Thursday, September 12, 2019

The purpose and outcomes of treatment


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

As we prepare for this year’s NOTA conference, we have been again discussing many of the controversies of our field, among these are the effectiveness of the work that we do. An important 2017 article by Karl Hanson and his colleagues is among the most recent to indicate that truly low risk/need people very often require no abuse-specific treatment at all. We certainly agree and continue to urge considerable thought in this area, as we did in 2017. However, it’s important to distinguish abuse-specific treatment from other mental health services that can help people lead a more fulfilling lifestyle in which offending is undesirable and unnecessary. One concern we have in the subsequent discussions is that it may become easy to confuse “doesn’t need treatment aimed at reducing his risk” with “doesn’t need treatment, period.” This leads to broader questions about what our goals are when providing treatment.

Criminal justice policy and practice, internationally, typically indicates that something should be done with people convicted of an offence, including sexual offences, parallel to their punishment/incarceration. These programs, including treatment and other interventions, are usually pro-social, educational and designed to help people integrate back into society and desist from future offending. However, it might behoove each us to ask ourselves honestly what our motivations are in believing in the effectiveness or ineffectiveness of abuse-specific treatment. Is it that we believe that an individual should receive treatment because it is the best outcome for them or is it because we feel that we are providing treatment to someone because something needs to be in response to their problematic behavior and treatment is the path of least resistance in the public as well as the political domain? Do we believe in treatment because we believe that people can change or because we want to be seen to be doing something and that treatment is an acceptable outcome? To what extent do we view treatment, and the accountability it brings, as part of required punishment and/or justice for the people who have been convicted of a sexual offence? Therefore, what is the purpose of treatment, especially “mandated” treatment?

Different readers will have different responses to the questions above. Much debate in our field has emerged from findings such as those by Schmucker and Lösel in 2015. That study found re-offense rates of 10.1 and 13.7 percent for treated and undertreated people convicted of sex crimes respectively. Although this represented a relative reduction of 26.3 percent, the numbers are clearly not what anyone would like them to be. Nonetheless, other studies have found that people who abuse very often believe that treatment is important and can be helpful. How should we understand all these findings?
A recent article in the New Yorker addressed problems in understanding statistics. Within the article, the author took note of a now-classic study:

Take a clinical trial on aspirin run by the Oxford medical epidemiologist Richard Peto in 1988. Aspirin interferes with the formation of blood clots, and can be used to prevent them in the arteries of the heart or the brain. Peto’s team wanted to know whether aspirin increased your chances of survival if it was administered in the middle of a heart attack.

"Their trial involved 17,187 people and showed a remarkable effect. In the group that was given a placebo, 1,016 patients died; of those who had taken the aspirin, only 804 died. Aspirin didn’t work for everyone, but it was unlikely that so many people would have survived if the drug did nothing. The numbers passed the threshold; the team concluded that the aspirin was working.

The story of these findings is a reminder that our findings are best understood when placed into a broader context. Obviously, there are differences between baby aspirin (where the benefits will nearly always outweigh the risks) and treatment for sexual abuse (where some clients have faced consequences from their treatment disclosures despite attempts to protect their rights against self-incrimination). Nonetheless, the numbers themselves remind us that even a small level of impact in sexual violence can produce dramatic improvements in the quality of life of both those who have abused and the people who won’t be abused thanks to our interventions. Marshall and McGuire compared various kinds of treatment in 2003, and in their conclusions suggested that using a harm reduction index to estimate effect sizes for treatment with sexual offenders would produce more meaningful results.”

Although treatment for people convicted of a sexual offence is rooted in language around reducing reoffending, this may not be the only outcome we should consider. We must remember this! Treatment for people convicted of a sexual offence does not stop offending behavior, it provides individuals with the skills to understand and manage their behavior better. Treatment is a process and not an outcome! Hence, we need a “what works”, individualized approach that is orientated towards the client, what they need, what they respond too and what will help them change their lifestyle.

Whatever the finer points may be, we keep returning to what the research shows:

·     Across time, place, and setting, people can benefit from talking to professionals to get on track and stay on track with their lives.
·      Punishment-only responses have not worked in any of the large-scale analyses that have taken place (e.g., Smith, Goggin, & Gendreau, 2002)
·       Treatment for sexual aggression can help to reduce re-offense and build better lives
·   For those returning to the community, treatment combined with supervision can increase its effectiveness
·        As others have observed, the safest person who has abused is:
o   Stable
o   Occupied with work or education
o   Accountable to others in his or her life
o   Has Plans for the future
o   And has everything to lose by doing it again

As we move into conference season, with the NOTA and ATSA annual conferences occurring over the next couple of months, we can continue these discussions and consider how our policies can most effectively put these principles into action. 


Thursday, September 5, 2019

Crossing the Social Ecological Pond at the 2019 National Sexual Assault Conference


By Deirdre D’Orazio, PhD

I find myself feeling inspired this Monday morning.  Typically, Mondays are a bit overwhelming when I look at the work week’s “to do” list for my state and private practice jobs in sexual abuse intervention. My inspiration comes from having “crossed the pond” last week, over to the National Sexual Assault Conference.   “What pond is she talking about?” you ask.   The pond I speak of is a metaphor for a few valuable things.

First, on an individual level, I “crossed the pond” from where I live in California to Philadelphia, Pennsylvania. I was born and raised right outside of Philly and since my parents are the first generations from their families to live in America (from Italy and Poland), there was a sense of homecoming. 

