What has research ever done for us?

 By Kieran McCartan, PhD, David S. Prescott, LICSW, ATSA-F, & Kasia Uzieblo, PhD

This week Kieran has been involved in several different conversations about research outcomes, Key Performance Indictors (KPI) and how we measure them. This has been equally engaging and frustrating. This week has really enforced in Kieran the need to emphasis the role, purpose, and use of research, which is often an afterthought or a bolt on for many organisations and programmes. This is a shame, as research should be seen as core business and essential to the development, roll out, and maintenance of any service or endeavour. This blog discusses why research matters and why we should all be concerned about doing it and getting it right.

Good quality research is essential for developing an evidence base that informs practice and policy; we all know that. We look to organisations like ATSA and NOTA through their publications and conferences that facilitate our access to this research and allow us to learn methods, theories, and outcomes. But it must be stated that not all areas of sexual abuse share a research parity or depth. Some areas may be over-researched (e.g., risk assessment, treatment, work with adolescent and adult males) and other areas having less (e.g., prevention of sexual abuse, women who sexually offend, Siblings/intrafamilial). This changes by country and region (e.g., outside of north America sex offender registries are barely researched). To borrow a phrase, “All research is equal, but some research is more equal than others”!

In universities, many researchers are adapting their methods towards being more impactful and being more grounded in practice, professional development, and policy rather than just being about publications. As a result, more research is about being collaborative and about co-creation with professionals, policymakers, and service users/clients. This means that research can also help shape ongoing policy and practice, research needs to be at the start and in the lifecycle of our professional activities, not [as is far too often the case] bolted on at the end or neglected all together. Research needs to be central to good practice and building an evidence base, but it’s also central to commissioning, funding, recruitment and retention of staff, referrals, partnership working, sustainability, and quality assurance. However, the value of research is not always seen as these things with frontline services not always seeing the value reading studies and wanting to focus more, and understandability so, on their clients and practice. In worst case scenarios research can be seen as an add-on or a costly burden, which can mean that it’s not always well developed, well-funded, or at times well executed.

Therefore, it’s important to understand the role and purpose of research and what it brings to practice and policy. One of the best ways to do this is to think about research as a core business for any organisation and/or practice. So, whether you are working in sexual abuse prevention, treatment with men convicted of sexual offences, community risk management or policing; what does research mean to you and your organisation? Maybe the place to start is to think about the role that research has played in your daily practice, in shaping what you do and how you do it. To borrow from and emulate Monty Python…

What has research,
what has research,
what has research ever done for us?

An practice evidence base.
What?
...they, they gave us a practice evidence base...

Yes, they did give us that, that's true
And evidence for future funding Yes, that too
A practice evidence base I'll grant is one
thing the research may have done
And the policies, now they're all new
And the great theories too

Well, apart from the theories and evidence,
And the risk assessment tools
Public health for all the nation
Apart from those, which are a plus,
what has research ever done for us?

Along these lines, it may be helpful to think about how research has improved our professional lives (as well as our personal lives, such as research into health care). Research in our field has informed our understanding of assessment and evaluation measures; how we communicate risk; what goals to work on in treatment; how to work with different individuals; how to understand denial; how to understand human sexuality, etc. In some corners of social media but also in practice and policy, it has become fashionable to disrespect science and scientists. At the end of the day, however, we would do well to stay respectful and keep current with the advances of science; it often advances in multiple directions (as we blogged about last week).

