Wednesday, July 28, 2021

Risk of what?

By David S. Prescott, LICSW, and Kieran McCartan, Ph.D.

In a recent discussion of assessment measures, an ATSA member referred to an instrument saying in essence, “Don’t forget that it is not a risk assessment instrument; it assesses areas of risk.” Among professionals who conduct risk assessments across diverse settings, this sentence actually makes perfect sense. Translation: While the instrument helps assess risk factors as part of a broader assessment process, it does not provide a total picture of the specific risk for a specific risk outcome (for example, “individuals with Mr. X’s score have been found to re-offend at a rate of Y over Z number of years”). It is not simply an academic discussion; different assessment instruments are designed for very different purposes, ranging from estimations of the likelihood for re-offense to case formulation and planning. Static-99r is an excellent choice for the former but might not be as helpful in many aspects of case formulation. On the other hand, some measures can aid case planning but lack the empirical support of Static-99r for arriving at a baseline.

Assessing risk has eternally been an area of great importance in our field, and rightfully so: How can we design empirically grounded programs without some idea of what kinds of risk, a person poses and what level of intervention they require? On the other hand, we often benefit from taking a step back and reflecting on how we conceptualize “risk.”

 A quick Google search on “definition of risk” yields a top result of “expose (someone or something valued) to danger, harm, or loss” as in, "He risked his life to save his dog." Right away, there is a question within “risk assessment” of whether we are trying to understand the danger, the exposure to danger, or the likelihood of the worst outcome. One could argue we each conduct a risk assessment each time we cross a busy street.

These questions, in turn, provide more opportunities for reflection. It is not uncommon to hear the expression “risk prediction” which begs the question of whether the professional is assessing, predicting, or some combination. Assessment and prediction are not the same things. If they are predicting, are they trying to predict re-offense itself or simply the exposure to danger or harm described above. Are we trying to predict what circumstances will be in place in the future? Or are we saying “prediction” when we are actually examining historical risk factors that might become present in the future? When we say “risk assessment” do we mean assessing risk itself or the circumstances under which risk would become unmanageable? Should we clarify this in our reports?

In the context of civil commitment “risk” is defined in the statutes that give rise to the assessment itself. In other circumstances, risk assessment may be a broader term covering many areas, which professionals use because it is so common. For example, “risk assessment” in the juvenile world often indicates a more comprehensive process that encompasses the identification of treatment needs and strategies for producing the best outcomes.

Further questions remain, such as the risk for what? Often, risk assessments consider some areas but not others. Assessors sometimes focus on specific areas, such as the risk for violence and general criminality, as well as for sexual re-offending. All too often, the same reports are silent on the possible risks of self-harm, suicide, or simply not living up to one’s full potential (which is often the highest risk of all). While we often talk about victim access in general, we seldom reflect on what risks might exist for those who have been harmed. Unfortunately, this area can be far less clearly defined in our referral questions.

Strikingly absent in many discussions of risk assessment are considerations regarding risks to the health and welfare of those who have been abused.  Few of our processes (and the actions of the criminal justice systems beyond) were designed to calculate how assessment or treatment can aid those who have been harmed, including by involving them or leaving them alone. Mistakes in this domain of our work only seem to create new risks of harm to others.

It also behooves us to consider the fundamental purpose of understanding risk. Clearly, it should enable rehabilitation and safe community integration. It’s also about management and incapacitating truly high-risk cases. One challenge in risk assessment is the perennial question of who manages the different risks? Is it the professional’s job to manage and be responsible for the individual’s risks? Or specific risks? Or is it the client’s responsibility to manage their own risk? Or specific risks? Or is it somewhere between the two?

These can be difficult conversations, as risk changes depending on the context and the place that the person is at in their rehabilitation. Central to the process can be helping the client to identify and manage risk(s). Of course, not every client is ready, willing, or able to do that. Ultimately, risk assessment creates a space in time to understand the context of that individual, which is why it’s an ongoing process, frequently redone and refined.  No one can fully predict future offending. We can only make our best judgments based upon the existing data and using the most appropriate research.

While some of these reflections may mystify some and be crystal clear to others (and there are many more considerations that we can’t discuss within the space limitations of a blog post), we have to acknowledge that with the explosive growth in our understanding of risk and risk assessment across the past thirty-plus years, our answers continue to pose new questions. For our communications, however, the very idea of risk itself may be in danger of being clearer in our minds than in our reports.

