Chttd Abuse 8, Ne&cff. Vol. 1.5, pp. 467-476, Printed in the U.S.A. All rights reserved.
0145~2134/91 $3.00 + .# Copyynght 0 1991 Pergamon Press plc
1991
FACTORS ASSOCIATED WITH SUCCESSFUL ENTRY INTO THERAPY IN CHILD SEXUAL ABUSE CASES MARY E. HASKETT Department of Psychology, North Carolina State University, Raleigh, NC
NANCY I?. NOWLAN, JAMES S. HUTCHESON,
AND JAY M. WHITWORTH
Children’s Crisis Center, Inc., Jacksonville, FL
Abstract-Given the well-documented, long-term, negative mental health consequences of child sexual abuse, it is important that children receive counseling following abuse. Often, the social worker’s r~~nsibil~ty is to insure that abused children are appropriately referred for counseling foliowing disclosure of sexual abuse. There are multiple factors that could facilitate or hinder this process, and identification of these factors is important in assisting families in becoming engaged in therapy. The purpose of this study was to ( I ) determine the extent of the problem of sexual abuse victims failing to keep their first scheduled therapy ap~intmen~ and (2) identify factors associated with failure to attend. Subjects were f 29 consecutive child sexual abuse clients referred to long-term therapy by counselots at a crisis intervention center. Those who attended their first therapy session (n = 84) were found to differ from those who did not (n = 45) on the basis oftheir race, the center to which they were referred (private or public), whether the family had a telephone in the home, and whether the child’s mother agreed that the family needed counseling. Implications of this study for increasing attendance at therapy are presented and recommendations are made for further research. Kcjp Words-Sexual
abuse, Therapy dropout, Therapy referral.
COMMUNITY SURVEY RESEARCH indicates that approximately one-third of female children experience some form of sexual assault by the time they reach adulthood (Bagley & Ramsey, 1986; Kilpatrick, Saunders, Veronen, Best, & Von, 1987). As the extent of sexual abuse of children has become increasin~y clear during the past decade, there has been a surge of interest in identifying the short- and long-term effects of child sexual abuse. A “child sexual abuse syndrome” has been proposed as an explanation for the mental health outcome of child sexual abuse (Summit, 1983); however, there is limited evidence to support the presence of a syndrome per se (Browne & Finkelhor, 1986; Saunders, McClure, & Murphy, 1987). Rather, the experience of sexual abuse appears to have a diverse effect on victims. The effects may include behavior problems (Friedrich, Urquiza, & Beilke, 1986), Post-Traumatic Stress Disorder (McLeer, Deblinger, Atkins, Foa, & Ralphe, 1988), anxiety (Wagner, 1988), and lowered self-esteem and social competence (Tong, Oates, & McDowell, 1987). Retrospective studies indicate that adult women sexually abused as children show more problems of depres-
Paper presented at the Eighth National Conference on Child Abuse and Neglect, Salt Lake City, UT, 1989. Received for publication February 2 1, 1990; final revision received June 13, 1990; accepted June 13, 1990. Requests for reprints should be sent to Mary E. Haskett, Department of Psychology, Campus Box 7801, North Carolina State University, Raleigh, NC 27695. 467
468
M. E. Haskett,
N. P. Nowlan,
J. S. Hutcheson,
and J. M. Whitworth
sion and low self-esteem, sexual dysfunction, anxiety, and self-destructive behavior than control groups of nonabused women (Murphy, et al, 1988; Stein, Golding, Siegel, Burnham, & Sorenson, 1988). Symptom patterns may be mediated by a number of variables (e.g., the typology of the abuse, when the abuse occurred in the child’s development, gender of the child), but it is clear from this body of research that sexual abuse, regardless of mediating variables, has potentially deleterious effects on child victims. While not all children who have experienced sexual abuse will need long-term therapy, every abused children should have the opportunity for evaluation and treatment by a mental health professional. Three factors potentially interfere with a child’s attainment of adequate treatment. First, child sexual abuse is very rarely reported (Kilpatrick, et al., 1987); thus, a large proportion of abused children are unlikely to receive immediate intervention directed specifically to the abuse. Second, research in child and family therapy suggests that the dropout rate from treatment is approximately 50% (e.g., Gaines & Stedman, 198 1; Sir@, Janes, & Schechtman, 1982) with estimates as high as 65% (Pekarik & Stephenson, 1988). Due to the high rate of premature termination of treatment, many children, including victims of sexual abuse, do not complete necessary therapy. A third factor that potentially hinders child victims from obtaining therapy is failure of parents to follow through with recommendations and referrals to long-term therapy. Given the dynamics in families of sexually abused children, including solid family boundaries (Saunders, McClure, & Murphy, 1987) many parents may never voluntarily follow recommendations to obtain treatment. It is important to have an understanding of variables associated with a client’s failure to attend their first therapy session since crisis managers, largely responsible for making referrals to counseling, could use this information to increase the likelihood of successful initiation of therapy. This would reduce the cost associated with missed appointments and, more importantly, insure that clients obtain needed therapeutic services. As noted by Gould, Shaffer, and Kaplan (1985), it is important to consider the phase of the clinic process in assessing therapy drop out since factors associated with nonattendance may differ at the referral phase, intake phase, and treatment phase. Literature addressing the factors associated with dropping out of therapy dates from the late 1950s (see Baekeland & Lundwall, 1975) but information regarding characteristics of clients who do not follow recommendations to attend initial appointments for evaluation and therapy is more limited. Data that exist on dropout during the referral phase, the specific focus of this study, suggest that lo- 12% of clients screened for therapy do not attend their first session (Gould, Shaffer, & Kaplan, 1985; Lefebvre, Sommerauer, Cohen, Waldron, & Perry, 1983). The purpose of the present study was to determine the extent to which nonattendance at the initial therapy session is a problem in the area of child sexual abuse, and to identify variables associated with attendance. Variables, selected for study on the basis of previous research and clinical judgement, included sociodemographic and situational variables, parental attitudes, and family symptomatology. A review of the literature indicates that child and family therapy dropout research has not found race to be a discriminating factor in determining which clients continue therapy to completion (Gould, et al., 1985; Singh, et al., 1982), but race has been shown to be a factor in predicting which clients will initially seek therapy (e.g., Neighbors, 1984). Parental factors such as motivation to attend therapy (Ross & Lacey, 196 1) and awareness of their contribution to the child’s problem (Lake & Levinger, 1960) are also associated with continuance. There are conflicting findings regarding the importance of socioeconomic status (SES) in predicting dropout. Lefebvre and colleagues (1983), as well as Lake and Levinger ( 1960), found that lower SES was associated with failure to attend an initial therapy appointment, but others (e.g., Beitchman & Dielman, 1983; Berrigan & Garfield, 198 1; Gaines & Stedman, 198 1) have reported conflicting results with respect to the importance of SES on continuance.
