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.