Sunday, February 1, 2015

The Minnesota Sex Offender Program: Federal Intervention Part 1 – The Challenges

This opinion piece is the first of a three-part series on the Minnesota Sex Offender Program (MSOP).  On February 9, 2015, at the US District Courthouse in St. Paul, a federal trial is scheduled to begin to determine the constitutionality of MSOP.  Part 1 discusses some of the issues and concerns that led to the federal trial.  Part 2 reviews the 2014 report from a team of experts appointed by the federal court to examine the program.  After the conclusion of the trial, and the court has issued its ruling, Part 3 will review the decision and discuss implications.

Three years ago, a group of clients at the Minnesota Sex Offender Program (MSOP) petitioned the US District Court for Minnesota for relief from conditions of incarceration that they claimed were unconstitutional.  A central concern was that the program had then been operating for 17 years, had received more than 700 “sexually violent persons” (SVPs), and not one individual had been able to fully complete the program.  Federal Judge Donovan Frank believed the petition had merit, appointed counsel to represent the plaintiffs, added all MSOP clients as a class, and set into motion a review of both MSOP, as a program, and sexual offender civil commitment (SOCC) in Minnesota, as a system.
 
Also three years ago, this blog called attention to “Doubts about SVP Programs,” raising questions about the legitimacy of SOCC, as least as it has been implemented in Minnesota.  In a federal ruling (2/20/14) Judge Frank wrote that SOCC in Minnesota is “clearly broken,” and suggested that MSOP might be “one of the most draconian sex offender programs in existence.”    Now, a year later, on February 9, 2015, at the US District Courthouse in St. Paul, a federal trial is scheduled to begin to determine whether MSOP and SOCC in Minnesota is unconstitutional.

The authors want readers to know that our motivation in writing this blog is to advocate for the highest standards of practice and policy. We believe advocating for credible and effective treatment for those who have sexually offended, and supporting those who have been victims of sexual abuse, is a not a zero-sum proposition.  We further believe that the issues addressed herein are in the public interest and of importance to all professionals in our field.  Ultimately, a successful recovery for offenders does not come at the expense of victims – it honors victims.  Mandating effective treatment to offenders and protecting everyone’s rights can help to ensure a beneficial outcome for the many stakeholders of sexual abuse: offenders, victims, their families, friends, and society at large.  However, to be credible and constitutional, treatment for offenders must have an end point.  The authors are aware of no bona fide form of treatment for sexual offending that requires twenty years or more to complete.

Given that society considers sexual violations as one of the most despicable crimes against a person, civil liberties for sexual offenders might be among the most unpopular civil rights causes of our time – perhaps of all time.  Since the US Supreme Court ruled, just seven years ago, that sex offenders cannot be subject to capital punishment, the State of Minnesota has effectively accomplished what a vengeful segment of society has long demanded as an alternative to the death penalty – lock up sex offenders and throw away the key.

Since Minnesota reconstituted SOCC 20 years ago, some 740 individuals have been committed to MSOP (including approximately 30 who have died during incarceration).  Only two clients have achieved and survived a conditional release, and no one has been fully discharged.  Effectively, MSOP has a one-way door.

The criteria for release from MSOP has essentially been: completion of treatment, establishment of an aftercare plan, recommendations from MSOP staff and the Special Review Board (SRB), and final approval by the Supreme Court Appeal Panel (SCAP).  Unless a client is released by court order, administrative releases can be politically blocked by the governor

Most clients and staff at MSOP understand the intellectual dishonesty of treatment goals that no one has ever completed.  Clients have the impossible choice of “consenting” to participate in treatment and having less than a 1% chance of release, or withdrawing from treatment and having no chance of release.  Staff have the impossible job of trying to maintain client motivation for unending treatment.  To the credit of many, according to MSOP reports, more than 80% of clients participate in treatment.
 
By all accounts, most clients at MSOP sincerely regret their sexual transgressions, are willing to diligently work on attainable treatment goals, and express their desire to be contributing members of society. They also recognize that, no matter how great their efforts or successful their recovery, they will never escape the state label of “sexually violent person” (SVP) or “the worst of the worst.”  While it is easy to be suspicious of statements by sex offenders that they regret their actions, two studies have found that SOCC treatment clients truly believe that treatment is important (Levenson, et. al., 2009, 2014).  However, as it currently exists, MSOP and SOCC in Minnesota is not a level playing field for clients who earnestly want to achieve their release.

In Judge Frank’s 2/20/14 ruling, he warned that if, “Plaintiffs are able to demonstrate that the commitment statutes are systematically applied in such a way as to indefinitely commit individual class members who are no longer dangerous, or that MSOP is administered as a punitive system despite its statutory treatment purpose, Plaintiffs will likely prove up their claims.”  (p.20)
 
The perilous challenges of “preventive detention,” are well understood by Eric Janus, President and Dean of William Mitchell College of Law.  The promises to balance civil liberties with public safety, and the use of preventive detention under the guise of treatment are discussed in Janus’ intelligent, well-researched book, Failure to Protect; American’s Sexual Predator Laws and the Rise of the Preventive State (Cornell University Press, 2006).  Janus reveals the often-deceptive appeal of SOCC, explains the complexity (and failure) of existing public policies to effectively abate sexual offending, and outlines several measures as prudent alternatives to the problematic and constitutionally compromised use of preventive detention.

It is not the case that the State doesn’t know what to do with MSOP; it is a lack of professional courage and absence of political will.  In 2011, the Minnesota Office of the Legislative Auditor published a detailed review of MSOP and a list of recommendations.  In 2012 the Federal Court directed a SOCC Task Force to be convened and make recommendations.  The Task Force released their final report in 2013.  In 2014, a panel of sex offender treatment experts thoroughly reviewed the program and issued their report in November, 2014.

