Therapy to Prevent Abuse or Therapy as abuse?

By David S. Prescott, LICSW

Our recent blog on conversion therapy prompted lively discussions in social media.  While efforts around the world seek to end practices aimed at changing people’s sexual orientation, therapists working with individuals hoping to prevent further offending often use methods developed to help clients manage their sexual thoughts and urges. As we suggested in our earlier blog, it is important for professionals to consider the aims of the methods they use. Unfortunately, many laypersons only hear of these methods outside of the context in which treatment occurs. Research has long shown that the context of treatment matters. Used in the wrong context, treatment methods can cause harm. A scalpel that saves lives in surgery can become a murder weapon when used in a bar fight. Not all treatment contexts are alike.

The simple facts are: There are many people in the world who feel a sexual attraction to children but do not want to act on that interest. For them, many elements of daily life are challenging, and they often experience shame and self-hatred resulting from attractions they didn’t ask for and sometimes feel they cannot entirely control. Some of these individuals attempt to live as quietly as they can, while others seek out services, support groups, and other types of help. This has all been documented elsewhere and serves as the foundation to what follows. To be clear, however, sexual interest in children is not something that people ask for or a choice they make.  

While some degree of overlap in methods used in helping people manage sexual urges may also be employed in conversion therapy, there are substantial differences between programs that treat people with a sexual interest in children and conversion therapy as the world has come to understand it. One major difference is that behavioral treatments are only one component of a broader, a more comprehensive approach to helping people lead better, more self-determined lives.

The vast majority of programs treating individuals who have abused others regard their behavioral treatments as methods to help people to manage urges or fantasies that would lead to further harm to themselves or others if they acted on them. On the other hand, conversion therapy seems to hold out some kind of promise that the client will become a different person as a result of this treatment, viewing being gay as an accident to be cured, remedied, etc. It’s easy to write those words in a paragraph, but how they play out in the social context of the client and their alliance with the clinician can be quite another matter.

For example, the client who says, “Please can you help me. Even though I have some attraction to people my own age, I also have this strong desire for kids. I do not want to take the chance of hurting anyone. My thoughts about kids often interfere in my relationship with my girlfriend, which is already tenuous enough. I really want to do anything I can to manage these urges. Please can you help me?” In cases like this, where the client is asking freely and independently, there is the possibility that some of those methods may help, at least in the short term. Can we really compare that to the pain and suffering this video of this man who experienced conversion therapy as some kind of torture? And if there are things that might help, should we really put them off-limits? We’ll come back to that point.

Reading about the contexts in which conversion therapy has taken place can be horrifying. There are good reasons why these approaches, too often delivered intrusively and with prejudice and ignorance, are unethical in most places and illegal in many. But it’s not just the actual methods: They are often provided by people whose knowledge of sexuality harken back to a less enlightened era, and the professionals violate all the tenets of the therapeutic alliance. Further, they blithely ignore the principles of informed consent. These treatments are often unethical on their face in the ways that they run roughshod over clients’ autonomy and beneficence (central to the codes of ethics of all the helping professions).

All of this calls to mind some of the things that Thomas Szasz said in 1961: that therapy can only be ethical when the client comes to the therapist for help and is willing to pay out of their own pocket. His point (as someone who had fled then-communist Hungary) was that we should all watch out for the negative consequences that can occur when the state gets involved in providing treatment.  He might have added the family and societal pressures brought to bear on clients as well. We’ve written elsewhere on how these conflicts can be managed.

The techniques for helping clients manage their sexual behaviors are far less important than whether the treatment experiences:

·         are consistent with the client’s goals; goals that are personally meaningful and relevant, held strongly, and arrived at independently.

·         take place in an environment in which the client feels heard, understood and respected.

·         consider whether the client believes that the techniques of treatment are a good fit for him.

·         include informed consent for treatment that is reviewed frequently.

