Legal and Ethnical Issues in the Treatment of Multiple Victimization Child Maltreatment
Sonkin, Daniel Jay & Liebert, Douglas Scott
In Rossman, R. and Rosenberg, M.(1999)(Eds.). Multiple victimization child maltreatment: Clinical and Research Perspectives. New York: Hayworth Press.
The problem of child maltreatment has reached epidemic proportions with nearly 1.9 million reports received for investigation on approximately 2.9 million children who were the alleged subjects of child abuse and neglect in 1992 (US Department of Health and Human Services). These figures may well represent the "tip of the iceberg" as many cases are never detected, especially when taking into account unreported allegations and instances of marginal physical abuse, psychological maltreatment and neglect. Since Congress passed the Child Abuse Prevention and Treatment Act in 1974, every state in the union has passed compulsory reporting laws geared toward various professionals who are likely to detect child abuse during the course of their work. Many of these reports are made by mental health professionals who are identified as mandated reporters (i.e., psychiatrists, clinical psychologists, marriage, family and child counselors and licensed clinical social workers). Mental health professionals are quite likely to encounter child abuse in their treatment of children, adolescents, adults, couples and families. Given the prevalence of this devastating problem, it is the unusual clinician who has not made a child abuse report at some time in their career or has not encountered a former victim of child maltreatment. Thus, as the nation attempts to come to terms with this difficult social issue, legislation resulting in legal statute has identified certain groups who must respond and alert a variety of protective institutions (i.e. Child Protective Services, etc.) as mandated reporters to minimize harm and protect the victim.
Since the initial description of "Battered Child Syndrome" was introduced in 1962 (Kempe, Silverman, Steele, Droegmueller & Silver, 1962) the literature on the subject has evolved such that there are numerous journals dedicated to the study of violence within the family. Given the prevalence of this problem and thousands of articles and books available on the topic, we find it curious that little has been written addressing legal and ethical issues relating to the treatment of victims, perpetrators and their family members. The only apparent exception are those researchers interested in clinicians' reports of suspected child abuse (Brosig & Kalichman, 1992). However, aside from this one important, but limited area, legal and ethical issues are rarely discussed in the research literature or in professional books on child abuse even though many clinicians frequently confront these issues when treating patients contending with maltreatment related concerns.
As forensic consultants and members of a state-wide ethics committee representing over 22,000 mental health professionals, we have found that many of the complaints filed with the committee, the courts and licensing authorities frequently pertain to issues involving the treatment of child abuse. While often addressed inadequately in traditional mental health training, clinicians frequently face situations that require thoughtful consideration of legal and ethical issues within the context of treatment. Thus, without adequate training clinicians can become overwhelmed or confused by the intricacies of treating victims of abuse. In this chapter we discuss a number of the most common legal and ethical issues faced by clinicians when treating families where child maltreatment is a significant consideration. Specifically, we will differentiate between what constitutes a legal requirement as opposed to an ethical mandate, explore what factors affect the decision to report or not report child abuse, discuss how dual roles can compromise the treatment process and how a clinician's scope of competence and professional knowledge is critical to effectively responding to the clinical needs of abused children and their families. Lastly, these issues will each be discussed within the context of responding to cases where a child(ren) has been multiply victimized.
Legal versus Ethical Requirements
Mental health practitioners, like many health providers, must adhere to legal reporting requirements related to the performance of their work. Mandates exist in many states to report elder abuse, spouse abuse and dangerous threats and behaviors. These legal requirements are mandatory and, in many states, a practitioner can be charged with a crime if they fail to report. Ethical issues, on the other hand, reflect standards of performance and practice that are usually identified by professional organizations and often provide guidance to licensing bodies. Failure to adhere to those standards can result in loss of license and/or expulsion from a professional organization. Standard of practice is the minimal national criteria recognized among similar specialists, rather than a local community based standard (Liebert and Foster, 1994). This standard often becomes the benchmark used by ethics committees and licensing authorities when trying to assess if a practioner has followed an appropriate course of action and standard of care. Common areas of difficulty include the handling of dual relationships, practicing within the scope of his or her competence and psychotherapist-patient privilege and confidentiality. In either case, whether legal or ethical, laws and ethical standards are presumably set forth with the directive of "primum non nocere", do not harm anyone, thus reminding the therapist of their responsibility to protect.
