Wednesday, March 25, 2020

Self-care in self-isolation: The social, mental, physical and spiritual dimensions.

By Andrew J. R. Harris, ATSA Member

“Physician, heal thyself” (King James Version, Luke, 4:23)

Newly incarcerated people are occasionally referred to the psychologist for depression and despair after being locked away in a very small cell for what must seem like forever.  And now, thanks to COVID-19, my wife Tracey and I are on day 7 of a 14-day quarantine after international air travel.  Our home is nothing like a jail cell, but it may be time to take a bit of my own medicine. 

When working with a person new to jail, I ask them what is truly important to them, deep down, to the person they are.  This discussion almost invariably reveals four concepts integral to who we are: social connection, physical health, mental stimulation, and spiritual connection.  Psychologists and other care providers tell the incarcerated that being in jail does not mean the end of their relationship with family, friends, or indeed the world, but that it will take extra effort to maintain these connections.  In jail, this usually means writing snail-mail letters and scheduling scarce, critical phone calls.  Here in the new COVID-19 universe Tracey and I have been calling friends and family more often just for a chat and to check-in.  Also, we have been taking advantage of social-media platforms and some amazing new free programs and apps that allow video conferencing.  When working in jail, we encourage the person to take advantage of exercise time in the yard and not to lie on their bunks through their exercise time.  Fresh air is restorative.  Tracey and I have upped our outdoor walks and are making use of some in-home exercise equipment.  While options are admittedly limited during the initial days of incarceration, mental activity and growth can be maintained most easily by reading.  For us, it is tempting to spend the evening Netflixing.  Tracey is painting and we are both trying to get more practice on our musical instruments.  We have the most difficulty interpreting the fourth concept, the spiritual.  Despite starting this note with a biblical quotation, traditional spiritual connection is not top of mind for us, realizing that spiritual connection and religious observance form a major life support for many people.  In jail, religious texts are available, and I frequently recommend a visit from a spiritual leader or tribal elder.  Under the present circumstances, an online church service or a pastoral phone conversation may provide comfort.  For the two of us, this need is filled by maintaining close connections with family and friends of long standing who truly form our sustaining community.  At home we godless heathens survive on stand-up comedy specials (Billy Connelly videos lighten the load) but, admit this may reflect the vacuous nature of our all-too mortal souls.  Very recently a close friend reminded me that much like the new inmate sitting alone in his cell, those of us in home isolation cannot control the impact of COVID-19 – but we can control our response to it. 

Wednesday, March 18, 2020

Love in the time of COVID?

By David S. Prescott, LICSW, & Kieran McCartan, Ph.D.

Please note that this is a joint blog with NOTA blog site, take care, Kieran & David.

Like everyone else, we’ve had our share of worries and concerns as we enter the rising side of the COVID-19 curve. Canceled trainings, travel, and classes, ensuring the safety and wellbeing of loved ones have shaped the lives of many for a long time to come. For many of us, it’s the state of not knowing that is the most frustrating. On the other hand, there are some areas of good news, such as indications of decline in some areas, and medical advances in others. And proving the axiom that “Alone I travel faster; together we travel further”, the word “caremongering” has entered our lexicon.

At this writing, numerous state chapters of ATSA, regional branches of NOTA (NOTA Scotland) and ANZATSA has had to cancel or postpone its conferences, workshops, seminars, and training.. Ditto with the otherwise seemingly indestructible NAPN conferences. Many trainers are taking to web-based and videoconferencing technologies, where the questions of the day involve the best ways to break participants up into small group discussions and paired practice exercises. Everywhere we look, discussions abound about how to balance the needs and rights of our clients with our own obligations for self-care and safety. These discussions have ranged from how many clients in group therapy in some areas to whether or not clinicians can work with videoconferencing platforms and which methods adhere to confidentiality laws. Additionally, these discussions raise questions of access to online technology, which can be a challenge to some of our clients because of the conditions to their license conditions, the speed of internet in certain areas and whether professionals can work from home (i.e., access to encrypted networks and client reports).

One opportunity that we all have in these uncertain times is to work on our messaging. As the world talks about “social distancing”, we are painfully aware of the elements of social isolation that have long been recognized as a risk factor for offending and re-offending. Professionals in our field find themselves in a subtle bind: Social isolation is a risk factor in some respects, and yet social distance is a protective factor in others. How do we ensure that we don’t approach clients as if they are one more surface to sanitize?

Maybe it’s time to move beyond focusing on the construct of social distance and turn our message in other directions. Instead, we might think of this in terms of promoting “physical distance and safety” and “creating a healthy space”. From a prevention perspective, social distance can facilitate abuse and create the conditions where people at risk of committing an offense, whether for the first time or as part of an ongoing pattern may be more likely to do so. For this reason, we should also think of increased social isolation as an opportunity for us to intervene and talk about prevention.

Of course, creating and transmitting healthy and safe spaces can begin with maintaining a positive and hopeful attitude (which itself is a protective factor against illness) and with being careful with media coverage. In some ways, the rapidly escalating strong emotions inspired by media coverage may be a bigger risk factor for negative outcomes all around. As one comedian observed, “If I don’t watch the news, I’m uninformed. If I do watch it, I’m misinformed.”

