Diagnosing Incest: The Problem of False Positives and
Terence W. Campbell1
ABSTRACT: Incest resolution therapies have developed to counter
treatment traditions predisposed to false negative diagnoses when
confronted with client histories of sexual abuse. Nevertheless, attempts
at systematically reducing the frequency of false negative errors in any
diagnostic endeavor correspondingly increase the frequency of false
positive errors. This paper contends that the theoretical premises of
incest resolution therapy alarmingly increase the probability of false
positive conclusions when diagnosing a formative history of incest.
In 1896, Freud's classical paper examining the origins of hysteria
emphasized the etiological influences of seduction, or what is now
more often referred to as incestuous experiences. By the end of the
19th century, Freud had shifted his position insisting that patient
reports of incest were merely fantasies in the service of
wish-fulfillment. Masson (1984) argued that Freud's revised opinion
served to suppress awareness of the prevalence and significance of
intrafamilial sexual abuse for the next 70 to 80 years.
The previous decade, however, has seen an increasing emphasis on
the extent of childhood incest and its subsequent effects on adult
functioning (Deighton & McPeek, 1985; Gelinas, 1983; Reiker &
Carmen, 1986). Russell (1986) contended that one out of every three
females and one of every six males has experienced incest or some
other sexual trauma over the course of their formative
development. Hart and Brassard (1987) cited an incidence of child maltreatment
(including but not confined to incest) ranging from 200,000 to 1.7
million cases per year. This literature, and the work of others
(Armstrong, 1978; Herman, 1981; Miller, 1985), has increased the
awareness of mental health professionals regarding the tragic costs of
false negative conclusions when assessing incest. Disqualifying the
traumas of incest victims as mere figments of their imaginations
subjects them to further self-doubt and self-depreciation.
On the other hand, clinicians
concerned with the extent and effects of
incest must contend with another
difficult consideration: Attempts at
systematically reducing the frequency of
false negative errors in any diagnostic
endeavor correspondingly increase the
frequency of false positive errors (Anastasi,
1982). For instance, when false negative
errors (e.g., erroneously concluding
that a client endured no formative
incest) decline because of some
standardized decision-making strategy,
false positive errors (e.g., erroneously
concluding that another client did
endure formative incest) inevitably
increase. Consequently, it is not
surprising that clinicians do commit
false positive errors when diagnosing
sexual abuse (Blush & Ross, 1987;
Campbell, in press-a; Coleman, 1990;
Gardner, 1987; Spiegel, 1986; Wakefield
& Underwager, 1988). Eckenrode and
his colleagues underscored the magnitude
of this problem when they reported a
declining rate of substantiation for
sexual abuse allegations over the past
decade-even though the number of reports
have soared. For example, 61% of a
sample of sexual abuse allegations for
the year 1985 in the state of New York
could not be substantiated Eckenrode et
Despite those who would confidently
conclude otherwise (e.g., Russell,
1986), the necessary data are not
available to accurately define the base
rate with which incestuous abuse occurs
throughout the population. Research
addressing this issue must contend with
the inevitable shortcomings associated
with retrospective data. The reliability
of survey investigations declines the
more removed they are in time from the
events they are examining (Finkelhor,
1986). As a result, the validity of
retrospective reports addressing a
population's formative history is always
subject to challenge (Gerlsma,
& Arindell, 1990; Green & Hall,
Above and beyond the methodological
problems involved with retrospective
surveys, experimenter biases can also
undermine the value of this research.
Okami (1990) insists that Russell's
(1986) work was severely compromised by
virtue of how she selected and trained
her interviewers. These interviewers
learned to ask questions actively
encouraging subjects to disclose a formative history of sexual abuse.
Gilbert (1991) argues that such
biases promote "advocacy numbers" as opposed to legitimate
data. Rather than respond to considerations of intellectual honesty,
advocacy numbers attempt to persuade public opinion that the extent of
formative sexual abuse is significantly greater than previously
recognized. Given these sobering considerations, the readiness of the
popular media to shrilly publicize an "incest epidemic" may
qualify more as "social science fiction" (Tavris, 1987) than
This paper addresses the problem of false positive diagnoses of
childhood incest transpiring over the course of psychotherapy for
adults. It discriminates between clients who report experiences of
incest at the start of treatment independent of a therapist's
influence, and clients who conclude they have endured a formative
history of incest after initiating treatment. These latter
circumstances seem more conducive to diagnoses of childhood incest as
false positives. Admittedly, there are situations where popular
self-help publications could erroneously persuade people that they
were sexually abused before they undertake therapy. Nevertheless, that
issue is far too complex for consideration here.