Friday, July 16, 2021

Do high risk offenders remain high risk forever, or do we just want them to be?

 By Kieran McCartan, Ph.D., & David Prescott, LICSW.

NOTE: It is important to state that the authors have no more information on the risk posed by Colin Pitchfork than has been released into the public domain. The aim of this blog is not to challenge or validate any decisions that have been made, rather to debate the question of change and, ultimately desistence, in high-risk individuals – Kieran

Earlier this week it was announced that Colin Pitchfork, one of the UK’s most notorious child killers would be released from prison back into the community after the parole board stated that it was safe to return him to the community. As well as killing his victims, Pitchfork also sexually assaulted and raped them. At the time of his offence and conviction his case made national headlines, which has not abated during his time in the prison system and all his parole hearings as well as appeals. The Pitchfork case presents a challenge between evidence, practices, public opinion, and “politics” and in doing so reminds us of the mantra, and challenge laid down by Karl Hanson that not all high-risk offenders will always remain high risk.

The balancing act in the pitchfork case is multi-layered and complicated, involving the nature of his offence, the public and political reaction, media commentary, trust in the state to manage people after their release and a fundamental question of whether we believe that people can change. To start to understand the complexity we need to pick apart the social, political, and cultural dimensions that surround the case.

The offence: Colin Pitchfork raped and murdered two schoolgirls in the 1980s in Leicester England. They where Lynda Mann and Dawn Ashworth, both 15, in 1983 and 1986 respectively. The offences while harrowing, are particularly salient given the nature of the crimes and victims. These events have provoked public and political reactions, creating, and reinforcing stereotypes and misperceptions about the reality of these offences as well as the people who perpetrate them. One reason that this case made national headlines was that Pitchfork was the first person in the UK to be convicted, in 1988, by use of DNA evidence. At the time of conviction, he was sentenced to two life sentences, 30 years in the UK, to be executed simultaneously, which meant that it was initially due for release in 2018.

Public and political reaction: Given the nature of the crime and the conditions of the conviction, and international media coverage at the time, Pitchfork’s case was in the public and political interest. This resulted in many consecutive Secretaries of State becoming involved, right up to and including the current one. Currently, the Ministry of Justice and Robert Buckland, MP, has come out and said that they are disappointed by Pitchfork’s release and are considering a root and branch review of the parole board and their decision-making processes. This adds complexity to the case; it reinforces public concerns (that can often be laden with misconceptions) and calls into question professional standards and decision-making processes. It begs the question of whether high profile offenders should, could, and are being treated differently than other offenders because of the reaction that their release creates. 

Media commentary: The media’s close attention to the case often highlighted the salacious nature of Pitchfork’s offending behaviour, especially at key points in the trial, sentencing, and previous attempts at release. The media have often reinforced the public and political view that pitchfork is a constant and unrelenting threat, and therefore he should not be released. No counterpoint has examined the legitimacy of the potential risk management plans, the risk assessment, or the expertise of the professionals responsible for these decisions. The media often state that they are following and discussing the story because it’s in the public interest. The real question, however, is whether they are framing the story in a way that is in the public interest.

Practice and evidence base: The extant research and practice evidence bases highlight that people can and do change, especially over the course of many decades and as they age. They very often desist from further crime and community as well as social support often help in this. This knowledge base includes not only people who have committed sexual offences and murders but also other people who have committed serious offences that have resulted in life sentences. The reality is that Pitchfork was given a life sentence (i.e., 30 years) and not a whole life tariff (i.e., that he would die in prison). Therefore, there has always been the expectation that he would be moving towards release and community integration at some point. We can see through his time in prison that this was the objective, especially given the treatment and rehabilitation programs that he attended as well as the fact that was moved to an open prison towards the end of his sentence. Additionally, Pitchfork has had an extensive and restrictive risk management plan developed as part of his release, highlighting the centrality of community safeguarding and public protection in his release from prison. All of this raises the question of whether the real issue is whether the sentence, tariff, and process are not what the public, media, and politicians wanted. After all, the prison service and parole board’s methods are obliged to be in line with the evidence base.

