The forgotten risk

By David S. Prescott, LICSW & Alissa Ackerman, Ph.D

An ever-emerging body of scientific research has found that punitive responses to crime don’t actually decrease risk. The findings are so clear as to not be uncontroversial: punishment is not anything more than punitive. While punishment can have its place, we should never consider it a meaningful deterrent from crime, a form or rehabilitation, or even a fully adequate response for those who have been abused. While one can easily find media accounts of people who want those who abuse to suffer as a result of their actions, there are many more who simply wanted the abuse to stop and the person who abused them to get help. Sadly, their accounts rarely lend themselves to sensational media. Indeed, excellent documentaries of the results of America’s legal system, such as Pervert Park and Untouchable garner some attention and then too often disappear from our sustained awareness.

Likewise, what seems to go further unnoticed is that even our “intermediate sanctions” – the term that criminologists have used for measures such as registration, community notification, and residence restrictions – also produce no appreciable effects on the re-offense risk of those who sexually abuse. Many have fought these laws in court, and while some have prevailed, the courts have consistently ruled that sex crimes policies are not criminal sanctions. They are civil in nature, so many of the arguments used to fight them in court hold no water.

Let us be clear: there are no appreciable positive changes with respect to re-offense risk that have resulted from these policies. To this point, there have been no documented improvements as a result of these policies beyond occasional (and frankly, highly infrequent) anecdotes.

Followers of the risk assessment literature are aware of many of the primary risk factors for re-offense: abuse-related sexual interests, high levels of psychopathic traits, problematic responses to stress, impulsivity, all alone and in combination can serve to increase risk. It is easy to forget, however, the risks involved in the chronic social isolation experienced by people who have abused and are now attempting to reintegrate into society (or integrate for the first time).

The isolation and lack of connection experienced by registered people has been documented in the literature for over a decade. Most recently, Dr. Danielle Bailey of University of Texas in Tyler has written that the isolation experienced by registered people also extends to their significant others. Importantly, loved ones often experience disenfranchised grief when they learn about the sexual abuse that has transpired. They must learn to adjust to life after losing the person they thought they knew.

Unlike family members who experience loss as a result of a medical diagnosis such as Alzheimer’s or stroke, family members who support a registrant have little social or community support to process their grief. This leads them into further isolation. The prosocial bond formed between the registrant and the significant other may be disrupted or it may fully disintegrate as a result.

 You may be wondering how punitive measures and intermediate sanctions impact people who have experienced sexual abuse. For starters, most people who have experienced sexual victimization know the person who committed the abuse. According to Dr. Rachel Bandy’s research, coalitions against sexual assault caution against current sex crimes policies because they have the capacity to silence people who have experienced victimization. First, because the person who victimized them is often someone they know and love, they are hesitant to come forward knowing that doing so could result in a lifetime of mandates and hardships. Second, most people who have experienced sexual victimization see no reflection of themselves in current laws. Finally, current policies do nothing to promote healing for people who have experienced abuse, and, in fact, these policies may have detrimental impacts on the healing process.

The forgotten risk of isolation and disconnection stem far beyond people who have sexually abused. It permeates families and communities. It silences people who have experienced sexual victimization. Human beings are social animals. We are meant to be in close relationship with others. Research shows that social isolation is associated with health risks and early death!

And it begs the question: what is our end goal?  Do we want to decrease sexual victimization? Do we want to feel safe? Or do we actually want to be safe? 

Families of the perpetrator: The hidden victims of online sexual abuse

By Kieran McCartan, PhD

Please note this is a reposting of a NOTA blog post by the same author, the original can be found here – kieran.

Late last week I attended a conference on online perpetrators of sexual abuse hosted by the Lucy Faithful Foundation, the aim of which was to make us reflect upon the reality of downloading and viewing child sexual abuse imagery in the UK (i.e., that is 100,000 individuals downloading material in the UK currently), but especially in the South West of England, as well as how to best respond to it. Although the conference was interesting, informative and worthwhile, it was the questions that were not answered or addressed that had the biggest impact on me. Not the questions about perpetrators, policing or offence characteristics; but rather, the questions about the collateral consequences of downloading and viewing child sexual abuse imagery on the families, friends and communities linked to the perpetrator.