SOCC in Minnesota, and 19 other states, are driven by justifiable public outrage over an unacceptable level of sexual violence in the US.  But sexual predator laws in the US are also rooted in antipathy toward “sex offenders” and pervasive myths about sexual offending - chief among them: that sexual offenders are a homogeneous group of people that can be readily identified, that most sex offenders will reoffend, that treatment doesn’t work, and that experts can accurately identify which individuals are “highly likely” to reoffend – one standard which must be met for SOCC (Brandt, Wilson, & Prescott, in press).

In recent years there is a growing body of literature that creates further doubts about what it means to be “highly likely” to reoffend.  In 2013, Dr. Grant Duwe, Director of Research for the Minnesota Department of Corrections published research which concludes that the majority of clients at MSOP are likely to NOT reoffend, even when actuarial research is extrapolated to “lifetime.”  In 2014, Dr. Karl Hanson and colleagues released their latest research on one of the most prevalent actuarial tool used for SVP assessments – the Static 99R.  Their research strongly supports Duwe’s findings - that sexual re-offending, even among offenders considered at high-risk, has been overstated, and that the correlation between desistance and time/aging is even stronger than previously believed.  Further, Hanson and his colleagues found that re-offense rates decreased with time that offenders lived in the community (as opposed to in institutions).  It seems that the same actuarial research that is used to put many clients under SOCC, now indicates that most MSOP clients will not reoffend.  Whether or not this new research supports a finding that MSOP is operating in an unconstitutional manner, it is clear that SOCC as applied in Minnesota is greatly overreaching.

With no MSOP clients having been released via completion of treatment, many clients are pinning their hopes on a judicial release.  Indeed those hopes may not be misplaced.  In 2014, there was actually one release from MSOP which got little attention, because it was out “the back door.”  For one client at MSOP, a powerful dissenting opinion in the Minnesota Court of Appeals set-up an appeal to the Minnesota Supreme Court.  As a result, his case was remanded to district court.  After splitting hairs on the differences between “likely” and “highly likely” to reoffend, the district court ordered the client released, as not meeting criteria for commitment.     

Judge Frank wrote in his preliminary ruling that the court will not allow clients to remain at MSOP if they do not meet legislative and/or constitutional criteria for confinement.  While the trial has not yet begun, there is much evidence already in record to support the need for a major overhaul at MSOP.  What is soon to be determined is whether SOCC in Minnesota, as applied, is unconstitutional. 

Despite the Federal Court’s admonishment to state leadership to take immediate action to correct course, all three branches of Minnesota’s state government remain in paralysis.  The last two governors have placed moratoriums on administrative releases from MSOP, and the state courts have repeatedly ignored opportunities to step-up judicial oversight.  A few courageous lawmakers have tried to take up the cause, but two legislative sessions have passed without enacting necessary reforms.  

Going into the third legislative session since the Federal Court put Minnesota on notice, the Minnesota legislature has capitulated to a faux chicken-egg dilemma:  the federal court has indicated that the state legislature is the best political body to enact reforms, but reforming MSOP is too politically explosive for elected lawmakers, who would prefer to take political refuge in explicit directives from the federal court.  Metaphorically, Minnesota seems to have approached SOCC with the same lack of foresight of grabbing a wolf by the ears – don’t want to hold on, too scared to let go.
 
In a 8/11/14 Federal Ruling, when Judge Frank could have acted but demonstrated extraordinary judicial restraint, he wrote that, “It is obvious that but for this litigation [clients] would likely have languished for years in the prison-like environment of MSOP-Moose Lake, without any realistic hope of gaining [release].” (p.34)  Several other states with SOCC have a simple criteria for release, consistent with numerous court rulings – clients who no longer meet criteria for commitment must be released.  It appears there may be hundreds of clients at MSOP whose confinements are not supported by squishy criteria for commitment or virtually unattainable standards for release.  By growing indications, it appears that many clients at MSOP could be safely and unconditionally released, and many more clients could be treated successfully in the community. 

Judge Frank wrote in his February 2014 ruling, “To be clear, should plaintiff’s prove up their claims, the statutes as applied and implemented are not likely to survive constitutional scrutiny.” (p.21)  After 20 years of failed attempts at reforms by the State, putting MSOP under the supervision of the Federal Courts is only controversial to those who accept status quo, or believe that “lock them up and throw away the key,” is acceptable public policy.  There is precedence for the Federal Courts to assume control of SVP programs that have run afoul of the US Constitution.  In 1994, the Federal Courts put Washington’s State SOCC program under federal supervision for 13 years.  This federal lawsuit has now made Minnesota ground-zero for the debate about SOCC.  To redirect all three branches of State government, and coordinate all the moving parts of SOCC in Minnesota, it now seems likely that meaningful reforms will require the courage of a Federal Judge and no less than the power of the Federal Courts. 

Jon Brandt, MSW, LICSW
David S. Prescott, LICSW

Blog Note: Part 2 of this three-part series will discuss the 2014 report prepared by four sex offender treatment experts appointed by the Federal Court to review MSOP to try to determine why Minnesota has the highest per capita rate of SOCC in the US.

References

Brandt, J., Wilson, R.J., & Prescott, D.S. (in press). Doubts about SVP programs: A critical review of civil commitment in the US. In B. Schwartz (Ed.), The Sex Offender, Volume VIII. Kingston, NJ: Civic Research Press.

Duwe, G. (2014). To what extent does civil commitment reduce sexual recidivism? Estimating the selective incapacitation effects in Minnesota. Journal of Criminal Justice. Volume 42, Issue 2, March–April 2014, Pages 193–202.  OnlineFirst 2013.  Retrieved from http://www.sciencedirect.com/science/article/pii/S0047235213000482

Hanson, K.,  Harris, A. J. R., Helmus, L., & Thornton, D. (2014). High-Risk Sex Offenders Might not be High Risk Forever.  Journal of Interpersonal Violence. October 2014, vol. 29, no. 15, 2792-2813.

