Tuesday, December 21, 2021

Is it the most wonderful time of the year?

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

Christmas and the winter break have long been a time to reconnect with friends and family. This is indeed welcome, especially given the challenges that we have had with COVID-19 over the last couple of years. The fact that we are now overloaded with the typical jolly Christmas movies and uncountable pictures of family members laughing at the Christmas table in the media and in advertisements, it is always good to remember that the festive reconnect is not positive or welcome to all. When we think about the impact of seasonal holidays, we often think about Halloween and its safeguarding issues, but we don’t think about Christmas and its capacity to cause trauma; Why?

Research and practice tell us that most people who have been sexually abused are sexually abused by someone that they know. Often this is a family member, either a parent, sibling, or close relation. This means that individuals who have been victimized often must learn to navigate a new status quo in family life after their abuse experiences, often regardless of whether they have disclosed their abuse to anyone or have reported it to the police. People who have survived sexual abuse often talk about having to choose what family gatherings to attend, whether they stay at family member’s homes, who they want to be in the room with, or if they even want to be in the room, they have to explain why they are being “weird”, why they cannot just “let the past be,” or why they “can’t just put on a smile for everyone’s sake”. This means that a sometimes-stressful situation for some can be more stressful and potential retraumatizing for others.

The other outcome of festive reconnections is the possibility of increased disclosures, especially of historical sexual abuse experiences, which will be additionally stressful for the individual which is disclosing and the family unity trying to process it.

The question is how we tackle the legacy of sexual abuse during the festive season. While there is no protocol for it, there are several things we can all do:

·     Be aware of people’s engagement, or lack of engagement, in family activities. Use it as an opportunity to "lean in" and learn more about what's going on in peoples lives.

·      Approach conversations with care, in a trauma-informed way, recognizing that behaviors and actions may not be related to the immediate context.

·   Don’t force conversations, meetings, or activities - especially in respect to hugging, kissing, and physical contact. Remember that consent and understanding is essential in all parts of life.

·       Consider having more smaller, bespoke gatherings rather than single larger ones.

·       Think about the location of activities, who’s involved, and what there activity is.

·       In terms of any disclosures, it’s important to let people speak, hear what they are saying, not to judge the person disclosing it, and offer the help, and support, that they want.

·      Most importantly listen to the person in question, whether disclosing for the first time or revisiting past, known experiences, rather than “knocking it down the line” to discuss in the new year. 

These considerations may seem obvious in print, but too easily go missing in daily life. They require not only empathic action, but also an open mind and the ability to listen and not immediately judge. These are skills that are not given to everyone to the same extent and are certainly not evident in a situation where one might want to reflexively react in a defensive and denialist manner, based on the idea of not damaging the family's happiness, as well as protecting family members and/or oneself.

That is why it remains so essential that we continue to strive to make sexual abuse a topic for discussion in society and give people – including lay people – insights not only into the often-complex interpersonal dynamics present in e.g. chronic abuse, but also into the coping process of people who have been victimized and how this can be expressed in very different ways.

Wednesday, December 15, 2021

NL-ATSA webinar: An update on Internet Offenders.

By Minne De Boeck, Kasia Uzieblo, Isabelle Eens & Larissa Van Puyvelde Dutch affiliation of ATSA, NL-ATSA

The virtual world is a world that is complex and is continuously evolving; so it is not surprising that different facets of this world are still unknown for many. However, this world is very relevant to our field. The online world is an attractive environment for child sexual abuse (CSA) because of its affordability, accessibility, and especially its anonymity. Online CSA has an enormous scope, though the effective prevalence is unknown. What we do know is that it has been increasing in recent years. The COVID-19 pandemic revealed many vulnerabilities in this context. In June 2020, Europol published a report on the increase in online CSA in terms of downloading sexual abuse images, (potential) perpetrators and (potential) victims active on social media, instant messaging, etc. Justice and treatment services indicate that this increase goes hand in hand with very big challenges in dealing with the issue. The main challenge is to tackle this problem at its cause: As long as there is demand, there will be supply. Reasons enough, to pay attention to the approach of internet offenders.

On November 25, NL-ATSA, the Dutch affiliation of ATSA, organized an online webinar on online sex offenders. The webinar included three plenary sessions, of which one extended session on the assessment and treatment of internet offenders which was provided by two ATSA colleagues. 

