Friday, April 26, 2019

Treatment Options and Outcomes for the Other Recidivism

By Norbert Ralph, PhD, MPH
Please note that this is Part 2 of a 2 part blog, Part 1 can be found here. Kieran

In a recent blog posting (Ralph, 2019) I discussed the "Other Recidivism", that is nonsexual recidivism, for juveniles who sexually offended (JwSO). Caldwell's (2016) meta-analytic study of research since 2000, found low base-rates for sexual recidivism (2.75%) but nonsexual recidivism was 27.25%, 10 times higher. Steinberg, Cauffman, and Monahan (2015) studied 1,300 serious juvenile offenders and found that individuals who psychosocially mature are more likely to desist from criminal behavior. Cauffman, Skeem, Dmitrieva, and Cavanagh (2016) in assessing psychopathy found that increased psychosocial maturity was associated with decreased psychopathy scores in juveniles. Férriz Romeral, Sobral Fernández, and Gómez Fraguela (2018) in their recent meta-analytic study found that lower levels of moral reasoning were associated with juvenile recidivism generally, but a higher effect was found for older adolescents and females.

Methods to promote psychosocial maturity

The above findings are complemented by research providing evidence that specific treatment methods are associated with increasing psychosocial maturity in juvenile probation populations. Moral Reconation Therapy (MRT) promotes moral reasoning for juveniles (Little & Robinson, 1988). Two studies (Burnette, et al., 2003; Burnette, et al., 2004) showed positive changes with youth on probation using MRT, including increases in the level of moral reasoning. Brown (2016) in a more recent study using a sample of 86 offenders in Colorado found that juveniles who completed MRT treatment were 3.89 times less likely to re-offend compared to non-completers. Aggression Replacement Training (ART) (Goldstein, Glick, & Gibbs, 1998) is another treatment method with significant research which promotes prosocial maturity in probation youth. It has modules promoting social skills, moral reasoning, and anger control. Its effectiveness with juveniles on probation has been described in research studies (Goldstein, Nensén, Daleflod, & Kalt, 2005). Amendola and Oliver (2010) note that ART is a "Model Program" for the United States Office of Juvenile Justice and Delinquency Prevention and the United Kingdom Home Office. Also, Ralph (2015a; 2015b) in three studies with ART with JwSO found beneficial outcomes on psychological measures.

A meta-analysis and review of effective practices for juveniles on probation was done by Lipsey (2009). He notes that the most effective methods associated with reduced recidivism for probation youth in rank order are approaches which utilize: 1. Counseling, 2. Skill building, 3. Multiple wrap-around services, 4. Restorative justice methods, and 5. Surveillance (structured probation supervision). The approaches that used counseling and skill building can be characterized as promoting psychosocial maturity. Kettrey & Lipsey (2018) suggested that best practices for treatment of JwSO should include interventions for the general probation population. While treatment in the eight studies reviewed was associated with reduced sexual recidivism, the effect was not statistically significant, although there was a significant treatment effect for decreased general recidivism.
Two studies by the author using a prosocial skills training workbook (Ralph, 2016; Ralph, 2019a) used outcome measures of psychosocial maturity. In both studies, an instrument rating prosocial behaviors of adolescents completed by counselors was used before and after treatment. Total scores for the instrument showed statistically significant gains in prosocial characteristics in both studies. An item analysis showed statistically significant changes in the following areas: 1. Cooperation with adults and rules, 2. Improved emotional control and regulation, 3. Resisting peer pressure, and 4. Planning and thinking ahead.

This brief literature review describes that interventions to promote psychosocial maturity and moral reasoning are associated with desistance from criminal behaviors in juveniles. These treatment methods have been used with JwSO. Interventions to promote psychosocial maturity are cost-effective and can be readily implemented in most programs (Ralph, 2017). These approaches, along with supportive family, school, and neighborhood environments, can likely promote prosocial functioning not only in probation youth generally but JwSO.

Amendola, M., & Oliver, R. (2010). Aggression replacement training stands the test of time. Reclaiming Children and Youth, 19, 47-50.

Brown, B. L. (2016). The Efficacy of Juvenile Moral Reconation Therapy in Gunnison, Colorado. (Doctoral dissertation). Retrieved from , ProQuest Dissertations Publishing, number 10253255.

