A 1989 review of sex offender recidivism found that because of methodological errors, no statistically significant differences in recidivism were reported
A 2013 re-review found more weaknesses, including the lack of randomized controlled trials and highlighting the ethical issues inherent with control groups receiving no treatment
The age of the studies used for both reviews was of concern; most of them collected before CBT became the standard
Their review continues, noting conflicting research but also that the same elements of methodological rigour associated with well-designed studies may also mask treatment effects.
For instance, if a study ends after one year and a client is still scoring “high” on an assessment tool, does that mean the treatment has failed? What about if their tool declines in a non-statistically significant way? What if they haven’t reoffended in that time? What if decline continues beyond the end of the study but that information isn’t recorded?
Additionally, treatment manuals (often required in studies to ensure that treatment is consistent) can limit the ability of the therapist to be flexible to client needs, and may make their therapy less effective as they are constrained by limits on number and length of sessions and precluded from using techniques outside of, for instance, the cognitive behavioural repertoire even if those techniques may show promise with the client.
The Sex Offender Treatment and Evaluation Project (SOTEP) program was a “compared the reoffense rates of offenders treated in an inpatient relapse prevention (RP) program with the rates of offenders in two (untreated) prison control groups” (Marques, et. al., 2005) It had negative results – that is, the program was not any more effective than the control group in controlling relapse rates as a whole.
One interesting finding though, was that individuals who met their treatment goals had lower rates of re-offending than those who merely completed the program (or were in the control group) who did not reoffend.
Psychotherapy for sex offenders is something that is new to me — I knew it was practiced but knew very little about it before this blog post (and after reading a few articles have still only scratched the surface), but it appears to a field in it’s infancy as far as research converted into practice goes.
Levenson, J., Prescott, D.S. (2014): Déjà vu: from Furby to Långström and the evaluation of sex offender treatment effectiveness, Journal of Sexual Aggression: An international, interdisciplinary forum for research, theory and practice, DOI: 10.1080/13552600.2013.867078
Marques, J.K., Wiederanders, M., Day, D.M., Nelson, C., van Ommerman, A. “Effects of a relapse prevention program on sexual recidivism: final results from California’s sex offender treatment and evaluation project (SOTEP).” Journal of Sex Abuse. 2005. 17(1); 79-107
The purpose of the Crisis Center Discrimination Index (CCDI) is to evaluate helpline workers. It was based on the 1967 research of Carkhuff & Truax, published in their book “Toward Effective Counseling and Psychotherapy”, that identified three “core conditions” important in effective counselling and therapy. The three conditions are: Empathy, Genuineness and Unconditional Positive Regard.
Empathy refers to understanding the feelings of the client, this is a core element of helpline work and of all counselling. If a person doesn’t feel like you truly understand things from their point of view (being careful not to use the word “understand” because it can be insensitive), they won’t be able to do the exploration they need to do.
Genuineness, also called concreteness or congruence refers to your being a warm, “real” person in the counselling situation. You’re not acting like a therapist or a doctor with an expert answer, you’re just a normal human being. This was not always the case; in Freud’s time, psychoanalysts acted like a blank slate rather than a human being.
Finally, Unconditional Positive Regard refers to an unconditional caring about the client. Many people find they have “conditional love” in their lives. From their parents, from their friends or relationships. But a therapeutic relationship isn’t restrained by liking the client, or being judged.
The Crisis Center Discrimination Index (CCDI) provides 16 excerpts of helpline conversations that are rated on these dimensions from 1.0 (worst) to 5.0 (best).The reason for this is that (ideally) high-quality volunteers should perform better on this skill than low-performing volunteers.
The CCDI was tested in Argo (2002), with negative results – the CCDI scores did not significantly improve during training. This means the CCDI may not be an effective tool to assess active listening, although it could have been a weakness of the original design which used only 27 volunteers.
The book “Crisis Center/Hotline – A Guidebook to Beginning and Operating” (Delworth, 1972) includes a cut-off score of 70 as one useful for assessing new volunteers.
Truax, C., & Carkhuff, R. (1967). Toward effective counseling and psychotherapy: Training and practice
Argo, A. (2002) “The Assessment of Active Listening Skills in HelpLine Workers” BA Thesis. Texas A&M University.
