Intrafamilial abuse is one of the most heated social policy questions of the day. It generates headlines, evokes intensely polarized disputes among professional colleagues and zealous advocacy by citizen groups, and frustrâtes the judiciary. With all this atieniion, we do not yet know exactly how io define or lo measure the manifold varieties of abuse (for example, incest, child abuse, and spouse abuse are not DSM-IIi diagnoses). Moreover, the long-term consequences of abuse itself or the impaci of various forms ol investigation and intervention remain obscure. Whal is clear is that abuse and allegations of abuse are lightning rods for immediate social aetion. This article seeks to clarify one troubling aspect of families who require abuse intervention: what are ihc dynamics of uncertainty that surround some abuse allegations, and how do some abuse allegations become exaggerated?
The impact of group process on individuals has been standard knowledge in the social psychological literature for generations' and families as a special class of groups have received increasing iheoretical and clinical attention over the last 10 to 15 years. Over the same two decades, two other social phenomena have become increasingly obvious.
The first is a radical restructuring of the mythic prototype family. Whether or not the "nuclear family" was ever truly modal, it is clear that there has been a dramatic increase in the prevalence of divorce and remarriage. This has generated new forms of families based on "horizontal." legal relationships radice than on blood kinship. These new relationships have more permeable boundaries and instant identities,2 which confer less support on their members from cultural tradition than do the former nuclear-extended kinship families.
The second social phenomenon emerging over the past decade and a half has, been a long wave of evolving child abuse reportage. Prior to the 19bOs. child abuse was underreported and much was probably ignored. Beginning in the 1970s, family courts and social agencies (including hospital emergency rooms) became aware of increasing reports of child physical abuse. In the decade of the 1980s, reports of child sexual abuse and other forms of intrafamilial abuse have become epidemic. These include spousal physical abuse (with husbands and wives as victims), intergenerational physical abuse (with parental victims of leenaged children or elderly parental victims of adult children), and all forms of child sexual abuse (perhaps the one form of sexual abuse which is still under-reported is intersibling incest). It is not known whether ihese increased reports represent truly increased incidence of abuse or merely an enhanced social awareness of such pathologic activity.
Any connection between the increasing breakdown of traditional family forms and increasing reports of sexual abuse of children (or of other forms of abuse) is not clear, if indeed any causal connection exists at all. Yet it is in the context of family breakdown that many of the current epidemic complaints of abuse occur. The settings of marital separation, divorce, custody, or visitation disputes, contested adoption by a stepparent, or remarriage a !'ter a bitter divorce all provide fertile ground tor allegations of abuse.'' There is a growing body of anecdotal experience that a bitter spouse can use "false allegations" ot abuse as a "perfect weapon" to exert leverage in a civil ease/ Other anecdotal concems center on over-zealous reporting or investigation uf ambiguous comments by children in day-care centers.
The problem of valid reports of ab UhC as distinct from exaggerated or fabricated reports may be inherent in the nature of social relationships. One thesis of this article is that "truth" resides within a social network in many abusive situations when an alleged perpetrator knows the putative victim, rather than in pseudo-individual, quasi-objective format. If so. then there are important messages to be learned for investigatory procedures and tor clinicians who often now try to function as truth-detectors. Certainly the record of "clinical verification" of abuse reports ought to teach humility, with results uf "founded" vs. "unfounded" reports varying from 35% to 95'V depending un the sample"* (Horowit/ I. Salt H. unpublished data*. There seems to be no clear correlation between mental illness and physical or sexual abuse ol a child or ol a parent (ic. most mentally ill people are not a busers, and moit abuscrs arc not diagnosablv mentally ill.
THE POSITIVE FEEDBACK LOOP
Marital breakdown ranks as one of the most highly stress tul experiences our culture can impose on its victims. The loss of parenting status is inherent in custody contests and also lurks in the background of visitation disputes/'' The magnitude uf this loss - actual or potential - generates much of the perceived stress of domestic relations disputes, but il can ailect parents and children differently.
The adult generation cum prices both parents and grandparents who arc bolstered by networking abilities that support them in crisis. Unfortunately, such networks are subject tu lack ol external validation when they consist of kinship groups or small social circles. Often when families break down, these narrow networks generate enhanced polarization through shared anxiety and loss. This is especially true if the family or social group is "luss-aversive," ie. if it is psychologically allergic to the experience of loss and tends to revert to primitive coping devices such as denial or external blaming. In clinical work with families of divorce with abuse allegations, it is therefore important to take careful histories ol how a protagonist and his/her family have responded tu previous losses as a micro-culture cameo that has predictive value regarding their inclination to respond to the domestic crisis with atavistic mechanisms. In essence, a suppuri system is a good idea in general, but some support systems unfortunately can aggravate an individual's native tendency toward polarization under the stress of primary losses.
