Friday, August 26, 2016

Denial, Risk, and Good Lives:The Need for Protective Processes

At a recent training on treating adolescents who have sexually abused, the discussion of polygraph came up, as it often does. My standard approach is to inquire whether professionals have truly asked all the questions they need before resorting to this measure. I explained that in the programs where I work, I have little reason to use it and outlined some reasons why. This led to a familiar case example: “Mr. Prescott, what if you are returning a young person who abused a sibling to his home where there are even younger siblings. Wouldn’t you want to know whether the younger siblings have been abused?” On its face, this is a fair question. My answer is almost always the same: That I typically assume that the the younger siblings have either been harmed, exposed to harm, or have otherwise been through bad experiences. This calls for diligent family interventions in order to restore safety and balance (and often to create it for the first time). The polygraph would only provide limited information about past events, while my sights are set on building better futures and preventing further harm.   

At the same time, I do not want to “out” anyone who has been abused and has not reported it. Decades of work with people who have been victimized has made clear that people who have been abused need to disclose this information in their own time and in their own way. It’s one thing when family members disclose their actions or those of others; it’s another matter to go in and coerce this information, no matter how good the intentions. In the meantime, it is the responsibility of adults to keep all young people safe and provide access to rehabilitation and growth. A final consideration is in resource allocation: with scant resources, is it wiser to put money into a polygraph exam or family therapy?

The training organizers told me afterward that the person asking the polygraph questions was likely a proxy for someone seated next to her. This person is apparently known for adopting a stance of, “I don’t care if it lacks research, I’m still using it.” In the end, I found myself wondering if, as a field, we only endorse evidence-based practice up to the point where it challenges our beliefs, many of which have little grounding in evidence. It’s not just an academic question; how many of us have seen actuarial risk estimates in adults revised upwards versus downwards?

A couple of days after this experience, an interested person asked whether the Good Lives Model (GLM) might be useful with people who categorically deny crimes for which they received convictions. This was another very good question and my answer here was that at a broad level, its collaborative and strength-based nature might help to elicit disclosures of past wrongdoing, but that there are other approaches in the literature that are also positive in nature (e.g., Serran & O’Brien, 2009). The GLM might help clients build on existing capacities, although without examining how one’s “good life plan” had gone awry in the past, its usefulness would be limited.

Together, these situations brought home the point that as professionals, we can often focus on managing risk to the detriment of building strengths. As others have observed, we tend to focus on having clients accept responsibility for the past when we may want to expend more energy on their taking more responsibility for their future.

Obviously, an understanding of past behavior and its connection to future risk is important. In some cases, however, one wonders if the cultural value we place on “confession” can actually impede conversations that build the trust and honesty that result in meaningful disclosure and further dialog. At a time in our profession when we have an increased focus on protective factors (those factors that protect against future recidivism), perhaps it is also important to think in terms of “protective processes” – those conversations and therapeutic intervention that actually build the capacities for accountability and honesty. While our field often finds itself looking for the newest technology for aiding assessment and treatment, it can be easy to overlook the role of skillful conversation.

David S. Prescott, LICSW


Serran, G., & O’Brien, M. (2009). A treatment approach for sexual offenders in categorical denial. In D.S. Prescott (Ed.), Building motivation to change in sexual offenders (pp. 96-117). Brandon, VT: Safer Society Press.

Ware, J., & Mann, R. (2012). How should “acceptance of responsibility” be addressed in sexual offending treatment programs? Aggression and Violent Behavior, 17, 279-288.