Philadelphia is considered a symbol of freedom and American values, because it is the birthplace of the United States of America, where the Liberty Bell rang and the Declaration of Independence was signed after America won its freedom from Great Britain in the Revolutionary War in the 1700s.  Not too long after, Pennsylvania and the other Union states played an important role in the American Civil War opposing slavery and the secession of the southern states. In the early 1900s huge waves of immigrants settled in Philadelphia, along with a Great Migration of African Americans. Philadelphia was known as a melting pot where many ethnicities assimilated into a new America.  Despite this inspiring legacy, a shadow side of Philadelphia as the archetype of freedom is clearly evident in its subsequent long history of racial injustice, and earlier history of having been taken from its first residents, the Native American Lenape tribe.  Likewise, the milieu of the National Sexual Assault Conference seemed to embody both a zealous actualization of sexual abuse’s demise and also a wounded awareness of complex layers of collective, cultural, and personal trauma affecting this public health problem.

A second “pond” is a crossing over from the familiar land of treating sexual abusive individuals to that of a conference hosted an organization that focuses on abuse recipients. There is a valuable relationship to be further strengthened between we “ATSA types” and our allies in fighting sexual abuse that come from victim service organizations.   The conference theme, “Beyond the Breakthrough” was impressively apparent in workshop programming right at the growing edge of sexual abuse prevention. This was not a conference singularly focused on victims/survivors of sexual abuse. This conference was about acknowledging advancements over the past year exemplified with the “#me too” movement, celebrities accused and/or convicted of a sexual offense AND using that momentum to break through new prevention territory.

Workshops were inspiring and deeply thought-provoking. For example, Alan Heisterkamp and Michael Fleming’s session on Men’s Accountability Around #Me Too; Captain Noah Coakley and Sergeant Jessica Whitestone’s session on Sexual Assault and Direct Victim Services in the Air Force; Lisa Winchell-Caldwell’s session United in Mission:  Coordinating Intervention and Prevention Efforts. The conference also hosted an ATSA track where Maia Christopher, Kieran McCartan and I provided sessions that discussed what is known about sexually abusive individuals, their treatment and how we can work toward developing collaborative partnerships to progress our shared goal of ending sexual abuse. 

A third “pond” crosses time. It has to do with taking a step beyond a typical ATSA perspective to what is going on now in our communities and society.  This is a lens of social justice and it rewinds to the point in time before abuse happens in the first place.  Workshops tied together with the best from numerous intersecting fields to talk seriously about small and large changes that can have a big impact on preventing sexual abuse.  For example, Nwando Ofokansi’s session on The Other Birds and Bees:  Discussing Healthy Sexuality with Kids; Rolanda McCall’s The Sexuality of Black Women:  From Traumatized to Empowered, and Social Justice as Our Prevention Framework by Nubia Pena.

With our own children, do we model consent, respect boundaries, teach healthy sex, and disavowal coercion?  Examples are: asking kids’ consent to be hugged; retiring the common parenting tactic, “because I told you so” and getting that discussion about sex started before the hormonal flood of puberty.  As community members, are we showing our commitment to ending sexual abuse?  Intervening instead of being a passive bystander when abuse is happening; initiating, instead of avoiding, conversations about “what I do for a living” to get thoughtful dialogue going about the kinds of things everyday people can do on an everyday basis to prevent abuse; volunteering to do a talk for a local group; listening thoughtfully and openly to all perspectives.  

Workshops also addressed deep societal and cultural realities that support abuse and its root cause, - oppression.  For example, how the media and entertainment industries promote the sexualization of children and “rape culture”; the ongoing effects of slavery and racism on the high prevalence and low prosecution rates of sex crimes against black women; the lost boys of sexual abuse, the males that are recipients (and often future perpetrators) of sexual abuse; and the impact of verbiage such as “predator” on outcomes and expectations.  For example, Elizabeth Stahler and Alexandra Lenzen’s session Missing Nuance:  How Dehumanizing Perpetrators Can Cause More Harm than Good.


There has been increasing talk lately about how ATSA members can improve our efforts to prevent sexual abuse.   Attending the National Sexual Assault Conference proved a valuable journey across the social-ecological pond. There are exciting opportunities at individual, relationship, community, and social levels. Actualizing our goal of preventing sexual abuse starts with ourselves as individuals and how our behaviors align with our “no more abuse” goal. It includes promoting equanimity in how we relate to others and finding ways to collaborate in our communities and “across the pond.”  Small changes now can help evoke the social change we envision.



Friday, August 30, 2019

ReThink-DC: Preparing boys to end rape

By Tahir Duckett (President, ReThink at tahir@we-rethink.org) & Julie Patrick (National Partners Liaison, Raliance at jpatrick@raliance.org)

 This is a blog posting on behalf of the ATSA Prevention committee – Kieran.

 Researchers have identified a variety of risk factors associated with the likelihood of committing an act of sexual violence, including hostile views of women, rape-supportive beliefs, and perception of peers’ attitudes towards women and sex. (Lonsway & Fitzgerald, 1995; Abbey & McAuslan, 2004; Abbey, McAuslan, Zawacki, Clinton, & Buck, 2001; Knight & Sims-Knight, 2004; Swartout 2013).

These cultural norms that make sexual violence so common remain deeply embedded in society, especially among men and boys (Prevention Institute, October 2014). Adolescent boys are bombarded with toxic messages that normalize misogyny, sexual entitlement, and violence, and these myths are redoubled and reinforced by their peer groups who are receiving similar messages from similar sources (Schwartz & DeKeseredy, 1997).
 
If the problem is cultural, then the solution must be as well.

ReThink is a Washington, DC-based nonprofit that works with adolescent boys aged 12-18 to break down the cultural norms that underpin sexual violence. ReThink sought funding from RALIANCE, a national partnership among leaders in the prevention of sexual harassment, misconduct, and abuse. Raliance is dedicated to ending sexual violence in one generation and supports an impact grant program with a specific funding category to prevent primary perpetration.