Incest Resolution Therapy
Incest resolution therapies (Courtois, 1988; Gil, 1988; Maltz &
Courtois, 1987) have developed to counter treatment traditions that
overlooked the extent and effects of childhood sexual abuse-especially
for women. Adherents of this treatment model see themselves as filling
a void created by therapists who "... lack the ability to help incest
victims because they have never been trained to deal with the issue.
In fact, they have been trained to avoid it" (Herman, 1981,
p.180). Theoretically, incest resolution therapists gravitate toward
the many variations of object relations thinking (Haaken & Schlaps,
1991). Thus, the fundamental assumptions of this treatment approach
predispose it to emphasize the outcomes of pathogenic parenting.
All psychotherapy inevitably responds to the theoretical
predilections of the treating therapist (Brunink & Schroeder,
1979; Stiles, 1979). Consequently, it seems reasonable to assume that
incest resolution therapists are particularly sensitive to client
reports which could be interpreted as indicating a formative history
of incestuous abuse. The determination of these therapists to avoid
the false negative errors previously committed by others practically
guarantees such sensitivity. Moreover, the basic premises of incest
resolution therapy can lead therapists to assume: "Therefore, it
is likely that the majority of patients seen in a general outpatient
therapy practice will be survivors of some form of abusive or neglectful
parenting" (Suffridge, 1991, p.67). As is the case with therapists
of other theoretical persuasions, however, the sensitivities of incest
resolution therapists also predispose them to biased judgments.
The theoretically derived expectations of all therapists result in
them directing particular kinds of questions to their clients (Arkes,
1981). For incest resolution therapists, it seems reasonable to expect
that they frequently pose questions searching for evidence of parental
failure or betrayal. Nevertheless, Arkes (1981) has demonstrated that
asking enough questions about a particular topic encourages clinicians
to mistakenly assume they have found the answers they are seeking.
Specifically, the expectations of clinicians can lead them to conclude
that symptoms consistent with their diagnostic impressions were
exhibited in an interview-when in fact, they were not (Arkes &
Harkness, 1980). Conversely, clinicians are also less likely to recall
symptoms that were actually present during an interview but
inconsistent with their diagnostic impressions. These data also
support the position of Spence (1982) who argues that psychotherapy
rarely discovers any objective truths related to a client's history.
Rather than uncover the "historical truths" of clients'
lives, Spence emphasized that therapy invents "narrative
truths." Therapists organize the information that clients present
them into consistent-but potentially distorted-themes. Subsequently,
these themes are outlined for clients via the interpretations,
summaries, and reflections of their therapist. In turn, clients
respond to their therapist's influence by reporting new information
that appears to validate the preliminary versions of narrative truth
they have already created via their previous dialogues. In other
words, narrative truths develop over the course of treatment as
clients "discover" information consistent with their
therapist's suggestions. To belabor the obvious, narrative truths can
substantially distort the historical truths of a client's formative
history-and moreover, they may lead to false positive diagnoses of
childhood sexual abuse.
The tenacity with which some therapists pursue verification of
their theoretical convictions related to incest should not be
underestimated. For example, a California psychologist reported
blatant examples of biased assumptions regarding the prevalence of
childhood sexual abuse:
In the past two years, many patients have told me that previous
therapists have presumed that they must have been sexually molested as children.
