American Psychologist © 2017 American Psychological Association 2017, Vol. 72, No. 9, 920–931 0003-066X/17/$12.00 http://dx.doi.org/10.1037/amp0000282

Psychological Counseling and Accuracy of for Child Sexual Abuse

Gail S. Goodman and Deborah Goldfarb Jodi A. Quas University of California, Davis University of California, Irvine

Alexandra Lyon University of California, Davis

Tens of thousands of child sexual abuse (CSA) cases are reported to authorities annually. Although some of the child victims obtain psychological counseling or therapy, controversy exists about the potential consequences for the accuracy of victims’ memory of CSA, both in childhood and adulthood. Yet, delaying needed therapeutic intervention may have detrimental effects on the victims’ well-being and recovery. To address this controversy, this study examined whether psychological counseling during a CSA prosecution predicts accuracy or inaccuracy of long-term memory for CSA. Participants (N ϭ 71) were CSA victims who took part in a longitudinal study of memory and legal involvement. Data regarding participants’ counseling attendance during the prosecution and details of their CSA cases were gathered throughout legal involvement and shortly thereafter (Time 1). Ten to 16 years later (Time 2), participants were questioned about a range of topics, including the alleged abuse. Time 1 counseling attendance significantly predicted more correct answers to abuse-related questions and (for corroborated cases) fewer overreporting responses at Time 2. Counseling was unrelated to underreporting responses. These results held even with other potential influences, such as abuse severity, victim–defendant relationship, posttraumatic stress disorder criteria met, testifying in the case, and delay, were statistically controlled. Although further research is needed, this study provides evidence that psychological counseling received by CSA victims during or shortly after prosecutions may improve later memory for abuse-related information.

Keywords: therapy, memory, child sexual abuse, legal involvement

Of the tens of thousands of child sexual abuse (CSA) efits of psychological counseling for victims, controversy cases reported every year in the United States (Child exists about its effects on memory accuracy and victim Trends, 2016), a subset of the victims seek psychological testimony. For example, concerns have been raised that if services (Turner, Finkelhor, & Ormrod, 2007), the goal of memory is particularly malleable in vulnerable individuals which is to reduce negative sequela that result from sexual (young children as well as adults suffering from posttrau- victimization in childhood. Despite potential emotional ben- matic stress disorder [PTSD] symptoms), therapeutic inven- This document is copyrighted by the American Psychological Association or one of its allied publishers.

This article is intended solely for the personal use of the individual userEditor’s and is not to be disseminated broadly. note. Gail S. Goodman received the 2017 Award for Distinguished ions, findings, conclusions, or recommendations expressed in this article are Senior Career Contributions to Psychology in the Public Interest. This article is those of the authors and do not necessarily reflect the views of the National based on an invited presentation at the 125th Annual Convention of the American Institute of Justice or the National Science Foundation. We thank the partici- Psychological Association, held August 3–6, 2017, Washington, DC. pants for generously sharing their time and with us. We also thank our research teams from the University of Denver; the University of Colorado Authors’ note. Gail S. Goodman and Deborah Goldfarb, Department of Medical School; and the University of California, Davis. In particular, we are Psychology, University of California, Davis; Jodi A. Quas, Department of grateful to Lisa Pyle, David P. H. Jones, Leslie Rudy, Linda Port, and Lydia Psychology and Social Behavior, University of California, Irvine; Alexandra Prado (the Colorado team) and Simona Ghetti, Robin Edelstein, Kristen Lyon, Department of Psychology, University of California, Davis. Alexander, Allison Redlich, and Ingrid Cordón (the California team). We also Alexandra Lyon is now at the School of Psychology, Xavier University. thank Jim Peters, John Jordan, Karen Steinhauser, Norman Early, Contributions of the first and second authors to this article should be Bill Ritter, and Robert Grant and their devoted staff of Victim Assistants. considered equal. Correspondence concerning this article should be addressed to Gail S. This research was supported in part by National Institute of Justice Grant Goodman, Department of Psychology, University of California, 1 Shields 85-IJ-CX-0020 and National Science Foundation Grant 0004369. Any opin- Avenue, Davis, CA 95616. E-mail: [email protected]

