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.

 

The Second Edition of ATSA’s Task Force Report on Children with Sexual Behavior Problems is now Available

 By David S. Prescott, LICSW & Amanda Pryor

In 2005 and 2006, I was fortunate enough to be a part of ATSA’s task force on children with sexual behavior problems. The task at that time was simple; we would write a report summarizing what is known, and provide recommendations for assessment, treatment, and policy.

Chair Mark Chaffin made the task simpler still. He organized the task force members into three groups, each of which would tackle one of the content areas and produce a section three pages long He would then edit the document and send it on to the board. Not surprisingly, none of the groups could limit their contribution to just three pages, but this clever approach made the process significantly easier, and the result was both comprehensive and concise.

In 2018, ATSA’s leadership requested an update to this report. The idea was not to start from scratch, but merely to update the first edition.  Again, this seemed like an easy task, but became more complicated along the way, including by significant changes in the office and the onset of the pandemic. The project that started with Phil Rich as the board liaison was then shepherded by Amanda Pryor, who succeeded Phil. Although I had been asked to Chair the task force, the final document reflects collaboration between many players in the task force, the ATSA office, ATSA’s Executive Board of Directors, and its Child and Adolescent Committee.

In other words, both the content and the processes changed over the years, and resulted in a stronger yet more flexible document in an era where the level of scrutiny by stakeholders has only grown higher. This document, which emphasizes person-first language, has been as thoroughly reviewed and considered as any document that ATSA has produced.

 What else has changed over the years?

To start, the research in this area has come a long way. Many people are to be congratulated for this. This research has emerged from many areas, from the University of Oklahoma to the United Kingdom.

During the initial review of the first edition, it became clear that we needed more of a focus on trauma and adversity. Anyone working with children and teens has long had an appreciation for the importance of understanding the role of trauma and adversity in the lives of our young clients. However, our understanding of these areas has become much more granular over time. Working with the task force was a great opportunity to reflect on this.

The role of technology has also changed dramatically. When the first task force report came out, the iPhone was still in development, early exposure to sexually explicit media was less common, and social media was in its infancy. Further, the “tube” sites (a generic term for online pornography sites that provide free content) had begun to flourish only at around the same time as the first edition of the task force’s report.

It is also important to note that our field’s understanding, sensitivity, and appreciation of diversity has also come a long way, in research, professional discourse, and clinical practice. This focus has included considerations related to LGBTQ+ youth and other marginalized communities.

There has been impressive innovation in treatment approaches and modalities. This includes more sophisticated think about family involvement, group-based approaches, and individual therapy. We now have even greater confirmation of the important and very noble role that families and other caregivers can have in helping children emerge into a safer adolescence.

Further, the process led us (and this was really Amanda’s contribution) to produce this as a foundational document focusing on assessment, treatment, and placement considerations. Across the coming months, there will be addenda produced to address specific areas. These include considerations in the areas of technology, sexuality, culture, intellectual and developmental disabilities, sibling abuse, policy, and collaboration with Child Advocacy Centers.

Also in the background is knowledge that the document we produced is aimed at primarily North American audiences and that additional materials with more of an international slant would also likely be welcome. While ATSA is truly an international organization, it also recognizes that North American practitioners can sometimes face unique challenges.

Ultimately, no document can be all things to everyone, but this project, thanks to uncountable numbers and drafts across many years, will hopefully guide many professionals in a more empirically grounded and helpful way.

Download the document: https://www.atsa.com/CSBP-2023

‘Tis the season of restoration

 By Kieran McCartan, PhD

Our friends in America celebrate Thanksgiving this week, a sometimes fraught and challenging holiday.  Families and friends come together to celebrate reunion, restoration, and a rekindling of relationships. It sounds easy, but it’s not! It can be difficult and sometimes irreconcilable. Establishing and re-establishing a sense of family or community is not always easy.

Interestingly, this week is also Restorative Justice week. Across Europe, it’s a time to discuss restorative practice in the criminal justice system. Like Thanksgiving in the US, restorative practice is also challenging and complex. It can also help people resolve issues, rebuild lives, and move forward from the trauma they experienced or caused. Restorative practices are common across social justice; we have seen them used in personal, community, and social conflict cases. My first exposure to restorative practice was long before studying criminal justice; it was in my native Northern Ireland, where the process was encouraged as a community-building device in the peace talks and the creation of the Good Friday agreement. However, there is one area where restorative practice is not always accepted, where it’s seen as challenging, difficult, and, at times, a risk: Sexual abuse!

