Wednesday, May 6, 2020

Prehabilitation & sexual abuse prevention

By Sarah Christofferson, PhD, Kieran McCartan, PhD, & David Prescott, LICSW

The field of sexual abuse has gone through a theoretical and multi-disciplinary shift over the last 10 to 15 years, whereby we have moved from talking about responding to sexual offences through a criminal justice-only approach to a more holistic, health-based approach that includes prevention as well. The language of sexual abuse prevention has moved practice landscapes, allowing us to better incorporate research, learning and practice from the allied fields of social work, social care, criminology, sociology, health and public health, to name a few, which has improved how we conceptualize and understand sexual abuse. As a field we now talk about prevention, the service user voice, multi-disciplinary/multi-agency working, first person language, Adverse Childhood Experiences, trauma informed practice/care, and consider working with at-risk populations good practice. Therefore, reinforcing what everyone working in treatment/interventions already knows, that sexual offending is a life course issue rooted in experiential pathways that needs a holistic response to help people manage their behavior. So, what is the next big thing to be adapted into the field of sexual abuse prevention from health? Prehabilitation!

In recent years the first author, along with her New Zealand based team including Gwenda Willis, Jacinta Cording, and Waikaremoana Waitoki, have started to consider the role of prehabilitation in helping individuals concerned about their sexuality or possible risk of committing a sexual offence. Prehabilitation reflects the bridging of therapeutic services typically offered as rehabilitation (e.g., in a prison or other justice system context after the point of conviction), with an earlier preventative approach. The term prehabilitation is not new but is new to our field. It comes from the medical literature and is tied into preparation for a stressor, such as major surgery, which can be debilitating and therefore the patient needs to prepare their body in advance to reduce the negative consequences. In such settings, prehabilitation has been described as a process of enhancing functional capacity to enable an individual to withstand these kinds of challenges (Banugo & Amaako, 2017; Ditmyer et al., 2002). Translating this to a sexual abuse prevention frame, prehabilitation can therefore be viewed as a strength training of sorts for people who experience problematic sexual interests – assisting them to enhance their functional capacity to cope with these interests, and associated stressors, in nonharmful ways (Beggs Christofferson, 2019).

So where does sexual abuse prehabilitation occur currently in the field? Prevention Project Dunkelfeld, in Germany, is a well-known example. Whether or not they have ever committed an offence, individuals with diagnosable pedophilic or hebephilic interests can self-refer to Dunkelfeld and receive therapy on a confidential basis (Beier et al., 2015). In some other parts of the world, therapy for this same purpose may be offered by independent practitioners or (less frequently) publically funded clinics, or as a brief in-person follow-up to helpline services such as Stop It Now! (Heasman & Foreman, 2019). Except for Dunkelfeld, evaluations of these kinds of services are rare, partly due to the anonymous nature of delivery.

Stand Strong, Walk Tall: Prehabilitation for a Better Future (SSWT; Christofferson et al., 2020) is a newly developed prehabilitative intervention from the New Zealand team, designed to provide access to effective services for people in the community who experience sexual interest in children. The target population is broader than Dunkelfeld – not limited to those with a diagnosis but open to any adult seeking help in relation to sexual interest in children/minors (a subsequent adaptation for youth is slated as a future priority). Design took a bottom-up approach – seeking to understand and cater to the needs of minor-attracted members of the general population, rather than simply transposing justice-setting rehabilitation approaches into an earlier prevention context. Whilst goal setting for treatment in SSWT is undertaken collaboratively with each client, taking an individualized case formulation approach and incorporating the client’s valued life goals, key broad targets of the SSWT intervention are alluded to in the name:

Stand Strong denotes self-efficacy and self-regulation building aspects;

Walk Tall denotes self-acceptance, dealing with the stigma often faced by those with sexual interest in children and tackling self-stigmatization; also a sense of forward momentum;

Better Future carries a double reference:
 the better future clients can expect because of engaging with prehabilitation; 
-  the better future we are all collectively striving towards, of a society free from child sexual abuse.

The SSWT intervention framework is informed by broad theoretical underpinnings including the strengths-based Good Lives approach, the principles of risk, need and responsivity, etiological and process models of child sexual abuse, all supported by the Hauora Māori Clinical Guide for effective bicultural practice (Pitama et al., 2017). The intervention is evidence-based; in addition to the theoretical foundations the content, targets, and delivery are further informed by the growing empirical research base regarding the target population (often referred to in the literature as minor-attracted persons or MAPs), along with the principles of feedback-informed treatment and trauma-informed care. Importantly, SSWT is by design a joint treatment and research initiative, with evaluation planning directly built in. The assessment protocols will enable not only robust evaluation but also contributions to the knowledge base regarding those who experience sexual interest in children, their treatment needs, and effective interventions. Pilot delivery is planned to commence across New Zealand and Norway during 2020.

The hope is that SSWT and similar prehabilitation efforts may offer a missing link, in the context of a behavior that all of us would like to see eradicated (child sexual abuse), system responses traditionally focusing on post-offence recidivism reduction as opposed to preventing initial offending, and a minor-attracted population in need who are often unable to access effective interventions outside of the justice system.

Readers interested in learning more about Stand Strong, Walk Tall are welcome to contact the first author, at

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