Burnette, K. D., Swan, E. S., Robinson, K. D., Woods-Robinson, M., & Little, G. L. (2003). Effects of MRT on male juvenile offenders participating in a therapeutic community program. Cognitive-Behavioral Treatment Review,12(2), 2-5.
Burnette, K. D., Swan, E. S., Robinson, K., Woods-Robinson, M., & Little, G. L. (2004). Treating youthful offenders with moral reconation therapy: A recidivism and pre-posttest analysis. Cognitive-Behavioral Treatment Review, 3(4), 14-15.
Caldwell, M. F. (2016). Quantifying the Decline in Juvenile Sexual Recidivism Rates. Psychology, Public Policy, and Law. Advance online publication.
Cauffman, E., Skeem, J., Dmitrieva, J., & Cavanagh, C. (2016). Comparing the stability of psychopathy scores in adolescents versus adults: How often is “fledgling psychopathy” misdiagnosed? Psychology, Public Policy, and Law, 22(1), 77-91. doi:10.1037/law0000078
Férriz Romeral, L., Sobral Fernández, J., & Gómez Fraguela, J. (2018). Moral reasoning in adolescent offenders: A meta-analytic review. Psicothema777, 30(3), 289-294.
Goldstein, A. P., Nensén, R., Daleflod, B., & Kalt, M. (Eds.). (2005). New perspectives on aggression replacement training: Practice, research and application. John Wiley & Sons.
Goldstein, A., Glick, B., & Gibbs, J. (1998). Aggressions replacement training (Rev. Ed.), Champaign, IL: Research Press.
Kettrey, H., & Lipsey, M. (2018). The effects of specialized treatment on the recidivism of juvenile sex offenders: a systematic review and meta-analysis. Journal of Experimental Criminology, 14(3), 1-27.
Lipsey, M. W. (2009). The primary factors that characterize effective interventions with juvenile offenders: A meta-analytic overview. Victims and Offenders, 4, 124-147.
Little, G. L., & Robinson, K. D. (1988). Moral reconation therapy: A systematic step-by-step treatment system for treatment resistant clients. Psychological Reports, 62(1), 135-151.
Ralph, N. (2015a). A follow up study of a prosocial intervention for juveniles who sexually offend. Sex Offender Treatment, 10(1).
Ralph, N. (2015b). A longitudinal study of factors predicting outcomes in a residential program for treating juveniles who sexually offend. Sex Offender Treatment. 10(2).
Ralph, N. (2016). A validation study of a prosocial reasoning intervention for juveniles under probation supervision. Sex Offender Treatment. 11(2).
Ralph, N. (2017). Prosocial Treatment Methods for Juveniles Who Sexually Offended. ATSA Forum, IX (3).
Ralph, N. (2019a). A Replication of a Prosocial Reasoning Intervention for Juveniles. Manuscript submitted for publication.
Ralph, N. (2019b). The Other Recidivism. Manuscript submitted for publication.
Steinberg, L. (2015). Age of opportunity: Lessons from the new science of adolescence. Boston: Mariner Books, Houghton Mifflin Harcourt.
Steinberg, L., Cauffman, E., & Monahan, K. (2015). Psychosocial Maturity and Desistance From Crime in a Sample of Serious Juvenile Offenders. Retrieved February 4, 2019, from

Wednesday, April 17, 2019

The impact of working with sex offenders: how to take care of yourself as a professional working with (sex) offenders?

By Marije Keulen-de Vos, Minne De Boeck & Kasia Uzieblo (Dutch Chapter of ATSA, NL-ATSA)

On March 26th NL-ATSA, the Dutch Chapter of ATSA organized a symposium in Utrecht (the Netherlands) on the impact of working with sex offenders. Colleagues from police and forensic hospital settings addressed the issue of secondary trauma. Secondary or vicarious trauma relates to the behavioral and emotional consequences of exposure to the traumatic events experienced or inflicted by others. These traumatic experiences in professionals may include changes in the professional’s sense of self, interpersonal relationships, and behavior. Individuals working in mental health care are among the occupational groups identified as being at high risk of secondary trauma (Moulden & Firestone, 2007). Nevertheless, there is fairly limited research on this topic, let alone on traumatic experiences in professionals working with sex offenders. 