·         occur in context such that clients view the therapist’s role as that of a helping professional and fellow traveler.

One colleague expressed it like this: “I can’t change what people want; I can only help them to change how they behave around what they want.” Likewise, in describing Motivational Interviewing, Miller and Rollnick (2013) have said that, “Treatment is something we do for and with clients, not to and on them.” These two quotes embody the fundamental differences between legitimate treatments offered to individuals who have abused them and the more controversial conversion therapy that appears in the news and social media.

There are still reasons to be vigilant about implementing any kind of treatment under conditions where personal liberties hang in the balance. How consensual is the treatment when the informed consent was signed under the duress of being imprisoned longer? In addition, the therapist believes it’s important to use these methods. At the same time, the client is going along with the process in order to complete treatment even though they don’t want to. On the other hand, millions of us have signed consent for medical procedures that we didn’t want, that caused us pain and anguish, but that added many years to our lives. There are many, many nuances involved.

Ultimately, professionals have an obligation to consider all aspects of treatment that they deliver, including the context in which treatment occurs.

It’s not the cure, but the delivery system that matters: the importance of community

 

By Kieran McCartan, Ph.D., David Prescott, LICSW, & Kasia Uzieblo, Ph.D.

 

This has been a frustrating week for writing. With respect to developments in our field, it seemed as though the goalposts kept moving; the blog could have been on anything and nothing. As the week started, we were looking at recent reports (The Sun; Complex;  New York Times) about the reality of Pornhub was, despite their protestations, all is not happiness, smiles, sanitized sex, and sexuality; instead, there is a dark side. It wasn’t long before Pornhub took remedial action; we will have to wait to see the results.

Next, the blog was going to examine the unintended impact of new encrypted messaging policies and practices that can put children at risk for grooming and abuse (The Guardian; The Children’s Commissioner for England). This promised much to discuss. However, that debate has been moved down the agenda, in the UK at least, with increased discussions around Brexit and COVID-19. important messages and conversations are getting overshadowed. Stimied again! However, this is a topic that we will return to in the new year, as it highlights the balancing act between risk and safety in child protection with an evolving frame of online protection.

The third and final, blog that we were going to write is about the balancing act between internet filters and prevention messaging after Kieran attended a meeting that discussed whether the cost of implementing such tools was an appropriate and relevant investment. Interestingly, this meeting went round in circles and it was decided that more research and evidence was needed. All of this highlights and focuses the challenge of prevention: do we prevent and try to stop what might happen or do we respond to what is happening? This, in turn, feeds into larger debates and reflects previous blogs on this site, so it felt like retracing old ground.

Another day brought headlines reporting the first people in the UK–first in the world – outside of clinical trials to be vaccinated against COVID-19 with the Pfizer jab, which was great news! Interestingly, the news coverage throughout the day and ensuing discussions about evidence, effectiveness, patient safety, and rollout highlighted the lynchpin that brought all these potential blogs together. The real issue is not necessarily the vaccine itself, but the mechanism through which the vaccine is delivered. The biggest challenge is changing public minds, education, prevention, engagement, inclusion, and community building. All these same challenges confront us in the field of sexual abuse.

Like COVID-19, preventing sexual abuse means understanding and responding to it directly (and does not involve behaving as though it does not exist or will go away on its own). Also, like COVID-19, sexual abuse can be overwhelming, omnipresent, and presents challenges for individuals, communities, and society. This means (again like COVID-19) our response is often divided – even divisive – and results from a spectrum of belief and acceptance. Beneath this are considerations of people’s knowledge, understanding, trust in the system, belief in science, and hopes for the future. In many circumstances, we find ourselves at a stalemate: in recent years, the field of addressing sexual abuse has tried new approaches to tackle the issue, including prevention, reframing messages, groups of people reaching out to the public, and listening systematically to who people who have abused – and those who have been abused – have to say.