Janus, E. S. (2006). Failure to Protect: America's Sexual Predator Laws and the Rise of the Preventive State. Cornell University Press.

Levenson, J.S. & Prescott, D.S. (2009). The treatment experiences of civilly committed sex offenders: A consumer satisfaction survey. Sexual Abuse: A Journal of Research and Treatment, 21, 6-20.

Levenson, J.S., Prescott, D.S., & Jumper, S. (2014).  A consumer satisfaction survey of civilly committed sex offenders in Illinois. International Journal of Offender Therapy and Comparative Criminology, 58, 474-495.

Friday, January 23, 2015

Preventing sexual abuse in the UK: A conversation with Donald Findlater by Jon Brown

As part of the new prevention series I had a conversation with Donald Findlater, Director of Stop it Now UK. (www.stopitnow.org.uk)   Stop it Now UK was established in 2002 by the Lucy Faithful Foundation ( www.lucyfaithful.org.uk) as a result of the inspirational work of Fran Henry, Joan Tabachnick, Alisa Klein and others who of course set up Stop it Now in the U.S.  The Lucy Faithful Foundation is the only UK wide charity dedicated solely to reducing the risk of children being sexually abused. Stop it Now UK was advocating for the primary prevention of sexual abuse before it was really on the social or political agenda in the UK. Under Donald’s leadership, Stop It Now UK has played a pivotal role in raising the profile and importance of preventing sexual abuse and violence.

Stop it Now UK provides a helpline for people who are concerned about their sexual thoughts and behaviour as well as for other family members and for professionals wanting to know more about sexual abuse prevention. It also provides a range of prevention and treatment services.

Before taking on the leadership of Stop it Now UK Donald, who originally trained and worked as a Probation Officer and manager and then  Director of the Wolvercote Clinic, , another initiative ahead of its time in many ways. The clinic provided residential treatment for men who had sexually offended and was the only one of its kind in the UK. The clinic was forced to close due to funding difficulties and to this day the UK still does not have a specialist residential treatment centre for sexual offenders outside the Criminal Justice System.  Funding challenges have also been an issue at Stop it NowUK. Not surprisingly, Donald talks with frustration about the way in which support for prevention activity has been reduced at a time when there is finally a greater recognition of the need to intervene earlier and more proactively to stop sexual abuse and violence occurring in the first place. Donald’s persistence and optimism has been really important in ensuring a continued  focus on sexual abuse prevention in the UK.

Other prevention services provided by Stop it Now UK include Inform, a programme for family members of internet offenders with the aim of helping them to understand the offenders’ motivations and how they can best support the family member to help them remain offence free in the future.  Inform is an individually treatment programme for online offenders that aims to ensure the recipient understands their motivation to offend online and what they need to do to remain offence free in the future. An adapted Inform programme has also been developed for young people; this is also delivered individually.  

All Stop it Now interventions address healthy sexual development through offering information and education; they are based on the premise that sexual abuse and violence is a public health problem that can and should be prevented and this belief has been central to Donald’s motivation to develop Stop it Now. Donald is clear that if we are to make progress in reducing levels of sexual abuse we need to have better informed and aware individuals, families and communities. The work of ATSA member, Stephen Smallbone in Australia has been particularly influential for Donald in developing a prevention framework.

When considering the future, Donald speaks eloquently about the need for more outcome data in the UK to measure the effectiveness of prevention interventions.   Under Donald’s leadership, Stop It Now UK is playing its part with the evaluation of the Helpline (for more information go to www.stopitnow.org.uk).  In fact, in June 2014 an independent evaluation of the Stop it Now! Helpline, conducted by specialist researchers from NatCen Social Research, was published. The report has been described as 'overwhelmingly positive' with findings showing that the Helpline provides a valuable contribution to tackling child sexual abuse by helping people who have sexual thoughts, feelings and behaviour towards children manage their behaviour, and by assisting all callers to be informed about how to protect children and young people from risk of harm. Study participants who had offended could report feeling more in control of their sexual thoughts and behaviour after using the helpline. Positive change was also reported in areas identified as protecting against re-offending, such as:- improving emotional and psychological well-being; addressing beliefs that can facilitate and maintain sexually abusive behaviour; strengthening motivation to desist; reducing the risk of social isolation; and increasing engagement in fulfilling and productive activities. The findings from the research were synthesised and used to develop a toolkit outlining how similar programmes could be implemented elsewhere in the UK. The toolkit was also tested with other project partners in Germany and Finland. More information can be foundhttp://www.stopitnow-evaluation.co.ukStop it Now continues to grow and now has a presence in a number of other European nations.    

Jon Brown, MSc

References

Smallbone, S., Marshall, W.L. and Wortley, R. (2008) Preventing child sexual abuse: evidence, policy and practice, Cullompton, Devon: Willan Publishing.

Friday, January 16, 2015

You Can’t Always Get What You Want: Research and Policymaking


In October 2013, Bill Miller (the primary developer of motivational interviewing [MI]) addressed a group of MI trainers in Krakow, Poland. He took note of the fact that despite its nearly mythical status, randomized clinical trials of MI have only shown treatment effects 58% of the time; 42% of studies have found little or no effect. Make no mistake about it: MI has produced significant effects across diverse areas of psychotherapy, including within prison-based treatment settings. Just the same, the wisdom and courage of Miller’s statement belies the understated tone in which he made it. As our field patiently awaits the results of gold-standard studies proving that what we do works, some researchers, like Bill Miller, have gone beyond the has-it-been-effective-in-a-randomized-clinical-trial question and are taking note of an emerging but often unrecognized trend: treatments competently implemented in many areas are not necessarily effective in all of them.