Initiation of therapy in sexual abuse
469
Weisz, Weiss, and Langmeyer ( 1987) suggest that perhaps continuance depends less on child and parent characteristics than on situational variables such as availability of transportation. Given the paucity of consistent findings in the literature on dropout at the referral phase of therapy, and since this was the first research on dropout among sexual abuse victims, the present study was considered exploratory. Specific directional hypotheses were therefore limited in number; we predicted that, compared to the group of children who attended the first therapy session, those who did not attend would have a greater degree of parental psychopathology, less maternal support, would not have a telephone or transportation, and would more likely be nonwhite. METHOD
Participants were the counselors and clientele of a crisis intervention center serving victims of child abuse and their families. The center is hospital-based, and serves clients in urban, suburban, and rural areas within a five-county area. Services are multidisciplinary (e.g., child abuse validation interviews, medical evaluations, psychological evaluations) and clients are referred to the center by the state child protection agency on the basis of need for these services. Approximately 75% of all cases of sexual abuse in the five-county area are referred to this center. The policy of the center is to refer every sexually abused child (and when appropriate, the child’s family) to long-term counseling after crisis stabilization. For the purpose of this study, every sexual abuse victim referred to counseling within a six-month period was included in the subject population. The final subject sample consisted of 129 child victims (22 males; 107 females) of sexual abuse. The mean age of the child was 8.24 years (range = 1 to 17). White children represented 77.5% of the group, while the other 22.5% were African American. Of the children, 46% had been abused by their father or stepfather, and 19.4% by another male family member (e.g., uncle); 16% had been abused by an adult male family acquaintance, and 18.6% by a juvenile babysitter. Six full-time crisis counselors furnished data on the clients they referred for counseling. Five crisis counselors had competed a bachelor’s degree in a social science field and one had a master’s degree in social work. All had experience in the field of social work, with an average of 2.5 years of specialized training in the field of child abuse and neglect. They remained blind to the specific hypotheses of the study.
When crisis counselors referred a child or family to therapy, they completed a questionnaire based on a face-to-face interview with the child’s nonoffending parent. This information served as the data base for the study. To make a referral, crisis counselors sent a referral form that included background information on the family to the counseling agency. Parents were then either given the number of the agency to schedule an appointment at their convenience or the crisis counselor made the appointment while the client was present. Six to eight weeks after the referral was made, the counseling center was contacted to determine whether the family attended their first appointment. Those who attended made up the “attender” group, and those who did not comprised the “nonattender” group. Dependent Variables All information collected was based on parents’ self-reports. Demographic data included the child’s age, gender, and race, parent’s marital status and education, family socioeconomic
470
M. E. Haskett, N. P. Nowtan, J. S. Hutcheson, and J. M. Whitworth
status (Hollingshead, 1975) and whether the family had a telephone and transportation. An assessment of mother’s supportiveness included whether she felt counseling was needed for her child and family, and whether she believed the abuse occurred. Family symptomatology variables included parents’ self-reported history of child abuse, alcohol and drug abuse, criminal record, and presence of an identified mental illness. Data were also collected regarding the child’s history of prior counseling and presence of mental illness. Other data included where the family was referred (public or private center) and the relationship of the offender to the abused child (e.g., babysitter, father).
RESULTS To assess the relationship of the variables studied to attendance at the first therapy session, two sets of analyses were conducted: (1) chi-square and t tests to identify variables that differentiated attenders from nonattenders (see Table l), and (2) a multiple-regression analysis on all variables for which significant group differences were identified. There were no significant group differences in the age of the child. The mean age of the attender group was 8.5 years, while the mean age of the nonattender group was 7.7 years. A higher percentage of male children (77.2%) than female children (62.6%) were attenders, but the difference was not significant. A significant group difference did emerge in race, with a larger percentage of Caucasian children (72%) than African American children (4 1.3%) attending, x2 (I) = 9.28, p < ,005. Attenders and nona~enders did not differ in the educational level of their mothers or fathers. Marital status of the attender and nonattender groups was not significantly different, nor was there a difference in family SES. Children in homes with a telephone were significantly more likely to attend their first therapy session than children in homes without a phone, x2 (1) = 5.04, p < .05. Since only seven families did not have transportation, this factor was not subjected to statistical analysis. Whether the child’s mother believed that the abuse occurred, whether she felt that her child needed counseling, and whether she agreed to separate her child from the offender were not significant factors in disc~minating the attender and nonattender groups. However, if mothers felt that their entire families needed counseling, their children were significantly more likely to attend the first therapy session, x2 ( 1) = 6.42, p -c .O1. There was limited variability on many family symptomatology variables, so statistical analyses were considered inappropriate on these variables. The three variables on which analyses were conducted (i.e., mother’s history of abuse, and father’s substance abuse and criminal record) yielded nonsignificant group differences. A significant group difference was found in the counseling center to which attenders and nonattender were referred, x2 (1) = 7.43, p < .O1. Children referred to private centers were much more likely to attend their first therapy session than those referred to public agencies. The relationship of the offender to the child did not discriminate attender and nonattender groups. All variables for which attenders and nonattenders differed were included in a multiple-regression analysis to assess their relationship to attendance. This stepwise regression analysis showed that two variables made a significant contribution to the prediction of attendance, and accounted for 10.7% of the variance in attendance. These variables were (1) race, increment in R2 = .074, F (1, 120) = 9.58, p -c .O1; and (2) mother believes that her family needs counseling, increment in R2 = .033, F (2, 119) = 7.09, p < .O1. Post hoc analyses (see Table 2) were conducted to further explore the racial difference found in initial analyses. There was a significant racial difference in the center to which families were referred, x2 ( 1) = 8.88, p < .O1; and in whether the mother felt her family needed counseling, x2 (1) = 9.45, p < .O1. There were no racial differences in whether the family had a telephone or in family SES.
