sexual abuse and gone on to tell their stories via books and lectures, Mrs. Nicholas stands out. Her presentation was passionately heartfelt and authentic. It was clear that she had come to tell the truth from her first words: “Some names have been changed due to suppression orders by the court.” Mrs. Nicholas’ persistence in seeking justice for herself and others is remarkable. There is now a wing of the New Zealand police named after her. In April 2015 she was awarded the Governor General's Anzac award and later same year (June) she was made an Officer of the NZ Order of Merit in the Queens Birthday Honours. Louise co-wrote the bestselling book Louise Nicholas – My Story, which was later made into a film.
Tony Ward followed with an exceptional keynote derived from a special issue of Psychology, Crime, and Law that he is editing with Clare-Ann Fortune. In essence, he argued that the current state of our understanding of dynamic risk factors (and by extension, protective factors) risks bring our field to a dead end unless research can better separate correlation and causation, and develop more explanatory models. He illustrated his point using the risk factor of emotional congruence with children, and outlining different ways it could result in sexual abuse. Without a keener eye turned to the nature of explanatory forces, he argued, our understanding of risk factors is less helpful than we are capable of, and the factors themselves reified constructs without explanatory power. As one might expect, Tony was passionate in his style. The special issue certainly promises to be as provocative as it is thoughtful.
The ANZATSA workshops were also very worthwhile. Caroline Burrowes presented on a 10-week trauma-focused curriculum using Acceptance and Commitment Therapy, while Fernanda Mottin gave an engaging talk on how she anchors her practice in Dan Siegel’s interpersonal neurobiology. All in all, the conference was an excellent experience, and the setting of Melbourne made it a great time for all. Good things are happening in Australia and New Zealand!
David S. Prescott, LICSW

Friday, November 13, 2015

What Makes a “Good” Risk Assessment? A Note on the Importance of Quality Control

The Issue

Most risk assessment scales are developed and validated by researchers based on file information scored by research assistants, who may have extensive training in the behavioural sciences, but no field experience. An essential question is whether the accuracy of these research studies will be similar to the results of real cases assessed by front-line staff. In other words, how can we implement a scale so that it works with similar (or even better) accuracy as research studies? Before delving into concrete recommendations for conducting high quality assessments, I will first use an illustrative example and summary of research to demonstrate that the commitment of individual staff members and organizations can make a huge difference in how well a risk assessment scale will work.


Illustrative Example: A Tale of Two States

Static-99 (and its revised version, Static-99R) is the most commonly used sex offender risk scale and there are over 60 studies of the scale, which have found that on average, it has moderate predictive accuracy. Unfortunately though, there are very few studies of how it works in field settings.


Among many states to mandate the use of Static-99/R for imprisoned sex offenders are Texas and California. Texas found low predictive accuracy – their results were lower than most studies of the scale. In contrast, California found remarkably high levels of predictive accuracy – their results were among the best of all studies conducted on the scale, or any other risk scale.


How could two American jurisdictions implementing the same risk scale achieve such remarkably different results?


There are many methodological or policy differences that could affect these findings, but at least part of the difference likely has to do with the quality of implementation. The study from Texas provides no information on how the correctional system maintains the quality of their risk assessments. In contrast, California has a remarkably rigorous implementation and quality control system. All staff who use the scale must be trained by someone certified by the Static-99R developers or a ‘super trainer’ who is certified by a certified trainer and has at least two years of scoring experience. All staff receives training from a detailed, standardized curriculum and by law, they must be retrained in the scale every two years. Additionally, they must pass scoring tests after training, and ideally, their first 10-20 cases are reviewed by a super trainer. Novice users are also encouraged to work with a mentor to maintain the quality of their assessments. With such diligent attention paid to the quality of their risk scale implementation, it is not surprising that California has found some of the highest predictive accuracy ever obtained in a field setting for a risk assessment scale.


What Does Research Tell us About Risk Assessment Quality?

In previous research, quality of risk scale implementation, defined either as involvement of the scale’s developer to (hopefully) help ensure fidelity to the scale or whether community supervision officers completed all the steps that were requested of them, was associated with substantial increases in predictive accuracy. Additionally, quality of training has also been linked to quality of risk scores.


What Can Staff and Organizations Do to Promote High Quality Assessments?

The jurisdiction examples and research discussed above show that it is not enough merely to implement a risk assessment scale. Care should be taken to ensure the assessments are done well. This is particularly important given that any risk assessment conducted can be challenged in court.


