Thursday, May 30, 2019

Risk Management and Prevention

By Kieran McCartan, David S. Prescott, LICSW & Katherine Gotch, LPC

The field of sexual abuse continues to embrace a prevention narrative and its real-world application. Although the sexual abuse prevention narrative has traditionally focused on the prevention of reoffense (tertiary prevention - see below) or providing broad-based community/societal messages (primary prevention), there has been a focus more recently on the development of services for populations at risk of offending (secondary prevention), as well as considerations regarding the role of effective risk management and safeguarding practices after conviction to ensure our interventions themselves do not cause harm (quaternary prevention).

A major challenge in the prevention of sexual abuse is not in the framing, which is appropriate and fit for purpose, but rather the development of the evidence base and its practical, real-world application. People and policymakers recognize that prevention of abuse is better than after-the-fact responses as prevention results in no more victims. However, prevention also creates complicated (and some would even argue, complicit) narratives around people who commit sexual abuse as prevention efforts are offered from a holistic, life-course perspective. This requires communities, individuals, and policymakers to acknowledge the complexities inherent within the perpetration of sexual abuse, something which is especially difficult within legislative systems which often require black and white solutions to complex problems. Some have also felt that a holistic, life-course perspective is used to justify and explain away sexual abuse, which is not the case at all! Prevention efforts become more effective when they are based in solid knowledge about those who abuse and this information is then incorporated within all levels of prevention. There is more to preventing sexual abuse than tick-box criteria of adverse experiences, past trauma, mental health issues, and poor socialization – effective prevention efforts recognize the impact of contextual factors on the antecedents of sexual abuse and emphasize knowledge about how interventions can be most effective at different points to stop abuse from happening at all levels. It is about incorporating what we now know regarding the aetiology of offending and embracing the importance of recognizing warning signs, talking about problematic behavior and developing healthy lifestyles, including support systems, that lead to effective prevention efforts.

Preventing sexual abuse is also about effective risk management, either by the individual themselves or in conjunction with their families/peers or a third party if needed (e.g., probation, parole, counsellor); however, we do not often frame the prevention of sexual abuse in risk management terms. Risk management is often seen as a punitive, controlling and restrictive standpoint – something that is done to an individual rather than with an individual. However, as research and practice have shown over the years, the effective reduction in reoffending or the curtailing of first-time offending is most successful through a partnership among stakeholders and with buy-in from the individual in question. To this end, we offer that effective risk management neatly sits within the public health prevention framework and should adhere to the socio-ecological model of prevention:

Raise public awareness of the reality of sexual abuse and dispel common myths about victims and preparators. Which enables individuals and communities to be better at identifying sexual abuse, risky behaviors and be better able to support people impacted by sexual abuse. Increased education leads to increased awareness and more proactive behavior.

For instance, public education campaigns, bystander intervention, Eradicating Child Sexual Abuse, etc.
Enabling “at risk” populations to understand their potential risks, triggers and the potential outcomes of them. This means that they can seek appropriate support and be empowered to seek help. Individuals and communities better understand risk and therefore are better able to help people manage their own (potential) risk.

Working with people convicted of sexual offences to hold them accountability for their past problematic behavior, get support and move forward, integrate back into their communities. These interventions move people towards an offense-free lifestyle and encourage desistence. They help people manage their own risk (i.e., treatment programs and interventions).

For instance, treatment programs and interventions for people who have committed sexual abuse, etc.
This enables people to successfully integrate back into the community by protecting people from collateral consequences or risk management policies and practices. This is done through supportive integration programs that help the person who has sexually abused, aid their re-entry and support them pro-actively to negative the range of policies and practices that negate their integration.

For instance, Circles of Support and Accountability (UK, Circles 4 EU, Canada, & USA), etc.

For risk management to work as an effective prevention strategy, it requires a foundation in the socio-ecological model that is complemented with multi-agency and multi-disciplinary collaboration in conjunction with individual involvement. Prevention is the most effective and impactful when all aspects of our knowledge are incorporated into a holistic approach to understanding sexual abuse which includes risk management strategies such as the individual knowing their risk and how to manage that risk both pre and post offending.

Friday, May 24, 2019

Morals Versus Evidence: The Role of Pornography

By David S. Prescott, LICSW, & Kieran McCartan, PhD

It has now been ten years since Drew Kingston, Neil Malamuth, Paul Federoff and Bill Marshall (2009) published a study finding that pornography usage was a risk factor for people who had sexually abused primarily only among those already at high risk and who used pornography frequently. Perhaps most significantly, the authors emphasize that research and practice highlight the importance of individual differences between people when considering the impact of pornography on violence. To date, this is the most authoritative study of its kind on this topic. In addition, these findings have played out with respect to the complexity of individuals who view indecent images of children and whether or not they go on to commit a contact offence (Meridan et al, 2018).