471
Initiation of therapy in sexual abuse Table 1. Group Characteristics
(Number and Standard Deviation) on Each Variable
Attenders
Age Gender Male Female Race Caucasian African American Mother’s Education Father’s Education Marital Status Married Separated/Divorced Single Socioeconomic Status I and II III IV V Family has telephone Family has transportation Center referred to Private Public Offender-Victim Relationship Parent Other family memeber Babysitter Adult acquaintance Mother’s Supportiveness Believes abuse occurred Believes child needs therapy Believes family needs therapy Family Symptomatology Mother victim of abuse Father victim of abuse Mother substance abuser Father substance abuser Mother mental illness Father mental illness Mother criminal record Father criminal record
Nonattenders
8.5 (4.2)
7.7 (3.9)
17 67
5 40
72 12 12.3 (1.8) 11.5 (3)
28 17 12(1.6) 12 (1.5)
51 13 20
25 10 10
11 7 46 16 66 80
4 8 20 11 27 38
51 33
16 29
40 15 16 13
19 10 8 8
72 76 72 19 7 7 17 3 1 0 17
t or F value
D value
.982 1.72
,327 .I89
9.28
.002
.95 .81 .912
.341 .415 ,633
4.04
,400
5.04 1.84 7.43
,024 ,174 ,006
,595
,897
36 39 30
,702 .44 6.42
,402 .507
12 0 3 7
.384 1 * ,559 * * * .125
,535
0
2 11
.Oll
,454
,724
* No analysis conducted due to limited variability.
DISCUSSION The purpose of this study was to examine the issue of noncompliance with recommendations to attend therapy in cases of child sexual abuse. Given that only 65% of the total sample of 129 child victims of sexual abuse in this study attended their first scheduled therapy session, nonattendance can be considered a significant problem among this population of children who are high-risk for later adjustment problems. These results, together with the low disclosure and reporting rate of child abuse and the high therapy dropout rate, indicate that a large majority of children who experience sexual abuse will remain without therapeutic intervention. This study identified several factors associated with the underutilization of therapy in cases of child sexual abuse. A growing body of literature suggests that non-white ethnic groups are less likely to utilize the mental health care system (e.g., Hough, et al., 1987; Neighbors, 1984). Consistent with prior research was the significant racial difference identified in this study. Specifically, a
472
M. E. Haskett, Table 2. Post Hoe Analyses Variable
Family has phone Yes No Missing Data Center referred to Private Public Mother feels family needs counseling Yes No SES (Hollingshead) I II III IV V
N. P. Nowlan, of Significant
J. S. Hutcheson,
and J. M. Whitworth
Difference in Race of Attenders and Nonattenders
African Americans
Caucasians
X2
p
value
I8 (62%) 10 (34.5%) 1 (3.5%)
76 (76%) 19 (19%) 5 (5%)
2.86
.090
8 (27.5%) 21 (72.5%)
89 (89%) 41(41%)
8.87
,002
17 (58.6%) 12 (41.4%)
85 (85%) 15 (15%)
9.45
,002
1 (3.5%) 1 (3.5%) 5 (17.2%) 14 (4.83%) 9 (31%)
l(l%) 13 (13%) 10 (10%) 52 (52%) 18 (18%)
4.83
,305
greater percentage of Caucasian than African American clients attended the first therapy session. Regression analyses indicated that the race of clients contributed to a high percentage of the variance in attendance and was the most important variable (among the variables included in this study) in the prediction of attendance. In order to explore potential explanations for the racial difference, a number of post hoc analyses were conducted. Results indicated that there were no racial differences in SES or in availability of a telephone. Since African American clients were significantly more likely to be referred to public centers, a potential bias in the referral process was explored. However, families were referred to the center closest to their home, and African American clients more often lived near public centers. Even though there is no evidence specifically for a racial bias per se, referral to a public center may have been a disadvantage to clients since prior research has shown that nonattendance increases with longer waiting lists (Lefebvre, et al., 1983). While length of waiting lists was not assessed in this study, we know from experience that private centers in our community are able to schedule appointments in a more timely manner than public centers. Thus, nonattendance among African American clients may have been a result of long waiting lists at public centers. While that is a reasonable explanation for the racial difference, it is more likely that some other factors lead to under-utilization of therapy by African American clients, particularly since the regression analysis did not show type of center to contribute significantly to the prediction of attendance. A complex combination of factors likely contributes to the low attendance rate among African American clients. Research suggests that African American subjects are more likely than Caucasian clients to use an informal helper network of community, family, and religious organizations rather than to seek professional help for personal problems. Neighbors and colleagues (Chatters, Taylor, & Neighbors, 1989; Neighbors & Jackson, 1984; Neighbors, Jackson, Bowman, & Gurin, 1983) have found that 43% of black respondents to a national survey used only informal help for personal problems and were less likely to seek professional help if the problem was described as emotional (as opposed to physical). Further, almost half of the respondents who stated that they were about to the point of a nervous breakdown did not seek professional help. Among those who did seek professional assistance for problems, the most frequently utilized sources were hospital emergency rooms, private physicians, and ministers. Certainly these sources and informal helper systems may be extremely useful in alleviating the stress associated with sexual abuse; however, these systems are not likely to be
473
Initiation of therapy in sexual abuse
sufficient to ameliorate the negative effects of sexual abuse on the child and family system and to insure that the abuse will cease. Underutilization of therapy by African American clients should be further explored in an effort to increase the rate at which these children obtain professional counseling. Univariate analyses indicated that families who had their own telephone were more likely to attend their first session. While it might seem reasonable to attribute the failure to attend therapy simply to the inconvenience of not having a phone, the reason for nonattendance among these subjects is probably more complex. Specifically, not having a phone may be indicative of the social isolation typical of families of sexually abused children. One might reasonably hypothesize that families who are more socially isolated and who function with more rigid family boundaries would be less likely to accept professional help. This hypothesis was not assessed in the present study and deserves further attention in subsequent research. In contrast to our expectations, whether or not mothers felt their abused child needed counseling was not a factor in whether they took the child to the first therapy session. However, if mothers felt the entire family needed counseling, they were more likely to take their children to therapy than if they did not feel their family would benefit from therapy. Perhaps mothers of abused children feel they can help their child adjust following an abusive experience (particularly if they deny or minimize the child’s distress), but when the family system is disrupted, motivation to attend therapy increases. This finding is consistent with prior research which