Although in an ideal world legal and ethical requirements of practice should be clear, the opposite appears to be the case. Not only are there inconsistencies between states, but there are also inconsistencies within jurisdiction, within each state. For example, child abuse reporting is a statutory requirement in every state. In Massachusetts, the standard for reporting is "...reasonable cause to believe...", whereas in Mississippi the standard is "...that a child brought to him or coming before him..." Thus the standard can vary from reasonable suspicion to actually seeing the abused child. Similarly, it has been the authors experience that a child protective service worker in one county in California, when given a specific set of circumstances, will suggest making a formal report whereas another worker either in the same or different county may not recommend making a formal report.
There are similar discrepancies with ethical issues. For example, prior to recently revised ethical standards that prohibit sexual relations with a "former" patient for up to two years after termination, the California Association of Marriage and Family Therapists (CAMFT) Ethics Committee would not act upon a patient's complaint stating that they had been sexually exploited by their "former" therapist when the sexual act took place after a "proper termination" (i.e., "proper termination" being generally defined as, termination not occurring for the express or implied purpose of becoming sexually intimate). In apparent contrast the California Board of Behavioral Science Examiners, who have statutory authority to administer and monitor the Marriage, Family and Child Counselor license, would routinely pursue and prosecute cases of therapists having sex with "former" clients. Similar differences in enforcement exist when discussing the controversial and often vague issue of dual relationships.
Experience shows us that not only are there differences in specific laws and ethical standards but there are also differences in their interpretation across individuals. Legal and ethical standards can appear, at best, ambiguous and open to interpretation guided by such vagaries as the "unique aspects of the case", personal and professional experience, theoretical bias, and other such issues, yet statute and the teleogic basis underlying most ethics codes assume a decision rule based on predictable outcome.
Legal Issues: Mandatory Reporting of Child Maltreatment
One of the most common dilemmas addressed in the child abuse literature relates to the violation of privilege and/or confidentiality. Privilege is a legal term that refers to the clients' statutory right that varies by jurisdiction, while confidentiality is a legal and ethical concept that implies a responsibility assumed by the clinician to reveal nothing learned during the course of treatment except what may be mandated in law or agreed to by the client. When surveyed, psychologists indicated that this mandate was the most common of a number of confidentiality issues confronted in the course of their work (Pope & Vetter, 1992). The findings of numerous studies have indicated that a significant number of clinicians have complied inconsistently with the legal mandate to report abuse (Pope & Bajt, 1988). While there has been speculation that under-reporting results from professional responsibility and clinical judgement being subordinated to clinicians serving a policing function (Ansell & Ross, 1990) and concern for the patients' welfare (Wright, 1984) other believe that under-reporting, in part, stems from differences in the interpretation of the child abuse laws as well as situational and therapist characteristics (Brosig & Kalichman, 1992; Kalichman & Craig, 1991; Kalichman, Craig, & Follingstad, 1990; 1989; Zellman, 1990; Weinstock & Weinstock, 1989; Barksdale, 1989). The problem of reporting is critical in cases of multiple child maltreatment as treatment decisions will be made based on the types of abuse occurring within the family. Moreover, additional acts of abuse are frequently detected and/or perpetrated after the commencement of treatment.
Because the standard for reporting child abuse can vary from state to state, it is impractical for this chapter to set forth specific criteria for clinicians to report. We recommend that mental health practitioners become familiar with the threshold criteria in their state by reading the law and contacting the proper reporting authorities. Instead, we will describe a number of decision-making strategies that have been found effective in the reporting of child maltreatment and what factors may enter into a decision to either report or not to report.
