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The Role of the Forensic Psychiatrist

Richard C. W. Hall, M.D.
Courtesy Clinical Professor of Psychiatry
University of Florida, Gainesville

Ryan C. W. Hall
Second-year Medical Student
Georgetown University School of Medicine

As forensic psychiatrists, we are often asked to see and evaluate individuals to determine if the nature of the allegations that they are making against others, particularly health care providers and persons in authority, are valid and accurate. The more heinous the allegation, the more serious the subsequent investigation is likely to be. Allegations based on sexual misconduct, physical violence, or child abuse carry a particularly charged quality. The sensational nature of these charges is often unsettling and touches on underlying emotional issues in both the examiner and the accused.1, 2 Professional review boards and medical ethics and review committees are often polarized and respond to personally-held biases and beliefs. The concepts of "where there's smoke, there's fire" and there has to be "at least a grain of truth" in every allegation are often evoked to further justify elaborate and extensive investigations, which can place the accused in the unfortunate and impossible position of trying to disprove a negative. As Chairman of a state Ethics Committee, we have reviewed many allegations that are patently preposterous. There is rarely difficulty in dealing with complaints of abductions by aliens or physicians employed by the KGB. Conversely, investigative, feminist, and religious passions are regularly raised by any hint that a healthcare provider has been sexually, interpersonally, or socially inappropriate with a patient. Charges of child abuse, incest and sexual misconduct by police are other allegations that psychiatrists are frequently called upon to evaluate. Several authors have reviewed specific types of false complaints.3-8

In 1994, Kimberly Mays (who had been switched at birth) accused the man who had raised her of sexual abuse. She made the allegation after meeting her biological parents. The local and national press was filled for months with reports that this troubled young woman had subsequently disowned her biological family, then that she abruptly moved in with them, telling authorities that she had been abused since age seven by the man who had raised her. Later, she reported she made the whole story up and that her charges against her father were false.9 This case may well represent a troubled young woman's attempt to establish boundaries and to seek attention through the public media.

In an interesting letter written to Robert Wallace's Talking With Teens column, a teenager wrote "Dear Dr. Wallace: I need your advice -- and make it fast. My best friend hates her stepfather. About a month ago, she told me she was going to tell the police that he molested her sexually even though it wasn't true. Well, last week she did just that and has caused a big stink. Her stepfather had to hire a lawyer to defend himself even though he was 100% innocent. He was also tossed out of their house by my friend's mom. The main reason she hates her stepfather is that he made her break up with her 19-year-old boyfriend. My friend is 14. The only people who know that this man is innocent is my friend, her boyfriend, who also hates him, and me. So that means I am the only one who can save him. What should I do? I really don't want to lose my best friend, and if I speak the truth, I know that she will never talk to me again." Dr. Wallace advised the teen to talk to her parents and let them know that her best friend was lying and that the stepfather never molested her. He suggested that her parents then talk to the mother and contact the police.10 This case illustrates revenge as a motive for making a false allegation.

The Ramona case 11,12 deals with the "cottage industry" of false sexual complaints, as does the McMartin Preschool case. It illustrates the risks therapists face when taking controversial adversarial positions, which grant credibility to unsubstantiated allegations in the guise of "therapy." Holly Ramona, a young woman in psychotherapy, exhibited what her therapist felt were telltale symptoms of sexual abuse. She reportedly dreamed of a snake crawling up her vagina, refused gynecological examinations, and feared men with "pointy canine teeth" -- the kind of teeth that reminded her of her father, who she had accused of sexually abusing her. She reported an aversion to whole bananas, melted cheese and mayonnaise -- items, it was claimed, that reflected her trauma over having to perform oral sex on her father. When the case went to court, a Napa, California jury felt that the culprit was not the father, but rather two therapists who helped Holly "remember" this alleged abuse.

The patient's father, Gary Ramona, a respected industrialist, charged that therapists had planted ideas of abuse in Holly's already-unstable mind and in the process ruined his life. The case became a landmark and "struck a blow against the increasingly controversial techniques of recovered-memory therapy." Courtroom testimony illustrated an unusual pattern of events that led to the allegations against Mr. Ramona. Holly had suffered from bulimia and her counselor advised the mother that 80% of all bulimic cases are caused by childhood sexual abuse, an unfounded and untrue statement. Holly began having "flashbacks" after being in therapy for several months. She was then given sodium amytal to help her remember specific details of sexual molestation. Holly accused her father of raping her and when Holly's mother found out about this, she served the father with divorce papers. The rumors of abuse resulted in serious damage to Mr. Ramona's reputation. The jury awarded Mr. Ramona $500,000 in damages. The jury foreman commented, "We felt that there was nothing done [by the therapists] that was malicious. It was more a case of negligence."