shows that parents who attended therapy after an application interview were more likely to see the problem as something for which the family as a whole was responsible and in which they all had to participate to find a solution (Lake & Levinger, 1960). Given these results, crisis counselors should help nonoffending parents, especially African American parents, view sexual abuse as a family problem in which all members are affected. Even in cases of extrafamilial abuse, the abused child will need the support of parents and siblings, and nonabused children should have an opportunity to address any personal fears or sadness resulting from their sibling’s abuse and to obtain prevention information. As noted previously in this paper, dropout research has not been consistent in identifying socioeconomic status as a differentiating variable between those who continue therapy to completion and those who do not. We did not find a difference in the SES of attenders and nonattenders; however, the present study might not be an adequate assessment of the impact of SES due to the restriction in range of SES in our families. Failure to find a group difference may have been a function of a “floor effect” since this sample was not representative of the full economic range. Possibly the nonattendance rate of 35% would have been different if there were a greater number of families from the higher SES included in the sample. There are a number of factors that may limit the generalizability of the present results. First, our sample represented only 75% of the total abuse cases in our area. Possibly the families referred to our center were more distressed and dysfunctional than the total population, resulting in a lower attendance rate than would be found in the general population of abused children. Second, these data are based solely on parent self-report during face-to-face interviews. Data may be confounded by demand characteristics since the crisis counselor does have some influence in the decision as to whether abused children are detained from their parents’ custody. For this reason, parents may have been motivated to minimize personal and family pathology.
RECOMMENDATIONS
FOR FUTURE
RESEARCH
AND PRACTICE
The total variance accounted for by the four factors for which significant differences were found was only 10.7%, suggesting that there are other important factors that should be ex-
474
M. E. Haskett, N. P. Nowlan, J. S. Hutcheson, and J. M. Whitworth
plored to increase our understanding of nonattendance among sexually abused children and their families. Situational barriers such as illness, transportation problems, and failure to remember the appointment should be explored. Additional mediating variables that should be assessed include parents’ understanding of the abusive experience and their perception of personal guilt and self-blame for the abuse. A second recommendation for future research is a continued investigation of the racial difference in therapy attendance among sexually abused children. The research design employed in this study was admittedly limited in ability to fully understand cultural and ethnic differences. Future research should lead to a better understanding of the failure of non-white clients to take advantage of therapeutic intervention and to an increase in the rate at which these clients obtain professional therapy. Interventions to improve the attendance rate at the initial therapy session should be explored. Specifically, written reminders and the use of an orientation letter explaining clinic procedures (Swenson & Pekarik, 1988) have been used successfully in increasing compliance with attendance at the initial therapy session and might be useful in counte~ng the effects of a long waiting list. Results of telephone prompting have been inconsistent (Burgoyne, Acosta, & Yamamoto, 1983; Turner & Vernon, 1976) and obviously would not be useful for families without phones. Dropout research suggests that clients who initiate their own therapy are more likely to continue therapy to successful completion (Gaines & Stedman, 198 1). Perhaps allowing nonoffending parents greater decision-making power and responsibility in the referral process would result in greater compliance with recommendations to obtain therapy for their children and families. Self-help support groups (e.g., Parents United), available in an increasing number of communities, might also serve to improve the attendance rate by increasing social support and decreasing the stigma often associated with obtaining therapy. Woods ( 1974) presented a group method to reduce dropouts from a child psychiatry clinic. Our center is developing a similar program in which nonoffending parents will be invited to a group session where information will be presented on the impact of sexual abuse on the family and the importance of therapy to restore family functioning. In light of the present results, parents will be encouraged to view sexual abuse as a family issue requiring counseling for all members. Parents will also have an oppo~unity to present their concerns regarding the therapeutic process, the stigma associated with attendance at therapy, and their own feelings of guilt, anger, and self-blame for the sexual abuse. A final note is warranted regarding the impact of the present findings on research in child sexual abuse. The fact that attenders and nonattenders were different on a number of variables calls into question the practice of using samples of convenience in research on sexually abused children. That is, many reports are based on abused children who are engaged in therapy rather than on community samples (e.g., MeLeer, et al., 1988; Yates, Beutler, & Crago, 1985). The present results suggest that findings from these reports may not be generalizable to all abused children; in particular, African American children are not likely to be fully represented in samples of convenience. To avoid this bias, research involving communitybased samples is encouraged. Acknowledgement-The
authors wish to thank Kelly Jenkins and the crisis counselors ofthe Child Protection Team, Jacksonville, F’L for their assistance in data collection and their contribution to the conceptualization of this paper. Appreciation is extended to Marie-Paule Lessard for her assistance in the preparation of the manuscript.
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Saunders, B. E., McClure, S. M., St Murphy, S. M. (1987, July). Structure, function, andsymptoms infather-daughter sexual abusefamilies: A multilevel-multirespondent empirical assessment. Paper presented at the Family Violence Research Conference, Durham, NH. Singh, H., Janes, C. L., & Schechtman, J. M. (1982). Problem children’s treatment attrition and parent’s perception of the diagnostic evaluation. Journal of Psychiatric Treatment and Evaluation, 4, 257-263. Stein, J., Golding, J., Siegal, J., Bumham, M., & Sorenson, S. (1988). Long-term psychological sequelae of child sexual abuse: The Los Angeles Epidemiologic Catchment Area Study. In G. Wyatt & G. Powell (Eds.), Lasting effects of child sexual abuse (pp. 135- 154). Newbury Park, CA: Sage. Summit, R. (1983). The child sexual abuse accommodation syndrome. Child Abuse & Neglect, 7, 177-193. Swenson, T. R., & Pekarik, G. (1988). Intervention for reducing missed initial appointments at a community mental health center. Community Mental Health Journal. 224. 205-218. Tong, L., Oates, K., & McDowell, M. (1987). Personality development following sexual abuse. Child Abuse & Neglect, 11, 371-383.
