Historical Abuse Claims and the Future of Psychiatry Practice.
When I left clinical practice in 2022 and moved into medicolegal practice, I was riding the wave of an increased need for medicolegal services, but also the wave of survivors of historical sexual abuse who were coming forward and required assessments related to the damages sustained by historical abuse.
Psychiatrists in all areas of clinical practice have treated people who have experienced some form of abuse in childhood, whether it be by a family member or a member of their community. I noticed during my years of clinical practice that people with these experiences would often present in crisis, probably attributing the precipitant to some other event rather than reveal a history of abuse to a stranger in a busy emergency department, when their ability to survive often relied on them burying the past.
My private practice of over 10 years looked after many victims of childhood abuse, and I often felt helpless when it came to actually providing relief of the related suffering, and inappropriate shame. My role was to be a consistent presence in their life, and help them navigate relationships and incidents that were difficult for them because of inherent problems they had developed as a result of abuse. A common predicament for my patients was the inability to trust others and a need to be independent at all costs, falling badly when they perceived they had been let down or taken advantage of by others. Many took a very long time to learn to trust me, with a lot of testing of that, but eventually they had a corrective experience of forming trust which they could apply to their own relationships. I also supported many survivors of childhood sexual abuse who were retraumatised as they listened to or read about the Royal Commission into Institutional Responses to Childhood Sexual Abuse. Many clinicans cared for patients who provided submissions to the Inquiry, in some cases providing emergency care as they questioned whether they could continue living.
In some of my patients who came to see me weekly or fortnightly, I presumed abuse had occured but the details were not revealed for months or years. It has only been of recent times that we have learnt more and more about the role of trauma in the aetiology of human suffering, and adopted principles aligned with trauma informed care. Previously, many patients were treated for the symptoms they were presenting with, such as low mood or panic attacks without me understanding the bigger picture. Once the abuse was disclosed, the work changed direction. In some cases only myself and the perpetrator were aware that the abuse had occured, with husbands, children or parents never knowing.
I had a limited repertoire when it came to helping my patients who had been abused. I had medication options to mitigate some symptoms, and I had some experience with psychotherapies. If I had remained in private practice I would have undergone more specialist training in treatments such as eye movement, desensitisation and reprocessing (EMDR) therapy, something I referred some of my patients out for with great effect.
I experienced many patients with a longstanding history of abuse be misdiagnosed with conditions such as schizoaffective disorder, having intrusive thoughts, images or flashbacks wrongly diagnosed as auditory hallucinations, and being prescribed antipsychotics such as clozapine, or undergoing electroconvulsive therapy (ECT). All of this is made more complicated by the fact that victims of abuse rarely tell others, including treating doctors, for fear of judgement and because of shame. And because sometimes the experience of abuse in the early developmental years can have such catastrophic consequences on the development of self and identity, and can lead to what appears to be psychosis.
When I cared for a patient with a history of abuse, my role was to be the staunch advocate, the believer of their truth, and the person that would help them try and recover. My role of independent medical examiner in these cases with the same people is vastly different to this. I have had to retrain myself and receive supervision about this as it doesn’t come naturally after years of clinical training and experience.
Nowadays, I respect that my role an an independent medicolegal examiner is solely to the Court and the legal process, and I am bound by respective Codes such as the Expert Witness Code of Conduct. At all times I maintain my independent stance, and ask questions in a two hour sitting that I would probably take months to ask in a clinical one. I have to be able to defend my report in court should the need arise. There is no room for confidentiality in the court room but my medicolegal practice must adhere to principles of privacy and confidentiality with regards the assessment process. I need to obtain informed consent but in a different way than I did in clincial practice, and I must balance the process with the principles of doing no harm.
Nowadays, I use my psychiatry skills and experience to take a thorough history and diagnose psychiatric conditions based on an account of symptomotology. I am asked questions posed by the examinee’s lawyer in their Letter of Instruction that involve not only details of what is referred to as “the subject abuse” but how the effects of the subject abuse may have caused conseqences in their life. I take an extensive history about their employment and career progression, their education, relationships, problems with substance abuse or offending behaviour. I have to establish enough rapport that the examinee is able to disclose the details required for the report without appearing too empathic or be seen to be leading them. I cannot provide details of recommended treatment directly to the examinee although this is often one of the questions in the report.
My work in historical sexual abuse cases is expanding as I gather experience in this field, at the same time that there have been developments in the High Court of Australia. These developments involve two cases where the the decision for a “Permanent Stay of Proceedings” were overturned. Since the Royal Commision into Institutional Resonses to Childhood Sexual Abuse delivered its findings in Decemebr 2017, some institutions have applied for and received permanent stays for claims against alleged perpetrators, meaning that victims could not proceed with their claims. It is believed that with the overturning in these two cases, precendents will mean victims who have been obstructed will now proceed with claims for redress.
Although this work lies within the legal profession, the field of psychiatiry has a much deserved and valuable place. Psychiatry experts will be required to meet the demand for independent medical assessments that not only determine if psychiatric injury followed the subject abuse, but also the apportionment of the subject abuse on the development of the psychiatric injuries. Expert witnesses who are psychiatrists will be called upon more often to appear in Court and answer questions about the effects of the subject abuse on the victim, and the material costs required to provide clincial care to effect recovery. Psychiatrists, with unique skills in formulation and phenomenology will be able to assist the Court with understanding why some victims have led the lives they have, or have made certain decisions over time. There is a huge opportunity to inform the legal fraternity about why victims take so long to come forward, or why they have gaps in recollection of details of the subject abuse, due to the inherent nature of how traumatic memories are formed.
It is a challenging and rewarding time to be a psychiatist with years of clinical experience that can now be used to prepare reports as part of redress schemes and in independent civil matters. A time to reflect that by being able to prepare a report and have the skills required to draw upon and synthesise critical facts in the assessment history and related documents, and then prepare that for legal proceedings, may just provide for some the closure and the validation they seek, but can elude them even with years of therapy.
Dr Helen Schultz is a consultant psychiatrist, medicolegal expert and professional writer. She specialises in the area of abuse law and has a medicolegal practice in Collins St, Melbourne and online. She has particular experience with examinees who are incarcerated, and also provides assessments for victims of historical forced adoption schemes. Dr Helen Schultz is the founder and director of CPD Formulations Pty Ltd, creating and developing niche medical education programs for professionals. For more information, contact her assistant, Courtney Murray at courtney@truebusinessco.com.au.