 

A few years ago, this was the case with an implementation of multi-systemic therapy in Ontario (for a more complete description of these findings, click here). More recently, another examination of MST in Canada appears to have produced beneficial preliminary effects, but is not without acknowledged methodological problems such as a small sample size and process issues (e.g., 65% of participants who provided scores on the Therapist Adherence Measure –Revised rated their therapists as being sufficiently consistent with MST principles. This is below the recommended target of 80%). Between the experiences of multi-systemic therapy and motivational interviewing, professionals should always keep in mind the bigger picture of their efforts and bear in mind that in program implementation (as in life) we don’t always get what we want.

 

In 2012, a review of studies examining a parenting-skills program appeared, and did not get the level of attention that it deserved. Philip Wilson and his colleagues conducted a systematic review and meta-analysis of 33 studies of the Triple P parenting program. Although this may seem unrelated to the treatment of people who have sexually abused, their findings are valuable to all policymakers. At first glance, the Triple P parenting program boasts numerous successful randomized-clinical trials and meta-analyses; numerous jurisdictions have promulgated and paid for its implementation. While these accomplishments have been praiseworthy, Wilson and his colleagues found numerous problems with the research and question basing public policy on flawed research. Among the authors’ conclusions:

 

In volunteer populations over the short term, mothers generally report that Triple P group interventions are better than no intervention, but there is concern about these results given the high risk of bias, poor reporting and potential conflicts of interest. We found no convincing evidence that Triple P interventions work across the whole population or that any benefits are long-term. Given the substantial cost implications, commissioners should apply to parenting programs the standards used in assessing pharmaceutical interventions (p. 1).

 

The examined bias across studies as well as bias within studies, blinding of assessors, percentage of clients who dropped out, etc. In one instance, the authors noted that:

 

Although it claimed to have achieved a reduction in the incidence of episodes of child maltreatment [5], it actually demonstrated an unexplained rise in reports in control areas rather than a drop in Triple P intervention sites. The description of the random allocation was poor, and the analysis was simplistic, being a two-sample t-test of county-wide measures. In particular, although some form of stratification or matching was used (it was not clear exactly how this had been done), there was no evidence that this had been accounted for in the analysis. For example, if counties were randomized within pairs, then the within-pair differences in the changes from baseline would have been of interest, but these were not reported. Therefore, although there are positive conclusions from this study, some doubt remains as to their validity (P. 8).

 

In this author’s estimation, Triple P appears to have produced very good results and has doubtless improved many lives. Just the same, Wilson et al.’s points are well taken: where large-scale public policy is concerned, we should be very careful how we place stock in single studies or even groups of studies, and ask more questions than simply “does it work.” Likewise, there is a body of research finding that bona fide treatments often produce equivalent results (Wampold, 2001), returning us to the question “what works with what client under what circumstances.” Ultimately, professionals and policymakers should be data driven.

 

  David S. Prescott, LICSW

Wampold, B.E. (2001). The great psychotherapy debate. Mahwah, NJ: Lawrence Erlbaum Associates, Inc.

Sunday, January 11, 2015

Journal Spotlights for 2014

With the start of a new year, we at the SAJRT Blog (Myself, David and Jon) thought that we would devote the first blog to what we thought were three stand-out journal articles of 2014. We have each written about one journal article, which are personal choices by the bloggers, and not based on data regarding  any journal downloads or citations.

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Lewis, Klettke and Day published their paper, entitled “Sentencing in child sexual assault cases: factors influencing judicial decision-making”, in the December edition of the Journal of Sexual Aggression. This article stood out to me as being quite salient as it tackled one of the main issues that often arises in public understandings of sexual abuse, and related punishment, sentencing. The article discussed the factors that involve decision making in CSA cases in terms of sentencing and verdict. The research was based upon 113 cases of CSA in Australia from 1998 – 2009. The results indicated that the main factors that affected judicial decision making where (1) creditability (i.e., if the victim is not seen as credible by the judge this impacts the sentence handed down), (2) behavioral evidence (i.e., the behavior of the child victim before and/or post event, with lower level harmful behaviors being seen as indicative of CSA as well as higher level ones), and (3) offence factors (i.e., young victims and more victims resulted in long sentences). This research is important as it is on an under researched area, talks to the need more multi-profession working, the existence of sexual abuse myths within the system by professionals (who should have a better and more realistice perception) and a need for better education on the reality of CSA, and its impact upon victims, for the legal system.Although this research was based in Australia it speaks to a wider international issue. (KM)

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A study that has garnered less discussion than one might think is by Karl Hanson, Andrew J. R. Harris, Leslie Helmus, & David Thornton, “High-Risk Sex Offenders Might not be High Risk Forever,” published in Journal of Interpersonal Violence.  In brief (and taken from the abstract), the authors followed and aggregated sample (drawn from 21 smaller samples) of 7,740 sexual offenders to examine the risk they posed for sexual recidivism over a 20 year follow-up period. Overall, the risk of sexual recidivism was highest during the first few years after release, and decreased substantially the longer individuals remained sex offence-free in the community. This pattern was particularly strong for the high risk sexual offenders (defined by Static-99R scores). Whereas the 5 year sexual recidivism rate for high risk sex offenders was 22% from the time of release, this rate decreased to 4.2% for the offenders in the same static risk category who remained offence-free in the community for 10 years. The recidivism rates of the low risk offenders were consistently low (1% to 5%) for all time periods. The authors state that these results suggest that offence history is a valid, but time dependent, indicator of the propensity to sexually reoffend.

