Child Sexual Abuse: Is the Routine Provision of Psychotherapy Warranted?

Submitted to Social Work

Thomas D. Oellerich, Ph.D., ACSW, LISW, DAPA^*

ABSTRACT: This paper addresses the question: is the routine provision of psychotherapy for child sexual abuse warranted?  It reviews the literature on the impact of child sexual abuse and that on the outcome of child and adolescent psychotherapy.  It concludes that the routine provision of psychotherapy is not warranted and that child sexual abuse is an area exploited by many professionals for their own gain.  A number of recommendations are made with respect to social workers dealing with this problem of exploitation.
  

Neil Jacobson (1995), Director of the Center for Clinical Research in the Psychology Department, University of Washington, asserted that the conclusion that psychotherapy is effective is premature.  He pointed out that in studies showing effectiveness, the findings reflect statistical significance which has little or no bearing on clinical significance.  To illustrate this, he offered the example of a weight loss treatment that produces a statistically significant average weight loss of 10 pounds.  But since the clients entered the study weighing 300 pounds, this statistically significant weight loss was not clinically significant.  Psychotherapy is supposed to effect a meaningful change, not a minor statistical effect.

Jacobson reported that when psychotherapy outcome is examined in terms of clinical significance, the results are "disturbing" (p.43).  In a series of studies on conduct disorders in adolescents, marriage counseling for couples, and anxiety disorders, his research group has

found the recovered patient (the one who shows few or no signs or symptoms of the initial complaint and believes him- or herself to be "cured") to be the exception rather than the rule for every type of disorder examined and for every type of therapy that we have looked at — psychodynamic, behavioral, cognitive and family therapy.  When one considers even more intractable problems, such as addictive behavior, schizophrenia and personality disorders, the clinical significance data are even more bleak.  The only exception we have found thus far to these modest recovery rates is the cognitive behavioral treatment of panic disorder ... (p.  44).

He concluded that, "as an instrument of human change, psychotherapists have been overselling their product since the days of Freud" (p. 42).

The question can be raised as to whether or not there is an overselling of psychotherapy in in the area of child sexual abuse.  In most settings, children who have been sexually abused are routinely offered treatment even if asymptomatic (Beutler, Williams, and Zetzer, 1994; Finkelhor and Berliner, 1995).  Finkelhor and Berliner (1995) estimated that among substantiated cases of child sexual abuse, from 44 percent to 73 percent receive psychotherapy.  A recent report of the National Institute of Justice (Miller, Cohen, & Wiersema, 1996), indicated that victims of child sexual abuse were much more likely than victims of other crimes to receive mental health care.  These data showed that up to 50% and more of child sexual abuse victims receive mental health care as compared with no more than 4% of victims of other crimes.

One area of concern is that the cost difference is extreme.  According to the report of the National Institute of Justice, the average cost of mental health services for the typical victim of child sexual abuse was nearly sixty times greater than that for the victim of another crime ($5,800 vs. less than $100).

A basic question that has not been addressed adequately is whether substantial mental health care is necessary for the sexually abused or the allegedly sexually abused.  Current practice, according to Beutler, Williams, and Zetzer (1994), assumes that child sexual abuse nearly always causes psychological harm and that this harm requires treatment.  Moreover, it assumes that treatment correlates with the likelihood of mitigation of the psychological harm.  Are these assumptions valid?
  

The Impact of Child Sexual Abuse: A Review

Despite current practice, it is clear that there is a not need for the routine provision of psychotherapy for the sexually abused.  Browne and Finkelhor (1986), in their review article on the initial and long-term effects of child sexual abuse, warned against exaggerating the effects of child sexual abuse.  Despite this research, the mental health industry has described child sexual abuse as "a special destroyer of adult mental health," according to Martin Seligman , Past President of the American Psychological Association, (1994, p.232).  However, this is far from proven.  According to Seligman, the existing research indicating harm "abandoned methodological niceties" (p. 233).  These studies are characterized by sampling bias, lack of adequate control groups, and a failure to consider alternative explanations of the findings.