If the patient had no such
recollection, that was taken as evidence of severe "repression,"
or that the molestation must have happened very early in life, causing
unusually great harm. Such therapists employed Similar logic if the
patient recalled a pleasant, loving family life. Such therapists
repeatedly attempt to elicit fragmentary memories or fantasies, often
with the aid of hypnosis, to confirm their preconceptions. Several
patients told me their therapists went so far as to say, "I am
certain you were molested because you have all the classic
characteristics of adults molested as children" (Miller, 1991,
The potential for these kinds of tactics resulting in false
positive diagnoses of sexual abuse is so obvious as to be alarming;
consequently, they can only reduce more responsible clinicians to
Limitations of Human Memory
The accuracy with which any client can discover a history of incest
as a result of psychotherapy rests upon the reliability of long-term
memory. Nevertheless, the inevitable limitations of long-term memory
necessitate caution when interpreting the significance of such
Loftus (1979, 1980) has emphasized that memory does not necessarily
diminish with the passage of time; instead, it grows and expands.
fades from memory over time is the actual experience of an event.
Consequently, each time people recall some event they must reconstruct
it "What happened and how did it transpire"
and with each
reconstruction, the memory can change. Therefore, memory recall
reconstruction of some event responds primarily to any individual's
sense of what is plausible. People recall events so that they seem to
make sense, but what seems plausible the "sounds good"
effect can be grossly inaccurate. In particular, the influences of
incest resolution therapists could profoundly distort a client's
memory via biased definitions of plausibility.
Extrapolating from the earlier work of Loftus (1979) and Spence
(1982), Bonnano (1990) has outlined how therapists and clients can
invent mythical memories via "narrative revisions." Instead
of merely distorting recall, narrative revisions influence clients to
construct memories of past events which are consistent with their
therapist's assumptions. Suspecting that their clients have endured a
history of sexual abuse, therapists can lead them into speculations
about who might have perpetrated such acts, when and where they could
have occurred, and how they would have been concealed.
To the degree that clients feel depressed perhaps by questions
suggesting that their own family profoundly betrayed them or in
response to other circumstances their depression increases the
probability of them remembering their parents as rejecting and relying
on negative controls (Lewinsohn & Rosenbaum, 1987). When clients
report these memories to their therapist they may encounter lavish
praise for "the impressive commitment to your 'recovery',"
and this outcome obviously motivates them to search for more anecdotes
of parental betrayal.
The anecdotal speculations exchanged between uncertain clients and
overconfident therapists can eventually converge into commonly shared
theories leading to the same conclusion the client suffered episodes
of formative sexual abuse which remained repressed until uncovered by
the therapist. In fact, however, recollection of such memories often
responds more to current mood states than it involves any accurate
recall of past events (Lewinsohn & Rosenbaum, 1987). Thus,
verification of these "memories" typically relies more on
imagination than actual experience-and as a result, fiction can
prevail over fact in incest resolution therapy.
Examples of Incest Resolution Therapy
Uncovering or Indoctrination?
In May of 1991, a private mental health facility in a Detroit
suburb publicized the start of a "Process Group for Survivors of
Sexual Abuse/incest" designated as "Thrivers." This
treatment experience was described as "...an entry group; this is
appropriate for individuals who sense they were sexually abused yet
have no clear memories as well as for people who remember, yet are not
fully associated with the feelings." When clients enter a group
such as this wondering whether they have endured a history of abuse or
incest, how long will it take before they become convinced that they
have suffered such betrayals?
Given the processes of conformity (Asch, 1956) and compliance (Milgram,
1974) which characterize any group, clients in an incest resolution
group who decide that their formative history does not include sexual
abuse run the risk of being ostracized as denying deviants. In these
circumstances, the group pressure associated with "...an
insistent focus on sexual abuse can be manifested as a subtle as well
as an overt demand. Pleasing the therapist (and the entire group) and
wanting to 'do it right' are common responses for many patients"
(Haaken & Schlaps, 1991, p. 45). These circumstances also create
fertile ground for a bountiful harvest of false positive diagnoses
indicating childhood sexual abuse.
In the fall of 1991, Time magazine printed a story tided
"Incest Comes Out of the Dark." A Time reporter wrote a
sidebar for this article graphically summarizing her own history of
substance abuse, overeating, disappointing relationships,
hyperresponsibility, and betrayal by a previous therapist who sexually
exploited her (Dolan, 1991). She attributed all of these problems to
the sexual abuse allegedly perpetrated by her mother over the course
of her formative development. She lamented how her mother still
refused to acknowledge the alleged sexual abuse, and implied that this
Situation drove her to "...finally giving up my mother."
also spoke of more recently having undertaken "...five weeks of
intensive treatment and many hours of outpatient therapy."