920 ACCURACY OF CHILD SEXUAL ABUSE MEMORY 921

tions could lead to memory distortion or Taking these in turn, rehearsal improves memory, includ- (Lynn, Lock, Loftus, Krackow, & Lilienfeld, 2003; Mc- ing children’s long-term (Larkina Nally, 2005). If children’s receipt of psychological counsel- & Bauer, 2012; Peterson, 2015), especially when semantic ing during CSA prosecutions decreases their memory accu- meaning is activated (Bjorklund & Causey, 2017): In psy- racy for the abuse, or even raises concerns about the chological counseling, victims likely rehearse facets of the victims’ memory accuracy, prosecutors may be hesitant to abuse as their experiences are discussed, often in search of have child victims attend therapy prior to or during the greater meaning. In the process, improved understanding ongoing legal proceedings. However, having victims wait to and a more coherent narrative of the event may result, which receive needed psychological therapy out of fear of possible can also have positive effects on children’s memory (Good- adverse influences on accuracy can delay critically needed man, Quas, Batterman-Faunce, Riddlesberger, & Kuhn, support and intervention. 1997; Morris, Baker-Ward, & Bauer, 2010; Nelson & Fi- These dilemmas become all the more complex in “historic vush, 2004). abuse” cases, for example, CSA cases that are pursued only At the same time, therapy provides a supportive environ- after victims reach adulthood, often because when the vic- ment where children can talk about their prior abuse, which tims were young, they failed to disclose (London, Bruck, may make them more comfortable in disclosing and main- Ceci, & Shuman, 2005) or their disclosures were questioned taining their reports. This may result in increased comfort in (Read, Connolly, & Welsh, 2006), precluding prosecution at talking about a larger range of abuse-related details, possi- that time. However, in recent years, many states have ex- bly to multiple individuals. Indeed, studies have consis- tended their statutes of limitations to permit criminal and tently linked the support of nonoffending caregivers, foren- civil charges to move forward when adults allege that CSA sic interviewers, and psychological researchers during or occurred years if not decades earlier. In such cases, therapy following CSA disclosure to increased accuracy of CSA in childhood can raise the issue of false memory in adult- memories and willingness of victims to discuss their abuse hood (Read et al., 2006). histories (Alexander et al., 2005; Goodman et al., 2003; For such reasons, the topic of whether psychological Hershkowitz, Lamb, & Katz, 2014; Saywitz, Wells, Larson, counseling affects CSA memory accuracy has been of con- & Hobbs, 2016). siderable interest to both psychologists and legal profession- Finally, insofar as mental health counseling decreases als (Ghetti et al., 2006; Nadel, Campbell, & Ryan, 2007; trauma-related psychopathology, benefits to long-term Spinhoven, Van der Does, Van Dyck, & Kremers, 2006). memory may ensue. Child abuse victims who report high Unfortunately, a paucity of empirical research exists on trauma-related symptomology and evince associated indices whether and how psychological counseling shapes memory. of past trauma (e.g., cortisol response) show increased com- The present study took advantage of a unique opportunity to mission errors to specific and misleading questions com- evaluate, using a prospective longitudinal design, the links pared to child victims who report lower levels of such between psychological counseling and the accuracy of long- symptoms and indices (Eisen, Goodman, Qin, Davis, & term memory for CSA. The results provide much-needed Crayton, 2007). Moreover, individuals with increased de- insight into how psychological counseling relates to the pressive symptoms tend toward overgeneral memory (Val- accuracy of memory for trauma-related information, and entino, 2011; Williams et al., 2007), that is, are inclined to hence, the study informs ongoing debates about the ramifi- gist-level statements (e.g., when asked to recall a cations, during therapy, of raising or discussing the topic of specific happy event, stating, “I had a birthday party when childhood sexual abuse. I was young”) rather than details of the event. In alleviating psychopathology symptoms, therapy may contribute to memory correctness and completeness. Thus, to the extent

This document is copyrighted by the American Psychological Association or one of its allied publishers. Psychological Counseling as a Predictor of that therapy can help decrease trauma-related symptoms, it This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Memory Accuracy may also be related to an increase in memory report accu- There are several empirically supported reasons to expect racy. that mental health counseling can benefit memory accuracy, Yet, therapeutic conversations may also increase errors. although there is also the possibility that counseling could For instance, therapists may raise incorrect information introduce or reinforce errors. Turning first to possible mem- regarding the CSA event, and victims may incorporate that ory benefits, therapy may help maintain accurate recollec- information into their subsequent reports. Or through con- tion to the extent that it increases children’s opportunities to versations in therapy, incorrect information told by children rehearse their memories and reach a greater understanding to mental health professionals could inadvertently be rein- and more coherent narrative of events; provides a support- forced. Postevent misinformation, including misinformation ive setting, within which children can think and talk about introduced by others in social situations, can have deleteri- their experiences; and reduces psychopathology symptoms ous effects on a subset of children’s and adults’ memory that otherwise may inhibit accurate recall. reports (Bruck & Ceci, 1999; Otgaar, Howe, Brackmann, & 922 GOODMAN, GOLDFARB, QUAS, AND LYON

Smeets, 2016; Principe & Schindewolf, 2012). Children, ences (Epstein & Bottoms, 2002), which arguably decrease particularly preschoolers, can at times be misled or tricked recollection (Goodman et al., 2016). Although severity of to recall details of events that they did not themselves abuse could be associated with less accurate memory of experience (Principe, Haines, Adkins, & Guiliano, 2010). CSA, growing evidence has indicated that, by and large, Controversial therapeutic techniques, such as therapists’ negative events of high arousal, especially when relevant to cocreating recovered memory of abuse, have been linked to survival, which likely includes severe CSA, tend to be highly incredible allegations of satanic ritual abuse made by remembered particularly well (Alexander et al., 2005; children and adults (Bottoms, Shaver, & Goodman, 1996). McKinnon et al., 2015; Nairne & Pandeirada, 2008). Together, this research has suggested that, for some people A victim’s relationship to the defendant (parental vs. and in some circumstances, long-term memory accuracy nonparental figure) could also predict memory accuracy. may be particularly fragile, with a reduction in accuracy Victims related to their abusers may cognitively block abuse being larger when younger (compared to older) children information due to the internal conflict of being maltreated take part in therapy. by someone who is supposed to provide love and care The present study focused on psychological counseling (Freyd, 1996; Freyd, DePrince, & Zurbriggen, 2001). Vic- attendance during or shortly after a CSA criminal prosecu- tims who attempt to keep painful abuse-related memories tion, thereby increasing the likelihood that participants dis- out of their awareness because of a close relationship with cussed the alleged abuse with their therapists. Rather than the perpetrator may demonstrate less accurate long-term trusting retrospective reports of therapy attendance after memory for abuse-related experiences. long delays (Alexander et al., 2005; Ghetti et al., 2006), in Finally, PSTD symptoms should be considered as possi- our analyses we relied on reports of attending therapy that bly related to memory in CSA victims. Such symptoms are were obtained at or near the time of the original case. relatively common in child victims of sex crimes, although Approximately 14 years later, the child victims, now adults many CSA victims do not met criteria for a PTSD diagnosis or older adolescents, were interviewed about the CSA they (Kendall-Tackett, Williams, & Finkelhor, 1993; Messman- allegedly suffered in childhood. This enabled us to compare Moore & Bhuptani, 2017; Widom, 1999). Severity of PTSD the former victims’ current (e.g., adult) reports to the orig- symptomology in victims of CSA predicts memory accu- inal documentation and determine how well the individuals racy for the assault (Alexander et al., 2005). Moreover, remembered abuse-related experiences and whether psycho- higher levels of PTSD symptomology at the time of mem- logical counseling related to memory. ory retrieval predict more specific memories of childhood (Ogle et al., 2013). However, memory errors and memory Alternative Predictors of Memory Accuracy dissimilarities among individuals with and without PTSD or other trauma symptoms are also of note (McKinnon et al., 2015). Here, for participants who received therapy as chil- Multiple Factors dren, current PTSD symptomology could mediate the rela- Multiple factors influence long-term memory for CSA. tion between therapy and memory performance. Of these, some may reflect “third variables” that relate to In summary, severe abuse, close relationship to the de- both likelihood of therapy attendance and memory perfor- fendant, and PTSD symptoms each may contribute to a mance, requiring that these be considered in conjunction significant relation between psychological counseling and with therapy to ascertain the potential unique contribution memory and are thus statistically considered in analyses, as of therapy to memory. This study focused on three such presented later in this paper. variables: abuse severity, relationship to the defendant, and PTSD symptoms.

