Thursday, January 11, 2018

The Missing Link of Adversity

By David S. Prescott, LICSW

A recent BBC documentary highlights the work of a school in Glasgow, Scotland, to help young school children manage their aggressive behaviors. On its surface, the video is inspiring: with little to no resources, a group of dedicated teachers and behavior specialists design “nurture rooms” where these children can get specialized attention and guidance. This approach reduces the use of empty “time-out rooms” where adults sit with children who have no choice but to stew in their own challenges. The video ends with questions about how best to fund similar programs in the future. It can’t be easy; even the “comments” section of the video highlights the attitudes of many in the public. One viewer states, “A boy’s ears are in his backside. Bring back corporal punishment.”

Interestingly, 89% of the teachers in the video state that they blame the parents for their children’s behavior. There is no discussion of the ways in which the school environment itself may contribute to the children’s problems. Perhaps most revealing is that there is no mention whatsoever of the fact that many of these children likely have histories of adverse and traumatic experiences. It’s as though the same schools that would build handicap access for children with physical disabilities would not make similar accommodations for young people with the less obvious disabilities that can arise from growing up in adversity. Under these circumstances, blaming parents is perhaps less helpful than examining the broader context in which abuse and adversity occur. Parents should, of course, be held accountable for their actions. However, helping prevent further harm means understanding adversity and assisting people in moving beyond it.

These are not simply ideological statements. Research on complex trauma and aggression in secure juvenile justice settings – the obvious next step for the young people in the BBC video – by Julian Ford and his colleagues describes the extraordinarily high rates of traumatic experiences in the backgrounds of  incarcerated youth and the connection between formative events and future aggression. The study describes interviews with clinicians treating 40 youth who had perpetrated sexual abuse, finding that 95% of them had at least one traumatic experience in their past and that 65% of them met the diagnostic criteria for Post-Traumatic Stress Disorder. The clinicians viewed traumatic experiences as having set into motion the sex crimes of 85% of these youth. In other words, while many in the general public may see only the backsides in need of corporal punishment, a deeper examination of these youth reveals a much more disturbing truth. It should be no surprise that punishment-only responses don’t work.

Even among adults, it can be easy to overlook the amount of trauma and adversity in the backgrounds of men and women who sexually abuse. Levenson, Willis, and Prescott (2015; 2016) found elevated rates of adverse experiences (including over 13 times the odds of verbal abuse) in the backgrounds of these individuals. As lawmakers and the lay public talk about getting ever tougher on crime in the name of assisting victims, it’s easy to miss seeing how many of those who have abused have themselves been victimized. Indeed, the deeper one digs into research on people who abuse, the clearer it is that the forces driving abuse cannot be easily dismissed by statements such as “they should have known better.” As many have said before, recognizing abuse as a public health issue rather than simply trying to punish it away will be a good start.

In the “flashbulb moment” that comes in the immediate wake of abuse, it is easy – perhaps even natural – to experience the desire to destroy both the abuse and the abuser. Likewise, it can be easy for prison officials, supervising agents, and treatment providers to view irritating features of those in their charge, such as irritability, hypervigilance, emotional numbness, and apparent memory problems as efforts to avoid responsibility when they are also diagnostic criteria for PTSD. The real questions for all professionals include: How can we best understand the totality of our clients’ experiences and not simply view them as merely the sum of their worst behaviors? Can we stay true to our mission of assisting those who have been abused by including those who have also abused others? Can we go beyond holding people accountable and also teach them about accountability? Can we exercise the same compassionate working alliance (central to all of the world’s religions and successful forms of psychotherapy) with people whose actions can seem separate from their histories? Ultimately, can we accept the person in front of us even as we don’t accept abuse?

Understanding trauma in the lives of others has been a difficult undertaking in mental health practice since the time of Freud. Just the same, human beings have helped one another move forward from trauma as long as there have been traumatic experiences. Not everyone who has been traumatized needs specific treatment, but it seems that the majority of those who might be inclined to cause harm can benefit from trauma-informed care. 

Friday, January 5, 2018

As we move into 2018, are we still in a room without a view?

By Kieran McCartan, PhD, David Prescott, LICSW, & Alissa Ackerman, PhD.

The start of a new year is often a time of reflection and hope. We think about our experiences as well as practice over the last year and learn from poor practice as well as build upon good, existing practices. Having a solid, reliable, evidence base is central to all aspects of life, personal and professional!

Thinking back over the last 12 months, 2017 has been an interesting year to say the least with the common factor being one of ideology and “common sense” understandings winning out over an established evidence base many times. A recent example was the United States’ Centers for Disease Control emphasizing that it would not accept funding submissions that contain words such as “evidence-based”, “transgender”, etc. Although we all have ideologies, thoughts, and beliefs that govern our lives and practice, the majority of the time these are not based on facts, outcomes and analysis. Rather, these can be based on perceptions and collusion with friends, family and/or peers. This might be fine if we are deciding which diet to use, airline to fly or coffee shop to visit; but, are these the best metrics for deciding on larger, societal scale decisions? All too often it seems that we agree with science primarily when it supports our views.

This reliance on ideology has often times led – especially in northern hemisphere westernized countries – to a rejection of expert knowledge as well as evidence. In 2017, in our opinion, this resulted in a return to lay knowledge and ideologically driven theories, policies and practices. In other words, sometimes going backwards to debunked beliefs and practices!

Let us be clear here: we are not being elitist and saying that expert knowledge is the only way to develop policies and practices, because it is not. Instead, we are saying that in order to develop best practice we need to listen, to hear, and to understand all the voices in the debate without shutting any down. The transition away from evidence based policy and practice is worrying because it means that we are not listening to all the available information and are basing our ways of working purely on ideology. We want our taxes spent appropriately and we want governmental decisions to be realistic, appropriate and fit for purpose. We should want evidence based decisions, policies and practice! Why? Because it means that we are not spending time, money and resources blindly or causing harm along the way; we have an idea of what works and what does not work, therefore we can be more measured and realistic in terms of social, political, practice and policy change.

However, in many current northern and western hemisphere countries with right wing, or at least right-leaning, governments’ evidence is not the metric that they want to use in their policy and practice shifts, they want it to be ideological. Clear examples of this can be seen in the UK (via Brexit). Clear examples also abound in the USA. The best example is perhaps the election of Donald Trump during a year of campaigning not known for its reliance more on ideas than on evidence. Other examples include changes to Obama-care (which many people have found undesirable, but which provided millions of people access to healthcare), refusal for the CDC to fund research from transgender issues and the effects of gun violence, and defunding of the National Registry of Evidence-Based Programs and Practices).

In the field of sexual abuse, evidence based practice is central and needs to remain central. We have seen the cost and consequences of ideologically driven policies and practices on the ground, from funding of policies that don’t reduce risk (e.g., public registries and residence restrictions) to increasingly scarce funding for those that can reduce risk (e.g., treatment and supervision). As one example, in the state of West Virginia, probation officers specializing in supervising people who have committed sex crimes have lost their jobs at the same time as the state’s Supreme Court justices spent astronomical sums on office furniture.

Evidence tells us, if we do research well and in the most appropriate way for the question at hand, we can discern what works and what does not. Sometimes we don’t like what the research tells us and sometimes we do. Despite the outcomes of research the most important thing is that, whether we like it or not, we are called as professionals to do what actually works!