We’re Losing Ground Again

By David S. Prescott, LICSW, ATSA-F

I’ve long felt sympathy for our colleagues working in the area of family and interpersonal violence. These issues are widespread but receive little attention. It is well known that violence against women has only gotten worse in recent years, and yet many governments have considered abandoning the Council of Europe Convention on Preventing and Combating Violence Against Women and Domestic Violence, known as the Istanbul Convention. Too often, the reasons have been political, with governments claiming that while they are against family violence, they want to preserve traditional family values. Observers are quick to note the political aspects of these decisions; one media outlet noted Turkey’s objection to “promoting LGBTQIA identities” (although the treaty’s only reference to sexual orientation merely stipulates non-discrimination).

Of course, it’s not just governments that have difficulty finding ways to prioritize ending family violence. One might reasonably ask how we can end violence when so much of our media and political discourse contain violence and violent themes? Recent media coverage of ideologically based death threats suggests that matters are only getting worse. In my former state of Maine, a Diversity, Equity, and Inclusion coordinator recently fled the state in response to threats made against his life.

A central concern of this blog post is that at a time when too many people view violence as normal and sometimes desirable, those seeking to reduce its harm are too often lost in the mix. Whatever the data may show in one legal jurisdiction or another, we are all up against a cultural maelstrom in which violence and threats of violence have somehow become more acceptable.

What’s not acceptable is that our attempts to stop violence have become wrapped up in politics. Further, most people in our field understandably don’t want to talk about politics. As recently as a few days ago, a listserv for psychotherapists was taken offline for a period of time because of arguments over the current situation in the Middle East. It seems that even when we are open to talking about politics, we’re not particularly good at it.

ATSA has always championed ending sexual abuse. Unfortunately,  at the individual member level, too many potential discussions are off-limits because they are so hard to talk about. Wouldn’t it be great if professionals could talk about the relevant issues without political impediments?

All of this seems relevant at a time when a former US President has recently been found liable by a jury for sexually assaulting a woman. Another jury awarded her more money than most of us can realistically imagine. Lest readers think that mentioning this reflects a political agenda, it is vital to remember that there have been plenty of allegations across the political aisle, including in the 1990s. Indeed, questions of sexual abuse in national politics is nothing new.

It makes sense that discussing the actions of our leaders is difficult at best. Nonetheless, some important points emerge

- Sexual abuse and other forms of violence exist at all levels of society.

-  Current public debates make even acknowledging this fact challenging.

- Many of our policymakers have engaged in the same behaviors they seek to regulate.

- Given all of these things, we are compelled once again to look at sexual abuse through a public-health lens.

-  It would be unconscionable for us, and society, to soften our stance on ending violence simply because there is so much of it on the world stage. In truth, the mission has only become more critical.

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.