The Colin Pitchfork case creates more questions than it answers. It begs the question of whether the public, political, and media reactions are based on the nature of the crime and the perceived nature of punishment required. Looking at the evidence base, HMPPS and the parole board have delivered what they were meant to and that they have worked towards. If society at large is not happy with that, then the question needs to be asked if it is more that they are not happy with the sentence, tariff, or processes involved rather than what has currently been delivered. Therefore, we need to reflect upon the public and political perceptions of punishment, rehabilitation, risk assessment, and risk management versus the evidence-based reality of practice in this area. How do we bring perception and reality closer together? How do we create an informed, evidenced understanding of the challenges and processes involved in successful (risk) management of high-profile cases?  

 

 

Friday, July 9, 2021

An Update on ATSA’s Efforts with Sexual Misconduct on Campuses

 By Judith Zatkin & Joan Tabachnick

Recently, the White House requested comments and feedback on new Title IX regulations released in August of last year, regarding campus sexual harassment and assault.  With the previous administration, there were a number of changes that many colleges and individuals strongly objected to.  In fact, there were over 130,000 comments submitted, mostly voicing their concerns and objections during the comment period.  Without going into all of those changes and the seismic changes that these caused on our campuses, one change significant for ATSA was to encourage equitable respondent services alongside of similar services for survivors.  Equitable was not defined, but it opens the question about what are equitable services for complainant (those who were harmed) and respondents (those who have been accused or found responsible for that harm).  We believe that it is possible to both protect survivors, and match respondents with adequate services to promote healing and prevent further aggressive behaviors.

In 2020, Jenny Coleman and Becky Palmer put together some commentary, with our concerns about the initial changes.  For the current comment period, these comments were edited and updated by Joan Tabachnick with input from members of the campus sexual assault sub-committee.  This group is made up of members from the Prevention and Public Policy Committees. 

This update repeated our request for broader definitions for sexual harassment and assault, which would allow for those with lower-level harassment behaviors to access services that can prevent future misconduct.  With the narrow definition, colleges and universities lose the opportunity to address behaviors before they escalate to sex crimes and establish a social norm of respect and accountability. 

We requested a clearer definition of “equitable” services.  Anecdotally, we have heard that some campuses are ending their Memorandum of Understanding with local rape crisis centers because there is not equivalent service for students who have been accused of sexual misconduct.  Our statement noted that equitable is not necessarily equal, noting that those accused of sexual misconduct need very different services than survivors.  This also offered us an opportunity to describe some of the research from ATSA members which clearly note that services for those found responsible for sexual misconduct must be individualized. This individualized approach, a relatively new concept for many in the campus world, allows institutions of higher education to develop services that are best matched for the needs of their campus community.  Prevention works best when it is tailored to the needs of individuals and the systems in which they reside.

We also commented on the problematic shift in these new Title IX regulations from the use of interim measures, which could be required such as changing class schedules, room assignments, etc. to the use of supportive measures, which are purely voluntary.  Institutions need the ability to ensure safety for everyone, those who are harmed and those who are accused of causing the harm.   They also need the ability to respond to a situation once a complaint has been filed.  Under the new regulations, all of these measures must be voluntary by the party involved.  The only avenue now open to institutions is to conduct a detailed threat assessment to determine if the student is a significant threat to a student or the campus.  If that is founded, then a student can be removed from campus – the campus still cannot address behaviors that are significant, but do not reach the level of a threat to the campus. Again, the campus is losing the ability to respond to a situation when it is reported and begin a more robust conversation with everyone involved.  

We are thankful to ATSA members Tay Bosley, Katie Gotch, Keith Kaufman, Ray Knight, and Seth Wescott provided ideas about this update, which were essential to this work.  The ATSA Statement is now on our website at:  https://www.atsa.com/Public/Office/Legislation/ATSATitleIXRuleChangeComment2021.pdf. If you want to learn more about the public comment period, here is that link (https://web.cvent.com/event/ba5eef74-8f35-4a4e-b0a7-1f047fe033bc/summary).  We would be happy to hear any additional feedback surrounding ATSA’s involvement in the prevention of campus sexual misconduct.

 

Judith Zatkin, PhD

Co-Chair of the Prevention Committee

Member of Campus Sexual Misconduct Sub-Committee

 

Joan Tabachnick, MBA

Co-Chair of the Campus Sexual Misconduct Sub-Committee

 

 

Thursday, July 1, 2021

Let’s talk about healthy sex – the importance of sexual health care.