The first presenter, Madeleine van der Bruggen (the Dutch National Rapporteur on Trafficking in Human Beings and Sexual Violence against Children), focused on the criminal processes identified on the dark web. She analysed forums where images of child sexual abuse were distributed and shared. She explained that online CSA on dark web forums often takes place in four phases: The first phase is preparation, where the actor prepares himself to participate in the activities on a forum. After this, one enters the pre-activity phase. This phase, which precedes the actual online CSA, is mainly characterized by the development of a dark web identity, introducing him/herself to the forum members, and getting to know the process of online CSA. Then the actors become active on the forum (i.e., the activity phase), and start communicating and exchanging experiences with each other. These activities -thus, including criminal behaviours- take place in an atmosphere of recognition, respect, and trust. Van der Bruggen observed a sense of togetherness, which was facilitated mainly by a common goal (online CSA). The final, post-activity phase refers to the situation when someone has been active on the forum but wants to end his activities. This is often announced, and rules of conduct are also agreed upon this, so that others would not think that these individuals had been arrested and could pose a threat for further criminal activities. In addition to the anonymity efforts the dark web offers, the social component is also an important part of online CSA on the dark web. The members engage in long-term personal relationships, which go beyond merely exchanging images and experiences. They build up a relationship of trust with others on the dark web and it makes them feel part of a specific social community. For some these online relationships may even take over the role of social relationships in real life. Van der Bruggen identified two offender profiles, dependent on their role on the forum. First, there is the ‘management’ who is responsible for maintaining the forum and also for specifying the rules of conduct. Second, there are people who are technically inclined, give advice on online CSA, and/or support others; these individuals are the so-called ‘key players’. Van der Bruggen thus emphasized the importance of insights into the organisation of the dark web and the different roles regarding online CSA to adapt the treatment of internet offenders accordingly.


The second presenter, Cyril Boonmann (University Psychiatric Clinics, Basel, Switzerland), focused on online sex offending among adolescents. H he stated that the internet is part of adolescent sexual development, with pornography having both positive and negative effects on young people. Despite several positive effects it may have, the study ‘EU Kids Online’ (2020) indicates that about 20% of the children between 9 and 16 years old has been confronted with unwanted sexual exposure. Notably, research on child sexual exploitation material (CSEM) use among adolescents is limited. The few studies suggest that adolescent perpetrators are predominantly Caucasian young men of whom a minority exhibits some other sex-offender behaviour. The adolescent CSEM offenders seem to exhibit fewer other forms of sex-offending behaviour and less traumatic experiences compared to adolescents who commit hands-on sexual offences. Sexting is also an important topic to consider. In that regard, Boonmann distinguishes between experimental behaviour or behaviour with aggravating circumstances to delineate delinquent behaviour (i.e. sending sexual content without consent) from sexual experimentation. Sexting between adolescents should only be problematized and tackled in the latter case. Next to CSEM and ‘problematic’ sexting, online CSA also includes cybergrooming. One in five minors indicates having experienced cybergrooming, with almost half of the perpetrators being minors. Boonmann concluded with some tips and tricks for clinical practice in working with adolescents committing online CSA. He suggested incorporating modern technologies in therapy and highlighting the dangers and difficulties of social media, pornography, and internet use. However, he also stressed the importance of including the positive aspects of the internet and pornography during treatment.

In the final part of this webinar, Dr. Anton Schweighofer (R. Psych., Canada) and Dr. Lyne PichĂ© (R. Psych., Canada), focused on clinical practice with internet offenders. They also observed a significant increase in the number of men who come into contact with the criminal justice system because of online CSA. As a result, treatment providers are challenged to develop innovative -and as far as possible- evidence-based treatment plans. Dr. Schweighofer and dr. PychĂ© gave insights into relevant typologies and theoretical frameworks for understanding internet offenders. One of the typologies they discussed is the division between fantasy driven and contract-driven online offenders. The former group experiences more intimacy problems exhibit more arousal to deviant sexual material watches more extreme forms of material and is more intensively involved with the internet. The contact-driven group tends to endorse and justify the sexual agency of children more often and exhibits more antisocial behaviour. Next, they reviewed assessment requirements and clinical assessment tools currently available. With regard to risk assessment, they suggested using the CPORT, which is, for now, the only instrument to map the static risk factors for online CSA, in combination with the STABLE-2007 to solely obtain insights into the dynamic risk factors and to identify the most important treatment goals. The Static-99R can’t be scored in this population but may provide additional information on any static risk factors present in the client. They further recommended the use of questionnaires to assess the clients’ attitudes and cognitions (e.g., Internet Behaviours and Attitudes Questionnaire; IBAQ). Clinicians should also have the courage to ask questions about the clients’ specific sexual fantasies and behaviours, such as probing for what the most exciting images are for the client. Based upon research and their extensive clinical experience, they suggested the treatment needs to be based on an understanding of both static and dynamic risk factors, and unique treatment elements like sexual health, internet safety, sexual self-regulation, intimacy, self-hygiene (e.g., sleep cycle) as well as the use of internet resources for treatment purposes. They also recommend involving family members in the treatment process, as they are also affected by the online CSA, and given that these members may have a significant impact on the feasibility of the treatment goals. Finally, they gave two essential tips for treatment providers for internet offenders: ‘Don’t do this work in isolation' and self-care must not be forgotten.