Below is a list of policy and procedures that are recommended by the developers of the STABLE-2007 (Fernandez, Harris, Hanson, & Sparks, 2014) to keep quality high. This list was modified to be applicable to all risk scales, and is included with permission of the scale authors.


All risk assessment practices should have most, if not all, of the following components in place:

1. A Bring Forward system to cue when it is time to re-assess scorings, ensuring regular scorings (applicable for dynamic risk assessment scales).

2. A system of peer reviews so that everyone is working towards scoring calibration (i.e., all scoring the same case alike). Colleagues should meet on a regular basis and present their scorings to each other and discuss the scorings, working towards consensus.

3. Clinical supervision by a very experienced assessor so that those scoring have access to a resource person for tricky questions (this person may well organize the peer review sessions).

4. Mentorships with those who are more experienced in using the measure so that novice scorers have an identified person with whom they can discuss their cases and their risk scoring.

5. Participation in inter-rater reliability trials where about 10% of the cases are scored by more than one rater and the scores are compared. This technique leads to better calibration of scoring.

6. Your agency may wish to consider participating in webinars about scoring and other risk assessment issues.

7. When scoring risk assessments on any offender a jurisdiction should have a quality control process in place, either through regular professional development days, internal supervision by senior employees who are committed to the risk assessment process or possible “scoring clinics” run cooperatively within organizations.


L. Maaike Helmus, Ph.D., Forensic Assessment Group, Ottawa, ON, Canada


Friday, November 6, 2015

A discussion about the development and implementation of the Active Risk Management System (ARMS) in the UK

 Since 2009, National Police Chiefs’ Council (NPCC) –previously known as ACPO and the National Offender Management Service (NOMS) have been developing a dynamic risk assessment framework, to assist offender managers in both organisations to manage sex offenders. It has strengthened the Police’s ability to manage registered sex offenders (RSO’s) more effectively and efficiently. Highlighting the risk they pose at the here and now, together with the historic risk they had been assessed at.

Active Risk Management System (ARMS) was primarily developed to address the gap in England and Wales created by the lack of an agreed and consistent approach to evaluating dynamic risk and protective factors in adult male sex offenders so that a defensible risk management strategy or case formulation can be completed. Learning from research and current understanding of the role played by these factors and combining outcomes into a case formulation that measures progress in the management of the offender, which has been one of the core aims in the development of ARMS.

ARMS guides offender managers through the risk assessment process and into a case formulation for each offender. The framework focuses on the current evidence for these factors which are derived from information from the offender, environment, agencies and third party sources.

ARMS has 11 factors which are broken down into 7 risk indicators and 4 protective factors, these cover areas like opportunity to offend, sexual preoccupation, offence related sexual interest, positive routine, social investment and commitment to desist.

Rather than labelling the offender with a risk level the Police have identified the priority for work to be given to reduce the risk and strengthen the protective elements of the management of the offender that will guide the assessor in arriving at a general level of priority for work to be completed.  Once assessed the professional is required to consider the Risk Matrix 2000 assessment of re-conviction and by combining these two assessments arrive at the general level of risk management.  It is this general level of risk management that will guide the timetabling of future engagements with the offender.

The re-defining of the concept of risk is argued will provide something more meaningful and have a direct relationship with work, action and investigation.

A particular strength of ARMS has been its ability to draw these assessments together to arrive at a risk management strategy that over time will measure the effectiveness of the Police’s and National Probation Service actions and provide the framework for intervention.
The Police have been using ARMS since October 2014 and have completed thousands of assessments across England and Wales. ARMS is used in every Police Force by the MOSOVO (Management of Sex Offenders Violent Offenders) officers. These officers now conduct a more thorough, intrusive and challenging conversation with offenders so they can obtain the most complete assessment that is possible in the circumstances. This has involved better training for officers to understand the complexities of such conversations by asking more in depth questions about their behaviour, thoughts and plans.

When officers started to use ARMS and change the way they had conversations with offenders, some found it a real challenge. This represented a cultural change for the Police to understand that to assist an offender from reoffending they had to engage in a more meaningful and sometimes intrusive way to fully recognise what an offender was thinking, fantasying and planning to do. This has led to more comprehensive assessments of offenders which has allowed officers to adjust the overall level of risk. The result of this is that resources are now more effectively and efficiently managed with fewer RSO’s being managed at very high and high risk without effecting public safety. This has been a very successful change in Police’s management of RSO’s and represents the biggest single change in practice since this area pf work started in the late 1990’s.