Extending a Previous Blog Post: Ethical Considerations on the Costs of Resources

By David S. Prescott, LICSW, ATSA-F

In our December 13, 2023 blog post, Dr. Sophie King-Hill asks:

In many harmful sexual behaviour (HSB) services for children and young people (CYP) how resources are funded, developed, and delivered is coming under increasing scrutiny as frontline and third sectors organisations are having budgets cut and services reduced. Given this context, is it ever ethical to charge for these resources? . . . At face value the ethical principles of HSB work may appear clear-cut (i.e., work in a trauma informed way, do no harm, protect the patient/service user) . . . However, after scrutiny, the lines seem blurred. . . Whilst a multi-agency approach is clearly needed for HSB, a by-product of this way of working is that no steadfast and explicit ethical principles exist due to the range of specialisms involved. This lack of a sense of measure, accountability and consistent public pledge has perhaps created an environment where profitable endeavours have gained traction and power without the rigour of adequate ethical questioning.”

This last sentence regarding “profitable endeavors” is particularly intriguing and leads to questions about how we prioritize and think about resource allocation. In her discussion, she also notes the way some services are trained and delivered. She raises the age-old question of how best to combine implementation and training efforts in situations where staff turnover is a reality (this blog post from 2015 explores this question further).

Here in the US, I’ve long wondered about how we prioritize not just our resources, but the way we think about them. I’ve never forgotten an experience many years ago in which I was on a grant to implement an empirically supported trauma treatment package. The content of this treatment was clinically sound and under most circumstances easy to implement. However, it had been developed for use with adult women, while our agencies were tasked with implementing it with adolescent males and females. The positive findings in studies had occurred in outpatient treatment settings. We were tasked with implementing it in home-based services. In some cases, the clients were very clearly not ready to advance at the pace of the curriculum, while for others the curriculum itself was getting in the way of more substantive conversations that the clients were desperate to have. The curriculum had not been written specifically with the caregivers of these young clients in mind.

The clinicians in this project found themselves in a dilemma: meeting each client’s needs to ensure treatment engagement meant slight changes in adherence to the manual. On the other hand, even the slightest changes were considered a problem for treatment fidelity and needed to be approved by the outside consultant. Further, every session was video recorded for quality assurance purposes, making clinicians more likely to make momentary clinical decisions that prioritized the video review over the needs of the client. All of this took place in a context where those licensed professionals charged with administration of the curriculum had to take their orders from an unlicensed and sometimes irritable consultant.

There were many ways that these dilemmas could have been resolved, and doubtless many who are reading this post could have helped move the process forward. Unfortunately, the constellation of players was, as a group, ill-suited to get this implementation right. It can serve as a lesson for all of us. These were high-stakes circumstances: some of the clients felt retraumatized after participating in this treatment. The problem was not the content, which was indeed evidence-based, but in the implementation processes, which were not.

Virtually everyone wants to engage in evidence-based practice (EBP). Yet so many of us remain unaware that there is more to EBP than the research studies telling us that a treatment method has found to be effective. For example, the above efforts would have benefited from a solid foundation in implementation science, which examines the application of research. For example, Dean Fixsen and his colleagues outlined numerous conditions under which implementations of EBPs will be more and less effective. As encouraging as some studies can be, others have found that it can take a considerable amount of time to demonstrate significant improvements in wellbeing at the individual-client level.

Likewise, there is very little accumulated knowledge on adapting EBPs to meet local conditions. In the example above, applying a treatment developed in one context to another created problems and arguably caused harm to some clients. On one hand, there are the understandable concerns that changes to an empirically supported protocol reduces fidelity to the model, which in turn can potentially reduce its effectiveness. On the other hand, the APA definition of EBP emphasizes how it is a tripartite model involving the integration of best available research, clinical expertise, client characteristics, culture, and preferences. This discrepancy leads to questions about how those with genuine clinical expertise can effectively use protocols that may not be the best fit for clients. 

Dr. King-Hall’s original questions lead to others. We might well ask about the ethics not only of training costs and access to treatments, but of emphasizing implementation of a particular treatment approach without considering the evidence regarding successful implementation, or local conditions involving clinical expertise or client characteristics and culture.