The messaging from leaders is also a lesson for all in our field and provides an opportunity to reflect on what messages our clients and colleagues get from us. One world leader has already tried to monetize the eventual vaccine. Another has blithely reminded us that many of our loved ones will die. Yet another, from Ireland — a country that knows about staring directly into the eyes of violence, starvation, and despair— reminded his country that “Together we can save lives.” This last example gives us an opportunity to reframe our message to our clients, ourselves, and each other: at the very least, we’re all in this together. That’s one small step we can take to reduce social isolation.

Finally, there is one small message that we can remind ourselves about providing excellent assessments and treatments to people who have abused. For years, our field has grappled with providing the best evidence-based services, while implementation science has reminded us that optimizing service delivery can take years. Every time we’ve thought about the importance of implementing best practices, we’ve also thought about how long it takes to implement even the most basic of safety interventions, such as handwashing and seat belt usage. One silver lining to the Coronavirus crisis is that at least handwashing is up. As with reducing sexual violence, simply getting people to talk about the issues and forge a way forward can change lives for the better.

Many organizations have offered advice for professionals in this field;

British Association for Counselling and Psychotherapy:

Friday, March 13, 2020

Public & Policy engagement: A one-page overview on juveniles who have sexually offended

By Norbert Ralph, PhD, MPH

In consultations to probation officers, attorneys, judges, and mental health colleagues, I often find that many have no prior clinical or research background regarding these youth. However, these professionals are often in the role of having to make decisions regarding youth who have offended, decisions that have consequences both for public safety and the youth's future.

I've tried a variety of methods to provide relevant information including providing articles and presentations. Most recently I found the most useful method that seems to make a difference is to provide these individuals with a one-page handout regarding basic information. I am offering it here with the hope that others might find it useful. Its goal is to provide basic facts for decision-makers. The information included is reasonably "fact checked" and relevant references are noted. Although the handout is evidence-based, it reflects my own analysis of the literature. Others might develop different models and I would encourage that. The advantages of having a one-page handout that will be actually read, are counterbalanced with not having a more extensive discussion of the literature, including methodological limitations, considerations of cost and practicality, and competing models and theories, and this would be a limitation of the present method.


Juveniles who Sexually Offended (JwSO)

The most recent research on sexual recidivism for JwSO is encouragingly low, at about 3%. Of course, recidivism causes significant harm to victims, and so each case should be considered individually. The total recidivism for these youth is estimated to be 30%, which includes nonsexual crimes (Caldwell, 2016).
The peak age of persons accused of sexual offenses against children is age 13, a rate of almost 120/100,000 in the population, which drops off rapidly at 18 by about half (Statistics Canada, 2014). Dr. Barbara Bonner, Director of the National Center on Child Abuse and Neglect, describes early adolescence as a "high risk transitory period for sexual offending", and most JwSO can be treated successfully in the community (Bonner, 2012). It is this concept of offending being transitory that often gets lost in discussions of supervision and treatment.

Risk factors for recidivism in one research include being a victim of physical or sexual abuse, special education status, multiple victims, crimes committed in public places, and prior juvenile convictions of any type (Epperson, Ralston, Fowers, DeWitt, & Gore, 2006). Denial of the sexual offense at the beginning of treatment does not predict outcome or recidivism (Langton, et al, 2008). Factors which promote positive treatment outcome for juveniles who sexually offended are similar to those for the general probation population which include counseling methods that promote social problem-solving and skill building, rigorous probation supervision, and wraparound services (Lipsey, 2009; Kettrey & Lipsey, 2018).

Delays in social judgment and impulse control are an important risk factor for sexual offending for adolescents which can be remediated which is associated with positive outcomes (Ralph, 2019). Important elements of treatment include a review of specific sexual charges with the family, a Safety Plan, skill building to promote social problem-solving, what consent means in sexual relations and relevant laws, healthy sexual relationships, risk factors for the instant offense, developing a relapse prevention plan, and a plan for healthy prosocial relationships. Regular involvement and appropriate counseling of parents is essential. Dr. Bonner has a free guidebook for parents/caregivers of youth who sexually offended, Taking Action (Bonner, 2009). For a given youth, there is no evidence residential or secure placement compared to community placement promotes better outcomes (Lipsey, 2009).


Bonner, B. (2009). Taking Action (Adolescents) - PDF Download. [online] Safer Society Press. Available at: [Accessed 8 Mar. 2020].

Bonner, B. (2012, November 01). Don’t Shoot: We’re Your Children. What We Know about Children and Adolescents with Sexual Behavior Problems. Retrieved February 20, 2017, from Boy Scouts of America,

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

Epperson, D., Ralston, C., Fowers, D., DeWitt, J., & Gore, K. (2006). Actuarial risk
assessment with juveniles who sexually offend: Development of the Juvenile Sexual Offense
Recidivism Risk Assessment Tool-II (JSORRAT-II). In D. Prescott (Ed.), Risk assessment of youth who have sexually abused (pp. 118 169). Oklahoma City, OK: Wood N Barnes.

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.