What can professionals take away from these findings? Perhaps the most important lesson is that risk reduces with the passage of time in the community, and that this must be accounted for in risk assessment. However, professionals and the public alike have heard statements to the effect that “once a sex offender always a sex offender.” While many in our field have long known that this statement is untrue, Hanson, Harris, Helmus, & Thornton’s study challenges all professionals to think differently about persistence in, and desistance from crime.

What lessons can policymakers draw from this study? The current state of our research makes clear that we should consider short-term, high-intensity, cost-effective responses to sexual offending (such as providing opportunities to complete treatment programs) to longer term, cost-ineffective, and low intensity responses that have demonstrated no effect on reducing risk (such as lifetime GPS monitoring; see Smith, Goggin, & Gendreau, 2002). Clearly, even one sexual re-offense is one too many and virtually everyone wants to prevent further sexual harm. This study illustrates the need for empirically supported risk assessment in order to best allocate public resources. Only then can we claim that we are engaging in the most effective ways possible to prevent sexual abuse. (DP)

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Hanson’s 2014 article on desistance, as David reviewed, has implications that are far-reaching and yet to be realized.  If fidelity to evidence-based practices (EBP) is foundational in the treatment and management of those who have sexually offended, Hanson’s research, simply stated, should result in significant adjustments to sex offender policies and practices, both systemically and as applied to individual clients.  It is incumbent on professionals to actually use new research when it reveals outdated practices.  This point is central to a 2014 Aggression and Violent Behavior article by Theresa Gannon and Tony Ward.

In “Where has all the Psychology Gone?  A Critical Review of Evidence-Based Psychological Practice in Correctional Settings,” Gannon & Ward wrote, “The correctional psychology discipline is facing a crisis - [the] correctional psychologists’ mounting neglect of evidence-based practice… [that] stems from psychologists’ acquiescence to the risk and security oriented policies of correctional systems.” 

Gannon & Ward discuss the “immense tension between punishment and rehabilitation proponents,” which has existed for more than 100 years.  They describe the “dual relationship” that therapists must straddle when institutional security imposes constraints on privileged communication and therapeutic relationships.  Because security concerns are legitimate, the therapeutic alliance, which is vital to positive therapeutic outcomes, is continuously under pressure.  The therapeutic alliance is further compromised by institutional considerations masquerading as therapeutic concerns.  Sometimes, psychotherapists are forced into managing security issues, while correctional officers and undertrained paraprofessionals are often required to exercise roles that should be in the domain of experienced clinical staff.

Gannon & Ward are not na├»ve to the gap between the ideals of efficacious psychotherapy and the realities of providing services to a large number of clients, within institutions that operate under politically-imposed constraints.  Indeed, they argue that these are reasons why licensed psychotherapists should assert professional and ethical responsibilities to EBP, rather than simply capitulate to competing concerns.  Gannon & Ward don’t specifically refer to SVP or civil commitment programs, but their arguments would seem to be even more applicable in settings where there is a clear mandate to provide efficacious psychotherapy to involuntary clients.

It would be wrong to conclude that “Where has all the Psychology Gone” is a scolding of psychologists, or that the authors’ arguments don’t apply to all licensed psychotherapists.   Gannon and Ward have painstakingly reinforced every paragraph with links to sources that will support professionals who recognize both the efficacious benefits and professional responsibilities to maintain EBP in institutionalized treatment.  Clinical and administrative professionals who want to “put the psychology back” into institutional settings, will find a compelling case that evidence-based psychological practices do not have to take a backseat to institutional security.   (JB)
 
(Please note: The authors Professor Tony ward [Tony.Ward@vuw.ac.nz] and Professor Teresa Gannon [T.A.Gannon@kent.ac.uk] are happy to be directly contacted by any readers who would like a copy of their article.)

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We hope you enjoyed these snippets, that you will go  read the full articles and that they will give you food for thought. These three articles indicate that there is still educational and supportive work to be done in respect to sexual offending  with professionals (in all guises) across the Criminal Justice System, as well as outside of it.

Kieran McCartan, Ph.D, David Prescott, LICSW, & Jon Brandt, MSW LICSW.

References

Gannon, T. A., & Ward, T. (2014) Where has all the Psychology Gone?  A Critical Review of Evidence-Based Psychological Practice in Correctional Settings, Aggression and Violent Behavior, 19, 435-446.

Hanson, K.,  Harris, A. J. R., Helmus, l., & Thornton, D. (published online).High-Risk Sex Offenders Might not be High Risk Forever.  Journal of Interpersonal Violence.#

Lewis, T., Klettke, K.,  & Day, A. (2014). Sentencing in child sexual assault cases: factors influencing judicial decision-making.  Journal of Sexual Aggression, 20, 281 – 295.


Smith, P., Goggin, C., & Gendreau, P. (2002). The effects of prison sentences and intermediate sanctions on recidivism: General effects and individual differences. (User Report 2002-01). Ottawa: Solicitor General Canada.

Saturday, December 13, 2014

Putting the humans back into human services

The question of how and where psychologists draw the lines of ethical conduct has flourished in the news recently. Revelations of the American Psychological Association’s (APA) connections with the CIA interrogation-torture have surfaced both inside the Washington DC beltway (with the US Senate Select Committee’s report) and out (e.g., James Risen’s Pay and Price: Greed, Power, and Endless War, which inspired the APA to re-open their investigation).

Although the torture of detainees is very different from the treatment and supervision of people who have sexually abused, some points are worth noting as we consider the effects of our actions on our clients and society. CIA detainees and sexual offenders are often more vulnerable populations than they appear. It can be easy to feel an urgent need to use whatever means are necessary to reduce risks as quickly as possible. It can be easy for professionals to lose sight of just how much power they hold over the people in their charge. Finally, it can be easy to believe that one is not capable of causing harm to people in our care or custody. As one extreme example, CIA psychologist Kirk M. Hubbard stated in a journal article titled Psychologists and interrogations: What’s torture got to do with it?:

Constanzo (et al.) argue that ‘psychologists should not be involved in interrogations that make use of torture or other forms of cruel, inhumane, or degrading treatment’ . . . Their statement is ironic for torture is illegal in the United States. But even more importantly, it seems to come from and apply to a world that no longer exists. . . . We no longer live in a world where people agree on what is ethical or even acceptable, and where concern for other humans transcends familial ties. 