Each of these efforts has worked to a greater or lesser degree. We can see the same pattern, the same approaches, and the same frustration in these debates as we do in the rollout of the COVID-19 vaccine. The question then becomes, what now? Do we all need radical overhauls in our approaches? Is the answer to preventing sexual harm in doubling down on our current approaches and seeking out more evidence and opinion? Or is it a return to control and regulation? These are difficult questions with no obvious answers.

The one common element that arises in both the challenges around sexual abuse and COVID-19 – the element that ties together the threads of Pornhub, encryption, and filtering software is the community. Our communities. Sexual abuse is a community issue and therefore communities need to understand it better to respond to it more effectively and prevent its spread. Punishment and restriction do not stop sexual abuse. While such sanctions can help in some cases, awareness and support can do much more.

We are all members of our communities and society beyond, and together we shape the debates and actions that move us forward. Our greatest successes come when we work together, and our greatest failures happen when we resist new information and cooperative efforts. This is true across the board, from child protection to immunization. In many ways, especially in the political arena, our community is more fractured than ever before. While advances in accessing knowledge and resources have brought so much of the world together, they have also happened at the very times that many of us have become increasingly entrenched in our own echo chambers. If services to prevent abuse and rehabilitate those who have abused are the primary issues, then how do we respond? It seems safe to say that we need a new delivery mechanism and new ways to think about moving forward.

The challenge as we move in 2021 is how do we immunize ourselves against sexual abuse, the way that we are immunizing ourselves against COVID-19? And how do we immunize ourselves against both the panic and apathy that violence and the pandemic can bring? How do we get the “cure” out there (in COVID’s case, that means the Pfizer jab, and in sexual abuse, it is the education, knowledge, and understanding we need) in a more effective way? It is a challenge, but as a community, we can work together to solve it!

QAnon and the Hard Work of Preventing Sexual Abuse

 By David Prescott, LICSW, Kasia Uzieblo, Ph.D., and Kieran McCartan, Ph.D.

 According to Wikipedia, “QAnon is a far-right conspiracy theory alleging that a cabal of Satan-worshipping pedophiles is running a global child sex-trafficking ring and plotting against US president Donald Trump, who is fighting the cabal. QAnon also commonly asserts that Trump is planning a day of reckoning known as the "Storm", when thousands of members of the cabal will be arrested. No part of the conspiracy claim is based in fact. QAnon supporters have accused many liberal Hollywood actors, Democratic politicians, and high-ranking government officials of being members of the cabal.”

As scientists, practitioners, and academics, the authors have continued to marvel at the fact that QAnon has gained so much traction. They command an audience in the absence of evidence and when there is so much evidence that they could turn to if their aim really were to prevent child abuse (and we have no evidence of that, either). This raises significant questions about the role and significance of research, evidence, and expert knowledge in the world currently.  Tom Hanks and Hillary Clinton and others may be a lot of things, but calling them pedophiles detracts from the very serious work that at organizations such as ATSA and Stop It Now! (to name only two) are involved in.

In a recent blog post, Marty Klein stated that QAnon is “replacing child protection groups – who should blame themselves.” This comes as a surprise to many organizations committed to preventing abuse, who have mostly read about QAnon in the headlines. To our knowledge neither interest in their work nor their support from charitable foundations and concerned individuals has changed very much. Marty Klein actually only mentions two organizations, Save the Children and the National Center for Missing and Exploited Children (NCMEC), about which he had blogged in 2017. His argument is that, in particular, NCMEC has created the very conditions that allow QAnon to thrive by what he refers to as its scare tactics and “used statistics in a cynical fashion—with concepts like “at risk for exploitation,” “potential victims,” and “children gone missing.” While we are not defending NCMEC (and they can defend themselves), we believe that not every prevention-oriented organization is the same, and that the vast majority do so ethically.