 
ReThink-DC is a pilot project designed to help instill adolescent boys from a variety of backgrounds with critical values of empathy, consent and emotional awareness, preparing them to reject rape myths and embrace healthy attitudes towards women. Through ongoing, consistent contact with the trained community leaders, the program seeks to help boys learn to reject rape culture, both publicly and privately, now and in the future.
 
Flipping the status quo

The program hypothesized that boys who receive consistent messages normalizing consent, empathy, and emotional awareness, and receive these messages from multiple credible messengers over time will help saturate a community with a new set of norms. Boys are less likely to receive tacit approval when they echo broader social messages of misogyny, sexual entitlement, and violence, because these messages no longer go unchallenged as normal behavior. Research shows that messages are most effective at reducing the acceptance of rape myths when they are received often, and at younger ages (ICASA & Schewe).
 
Preparing for scale

ReThink partnered with the District of Columbia Rape Crisis Center (DCRCC) on the eleven final modules of the curriculum, ranging from 20 to 45 minutes each, designed to provide educators with the tools to teach young people about core concepts of consent, break down gender norms and stereotypes, and improve empathy and emotional awareness. The modules include general best practices, facilitation notes, real-world examples, and media resources to keep learners engaged.
 
In order to measure progress and prepare for scale, ReThink tracked the following indicators:
 
        Average change in boys’ understanding and views of consent, empathy, healthy masculinity and rejection of rape myths over the course of the year (through pre-/post-tests)

       Community leaders’ commitment to continue implementing ReThink methodology, trainings and intervention strategies at the end of one year.

        Number of community leaders committed to preventing sexual violence

        Number of trainings and interventions held by community leaders

        Number of adolescent boys who are reached through these trainings
 

Here’s what we learned – People are hungry for language and skills to help adolescents develop these skills.
 
ReThink trained more than twice our original goal of 50 leaders. Community leaders participating in the training were extremely hungry for practical, hands-on instruction and role-playing opportunities. Yet, prior to our training, many did not feel they had the language, skills, or comfort to talk to students about these issues. Further, a second step was to divide the subject matter into different sessions and allow participants to opt-in based on their personal strengths and gaps. For example, some participants came into the training with a strong understanding of theory and were seeking primarily practical instruction, while others needed the theoretical training regarding how cultural norms contribute to sexual violence.
 
Here’s what we learned – Shorter, subject-specific workshops are more effective than longer, comprehensive ones.

ReThink’s training of community leaders involved approximately 4-5 hours of subject matter, depending on the size of the group. Community leaders who experienced the training as a series of three shorter workshops focusing on narrower topics reported stronger familiarity and greater confidence with the material than those who experienced the training as one longer workshop covering the entirety of the available material.

Here’s what we learned – An investment of just a few hours meant significant changes in the attitudes of adolescent boys. 
 
ReThink’s evaluation through Pre- and post-surveys of adolescent boys who received the modules indicated a reduction in acceptance of rape-supportive beliefs and hostility towards women of at least 52%.

 

 

 

Wednesday, August 21, 2019

The Jeffrey Epstein case and why language matters


 A statement from the Association for the Treatment of Sexual Abusers

The country has understandably been shocked and appalled by the heinous actions, both confirmed and alleged, involving the sexual abuse and trafficking of children perpetrated by Jeffrey Epstein. However, high-profile cases such as Mr. Epstein’s also bring much-needed attention to a complex public health issue facing not only our country, but all communities worldwide – sexual abuse.

Sexual violence affects millions of people each year in the United States, with more than 1 in 3 women and nearly 1 in 4 men having experienced sexual violence involving physical contact at some point in their lives. International research focused on violence against women has estimated that 35% of women worldwide have experienced either physical and/or sexual intimate partner violence or sexual violence by a non-partner (not including sexual harassment) at some point in their lives. The prevalence of child sexual abuse can be difficult to determine because it is often not reported, but it is estimated that one in four girls and one in six boys will be victims of sexual abuse before age 18.

Sexual abuse is a complex public health issue that requires accurate information in order to support prevention efforts, and the media plays an integral role in information dissemination. However, the media does a disservice to prevention efforts by using terminology such as “pedophile” and “child rapist” interchangeably, as seen in the many articles about Mr. Epstein.

Pedophilia is an attraction to children who have not yet reached puberty. A person with pedophilic interests may or may not act on those desires. In contrast, a child molester is a person who has chosen to sexually abuse a child. In the latter case, even though the abuse is sexual in nature, the motivations for the behavior may not be driven by sexual interest. Other motivations for sexual abuse include but are not limited to, a desire for power and control, general antisocial thinking/beliefs, and intimacy deficits and loneliness. Hence, not everyone who sexually abuses a child has pedophilic interests and not everyone with pedophilic interests will sexually abuse a child. Attraction is not action and action is not attraction.

Whatever Mr. Epstein’s motives may have been, he chose to act on those desires and abuse minors. Unfortunately, his personal wealth allowed him to act with relative impunity. This was exacerbated by those around him either not recognizing what they were seeing due to a lack of awareness about sexual abuse, supporting and benefiting from his behavior, being indifferent to it, or being afraid to report his actions. People who knew him may have minimized his behavior and dismissed their concerns because, with his status and prestige, Mr. Epstein couldn’t be “that guy.”

Mr. Epstein’s case, as well as the cases of Jerry Sandusky, Larry Nassar, and Bill Cosby, are stark reminders that anyone can be “that guy.” Those who commit sexual harm come from all walks of life. They can be people we admire, people we like, people we trust, or people we despise. They cross all socioeconomic, educational, gender, age, and cultural lines.

