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The case against the routine provision of psychotherapy to children/adolescents labeled as "sexually abused"

Thomas Oellerich, School of Social Work, Ohio University, Athens, OH 45701 [USA]

Sexuality & Culture, Volume 6, number 2, 2002



The Issue of Substantiation  

The Issue of Psychological Harm 

The Question of Whether it was Abusive 

Child and Adolescent Psychotherapy: A Review   



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Whether symptomatic or asymptomatic, children labeled sexually abused are routinely offered treatment at considerable financial cost. One result of this is that mental health professionals are being charged with exploiting the problem of child sexual abuse (CSA).  Is the routine provision of psychotherapy for children and adolescents labeled sexually abused warranted? 

In this paper, it is argued that the evidence indicates it is not warranted.  Further, its provision is not in the best interests of either the children or mental health professionals. A number of recommendations are given which follow from the evidence.


Whether symptomatic or asymptomatic, children and adolescents (hereinafter referred to simply as children) labeled sexually abused are routinely provided psychotherapy 

(Beutler, Williams & Zetzer, 1994; Finkelhor & Berliner, 1995). 

A 1996 report of the National Institute of Justice (NIJ) indicated that up to 50 percent of the victims of CSA receive treatment (Miller, Cohen & Wiersema, 1996). This compares with the no more than 4 percent of victims of other crimes.

From the perspective of the therapist or counselor, providing psychotherapy is quite lucrative. According to the NIJ, the average cost of mental health services for the typical victim of CSA was

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nearly sixty times greater than that for the victim of another crime ($5,800 vs. less than $100). In the now infamous Manhattan Beach day-care case, the Children's Institute International interviewed about 400 children from late 1983 through 1984, receiving $455 for each of the interviews (Nathan & Snedeker, 1995: 83). The California Victims of Crime Fund will pay at least $200,000 to a handful of therapists for therapy for the accusers of Dale Akiki (Cantlupe & Hasemeyer, 1994).

This occurred despite the fact that experts had testified at trial that the interviews of the children by these very same therapists were experimental, unproven, and had contaminated the children's statements. Akiki was acquitted although he spent two-and-a-half years in prison prior to trial.

One can add to this the cost of treating adults who "recalled" abuse during treatment through the "recovered memory therapies." In Washington State's Crime Victims Compensation Program, the average cost associated with treating adults whose claims were based on repressed memory (RM) of childhood sexual abuse was approximately four times the average cost of other mental health claims (Loftus, 1997; Parr, 1996). The average cost of non-RM claims was less than $3,000. The average cost of RM claims was more than $12,000. In just over four years, the citizens of Washington paid out to mental health professionals over 2.5 million dollars for 325 RM claims.

As a consequence, critics within and outside of social work are charging mental health professionals with exploiting the problem of CSA by creating an artificial need for their services that does not serve the interests of service recipients. 

Social workers Costin, Karger, and Stoesz ( 1996) wrote:

the rediscovery of child abuse by the middle class has also led to the growth of a child abuse industry composed of opportunistic psychotherapists ...who have prospered from child sexual abuse, exploiting adults who have evidence of having been abused and encouraging memory recall from those who haven't. ... Unfortunately, one of the causalities of this new industry has been adult victims, who risk being victimized ... by a child abuse industry seeking out new forms of economic growth. (p. 7)

Another social worker, Sarnoff (2001 ), based on the findings of her dissertation study of crime victim compensation programs, came 

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to a similar conclusion. She noted that the expansion of benefits went to "self -defined victim 'experts' ", instead of going to the needs as defined by the victims themselves. She (2000, unpublished) reported that when the victim compensation programs were first begun, 70 percent of the monies went to victims; the remainder, to service providers, mostly counselors and therapists. Today, 80 percent goes to these service providers; only 20 percent goes directly to victims.