Turner, A. J., & Vernon, J. C. (1976). Prompts to increase attendance in a community mental health center. Journal of Applied Behavior Analysis, 9, 14 I- 145. Wagner, W. G. (1988, April). The brief-term effects of child sexual assault: Victim’s self-concept, depression, and hopelessness. Paper presented at the annual meeting of the Southeastern Psychological Association, New Orleans, LA. Weisz, J. R., Weiss, B., 8~Langmeyer, D. B. (1987). Giving up on child psychotherapy: Who drops out? Journal of Consulting and Clinical Psychology, 55, 9 16-9 18. Woods, T. L. (1974). A group method of engaging parents at a child psychiatry clinic. Child Welfare, 53, 394-40 1. Yates, A., Beutler, L. E., & Crago, M. (1985). Drawings by child victims ofincest. ChildAbuse & Neglect, 9, 183-189.
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FACTORS ASSOCIATED WITH SUCCESSFUL ENTRY INTO THERAPY IN CHILD SEXUAL ABUSE CASES MARY E. HASKETT Department of Psychology, North Carolina State University, Raleigh, NC
NANCY I?. NOWLAN, JAMES S. HUTCHESON,
AND JAY M. WHITWORTH
Children’s Crisis Center, Inc., Jacksonville, FL
Abstract-Given the well-documented, long-term, negative mental health consequences of child sexual abuse, it is important that children receive counseling following abuse. Often, the social worker’s r~~nsibil~ty is to insure that abused children are appropriately referred for counseling foliowing disclosure of sexual abuse. There are multiple factors that could facilitate or hinder this process, and identification of these factors is important in assisting families in becoming engaged in therapy. The purpose of this study was to ( I ) determine the extent of the problem of sexual abuse victims failing to keep their first scheduled therapy ap~intmen~ and (2) identify factors associated with failure to attend. Subjects were f 29 consecutive child sexual abuse clients referred to long-term therapy by counselots at a crisis intervention center. Those who attended their first therapy session (n = 84) were found to differ from those who did not (n = 45) on the basis oftheir race, the center to which they were referred (private or public), whether the family had a telephone in the home, and whether the child’s mother agreed that the family needed counseling. Implications of this study for increasing attendance at therapy are presented and recommendations are made for further research. Kcjp Words-Sexual
abuse, Therapy dropout, Therapy referral.
COMMUNITY SURVEY RESEARCH indicates that approximately one-third of female children experience some form of sexual assault by the time they reach adulthood (Bagley & Ramsey, 1986; Kilpatrick, Saunders, Veronen, Best, & Von, 1987). As the extent of sexual abuse of children has become increasin~y clear during the past decade, there has been a surge of interest in identifying the short- and long-term effects of child sexual abuse. A “child sexual abuse syndrome” has been proposed as an explanation for the mental health outcome of child sexual abuse (Summit, 1983); however, there is limited evidence to support the presence of a syndrome per se (Browne & Finkelhor, 1986; Saunders, McClure, & Murphy, 1987). Rather, the experience of sexual abuse appears to have a diverse effect on victims. The effects may include behavior problems (Friedrich, Urquiza, & Beilke, 1986), Post-Traumatic Stress Disorder (McLeer, Deblinger, Atkins, Foa, & Ralphe, 1988), anxiety (Wagner, 1988), and lowered self-esteem and social competence (Tong, Oates, & McDowell, 1987). Retrospective studies indicate that adult women sexually abused as children show more problems of depres-
Paper presented at the Eighth National Conference on Child Abuse and Neglect, Salt Lake City, UT, 1989. Received for publication February 2 1, 1990; final revision received June 13, 1990; accepted June 13, 1990. Requests for reprints should be sent to Mary E. Haskett, Department of Psychology, Campus Box 7801, North Carolina State University, Raleigh, NC 27695. 467
468
M. E. Haskett,
N. P. Nowlan,
J. S. Hutcheson,
and J. M. Whitworth
sion and low self-esteem, sexual dysfunction, anxiety, and self-destructive behavior than control groups of nonabused women (Murphy, et al, 1988; Stein, Golding, Siegel, Burnham, & Sorenson, 1988). Symptom patterns may be mediated by a number of variables (e.g., the typology of the abuse, when the abuse occurred in the child’s development, gender of the child), but it is clear from this body of research that sexual abuse, regardless of mediating variables, has potentially deleterious effects on child victims. While not all children who have experienced sexual abuse will need long-term therapy, every abused children should have the opportunity for evaluation and treatment by a mental health professional. Three factors potentially interfere with a child’s attainment of adequate treatment. First, child sexual abuse is very rarely reported (Kilpatrick, et al., 1987); thus, a large proportion of abused children are unlikely to receive immediate intervention directed specifically to the abuse. Second, research in child and family therapy suggests that the dropout rate from treatment is approximately 50% (e.g., Gaines & Stedman, 198 1; Sir@, Janes, & Schechtman, 1982) with estimates as high as 65% (Pekarik & Stephenson, 1988). Due to the high rate of premature termination of treatment, many children, including victims of sexual abuse, do not complete necessary therapy. A third factor that potentially hinders child victims from obtaining therapy is failure of parents to follow through with recommendations and referrals to long-term therapy. Given the dynamics in families of sexually abused children, including solid family boundaries (Saunders, McClure, & Murphy, 1987) many parents may never voluntarily follow recommendations to obtain treatment. It is important to have an understanding of variables associated with a client’s failure to attend their first therapy session since crisis managers, largely responsible for making referrals to counseling, could use this information to increase the likelihood of successful initiation of therapy. This would reduce the cost associated with missed appointments and, more importantly, insure that clients obtain needed therapeutic services. As noted by Gould, Shaffer, and Kaplan (1985), it is important to consider the phase of the clinic process in assessing therapy drop out since factors associated with nonattendance may differ at the referral phase, intake phase, and treatment phase. Literature addressing the factors associated with dropping out of therapy dates from the late 1950s (see Baekeland & Lundwall, 1975) but information regarding characteristics of clients who do not follow recommendations to attend initial appointments for evaluation and therapy is more limited. Data that exist on dropout during the referral phase, the specific focus of this study, suggest that lo- 12% of clients screened for therapy do not attend their first session (Gould, Shaffer, & Kaplan, 1985; Lefebvre, Sommerauer, Cohen, Waldron, & Perry, 1983). The purpose of the present study was to determine the extent to which nonattendance at the initial therapy session is a problem in the area of child sexual abuse, and to identify variables associated with attendance. Variables, selected for study on the basis of previous research and clinical judgement, included sociodemographic and situational variables, parental attitudes, and family symptomatology. A review of the literature indicates that child and family therapy dropout research has not found race to be a discriminating factor in determining which clients continue therapy to completion (Gould, et al., 1985; Singh, et al., 1982), but race has been shown to be a factor in predicting which clients will initially seek therapy (e.g., Neighbors, 1984). Parental factors such as motivation to attend therapy (Ross & Lacey, 196 1) and awareness of their contribution to the child’s problem (Lake & Levinger, 1960) are also associated with continuance. There are conflicting findings regarding the importance of socioeconomic status (SES) in predicting dropout. Lefebvre and colleagues (1983), as well as Lake and Levinger ( 1960), found that lower SES was associated with failure to attend an initial therapy appointment, but others (e.g., Beitchman & Dielman, 1983; Berrigan & Garfield, 198 1; Gaines & Stedman, 198 1) have reported conflicting results with respect to the importance of SES on continuance.
