Wednesday, March 27, 2019

Reducing harm in individuals who commit sexual abuse

By Kieran McCartan, PhD, & David Prescott, LICSW
Professional discussion about preventing sexual abuse is often couched in absolutes, especially when it comes to anti-social behavior. In our field, we often talk about eliminating abuse and/or stopping people from abusing, whether before it starts or after it has occurred. We find ourselves asking… is it really that easy? It is striking how rarely our discussions focus on harm reduction or how we might influence the nature of offending, offenses, or reconviction. By thinking in absolutes, we may be cutting ourselves off from innovative research and treatment practices.
Ultimately, all of our efforts are aimed at moving an individual from one end of a spectrum (offending) to the other end (desistence) in a short, often pre-determined time. In reality, meaningful behavior change takes time, faces unpredictable challenges, and has its stumbling blocks; genuine change can be a messy process. All of this begs the question of whether we are setting ourselves up for failure when we recognize only black or white in the management and treatment of people who sexually offend?  
A client treated by the second author (David) many years ago serves as an example. This young man entered treatment after an extremely serious sex crime. After nearly two years of treatment, he re-entered the community where he lived safely for one year. He then committed a lesser property crime. It was at that point that he realized what lay ahead in his future if he didn’t make even deeper changes. He lived offense-free as a stable and occupied person for many years thereafter. What can we make of this trajectory? Some would believe that his subsequent arrest is an indication that treatment didn’t work. Others would be encouraged by the fact that the severity of his behavior had decreased significantly. He would be coded as a recidivist in some studies but not those focusing solely on sexual re-offense. We believe his case highlights how a harm reduction perspective can be helpful.
Harm reduction policies and practices build upon the notion that people desist from specific harmful behaviors one step at a time, are guided in that process by professionals and the system is set up in a way that enables positive change. In many respects harm reduction policies are very closely linked to the notion of quaternary prevention (that is, actions taken to protect individuals from interventions that are likely to cause more harm than good). This approach is built on the understanding that behavior change takes time. Harm reduction can be a perspective, approach, or outcome. The key element is that the person in questions stops most damaging behavior and engages in a process of working on their other problematic behaviors systematically. A focus on reducing harm or the most problematic behavior, at the expense of other behaviors, is not an excuse for offending or an apology for it. It is a central part of many criminal-justice approaches (such as with youthful offending), health care (for example, drug addiction) and mental health treatment populations. Yet harm reduction is not fully embraced when it comes to working with people who commit sexual abuse.
In treating addictions, professionals do not expect a heroin addict to stop completely overnight. Instead, they consider intermediate approaches such as Methadone or Suboxone. Likewise, with alcohol abuse we talk about reducing an individual’s daily intake and enabling them to cut down their dependence over time. When it comes to the field of sexual abuse, the expectation placed on those who have abused is that they must recognize and eradicate every aspect of their problematic behavior overnight. In some areas, even minimizing the harm of one’s actions has been enough to deny entry into treatment programs. Keeping people out of treatment doesn’t make them less likely to cause harm.
Practitioners in our profession don’t talk in terms of reducing harm, especially from a policy, political and public view; instead we often talk about complete and immediate harm eradication. This is likely because the narrative surrounding the reduction of harm in regard to people who commit sexual offenses can be (and often is) misconstrued as an absolution for problematic behavior. Harm reduction requires nuanced thinking and practical approaches, and too often flies in the face of our more absolute ideals.
Recalling the earlier example, yes, he still committed an offense and still displayed problematic behaviors. However, the level of harm was reduced substantially. This does not justify his property crime, but history showed it to be a lesser crime on the road to desistance.
It seems worth mentioning that the recent evaluation (2017) of the prison-based Core Sex Offender Treatment Programme in the UK (which ultimately lead to its being abandoned) demonstrated a reduction in harmful behavior by participants. Within the outcomes, it found that there were a group of service users that were reoffending, but not at the same level or in the same fashion that they originally offended. Asking questions about the nature and use of interventions that contributed to de-escalation of these people’s offenses, and the time frames in which they took place would have been helpful.
Likewise, Karl Hanson recently spoke at the ATSA conference about how risk is dynamic. He argued that with the correct support and interventions, risk can drop from high to low over a 20-year period. All of this begs the question, how long does behavior change take and what does the journey look like?




