We need to talk about sexual violence by … health care providers

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

The forensic clinical field in the Netherlands has been shaken to its core several times in recent months by multiple serious incidents in psychiatric clinics following one another, including sexual and deadly assaults. Although serious incidents in these clinics are not a common occurrence, it is essential to reflect on the staff and patients affected and take further steps in trying to prevent such incidents.

When we learn that an incident has occurred in a forensic institution, we first assume that a patient has assaulted one or more staff members. Indeed, Dutch forensic clinical practice has faced very serious incidents in recent years, including a violent, sexual and deadly assault committed by a patient. Hence, such incidents occur and have a tremendous impact on the victim(s) and all those involved. Less often however, we hear about staff members mistreating or (sexually) abusing patients. Unfortunately, such cases occur as well. Without minimizing the seriousness of patients’ violent behaviors towards staff, we want to focus for a moment on sexually transgressive and violent behaviors caused by practitioners. We start from a recent case in the Netherlands.

In September of this year, it became known that an employee of a high-security forensic psychiatric clinic had been fired after sexually assaulting a patient. This employee had forced a patient to perform sexual acts. In April, this came to light during an interview with the woman in question. The employee was a sociotherapist who helps patients train pro-social behaviour and learn to cope with their mental health problems. When this came to light, the man was suspended and later eventually fired. On top of that, other problems came to light. At the same clinic, a staff member was fired for having a sexual relationship with a patient and an internship was stopped because the intern had started a relationship with a patient.

Especially the first case, but certainly also the other cases raise a lot of questions and concerns, first and foremost with respect to the patients. The patients that are admitted to such clinics have committed serious offences, but often also have a very traumatic past. Frequently, they have been mistreated, neglected and/or abused by those they should have been able to trust. These patients do not only struggle with their own often- extensive criminal past but also with their own repeated victimization. During their stay in the clinic, we try to teach them a prosocial lifestyle, which also means that they have to learn to trust others and to get attached again. This is anything but obvious to them and requires considerable work. Attachment problems and a deep distrust of others are characteristic of this population. It then almost speaks for itself, when the (little) trust they finally gained, is damaged, especially by someone to entrusted with their care. It leaves very deep wounds, Not to mention the psychological and physical damage they suffer from the sexual violence. The house of cards, being the new prosocial life, that staff and the patient have tried to build on often very weak foundations, then threatens to fall apart or just collapses at once.

The reach of this cannot be underestimated. Not only is the direct victim seriously affected, but also fellow patients. The questions then become whether their trust and faith in staff, and broader, in others, are still recoverable and how we, professionals, best try to restore it. And the third group we should not lose sight of is the staff. They, too, are badly affected by such incidents. They struggle with questions like “how did I not see this?”, “couldn’t I have prevented this?”, and “what now?”. Moreover, as was observed in this specific case, staff members were also confronted with stigmatizing remarks from the public. For instance, when the abuse was disclosed, staff members were confronted with condemning remarks in the vein of “You’re all the same,” and “you’re all rotten apples.” Also notable was the ripple effect: Staff from other clinics were very concerned, scared, and angry, and clearly felt the need to talk at length about this with colleagues, among others. Hence, the consequences of such violent and transgressive incidents are thus not limited to the setting where the incident took place but are felt far beyond.

Protocols for violent incidents by patients are in place in most, if not all forensic clinics. But do we have a protocol ready for situations when a staff member exhibits transgressive behavior? How can we best respond to this as a patient, as colleague, as manager, as society?

It is not our aim to propose specific guidelines here. However, we would like to point out some points of importance. As in other cases of (sexual) violence, we should start with the beginning and that is acknowledging the violence and the suffering it has caused. Abuse is abuse, no matter who the perpetrator is, no matter what status he/she has, no matter what position he/she holds, and no matter who the victim is. When you observe that the Dutch media described the abuse not as abuse but as 'sexual acts', you realize that this seemingly obvious starting point is already not obvious to many.