Langton, C. M., Barbaree, H. E., Harkins, L., Arenovich, T., McNamee, J., Peacock, E. J., Dalton, A., Hansen, K. T., Luong, D., & Marcon, H. (2008). Denial and minimization among sexual offenders: Posttreatment presentation and association with sexual recidivism. Criminal Justice and Behavior, 35(1), 69–98.

Lipsey, M. W. (2009). The primary factors that characterize effective interventions with juvenile offenders: A meta-analytic overview. Victims and Offenders, 4, 124-147. 23.

Ralph, N. (2019). Treatment Options and Outcomes for the Other Recidivism. Sexual Abuse Blog, April 26, 2019,

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


Thursday, March 5, 2020

Epidemiological Criminology as a means to understand sexual offending

By Kieran Mccartan, PhD, & David Prescott, LICSW

In recent years, professionals, researchers, and other interested people have made a slow but certain shift towards understanding sexual offending as a public health issue as well as a criminological and psychological challenge. This understanding has led to conversations about the role of the developmental, psychological, social, and behavioural histories of people who commit sexual abuse as precursors to abuse. Those discussions have in turn linked to understanding and implementing adverse childhood experiences, trauma informed care, strengthens based approaches, and other elements of rehabilitation and desistance at the levels of research, theory, and practice. In the UK we are seeing a close joining together of Public Health England, The NHS, and Ministry of Justice to discuss the prevention of, and response to, serious violence. Prevention of sexual and other serious forms of violence and abuse, is gaining momentum and we are now talking about primary, secondary and tertiary prevention more in a criminal justice frame than ever before; although, we still have a way to go with quaternary prevention (which is the harmful effects of overmedicalisation on patients health, or  in criminal justice terms how overly putative criminal justice responses prevent desistence and facilitate reconviction). However, despite all this movement, the vast majority of public dialog is  about responding to individual cases and people, not at a population level.

An emerging part of criminology, which has always been a multidisciplinary endeavor by its very nature, is Epidemiological Criminology (abbreviated as EpiCrim) (Waltermaurer & Akers, 2014). Epidemiology is a subdivision of public health and it focuses on health, and health-related issues, at a population level. Ultimately it is a methodology for understanding the health of a population and how this relates to individual members of said population. EpiCrim is defined as:

“the explicit merging of epidemiological and criminal justice theory, methods and practice. Consequently, it draws from both criminology and public health for its epistemological foundation. As such, EpiCrim involves the study of anything that affects the health of a society, be it: crime, flu epidemics, global warming, human trafficking, substance abuse, terrorism or HIV/AIDS.” (Lanier, 2014)

At its core, EpiCrim is about how different disciplines can come together to explain the intersection of crime and heath, and therefore it has relevance for the prevention of crime, the response to crime and the management of people who have committed crimes (especially via prison, probation/parole and social care). So how does this translate into sexual offending and sexual abuse?

The international growth in sexual abuse prevention research and practice over the past 10 years or so speaks to the relevance of EpiCrim for our field. Sexual offending, especially in westernized, anglophone countries, is becoming rooted in a in a health and justice frame. This is clear evidence of EpiCrim in action! It is now possible to discuss the societal and individual correlates of sexual offending and the contributions of health, psychology and behavior to them. Sexual abuse research has a number of methodological approaches that link marco and micro-level data about sexual abuse together. Currently, our field is also starting to see more calls for research and funding streams linked to this intersection of health and justice, both in terms of first-time prevention and treatment/relapse prevention. Research already exists, at a theoretical level, that ties Child Sexual abuse to EpiCrim principles (Skvortsova, 2013). This indicates that EpiCrim fits a theoretical gap in the field of child sexual abuse that existing theories have not bridged because it brings together behavioral, individual and societal elements. It therefore links the individual to society. Many would argue that EpiCrim acts as an umbrella for all three of the main stages of prevention (primary, secondary and tertiary). We would argue that it also includes quaternary prevention. EpiCrim acts, therefore, as a box to house research and practice into the developmental, social, health and psychological correlates of sexual offending in a way that can be used use in a cross-disciplinary fashion. As Lanier (2014) states, EpiCrim means that we have a common point of reference and a shared lexicon across social care and justice for thinking about crime; however, we in criminal justice related fields need to learn how to convey that message to the population in a constructive, easy to navigate fashion.

Thursday, February 20, 2020

Experiencing and coping with the “sex offender” label: An international challenge - Can we handle what our clients have to say about it?

By Ingeborg Jenssen Sandbukt, David Prescott, LICSW, & Kieran McCartan, PhD.

Please note that this blog is longer than normal but we felt that breaking the blog into two would have been artificial and would have broken up the flow of the piece. Kieran

The first author (Ingeborg) recently completed a thesis that studied the concerns expressed by individuals convicted of sexual offenses. It examined their experiences with stigma, both in prison and post-release, in Norway. The study is based on qualitative interviews with eight adult men, all convicted of at least one sex offense. The eight men interviewed were relatively recently released from prison, and most were still subject to terms and conditions set by the Norwegian Correctional Services. Five had been sentenced to regular prison sentences, two had been sentenced to preventive detention, and one had been given a community sentence in addition to imprisonment.