The first presenter, Henk Sollie (Phd., Twynstra Gudde, the Netherlands), focused on the mental resilience of police offers who investigate cases involving child sexual exploitation material (CSEM). Based on observational studies and semi-structured interviews, he examined what CSEM investigators consider demanding working circumstances and how they cope with these burdens. Henk Sollie’s studies show that many police officers may experience signs and symptoms of vicarious trauma at some point in their career as they often experience great internal and external pressure to cover the overwhelming number of leads that they receive, to substantiate cases, and to save lives. Many of these investigators voice a firm unwillingness to “abandon” the victims by changing work assignments. Also, exposure to disturbing photographs and videos, and intense contact with perpetrators and victims have an enormous impact on their well-being and on their personal life. For example, many remain preoccupied with (old) cases, many experience sexual problems within their own intimate relationship and/or struggle with the enjoyment of physical contact with their children. An important element in being able to deal with the emotional impact of CSEM investigations is mental resilience. Henk Sollie defines resilience as “the outcome of a coping process in which internal and external resources enable a criminal investigator to continue to function throughout stressful situations and to recover from such situations in a sustainable manner while retaining their motivation to carry on with their investigative work”. The stress associated with exposure to such traumatic events as child sexual abuse can be mitigated further by applying adaptive, proactive coping strategies such as compartmentalizing one’s emotional response to the disturbing content, pressure regulation (i.e., workload prioritization), task autonomy and social support. These strategies also depend on organizational resources, for example, joint instead of single case responsibility, classification software and design of the workplace. Henk Sollie concludes that the everyday mental resilience in these officers does not come from rare and special qualities but should be rather considered as the result of the everyday magic of ordinary resources. 

The second presenter, Anneloes Huitema (De Waag, Utrecht, the Netherlands), focused on the prevalence and severity of aggressive incidents in a forensic psychiatric hospital. Her study is part of Nienke Verstegen’s Ph.D. research (Vander Hoevenkliniek, Utrecht, the Netherlands). They have retrospectively analyzed over 3600 aggressive incidents by using the Modified Overt Aggression Scale in both forensic patients who are judged being legally insane and patients who have received forensic mental health care under civil law. Prevalence rates of incidents are substantially higher in the latter group. The latter group is often admitted to the hospital when they experience a crisis situation, which may explain these higher rates. Of all types of incidents (verbal, physical, sexual), verbal transgressions are most common with 2667 reports. Only a minority of incidents, 157 out of 3600 incidents, are characterized by sexual transgressions (e.g., rape, indecent remarks). Also, female patients are responsible for a relatively higher number of incidents than male patients. Remarkably, forensic patients who have committed a sex offense seem to cause less aggressive incidents compared to non-sex offenders. Notwithstanding these interesting findings, it is important to realize that these numbers probably regard an underestimation of the true prevalence of aggressive incidents in the forensic psychiatric hospital. 

In the final two presentations, Nicole Strijbos (de Rooyse Wissel, Venray) and Maarten Hoogslag (Dutch Institute for Psychotrauma) discussed how professionals can stay “healthy” when working with sex offenders. Nicole Strijbos is a member of a peer support and guidance committee in the forensic psychiatric clinic De Rooyse Wissel. This committee offers collegial support when colleagues experience aggressive incidents. In case of an incident, the committee provides immediate care and support and subsequently schedules three meetings with the colleague(s) in question. The first meeting (after 24 to 72 hours after the incident) focuses on structuring information, exploring current symptoms (e.g., poor sleeping, reliving the incident) and providing tools on how to deal with these symptoms. The second meeting is after one to two weeks after the first meeting. The aim of this meeting is to reflect on the situation and to explore possible symptoms of trauma. Four to six weeks after the incident, the third meeting takes place. In this meeting, the processing of and giving meaning to the incident is being addressed. If necessary, colleagues are referred to as a licensed trauma psychologist. The main purpose of this support system is to help those involved regain control and attribute meaning to events. Nicole Strijbos presented real-life case examples and discussed several do’s (e.g., respond to feelings of colleagues, ask open questions) and don’ts (e.g., encourage recovery and try to offer an immediate solution). 

The symposium closed with an interactive workshop. In this workshop, Maarten Hoogslag elaborated on possible self-protective skills for professionals working with (sex) offenders. Two actors were re-enacting real-life therapist-client interactions in which the bounds of the therapist were being overstepped by the client. Throughout the plays, participants were invited to provide input for these reenactments. Hoogslag’s take-home message was to always address the situation at hand, to set clear bounds, and to assess the nature of the aggressive behavior in the patient (i.e., is it personal or not) in order to enable a more efficient and self-protective response to this behavior. 

The fact that this symposium was sold-out, as well as the grateful feedback during and after the event, illustrates that many practitioners are struggling with how to deal with aggressive behavior in (sex) offenders. Opportunities to share best practices and more research to obtain an in-depth understanding of these aggressive behaviors in forensic patients and their impact on the professional’s well-being are clearly highly needed. 