By Marije Keulen-de Vos, Kasia Uzieblo & Minne De Boeck (Dutch affiliation of ATSA, NL-ATSA)

According to the World Health Organisation, sexual health refers to a state of physical, emotional, mental and social well-being in relation to sexuality. It encompasses not only certain aspects of reproductive health but also the possibility of having pleasurable and safe sexual experiences. This part of life is often neglected in working with persons with sexual offence histories. Treatment is typically aimed at inhibition, control and suppression of sexual feelings and behavior opposed to identifying healthy sexual behavior and promoting sexual health. Those in the field of providing therapy and education for persons with sexual offence histories are somewhat puzzled by the question of what constitutes healthy sexuality for these individuals. In persons with sexual offence histories, sexual health is not simply a synonym for absence of sexual violence. Instead, it relates to the absence of sexual dysfunction and the presence of sexual pleasure without suffering, without bringing harm to others and having sexual pleasure with mutual consent.

On June 1st NL-ATSA, the Dutch affiliation of ATSA organized an online symposium on the importance of talking about and facilitating sexual health in persons with sexual offence histories. The symposium started with three plenary sessions which were followed by three parallel sessions. 

The first presenter, Prof. Marieke Dewitte (Maastricht University, the Netherlands), focused on a biopsychosocial model towards sex. Sexuality is complex; it involves our brain system, neuroendocrinological system, and anatomy. For example, a sexual trigger may lead to positive appraisal, subjective arousal, genital arousal, sexual motivation and, ultimately, sexual behavior. Psychological mechanisms such as sexual rewards, thoughts and emotions, and attachment, all linked to the societal and relational context, define our sexual behavior. Hence, psychological theories on these mechanisms help us understand sexual behaviour. For instance, the attachment theory provides an important framework for understanding the dynamics of (sexual) interactions in romantic relationships across the lifespan. Because the attachment system primarily serves an emotion-regulation purpose, the attachment theory can help us explain how individuals cope with stressful or threatening situations within the context of their sexual relationship. For example, feelings of intimacy are a likely result of this sense of security. On the other hand, intimacy might also act as a buffer to prevent the activation of the attachment system when facing relational or sexual challenges. Marieke Dewitte concluded that 10% to 23% of the persons with sexual offence histories experience various problems with sexuality and intimacy. Some exhibit a negative self-image, fear of failure, and problems with intimacy and commitment – often triggered by insecure attachment styles, whereas others have erectile dysfunctions, experience orgasm problems, or an increased sexual drive. However, many treatment providers who work with persons with sexual offence histories lack the knowledge and skills to make informed decisions about improving sexual health care in their forensic clients. Marieke Dewitte thus emphasized the importance of including sexuological insights and methodologies in the treatment of clients who have committed sexual offences.  

The second presenter, Jantien Seeuws (forensic psychologist, Fides Beernem, Belgium) focused on policy in forensic centers regarding stimulating healthy sexual expression in persons with sexual offence histories. Despite the liberal view of sexual freedom in Western Europe, expression of sexuality in individuals in mandated care seems to cause fear and division among forensic health care providers. What complicates matters is the fact that – in these individuals – sexuality is intertwined with sexual violence and all kinds of sexual problems, such as a disrupted psychosexual development, deviant sexual scripts, limited sexual regulation and sexual disfunctions. Therefore, a multidisciplinary approach is important when addressing healthy sexual behaviours. The Good Lives Model suggests that treatment for persons with sexual offence histories must regard participants as whole beings in need of focus in many principal life areas, such as family, employment, leisure, community, and well-being including sexual health. Risk and good lives models are complementary models in forensic care, and by emphasizing the merits of each, management and well-being of patients can be maximized while community safety is increased. Furthermore, sexuality is a basic human right. Professionals should commit to this universal right when supporting sexual health of their patients. Forensic settings that offer long-term mandated care should have a clear policy, consistent with local law, aimed at accepting patients’ sexual needs and helping them to securely manage their privacy, sexuality and relationships. Yet, forensic hospitals or units rarely develop such a policy. Jantien Seeuws argued that there are several challenges in developing a sexuality policy in treatment wards for persons with sexual offence histories. First, perpetrators of sexual violence pose a heterogeneous group; there are distinct differences in psychosexual development, the nature of sexual violent behaviors and sexual deviances, criminal history, and other relevant characteristics among those who have offended. These individual differences call for tailoring treatment to the individual. Second, patients and staff may have different views on healthy relationships and sexuality preventing a unified vision. Also, public opinion typically emphasizes repression and punishment. This may induce the tacit acceptance in professionals that punishment is also justified with regard to intimacy and sexuality.  Finally, the interconnectedness of sexuality and violence means that themes such as masturbation, phantasies and pornography are approached very carefully and evokes various important questions. For example, an interest in playing with power dynamics is common and healthy for consenting adults, but is it healthy for someone convicted for sexual assault? Do these (sexual) behaviors all raise the risk for recidivism? Jantien Seeuws concluded that current policies on sexuality in forensic settings are long overdue. It is important to thoroughly map and discuss sexuality in persons with sexual offence histories as sexuality also influences their physical and psychological health. Treatment providers should also take initiative in providing non-judgmental language with regard to sexuality and sexual dysfunctions in their clients.   