Research based upon the ARMS pilot was published in 2014:

Duncan Sheppard

If you have any further queries please contact DCC Skeer’s staff officer T/Insp Helen Harkins, Mark Blandford, ARMS developer for National College of Policing, or DCI Duncan Sheppard –MAPPA National Policy lead for Police in England and Wales.

Saturday, October 31, 2015

ATSA -2015, Montreal – Conference Highlights

The 34th annual ATSA Conference ran from 13th – 17th of October in Montreal. It began with a public engagement event on Tuesday evening with seven speakers (in both French and English), followed by  27 pre-conference seminars, four plenary speakers, 84 symposiums and 38 poster sessions before ending on Saturday. In addition to this packed program the conference also had a student data blitz session, next generation student reception, special interest sessions, a meeting of the journal editorial board, committee meetings, and state chapter meetings.  Here are some highlights from this year’s conference by Kieran McCartan (KM) and Jon Brandt (JB). 

Public Engagement Event

The public engagement event this year was organized by Gen Martin in conjunction with Katie Gotch and I (KM). The event had approximately 65 people attend and was held in both French and English to reflect the bilingual nature of our host city. We had a range of speakers on a number of topics including sexual victimization (Delphine Collin-Venzina & Isabella Daigneault), child sexual abuse imagery (Caroline Girard), innovations in sex offender treatment (Patrice Renaud), and the Canadian sex offenders registry (Josee Rioux & David Herni). The presentations generated a variety of questions, in both French and English, with the speakers being well received.  The audience was mainly members of the public and non-professionals.  [KM]

Pre Conference Sessions

The 28 pre-conference sessions where a mix of full day and half day events with workshops on a number of topics including, risk assessments (Andrew J. R. Harris, Karl Hanson); sex offender treatment (Robert McGrath, Liam Marshall, William Marshall, Michael Miner); connecting theory with research (Kevin Nunes, Chantal Hermann, Michael Seto, Anthony Beech, Patrick Luisser); working with adolescent sex offenders (James Worling; Raymond Knight, Judith Sims-Knight, David Rothman, David Prescott); professional practice (Laura Jakal, Bobbi Walling, Lawrence Ellerby); and internet sexual offenders (Hannah Merdian & Derek Perkins).  [KM]

Plenary Sessions

The four plenaries at this year’s conference were diverse, interesting and well received. They spanned conversation covering the history and impact of sex offender treatment (Friedrich Losel), a developmental understanding of physical aggression from a gene-environment perspective (Richard Tremblay), gendered sexual responses and sexual stimulation (Meredith Chivers) and a psychosocial approach to understanding male sexual aggression (Anotnia Abbey).  Both Jon and I thought the plenary sessions were excellent this year, with a varied, multidisciplinary, international nature, and well applied.  There were some plenary topics that I knew a lot about but welcomed the opportunity for an update (Tremblay, Losel and Abbey), and others (Chivers) who spoke on topics that brought a fresh perspective on research which has not gotten much attention.  The plenaries reflected the varied and interconnect nature of our field.  [KM]

Highlights from Concurrent Sessions

As a clinician, I [JB] tend to find the clinical tracks at ATSA conferences most useful, but this year I attended three excellent sessions on research and have chosen one session to highlight: (F-13) Emerging Practices in Assessing the Risk of Sexual Recidivism.  The session was presented by KiDeuk Kim, Grant Duwe, Michael Caldwell, and Elizabeth Letourneau.

Presenters reviewed the evolution of the science of prediction, starting with the Burgess Method in the 1920’s, and the subsequent contributions of multivariate logistic regression.  The next generation of risk tools came with the computer age and the ability to analyze the predictive capacity of an array of variables.  The future of assessing risk would seem to be the ability to explore interactions between a virtually unlimited number of variables using Machine Learning (ML) algorithms.   Machine Learning enables researchers to design algorithms that learn from the data.