These men’s experiences in prison involved hearing about and witnessing violence and threats towards other persons convicted of sex offenses. A few of the men had been bullied themselves by other prisoners. Internationally, these experiences are not unusual for people incarcerated for sexual offenses. Some of the men were advised by prison staff to come up with a believable cover story to avoid negative sanctions from other prisoners. In some cases, these men told others that they had been convicted for various petty crimes. In one case, a man had been advised by a prison officer to simply state that he had ben convicted of fraud involving welfare benefits. Not surprisingly, most participants did their best not to be recognized as a “sex offender” in prison, although some could not avoid the label. However, the all the men who took part in the research were all highly aware that they were unwanted and seen as outcasts by the prison community, never mind the general society outside of prison, which reemphasizes the stigma that sexual offending elicits in society.  

The experiences that these men had in prison are relevant to their post-release use of coping strategies. The results highlighted that the strategies used in most cases were a reaction to and a result of others’ perceived attitudes towards people convicted of sex offenses as a group. The strategies were not the result of a proactive desistence strategy.

Informants in this study experienced high levels of stress linked to being recognized as someone who had committed a sexual offense, even after release. In many ways they limited their own life opportunities as a result of trying to cope with the threats they perceived. The reasons for these responses are easy to understand. In prison they learned that their offenses would not be forgiven. They were told to lie to stay safe. After release, their families and friends cut them off. Courtesy stigma and episodes of informal notification by others of their crimes led them to believe that there was no chance of redemption. Finally, through the media, they learned that others with similar histories as themselves were considered monsters. As a result, and as a group, informants in this study withdrew and isolated more, and their self-images were in some cases affected negatively.

This study reflects broader research in the field internationally, with many participants experiencing broken bonds with family and friends and a negative portrayal in the media. Further, they have seen how they are considered to be “monsters” in public discourses, with the associated perception that they are always going to be a threat. This is very relevant to post-release experiences in Norway, as media accounts are widespread, and the country has a comparatively small population and a deep sense of community that binds people together. Therefore, media discourses feed into wider stigma.

These media processes and resulting stigma are especially important because Norway is often seen as exceptional when it comes to post-release reintegration and inclusiveness. These findings challenge this belief. Norway does not have official registration and disclosure policies for people convicted of a sexual offense, but the nature of the offense was enough to create an informal, persistent label that the men could not escape. In light of this, Ingeborg’s research examined participants’ perspectives of the way that they were perceived and labelled focusing on how it impacted their self-image and capacity to desist as well as integrate back into the community. The research found that some participants presented their futures with hope and enthusiasm, while others seemed somewhat hopeless. The men described how their status as a person convicted of sexual offenses did, and could possibly, limit their opportunities to live the life they wanted post release.

The recidivism rates for this group of offenders are low* in Norway, as in the rest of the world. The challenge is that research consistently finds that one of the greatest contributors to desistance is strong social bonds and pro-social networks, but the way that these men are labelled and viewed in society breaks these bonds and, therefore, makes reoffending more likely. What the participants wanted was to be able to be open about their conviction and treated like any other citizen even though they had once committed a sexual offense. Their stories indicate that there is a need to review the idea of the inclusive Norwegian society, concerning this topic.

What is the international relevance of these findings from Norway? These findings add to what has been known from earlier studies (Levenson, Prescott, & Jumper, 2014; McCartan, Harris, & Prescott, 2019). Namely, that understanding the service user perspective is central to public safety as well as successful treatment and integration back into the community. Perhaps the most puzzling aspect of studying the service user’s voice regarding their treatment experience is how little study has taken place. Why? How is it that programs don’t consider feedback? What gets in the way?

First, remember that understanding client experiences and client satisfaction is not the same as monitoring outcomes or checking in on the working alliance. Ensuring that clients are generally happy with services is not the same as ensuring that those services are working, even though the latter is unlikely without the former. It’s important to consider every angle of the experience in order to produce services that effectively build community safety.

Second, the working alliance is about more than just the relationship; this has been found to be important in community supervision efforts as well as treatment. The working alliance involves building agreement on the goals of rehabilitative efforts (which itself can require a wide array of interpersonal skills). It also requires agreement on the tasks of treatment and agreement on who the therapist is in the life of the client. Finally, the alliance involves delivering treatment, supervision and support in a manner that fits with the strong personal and cultural values of the client.

Third, the vast majority of research into the treatment of people convicted of sexual offenses is about the model used and its impact in reducing re-offending, and not about behavior change or harm reduction; both are helpful key performance indicators in treatment.

Fourthly, and perhaps the biggest barrier to honoring the service user’s voice, is the belief of agencies and individual clinicians that they are already doing it. It can be easy for professionals to assume that they understand each client’s internal experience of treatment and to form further assumptions and plans for treatment accordingly. Unfortunately, research from within our field (Beech & Fordham, 1997 ) and outside it (Bertolino & Miller, 2013) finds that therapists typically overestimate their effectiveness. This can become a bitter pill to swallow, especially when so many forms of psychological approaches already come with an implicit assumption that treatment is something we do to our clients rather than with them or on their behalf.