In the final plenary presentations, Bas Frelier (psychiatrist, the Forensic Care Specialistis, the Netherlands) discussed the implementation of a Sexual Health Project in a forensic setting. In forensic settings, sex is often approached in a negative way. Also, even in patients for whom sexuality is not related to risk, treatment providers are cautious about the subject. In 2019, the Forensic Care Specialists instated a department of sexology with the goal to integrate sexology within their treatment program for their forensic patients. The department’s vision on sexuality is that a healthy sex life and healthy relationships are protective factors for all forensic patients, and that everyone has the right to sexual health. To achieve their goal, the department initiated the Sexual Health Project, which started with sexuological education for practitioners as treatment providers regularly feel shy about talking about sexual behavior and interests, and providing sexuological treatment. The sexology department is collaborating with two other forensic hospitals to develop a guideline for integrating sexuality as a vital component of forensic treatment programs. The guideline is anticipated by the end of 2022.

The symposium closed off with three workshops. The first workshop focused on providing sexual services to people with intellectual disabilities. The presenter of this workshop Miek Scheepers (vzw Aditi) explained and demonstrated with case studies that, in addition to supporting their social network, sexual services can offer these clients opportunities for learning and experiencing sexual interactions in which consent, equality and voluntariness are the common thread. The second workshop provided by Tom Platteau and Corinne Herrijgers (Institute of Tropical Medicine Antwerp) focused on drug use in combination with sex (“chem-sex”). A recent study on the needs of 20 chem-sex users led to the development of a health-app (“budd”). This app aims to sensitize and support chemsex users in safe sex participation, as well as to increase awareness and insight into their own (risky) behaviors. The third workshop provided by Zohra Lkasbi (ZNA, UKJA) and Jeroen Dewinter (GGzE, Tranzo & Tilburg University) focused on sexuality in adolescents who displayed sexual violent behaviour. They provided several methods to maintain and discuss healthy sex and relationships in forensic youth care and therefore pointed out the necessity of a good therapeutic relationship. These experts also emphasized the importance of paying attention to and cooperating with parents, counsellors and the social environment in order to enhance healthy sexual behavior.

The fact that this symposium was attended by over 250 practitioners (psychologists, psychiatrists, probation officers to name a few) from the Netherlands and Belgium, as well as the grateful feedback during and after the event, illustrates that many practitioners are struggling with how to deal with sexual health in persons with sexual offense histories, but are also acknowledging the importance of including this necessary topic in their work. Opportunities to share best practices to obtain an in-depth understanding of sexual wellbeing in forensic patients are clearly highly needed. 

Thursday, June 17, 2021

Embracing Restorative Approaches to Address Sexual Harm.

By Alissa R. Ackerman, PhD, Alexa Sardina, PhD, & Kevin Lynch 

In June 2018, four rape survivors of rape sat in an accountability circle for a man who had committed a rape 40 years prior.  We, the authors of this piece, are two of those women, and the man who committed the rape.  For over three hours, we grappled with topics related to our individual experiences with sexual harm. We did not know it at the time, but this accountability circle was the start of a journey that the three of us would take together.

