The goal of this patient preference randomized controlled trial is to investigate the efficacy of Talking for Change (TFC), an intervention for the secondary prevention of child sexual abuse and exploitation (CSA) perpetration. Blinded clinical raters will evaluate the primary endpoint-reductions in dynamic risk factors for sexual offending against children-and clients will provide self-reports to evaluate a second primary outcome-reductions in sexual contact with children, accessing online child sexual exploitation material (CSEM), and desire for sexual contact with children. Researchers will compare the following groups: (1) those receiving 20 weeks of the experimental TFC group psychotherapy; (2) those receiving 20 weeks of a control group psychotherapy targeting mental health and stress more broadly; and (3) those receiving no treatment.
Child sexual abuse (CSA) is a preventable public health issue that has significant mental health, physical health, financial, societal, and personal consequences. In Canada, perpetration prevention interventions are typically provided after CSA has occurred and its damaging sequelae have already occurred (i.e., tertiary prevention interventions are provided to those already convicted to prevent re-offending). These tertiary prevention interventions are reactive in nature and represent one form of the prevention spectrum. One approach to CSA perpetration prevention that has been historically neglected in Canada is secondary prevention. Secondary CSA perpetration prevention interventions aim to prevent the onset of CSA perpetration by targeting populations that are at elevated risk. These interventions focus on helping at-risk adults understand and manage psychosocial risk factors that are causes of CSA perpetration. By targeting these risk factors, secondary perpetration prevention treatment programs help at-risk individuals live offense-free lives. At present, there is a lack of data on whether secondary CSA perpetration prevention programs are efficacious in reducing CSA perpetration. Talking for Change (TFC) is a secondary CSA perpetration prevention intervention offering psychotherapy to adults who are concerned about their risk of perpetrating CSA or accessing online child sexual exploitation material (CSEM). The target client population of TFC are adults with a sexual interest in children, those who self-identify as being at-risk of viewing CSEM, or those who self-identify as at-risk of having sexual contact with children. TFC targets dynamic risk factors that are the causes of engaging in CSA or accessing CSEM, including (1) atypical sexual interests and sexual self-regulation problems; (2) problems in relationships; (3) offense-supportive attitudes; and (4) general self-regulation deficits and related traits (e.g., impulsivity, emotion regulation deficits). The primary objective of the proposed research is to examine the efficacy of TFC via a patient preference randomized controlled trial to test superiority over (a) active psychological control and (b) no-treatment control arms. More specifically, the present trial aims to understand whether TFC produces significantly greater improvement in established risk factors for CSA perpetration and reductions in CSA behavior compared to the two control arms. The secondary objectives of the research are to examine additional outcomes (including quality of life and treatment indicators) and examine mediators of treatment change. These secondary outcomes will allow for a more fulsome understanding of the effects of TFC and insight into mechanisms of change in TFC. This is a single-blind patient preference randomized controlled trial of TFC versus active control, with a third non-randomly allocated no treatment control arm (i.e., a natural history benchmarking arm). Briefly, eligible clients referred to TFC who consent to participate in the trial will first be asked if they are willing to be randomized into one of the two trial treatment arms. Those who decline to be randomized will enter the study arm they prefer. The advantage of this approach is that it can accommodate the methodological rigor associated with a randomized clinical trial while reducing trial non-participation among those with a strong treatment preference. Once clients complete one arm of the trial, they will be offered the opportunity to participate in the second arm of the trial. In either case, continuation into the alternate intervention will be optional as will the continued collection of study data. Benchmarking for natural history processes will involve data collection on online forums for individuals with pedohebephilic interests (i.e., those with an attraction to prepubescent and pubescent minors). Participants in the benchmarking arm will be involved in two assessment time points over the course of 20 weeks, which will allow for estimating change on primary and secondary outcomes over a period of time equivalent to the duration of the TFC and control treatment arms of the trial. Inclusion of a benchmarking sample allows the researchers to compare the effect of TFC to natural history processes (e.g., maturation, the passage of time). Two groups of benchmarking participants will be recruited, with participants in the two groups receiving a different assessment battery. The first group will complete an online survey of self-report measures and a psychosocial interview focused on risk factors for sexual offending and protective factors. Once an adequate number of benchmarking participants have completed an interview, recruited participants will complete only the online survey containing self-report measures. The decision to use this stopping rule for the benchmarking arm was based on power analyses using effect size data from a pilot evaluation of the TFC program.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
SINGLE
Enrollment
220
Talking for Change (TFC) is a secondary prevention program that targets dynamic risk factors for child sexual abuse, including (1) atypical sexual interests and sexual self-regulation problems; (2) problems in relationships; (3) offense-supportive attitudes; and (4) general self-regulation deficits and related traits (e.g., impulsivity, emotion regulation deficits). Participants will complete 20 weekly, 120-minute sessions delivered via WebEx.