In addition, we need to have difficult conversations with our colleagues, within forensic clinics or in any workplace. Thinking that such cases certainly can't happen in your department implies closing your eyes to the fact that sexual violence can happen anywhere and that several characteristics of our work, e.g., relationships that are disproportionate in terms of power, are risk factors for (sexual) abuse. Increasing awareness and daring to ask difficult questions and engaging in not obvious conversations about prevention and identification of (sexual) abuse by professionals, (bystander) strategies when such abuse occurs, and rehabilitation after the abuse of all those involved, are already key starting points.

Another important question is how to involve patients and clients? Asking for help after a violent incident as a victim or a bystander is not easy, let alone when you are in a dependency relationship and vulnerable. Some organisations, for example, have started to develop guidelines for clients and patients. It would be useful to reflect within our field on this as well; to make suggestions available to our patients and to explore how we can make them more resilient within clinics or other settings.

So let’s have these conversations now, and let’s not wait until a complaint of abuse by a professional arrives at your own doorstep.

Therapy or Training?

By David S. Prescott, LICSW

A recent article titled, Accelerating the development of effective psychological interventions has become the source of some discussion within our field and beyond. In it, the psychology researchers describe using a “leapfrog” method for developing treatment approaches to combat depression. It has implications for professionals working in abuse prevention. Central to the authors’ argument is that traditional approaches to research can take a long time, and it often becomes apparent that changes to an approach are needed even before the results are published. Their leapfrog method involves being able to tailor approaches as the research is happening. While the fields of psychology, criminology, education, and medicine have long emphasized the importance of maintaining the highest standards of research, this article offers an alternative perspective on treating depression based on the lack of availability of mental health treatment for the masses.

With respect to the study itself, the authors have developed an online training program for people who suffer from depression. Because it is online, it can be delivered inexpensively to those who have internet access. It is not difficult to see how this could be a helpful triage for a lot of people, and these efforts are certainly worth pursuing. The authors make cogent observations about some of the most important characteristics of depression to treat and have certainly been creative in their approach. When it comes to conditions that rise to the level of public-health crises, innovations are welcome for consideration. Nonetheless, it seems that there are still many other factors to sort through before this can be meaningfully replicated and implemented with the public. Despite the attempt to streamline research, it seems that much further study is needed.

In fairness to the authors, the intent of their study was to investigate the feasibility of their approach more than to develop an effective treatment methodology. Just the same, there may be implications of this work that are worth considering. Not only does our field focus on preventing harm, we also need to ensure that our research and practice methods don’t cause further harm along the way. New ideas are welcome as long as we also guard against their potential misuse.

Unfortunately, much of the premise for this approach appears confusing. The authors make the point that there is a need for new treatments, as if there aren’t already many evidence-based approaches to mental health conditions such as depression. At the front lines, it seems that the problem isn’t that new treatments are desperately needed, it’s that access to the many existing treatments is limited by factors outside of the office. These factors include ease of access to treatment (including finding therapists, parking, transportation, insurance considerations, and the stigmas involved in getting help).  With respect to stigma, it often seems that one needs a confidential source simply to find the person to whom one can speak confidentially.

Interestingly, the authors don’t call what they’ve created treatment or therapy. Instead, it’s called training. This leads one to question whether we are giving up something that has a far deeper evidence base than online training programs. 

Setting aside the empirical underpinnings of their methods (and whether they’re the best approach in this case), there are still questions and concerns in resorting to this form of approach to depression. To start, there is much we still don’t know about the etiology of depression (and many other conditions), leading to confusion about the purpose of this training (for example, some research has found a link between inflammation and depression in some circumstances). Further, the current training seems not to account adequately for the depressing and anxiety-producing situations that people find themselves in during the current era. Again, some kind of self-study training in these situations could be welcome, but maybe it’s not prudent to consider it a full-blown intervention. A reading of the article showed no place for a licensed, responsible professional.

Thinking of the lessons we’ve learned in our field, consideration of the principles of risk, need, and responsivity suggest that this training is far from an actual treatment package. How does a one-size-fits-all training account for variations in risk for depression to continue? How is it tailored to address differences in depressive symptoms among individuals? And how is it adjusted to meet the specific-responsivity needs of clients, such as intelligence, learning style, or comorbid conditions?