For several years, Alissa has been participating in, facilitating, and writing about restorative justice as it relates to sexual harm. While restorative justice has gained popularity in general, few people advocate for its use in instances of sexual harm, despite evidence that it can be effective in helping survivors to heal and holding those who have harmed accountable.  In 2016, Kevin had written a blog in the Huffington Post in which he admitted committing rape in his early 20s.  Kevin had subsequently learned about the work Alissa was doing and asked her to organize a vicarious accountability circle for him.  Alexa was one of the survivors who also participated. For Kevin and Alexa, the experience of that circle was enough to convince them that others should be made aware of the healing power of restorative justice and should be able to participate in restorative processes if they so choose.

Current criminal justice interventions do not prevent or decrease rates of sexual harm, nor do they address the needs of survivors.  As such, the criminal legal process should not be the only avenue available to address sexual harm. Restorative justice offers a trauma-informed, humane approach to holding people accountable and providing opportunities for healing for all parties.

Restorative justice is a human-centered approach to repairing and preventing harm. It requires honesty and often difficult conversations between people who have experienced harm and those who have caused it.  Restorative processes can take many forms, including one-on-one facilitated conversations and circle processes that provide everyone involved (and their support people) the opportunity to be seen and heard. Restorative justice allows people who have experienced harm to speak their truth and ask for their specific needs to be met.  It requires people who have caused harm to fully acknowledge the harm they’ve caused by naming it, discussing their understanding of the impact of their actions, actively listening to the person, they harmed (or a proxy), and then making amends for that harm.

Some of the most common needs expressed by survivors of sexual harm include telling their story in their own way, understanding why the harm was perpetrated against them, having their harm and their pain acknowledged and hearing how future harmful behavior by the person who harmed them will be prevented.  A restorative justice response encourages collaboration and reintegration of all parties, neither further coercing nor isolating either party, as our current criminal legal responses tend to do.

Not all survivors are willing to meet with the person who harmed them. Conversely, individuals who have been convicted of sexual offenses may not be allowed to meet the person they harmed.  Vicarious restorative justice is an alternative model that brings people who have been harmed together with those who have harmed. However, these individuals are not parties to the same acts of sexual harm. The accountability circle in which we engaged is a prime example of vicarious restorative justice.

Much of the work Alissa has done using the vicarious restorative justice model has been done in treatment groups with people who have committed acts of sexual harm.  Based on this work with over 500 individuals, she has come to understand the value of this process for use in clinical practice. As such, ATSA members may be interested in learning more about this process.

Since the accountability circle, we participated in three years ago, together we have learned a lot about the value of restorative justice. For Alexa, the most important lesson was that people who experience sexual harm and those who perpetrate it have more in common than most people would believe. There is more that unites us than separates us. For Kevin, it was the realization both of the lasting harm he likely had caused, and of the power of accountability as a means of healing for survivors.  For Alissa, it was the recognition that all people impacted by sexual harm could experience healing through restorative processes. Together, we have found that most people do not fully understand what restorative justice is, what it requires of people, or how they can participate in restorative processes if interested.

…. And we believe the time has come to take concrete steps to restore the world from sexual harm by making restorative justice inclusive of and accessible to more and more people and communities who are affected by it.  Such steps might include developing a model for how to use it, training facilitators and practitioners to use it, helping communities, organizations, and institutions develop restorative processes, advocating for restorative justice, and taking steps to engage more people who have been harmed, as well as people who have been harmed.

Current criminal legal processes have failed to prevent sexual violence, to help survivors to heal, or to truly hold people accountable for the sexual harms they cause. The time has come to embrace restorative approaches to address all forms of sexual harm. This requires that we accept the complex dualities and contradictions that must be understood and mastered to restore the world from sexual harm. We believe that ending sexual harm requires that everyone be at the table.

 

*Alissa R. Ackerman, PhD is a criminal justice professor at California State University, Fullerton. Alexa Sardina, PhD is a criminal justice professor at California State University, Sacramento. Kevin Lynch is a consultant and writer in the nonprofit and social enterprise fields.  Together they are co-founders of Ampersands Restorative Justice, an organization designed to brining restorative justice for sexual harm to scale.

Friday, June 11, 2021

The New World of Telehealth: The Challenges and Benefits.

By Janet DiGiorgio-Miller, Ph.D.