Friday, August 19, 2016

Juveniles who sexually offend: A view from 2016

This blog, like last weeks by Jon Brandt (New Research: Juvenile Sexual Recidivism < 3%), is linked to a recent publication by Michael Caldwell on the declining rates of juvenile sexual recidivism. Kieran
When I first started working with juveniles who sexually offend (JSO) in 2001, the focus was on sexual deviancy and compulsions. Our knowledge about this population has increased since then, and this population has likely changed as well, all of which has implications for practice and policy. The following is a personal view of how things look in 2016.
Knowing the prevalence rates of outcomes is an important starting point for assessment. Caldwell's (2016) article cited a weighted mean sexual recidivism rate of 2.75% for JSO youth, and a nonsexual recidivism rate of 30.00%. Measures of both sexual and nonsexual recidivism should be included in JSO assessment. The latter is a more recent development, and warranted given the high prevalence level noted by Caldwell and others. Nonsexual crimes also cause harm to victims.
Caldwell's study also suggests that the results from sexual risk measures, given a base-rate of 2.75%, may need to be qualified. For example, if a risk measure puts youth in the highest risk level, with say a risk of twice the base-rate of 3%, 94% of these "high risk" would be predicted to not sexually reoffend.[i] One study (Borowsky, Hogan, Ireland, 1997) examined rates of sexual offending behaviours reported in non-forensic, community samples, and found this rate for juveniles to be 4.8%, higher than the base-rate reported for reoffending of 2.75% by Caldwell. These considerations suggest decisions regarding out of home or secure placement, let alone civil commitment, may not be justified based primarily on findings from risk measures of sexual recidivism.
Developmental outcomes are also important to assess. These include psychiatric factors (depression, anxiety, etc.), neuropsychological conditions (ADHD, autistic spectrum, learning and intellectual disabilities, etc.), substance abuse, violence and trauma related conditions. The high prevalence of these conditions in this population, and also the availability of evidence-based treatment approaches to address them, argues for the inclusion of such factors in assessments. Also neighborhood, socio-economic, ethnic, cultural, and family factors are also important.[ii] Prevalence rates of psychiatric conditions in outpatient setting are likely lower than in residential or secure settings.
In 2001, the priority as I recall it for JSO youth was treating what was assumed to be an underlying sexual pathology. For most of these youth, however, I found there wasn't evidence of a pattern of enduring sexual deviancy. While there are such youth, they are rare in my experience. Impulsivity, poor judgment, supervision problems, and sometimes a history of sexual victimization, seemed to be the best explanations, rather than a primary disordered sexual behavior pattern.
This led me to believe that treatment approaches which promoted better social judgment and skills, along with family education, and a psychosexual education component, was optimal for most JSO youth. The theory and techniques of Moral Reconation Therapy and Aggression Replacement Training provided the framework for approaches to promote more mature social judgment and skills. One recent study (Ralph, 2016), documented deficits in prosocial reasoning for JSO youth, and three previous studies (Ralph, 2015a; Ralph, 2015b) documented the effectiveness of these approaches with JSO youth, including reducing sexual misbehavior.
In 2001, evidence-based practice with JSO youth wasn't in widespread use in my experience. Now it is a major consideration in treatment, and in California, some probation departments require evidence-based practices to obtain funding. In my view, evidence-based practice should include an evaluation of outcomes for treatment programs. You should be able to track your therapeutic outcomes so you can see not only if a given client improves, but also whether the program as a whole shows positive outcomes. Every surgery center in the USA has to do outcome studies (mortality and morbidity), and so should JSO treatment settings. In my experience highly committed, but rarely is any program evaluation done in JSO programs to document these admirable efforts. Worling, Littljohn, and Bookalam's (2010) study on a 20-year follow-up from the SAFE-T program in Toronto is probably the best known example of such research. A more modest effort was my own recent follow-up study of 129 youth in a residential JSO program (Ralph, 2015b).
The ultimate outcome to be tracked for JSO interventions had been sexual recidivism. This may not be the best measure to use in an era of recidivism less than 3%. Is a good program now one that reduces recidivism from 2% to 1%? Other outcomes might be tracked including non-sexual recidivism, reduction in psychiatric symptom ratings, and increases in prosocial reasoning and skills. Righthand's (2005) treatment progress scale is a useful tool with some normative information available. Examples of such measures are also found in my recent article (Ralph, 2016).
Norbert Ralph, PhD, MPH
Licensed Clinical Psychologist
Borowsky IW, Hogan M, Ireland M. (1997). Adolescent sexual aggression: risk and protective factors. Pediatrics. 1997 Dec;100(6):E7. 
Caldwell, M. F. (2016). Quantifying the Decline in Juvenile Sexual Recidivism Rates.
Psychology, Public Policy, and Law. Advance online publication.
Epperson, D., Ralston, C., Fowers, D., DeWitt, J., & Gore, K. (2006). Actuarial risk assessment with juveniles who sexually offend: Development of the Juvenile Sexual Offense Recidivism Risk Assessment Tool-II (JSORRAT-II). In D. Prescott (Ed.), Risk Assessment of Youth who have Sexually Abused: Theory, Controversy, and Emerging Strategies. (pp. 118 169). Oklahoma City, OK: Wood & Barnes.
Ralph, N. (2015a). A Follow Up Study of a Prosocial Intervention for Juveniles who Sexually Offend." Sex Offender Treatment. Retrieved from
Ralph, N. (2015b). A longitudinal study of factors predicting outcomes in a residential program for treating juveniles who sexually offend. Sex Offender Treatment. Retrieved from
Ralph, N. (2016). An instrument for assessing prosocial reasoning in probation youth. Sex Offender Treatment. Retrieved from
Righthand, S. (2005). Juvenile Sex Offense Specific Treatment Needs & Progress Scale. Retrieved from
Worling, J. R., Litteljohn, A., & Bookalam, D. (2010). 20-Year Prospective Follow-Up Study of Specialized Treatment for Adolescents Who Offended. Behavioral Sciences and the Law, 28, 46–57.