The decision to report or not report is complex where the interests of the individual, the family, the profession and the community potentially come into conflict (Lippitt, 1985). Although most would agree that child abuse is appalling, there are many disagreements as to what actions should be taken to protect children who have been victimized and are at risk for further abuse. The fact that many therapists do not report abuse, in spite of the potential legal and ethical consequences, is evidence that legislation is not a panacea to address this complex social phenomenon. In exploring clinicians' decision making, researchers have determined that a variety of factors appear to influence this process. These factors include responsibility for the abuse (Kalichman, Craig & Follingstad, 1990), history of abuse (Zellman, 1992), severity of abuse (Zellman, 1990, 1992), recantation (Zellman, 1992), perception of the therapist's role (Ansell & Ross, 1990; Fox 1984); type of abuse (Kalichman and Craig, 1991; Williams, Osborne & Rappaport, 1987), socio-economic status of patient and license of professional (Williams, Osborne & Rappaport, 1987), years of practice (Barksdale, 1989), clinicians' expectation of what potential expectations reporting may have on the individual or family (Zellman, 1990, Kalichman, Craig and Follingstad, 1989), the perpetrators admission or denial of abuse (Kalichman, Craig & Follingstad, 1989), sex of therapist and alleged perpetrator (Kalichman, Craig & Follingstad, 1990), age of child (Kalichman & Craig, 1991), behavior of alleged victim (Kalichman & Craig, 1991), therapists' history of reporting (Kalichman & Craig, 1991, Zellman, 1991), child's age (Kalichman & Craig, 1991), perpetrators' relationship to child (Kalichman & Craig, 1991), therapists' knowledge of law (Swoboda, Elwork, Sales & Levine, 1978) and clarity of legal requirements (Kalichman & Craig, 1991; Besharov, 1991; Brossig & Kalichman, 1992). Given the significant number of variables identified, it remains unclear in any given potential reporting circumstance how any unique combination of variables may operate synergisticly to impact the decision to report or not. It is the authors' belief that both statute and clinical training need to provide greater direction to enhance optimal decision making and thus, outcome. While a number of criteria should be considered for inclusion, one simple example of threshold criteria would be the greater the severity of abuse and the younger the child, the sooner the reporting threshold should be met.
Child Abuse Decision-Making - A Model for Clinicians
In their review of the reporting literature, Brossig and Kalichman (1992) propose a three tiered approach to decision-making in reporting child abuse. They propose that legal factors, clinician characteristics, and situational factors appear to interact synergistically to influence whether or not a clinician chooses to report.
Legal Factors. Common legal factors affecting child abuse reporting decisions include: the clinicians' knowledge of the child abuse laws, the wording of the law itself and the legal requirements of the law. Although reporting has increased since the passage of child abuse reporting laws (Andrew & Lamond, 1989), studies indicate that, as a rule, clinicians' compliance with the law does not increase with increased knowledge of the law (Kalichman, Craig & Follingstad, 1989). However, some clinicians are more inclined to make informed decisions because of the importance of adhering to the law. For these individuals, knowledge of the reporting law does seem to facilitate reporting (Haas, Malouf & Mayerson, 1988; Wilson & Gettinger, 1989; Brosig & Kalichman, 1992).
Similarly, the clarity of the specific child abuse statutes also effect the probability of reporting (Zellman, 1990). Laws that fail to adequately define child abuse and/or are unclear about the reporting procedure may impact the therapists' tendency to report or not.
As previously discussed, states that require a "reasonable cause to believe" versus other states that require that a "child be brought to him or coming before him" (i.e. the professional) often result in different outcomes for the same types of cases. The more narrowly defined statutes, such as the latter standard, result in under-reporting whereas the more broadly defined laws, i.e. reasonable suspicion standard, increase the probability of reporting (Brosig & Kalichman, 1992).
Clinician Characteristics. Typical traits identified in the research literature which appear to impact on the probability of a clinician reporting child abuse include; years of experience, as well as training, attitudes and experience making child abuse reports. (Brosig & Kalichman, 1992)
Yet, current data is inconsistent as research indicates that some experienced clinicians may report more than less experienced clinicians (Barksdale, 1989; Nightingale & Walker, 1986) whereas other studies have found the converse to be the case (Haas, Malouf & Mayerson, 1988). While a number of plausible explanations are possible, clearly one hypothesis remains individual differences between clinicians. For example, there is data that suggests some clinicians have had prior negative experiences with the child protective system or believe that not reporting may be the better way of protecting the child (Ansell & Ross, 1990). As with years of experience, training in child abuse may increase the probability of reporting (Nightingale & Walker, 1986) as well as the clinicians' previous experience filing child abuse reports (Kalichman, Craig & Follingstad, 1989; Kalichman & Craig, 1991).
From a social policy and ethical standpoint many clinicians remain concerned about the current degree of legislating human behavior; child abuse and duty to protect laws being only two examples of this (Ansell & Ross, 1990). They maintain that confidentiality is the cornerstone of the therapeutic relationship and that legislating a breach of confidentiality undermines the therapist's ability to do his or her job. The research on the impact of the client-therapist relationship after a report indicates that there is either no change or a change for the positive (Watson & Levine, 1989). We would argue that trust, not confidentiality, is the cornerstone of our profession (McNeil, 1987; Sonkin, 1986) and that clients trust that we will act in ways that have their best interest in mind, even if the immediate consequences of their actions may result in pain or discomfort. Certainly the discomfort and embarrassment of the child social services investigation pales in comparison to unnecessary trauma to a child, or criminal charges and a trial resulting from a child's serious injury or death.
Situational Factors. Lastly, Brossig & Kalichman (1992) describe a number of situational factors that also influence clinicians' decision-making on child abuse reporting. These factors include: victim attributes, type of abuse, severity of abuse and availability of evidence. Age appears to be an important variable in reporting child abuse. Current data infers that clinicians are more likely to report younger children than adolescent victims (Kalichman & Craig, 1991; Brossig & Kalichman, 1992). Similarly, race has been identified as a variable in the child abuse reporting (Newberger, 1983), which is consistent with data regarding other forms of domestic violence (Walker, 1985).
For a variety of psychological as well as social reasons, many clinicians believe sexual abuse is more serious than physical or psychological abuse or neglect, and as a result, are more inclined to report these types of cases (Nightingale & Walker, 1986: Zellman, 1990). Similarly, severity of abuse is also a factor in reporting rates. The literature suggests that clinicians are more likely to report abuse that is currently happening than past abuse (Wilson & Gettinger, 1989). However, this reliance on the treating therapists perception and clinical acumen remains potentially problematic in high risk families, if the therapist is ill trained, inexperienced or unfamiliar with the literature that demonstrates that all forms of family violence tend to be chronic in nature therefore resulting in increased victim vulnerability (Sonkin, 1986; Sonkin & Elison, 1986).
One of the most difficult areas for clinicians is the amount of clinical data or "evidence" necessary to meet the threshold level of reasonable suspicion. Increased "evidence" results in a greater degree of certainty (Watson & Levine, 1989), which results in a greater probability of reporting (Kalichman, Craig & Follingstad, 1990). Many reports are not ultimately made because clinicians either do not have enough "evidence" to support a reasonable suspicion or do not know the "reasonable suspicion" standard for their community.
The term "evidence" is parenthasized to refer to the physical and psychological indicators of child abuse, as opposed to the evidence that is used in criminal proceedings to prove guilt beyond a reasonable doubt to a "trier of fact". Later in this chapter we will discuss the ethical issue of clinicians taking on dual roles of therapist and investigator or social advocate (Melton & Limber, 1989).
Deciding to Report
Given this information, what can clinicians do to better respond to cases of child maltreatment? Although in many states the law indicates that a therapist must contact social services immediately and follow-up with a written report within thirty-six hours once the threshold standard has been met, consultation with colleagues remains an important component in assisting the clinician in deciding whether or not to report. In fact, consultation has been found to be correlated positively with child abuse reporting (Brosig & Kalichman, 1992). This may not always be possible, and in those situations when an immediate decision must be made, a clinician may call the appropriate agency and describe to the on-call intake worker the relevant case facts without initially revealing names of the parties. The intake worker may either ask the right questions that will help the clinician decide the best course of action or will inform them whether the reporting threshold has been met. Similarly, it is important for mental health professionals to meet with law enforcement and child protective service personnel in their community to discuss interpretations of the current statutes as well as polices and procedures for reporting and case follow-up. Clinicians are frequently unaware of the outcome of their reports to child social services, therefore building a relationship with these professionals tends to enrich both the clinical community as well as social service personnel.
Continuing education in the identification and treatment of child abuse will not only increase the clinician's ability to recognize the threshold standard, which assists in more accurate reporting, but also find more effective methods of treating families experiencing this problem. The literature in the field is rapidly expanding to such an extent that even the most experienced clinician needs to take the time to review the latest advances in treatment and research findings. Unfortunately, it is often all too easy for seasoned clinician to get into a rut by continuing to rely on old research data and treatment methodologies, compromising optimal treatment planning for clients.
Lastly, in order to minimize the trauma experienced by the family as a result of a child abuse report, many specialists suggest that the clinician make the report (i.e. call social services) while the client(s) are in the office or ask the client(s) to make the call from the office (the latter being most effective when the treatment is with the perpetrator). Similarly, a therapist may also attend meetings with police or social services as a support to their client(s) should their presence be desired and appropriate. In general, it remains important for the clinician to understand that the potential consequences of the report can be quite devastating to the client(s) and the therapist should be available for continued support and assistance during the investigation and evaluation process.
Feelings of betrayal are likely to be experienced by the patient and/or family members towards the therapist for initiating a report to social services. Therefore, the therapist needs to be prepared for handling a great deal of negative affect when providing appropriate boundaries with the goal of positive resolution in mind. However, many clients may not be able to overcome these deep feelings of resentment and lack of trust in the clinician. If this occurs, the therapist needs to seek consultation to evaluate if a referral is appropriate and participate in an orderly transition, if needed.
Reporting Child Maltreatment in Cases of Multiple Victimization
The legal issues of reporting child maltreatment are particularly significant in cases of multiple victimization. Therapists may be reluctant to describe all forms of abuse occurring within the family for fear that the consequences may be even greater to the client. This is most frequently seen with child sexual abuse or physical abuse reports. In both physical and sexual abuse, emotional abuse also occurs concurrently, but is often omitted in reports. Neglect is also all too commonly omitted from reports. It is critical that the clinician describe all forms of maltreatment when following through with reporting. If the full breadth of pathology is not adequately assessed, the treatment plan developed may not address appropriately the needs of the family. For example, a family where a father has sexually abused his oldest daughter seeks treatment with a therapist who ultimately reports this abuse to social services. The report fails to mention that the father is also physically abusing his youngest child and that the mother frequently becomes intoxicated during the day and neglects her newborn child. If the therapist only identifies the sexual abuse to authorities, the treatment plan may ultimately ignore other critical family needs. This can become especially problematic in those situations where the court system may mandate the scope of intervention required as a condition of probation. If it is unreported, it may go untreated.
It is also important to identify all forms of maltreatment within the family so that social services workers and law enforcement personnel can become more aware of the different forms that abuse may take, and that these forms of abuse will have different consequences to the various members of the family. Sexual abuse has received so much attention in the past decade even though other forms of maltreatment can be equally devastating (Navarre, 1987), that the net result can be that other forms of abuse are either minimized or altogether ignored.
Another important reason for the thorough documentation of child abuse involves keeping statistics. The Department of Social Services keeps statistics on the types and amount of child abuse in their community. This information is ultimately used by the Department of Justice for the compilation of state and national statistics and becomes a basis for programs to pursue funding for services, as well as research in the area of child maltreatment.
A controversial issue that frequently arises in the treatment of child abuse cases, and particularly in instances of multiple victimization, is what to do when the therapist becomes aware of an additional act of maltreatment that either differs from the type initially reported, falls into the category of a repeated offense, or is a similar or different victimization by or to another person. The therapist is faced with the dilemma of whether or not to report and initiate another investigation with charges filed or additional sanctions levied against their client. Examples of this would include the discovery of physical maltreatment or neglect (i.e. such as a parent refusing a child's breadth of care needs) while treating an individual or family for child sexual abuse.
Child abuse research, as well as other forms of interpersonal violence within the family (i.e., marital violence), unfortunately demonstrates its pattern of chronicity and that perpetrators are prone to relapse under stress, even while in psychological treatment. In California, state law require therapists to formally report additional acts of child abuse in situations of physical and sexual abuse, and neglect. In cases of emotional abuse, the therapist has the latitude for discretion (California Penal Code Section 11172). If this is the case in your state, we recommend using a similar decision-making model proposed earlier in making the determination of whether or not you have the legal and/or ethical duty to report. If your state law is not clear regarding this issue, it is important to discuss with your local social services how they treat multiple offenses and what they expect from mental health professionals.
Ethical Issues: An Overview
National and state associations that represent the various mental health professions have developed and continue to refine ethical standards in an attempt to create a model code of conduct to ensure the protection of patients' rights. Ethical standards are promulgated in part to provide guidance, and help prevent patient exploitation and impairment of therapists' judgement.
Ethical codes are frequently adopted or used to provide guidance by state licensing boards to set forth minimum standards of practice in their regulation of the various professions. Although there are some idiosyncratic and philosophical differences between the various ethical codes of mental health professions, there is generally greater consistency. For example, in California, the psychology, social worker and marriage, family and child counselor code of ethics all prohibit certain dual relationships that are likely to result in patient exploitation or impaired therapist judgement. Similarly, each professions code also dictate that licensees not practice beyond the scope of competence. The breach of ethical principles may result in dismissal from or conditions placed upon membership of their professional organization.
Violations of the licensing law can also result in loss of licensure or other remedial sanctions imposed by the state licensing board. Ethical violations may also lead to punitive damages from a malpractice lawsuit against the therapist and many malpractice carriers consider an ethics violation in their underwriting criteria.
As mentioned earlier, ethical principles range from clear to nebulous. For example, few would argue today that having a sexual relationship with a current patient is unethical behavior. However, there has been disagreement about the ethics of having sexual relations with a "former" patient. Recently, the ethical standards of many state and national organizations have amended their code to include sex with former patients for a specified period of time subsequent to an appropriate termination. However, the language lacked specificity until the 1992 revision of the American Psychological Association ethics, Standard 4.07 which states:
Because sexual intimacies with a former therapy patient or client are so frequently harmful to the patient or client, and because such intimacies undermine public confidence in the psychology profession and thereby deter the public's use of needed, psychologists do not engage in sexual intimacies with former therapy patients and clients even after a two-year interval except in the most unusual circumstances. The psychologist who engages in such activities after the two years following cessation or termination bears the burden of demonstrating that there has been no exploitation, in light of all relevant factors, including (1) amount of time that has passed since therapy terminated, (2) the nature and duration of the therapy, (3) the circumstances of termination, (4) the patients or clients personal history, (5) the patients or clients current mental status, (6) the likelihood of adverse impact on the patient or client and others, and (7) any statements or actions made by the therapist during the course of therapy suggesting or inviting the possibility of a posttermination sexual or romantic relationship with the patient or client.
However, there continues to be discussion and debate on this issue. Is if ever acceptable to have sex with former patients? Does placing a two year limit implicitly mean that having sex after two years is permitted? Other ethical standards remain even less clear in behavioral terms. For example, scope of competence issues are more prone to interpretation as they are typically addressed in vague aspirational language, such as, "Marriage and Family Therapists are dedicated to maintaining high standards of professional competence and integrity." While an advantage to ethical codes remaining vague and aspirational in scope is allowing committees the flexibility to be sensitive to the merits and idiosyncratic nature of each case, the disadvantage remains a lack of clear guidance for the practioner.
Dual Relationships in the Treatment of Child Maltreatment
In their article, "Psychologists' involvement in Cases of Child Maltreatment: Limits of Role and Expertise," Melton and Limber (1989) discuss a range of ethical and legal issues that mental health practitioners confront when evaluating victims and perpetrators of child abuse and their families. With increasing numbers of professionals specializing in this clinical area, the police and social service professionals in many communities are requesting that psychologists and other practitioners serve an investigative role in collecting evidence for the prosecution. Similarly, many clinicians are also being asked to serve as an expert witness in trials for the defense or prosecution testifying as to whether or not a particular witness was a victim of abuse or a particular defendant is guilty of victimizing the alleged victim. Additionally, experts are also testifying in sentencing hearing suggesting whether or not a particular defendant should be incarcerated or mandated into a rehabilitation program.
A dual relationship exists when a therapist and his or her patient engage in a separate and distinct relationship either simultaneously during the therapeutic relationship, or before a reasonable period of time has past following the termination of the therapeutic relationship. The most clearly unethical dual relationships include sexual relationships, friendships or business partnerships. On the other hand, there are relationships that may be categorized as dual in nature, involve a boundary violation, do not necessarily enjoy clear, explicit concrete definition, but nevertheless can potentially be harmful.
For example, when a therapist is treating a child victim, non-offending parent or perpetrator, and files a mandatory child abuse report, they may be asked by authorities or volunteer to collect investigative information that will assist in the development of the legal case. When a therapist takes on this investigative role, no matter how cooperative the patient may appear in the process, they are stepping outside their role as therapist. Some argue that this dual role of therapist and investigator can be exploitive to the client and impair the therapist's judgement (Weithorn, 1987). For example, a therapist who is treating an alleged perpetrator of abuse cannot protect their client's right to privacy and act as an arm of the justice system at the same time without obvious conflicts.
Additionally, exploitation is likely to occur because the client may believe that the therapist is acting on their behalf when in fact the therapist is acting as an agent of the state. Melton and Limber (1989) argue, "A particularly egregious example of mixture of roles in a manner that violates fidelity and privacy is when psychotherapy is used as a prosecutorial investigative tool." Similarly, victims of abuse may also put their trust in a therapist who ultimately places them in a position to pursue legal action when in fact they may not be emotionally ready for such a step. When a therapist acts as both therapist and investigator we believe this constitutes a dual relationship which is potentially harmful for the client as well as family members. Therapists must attempt to keep these roles separate by taking on one or the other but refusing to act as both. There is nothing to prevent a therapist from taking on this investigative function in communities where the authorities lack the skills to adequately make child abuse determinations. But because this is a different and distinct role than providing therapeutic treatment of an individual or family the boundary, by definition should be respected. Thus, taking on any single role, whether it be treater, evaluator or investigator may preclude any other role. Ethical guidance is clear, "Psychologists must always be sensitive to the potential harmful effects of other contacts on their work and on those persons with whom they deal" (American Psychological Association, Standard 1.17 Multiple Relationships, 1992).