 

 

Reflections on the recent NOTA & Lucy Faithfull Foundation sexual abuse prevention conference

By Megan Hinton, Victim and Survivor Advocate, Marie Collins Foundation

I recently joined the Marie Collins Foundation (MCF) as a Victim and Survivor Advocate. My role involves working alongside those with lived experience of technology-assisted child sexual abuse to champion and amplify their voice and embed it into policy, practice, and academia.

As a survivor myself part of my position includes speaking about my lived experience at conferences and events. So, when the Lucy Faithfull Foundation reached out to ask if I wanted to give the opening address at the Preventing Child Sexual Abuse Conference organized jointly with NOTA, I felt honored.

Prior to the conference, I needed to gain more knowledge about prevention methods and believed most prevention work was done through PHSE lessons in schools and charity-led awareness campaigns. Joining the conference, I felt intrigued to learn in order to identify any cross-over that may help with my role. But I also felt apprehensive about attending as I knew the conference would heavily focus on perpetrators rather than the voice of survivors.

During my presentation, I spoke about the importance of prevention from a survivor’s perspective, referencing my own experience and embedding key messages from MCF’s Lived Experience Group. During my address, I quoted one of our Lived Experience Group Members who said, “Survivors get a lifelong sentence”. I also emphasized that whilst child sexual abuse can take place over many years, it can also happen in as little as a few hours, and yet the impact is the same; it fundamentally changes who you are as a person. My hope was for my address to encourage attendees to anchor their thoughts on the children, victims and survivors they work to protect. I wanted attendees to challenge their thinking and reflect on how they could apply what they learned from the conference to their work and day-to-day life.

My apprehensions about the conference's content quickly dissipated as I listened to the presentations that followed my own. It was heartening to see each speaker cover a point I had made during my address, which ensured survivors' voices were visible throughout the day. Some key points that I was particularly happy to see focused on included challenging stereotypes of victims and offenders and highlighting that schools cannot be the only place where conversations about child sexual abuse take place. MCF’s Lived Experience Group told us they want to ‘blow the lid off’ child sexual abuse and the silence that surrounds it. Victims and survivors regularly tell MCF that sexual abuse is still rarely spoken about and that makes it difficult for children to identify abuse or find the words to explain what is happening to them. So it was encouraging to hear practitioners with similar views who were committed to raising awareness and involving wider society in conversations about child sexual abuse.

The impact of child sexual abuse can be profound and devastating and that impact does not stop with the victim or survivor, it can ripple through ‘secondary victims’ such as family, friends and the communities that surround the child. So, seeing each presentation looking at prevention through a multi-agency public health lens was excellent. The presentations were informative and easy to digest and covered a range of different aspects to prevention. I particularly enjoyed learning about the three levels of prevention – primary, secondary and tertiary - and how these would fit into a public health model. I also appreciated the level of detail given so that I could begin to understand the thinking and evidence base that supports compassionate and restorative intervention work.

The conference really challenged my own way of thinking positively. One personal learning point was the realization that tertiary prevention work is not about justification, excuses, or minimizing the harm caused to victims; it’s about preventing reoffending and protecting children. I found it encouraging to hear about the success rates of these types of interventions.

The conference definitely inspired people to learn and improve but also celebrated how far prevention work has come in such a short space of time. Seeing people so passionate about their work, recognizing the challenges that they face, and striving to improve their services gave the conference a real undertone of hope.

As a survivor myself, the concept of prevention rarely crossed my mind. I could lose years of my life thinking about ways my abuse could have been prevented but wasn’t. As many other victims and survivors will know, we often feel blame and accountability for our abuse, and it can make it seem as though it was inevitable. But this conference allowed me to consider how prevention strategies and services work, how they can improve and enabled me to reflect on how we can better evaluate outcomes.

Leaving the conference, I felt passionate about the messaging in primary prevention and how difficult it is to assess and measure outcomes for this type of intervention. In early prevention work, we often see too much responsibility placed on children to ‘keep themselves safe’, particularly online. Through MCF’s direct work with children and their families affected by technology-assisted child sexual abuse, we know this e-safety messaging can silence victims from disclosing as they expect blame and shame. Instead, we must focus on creating an environment where children and young people and adults feel empowered to talk about these issues without threat or fear of victim-blaming.