Meanwhile, we are at a loss as to what, if any, impact the extant research has had at the front lines of treating or supervising people who have sexually abused. Pornography is a complicated area, especially in terms of public perception. It has been the focal point of several moral panics over the years and there is a perceived link in the socio-political sphere between viewing and doing in the public’s eyes. This was the case when considering watching hardcore pornography and rape in the 1980’s and now the perceived link between viewing child sexual abuse imagery and committing child sexual abuse here in the 2000’s. The increase in the accessibility and variety of pornographic material since the advent of the internet has led to conversations about its role in the normalization of sexual violence in our communities and the reinforcement of cognitive distortions.

In short, pornography is a problematic and loaded conversation that crisscrosses social norms, stereotypes, vulnerability, and exploitation. Readers of this blog and our other works will know that we are not advocating the use of pornography, although we believe very strongly in evidence-based supervision, assessment, and treatment. Pornography is freely available, via the internet, in modern society and therefore clients will encounter it. Therefore, how we manage their expectations around it with respect to their potential to re-offend is a serious consideration. In the same way that desistence from sexual offending is manageable in prison because of the reality of the institution getting clients to avoid pornography helps them not get aroused by it, but it does help them manage their response to it should they encounter it? We are not saying that all forms of pornography are equal and that it is not harmful, rather we are saying we need to understand its role in the desistence and management process. Therefore, the question that we must ask is how we get individuals to manage their problematic sexual behavior in a way that is safe, exploitation-free and emphasizing no more victims, but is nonetheless relevant to them. Is there a place for ethical, exploitation-free pornography which models pro-social sex and relationships?

Just the same, viewing any kind of sexually explicit media is prohibited in most programs treating people who have sexually abused and is a common prescription in rules of supervision, despite the limited risks in evidence. Meanwhile, some authors have proposed that accessibility to pornography is associated with a decrease in sexual violence. As expressed by Brandt, Prescott, and Wilson in this blog in 2012:

Two additional facts are worthy of consideration. First, both biased and impartial groups have been funding research for more than 50 years to find a connection between pornography and sexual offending, and none have been able to find any definitive link. Second, despite the explosion of sexual media since the advent of the Internet and rapid transfer of visual imagery, there has been no increase in rates of sexual offending—everywhere it has been studied, around the world. Arguably, the same information superhighway that provides access to pornography has also brought attention to the numerous media outlets that remind us that true sexual violence is intolerable.

The case of pornography usage calls into question to what extent our practices are hindered by our own morals, attitudes, and beliefs. Our field demands evidence-based public policies, but are we willing to examine our own processes?

Again, there are many reasons to find pornography offensive. Nonetheless, the question remains: What are the goals of our supervision and treatment? If the answer is to reduce the risk of future crime, then it seems clear that curtailing access to pornography is not an evidence-based intervention. This, in turn, leads to other questions: What really is our goal when we limit the otherwise legal behavior of our clients? Is it wise to apply rules across the board without regard for risk or treatment/supervision need? There is a saying within some criminal justice circles that “It is always easier to say no than to say yes”. Is that really the most effective way forward? Is it possible that we may increase the risk for some clients? For example, by routinely prohibiting access to pornography do clients take on the belief that they are irredeemable or have no right to even normative sexual interests? Do they view all evidence of their sexuality as bad, wrong, or harmful? Do they then return again and again to fantasize about past abusive experiences instead of arguably more healthy scenarios? Once again, it seems that the characteristics of the individual client need to be considered.

Given the historical challenges in defining pornography and legislating its use, perhaps the place to start in understanding the difference between morals and the available evidence is ourselves.

Thursday, May 16, 2019

Learning to Take a Mindful Pause

By Janet DiGiorgio-Miller, Ph.D. & David Prescott, LICSW

Dr. Jon Kabat-Zinn describes mindfulness as a “process of being present in the moment without judgment and with care, concern, and compassion for self and others.” Teachings related to mindfulness have been around for thousands of years and are found in many religions. There have been numerous studies and meta-analyses showing mindfulness meditation to be a helpful adjunct to treatment for many types of physical and psychological issues. Neuroscience has also shown that regular meditation changes the composition of the brain and gives individuals techniques to manage their reactivity to stressful events.