This document is copyrighted by the American Psychological Association or one of its allied publishers. The Present Study In prior work, abuse severity has been associated with This article is intended solely for the personal use ofboth the individual user and is not to beincreased disseminated broadly. and decreased memory accuracy (Alexander The data analyzed here come from a longitudinal project et al., 2005; Goodman, Quas, & Ogle, 2010; Ogle et al., that examined the long-term mental health, legal attitudes, 2013). In the context of CSA, severe events may be more and memory outcomes of alleged CSA victims (see Good- important to survival and to one’s sense of self and thus man et al., 2003; Quas et al., 2005, for methodological better retained in autobiographical memory (Bower & Siv- details). The analyses reported in the present article have not ers, 1998; Nairne & Pandeirada, 2008). This trend, however, been published previously. Participants were involved in is not universal: In individuals who attempt to psychologi- criminal prosecutions from 1985 to 1987 in three Western cally remove themselves from memories of painful events, jurisdictions (Time 1). At that time, they and their (nonof- more severe abuse may have detrimental effects on long- fending) caregivers were invited to participate in a study on term memory accuracy (Edelstein et al., 2005; Goodman et the effects of legal involvement on children. Details con- al., 2010). Severe abuse is associated with dissociation cerning the participants’ CSA and legal experiences were (Freyd, 1996) and cognitive avoidance of traumatic experi- gathered as the criminal case progressed, including whether ACCURACY OF CHILD SEXUAL ABUSE MEMORY 923

participants were attending psychological counseling during Hispanic, and 19 were ethnic minorities (5.6% African the prosecution or shortly thereafter. Most of the CSA American, 9.9% Hispanic, 1.4% Asian American, and 9.9% information was verified objectively (e.g., through police multiethnic). Participants’ Time 1 parental socioeconomic reports, court documents, medical evidence), although some status (SES) scores ranged from .00 (unemployed) to 97.16 details (e.g., timing of the acts when no objective record on the 100-point scale of the 1989 Socioeconomic Index existed) were based solely on the participants’ original (Nakao & Treas, 1992, as printed in Entwisle & Astone, statements. 1994). Participants were then interviewed 10 to 16 years later To determine the representativeness of the Time 1 sub- (Time 2), first briefly via phone; second through mailed sample of 71 participants compared to the larger Time 1 questionnaires; and finally via in-depth, in-person inter- sample (N ϭ 218; Goodman et al., 1992), we conducted a views. Information reported at Time 2 was compared to that one-way analysis of variance, with age at the time of police gathered in Time 1 to derive three types of memory scores: report as the dependent variable and inclusion in the sub- proportion of correct responses, proportion of overreporting sample as a between-subjects factor (0 ϭ not included, 1 ϭ responses (compared to Time 1 documentation, CSA was included). It revealed that at Time 1, participants in the described at Time 2 as more severe, or exaggerated details subsample were significantly older (M ϭ 10.19, 95% con- regarding the CSA were included), and proportion of un- fidence interval [CI: 9.36, 11.03]) than participants who derreporting responses (compared to Time 1 documenta- were not included in the subsample (M ϭ 8.85, 95% CI tion, CSA was described at Time 2 as less severe, or [8.26, 9.43]), F(1, 216) ϭ 6.83, p ϭ .010. Chi-square information regarding the CSA was omitted). analyses revealed a significant difference as to ethnicity, The following hypotheses were advanced: First, psycho- ␹2(1, N ϭ 216) ϭ 8.22, p ϭ .004, but not as to gender, ␹2(1, logical counseling would be associated with better memory N ϭ 218) ϭ .018, p ϭ .894. Proportionally there were for CSA, as reflected in increases in the proportion of somewhat fewer minority participants in the present study correct responses and decreases in overreporting or under- than at Time 1. Age and ethnicity are thus considered in the reporting of abuse-related information. To the extent that preliminary analyses presented later. potential benefits of psychological therapy on memory, as mentioned earlier, reflect robust predictors of accuracy Measures (e.g., , which commonly occurs during Time 1 demographic measures. Relevant Time 1 de- therapy), therapeutic intervention should predict better mographic questions concerned participant age (in years) at long-term memory for documented CSA experiences (Bjorklund & Causey, 2017; Howe, 2011; Nadel et al., 2007). Second, given research reviewed earlier, abuse se- Table 1 verity, victim–defendant relationship, and PTSD symptoms Means and Standard Deviations (SDs) for Key Variables would be related to memory accuracy, but psychological of Interest counseling would significantly predict memory for CSA Variable MSD even after accounting for these factors. Finally, because preschoolers are often more susceptible to suggestion than Victim age (years, at police report) 10.15 3.58 Victim gendera,b .76 .43 are older children (Ceci & Bruck, 1995; Goodman & Reed, Socioeconomic statusc 40.35 19.86 1986), participants who entered therapy (during or shortly Minority statusb,d .27 .45 e after the prosecution) at a young age (compared to partici- Abuse severity 4.76 1.81 Relationship to perpetratorb,f .21 .41 pants who were young and did not attend therapy and PTSD criteria metg 3.73 1.96 compared to older participants generally) would be subject Testifyingb,h .37 .49

This document is copyrighted by the American Psychological Association or one of its allied publishers. Delay (years) 14.39 1.5 to greater long-term memory error at the Time 2 interview. b,i