When we talk about sexual abuse we tend to talk about perpetrators and victims. We do not tend to talk about the surrounding family and peers that are indirectly affected by the abuse and its consequences. Often there is an assumption in contact offending that the perpetrator is offending against members of their families, that members of their families are always at risk and that partners are complicit in the abuse; but this is generally not true. If it’s not true for contact offenders, is it also not true for individuals who download and view child sexual abuse imagery? The short answer is that we don’t know!

The conference really highlighted to me that we do not really know, empirically, what the impact of having a parent convicted of online sexual abuse, viewing inappropriate images, grooming children online or networking with other perpetrators on the dark web is. There is a perception that the collateral consequences of being convicted of viewing online child sexual abuse imagery is the same for the perpetrator and their families as being a contact offender, that is

-          That perpetrators receive a prison/community sentence, they go on the sex offenders register, are often being exposed in the press &/or community during their trial, have the  possibility of losing their family, friends, peers, home, job and  have a resultant social stigma;

 

-          That families of perpetrators are too being socially stigmatised because of their relationship to the perpetrator, can be exposed in the press &/or community by default have the possibility of losing a family member/friend, might lose their home, may lose additional income, may lose social standing and suffer from suspicion around complicity (i.e. a feeling that somehow you should have known).

These assumptions are problematic as we do not really know if they are as true in online offending as they are in contact offending. What we do know, which the conference discussed at length, is the recognition that the lives of people related to the online perpetrators have their worlds turned upside down, directly and indirectly, by the behaviour and that they struggle to cope with the related outcomes (i.e., the removal of technology, the police investigation, the re-evaluation of who the perpetrator is and what you really knew about them); but that there is not a lot of support for these indirect victims of online sexual abuse (i.e., they were not abused but they have been impacted by it). Which is problematic because families feel at a loss because of the nature of the offence and that there are many misconceptions about the perpetrators of online sexual abuse, the risk that they pose and the reality of their offences by the public – which includes members of the public misunderstanding what online offending looks like, its level off seriousness (is it as serious as contact offenders?), whether online offending leads to contact offending, whether it is easier to forgive the perpetrator compared to contact offending or who the victim is? All of which means that the families of online offenders can face collateral consequences similar to those of contact offenders, but with less understanding, nuance and (possibly) less sympathy. Over the past 10 or 15 years the level of support and help for the families of individuals who have downloaded and viewed child sexual abuse imagery has grown, but it still not common place and these individuals do not always get the help that they need. Research is starting to be done in this area. Lisa Thornhill presented on her recently concluded research on the impact of having a father or family member that has been arrested on suspicion of downloading and viewing child sexual abuse imagery. This research is important is as it will give us an empirical base to start developing and implementing appropriate services for people directly impacted by having a parent of family member who has child sexual abuse imagery so that they can understand the offences, the consequences of the offences, be helped to process and move past the impact that the offences have on their lives. Sexual abuse, in all its forms, impacts not only the perpetrator and the victims but also the communities in which it happens; therefore the more that we can help these communities understand and move past sexual abuse the more adaptive they will be.

 

How do we get better, really? The Achieving Clinical Excellence 2018 Conference in Östersund, Sweden

By David S. Prescott, LICSW

The evidence is in, and there’s no doubt. Psychotherapy works for a wide range of conditions and behaviors. People can and do change, often suddenly and unpredictably. Among the most effective mechanisms for change is the most ancient and fundamental approach: the human conversation. 

Why even mention this? Those working in the fields of violence and trauma (including sexual abuse) too often believe that people who harm others are either unwilling or unable to change, despite decades of evidence. Too many professionals argue over lesser findings or ask the wrong questions. While searching for the randomized controlled trial showing that treatment can reduce risk, we overlook other findings, such as that people who complete programs very commonly have lower rates of re-offense. What can we learn from these studies? And more importantly, from the clients that can inform our approaches? There are entire bodies of research in psychotherapy, criminology, and education that go unnoticed and under-discussed.

The research points to greater differences between the least and most effective therapists within treatment methods than differences between the methods themselves. This uncomfortable truth is that we may be looking in the wrong place for success when we pin our hopes on trainings about the latest technique or model. Instead, we might want to look inward at what we can do to become more effective, one client at a time.