There is emerging research regarding using mindfulness and meditation as a technique to enhance coping skills and reducing impulsivity with individuals involved in the criminal justice system. Gillespie, et. al (2012) found that controlled breathing techniques, which are the foundation to mindful based approaches and mediation could potentially increase prefrontal control over the amygdala thus leading to improved emotional control and sexual self-regulation.  Borders, et al (2009) determined that mindfulness decreased anger, hostility and aggression by decreasing rumination. Samuelson, et al (2007) found that mindful-based stress reduction courses offered in a correctional facility assisted the inmates with a decrease of hostility and an increase of self-esteem. Although this research has been criticized for methodological flaws, Van Dam, et. al. (2018), in self-report measures subjects report a difference in their reactivity to experiences after regular mediation.  

Why should professionals working with people who have abused care? The direct contributions of mindfulness and other forms of meditation described above can also assist clients in being more amenable to participating in treatment and supervision. Improved self-control can further boost client capacity in responding to the services once involved. Each of these aspects aids in programming adhering to the responsivity principle. Finally, there is one point that is often overlooked: Before a person can use cognitive-behavioral interventions to change their thought patterns and behaviors, they must first be able to more fully observe these patterns.  

Inasmuch as they include an explicit focus on examining – even contemplating – internal states and ultimate concerns, approaches such as the Good Lives Model and Motivational Interviewing can dovetail effectively with mindfulness. Likewise, it is not difficult to see how mindfulness can help people who have abused become more empathic. Further, clients practicing mindfulness are better poised to recognize that the tools they need for change exist within them and that they have better control over their thoughts and emotions than they realize. Eventually with practice, clients learn to better regulate themselves and to come to more thoughtful responses to the situations which present themselves. 

Kabat-Zinn, et al (2009) introduced the attitudinal foundations of mindfulness. 
He outlined 9 Principles of Mindfulness:

 Beginner’s Mind
 Letting Go
 Recently two principals were added: Generosity and Gratitude

How can we learn to take a mindful pause ourselves and allow our clients to do the same? There are any number of ways. An excellent first step is simply to take a meditative breath to a count of four in and a count of four out (sighing doesn’t count). In moments of stress, slowing your breath allows the prefrontal cortex to signal the amygdala to relax and in turn slow the body’s response to stress. This breath repeated over time allows the body to relax and thus a mindful space is created. In this mindful space, you can think more clearly about the events occurring and allow alternative explanations for the event, in turn allowing you to respond in a calmer, more deliberate way. While you are in the mindful space it is helpful to remember Dr. Kabat-Zinn’s foundational attitudes. 

As therapists, if we practice the tenets of mindfulness in our own lives, we are more likely to instill hope in our clients’ outlook. When we practice nonjudgement, we can convey to our client a sense of safety in therapy. We can be patient and allow clients to fully discuss their issues in a more reflective way. We can have a beginner’s mind and not expect the same results. We can learn to pause, which is also being patient and give ourselves a “mindful space” to fully examine all of the variables in the therapy not just one theory. We can be kind to ourselves and model this behavior to our clients as they learn to change. We can be generous with our time and thoughts as our clients navigate the road to change. Most importantly we can be grateful and teach our clients the value of gratitude. 

If we practice self-compassion and care for ourselves, we are more able to do this difficult work. As we become more focused on the good around us, we become more optimistic about positive change for our clients. At the same time, we become less attached to the outcomes, knowing we have done our best to facilitate change.

“The stiller you are the calmer life is.” – Rasheed Ogunlaru 

Borders, A., Earleywine, M., & Jajodia, A., (2009) Could Mindfulness Decrease Anger, Hostility, and Aggression by Decreasing Rumination? Aggressive Behavior, 36, 28-44

Gillespie, S., Mitchell, I., Fisher, D., Beech, A. (2012) Treating Disturbed Emotional Regulation in Sexual Offenders: The Potential Applications of Mindful Self-Regulation and Controlled Breathing Techniques. Aggression and Violent Behavior 17, 333-343

Kabat-Zinn, J., & Hanh, T. N. (2009). Full Catastrophe Living: Using the Wisdom of your Body and Mind to Face Stress, Pain, and Illness. Delta.

Van Dam, N. T., van Vugt, M. K., Vago, D. R., Schmalzl, L., Saron, C. D., Olendzki, A., ... & Fox, K. C. (2018). Mind the hype: A critical evaluation and prescriptive agenda for research on mindfulness and meditation. Perspectives on Psychological Science, 13, 36-61.