But another misuse of language – using terms such as “predator,” “monster,” “pedophile,” and “pervert” – to describe individuals who sexually abuse others artificially separates those who cause sexual harm from the rest of us, and does nothing to help the public understand who may perpetrate sexual abuse or develop effective strategies to prevent those actions. Instead, using this kind of language makes it harder to accept that even people we know and trust could be at risk to sexually abuse others.

We must embrace the harsh realities of who commits sexual harm:
·       -  93% of sexual abuse involving minors is perpetrated by someone known to the minor, not a stranger.
·        - 73% of rapes against females age 12 and older are perpetrated by someone known to the victim.

Those who commit sexual harm are those we know and even love, trust, and admire much more often than they are strangers. Effectively preventing sexual abuse requires we all learn about the complexities of sexual abuse, how to protect our children, and how to provide them with the necessary skills to protect themselves across their lifespan. It also requires us to recognize that sexual abuse is not perpetrated by the “monster” other, but by everyday people, famous people, and sometimes even those closest to us.

Accurate information and a shared approach to prevention are the keys to ending sexual abuse. Focusing on sexual abuse as a public health issue provides us with the correct lens to adequately tackle this pervasive issue by moving us beyond ensuring the health of individuals to the health and safety of an entire population. Through education, collaboration, and the involvement of everyone – community members, violence prevention professionals, victim advocates, law enforcement professionals, those who provide treatment to victims/survivors of sexual abuse, and those who provide treatment to persons who have perpetrated sexual abuse – the prevention of sexual abuse can become a reality.

Treatment is not only available to help prevent individuals at risk of abusing children from acting on their thoughts, it is also available to help individuals who have abused refrain from doing so again. The Association for the Treatment of Sexual Abusers offers access to treatment providers who can help individuals receive the assistance they need to avoid sexually abusing children and others. If you are seeking help for yourself, a family member, or a friend, visit www.atsa.com and click on “Referrals” to find a provider near you.



Thursday, August 15, 2019

Understanding and Responding to Pornography Use with Adolescents Who Have Engaged in Harmful Sexual Behavior: Developmental Considerations

By Russ Pratt & Cyra Fernandes

Introduction: ‘Teen rituals’

Fifteen-year-old Mikey* sits in his room, finishing his homework. From time to time, he closes the window on what he is working on, and watches a bit more of his most recent ‘favorite’ pornographic movie, After looking at this for a few minutes, and, becoming aroused, he picks up his phone, and scrolls through the dozen or so pictures of naked and semi-naked young women he goes to school with. All of them sent these ‘pics’ to him after he asked them to do so. They, in turn, have pictures of him, some requested, and some not. He hears his mother coming up the stairs, so quickly returns to his computer and homework. 

Is the above paragraph fantasy, fact, or somewhere between the two? Well, recent research suggests that this scenario is closer to the facts of the matter, rather than any responsible parents’ nightmare scenario. Not only is exposure to, or viewing of, pornography in adolescence now a normative experience, with research indicating that the majority of adolescents have viewed or been exposed to pornography by age 15 years (Lim et al, 2017), but also that the sending and receiving of naked pictures by adolescents has become a normative adolescent experience (Fisher, et. al., 2019; Smith, Mitchell, Barrett & Pitts, 2009; Mitchell et. al., 2014, Lim et. al., 2017).  In an Australian-based study of 2,136 15 to 17-year-olds, over half the sample had received a sexually explicit text message and had been sent a sexually explicit nude or nearly nude photo or video (Mitchell, et al., 2014). Over one-quarter of them had sent a sexually explicit photo to someone else. Thus it seems that sending and receiving sexually explicit (nude) pictures of themselves or others is the current broadly-acceptable, teenage courtship ritual.  

Does pornography influence sexual practices, behaviors, attitudes, and perceptions 

Well, the short answer to this question seems to be “yes” it does. And not only for adults, but clearly for adolescents commencing their sexual-developmental journey. Pornography significantly influences sexual practices, behaviors, and perceptions of both adults and adolescents when it comes to their view of “…what sex looks like. (Pratt & Fernandes, 2015)” In particular, it seems that consuming pornography (Fisher, et. al. 2019; Lim, et. al., 2017; Mitchell, et. al., 2014) is related to more permissive sexual attitudes and gender-stereotypical sexual beliefs, and, for those youths who view pornography at a very young age (pre-pubescent) we see earlier-onset sexual intercourse, higher rates of casual sex by early adulthood, and higher levels of sexual aggression by adults, in terms of both perpetration and victimization (Bridges, et. al., 2010; Wright, Tokunaga & Kraus, 2015),

The ‘young’ consumer

What do these young people who most frequently view pornography look like? As research indicates that the majority of young people have viewed pornography by 15 years of age, it seems more difficult now than ever before to ‘characterize’ what a ‘frequent consumer’ of pornography looks like, as compared to those who are not. As, authors, researchers, therapists, and even parents, we know how quickly the digital and online world is changing, and thus the patterns of usage we saw even ten years ago may not apply right now. This also means that less-recent research might not portray what the current situation is, as much as we would like. Peter and Valkenburg’s (2016) excellent 20-year summary of the research is a case in point. Findings cited by those authors may now relate to findings from before 1996 – well before the ‘digital revolution’. Given that pornography consumption is now ‘normative’ behavior for adolescents, it might be the case that we can only say that; more males than females view pornography; they (males) view it on a more frequent basis than females, and it is likely that the majority of young viewers do so for commonplace reasons, such as learning about sexual behaviors, and to achieve sexual arousal (Pratt & Fernandes, 2015). 