The active therapeutic control is a non-directive supportive psychotherapy that targets general mental health concerns. It consists of psychoeducation about human sexuality and common mental health concerns, as well as instruction and practice in applied relaxation and stress management, and group discussions that will facilitate sharing and problem-solving current stressors. This active control intervention is equivalent in length to Talking for Change (TFC), consisting of 120-minute long occurring weekly over the course of 20 weeks.
Centre for Addiction and Mental Health
Toronto, Ontario, Canada
RECRUITINGViolence Risk Scale - Sexual Offense Version (VRS-SO)
24 items (7 static and 17 dynamic risk factors) rated on a scale from 0 to 3; higher scores indicate higher risk; total static scores range from 0 to 21; total dynamic scores range from 0 to 51; dynamic risk factors rated 2 or 3 are designated treatment targets; each treatment target is further rated in terms of readiness for change (pre-contemplation, contemplation, preparation, action, and maintenance).
Time frame: Treatment arm: pre-treatment (within 4 weeks of starting) and post-treatment (within 4 weeks of completing). Repeated for the second treatment. Benchmarking arm: Week 1 and Week 20.
Structured Assessment of Protective Factors against Sexual Offending (SAPROF-SO)
14 items (and 6 additional optional items) rated on a scale from 0 to 4; higher scores indicate greater presence of the protective factor; total scores range from 0 to 56 (80, if the optional items are included).
Time frame: Treatment arm: pre-treatment (within 4 weeks of starting) and post-treatment (within 4 weeks of completing). Repeated for the second treatment. Benchmarking arm: Week 1 and Week 20.
Frequency of Use of Illegal Child Sexual Abuse Imagery
4 items rated on a 5-point Likert scale; higher scores indicate more frequent consumption of sexual imagery of children; total scores range from 4 to 20.
Time frame: Treatment arm: Pre-treatment (within 4 weeks of starting) and post-treatment (within 4 weeks of completing). Repeated for the second treatment. Benchmarking arm: Week 1 and Week 20.
Frequency of Desire for Sexual Activities with Minors
4 items rated on a 5-point Likert scale; higher scores indicate greater desire to engage in sexual contact with minors; total scores range from 4 to 20.
Time frame: Treatment arm: Pre-treatment (within 4 weeks of starting) and post-treatment (within 4 weeks of completing). Repeated for the second treatment. Benchmarking arm: Week 1 and Week 20.
Frequency of Sexual Activities with Minors
3 items on a 5-point Likert scale; higher scores indicate greater frequency of one's sexual contact with minors; total scores range from 3 to 15.
Time frame: Treatment arm: Pre-treatment (within 4 weeks of starting) and post-treatment (within 4 weeks of completing). Repeated for the second treatment. Benchmarking arm: Week 1 and Week 20.
Coping Using Sex Inventory (CUSI)
8 CUSI items, rated on a 5-point Likert scale, will be used in this trial; higher scores indicate greater tendency to use sex to cope with problematic situations; total scores range from 8 to 40.
Time frame: Treatment arm: pre-treatment (within 4 weeks of starting), Treatment Week 10, and post-treatment (within 4 weeks of completing). Repeated for the second treatment. Benchmarking arm: Week 1 and Week 20.
Compulsive Sexual Behavior Inventory - 13 (CSBI)
13 items rated on a 5-point Likert scale; higher scores indicate greater sexual compulsivity; total scores range from 13 to 65.
Time frame: Pre-treatment (within 4 weeks of starting), Treatment Week 10, and post-treatment (within 4 weeks of completing). Repeated for the second treatment. Benchmarking arm: Week 1 and Week 20.
Cognitions that Support Sexual Offending Against Children Scale - Short Form (CSSOC-SF)
10 items rated on a 4-point Likert scale; higher scores indicate greater endorsement of cognitions that support and condone sexual offending; total scores range from 10 to 40.
Time frame: Treatment arms: pre-treatment (within 4 weeks of starting), Treatment Week 10, and post-treatment (within 4 weeks of completing). Repeated for the second treatment. Benchmarking arm: Week 1 and Week 20.