Similarly, clinical psychologist Tana Dineen (1998) referred to sexual abuse as a " growth industry." She asserted that the recent expansion of the psychology industry has necessitated the creation of new "victims." Through a process of psychologizing, pathologizing, and generalizing, the psychology industry fabricates victims. This "victim making" is nothing more than "user making" to meet the needs of the growing numbers of service providers.

Costin et al. made a similar charge:

In the psychotherapy industry, the technological engine for the development of new products is the disease model, which can transform a range of personal problems into diseases, complete with a proven cure. (p. 28)

Social psychologist Carol Tavris (1993) also charged the mental health field with creating a demand for its services. In her review of survivor books, Beware the Incest-Survivor Machine, she wrote that the problem with these books was "their effort to create victims -- to expand the market that can then be treated with therapy and self -help books" (p. 16).

A number of professionals, then, are charging mental health professionals with exploiting the problem of CSA for their own gain. They charge as well that this does not serve the interests of those served.

In this paper it is argued that the routine provision of treatment to those children labeled sexually abused should be discontinued. 

First, the routine provision of treatment is not in the best interests of either these children or mental health professionals. 

Secondly, and more importantly, it is not warranted by the evidence.


A review of the literature indicates that:  

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1. A case which is identified as substantiated does not mean that sexual abuse has in fact occurred; 

2. There is a failure to differentiate between coercive and non-coercive sexual events;

3. Psychological harm is the exception rather than the rule and, when present, is likely to be due to factors other than the sexual event(s);

4. Treatment has not been found to be effective.


The Issue of Substantiation

That a case has been identified as "substantiated," or in the instance of a criminal case, guilt established does not mean that sexual abuse has occurred. For example, there are innumerable instances involving day-care cases where convictions have been overturned: 

Little Rascals, Edenton, SC; Grant Snowden, Miami, FL; Wee Care Nursery School, Maplewood, NJ, to mention but a few  (Ceci & Bruck, 1995; Nathan & Snedeker, 1995; Victor, 1993).

There are many other instances where the conviction has not been overturned, but where the accused person was innocent. The San Diego Grand Jury's (SDGJ) (29 June 1992) investigation of that county's child protective system found that prosecutors in CSA cases relied on the likelihood that a charge would bring about a plea to a lesser offense. Defense attorneys often encouraged their clients to plead guilty to a minor charge even if they were certain of their client's innocence "in order to facilitate the reunification of the family and to avoid a trial" (p. 12).

Some child protective service workers are known to have committed perjury to gain convictions. The SDGJ (February 1992) reported that 

"attorneys, psychologists, and parents have all testified that some social workers lie routinely, even when under oath in court [ and they] ignore or disobey court orders" (p. 21 ). 

Lorandos (1995) documented social workers withholding or falsifying evidence in court proceedings in order to secure a judgment they deemed "in the best interests of the child."

The number of cases erroneously identified as substantiated is not known. But it can be assumed there are many. Why might this be so? 

First, a 1996 NIJ report on the use of DNA evidence to establish innocence after trial suggests that up to 25 percent of those convicted of sex crimes, including sexual abuse, are innocent

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(Connors; Lundregan, Miller & McEwen, 1996). As a result, some have called for re-examining sex crime convictions (Churchill, 3 September 2000). In one Wenatchee, WA, case, where all convictions have been overturned, Innocence Project lawyers have called for the appointment of a state commission to re-investigate all CSA cases to ensure that further injustices were not committed (Maher, 29 October 2000).

Second, there is the question of competence of CPS workers. The SDGJ (February 1992) reported that "in too many cases, Child Protection Services cannot distinguish real abuse from fabrication, abuse from neglect, and neglect from poverty or cultural differences" (p. 4).


Additionally, many child protective service workers are "validators" (Dineen, 1998; Gardner, 1991). Validators assume that all allegations are true. They use only the evidence that supports the allegation and ignore or suppress evidence that does not support their prior beliefs (Bruck & Ceci, 1999). Dineen (1998) concluded that 


"while validators claim to identify victims, they are, in fact, manufacturing victims; both those that are labelled [sic] victims of abuse, and those that are victims of the legal system, the falsely accused" (p. 212).

