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?