Further, ethical considerations abound. Given that it is an online training and not interactive, where will responsibility lie when clients kill themselves? Will there be any feedback measures to ensure that the clients feel they are being helped and that the method is a good fit for them? Or will the measures used only examine symptom reduction? In some cases, will it not be even more depressing for clients that they have no one to talk to beyond the online training? One is reminded of comedian Rodney Dangerfield saying, “I called suicide prevention, but they put me on hold.”

Hundreds of research studies into “what works” in psychotherapy would also call this approach into question. The work of countless researchers, including Bruce Wampold, Zac Imel, Michael Lambert, Scott Miller, Jeb Brown, and many others, shows us that factors such as the therapeutic relationship, building hope and expectation that positive changes are possible, and ensuring that the goals of interventions match the client’s aspirations are critical components in efforts at change.  While any “training” is welcome, it seems that it can only fall short unless used in conjunction with an actual therapist.

A major reason to consider these issues is because similar efforts have taken place in the treatment of justice-involved individuals. One university developed treatment curricula that are so highly scripted that professionals administering them do not need a high level of education or experience. Common questions for which there have been few answers have included, “if it is this scripted, how do we tailor this curriculum to meet the needs of individuals in adherence to the principle of specific responsivity?” At the same time, it is also true that some organizations have developed self-help resources when no other options are available. “Helpful” is in the eye of the service user.

In line with the authors’ arguments, however, the trend in general psychotherapy seems to be in the direction of further medicalization. Fewer people look for therapists online than ask their physician for a referral. And that is against a backdrop of insurance companies that have so clearly prioritized profits over people in their business practices.

My hunch is that this approach will not bear fruit in the long term. Just because someone is trained does not mean that they will benefit in the long term from that training. It seems that the axiom most often forgotten in these endeavors is, “tell me and I’ll forget.  Show me and I’ll learn. Involve me and I’ll understand.” It’s easy to forget that people most often change not so much because of the insights they may gain from a book or training, but more through a relationship experience in which they can reflect on their lives, enact new skills, and build new futures.

ATSA conference 2022: Live again!

By Kieran McCartan, David Prescott, & Kasia Uzieblo

The annual ATSA conference has long been a time to come together, reconnect, establish new connections, partnerships, and develop new ideas and plans. This year’s conference was no different; except for the fact that it was. This was the first in-person conference that ATSA has held since 2019 in Atlanta, which meant that the reconnection was more powerful and relevant. Although the conference was online for the previous two years there is nothing like seeing people in person, attending sessions live, debating, discussing, catching up, and planning. The conference this year had excellence attendance with over 1,200 attending over four days (including the pre-conference workshops). Participants came from a range of countries including, but not limited to, the USA, Canada, Australia, New Zealand, UK, France, Norway, Denmark, the Netherlands, and Belgium to name a few. We will now look at each of our reflections on the conference and standout moments.

For Kieran the standout moment of the conference was the ability to reconnect with ATSA colleagues. This stood out more than most of the sessions and papers that he attended. The conference reignited the importance of collaboration, especially international collaboration, and the opportunity for people to come together and forge new paths. Additionally, the Keynotes by Apryl Alexander and Kelly Socia where standout performances. Their deliveries were powerful and commanding and their content powerful. Both focused on the power of truth at the individual and societal levels, as well as the need to engage, question, and step up. The conference had a range of posters, presentations, seminars, and workshops that covered everything from prevention, risk assessment, treatment, and desistance; it focused on the individual differences of many of the service users that we treat as well as support. The conference highlighted that sexual abuse is a global issue that needs global thought and collaboration that results in a nuance, globally informed response.

For David the standout moments of the conference included Drew Kingston and Liam Marshall provided an excellent pre-conference title on Compulsive Sexual Behavior Disorder. It is one agreed-upon term signaling a condition that has gone by many names over the years. Drew Kingston offered an excellent historical overview of the research and Liam Marshall offered ideas on treatment. As is often the case, what made it an excellent workshop was what was not said: All too often, presentations on this topic can become mired in the personal beliefs and moral judgments of the presenter. While no one is unbiased, especially when it comes to sexuality, Dr.’s Kingston and Marshall provided a refreshingly balanced overview of the issues at stake.