A shocking example of this is provided by the Alicia Wade case (SDGJ, 23 June 1992) which brought about a grand jury investigation of the San Diego child protection system. It involved an eight-year-old who was removed from her home, brutally raped, and sodomized.  Two and half years after this event, her family requested assistance from the SDGJ to stop a pending termination of parental rights. The father was accused of molesting her.

The mother was repeatedly told that the only chance to reunite with Alicia was to say she believed her husband did it. As a result of his wife's and attorney's pressure and in response to the promise that his daughter would be returned home almost immediately, the father falsely pleaded guilty to neglect. The promised return of Alicia did not occur.

Alicia, however, had denied that her father raped her. She described someone entering her bedroom and taking her to a nearby field, raping her, and then returning her to her bed. Alicia was not believed. She was told she would not be allowed to see her parents until she came up with a more believable story. She was put into

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court ordered treatment with a therapist who believed the father was guilty. As a result of the therapist's brainwashing over thirteen months of twice weekly "therapy" sessions, Alicia finally "disclosed" that her father had raped her.

Following this, the district attorney prepared to bring the case to trial. It was then that semen on Alicia's underpants were tested. It did not match her father's. As Alicia and her parents had previously maintained, she had been raped by a stranger -- a serial rapist who had raped another child using the same method. Appallingly, the therapist, the district attorney, the child abuse detectives, and the CPS workers not only knew about the earlier case but failed to disclose it to the defense. They continued to pursue terminating parental rights even after it was proven Mr. Wade could not have been the perpetrator.

Recently, U .S. District Judge Rebecca Palllmeyer found that the investigation process of allegations of child maltreatment by the Illinois Department of Children and Family Services is unconstitutional (Dupuy et al. v. McDonald, 2000). She concluded that these investigations were one-sided and decided on little evidence. As a result many cases were wrongly identified as "indicated," a finding which was overturned on appeal in over three-fourths of the cases.

Further, there are false allegations which can be the result of adult, including therapist, influence (Campbell, 1998; Ceci & Bruck, 1995; 1999; Loftus, 1994; Poole & Lindsay, 2001). Children are wont to provide their adult interviewers with the type of information that they think the adult wants. When there is a reliance on coercive and manipulative interviewing techniques, play therapy, guided imagery, or the use of anatomically correct dolls -- none of which have been proven effective -- the result is often to provide the interviewer with what the interviewer expects to be the answer. A finding of guilt or substantiation, then, does not mean that sexual abuse has occurred.

The Issue of Psychological Harm 

A major assumption underlying the routine provision of treatment to those labeled "sexually abused" is that CSA usually results in conditions that require treatment (Beutler, Williams & Zetzer,

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1994). Seligman (1994) asserted that the mental health industry describes CSA as "a special destroyer of adult mental health" (p. 232). But, according to Seligman, the evidence supporting this contention is seriously methodologically flawed and ideologically driven. He noted that 

"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 ).

Okami (1990) shares Seligman's view that much of the research in the area of CSA has been ideologically driven. He 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 

"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, Fisher, Broughton, Houston & Shafran, 1998).

The idea of CSA as a "destroyer" of mental health has been based largely on studies involving clinical samples. But even these, if objectively considered, indicated that for the vast majority, CSA is not a "destroyer" of mental health at any age. For example, Constantine (1981) reviewed 30 studies. Twenty-one of the studies involved clinical or legal populations; nine samples, the general population. Among these studies, 20 reported some subjects not experiencing harm and in 13 of these the majority of subjects experienced no harm. Six of the studies identified subjects for whom the experience was positive and beneficial.

