Monday, April 24, 2017

The 2017 ATSA Adolescent Practice Guidelines

The ATSA Adolescent Practice Guidelines (APG) has finally been published!  The APG addresses the expected areas of best practices, but also offers progressive perspectives on many related issues.  To obtain a copy of the 85-page 2017 APG, please see the end of this blog.  

Sexual offending by teenagers, as a class, is materially different from adults.  The APG boldly addresses these differences, proficiently noting distinctions of adolescence, understanding youthful etiologies of sexual violations, and offering cogent recommendations for sound assessments and appropriate treatment.  Such discernments are essential for systemic integrity in managing responsible interventions and successful recovery for teenagers and their families

Tom Leversee and Jacque Page co-chaired the committee that developed the APG.  Because Tom was invited to co-author this blog and it would be unseemly for him to gush about the excellent product that was crafted by the APG team, Tom’s comments are deliberately separated from the discussion by SAJRT blogger, Jon Brandt.  Tom writes…
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In addition to Tom and Jacque, the Adolescent Practice Guidelines were primarily authored by a committee that included Kevin Creeden, Elizabeth Letourneau, Sue Righthand, and Daniel Rothman. The revision and final approval process involved the ATSA Board and a response period for ATSA membership.  Maia Christopher provided her unwavering support, persistence, and guidance. 

The APG integrates a historical context, unique features of the adolescent population, empirical underpinnings, and foundational concerns.  The APG addresses interventions including Assessment, Treatment, Special Populations, and Policy considerations. 

A historical review of the treatment and supervision of those who have sexually offended reveals how policies and practices for adults gradually migrated into the juvenile system.  A survey of policies and practices in various jurisdictions, agencies, and individual practitioners would surely find that vestiges of adult models continue to impact the adolescent field.  The inclusion of a Policy section notes that the application of adult policies to adolescents is not only ineffective at reducing the low base rate for sexual recidivism, but comes with unintended consequences that can produce more harm than good. 

The APG seeks to further reverse this historical trend by offering an empirically grounded, caregiver-involved, developmentally appropriate approach for addressing abusive sexual behavior with adolescents.  This includes an emphasis on the social ecology in which adolescents reside and on the importance of therapeutic relationships.  Effective practices and policies reflect the heterogeneity that has been found in the research and the need for comprehensive assessments and individualized treatment plans.  Four fundamental aspects of effective public policy for adolescents are offered.

The enthusiastic response to the workshop on the APG that Jacque and I presented at the 2016 ATSA conference in Orlando suggests an excitement that goes beyond individual practitioners and programs.  Workshop participants spoke of a desire to utilize the APG to educate important participants, including probation and parole officers, human services caseworkers, attorneys, and judges.  Many have expressed the hope that the APG will not only be utilized to inform significant change in clinical practice and policy, but to inform legislation.  Meaningful change will require effective collaboration between a broad range of interdisciplinary stakeholders.
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The APG sensibly expects assessments to be empirically informed, and logically expects treatment to be “assessment informed.”  The APG points to the Risk-Need-Responsivity model as the gold-standard for guiding assessments and treatment.   With a 3% base-rate for sexual recidivism, as a practical matter, nearly all juvenile offenders are at low risk for sexually reoffending.  Therefore, exploring Needs and Responsivity may be vastly more beneficial than diligently trying to micromanage Risk.  The APG correctly notes that general delinquency correlates with sexual offending and therefore certain dynamic risk factors may be valid targets for treatment.

With the backdrop of sexual safety, personal accountability, and social justice, the APG supports the principles of Good Lives, positive psychology, and building on protective factors.  It encourages a pro-social, holistic reconciliation of individual needs, aspirations, human agency, family involvement, and community support – a synergistic milieu within which young clients can recover and prosper.

The APG confidently weighs-in on many competing concerns and perplexing controversies. It also acknowledges that some complex issues cannot be resolved by science alone.  Therein lies the intersecting domains of clinical judgement and professional ethics.  Being mindful of the involuntary nature of clients, and the value of well-informed assessments, the APG discusses many concerns that are ethically tinged, including: being part of a team intervention, managing unprivileged communication, determining when an assessment or treatment are (not) indicated, acknowledging the limitations of forensic psychology, challenging unwarranted legal interventions or sanctions, avoiding unnecessary conditions or undue burdens on clients, promoting least-restrictive placements, and supporting least-intrusive methods.  The APG, with participation from the ATSA Board, recommends against the use of the polygraph and PPG for clients under 18.*

With an eye on standards for practitioners, the APG expects clinicians to be qualified and technically skilled.  But it also wants clinicians to recognize that the therapeutic relationship is not only central to inspiring motivation and hope for recovery, but that it might be a therapist’s greatest asset.  The APG bravely comments on how unwarranted social controls and misguided policies may interfere with rehabilitation efforts.  The final section suggests that engaged practitioners can help to inform colleagues, mediate public policies, and perhaps intercede on behalf of clients.  Public safety is a systemic concern, and many stakeholders participate in reducing recidivism, but the clinician may be uniquely positioned to not only guide clients through recovery but to advocate for their well-being.