Delworth, U., Rudow, E.H., Taub, J. (1972) Crisis Center/Hotline – A Guidebook to Beginning and Operating. Springfield, IL: Charles C. Thomas.
Sexual violence is a term that applies to a number of crimes including sexual assault, sexual harassment, rape, and any other scenario where a person has experienced unwanted sexual contact or the threat of unwanted sexual contact.
At Durham College and UOIT, I sat on a Working Group that drafted a new “Sexual Violence Response Protocol.” The impetus for the formation of this working group was because of a posting on a Facebook page, Spotted at DC/UOIT. This page allows people to submit posts about the college and students which are posted anonymously.
In the days after CampusFest, the orientation event, a student posted that she had met a man at the beginning of the night and explained she wasn’t interested in having sex. Later in the night, after many drinks, they had sex; clearly she felt taken advantage of (and stated as much.) This was an obvious case of sexual violence, as she was too drunk to consent.
Unfortunately, the response from the campus community was not one of warmth and acceptance, but one of victim-blaming. While the post was deleted, the comments (from both men and women) were focused on the amount of alcohol she had drank. Obviously that was not a helpful response.
A group of concerned students (including a student who later became a member of the working group with me) spoke to the Durham College Leadership Team. This led to the formation of a “Building Respect” team and a smaller working group that drafted a new policy.
The old policy was focused on a Campus Safety model. If you reported sexual violence, you would be sent to Campus Security; if the event involved a student, an assessment would be made to determine whether the student posed a threat. Information could be passed to the police and you could referred to other resources like the Durham Region Domestic Violence and Sexual Assault Care Centre (DVSACC), as well as counselling, but for most people it was not a good experience.
The new model involves:
Single access point phone number
Focus on emotional support – what does the person in front of us want?
Respect and non-judgemental support
Training for Outreach Services, Campus Athletics and other front-line workers
The new protocol provides options for every situation, from someone who is reporting sexual violence anonymously to someone who wishes for direct police intervention – and any situation in between.
Elements for Helping Sexual Violence Survivors
Believe the person. Nobody asks to be sexually assaulted, and it doesn’t matter what elements precipitated the assault (clothing, intoxication, choice of transportation, etc.)
Tell the person that the violence was not their fault or responsibility. Part of the reason that reports of sexual violence are so low is the tendency to self-rationalize that it was not an assault or it was the fault of the survivor.
Validate the survivor’s feelings. After sexual violence, a survivor can be feeling a range of experiences including guilt, regret, anger, sadness, or simply numbness. All these experiences are okay.
The survivor may not want referrals. They may not want a solution. A survivor may not be able to talk about much. Stay with them. Simply listen. Be okay with silence.
Refer if necessary. Help the survivor identify or access the resources that they are interested in, while respecting their decision not to do so. Remember that you should respect confidentiality as much as your position requires you to. Know before you get someone in front of you what your confidentiality requirements are.
Men in particular have a difficult time reporting sexual violence because of long-standing beliefs that men cannot be assaulted; the above elements are even more important with them because of the stigma of sexual assault.
Knowing resources for male survivors will become more important; many women who are victims of sexual violence experience a difficulty working with male care providers (therapists, doctors, advocates) and men may find themselves similarly limited. Respect their choices for gendered helpers as they work through the healing process.
Additional Training for Sexual Violence
The US Office for Victims of Crime (OVC) produces a program for training Sexual Assault Advocates. This includes a comprehensive instructor’s manual and complete training, including slides. While the information is American-based it is still a fantastic resource.
Local Rape Crisis Centres. For women who have experienced sexual violence from men, rape crisis centres often provide advocacy, crisis intervention, suicide prevention, and emotional support on 24-hour helplines and with trained rape counsellors. One limitation of the Rape Crisis Centres (at least in Ontario) is that many of them do not provide support to men or to trans women who have not had sexual reassignment surgery.
The Crisis Call Outcome Form (CCOF) is a tool used to measure the impact of telephone crisis calls. It was originally used in a 1989 study in the Journal of Community Psychology (Echterling & Hartsough, 1989) to help them determine the stages or phases of helping in successful crisis calls to the Lafeyette Crisis Center.