In addition, we see widespread societal blame on parents, who often do all they can to safeguard their children. I believe actively engaging and listening to those with lived experience, including parents whose children have lived experience, could offer an insight into what primary prevention messages do and don’t work and, more importantly, why. The incredible group of brave victims and survivors in MCF’s Lived Experience Group is a testament that consultation with lived experience can, and does, positively improve services, practice, and policy. What we learn through our direct work can feed into prevention work, and MCF values partnership working. We know partnerships and collaboration improve outcomes for children, victims, and survivors, and this conference has further cemented the long-standing working relationship with LFF, NOTA, and MCF. I am excited to see how we work in partnership in the future. 

Problematic sexual behaviors as a juvenile outcome measure

By Norbert Ralph, PhD, MPH

 

For juveniles who sexually offended (JwSO), sexual recidivism is identified as one of the primary outcome measures. Reitzel and Carbonell (2006) titled their meta-analysis of treatment programs "The Effectiveness of Sexual Offender Treatment for Juveniles as Measured by Recidivism." Methodologically and clinically using this measure has virtues but also limitations. With sexual recidivism rates in some researchers estimated to be about 5% (Lussier et al., 2023) it would be difficult to obtain samples large enough to detect a treatment effect. Also would a reduction from 5% to even 0% be significant enough in terms of real-world impacts and cost/benefit considerations?

 

Other outcomes have been used. Nonsexual recidivism has been identified as another benchmark to assess treatment outcomes. Lussier et al. (2023) identified general recidivism for this population as 44% and Caldwell (2016) as 27% in meta-analytic studies. General recidivism has been a focus of study, and for example, Abei et al. (2022) carried out a study of high-risk JwSO youth to compare the efficacy of sexual offense-oriented therapy and social skills training in the prevention of both sexual and general recidivism. Further, the Multisystemic Therapy group used out-of-home placements, among other measures (Borduin & Munschy, 2021).

 

Another benchmark for juveniles who sexually offended is examining problematic sexual behaviors (PSB) that may not result in arrests or formal recidivism. Viljoen et al. (2007) reported a rate of such behaviors in a residential treatment program with 169 JwSO youth of 16.6% and an average JSORRAT-II score of 6.1. Ralph (2015) in a study of another residential treatment program with 129 JwSO youth reported a rate of PSB of 20.6% and an average JSORRAT-II score of 6.3. The average JSORRAT-II scores (6.1 and 6.3 respectively) of the samples indicated that both groups above the average risk levels (Epperson, 2019). In the latter study (Ralph, 2015), any sexual behavior that violated the rules of the setting was classified as misbehavior. Notably none of these behaviors resulted in charges, even though some were serious enough to be charged. Presumably, this was considered not necessary because these youth were already on probation for such offenses and were in court-ordered treatment. For context is important to note findings such as Ybarra & Mitchell (2013) which identified nearly 1 in 10 youths (9%) reported some type of sexual violence perpetration in their lifetime.

 

Another example including PSB is in Letourneau et al. (2009), which reported an outcome study regarding Multisystemic Therapy (MST) using the Adolescent Sexual Behavior Inventory (Friedrich, Lysne, Sims, & Shamos, 2004) and its Sexual Risk/Misuse subscale. Because of the nature of the scale, specific PSBs weren't possible to separate out, such as coercing others to have sex. Abei et al. (2022) in the study mentioned previously, classified as sexual recidivism not only formal charges but also PSB that may have resulted in a formal charge but did not. However, the rate of such PSB separate from charged offenses was not separately described.