Whether you have decided to take a hybrid approach or do all virtual therapy sessions you have come to find that there are challenges as well as benefits to telehealth. I moved out of my office on July 31st, 2020 after 18 years. It was a three-room, third-floor office space in a 1929 building with beautiful big windows in a bustling little town in New Jersey. It felt like a safe and secure place for my clients and for myself.

While I missed that office, I soon came to appreciate my home office with my furniture and my paintings and all the benefits that come with staying at home during the day. As my practice became totally virtual, I thought that I would begin to write down what worked and did not work. I also asked my clients. The following are the challenges and benefits of virtual therapy. Please feel free to continue this blog by posting your thoughts.

Challenges:

Telehealth presents challenges for both the provider and the client. Probably the most challenging issue is working with young children. It is difficult to keep their attention by just talking. Usually, when you are working with a child you have some play materials to assist in the conversation. This is a task that is exceedingly difficult to replicate virtually. In addition, teenagers may be viewing more than one screen at a time or multitasking. When this issue presents itself, it is good to address it and ask the client if they are attending the session. Another issue that I found is that you cannot see the whole person’s body and sometimes cannot tell if they gained weight/ lost weight or are fidgeting and or distracted.

The biggest challenge for some clients is to have a private conversation and worry if they are being overheard. This concern has led some to clients doing sessions in their car.

Another challenge is that parole officers will not allow a client to use the Internet to have a virtual appointment. Some clients have had their attorney lobby for this privilege and other clients must use the telephone to have appointments.

As we all know, you can have technology/internet issues. It is helpful to watch YouTube videos of the technical issues and find tips there. It is also helpful to remind ourselves that we as well as our clients are learning more and more about technology. So, I tell myself to be patient (with myself and others) which is one attitudinal foundation of mindfulness.

Benefits:

The biggest benefit by far is the convenience for clients. Therapy is now available for any client who has 45 minutes to take out of their day. Previously a client would have to find a therapist in their area, drive to the therapist's office, park and/or pay, find the office or suite, and then drive back to home or to work. Instead of taking 45 minutes to find a private place to talk clients have to take at least two hours out of their day to have a therapy appointment. It is easier for clients who work a regular job or work overnight to find 45 minutes. It is also easier get approval from their supervisor to leave for 45 minutes as opposed to two or more hours. They also save money on gas and parking. In addition, if a client forgets their appointment, I can text them and remind them and we can have a session instead of missing an appointment. I can also text clients to remind them of their appointments. Or if the client cancels an appointment at the last minute, I can fill the slot with someone who is waiting for an appointment. Another benefit is that client does not have to find childcare to attend their appointment. I had one client turn the camera away and breastfeed a baby while she was speaking in therapy.  

Teens and millennials are extremely comfortable using the computer as a forum to talk. Many times, I see adolescents and young adults in their hoodies, on their beds with a cup of tea talking. In fact, some people eat their breakfast and lunch because they are in a hurry to get to work or to get back to work. I have noticed that you can see a person’s personality when they are talking from different parts of their home. You can ask them about their surroundings to get to know them better. It is also a perfect forum for clients who have been in your care and then go off to college in a different state. They have continuity of care since telehealth. You can also invite other family members to join a session.

Another benefit is you can see different people throughout your entire state/territory as opposed to having geographical limitations regarding clients coming to your office. That means the expertise is spread throughout the state or territory. This is extremely helpful since therapists with expertise in treating sexual abusers are few and far between. Another benefit is that you can evaluate and treat clients in a safe place.

Telehealth is ideal for anxious clients. Clients who have anxiety are worried about getting to the office, finding parking, being on time, and then having to settle down to discuss their anxiety in therapy.

You can still use certain tools such as reading cards, sharing screens to test clients, and showing books to suggest that they read. You can also meditate virtually. You can do your progress notes while talking to a client in a discreet manner. You can also refer to the last session notes to have a point of discussion if needed.

One unexpected benefit is that the US government is supporting telehealth by waiving copays for mental health for most insurance companies

Clients Perspective

Some clients find telehealth extremely convenient and useful however some clients indicated that they like in person sessions because it is a space for them to feel safe talking about their issues. One client told me that on one hand “It is a designated safe space to have a conversation however due not having it, it allowed me to work on several safe spaces (in and around) my home to talk.”

My/Therapist Perspective:  

It is nice to be able to eat healthy food and have no commute. It also a pleasure that my husband is home more often. I can come down to my office at any time to do my work instead of having to drive anywhere. All my documents are in one place. I have more time to balance my work and self-care.