[i] When three categories of risk are used for the Iowa validation sample for the Juvenile Sex Offender Assessment Protocol-II (JSORRAT-II), the highest risk category (7 or higher) has about twice the risk of the middle level category which is at about the base-rate.
[ii] Ralph (2015) documents in a JSO residential setting 55.8% had an Individual Education Plan, 43.2% had prior mental health treatment, and 83.1% had used psychiatric medications at any time. Using DSM-IV TR criteria, the rates for various diagnoses are as follows: attention deficit disorder 39.7%, posttraumatic stress disorder 34.9%, depressive disorders 30.2%, conduct disorder 27.8%, anxiety disorders 11.9%, bipolar and mood disorders 8.5%, adjustment disorders 4.8%, and oppositional defiant disorder 1.6%. One youth, 0.8%, had a DSM-IV TR diagnosis of pedophilia, and no other sexual disorders were diagnosed for this sample.

Friday, August 12, 2016

New Research: Juvenile Sexual Recidivism < 3%

It is not often that research in any field is so persuasive that it can propel systemic changes, but that is not an overstatement for the potential of the compelling 2016 meta-analysis conducted by Michael Caldwell at the University of Wisconsin - Madison.  Caldwell provides the strongest evidence to date that the base-rate for sexual recidivism by adolescent offenders is so low that it demands reconsideration of best practices with juvenile offenders, and a course-correction for public policies.

In the Online First Publication of “Quantifying the Decline in Juvenile Sexual Recidivism Rates,” (Psychology, Public Policy, and Law; July 18, 2016), Dr. Caldwell reviews 106 international recidivism studies involving more than 33,000 juveniles who have sexually offended.  After transparently controlling for variations between studies, Caldwell determined that the mean five-year sexual recidivism rate for offenses committed over the last 30 years is less than 5%.  Looking at the most recent 33 studies, since 2000, Caldwell determined “a mean sexual recidivism rate of 2.75%.  This suggests that the most current sexual recidivism rate is likely to be below 3%.”  Longer follow-up periods, up to 36 months, revealed more sexual recidivism; but thereafter, follow-up times did not significantly increase recidivism rates.

Caldwell thoughtfully considered, and methodically dismissed several potential factors that might explain the decline, concluding that civil regulations and incapacitation do not explain such a significant drop in recidivism, but noted, “… improvements in treatment and supervision is one of the few possible explanations for which there is no contradictory evidence,” and that “preliminary evidence suggests that treatment can be moderately effective.”  Caldwell suggests that public discourse might be raising awareness about sexual violence, with a possible mitigating effect.  However, he went on to write, “These results offer no conclusive explanation as to the cause of the decline in juvenile sexual recidivism rates.”