Dr. Alissa Ackerman gave an unforgettable talk on involving the “authors of sexual harm” – those who have sexually abused others – in restorative justice efforts. After providing an overview of restorative justice and how she has worked within it, she discussed topics such as processes for how these authors can make amends. As she often does, Dr. Ackerman shared how her own history of victimization led her to share her experiences with others, including in treatment groups for individuals who have abused others. As one might imagine, these can be powerful experiences that leave virtually no one unmoved. Dr. Ackerman’s work and charismatic style are a reminder that practicing restorative justice, and the accountability processes within it, can be very difficult work indeed.

For Kasia the standout moments of the conference included: The conference experience was again wonderfully diverse. As every year, it is enormously difficult to choose only a few items from the conference program. But what has stayed with me most of all is that feeling that we are more committed than ever to sexual abuse prevention. In doing so, new paths are being explored and we are clearly also taking the time to critically reflect on our current knowledge, on where things need to be improved, and on what we do not yet know.

Take risk assessment, for example. A topic that has dominated our field in recent years. Although several sessions focused on the important topic of accuracy, the gaps in our knowledge regarding risk assessment as well as the implementation of the tools were also extensively discussed. For instance, Maaike Helmus, Seung Chan Lee, and others raised the importance of cross-cultural comparisons regarding – for example – the accuracy of risk assessment tools. Differences are indeed found that may have negative implications for – for instance - already generally disadvantages minorities. A thoughtless application and interpretation of risk assessment outcomes within specific ethnic groups (among others) is clearly inappropriate and potentially harmful. However, more research is needed to assess how to deal with these differences in practice.

What I also strongly appreciated was the attention given to the person exhibiting deviant sexual interests and/or behaviors as such. This included extensive consideration of the psychosocial well-being of this group and the impact of social and self-stigma by Sara Jahnke, Nick Blagden, Maggie Ingram, and several others. In addition, several speakers (e.g., Caoilte O Ciardha and Gaye Ildeniz) delved into the help-seeking behaviour of this group, examining what factors facilitate or hinder this behavior. These sessions provided insights that are crucial for all professionals working on prevention, but certainly also for preventive projects such as Stop it Now! and Circles of Support and Accountability, which were also highlighted extensively during the conference. Various sessions also herald an exciting time in terms of the treatment of people who have committed sexual offences and/or are struggling with deviant sexual interests. For example, Eveline Schippers explored a crucial question of how sexual deviance develops and how we can use this knowledge in treatment. Wineke Smid, Ross Bartels, and Nina ten Hoor explored the implementation of EMDR treatment in these groups. Franca Cortoni, Michael Miner, and Ian McPhail described how they aim to unravel the black box for us by finding better ways to identify what changes are elicited by our treatment programs and whether these changes are indeed related to a reduced recidivism risk. I am already extremely curious to see what new insights all these research projects will bring at the next ATSA conference.

Despite all this enthusiasm from researchers and professionals that I was able to experience once again, my spirits did sink a little at the end when Allyn Walker took the stage. Walker described the horror they had to endure when their research got media coverage. Their story once again made one realize that what we do within ATSA and beyond should not be taken for granted, that still many are opposed to what we do. But Walker’s story and the public’s reactions also spoke of hope: it showed how we can support each other in the prevention of sexual abuse and how important is that we bring solace to each other. 

ATSA 2022 was also a time of change, we said goodbye to our long-standing Executive Director Maia Christopher and welcomed in our new Executive Director Amber Schroeder, in doing so we opened a new chapter in our organization. The annual conference has always been the hear and soul of ATSA, and the passing of the baton from one Executive Director to another was the ideal place to do it, the way that we have passed the baton from one president to another as well as from one board member to another. It solidifies the importance of ATSA and ATSA as almost everyone has noticed, the primary feature of this year’s conference was the enormous sense of homecoming. Friends who hadn’t seen each other in all that time were reunited, if only briefly. And the nature of the conference meant that we weren’t as affected by the (in)famous Los Angeles traffic nearly as much as we feared!