Similarly, Browne and Finkelhor ( 1996) reviewed 28 studies that involved either coerced sexual behavior or sexual behavior between a child and a much older person or a caretaker. They found that among adults who had experienced CSA less than 20 percent evidenced serious psychopathology. They observed that these findings

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should provide comfort t6 victims since severe1ong-term harm was not inevitable. 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 ... the intensity or inevitability of [negative] consequences ... victims and their families ... may be further victimized" (p. 178) 

by these exaggerated claims about the effects of sexual abuse.

Kendall-Tackett, Williams, and Finkelhor (1993) reviewed 45 studies on the effects of CSA. Samples in these studies were drawn primarily from sexual abuse evaluation or treatment programs. Despite this, Kendall-Tackett and her colleagues found that up to 49 percent of the children in their study evidenced no psychological harm. They concluded that the absence of symptoms could not be used to rule out sexual abuse because 

"there are too many sexually abused children who are apparently asymptomatic"  (p. 175). 

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.

The use of clinical samples is problematic; namely, bias is inherent in them. Consequently, they do not constitute evidence that abuse gives rise to clinical disorders. Nor are they representative of the general population. Hence, their findings cannot be generalized to that population.

When non-clinical samples are used, the findings indicate that psychological harm is neither an inevitable nor a typical result of CSA. 

Rind and Tromovitch (1997) conducted a meta-analytic review of seven studies on the effects of CSA. Unlike prior reviews, this involved studies that used national probability samples: four from the United States, and one each from Great Britain, Canada, and Spain. The major finding indicated that CSA 

"is not associated with pervasive harm and that harm, when it occurs, is not typically intense:' i.e., severe (p. 237).

These findings were confirmed in a later meta-analytic study conducted by Rind, Tromovitch, and Bausernlan (1998). This review involved 59 studies of CSA using college samples: 36 were

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peer-reviewed research studies; 21 were dissertations; and two were master's theses. Again, Rind and his colleagues found that negative effects of CSA were neither pervasive nor severe. College students who had experienced sexual abuse were slightly less well adjusted than their counterparts, but they were still well adjusted (p. 31 ). Further, less than 1 percent of the adult adjustment was attributable to a history of CSA (p. 31 ).

One of the questions surrounding CSA has been whether it has any influence upon the adult personality. 

Pope (1997) concluded that the existing research with respect to this question was so seriously methodologically flawed that it was virtually valueless. 

Rind and Tromovitch's 1997 study found that one could not conclude that CSA was the cause of adult psychological maladjustment in the general population because of the presence of confounding factors. 

Beitchman et al. (1992), based on their review of 32 studies of the effects of CSA, came to the same conclusion. 

Levitt and Pinnell ( 1995) concluded their review of the literature noting that the "traditionally accepted link between childhood sexual abuse as an isolated cause of psychopathology in adulthood lacked empirical verification" (p. 151).


Nor is there any conclusive evidence that CSA causes specific psychological disorders. According to Laidlaw, Goodyear-Smith, and Gorman (2000):

As morally reprehensible as child sexual abuse is, studies overall have failed to demonstrate ... a causal relationship between childhood molestation and any specific psychological disorder [such as eating disorders or depression]. (p. 73)

Neither does the research support the idea that there is a cycle of sexual abuse. 

The U.S. General Accounting Office (GAO) (1996) reviewed 25 studies and 4 review articles relative to this issue. Twenty-three of the studies were retrospective; the other two were prospective: one by Widom and the other by Williams. Neither study found a relationship between CSA and later sex offending. The GAO report concluded that 

"the experience of childhood sexual victimization is quite likely neither a necessary nor a sufficient cause of adult sexual offending" (p. 13 ).

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However, the Rind et al. study (1998) indicated that CSA is non-causative with respect to adult psychopathology. Poorer adjustment among the sexually abused could not be attributed to the sexual abuse; CSA-adjustment relations became non-significant when family environment was controlled for. The family environment in which these adults had grown up was a much more important predictor of adult maladjustment than was CSA.

The evidence indicates that the impact of CSA has been greatly exaggerated as noted by Dr. Sarah Romans, Professor at the Dunedin School of Medicine, NZ (cited in Bowman, 1999). It tends to confirm Waiters' (1975) earlier assertion that the widespread belief that CSA necessarily and usually causes psychological damage is a myth.

Many clinicians refuse to accept such findings. Kilpatrick (1992), a professor of social work at the University of Georgia, wrote of the response to her findings:

When I have discussed my study with individuals and groups, my experience thus far has been that many people do not want to hear ... about positive reactions to early sexual experiences. They do not want their preconceived notions that all early sexual experiences are harmful to be challenged. They especially do not want to hear of incestuous experiences that do not cause irreparable harm. This is particularly true of those who work with the clinical population of survivors of child or adolescent sexual abuse. (p. viii)

As a clinician, she too had to come to grips with the fact that her findings were not always as she had expected. Children's resilience is not well received by many clinicians as it conflicts with their economic and ideological interests according to Rind, Bauserman, and Tromovitch (2000).

The Question of Whether it was Abusive

What might explain the fact that most people who have been sexually abused do not suffer psychological harm either in the short-term or the long-term? 

The simplest of explanations is that most people demonstrate resilience. The unfortunate few who do not have inherent vulnerabilities to develop psychological problems irrespective of a sexual abuse history. 

For example, in a review article of posttraumatic stress disorder (PTSD), Bowman (1999) 

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reported that most people experience traumatic or seriously life-threatening events, but very few develop PTSD. She concluded that the distress arises from individual differences and not from event characteristics.

Children labeled sexually abused are most likely to be diagnosed as suffering from PTSD

(Kendall-Tackett et al., 1993; Saywitz, Mannarino, Berliner & Cohen, 2000). 

But this is often based on the assumption that CSA results in PTSD as opposed to their being any evidence for the diagnosis (New, Berliner & Fitzgerald, 1998). As noted by Szasz (2001), 

"PTSD is now routinely imputed to people, especially children helpless to reject the label" (p. 507, emphasis in original).

A more contentious explanation is that those events that clinicians and researchers have labeled abusive either were not abusive or were not experienced as abusive. The term CSA is used in the social science and legal literature to refer to any sexual interaction between a child or adolescent and significantly older persons as well as between peers when force is involved. Mental health professionals do not distinguish between abuse as harm done to a child or adolescent and abuse as a violation of a social norm (Kilpatrick, 1992). However, it cannot be assumed that a violation of asocial norm leads to harm. Recall the mental health field's perspective on homosexuality a generation ago.

Kilpatrick conducted a study of 501 non-clinical, middle class black and white females in Florida and Georgia, inquiring whether they had sexual experiences as a child (defined as ages 0 through 14) or as an adolescent (ages 15 through 17). 

Fifty-five percent of the women reported having at least one childhood sexual experience of some type; 

83 percent reported having at least one adolescent sexual experience. 


The adult functioning of women with no sexual experiences was compared with the adult functioning of women who did have sexual experiences. Kilpatrick found that early childhood and adolescent sexual experiences had no influence on later adult functioning, unless force or high pressure were involved.

Kilpatrick also found that most of the women in her study were active in initiating the sexual experience. They were willing par

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participants. Her findings indicate that the issue of willingness or "consent" is important in differentiating a sexual event as abusive or non-abusive. These are compatible with the more recent findings of Rind et al. (1998) and Coxell, King, Mezey and Gordon ( 1999). Sexual activities willingly engaged in were not associated with psychological harm, while sexual activities unwillingly engaged in were.

Not all of the sexual encounters between a child and an adolescent or an adult or between an adolescent and an adult are abusive. Legally, however, those under age 18 cannot give consent and sexual contact with anyone other than a peer is defined as abusive. Mental health professionals also consider such contact abusive (Kilpatrick, 1992).

This view is not supported by either empirical evidence or by common sense. For example, in an October 1989 amici brief to the U .S. Supreme Court, the American Psychological Association, the National Association of Social Workers and the American Jewish Committee argued that pregnant girls do not need parental consent to obtain abortions because they are capable of making a decision based on informed consent. The associations wrote:

psychological theory and research about cognitive, social and moral development strongly supports the conclusion that most adolescents are competent to make informed decisions about important life situations ... .by middle adolescence (age 14-15), teens have developed abilities similar to adults in reasoning about moral dilemmas, understanding social rules and laws, reasoning about interpersonal relationships and interpersonal problems ... by age 14 most adolescents have developed adult-like intellectual and social capacities including specific abilities outlined in the law as necessary for understanding treatment alternatives, considering risks and benefits, and giving legally competent consent. ... [Further,] there are some 11-to-13-year-olds who possess adult-like capabilities in these areas. (pp. 18-20)

The associations went on to note that in many states young adolescents (11-to-13 year olds) are deemed capable of giving informed consent to medical procedures for themselves, and, if they have a child, for their child.

Given this, it seems inconsistent for these associations and mental health professionals in general to reject the assertion that there

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can be consent or willingness on the part of the adolescent to participate in sexual experiences with an older person.

As to the common sense argument, a child or adolescent can give what Rind et al. (2000) refer to as "simple consent." For example, parents may ask children if they would like to go to the movies. If the children say "yes," they have consented to do so and thus are "consenting" or willing participants. If they say no and are forced to go to the movies, they are being coerced and are unwilling participants.

In other words, while sexual activity between children and/or adolescents and a non-peer is for most of us morally reprehensible and illegal, it is not necessarily abusive. Abuse is something to be established as a conclusion rather than simply accepted as a premise. And it is essential in the mental health context to differentiate between abusive and non-abusive sexual experiences, based on the facts presented by the participant(s) and not based on a priori belief.

Child and Adolescent Psychotherapy: A Review

Once there is a referral for therapy another question is raised: will it be effective -- even if it is indicated? Current practice assumes that it is. However, there is no empirical proof that therapy for the sexually abused is effective 

(Becker et al., 1995; Beutler, Williams & Zetzer, 1994; Reid, 1996).

The few empirical treatment outcome studies that are available suggest that treatment is not effective. 

Firlkelhor and Berliner (1995) reviewed 29 outcome studies on the effectiveness of treatments for the sexually abused. Of the 29 studies, 17 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 without treatment (p. 1409; see also KendallTackett et al., 1993: 171). This is an unremarkable and to be expected finding. 

KendallTackett et al. (1993) report that one of the more common consequences of CSA is posttraumatic stress disorder (PTSD). But the evidence on treating those with PTSD indicates that the symptoms typically diminish over time without treatment (Bowman, 1999).

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Of the seven experimental design studies included in this review, four involved a comparison of treatment alternatives. Three 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 that had equivalent groups (3 of the 5 reviewed) there was no advantage for children receiving therapy compared with children not receiving therapy. While Berliner and Finkelhor took an optimistic posture with respect to the outcome of therapeutic intervention, they concluded that there is no scientific evidence demonstrating the effectiveness of sexual abuse treatment (p. 1415).

However, the weight of the evidence in this review parallels findings of studies conducted in naturalistic as opposed to laboratory settings. As noted in the Surgeon General's report on mental health 

(U.S. Department of Health and Human Services, 1999: 168-169) 

and in his report of a conference on children's mental health 

(U .S. Public Health Service, 2000), 

studies indicate that child and adolescent psychotherapy as practiced in community settings are no more helpful than having no treatment. This is the case even when the therapy is provided as part of a costly integrated system of care 

(Bickman, 1996; Bickman, 1997; Bickman, Noser & Summerfelt, 1999; Weisz, Huey & Weersing, 1998).

But if child and adolescent therapy is not effective, can therapy for CSA be harmful ? 

According to Seligman (1994), the answer to this question is yes. He cautioned against therapy for the sexually abused. He noted that it is often asserted that the sexually abused need to relive the event 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.

