W. W. Norton & Company Description: This 318 page book is about much more than doing psychotherapy with child victims of sexual abuse and their families. It is about the practice of clinical psychology as it is applied to the needs of children and their families. The approach described here begins in Chapter 1 with the fundamental concept upon which the practice of clinical psychology must be based: that there is hope. Human beings cope with adversity. What a clinical psychologist does can make a difference. If we did not believe this, we would have no business practicing clinical psychology. Chapter 2 presents the reality that human life is a process
of development both for individuals and for families. Healing begins with
awareness and recognition of the dynamic and living nature of individual growth
and the significance of the place the individual occupies in the process. Chapter 3 is a plea for careful and thorough assessment of the situation, the
individual(s) involved, the resources, and the problems. In a responsible and
professional manner, it is acknowledged that an assessment may show either
little therapy or no therapy is needed. Not every sexually abused child needs to
be put into treatment. Chapter 4 is an attempt to balance therapists who
"lead with their hearts" and those who "lead with their
heads," that is, relational and analytic approaches. There are cautions
that are both wise and necessary (i.e., the first step for a therapist is to be
aware of personal biases and experiences). Chapter 5, on individual treatment,
acknowledges the research evidence suggesting behavioral treatments are most
effective, but then, with respect to sexual abuse victims, repeats much of the
nonbehavioral approach to treatment. Chapter 6 supports treating the family as
an effective procedure and outlines a standard family therapy approach. Chapter
7 correctly sees group therapy as a distinct modality that is not just
individual treatment done at less cost. Group therapy may be an effective
primary treatment approach for sexual abuse victims. Hypnosis is presented as a
valuable therapeutic modality for children in Chapter 8. There is endorsement of the view that
hypnosis can be used to bring about recall of prior sexual abuse that had been
neither remembered nor known in consciousness. Based upon the assertion that
sexually abused children display sexually inappropriate and aggressive
behaviors, Chapter 9 suggests a treatment approach to resolve these problem
sexual behaviors. The final chapter is an open and forthright effort to consider
the person of the therapist. The impact and involvement of the therapist is most
often overlooked as a contributing, even causal, factor in responding to sexual
abuse of children. Open acknowledgment of factors such as countertransference,
the stressful emotional demands, and conflicts between roles can only be a
helpful step forward for those mental health professionals who are in good
conscience trying to do the best possible job for sexual abuse victims and their
families. Discussion: This is a good book. This is a very dangerous book. This is a good book because it presents a comprehensive and detailed review of much of the research literature relating to child sexual abuse. The author makes a serious effort to present relevant empirical data for all the issues considered in the book. When the data requires it, limiting and cautioning statements are made. An example is the discussion on behavioral symptoms. There is recognition that behavioral symptoms exhibited by sexually abused children are not unique to this group (p.74) and "... the presence of several specific behavioral problems cannot, in itself, be viewed as conclusive evidence of sexual abuse" (p.78). In discussing sexual behavior by children, while saying sexualized behavior has consistently been linked to sexual abuse, reference is made to the author's own research showing that "... this is not necessarily the case for even the majority of children" (p.74). Throughout the book a balanced and relatively accurate summary of the empirical data bearing on a given issue is quite succinctly expressed. "However, no studies exist that document the success of individual therapy with sexually abused children" (p.132). "The current literature on families with a sexually abused child is primarily clinical in nature, with empirical research only recently emerging" (p.171). These kind of statements are both accurate and important for a clear grasp of the current state of knowledge in the science of psychology about the phenomenon of sexual abuse of children. This is a good book because the compassion, caring, and love of children that may characterize the best and most admirable of adult behaviors toward children is evident in almost every page. A responsible and competent mental health professional can be compassionate, caring, and loving. A thoughtful mental health professional will understand the nature of hope, the strength of our shared humanity, and the courage every human being shows in living. There is considerable evidence suggesting these may well be the most important curative factors in psychotherapy. A book that succeeds in sharing that quality as well as this book does is a good book. There is much here to be learned about the heart of a clinician. The inevitable conflict of the clinician comes clear in these pages. The clinician cannot wait for complete and full knowledge. The clinician is confronted with a person who is in trouble. The clinician has made a decision to help. So the clinician acts and does what seems reasonable at that time to that clinician. You cannot tell the anguished and troubled person standing before you to wait until you run an experiment or get a grant of a million dollars to do a study. You act. This is the