Children and Sex Questionnaire: Emotional Congruence with Children
3 items from this scale, rated on a 4-point Likert scale, will be used in this trial; higher scores reflect greater emotional congruence with children; total scores range from 3 to 12.
Time frame: Treatment arms: pre-treatment (within 4 weeks of starting), Treatment Week 10, and post-treatment (within 4 weeks of completing). Repeated for the second treatment. Benchmarking arm: Week 1 and Week 20.
Difficulties in Emotion Regulation Scale - Short Form (DERS-SF)
18 items rated on a 5-point Likert scale; higher scores indicate greater difficulties with emotion regulation; total scores range from 18 to 90.
Time frame: Treatment arms: pre-treatment (within 4 weeks of starting), Treatment Week 10, and post-treatment (within 4 weeks of completing). Repeated for the second treatment. Benchmarking arm: Weeks 1 and 20.
Aggression Inventory (AI)
9 items rated on a 5-point Likert scale; higher scores indicate greater aggression; total scores range from 9 to 45.
Time frame: Treatment arms: pre-treatment (within 4 weeks of starting), Treatment Week 10, and post-treatment (within 4 weeks of completing). Repeated for the second treatment. Benchmarking arm: Weeks 1 and 20.
Brief Aggression Questionnaire (BAQ)
6 items from this measure, rated on a 7-point Likert scale, will be used in this trial; higher scores indicate greater aggression; total scores range from 6 to 42.
Time frame: Treatment arms: pre-treatment (within 4 weeks of starting), Treatment Week 10, and post-treatment (within 4 weeks of completing). Repeated for the second treatment. Benchmarking arm: Weeks 1 and 20.
Problems in Interpersonal Relationships
22 items rated on a 4- to 7-point Likert scale; higher scores indicate greater loneliness, social isolation, and experience of jealousy in intimate relationships; total scores range from 22 to 134.
Time frame: Treatment arms: pre-treatment (within 4 weeks of starting), Treatment Week 10, and post-treatment (within 4 weeks of completing). Repeated for the second treatment. Benchmarking arm: Weeks 1 and 20.
Dimensions of Skillfulness and Use Scale (DSUS)
4 items rated on a 5-point Likert scale; higher scores indicate greater understanding and use of skills learned in the session; total scores range from 4 to 20.
Time frame: Weekly over the course of the 20 treatment weeks. Repeated for the second treatment.
Clinical Outcomes in Routine Evaluation -10 (CORE-10)
10 items rated on a 5-point Likert scale; higher scores indicate more problems with psychological symptoms, functional impairment, and risk to self; total scores range from 0 to 40.
Time frame: Weekly over the course of the 20 treatment weeks. Repeated for the second treatment.
The Multitheoretical List of Therapeutic Interventions 30
30 items rated on a 5-point Likert scale; higher scores indicate higher quality and intensity of interventions provided during therapy sessions; total scores range from 30 to 150.
Time frame: Weekly over the course of the 20 treatment weeks. Repeated for the second treatment.
Curative Climate Instrument (CCI)
9 items rated on a 4-point Likert scale; higher scores indicate greater presence of therapeutic factors; total scores range from 9 to 36.
Time frame: Treatment Weeks 1, 7, 14 and 20. Repeated for the second treatment.
Group Climate Questionnaire - Short Form (GCQ-S)
12 items rated on a 7-point Likert scale; higher scores indicate a more favorable perception of the group therapeutic environment; total scores range from 0 to 72.
Time frame: Treatment Weeks 1, 7, 14 and 20. Repeated for the second treatment.
Treatment Motivation Questionnaire - Revised (TMQ-R)
19 items rated on a 7-point Likert scale; higher scores indicate greater motivation to participate in treatment; total scores range from 19 to 133.
Time frame: Pre-treatment (within four weeks of starting) and at Treatment Week 3. Repeated for the second treatment.
Group Questionnaire - 12
4 items from this scale, rated on a 7-point Likert scale, will be used in this trial; higher scores indicate a more positive experience in the therapy group; total scores range from 0 to 24.
Time frame: Treatment Weeks 1, 7, 14 and 20. Repeated for the second treatment.
Trust and Respect for Clinician Scale (TRCS)
8 items from this scale, rated on a 7-point Likert scale, will be used in this trial; higher scores indicate greater level of trust and respect for the clinician; total scores range from 8 to 56.