Finally, it is worth noting that if we are truly to help efforts at public safety, it makes perfect sense to study those who experience our interventions the most. As research indicates, they are often the ones most motivated to make treatment work.

* In a Nordic study of recidivism (Graunbøl et al., 2010), 3% of individuals convicted of sexual offenses in Norway recidivated within 2 years after release from prison, none of them into new sex crimes. Longer follow-up periods naturally provide higher recidivism rates, as indicated by a 5-year sexual recidivism rate of 8% in Norway (Grünfeld et al., 1998).


Beech, A. R. & Fordham, A. S. 1997. Therapeutic climate of sexual offender treatment programs. Sexual Abuse:  A Journal of Research and Treatment 9: 219–237.
Bertolino, B. & Miller, S.D. (Eds.) (2013). The ICCE Feedback Informed Treatment Manuals (6 Volumes).  ICCE: Chicago, Illinois.
Graunbøl, H.M., et al. (2010). RETUR En nordisk undersøgelse av recidiv blandt klienter i kriminalforsorgen.

Grünfeld, B., Noreik, K., & Sivertsen, E.A. (1998). Straffedømte sedelighetsovergripere. Hvor stor er tilbakefallsrisikoen? Tidsskrift for Den norske lægeforening, 118(1), 63-66.
Levenson, J.S., Prescott, D.S., & Jumper, S. (2014).  A consumer satisfaction survey of civilly committed sex offenders in Illinois. International Journal of Offender Therapy and Comparative Criminology, 58, 474-495.

McCartan, K.F., Harris, D.A., & Prescott, D.S. (2019). Seen and not heard: The service user’s experience through the justice system of individuals convicted of sexual offenses. International Journal of Offender Therapy and Comparative Criminology, 1-17.  doi: 10.1177/0306624X19851671.

Friday, February 14, 2020

At the crossroads 2.0: Future directions in sex offender treatment and assessment

By Kasia Uzieblo, PhD, Minne De Boeck, PhD, & Kieran McCartan, PhD

NL-ATSA (the chapter of ATSA based in the Netherlands and Belgium), the University Forensic Centre) (UFC) and the University of Antwerp organized the second edition of the conference “At the Crossroads: Future directions in sex offender treatment and assessment” in Antwerp, Belgium. The second edition took place from the 6th – 7thFebruary in Antwerp, following on from two days of pre-conference sessions focused on treatment and risk assessment. The conference was a real mix of research, practice, and policy with approximately 250 participants from the Netherlands, Belgium, Germany, Slovenia, Spain, Iceland, USA, Canada, and UK; in addition Zuhal Demir, Flemish Minister of Justice and Enforcement, opened the conference and attended the first session on the first day. In this blog we are going to take you on a whistle-stop tour of the event.

The conference had 2 pre-conference sessions, which were separate from but connected to the main conference, on Static-Stable-Acute training (Wineke Smid, Minne De Boeck and Kasia Uzieblo) and how to effectively apply Risk-Need-Responsivity principles to treatment (Sandy Jung). The first day of the conference was all keynote sessions, which included, Maia Christopher (ATSA) on working with victims organization to co-create effective public policy;  Erick Janssen (KULeuven) on the relationship between arousal and emotions on decision making in risky sexual behaviors and/or sexual offences; Georgia Winters (Fairleigh Dickson University) on sexual grooming behaviour; Ross Bartels (University of Lincoln) on the sexual fantasies and their role, or not, in sexual offending; and Nicholas Blagden (Nottingham Trent University) in the importance of the rehabilitative climate and how prison can be a place for therapeutic change. The second day the conference had started out with two back to back workshop sessions: There were 5 sessions and they were repeated twice which enabled the attendees to get the most out of the conference. The workshop sessions were more practice-based and focused on online sexual offences (Hannah Merdian, University of Lincoln), risk communication (Daniel Murrie, University of Virginia), case formulation incorporating risk assessment (Leam Craig, Forensic Psychology Practice, LTD), sibling sexual abuse (Peter Yates, Edinburgh Napier University) and professional self-care (Joanna Clarke, Petros People). The second half of the second day focused on keynotes from, Klaus Vanhoutte (Payoke) talking about human trafficking, sexual exploitation and how the “lover boy method” could be used to understand this process;  Eric Beauregard (Simon Frasier University) on research and practice into serial sexual homicide and what that means for practitioners; desistance from online sexual offending (Hannah Merdian, University of Lincoln); and how we move on from the crossroads in terms of using evidence in policymaking (Kieran McCartan, University of the West of England). On the second day, like the first, there were about 10 poster presentations during lunch (21 in total) that highlighted the breadth and depth of research in the Netherland, Belgium, Germany and UK on sexual abuse, including, research on BDSM, Minor Attracted Persons, Stop it Now!, COSA & Circles Europe, and desistance.