Three weeks after the previously cited article appeared, Time
printed a letter in response to the reporter's first-person account
from her sister. The letter read:
With the publication of my sister Barbara Dolan's article
"My Own Story," our mother has essentially been tried and
convicted of actions she thought were those of a loving, carefully
protective mother. Fifty years after the fact, my sister has
blindsided the reputation of our 83-year-old mother, who had no
intent to harm. My sister did not have the courage to discuss this
mailer face-to-face with our mother, choosing a cowardly solution,
the pen, so she would not have to view the destruction of a life.
Where is the justice in this? What about my sister's responsibility
for her own life? How did Time magazine stoop to this level of
sensationalism? (Lendabaker, 1991, p.11).
The reporter insists that she suffered repeated episodes of sexual
abuse at the hands of her own mother. Her sister argues that while
their mother may have been misguided, her behavior was not willfully
abusive. This tragic situation raises the question of who is reporting
historical truth, and who is reporting narrative truth? This writer is
not so presumptuous as to assume that he can decide this matter.
Nevertheless, the issues of this case certainly raise the possibility
of a false positive diagnosis of sexual abuse.
In fact, the reporter's case presents more questions than it
answers; but the questions it poses are so important that they demand
serious attention. For example, did the therapist solicit biased
information to confirm her or his expectations? Were the client's
reports interpreted in the service of constructing narrative truths?
Could the therapist's influence have led the client into significant
memory distortions? Was the diagnosis of incest a narrative revision
contaminating real events with imaginary events?
As in all cases of child maltreatment (Hart & Brassard 1987),
the accuracy with which therapists can diagnose a formative history of
incest also suffers from persistent definitional problems. Quite
simply, the question of exactly what constitutes incest is not
well-defined. In response to the influence of the growing incest
resolution literature, the popular media considers incest as including
but not limited to "fondling, rubbing one's genitals against a
child, and excessive or suggestive washing of a youngster's pubic
area..." (Dolan & Horowitz, 1991, p. 46). Obviously, there is
little about these criteria that qualify them as operational
definitions increasing the reliability with which a history of incest
can be accurately diagnosed. Given the gross subjectivity of these
criteria, the rate of diagnosed incest could soar precipitantly
depending on who interprets the data.
Consequences of Incest Resolution Therapy
Centrality of Incest
Incest resolution therapy identifies incest as the central
experience in the lives of clients (Haaken & Schlaps, 1991).
result, it typically assumes that all the problems of clients
originated with the formative betrayals they presumably endured.
Consequently, this therapy can overlook contemporary client problems
that develop as a result of contending with the vicissitudes of adult
life. Despite the prevalence of substance abuse, depression, anxiety,
and marital conflicts distributed throughout a population that never
endured a formative history of incest, incest resolution therapists
seem determined to attribute these problems and others exclusively to
their clients' assumed histories of incest.
The emphasis on the centrality of incest in this treatment model
corresponds to its linear thinking. How clients function as spouses or
parents, for example, is assumed to directly reflect their apparent
history of incest. Thus, clients are designated as passive objects
suffering the persistent effects of pathogenic histories. In
designation of passivity discourages clients from viewing themselves
as active participants in their own lives who influence as well as are
influenced by the interpersonal systems in which they operate.
Instead, incest resolution therapy attributes substantial fragility to
its clients. For example, Miller (1985) has emphasized: "...I
always regard myself as the advocate for the child in my
patients..." (p.59). To the extent that incest resolution therapy
relates to clients as fragile children, it can underestimate their
strengths while subtly discouraging them from viewing themselves as
The following case vignette outlines the counterproductive effects
associated with inappropriately defining incest as the central issue
in a client's life.
