Tuesday, March 14, 2017

Beware of Easy Answers: The perils of single studies

The ATSA listserv was recently immersed in a discussion about mixing various clients in treatment groups, including those who are higher risk with lower risk. The discussion arrived at a familiar place: the idea that treatment can actually elevate risk among those who are lower risk. There has been research suggesting that high-intensity interventions can sometimes increase risk among lower risk people in the criminal justice system (Smith, Goggin, & Gendreau, 2002), but the idea that treatment can make people worse is one that we should examine very seriously. Ours is a field in which we continue to ask questions about whether treatment works in reducing future sexual violence, and if so, how, with whom, with which methods, and with what kinds of therapists.

The discussion focused an influential paper by Brian Lovins, Christopher Lowenkamp, and Edward Latessa in 2009, which found that “low-risk sex offenders who successfully completed treatment were 27% more likely to be reincarcerated than sex offenders who did not receive halfway house services” (p. 353).

Although that finding appears at first to say that intensive sex-offender treatment of low-risk sex offenders caused an increase in sexual recidivism, we think it would be a mistake to draw that conclusion, both from the paper and in general application to practice.  Although this finding has apparently been put forward as an indication of treatment somehow increasing recidivism or sexual recidivism, it’s not clear that it’s treatment that accounts for the results.

Page 348 of the Lovins paper includes:

Recidivism was coded as incarceration for any new offense, return to incarceration for a technical violation, and any new arrests for a misdemeanor or felony offense. For the purpose of this study, incarceration for any new offense and return to incarceration for a technical violation were collapsed into a single measure of return to incarceration for any reason.

As we read this study, comparisons were made between people who were released from prison (a) directly into the community or (b) into halfway houses.  It seems important to note that:

1.     The two groups differed in terms of their living situation and level of supervision, not just intensity of treatment, and
2.     The recidivism variable was re-incarceration, not detected SEXUAL recidivism per se.

One has to wonder what other factors might have influenced release decisions that were not accounted for in the study? After all, the groups were not randomly assigned to their conditions and there is therefore no reason to think that they were equivalent.

Our reading of this study is that it might reflect different re-incarceration rates for returning citizens who are faced with different levels of community supervision (halfway house or not) rather than different intensity levels of sex-offender treatment. For example, on pages 347-348, the authors state:

The second sampling frame comprised parolees who were released directly to the community on discharge from the institution. Out of the original 3,273 offenders in the comparison group, 238 had a sexual crime as their instant offense. These comparison offenders may have been mandated to outpatient treatment in the community at release, but they did not receive the more intensive residential sex offender treatment.

This highlights the fact that neither of the comparison groups consisted specifically of untreated low-risk sex offenders. Further, page 348 of the Lovins et al. study states that:

Because there was no consistent measure of risk across programs and parole, the modified SFS (Note: this stands for Salient Factor Score; it is not a validated, stand-alone measure of recidivism risk for people who have sexually abused) was used to determine level of risk. The modified SFS includes the following risk factors: prior arrest, prior commitment, age at current offense, employed at arrest, history of community control violations, and history of drug use. The values for each variable are weighted and the total ranges from 0 to 10. Risk categories were developed based on the raw values. The modified SFS consists of four categories: low, low/moderate, moderate, and high.

As we understand this statement, not only is the study not reporting on differences in detected sexual recidivism, it is also the case that the “low risk offenders” are given that classification on the basis of something other than a commonly accepted assessment of their risk to sexually reoffend.

Taken together, there are good reasons not to consider this study as an indication that providing intensive sex-offender treatment to “low-risk” sex offenders causes an increase in (sexual) recidivism. To sum up our concerns about taking the Lovins et al. (2009) study as compelling evidence that low-risk people should not receive treatment:

·     Recidivism in this study refers to ANY re-incarceration, not specifically to a new sex crime, or even to a new crime at all.
·    None of the groups specifically consisted of people who did not receive sex-offender treatment. More specifically, it is a comparison of people who were or were not required to live in a halfway house after release from confinement.
·    Classification of “low risk” had very little or no relationship to what we would think of as “low risk” for sexual re-offense. Measures specifically developed and tested for this purpose were not used.
·    The number of people in the comparison group was 14, and in the “low-risk” “successful completion” group, even lower.  The actual differences in re-incarceration are likely around 3 of 14 for the comparison group, and perhaps 3 of 11 for the “successful completion” group.