The NL-ATSA conference really highlighted the diversity of sexual abuse and how wide, although interconnected, the field is. The multi-day conference connected all the domains from theory to treatment with each other. Current trends and lesser-known phenomena were also cited. For if we don’t understand sex and sexuality in everyday life, how can we tell normal/accepted sexual practices from “deviant”/non-normal ones? How can we understand the way that the public, as well as policymaker, attitudes to sex and sexual abuse are formed, and therefore how they impact real-world responses to sexual abuse? If we do not know the difference between fantasying and doing, or viewing and doing, how can we present first time offending or recidivism? If we do not know how people groom, offend or behave, how can we prevent or respond to sexual abuse? This also means that we must hear the client as the service user and recognize professional experience and knowledge to frame best practice. So that we can build rehabilitative climates that are fit for purpose, help treat people and stop burn out in staff. Therefore, we must recognize that rehabilitation is possible and that desistance can happen. The evidence base in sexual abuse is often varied, but we do know that treatment/interventions are more effective than doing nothing. Do we acknowledge that enough? And how do professionals and researchers convey that to the public and policymakers? This conference highlighted and incorporated all these points. Yes, we are at a crossroads and we have been there for a time, but we need to go forward not back. We go forward together united in a multi-disciplinary, multi-agency way and by connecting all the different subdomains within our field. The conference reinforced the importance of international collaboration, conversation, and research.

Wednesday, February 5, 2020

Moral Injury and Radical Hope: Part 2

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

Note: This is part 2 of a 2-part blog, Part 1 can be found here. Kieran

One problem with working individually to combat moral injury is that we very often do it on our own and in isolation. Our field is now rife with discussion about self-care (and we note, to some degree, unfortunately, that our blog on self-care was among the most read and shared blogs of 2019). An aspect of our work that we only rarely discuss is hope and how we keep hope alive.

In 1999, the late Rick Snyder produced an excellent chapter on hope in which he broke it down into two components. The first, “agency thinking” refers to the awareness that a goal is possible. The second is “pathways thinking”, which involves an awareness of how to achieve a goal. It can be enormously helpful to break hope down into these components to see where we, as individuals, may best become more helpful to our clients, colleagues, and selves. In our field, there has been only one article and a book chapter, both well over ten years old, published on the topic of hope in treatment. Nothing has been written on how professionals can remain hopeful about their work.

The case example discussed in part 1 calls to mind that hope at the individual level may not be enough. Even if we practice excellent self-care and keep hope alive for ourselves, how do we best work together as teams to remain engaged in improving the systems that often seem to do their best to spread fear, anxiety, and moral injuries?

Another recent article may begin to yield clues about possible ways forward. Della Mosley and her colleagues recently published on the topic of “radical hope”. Mosley er al's specific focus is in the direction of community-based hope for marginalized groups, but may yield insights into how professionals in our field might also become more effective (as well as more culturally safe, humble, and competent). Mosley and her colleagues introduce radical hope as:

“A culturally relevant psychological framework of radical hope, which includes the components of collective memory as well as faith and agency. Both components require an orientation to one of four directions including individual orientation, collective orientation, past orientation, and future orientation.”

The authors go on to describe how their framework also “consists of pathways individuals can follow to experience radical hope including (a) understanding the history of oppression along with the actions of resistance taken to transform these conditions, (b) embracing ancestral pride, (c) envisioning equitable possibilities, and (d) creating meaning and purpose in life by adopting an orientation to social justice.” These pathways can inform how professionals think about the hope within the work of treating sexual aggression.

We acknowledge that the focus of Mosley’s article is  directed toward marginalized people (in this case, people of color) and not simply those who often work with them. We further acknowledge being the beneficiaries of some forms of privilege, even as our lives have not been without their own significant challenges. Nonetheless, the idea of radical hope provides an approach that may be helpful to us. As a start to how we might consider moving from individual self-care and hope, professionals in our field might wish to ask:

· How can we build mechanisms of best practice that encourages the service-user voice while recognizing the gap between client success and key performance indicators?
·  How well do we understand the systems that so often create barriers to helping people build healthier, risk-reduced lives for themselves?
· How well do we understand the history of thinking that resulted in these systems functioning as they do?
·  How might we better celebrate the work that we do? After all, working with clients who have abused provides an important function in keeping our communities safe. The work we do matters, and as recent meta-analyses have shown, the work we do can be effective, even as we acknowledge that no efforts in any human endeavor are effective all the time.
·  How can we best argue on behalf of equitable outcomes for all of the people who come to our attention? All too often, it seems that there are internecine rivalries between professionals of various beliefs, including those who believe that being empathic with those who have caused harm is somehow disrespectful of those who have been harmed (and despite research showing that those who harm have very often been harmed themselves).
·  How can we best remind the world at large that this work matters and is in the public interest? The simple fact is that this work has great meaning and an important purpose.
· And finally, in terms of moral injury, how do we remind others of the need to practice both autonomously and as members of teams? Getting this balance right can be a true challenge. Nobody ever said collaboration was easy.

Thursday, January 30, 2020

Moral Injury and Radical Hope: Part 1

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

Note: This is part 1 of a 2 part blog. Kieran.