Violent crimes in the US, including sex crimes, have been in steep decline for more than three decades.  Over the same time period, Caldwell found a 73% decrease in sexual recidivism.  Despite the dramatic 30-year decline in both first time and repeat sexual offending, there has been growing public anger about sexual abuse, and a deepening antipathy for those who have sexually offended.  In the US, this led to a dramatic increase in sentencing, and a proliferation of “civil regulations” for ‘sexual offenders,’ including a nationwide sex offender registry, regional residence and zone restrictions, local notification laws, domestic and international travel restrictions, and 21 states now provide for the civil commitment of sex offenders, including juveniles.
In the US, many civil regulations were initiated in reaction to serious, high-profile sex crimes by adults, but ensuing changes in public policies gradually migrated into the juvenile system.  Caldwell writes, “The bulk of available evidence indicates that the decline in adult and juvenile sexual recidivism rates has occurred, unrelated to, and perhaps despite, these recent policy trends.”  He goes on to express his concern that civil regulations “have unintended consequences that harm the adolescent perpetrator, their families, and at times their victims.”  In 2013, The Human Rights Watch published a rebuke of the registry for juveniles.  It is not an overstatement that most juvenile offenders, no matter how low their risk or how great their effort, cannot escape the devastating, lifelong consequences of current public policies.
Public policies and practices for both adults and juveniles with sexual offenses are predicated on the popular misperception that most sex offenders are destined to reoffend.  In 2014, Karl Hanson and colleagues published ground-breaking research which revealed that even men considered at high risk for reoffending were not high-risk forever.  Hanson determined that the longer one remained offense-free in the community, the lower the risk for sexually reoffending (a five-year “half-life”).   Hanson wrote:

The current results suggest that sexual offenders who remain offence-free could eventually cross a “redemption” threshold in terms of recidivism risk, such that their current risk for a sexual crime becomes indistinguishable from the risk presented by non-sexual offenders.  Previous large sample studies have found that the likelihood of an “out of the blue” sexual offence to be committed by offenders with no history of sexual crime is 1% to 3%.*

Now, Caldwell has essentially determined that sexual recidivism data for juvenile offenders yield similar results and conclusions; recidivism is not only much lower than previously believed, but it might be that juveniles who have sexually offended have about the same risk of sexual reoffending as first time offenders - in the range of 1-3%.  One 2008 study determined that about 95% of sexual offenses are first-time offenders.  Collectively, these findings suggest that the base-rate for sexual recidivism might be the same or less than the rate of first-time juvenile sexual offending.  There is mounting research that the basis for civil regulations are largely unfounded, raising significant doubts about not only their efficacy, but whether corresponding public policies for juveniles are both unwarranted and indeed harmful.

Caldwell’s meta-analysis reveals persuasive evidence that many practices currently in place for the treatment and management of juvenile offenders are not really about public safety, but rather about public policy.   Sexual misconduct comes at a high cost to victims, their families and friends.  Interventions with juvenile offenders also come with a high cost – to those juveniles, their families, and to society.   For these reasons, we must commit more resources to reforms, starting with primary prevention.  When sexual abuse occurs, Caldwell’s research should strengthen professional courage to not overreact, to avoid the tendency to pathologize or criminalize offending juveniles, to not conflate serious sexual misconduct with public “dangerousness,” and to thoughtfully apply science to effective interventions.

Going forward, an empirically-derived base-rate of less than 3% should be overarching in sexual risk assessments.  One challenge of rendering meaningful risk assessments has always been to determine what qualitative or quantifiable variables appear to separate those who sexually reoffend from those who remain offense-free.   Unless risk factors or protective factors are determined to be overriding, a 3% base-rate is likely to make it difficult to prove that any specific aggravating or mitigating factor carries enough weight to override such a low base-rate for recidivism.  It seems a bit simplistic to set aside established static and dynamic risk factors that are often integrated into a psychosexual assessment, but if clinicians used only this new base-rate to prognosticate sexual reoffending, they would be accurate 97% of the time.