We very definitely intend no disrespect to the authors, Brian Lovins, Christopher Lowenkamp, and Edward Latessa; this is an informative study. Quite the opposite: we want more studies to examine this question. For the moment, however, we are serious in our discouragement of professionals viewing this study as evidence that providing treatment to some released sex offenders causes an increase in (sexual) re-offending.

The authors of this post are people who have read the extant research and overseen programs, and at times have come to many differing conclusions as to the future of our field. This is precisely why we need better research. In our view, a primary take-away is that professionals in our field should continue to humbly, even quietly, try to go about the work of doing no harm and making every effort to prevent and reduce the harm of sexual abuse.


Gregory DeClue, Ph.D., ABPP (forensic), and David S. Prescott, LICSW

Thursday, March 9, 2017

Using the Rock & Water method in the treatment of forensic psychiatric patients

 
This is linked to a previous blog entitled “Holland and Belgium Are Getting It Right: The 2017 ATSA-NL conference”. Kieran.

 
We are honored to write a blog about our work at the Van der Hoeven Kliniek, a forensic psychiatric hospital in Utrecht the Netherlands.

 On the 26th of January 2017 Kieran and Bill had a guided tour in our hospital. At the Sports department they were very interested in the Rock & Water method which Lonneke v/d Pol, Ernst Janzen and Erik Timmerman provide besides other sport lessons. After their visit they asked to write this blog and so we did.

The Rock & Water method has been implemented within this hospital in 2008. The workshops for patients focus on aggression regulation, learning how to set boundaries, and how to improve social skills. The focus is on becoming aware of their own behaviour and the impact of their behaviour on others in daily life.

 
The Rock & Water method

 
The Rock & Water method provides participants with skills for physical-social teaching with a focus on body awareness, emotional awareness and self-awareness. The concepts 'rock' and 'water' are being used as a metaphor to explicit different forms of communication.

By experiencing practice-focused physical exercises, it is easier to transfer these skills to situations in daily work or life. By creating moments of choice, the participants can learn to consciously make decisions and regain control over their behaviour in complicated situations, for instance, when it is needed to set boundaries without getting in an escalating conflict. Participants will learn to become aware of personal possibilities, qualities and responsibilities. The workshop focuses on social competence and inner strength. In daily life, individuals will have to be able to function as a rock (strong, immovable and with self-confidence) and as water (remaining in contact, flexible and connecting). The basics of the program include grounding and centring exercises, standing strong and rock and water attitude in physical and verbal communication. The power of this method is that by practicing and experiencing the different physical exercises, one can learn to regain control in their daily life at work, school or society.

Golden triangle:

 The golden triangle comprises of
                 -              Self-awareness
                 -              Body awareness                              
                 -              Emotional awareness

Applicability in daily clinical forensic psychiatric practice:

Since 2008, the Rock & Water program is being used with the Sports department. Just like the other sport activities, the program is part of the treatment program of the patient. When the method was implemented, it was immediately successful. All patients easily recognized the terms Rock and Water and the active part was appealing to them. These lessons are provided for individual patients or to small groups of maximum 6 patients.

For the TBS (disposal to be treated on behalf of the state implying mandatory treatment) patients with severe and complex psychopathology, we offer individualized programs in close collaboration with their psychotherapists or their supervisors. For patients with other judicial titles who are usually admitted for shorter-term , we provide series of 10 lessons supervised by a sports teacher together with a therapist. The workshop has multiple aims. Generally, the workshops focus on reduction of tension and emotion regulation, learning how to set boundaries and improving social skills.

After the implementation in 2008, the use of the method has expanded enormously. For the TBS patients the method is oftentimes mentioned as one of the indicated treatment activities and there is constructive deliberation between the trainers and psychotherapists in improving treatment of patients. For the patients with other juridical titles, the Rock & Water program is standardly adopted in the treatment plan. Both patients and staff members are very enthusiastic about the method. Patients indicate that “not just talking” works well for them and that they like to be able to put in their own perspective.

More and more, the program is being incorporated by patients in their early signal plans and relapse prevention plans. Multiple patients state that months or years later they still make use of the techniques and benefit from it. For us, this is a strong indication that the Rock & Water program is effective and suitable for forensic psychiatric patients.

Erik Timmerman (etimmerman@hoevenkliniek.nl) is sports teacher, staff trainer and coordinator of the Sports department in the Van der Hoevenkliniek. As advanced Rock & Water trainer he provides individual workshops and group workshop for patients, as well as for staff members.  He is owner of EighT – Opleidingen, Trainingen & Coaching in which he also predominantly works with the Rock & Water method.