One path to professional development is feedback-informed treatment (FIT), which we have discussed in previous blogs. Critical to understanding FIT is that it is not enough to engage in routine outcome monitoring through the use of measures such as the Outcome Rating Scale (ORS) and Session Rating Scale (SRS). Practitioners don’t always respond with adequate professional self-development based on the feedback they’ve received. This has led to a movement within psychotherapy aimed at focusing on specific steps clinicians can take to become more effective and involves solitary, deliberate practice between sessions.

As revolutionary as much of this information may seem, the ACE 2018 Conference took the discussion to a new level. Routine outcome monitoring cannot result in actual improvement without the clinician actively working to improve performance based on the results. Some measures of outcome (such as the ORS) can provide benchmarks of success in performance, while others (such as the SRS) yield insights for practice aimed at improvement.

At the start of the conference, researchers Bruce Wampold and Scott Miller reviewed the evidence for what works in treatment. Wampold took careful note of emerging evidence that the effects of cognitive-behavioral therapy (CBT) may have declined over the years, and wondered aloud if that isn’t a natural part of the evolution of methods. That is, that the pioneers of CBT had started out as highly trained therapists in general, whereas therapists are now trained more in the methods than in the core conditions of effective therapy. Also significantly, Wampold noted that therapists often overlook the most important therapist skills (e.g., the effective demonstration of empathy) in favor of novel techniques. He emphasized that “basic counseling skills” should be re-framed as “critical counseling skills.”

Birgit Valla, the director of Stangejelpa in Norway, provided a narrative of how her agency became demonstrably more effective in helping clients. She took issue with approaches to mental health agency development based on the traditional medical model. Valla described differences between how successful business and mental health agencies operate in designing actions that will be useful and effective for their customers. Her agency has defined the development of wellbeing as its primary product rather than over-emphasizing diagnoses and focusing exclusively on problems. She further described an agency culture in which “helping people is a team sport” and that before starting employees understand they will be expected to practice deliberately in response to client feedback.

Scott Miller gave a keynote address that reflected his recent provocative article titled “How Psychotherapy Lost its Magick.” In his address, he noted that in recent years, more people have visited psychics than have seen therapists. He concluded that, in part, this was because too often therapists practice within a narrow framework of models and techniques that may look impressive, but are not actually as helpful to clients as they could be.

Ultimately, there is a difference between models and techniques as developed and intended versus how they get applied in actual practice.  Implementation and integration of models can bring many challenges. Perhaps the most heartfelt example of this at the ACE 2018 Conference was Heidi Brattland. In her keynote address, she described going to see a therapist as part of her training to become a psychologist. By her account, the biggest lesson she learned was the resolve never to become the kind of psychologist she had gone to see.

Finally, Daryl Chow urged every professional to develop a broader view of the work we do. He is the first researcher to have published on deliberate practice approaches in psychotherapy.

Where does this leave the rest of us? Take-home messages include:

·    Basic counseling skills are only basic in theory. Combining them in actual practice is an advanced skill.

·       Conversation can be curative.

·     The most effective professionals in our field engage in solitary, often very difficult practice between sessions.

·    Treatment sessions are best thought of as performance that is different from the practice aimed at improving performance.

·       Clinicians in our field can learn from trends happening elsewhere.

I hope that the links provided throughout this post offer ideas for the way forward for readers.

Person-first language: Establishing a culture that transcends labels

By Gwenda Willis, PhD, Alissa Ackerman, PhD, & David Prescott, LICSW

The joint MASOC/MATSA conference took place earlier this month in Marlborough, Massachusetts. In a presentation on establishing person-first language across the fields of sexual abuse treatment and prevention, we (Gwen and Alissa) began our session introducing ourselves by several of the labels we hold. Gwen introduced herself as New Zealander, wife, friend, colleague, researcher, clinical psychologist, ATSA member and advocate. Alissa followed with mother, wife, lesbian, friend, colleague, professor, ATSA member, public speaker, advocate, and survivor, among others.

