Implementation, Integration, and “Implegration”: Science and Practice

Many years ago, I had a bad experience with a consultant. She promulgated an evidence-based treatment curriculum for a specific condition that my programs treat. The curriculum was excellent; the consultant was not. She complained bitterly to others when cases were not improving rapidly, and blamed some therapists even as she attempted to hire others away from our employ. At no time did she critically examine her own contribution to these circumstances. Good treatment with bad implementation does not produce a good outcome for anyone.

Central to our implementation problems was that our therapists needed time to get their minds around the specific treatment processes. Unfortunately, she and the funders were not patient. This was before I became aware of Dean Fixsen’s research on implementation efforts. He would argue that it takes two years to implement a treatment program with fidelity. In our case, this meant a good curriculum, good therapists, but poor consideration of implementation science.

Fast forward a few years and I have twice consulted to agencies this week on implementing treatments such as the good lives model and motivational interviewing. As you might expect, time is tight and money is short. From an administrator’s perspective, it always seems like a good idea at the time: “there is a good new treatment method out there; let’s get someone in to do training.” What often gets lost in the mix are some of the basics. For example, with every rollout of a new treatment method there is a minority of people who readily embrace change and another minority who wants nothing to do with it. One example of this took the form of “we’ve seen these new models come and go over the years. This one will probably go away as well.”

Even the greatest attempts at improving services meet with challenges along the way. An important consideration lies in how we can prevent implementation problems before they happen. Professionals sometimes do not want to change their behavior any more than mandated clients do.

Perhaps one place to start is in considering how best to get the program’s context right for change. Are we considering full implementation of a specific approach such as motivational interviewing or the good lives model? To do so with fidelity can mean even more effort in curtailing old approaches than in learning new ones. It can also mean stopping a program in its tracks and changing course, which can result in as much or more tumult for the clients as the program staff.

On the other hand, one might try integrating program components piecemeal. For example, one might try to go in a good-lives-model direction through a series of steps:

1)      Ensuring that the mission of the program is to build client capacities and wellbeing even as clients manage risks

2)      Focusing on developing goals that every client can approach rather than avoid

3)      Developing a deep understanding of each client’s common life goals

4)      Collaborative work with clients to understand their past behavior in accordance with the self-regulation model

5)      Consider full implementation of the good lives model

Another possible approach is to consider “Implegration.” This is a term coined by Swedish prison psychologist Carl Åke Farbring and refers to an integrated implementation effort (see here for a series of presentations in English and Swedish). Farbring came to conclude that simple efforts at motivational interviewing implementation were doomed to be less effective when they did not take place in the cultural context of the program. From his notes, he describes Implegration as involving:

• An intentional process of implementation
• Bottom-up perspective
• An attitude of exploring and listening
• Local ownership of processes (separate from the centrally decided goal orientation)
• Balance between guidelines and mindlines
• Adjusting to local conditions means deliberate integration
• Positive monitoring and support

When considering the implementation of a treatment approach, it is often easy to overlook the potential contribution of local expertise. This can be achieved as simply as through the appointment of in-house experts who consult to both the model’s developer and the front-line clinicians. It can also use in-house relationships, such as having an enthusiastic front-liner organize regular discussions about how implementation is progressing.

For many years, it seemed acceptable to view clinicians as widgets in the service of sophisticated treatment regimens established by experts who were too often in another region. Recent research has confirmed the importance of improving treatment services one client at a time through close attention to the alliance. As our field continues its discussion of best treatment practices, it also seems vital to consider how we make these practices happen.

David S. Prescott, LICSW

The prevention of sexual abuse and violence in the UK

 Over the last four decades in the UK, survivors of sexual abuse and the women’s movement brought growing recognition of sexual abuse and sexual violence. For the purposes of this blog sexual abuse refers to the abuse of children and young people and sexual violence is a broader umbrella term which also includes sexual assaults against adults.  

During the 1980s small, mainly voluntary sector organisations began to provide help, support and treatment for victims and survivors of sexual violence.  Also during this time, many of the same organizations began to recognize the need to work with the source of the problem, the person causing the sexual harm. The Probation Service began to deliver relatively small scale individual and group work to  convicted sex offenders.

With a developing interest in “What Works” in treatment and rehabilitation, there was a growing  investment in treatment programmes for offenders that were subject to quite rigorous evaluations. Accredited sex offender programmes were developed and by the first decade of the 21^st century and a growing body of research began to articulate the components of  effective assessment and treatment for those who sexually harmed children and/or adults.

This development in knowledge and resources was not matched in work with victims, with children and young people with harmful sexual behaviour and even less focus on  primary prevention. And this in the main remains the case today.  It seems that this is primarily due to the political attractiveness of being seen to address a “threat”(e.g., adult sex offenders) rather than the sometimes complex steps to prevent sexual violence from happening in the first place.