Time frame: Treatment Weeks 1 and 7. Repeated for the second treatment.
Therapeutic Factors Inventory - Short Form
13 items from this scale, rated on a 7-point Likert scale, will be used in this trial; higher scores indicate stronger perceptions of four therapeutic factors (instillation of hope, secure emotional expression, awareness of relational impact, and social learning); total scores range from 13 to 91.
Time frame: Treatment Weeks 1, 7, 14 and 20. Repeated for the second treatment.
Therapeutic Agency Inventory (TAI)
10 TAI items, rated on a 5-point Likert scale, will be used in this trial; higher scores indicate more experience of agency in therapy; total scores range from 10 to 50.
Time frame: Treatment Weeks 1, 7, 14 and 20. Repeated for the second treatment.
Relationship Questionnaire (RQ)
4 items rated on a 7-point scale; higher scores on each item indicate greater identification with the attachment style the item describes; scores for each attachment style range from 1 to 7.
Time frame: Treatment arms: pre-treatment (within 4 weeks of starting). Repeated for the second treatment. Benchmarking arm: Week 1.
Forms of Self-Criticizing & Self-Reassuring Scale - Short Form (FSCRS-SF)
14 items rated on a 5-point Likert scale; higher scores indicate a greater sense of inadequacy (scores range from 0 to 20), self-hate (scores range from 0 to 16), and self-reassurance (score scores range from 0 to 20).
Time frame: Treatment arms: pre-treatment (within 4 weeks of starting), Treatment Week 7, Treatment Week 14, post-treatment (within 4 weeks of completing). Repeated for the second treatment. Benchmarking arm: Weeks 1 and 20.
Multidimensional Psychological Flexibility Inventory (MPFI)
45 items from this scale, rated on a 6-point Likert scale, will be used in this trial; higher scores reflect greater psychological flexibility; total scores range from 45 to 270.
Time frame: Treatment arms: pre-treatment (within 4 weeks of starting), Treatment Week 7, Treatment Week 14, post-treatment (within 4 weeks of completing). Repeated for the second treatment. Benchmarking arm: Weeks 1 and 20.
Coping Strategy Indicator Short Form (CSI-SF)
18 items rated on a 3-point Likert scale; higher scores reflect a greater tendency to cope using problem-solving, seeking social support, or avoidance; total scores range from 18 to 54.
Time frame: Treatment arms: pre-treatment (within 4 weeks of starting), Treatment Week 7, Treatment Week 14, post-treatment (within 4 weeks of completing). Repeated for the second treatment. Benchmarking arm: Weeks 1 and 20.
CBT Suitability Scale (CBT-SUITS)
13 items rated on a 5-point Likert scale; higher scores indicate greater beliefs and attitudes consistent with cognitive behavioral therapy; total scores range from 13 to 65.
Time frame: Treatment arms: pre-treatment (within 4 weeks of starting), Treatment Week 7, Treatment Week 14, and post-treatment (within 4 weeks of completing). Repeated for the second treatment. Benchmarking arm: Weeks 1 and 20.
Cognitive and Behavioral Response to Stress Scale
6 items from this scale, rated on a 7-point Likert scale, will be used in this trial; higher scores indicate more frequent cognitive and behavioral responses to stressful or upsetting situations; total scores range from 0 to 36.
Time frame: Treatment arms: pre-treatment (within 4 weeks of starting), Treatment Week 7, Treatment Week 14, and post-treatment (within 4 weeks of completing). Repeated for the second treatment. Benchmarking arm: Weeks 1 and 20.
General Self-Efficacy Scale
10 items rated on a 4-point Likert scale; higher scores indicate greater self-efficacy; scores range from 10 to 40.
Time frame: Treatment arms: pre-treatment (within 4 weeks of starting), Treatment Week 7, Treatment Week 14, and post-treatment (within 4 weeks of completing). Repeated for the second treatment. Benchmarking arm: Weeks 1 and 20.
Experience, Understanding, and Management of Risk-Relevant Sexuality
12 items rated on a 7-point Likert scale; higher scores reflect greater ability to manage one's sexual arousal and behavior in one's daily life; total scores range from 12 to 84.
Time frame: Treatment arms: pre-treatment (within 4 weeks of starting), Treatment Week 7, Treatment Week 14, and post-treatment (within 4 weeks of completing). Repeated for the second treatment. Benchmarking arm: Weeks 1 and 20.
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