Child Abuse: THE Fundamental Issue
in Forensic Clinical Practice
By Jay Adams, Ph.D.
Originally published in The Trowbridge Foundation Report,
Vol. III, Issue 1, Winter 2002
The practice of forensic psychology and psychiatry has made tremendous
advances in the past 20 years. We have moved from a field based solely
on vague, subjective opinion, devoid of any support in objective research,
to a plethora of well-established research instruments and a vast body
of well-founded research studies. Recently, however, some of our colleagues
have begun to question whether we have possibly embraced our research
findings with too much confidence and enthusiasm (Rogers, 2000; Zonana,
2000). Our field has become almost exclusively devoted to assessment,
offering little help to those of us who are charged with the treatment
of forensic clients in settings such as prisons, forensic state hospitals,
parole outpatient clinics and conditional release programs. Many clinicians
in forensic settings tend to throw up their hands and feel that they
can’t really be expected to provide meaningful or effective therapy
for their clients.
During the same 20 years there has been a veritable explosion in the field
of child abuse research and treatment. Unfortunately, with few exceptions (e.g.,
Gilligan, 1996; Lisak, 1997), there is an almost total lack of communication
between these 2 fields. This void is quite startling in light of studies on
the prevalence of child abuse histories among various populations. About 15%
of the general population is thought to have experienced physical abuse as a
child, based on findings of a number of studies (Briere, 1992). A large random
study (N=2,627) conducted by the Los Angeles TIMES in 1984 found that 1 out
of every 3 females and 1 out of every 6 males reported having experienced unwanted
sexual contact with an adult before the age of 18, and other studies have found
roughly similar rates of sexual abuse for the general population. These rates
are somewhat higher among psychiatric outpatients and psychiatric emergency
room patients, but they increase dramatically among the incarcerated. A study
published in 1984 by Childhelp, Inc., a foundation for abused children located
in southern California, reported that 5 of every 6 offenders serving time for
violent offenses in California were physically and/or sexually abused as children.
Former Los Angeles County District Attorney Gil Garcetti has stated that 95%
of those on death row in California were abused as children.
Histories of abuse are frequently noted in the clinical records of the incarcerated
(9 out of 10 randomly selected charts at my own facility, a medium security
state prison), but psychologists and other staff in prisons and forensic state
hospitals have rarely received any specific training in how to pursue this information.
Since the severity of abuse tends to be greater among the incarcerated, many
of them suffer from complex posttraumatic stress disorder, anxiety disorders,
and dissociative disorders, which are often misdiagnosed, overlooked, or regarded
as malingering by forensic mental health professionals largely unfamiliar with
child abuse and trauma issues. Sometimes forensic clients do malinger in an
effort to get help (usually medication) with their trauma symptoms.
Nick Groth, a pioneer in sex offender treatment, used to say that if you want
offenders to come to treatment, you must offer them something that feels like
help. It is crucial that forensic professionals help their clients deal with
their abuse issues, not only because of the clients’ personal pain, but
because the skills they learned that helped them survive their childhood abuse
now enable them as adults to commit violent acts without experiencing fear,
horror, or other normal emotional reactions. This is not to say that ALL individuals
who behave violently do so because of a history of abuse, or that all those
who have been abused as children are amenable to treatment. It IS to say that
those of us who work in prisons, forensic state hospitals, county jails, and
conditional release programs have an ethical obligation to expand our proficiency
and knowledge in an area that affects so many of our clients. Forensic professionals
who have conducted typical forensic groups like Anger Management and Criminal
Thinking are certainly aware of how often child abuse issues come up during
group discussion. Many of the “thinking errors” and core beliefs
cited in manuals for Criminal Thinking groups are directly traceable to childhood
abuse experiences. Such groups would be infinitely more effective if they were
followed by survivor groups where clients could process their child abuse issues
rather than being limited to confrontational and cognitive-behavioral approaches.
Contrary to popular (and sometimes, professional) stereotypes, it has NOT been
my experience that inmates involved in this type of therapy use it as an excuse
for their criminal behavior. Most, especially repeat offenders, welcome the
opportunity to explore the reasons for their violent and self-destructive actions,
and are often able to use this understanding to gain greater benefits from other
forms of treatment such as substance abuse therapy.
Paradoxically, some of the same factors which make the treatment of abuse issues
difficult in forensic facilities also support such treatment. The reduced availability
of street drugs allows memories and feelings to surface that are usually blocked
from awareness. While this causes fear, pain, and trauma, it can also create
strong motivation for therapy. The power imbalance that exists in prison, and
other non-voluntary settings, re-capitulates many aspects of the original abuse
situation. Such conditions are difficult for clients to handle, but at the same
time generate much therapeutic “grist for the mill,” which may be
used to help them better understand the ways in which their abuse histories
continue to affect their current feelings, perceptions, and behavior. The support
and bonding that occurs in survivor therapy groups hopefully may provide a powerful
antidote to the usual “prison code.”