More recently high profile cases of historic abuse (Savile -  http://www.bbc.co.uk/news/uk-20026910, Hall - http://www.bbc.co.uk/news/uk-england-manchester-22942439 and others), child  sexual exploitation,  and an increased focus towards online abuse, combined with growing fiscal constraints have led policy makers to become more interested in primary prevention. Work by the NSPCC[1] has shown that the sexual abuse of children costs the UK economy over £3 billion (approximately $4.5 billion) a year. Government is beginning to understand and recognise that sexual abuse and violence is best understood as a public health problem. To the UK we now have a growing interest in prevention and real opportunities to evaluate what works, particularly in relation to primary prevention.

Two members of NOTA (who are also members of ATSA and on ATSA’s Prevention Committee) have taken the lead to  establish a prevention committee within NOTA.  The newly formed committee Is currently exploring how to best identify; promote and disseminate good and promising prevention practice, particularly in relation to primary prevention. The NOTA Prevention Committee works from the standpoint that there is much to be learned and adapted from other successful public health campaigns and initiatives. The main aims of the committee are:

·         To contribute to the development of awareness raising and practices to prevent  sexual  violence against children and adults in the UK and Ireland

·         To focus on all aspects of the prevention of sexual abuse and violence against children and adults and to have a particular focus on primary and secondary prevention 

·         To develop an annual, costed work plan

·         To develop a common understanding of what constitutes prevention is in the context of sexual violence

·         To oversee and drive the development of the Prevention Matters online forum

·         To develop policy positions

·         To facilitate links to other prevention activity in national or local governments or other organisations  

The NOTA Prevention Committee has already begun to meet and plans to address the goals above throughout the year.  And to help increase communications across the Atlantic, NOTA has invited ATSA prevention committee members to join the NOTA meetings.  From these collaborations, we expect to see some excellent opportunities to address this issue before it is a large institutional issue. 

One example of ATSA and NOTA working together is the community engagement events in San Diego (ATSA conference 2014), McCartan who organized the first event, is now coordinating events in Bristol UK and Dublin Ireland.  These events can help improve public understanding about sexual abuse and violence and articulate what can be done to prevent it.

The growth of these initiatives and the growing public attention to the issue of sexual violence, there are many new opportunities opening up with the possibility of having a significant impact in communities on both sides of the Atlantic. 

Jon Brown, M.Sc. , (NSPCC & Chair of the NOTA Prevention Committee)

Kieran McCartan PhD (NOTA Prevention Committee member)                   

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[1] NSPCC (2014) Estimating the costs of child sexual abuse in the UK

The “I” in “Collaboration”

We work in a field that is orientated around the individual, either in terms of our own working practices and/or the clients that we work with (victims or perpetrators of sexual violence); which means that collaboration can be a difficult balancing. What we are learning about our field and working environments is that individualism, in all respects, is problematic and we need to shift towards a more collaborative approach. There are many reasons for collaboration some practical, some financial, some strategic and some common sense; however, the most important reason for collaboration is that it makes us better at our individual jobs and pushes the field forward in new a innovative ways. 

Collaboration is an interesting endeavor that we all struggle with, but has become the staple of our working environment regardless of one’s career (researcher, therapist, civil servant, policy maker, etc), and we are not always effectively taught to collaborate.  Consequentially, true collaboration is a difficult balancing act and does not always work under the best of circumstances. Often times we will hear colleagues and friends telling us about how they collaborate within the teams that they work with; however, this can be misleading as teamwork often involves working on our own part of any project and not always contributing to the big picture. When we collaborate we are effectively surrendering control of a project or task to a group of people, which means that the end result may not be as we individually envisioned and/or a series of compromises.

This then raises the question, why collaborate at all? The simple answer is that it makes our field, our research and our understanding of the world better. For example, the ideal of the lone individual (academic, policy maker, therapist, etc…) is quickly vanishing from the workplace and in its place are a series of collaborations with other others, so other academics (sometimes from other disciplines), other external partners, other professionals and ultimately the public. These collaborations means that the work that we are doing together is fit for purpose, stands up to scrutiny and is applicable in the real world. Collaboration means that that all research can be designed with impact in mind, that the people who will be effected by the research can have an input into how its designed, the questions that are asked and then consider (at the start) what the implications of it maybe.

However, to do good effective collaborative working there are some things that have to do, all of which are not promoted across the board (from degrees to employment) including,

-   Listening to each other and taking on board each others concerns;

-   Effective communication across the group;

-  Making sure that everyone is on the same page, which means using agreed language, goals and compromise;

-    Utilizing constructive criticism, not criticism for its own sake but rather criticism/critical reflection that allows projects to develop ; being a “critical friend”; &

-   Being honest when there are issues as well as working together to overcome them.