Initiation of therapy in sexual abuse
469
Weisz, Weiss, and Langmeyer ( 1987) suggest that perhaps continuance depends less on child and parent characteristics than on situational variables such as availability of transportation. Given the paucity of consistent findings in the literature on dropout at the referral phase of therapy, and since this was the first research on dropout among sexual abuse victims, the present study was considered exploratory. Specific directional hypotheses were therefore limited in number; we predicted that, compared to the group of children who attended the first therapy session, those who did not attend would have a greater degree of parental psychopathology, less maternal support, would not have a telephone or transportation, and would more likely be nonwhite. METHOD
Participants were the counselors and clientele of a crisis intervention center serving victims of child abuse and their families. The center is hospital-based, and serves clients in urban, suburban, and rural areas within a five-county area. Services are multidisciplinary (e.g., child abuse validation interviews, medical evaluations, psychological evaluations) and clients are referred to the center by the state child protection agency on the basis of need for these services. Approximately 75% of all cases of sexual abuse in the five-county area are referred to this center. The policy of the center is to refer every sexually abused child (and when appropriate, the child’s family) to long-term counseling after crisis stabilization. For the purpose of this study, every sexual abuse victim referred to counseling within a six-month period was included in the subject population. The final subject sample consisted of 129 child victims (22 males; 107 females) of sexual abuse. The mean age of the child was 8.24 years (range = 1 to 17). White children represented 77.5% of the group, while the other 22.5% were African American. Of the children, 46% had been abused by their father or stepfather, and 19.4% by another male family member (e.g., uncle); 16% had been abused by an adult male family acquaintance, and 18.6% by a juvenile babysitter. Six full-time crisis counselors furnished data on the clients they referred for counseling. Five crisis counselors had competed a bachelor’s degree in a social science field and one had a master’s degree in social work. All had experience in the field of social work, with an average of 2.5 years of specialized training in the field of child abuse and neglect. They remained blind to the specific hypotheses of the study.
When crisis counselors referred a child or family to therapy, they completed a questionnaire based on a face-to-face interview with the child’s nonoffending parent. This information served as the data base for the study. To make a referral, crisis counselors sent a referral form that included background information on the family to the counseling agency. Parents were then either given the number of the agency to schedule an appointment at their convenience or the crisis counselor made the appointment while the client was present. Six to eight weeks after the referral was made, the counseling center was contacted to determine whether the family attended their first appointment. Those who attended made up the “attender” group, and those who did not comprised the “nonattender” group. Dependent Variables All information collected was based on parents’ self-reports. Demographic data included the child’s age, gender, and race, parent’s marital status and education, family socioeconomic
470
M. E. Haskett, N. P. Nowtan, J. S. Hutcheson, and J. M. Whitworth
status (Hollingshead, 1975) and whether the family had a telephone and transportation. An assessment of mother’s supportiveness included whether she felt counseling was needed for her child and family, and whether she believed the abuse occurred. Family symptomatology variables included parents’ self-reported history of child abuse, alcohol and drug abuse, criminal record, and presence of an identified mental illness. Data were also collected regarding the child’s history of prior counseling and presence of mental illness. Other data included where the family was referred (public or private center) and the relationship of the offender to the abused child (e.g., babysitter, father).