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Psychological counseling attendance .68 .47 Proportion correct abuse questions .72 .17 Proportion overreporting responses .14 .17 Method Proportion underreporting responses .14 .17 Note. Ns ϭ 71 for all variables except PTSD criteria met (N ϭ 66). Participants PTSD ϭ posttraumatic stress disorder. Unadjusted means and SDs are reported. ϭ a ϭ ϭ b c Seventy-one participants (76% female; Mage 24.20 0 male, 1 female. Dichotomous variables. Coded using the years, range ϭ 17.25 to 30.83) answered the questions of 1989 Socioeconomic Index (range ϭ 0 to 100; Nakao & Teas, 1992, as printed in Entwisle & Astone, 1994). d 0 ϭ nonminority status and 1 ϭ interest for this study and completed the in-person interview minority status. e Determined by composite score of abuse duration, (Alexander et al., 2005). Characteristics of the sample are extent of sexual contact, injury, and level of force on a 12-point scale, with presented in Table 1. Victims’ age ranged from 3 to 16 years higher scores indicating more severe child sexual abuse. f 0 ϭ nonparen- tal figure, 1 ϭ parental figure. g Scores ranged from 0 to 6 criteria at the time of the original police reports. With respect to met. h 0 ϭ no, 1 ϭ yes. i During or shortly after the child sexual abuse ethnic background, 52 (73.2%) were Caucasian non- prosecution was coded as 0 ϭ no, 1 ϭ yes. 924 GOODMAN, GOLDFARB, QUAS, AND LYON

the time of the police report, gender (0 ϭ males, 1 ϭ comparison between current reports and the original docu- females), SES, and minority status (0 ϭ nonminority, 1 ϭ mentation. For example, a question about type of sexual acts minority). SES scores were based on 1980 census data included four options: exhibitionism, nongenital contact concerning the parents’ level of education and income. (e.g., fondling of the breasts), genital contact (including oral Participants with two working parents were assigned the sex but no vaginal or anal penetration), and vaginal or anal higher score of the two. penetration–intercourse.1 Time 1 Sexual Assault Profile (SAP). Information as- sociated with the sexual assault and legal case (e.g., age at Procedure the end of the CSA) was recorded on a modified SAP (Conte & Berliner, 1984; see Goodman et al., 1992). In- The university Institutional Review Board approved the cluded was the question “Is this child receiving psycholog- study. At Time 1, data regarding demographics, specific ical counseling?” (0 ϭ not attending, 1 ϭ attending). Of the abuse details (e.g., type of sexual activity, relationship to the 71 participants in the present study, 48 were receiving defendant, corroborative evidence), ongoing psychological psychological counseling during the CSA prosecution or counseling attendance, and legal case involvement were shortly thereafter (i.e., during Time 1 data collection), gathered from nonoffending caregivers, participants, and/or whereas 23 were not. court observations and records (Goodman et al., 1992). At Abuse severity was determined by a composite score of Time 2, trained researchers conducted an initial phone in- abuse duration, extent of sexual contact, level of force, and terview. For scientific and ethical reasons, participants were extent of injury and ranged from 2 to 9 on a 12-point scale not informed that the study concerned child sexual abuse or (Alexander et al., 2005; Goodman et al., 1992), and rela- memory. Rather participants were simply told that this was tionship to the defendant was coded as nonparent (e.g., 0 ϭ a study of children’s experiences growing up in their com- neighbor, teacher, stranger) or parent (1 ϭ parent, step- munity and that a wide range of topics would be addressed. parent). Of the 71 cases where information regarding level After the phone interview, questionnaires (including the of corroboration (0 ϭ no corroboration, 1ϭ corroboration) PDS) with instructions were mailed to participants. If com- was available, 44 had corroborating evidence (e.g., medical pleted questionnaires were not returned, the PDS was ad- evidence, an eyewitness, defendant confession). For inter- ministered over the phone. Later, during in-person inter- rater reliability of coding of the two scaled variables in the views at Time 2, participants were asked by clinically present study (abuse severity and relationship to defendant), trained psychologists (blind to individuals’ prior experi- proportion of agreement of .80 or higher was obtained. ences and to the hypotheses of this study) about the abuse Relationship to defendant was then dichotomized, as above, and legal case history details recorded at Time 1. Partici- for analyses. Interrater reliability on the SAP overall ranged pants and caregivers were thanked and paid for their par- from .67 to 1.00 (see Goodman et al., 1992, and Quas, ticipation. Goodman, & Jones, 2003, for details on reliability of cod- ing). Memory Coding Time 2 Post-Traumatic Diagnostic Scale (PDS). The PDS, completed at Time 2, measures posttraumatic stress Time 2 in-person memory interviews were coded for symptomology (Foa, Cashman, Jaycox, & Perry, 1997). whether participants’ answers at Time 2 matched facts Victims can meet up to six PTSD criteria. The current study recorded at Time 1 (Alexander et al., 2005). When neces- focused on the number of PTSD criteria satisfied rather than sary for clarification, participants’ responses to the phone relying on a PTSD diagnosis (Alexander et al., 2005). PTSD interview or mailed questionnaires were consulted. Eleven symptomology scores here ranged from 0 to 6. The PDS points of information were relevant to memory for the CSA This document is copyrighted by the American Psychological Association or one of its alliedreveals publishers. high reliability, with internal consistency scores (i.e., perpetrator’s name, perpetrator’s age, sexual acts, vic- This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Ϫ ranging from .78 to .84 for the criteria (Foa et al., 1997).1 tim’s age at onset and conclusion of acts, child perpetrator Ϫ Time 2 memory questions. The Time 2 memory ques- relationship, child perpetrator living arrangements, fre- tions covered a variety of topics (e.g., disclosure, memory, quency and duration of CSA, and force and coercion in- legal involvement) and included a number of specific ques- volved; Alexander et al., 2005). Seven of the 11 questions tions about the target CSA incident(s). These questions probed for details of the abuse (e.g., “How old were you 1 Other mental health indices (composite scores) collected during Time when the sexual abuse/assault first happened?”; “What was 1 (i.e., Child Behavior Checklist: Achenbach & Rescorla, 2000) or Time 2 (i.e., Dissociative Experiences Scale: Bernstein, & Putnam, 1986; Youth the defendant’s name?”; “What was the defendant’s rela- Self Report: Achenbach, 1997; Behavior Symptom Index: Derogatis, 1983; tionship to you? [e.g., parent, stepparent, teacher, neighbor, Beck Depression Inventory: Beck, & Beamesderfer, 1974; Trauma Symp- stranger, etc.]”). For some details, response options were tom Inventory: Briere, Elliott, Harris, & Cotman, 1995) were not signifi- cantly related to memory accuracy or inaccuracy (rs Ͻ |.16|). For a full list presented corresponding to those used for coding informa- of measures at Time 1 and Time 2, please see Goodman et al. (1992) and tion by Goodman et al. (1992), thus allowing for direct Quas et al. (2005) or contact Gail S. Goodman. ACCURACY OF CHILD SEXUAL ABUSE MEMORY 925