On one occasion when he was six, Clifford was fondled by his
uncle. After he first recalled the incident during counseling in his
early twenties, his therapist suggested he join a self-help group
for victims of sexual abuse. Clifford began attending group meetings
once a week. By the time he started therapy with me, he was still in
the group, had received counseling for more than eight years, and
had never moved beyond his outrage at his uncle, now dead. I saw
Clifford for more than three months before he finally agreed to look
at the other aspects of his life. Only then did he reveal that his
father had died when he was twelve, that he had a mentally retarded
sister, and that he had had four affairs during his nine-year
marriage all with members of his self-help group.
As critical as Clifford's encounter with his uncle was, it did
not occur in a vacuum and should not have been allowed to overshadow
everything that happened before and after, yet because his identity
as a sexual abuse victim was constantly reinforced by his former
counselor and his group, it not only remained the central focus but
automatically was blamed for everything that went wrong in
Clifford's life (Katz & Liu, 1991, p.38).
Clifford's case demonstrates how incest resolution therapy can
leave clients seriously misdirected. His treatment of eight years
amounted to an iatrogenic outcome because it created problems for him
that otherwise would not have existed. Distracted by his
therapeutically ascribed status as a sexual abuse victim, Clifford
overlooked the significance of more pressing issues in his life.
Incest resolution therapy encourages clients to identify themselves
as "survivors," but the status of survivor necessitates a
preexisting condition as "victim." When clients organize
their self-concepts about the identities of survivor and victim, a
supposed history of incest remains the paramount issue in their lives.
Consequently, it becomes more difficult for them to resolve that history
if it does exist because their self-concept forever reminds them
of it. These practices of incest resolution therapy also correspond to
a larger issue in psychotherapy: Is treatment more effective when it
seeks to compensate for the presumed deficits of a client's formative
history? Or is treatment more effective when it attempts to capitalize
on the strengths that clients demonstrate in the here-and-now? (O'Hanlon
& Weiner-Davis, 1989).
Capitalize or Compensate?
The issue of a "compensate" versus a
"capitalize" focus in psychotherapy is relevant to the case
of the Time reporter. To say the least, this woman presents a variety
of impressive strengths. By virtue of her career as a journalist, it
appears safe to assume that she is well-educated (it seems unlikely that
Time magazine hires high-school drop outs for its journalistic staff).
She writes with qualities of such vigor and flow that those with lesser
talents could feel envious of her style. Moreover, she has realized
substantial success in her career; her status as a reporter for Time
publication of international prominence underscores her journalistic
Compared to the compensate emphasis of incest resolution therapy, a
capitalize focus would have addressed the personality strengths of the
Time reporter responsible for her impressive accomplishments. Additionally, a capitalize focus would have identified the
contemporary problems with which she was struggling, and then assisted
her in bringing her strengths to bear on those here-and-now problems.
This kind of capitalizing approach to treatment leaves clients feeling
empowered by emphasizing their competence as adults rather than
dwelling upon their supposed fragility as children.
Incest resolution therapists appear motivated to rescue their
clients by providing them an idealized relationship designed to
compensate for their history of alleged betrayals (McElroy &
McElroy, 1991). This kind of positive countertransference can lead
clients into unrealistic expectations regarding the continuing
centrality of their therapist in their lives. These circumstances make
therapists more important than they should be by inviting their
clients' dependency; and in turn, clients over-identify with their
presumed status as incest victims. If the therapist is to continue
relating as a savior to the client, the client must remain a victim;
otherwise, the client would not need the therapist's savior services.
Thus, in order to perpetuate the significance of their therapist,
clients could be motivated to cling to their identities as victims.
Beutler and Hill (1992) challenge the readiness with which incest
resolution therapies assume that adult survivors of formative sexual
abuse constitute a unique population requiring special therapeutic
expertise. They contend that when this population is compared to other
clients whose disorders originated subsequent to nonsexual or
adulthood sexual traumas, there is minimal evidence to support
assumptions regarding the uniqueness of victims of childhood sexual
abuse. Consequently, Beutler and Hill question the effectiveness of
treatments that respond to unique precipitants compared to treatments
that address clinical manifestations of trauma related to a variety of
etiologies. Additionally, the extent to which a formative history of
sexual abuse-in and of itself-necessitates treatment appears less
frequent than might otherwise be expected. Of a total sample of 246
women, including 176 who reported a history of sexual
abuse l54 of whom experienced sexual abuse as children
only 5% of
the total sample sought referrals for mental health services after
participating in research interviews about their abusive experiences
(Wyatt, Guthrie, & Notgrass, 1992).