 

The above information has several implications regarding assessment and treatment for these youth. One is the recommendation that such behaviors be included in outcome studies assessing treatment effectiveness and also for individual programs as part of their quality assurance procedures. These behaviors are important to address since they may have victims too and likely increase the risk of future such behaviors. Once identified, these behaviors are more likely to become an explicit focus of treatment. Notably, the Abei et al. (2022) study has already included PSB. Also, PSB may be tracked systematically in future MST studies

 

There is another consideration. It might be possible to develop risk measures to assess for PSB that do not result in formal charges. For example, in the study by Ralph (2015) youth examining PSB, who had a male victim and previous mental health treatment had an AUC (Area Under the Curve) of .74. Practically, developing risk measures to assess for PSB might be more possible than developing measures to assess sexual recidivism alone, given the low sexual recidivism rates. Clinically, such measures would be useful to assess the risk of a given youth for sexual acting out at the beginning of treatment, particularly for high-risk youth, so that treatment methods and the amount of treatment could adequately be planned.

Ethical considerations of the financial cost of resources on harmful sexual behaviour services

 By Sophie King-Hill, Ph.D., University of Birmingham

In many harmful sexual behaviour (HSB) services for children and young people (CYP) how resources are funded, developed, and delivered is coming under increasing scrutiny as frontline and third sectors organisations are having budgets cut and services reduced. Given this context, is it ever ethical to charge for these resources?

Preventing and responding to (HSB) in children and young people forms a significant proportion of the work social services, the third sector and social justice organisations carry out. Due to this there are many tools, assessments and interventions (referred to as resources) that have been developed that make a tangible and positive difference to the lives of CYP and their families. This, and the other points made in this article, also hold true for the adult criminal justice field, but it is beyond the scope of the authors expertise to discuss these in-depth and the focus will be on HSB services for CYP.

When considering HSB the moral philosophy appears to be underpinned by the reduction and prevention of sexual abuse and harm and the promotion of well-being and recovery. So the reduction of harm and the maximising of benefits. Ethics are often highlighted in practice in terms of work carried out with CYP and their families and of the practice that is delivered, and the research that is conducted. Yet these ethical considerations are sparse when considering products that are commissioned and used.

At face value the ethical principles of HSB work may appear clear-cut (i.e., work in a trauma informed way, do no harm, protect the patient/service user). However, after scrutiny, the lines seem blurred. This field is inhabited by professionals from a range of specialisms and fields (i.e., sociology, psychology, criminology, social work, police, probation, prisons, social care); therefore, HSB services are a multi-disciplinary, multi-agency area that exist at a crossroads between practices, policies, and processes. This means that the ethical considerations are somewhat complex as no core set values and principles exist as they do in medicine, law or criminal justice for instance. In social work for example, there is an explicit commitment to human dignity and worth. In medicine there is a framework that is built around doing good and no harm, free choice, justice and fairness. These are ethical principles in which professions are bound - being built around trust and held to account by bodies such as the General Medical Council.

Whilst a multi-agency approach is clearly needed for HSB, a by-product of this way of working is that no steadfast and explicit ethical principles exist due to the range of specialisms involved. This lack of a sense of measure, accountability and consistent public pledge has perhaps created an environment where profitable endeavours have gained traction and power without the rigour of adequate ethical questioning. Given that preventing and responding to HSB is both social justice and social care work, and given the rise of health approaches and thinking in the HSB field there is a strong argument that work, including tools and interventions, needs to be framed by social not private enterprises.  Therefore, profitability, in its purest form does not seem to align when considering the field of HSB and the underpinning principles of minimising harm and suffering and supporting recovery.

The impact of the financial costs of resources on practice and provision in harmful sexual behaviour services

Consideration needs to be given to the impact of the financial costs  of resources. If the costs of resources is not equitable and is the same for all, in HSB services it risks failing CYP and their families for a number of reasons, for example:

 If some professionals can access the resource and others can’t then this can result in miscommunication and misunderstanding between the differing agencies. Research tells us that multi-agency work is a crucial aspect of positive HSB outcomes, so this has the potential to cause conflict in this space.

