Thursday, March 14, 2019

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

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

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

Thursday, March 7, 2019

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


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

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

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

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

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

Thursday, February 28, 2019

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

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

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

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

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

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

Lesson 1: Listening to caregivers

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

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

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

Lesson 2: Kids in the system

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

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

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

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

References

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

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

Thursday, February 21, 2019

A plea for compassionate self-care

By David S. Prescott, LICSW

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

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

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

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

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

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

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

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

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

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

Friday, February 15, 2019

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


By Kieran McCartan, PhD & David Prescott, LICSW

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

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

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

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



Friday, February 8, 2019

The collateral consequences of sexual abuse


By Kieran McCartan, PhD, & David Prescott, LICSW

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

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

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

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

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

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

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

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

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

Thursday, January 31, 2019

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

By Kieran McCartan, PhD, and David Prescott, LICSW

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

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

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

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

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

Wednesday, January 23, 2019

Understanding the Obstacles to Help-Seeking for Minor-Attracted Persons

By Jill Levenson, PhD,  Barry University, Inc. at JLevenson@barry.edu; Melissa Grady, Ph.D, The Catholic University of America at grady@cua.edu; and Julie Patrick with RALIANCE at jpatrick@raliance.org
 
W. Edwards Deming once famously said, “In God we trust, all others must bring data.” Designing effective primary prevention services starts with collecting good data. Yet this proves challenging for many stigmatized populations who remain “in the shadows.”
The scholarly literature, for instance, about non-offending minor attracted persons (MAPs) is in a nascent stage. Though they remain an under-studied and somewhat misunderstood population, we are learning more about individuals who have sexual interests in children (Cantor & McPhail, 2016). Studies have revealed that most MAPs become aware of their unusual sexual interests in early adolescence (B4UAct, 2011b; Buckman, Ruzicka, & Shields, 2016), and that among MAPs, about 42% report a primary attraction to pre-pubescent youngsters (Mitchell & Galupo, 2016; Piché, Mathesius, Lussier, & Schweighofer, 2016).
Due to stigma, fear, and shame, and many other factors, many MAPs have not sought help from professionals, and others have been discouraged by the services they received (Jahnke, 2018). Some MAPs who did seek services but did not receive them reported that failure to obtain adequate help resulted in negative ramifications. These include an exacerbation of mental health symptoms such as depression, suicidality, withdrawal and isolation, lost productivity, fear and anxiety, hopelessness, and substance abuse (B4UAct, 2011a). Furthermore, a small group (3-4%) said that after being unable to obtain counseling, their attraction to youngsters continued or escalated and that they were later convicted of a sexual crime (B4UAct, 2011a). MAPs in non-forensic samples tend to have higher education and socio-economic status than those convicted of sex crimes, and may have greater willingness and opportunity to engage in formal and informal help-seeking through various professional or online resources.
Thanks to an impact grant by nonprofit leadership collaborative RALIANCE, Dr. Jill Levenson at Barry University and Dr. Melissa Grady at Catholic University surveyed minor-attracted persons (MAPs)​ ​to better understand the obstacles they faced when seeking help[JP1] .
The project complemented information gained from the “Help Wanted” project developed by Dr. Elizabeth Letourneau [described in Buckman, Ruzicka & Shields (2016)] by collecting data from a larger sample with a greater age range. The quantitative survey for more robust data analyses including group comparisons and associations between variables.
Good data and collaborations
The researchers built relationships to partner with consumer groups that provide online support, resources, education, and information for MAPs who are concerned about their sexual interest in children. With the help of organizations like Stop It Now! and VirPed, the project was able to collect a non-random, purposive sample of MAPs (n = 293; 154 completed all questions). The on-line survey included quantitative questions to gather information about their histories, help-seeking experiences and behaviors, as well as 10 open-ended prompts designed to capture their lived experiences of seeking counseling for minor-attraction.
Overcoming challenges
Confidentiality and anonymity concerns were addressed by building in protections in the survey platform. Many MAPs have worked to separate the constructs of minor-attraction or pedophilia from “sex offender.” The conflation of these terms perpetuates the stigma and shame felt by MAPs. For this reason, some MAPs did not want to be part of a study focused on the prevention of sexual abuse, arguing that many MAPs are not at risk for abuse.
Implications for service delivery
The participants reported that stigma was the primary barrier to seeking help from others. Although stigma was reported as a stand-alone theme, it overlapped with many of the other themes, such as fear of being judged or being reported to authorities even though they had never acted on their attractions. They also reported high levels of shame, which focused on internal views of themselves as a “bad person,” which was sometimes reinforced by mental health professionals. To counter these negative experiences, many noted the importance of building a community with other non-offending MAPs (either in person or online). To learn more about the implications for practice and policy, please review: “I can’t talk about that”: Stigma and fear as barriers to preventive services for minor-attracted persons [JP2] [Original Journal article in Stigma & Health] and Preventing Sexual Abuse: Perspectives of Minor-Attracted Persons About Seeking Help [JP3] [Original Research Article in Sexual Abuse].
This project promotes the idea that we can make communities safer when we provide compassionate, relevant, ethical, and effective psychotherapy services accessible and available for non-offending MAPs who wish to maintain an emotionally healthy and non-victimizing lifestyle.
References
B4UAct. (2011a). Mental Health Care and Professional Literature Survey Results. Retrieved from http://www.b4uact.org/research/survey-results/spring-2011-survey/
B4UAct. (2011b). Youth, suicidality, and seeking care. Retrieved from http://www.b4uact.org/research/survey-results/youth-suicidality-and-seeking-care/
Buckman, C., Ruzicka, A., & Shields, R. T. (2016). Help Wanted: Lessons on prevention from non-offending young adult pedophiles. ATSA Forum Newsletter, 28(2).
Cantor, J. M., & McPhail, I. V. (2016). Non-offending Pedophiles. Current Sexual Health Reports, 8(3), 121-128. doi:DOI 10.1007/s11930-016-0076-z
Jahnke, S. (2018). The stigma of pedophilia: Clinical and forensic implications. European Psychologist, 23(2), 144-153. doi:10.1027/1016-9040/a000325
Mitchell, R. C., & Galupo, M. P. (2016). The role of forensic factors and potential harm to the child in the decision not to act among men sexually attracted to children. Journal of Interpersonal Violence, 0886260515624211.
Piché, L., Mathesius, J., Lussier, P., & Schweighofer, A. (2016). Preventative Services for Sexual Offenders. Sexual abuse: a journal of research and treatment. doi:10.1177/1079063216630749

