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.