Book Review

Family Violence: A clinical and legal guide

N Engl J Med 1996; 335:982-983September 26, 1996

Article

Family Violence: A clinical and legal guide
Edited by Sandra J. Kaplan, with a contribution by Howard A. Davidson. 332 pp. Washington, D.C., American Psychiatric Press, 1996. $46.50. ISBN: 0-89042-010-6

Family Violence: A Clinical and Legal Guide examines the psychological sequelae for victims of family violence and provides important information about therapeutic interventions. It addresses the physical abuse, neglect, and maltreatment of children and adolescents; the sexual abuse of children; domestic violence; and the abuse of elders. Each chapter defines the problem and presents options for intervening with victims and their families.

The preface states, “Each of the first six chapters reviews the mental health literature, advises how to do a physical and mental health assessment, and discusses treatment methods as well as prevention and legal advocacy needs.” The chapters vary in how well they accomplish this goal. For example, the discussion of the assessment of physical findings in the case of the physical abuse of a child consists of one long paragraph, taken from the 1985 American Medical Association guidelines on child abuse and neglect, that lists a variety of injuries that may be indicative of abuse. The physical examination for sexual abuse is covered in only 1 1/2 pages, but this discussion does refer to important signs of abuse and appropriate laboratory testing. Nevertheless, the comprehensive assessment of the psychological needs of victims is important to health care providers and specialists in family violence.

One of the outstanding features of the book is the inclusion in each chapter of a legal commentary by Howard A. Davidson, director of the American Bar Association's Center on Children and the Law. Davidson discusses a variety of topics, including mandates for reporting abuse, nuances in the legal definitions of physical and sexual abuse, and current legal controversies, such as that involving laws that require children to testify in front of the accused. This is followed by a section for mental health professionals and practitioners that addresses their legal rights and responsibilities, such as protecting therapist–client confidentiality and the admissibility of such evidence as profiles of abusers. Of great importance is the information on what professionals may expect if they are asked to testify at or assist with court cases involving family violence.

Chapter 3, “Overview of Child Sexual Abuse,” presents the story of Cindy, a child who is being evaluated as a potential victim of sexual abuse. Interviews with Cindy, her mother, and her father (the alleged perpetrator) are presented, and the findings consistent with a diagnosis of sexual abuse are outlined. For uninitiated readers, the criteria for determining the credibility of an accusation will be eye-opening. Chapter 8, “Memories of Childhood Trauma: Therapeutic Considerations for Assessment and Treatment,” deals with research on the veracity of children's statements and the suggestibility of children. Convincing data are presented that interviewer bias, the effects of repeated suggestion, and errors in “reality monitoring” can radically change a child's perception of events; the use of anatomically correct dolls is questioned. Despite the lack of data in support of opposing views, this chapter is a persuasive discussion of the difficulties inherent in calling children as witnesses. Finding the correct balance between believing the child who is truly abused and protecting accused persons who are innocent is a formidable challenge.

The chapter on domestic violence tends to emphasize the psychological makeup of female partners in violent relationships and presents their psychological distress in terms of “traumatic bonding,” “dependence,” and “learned helplessness.” The focus is on the victim, not the batterer, which can reinforce the masochistic stereotype and fail to address the actual danger the woman faces. Also of concern is the inclusion of couples therapy under treatment options. When one partner controls the other with violence, couples therapy may actually be dangerous. This section suggests that the safety of such therapy be evaluated, but gives no information on how safety is assessed. Readers unacquainted with the potential lethality of domestic violence may be misled into believing that couples therapy is an appropriate alternative for most couples.

Missing from this book is a chapter on perpetrators. The chapter on the treatment and prevention of the sexual abuse of children does briefly address the treatment of people who commit sexual abuse, but the book does not discuss other types of perpetrators. Since many states require that a person obtain a specific certification to treat batterers, an understanding of what that specialized training entails would be valuable, as would statistics on the rate of success of treatment. Given that the root of the problem lies with the person committing the violent act, information on the psychological profiles of batterers and appropriate programs of treatment would have rounded out the book nicely.

This is an excellent book for mental health professionals and medical care providers who want to know about the psychological sequelae and treatment of family violence. Readers looking for a comprehensive book on both the mental and the physical assessment of victims will be disappointed by the lack of information on physical manifestations. It is ironic that a book that delineates the mental health needs of victims of family violence so clearly and concisely comes at a time when the funding for mental health treatment is in jeopardy.

Nancy Sugg, M.D.
University of Washington School of Medicine, Seattle, WA 98195