Treatment of adult survivors of child abuse proceeds through several stages
(Sgroi, 1989), beginning with the acknowledgement that abuse did occur, coupled
with work on memory retrieval and efforts to link feelings with the memories.
Survivors must learn that they can tolerate fear, anger, shame, guilt, and other
intense feelings without losing control, lashing out, or going crazy. They are
taught more adaptive ways of dealing with such feelings. Gradually they begin
to understand the secondary effects of their abuse, such as trust and intimacy
problems, hyper-vigilance, impulsivity, low self-esteem, depression and anxiety,
and to see how their lives continue to be affected by what happened to them
as children. Often they make connections between these early experiences and
their adult substance abuse and criminal behavior.
Adult survivors are considered well on the way to recovery from their abuse
when they have:
- filled in at least some of the gaps in their memory,
- learned how to modulate affect without becoming numb or flooded
- reduced any PTSD symptoms present at the beginning of treatment,
- improved their self-esteem,
- developed a capacity to trust appropriately and form healthy relationships.
It should be noted that this type of therapy does not proceed in a linear manner,
but more in a spiral, such that various issues may be worked through on a number
of different levels from varying perspectives (Sgroi, 1989; Kritsberg, 1993).
It is extremely helpful to have group members who are at different points in
this process, so that more advanced clients can serve as role models and provide
feedback and support to those who are just beginning. It is also extremely important
to have the opportunity to practice newly acquired coping skills.
Although many abuse survivors initially express reluctance to discuss their
abuse in a group, particularly in a prison setting, there is some consensus
in the literature that group therapy, in some cases combined with a limited
number of individual sessions, is the treatment of choice (Courtois, 1988; Sgroi,
1989), at least for those who were sexually abused. Perhaps the most difficult
concept for many incarcerated survivors to grasp is that of legitimate empowerment.
For most of them, their adaptation to abuse has been strong identification with
the aggressor, and they have observed few role models for getting their own
needs met without infringing on the rights and needs of others. Conversely,
their life experiences have given them little reason to expect that others will
respect their rights and needs. Prisoners, like many other abuse survivors,
often oscillate between lashing out aggressively and being passive victims who
are unable to set appropriate limits and boundaries.
In a forensic setting, confidentiality assumes an even more important role
and must be carefully explained and repeatedly stressed. When screening potential
participants for survivor groups, clinicians should make sure that clients are
not overtly psychotic and are able to discuss at least one incident of their
abuse without becoming overwhelmed. Since they must also be able to process
anger without acting out, recipients of recent disciplinary actions are not
good candidates until they have successfully completed an anger management group.
Individuals who are engaging in self-mutilation or other overtly self-destructive
behavior should be referred to a highly structured and focused group designed
to teach more adaptive behaviors, as described by Linehan (1993).
Psychotherapy for adult survivors of child abuse is based on a “phenomenological
perspective” (Briere, 1992). The client’s symptoms and behavior
are not viewed as evidence of mental illness or defect, but rather as adaptive
behavior that represents accommodation to a long-term abusive situation. Work
of re-experiencing trauma and linking it with affect should not occur until
some ego-strengthening work has been done, the client has learned new coping
strategies, and a strong relationship with the therapist has been established.
Premature processing of trauma may produce a reaction in the client that is
like pulling a thread of a sweater and seeing the entire garment unravel. Educational
interventions may be particularly useful at times when clients are feeling emotionally
overwhelmed. Education could include talking about common ways that child abuse
survivors respond to their abuse and challenging self-derogatory and self-blaming
statements.
This type of therapy is obviously an extremely sensitive and difficult undertaking
for forensic clients, who have often suffered multiple forms of severe abuse.
It is absolutely necessary that psychopaths be identified and excluded from
this type of therapeutic work, as they are likely to violate confidentiality
and use personal information obtained in the group in a sadistic and destructive
manner (Rice, 1997). However, this can be a difficult discrimination to make,
since there is a subgroup of individuals who appear very antisocial but are
actually abuse reactive. Robert Hare has noted, “The neglect and abuse
of children can cause horrendous psychological damage. Children damaged in this
way often have lower I.Q.’s and an increased risk of depression, suicide,
acting out and drug problems. They are more likely than others to be violent
and to be arrested as juveniles. Among preschool children, the abused and neglected
are more likely than other children to get angry, refuse to follow directions,
and to show a lack of enthusiasm. By the time they enter school, they tend to
be hyperactive, easily distracted, lacking in self-control, and not well liked
by their peers, but these factors do not make them into psychopaths” (Hare,
1993, p.l70). Unfortunately Hare’s description sounds like many of our
clients, and it is clear that some of them will attain hefty scores on the Hare
Scale. My personal experience suggests that abuse reactive anti-social individuals
are likely to score high on Factor 2 (anti-social behavior), but not on Factor
1 (aggressive narcissism). However, the results of the Hare Scale must be interpreted
cautiously. There are instances in which signs that clearly suggest psychopathy
may actually be attributable to some other cause or dynamic. For example, high
scores on Factor 1 items “lack of guilt or remorse” and “shallow
affect” may be due to the presence of dissociation. In general, individuals
with low to moderate scores on the Hare Scale may be appropriate for abuse survivor
treatment, but those with high scores are likely not suitable and may wreak
havoc. It is recommended that forensic clinicians familiarize themselves with
other instruments that may help identify clients who suffer from trauma-related
problems (Briere, 1997).