Relevant here is a study by Mayou, Ehlers and Hobbs (2000) on providing psychological debriefing to trauma victims. This study involved victims of traffic accidents who were randomly assigned

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to psychological debriefing (early counseling) or no treatment. At the end of three years, those who had received early counseling were found to have had a significantly worse outcome in terms of general psychiatric problems, travel anxiety, pain, physical problems, overall level of functioning, and financial problems. The researchers concluded that not only was early counseling not effective, but that it had adverse long-term effects. 

A Cochrane Review (Rose, Wessely & Bisson, 2001) also concluded that psychological debriefing was not only ineffective in preventing later PTSD but increased the risk of its occurrence. Mayou et al. suggested the reason for this:

very early exposure to the memory of the traumatic event is counter-productive in that it may interfere with the normal cognitive processes that lead to recovery (because it requires) patients to ruminate excessively about (the incident) rather than putting it behind them. (p. 592)

As earlier suggested by Seligman, intervention interfered with the natural healing process.

In the area of treating adults with repressed memory therapy, a study of the state of Washington's Crime Victims Compensation Program is suggestive, though not probative, of the harm that can occur in therapy for repressed memories of sexual abuse (Loftus, 1997; Parr, 1996).  Between 1991 and 1995, in the state of Washington, 325 repressed memory therapy claims were awarded victitim compensation. 

Loni Parr, a nurse consultant, and staff employees reviewed 183 of these claims. They randomly selected 30 of these to gain a preliminary profile of the cases. Their findings are or should be alarming.

Overall, the status of these claimants deteriorated during treatment. Before recovering memories, 

three (10% ) had attempted or thought of suicide; after recovering memories, 

20 (67%) were suicidal. 


Before memories, only 2 (7% ) had been hospitalized; 

after, 11 (37% ) had been. 


Before the emergence of memories, only one woman (3%) had engaged in self-mutilation; 

after, 8 (27%) had mutilated themselves (Loftus, 1997).



before entering therapy, twenty-five (83% ) of the patients had a job; 

after three years of therapy, only 3 (10%) were still employed.


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Twenty-eight (93%) were married when they entered therapy; within five years, 18 of the 28 (64%) were divorced or separated. Twenty-one of the patients had minor children and one-third (7) lost custody of their children during therapy.

All were estranged from their extended families (Loftus, 1997 ; Parr, 1996).

These patients were in therapy longer than other mental health patients, and evidenced a high rate of mental and emotional problems, all of which arose and worsened during therapy. In fact, the longer the patients were in therapy the more disabled they became. The primary diagnosis in these cases was Multiple Personality Disorder, and it was not unusual for claimants to report having dozens or even hundreds of personalities; one person claimed over 3000! The findings of this study buttress the conclusion of Ofshe and Watters (1994):

Examining the fad diagnosis of MPD, the cruelty of recovered memory therapy becomes particularly clear. Thousands of clients have learned to display the often-debilitating symptoms of a disorder that they never had. They become less capable of living normal lives, more dependent on therapy, and inevitably more troubled. (p. 223)

As a result of Parr's review, in December of 1996, Washington became the first state to prohibit compensation for any therapy deemed experimental, such as any therapy that focuses on the recovery of repressed memory (Staff, March 1997; April 1997).

In short, the evidence does not support the contention that therapy for those labeled sexually abused is helpful. It may, in fact, be harmful.


If mental health professionals are to minimize the likelihood of being accused of exploiting the problem of child/adolescent sexual abuse, a number of things need and should be done. These include:


Mental health professionals should not routinely provide treatment to children and adolescents labeled "sexually abused." As was pointed out to this author by a clinician at a presentation on this topic, sexual

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abuse is not a psychiatric disorder (see also, Finkelhor & Berliner, 1.995). Rather, it is an event or a series of events in a person's life.


Mental health professionals should consider treatment only if there is demonstrable harm, i.e., the child/adolescent is symptomatic. It should be undertaken with caution because: 

(a) the evidence that the treatment will be effective is at best tentative; and 

(b) it may well be harmful. 

