Sunday, May 24, 2015

The “I” in “Collaboration”


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

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

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

However, to do good effective collaborative working there are some things that have to do, all of which are not promoted across the board (from degrees to employment) including,
-   Listening to each other and taking on board each others concerns;
-   Effective communication across the group;
-  Making sure that everyone is on the same page, which means using agreed language, goals and compromise;
-    Utilizing constructive criticism, not criticism for its own sake but rather criticism/critical reflection that allows projects to develop ; being a “critical friend”; &
-   Being honest when there are issues as well as working together to overcome them.

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

Kieran McCartan, PhD
David S. Prescott, LISCW

Friday, May 15, 2015

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



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

 

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

 

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

 

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

 

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

 

References

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

Friday, May 8, 2015

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


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

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

Abstract

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

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

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

What kinds of challenges did you face throughout the process?

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

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

Working with great colleagues is a delight.

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

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

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

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

 

Saturday, May 2, 2015

Capacity and Consent: When is Rape “Statutory”?

In April this year, an unusual twist on sexual consent ended up in an Iowa courtroom.  It is the bittersweet story about an older couple finding a second chance for love, being robbed of their relationship by Alzheimer’s, and then having the State question their right to marital intimacy.  If Henry Rayhons had been able to care for his wife, Donna Lou, at home, instead of a nursing home, it seems doubtful that Henry would have been prosecuted for rape.  At the time they were both 78.   Even after the trial there is some uncertainty about what happened and when, but perhaps Henry’s undoing was that Donna Lou did not have a private room.  Seems when Henry came to visit one day in May 2014, there was only a privacy curtain between Donna Lou and her roommate, Polly, who apparently got an earful.

Given Henry’s status at the time as a sitting Iowa legislator, the possibility of political mischief can’t be ruled out, but regardless, it’s not clear that Donna Lou was actually harmed, or what goals of justice were served by prosecuting Henry.  To complicate this case, Donna Lou’s daughter had been granted guardianship, and apparently the extent of the daughter’s role and authority was an issue at trial.

Henry had been advised that Donna Lou no longer had the capacity to consent to sex.  But in the presence of diminished capacity, who determines that sex is making love or marital rape?  Does a married dementia patient have the right to sex, or the right to be protected from sex?  One expert said, “Someone with dementia is not incapacitated all the time for all things. If they are not incapacitated at the moment of the sex act, they have a right to have sex.”  Before the case went to trial, Donna Lou passed away and Henry declined to run for re-election.  The trial required Henry to discuss his sexual relationship with Donna Lou in open court, and after two days of deliberations, the jury found Henry not guilty.
  
It seems nursing home personnel might need to reconsider policies and practices to meet the unique needs and circumstances of their sexually active residents.  But this case serves as a reminder that, across the life span, clarity and capacity for sexual consent is too often not as crisp as we all want it to be, and that the responsibility for respectful sex has no age limits.

When laws governing consensual sex are overly proscriptive, it can obscure allowances that should be made for respectful sex, when capacities might be reduced.  When it comes to sex between people who might have diminished capacities because of age, intellectual disability, mental impairment, or drugs/alcohol, there are a myriad of considerations, complicated by statutes that vary by jurisdiction.  It’s entirely likely that interpersonal sex that is legal in one jurisdiction might be illegal in another.  Marriage, religion, and personal morals aside, well-crafted laws should make allowances for sexual behaviors between certain people who are developmentally compatible, and have a demonstrable capacity for consent.  The problem, of course, is that physical, mental, and social capacity for sexual consent is not as uniform as the laws that might govern such conduct.

“Statutory rape” has typically been associated with sex involving minors, but broadly, it seems, “statutory rape” has more to do with the capacity of one or both parties to consent.  Statutory rape laws have a tendency to conflate “unlawful” (because of legal capacity) with “non-consensual” (dominion over one’s body).  In the absence of actual coercion, it seems statutory “rape” might be a misnomer, or at least misleading.  Or perhaps, in reality, all rape laws are “statutory.”

The age of consent for minors in North America ranges between 16 and 18, depending on state laws, and even younger between consenting teenagers.  The age of consent in most European countries is 14-16.  We shouldn’t assume that young people understand their unique capacities, or limitations, for sexual consent.  The confluence of alcohol and sex is inherently hazardous when it comes to capacity for consent.  Alcohol should never be an excuse for sexual misconduct; but when at least half of all sexual violations are alcohol related, it should be concerning to potential sexual partners that there is no obvious demarcation for when the use of alcohol has legally compromised the capacity for sexual consent. 

Experts in this Iowa case discussed how difficult it is to determine diminished capacity to consent to sex.  Even when circumstances indicate that someone should be held accountable for misguided sexual behavior, laws are written to allow, not require, prosecution.  When sexual misconduct or capacity to consent is questionable, it sometimes calls for intervention, or diversion, not prosecution.  Just when we think we can be guided by simple models of “no means no” or “yes means yes,” we are once again reminded that both capacity and sexual consent have insidious shades of gray.


Jon Brandt, MSW, LICSW