Last week, Thursday and Friday, I chaired two separate and quite distinct events for the Thriving Survivors organization. One was an event hosted by the Lord Provost of Glasgow, where members of the organization discussed their work and highlighted their good practices. The second event was a traditional conference focusing on restorative justice and sexual abuse, calling for the need to have systematic change in the way that restorative justice is responded to. The events focused on the need for a coherent restorative practice to offer to victims of sexual abuse, one that’s victim-led, holistic, strengths-based, and sustainable. The conference illustrated how those who are victimized by sexual abuse should have access to and engagement with the services that they want, not just the services that the state and third parties want to offer them (or, even worse, feel that they should have). The conference showed that sexual abuse is a complex and multifaceted issue that cannot be separated from real life, especially when the abuse is committed by and connected to family systems, friend groups, and peer networks. Sexual abuse needs to be confronted, and people who are victimized seek help as well as support in whatever form they feel comfortable. The speakers (including Dr Marie Keenan; Dr Estelle Zinsstag; and David Russell) and organisations (Stop it now Scotland; The Consent Collective; Restorative Justice Council; All party working group on restorative justice) reiterated the importance of personal choice, support, collaboration, and taking a victim-centred approach. This was brought together by a keynote from Professor Judith Herman, who talked about her new book emphasizing the importance of the voices of those victimized in the healing process. That system-wide change is needed to make the criminal justice system less traumatizing for victims. One way of doing that is through thoughtful, well-planned restorative practice.

The two days reinforced the importance of personal choice and careful, detailed, trauma-informed, and strengths-based services. If done well, restorative practice can support victims in moving forward and finding closure or acceptance. Restorative practice needs to be victim-led, flexible, and accessible to all. The system needs to change to hear the voices of those harmed. In this season of restoration, please ask yourself what everyone needs to come together and talk about and the best way to do this.

Bridging Science and Various Practices: Insights from NL-ATSA Symposium

 Kasia Uzieblo & Minne De Boeck

An essential goal of the Dutch-speaking affiliation of ATSA, NL-ATSA, is to bring science closer to local professionals, and thus, strengthening the bridge between theory and practice. In our countries, professionals traditionally attend fewer international scientific conferences due to limited budgets and language barriers. Often, our researchers travel abroad to share their insights, having limited chances to connect with local professionals.  Therefore, NL-ATSA provides a platform for individuals who have spoken at the annual ATSA conference. This year, NL-ATSA organized a 'Best of ATSA' symposium with a specific focus: offering Dutch-speaking colleagues who presented at the ATSA conference in 2022 the opportunity to share their insights with local professionals. Additionally, we invited Russell Pratt from Australia as our international guest speaker.

Russell Pratt's Insightful Lecture

Forensic psychologist and D. Psych, Russell Pratt delivered an online lecture titled 'Treating Youth Engaging in Harmful Sexual Behaviour: Considering Developmental Trauma and Pornography Consumption.' Pratt emphasized the importance of approaching minors engaging in sex offenses from a developmental perspective rather than an adult one. He explored how developmental trauma impacts adolescent behavior, including harmful sexual behaviors, through its influence on attachment and brain development. Pratt expressed concerns about easy access to pornographic material and its impact on the well-being and sexual behavior of minors. He stressed the need for addressing such issues from an early age through educational programs, preferably starting at age 6. He discussed The SAVVY CONSUMER Model, a simple, effective framework for professionals and parents to assist children and young people to critique pornography as well as assist in developing their understanding of healthy sexual practices.

Insights from our Dutch Professionals

Minne De Boeck (criminologist and program manager Stop it Now! Flanders) and Kelly van den Heuvel (Stop it Now! the Netherlands), presented The Stop it Now! model of perpetration prevention. On the occasion of its 30th anniversary in 2022, the following three questions were discussed: Where are we now? What innovative projects are currently being implemented? And where do we need to go from here? They described how CSA can be approached using the comprehensive framework for the prevention of child sexual abuse (Smallbone et al., 2008), and demonstrated how specific preventive initiatives (e.g., helpline services, online self help tools, conversation guides, support groups for relatives…) fit in this framework and contribute to the prevention of CSA. By means of the framework, they discussed what is needed for effective prevention of offending behaviors according to Stop it Now!. Furthermore, they presented a case study to illustrate how Stop it Now! helplines work and how prevention can be achieved. They concluded with current common challenges, like the extensive grow of CSEM material, uncertain funding and difficulties with professional secrecy and the rules of mandatory reporting. Furthermore, they formulated suggestions to move forward in offender-oriented prevention, emphasizing the need of social awareness, research, and a public and political shift.

Nina ten Hoor, clinical psychologist and psychotherapist at De Waag, a forensic outpatient service in the Netherlands, shared her research on utilizing EMDR treatment for individuals who have engaged in sexual offending. Her exploration included restructuring distorted implicit cognitions and personal vulnerability factors, reducing emotional responses associated with offending, and addressing deviant sexual arousal. In addition, she looked at how EMDR can also help our clients with processing one’s own trauma as well as offending-related trauma. She presented a case study of a man convicted of child sexual abuse, highlighting the application of EMDR therapy to directly address one’s deviant sexual arousal. A 5-year follow-up conversation with the former client revealed that although his interest in young girls seemingly returned, this client to avoid letting these feelings overwhelm him.

