||Casebook of Sexual Abuse Treatment /
|| William N. Friedrich
|| W. W. Norton & Company © 1991
W. W. Norton & Company, Inc.
500 Fifth Avenue
New York, NY 10110
This 327-page book presents 15 case descriptions of sexually
abused children and adolescents. The editor, psychologist William Friedrich,
solicited different clinicians to write the histories. The clinicians are
primarily psychologists but there are two psychiatrists and two social workers.
Each case history follows a standardized format in which the clinicians'
theoretical orientations are discussed followed by case descriptions,
assessment, therapy techniques, and outcomes. The authors also describe their
perceptions of the obstacles to treatment and mistakes they made along with
their personal reactions to the case. Dr. Friedrich begins each chapter with an
The clinicians represent different theoretical orientations,
including cognitive behavioral, family systems, and psychodynamic. Although most
use play therapy with the younger children, many other techniques are used
including family therapy, child and adult groups, insight and supportive
therapy, various behavioral techniques, and caregiver instructions. The children
have a wide variety of abuse histories, including abuse by parents, relatives,
neighbors, and babysitters.
Several interesting observations can be made from these 15
cases. The intrafamilial victims come from obviously dysfunctional families,
some of them severely so. This contradicts what is often heard about incest and
sexual abuse — that it is not limited to problem families, but routinely occurs in
outwardly functional and normal families. The therapists become actively and
emotionally involved with their clients, frequently falling into the role of
advocates and spending much time beyond therapy sessions. The possible role
conflicts between therapist and advocate and between therapist and investigator
or evaluator are discussed in a few of the chapters. The 15 cases are
complicated and the therapy is long-term, lasting as long as five years in one
case. None of the authors discuss the potential for the inadvertent influence of
therapy which results in reconstructed memories of events which may not have
happened, although one of the cases describes the "bizarre fantasies"
of a six-year-old girl in play therapy.
The 15 cases also represent a spectrum of effectiveness on
the part of the clinicians, although this is not discussed in the book where the
assumption is made that all the the clinicians are skilled experts. The various
approaches and techniques used demonstrate that there is no single treatment
approach that is most effective for all sexually abused children. This
highlights the importance of a careful assessment and individually tailored
treatment approach. In several chapters sensitive and skilled therapists using a
variety of approaches persevere in difficult and complicated situations and
produce positive outcomes.
Other therapists, however, appear to be mistaken and
misguided in their therapeutic approaches. In one case, the child, who didn't
disclose abuse for several months, was interviewed by 15 different people and
given two medical examinations. Two others claim to be treating satanic ritual
abuse. This is disturbing since this book purports to represent the work of
"expert" therapists and there is no skepticism expressed about the
veracity of these two cases. Although in one of the satanic cases, the child
appears to have been neglected and abused, she can not have been helped by being
taught to believe she was a victim of bizarre and sadistic ritual abuse.
The therapist in this case, Barbara Boat, is well known for
research with anatomical dolls. Dr. Boat provided therapy for a four-year-old
child who had documented physical abuse and whose parents were clearly
dysfunctional. The child was placed in a foster home following the evaluation and the foster parents were
used as "surrogate therapists." There was no physical evidence of
sexual abuse and the child, although possessing advanced verbal abilities, was
"inarticulate" about the alleged abuse. Therefore, therapy was
"disclosure based" and both the therapist and the foster parents
devoted much time and energy towards encouraging disclosure of abuse. Techniques
such as "bathtub" therapy, in which the child was encouraged to
reenact abusive events while in the bathtub, were used. After a year of foster
care and therapy, the child was describing drinking blood, eating feces,
mutilating animals, eating body parts, murdering and cannibalizing new-born
infants, killing children and adults, and engaging in sexual activities with
animals. The therapist took the role of an advocate, pitting herself against the
CPS case worker who believed that the foster care system should preserve
families and who wanted the child to visit her mother. The therapist persevered
and the visits were stopped and the parental rights eventually terminated.
The other case of alleged ritual abuse appears to be from one
of the Manhattan Beach day care cases which followed McMartin, although it is
not identified as such. The four-year-old boy originally made no disclosures of
abuse but gradually provided information through play therapy and questioning
from the therapist. Eventually, the child provided accounts of sexual
molestation, animal mutilation and torture, bad guys who pooped and peed on the
floor, games where the children removed their clothing and smeared feces on each
other, being taken to a house where the children were tied up, forced to eat
feces, and urinated on, mind-altering drugs, and adults wearing masks and green
wigs dancing naked around a fire. The case description suggests that the child
became eroticized in the course of therapy and began to act out sexually. No
evidence was found of the alleged activities and the day care teachers were not
prosecuted. The therapist networked with other groups reporting ritualistic
This is an interesting and worthwhile book if it is read with
skepticism. It describes what is actually done in therapy by people in the field
and inadvertently illustrates misguided approaches as well as effective ones.
suffers from the lack of a critical rational examination of the epistemological
assumptions of some of the therapists.
Reviewed by Hollida Wakefield, Institute for Psychological
Therapies, Northfield, Minnesota.
This edited book of readings consists of 15 chapters written
by various experts on treatment methods with sexual abuse victims and includes
treatment of young boys, religious use of treatment, the reconstructed family,
visitation issues, ritualistic abuse, and treatment of retarded victims. Most of
the authors, in addition to William Friedrich, will be well known to readers.
The book closes with a small bibliography.
The book has no discussion on the controversy over the issue
of the validity of alleged sexual abuse, even though three of the chapters are
about satanic ritualistic abuse. There is no discussion of the role of the
mother as a contributing agent, sibling abuse treatment, or of ways to assess
treatment outcome. There is overlap and redundancy and the authors make
assumptions with a disregard for research evidence. There is no discussion of
children's and adolescents' rights regarding treatment and how this is related
to court-referred clients and the therapeutic use of social authority. Guilt
and denial are viewed as negative and the emphasis is on getting the child to
disclose and admit the abuse. The discussion of treatment methods frequently are
ambiguous and lack definition as to what is actually done. Conclusions are often
stated without the rationale for the conclusions.
The book also has strengths. The section in each chapter
called "mistakes" is useful and is a needed ethical breakthrough in
books about treatment. The chapter by Mannarino is helpful in terms of its
discussion of prosecution-treatment problems, involving the abuser in assessment
and treatment, and issues involved when the same professional takes on the role
of evaluator and therapist.
The greatest value in the book is in the fact that these are
actual cases. The book is recommended to front line workers and parents of
abused children so that they can see what actually happens to the victims in
Reviewed by LeRoy Schultz, Professor of Social Work, West