The role of pornography

So, what is the role of pornography in the development and maintenance of adolescent harmful sexual behavior? The answer is frustratingly unclear. While it is neither possible nor accurate to state that adolescent pornography use leads to harmful sexual behavior, it may be the case that repeated exposure to pornography might lead to desensitization and contribute to distorted views of what are normative, acceptable, or desired sexual behaviors and relationships. For some children and adolescents, this exposure could provide such a “skewed template” for the “how-to” and “what” of sexual behavior, and, more importantly, provide information and images that are so inappropriate for their developmental stage (Pratt & Fernandes, 2015) that it cannot be decoded nor understood; 

Young people who engage in sexually abusive behavior often present with deficits in important psychosocial skills (Peter & Valkenburg, 2016), and may lack the developmental maturity to both understand the explicit sexual content of pornography, and that it may not represent ‘real-life’ sexual relationships and behaviors and what people seek in sexual relationships (Pratt & Fernandes, 2015). 
In addition, due to sexual inexperience, learning disorders, intellectual disabilities and autism spectrum disorders, some youth may be even less able to critique and comprehend that what they see in pornography is not what “real-world” sex looks like. They may also be either reluctant or unable to seek support from adults to help them make sense of what they saw in pornography.

Conclusion

To conclude (and there is so much more to say), educating adolescents about healthy sexuality is a key component of treatment. For adolescents who have engaged in harmful or sexually abusive behaviors, the development of healthy sexual practices is key. Whilst sex education should include a focus on the relational aspects and boundaries of sexual behavior, more is needed. The authors have created a developmentally focused, “savvy consumer” model for youth which advocates ‘zero-tolerance’ for pornography viewing for very young children, combined with a ‘harm-minimization’ model for older adolescents. The model has, at its heart, the belief that the ability to both critique the falseness of pornography, and highlight positive, real-world sexual health practices will ensure that the qualities of healthy, safe, and desired sexual practices remain in-focus during treatment. 
In particular:
Respect,
Mutual consent,
Equality and partnership, 
The freedom to say no, and;
The freedom to negotiate equally regarding healthy, respectful sexual pleasure and activity.

References

Bridges, A J.,Wosnitzer, R., Scharrer, E., Sun, C., & Liberman, R. (2010). Aggression and Sexual Behavior in Best-Selling Pornography Videos: A Content Analysis Update, Violence Against Women 16(10), 1065-1085.

Fisher, C. M., Waling, A., Kerr, L., Bellamy, R., Ezer, P., Mikolajczak, G., Brown, G., Carman, M. & Lucke, J. (2019). 6th National Survey of Australian Secondary Students and Sexual Health 2018, (ARCSHS Monograph Series No. 113), Bundoora: Australian Research Centre in Sex, Health & Society, La Trobe University. 

Lim, M.S.C., Agius, P.A., Carrotte, E.R., Vella, A.M., & Hellard, M.E. (2017). Young Australian’s use of pornography and associations with sexual risk behaviours, Australian and New Zealand Journal of Public Health, 2017 online, doi: 10.1111/1753-6405.12678.

Mitchell, A., Patrick. K., Heywood, W., Blackman, P., & Pitts, M. (2014). 5th National survey of Australian secondary students and sexual health 2013. ARCSHS Monograph Series No. 97,  Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Australia.

Peter, J., & Valkenburg, P. M. (2016) Adolescents and pornography: A Review of 20 Years of Research, The Journal of Sex Research, 53:4-5, 509-531.

Pratt, R., & Fernandes, C. (2015). How Pornography May Distort Risk Assessment of Children and Adolescents Who Sexually Harm. Children Australia, 40, pp 232-241 doi:10.1017/cha.2015.2.

Smith, A. P., Mitchell, A., Barrett, C., & Pitts, M. (2009) Secondary Students and Sexual Health 2008: Results of the 4th National Survey of Australian Secondary Students, HIV/AIDS and Sexual Health, Australian Research Centre in Sex, Health and Society (Latrobe).

Wright, P.J, Tokunaga, R.S., & Kraus, A., (2015), ‘A meta-analysis of pornography consumption and actual acts of sexual aggression in general population studies’, Journal of Communication, 66(1), 183-205.

Wednesday, August 7, 2019

When we become the barriers to progress


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

At first, it all seems so easy. The large institution or agency decides they are going to get serious about professional development and quality improvement. “I’ve done some research on evidence-based practices and have concluded that we need to implement the Forensic Version of the XYZ-PSB model. It has all the qualities that we’re looking for, combining elements of all the popular models that are available, and even has some mindfulness. The fact that there are some deep breathing exercises at the start of some sessions qualifies it as a biopsychosocial approach.”

We’re kidding, of course. It often seems to us that the latest/greatest models make the largest promises until the implementation effort begins. The history of psychotherapy is certainly replete with examples of fad treatments, each one appearing to be bigger, better, faster, or just plain more. Many a well-intended agency and director (including the first author, David) have sought training in a particular method because it had worked in some other setting or been proven in a study or two, only to find out that the old adage is true: All too often what is new is not what makes a treatment approach effective. At the same time, what makes the same treatment effective is not new.

The above example of the fictitious XYZ-PSB: FV is ironic because there is a chance that it will work if implemented with diligence, confidence, and a shared belief between therapists and clients that it will work (Wampold & Imel, 2015). In other words, the belief that something will work very often contributes to its success. This is one reason why we have science: to understand not only what works, but how and in what ways.

The rest of the picture may not be so pleasant, however. The unfortunate reality at the front lines, often not reported in research, is that there are any number of ways that good treatment can go bad under the wrong conditions. Let’s take the above director’s plan for implementing XYZ-PSB: FV. Even before implementation, what kinds of exploration of the agency’s needs and staff attitudes takes place? Are the staff excited for the opportunity or feeling beleaguered that they are having to learn yet another approach at high risk of passing into history like the others?