Eveline Schippers, project manager and researcher at the Forensic Care Specialists (the Netherlands), presented her doctoral research on understanding the origins of deviant sexual interests. Defining sexual deviance proves challenging, and Schippers emphasized that we mainly tend to consider its impact on the individual and/or others, and not the nature of the sexual interests/behaviors itself. Despite acknowledging the risks associated with deviant sexual interests in our clients, theoretical explanations for their development remain limited. Still, it is vital to gain insights into how these develop so that we could implement more targeted interventions. Schippers discussed factors such as the excitation transfer between emotions and sexual arousal, highlighting how emotions like dominance/aggression and fear can contribute to stronger sexual arousal. In addition, she presented her study in which she found evidence for four overarching themes within unusual sexual interests, being "forbidden-extreme," "light BDSM" and "BDSM-heavy" and "fetish-forbidden, emphasizing that these interests occur in the general population. Finally, she discussed her meta-analysis showing that child abusers with pedophilia exhibit stronger sexual interests in children than control groups, but at the same time exhibit less sexual interests in adults, suggesting that the latter may be a meaningful factor in treatment.

Promoting Collaboration across Work Fields

The symposium served not only as a meeting ground between theory and practice, but also as a successful meeting ground for professionals working with offenders and those working with victims of sexual offenses. This cross-pollination of ideas, insights, and experiences between the two fields is encouraging and should be stimulated. It became for instance evident that professionals working with offenders may not fully appreciate the many questions those working with victims often have regarding the underlying mechanisms of sexual violent behavior and prevention, amongst others. Encouraging further collaboration between these fields is crucial in our collective effort against sexual violence.

In conclusion, the symposium highlighted the importance of bringing together science and various practices. The engaging lectures underscored the need for ongoing collaboration and the sharing of knowledge to enhance our collective understanding of and response to sexual offending behavior.

 

 

The Impact of World Events on Our Work.

By David S. Prescott, LICSW

I recently discussed the Good Lives Model with a psychologist from the UK. She was not the first to ask a question along the lines of, “How do I work in treatment with a client on the goal of ‘living and surviving’ when they have no job, little help from the government, and are at risk of losing their residence?” It became apparent that the best way forward under the circumstances was to provide resources for her client to remain housed and employed. She had been thinking of living and surviving in the abstract, viewing it through a purely clinical lens.

 

At a time when so many are focused on maintaining fidelity to evidence-based treatment approaches, we can miss the fact that our clients sometimes have urgent needs. Therapeutic conversations and case management can have a role in our work. We may even overlook not only the solutions around us, but our own strengths and resources in finding solutions with our clients. In so doing, we can improve our alliances and specific responsivity. 

 

It's clear that many aspects of our changing world have at least moderately close relationships to risk. Global conflicts, climate change, decreased funding, and the evolving nature of public discourse around inclusion and equity can all influence client risk and protective factors. Although we have historically improved our ability to understand individual clients’ functioning, there is much we don’t understand about how a changing and increasingly uncertain world intersects with re-offense risk. To examine this further:

 

·         While climate change is beyond the scope of this blog and ATSA’s mission beyond, if the trends continue, treatment providers, supervising agents, and clients will all be affected. For example, how does extreme weather interact with risk factors such as relationship stability, self-regulation, and proneness to rapidly escalating affect and emotions? We’ve already seen how community distress can quickly result in looting. Are treatment programs and providers in a position to address these challenges with their clients?

 

·         Recent reports show that housing  and food insecurity are growing, while resources to alleviate them are not. These have occurred contemporaneously with deaths of despair and domestic violence. Meanwhile, within our field, many professionals have had difficulties finding staff due to cost of living increases. One might reasonably ask how we are all doing managing our own risk factors? Have our anxieties had an effect on our own self-regulation skills?

 

·         Further, in many quarters, funding for treatment has decreased, while expectations around billing, documentation, and the threat “clawbacks” of payments already made to providers have increased. At the same time, many states maintain high standards for professionals working in this field. One wonders about a possible collision course between decreasing pay and the ever-increasing responsibilities that come with this work.

 

·         Finally, there are the lingering after-effects of the pandemic. We still don’t know the full impact of the past several years on other forms of interpersonal violence, although we know that violence interacts with sexual re-offense risk.

 

Other questions remain. What are the effects of other world events? As of this writing, there are two major wars in the headlines. Coverage of them has been rife with partisan rhetoric that can make violence seem acceptable in the eyes of clients who have their own violent histories. 

 

Speaking only for myself, I’ve experienced both sensitization and desensitization in response to world events and the ways that media outlets report on them. It can be difficult to place current events into any meaningful or predictive context. Certainty about anything in short supply. We professionals are experiencing these changes, often intensely.  There is no way our clients aren’t as well. The question is how we respond to this, empirically and in practice.

 

Professionals in our field, like our clients, can be remarkably resilient and creative. The hope of the author and the intent of this blog post is that by outlining some questions that don’t often get discussed, we may be better poised to find solutions.