Further, Seligman noted that much of this research has been ideologically driven.  This is a point made earlier by Okami (1990).  Okami asserted that adherents to the victimological paradigm have dominated the study of and response to child sexual abuse.  This paradigm is based on the conviction that the child or adolescent is incapable of experiencing sexual desire or initiating sexual contact.  According to Okami, this conviction, "attributes participation in peer sexual behavior to 'curiosity' and participation in adult/non-adult sexual behavior to 'coercion'" (p. 93).  Even behavior that is self-reported as positive by the child or adolescent is defined by the victimologists as abusive.  The victimological paradigm reflects a Victorian idealization of children as sexless innocents.  This is politically correct in the current sociopolitical climate.  It is, however, both historically incorrect (Bullough, 1990) and scientifically incorrect (Ceci, & Bruck, 1995; Friedrich, Grambsch, Broughton, Kuiper, & Beilke, 1991; Friedrich, Fisher, Broughton, Houston, & Shafran, 1998; Lamb, & Coakley, 1993).  According to Seligman: "Once the ideology is stripped away, we still remain ignorant about whether sexual abuse in childhood wreaks damage in adult life and, if so, how much" (p. 234).

The notion that child sexual abuse is a "destroyer" of mental health has been based largely on studies involving clinical samples (Berliner & Elliott, 1996).  But even these, if objectively considered, indicated that child sexual abuse is neither necessarily nor usually psychologically harmful.  That is, for the vast majority child sexual abuse is not a "destroyer" of mental health at any age.

For example, an early review of the literature was conducted by Constantine (1981).  He reviewed 30 studies and found that

20 report at least some subjects without ill effects; 13 of those conclude that, for the majority of subjects, there is essentially no harm; and six even identify some subjects for whom, by self-evaluation or other criteria, the childhood sexual encounter was a positive or possibly beneficial experience (p. 224).

In his review of 25 studies, Conte (1985), taking issue with Constantine's using the research "to make a case for 'legitimate instances of child-adult sex,'" concluded that "a review of the literature describing the effects of sexual abuse on children leads irrefutably to the ambiguous conclusion that sexual abuse appears to affect some victims and not others" (p. 117).

Similarly, Browne and Finkelhor (1986) reviewed 28 studies.  They found that among adults who had experienced child sexual abuse, less than 20 percent evidenced serious psychopathology.  They observed that these findings should provide comfort to victims since severe long-term harm was not inevitable.  Further, they expressed concern over the efforts of child advocates to exaggerate the harmful effects for political purposes because of its potential to harm the victims and their families:

advocates [should] not exaggerate or overstate the intensity or inevitability of [negative] consequences [because] victims and their families ... may be further victimized by exaggerated claims about the effects of sexual abuse (p. 178).

Kendall-Tackett, Williams, and Finkelhor (1993) reviewed 45 studies on the effects of child sexual abuse.  The samples for these studies were drawn primarily from sexual abuse evaluation or treatment programs.  Despite this, Kendall-Tackett et al. found that up to 49 percent of the sexually abused children evidenced no psychological harm.  They concluded that "the absence of symptoms certainly cannot be used to rule out sexual abuse.  There are too many sexually abused children who are apparently asymptomatic" (p. 175).

Among the children who were symptomatic, these reviewers found that symptom abatement occurred for most within two years with or without treatment.  These authors also found that when sexually abused children in treatment were compared with non-abused children in treatment, the sexually abused were less symptomatic than their non-abused clinical counterparts.

That psychological harm is neither inevitable nor typical is substantiated by Rind and Tromovitch (1997).  They conducted a meta-analytic review of seven studies on the effects of child sexual abuse.  Unlike prior reviews which were based primarily on clinical samples, this one involved studies that used national probability samples: four from the United States, and one each from Great Britain, Canada, and Spain.  The findings indicated that child sexual abuse "is not associated with pervasive harm and that harm, when it occurs, is not typically intense" (p. 237).

These findings were confirmed in a later meta-analytic study by Rind, Tromovitch, and Bauserman (1998).  This review involved 59 studies of child sexual abuse using college samples.  Again, Rind et al. found that negative effects of child sexual abuse were neither pervasive nor severe.