Several years ago, our office had occasion to see a young woman, at the request of her father, who was emotionally distraught because her high school teacher had "fingered her." In talking with the young girl, she broke into tears and reported that her current situation had gotten totally out of hand. She had failed one of her high school courses and when confronted by her father over her poor grades she told him that she had failed because the teacher had it in for her because he attempted to "finger" her and she refused. The father became enraged, called his boyhood friend, the Sheriff, and had his daughter file charges of sexual assault. The teacher was arrested. The local newspaper prominently featured the story. We subsequently learned that even the teacher's wife was unsure that he did not actually commit this act. Although he vehemently denied any inappropriate contact with the young woman, it was a matter of his word vs. hers as there was no physical evidence. In interviewing the child, she reported that her father's anger at her failed grade took her by surprise and "that was the first thing that came to my mind." After making the allegation, she felt trapped and was unable to withdraw it. We called both the Sheriff and the father, with the girl's knowledge and permission, and charges were subsequently dropped, but the teacher's standing and career in the community were adversely affected. He and his wife ultimately sold their home and moved to another state. This young woman made a protective false allegation to protect herself.

On another occasion, we talked with a young borderline woman, who reported that she had made allegations to her county medical society that her psychiatrist had been sexually inappropriate with her. She reported that she was angry at him, that he had not given her the attention that she wanted, and that she made up the charges to get even. Although she candidly reported that he had never touched her, she said that she "was sure that he wanted to." Her physician was subjected to a lengthy series of hearings, but the accuser left the state prior to the conclusion of any formalized complaint. The charges were dropped when she refused to further pursue them or attend a hearing to tell her story. The doctor had clearly been made to "pay the price" for not meeting her narcissistic and borderline needs for attention and recognition.

Meadow13 reports on 14 children from seven families where false allegations of sexual abuse were made by an emotionally disturbed mother. Twelve of the 14 children were alleged to have incurred sexual abuse, one both sexual and physical abuse, and one physical abuse alone. Thirteen of these children had incurred or were currently victims of factitious abuse that had been invented by the mother. The one child with no factitious illness abuse has a sibling that had incurred definite factitious illness abuse. These were all cases of Munchausen syndrome by proxy. The ages of the children ranged from three to nine. The mother was the source of the false allegations and was the person who encouraged or taught six of the children to substantiate the allegations of abuse.

All these cases emphasize the need for psychiatrists evaluating such charges to keep an open mind and to realize that false allegations do occur and are, in fact, common. Myers14 notes that 45% of allegations of sexual abuse in the U.S. are totally unsubstantiated. Forensic psychiatrists and psychiatric clinicians in general need to remain vigilant to the fact that, although allegations may be genuine in many cases, in an almost equal number of cases, if Myers' data can be believed, they are not. This is particularly true when they emerge in the context of an angry doctor/patient relationship, an ugly divorce, an angry child custody case, or a situation where a patient with a significant personality disorder is confronting a legal authority.

False allegations of abuse occur in a variety of contexts; the most frequent being 1) disputed and ugly divorce cases; 2) in custody disputes involving children; 3) by angry borderline patients; 4) by patients with Munchausen's syndrome by proxy; 5) by psychopaths against authority figures; 6) by inadequate patients with strong needs for recognition and attention; 7) by patients with personality disorders; 8) by substance abusers, particularly alcoholics; 9) by patients with paranoid psychoses; 10) by patients with paranoid personality; 11) by patient with "multiple personalities"15; 12) by passive patients urged to file complaints by their therapists to meet the unspoken needs of the therapist.

Knight16 notes that "the fact is that a significant proportion of allegations of rape and indecent assault reported to the police are found to be untrue. This is often hotly denied by women's groups, but is an indisputable fact, proven by many subsequent admissions by girls that no such attack took place." "However, against this is the equally true fact that only a minority of real sexual assaults are reported to authorities."