The stages identified were:
Developing a positive relationship
Determining role of helper and caller
Assessment of the crisis
Identifying the problem
Determining the factors affecting the crisis
Working to express feelings and understandings around the crisis
Identify goals and explore options
Make an action plan
The results supported that helpline volunteers were generally effective, although less effective with chronic callers who needed more problem-solving. This was later validated by Mishara (2007) who examined calls to the National Suicide Prevention Lifeline and determined that a collaborative problem solving model was more effective for repeat callers than an active listening model.
It has no built-in score but you can code the presence of each behaviour with a 1 and the absence with a 0 and use this to classify calls.
Echterling, L.G. & Hartsough, D.M. (1989) Phases of helping in successful crisis telephone calls. Journal of Community Psychology. 17, 249-257
Mishara, B.L., Chagnon, F.C., Daigle, M., Balan, B., Raymond, S., Marcoux, I., Bardon, C., Campbell, J.K., Berman, A. (2007 ) Which Helper Behaviors and Intervention Styles are Related to Better Short-Term Outcomes in Telephone Crisis Intervention? Results from a Silent Monitoring Study of Calls to the U.S. 1-800-SUICIDE Network. Suicide and Life-Threatening Behavior. 37(3). 308-321.
The five elements (which are also available on a pocket card) are:
Identify Risk Factors
Identify Protective Factors
Conduct Suicidal Inquiry
Determine Risk Level/Intervention
Each of these elements is explored more fully below.
Identify Risk Factors
Risk factors include elements that increase risk on a demographic basis, rather than warning signs (which are imminent signs of someone planning suicide). They include:
History of prior suicide attempts
Mental health issues
Family history of suicide attempts
Current substance abuse
Major life changes/loss
Change in treatment (e.g. recently discharged)
Access to lethal means
Some of these (for instance, current substance abuse and access to lethal means) can and should be mitigated in clients where this is possible. Other factors like a history of prior suicide attempts, and a family history of suicide attempts can’t be mitigated but you should stay aware.
Identify Protective Factors
Protective factors, being the opposite of risk factors are things that lower a person’s suicide risk. These may also be spoken of in terms of “hooks”, reasons that a person keeps holding on and does not attempt suicide. They include:
Friends and family (positive social relationships)
Connection to a religion that prohibits suicide
Peripheral resources like physicians, counsellors, etc.
Future hopes and dreams
Internal coping skills
Again, you can work to remind and improve clients of their connections to their pets, their children, and to peripheral resources like counsellors and doctors. An additional resource that may help you explore this is my article on Building Your Support Network.
Conduct Suicidal Inquiry
This element of the SAFE-T tool involves exploring the details of the client’s plan, intensity of suicidal thoughts and their intent.
Some questions suggested by the items in this part of the tool include:
How long have you been feeling suicidal?
Do you have a plan? (remember to explore if they have access to this plan)
How intense are your suicidal feelings?
Have you made any preparations to put your plan in motion?
Do you expect the plan to kill you, or just injure you?
Do you expect to be rescued?
Have you ever rehearsed your plan?
This will help you explore the depth of the client’s suicidal thoughts and get a feel for how suicidal they are. Remember that suicidality can change minute to minute or hour to hour, but this will give you an idea where they are in the moment you’re talking to them.
The CPR Risk Assessment can also help you explore this particular part of the suicidal process for that person.
Determine Risk Level/Intervention
The next task is to determine the actual level of risk. Often tools conceptualize this as Low, Medium, or High Risk, though there are issues with this (someone who is low risk could still go on to attempt or die by suicide while plenty of people who are high risk do not.)
This involves an element of clinical judgement and weighing the risk and protective factors on your own. This is why untrained and low-trained individuals cannot perform suicide risk assessments without close supervision, and all others should still not without regular supervision.
Document the Assessment
Finally, documenting the risk assessment involves writing out the above information, your reasoning for coming to your decision and any recommendations about ways to limit suicide risk.
This is often overlooked by professionals in a hurry but should a client die by suicide, “If it isn’t written down, it didn’t happen.”