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