choice of Dr. Friedrich. "There is a tension within the book between theory and technique. Both are present because I believe both are absolutely necessary. Yet we each have different needs, and when we are feeling pressed we usually want to know 'What might I try next?' rather than the underpinnings of the technique." This is why the book is dangerous. It appears to be so right, so kind, and so courageous for you to act and to do what you can, knowing that you do not have all the information and data that you need. Who can criticize such bold and compassionate clinical judgment? However, erroneous information and error-riddled procedures covered with a veneer of scientific plausibility is more harmful than no information at all, especially when dealing with issues as sensitive and volatile as child sexual abuse. The lives of children, parents, families, and the nation as a whole are powerfully affected by the legal system and the steps, procedures, and techniques suggested in this book. If adults make a mistake and nonabused children and nonabusive families are treated as if abused and abusing, the consequences may well be disastrous. This book is an illustration of the Russell-Whitehead dichotomy between simple-minded and muddle-headed psychologists. Simple-minded psychologists seek to submit to data. Muddle-headed psychologists attend to internal realities and choices. Wherever there is a choice point, Dr. Friedrich chooses to abandon what is known from the data he has already cited and elect a choice based upon his internal values and intuitions. Having reported his own research on developing a Child Sexual Behavior Inventory and acknowledged that parents of normal children, ages 2 to 6, endorsed items at a 40% level or more, he continues "... this will miss the sexually abused children who are not sexualized, it can identify those sexually abused children who are sexualized and who may or may not be disclosing the abuse" (p.82). What about the nonabused children who may be sexualized and eroticized as he discusses in Chapter 1? He then continues "It is only logical that sexual behavior discriminates sexually abused children from nonabused children" (p.82). This is a choice to contravene the fundamental character of a scientific approach to an issue. Science and the scientific method was developed to assure that human beings do not choose that which seems to be clearly logical. At one time human beings thought it was logical that the sun revolved around the earth, sailing west meant you would fall off the edge of the earth, and that smoking was beneficial to health. Friedrich states, "Despite the failure of projective drawings to be empirically diagnostic for almost any disorder, several papers have been written about their clinical utility with sexually abused children. ... It is always too easy to overinterpret drawings" (p.84-85). He then reports his own research findings on drawings of human genitalia, that a larger than expected percentage of normal children were reported to have drawn them at least once. "The presence of genitals on human figure drawings done in a clinical setting is probably appropriately viewed as pathognomic" (p. 86). In the discussion of treatment, the empirical data demonstrating the superiority of behavioral methods is cited. The remainder of the chapter presents a feeling-expressive, insight-oriented talking therapy as the most desirable way to help a sexually abused child. Throughout the book the dogmas and uncritically examined myths of the relatively small group of mental health professionals who claim to know what and how to do it based upon clinical judgments and experience are presented as factual. Summit's concept of a sexual abuse accommodation syndrome, though rejected by the legal system as not generally accepted in the relevant scientific community and rejected by the revision committee of DSM-III-R as without scientific merit, is presented as factual by Friedrich. This approach may contribute to much mischief and harm. It fails to take two considerations into account. By abandoning empirical data and acting contrary to it in some instances, choosing lower validity clinical inferences, the clinician is not doing the best he or she can for the troubled individual seeking assistance. While thinking or feeling that he or she is, the probabilities are that the therapist is not. The probabilities are that an error will by made which may damage the individual. Even if it should be that in the individual case clinical inferences result in a correct decision for that particular case, this desirable result has been reached by a decision policy that will mean error and mistreatment for other patients presenting an equally valid claim for assistance. Such a policy is indefensible no matter how good it may make us feel at the time. The danger of this book is that it will appear so reasonable, so well done, and so supported by a scientific approach that mistakenly is transferred as if it supported all of the positions taken by Dr. Friedrich. It may lead unsophisticated mental health professionals, who do not distinguish what is empirically supported from what is not, to become more convinced of the rightness of their choices and the correctness of their procedures. It would be better for all professionals to have a more open, more seeking, and more provisional understanding of the research and what is best for their clients. This provides the best hope for helping or at least not harming a patient, a child, a family, or the legal system. Unfortunately, it appears likely that muddleheadedness is a terminal disease and highly resistant to correction. Reviewed by Ralph Underwager, Institute for Psychological Therapies, Northfield, Minnesota 55057.
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