A clinical director recently shared a concern in a staff meeting about an adolescent on probation. The treatment team had built a program around the youth to address his sexually abusive behavior and general mental health.  Now, the treatment team assessed him as being at low risk and were understandably proud of their contributions to his progress in building a lifestyle incompatible with causing harm to others. Their approach had been team-based, multidisciplinary, and comprehensive. As he neared the end of treatment, his probation officer expressed concerns. “As we all know,” he said, “his seemingly good behavior is a huge red flag that things aren’t right,” which raised concerns about the implications for the youth’s future, as well as their own clinical judgment.

The treatment team found itself in a paradox. If the young man were to behave badly, others would judge him to be in need of treatment. If he behaved well, the natural assumption for some would be that he must be behaving in a secretive manner.  Those working in the field will recognize this as a belief that persists in some quarters despite very strong evidence to the contrary. If your work is simply about managing risk, it’s easy to see risk everywhere.

The impact on the young man’s treatment team was apparent almost in its absence; they had heard this before. Despite a solid base of scientific evidence, it would be difficult to convince others that this young man really was more than the sum of his worst behavior. Although he posed a low risk to abuse again, the team recognized that he was at very high risk to be prevented from living up to his full potential. Concerning to the author who sat in on this team meeting was that the staff had heard this all before. They have spent their careers aware of risks, helping people change, and being merchants of hope for young people in their families, all the while surrounded by people who would not support their efforts.

To be blunt, these experiences of disrespect have a cumulative effect and cause harm to the people who do so much to help others build worthwhile lives and safe communities.  Such experiences beg the question that if we cannot believe people are able to change, then what is the point in treatment? It can feel that we are simply moving the deckchairs around and biding time as the Titanic sinks. Treatment – especially belief in treatment – is fundamental to its process. If we want clients like this young man to cooperate and prosper, then we need to have buy-in throughout the whole multidisciplinary system, not just a few members of staff. Risk management is not simply about containment and control, it’s about skill-building, desistance, and change. When we are caught up in our client’s journeys, then their successes and failures reflect on us. The staff was not acutely burned out yet, but neither were they allowed to work at their best. Instead, they found themselves in an ongoing state of lamenting that so many of their efforts were unrecognized, undervalued, and disrespected.

In 2018, Simon Talbot and Wendy Dean wrote an article on what they termed the “moral injury” of physicians who do not have the opportunity to be as effective as they could be. More recently, they have noted that these professional moral injuries are the precursors to burnout. They state:

“We have come to believe that burnout is the end stage of moral injury, when clinicians are physically and emotionally exhausted with battling a broken system in their efforts to provide good care; when they feel ineffective because too often they have met with immovable barriers to good care; and when they depersonalize patients because emotional investment is intolerable when patient suffering is inevitable as a result of system dysfunction. 

“We believe that moral injury occurs when the basic elements of the medical profession are eroded. These are autonomy, mastery, respect, and fulfillment, which are all focused around the central principle of purpose.”

As the authors note, autonomy is a basic element of training. Whether we are physicians or mental health clinicians, we are taught to think independently when considering diagnoses and to guard against the competing interests of those who may try to sway our treatment decisions away from our patients’ best interests. However, in many facets of our work, we are required to forfeit our autonomy and allow other interests to sway our decisions about care—most commonly for financial reasons. This can be a serious consideration for professionals who feel pressured into ethically questionable actions and whose licenses may be on the line.

When our own autonomy, mastery, fulfillment, and sense of respect are constantly on the line, how can we expect to be at our most effective with clients? Ultimately, this poses its own dilemmas related to public safety.

Friday, January 17, 2020

1 in 5 experienced child abuse in England & Wales: A call for prevention

By Kieran McCartan, PhD, & David Prescott, LICSW
New official statistics from the Crime Survey for England and Wales (CSEW) state that one in five adults in the UK aged 18 – 74 have experienced at least one form of child abuse before the age of 16. The survey estimates this at approximately 8.5 million people. While this figure may seem shocking at first, it actually reinforces what we know about child abuse prevalence and hints that this maybe the tip of the iceberg, with these numbers being an underestimation and not an overestimation. The report indicates that (please note that the below statistics are directly quoted from the report);
  • Many cases of child abuse remain hidden; around one in seven adults who called the National Association for People Abused in Childhood’s (NAPAC’s) helpline in the last year had not told anyone about their abuse before.
  • In the year ending March 2019, Childline (a free service where children and young people in the UK can talk to a counsellor about anything) delivered 19,847 counselling sessions to children in the UK where abuse was the primary concern; around 1 in 20 of the sessions resulted in a referral to external agencies;
  • As of 31 March 2019, 49,570 children in England and 4,810 children in Wales were looked after by their local authority because of experience or risk of abuse or neglect;
  • Around 4 in 10 adults (44%) who were abused before the age of 16 years experienced more than one of emotional abuse, physical abuse, sexual abuse, or witnessing domestic violence or abuse. This proportion is higher for women than men (46% compared with 41%);
  • Sexual abuse was reported in around two-thirds (63%) of calls to National Association for People Abused in Childhood’s helpline;
  • Around half of adults (52%) who experienced abuse before the age of 16 years also experienced domestic abuse later in life; compared with 13% of those who did not experience abuse before the age of 16 years.
Previously in this blog we have talked about the challenges of understanding the base rate data on experiences of sexual abuse, which is just as important for broader definitions of abuse. We know that there is under reporting, under recording, poor prosecution rates, cases being dropped, and acquittals within the system. The volume of people sentenced for abuse does not accurately reflect the volume of abuse that there is. This new data from England and Wales, as Scotland and Northern Ireland collect and record data separately, data is more than likely an underestimation, especially given the way that the CSEW is constructed. That is, it relies on (1) self-completion modules of Survey by men and women aged 16 and over who are resident in households in England and Wales, & (2) offences reported to and recorded by the police. Therefore, if you have not reported a crime to the police or are not a home owner you are unable to take part. Interestingly, in recent years the CSEW have contacted some children between 10 -15 to take part to get a broader spectrum.
The data from the CSEW highlights the challenges that child abuse causes in England and Wales, especially in terms of trauma, Adverse Childhood Experiences, ongoing development impacts and the costs/demands on the social care and criminal justice systems. The growing recognition of ACE’s and past trauma in our adult victims and perpetrators population is massive in the UK, with Scotland and Wales putting it at the heart of their social care and social welfare policies; however, it has not been as straightforward for England and Northern Ireland. The CSEW data really highlights the need for a more preventative/interventionist approach to child abuse. We need to intervene sooner and develop more coherent secondary prevention approaches to reduce child abuse. We also need to provide those at risk of abusing others with the skills to prevent offending and to assist those at risk of being victimized to be better safeguarded. 