Moreover, it has yet to be demonstrated that childhood sexual abuse has any influence upon the adult personality.  For example, Beitchman, Zucker, Hood, DaCosta, Akrnan, and Cassavia (1992) reviewed 32 studies.  While they concluded that the evidence suggested that child sexual abuse had serious long-term effects, they noted that it was not clear that these effects were, in fact, due to child sexual abuse per se (p. 115).  Levitt and Pinnell (1995) concluded, based on their review of the literature, that "the traditionally accepted link between childhood sexual abuse as an isolated cause and psychopathology in adulthood lacks empirical verification" (p. 151).  Along the same line, Pope and Hudson (1995; see also Pope, 1997) concluded that the existing research was so seriously flawed in this regard that it was valueless.

However, the recent Rind, Tromovitch, and Bauserman study (1998) indicated that child sexual abuse is non-causative.  They reported that students who had been sexually abused were, on average, slightly less well adjusted than the students who had not been sexually abused.  But the poorer adjustment could not be attributed to the sexual abuse.  The child sexual abuse-adjustment relations became non-significant when family environment was controlled for.  The evidence, then, tends to confirm Seligman's earlier conclusion that

the case for childhood trauma — in anything but its most brutal form — influencing adult personality is in the minds of the inner-child advocates.  It is not to be found in the data (p. 235).

The empirical evidence lends credence as well to Walters (1975) who earlier contended that the widespread belief that child sexual abuse necessarily and usually causes psychological damage is a myth (p. 113).  In other words, the assumption that child sexual abuse typically causes psychological harm requiring psychotherapy is false.
  

Child and Adolescent Psychotherapy; A Review

Once there is a referral for therapy a second question is raised: will it be effective — even if it is indicated?  Current practice assumes it is.  Sadly, there is no empirical proof that therapy for the sexually abused is effective ((Beutler et al., 1994; Reid, 1996).  Hollenberg & Ragan (1991), in their summary of all the child sexual abuse projects funded by NCCAN from 1985 to 1990, reported that most of the information on treatment efficacy was based on anecdotal case studies or descriptions of treatment programs rather than systematic investigations (p. 93).

More recently, Finkelhor and Berliner (1995) reviewed 29 outcome studies on the effectiveness of treatments for the sexually abused.  Of the 29 studies, seventeen used a pre-test—post-test design.  While nearly all reported positive improvement, it cannot be said that the improvement was due to the treatment.  These authors note that longitudinal studies have shown that sexually abused children improve over time with or without treatment (p. 1409; see also Kendall-Tackett et al., 1993, p.171).

Three of the 7 experimental design studies compared treatment and no-treatment groups.  These found significant effects of treatment, but the reviewers commented that their "relatively small-scale designs ... detract from their scientific weight" (p. 1414).  Among the quasi-experimental studies which had equivalent groups (3 of the 5 reviewed) there was no advantage for children receiving therapy compared with children not receiving therapy.  While these reviewers took an optimistic posture with respect to the outcome of therapeutic intervention, they noted that current research is methodologically flawed and concluded that the effectiveness of sexual abuse treatment has yet to be proven (p.1415).

However, the weight of the evidence in this review parallels those found in naturalistic or real-world (as opposed to laboratory) studies on the effectiveness of child and adolescent psychotherapy, namely, that child and adolescent psychotherapy have little or no effect (U.S. Department of Health and Human Services, 1999; see also Weisz, Weiss, & Donenberg, 1992; Weisz, Weiss, Han, Granger, & Morton, 1995).  These findings are reinforced by evidence from studies on continuum of care programs for children and adolescents.  One of the more ambitious of these was the Fort Bragg Project (Bickman, 1996).  The U.S. Army spent 80 million dollars to demonstrate that "a continuum of mental health and substance abuse services for children and adolescents was more cost-effective than services delivered in the more typical fragmented system" (p. 689).  The project offered in- and out-patient services to more than 42,000 child and adolescent dependents of military personnel in the Fort Bragg (North Carolina) catchment area for more than five years from June 1990 to September 1995.  It was considered a model program by the American Psychological Association's section on Child Clinical Psychology and the Division of Child, Youth and Family Services Joint Task Force.