When evaluating these allegations, the forensic psychiatrist must remain impartial, be aware of their own gender biases, and resist pressure by other members of the team who may have their own agendas to avenge some social wrongdoing or who identify too strongly with the accuser. They should respond methodically and cautiously. In the absence of positive forensic proof, the allegations must be looked at carefully and impartially. Conclusions should be reached only after carefully reviewing all objective facts and after a detailed history and examination. The accused should be given the benefit of doubt as it is almost impossible to disprove a negative.

False accusations are most likely to occur in the context noted above. Where clear-cut revenge is a motive, where patients are psychotic or delusional, or where the allegations occur at a time when the accuser is intoxicated with alcohol or drugs, particular caution should be exercised. If there is a history of repetitive allegations made against many figures in the past, the index of suspicion should go up. One must also consider the timing of allegations, particularly date rape, where a female sees a boy regularly, dates for several months, gives consent for intercourse, and then later makes accusations of rape or sexual misbehavior when the relationship ends. The investigator must always be cautious of a patient's desire for revenge or mischief.

The use of regressive technique, inferences about early sexual trauma from dreams or symptoms, such as gastrointestinal complaints, and the use of nonstandardized "psychiatric tests," such as figure drawing, to support allegations should be discouraged. The amount of harm that can be done by failure to obtain a full and complete history is evidenced by the following case.

A university professor was accused of attempting to impose sexual activity on a coed with threats that should she fail to satisfy him sexually, she would receive a failing mark in his class. The coed also alleged that he had fondled her and called her repetitively at her home. Her charges were initially quite creditable and were taken seriously by the university. The professor was placed on administrative leave. The young woman gave elaborate details. Toward the end of her evaluation, she reported that she was distressed that one cannot trust teachers as they "always do this sort of thing." When questioned as to whether this had ever occurred before, she reported that she had been sexually accosted by both the principal of her high school and a band director. In addition, several years earlier she had made charges that she had been raped by a sailor on leave. The probability that this same young woman would be the victim of four sexual assaults within such a short period of time led to a careful inquiry of the previous cases. Her allegations had caused considerable harm to all of the individuals so accused and we subsequently learned from her parents that they were aware that the allegations that she had made against the high school principal and the band director were unfounded and that the parents also suspected consequently that her initial complaint of having been raped by a sailor was an attention-seeking device. When this information was made available to the university, the charges against the professor were dropped.

In another case, a police officer was accused of attempting to drag an intoxicated woman into the woods to have sex with her. On careful inquiry, she reported a similar situation had occurred in a remote state under similar circumstances when she had been stopped by a highway patrolman for driving while intoxicated and speeding. The fact that there had been two allegations made under almost identical circumstances when she had been apprehended and was being charged with DUI raised questions as to the credibility of her statements.

The forensic psychiatrist, thus, has a responsibility to protect both the accused and the accuser. He/she should obtain a careful, detailed review of the allegation and the accuser's mental state and circumstances. The allegation should be examined with cautious skepticism and an unwillingness to jump to absolute conclusions in the absence of specific credible evidence.

  1. Orlando Sentinel, July 14, 1993; March 1, 1994; September 27, 1994; November 6, 1994; December 16, 1994; March, 21, 1996; April, 1996; April 4, 1997.
  2. Florida Today, April 6, 1995.
  3. Adshead, Gwen: Psychological Trauma and its Influence on Genuine and False Complailnts of Sexual Assault. Med. Sci. Law; Apr. 1996; 36(2)95-99.
  4. Williamson, Tom: Police Investigations - separating the false and genuine. Med. Sci. Law; Apr. 1996; 36(2)135-140.
  5. Kanin, Eugene: False Rape Allegations. Arch Sex Behav; 1994; 23(1)81-92.
  6. Jamieson, MA; Walker, M; Daicar, A; et al: False Allegations of Pregnancy Resulting From Incestuous Rape and Physician Misconduct: Proof Positive. J Pediat Adolesc Gynecol; 1998; 11:181-184.
  7. Mantell, D: Clarifying Erroneous Child Sexual Abuse Allegations. Amer J Orthopsychiat. Oct. 1998:58(4)618-621.
  8. Schreier, Herbert: Repeated False Allegations of Sexual Abuse Presenting to Sheriffs: When Is It Munchausen By Proxy? Child Abuse & Neglect; 1996; 20(10)985-991.
  9. Orlando Sentinel, 6B and C6, October 20, 1994.
  10. