At the crossroads 2.0: Future directions in sex offender treatment and assessment

By Kasia Uzieblo, PhD, Minne De Boeck, PhD, & Kieran McCartan, PhD

NL-ATSA (the chapter of ATSA based in the Netherlands and Belgium), the University Forensic Centre) (UFC) and the University of Antwerp organized the second edition of the conference “At the Crossroads: Future directions in sex offender treatment and assessment” in Antwerp, Belgium. The second edition took place from the 6^th – 7^thFebruary in Antwerp, following on from two days of pre-conference sessions focused on treatment and risk assessment. The conference was a real mix of research, practice, and policy with approximately 250 participants from the Netherlands, Belgium, Germany, Slovenia, Spain, Iceland, USA, Canada, and UK; in addition Zuhal Demir, Flemish Minister of Justice and Enforcement, opened the conference and attended the first session on the first day. In this blog we are going to take you on a whistle-stop tour of the event.

The conference had 2 pre-conference sessions, which were separate from but connected to the main conference, on Static-Stable-Acute training (Wineke Smid, Minne De Boeck and Kasia Uzieblo) and how to effectively apply Risk-Need-Responsivity principles to treatment (Sandy Jung). The first day of the conference was all keynote sessions, which included, Maia Christopher (ATSA) on working with victims organization to co-create effective public policy;  Erick Janssen (KULeuven) on the relationship between arousal and emotions on decision making in risky sexual behaviors and/or sexual offences; Georgia Winters (Fairleigh Dickson University) on sexual grooming behaviour; Ross Bartels (University of Lincoln) on the sexual fantasies and their role, or not, in sexual offending; and Nicholas Blagden (Nottingham Trent University) in the importance of the rehabilitative climate and how prison can be a place for therapeutic change. The second day the conference had started out with two back to back workshop sessions: There were 5 sessions and they were repeated twice which enabled the attendees to get the most out of the conference. The workshop sessions were more practice-based and focused on online sexual offences (Hannah Merdian, University of Lincoln), risk communication (Daniel Murrie, University of Virginia), case formulation incorporating risk assessment (Leam Craig, Forensic Psychology Practice, LTD), sibling sexual abuse (Peter Yates, Edinburgh Napier University) and professional self-care (Joanna Clarke, Petros People). The second half of the second day focused on keynotes from, Klaus Vanhoutte (Payoke) talking about human trafficking, sexual exploitation and how the “lover boy method” could be used to understand this process;  Eric Beauregard (Simon Frasier University) on research and practice into serial sexual homicide and what that means for practitioners; desistance from online sexual offending (Hannah Merdian, University of Lincoln); and how we move on from the crossroads in terms of using evidence in policymaking (Kieran McCartan, University of the West of England). On the second day, like the first, there were about 10 poster presentations during lunch (21 in total) that highlighted the breadth and depth of research in the Netherland, Belgium, Germany and UK on sexual abuse, including, research on BDSM, Minor Attracted Persons, Stop it Now!, COSA & Circles Europe, and desistance.

The NL-ATSA conference really highlighted the diversity of sexual abuse and how wide, although interconnected, the field is. The multi-day conference connected all the domains from theory to treatment with each other. Current trends and lesser-known phenomena were also cited. For if we don’t understand sex and sexuality in everyday life, how can we tell normal/accepted sexual practices from “deviant”/non-normal ones? How can we understand the way that the public, as well as policymaker, attitudes to sex and sexual abuse are formed, and therefore how they impact real-world responses to sexual abuse? If we do not know the difference between fantasying and doing, or viewing and doing, how can we present first time offending or recidivism? If we do not know how people groom, offend or behave, how can we prevent or respond to sexual abuse? This also means that we must hear the client as the service user and recognize professional experience and knowledge to frame best practice. So that we can build rehabilitative climates that are fit for purpose, help treat people and stop burn out in staff. Therefore, we must recognize that rehabilitation is possible and that desistance can happen. The evidence base in sexual abuse is often varied, but we do know that treatment/interventions are more effective than doing nothing. Do we acknowledge that enough? And how do professionals and researchers convey that to the public and policymakers? This conference highlighted and incorporated all these points. Yes, we are at a crossroads and we have been there for a time, but we need to go forward not back. We go forward together united in a multi-disciplinary, multi-agency way and by connecting all the different subdomains within our field. The conference reinforced the importance of international collaboration, conversation, and research.

Moral Injury and Radical Hope: Part 2

By David S. Prescott, LICSW, and Kieran McCartan, PhD

Note: This is part 2 of a 2-part blog, Part 1 can be found here. Kieran

One problem with working individually to combat moral injury is that we very often do it on our own and in isolation. Our field is now rife with discussion about self-care (and we note, to some degree, unfortunately, that our blog on self-care was among the most read and shared blogs of 2019). An aspect of our work that we only rarely discuss is hope and how we keep hope alive.

In 1999, the late Rick Snyder produced an excellent chapter on hope in which he broke it down into two components. The first, “agency thinking” refers to the awareness that a goal is possible. The second is “pathways thinking”, which involves an awareness of how to achieve a goal. It can be enormously helpful to break hope down into these components to see where we, as individuals, may best become more helpful to our clients, colleagues, and selves. In our field, there has been only one article and a book chapter, both well over ten years old, published on the topic of hope in treatment. Nothing has been written on how professionals can remain hopeful about their work.

The case example discussed in part 1 calls to mind that hope at the individual level may not be enough. Even if we practice excellent self-care and keep hope alive for ourselves, how do we best work together as teams to remain engaged in improving the systems that often seem to do their best to spread fear, anxiety, and moral injuries?

Another recent article may begin to yield clues about possible ways forward. Della Mosley and her colleagues recently published on the topic of “radical hope”. Mosley er al's specific focus is in the direction of community-based hope for marginalized groups, but may yield insights into how professionals in our field might also become more effective (as well as more culturally safe, humble, and competent). Mosley and her colleagues introduce radical hope as:

“A culturally relevant psychological framework of radical hope, which includes the components of collective memory as well as faith and agency. Both components require an orientation to one of four directions including individual orientation, collective orientation, past orientation, and future orientation.”

The authors go on to describe how their framework also “consists of pathways individuals can follow to experience radical hope including (a) understanding the history of oppression along with the actions of resistance taken to transform these conditions, (b) embracing ancestral pride, (c) envisioning equitable possibilities, and (d) creating meaning and purpose in life by adopting an orientation to social justice.” These pathways can inform how professionals think about the hope within the work of treating sexual aggression.

We acknowledge that the focus of Mosley’s article is  directed toward marginalized people (in this case, people of color) and not simply those who often work with them. We further acknowledge being the beneficiaries of some forms of privilege, even as our lives have not been without their own significant challenges. Nonetheless, the idea of radical hope provides an approach that may be helpful to us. As a start to how we might consider moving from individual self-care and hope, professionals in our field might wish to ask:

· How can we build mechanisms of best practice that encourages the service-user voice while recognizing the gap between client success and key performance indicators?

·  How well do we understand the systems that so often create barriers to helping people build healthier, risk-reduced lives for themselves?

· How well do we understand the history of thinking that resulted in these systems functioning as they do?

·  How might we better celebrate the work that we do? After all, working with clients who have abused provides an important function in keeping our communities safe. The work we do matters, and as recent meta-analyses have shown, the work we do can be effective, even as we acknowledge that no efforts in any human endeavor are effective all the time.

·  How can we best argue on behalf of equitable outcomes for all of the people who come to our attention? All too often, it seems that there are internecine rivalries between professionals of various beliefs, including those who believe that being empathic with those who have caused harm is somehow disrespectful of those who have been harmed (and despite research showing that those who harm have very often been harmed themselves).

·  How can we best remind the world at large that this work matters and is in the public interest? The simple fact is that this work has great meaning and an important purpose.

· And finally, in terms of moral injury, how do we remind others of the need to practice both autonomously and as members of teams? Getting this balance right can be a true challenge. Nobody ever said collaboration was easy.

Moral Injury and Radical Hope: Part 1

By David S. Prescott, LICSW, and Kieran McCartan, PhD

Note: This is part 1 of a 2 part blog. Kieran.

A clinical director recently shared a concern in a staff meeting about an adolescent on probation. The treatment team had built a program around the youth to address his sexually abusive behavior and general mental health.  Now, the treatment team assessed him as being at low risk and were understandably proud of their contributions to his progress in building a lifestyle incompatible with causing harm to others. Their approach had been team-based, multidisciplinary, and comprehensive. As he neared the end of treatment, his probation officer expressed concerns. “As we all know,” he said, “his seemingly good behavior is a huge red flag that things aren’t right,” which raised concerns about the implications for the youth’s future, as well as their own clinical judgment.

The treatment team found itself in a paradox. If the young man were to behave badly, others would judge him to be in need of treatment. If he behaved well, the natural assumption for some would be that he must be behaving in a secretive manner.  Those working in the field will recognize this as a belief that persists in some quarters despite very strong evidence to the contrary. If your work is simply about managing risk, it’s easy to see risk everywhere.

The impact on the young man’s treatment team was apparent almost in its absence; they had heard this before. Despite a solid base of scientific evidence, it would be difficult to convince others that this young man really was more than the sum of his worst behavior. Although he posed a low risk to abuse again, the team recognized that he was at very high risk to be prevented from living up to his full potential. Concerning to the author who sat in on this team meeting was that the staff had heard this all before. They have spent their careers aware of risks, helping people change, and being merchants of hope for young people in their families, all the while surrounded by people who would not support their efforts.

To be blunt, these experiences of disrespect have a cumulative effect and cause harm to the people who do so much to help others build worthwhile lives and safe communities.  Such experiences beg the question that if we cannot believe people are able to change, then what is the point in treatment? It can feel that we are simply moving the deckchairs around and biding time as the Titanic sinks. Treatment – especially belief in treatment – is fundamental to its process. If we want clients like this young man to cooperate and prosper, then we need to have buy-in throughout the whole multidisciplinary system, not just a few members of staff. Risk management is not simply about containment and control, it’s about skill-building, desistance, and change. When we are caught up in our client’s journeys, then their successes and failures reflect on us. The staff was not acutely burned out yet, but neither were they allowed to work at their best. Instead, they found themselves in an ongoing state of lamenting that so many of their efforts were unrecognized, undervalued, and disrespected.

In 2018, Simon Talbot and Wendy Dean wrote an article on what they termed the “moral injury” of physicians who do not have the opportunity to be as effective as they could be. More recently, they have noted that these professional moral injuries are the precursors to burnout. They state:

“We have come to believe that burnout is the end stage of moral injury, when clinicians are physically and emotionally exhausted with battling a broken system in their efforts to provide good care; when they feel ineffective because too often they have met with immovable barriers to good care; and when they depersonalize patients because emotional investment is intolerable when patient suffering is inevitable as a result of system dysfunction. 

“We believe that moral injury occurs when the basic elements of the medical profession are eroded. These are autonomy, mastery, respect, and fulfillment, which are all focused around the central principle of purpose.”

As the authors note, autonomy is a basic element of training. Whether we are physicians or mental health clinicians, we are taught to think independently when considering diagnoses and to guard against the competing interests of those who may try to sway our treatment decisions away from our patients’ best interests. However, in many facets of our work, we are required to forfeit our autonomy and allow other interests to sway our decisions about care—most commonly for financial reasons. This can be a serious consideration for professionals who feel pressured into ethically questionable actions and whose licenses may be on the line.

When our own autonomy, mastery, fulfillment, and sense of respect are constantly on the line, how can we expect to be at our most effective with clients? Ultimately, this poses its own dilemmas related to public safety.

1 in 5 experienced child abuse in England & Wales: A call for prevention

By Kieran McCartan, PhD, & David Prescott, LICSW

New official statistics from the Crime Survey for England and Wales (CSEW) state that one in five adults in the UK aged 18 – 74 have experienced at least one form of child abuse before the age of 16. The survey estimates this at approximately 8.5 million people. While this figure may seem shocking at first, it actually reinforces what we know about child abuse prevalence and hints that this maybe the tip of the iceberg, with these numbers being an underestimation and not an overestimation. The report indicates that (please note that the below statistics are directly quoted from the report);

• Many cases of child abuse remain hidden; around one in seven adults who called the National Association for People Abused in Childhood’s (NAPAC’s) helpline in the last year had not told anyone about their abuse before.
• In the year ending March 2019, Childline (a free service where children and young people in the UK can talk to a counsellor about anything) delivered 19,847 counselling sessions to children in the UK where abuse was the primary concern; around 1 in 20 of the sessions resulted in a referral to external agencies;
• As of 31 March 2019, 49,570 children in England and 4,810 children in Wales were looked after by their local authority because of experience or risk of abuse or neglect;
• Around 4 in 10 adults (44%) who were abused before the age of 16 years experienced more than one of emotional abuse, physical abuse, sexual abuse, or witnessing domestic violence or abuse. This proportion is higher for women than men (46% compared with 41%);
• Sexual abuse was reported in around two-thirds (63%) of calls to National Association for People Abused in Childhood’s helpline;
• Around half of adults (52%) who experienced abuse before the age of 16 years also experienced domestic abuse later in life; compared with 13% of those who did not experience abuse before the age of 16 years.

Previously in this blog we have talked about the challenges of understanding the base rate data on experiences of sexual abuse, which is just as important for broader definitions of abuse. We know that there is under reporting, under recording, poor prosecution rates, cases being dropped, and acquittals within the system. The volume of people sentenced for abuse does not accurately reflect the volume of abuse that there is. This new data from England and Wales, as Scotland and Northern Ireland collect and record data separately, data is more than likely an underestimation, especially given the way that the CSEW is constructed. That is, it relies on (1) self-completion modules of Survey by men and women aged 16 and over who are resident in households in England and Wales, & (2) offences reported to and recorded by the police. Therefore, if you have not reported a crime to the police or are not a home owner you are unable to take part. Interestingly, in recent years the CSEW have contacted some children between 10 -15 to take part to get a broader spectrum.

The data from the CSEW highlights the challenges that child abuse causes in England and Wales, especially in terms of trauma, Adverse Childhood Experiences, ongoing development impacts and the costs/demands on the social care and criminal justice systems. The growing recognition of ACE’s and past trauma in our adult victims and perpetrators population is massive in the UK, with Scotland and Wales putting it at the heart of their social care and social welfare policies; however, it has not been as straightforward for England and Northern Ireland. The CSEW data really highlights the need for a more preventative/interventionist approach to child abuse. We need to intervene sooner and develop more coherent secondary prevention approaches to reduce child abuse. We also need to provide those at risk of abusing others with the skills to prevent offending and to assist those at risk of being victimized to be better safeguarded. 

Pornhub’s 2019 Year in Review

By David S. Prescott, LICSW, & Kieran McCartan, PhD

Not many professionals are aware that the world’s largest adult pornography site, Pornhub, publishes annual statistics about its use and users. Obviously, readers will want to be judicious in how they read the report (in the language of porn, the website itself is NSFW or “not suitable for work”), although the findings themselves are presented in a provocative but not necessarily offensive manner. Each reader’s opinions will vary.

What have we learned about Pornhub this year? Once again, the numbers are vast: In 2019 alone, there were 42 billion visits to the site (averaging 115 million per day), 39 billion searches performed, and 6.83 million uploads. For just the videos uploaded in 2019, if one were to watch them all in sequence, beginning in 1850, they would still be watching today. Reading such statistics as “6597 petabytes of data transferred” is a little bit like trying to come to terms with the national debts of nations; it can be nearly impossible to comprehend.

Beyond this, the statistics track, to the best of their abilities, who the most popular stars are, what people search for, what they actually watch, for how long, and where. They also report on the age and gender of their viewers, leading to questions of how they are able to divine this information (and is there a bias in the direction of attracting advertisers). Nonetheless, the data is remarkable.

Digging a little deeper, however, it seems that there is much we can learn about sex and sexuality that can inform our understanding of clients in assessment and treatment situations. First, of course, is obvious: Porn is ubiquitous. Even the best available research does not show it to be a risk factor for re-offense, as this earlier blog describes. Pornography continues to be controversial, with some politicians declaring it a public health crisis despite the most recent scientific findings. To our minds, the most interesting and concerning questions have to do with the effects of pornography on children, adolescents, and other vulnerable people. The reality is that porn without context, as ill-informed sexual education, lays problematic, difficult and unrealistic notions of sex and sexuality; as indicated in a recent BBC poll suggesting that women’s exposure to violent sex and violence during sex is on the increase. Hence, we need sex education, informed debate and realistic relationship expectations in modern society.

Questions arise: These findings show that what people search for is not necessarily what they end up watching. Further, as the authors of the report note, there is a trend in the direction of real people and not simply actors. “Amateur” was amongst the most frequent search terms, leading to questions about to what extent viewers are looking for the most authentic or genuine experience (as opposed to the gymnastics of many of the more commercially produced videos). At the same time, however, animated pornography is also at the top of the list, speaking to the role of novelty and fantasy for many viewers. These trends raise questions for how we understand our clients in treatment as well as those on other problematic pathways. As the Internet Watch Foundation points out child sexual abuse material, and related content, is often viewed on Facebook, Twitter, and other legally accessible internet sites, not purely on the dark web. Most of this accessible material is homemade, not “produced” which is in line with trends in mainstream porn.

Many more questions follow regarding what people watch. There is plenty to be offended by and concerned by. The prevalence of incest themes (mothers, fathers, stepmothers, stepsisters, “Daddy” etc.) can and should raise any number of questions for those understanding the sexuality of clients in treatment. On one hand, many professionals working with adolescents who have sexually abused report seeing cases in which these themes were used in the service of abusing within families. On the other hand, one wonders about the underlying allure of the relational aspects. As repulsive as incest is to society, do these videos also, however strange it may seem, provide a sense of connection to viewers? What is clear is that, as we have argued in the past, viewing porn through the lens of our own individual sense of morality is not a tenable approach to understanding or treating people who have abused.

In the end, the statistics provide more questions than answers. What do we really know about the sexual interests of viewers? 32% of visitors were female, indicating that it’s not as simple as men wanting to look at naked women. What will be the long-term effects on young people who grow up porn-educated and without funding for meaningful sex education in schools? And ultimately, what are people really looking for when they enter the search terms that they do?

Race, Bias, and Risk Assessment

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

Note: We are grateful to Tyffani Dent for her contributions to the discussions that led to this post.

On August 1, 2014, in a speech about risk assessment processes, then–United States Attorney General Eric Holder said of the available measures:

Although these measures were crafted with the best of intentions, I am concerned that they may inadvertently undermine our efforts to ensure individualized and equal justice.  By basing sentencing decisions on static factors and immutable characteristics – like the defendant’s education level, socioeconomic background, or neighborhood – they may exacerbate unwarranted and unjust disparities that are already far too common in our criminal justice system and in our society.

His points were well-taken and yet not without considerable push back. The most common response at the time was that the existing tools certainly outperformed the unstructured judgment that in turn was wildly susceptible to bias. This point, too, was a good one. Earlier this Autumn, Jennifer Skeem, associate dean of research and associate professor of social welfare and public policy at the University of California, Berkeley, stated in a major address to the National Forum on Criminal Justice that extensive review of post-conviction risk assessments of federal convicts found “no evidence of predictive bias by race.”

Perhaps that’s one of the issues we need to address first; many aspects of racism take place beyond the awareness of those who work within the structures where racism is found.

As outside observers who have tried to watch developments in risk assessment closely, there is no question that the right risk assessment methods can be useful, but we question whether there isn’t evidence of inherent bias available right in plain view. For example:

-  It’s well-established that people of color are more likely to be arrested, often as a result of over-policing. They are incarcerated at a rate of more than five times that of white people. 

-  It’s also established that people of color are less likely to be referred to diversion programs, and can be subject to bias even within that referral process. All of these points can result in higher scores on risk assessment instruments compared with whites, especially against a backdrop of true crime rates remaining unknown. 

-  Likewise, racial disparities can be found in the bail system. This fact often goes missing in broader discussions of racial disparities in the legal system.

-  Obviously, not all risk assessment methods are created equally; many rely on items that lend themselves, more and less, to racial bias. Items related to family (for example, past family incarceration) and community stability scored outside of an understanding of their context may not accurately reflect a person’s propensity to commit crime.

In some circumstances, further questions arise as to whether many instruments aren’t more effective at predicting who will be arrested than predicting who will commit crimes.

People of color tend to experience intersectionality more than white counterparts, which means that their different socio-political and individuals labels put them at risk of being a victim of crime and of, potentially, being someone who could commit a crime. In addition, people of colour, sometimes because of factors crystalized through intersectionality, are more likely to experience trauma as well as adverse experiences; which matters in how we work with and respond to them. This means that there is an opportunity for better primary, secondary, tertiary & quaternary prevention (see previous blog). However, because of the socio-political aspects of race, vulnerability, trauma, economics, and access to social care in America (and worryingly so in the UK as well) issues related to intersectionality, race and crime never gets truly understood or dealt with.  A clear example of this is a recent report that indicates that UN peacekeepers from multiple countries, of multiple races committed systematic sexual abuse while in Haiti. Experiences of sexual abuse, whether through victimisation or perpetration, does not have a race determinate; but race does play a significant role, though intersectionality and socio-economic-political factors, in the way that we define, prevent and respond to sexual abuse.

Of course, we are not the first, by far, to address this and related topics. We do, however, believe that professionals can become more effective by studying the myriad issues involved that this blog post is only barely able to touch upon. Despite the excellent advances made by our risk assessment instruments, very serious challenges remain.  

A Statement from the Association for the Treatment of Sexual Abusers

As an organization, our mission is to prevent sexual abuse. We believe every individual has the right to live free from sexual victimization. We believe that people who commit sexual abuse should be held accountable for their actions and supported in their rehabilitation, while supporting the victims of sexual abuse.

ATSA promotes evidence-based treatment and guidance for individuals at risk of committing abuse and for those who have abused others. Our ethical standards demand high ethical behavior and professional integrity among our members, without exception.

We know that individuals who sexually abuse others cross educational, socioeconomic, gender, and ethnic lines, and are frequently respected members of families and communities. 

On December 9th, ATSA learned that Dr. Kurt Bumby had been charged with sexual abuse. He has been a respected member of ATSA, and a past leader in the organization and in the broader sexual abuse research and treatment community. Once we learned of the charges, the Executive Board immediately suspended Dr. Bumby’s membership pending the outcome of the case.

These allegations have shocked and saddened all of us at ATSA. Like any community, we are dealing with the emotional and practical impacts of this situation. We are experiencing the ripple effects of allegations of abuse and how it impacts everyone involved in these situations. 

Our mission to end sexual abuse will continue. And, as always, we encourage you to be part of this effort.