involved responses that could be coded as either overreport- collinearity; Cohen, Cohen, West, & Aiken, 2003). Normal- ing (CSA was described as more severe or additional details ity violations of the variables were not indicated (skew and regarding the CSA were included) or underreporting (CSA kurtosis fell between Ϫ1.96 and ϩ1.96). was described as less severe or information regarding the CSA was not included). Memory accuracy was determined Main Analyses by the total proportion of correct or incorrect (overreporting or underreporting) answers, which was calculated by divid- The main hypotheses, which focused on therapy predict- ing the number of correct or incorrect responses by the total ing participants’ CSA memory accuracy, were tested via possible points. From these, three primary dependent mea- linear regression analyses. First, to test the main hypotheses, sures were of interest: proportion of correct answers regard- we entered Time 1 demographic variables (victim age and ing the CSA, proportion of CSA-related overreporting re- SES), followed directly by adding psychological counseling sponses, and proportion of CSA-related underreporting attendance in a second model. However, to evaluate responses. whether psychological counseling was related to memory Four raters, blind to hypotheses, obtained reliability for accuracy, even when other potential predictors were con- coding the interviews. They each independently coded 12% sidered, we reconducted the aforementioned regression but of the participants’ interview responses and obtained reli- added CSA severity, participants’ relationship to the defen- ability for the three dependent variables, as measured by dant, and PTSD criteria met in the second model prior to proportion agreement, ranging from .83 to .99 (M ϭ .93) for including psychological counseling in the third model. This each pair of raters. The remaining 88% of transcripts were second series of regression analyses was conducted sepa- divided among the raters for coding. rately for each of the three dependent variables. In the next sections, each regression series is described in turn per Results dependent variable. However, because five participants were missing PTSD criteria met scores (approximately 10% Preliminary Analyses of the data), the SPSS Multiple Imputation function was used to create 10 imputed data sets for the analyses involv- Means and standard deviations of key variables are pre- ing PTSD criteria met in the next sections. sented in Table 1. Correlations among them are presented in Proportion correct for abuse-related questions. When Table 2. Because neither gender nor ethnicity was signifi- age and SES were entered, the model was statistically signif- cantly related to any of the memory variables of interest, icant (see Table 3). The only significant predictor was partic- they are not considered further. SES, however, was signif- ipants’ Time 1 SES: Higher SES predicted a greater proportion icantly related to proportion correct. It was thus entered, of correct answers to abuse-related questions. When psycho- along with age, in the first model of the regression analyses. logical counseling was added, the model was also significant. Variance inflation factor (VIF) scores among predictors Psychological counseling significantly predicted proportion entered into the same model ranged from 1.00 to 1.15, correct memory of the abuse. indicating that collinearity between variables was not prob- To examine whether psychological counseling remained a lematic (VIF scores larger than 10 typically indicate high significant unique predictor of the proportion of correct

Table 2 Correlation Matrix Among Key Variables of Interest

Variable 1 2 3 4 5 6 7 8 9 10 11 12 This document is copyrighted by the American Psychological Association or one of its allied publishers.

This article is intended solely for the personal use of the1. individual user and isVictim not to be disseminated broadly. age (at police report) — 2. Victim gender .12 — — ءءSocioeconomic status .04 Ϫ.40 .3 4. Minority status Ϫ.06 .12 Ϫ.10 — 5. Abuse severity .03 .11 .004 .08 — — Ϫ.06 Ϫ.08 .05 21. ءءRelationship to perpetrator .36 .6 7. PTSD criteria met .19 .01 .004 Ϫ.14 .05 .03 — 8. Testifying Ϫ.06 Ϫ.12 Ϫ.06 .13 Ϫ.03 Ϫ.11 .16 — 9. Delay from age at reported end of abuse to age — Ϫ.15 .00 ءat Time 2 interview .14 Ϫ.06 .10 Ϫ.02 Ϫ.03 .30 — 04. 09. 05. 06. ءءPsychological counseling attendance Ϫ.21 .03 .07 Ϫ.06 .40 .10 — ءϪ.12 .13 .01 .16 .15 .13 .24 ءءProportion correct abuse questions .16 Ϫ.08 .32 .11 — ءءϪ.60 ءءϪ.06 Ϫ.15 Ϫ.11 Ϫ.32 15. ءءProportion overreporting to abuse questions .07 .15 Ϫ.10 Ϫ.01 Ϫ.33 .12 Ϫ.19 ءءϪ.05 .11 .11 Ϫ.38 ءProportion underreporting to abuse questions Ϫ.19 Ϫ.13 Ϫ.18 .13 .18 Ϫ.22 Ϫ.30 .13 Note. N ϭ 71 except for correlations with PTSD criteria met (N ϭ 66). PTSD ϭ posttraumatic stress disorder. .p Ͻ .01 ءء .p Ͻ .05 ء 926 GOODMAN, GOLDFARB, QUAS, AND LYON

Table 3 Linear Regressions Predicting Proportion Memory Scores for CSA Abuse-Related Questions

Correct Overreporting Underreporting Model and variable bSE␤ 95% CI bSE␤ 95% CI bSE␤ 95% CI