RESULTS To assess the relationship of the variables studied to attendance at the first therapy session, two sets of analyses were conducted: (1) chi-square and t tests to identify variables that differentiated attenders from nonattenders (see Table l), and (2) a multiple-regression analysis on all variables for which significant group differences were identified. There were no significant group differences in the age of the child. The mean age of the attender group was 8.5 years, while the mean age of the nonattender group was 7.7 years. A higher percentage of male children (77.2%) than female children (62.6%) were attenders, but the difference was not significant. A significant group difference did emerge in race, with a larger percentage of Caucasian children (72%) than African American children (4 1.3%) attending, x2 (I) = 9.28, p < ,005. Attenders and nona~enders did not differ in the educational level of their mothers or fathers. Marital status of the attender and nonattender groups was not significantly different, nor was there a difference in family SES. Children in homes with a telephone were significantly more likely to attend their first therapy session than children in homes without a phone, x2 (1) = 5.04, p < .05. Since only seven families did not have transportation, this factor was not subjected to statistical analysis. Whether the child’s mother believed that the abuse occurred, whether she felt that her child needed counseling, and whether she agreed to separate her child from the offender were not significant factors in disc~minating the attender and nonattender groups. However, if mothers felt that their entire families needed counseling, their children were significantly more likely to attend the first therapy session, x2 ( 1) = 6.42, p -c .O1. There was limited variability on many family symptomatology variables, so statistical analyses were considered inappropriate on these variables. The three variables on which analyses were conducted (i.e., mother’s history of abuse, and father’s substance abuse and criminal record) yielded nonsignificant group differences. A significant group difference was found in the counseling center to which attenders and nonattender were referred, x2 (1) = 7.43, p < .O1. Children referred to private centers were much more likely to attend their first therapy session than those referred to public agencies. The relationship of the offender to the child did not discriminate attender and nonattender groups. All variables for which attenders and nonattenders differed were included in a multiple-regression analysis to assess their relationship to attendance. This stepwise regression analysis showed that two variables made a significant contribution to the prediction of attendance, and accounted for 10.7% of the variance in attendance. These variables were (1) race, increment in R2 = .074, F (1, 120) = 9.58, p -c .O1; and (2) mother believes that her family needs counseling, increment in R2 = .033, F (2, 119) = 7.09, p < .O1. Post hoc analyses (see Table 2) were conducted to further explore the racial difference found in initial analyses. There was a significant racial difference in the center to which families were referred, x2 ( 1) = 8.88, p < .O1; and in whether the mother felt her family needed counseling, x2 (1) = 9.45, p < .O1. There were no racial differences in whether the family had a telephone or in family SES.
471
Initiation of therapy in sexual abuse Table 1. Group Characteristics
(Number and Standard Deviation) on Each Variable
Attenders
Age Gender Male Female Race Caucasian African American Mother’s Education Father’s Education Marital Status Married Separated/Divorced Single Socioeconomic Status I and II III IV V Family has telephone Family has transportation Center referred to Private Public Offender-Victim Relationship Parent Other family memeber Babysitter Adult acquaintance Mother’s Supportiveness Believes abuse occurred Believes child needs therapy Believes family needs therapy Family Symptomatology Mother victim of abuse Father victim of abuse Mother substance abuser Father substance abuser Mother mental illness Father mental illness Mother criminal record Father criminal record
Nonattenders
8.5 (4.2)
7.7 (3.9)
17 67
5 40
72 12 12.3 (1.8) 11.5 (3)
28 17 12(1.6) 12 (1.5)
51 13 20
25 10 10
11 7 46 16 66 80
4 8 20 11 27 38
51 33
16 29
40 15 16 13
19 10 8 8
72 76 72 19 7 7 17 3 1 0 17
t or F value
D value
.982 1.72
,327 .I89
9.28
.002
.95 .81 .912
.341 .415 ,633
4.04
,400
5.04 1.84 7.43
,024 ,174 ,006
,595
,897
36 39 30
,702 .44 6.42
,402 .507
12 0 3 7
.384 1 * ,559 * * * .125
,535
0
2 11
.Oll
,454
,724
* No analysis conducted due to limited variability.
DISCUSSION The purpose of this study was to examine the issue of noncompliance with recommendations to attend therapy in cases of child sexual abuse. Given that only 65% of the total sample of 129 child victims of sexual abuse in this study attended their first scheduled therapy session, nonattendance can be considered a significant problem among this population of children who are high-risk for later adjustment problems. These results, together with the low disclosure and reporting rate of child abuse and the high therapy dropout rate, indicate that a large majority of children who experience sexual abuse will remain without therapeutic intervention. This study identified several factors associated with the underutilization of therapy in cases of child sexual abuse. A growing body of literature suggests that non-white ethnic groups are less likely to utilize the mental health care system (e.g., Hough, et al., 1987; Neighbors, 1984). Consistent with prior research was the significant racial difference identified in this study. Specifically, a
472
M. E. Haskett, Table 2. Post Hoe Analyses Variable
Family has phone Yes No Missing Data Center referred to Private Public Mother feels family needs counseling Yes No SES (Hollingshead) I II III IV V
N. P. Nowlan, of Significant
J. S. Hutcheson,
and J. M. Whitworth
Difference in Race of Attenders and Nonattenders
African Americans
Caucasians
X2
p
value
I8 (62%) 10 (34.5%) 1 (3.5%)
76 (76%) 19 (19%) 5 (5%)
2.86
.090
8 (27.5%) 21 (72.5%)
89 (89%) 41(41%)
8.87
,002
17 (58.6%) 12 (41.4%)
85 (85%) 15 (15%)
9.45
,002
1 (3.5%) 1 (3.5%) 5 (17.2%) 14 (4.83%) 9 (31%)
l(l%) 13 (13%) 10 (10%) 52 (52%) 18 (18%)
4.83
,305
greater percentage of Caucasian than African American clients attended the first therapy session. Regression analyses indicated that the race of clients contributed to a high percentage of the variance in attendance and was the most important variable (among the variables included in this study) in the prediction of attendance. In order to explore potential explanations for the racial difference, a number of post hoc analyses were conducted. Results indicated that there were no racial differences in SES or in availability of a telephone. Since African American clients were significantly more likely to be referred to public centers, a potential bias in the referral process was explored. However, families were referred to the center closest to their home, and African American clients more often lived near public centers. Even though there is no evidence specifically for a racial bias per se, referral to a public center may have been a disadvantage to clients since prior research has shown that nonattendance increases with longer waiting lists (Lefebvre, et al., 1983). While length of waiting lists was not assessed in this study, we know from experience that private centers in our community are able to schedule appointments in a more timely manner than public centers. Thus, nonattendance among African American clients may have been a result of long waiting lists at public centers. While that is a reasonable explanation for the racial difference, it is more likely that some other factors lead to under-utilization of therapy by African American clients, particularly since the regression analysis did not show type of center to contribute significantly to the prediction of attendance. A complex combination of factors likely contributes to the low attendance rate among African American clients. Research suggests that African American subjects are more likely than Caucasian clients to use an informal helper network of community, family, and religious organizations rather than to seek professional help for personal problems. Neighbors and colleagues (Chatters, Taylor, & Neighbors, 1989; Neighbors & Jackson, 1984; Neighbors, Jackson, Bowman, & Gurin, 1983) have found that 43% of black respondents to a national survey used only informal help for personal problems and were less likely to seek professional help if the problem was described as emotional (as opposed to physical). Further, almost half of the respondents who stated that they were about to the point of a nervous breakdown did not seek professional help. Among those who did seek professional assistance for problems, the most frequently utilized sources were hospital emergency rooms, private physicians, and ministers. Certainly these sources and informal helper systems may be extremely useful in alleviating the stress associated with sexual abuse; however, these systems are not likely to be