Thursday, May 9, 2019

Good things are happening in Italy

By Carla Maria Xella, PhD  (CIPM & President of the Scientific Committee of CoNTRAS-TI)

Among European countries, Italy is one of the few lacking any public action regarding the treatment of people who committed or are at risk of committing sexual abuse. In Italy, projects for the treatment of sexual offenders, both in detention and in the community, do exist, but currently, depend on uncoordinated personal initiatives. Consequently, treatment programs are aleatory and insufficient. 

The Public institutions’ approach to the issue of sexual abuse is focused only on punishment. Approximately one month ago, the new Italian Government issued a new so-called Security Bill, increasing the length of sentences for sexual abuse against children from 5-10 years to 6-12 years, and to 14 years for gang rape. Not a word about risk assessment! The translating and validating STATIC-99-R and STABLE plan, approved by the former Government, has been canceled. The new Security Bill does mention “treatment programs for sexual offenders”, but… with no funds established to carry them out!

So, indeed, no treatment is currently provided by law to sex offenders, either in prison or in the community. Sex offenders serve their long sentences restricted in special wards, they are rarely admitted to probation or parole for community management/reintegration. Post-release they have no registry, no treatment, no follow-up. In Italy sexual offense prevention, not to mention recidivism prevention, is non-existent in policy and practice.

If you are wondering what the good news is, the answer is that professional practice is starting to change in Italy, slowly but surely. Several treatment programs are now in place, often with European or private funds, and they follow or try to follow, the best international practices. The common need of the providers of these programs is, anyway, sharing common experiences and practices. In October 2017, a national association, named CoNTRAS-TI (in English: National Coordination of Treatment and Research about Sexual Offending – Italian Experiences, and the acronym can be translated in Pathways to stop it) has been founded. The aim of CoNTRAS-TI is to share research data and best practices among its members and with members of other similar international associations, and to foster collaboration with public Institutions, to promote a climate of sensitivity towards sex offender treatment and reintegration in the community.

Last year CoNTRAS-TI and ATSA have signed their affiliation and I, as the President of the Scientific Committee, had the chance to attend the Board of Directors and the Conference in Vancouver. A precious collaboration has been established, with our ‘elder siblings’ offering us their help to spread scientific evidence about sex offender assessment and treatment.

Building upon the development of CoNSTRAS-TI on May 20th  our first National Conference is taking place in Milan, Italy. The main aim of this first Conference is to promote exchange among those who are concerned with sexual abuse at various levels. The conference will be opened by Fabian M. Saleh, from Harvard University, who will discuss the assessment and treatment of paraphilic disorders in sexual offenders. Col. Antonio Manzi, Carabinieri Force, will speak about the importance of training in scientific risk assessment for those concerned with the safety of the community; Judge Annamaria Gatto (Surveillance Court) will speak about the lack of any system of monitoring and control for high-risk sexual offenders in Italy currently. Most importantly, we will have Gloria Soavi, president of CISMAI (the network of Italian association and stakeholders concerned with child protection against abuse and neglect) speaking as well. Her presence at the Conference can be hardly underestimated: she will highlight the importance of a strong collaboration between professionals who deal with victims and those who deal with perpetrators in the prevention of sexual abuse. Unfortunately, often the services dealing with victims are unwilling to share information and to build a net for taking charge together of complex cases, like family sexual abuses. As a member of the International Committee of ATSA, I will close the morning conference with a review of international approaches to sexual offending.

In the afternoon, two roundtables are planned. The first roundtable will propose some Italian Experience of Research and Treatment regarding Sexual Offending with (1) Andrea Scotti speaking about the C.I.P.M. model of treatment (now ongoing in Milan and in Rome Region); (2) Maura Garombo speaking about the Vercelli Program; Dante Ghezzi (TIAMA) will discuss the issues of youths who sexually abuse; (3) Davide Dettore will explain his model for the treatment of people who sexually offend online; (4) Georgia Zara will speak about the Italian validation and translation of the CID-SO, a tool for denial assessment in sexual offenders developed by Sandy Jung; & (5) Amelia Ciompi (Prison Administration Department) will speak about the need of a review of recidivism rate in Italian sexual offenders, which is lacking at present. The theme of the second roundtable is the public perception of sexual offending, and the participants will be journalists of various Italian newspapers. The roundtable will be moderated by Paolo Giulini, Secretary of CoNTRAS-TI.

The Conference is the first attempt to publically share experiences and research results about sexual offender assessment and treatment, to prevent new offenses and make the society safer.  We hope that spreading scientific information can hopefully lead Public Institutions to listen!