However, risk is not, and should not be the only consideration in a good psychosexual assessment.  On the cautionary side, Caldwell noted that there is considerable evidence that juveniles with sexual offenses have often engaged in other delinquent behaviors, and that general delinquency for juveniles is a risk factor for sexually offending as adults.  A challenge to using new research that portends exceptionally low detected recidivism rates, will be to strike a better balance between sometimes competing concerns, for victims, offenders, their families, and legitimate public interests.

Researchers typically are neither clinicians nor policymakers, and most are too modest to actively promote their own research.  So it is incumbent on colleagues, and all stakeholders, to recognize credible research and have the professional mettle to actually use it – to light the way to informed public policies, and follow it to logical applications with individual clients.  For too long it seems we have had it backwards – we have been managing nine out of ten teenagers with sexual offenses as if they are likely to sexually reoffend.  In light of Caldwell’s findings, I would like to ask clinicians, social workers, probation agents, prosecutors, judges, law enforcement, and other professionals in the juvenile justice system to consider this question: if you knew, and believed, that 97 out of every 100 young people to whom you are providing services are not destined to sexually reoffend, how would it change, case by case, your treatment and management of those teenagers and their families?

In my experience, once young men come to understand that they have caused harm to another, most feel genuine remorse and profound regret.  They know there are no ‘do-overs’ – there is only ‘never again.’  Every individual who has sexually offended can be held accountable through restorative justice, and by employing principles of Risk, Need, and Responsivity, we can uniquely tailor and target treatment as a pathway to restoration.  We can wrap every youthful offender in the protective factors of Good Lives, and endeavor to help every juvenile offender to quickly, responsibly, and safely return to their families and communities.  Caldwell’s research indicates that they, and we, will succeed 97% of the time.

Jon Brandt, MSW, LICSW

Note: Michael Caldwell has given permission to post his email address, for readers who would like to request a copy of his research:

Caldwell, M.F. (2016, July 18). Quantifying the Decline in Juvenile Sexual Recidivism Rates. Psychology, Public Policy, and Law. Advance online publication.

*Hanson, R.K., Harris, A.J.R., Helmus, L, & Thornton, D;  High-Risk Sex Offenders May Not Be High Risk Forever, Journal of Interpersonal Violence October 2014, 29: 2792-2813, first published March 24, 2014

Monday, August 1, 2016

Sexual Assault: A Restorative Justice Model

The compelling and articulate statement made by the courageous survivor in the Stanford Rape case highlighted the failings of our criminal justice system. Our adversarial process silences many survivors, however, and therefore perpetrators rarely learn about the long-term effects of their actions, leaving little opportunity to cultivate empathy.  Perpetrators are silenced as well, providing few chances for victims to hear the acknowledgement of harm they so desperately need and deserve.

We’d like to offer a different perspective - a change in the dialogue. We argue that the conversation should shift to harm reduction, promoting restorative and transformative justice. We offer an example of a restorative justice narrative in which a rape survivor and a SOTX group came face to face for a life-changing experience.

What is Restorative Justice?

Restorative justice is concerned with violations of people and relationships, not statute definitions and sentencing guidelines. The process allows victims to be heard, to seek the acknowledgement of culpability they need, and for perpetrators to hear, firsthand, the personal narrative of suffering they have caused that permeates, like a ripple effect, across time and relationships.

For the last two decades there has been considerable debate on restorative justice and sexual violence, but limited empirical evidence exists to inform our understanding its effectiveness. Still, several courageous survivors have opened up publicly about the profoundly positive impact it has had on their healing. In these instances, survivors like Carmen Aguirre, Joanne Nodding, and Dr. Claire Chung, have come face to face with their perpetrators and have found peace and closure; however that closure can be found in other restorative justice frameworks.

For almost a decade we have extensively researched sex offender policies and treatment practices, both independently and as co-authors. We have maintained a friendship close enough that in early 2014 Alissa chose Jill as one of the first people to whom she disclosed her own rape -- fifteen years after it occurred.  

Alissa never reported the rape that happened when she 16, though it had profound impacts on her life. In silence, she endured intense flashbacks and nightmares of the assault. For over a decade and a half she lived with general and social anxiety, believing it would never (and could never) cease.