First model Victim age .007 .005 .15 [Ϫ.003, .018] .003 .006 .07 [Ϫ.008, .015] Ϫ.009 .006 Ϫ.19 [Ϫ.020, .002] [Ϫ.001 .001 Ϫ.11 [Ϫ.003, .001] Ϫ.002 .001 Ϫ.18 [Ϫ.004, .001 [005. ,001.] ءءVictim SES .003 .001 .32 R2 .13 .02 .07† 2.47 56. ءF 4.94 Second model [Ϫ.194, Ϫ.027] .03 .05 .09 [Ϫ.057, .121] ءϪ.11 .04 Ϫ.31 [172. ,013.] ءCounseling attendance .09 .04 .26 R2 .19 .11 .08 1.81 †2.74 ءءF 5.30 007. ء09. ءR2 .07⌬ Note. CSA ϭ child sexual abuse; CI ϭ confidence interval; SES ϭ socioeconomic status. .p Ͻ .01 ءء .p Ͻ .05 ء .p Ͻ .10 †

responses when CSA severity, defendant relationship, and icant predictor (ps Ն .221). In the final model, which PTSD criteria met were considered, these variables were included receiving psychological counseling during or added to the demographic variables in a second model; they shortly after the CSA trial, attending psychological coun- were not significant predictors (ps Ն .288). When psycho- seling did not significantly predict abuse-related overreport- logical counseling was added in a third model, the model ing responses (b ϭϪ.08), t(64) ϭϪ1.85, p ϭ .064, 95% CI 2 was significant across all of the imputations (Rs Ն .20), [Ϫ.173, .005]. 2 Fs(6, 64) Ն 2.60, ps Յ .026, ⌬Rs Ն .05, p ϭ .043 (pooled Underreporting responses to abuse-related questions. significance level), with attending counseling predicting There was no statistically significant link between psycho- more correct answers to abuse-related questions (b ϭ .09), logical counseling attendance and underreporting responses, t(68) ϭ 2.02, p ϭ .043, 95% CI [.003, .180]. coded here as Time 2 reporting that the abuse was less Overreporting responses to abuse-related questions. severe than documented at Time 1 or failing to report details The second set of analyses predicted proportion of abuse at Time 2 that were recorded at Time 1. Neither the first overreporting responses (reporting the abuse as more severe model (age and SES) nor the second model (counseling or adding more details at Time 2 than were documented at attendance) was significant (ps Ն .093). Time 1). As shown in Table 3, the first model, with demo- The next set of models considered whether psychological graphics as the predictors, was not significant. The addition counseling predicted abuse-related underreporting re- of psychological counseling approached significance (p ϭ sponses when abuse severity, relationship to the defendant, .05), with counseling attendance significantly negatively and PTSD criteria met were added to the demographic 2 predicting abuse overreporting responses: Participants who variables. The model (Rs Ն .20), Fs(5, 65) Ն 3.17, ps Յ 2 received therapeutic intervention (compared to those who .013, and the amount of variance explained (⌬Rs Ն .13, did not) reported fewer additional details about the abuse at ps Յ .021) were both significant. Relationship to the defen- Time 2 than at Time 1. dant and abuse severity were not significant predictors The analyses then considered whether controlling for (ps Ն .080). PTSD criteria met, however, significantly abuse severity, relationship to the defendant, and PTSD predicted less under reporting (b ϭϪ.02), t(64) ϭϪ2.33, This document is copyrighted by the American Psychological Association or one of its alliedcriteria publishers. met affected the relation between psychological p ϭ .020, 95% CI [Ϫ.043, Ϫ.004]. In the final model, This article is intended solely for the personal use ofcounseling the individual user and is not to be disseminated broadly. and proportion of overreporting responses (i.e., psychological counseling was not a significant predictor the report at Time 2 of additional details or that the abuse as (p ϭ .599). more severe than was documented at Time 1) to abuse- Interaction of age and psychological counseling. related questions. Although addition of these variables cap- Given research showing that preschoolers are more suggest- 2 tured more of the variance (⌬Rs Ն .13, ps Յ .025), the ible, at least under certain circumstances, than are older model itself was significant in only one imputation (p ϭ children, it is possible that younger participants would be 2 .046); there was a trend for the rest (Rs Ն .15), Fs(5, 65) Ͼ more susceptible to underreporting or overreporting re- 2.25, ps ϭ .056 to .060. Abuse severity was a significant sponses in memory due to therapy attendance. To test for predictor (b ϭϪ.03), t(65) ϭϪ2.95, p ϭ .003, 95% CI this possibility, a third model was added including the [Ϫ.052, Ϫ.011]. More severe abuse predicted fewer abuse- interaction between psychological counseling and Time 1 related overreporting responses. Neither number of PTSD age (with demographics entered in the first model and criteria met nor relationship to the perpetrator was a signif- counseling added in the second model). The third model ACCURACY OF CHILD SEXUAL ABUSE MEMORY 927

