Thursday, February 15, 2018

Beware of the Buzzwords! Our field’s Tower of Babel

By David Prescott, LICSW, & Kieran McCartan, PhD

A conference presenter, who really should remain anonymous, once adopted a faux Biblical tone in commenting on the history of attempts to treat people who have sexually abused: “In the beginning, there was relapse prevention.” This was inaccurate, of course; many people, including Nicholas Groth and Albert Ellis had been developing treatment methods prior to the adoption of relapse prevention (RP) from the addictions world. However, many a truth is told in jest, and in this instance, the presenter was completely accurate in recalling how the phrase relapse prevention took hold of treatment programs as much as the model and methods themselves. The lead author has vivid memories of a colleague in the 1980s exclaiming, “If you’re not doing RP, you’re not doing treatment.”

Setting aside the competitive jealousy and premature and incorrect assumption that there is a single right way to do treatment, one has to have some sympathy for the professionals operating at that time. There were no methods for classifying dangerousness and little research to guide these efforts. There was talk of a “forensic sound barrier” in risk assessment that might never be broken (set as a correlation of .40). It was perfectly natural that at a time in which professionals knew less about what they were doing than today, the field would focus, obsess even, on risk and risk reduction.

Fast forward to just a few years ago, and much had changed. By the late 1990s and early 2000s, professionals involved in assessing and treating youth who had sexually abused were starting to empirically examine “protective factors”, those elements in a youth’s life that mitigate risk or assist him or her from growing beyond their past harmful actions. In around 2002, when the second edition of the influential book, Motivational Interviewing, came out, professionals began to adopt this approach as a part of their treatment protocols. In each case, some professionals became early adopters while others dismissed these methods as fads. Similar responses happened with the emergence of the Good Lives Model and trauma-informed care.

An area that is rarely discussed, however, is how adherents to one core idea or set of ideas seem to view other sets of ideas as more different than they actually are. Although much discussion is never published, it has not been uncommon to hear one claim that motivational interviewing is nice but not strengths-based; one might just as well criticize strengths-based approaches as being nice, but not addressing the ambivalence that people often have about change, especially when addressing sexual violence. The simple fact is that both approaches have very similar features in common. Indeed, sometimes the greatest difference is in the language used to describe them. Likewise, many have mistakenly described the principles of effective correctional treatment (risk, need, and responsivity) and the Good Lives Model as if they were irreconcilably different (in truth, one can deliver treatment in a way that is adherent to both). The same goes for resilience-based approaches and trauma-informed care. Each approach can be implemented poorly, and each share (when properly implemented) a great deal of their conceptual underpinnings.

It often seems we are describing the same basic elements of treatment with different words. How can professionals rise above this Tower of Babel? Perhaps the most important place to start is by understanding the limitations of language itself. In recent articles and presentations, Tony Ward has warned against reifying “factors”, whether risk or protective, and focusing on the processes that underlie them. In other words, if we only think in terms of factors, we may neglect the processes that make up those factors. For example, if we think primarily of relationship stability as it is defined within risk assessment measures, we may take needed focus away from how that stability has manifested elsewhere in a person’s life.

These problems extend beyond how we talk about “treatment” and “factors” by treatment providers; it reflects a big Tower of Babel issue across the field as a whole. Different parts of the sexual abuse field including, but not limited to police, probation, parole, treatment providers, and third-party organizations not only use the term “treatment” to explain their processes but also  “rehabilitation”, “Risk Management” and “Public Protection”. This too is problematic as the non-common language and definitions lead to one single, problematic outcome measure – risk of recidivism. While “risk management” and “public protection” maybe neatly lead to a reduction in reoffending, this is not the main outcome of treatment and the main driver of factors involved with it. The Tower of Babel issue in defining what happens with perpetrators by default shapes the outcomes, success rates, and successful (re)integration of people who have abused. Maybe we should try to stop calling everything apples and recognize that we have a variety of fruit at our disposal. Those pieces of fruit look and feel different but ultimately contribute to the same goal: our health! They don’t all do it in the same way and that’s fine!

In the end, as we continue to move from a nothing works agenda towards a what works one (all the while fighting a backslide) all professionals will benefit from attention to both the continuing evolution of our field as well as the subtleties of the language within it.

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