Other questions follow. Will the director participate in the training? The absence of key decision-makers from the process itself can have a significant effect on staff, even though it is not mentioned in any manuals. Likewise, does the agency or institution bring in an outside trainer who trains, perhaps does some consult calls, and leaves without a succession plan? Some way to keep the spirit and practice of the treatment alive? And then during the initial phases of this implementation, what other barriers occur, such as the director getting a new job, or another influential actor going out on medical leave?

Of course, the picture can become even more pernicious. Are there other challenges competing with the meaningful implementation of a high-quality approach? For example, many agencies experience severe pressure to ensure complete adherence to complicated licensing requirements or accreditation. At what point is the search for excellence – that burning desire to become more effective – compromised by the need to ensure timely documentation? Does adherence to regulations end up compromising adherence to a new model? Do we then expend so much effort pursuing fidelity to the model that we then forget to maintain fidelity to the actual client and his or her individual characteristics?

These are questions too often omitted from any manual or introductory training, but they threaten treatment integrity nonetheless. This is why collaboration between researchers, trainers and professionals is so important in the creation of evidence-based practice that is fit for purpose in the real world (see another blog by Kieran on the importance of co-creation).  One of the sadder outcomes of implementation efforts, in our view, is when professionals work treatment jargon into case notes as a signal to auditors and licensors that they were using a model when in fact they really weren’t.

We (David and Kieran, along with our collaborator Danielle Harris) have argued in our training, and in a recent paper, that we can learn a lot about improving services by listening to the voices of the service user. Yet, most treatment providers work in environments where the same service user has little or no voice in their treatment planning.

Out hope is that by raising these questions we may better inspire dialog among professionals, researchers, and trainers as to how we might better anchor our practice in the evidence. All too often the enemy to successful implementation is ourselves.

Wednesday, July 31, 2019

ANZATSA Biennial Conference 2019


By Kieran McCartan, Ph.D.

The biennial ANZATSA conference took place from the 24th – 26th July in Brisbane. The conference was a real mix of research, practice, and engagement with colleagues from across Australia, New Zealand and internationally (with attendees and speakers from a range of countries including the USA, Canada, UK). In this blog, I am going to take you through the conference highlights.

On the first day (Wednesday) there were 11 ½ day workshops that focused on a range of topics, including Risk Assessment (David Thornton; Simon Hackett & Marcella Leonard; Maaike Helmus; Ray Knight & Judith Sims-Knight); the registration and disclosure of information relating to people who had committed sexual offences  (Katie Gotch, Margret-Anne Laws, Karla Lopez & Kieran McCartan); the voices of victims on the integration of people who have been convicted of sexual offences back into the community (Kelly Richards, Jodi Death, Carol Ronken & Kieran McCartan); the prevention of sexual abuse (Stephen Smallbone); and treatment/interventions (Richard Parker; Sharon Kelley) The workshops enabled professional, policy and practice conversations to take place in a controlled, informed environment.

The 2019 plenaries combined research, practice and innovate approaches from an international group of speakers, most of whom were from outside Australia and New Zealand. The Thursday keynotes addressed children who had committed Harmful Sexual Behaviour, their client voice and the impact of treatment/interventions, on their life course desistence as well as how we could adapt our practice to better serve them (Simon Hackett). This was followed by a discussion of what matters and what works in risk assessment and how it ties to reducing risk of recidivism (David Thornton), The third keynote on Thursday was a panel discussion on the process and impact of the Australian Royal Commission, which highlighted the challenges of implementing its recommendations in practice (Gary Foster, Kathryn Mandla & Professor Stephen Smallbone).

One of the main themes of the conference was hearing different voices and it's fitting that the Indigenous voices (Maori, Aboriginal and Tori Strait Islanders) and the victim's voices (through conversations on the Royal Commission) were front and center in the plenaries as well as in the parallel sessions. These sessions were important and thoughtfully developed, highlighting the ways that Australia and New Zealand where moving forward in the arena of hearing and respecting the Indigenous voices and how we can develop appropriate risk assessment, treatments/interventions, and integration strategies developed with traditional peoples in mind. Which should give all participants, especially from anglophone northern hemisphere countries, pause for thought in the way that we address these issues in our own countries. In addition, it was good to see and hear a focus on the victim's voice at a treatment and management conference for people convicted of sexual offenses as it reinforced that these two sides of the field are not as detracted from each other as they are often portrayed; the only way to truly understand, respond to and prevent sexual abuse is to hear all voices.

The National Office for Child Safety led two co-design workshops for the development of a National Strategy to Prevent Child Sexual Abuse on the last day of the conference. Which was interesting to attend and quite innovative in the context of a conference as policymakers got to discuss issues with researchers and practitioners, hearing each other’s voices and building approaches that were fit for purpose. These sessions where quite innovative and I would recommend that sister conferences in the field (NOTA, ATSA, ATSA-NL, CoNTRAS-TI & IATSO) would consider doing the same thing.

Other parallel workshops spanned a full range of topics and speakers of which this is just a flavour) including, integration of people who have sexually offended back into the community; public health approaches to sexual abuse and prevention; youth who sexually harm; institutional sexual abuse; & pornography. The parallel sessions were a good mix of research, evaluation, practical working, professional learning and knowledge exchange.

The second day of the conference (Friday) closed with an interesting mix of keynotes, a panel session that focused on the voices of Indigenous peoples (Lynore Geia, Neil Campbell, Carol Vale, & Claire Walker), another that addressed research on typologies of people who commit rape (Ray Knight) and how much we know about undetected sexual abuse (Sharon Kelley).  All the keynotes tied together ideas of the importance of assessment, management, and integration in a thoughtful, fit for purpose fashion tying together research, practice and policy effectively.