The fact that this symposium was attended by over 100 practitioners (psychologists, psychiatrists, probation officers to name a few) from the Netherlands and Belgium, as well as the grateful feedback during and after the event, illustrates that many practitioners acknowledge this growing problem and look for tools on how to deal with internet offenders in practice. It also became clear that this target group is relatively ‘uncharted’ territory for many professionals and that there is a great need for more research and sharing best practices.

Friday, December 10, 2021

Reflections on Evidence-Based Practice in 2020-2021

By David S. Prescott, LICSW

Readers will be forgiven for taking one look at the “2020-2021” portion of the title and turning immediately away. It has been a very difficult time for many of us. Setting aside the personal toll on professionals, this era has brought trends over recent years into sharper relief. Professionals have long faced difficult challenges such as shrinking budgets, scant resources, and societal misunderstandings about the nature of our work. My concern – based solely on my own experiences and conversations with others – involves the forces exerted on our programs that often go unrecognized or unacknowledged. My intent in writing this brief summary of observations is to empower clinicians and others working at the front lines. Where other blogs might say that the opinions expressed are those of the authors, it would be better to say that the questions asked below are primarily my own. However, they may resonate with others.

In past decades, programs and practitioners treating individuals who had abused (whether as adults or juveniles) often designed their work around available research as they could apply it with their specific clientele. In brief, programs were innovative, often because they had to be. In the case of inpatient programs, this was especially true. Even now, very little knowledge is easily available to those working with clients who have special needs. Virtually all programs operated within a context in which a governmental office authorized the program to practice; typically, these authorities kept their fingers on the pulse of these program, intervening only when necessary.

It’s difficult to pinpoint how and when it happened, but increasingly programs in the US have opted to gain additional forms of certification through organizations such as JCAHO, CARF, and COA. And why not? Additional accreditation can only be good, right? Likewise, programs began to bring in empirically supported treatments (ESTs), a welcome addition in virtually every respect. In some regions, systems of treatment have involved a case-management agency making referrals to treatment programs (which they often come to think of not as specialized entities with expertise, but as “vendors” for hire). While this structure is not inherently problematic, past disasters have led some case-management agencies to be authoritarian, leaving programs to make few decisions about treatment independently. While teamwork and collaboration are always welcome, the committees to review these decisions and proposals may only meet occasionally.

As is often the case, great ideas often become problematic in stages that are only barely perceptible. The onboarding of accreditation and wholesale adoption of ESTs have, in some cases, met with problems in their actual implementation. Often, efforts at implementation are stymied by the structures in which they occur and the processes surrounding them.

As one case in point, the author has watched as clinical directors who once charted the therapeutic course of their programs had to spend increasing amounts of time assisting in ensuring quality in areas such as documentation for outside review, very often at the expense of time spent ensuring that the actual treatment delivered is of the highest quality. While there is no question as to the importance of areas such as documentation, broader questions often go unconsidered, such as, “What is the best use of my time as a director to ensure the best outcomes.” For some, the race to make an agency look good has gained a higher priority than making a program actually do good. Too often lost along the way is the therapeutic alliance, which itself has an overwhelming evidence base.

In some cases, however, much time has been lost in the process of appeasing outside entities. “David,” said the Clinical Director of one program, “We had this great evidence-based program for trauma-informed care. It took us years to get it this good. But the CEO wanted (XYZ) accreditation, and (XYZ) only recognizes EMDR. The problem is that most of our clients aren’t actually good candidates for EMDR. We stopped doing what was really working and started getting trained in EMDR. It’s great stuff, but it’s not really working in this environment. So now we’ve been spending all our time doing that. I tried talking with the CEO but he wouldn’t listen.” In the end, those who once steered the ship and produced innovations have increasingly ended up managing processes imposed from outside the program, whether they help the clients or not.

Along similar lines, many programs have understandably raced to use ESTs, even when they are not the best match for clients. For example, the adolescent who, after his mother’s death and father’s return to prison, burned down an outbuilding on his grandmother’s property. A psychological evaluation recommended that he receive grief counseling with family involvement. However, the referring agency (which had not done an assessment) said that because burning a building is an antisocial act, then they would only fund Multi-Systemic Therapy (MST). On the surface, this could have worked. However, it didn’t and as implemented only made matters worse. The case-management agency demanded that the young man go through MST a second time because, “It has the strongest evidence.” Again, the author has seen treatments such as EMDR and MST produce results akin to miracles. The issue isn’t the treatment; it’s the misapplication.