In another blog, Jeremy Malcolm of the Prostasia Foundation offers very different insights, beginning with a description of the evolution of the origins of many of QAnon’s statements and beliefs. Malcolm also takes issue with NCMEC, noting for instance, that “A NCMEC figure that QAnon sources commonly quote is that 800,000 children go missing each year. Less often acknowledged is that in over 99% of those cases the child returns safely, often within hours.” Malcolm’s blog for Prostasia also examines the panic around Satanic cult abuse (which many readers will remember) from the mid-1980s into the 1990s. In the end, when we visited to NCMEC’s website in preparing this blog, we did not turn up any wildly inflated facts, although its aims are clear. We have concluded that there are many points worth noted in these blog posts, and while we may differ in some key areas, we respect the authors’ work very much.

What can we take away from these passionate disagreements? While there is no shortage of overt disinformation in QAnon’s efforts, everyone in these debates appears to agree that the sexual victimization of children should be prevented. That might be a place to start.

 In our view:

·         It’s important to examine the evidence base in deciding what directions we take in any course of action. We need to make sure that people with deep knowledge of the issues are at the table and being listened to. This leads to the question of how we can best “reframe” or “relaunch” expertise in a way that captures the imagination of individuals who are more susceptible to conspiracy theories?

·         Conspiracy theories are not helpful in preventing abuse, especially when so much credible evidence about effective approaches already exist.

·         Accusing people of child abuse has a deep and long-lasting impact; even when the accusation is withdrawn afterward or no proof is being offered, the suggestion will linger for a long time and will remain a stain on someone’s reputation.

·         Groups like QAnon are making the work of preventing abuse more difficult for all of us through their spreading of information for which there is no evidence.

·         Individuals and groups that focus passionately in one specific area are at risk for not taking other perspectives into consideration.

·         Missing from many mainstream and social media accounts is that child abuse is preventable, that many people have developed and tested ways to prevent it, and that knowledge about prevention is there for the taking.

·         A fact that often goes missing in these debates, especially among organizations, is that ordinary individuals can play a powerful role in preventing abuse.

·         Ultimately, all people will be able to prevent abuse most effectively when they are in possession of high-quality knowledge and are willing to speak up and speak out about abuse prevention.

In the end, we need to reaffirm that sexual abuse is an individual, interpersonal, community and a societal level issue; which means that we all need work collectively to prevent sexual abuse and the existent of conspiracy theories undermines this collective working.

In the News: Conversion Therapy in the US and Beyond

By David S. Prescott, LICSW, Kasia Uzieblo, Ph.D., & Kieran McCartan, Ph.D.

 

According to Forbes and other media outlets, a federal appeals court in the US recently struck down local ordinances prohibiting conversion therapy. This has happened at a time when conversion therapy has been condemned in many locations around the world, including Germany this past spring and then Israel in the summer. As many readers will know, the term “conversion therapy” (also known as reparative therapy) is used to describe “any attempt to change a person’s sexual orientation, gender identity, or gender expression”. (This is taken from the GLAAD website’s description, which is worth reviewing, as is this document from a United Nations Independent Expert.) We freely acknowledge that we are not lawyers; we are interested in this case as professionals in the area of preventing sexual offending.

 

A quick Google search on the term “conversion therapy” identifies many ways that it harms people, despite a robust literature showing that it is ineffective. The American Psychological Association and the American Psychiatric Association have issued statements condemning it, as have numerous other professional organizations. In the US, 14 states and the District of Columbia have put laws into place protecting LGBTQ+ youth. There is a considerable historical context that is beyond the scope of this blog, involving the medically and psychologically false idea that LGBTQ (and for that matter, gender-diverse individuals) are sick or pathological, just as there is a long history of severe pain and suffering resulting in long-lasting psychological and physical damage. Conversion therapy continues to take place in a multitude of countries, in all regions of the world.

 

This last point, regarding conversion therapy with youth, could be worthy of an entire conference, given the numerous questions of what would actually constitute informed consent. For example, young people who may be unable to judge the risks and benefits for themselves and the question of parental consent for various forms of treatment, may signal pressure on the youth, whose identify and wellbeing may hang in the balance.

