Thursday, December 17, 2020

Therapy to Prevent Abuse or Therapy as abuse?

By David S. Prescott, LICSW

Our recent blog on conversion therapy prompted lively discussions in social media.  While efforts around the world seek to end practices aimed at changing people’s sexual orientation, therapists working with individuals hoping to prevent further offending often use methods developed to help clients manage their sexual thoughts and urges. As we suggested in our earlier blog, it is important for professionals to consider the aims of the methods they use. Unfortunately, many laypersons only hear of these methods outside of the context in which treatment occurs. Research has long shown that the context of treatment matters. Used in the wrong context, treatment methods can cause harm. A scalpel that saves lives in surgery can become a murder weapon when used in a bar fight. Not all treatment contexts are alike.

The simple facts are: There are many people in the world who feel a sexual attraction to children but do not want to act on that interest. For them, many elements of daily life are challenging, and they often experience shame and self-hatred resulting from attractions they didn’t ask for and sometimes feel they cannot entirely control. Some of these individuals attempt to live as quietly as they can, while others seek out services, support groups, and other types of help. This has all been documented elsewhere and serves as the foundation to what follows. To be clear, however, sexual interest in children is not something that people ask for or a choice they make.  

While some degree of overlap in methods used in helping people manage sexual urges may also be employed in conversion therapy, there are substantial differences between programs that treat people with a sexual interest in children and conversion therapy as the world has come to understand it. One major difference is that behavioral treatments are only one component of a broader, a more comprehensive approach to helping people lead better, more self-determined lives.

The vast majority of programs treating individuals who have abused others regard their behavioral treatments as methods to help people to manage urges or fantasies that would lead to further harm to themselves or others if they acted on them. On the other hand, conversion therapy seems to hold out some kind of promise that the client will become a different person as a result of this treatment, viewing being gay as an accident to be cured, remedied, etc. It’s easy to write those words in a paragraph, but how they play out in the social context of the client and their alliance with the clinician can be quite another matter.

For example, the client who says, “Please can you help me. Even though I have some attraction to people my own age, I also have this strong desire for kids. I do not want to take the chance of hurting anyone. My thoughts about kids often interfere in my relationship with my girlfriend, which is already tenuous enough. I really want to do anything I can to manage these urges. Please can you help me?” In cases like this, where the client is asking freely and independently, there is the possibility that some of those methods may help, at least in the short term. Can we really compare that to the pain and suffering this video of this man who experienced conversion therapy as some kind of torture? And if there are things that might help, should we really put them off-limits? We’ll come back to that point.

Reading about the contexts in which conversion therapy has taken place can be horrifying. There are good reasons why these approaches, too often delivered intrusively and with prejudice and ignorance, are unethical in most places and illegal in many. But it’s not just the actual methods: They are often provided by people whose knowledge of sexuality harken back to a less enlightened era, and the professionals violate all the tenets of the therapeutic alliance. Further, they blithely ignore the principles of informed consent. These treatments are often unethical on their face in the ways that they run roughshod over clients’ autonomy and beneficence (central to the codes of ethics of all the helping professions).

All of this calls to mind some of the things that Thomas Szasz said in 1961: that therapy can only be ethical when the client comes to the therapist for help and is willing to pay out of their own pocket. His point (as someone who had fled then-communist Hungary) was that we should all watch out for the negative consequences that can occur when the state gets involved in providing treatment.  He might have added the family and societal pressures brought to bear on clients as well. We’ve written elsewhere on how these conflicts can be managed.

The techniques for helping clients manage their sexual behaviors are far less important than whether the treatment experiences:

·         are consistent with the client’s goals; goals that are personally meaningful and relevant, held strongly, and arrived at independently.

·         take place in an environment in which the client feels heard, understood and respected.

·         consider whether the client believes that the techniques of treatment are a good fit for him.

·         include informed consent for treatment that is reviewed frequently.

·         occur in context such that clients view the therapist’s role as that of a helping professional and fellow traveler.

One colleague expressed it like this: “I can’t change what people want; I can only help them to change how they behave around what they want.” Likewise, in describing Motivational Interviewing, Miller and Rollnick (2013) have said that, “Treatment is something we do for and with clients, not to and on them.” These two quotes embody the fundamental differences between legitimate treatments offered to individuals who have abused them and the more controversial conversion therapy that appears in the news and social media.

There are still reasons to be vigilant about implementing any kind of treatment under conditions where personal liberties hang in the balance. How consensual is the treatment when the informed consent was signed under the duress of being imprisoned longer? In addition, the therapist believes it’s important to use these methods. At the same time, the client is going along with the process in order to complete treatment even though they don’t want to. On the other hand, millions of us have signed consent for medical procedures that we didn’t want, that caused us pain and anguish, but that added many years to our lives. There are many, many nuances involved.