 [JP2]http://psycnet.apa.org/doiLanding?doi=10.1037%2Fsah0000154
 [JP3]https://journals.sagepub.com/doi/full/10.1177/1079063218797713

Thursday, January 17, 2019

We never know where the next innovation will come from

By David S. Prescott, LICSW

I recently had the opportunity to provide training on the Good Lives Model and Feedback-Informed Treatment in a secure treatment center for adolescents. The program has been able to accomplish what others only dream of with kids deemed by the courts to need this intensive level of supervision and structure. After the training, I had the privilege of meeting with a number of treatment graduates as well as their student advisory board, an independent collection of students currently in treatment. I also toured the facility, observed people and situations, often beyond their full awareness, etc. Just imagine:

·   In a program that serves well over 100 adolescents, they have not had to engage in physical management in over 560 days.

·   As a part of eliminating physical management, they also reduced the number of staff injuries significantly.

·    They present at national conferences on the methods they used to accomplish this remarkable feat. The short version is that it involves strong leadership, a philosophy of trusting kids to do the right thing under the right circumstances, and intensive in-house training on how to have a conversation with a distressed teenager and how to prevent appearing threatening.

·    The program was an early adopter of trauma-informed care and has used trauma-focused cognitive behavioral therapy for the better part of a decade.

·    They incorporate client feedback in a number of areas through the use of anonymous surveys. The process itself is further anonymized through the way staff members handle each survey.

·    The student advisory board takes an active role in the hiring of staff and has actually contributed substantively, including accurately identifying candidates who were unfit to hire.