The study showed that the program produced better access to treatment, higher levels of client satisfaction, and fewer restrictions on treatment.  However, the cost was higher and the clinical outcomes were no better than those at the comparison site.  The findings led Bickman "to question the assumption that clinical services provided in the community are effective" (p. 699).

Bickman's findings were not unique.  Weisz, Huey, and Weersing (1998) reported that comparable findings have emerged from other studies designed to improve the delivery of clinical services.  These authors offered as one of the likely explanations for this finding that "the various treatments that are linked and coordinated within these continua of care may simply not be very effective" (p. 62).  The findings confirmed Jacobson's conclusion that child and adolescent psychotherapies "are not better than no therapy at all" (emphasis in original, p. 45).

But if it is not effective, can therapy for child sexual abuse be harmful?  This is an area requiring research.  However, according to Seligman (1994), the answer to this question is: yes.  He cautioned against therapy for the sexually abused and noted, for example, that it is often asserted that the sexually abused need to relive the experience and experience a catharsis in order to improve.  Despite the fact that catharsis has a long history as a therapeutic technique, there is no evidence that it works (Bushman, Baumeister, & Stack, 1999; Seligman, 1994).  On the contrary, as Seligman suggested, reliving the event may be harmful as it heightens the event in the child's mind and interferes with the natural healing process.
  

Exploiting Child Sexual Abuse

The evidence clearly indicates that the routine provision of psychotherapy for the sexually abused is not warranted.  Why, then, is it provided routinely?  Unfortunately, child sexual abuse is a problem that is widely exploited by professionals according to Costin, Karger, and Stoesz (1996):

the rediscovery of child abuse by the middle class has also led to the growth of a child abuse industry composed of opportunistic psychotherapists and aggressive attorneys who have prospered from child sexual abuse, exploiting adults who have evidence of having been abused and encouraging memory recall fro those who haven't. ... Clearly, the psychological paradigm of child abuse has been a godsend ... for mental health professionals looking for new diseases.  Unfortunately, one of the causalities of this new industry has been adult victims, who risk being victimized yet again, this time by a child abuse industry seeking out new forms of economic growth. ...

... Ironically, a public that is sympathetic to the plight of abused and neglected children fails to understand that it foots much of the bill for an out-of-control and demand-driven legal and psychotherapy industry. ... (p. 7)

Dineen (1999) took a similar position.  She charged that the psychology industry (which she defines broadly to include psychologists, psychiatrist, psychoanalysts, clinical social workers, and psychotherapists) needs victims to justify the expansion of its domain.  Accordingly, it "manufactures victims."  Tavris (1993) made a similar charge with respect to the incest-survivor recovery movement.  Thus, according to Costin et al., Dineen, and Tavris, child sexual abuse has become an arena of opportunism for and exploitation by some in the mental health industry
  

Recommendations

What can be done to deal with this opportunism and exploitation?  There are a number of things that can and should be done, especially by social workers and the social work profession.  According to their code of ethics (NASW, 1996; Reamer, 1998), social workers have an ethical responsibility to base their practice on knowledge relevant to social work practice, including empirically based knowledge (Std. 4.01 [c]).  They are also to assure clients are appropriately informed of the evidence concerning the need for and effectiveness of interventions for the purpose of informed consent (Std. 1.03 [a]), and they also have a responsibility to assure the public is informed so that it may shape social policies and programs (Std. 6.03).  Accordingly,

1.  Social workers should educate the community and the courts about the myths surrounding the problem of child sexual abuse.  This includes laying to rest the myth that because a sexual activity violates a moral and/or a legal code that it is thereby necessarily or even usually psychologically harmful.  In other words, it is time to stop equating wrongfulness with harrnfulness in sexual matters as suggested by Rind and Tromovitch (1997).

Perpetuating the myth that sexual abuse is necessarily or usually harmful is unethical and creates possible iatrogenic effects, as noted sometime ago by Schultz (1980):

We seem to arbitrarily create "norms" for minors and then justify departures from them as traumatic.  Such fabrication is professionally unethical and possibly damaging to minors involved in sexual behaviors with others.  What inappropriate trauma ideology does is to pit the professional (true believer) against the child or the parents who may feel differently.  The risk is that a type of self-fulfilling prophecy emerges that manages to produce the problem it claims to abhor, but which it, in fact, must have in order to sustain the ideology it is based upon. ... Sexual behavior between adult and child or between two minors in neither harmful or (sic) harmless always (p. 40).