In this interactive presentation, we prompted attendees to explore the labels they use to describe themselves and the people they work with.  Like us, attendees were spouses, parents, clinicians and advocates.  Some were animal lovers and some were music lovers. All participants used positive labels to describe who they are. Next, we asked participants to describe who they work with and we explored which of these might not be self-selected by the very people we work with. Overwhelmingly, the labels we used to describe the individuals we work with were those that our clients might not use to describe themselves. Some of these labels included “victim”, “ex-prisoner”, “sexually violent person” and “offender”.

Importantly, there was agreement that use of such labels in our field is widespread: beyond their use in everyday conversation, such language is rife in the names of treatment programs, agencies, professional organisations and academic publications.  The American Psychological Association (APA), The National Association of Social Workers (NASW) and most professional organizations even tangentially related to our field articulate the need for person-first language in their Codes of Ethics, and yet in our field, we tend not to honor this need. Do we have an ethical dilemma? 

As part of our presentation, we considered core ethical principles of helping professionals including respect for human dignity, professional integrity and beneficence and non-maleficence.  We discussed how the “victim” and “survivor” labels might be self-selected by some people and not others, despite similar lived experiences.  Similarly, we acknowledged that some individuals with pedophilic interests self-identify as “pedophiles” while other individuals with pedophilic interests would find the “pedophile” label repulsive. 

We cannot assume which labels people want to use to describe themselves and if we truly honor human dignity, we must call people by what they prefer to be called. It is a matter of basic respect. For example, in our introductions, Alissa used the label “lesbian” to describe herself, while Gwen did not, despite both of us being married to same-sex spouses.

Discussion turned to the inaccuracies that normative labels such as “offender” and “abuser” portray – that anyone assigned such a label has the same (i.e., high) risk of reoffending.  As professionals working to address misperceptions about sexual abuse we highlighted the importance of communicating accurately about individuals who have abused, in the hope that they will have opportunities to live safe, fulfilling and offense-free lives. We turned to labels with scientific validity, including “psychopath” and “pedophile”, and conversation returned to their potential to stigmatise and ostracise.  Finally, we explored how labels might hinder the work we do to promote desistance from offending as well as healing from sexual abuse: What messages do the “offender” and “victim” labels communicate?  Possibly that this is how we see you. In the criminological literature, labelling theory suggests that the individuals internalize the labels we use to describe them and often live their lives accordingly.

How might we transcend potentially stigmatizing labels?  We introduced person-first language as an alternative to potentially stigmatizing language, which separates the person (e.g., man, woman, young person, individual, child) from a condition, disorder or behavior (e.g., individual adjudicated for a sexual offense, people who have committed crimes of a sexual nature). 

Labels are commonplace in every-day communication, and when self-selected they can aid communication.  However, assigned to us, labels have potential to stigmatise and harm.  As highlighted by Brene Brown (2017):

“The sorting we do to ourselves and to one another is, at best, unintentional and reflexive.  At worst, it is stereotyping that dehumanizes.  The paradox is that we all love the ready-made filing system, so handy when we want to quickly categorize people, but we resent it when we’re the ones getting filed away” (p. 48)

Person-first language avoids making assumptions about how someone wants to be labelled.  Additional exploration of issues raised in this blog and guidance on person-first language can be found in the 6th edition of the APA Publication Manual (American Psychological Association, 2010) and in Willis (in press).

In some quarters, the push towards person-first language has existed for years. It has occurred in other areas of psychology and human service (Willis, in press) as well as the field of treating adolescents who have sexually abused. Although it has long been known that adolescents can change dramatically over time, it is also worth remembering that adults can, and very often do, change as well. Further, the contexts in which they live their lives can change dramatically as well Now that our field knows what it does about building desistance and managing risk, it is clear that the use of labels has now outlived its usefulness. Indeed, it can cause harm.

References

American Psychological Association. (2010). Publication Manual of the American Psychological Association (6th ed.). Washington, D.C.: American Psychological Association.

Brown, B. (2017). Braving the Wilderness. New York, NY: Random House.

Willis, G. M. (in press). Why call someone by what we don’t want them to be? The ethics of labelling in forensic/correctional psychology. Psychology, Crime & Law doi: 10.1080/1068316X.2017.1421640