Sexual Exploitation of Victims of Abuse
Studies have suggested that individuals who have a history of childhood sexual victimization are more likely to be victimized by therapists who become sexually involved with their patients (Armsworth, 1990). Kluft (1990) coined the term, "sitting duck syndrome" in discussing the phenomena of incest victims being vulnerable to revictimization. Marvasti (1993) suggests that therapists who are incest survivors are increasingly vulnerable to boundary difficulties, perhaps due in part to repetition compulsion and identification with the aggressor. Kroll (1988) suggests that countertransference issues exist ". . .on a continuum of sexual exploitation, but that never manifest themselves beyond subtleties. . ." (203) and raises concern that these behaviors may occur beyond the conscious awareness of the therapist and thus acted out without consideration to the impact or implication to the client. Our experience as forensic consultants and while serving on a state wide ethics committee has been that therapists who are inadequately trained, experienced or supervised are more prone to act out when presented with extremely dependent patients or those with erotic transference, and these patients are frequently those who were victims of child sexual abuse. Frequently, these therapists were treating their patients for abuse-related issues when they became sexually involved with their patients.
Some adolescents, young adults and older adults who were sexually abused as children may have a pattern of relating to persons in a position of authority in a seductive manner. They may also be prone to submitting to the control of authority figures (Armsworth, 1990) thus being an easy target for therapists who, for a variety of reasons, are susceptible to acting out in this way. Therefore, it is vital for the mental health professional to be aware of potential transference and countertransference reactions they are likely to encounter when working with this patient population. Special favors and treatment needs are likely to be misinterpreted by these patients and have the potential of being misinterpreted and not adequately understood by clinicians. A number of authors speculate that many survivors of sexual abuse become highly eroticized (Yates, 1987; Carnes, 1983; Brunnegraber, 1986; Russell, 1986) and unfortunately, all too often victimized during the course of treatment (Bouhoutsos et al., 1983; Herman et al., 1987).
Scope of Competence in Responding to Child Maltreatment
As discussed previously, issues relating to therapists' scope of competence are difficult to measure and evaluate. Ultimately, clinicians are often left to evaluate their own strengths and weaknesses, which never emerge as a problem until a violation is alleged. Appropriate clinical training, mandatory continuing education and a commitment to clinical consultation are factors which can mitigate the issue of competence. However, there is no guarantee that the clinician will either learn the specific material or apply it in the clinical setting appropriately. Nevertheless, advertisements of continuing education in the assessment and treatment of child abuse can be found in practically every professional newsletter, magazine and journal today. Opportunities abound for expanding one's knowledge and skill in this area of mental health treatment. Yet do these workshops ensure that clinician will practice solely within his or her scope of competence? Additionally, any clinician can procure any one of a number of child abuse screening instruments or tools (such as sexually anatomically correct dolls) and incorporate their use in a clinical practice with little or no formal training.
Frequently, mental health providers who become involved with forensic evaluations lack familiarity with the appropriate legal standards and procedures that need to be integrated into psychological assessment procedures. By practicing only within the scope of practice, based on training, experience and licensure misuse of tools, techniques or psychometric tests to misdiagnose child abuse or any other inaccurate psychological or legal assessment can be mitigated (Grisso, 1986; Weithorn, 1987). To date there remains no error free behavioral test or technique for identifying child abuse (Melton & Limber, 1989), e.g. hypnosis, Eye Movement Desensitization and Reprocessing, Sexually Anatomically Correct Dolls, Child Abuse Behavioral Inventory. False positive and negatives remain problematic depending on a variety of variables including, the administration of the test, technique, or interpretation of results (Goodman & Aman, 1987; Milner, Gold, Ayoub & Jacewitz, 1984). Several techniques whose application may vary greatly (e.g. EMDR and hypnosis) have not been sufficiently empirically tested to support or refute their efficacy in assessing and treating child abuse. Therefore, clinicians must exercise extreme caution when interviewing clients and take into account the multiple levels of data that either support or refute the existence of child abuse (Faller, Froning & Lipovsky, 1991).