473
Initiation of therapy in sexual abuse
sufficient to ameliorate the negative effects of sexual abuse on the child and family system and to insure that the abuse will cease. Underutilization of therapy by African American clients should be further explored in an effort to increase the rate at which these children obtain professional counseling. Univariate analyses indicated that families who had their own telephone were more likely to attend their first session. While it might seem reasonable to attribute the failure to attend therapy simply to the inconvenience of not having a phone, the reason for nonattendance among these subjects is probably more complex. Specifically, not having a phone may be indicative of the social isolation typical of families of sexually abused children. One might reasonably hypothesize that families who are more socially isolated and who function with more rigid family boundaries would be less likely to accept professional help. This hypothesis was not assessed in the present study and deserves further attention in subsequent research. In contrast to our expectations, whether or not mothers felt their abused child needed counseling was not a factor in whether they took the child to the first therapy session. However, if mothers felt the entire family needed counseling, they were more likely to take their children to therapy than if they did not feel their family would benefit from therapy. Perhaps mothers of abused children feel they can help their child adjust following an abusive experience (particularly if they deny or minimize the child’s distress), but when the family system is disrupted, motivation to attend therapy increases. This finding is consistent with prior research which shows that parents who attended therapy after an application interview were more likely to see the problem as something for which the family as a whole was responsible and in which they all had to participate to find a solution (Lake & Levinger, 1960). Given these results, crisis counselors should help nonoffending parents, especially African American parents, view sexual abuse as a family problem in which all members are affected. Even in cases of extrafamilial abuse, the abused child will need the support of parents and siblings, and nonabused children should have an opportunity to address any personal fears or sadness resulting from their sibling’s abuse and to obtain prevention information. As noted previously in this paper, dropout research has not been consistent in identifying socioeconomic status as a differentiating variable between those who continue therapy to completion and those who do not. We did not find a difference in the SES of attenders and nonattenders; however, the present study might not be an adequate assessment of the impact of SES due to the restriction in range of SES in our families. Failure to find a group difference may have been a function of a “floor effect” since this sample was not representative of the full economic range. Possibly the nonattendance rate of 35% would have been different if there were a greater number of families from the higher SES included in the sample. There are a number of factors that may limit the generalizability of the present results. First, our sample represented only 75% of the total abuse cases in our area. Possibly the families referred to our center were more distressed and dysfunctional than the total population, resulting in a lower attendance rate than would be found in the general population of abused children. Second, these data are based solely on parent self-report during face-to-face interviews. Data may be confounded by demand characteristics since the crisis counselor does have some influence in the decision as to whether abused children are detained from their parents’ custody. For this reason, parents may have been motivated to minimize personal and family pathology.
RECOMMENDATIONS
FOR FUTURE
RESEARCH
AND PRACTICE
The total variance accounted for by the four factors for which significant differences were found was only 10.7%, suggesting that there are other important factors that should be ex-
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M. E. Haskett, N. P. Nowlan, J. S. Hutcheson, and J. M. Whitworth
plored to increase our understanding of nonattendance among sexually abused children and their families. Situational barriers such as illness, transportation problems, and failure to remember the appointment should be explored. Additional mediating variables that should be assessed include parents’ understanding of the abusive experience and their perception of personal guilt and self-blame for the abuse. A second recommendation for future research is a continued investigation of the racial difference in therapy attendance among sexually abused children. The research design employed in this study was admittedly limited in ability to fully understand cultural and ethnic differences. Future research should lead to a better understanding of the failure of non-white clients to take advantage of therapeutic intervention and to an increase in the rate at which these clients obtain professional therapy. Interventions to improve the attendance rate at the initial therapy session should be explored. Specifically, written reminders and the use of an orientation letter explaining clinic procedures (Swenson & Pekarik, 1988) have been used successfully in increasing compliance with attendance at the initial therapy session and might be useful in counte~ng the effects of a long waiting list. Results of telephone prompting have been inconsistent (Burgoyne, Acosta, & Yamamoto, 1983; Turner & Vernon, 1976) and obviously would not be useful for families without phones. Dropout research suggests that clients who initiate their own therapy are more likely to continue therapy to successful completion (Gaines & Stedman, 198 1). Perhaps allowing nonoffending parents greater decision-making power and responsibility in the referral process would result in greater compliance with recommendations to obtain therapy for their children and families. Self-help support groups (e.g., Parents United), available in an increasing number of communities, might also serve to improve the attendance rate by increasing social support and decreasing the stigma often associated with obtaining therapy. Woods ( 1974) presented a group method to reduce dropouts from a child psychiatry clinic. Our center is developing a similar program in which nonoffending parents will be invited to a group session where information will be presented on the impact of sexual abuse on the family and the importance of therapy to restore family functioning. In light of the present results, parents will be encouraged to view sexual abuse as a family issue requiring counseling for all members. Parents will also have an oppo~unity to present their concerns regarding the therapeutic process, the stigma associated with attendance at therapy, and their own feelings of guilt, anger, and self-blame for the sexual abuse. A final note is warranted regarding the impact of the present findings on research in child sexual abuse. The fact that attenders and nonattenders were different on a number of variables calls into question the practice of using samples of convenience in research on sexually abused children. That is, many reports are based on abused children who are engaged in therapy rather than on community samples (e.g., MeLeer, et al., 1988; Yates, Beutler, & Crago, 1985). The present results suggest that findings from these reports may not be generalizable to all abused children; in particular, African American children are not likely to be fully represented in samples of convenience. To avoid this bias, research involving communitybased samples is encouraged. Acknowledgement-The
authors wish to thank Kelly Jenkins and the crisis counselors ofthe Child Protection Team, Jacksonville, F’L for their assistance in data collection and their contribution to the conceptualization of this paper. Appreciation is extended to Marie-Paule Lessard for her assistance in the preparation of the manuscript.
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