Thursday, March 14, 2019

Author Q&A with Sharon Kelley discussing “How Do Professionals Assess Sexual Recidivism Risk? An Updated Survey of Practices.”

Kelley, S. M., Ambroziak, G., Thornton, D., & Barahal, R. M. (2019). How Do Professionals Assess Sexual Recidivism Risk? An Updated Survey of Practices. Sexual Abuse. Online First
Forensic evaluators may be assisted by comparing their use of instruments with that of their peers. This article reports the results of a 2017 survey of instrument use by forensic evaluators carrying out sexual recidivism risk assessments. Results are compared with a similar survey carried out in 2013. Analysis focuses primarily on adoption of more recently developed instruments and norms, and on assessment of criminogenic needs and protective factors, and secondarily, on exploring factors related to differences in evaluator practice. Findings indicate that most evaluators have now adopted modern actuarial instruments, with the Static-99R and Static-2002R being the most commonly used. Assessment of criminogenic needs is now common, with the STABLE-2007 being the most frequently used instrument. Evaluators are also increasingly likely to consider protective factors. While a majority of evaluators uses actuarial instruments, a substantial minority employs Structured Professional Judgment (SPJ) instruments. Few factors discriminated patterns of instrument use.
Could you talk us through where the idea for the research came from?
Contemporary surveys of practitioners who complete sexual risk assessments are important for researchers, evaluators, and decision-makers. Researchers benefit from staying informed of what methodologies are actually being implemented in practice in order to consider whether additional research or more effective strategies of communicating research results are needed. Decision-makers such as courts need to have objective data to help guide their understanding of what results should be taken under consideration and how much weight it should be given (e.g., admissibility issues). My colleagues and I also noticed that evaluators in different settings/jurisdictions tended to develop their own norms and culture regarding what is considered common risk assessment methodology, but we wondered how that might translate into the larger field. We also found that while other surveys provided useful information, we were interested in factors that had not yet been examined such as use of old versus new static instruments, use of criminogenic needs instruments, and how evaluators chose to communicate the results of such instruments. 
What kinds of challenges did you face throughout the process?
We initially had the idea to conduct a survey in 2013, but we chose to add a few survey questions to a larger study on evaluator decision-making that we were conducting at the time. As a result, the information we obtained was fairly limited. However, the process allowed us to better consider the questions we wanted to know, and we set to work designing an independent research project. Designing survey questions is actually more difficult than it appears. In 2017, we spent a considerable amount of time designing the survey and deliberating on the wording of the questions. Even so, after the data was collected and analyzed we recognized the need for additional questions or how existing questions could have been re-worded to better understand the results. Obtaining participation is also a challenge with online surveys. Getting formal approval to utilize the ATSA-listserv and American Psychology – Law Society (AP-LS) email distribution list was important in achieving our results. However, future surveys will need to get formal approval to reach international forensic professional groups as well.

What do you believe to be the main things that you have learnt about the professional practices in assessing Sexual Recidivism Risk?
Overall, most practitioners are modifying their methodology to keep up with research advances including using newer static and criminogenic needs instruments as well as communicating risk results based on current norms. However, there continues to be practitioners using older static instruments (e.g., RRASOR) as well as outdated norms associated with these instruments. Divergence was notable in how evaluators appear to be choosing the Static-99R normative group (i.e., Routine/Complete vs. High Risk/Needs groups) and their use of a criminogenic needs measure to assess for dynamic risk factors and treatment change. Within the sample, about 22% reported not using a criminogenic needs instrument due to concerns that the research was insufficient to support its use and concerns about the adequacy of the norms. Similarly, of those who reported that measuring treatment gains was relevant to their work, a third did not use a formal instrument to assess for treatment progress. This divergence did not appear clearly related to educational activities, years of experience, and freedom in selecting their own instruments. However, the tendency to only use the Routine/Complete Static-99R norms was associated with evaluators working in private practice regardless of the setting in which they worked (e.g., outpatient vs. forensic commitment).
Now that you’ve published the article, what are some implications for practitioners?
 While we were unable to ascertain why some practitioners continue to use older measures and norms, we did identify concerns related to new measures of dynamic risk and treatment need. Frequent concerns were related to a lack of research demonstrating their validity and reliability, concerns about the instruments’ norms, and the belief that no existing measure can predict a reduction of sexual recidivism due to treatment change. Ultimately, the decision to adopt measures and make changes to one’s methodology will be based on demands of the environment and evaluator standards, and this will be different between jurisdictions and practitioners. Our concern is the possible tendency of overlooking or discounting new research findings and becoming comfortably “stuck” in old practices. As such, we emphasize that a good standard of practice would involve making a priori determinations of what one would need (e.g., research or norms), staying informed of research advances, and then changing methodology once the predetermined criteria are met. Such determinations should also be consistent with professional guidelines (i.e., Section 6.08 of the 2014 ATSA Adult Practice Guidelines). Use of forensic checklists can be important in determining when to start or stop using an instrument. I strongly suggest utilizing a checklist or table to track the pros and cons for each instrument under consideration, and to modify this document over time as research advances. I have provided an example of what I termed an Informed Decision-Making Table, which readers will be able to retrieve by contacting me at 