It may be better if mental health professionals were to follow Seligman's recommendation to parents of those labeled sexually abused: "to turn down the volume as soon as possible" (p. 235). In other words, a wait and see stance is preferable, given that most children and adolescents become asymptomatic without treatment.


Mental health professionals should not treat the asymptomatic child or adolescent. To do otherwise is comparable 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.

Some might argue that since CSA is a risk-factor for later psychopathology (Sayvitz et al., 2000), treatment should be provided to prevent future pathology. Treatment, however, is not provided for risk-factors. Smokers are not treated for lung cancer unless they develop lung cancer. Moreover, there is no evidence that preventive psychotherapy works.


Mental health professionals should only treat those who were in fact sexually abused. Those who retract or deny that abuse occurred should be believed and not provided treatment.


In treating the symptomatic, mental health professionals should look for factors other than the sexual event(s) as causative since evidence does not support that sexual abuse per se is causative of psychopathology.


Mental health professionals must assure that clients are appropriately informed of the evidence concerning the need for and effectiveness of interventions for the purpose of informed consent. This includes advising prospective clients and their parents of the likelihood of a successful versus non-successful outcome as well as the risk of deteriorating as a result of treatment. It includes also informing prospective clients and their parents as to whether or not the treatment they are to be offered has been empirically validated, is still experimental, or has been discredited by sound research.


Mental health professionals should educate judges and CPS workers about the evidence concerning 

(a) the impact of CSA and 

(b) the effectiveness of treatment 


so that they will not make routine referrals for psychotherapy or counseling. 

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Referral for these services has become too routine. Even in instances of serious physical abuse, counseling is typically recommended. But, as pointed out by the U.S. Advisory Board on Child Abuse and Neglect (1995), this is not effective because what abusive parents often need is respite care (see p. 110). There is a need, then, to begin to think more creatively about meeting the needs and interests of the sexually abused and their families.


Mental health professionals need to avoid the socio-political and legalistic biases contained in the use of such terms as "victims" and "perpetrators." Until it has been established that coercion or harm was involved in the sexual encounter, more neutral terms, such as "participant" would be more appropriate.


Mental health professionals should avoid the use of the terms: "sexual abuse:' "molestation:' and "rape," until it has been determined that coercion was present.

Further, to define experiences as abusive when they are described by those labeled "sexually abused" as loving, caring, or non-coercive is not only a contradiction in terms, it is also an imposition of one's value system upon the client (Okami, 1994). According to Schultz (1980), it is unethical to do so. The term "abuse" should be replaced by such terms as "experience" or "event," until it is determined the event was in fact harmful or coercive. Should this be viewed as politically incorrect or potentially incendiary, then one could use the terms "forced/non-forced sexual activity."


Mental health professionals must base more of their practice on empirical evidence. They must engage in outcome research to determine what works.


Mental health professionals have a responsibility to assure the public is properly informed so that it may shape social policies and programs.


This paper addressed the question: is the routine provision of psychotherapy for CSA warranted? 

It noted that one of the consequences of the routine provision was that mental health professionals have become open to the charge of exploiting the problem of CSA for their own gain -- what some professionals are calling "the abuse of abuse" by mental health professionals.

A review of the literature on the impact of CSA and on the outcome of child and adolescent psychotherapy indicates that the routine provision of treatment is not warranted and may well be iatrogenic. Moreover, the review clearly indicates that the asymptomatic

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child or adolescent should most definitely not be referred for psychotherapy. It is not in the interest of either the child or adolescent labeled "sexually abused" to routinely receive treatment or of the mental health professional to routinely provide treatment to them.

Additionally, the excessive and unnecessary provision of CSA treatment takes resources from other victims and other victim needs (Costin et al., 1996). 

Lastly, and most importantly, the mixing of the truly abused with the non-abused in treatment 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.