Book Review

The Clinical Detective: Techniques in the Evaluation of Sexual Abuse

N Engl J Med 1993; 328:1580May 27, 1993

Article

The Clinical Detective: Techniques in the Evaluation of Sexual Abuse
By Aaron Noah Hoorwitz. 303 pp. New York, W.W. Norton, 1992. $34.95. ISBN: 0-393-70124-7

This book has long been needed. It is a clear, concise, well-written treatise on the evaluation and management of sexual abuse in children and adolescents. It will be of most use to clinicians engaged in the psychological evaluation and treatment of abused children. It will also be of great value to therapists involved in judicial aspects of sexual abuse. Physicians and others on the front lines will also appreciate it when a clinical interview results in the disclosure of abuse or when in an emergency room setting.

The book is organized around the interview process. For example, the first chapters focus on what one needs to know before the interview and on how to determine whom to interview first. This issue is critical. Interviewing the parents together before speaking with the child often leads them to reinforce each other's denial and promotes the tacit collusion that is routine in these situations. Subsequent chapters lead the reader step by step through the complex process of evaluation. Interviewing techniques are presented to guide clinicians through the complicated and confusing array of options available to them at each stage of the process.

The book has only 293 pages of text, but it manages to touch on most major themes, including issues that are seldom explored adequately, such as the disgust the clinician may feel in interviewing perpetrators. Hoorwitz also discusses the issue of evaluators who themselves were sexually abused as children. Other highlights of the book include a sophisticated discussion of how to establish rapport with a child and how to ask open-ended questions. Hoorwitz also supplies a “crib sheet” of questions that the therapist can use to explore issues such as the limitations of confidentiality. Techniques for improving bonding and empathy with the patient are also described. Hoorwitz explains techniques designed to distinguish true from false allegations and to maintain mutual understanding during confrontation. Finally, in the section “Putting It All Together,” we learn how to prepare documents for court use and how to make recommendations to the judiciary.

Overall, this is a worthwhile book for clinicians interested in the long-term treatment of sexual abuse. It is also useful for those of us who routinely elicit disclosures concerning abuse and yet still feel the need for a road map of the best way to proceed. Hoorwitz has provided us with this necessary guidance.

William G. Bithoney, M.D.
Children's Hospital, Boston, MA 02115