This statement does indeed contain ironies (e.g., it seems that no one is disputing that torture took place outside the US, or the belief that whatever happened could not be torture because that would be illegal, or that because it took place outside the US it was somehow less unethical).  This statement also illustrates how people in the helping professions can find or imagine exceptions to standards of professional conduct (e.g., behavior that would be unethical under other circumstances is ethical when the world is changing and we believe that old rules don’t apply). Certainly, the behavior of nations in wartime is beyond the scope of this blog and the expertise of this author. However, professionals at the intersection of mental health and the law will want to consider factors that influence our understanding of ethical conduct, as well as how these same factors may appear to change over time. Lost in the current media discussion are other discussions about the involvement of mental health professionals in interrogations (e.g., Chaffin, 2010).

A new article appeared in the Journal of the American Academy of Psychiatry and the Law, this time by psychiatrist and retired Brigadier General Stephen Xenakis, titled, The role and responsibilities of psychiatry in 21st century warfare. In it, he states:

When I first worked with detainees at Guantanamo Bay, I was troubled by a peculiar and unsettling awareness . . . Here I was, focusing on torture and cruel, inhuman, and degrading treatment of prisoners and yet, these were the very men who were the “enemy.” As a career Army officer, I pledged to protect our nation against all enemies, foreign and domestic. As a physician, I pledged to care for all who were hurting and needed help. Facing some detainees who were tortured because they were our enemies, sometimes with the aid of military physicians, I felt I had entered a domain in which the old paradigms ceased to apply. Perhaps that is one of the fundamental problems with Guantanamo. . . . I have always believed that doctors are champions of human rights, no matter what role or assignment we accept. After all, every society endows their doctors and healers with special trust and confidence. We symbolically wear the white coat at all times, even as psychiatric experts for the prosecution or in military uniform.

What does this have to do with the treatment of sexual violence?

In 2010, the late psychiatrist Bill Glaser wrote (among other things) that in its current state, sex offender treatment is punishment and that professionals should not kid themselves about this.  Jill Levenson and I wrote a reply in which we argued that this is simply not the case, and that licensed professionals are bound by ethical codes that make it unlikely for treatment to be entirely punitive. Just the same, Glaser’s point was well-taken, in that our clients don’t always view their treatment to be as helpful as their therapists do (Beech and Fordham, 1997), even though consumer-satisfaction surveys of sex offenders have often produced positive results (e.g., Levenson, Prescott, & Jumper, 2013).

In 2011, Steve Sawyer and I published an article on boundaries and ethics in sex offender treatment. We observed that:

The licensed therapist treating sexual offenders has an ethical responsibility to the client, a legal responsibility to the court, and an ethical/moral responsibility to the community. Specifically, the therapist’s primary responsibility to the client’s welfare is checked in part by the standard of practice to share information with county/state corrections and/or the community as required by law or by contractual obligations or as needed to protect the community. This is done with informed consent from the client or as needed by law. Within these limits of confidentiality, however, the therapist’s focus is on the sexual offender client. This situation recognizes that the client is best served—and the public is best served—when the therapist and the client develop a therapist–client relationship that is separate from the sexual offender’s relationship with the probation officer and the court.

This seems clear enough; professionals in our field are almost always involved in balancing the rights and welfare of others and develop specific practice skills for doing so. Yet the recent events involving large agencies and organizations (the APA, CIA, etc.) should still make us wonder if there aren’t other concerns to bear in mind. In what ways might we go wrong? What should we look out for in order to prevent harm to clients? How can we maintain the highest level of professional conduct?  Anecdotally, it seems to the author that the most common forms of grievances and ethics complaints (when they occur) are in the areas of misuse of evaluation measures, and coercive treatment experiences.  

Readers may be aware of an ongoing class-action suit in Minnesota. After 20 years of operation, only three people of a current census of over 700 have ever received provisional discharges (one within the past few days), raising inevitable questions of constitutionality of the program. The federal judge in the case established an expert panel to examine the program; their report was published recently. This expert panel consisted of four experts, three of whom have served as directors of civil commitment programs. After nearly a year of reviewing the program, they released a 108-page report with 44 broad recommendations. Within their (at times devastating) conclusions, the panel comments on the apparent failure of many clients to advance in treatment, although they note efforts to expand a pre-release portion of the program:

This delay appears to be a result of a pervasive belief on the part of MSOP administration and staff that it is not their responsibility to proactively petition and rigorously advocate for clients to advance in phases and to CPS. There is a shared belief of having no control because the structure of the law and its processes have created the inability to release clients. . . Clinical staff and clinical supervisors do not appear to be supported or encouraged to appropriately modify the treatment offered in order to appropriately respond to the individual and complex needs of these clients. From a clinical point of view, this population seems to be administratively unrecognized, misunderstood, and inappropriately served (or underserved). It was clear to the Panel that staff who work with these clients have genuine and compassionate concern for the wellbeing and future aspirations of their clients, in spite of feeling unsupported in their attempts to advocate for programmatic changes.

Although there is always more to any story, two themes emerge for purposes of this discussion:

·         One is the theme (often heard in discussions as diverse as CIA abuses and good programs that fall on hard times) of good, decent staff at the front lines feeling powerless and helpless (apparently, a parallel process to the experiences of the clients in the program).  

·         Another is the theme that apparently no one was advocating for the rights or wellbeing of the clients.

