The untreatable family

The untreatable family is defined as one in which it is unsafe to permit an abused child to live. Despite the fact that many families turn out to be resistive to treatment, they have received very little attention. In the field of physical abuse, 16-60% of parents reabuse their children following the initial incident. Sexual reabuse is estimated to occur in 16% of cases. Treatment of abusive families also aims to alter family functioning. From studies in physical abuse we find 20-87% of families are unchanged or worse at the end of treatment. In sexual abuse the equivalent figures are 16-38%. Parental factors associated with a poor outcome include parental history of severe childhood abuse, persistent denial of abusive behavior, refusal to accept help, severe personality disorder, mental handicap complicated by personality disorder, parental psychosis with delusions involving the child, and alcohol/drug abuse. Parents lack empathy for their child and fail to see the child's needs as separate from their own. Severe forms of abuse (fractures, burns, scalds, premeditated infliction of pain, vaginal intercourse or sexual sadism) are more likely to prove untreatable. Munchausen by proxy, nonaccidental poisoning, and severe forms of nonorganic failure to thrive are similarly resistant. An early recognition of untreatability may help to reduce burnout by diverting precious resources from the untreatable to the families for whom there is relatively more hope.