(with the interaction term) did not significantly account for Finally, the same analyses were considered but for un- additional variance (ps Ն .285), and the interaction term derreporting responses about abuse-related information. was not significant for any of the three dependent variables The models were not significant ps Ն .187. (proportion correct, proportion overreporting, and propor- Testifying at trial. Children who testified in their crim- tion underreporting). Thus, it did not appear that partici- inal case may have additional opportunities to rehearse the pants who were younger at the time of psychological coun- alleged CSA memories. To ensure that these individuals seling evidenced a different pattern of results than did were not driving the relation between therapy and accuracy participants who were older. of memory, we conducted a new set of analyses: with age at the time of the police report and SES entered as predictors in the first model, whether the child testified in the CSA Additional Analyses legal proceedings added to the second model, and whether the child received psychological counseling added to the The main analyses just presented focused on the role that third model. Including testifying did not significantly ex- psychological counseling played in victims’ long-term plain more of the variance for any of the dependent vari- memory for documented CSA. Although the expected as- ables, proportion correct, overreporting responses, or under- sociations were found, multiple factors contribute to long- reporting responses (ps Ն .128). After we controlled for term memory. The unique nature of the data set permitted testifying, psychological counseling significantly positively examination of several other potential factors that could predicted proportion correct (b ϭ .09), t(66) ϭ 2.21, p ϭ affect the interpretation of the findings. Specifically, the .031, 95% CI [.008, .167], and negatively predicted over- three factors were: the presence of corroborative evidence to reporting responses (b ϭϪ.11), t(66) ϭϪ2.55, p ϭ .013, support the CSA allegation, whether or not children testified 95% CI [Ϫ.190, Ϫ.023]. Psychological counseling did not, during the prosecution, and the delay between the reported however, significantly predict underreporting responses end of the CSA and the participants’ Time 2 memory (b ϭ .04), t(66) ϭ 0.77, p ϭ .443, 95% CI [Ϫ.055, .125]. interview. Thus, children who testified during the prosecution were not Corroborative evidence. Given the findings just pre- driving the previously mentioned positive relations between sented, analyses were conducted to determine whether the counseling and memory accuracy. key results held when only cases with corroborative evi- Delay. To examine whether delay also explained the dence of the sexual abuse were considered. Because cor- primary findings, we tested another set of models that roborative evidence adds support for the victim’s recollec- included Time 1 age and SES in the first model, delay tion at Time 2, this provided a more stringent test of the (number of years between the reported end of the CSA and hypotheses. the memory interview at Time 2) in the second model, and For predicting proportion correct, the first model was psychological counseling attendance in the third model. significant (R2 ϭ .19), F(2, 41) ϭ 4.79, p ϭ .013. In this Delay was not a significant predictor for any of the three first model, participants’ Time 1 SES (b ϭ .003), t(41) ϭ dependent variables (proportion correct, proportion overre- Ն 2.68, p ϭ .011, 95% CI [.001, .006], significantly predicted porting, and proportion underreporting; ps .173). Further, correct responses. The second model, with the addition of counseling attendance significantly predicted proportion correct (b ϭ .09), t(66) ϭ 2.27, p ϭ .027, 95% CI [.011, counseling, was significant (R2 ϭ .27), F(3, 40) ϭ 4.85, p ϭ .171], and inversely predicted proportion overreporting .006, ⌬R2 ϭ .08, p ϭ .047. Receiving counseling was a (b ϭϪ.11), t(66) ϭϪ2.59, p ϭ .012, 95% CI significant predictor of accuracy for the corroborated cases [Ϫ.192, Ϫ.025], although for the model, there was only a (b ϭ .10), t(40) ϭ 2.05, p ϭ .047, 95% CI [.001, .188]. trend (p ϭ .080). Psychological counseling was not a sig- This document is copyrighted by the American Psychological Association or one of its allied publishers. When the relation between overreporting responses and psy- nificant predictor of proportion underreporting (p ϭ .522). This article is intended solely for the personal use ofchological the individual user and is not to be disseminated broadly. counseling for only the corroborated cases was considered, the first model was not statistically significant (R2 ϭ .05), F(2, 41) ϭ 1.12, p ϭ .337. The second model, with Discussion 2 ϭ the inclusion of counseling, was significant (R .19), F(3, This article addresses an ongoing debate about the effects ϭ ϭ ⌬ 2 ϭ ϭ 40) 3.19, p .034, R .14, p .012, with attending of psychological counseling on CSA victims’ memory. As therapy significantly negatively predicting overreporting re- predicted, psychological counseling was positively associ- sponses to abuse-related questions (b ϭϪ.13), t(40) ϭϪ2.65, ated with long-term memory accuracy; specifically, the data p ϭ .012, 95% CI [Ϫ.228, Ϫ.030]. Thus, even when consid- reveal that attending counseling was predictive of a higher ering only the corroborated cases, individuals who received proportion of correct responses about abuse-related infor- therapeutic services were less likely to add new details or mation. Stated another way, individuals who received psy- report the abuse as more severe at Time 2 compared to the chological counseling, such as therapy, at Time 1 generally evidence at Time 1. had better memory at Time 2 for the earlier CSA-related 928 GOODMAN, GOLDFARB, QUAS, AND LYON