·    Taken in sum, the program has worked like very few others to develop a “culture of feedback” in which its students are free to speak with staff at all levels about their doubts and concerns. They are able to do so without fear of retribution and with confidence that they will be taken seriously. In a large institution, this is itself a  major accomplishment.

·     The program tracks outcomes and finds that only a small number of its clients return to a similar or higher level of care. They break this data down further to identify which clinicians are more and less successful in this regard so that all can improve the services they deliver.

Although there are good and not-so-good youth-serving programs all around North America, what makes one of the biggest differences? This program uses the polygraph. Those familiar with my work know that I have long been sceptical of the polygraph with adolescents. As just one example, consider this post by myself, Kieran McCartan, and Alissa Ackerman from last year, in which we discussed how the success of an intervention can rise and fall on its implementation.

To a sceptic such as myself, this implementation comes as a refreshing surprise. From internal data collected, it is clear that the majority of clients are not only comfortable with the polygraph as it is implemented but endorse its use wholeheartedly. Comments from students who had nothing to gain or lose by being honest in interviews focused on how the process of using the polygraph helped them to be honest with themselves about their treatment needs. Inconclusive results were as likely to activate discussions in treatment as to the possible role of adversity and trauma in the backgrounds of the students as anything else. Policies are in place that firmly establishes its use as a treatment tool. In fact, to an outside observer like myself, it appeared that the program had worked to wrest polygraph processes away from professionals outside the program in order to implement its use in the context of the client-centered values described above.

Of course, some aspects of this program’s polygraph use are clearly at variance with other implementations and deserve comment. I have personally worked with some polygraph examiners who should probably never work with adolescents. That is a fair enough statement, as I have also spoken with examiners who don’t want to work with this population. Likewise, this program has no expectation that the polygraph will do anything except help teens to demonstrate to themselves or others that they are giving treatment, honesty, and meaningful personal change their best shot. Importantly, in the context in which these young people find themselves (entangled in the legal system and often at odds with their families), they are grateful for anything that helps them to get back on track quickly.

In addition to their consumer satisfaction and feedback measures, the program further uses these approaches to ensure that the polygraph is helping and not hurting any of the kids or their futures. Questions related to how comforting the examiner was to the child are at the forefront of questionnaires and clinical discussions; indeed, the students give specific feedback on the examiners themselves. Just as importantly, the polygraph is billed as something that confirms students’ statements rather than catching them lying. Ultimately, there is no over-selling or misrepresentation of the polygraph; the students are aware that it is far from perfect, and this is evidenced in their feedback.

Ultimately, any intervention can do harm when misapplied. This is why we have practice guidelines and codes of ethics. I have personally witnessed polygraph examinations that were anything but helpful. Unfortunately, as with other agency settings, it is a very difficult process to obtain approval for research from the court system involved. For the time, it is limited to its own practice-based evidence. At the present time, the program is continuing to work to improve. For example, while a very considerable majority felt that the polygraph process had helped them to forge better relationships with others, a majority also felt that they could have been better prepared.

In all, I left the experience feeling that the real question is not whether the polygraph should be used or not, but rather how programs can best focus on all of the myriad elements that make up a solid, youth-guided intervention. Although I have no plans to change my own practice, this experience points to the obvious need for professionals to keep an open mind and not simply assume that any other professional is either wrong or in need of instruction.

The challenge for practitioners in the field ultimately has to do with balancing the promise of better futures with minimal risk of harm. Like many other aspects of treatment (e.g., disclosing past abuse without the polygraph, focusing on victim empathy), it can take years of teamwork to accomplish this.

Again, one never knows where the next innovation will come from.



Tuesday, January 8, 2019

The “right” relationship in assessment and treatment: What does it look like?

