Effectiveness of Making Therapists Report All Child Abuse Questioned

In every state, laws require psychiatrists and other therapists to notify authorities when an adult patient admits to sexually abusing a child. But a new study has raised disturbing questions about whether these laws protect children, as they were intended.

The study by Johns Hopkins University psychiatrist Fred Berlin showed that child sexual abuse reporting laws in Maryland have caused adult offenders to avoid therapeutic treatment because of criminal penalties incurred when abuse is reported. The Maryland laws are similar to those in most states.

The effect, Berlin said, is that fewer abused children are identified and fewer adult offenders get psychiatric help.

“One can pass laws mandating reporting, but they do little to protect children if they stop sexual abusers from identifying themselves in the first place,” said Berlin, whose research was published in the April issue of the American Journal of Psychiatry.

BACKGROUND: Before 1964, Maryland law required reporting if abuse was suspected when a physician examined a child. The law was amended in 1988 to require reporting of disclosures by adult patients about child sexual abuse that occurred when they were in treatment. In 1989, the law was further amended to make all patient disclosures, even about abuse that occurred before treatment, reportable.

After passage of the 1988 law, the number of patients who disclosed that abuse had occurred when they were in treatment dropped from an average of 21 a year to zero between 1984 and 1988 at the Johns Hopkins Sexual Disorders Clinic, according to the study.

After passage of the 1989 law, the rate of abusers referring themselves for treatment dropped from an average of seven a year (73 over a 10-year period) to zero, the study showed.

The amendments to the Maryland law were highly controversial and illustrate the emotional nature of the issue, Berlin said.

ARGUMENT: “The way in which these laws have been packaged, it’s very popular to want to be on the side of showing concern for victims. In Maryland, it became very emotional,” he said.

The issue of how effective the laws are in protecting children became secondary, he added.

Instead, he said, legislators who supported the idea that therapists should be excluded from reporting laws in some cases--such as when the abuse occurred long ago--were considered to be in favor of protecting abusers, he said.

Even legislators who understood that the laws might be counterproductive “did not want to take the political heat by appearing to be not responsive to legislation intended to be helpful to children,” Berlin said.

The effectiveness of reporting laws is a concern among mental health professionals nationwide. However, the American Psychiatric Assn. has taken no stand on whether therapists should be excluded from mandatory reporting.

A growing number of therapists have expressed dissatisfaction with reporting laws that end up only punishing the patient in therapy, said Dr. Paul Appelbaum, director of the law and psychiatry institute at the University of Massachusetts Medical School.

“There are situations where people are in danger, and the ethical thing to do is to protect someone in danger. But where the problem comes up is when you’ve got statutes that require reporting of past episodes of abuse, which may have occurred years before, and where children are now much older or out of the house and unlikely to be victimized again. It leaves therapists wondering what the purpose (of the laws) is,” he said.

Conversely, therapists have to be reminded that they are not above the law, said Virginia Weisz, a lawyer and visiting professor in psychiatry at UCLA.

“Psychiatrists tend to look at the viewpoint of their client and their confidentiality, failing to realize that part of the mental health profession is being responsible to what happens to victims of abuse,” said Weisz, who teaches a course to mental health professionals on the need to report child abuse.

PROPOSAL: A possible solution, she suggests, is a legal system that would take into account that the abuser stepped forward for help and was in treatment.

“The problem is the system is imperfect,” Weisz said. “If the psychiatrist reports abuse to the authorities, then the authorities should look on the fact that the abuser is in therapy as very positive. But sometimes the authorities intervene in a punitive way where they would mandate that the abuser leave the home or remove the child from the home.

“We need to work at services so there won’t be such a negative impact and so (abusers seeking treatment) are supported and get the therapy they need.”