Journal articles and text books are vital conveyances of knowledge that help to build a sound framework for practicing in our field, but best practices depend on the skilled, ethical applications of knowledge, experience, and the ‘professional self,’ uniquely applied to each client.  The 2017 Adolescent Practice Guidelines is a compendium of wisdom.  Potentially, it will help good practitioners become great clinicians, and interventions with adolescents will be more empirically rich and ethically sound.

Jon Brandt, MSW, LICSW
Tom Leversee, LCSW

*Note: these and other controversial areas of juvenile practices are topics for future SAJRT blogs.

The Adolescent Practice Guidelines is available free to ATSA members by logging into the Member’s Page.  When the APG is available for purchase by non-members, information will be posted here. 

Thursday, April 13, 2017

Risk and those who experience harm

A friend of one of the authors was a forensic psychologist in a European country and gave permission to share her story. The short version is that she was on her way to meet her son and took a shortcut through a park. There, she was raped by a stranger. It was a nasty assault that could have ended much worse due to a health condition. Thanks to her quick thinking and smartphone, her son helped the police to apprehend the person before he left the park. He apparently had a lengthy criminal record, including similar assaults. There is little question that he was a high-risk, high-velocity person in need of outside forces to stop him.

To hear her tell the story, it seems that the most devastating effects of this life-threatening experience actually occurred in its aftermath. The nature of the local police department, and her work at the intersection of law and psychology, meant that all of her colleagues had access to every detail of her experience, and were unafraid to express judgment about her circumstances. This serious breach of privacy was a primary motivator in her leaving her country and relocating elsewhere. Once resettled, her primary concerns for getting on with her life typically had more to do with her children and pets. Any lingering bitterness had more to do with the response from the legal system than the assault itself. It’s quite possible that the presence and actions of her son prevented years of more serious problems. 

On the other hand, a pioneer in the field of prevention (no longer active) used to publicly describe how her father molested her growing up, and the devastating after-effects that lasted across the rest of her life. She was a force of nature as she described how the only thing she ever wanted was for the abuse to end. As one might imagine, she had few places to go, and fewer people to whom she could turn to make her father stop. By all appearances, had her father come to the attention of the legal system, his risk would have been low in accordance with actuarial risk measures. For that matter, so would many famous people who have abused, including Jeffrey Dahmer, Jimmy Savile, and Jerry Sandusky; and yet the harm in their wake has been horrific. 

The narratives that we hear from people who have experienced sexual abuse reflects these experiences. Often we hear that they did not report as they felt that they would not be believed or that nothing would be done. Often, they believed that they type of abuse perpetrated, their relationship with the perpetrator or the context of the abuse [in their eyes or their beliefs around the perceptions others] mitigated the abuse. In some cases, people don’t report because they are afraid that it will lead someone to cause harm to the person who abused. All of this highlights the complexity in experiencing and living with sexual abuse, especially if the individuals involved are in close proximity to each other and therefore have to come into contact frequently; in that sense no risk is low risk to the victim, more a constant low-level trauma.

All too often, it seems that in our rush to improve risk classification, we also create an appearance of uncaring and benign neglect of the experiences of those who are abused. What is striking is how the harm of abuse was mitigated by family relationships in the first case and aggravated in the second. And yet from a purely risk-based perspective, the second case involved a lower-risk abuser.

This, in turn, creates terrible dilemmas. As the saying goes, bad cases can result in bad laws, and the authors certainly advocate for reserving the most intensive interventions who pose the highest risk. At the same time, however, our field creates risks of its own at those moments when we appear disconnected from the relational harm of trauma.

At a time when we advocate person-first language for people who have abused, it’s vital that we have the same consideration for those who have been harmed. Not everyone who has experienced abuse wishes to be called a “survivor” or “victim”. Taking this further, however, the above vignettes who how important it is that all professionals communicate in a way that demonstrates respect for all who have experienced sexual abuse, without creating the appearance of being dismissive of harm or of overstating risk for future abuse. In the end, skills for demonstrating respect, understanding, and effective communication are intertwined.

David Prescott, LISCW, and Kieran McCartan, Ph.D.