Friday, April 12, 2019

The MASOC/MATSA conference and thoughts on why we do this work

By David S. Prescott, LICSW

The partnership between MASOC and the Massachusetts chapter of ATSA took place last week in Marlborough, MA. Now in its third decade, this conference has become one of the most successful of its kind in the world. This year’s presenters came from as far away as Australia and Sweden. Participants traveled from California and Iceland. Just as significantly, these people were not just coming for the first time; they’re regulars.

It’s hard to describe what makes the MASOC-MATSA experience work so well. Marlborough is not close to Massachusetts’ most desirable destinations. Not only is the hotel not the best in the world; it probably isn’t even the best hotel in Marlborough. Outsiders naturally wonder: what is it that makes the experience so special?

In the end, the MASOC/MATSA conference magic comes down to the people who organize and participate in it. Before his untimely passing a few years ago, MASOC founder and pioneer Steve Bengis was the most outward-facing representative of the conference. He would stand for hours at a spot equidistant from the registration tables, hotel elevators, and walkway to the exhibitors, welcoming one and all. As much as Steve is missed, it is remarkable how the conference organizers, almost all of whom have been around since the beginning, continue to create the same atmosphere. It is one that isn’t just welcoming, but about coming home.

There were numerous offerings this year. Personally, I attended an excellent intensive full-day presentation by Russ Pratt on adolescents and pornography, in which he described his “savvy-consumer” model. It is a framework for how adults can guide youth through the ubiquitous, porn-related dilemmas and controversies that they experience as they grow up. Robert Kinscherff gave an excellent half-day pre-conference workshop on neurobiology, human development, and attachment. Keith Ramsey presented an excellent overview of mindfulness research and application within broader empirically supported frameworks. Perhaps the most dynamic of all was Laurie Guidry’s keynote. Many outside of the Northeastern US don’t know just how highly regarded – and loved – Laurie is. She has been a teacher to many up-and-coming professionals. Her keynote focused on the need for all professionals in our field (as she explained it) to build on the #metoo-movement momentum and break through the reactive noise that pervades efforts to inform public conversation and policy. At her invitation, dozens of people who have survived sexual abuse joined her on stage in solidarity.

In the end, the conference experience always comes down to people. For me, the turning point came in a quiet side conversation with Alissa Ackerman at a large dinner gathering.  We both agreed that after too many months of working at a breakneck pace, we both felt immensely restored simply being together with so many people united in a common cause.

I then returned home only to engage in dialog with others outside of our field. I took part in a social-media discussion about honoring those victimized by abuse and oppression. One person felt that cultivating compassion for those who have caused harm and oppression sends the wrong message to those who have been abused. My point was that the emerging consensus in research is that they are often the same people. In the end, my thinking about our work, refreshed by my colleagues at the MASOC-MATSA conference is that it is time not only to influence the direction of public dialog and policy, but that we can do so by asking the right questions based on our empirical and practical knowledge. For example:

·         Can we reduce oppression and harm by understanding those who cause oppression and harm?
·     To what extent are those who have harmed and oppressed others willing to change? How effectively can we help them if we don’t work to understand and have compassion for them?
·        Are those who harm and oppress ambivalent about their own actions, or at least those actions that are within their awareness?
·         Can we improve our understanding and work by developing compassion for them?
·         How do we reconcile the disparities when those who have harmed and oppressed have themselves experienced harm and oppression?
·   Under what conditions can/should we be compassionate towards those who have harmed or oppressed?
·         Do people who harm and oppress also suffer? 
·       Have those who have harmed and oppressed also experienced harm and oppression as a result of their own actions?
·         Should we not use treatment to (at least partially) address this harm?
·       Are there some types of human being that are simply irredeemable and with whom we shouldn’t use treatment ever? If so, who are they?
·         If we decide that there are some human beings to whom we should not provide treatment, at what point do we begin to throw other humans away or kick the solutions further on down the road into the future?
·        Under what conditions do we begin to view other human beings as unworthy of assistance? Do we then risk creating our own forms of harm and oppression?

Thursday, April 4, 2019

The Other Recidivism.

By Norbert Ralph, PhD, MPH

Please note this is part 1 of a 2-part blog, part 2 will follow over the next couple of weeks. Kieran

In 2001 when I started treating juveniles who sexually offended (JwSO) the focus was on sexual crime and sexual pathologies. This approach was described in publications like Pathways (Kahn, 2001), Steen and Monnette (1989), and Ryan (1999). A paradigm shift was crystallized by Calwell's article (Caldwell, 2016) reporting the average sexual recidivism for JwSO since 2000 as 2.75% and total recidivism as 30%. This implied that for JwSO nonsexual recidivism needed to be addressed, in addition to sexual issues. In this brief blog, I'll address issues related to the "other" recidivism, nonsexual recidivism when treating JwSO, and developmental factors influencing it.