Friday, January 10, 2020

Pornhub’s 2019 Year in Review

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

Not many professionals are aware that the world’s largest adult pornography site, Pornhub, publishes annual statistics about its use and users. Obviously, readers will want to be judicious in how they read the report (in the language of porn, the website itself is NSFW or “not suitable for work”), although the findings themselves are presented in a provocative but not necessarily offensive manner. Each reader’s opinions will vary.

What have we learned about Pornhub this year? Once again, the numbers are vast: In 2019 alone, there were 42 billion visits to the site (averaging 115 million per day), 39 billion searches performed, and 6.83 million uploads. For just the videos uploaded in 2019, if one were to watch them all in sequence, beginning in 1850, they would still be watching today. Reading such statistics as “6597 petabytes of data transferred” is a little bit like trying to come to terms with the national debts of nations; it can be nearly impossible to comprehend.

Beyond this, the statistics track, to the best of their abilities, who the most popular stars are, what people search for, what they actually watch, for how long, and where. They also report on the age and gender of their viewers, leading to questions of how they are able to divine this information (and is there a bias in the direction of attracting advertisers). Nonetheless, the data is remarkable.

Digging a little deeper, however, it seems that there is much we can learn about sex and sexuality that can inform our understanding of clients in assessment and treatment situations. First, of course, is obvious: Porn is ubiquitous. Even the best available research does not show it to be a risk factor for re-offense, as this earlier blog describes. Pornography continues to be controversial, with some politicians declaring it a public health crisis despite the most recent scientific findings. To our minds, the most interesting and concerning questions have to do with the effects of pornography on children, adolescents, and other vulnerable people. The reality is that porn without context, as ill-informed sexual education, lays problematic, difficult and unrealistic notions of sex and sexuality; as indicated in a recent BBC poll suggesting that women’s exposure to violent sex and violence during sex is on the increase. Hence, we need sex education, informed debate and realistic relationship expectations in modern society.

Questions arise: These findings show that what people search for is not necessarily what they end up watching. Further, as the authors of the report note, there is a trend in the direction of real people and not simply actors. “Amateur” was amongst the most frequent search terms, leading to questions about to what extent viewers are looking for the most authentic or genuine experience (as opposed to the gymnastics of many of the more commercially produced videos). At the same time, however, animated pornography is also at the top of the list, speaking to the role of novelty and fantasy for many viewers. These trends raise questions for how we understand our clients in treatment as well as those on other problematic pathways. As the Internet Watch Foundation points out child sexual abuse material, and related content, is often viewed on Facebook, Twitter, and other legally accessible internet sites, not purely on the dark web. Most of this accessible material is homemade, not “produced” which is in line with trends in mainstream porn.

Many more questions follow regarding what people watch. There is plenty to be offended by and concerned by. The prevalence of incest themes (mothers, fathers, stepmothers, stepsisters, “Daddy” etc.) can and should raise any number of questions for those understanding the sexuality of clients in treatment. On one hand, many professionals working with adolescents who have sexually abused report seeing cases in which these themes were used in the service of abusing within families. On the other hand, one wonders about the underlying allure of the relational aspects. As repulsive as incest is to society, do these videos also, however strange it may seem, provide a sense of connection to viewers? What is clear is that, as we have argued in the past, viewing porn through the lens of our own individual sense of morality is not a tenable approach to understanding or treating people who have abused.

In the end, the statistics provide more questions than answers. What do we really know about the sexual interests of viewers? 32% of visitors were female, indicating that it’s not as simple as men wanting to look at naked women. What will be the long-term effects on young people who grow up porn-educated and without funding for meaningful sex education in schools? And ultimately, what are people really looking for when they enter the search terms that they do?