Children are structurally dependent on the parental generation, so they inherently lack some capability fur self-sustaining balance under stress. Obviously, the younger the child, the more fragile his or her character structure, and the more intense the pressures exerted by parents, then the mure vulnerable the child will be to domestic relations stress. It is not clear at all that one developmental stage of childhood is more at-risk than another une for safe traversing of a domestic litigation chasm. Usually one party or another hat, handy ratiunalizations for "wailing until . . ." ur "for (he child's sake . . ." as excuses lor delaying implementation uf domestic actions. Divorce per se is painful trauma for children, but we do not know whether it is more or less harmful tu children than the preceding pathulogic marriage was. Mental health professionals should be chary of hypothesizing that domestic management has to wait upon a child's attaining of some arbitrary psychusexual developmental level.
Those uncertainties notwithstanding, and the known resiliencies of many children ol divorce acknowledged/ children nevertheless do fall prey to their own anxiety, guilt, and unger about any divurcc-rclated action. They arc also exquisitely sensitive to their parents' emotions, thus setting the stage for an intense, rapidly-oscillating feedback loop that usually operates within the privacy of the family, isolated from outer visibility.
In many divorce situations, these ingrethents comprise a sour ferment of parental loss transmuted into bitterness as defense; childhood sensitivity to parental affect (ic. family "politics" that impuse intangible reality fur the child to deal with); with a child's uwn affects and regressive potential, which can emerge as pleasure-seeking sexual hehaviur ur as angry retaliation for the child's helplessness and loss.
Children who are quite dependent un a parent's perceptions for their own self-esteem, or parents who compel agreement (even inadvertently) in order to assuage their uwn intulerable negative affect at times o I domestic stress, are particularly at risk lor developing feedback loops within (part of) the family. These feedback loops are both self-reinforcing and increasingly distorted. It bears specific note that such evolutions do not comprise the standard concept of "mental illness," but rather their potential is inherent in small, intense, stressed human systems characterized by dependency and lack of tolerance for loss. "Positive" feedback in this sense is often affectively unpleasant, not loving or desirable.
The notion of "accommodation" has been invoked to describe a "victim personality" in cases of child sexual abuse ("brainwashing" seems lo connote intentionality or malign device, which is a separate issue).* Accommodation by children to chronic abuse or misuse is wellknown to clinicians, but it is equally true that children also accommodate to parental expectations and perceptions when the parents are substantially self-directed4 or when the parent and child are locked in a reciprocating cycle ol'projcctive anxiety. IU At the end of such cycles, children or parents can be "shaped" toward true beliefs that are not valid but which are not "lies" either. Such reports have conveyed explicit, convincing detail and genuine affect that persuade courts and clinicians who are unwary. "Accommodation" in domestic relations disputes is often a misplaced concept.11
The Case Reports indicate that childhood accommodation to adult attitudes is misleading and common. In Case 1 . the boy was clinically convincing to one therapist (oui ol, eventually, several) with explicit, detailed reports. In Case 2, the teenager accommodated to his mother's protective anger by becoming alienated and negativistic. thus confirming and justifying her accusations in her own mind. His relationships with peers and with the outside world remained gentle and generous.
Likewise, children accommodate to their cvaluators as well. In Case I. the therapist acknowledged having been alerted by mother to possible sexual abuse prior to his first meeting with his patient. He had been in practice for several years, but had not previously handled abuse cases and he took the boy's report at face value. Subsequent discussions he had with mother, patient, and agencies served to "reaffirm" the initial report in his mind. Ultimately he became angry and fearful of father, never having met him. In therapy, the boy followed the same affective path, which was completely belied by his real-life contact with father. Videotapes of the therapy sessions refuted the therapist's own perceptions of the "reaffirmaiions."
As shown in Case 3, faced with abuse allegations in the context of domestic relations contests, therapists have awesome problems and accrue an ethical responsibility not to simplify and jump to conelusions. The dependency of child patients is a major responsibility, and counter-transference or social zeal by a therapist can subject a patient to distortions of a "passionately detached" clinical point ol'view.
A child confronted with sequential "evaluations" begins to demonstrate increasing accommodation of memory as well as of affect. In adults. memory function can be said to comprise conviction along with historical verification by retrospection within one's own data bank. Children younger than puberty seem to "remember" differently, using an amalgam of conviction along with verification by "check-in" with an external, trusted ally.
Clinical personnel are accustomed to encouraging trust and dependency in their child patients, thereby offering themselves as role models and reality testers. They can easily mold. shape, and ultimately create children's memories by selective reinforcement of children's responses. Ultimately, children often come Io have little "memory" of events that is independent of (ie. separate from) what they have discussed with their therapeutic-type evaluators and the way they have discussed it.
"Positive" feedback thus operates on both affective and cognitive axes. Both operations stem from children's alliances with, and dependency on. powerful caretakers at times of loss and anxiety. Affectively, they affiliale with a frightened, dependent parent. Cognitivcly, (heir perceptions can be "shaped" inadvertently but with exquisite detail by selective, positive reinforcement.12 The dynamics of folie a deux are often more relevant to (his process than is "brainwashing" or lying (Case 4).