In Canadian data, 17 is the age of highest incidence of those accused of property crimes, and age 13 likewise the age of highest incident of those accused of sexual crimes against children (Statistics Canada, 2016). These ages are "humps" in these curves and crime rates decline significantly after these ages. Steinberg, Cauffman, and Monahan (2015) studied 1,300 serious juvenile offenders for seven years after conviction. Less than 10 percent of the sample could be characterized as chronic offenders. Even for juveniles who were high-frequency offenders at the beginning of the study, the majority stopped offending by age 25. They developed a measure of psychosocial maturity which included impulse and aggression control, consideration of others, future orientation, personal responsibility, and resistance to peer influences which increased through all subgroups through age 25, consistent with current research regarding brain maturity and harmful behaviors (Steinberg, 2015). Less mature individuals were more likely to be persistent offenders, and even high-frequency offenders who psychosocially mature were more likely to desist from criminal behaviors.

Cauffman, Skeem, Dmitrieva, and Cavanagh (2016) studied 202 male juvenile offenders and 134 male adult offenders, all in secure detention facilities using versions of the Hare Psychopathy Checklist. A measure of psychosocial maturity was also used. They found that there was a greater risk of exaggerating psychopathic traits with juveniles compared to adults. They noted that 37% of juveniles who met the cut score for psychopathy continued to meet this criterion two years later compared to 53% of adults. False positive errors appeared to be more common among the youngest and least psychosocially mature juveniles. Increased psychosocial maturity, in turn, predicted decreased psychopathy scores in adolescents but not adults. Férriz Romeral, Sobral Fernández, and Gómez Fraguela (2018) conducted a meta-analytic analysis of 72 studies regarding the relationship between moral reasoning and juvenile criminal behavior. They found a moderate positive effect size (d=.662) which was larger for older adolescents and females.

The above review suggests that the "other" recidivism to be targeted for assessment and intervention with JwSO is nonsexual recidivism which in the Caldwell (2016) study was 10 times the rate of sexual recidivism (27.25% vs 2.75%). A variety of instruments exist for the assessing of the nonsexual recidivism with significant research including the Structured Assessment of Violence Risk for Youth and the Youth Level of Service/Case Management Inventory (Vincent, Drawbridge, & Davis, 2019). Also Férriz Romeral, Sobral Fernández, and Gómez Fraguela (2018) reviewed methods for assessing moral development, one component of psychosocial maturity.


Caldwell, M. F. (2016). Quantifying the Decline in Juvenile Sexual Recidivism Rates. Psychology, Public Policy, and Law. Advance online publication.

Cauffman, E., Skeem, J., Dmitrieva, J., & Cavanagh, C. (2016). Comparing the stability of psychopathy scores in adolescents versus adults: How often is “fledgling psychopathy” misdiagnosed? Psychology, Public Policy, and Law, 22(1), 77-91. doi:10.1037/law0000078

Férriz Romeral, L., Sobral Fernández, J., & Gómez Fraguela, J. (2018). Moral reasoning in adolescent offenders: A meta-analytic review. Psicothema777, 30(3), 289-294.

Kahn, T.J. (2001). Pathways: A guided workbook for youth beginning treatment (3rd Ed.). Brandon, VT: Safer Society Press.

Ryan, G. (1999). Treatment Of Sexually Abusive Youth. Journal of Interpersonal Violence, 14(4), 422-436. Doi:10.1177/088626099014004005

Statistics Canada. (2016, May 10). Young adult offenders in Canada, 2014. Retrieved from

Steen, C., & Monnette, B. (1989). Treating adolescent sex offenders in the community. Springfield, IL: Charles C. Thomas Publisher.

Steinberg, L. (2015). Age of opportunity: Lessons from the new science of adolescence. Boston: Mariner Books, Houghton Mifflin Harcourt.

Steinberg, L., Cauffman, E., & Monahan, K. (2015). Psychosocial Maturity and Desistance From Crime in a Sample of Serious Juvenile Offenders. Retrieved February 4, 2019, from

Vincent, M., Drowbridge, D., & Davis, M. The Validity of Risk Assessment Instruments for Transition-Age Youth. Journal of Consulting and Clinical Psychology, 87, 171-18