Thursday, May 2, 2019

What Different Research Methodologies Tell Us

By Jeff Sandler, Research Scientist New York State office of Mental Health & ATSA research committee

This is a blog posting by the ATSA research committee. Kieran
A few weeks ago, an entry was posted to the ATSA blog entitled “Hearing the Narrative, Seeing the Person: Considering the Appropriate Research Methodology.” The piece discussed the importance of using various research methodologies to investigate questions surrounding sexual offending and treatments for sexual offending. The central thesis of the piece was that no single research methodology, or style of research, should be used for all studies on topics related to our field. The ATSA Research Committee would like to support the importance of using different research methodologies when studying a topic, but also offers a note of clarification and caution.

The ATSA Research Committee is, not surprisingly, very pro-research. As the blog from a few weeks ago correctly points out, there are many different types of research and research designs: large-sample, small-sample, cross-sectional, longitudinal, experimental, archival, prospective, retrospective, quantitative, qualitative, and many more. Each different type of study allows for different conclusions to be drawn from its results.

The blog from a few weeks ago argued that case studies and qualitative research have an important role to play in the study of sexual offending and the treatment of sexual offending. The Research Committee would like to echo that sentiment. There is no question that case studies and qualitative research play an important role in the research process.

A note of caution needs to be struck, however, about what the results of case studies and small-sample studies can tell us and how the results of such studies can be used. Specifically, the results of case studies and small-sample studies cannot be assumed to generalize to other people or populations.
That is, showing that a particular treatment model or intervention was effective for one, or five, or ten people is just that: A finding that one, or five, or ten people benefitted from a particular treatment model or intervention. It is not an indication that the treatment model or intervention is likely to benefit larger groups of people (particularly groups with different cultural backgrounds or from different geographic settings). To be able to make statements about the likelihood of an intervention being effective with other groups, quantitative, inferential studies are required.

Furthermore, the results of case studies and small-sample studies almost never have confirmatory or disconfirmatory value. That is, the data from such studies, as usually conducted in our field, cannot be used by themselves to either validate or refute a particular belief. Not only is it incorrect to cite a single case or a handful of cases as proof that a certain treatment model or intervention works, but it can also actually be dangerous to do so. This is something that we, who work in the field of sexual offending, have seen firsthand and all too often. Time and again, we have seen legislatures draw up and enact well-intentioned, but ultimately failed, laws based on a single case or a handful of cases. This is how we ended up with public policies such as community notification and residence restrictions that likely would never have been enacted had lawmakers consulted and heeded the findings of empirical quantitative studies.

With so much research being conducted and published these days, it is important to understand what we can and cannot learn from various types of studies. Case studies and qualitative studies are most important in the context of discovery: exploring a new line of inquiry or further understanding the lived experiences of participants. For those purposes, case studies and qualitative studies are invaluable. For clinicians, they offer possible avenues of treatment to explore once all evidence-based treatment options have been exhausted. For researchers, they offer a hypothetical roadmap, indicating places where further quantitative research is both warranted and needed. Case studies and qualitative studies should not be used, however, to assess either the effectiveness of treatment models or interventions that have been shown by quantitative research to be effective or ineffective, or to test a particular theoretical model.
One final cautionary note the Research Committee would like to offer relates to confirmation bias, the tendency to seek out and favorably view research that supports our beliefs and discount research that refutes our beliefs. Confirmation bias is a natural human tendency. We all want to believe that what we believe is correct, that what we are doing is good. As such, it is easy to look for findings that support our convictions and to search for reasons to discount the findings of studies that do not support our beliefs or actions. It is problematic, however, to hold up a case or a handful of cases as evidence that a particular empirical finding is wrong or that the finding does not apply to us and our unique circumstances. Case studies are valuable and can stimulate empirical research studies that researchers can and should conduct, but they are a starting point and cannot replace the findings of rigorous empirical research.
Being evidence-based means being open to the results of all rigorously-conducted research, even research that contradicts our beliefs or tells us that we should be doing things differently. It means being vigilant and explicit about the certainty and uncertainty of our claims, interpretations, conclusions, and recommendations. It means recognizing that although almost all research methodologies can contribute some insight, that does not mean that all research should be considered equal in quality or in the weight given to it. It means recognizing that informed speculation is valuable and necessary to bridge the gap between what has been demonstrated by available evidence and what has not yet been rigorously tested, but that speculation should not be used to circumvent available evidence.

Being evidence-based is tough and occasionally unpleasant. It means being open to the idea that we are wrong, that what we believe is not accurate, and that we should adjust our actions accordingly.