References

-          Ykema, F., Het Rots & Water Perspectief – basisboek (2002)
www.rockandwaterprogram.com

 
-          Ykema, F., Hartman, D. and Imms, W. (2012) Bringing it Together, - Includes 22 case studies of Rock & Water in practice in various settings

 
-          Timmerman, E. (2012) WESOCO training, EighT – Opleidingen, Trainingen & Coaching. www.eight-trainingen.nl

 
-          Graaf I. de, Haas S. de, Zaagsma M. and Wijsen C. (2015) Trimbos-institute Utrecht, The Netherlands. Effects of Rock and Water: an intervention to prevent sexual Aggression. Journal of Sexual Aggression.

 

 

 

Wednesday, March 1, 2017

Considering the alternatives to traditional Child Sexual Abuser risk management: Prevention?

Risk management often involves a difficult balancing act between public protection, victim empathy, victim support as well as offender punishment, deterrence and rehabilitation; quite often one is achieved at the cost of others. This balancing act becomes compounded if you are dealing with a high profile offender population, like child sexual abusers and/or paedophiles, because you are dealing with many interested parties outside of the state-run criminal justice system who understandably want their voice heard and their opinions counted; which is appropriate and correct, however you factor into financial austerity, cuts in frontline services, an increase in reporting /recording crime, more people being sent to prison, more people being managed in the community and an increase in penal populism you can end up with the “perfect storm” of a crisis in risk management. Currently, in the UK, and in other western countries including Australia and USA, we are seeing this in regard to child sexual abuse with increasing offenders numbers of victims and offenders being identified and entering the system. The increase in reporting rates and therefore the identification of perpetrators, victims and the resulting finical impact of child sexual abuse is as a result of a number of distinct, but integrated factors, including;
Consequentially, how do we weather this storm? It is becoming more and more obvious that a change in tactics is needed; a balancing act of more effective/increased prosecutions, with more victim support, better risk management approaches and preventive strategies. Yesterday Chief Constable Simon Bailey, of the National Police Chiefs' Council, stated that the police cannot cope with the current influx of child sexual abuse investigations and that we have to look differently at how low-risk offenders are managed (BBC NEWS). While this may seem like a controversial statement on the outside it is not the first time that the police have said this regarding online sexual abuse and child sexual abuse imagery (Jon CarrNSPCCNational Crime AgencyJournal of Sexual Aggression Special edition 2). It is important to state that not all types of Child sexual Abusers are the same, not all pedophiles abuse and not all abusers are pedophiles; they are a diverse and individualistic group. We know that not all individuals who sexually abuse children, either through viewing imagery or a contact offence, are share same level of risk and that not all levels of risk get the same punitive and/or rehabilitative response from the state. In terms of low-risk offenders, who Simon Bailey was discussing, they will not receive a sex offender treatment programme or receive a full risk management plan or MAPPA (Multi-Agency Public Protection Arrangement) in the community. We are dealing with them differently in all other aspects so his argument is an extension of this. Additionally, in rethinking how we tackle low risk, and possibly medium risk, offenders it means that we can look to prevention as a viable means of intervention; can we identify these individuals earlier, through other means (i.e., through redirection from online sites [Stop it now], predictive analytics [current piece of research being carried out  with Avon and Somerset police, Bristol City Council and the University of Western England] or encouraging people who are concerned about their behavior to come forward and seek support [Safer Living Foundation; Circles South West]). Interestingly today the English government has decided to re-examine sex education and healthy relationships in primary and secondary schools (BBC 01/03/2017), which is a departure from their previous position (BBC 11/02/2016)
It seems obvious that an alternative to our past practice is needed (and even police officers are now saying this publicly), we need to recognizing that rethinking sex offender risk management is an not an act of acceptance of offending, offenders or their lifestyles as appropriate, but rather its recognition of practicality, resource management and effective engagement. The ultimate question is whether we want them to do it again or not? And assuming the answer is no, what effective action can we take?
Effective risk management must comprise deterrence, sufficient and effective treatment for victims/survivors and offenders and crucially primary prevention activity including sex and relationships education in all schools, advice and information for parents, professionals and communities as a whole to ensure full engagement and a promotion of the understanding that we all have a role to play in child and public protection.
Kieran McCartan, Ph.D, Jon Brown, MSc, & David Prescott, LICSW.