Where does all of this leave us? Since 2005, the American Psychological Association has defined evidence-based practice as “the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences.” Perhaps its time to re-visit the “clinical expertise” part of this equation. Lost in much discussion about the importance of ESTs is the extensive body of research pointing to the importance of the practitioner delivering treatment. It has recently seemed that treatment programs and their practitioners are viewed by outsiders as entities to be directed and managed, often by people lacking credentials and without liability. As the saying goes, the question to ask is not, “Does nothing work?” but instead, “Is nothing implemented?”

To that end, my vote is that we never forget the expertise that individual programs and professionals bring to our work.

Thursday, December 2, 2021

Restorative justice in sexual abuse cases: A lighting rod or an opportunity to rehabilitate?

By Kieran McCartan, PhD, David Prescott, LISCW, & Kasia Uzieblo, PhD

Earlier this week two of the authors, Kieran and Kasia, took part in a webinar for the European Forum on restorative Justice as part of Restorative justice week. The purpose of the talk was to discuss the new Council of Europe guidelines on the assessment, management, and integration of people accused or convicted of a sexual offence and its link to restorative justice. The recommendations were developed by a broad group of experts involving Kieran, Marianne Fuglestved, and Harvey Slade as well as members of the PC-CP and external organisations (including, ATSA, NOTA, NL-ATSA, IATSO AND Les Centres Ressources pour les Intervenants auprès des Auteurs de Violences Sexuelles (CRIAVS). The recommendations are based on the importance of delivering effective practices to people who are convicted, or accused, of a sexual offence. This involves the events and processes from arrest and conviction through to their integration back into the community. The recommendations focus on different parts of the process, including risk assessment tools and processes, the role of treatment in prison and probation (especially the importance of a trauma-informed, service user-engaged rehabilitative process), the role of supporting and working with those who have been victimized (especially in respect to restorative justice), engagement with the media when individuals are released and the need for effective, evidence-based staff training and development. The aim of this blog is not to talk through the full remit of the recommendations and their impact – we would suggest that the reader look at the recommendations (see: https://www.coe.int/en/web/portal/-/managing-persons-accused-or-convicted-of-a-sexual-offence-council-of-europe-issues-new-guidelines) – but rather to look at one recommendation in particular, the recommendations linked to restorative justice.

The use of restorative justice in the field of sexual abuse, and in the processes of treatment and recovery for those who have been harmed as well as the person that has committed the sexually abusive behaviour has sometimes been controversial. In 2018, the Council of Europe published Recommendations concerning restorative justice in criminal matters and as such were committed to seeing restorative justice as part of the criminal justice process. When developing the recommendations relating to people arrested or convicted of a sexual offense, the PC-CP suggested incorporating rights for those victimized and examining restorative justice. The team went and talked with Dr. Ian Marder, who had played a role in the development of the restorative justice recommendations, and developed a recommendation linked to it. The recommendation was:

Rule 31: Where appropriate, prison services and probation agencies should liaise with other criminal justice agencies as well as with victim support services and other agencies as appropriate, to ensure that the needs of victims are met and in order to avoid continuing victimisation.

Commentary:. Probation, and related services, should work with victim services in an appropriate and professional way to safeguard and protect the rights of victims. This is particularly important in cases where the victim is part of a vulnerable or protected group, or where they have an ongoing relationship, direct or indirect, with the person accused or convicted of the sexual offence. As outlined in Rule 30, this rule aims to support victims’ journeys, rather than enabling victims to influence the sentencing or release of the person convicted of a sexual offence. In terms of restorative justice, the victim can ask for a restorative justicebased intervention if it is part of the suite of outcomes available to them upon or after sentencing.

The rule, or recommendation, indicates that restorative justice should not be taken off the table in respect to services offered people who have committed sexual abuse and those who have been victimized; rather, it should be used, where appropriate, in a thoughtful manner that considers the needs of those harmed. Kieran, Kasia and Linda Millington (from Why me?) discussed in a recent webinar. The webinar focused on the need to discuss the reality of sexual abuse and what this means for those impacted by it (both those who abuse and those harmed) and that restoration was an important part of the rehabilitative process. The webinar emphasized that restorative justice is not always about forgiveness or confrontation, but rather about an opportunity for discussion and to be heard and acknowledged, which is a central aspect of the healing process. The take-home message was that the victim’s journey is a central part of the criminal justice process and that it can be, but dies not have to be, a central part of the people convicted or accused of a sexual offences journey but it can be if all parties are open to it and respectful of it.