10/09/03

Teenagers Rebel

James Le Fanu

Daily Telegraph

It doesn't mean they were sexually abused.

The child psychiatrist Dr John Eastgate may have been cleared of professional misconduct by the GMC, but the account of how a troubled teenager came to believe she had been sexually abused, first by an eminent doctor and then by three others - including her father - sent shivers down the spine.

The significance of the GMC's ruling extends far beyond its likely effect on Dr Eastgate's future as a psychiatrist - and ends up touching everybody's lives. During the proceedings, professorial colleagues from Great Ormond Street Hospital and the Tavistock Clinic argued that his conduct fell within the boundaries of legitimate clinical practice.

And if that is what they believe, it raises disturbing questions about mainstream NHS psychiatric practice. These issues have so far been concealed from public view and so require some clarification.

The worst parental nightmare must be that a much loved and loving child should, on reaching adolescence, suddenly go off the rails. It can, as many parents know only too well, happen to anyone. These can be difficult times when the instinctive desire to rebel against parental authority produces an evasive and hostile pattern of behaviour that, in technical jargon, is known as the "adolescent adjustment reaction".

Most parents, with patience and perseverance, somehow manage to ride it out in the hope that, sooner or later, their child's behaviour will improve. But when such problems are compounded by others - eating disorders, drug abuse or self-harm, there is little alternative than to seek professional psychiatric help.

There is initially a honeymoon period, with the reassurance of feeling that one's child is in safe hands and receiving appropriate treatment. But the hoped-for improvement does not materialise. The families may learn instead that their daughter has been sexually abused and that this serious allegation has already been acted on without their knowledge. Worse still, they find the focus of accusation shifting to themselves. Their ordeal has begun.

That, in brief outline, was the sequence of events immediately following Miss A's admission to Dr Eastgate's unit. Over the following months, her mental and physical condition continued to deteriorate. Her father, whom she had wildly accused of sexual abuse, along with two others, was served with a court order preventing any contact with his daughter.

Repeated attempts at obtaining a second opinion or transfer to another unit were denied. Miss A was eventually taken into foster care, after which she made a rapid recovery before finally being reunited with her family after three-and-a-half years, acknowledging that all her allegations had been unfounded.

The GMC's disciplinary committee then found that Dr Eastgate's conduct in the interview with Miss A "was inappropriate and unprofessional because it was likely immediately to strengthen her impression that she might have been improperly touched at medical examination". The judgment, furthermore, brought to public attention just how common the subsequent pattern of events turned out to be.

Late last year, forensic examiner and consultant gynaecologist Mary Pillai, writing in the journal Medicine, Science and Law, reported no fewer than 17 similar cases from adolescents' psychiatric units across the country. In every instance she gives, there was no corroborative evidence of the child's allegations, and, while "a robust alternative explanation" was available, it was not pursued.

"The ramifications were widespread harm to all involved," she concludes, "but the falsely believed teenagers suffered the most, with a dramatic deterioration in their mental condition. The cases with the worst prognosis were those where all contact with the family had been severed."

The notion that psychiatrists can view with equanimity this chilling pattern of events, seeing it as part of the therapeutic process, seems too incredible to be true. But, as psychiatrist Janet Bokes of St George's Hospital in London points out, it is an almost inevitable consequence of a very influential "belief system" that has come to permeate psychiatric thinking.

The first priority in psychiatry - as in medicine generally - is to try to define what might be the cause of the child's problem if there is to be any hope of treating it effectively. This is not easy, as many factors may be involved, not only family tensions and surging hormones, but also depression, hypomania or some other form of mental illness. Not surprisingly, the process of sorting it out can be complex, requiring considerable experience in clinical judgment.

But then, about 15 years ago, some psychiatrists started to claim that the fundamental cause of teenagers' psychiatric problems was actually much more straightforward than had previously been supposed - it had just been ignored or overlooked. They had been sexually abused.

They may have been reluctant to disclose this or may even have forgotten about it altogether, but whatever the problem - perhaps an eating disorder such as anorexia or repeated attempts at self-harm - the chances were that sexual abuse lay at the heart of it.

And if that was the case, then clearly every attempt had to be made to encourage the patient to disclose the identity of the abuser. Only then, as Dr Bokes describes, do the protagonists of this false "belief system" maintain that it becomes possible to "free the patient from the pathologising effect of their past, so that they can lose their symptoms and move forward".

But that, as has been noted, is precisely what may not happen. The teenager's mental condition can deteriorate and, in the process, the child can be estranged from the only disinterested source of support in her distress - her family. This process is further compounded by the adversarial legal proceedings and the police investigations of the allegations which so undermine the parents' morale that they, too, become seriously mentally distressed.

The person who emerges with most credit from this saga is Miss A's father, a doughty opponent who, at considerable personal and financial cost to himself, overcame the many obstacles placed in his path, before finally bringing Dr Eastgate to the GMC's council chamber. It must be hoped that this case might inspire the medical profession to bring the litany of false belief cases to a belated end.