To summarize, I have found that telehealth primarily benefits clients. I do not see a difference in live or virtual therapy regarding rapport with clients or having them open up to discuss their issues. In fact, they seem more comfortable in their own home discussing personal issues. In addition, they do not have to worry or stress about getting to an office. Regardless of the shift of their work they can find 45 minutes a week to be available for a therapy session as opposed to over 2 hours if they would have to leave their home and go to the office.

I have chosen to continue doing telehealth as it is the best option for clients and has the added bonus of being home. Another major advantage of staying home is saving money by having no rent or additional expenses related to having an office, and less wear and tear on my car.

The lack of commute is a definite bonus.   

I think telehealth is convenient, benefits clients, and is here to stay. So, embrace the change, notice the benefits, and enjoy.

 

Tuesday, June 1, 2021

Double Standard, Human Rights, and beyond?

 By David S. Prescott, LICSW and Kasia Uzieblo, Ph.D

The week before last we wrote about the apparent double standard involved in a European singer’s affair with a 15-year-old. We took note of how many in society condemn sex with underage people even as they seem to make exceptions for those who are well-to-do and/or celebrities. Within hours of its publication, we learned of a related news item in the USA. In this case, a state senator seeking to replace a member of the US House of Representatives openly acknowledged impregnating a 14-year old who he later married (and divorced).

Recognizing that sexual misconduct is not the province of any one political party and that it has often appeared to be rampant in some governments, it was hard not to notice the shifting of blame in this case. The person involved blamed the political status quo. To some, his account may seem familiar:

"Everybody has something in their life that they did ... We’ve all had these problems. Why is this a big deal?" .... So, bottom line, it's a story when I was young. Two teenagers, girl gets pregnant. You've heard those stories before. She was a little younger than me, so it's like the Romeo and Juliet story," he said.

The news account further states, “He said he tried to ‘do the right thing’ and told the paper he married the girl when she was 15. They later went through what he described as ‘kind of a bitter divorce,’ … the ex-wife died by suicide when she was 20.” There is no description of her motivation to take her own life and so readers can only speculate. The aspiring politician says he tried to do the right thing but never says what the right thing is. Strikingly absent is the perspective of those who have other perspectives, in particular those with less power

It’s been the authors’ experience that some readers comment on how men marrying adolescent females has, at times throughout history, been commonplace. Many of these marriages end up being described and/or remembered as happy. We don’t doubt that this is the case; happiness and fulfillment can occur under all kinds of circumstances. Even in cases of chronic abuse, victims are struggling with the fact that they sometimes also experience positive emotions toward the person who abuses them – which confuses them even more. These observations, in turn, lead to further questions which are worthy of reflection for all seeking to prevent abuse from (re)occurring.

The first question is whether there are bright lines discerning abuse from non-abuse in situations like this and the celebrity we discussed last week? We suspect that there will always be situations that don’t fit into neat categories. Humans, and the lives we lead, tend to be too complex for that.

Still, the question that follows from there is what price young women pay when married off at an early age. Were they able to provide anything close to informed consent? Are the cases we hear about situations in which people made the best of circumstances that didn’t go their way? Did anyone ask the young women involved whether they saw or preferred other options? Did the young women have the opportunity to ask what part of their full potential they would not live up to through sexual behaviors and/or marriage in mid-adolescence?

Given the stakes involved in this recent news item, where the wife took her own life at the age of 20, we are reminded that the outcomes of sexual relationships in early and mid-adolescence are never entirely known. Whatever has unfolded in the past, it seems that all young people should have the chance to make these decisions in a fully informed way as well as in accordance with the law. Our collective years in working to prevent abuse has led us to conclude that unless we are working to uphold others’ autonomy we may be preventing them from living up to their full potential.

These cases highlight how far we’ve come as a society and how far we still have to go. The first author (David) had a great-grandmother who was considered “insane,” in large part because she insisted that her brother had forced her into having sex; this did not fit with her family’s wishes. Her circumstances would, hopefully, have been far more fortuitous today. Nonetheless, the news item described here, in which the voice of the young wife who killed herself is absent, reminds us how important it is to listen to our most vulnerable members of society outside the often implicit paradigms that belong to the past.