 

In the main, however, it’s important to clarify that the federal appeals court in this case has struck down laws, but made no changes to the ethics codes of the numerous professional organizations that render the practice of conversion therapy unethical. Practicing conversion therapy and holding a license to practice psychotherapy no longer mix, and rightfully so. We are not advocates of conversion therapy as it has been practiced (which has often involved undue coercion either by the therapist, family members, or both). In fact, earlier this year, the Independent Forensic Expert Group (IFEG) of health specialists, declared that conversion therapy is a form of deception, false advertising, and fraud.

 

There are implications, however, of these and related legal proceedings for people working with those who have abused and have sexual disorders. The rationale of the federal appeals court centered on free speech. Number one on the list of freedoms in the US Constitution’s Bill of Rights, free speech is near and dear to the vast majority of people in the world, and not given to many. People have fought and died for it and other freedoms. The court used as one example, that other free-speech cases have involved a Florida law that prevents doctors from talking with their patients about gun ownership (for example, a doctor would not be allowed to talk about the potential health hazards of weapons access where children are present despite the empirical research regarding weapons access and ownership; does free speech end at the door to the doctor’s office?).

 

What are some potential implications of the federal appeals ruling for professionals who work with those who have offended? At the front lines, a number of possible questions emerge. We know that sexual orientation as a broad term is different from sexual interest, sexual arousal, and sexual behavior, but at the front lines of practice, the situation can be more obscure. For example:

 

Between the ethical codes of my profession and the laws protecting free speech, in what ways might I be at risk for treating people who have sexually abused others? There would seem to be a difference between conversion therapy and helping people who have a sexual interest in children, but do I possess the requisite scholarly papers to make a case should I be accused of practicing a variation of conversion therapy? Conversion therapy has traditionally been about changing someone’s same-sex interests; where is the line with changing someone’s age-related interests? I understand that changing someone’s sexual orientation is unethical, but what about changing someone’s sexual interests? How possible is that really? Am I in a safer position trying to help people manage those sexual interests without directly influencing them? Or do I need to think about all this differently?

 

Further, there has been debate about whether pedophilia is a sexual orientation; am I at risk for ethics complaints or prosecution under the wrong conditions? Can I work to change someone’s sexual arousal patterns? Is there a clear line between these and orientation? How would I communicate that to a licensing board? Is it really different when the sexuality I am attempting to influence has to do with harming others (as opposed to traditional conversion therapy focusing on gender-related orientation? Where is the line between influencing someone’s sexuality and helping them to manage urges, thoughts, and fantasies? What are the implications when working with a client who is not their own guardian?

 

We wish to emphasize that we have neither all the questions nor all the answers. To our minds, this is a discussion that has not yet occurred in any meaningful fashion. Questions about pathologizing sexuality will likely exist well into the future, including to what degree various elements of sexuality are innate and biologically based versus learned. Our point in bringing this discussion to the fore is to encourage all professionals to think about the broad dimensions and diversity of the questions that emerge in the assessment, treatment, and prevention of sexual offending.

Under the same sky, seeing different horizons

By David S. Prescott, LICSW

 

An interesting situation arose at a program where I consult on treatment for people with complicated backgrounds and complex needs. At the start of the flu season, many clients were declining to have a flu shot. However, these were the same clients who routinely take antidepressant and antipsychotic medications are known to have fairly significant side effect profiles. At first, this made no sense to me. I wondered whether this was due to historical concerns about the effects of vaccinations that have since been loudly debunked, but they were unfamiliar with those concerns. In some cases, they stated that they didn’t want the irritation of the shot itself. Others said they were concerned about side effects such as flu-like symptoms. In my mind, very little made sense until I considered the interpersonal circumstances. The clients had worked closely with a specialist to determine the most effective medication regime. The professional involved had worked to gain their trust by providing information, asking questions, and – importantly – discussing side effects as well as reminding them of their rights in order to obtain truly informed consent.