In addition to the traditional conference activities, ANZATSA 2019 also had an engagement event. This year we changed our focus from members of the public to professionals. We advertised the engagement event to professionals who have safeguarding as part of their jobs, but that safeguarding is not their main role (and therefore would not be attending the ANZATSA conference) including, teachers, foster carers, members of charities and NGO’s, etc. They had approximately 70 participants sign up to attend the event. The session heard from national (Detective Inspector Rouse, Professor Martine Powell & Carol Ronken) speakers, chaired by Nance Haxton (the wandering journo), about how to raise informed and confident children that can discuss sexual abuse, and exploitation, and able to ask for help. The engagement event reinforced the main theme of the conference and highlighted that we as a community need to come together to stop child sexual abuse.

ANZATSA 2019 fitted a massive amount of material in across three days, which left me informed, refreshed and looking forward to 2021’s meeting.

Friday, July 26, 2019

Prevention of sexual abuse and the treatment of people who have committed sexually violent behavior: A current state of affairs


By Kasia Uzieblo, Jeffrey Lauer, & Minne De Boeck (Dutch Chapter of ATSA, NL-ATSA)

Five years ago, two colleagues, Wineke Smid, Jan-Willem van den Berg (Van der Hoeven kliniek, Utrecht, the Netherlands) and Jules Mulder (De Waag & Stop it Now! Netherlands) dreamed of founding a Dutch Chapter of ATSA (NL-ATSA). With this chapter, they wanted to enhance Dutch and Flemish practitioners’ knowledge on evidence-based and best practices in prevention, assessment, and treatment of sexually deviant behavior. They also wanted to encourage and facilitate a fruitful two-way interaction between North-American and Dutch speaking researchers and practitioners. A mere five years later, NL-ATSA has become a fully-fledged chapter of ATSA. Moreover, the chapter can be regarded as a prominent player in both the Netherlands and Flanders (Belgium), when it comes to informing practitioners about the scientific understanding of sexual violence and the treatment of people who have committed sexual offences. Proud of its achievements, NL-ATSA doesn’t want its fifth birthday to pass quietly and organizes two events to place this festive year into the spotlight.

A first event took place on the 25th of June. This event was entirely devoted to a special edition on sexually deviant behavior published by the Dutch Journal of Sexology which was edited by former and current NL-ATSA board members, Jan Willem van den Berg and Kasia Uzieblo. During each conference, session experts elaborated on a topic depicted in the special edition by zooming in on best (research) practices within this particular field.

The first presenter, Eveline Schippers (De Waag, Utrecht, the Netherlands), described the results of her innovative study on creating sexual deviance through incentive transfer in a male community sample. Antisocial behavior and sexual deviant interests are regarded as two important risk factors for sexually deviant behavior. However, current knowledge on how these sexual deviant interests originate is very limited. The Incentive Motivational Model (Smid & Wever, 2018) describes sexual arousal as an emotion, that is triggered by a competent stimulus signaling potential reward, and comparable to other emotions coupled with strong bodily reactions. According to this model, sex can be used to regulate emotional states, and emotions can be used to consciously or automatically regulate sexual arousal. Excitation transfer implies that one emotion triggers or reinforces another. But there might also be a sexual component to it. An example of sexual excitation transfer is when athletes become sexually aroused when they won a competition (i.e., when euphoria leads to sexual arousal). With the current study, Schippers aimed to examine whether people become more sexually aroused when experiencing a strong positive and/or negative emotion than when they are in an emotionally neutral state. Her first results suggest that mainly movie clips depicting aggressive content seem to elicit sexual excitation transfer and that genital excitation transfer might not fully align with the subjective (thus self-reported) experience of sexual arousal. This coupling between emotion and sexual arousal could provide interesting new avenues for treatment programs.

The importance of prevention strategies was highlighted in the second plenary session by Minne de Boeck (University Forensic Centre and Stop it Now! Flanders, Belgium) and Jules Mulder (Stop it Now! Netherlands). Taking into regard the high prevalence rates of child sexual abuse and the gravity of the impact of sexual abuse on someone’s life, it is astonishing that only a few programs focus on the prevention of sexual abuse on a primary -and even- secondary level. Notably, most of these projects focus on (potential) victims and on the environment (e.g., parents and school) of potential victims - and exceptionally- perpetrators, but not so much on the (potential) perpetrator him-/herself. Also, most of current prevention programs focusing on the (potential) perpetrator are situated on the tertiary level and hence focus on the prevention of recidivism, and not on preventing sexual abuse of ever happening in the general population (i.e., on the primary level) or in specific risk groups (i.e., on the secondary level). The presenters emphasize that if we want to be serious about preventing sexual abuse, all stakeholders (e.g., schools, sports clubs, practitioners, and policymakers) should start thinking in terms of prevention on the three levels and should start developing initiatives accordingly. De Boeck and Mulder presented three real-life cases (a case of child sexual abuse in a daycare center, sexual abuse by Jehovah’s witnesses, and sexting). These illustrations elicited inspiring discussions with the audience on the benefits and limitations of preventive strategies.

In the third and final plenary session Zohra Lkasbi and Daniël Neves Ramos (ZNA University Psychiatric Center for Children and Youth, Antwerp, Belgium) discussed the assessment in and treatment of minor perpetrators of sexually violent behavior. It is astonishing to note that this topic receives so little attention in literature and practice. Current theoretical knowledge on this issue remains very limited. And in practice they are often confronted with denial from different agencies: even for professionals, it seems to be difficult to acknowledge the existence of such behavior in minors, with all that this implies for the treatment of these minors. The presenters described the limited empirical knowledge on prevalence rates, the risk and protective factors for sexual violent behavior in minors, and interventions. The presenters illustrated the problems they are encountering in practice by describing a clinical case. With this case, they demonstrated that their patients are often minors who exhibit a wide range of psychosocial problems and risk factors. It also became clear that many of these patients have experienced traumatic events and that treatment programs should sufficiently take these traumas into regard. Finally, these clinicians often struggle with pharmaceutical interventions given that little is known about the efficacy and side effects of these interventions.