By David S. Prescott, LISCW

It’s a little late for this to be a 2018 year in review post, but if I had to pick a single study from the last year with maximum implications for professionals working with people who abuse (whether sexually or otherwise), it would be one by Brandy Blasko and Faye Taxman. They found that “when the community supervision process was perceived [by the client] as procedurally fair, individuals under community supervision demonstrated positive criminal justice outcomes, that is, less self-reported criminal behavior, fewer official arrests, and fewer technical parole violations” (p. 414). Their measure of fairness included the client’s perception of being listened to by their probation officer.

Why is this study so important? For starters, it adds to what over 1,100 studies have found outside of forensic treatment circles: that the therapeutic alliance (also known as the working alliance) is fundamental to making treatment effective. And yet, too few in our field can even define it. Of course, developing any kind of professional relationship with people whose actions have been reprehensible can be a challenge, especially for those starting out in the field.
Bill Marshall and his colleagues found that the most effective treatment providers are warm, empathic, rewarding, and directive, but translating these qualities into one’s own practice can be a challenge.

Questioning the nature of professional relationships is not merely an academic point. Sexual and other forms of violence can cut deeply into the hearts and souls of professionals, as anyone who has followed the recent media attention to R. Kelly can attest. Virtually anyone who works in the areas of abuse and trauma has experienced those cases that leave a lasting mark on our souls, often with apparently indelible imagery. As some have recently noted, when the person who perpetrates violence has been a hero or practically wrote the soundtrack to one’s adolescence, the resulting anguish can be hard to escape and even contribute to burnout.

Recent discussions within and outside of ATSA circles have focused both on the impact of doing this work and the extent to which we should “like” our clients. To outsiders, one of the surprises of working in our field is how likable some of our clients can actually be. In some cases, this can become disconcerting, leading to questions as to where the boundaries are in developing the best working relationship. Complicating matters are the moral judgments professionals can have about their client’s actions, as well as concerns that their clients may be engaged in manipulation processes that resemble the approach behaviors used with those they’ve harmed. With all of these factors in the mix, how could we not wonder about what kind of relationship is most effective? Even beyond likability, many of us remember that the teachers, coaches, and colleagues we learned the most from were not necessarily those that we liked the best, but we respected them.

“What is the right relationship” may not, however, be the best question. Just as there are “treatments of choice”, there can also be “relationships of choice” … And these can vary based on who the therapist is. Implied within the Blasko and Taxman study is that it’s not a question about what kind of relationship you have as much as do you have agreement and buy-in as to the nature of your relationship. Very often, this centers on to what extent you have built up agreement on the goals you are working towards and the approaches used in treatment. This agreement on the nature of the relationship as well as the goals and tasks of treatment are the three areas originally defined by
Edward Bordin in 1979. Although mentioned frequently in trainings and social media (including this article by Scott Miller and me, and a blog post with our colleagues), it often appears to be an idea whose time is yet to come in the forensic arena.

One way to think about building the “right” relationship with clients might be to think about it one client at a time. You can ask yourself:

1.      What are this client’s goals and how can I best align them with the goals set out in his (or her) treatment plan and/or assessment reports?
2.      What kind of approach works best with this particular client and how can we develop agreement on the best way forward?
3.      Who am I to this client and how does s/he view my role within it? Do we have agreement on who I am to this person?
4.      Finally, how can I provide services in a way that are aligned with this person’s unique culture and strongly held values?

Seen through this lens, the question of the right relationship (and the boundaries within which it exists) may be easier to negotiate.

Of course, what is missing from this mix can be as important as what is there. In this way of working, professionals must strive to keep whatever moral judgements they have about clients’ actions separate from the assessment or treatment process itself. Likewise, it can be easy to overlook the importance of establishing agreement in these areas to begin with; all too often, professionals view the working alliance as something to establish at the start of treatment rather than an essential component throughout the experience. Finally, it can be tempting to think that we already have a good enough working alliance, and that we don’t need to ensure this on an ongoing basis. Unfortunately, Beech and Fordham found otherwise in our field. Finally, it assumes that professionals are willing to take into account their clients’ experiences, are able to think flexibly about their clients, and be willing to switch up their styles as needed.

In the end, however, I’ve always found that the additional attention to these areas pays dividends in terms of time saved trying to sort out why treatment isn’t moving faster.