Additionally, therapists who become involved in forensic practice have an ethical obligation to follow the standard of practice which includes a working familarity with legal standards necessary to apply psychological data and concepts within the legal arena. Not all practitioners have this interest,understanding or ability to integrate these two disparate disciplines and, therefore, should resist getting involved beyoun providing treatment so as to not practice beyound their scope of competence (Monahan, 1981). While beyound the scope of this chapter, the therapist is refered back to the extensive literature regarding training in this subspeciality as numerous clinical professional organizations have attempted to elucidate the necessary background to become involved with child abuse evaluations either at the criminal or civil level (Weithorn, 1987).
Limit of Professional Knowledge
Mental health providers do not form opinions based in exactitude but in degrees of possibility or probability. It is not possible to know whether or not a particular child or adult was abused. Instead we may talk about degrees of certainty based on the factors observed or evaluated by the professional. Therefore, clinicians need to be cautious about statements made to clients, other professionals, law enforcement personnel and in court regarding the level of certainty about a particular individual's abuse assessment. Because an individual says they were abused does not necessarily mean that they were abused or, if they were, by the person they say committed the abuse.
Similarly, decisions about a particular person's guilt of abuse must be clearly left in the hands of the judicial process and not with mental health professionals or child abuse advocates. While an attorney may advocate for a particular position and may attempt to convince, trick or cajole the mental health professional to testify to "the ultimate issue," this may well be an invitation to exceed the boundary of the expert's specialized knowledge. As such, the mental health professional has an opportunity and responsibility to educate the "trier of fact" (i.e. the judge or jury) about the bounds of their competence and points of uncertainly.
In the past five years, there has been a plethora of pop-psychology books on the topic that are not grounded in the literature but grew out of the clinical experience of both professionals and paraprofessionals. Relying on this material may result in erroneous assumptions being made about the characteristics of victims and perpetrators. For example, many of these books offer a laundry list of characteristics that could be symptoms of any one of a number of problems, but are attributed to child abuse (Loftus, 1993). Professionals are cautioned not to form their conclusions based on superficial observations of clinical characteristics that by definition can be transient, but rather, to form the basis of their evaluation of child abuse on sound, broad based clinical data that is supported by the literature and offer alternative hypotheses as appropriate.
Not all children demonstrate observable reactions to child abuse (Browne & Finkelhorr, 1986). Similarly, many symptoms attributed to child abuse (e.g. bedwetting) may also be symptoms related to other family problems or may simply be a reflection of normal developmental patterns. If a clinician relies too heavily on these "typical" characteristics, the possibility greatly increases that he or she is going to misdiagnose child abuse when in fact it hasn't occurred. Relying on nonscientific material can lead to a clinician unethically misrepresenting the state of psychological knowledge and techniques (Weithorn & Grisso, 1987).
In many ways, the legal and ethical issues clinicians confront in treating patients involved in child maltreatment are similar whether the abuse is singular or in multiple forms. The clinician needs to maintain an awareness of the issues of reporting requirements, confidentiality, boundry issues including dual relationships, and scope of practice and competence in order to meet the treatment needs of the individual or family while at the same time practice within the legal and ethical standards of their profession. Because laws and ethical standards have been created to protect both the consumer and society at large, decisions in this regard must be taken seriously.
The most obvious area that multiple abuse differs from cases of singular victimization is in the legal mandate to report. Therapists may not report for unconscious reasons or may be reluctant to report child abuse for both deliberate and unintentional purposes. This problem may be exacerbated by the fact that the therapist is confronted with the decision to report or not report secondary forms of child maltreatment. The authors discuss a model proposed by Brossig and Kalichman (1992), who propose a three tiered model for reporting child maltreatment. this model is equally applicable for singular and multiple cases of victimization and, therefore, clinicians are encouraged to utilize this approach in either situation. Given the complexity of child maltreatment cases, we recommend that clinicians receive either legal (i.e. consulting with protective services) or professional (i.e. consulting with clinical consultant) consultation when confronted with all cases of child maltreatment or other situations that involve a legal mandate to report.
Many patients, abused or not, pull for the clinician to cross over ethical boundaries. This is particularly strong with the most wounded of patients who are frequently in therapy to develop healthier relationships with others. There is often a strong pull for the therapist to meet the patient at the patient's level which can, in the case of an unconscious professional, lead to the blurring of professional boundaries. Even the most highly skilled clinician may lose sight of his or her ethical obligations. Therefore, the authors strongly recommend that clinicians become involved with regular peer or professional supervision/ consultation and not just when things become difficult.
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