We need to be better at collaboration because that will mean that the work that we do impacts more people, especially in the field of sexual abuse. We need to bring policy makers, academics, professional, practitioners and the public to the table to discuss these matters. We need to make sure that collaboration is rooted in the real world, the real issues that people face (whether it be being directly impacted by sexual abuse, not having the funding to keep a programme running, having policies that do not recognize alternatives) and recognize that this will not be solved over night. Collaboration takes time, is built on trust and is a shared endeavor; in working together we all benefit more than we would by working in our own silos.

Kieran McCartan, PhD

David S. Prescott, LISCW

In 500 words (or less): Talking Trauma-Informed Care with Jill Levenson

About two thirds of American adults report at least one type of childhood maltreatment or household dysfunction, and nearly 13% experienced four or more (Centers for Disease Control and Prevention, 2013). These numbers underestimate the rates of early adversity in poor, disadvantaged, clinical, and criminal populations, and in sex offender samples (Levenson, Willis, & Prescott, 2014). As adverse childhood experiences (ACE) accumulate, the risk for myriad health, mental health, and behavioral problems in adulthood also grows in a robust and cumulative fashion (Felitti, et al., 1998). Trauma-informed clinicians recognize the prevalence of trauma in the population, expect the majority of clients to have experienced early adversity, and understand the biological, social, psychological, cognitive, and relational impact of trauma on adult functioning and high-risk behavior.

 

Trauma-Informed Care (TIC) is a framework that is infused throughout a service delivery setting, and it embraces several crucial principles: It is client centered and provides a safe, trustworthy, consistent, validating, empowering environment, and promotes respect, compassion and self-determination (Bloom & Farragher, 2013; Harris & Fallot, 2001). TIC is not trauma resolution therapy. Rather, trauma informed therapists view presenting problems through the lens of early experiences, knowing that children often survive adversity by developing coping strategies that work well in traumogenic households but then become obstacles to healthy functioning in other (more “normal”) environments later in life. The question becomes not “what’s wrong with you?” but “what happened to you?” in understanding how maladaptive cognitive schema and behaviors evolved and became well-rehearsed across various domains of life. Trauma-informed clinicians infuse CBT models with relational interventions that utilize the counseling relationship itself as an opportunity to help clients develop attachments to healthy others, have corrective emotional experiences, and practice new skills (Levenson, 2014). Above all, TIC avoids replicating disempowering dynamics in the helping relationship, including confrontational approaches that reinforce the shame and marginalization that many of our clients endured in their own homes and communities.

 

TIC provides an innovative framework for facilitating change within a larger model of cognitive-behavioral sex offender therapy. TIC complements RNR principles which promote individualized treatment planning to match criminogenic needs, risk factors, motivation, and characteristics impacting the ability to embrace and engage in treatment (Andrews & Bonta, 2007, 2010). TIC also fits well with Good Lives Models that help clients attain self-actualization goals while improving affective and behavioral self regulation (Willis, Ward, & Levenson, 2013; Yates, Prescott,& Ward, 2012).

 

It is time for ATSA to start talking about TIC. For the past 25 years we have almost exclusively emphasized content-focused, offense-specific, skills-based relapse prevention programming. It is perhaps unsurprising that our treatment effectiveness studies have sometimes been disappointing. There are huge literatures that can inform our work: neurobiology of trauma, developmental psychopathology, ACE prevalence and impact on psychosocial outcomes, and the "common factors" of therapeutic alliance and engagement. Evidence-based practice is sometimes too narrowly defined as only those interventions which have shown effectiveness in randomized controlled trials. But EBP begins with building treatment programs that are informed by research in various areas. TIC approaches recognize the role of trauma in the development of problematic behavior, and might mitigate risk to re-offend as sex offender clients experience empowering relationships and learn to meet emotional needs in non-victimizing ways.

 

Jill S. Levenson, Ph.D., LCSW, Barry School of Social Work

 

References

Andrews, D. A., & Bonta, J. (2007). The psychology of criminal conduct (4th ed.). Cincinnati, OH: Anderson Publishing.

 

Andrews, D. A., & Bonta, J. (2010). Rehabilitating criminal justice policy and practice. Psychology, Public Policy, and Law, 16(1), 39-55.

 

Bloom, S., & Farragher, B. (2013). Restoring Sanctuary: A New Operating System for Trauma-informed Systems of Care. New York: Oxford University Press.

 

Centers for Disease Control and Prevention. (2013). Adverse Childhood Experiences Study: Prevalence of Individual Adverse Childhood Experiences. Retrieved from http://www.cdc.gov/ace/prevalence.htm

 

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., et al. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American journal of preventive medicine, 14(4), 245-258.