By way of example, Schultz cited Germaine Greer.  She wrote of the experience of one of her friends:

From the child's point of view and from the commonsense point of view, there is an enormous difference between intercourse with a willing little girl and the forcible penetration of the small vagina of a terrified child.  One woman I know enjoyed sex with her uncle all through her childhood, and never realized that anything was unusual until she went away to school.  What disturbed her then was not what her uncle had done but the attitude of her teachers and the school psychiatrist.  They assumed that she must have been traumatized and disgusted and therefore in need of very special help.  In order to capitulate to their expectation, she began to fake symptoms she did not feel, until at length she began to feel truly guilty for not having felt guilty.  She ended up judging herself quite harshly for this innate lechery (cited in Schultz, 1980, p.39).

2.  Social workers must advise prospective clients of the risks of serious side-effects associated with therapy.  They have the right to know the probabilities of a successful outcome versus a non-successful outcome, i.e., of getting worse and of not improving.  Prospective clients have a right to know whether the treatment they are to be exposed to is empirically validated, is still experimental, or has been discredited by sound research (Reamer, 1998).

With this information, prospective clients can make an informed decision as to whether or not to subject themselves or their children to the risks associated with therapy.  They also can choose to seek an alternative.  Jacobson (1995) related that a dissatisfied patient told him that "in retrospect, after spending $5,000 on unsuccessful psychotherapy, with no suggestion from the therapist that there was any alternative, it occurred to me that it would have been much more therapeutic to use that money to hire babysitters, a maid service, even a butler" (p. 46).

This patient echoes the U.S. Advisory Board on Child Abuse and Neglect's report, A Nation's Shame (1995).  The report expressed concern about the over-reliance on counseling and parenting education for maltreating parents.  It suggested that often what these parents needed was simply a few hours of respite from child care.

3.  Social workers should educate courts to stop routinely referring the sexually abused for therapy.  Child sexual abuse is not a psychiatric disorder or a syndrome (Finkelhor, & Berliner, 1995).  Rather it is an event or series of events in a person's life.  Treatment is indicated only when there is currently demonstrable harm.  To do otherwise is similar to a physician treating children for bicycle accidents.  Many children who have a bicycle accident do not require treatment.  When they do need treatment, it is for a clinical condition rather than the event responsible for that condition.  In other words, the asymptomatic child or adolescent should not be treated.

However, even when there is demonstrable harm, treatment should be recommended only with caution since it may, as pointed out by Seligman, only worsen the harm by interfering with the natural healing process.  According to Seligman, the overreaction of parents and police, and early therapeutic intervention to undo "denial," and later therapeutic intervention to recover "repressed" memories and then to relive the experience may do more harm than good.  Thus, he recommends to parents whose children have been abused or who were themselves abused that they "turn the volume down as soon as possible" (p. 235).

Additionally, the excessive and unnecessary provision of child sexual abuse treatment takes resources from other victims and other victim needs (Costin et al., 1996).  Lastly, and most importantly, it also makes the accurate evaluation of treatment effectiveness impossible since the treatment pool is contaminated by including those who do not need treatment in the first place.
  

Conclusion

This paper addressed the question: is the routine provision of psychotherapy for child sexual abuse warranted?  A review of the literature on the impact of child sexual abuse and on the outcome of child and adolescent psychotherapy indicates that it is not warranted.  Moreover, it indicates that the asymptomatic should most definitely not be referred for psychotherapy.

Child sexual abuse has become an arena for opportunistic therapists to exploit and revictimize victims of child sexual abuse.  It is time to heed and respond to the earlier warning of Browne and Finkelhor (1986).  They warned that "advocates not exaggerate or overstate the intensity or inevitability of these consequences" because "victims and their families ... may be further victimized by exaggerated claims about the effects of sexual abuse" (p. 178).  Indeed, it is time that, as recommended by Seligman, parents of sexually abused children were encouraged "to turn down the volume" lest they create or aggravate a negative reaction to the abuse.
  

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