experiences. Further, despite concerns that therapy may lead counseling received, the length of the counseling, or the to increased , the analyses did not support this therapists’ training, which anecdotally varied considerably relation; therapeutic intervention was not associated with (e.g., religion-oriented therapists, clinical social workers, increased under- or overreporting responses, even for the PhD psychologists, and MD psychiatrists). Data on such participants who at Time 1 were younger children. In fact, factors could provide important insights into the mecha- psychological counseling negatively predicted overreport- nisms involved. ing (e.g., for corroborated cases). Even after statistically Of interest, therapy attendance predicted decreased over- controlling for age, SES, abuse severity, relationship to the reporting responses. This relation, however, was not signif- defendant, PTSD criteria met, testifying during the CSA icant when severity of the CSA at Time 1 was statistically prosecution, and delay since the end of the CSA to the controlled, because participants who experienced more se- memory test, and even after testing the Age ϫ Psycholog- vere abuse reported fewer overreporting responses (e.g., ical Counseling interaction, as well as examining corro- fewer additional CSA details) at Time 2. Increased abuse borated cases, therapy still uniquely predicted increased severity may have led to more robust of the event correct memory report and did not predict increased over- because of the emotionality of the CSA experience (Bower reporting or underreporting responses. & Sivers, 1998; Goodman et al., 2003), and participants There are a number of potential reasons why psycholog- with more severe CSA may have chosen to attend therapy ical counseling would be related to increased correct mem- longer. That said, therapy attendance did significantly pre- ory of the CSA years later. First, therapeutic conversations dict decreased overreporting responses for corroborated regarding the CSA experience itself and/or the CSA prose- cases, which is a particularly stringent test of the hypothesis. cution would have enabled rehearsal of the CSA details and It should be mentioned, however, that severity ratings might have also led to a more coherent narrative and greater were based, in part, on participants’ reports regarding the understanding of what occurred, all of which then could CSA at Time 1. Thus, severity was partially driven by have sustained participants’ memory accuracy over time participants’ willingness to disclose the extent of the abuse. (Nadel et al., 2007). The likelihood of therapeutic discus- It may be that participants who had more severe cases were sion of the CSA and legal case is supported by the fact that also those who had already fully disclosed many if not all of participants’ therapy attendance was measured during or the details at Time 1. shortly after the CSA prosecution, which increased the It was of interest that Time 1 age was not a significant likelihood that therapeutic discussions focused around the predictor of memory accuracy, even though children, across prosecution and the victimization. Theoretical mechanisms the wide age range tested (3Ϫ16 years old), typically show behind the relation of psychological counseling and accu- dramatic age differences in memory performance. That the rate memory could be investigated in the future by analyz- Age ϫ Psychological Counseling interaction was also a ing the content of participants’ clinical discussions. Consid- nonsignificant predictor of memory accuracy may be due to eration of both the timing and content of counseling, the personal significance of the CSA experiences, resulting including the quality of discussion, and whether these fac- tors relate to memory, will help clinicians better understand in equally robust memory regardless of age for the type of the parts of their practice that enable later accurate memory information tapped by the questions. SES, however, signif- retrieval without increasing memory errors. icantly predicted accuracy and deserves further study (e.g., Furthermore, therapy may have been related to decreased Chae, Kulkofsky, Debaran, Wang, & Hart, 2016). symptomology that, in turn, increased memory of the pre- sumably traumatic event. Certain symptoms are thought to Limitations decrease memory accuracy as individuals distance them- This document is copyrighted by the American Psychological Association or one of its alliedselves publishers. from the traumatic experience (Briere & Conte, 1993; Of note, the memory responses from Time 2 in the This article is intended solely for the personal use ofWilliams the individual user and is not to be disseminated broadly. & Broadbent, 1986). If a reduction in symptom- present study were only as accurate as the original docu- ology due to therapy were driving the findings, one would mentation. Participants may have provided inaccurate infor- expect the inclusion of indices of current psychopathology mation when asked about their CSA and abuse-related ex- to result in psychological counseling’s being nonsignificant. periences at Time 1. This is especially plausible for Here, statistically controlling for whether a current index of information that could not be objectively verified (e.g., trauma-related psychopathology symptoms (PTSD criteria through police reports, court documents). However, the met) explained therapy’s relation to memory accuracy, we models’ significance held even when only corroborated found that it did not. PTSD criteria met was our only Time cases were considered. Thus, to the extent that corrobora- 1 or Time 2 measure of psychopathology that correlated tion is support for the veracity of children’s statements at with Time 2 memory performance. However, systematic Time 1, this is further evidence bolstering Time 1 psycho- information was not available on the exact reason why the logical counseling’s relation to more accurate memory at child victims were in therapy, the type of psychological Time 2. ACCURACY OF CHILD SEXUAL ABUSE MEMORY 929

The interpretation of the analysis is limited here in that chronicity (single or repeated episodes), and abuse duration the participants were all alleged victims of CSA (some (length of time) are theoretically separable, and each may without physical documentation of the acts), and as such, have different effects on memory. That said, it is problem- this study was unable to include analyses of the relation atic to have confidence in some of these potentially impor- between counseling and false reports of victimization. Fur- tant variables because children may experience difficulty ther, all of the cases here were prosecution cases and not reporting them (e.g., chronicity, duration). examples of where participants as adults allegedly recov- Finally, the sample size may not have been large enough ered in therapy a lost memory of prior abuse (Bottoms et al., to detect small effects of psychological counseling on later 1996; Loftus, 1993). Although psychological counseling memory reports. This may have particularly been the case during the pendency of the prosecution or shortly thereafter for the analyses of corroborated cases. That said, the unique was not associated with an increase in overreporting re- nature of the data, including having documentation of par- sponses (reporting additional details or greater abuse sever- ticipants’ counseling attendance at Time 1 (rather than ity) or underreporting responses (downplaying severity or retrospective reports), allows for important insight into the withholding details regarding the abuse) by these victims issue of whether child victims should be made to wait to over a decade later, whether—and if so under what condi- receive therapeutic intervention during a prosecution out of tions—therapy attendance, on average, would increase the fear that it will degrade or distort their memory for the rate of false reports of maltreatment is still an unanswered abusive event. question. Future work should consider whether any cur- rently used therapeutic techniques would lead to such an Conclusion increase. Given that the Time 1 data on attending psycho- This study provides evidence relevant to the debate over logical counseling services were obtained in the 1980s, it is therapy’s relation to the accuracy of memory for CSA, worth noting that mental health services may have changed including in historic abuse cases when victims provide in important ways since then, possibly leading to different memory reports of decades-old sexual assaults. The data, results than presented here. albeit correlational, support the contention that therapy does The nature of the memory at issue in the study is long- not hurt and, indeed, may help victims’ accurate recollec- term recollection of CSA. Participants were asked to de- tion of prior traumatic events. This assumes, however, that scribe maltreatment that occurred to them over a decade the therapeutic techniques are not ones associated with false prior (16 years or more in some cases). These data are thus memory formation or other memory errors in vulnerable most informative for cases in which adults are asked to children (e.g., Bottoms et al., 1996; Melinder et al., 2010). testify regarding abuse that happened during their childhood Under that assumption, the findings have significant impli- (e.g., historic CSA cases). This study does not reveal the cations for psychological theory relevant to understanding effect of psychological counseling on children’s memory long-term memory of childhood trauma and for the legal accuracy while therapy is ongoing. In other words, does system and clinical practice. In addition to potentially pro- psychological counseling have a different effect when chil- viding emotional benefits, psychological therapy may pre- dren are interviewed a month or two after counseling has dict better long-term memory of abuse-related experiences. started from when counseling and the event occurred years In terms of application, this evidence may make legal au- prior? This is an important and vital question for future thorities less hesitant to refer victims to psychological coun- work. seling, perhaps especially in corroborated cases. The find- The study is correlational, and thus causal inference must ings may also encourage more children to seek needed be drawn with caution. A true experiment would require therapy for sexual abuse experienced in childhood (Turner random assignment to psychological counseling compared

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W., Edelstein, R., Revision received November 14, 2017 Redlich, A. D.,...Jones, D. P. H. (2005). Childhood sexual assault Accepted November 14, 2017 Ⅲ This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.