Neuroscience is now pointing to the importance of early interpersonal relationships
in forming and actually shaping the structure of the young child’s brain.
Attachment research has been focusing on the effects of abuse and neglect on
brain development. Early socialization events are imprinted into the developing
brain, with early trauma resulting in a lifelong inability to cope with stress
(Siegal, 1996; van der Kolk et al., 1996). All too often forensic treatment
professionals are content to dismiss their clients with labels such as “manipulative,”
“attention-seeking,” and “personality disorder.” This
is a grave disservice to client and clinician alike. As one forensic expert
has put it, “If we see their problems as current moral weakness rather
than the scabs of old wounds, we rob them of their history” (Dwoskin,
2000). Merely reading this article will not make you an expert on the treatment
of adult survivors of child abuse, but I hope it will encourage you to see your
clients in a different light and to seek further training so that you can begin
to offer trauma treatment to some of your clients. I guarantee that your clients
will be more motivated to participate in treatment, you will have a much greater
understanding of their symptoms and behavior, and you will find your work with
them much more effective and rewarding.
[Dr. Jay Adams has done clinical work with forensic populations for more
than 25 years, and is particularly interested in furthering the treatment of
trauma-related disorders in forensic settings. If you would like further information
about the treatment of adult survivors of child abuse, you may contact her by
phone at (805) 238-4454, or by e-mail at jayklaus@msn.com.]
References:
Briere, John (1992). CHILD ABUSE TRAUMA: THEORY AND TREATMENT OF THE LASTING
EFECTS. Newbury Park, Ca.: Sage.
Briere, John (1997). PSYCHOLOGICAL ASSESSMENT OF ADULT POSTTRAUMATIC STATES.
Washington, D.C.: American Psychological Association.
Courtois, Christine (1988). HEALING THE INCEST WOUND. New York: Norton.
Dwoskin, Joel (2000). “Misuse and Abuse of Psychiatric Diagnoses in Prisons.”
Address to the Forensic Mental Health Association of California in Pacific Grove,
Ca.
Gilligan, James (1996). VIOLENCE: REFLECTIONS ON A NATIONAL EPIDEMIC. New York:
Random House, Inc.
Hare, Robert (1993). WITHOUT CONSCIENCE. New York: Simon & Schuster, Inc.
Kritsberg, Wayne (1993). THE INVISIBLE WOUND. New York: Bantam Books.
Linehan, Marsha (1993). COGNITIVE-BEHAVIORAL TREATMENT OF BORDERLINE PERSONALITY
DISORDER. New York: Guilford.
Lisak, David (1997). “Male Gender Socialization and the Perpetration
of Sexual Abuse,” in MEN AND SEX: NEW PSYCHOLOGICAL PERSPECTIVES, ed.
by Levant. New York: John Wiley and Sons.
Rice, Marnie (1997). “Violent Offender Research and Implications for
the Criminal Justice System,” in AMERICAN PSYCHOLOGIST, April 1997, pp.
414-423.
Rogers, Richard (2000). “The Uncritical Acceptance of Risk Assessment
in Forensic Practice,” in LAW AND HUMAN BEHAVIOR, Vol. 24, No.5, pp. 595-605.
Sgroi, Suzanne (1989). “Stages of Recovery for Adult Survivors of Child
Sexual Abuse,” in VULNERABLE POPULATIONS, Vol. II, ed. by Sgroi. Lexington,
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Siegal, Daniel (1996). “Cognition, Memory and Dissociation,” in
CHILD AND ADOLESCENT PSYCHIATRIC CLINICS OF NORTH AMERICA, Vol. 5, No. 2, pp.
509-536.
van der Kolk, Bessel, David Pelcovitz, Susan Roth, Francine Mandel, Alexander
McFarlane and Judith Herman (1996). “Dissociation, Somatization, and Affect
Dysregulation: The Complexity of Adaptation to Trauma,” in AMERICAN JOURNAL
OF PSYCHIATRY, Vol. 153, No. 7, pp. 83-93.
Zonana, Howard (2000). “Sex Offender Testimony: Junk Science or Unethical
Testimony?” in JOURNAL OF THE AMERICAN ACADEMY OF PSYCHIATRY AND THE LAW,
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