INTERVIEW AND EVALUATION
It is now a cliche that child abuse interviewing ought not to be suggestive. The term "suggestive" is so vague as to be misleading. It is more important and more difficult to avoid (he pitfalls of positive feedback influence indicated above. At issue is the risk of an entire therapeutic relationship (even during evaluation) if an interviewer cares loo intensely rather than prudently. n Delicacy of clinical judgment is required to guard against overinvolvement on the one hand, denial on a second hand, and inadvertent coercion by a naive interviewer on a third hand.'4
It is essential that child sexual abuse evaluators avail themselves of the broadest possible data base. An evaluation without interview of the alleged perpetrator cannot be complete. Likewise, awareness of the social/family context from which an allegation emerges is equally essential. Domestic relations disputes must raise particular concerns in the minds of evaluators with respect to tangled perceptions and motivations.
Single-interview evaluations, evaluations in coercive situations (police stations, or when a distraught parent is nearby, etc.). evaluations that proceed under conditions of fatigue or fear, and evaluations that manifest other stigmata of investigative interrogations as distinct from clinical interviewing are fatally contaminated. Such caveats might seem overdone, but in haste to document abuse many experienced clinicians have cut corners that eventually harm the process and their patients.
The use of sexually-explicit, genital doils is an area oí passionale commitment in this field. The dolls have never been validated as a diagnostic tool, do not have any standardized set of methods for application, and are subject to wide variability ol construction. The mannequins are certainly not anatomically accurate. They do provide a handy shortcut from careful and time-consuming interviews, but such shortcuts are almost never identified as such. Instead, the mannequins themselves are put forward as reliable and valid diagnostic tools. At some prudent time in a therapeutic evaluation, they could have adjunclive value, but as diagnostic quick-fixes they are misleading and often harmful in that they pollute the data pool in a complex case.
Videotaping of "initial" interviews is a controversial subject. It is almost unheard-of that a truly initial interview is taped. Rather, a staged reenactmcnl of an earlier interview is usually filmed, generating covert pressure on the interviewer to produce footage that will be useful. In the future, leisurely, truly routine videotaping of interviewing may become a valuable clinical aid that can avert duplication of interviews. However, that lime has not yet come in most facilities. On the other hand, some clinicians have complained bitterly about recording of evaluation or therapy sessions. There is little or no validity to such defensiveness. In most cases, adults and/or child patients relax in front of the recording medium much sooner than the clinician does.
In a careful evaluation, the interviews will conform to traditional, patient-centered guidelines. There will be enough time taken to build trust, good anamnestic review, no abrupt intrusion of external pressure into the interview, and a clinical readiness to accept what the patient has on his/her mind as being the major focus of the conversation. Even with children, proper technique demands a patient-focus rallier than a qui/- on body parts within the tirsi 15 minutes of an initial interview.
Interviews themselves may never be able to provide the divining rod for faci finders. There are lew hard signs of sexual abuse: pregnancy. venereal disease, and physical damage being among them. Admissions and/or some forms of major sexual psychopathology in alleged perpetrators are also worrisome indicators. Grossly abnormal sexual behavior or sexual behavior with marked aggression in the absence of other psychopathology in the child are also cause for major concern.
Abide from this short list, almost every other psycho-physiologic symptom has been invoked as indicating sexual abuse: headaches, gastrointestinal dysfunction, sleep disturbances, and anxieties of all types. genitourinary system complaints, and sexual knowledge or exaggerated sexual curiosity, which are benign in the vast majority of situations. The most that can be said ol this plethora of soft signs is that some children who have been sexually abused sometimes show some of these behaviors, but we are not even sure that most children who have been abused s h o w such behavior.
Clinicians and society at large are gratilyingly sensitive now to the reality of child abuse and sexual abuse. It is equally true that some unknown proportion of abuse reports is exaggerated if not false. Some of this latter group exists as a phenomenon separate from intentional malice, ie, lying or deliberate brainwashing. Examining this group of exaggcrated-bul-sincerc reports is a delicate but necessary task in view of intensely polarized views held by advocacy groups and by some overinvolved mental health personnel.
Therapists and menial health clinician-evaluators generate clinical information about patients and families that is useful for treatment purposes and which is usually sincerely believed by the patient. Such information is not equivalent to historical/factual veracity. It is subject to context, to interpretation, to evolutions of memory and affect, and to motivational pressures.
Such variables are particularly infense in the crucible of family discord, a setting which generates increasing numbers of reports of abuse. The impact oi family dynamics on abuse reports is a critical factor that all evaluators must consider as a shaping force on the inlormation that comes to them. In this article a positive feedback loop has been described that operates between child-parent and/or between childcvaluator that can have (he effect of exaggerating whatever initial report was aired. The system in which such reinforcing/exaggerating feedback functions is often characterized by mutual dependency and an aversion to affects centering on experiences of loss. These factory are obviously common in almost all child custody cases. Therefore, abuse reports arising in the context of custody disputes are particularly susceptible (o inllucnce and reinforcement. In such cases, clinicians must take particular care not to try to substitute clinical material for fact-finding.
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