 

Harris, M. E., & Fallot, R. D. (2001). Using trauma theory to design service systems. San Fransisco, CA: Jossey-Bass.

 

Levenson, J. S. (2014). Incorporating Trauma-Informed Care into Sex Offender Treatment. Journal of Sexual Aggression, 20(1), 9-22.

 

Levenson, J. S., Willis, G., & Prescott, D. (2014). Adverse Childhood Experiences in the Lives of Male Sex Offenders and Implications for Trauma-Informed Care. Sexual Abuse: A Journal of Research & Treatment. doi: 10.1177/1079063214535819

 

Willis, G. M., Ward, T., & Levenson, J. S. (2013). The Good Lives Model (GLM):: An Evaluation of GLM Operationalization in North American Treatment Programs. Sexual abuse: a journal of research and treatment.

 

Yates, P. M., Prescott, D., & Ward, T. (2012). Applying the good lives and self-regulation models to sex offender treatment: A practical guide for clinicians: Safer Society Press.

Q&A with Karl Hanson, co-author of “Less is more: Using Static-2002R Subscales to Predict Violent and General Recidivism among Sexual Offenders”

 

Babshishin, KM, Hanson, RK, & Blais, J. (2015). Less is more: Using Static-2002R Subscales to Predict Violent and General Recidivism among Sexual Offenders. Sexual Abuse: A Journal of Research and Treatment. Advance online publication. doi:10.1177/1079063215569544

http://sax.sagepub.com/content/early/2015/02/07/1079063215569544.abstract?rss=1

Abstract

Given that sexual offenders are more likely to reoffend with a nonsexual offense than a sexual offense, it is useful to have risk scales that predict general recidivism among sexual offenders. In the current study, we examined the extent to which two commonly used risk scales for sexual offenders (Static-99R and Static-2002R) predict violent and general recidivism, and whether it would be possible to improve predictive accuracy for these outcomes by revising their items. Based on an aggregated sample of 3,536 adult male sex offenders from Canada, the United States, and Europe (average age of 39 years), we found that a scale created from the Age at Release item and the General Criminality subscale of Static-2002R predicted nonsexual violent, any violent, and general recidivism significantly better than Static-99R or Static-2002R total scores. The convergent validity of this new scale (Brief Assessment of Recidivism Risk–2002R [BARR-2002R]) was examined in a new, independent data set of Canadian high-risk adult male sex offenders (N = 360) where it was found to be highly correlated with other risk assessment tools for general recidivism and the Psychopathy Checklist–Revised (PCL-R), as well as demonstrated similar discrimination and calibration as in the development sample. Instead of using total scores from the Static-99R or Static-2002R, we recommend that evaluators use the BARR-2002R for predicting violent and general recidivism among sex offenders, and for screening for the psychological dimension of antisocial orientation.

 

Could you talk us through where the idea for the research came from?

The idea for this paper arose when updating norms for the STATIC sexual offender risk assessment tools (Static-99, Static-99R, Static-2002, Static-2002R). With the original Static-99, we used the same items to predict both sexual and violent recidivism. We knew this was not optimal, but it was close. As we explored the STATIC items further, we found that certain items may be negatively related to non-sexual recidivism.  In other words, high scores on these items were related to lower rates of non-sexual violent and general recidivism (e.g., male victims). This was surprising. With the help of Robert Lehmann, we were able to quickly replicate the effect in a new data set from Germany. This gave us confidence that the effect was real.  Then, in our factor analysis work with Sébastien Brouillette-Alarie, we found that many of the items associated with non-sexual recidivism formed a clean factor.  Consequently, we thought it would be possible to improve the prediction of non-sexual recidivism by concentrating on items measuring general criminality.

What kinds of challenges did you face throughout the process?

When we started, there was a relatively small literature on the content validity of actuarial risk scales. Howard Barbaree and others had made some important contributions, but many evaluators (and more than one reviewer) seemed to have difficult thinking of criterion-referenced measures as different from norm-reference measures. We needed a framework that included both approaches. Consequently, we had to justify the conceptual frameworks as well as the specific findings.  

What kinds of things did you learn about co-authorship as a result of producing this article?

Working with great colleagues is a delight.

What do you believe to be to be the main things that you have learnt about the effectiveness of risk scales to Predict Violent and General Recidivism Among Sexual Offenders?

It is essential to understand what is being assessed by risk assessment tools, even when tools are used solely for the purpose of estimating recidivism risk.

Now that you’ve published the article, what are some implications for practitioners?

The main factors underlying sexual recidivism risk are sexual criminality, general criminality, and age.  If evaluators are interested in sexual recidivism, than all three factors should be considered.  If evaluators are interested in general or violent recidivism, then they can do better by dropping the sexual criminality items and focusing just on age and general criminality.  Less is more.