Incest resolution therapy emphasizes the supposed benefits of
emotional catharsis (Haaken & Schlaps, 1991). Therapists actively
promote intense expressions of client pain and anger for purposes of
"getting the feelings out." More often than not, clients are
encouraged to direct expressions of bitterness and resentment toward
the significant others who allegedly betrayed them but these
"ventilating" tactics (Tavris, 1982) can create more
problems than they solve. Faith in the value of ventilation is
frequently premised on "blame-and-change" assumptions which
suggest to clients that therapy blames your family in order to
you (Campbell, In press-b).
Rather than assist clients to resolve the conflicts they may
experience with their families, the bitterness and resentment
associated with blame-and-change maneuvers typically exacerbate those
conflicts (Murray, 1985). Angered by the narrative truths of treatment
underscoring their supposed history of betrayal by significant others,
clients seek additional evidence to legitimize their reactions of
bitterness and resentment. Applauded by their therapist for diligently
responding to the working-through process, clients find more examples
of apparent betrayal that further arouse their anger. Consequently,
this outcome necessitates additional searches for even more evidence
to justify their still increasing anger and a vicious cycle ensues
that can polarize any existing conflicts between clients and
significant others in their families.
Unfortunately, incest resolution therapy appears to have seriously
polarized the relationships between the Time reporter and her mother
and sister and perhaps even others in her family. Given the
relationship between the availability of social support and overall
psychological adjustment (Hobfoll, 1985; Sarason, Sarason, &
Pierce, 1990), one is obligated to question whether this kind of
familial alienation ultimately served the reporter's welfare.
Admittedly, a variety of recovery groups are available to this
client, but such groups run the risk of reinforcing her status as a
victim via a preoccupation with the betrayals she allegedly suffered
in the past. Additionally, resorting to recovery groups for social
support discourages clients from attempting to repair and restore
relationships with their families (Brooks, 1991).
Participation in these groups can encourage clients to substitute
them for familial identification and support. When such outcomes
transpire because of incest as a false positive diagnosis, the results
are tragic to say the least.
In medicine, diagnosticians have responded to the false
positive/false negative dilemma by considering the costs of each
error. Confronted with the possibility of a patient's life-threatening
illness, physicians understandably prefer false positive diagnoses
compared to false negatives. Though false positive errors waste time
and money via unnecessary treatment, false negative errors too often
lead to fatal consequences. Unfortunately, weighing the costs
associated with false positives and false negatives offers mental
health professionals little guidance when contending with diagnostic
questions of sexual abuse. Neither false positive nor false negative
errors are preferable when dealing with the issue of incestuous
betrayals because both mistakes exact an enormous toll from clients.
Given the consequences of both false positive and false negative
conclusions, responsible and ethical clinicians are obligated to avoid
rushing to judgment when diagnosing a formative history of incest.
Because incest resolution therapists have struggled long and hard to
reduce the frequency with which clients endure false negative
diagnoses, it may be difficult for them to adopt necessary safeguards
in their diagnostic endeavors. For those who align themselves with an
incest resolution model of therapy, rethinking their position could
strike them as a retreat into the past. Therapists whose professional
identities and incomes depend largely on their reputations as
"incest resolution experts" might find it particularly
difficult to objectively assess the pitfalls of their orientation.
Nevertheless, the welfare of innumerable clients dictates that
clinicians respond to their needs while checking their own theoretical
assumptions which may be seriously biased.
If mental health professionals disregard the necessity for
approaching issues of incest more cautiously, the consequences of
their oversights could extend beyond the considerations of treatment
effectiveness previously outlined. Neglecting professional
responsibilities related to these issues could eventually result in
legions of attorneys taking legal action on behalf of families who
regard a therapist as having defamed or slandered them (Dickson,
1991). To say the least, developments such as these would be equally
catastrophic for clients, families, and therapists alike.
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W. Campbell is a clinical and forensic psychologist at 36040
Dequindre, Sterling Heights, MI 48310. [Back]