Ultimately, professionals have an obligation to consider all aspects of treatment that they deliver, including the context in which treatment occurs.

Thursday, December 10, 2020

It’s not the cure, but the delivery system that matters: the importance of community


By Kieran McCartan, Ph.D., David Prescott, LICSW, & Kasia Uzieblo, Ph.D.


This has been a frustrating week for writing. With respect to developments in our field, it seemed as though the goalposts kept moving; the blog could have been on anything and nothing. As the week started, we were looking at recent reports (The Sun; Complex;  New York Times) about the reality of Pornhub was, despite their protestations, all is not happiness, smiles, sanitized sex, and sexuality; instead, there is a dark side. It wasn’t long before Pornhub took remedial action; we will have to wait to see the results.

Next, the blog was going to examine the unintended impact of new encrypted messaging policies and practices that can put children at risk for grooming and abuse (The Guardian; The Children’s Commissioner for England). This promised much to discuss. However, that debate has been moved down the agenda, in the UK at least, with increased discussions around Brexit and COVID-19. important messages and conversations are getting overshadowed. Stimied again! However, this is a topic that we will return to in the new year, as it highlights the balancing act between risk and safety in child protection with an evolving frame of online protection.

The third and final, blog that we were going to write is about the balancing act between internet filters and prevention messaging after Kieran attended a meeting that discussed whether the cost of implementing such tools was an appropriate and relevant investment. Interestingly, this meeting went round in circles and it was decided that more research and evidence was needed. All of this highlights and focuses the challenge of prevention: do we prevent and try to stop what might happen or do we respond to what is happening? This, in turn, feeds into larger debates and reflects previous blogs on this site, so it felt like retracing old ground.

Another day brought headlines reporting the first people in the UK–first in the world – outside of clinical trials to be vaccinated against COVID-19 with the Pfizer jab, which was great news! Interestingly, the news coverage throughout the day and ensuing discussions about evidence, effectiveness, patient safety, and rollout highlighted the lynchpin that brought all these potential blogs together. The real issue is not necessarily the vaccine itself, but the mechanism through which the vaccine is delivered. The biggest challenge is changing public minds, education, prevention, engagement, inclusion, and community building. All these same challenges confront us in the field of sexual abuse.

Like COVID-19, preventing sexual abuse means understanding and responding to it directly (and does not involve behaving as though it does not exist or will go away on its own). Also, like COVID-19, sexual abuse can be overwhelming, omnipresent, and presents challenges for individuals, communities, and society. This means (again like COVID-19) our response is often divided – even divisive – and results from a spectrum of belief and acceptance. Beneath this are considerations of people’s knowledge, understanding, trust in the system, belief in science, and hopes for the future. In many circumstances, we find ourselves at a stalemate: in recent years, the field of addressing sexual abuse has tried new approaches to tackle the issue, including prevention, reframing messages, groups of people reaching out to the public, and listening systematically to who people who have abused – and those who have been abused – have to say.

Each of these efforts has worked to a greater or lesser degree. We can see the same pattern, the same approaches, and the same frustration in these debates as we do in the rollout of the COVID-19 vaccine. The question then becomes, what now? Do we all need radical overhauls in our approaches? Is the answer to preventing sexual harm in doubling down on our current approaches and seeking out more evidence and opinion? Or is it a return to control and regulation? These are difficult questions with no obvious answers.

The one common element that arises in both the challenges around sexual abuse and COVID-19 – the element that ties together the threads of Pornhub, encryption, and filtering software is the community. Our communities. Sexual abuse is a community issue and therefore communities need to understand it better to respond to it more effectively and prevent its spread. Punishment and restriction do not stop sexual abuse. While such sanctions can help in some cases, awareness and support can do much more.

We are all members of our communities and society beyond, and together we shape the debates and actions that move us forward. Our greatest successes come when we work together, and our greatest failures happen when we resist new information and cooperative efforts. This is true across the board, from child protection to immunization. In many ways, especially in the political arena, our community is more fractured than ever before. While advances in accessing knowledge and resources have brought so much of the world together, they have also happened at the very times that many of us have become increasingly entrenched in our own echo chambers. If services to prevent abuse and rehabilitate those who have abused are the primary issues, then how do we respond? It seems safe to say that we need a new delivery mechanism and new ways to think about moving forward.

The challenge as we move in 2021 is how do we immunize ourselves against sexual abuse, the way that we are immunizing ourselves against COVID-19? And how do we immunize ourselves against both the panic and apathy that violence and the pandemic can bring? How do we get the “cure” out there (in COVID’s case, that means the Pfizer jab, and in sexual abuse, it is the education, knowledge, and understanding we need) in a more effective way? It is a challenge, but as a community, we can work together to solve it!