Thursday, March 7, 2019

Good Intentions or The Proverbial “Road to Hell?”: Trying to Understand the APA guidelines for Men and Boys.

By David S. Prescott, LICSW & Scott D. Miller, Ph.D.
Note: This will also be reposted on Scott’s own blog site as well. Kieran
Several weeks ago, the American Psychological Association (APA) released its latest in a series of practice guidelines for psychologists – this time for “Psychological Practice with Boys and Men.”   Prior years had seen guidelines focused on ethnicity, older adults, girls and women, LGBT, and “transgender and gender-non-conforming” persons.
Curiously, despite claiming to be based on 40 years of research, and the product of 12 years of intensive study, the latest release attracted little attention.  More, the responses that have appeared in print and other media have largely been negative (1, 2, 3, 4, 5). 
What happened?

At first blush, the development and dissemination practice guidelines for psychologists would seem a failsafe proposition.  What possibly could go wrong with providing evidence-based information for improving clinical work?  And yet, time and again, guidelines released by APA end up not just attracting criticism, but deep concern.   Already, for example, a Title IX complaint has been filed against the new guidelines at Harvard.

Consider others released in late 2017 for the treatment of trauma.  Coming in at just over 700 pages ensured few, if any, actual working professionals would read the complete document and supportive appendices.  Beyond length, the way the information was presented–especially the lack of hypertext for cross referencing of the studies cited–seriously compromised any straightforward effort to review and verify evidentiary claims.  Nevertheless, digging into the details revealed a serious problem:  none of the specific approaches “strongly recommended” in the guidelines had been shown by research to be more effective than any other. 

Guidelines are far from benign.  They are meant to shape practice, establishing a “standard of care” -- one that will be used, as the name implies to guide training and treatment.  As such, the stakes are high, potentially life altering for both practitioners and those they serve. 
And so, on reading the latest release from the APA, we wonder about the consequences for men and boys.  Even a superficial reading leaves little to recommend “being male.”  Gone are any references to the historical or current contributions of men -- to their families, communities, marginalized peoples, culture, or civilization.  In their place, are a host of sweeping generalizations often wrapped in copious amounts of politically, progressive jargon on a wide variety of subjects, many of which are the focus of research and debate by serious scientists (e.g., the connection between media violence and male aggression, socialization as a primary cause of gender and behavior, the existence of a singular versus multiple masculine ideal, etc.). 
Cutting to the chase, when viewed in this way, is it any wonder really, that many men – as the document accurately points out – “do not seek help from mental health professionals when they need it?” (p. 1). 
And lest there be any doubt, men as a group, are in need help. 
You’ve likely read the statistics, seen examples in your practice, perhaps in the life of your family or friends.   It starts young, with boys accounting for 90% of discipline problems in schools, and continues to the end of life, with women living 5 to 10 years longer on average.  The “in between” years are not any better, with men significantly more likely to be incarcerated, addicted to drugs, drop and fail out of school, and end their lives by suicide.    
To be clear, the document is not overarchingly negative.  At the same time, if our goal, as a profession, is to reduce stigma -- which previous, and even the present, guidelines do for other groups and non-traditional males -- then the latest release risks perpetuating stereotypes and prejudices of “traditional” men and the people in their orbit.

Sticking to the science of helping, instead of conforming to popular standards of public discourse, would have lead to a very different document – one containing a more nuanced and appreciative understanding of the boys and men who are reluctant to seek our care.  In the fractious times in which we find ourselves, perhaps it’s time for guidelines on how to live and work together, as individuals and as a species.