Duwe and Kim presented their 2015 research that supports the predictive capabilities of newer ML algorithms.  One of the benefits of ML algorithms is the ability to compare variables (e.g. static and dynamic risk factors) in ways that might more accurately address absolute risk of sexual reoffending, rather than the relative risk of recidivism which is the product of most current risk assessment tools.  One drawback with ML algorithms is that the interaction between variables is not as evident or transparent as logistic regression.  Duwe discussed the calibration of ML algorithms in two studies involving 4,200 juvenile offenders in Virginia and Oregon, which demonstrated encouraging results.  When the base rate for recidivism may be as low as 1-2%, risk assessment tools that can more accurately determine the true risk of reoffending have enormous implications for the treatment and management of offenders across the spectrum of sexual offending. 

There is some agreement in our profession that interventions with sexual offenders are overreaching - from juveniles on sex offender registries, to endless treatment for the civilly committed.  In part, this might be due to the tendency to inflate levels of risk, when risk can’t be accurately ascertained.  Machine Learning algorithms seem promising in adding to the science that is needed to support the “art” of the prediction of risk – and to truly inform needs and facilitate responsivity. [JB]


I [KM] attended a session (T-1) on the use of Virtual Reality technology in the treatment of sexual offenders (chaired by Patrice Renaud and Joanne-Lucine Rouleau), this was something that I knew very little about and gained a great deal of information.  The session gave insight into using existing measures (fMRI, penile plethysmography) and the impact of using computer generated imagery; the research indicates that the technology continues to evolve and its utility in treatment and its impact continues to grow. I think that this area has a lot to offer models of sex offender treatment, especially in prisons or confined arenas, as it develops.  [KM]

The research symposiums covered topics including sex offender treatment, Risk Assessment, sex offender policy, the prevention of sexual harm, desistence from sexual offending and community integration of sexual offenders. Talking with people at the conference, other standout symposiums that were mentioned included a session on working with Native American sexual offenders (Chris Lobanov-Rostovsky, Juli Ana Grant & Dewey Ertz, Lawrence Ellerby); a session on the impact of the Jimmy Saville case in the UK (Marcus Erooga); the use and effectiveness of the polygraph (Robin Wilson & David Prescott); public opinion research on sex offender management policy (Andrew Harris, Lisa Sample, Todd Hogue, Sandy Jung, Craig Harper, Kelly Socia, Gwenda Willis); and exploring links between childhood victimization and sexual abuse (Jill Levenson, Anna Pham, Carolyn Blank, Sacha Maimone, Kevin Nunes, Tess Bolder, Melissa Grady, Jill Levenson).  [KM]

Conclusion: This year’s conference was packed with highly relevant and interesting topics. It was an engaging and diverse conference with continuous opportunities to meet colleagues, share knowledge, disseminate research, advance best practices, consider public policies, and maintain connections that are vital to ATSA’s membership and mission.
Kieran McCartan, PhD
Jon Brandt, MSW, LICSW

Saturday, October 10, 2015

What are Young People Hearing? Getting the Message Right

Social rules and laws around interpersonal sexual conduct are culturally defined but locally enforced.  It is up to adults to help young people know the expectations, navigate the hazards of interpersonal sex, and understand that there are a lot things that can go wrong.  When sexual violations occur, it is also the responsibility of adults to help young people make sense of what happened, and whether they might be a victim or an offender, help guide them through recovery.

Sometimes sexual violence is so horrific that culpability is clear.  But other times sexual violations occur under ambiguous or mitigating circumstances.  When this is the case, too often adults ignore the social complexity of interpersonal sexual behavior, overreach with interventions, and send distorted, polarizing messages to young people.  When kids are involved in sexual violations, as a victim or an offender, what are the messages that they are getting from adults?   Do these messages help young people understand what happened, or do they just leave them more confused, full of anger or shame, or feeling hopeless?  Three cases to illustrate…

(A) In September, 2010, a federal judge in Minneapolis sentenced a man to 30 years in prison for taking sexual pictures of two teenage girls (he had also molested one of them and faced separate charges in state court).  When asked if he would like to make a statement before sentencing, the offender expressed remorse, apologized, and said that he prayed for the girls; which prompted the judge to say:

“These victims are never, ever, ever going to recover.   No matter how much you want God to do that, no matter how much you pray, it is not going to happen.”

The judge’s message was intended, of course, for the offender, but the judge’s comments were heard by everyone in open court and broadcast by the media.  Imagine the secondary trauma that the judge carelessly inflicted on the girls, their families, and friends...  that these kids are never, ever, ever going to recover, and not even God can change that?  Wrong message.