She became a sex crimes researcher, in part to better understand why people commit such crimes, and she worked diligently to compartmentalize the personal from the professional.  She was terrified that people would not take her work seriously if they knew she was a survivor. Jill assured her that her narrative was important to share.

Alissa began speaking publicly sharing her unique role as a sex crimes expert and survivor, but believed the effects of the rape would be with her forever. Then she agreed to participate in two group therapy sessions with men convicted of sexual crimes:

To say I was apprehensive about walking into that room is an understatement. During the course of my career I have come face to face with many individuals who have committed sexual violence, but I always had my researcher hat on. I became very good at compartmentalizing. In this case, I knowingly took off my research hat and allowed myself to be vulnerable.

As soon as we sat down, I saw that the men in the room were far more nervous than I was. I knew I had the opportunity to provide insight into what it is like to live life in the aftermath of rape. I explained the flashbacks and nightmares, the impacts on my relationships, the anxiety, the guilt I felt when I snapped at my child because he jumped on my back. I believed this would help them to understand the consequences of their actions. I had no idea that sharing so vulnerably would be life-altering for me.

I have always maintained that if given the opportunity, I would, without hesitation, sit face to face with my perpetrator. So when I was asked what I would say to my perpetrator if I had the opportunity, I did not hesitate to answer honestly and from my heart. I challenged these men to think about their actions form a different vantage point and they challenged me to see them as human beings and not just the label that has been placed on them. Even though in my role as a researcher and academic I knew this to be the case, by the end of the evening I came to the personal conclusion that we were not so different.

I walked away from the evening a different person.  These men helped me find the closure I had been seeking for more than half my life. I now have space  to focus my attention on other important aspects of who I am. I am no longer fighting the bogeyman in my dreams.  I may not have known my perpetrator, but I know he is a person. He has a face and a name. He committed a terrible act of violence that I never received “justice” for, but he is no longer the monster I wrestle with.  Going through the criminal justice process would not have helped me to heal. I would have been re-traumatized and it wouldn’t have changed having been raped. Participating in these sessions brought me justice, peace, and answers to questions I’ve pondered for 17 years.

I have always known that my identity involves so much more than the label “rape survivor.” I now fully understand that my perpetrator is so much more than a rapist. I forgave him for his actions many years ago, this recent experience allowed me to forgive myself.

Jill started her career as a child protection social worker, investigating child abuse cases, helping victims and counseling survivors. In the early 1990s, when she was treating survivors at a mental health clinic, she asked the psychologist running the sex offender treatment program: “Why do your clients do these things to my clients?” He answered: “Why don’t you sit in on a treatment group and see for yourself?” She explains:

I did that, and I never left. I’ve been counseling offenders for 24 years. Why do I do it? I do it because it’s a crucial public protection service. I help these men to understand their behavior and learn how to prevent it from happening again.  How do I work with “those people?” Well, they are just people. Does treating them even help? Yes, research tells us that proper psychological interventions can reduce the likelihood of reoffending.

When Alissa came to talk to the men in my treatment groups, I knew they were anxious. They were afraid of her anger, her judgement, her shaming. We prepared the week before by generating a list of questions they would want to ask their own victims. We speculated about what she might need to hear from them. When she arrived, they were surprised when she approached them with curiosity and compassion. As she told her story, they were able to hear the various, subtle, and insidious ways that her assault has permeated through all aspects of her life. They were able to understand the far-reaching impact to victims of sexual assault and everyone else in their lives. Of course these men always knew that what they did was wrong and illegal, but now they were better able to appreciate the psychological harmfulness of abuse, why it was wrong, and how it leaves such a lasting scar. Several of them have requested to contact Alissa directly, and they all want to invite her back for another session. Their capacity for empathy has been forever altered, in an extraordinary and unique way.

A society that measures justice only in the length of a prison term is limited in its capacity to effect change and reduce harm. Let’s move the conversation toward understanding the needs of survivors in their healing journey, and fashion our responses accordingly.

 Dr. Alissa Ackerman is an Associate Professor of Social Work and Criminal Justice at University of Washington Tacoma. 

Dr. Jill Levenson is an Associate Professor of Social Work at Barry University in Miami Shores, Florida.