Diagnosing Incest: The Problem of False Positives and Their Consequences

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 al., 1988).

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, Emmelkamp, & Arindell, 1990; Green & Hall, 1984).

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 scientific fact.

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.

Potential Biases

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, p.4).

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 head-shaking disbelief.

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 discoveries.

Loftus (1979, 1980) has emphasized that memory does not necessarily diminish with the passage of time; instead, it grows and expands.  What 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 — or the 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.

Multiple Realities

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."  She 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?

Definitional problems

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).  As a 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 turn, this 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 competent adults.

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 — a publication of international prominence — underscores her journalistic competence.

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).

Familial Polarization

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 change 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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1 Terence W. Campbell is a clinical and forensic psychologist at 36040 Dequindre, Sterling Heights, MI 48310.  [Back]

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