 If, because of the cost, only a few professionals in one agency can access certain resources then this may also risk the dilution and misuse of what has been paid for. This points to a flawed and unsustainable model – and may also indicate that in social welfare contexts a model based purely on profits may make the overall issues worse, not better.

 Training costs will always have to be ongoing if there is a commitment to a certain resource, which again may be unsustainable for agencies with small budgets. High staff turn-over may result in resources not being used adequately as the trained experts will have left. Additionally, when the case loads of those who are trained are full, what then happens to CYP who need support.

The exclusion of CYP and families from accessing services if professionals aren't trained or have knowledge is also inadvertently causing them harm. This runs the risk of a two tier model – even in the same service with some CYP and their families getting good support and others not. When something exists that can make a tangible positive difference to the lives of CYP and their families in an area as damaging as HSB, with no equitable approach, can be measured against ethical principles as inherently morally wrong.

The financial cost of resources can, inadvertently, create a postcode lottery of service delivery and interventions. For example, services in poorer socio-economic areas may not have the resources to pay for resources and therefore CYP and their families maybe excluded from accessing services.

Additionally, consideration needs to be given as to how resources are commissioned and adopted by services and how this is supported by them as well as by government and local authority budgets and spending. If resources are shown to be working and making a measurable difference to the lives of CYP, and their families, then large-scale funding and commissioning should be considered. This may negate the issues with the profiting from damaging social welfare issues that have gained traction.

What can be done?

It is important to consider the role, impact, and purpose of charging for resources on the HSB sector has. If the purpose is to positively support CYP who have sexually harmed or been harmed in an evidence-based way to reduce harm, then of course the materials used need to be based on research as well as expertise. The reality is that costs need to be covered, this is not unrealistic. And to protect their fidelity through this should always be considered. However, questions need to be asked in terms of the level of profitability over social good and where this is ethically situated.  A pure profitability perspective still appears ethically flawed in this field and considerations of revenue sacrifice, when bearing in mind the positive impact on people’s lives, should be made. Perhaps a case could be made for a ‘robin hood’ model of working when charging for services in this arena. In its simplest form this means charging those that can afford it more and providing subsidies, resources and free services, to those who can’t. This model emerged in the 1970s as can be seen in the work on cataracts by the Aravind Eye Care Hospital in India at this time. Other businesses have followed suit such as Warby Parker (buy one, give one for glasses) and Cotopaxi (donating money for social good from profits) and is underpinned by increasing social responsibilities of profit-making businesses. With the right policy transfer frameworks in place this application of values and approach can work in the field of resources and interventions that are being charged for in the field of HSB.

Work in field of prevention of and response to HSB is a moral and ethical issue, it is carried out by professionals who, in the main, deeply care and are motivated to help the people they work with, and therefore should be given access to the best resources available, regardless of cost. This is even more relevant in working with children and young people in this space. Therefore, should businesses that trade in this arena be held to account and be bound to shared ethical principles, standards, and safeguards. These principles could be set out in a charter mark for example, that has a clear ethical criterion when making profit in this field that is underpinned by the aim of maximising benefits and minimising harm to CYP and their families.  The aim should be geared around considering where they can make profitable sacrifices to maximise benefits and reduce harm - being held to account when this is not evidenced, via an ethical framework. It can be argued that in this field that the outcomes for CYP and their families should be paramount and a recognition first and foremost for the lives of the people who can benefit from services should be at the forefront of any business considerations. That public benefit, as outlined by the Charity Commission, is a key component of work in this area, especially in frontline services (i.e., social work, policing, child protection) that are publicly funded. The landscape, when explored through the lens of ethics, provides a concerning picture of an environment where the lack of consistent ethical principles means there is no bar to measure against. Therefore, when considering maximising benefits and minimising harm, in the field of HSB this lack of accountability runs the risk of becoming incredibly dangerous.