 

The flu shots, in contrast, were offered by different staff members who did not take these processes as seriously and had a very different relationship with the clients. All of this reinforced research findings regarding the importance of building alliances in establishing treatment compliance. In order to come to terms with the surface issue of flu-shot motivation, it’s necessary to understand a much broader background of trust, mistrust, and the processes by which each is earned. As the saying goes, we all live under the same sky, yet see different horizons.

 

Of course, this is just one example of the effects of trust and trustworthiness on activities that contribute to health. It shows that the one recent survey, conducted on behalf of The Undefeated, sheds light on the experiences of people of color as well as those from majority culture backgrounds. Among their findings:

 

·         “About half of Black adults say they would not want to get a coronavirus vaccine if it was deemed safe by scientists and freely available, with safety concerns and distrust cited as the top reasons. By contrast, most White adults say they would get vaccinated, and those who wouldn’t get a vaccine are more likely to say they don’t think they need it. Majorities of Black adults also lack confidence that the vaccine development process is taking the needs of Black people into account, and that when a vaccine becomes available it will have been properly tested and will be distributed fairly.”

 

As with the clients I encountered in treatment, considering the context is vital:

 

·         “The share of Black adults who believe it is a good time to be Black in America has plummeted in recent years . . . Just a quarter of Black men now say it is a good time to be a Black man in America, down from 60% in 2006, and just a third of Black women (34%) now say it’s a good time to be a Black woman, down from 73% in 2011. Yet almost six in ten Black adults (57%) believe the current protest movement and fight for racial equality will lead to meaningful change that will improve the lives of Black people in the United States.”

 

Given that this represents the views of so many people, it’s hard not to imagine that it represents the views of the clients of color who are in our treatment programs. It is not difficult to imagine that both our current situation in the US and elsewhere (which we have blogged about here and here) and past horrors, such as the forced sterilization of black women and the Tuskegee Syphilis Study, live on in the memories of many.

 

Meanwhile, a recent study appearing in The Lancet, has found that the presence of psychiatric concerns within the past year is itself a risk factor for COVID-19. Although perhaps not surprising, it highlights the deep connection between physical and mental health, for better or worse.

 

What are the implications of these recent findings?

 

First, unless we are directly asking our clients for their perspectives, we may be missing important information about their experiences, and therefore not have the working relationship with them that we believe we have. Where many treatment providers may see “treatment-interfering factors” our clients maybe seeing a legacy of harm and guarding against it.

 

Second, when we do not have a comprehensive understanding of how they view the world and haven’t taken their perspectives into account, we should not be surprised when our attempts to develop treatment and safety plans fail. Although we may comfort ourselves saying that our clients are responsible for their actions and should be bringing their concerns to us, this is simply not how these things work.

 

Most importantly, it is crucial for majority-culture clinicians to develop an understanding the history of interventions used against People of Color rather than for their benefit.

 

Unless we (evaluators, treatment providers, supervising agents) can create a safe space, we may end up in the same place that the study of history finds. Our clients of color have not forgotten the lessons of history, will be under the stresses of inequity, unfairness, and outright racism, and therefore be more prone to the physical and mental health conditions that lead to COVID-19 and other illnesses resulting in foreshortened futures and early death. They will be less likely to engage fully in interventions that have historically been used against them, or worse, will create an appearance of going along to get along with the goal of returning to less restrictive conditions as soon as they can. 

 

These conditions serve no one. Meaningful participation in treatment can build healthier lives and safer communities. If we are not addressing the very real conditions that clients of color face, how can we consider ourselves to be effective? 

 

We may think that these conditions don’t apply to us as individuals, but recent events show otherwise, from Selma, Alabama, to Ferguson, Missouri, and from Breonna Taylor to George Floyd.