In my view, there may be two areas of focus for professionals that might be helpful and that are often outside strict interpretations of ethical codes.

The first is advocacy of quaternary prevention, as described in our field by Geral Blanchard and others. While primary, secondary, and tertiary efforts focus on preventing sexual violence among specific populations, quaternary prevention focuses on the prevention of harm being caused by these same efforts. Most, if not all professionals who enter our field want to practice ethically. Yet, many providers and treatments have caused harm under the mantle of helping others.

The second is that all people in our field should re-visit the idea of advocacy, alluded to recently in an article titled Where has all the psychology gone? by Gannon and Ward. Where our field once advocated for community safety to the point of placing clients’ needs second to community safety, it may be time to consider just how far back that second place is.  For example, the Texas Department of State Health Services defines sexual offender treatment, in part, as: “Sex offender treatment is different than traditional psychotherapy in that treatment is mandated, structured, victim centered, and the treatment provider imposes values and limits. Providers cannot remain neutral because of the risk of colluding with, adding to, and/or contributing to the offender’s denial” (Texas Department of State Health Services, 2012).

As an example of context of advocacy elsewhere, consider this section of the preamble of the NASW Code of Ethics:

Social workers promote social justice and social change with and on behalf of clients. “Clients” is used inclusively to refer to individuals, families, groups, organizations, and communities. Social workers are sensitive to cultural and ethnic diversity and strive to end discrimination, oppression, poverty, and other forms of social injustice. These activities may be in the form of direct practice, community organizing, supervision, consultation administration, advocacy, social and political action, policy development and implementation, education, and research and evaluation. Social workers seek to enhance the capacity of people to address their own needs. Social workers also seek to promote the responsiveness of organizations, communities, and other social institutions to individuals’ needs and social problems.
The mission of the social work profession is rooted in a set of core values. These core values, embraced by social workers throughout the profession’s history, are the foundation of social work’s unique purpose and perspective:

·         service
·         social justice
·         dignity and worth of the person
·         importance of human relationships
·         integrity
·         competence

The preamble to the APA Code of Ethics is more succinct: “Psychologists respect and protect civil and human rights.”

Perhaps our next step as professionals is to ask ourselves:

·         Even though our clients provide informed consent to our treatments, how much duress must they be under to do so before it is not meaningful consent to treatment (e.g., “I am only consenting because if I don’t it’s four years added to my sentence”)
·         To what extent are we advocating for both our clients’ needs as well as community safety?
·         At what point is it acceptable for a mental health professional to induce suffering, whether directly or indirectly?
·         At what point do mental health providers in large institutions (such as civil commitment programs) have an ethical obligation to advocate for their clients over and above what the administration is (or is not) doing?

And in the shorter term, and against the backdrop of the axiom that the only thing necessary for the triumph of evil is that good men do nothing, how can professionals best discuss these topics publicly while maintaining the highest standards of professional conduct?

 David S. Prescott, LICSW

Monday, December 1, 2014

Connecting Sexual Violence Expertise with Bullying Prevention

A conversation with Ray Knight
Written by Joan Tabachnick

As part of our new prevention series, I had the chance to speak with one of my ATSA heroes, Ray Knight about his relatively new work and interest in bullying prevention.  Most people know Ray as a passionate public speaker who once literally presented on stage while in bed from a back injury. He is remarkable for his ability to race through 180 slides in an hour and still leave the audience wanting more.  If felt that way in my interview with him about this new avenue of his work. 

 
Ray’s relatively new focus on bully prevention grew out of his desire to apply what he has learned in aggression research to a practical prevention project.   It is also a great example of how ATSA members are using their skills and knowledge to have an impact on prevention in their community. 

 
A few years ago, Ray and his wife, Judith Sims-Knight, began working with the Foxboro School system, monitoring the effectiveness of a Caring School Community (CSC) program in grades K through 4th.   The children are then followed up through high school.  In the K-4th grade intervention, children are taught through cooperative learning about how to mediate conflict and through modeling and participation about the importance of prosocial behavior and community involvement.  Both teachers and children model these behaviors throughout the school.  In Ray’s own words, “So far, it is showing promise in reducing aggression as those that have experienced the program progress to higher grades.”   

 
Ray and Judith began their work in Foxboro as part of their work with a parent task force and then brought their well-regarded research skills to this project.  As parent-researchers, they are administering, scoring, and interpreting for the school system an annual computerized inventory that assesses the incidence of both perpetrating and being targeted for various forms of bullying.  If a respondent is identified as a bully or a target, the computer program asks more detailed questions about the circumstances and consequences of this behavior. Not only does this identify for the school system areas for potential intervention, but it also serves as a consistent monitor of the frequency of these behaviors so that they can determine whether programs that they implement to reduce aggression have any effect. 

 
The assessment protocol that Ray and Judith created, which is based upon the bullying literature, serves as a metric to measure the efficacy of this program. This protocol is, however, more than just a research tool; it also helps the school system identify problem areas they need to address.  For example, Ray described how the children identified a problem with the band room in the high school – significant bullying occurred there before, during, and after school. The administrators used the computer survey to examine what was happening and take steps to solve this problem. 

 
In addition to physical and verbal bullying, the research is also looking at relational aggression such as gossiping, telling stories about someone, exclusion behaviors such as who sits alone at lunch and who is invited to parties, and cyber bullying, which exclusively uses the internet and social media for bullying. In 2013, 5th, 6th, and 7th grades had experienced varying amounts of CSC, and those experiencing the program could be compared to students who had not experienced CSC.

