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.

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. 

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?