Thursday, December 3, 2020

QAnon and the Hard Work of Preventing Sexual Abuse

 By David Prescott, LICSW, Kasia Uzieblo, Ph.D., and Kieran McCartan, Ph.D.

 According to Wikipedia,QAnon is a far-right conspiracy theory alleging that a cabal of Satan-worshipping pedophiles is running a global child sex-trafficking ring and plotting against US president Donald Trump, who is fighting the cabal. QAnon also commonly asserts that Trump is planning a day of reckoning known as the "Storm", when thousands of members of the cabal will be arrested. No part of the conspiracy claim is based in fact. QAnon supporters have accused many liberal Hollywood actors, Democratic politicians, and high-ranking government officials of being members of the cabal.

As scientists, practitioners, and academics, the authors have continued to marvel at the fact that QAnon has gained so much traction. They command an audience in the absence of evidence and when there is so much evidence that they could turn to if their aim really were to prevent child abuse (and we have no evidence of that, either). This raises significant questions about the role and significance of research, evidence, and expert knowledge in the world currently.  Tom Hanks and Hillary Clinton and others may be a lot of things, but calling them pedophiles detracts from the very serious work that at organizations such as ATSA and Stop It Now! (to name only two) are involved in.

In a recent blog post, Marty Klein stated that QAnon is “replacing child protection groups – who should blame themselves.” This comes as a surprise to many organizations committed to preventing abuse, who have mostly read about QAnon in the headlines. To our knowledge neither interest in their work nor their support from charitable foundations and concerned individuals has changed very much. Marty Klein actually only mentions two organizations, Save the Children and the National Center for Missing and Exploited Children (NCMEC), about which he had blogged in 2017. His argument is that, in particular, NCMEC has created the very conditions that allow QAnon to thrive by what he refers to as its scare tactics and “used statistics in a cynical fashion—with concepts like “at risk for exploitation,” “potential victims,” and “children gone missing.” While we are not defending NCMEC (and they can defend themselves), we believe that not every prevention-oriented organization is the same, and that the vast majority do so ethically.

In another blog, Jeremy Malcolm of the Prostasia Foundation offers very different insights, beginning with a description of the evolution of the origins of many of QAnon’s statements and beliefs. Malcolm also takes issue with NCMEC, noting for instance, that “A NCMEC figure that QAnon sources commonly quote is that 800,000 children go missing each year. Less often acknowledged is that in over 99% of those cases the child returns safely, often within hours.” Malcolm’s blog for Prostasia also examines the panic around Satanic cult abuse (which many readers will remember) from the mid-1980s into the 1990s. In the end, when we visited to NCMEC’s website in preparing this blog, we did not turn up any wildly inflated facts, although its aims are clear. We have concluded that there are many points worth noted in these blog posts, and while we may differ in some key areas, we respect the authors’ work very much.

What can we take away from these passionate disagreements? While there is no shortage of overt disinformation in QAnon’s efforts, everyone in these debates appears to agree that the sexual victimization of children should be prevented. That might be a place to start.

 In our view:

·         It’s important to examine the evidence base in deciding what directions we take in any course of action. We need to make sure that people with deep knowledge of the issues are at the table and being listened to. This leads to the question of how we can best “reframe” or “relaunch” expertise in a way that captures the imagination of individuals who are more susceptible to conspiracy theories?

·         Conspiracy theories are not helpful in preventing abuse, especially when so much credible evidence about effective approaches already exist.

·         Accusing people of child abuse has a deep and long-lasting impact; even when the accusation is withdrawn afterward or no proof is being offered, the suggestion will linger for a long time and will remain a stain on someone’s reputation.

·         Groups like QAnon are making the work of preventing abuse more difficult for all of us through their spreading of information for which there is no evidence.

·         Individuals and groups that focus passionately in one specific area are at risk for not taking other perspectives into consideration.

·         Missing from many mainstream and social media accounts is that child abuse is preventable, that many people have developed and tested ways to prevent it, and that knowledge about prevention is there for the taking.

·         A fact that often goes missing in these debates, especially among organizations, is that ordinary individuals can play a powerful role in preventing abuse.

·         Ultimately, all people will be able to prevent abuse most effectively when they are in possession of high-quality knowledge and are willing to speak up and speak out about abuse prevention.

In the end, we need to reaffirm that sexual abuse is an individual, interpersonal, community and a societal level issue; which means that we all need work collectively to prevent sexual abuse and the existent of conspiracy theories undermines this collective working.