 

The initial data are showing that the intervention is working. Ray and Judith are also finding that physical bullying seems to break into two components, instrumental/proactive and reactive aggression.  For those who don’t know the terms, instrumental or proactive aggression is an aggressive act intended to achieve a goal, while reactive aggression is retaliatory and stems from anger or hurt. The CSC program does affect the anger and dysregulation that contributes to reactive aggression, but is less effective for reducing instrumental aggression.  The program also appears to reduce the active forms of relational aggression (rumors, gossiping) but not the more passive exclusionary types of relational aggression (not enough room for one more at the lunch table…). Direct meanness and verbal harassment also decrease. Next year, they will be able to analyze whether CSC also decreased sexual harassment, when the participating students reach the age at which these questions are asked.

 
 Overall, the initial results show that the Caring Schools Program is working.  It has had a huge impact on the community and the teachers.  What might be hardest to measure is how it also motivates and energizes the teachers so that the motivation and interest in the program keeps growing!  You can check out the feedback that Ray and Judy have given to the school committee and administrators, and a doctoral dissertation that has examined the first three years of the follow-up at http://www.raymondknightphd.com/research.

 

 

Tuesday, November 25, 2014

Sexual Violations and Sexual Violence

 
“When sexual abuse occurs in the absence of violence,
and in the presence of trust, kids may be totally disarmed.” 
 Early in my career, as a child protection social worker, I was dispatched to a school, accompanied by a police officer.  A school nurse had reported a 12-year-old girl who disclosed sexual abuse.  The nurse asked “Amy” if she would tell us how her father would come into her room at night and hurt her.   Amy quietly shook her head, “No.”  It seemed Amy was recanting.  Then the nurse asked, “Amy, do you remember telling me how your dad would come into your bedroom at night and touch you under your pajamas?”  Amy nodded, “Yes, but he didn’t hurt me.”  The ‘ah-ha’ moment struck all of us - the nurse had chosen words that conflicted with Amy’s experience.  Amy added tearfully but confidently, “I love my dad.  I just don’t want him to come into my room at night.”
In that short exchange, Amy conveyed two important lessons: first, that professionals should let victims tell us how they experienced sexual violations, and second, a victim will often have an otherwise valued relationship with their abuser.  This is especially true for child victims, when more than four out of five sexually abused kids are abused by a friend or relative.
Amy was indeed harmed, in ways that she would need help understanding, but she didn’t experience the kind of violence that immediately cues kids that something bad is happening.   When sexual violations occur with the recognizable violence of pain, bodily injury, force, or threats, even young children instinctively know that something is very wrong.  Sexual abuse that includes “violence” is easily recognizable, always harmful, and always against the law.  But when sexual violations occur without veritable violence, many children, predisposed to trust their abuser, often don’t recognize that they are in the midst of sexual abuse.  Sometimes sexual abuse is a violation of a relationship.
One insidious characteristic of non-violent sexual abuse is that it may be unrecognized.  When people are asked why they didn’t report the abuse, they sometimes say they felt duped, perhaps complicit, but mostly confused.  And when victims otherwise liked their offender, they often didn’t report because they were afraid of the uncertainty of the aftermath – for themselves and for the offender.
These are among the findings of research conducted by psychologist Susan Clancy.  Dr. Clancy interviewed hundreds of adult survivors of child sexual abuse for her 2009 book, The Trauma Myth; The Truth About the Sexual Abuse of Children – and Its Aftermath.  Clancy reported that the vast majority of sexual abuse of children occurs without violence, and, as a result, adult survivors typically expressed that, as children, they felt more confused than traumatized by the experience, especially if the abuser was someone who they otherwise liked and trusted.  Clancy suggested that children experience sexual abuse in a range of unique ways and that professionals should be supportive in letting kids tell us how they experienced sexual abuse, with cautious judgment.  Clancy validated Amy’s experience.
In the years after “lessons from Amy,” when I began to work with offenders, I discovered that offenders are similarly disabled by the other side of the same coin: offenders usually admit they knew they were taking advantage of another, but are slow to understand sexual harm that is not accompanied by violence.  Non-violent sexual violations often occur in a blind spot for both victims and offenders, especially when abuse is within families or between friends.
When people have an understanding of “sex offenders” as violent rapists, predatory child molesters, or otherwise “evil monsters,” and family or friends don’t fit that description, children are unguarded by familiar relationships.  When sexual abuse occurs in the absence of violence, and in the presence of trust, kids may be totally disarmed.  The “monster myth” and perceptions that sexual abuse must be “violent,” may obscure both victims and offenders from recognizing a broad range of sexual violations.
More than half of all children who are sexually abused, are abused by an older child.   Depending on the age difference between kids, sexual contact might be against the law in one state (or province), but not in another.  In many states, sex between teenagers might be “statutory rape,” even if it meets criteria for consent.   If certain sexual behaviors are “statutorily” proscribed, they are, by definition, illegal, but if it is truly consensual should it be called “rape,” which in any form is understood to embody violence?
Prevention of sexual abuse should begin by teaching kids about sexual respect, but teenagers need to also know local “statutory rape” laws, or risk becoming a “child molester” or “rapist” because they crossed a legal definition or jurisdictional line.  People are taught from a young age that violence is never okay, and that sexual violence is particularly reprehensible.  But in the absence of violence, the rules for interpersonal sex are often confusing for young people.  Teaching people about sexual respect goes beyond avoidance of sexual violence, and inoculates both future victims and would-be offenders.
In summary, sexual violence is not a synonym for sexual abuse – it is a subset.  When we describe all sexual abuse as sexual assault or sexual violence, we risk losing recognition by victims as well as offenders.  We also lose the critical importance of context and the actual continuum of sexual abuse.  Perhaps in our zeal to convey that sexual abuse is a serious matter, we use “sexual violence” as an attention-getting, generic term, however, using “sexual violence” to describe all sexual violations might exacerbate deceptive myths, and unwittingly hinder public education and prevention efforts.
Jon Brandt, MSW, LICSW