A better message might have been, “No child should ever have to endure the sexual violations that you inflicted upon these girls.  I’m sending you to prison for a long time to ensure that you will not have the opportunity to do this again.  You, sir, are a bit late in wishing the best for these children, but I will leave it to the girls and their parents to determine the sincerity of your message.  But let me assure the girls, and their family and friends, that these courageous teenagers will get the help they need that turns victims into survivors.  With support and guidance, these events and the sense of having been violated will fade with time, and these brave young ladies will move on with their lives.  Court adjourned.”

(B) In the fall of 2013, as a prank at a Sparkman High School football game near Huntsville, Alabama, 15 year old Christian Adamek ran naked across the football field.  Classmates cheered, and the next day they called him a “legend.” But the school proceeded to expel him and referred him for prosecution for lewd behavior.  A conviction could have resulted in Christian being put on the state’s sex offender registry.  Alabama has lifetime registration for sexual offenders, including juveniles.  The school moved quickly to expel Christian and, after he was cut-off from his friends, perhaps he decided not to wait to see if he was also going to be a “sex offender.”  Five days later Christian killed himself.  His father later reported that Christian was a troubled kid, but that does not change the message that Christian apparently got from the school.  One incident of streaking and he lost his school, his peers, his hope, and his life.   Wrong message.

One can only wonder if there would have been a different outcome with a different message, “Hey Christian, pretty funny streaking at the football game Friday night.  I totally understand why teenagers do those things.  Some staff have suggested that you should be charged with disorderly conduct, or maybe even indecent exposure, because we have to discourage that kind of thing – some people are offended and it is quite disruptive to football games.  But I am trying to not overreact so I’m going to suspend you from school for a couple days and if you do that again, you will be banned from participation in school sporting events.  Understood?   Great, thanks.  Game over.  See you on Wednesday.”

(C) Over this last summer a very public trial unfolded in New Hampshire regarding two prep school students who engaged in some sexual behavior.  He was 18; she was 15.  This was not the “Romeo and Juliet” situation that is quite common in high schools.  It seems he was participating in a school “tradition” that students called, “senior salute.” There was evidence presented at trial that she had agreed to getting together, but “only if it’s our little secret.”  Unfortunately, rather than keeping a secret, he was keeping score.  As often happens in cases of equivocal sex, it’s difficult for any third party to know the truth.  But even if there was some measure of sexual consent, there was clearly an absence of sexual respect.  He was charged with several misdemeanors and felonies.  The jury had to determine what versions of events to believe and decide each count.  After several hours of deliberations the jury delivered a split verdict.

The jury acknowledged that she was, in fact, underage, but apparently believed that there was some level of consent.  He was cleared of the most serious charges, but when he is sentenced on October 29, 2015 he still faces up to 11 years in prison and lifetime registration as a sex offender.  Both teenagers broke down in the courtroom.  He thought he was on his way to Harvard; now he is most likely on his way to prison.  Whatever the judge decides, everyone has lost – both the students, their families, their friends, and everyone at the prestigious prep school.  While the school administration has disavowed any “tradition” of “senior salute,” it apparently was well known to students over many years.  This story is another reminder that adults need to get ahead of any indications of hazing-like activities that often go unrecognized by kids and young adults, and help young people navigate interpersonal relationships, and the nuances of social acceptance. 

Sexual misconduct might not be the worst thing that kids have ever done, or the worst life experience that they have encountered, but the messages that young people too often get is that sexual abuse is so horrible that, whether they are victims or offenders, they will forever be defined by it, and they might never recover.  Professionals and other adults need to be vigilant about the messages we send, and ensure that young people, and their families, hear the important messages of hope and restoration. Whether it’s part of prevention, or part of recovery, people of all ages need help to understand the simplicity of sexual consent and the complexity of sexual respect.

Jon Brandt, MSW, LICSW

A Post Script:  On 10/29/2015, the young man convicted for his role in the “senior salute” received a suspended sentence of seven years in prison for the felony conviction of using a computer to lure a minor, and was sentenced to serve one year in jail on the remaining misdemeanor convictions.  He will be on probation for five years and must register as a sex offender for at least 15 years.  He was released pending appeal.  During sentencing, the young woman expressed that, “What he did to me made me feel like I didn’t belong on this planet and I would be better off dead.”  The judge expressed that both their “lives have been destroyed,” but quickly noted that they were both young and that he hoped he was wrong.  It is now up to adults to reframe the personal and social context of these events with a narrative of resiliency – one that will help both young people to get their lives back.  [JB]