In the afternoon, four workshops took place. In a first workshop Jan Willem van den Berg and Marc Lexmond (Van der Hoeven kliniek, Utrecht, the Netherlands) presented “A Positive Life Plan”, which is a treatment plan developed by van den Berg and colleagues. With this treatment, plan practitioners are offered a tool to develop a treatment module that adheres to the principles of the Good Lives Model (Ward & Stewart, 2003). In the second workshop, Els Van Daele and Kris Vanhoeck (I.T.E.R., Brussels, Belgium) focused on the factors that might facilitate the development of a therapeutic alliance with clients who have committed sex offences. Through role-plays with the participants, they developed suggestions on how to avoid pitfalls and create opportunities to develop such an alliance with their client. The third workshop of Kasia Uzieblo and Eelco van Doorn (Van der Hoeven kliniek, Utrecht, the Netherlands) aimed to counter the most prominent myths about psychopathy and to illustrate that positive treatment outcomes can be obtained in patients with psychopathic traits. In the final workshop, Kim Ellen Biesmans, and Lieke Nouwen (STEVIG, Forensic Care and Centre of Expertise, the Netherlands) introduced a treatment program that they developed for individuals with intellectual disabilities who committed a sexual offence. This treatment program uses the Integrated Theory of Sexual Offending (ITSO; Ward & Beech, 2005) as a reference point.

This successful, sold-out event was again a reminder of what Wineke Smid, Jan Willem van den Berg and Jules Mulder have accomplished: Five years after the launch of NL-ATSA, the chapter plays a crucial role in building bridges between the production of knowledge and its diffusion to Dutch and Flemish practice and broader, to society. Hence, we are in great debt to the founders of NL-ATSA.

And for the curious readers amongst you: Our second birthday event will be a four-day conference on the assessment and treatment of sex offenders, which will take place from February 4 until February 7, 2020, in Antwerp, Belgium. More information is coming soon!

References
Smid, W. J., & Wever, E. C. (2018). Mixed emotions: an incentive motivational model of sexual deviance. Sexual Abuse, doi: 1079063218775972.

Ward, T., & Beech, A. R. (2006). An integrated theory of sexual offending. Aggression and Violent Behavior, 11(1), 44–63. http://dx.doi.org/10.1016/j.avb.2005.05.002

Ward, T., & Stewart, C. A. (2003). The treatment of sex offenders: Risk management and good lives. Professional Psychology: Research and Practice, 34(4), 353–360. http://dx. doi.org/10.1037/0735-7028.34.4.353.


Thursday, July 11, 2019

ATSA’s Role in Addressing Campus Sexual Misconduct as an Opportunity for Prevention


By Joan Tabachnick Katie Gotch

Please note that this is a joint blog by the ATSA prevention and policy committees - Kieran 


Over the past ten years, the media and a growing advocacy movement have focused the public’s attention on campus sexual misconduct. Campuses throughout the world are facing this issue, and a growing number of countries are issuing guidelines that call on colleges and universities to improve the way they respond to and prevent sexual misconduct on campus. 

Advocates worldwide acknowledge that preventing sexual misconduct on college and university campuses requires comprehensive prevention strategies and policies for students, faculty, staff, and institutions.  A comprehensive prevention strategy includes providing services to all persons impacted by sexual harm – those who have been harmed, those who have caused harm, those at risk to cause harm, and the people connected to these individuals.

Given the importance of this issue, you may ask yourself: what could ATSA and its members provide in addressing campus sexual misconduct?  

We believe that ATSA has a unique lens and expertise in this growing conversation based upon our collective expertise and understanding of the perpetration and prevention of sexual misconduct.  The Centers for Disease Control and Prevention (CDC) in the United States has argued for the importance of this lens, stating that “a decrease in the number of actual and potential perpetrators in the population is necessary to achieve measurable reductions in the prevalence of sexual violence” (DeGue, Simon, Basile, Yee, Lan, & Spivak, 2012; DeGue, Valle, Holt, Massetti, Matjasko & Tharp, 2014).  Therefore, by incorporating the available knowledge and ATSA’s expertise on the assessment, treatment and prevention of abusive, illegal, or harmful sexual behaviors, a college or university’s ability to prevent and respond effectively to campus sexual misconduct will be strengthened. This includes what we know about effective interventions and protective factors for individuals who have committed some form of sexual harassment, misconduct, assault, or violence. 

To help articulate this point of view, ATSA’s Public Policy Committee and ATSA’s Prevention Committee joined together to develop a document outlining our contributions to this important conversation.  The document discusses the need to identify evidence-informed policies and practices that: 

hold individuals who perpetrate sexual assault accountable for their behavior; 

provide safety and support to individuals who have been harmed to facilitate healing; 

provide services for those who have caused harm with the resources necessary to stop their harmful behavior; and 

prevent sexual assault from happening in the first place.

The document additionally offers some key recommendations which are provided as suggestions to build a more effective response and prevention approach targeting the perpetration of sexual misconduct.  The recommendations include: 

connect with local expertise on the perpetration of sexual misconduct;

appropriately sanction and provide treatment to those who have caused sexual harm that is grounded in an individualized evidence-based approach; and

include perpetration prevention lens to existing prevention programs.

It is our hope that, by including the current knowledge regarding individuals who have sexually harmed with the emerging research and programs that show early and effective interventions can stop sexual misconduct, colleges and universities will be one step closer to achieving the important goal of preventing sexual misconduct. 

For more information, including additional resources on this important topic, check out the ATSA document: Addressing Campus Sexual Misconduct. It is a resource for all and we encourage you to share it widely!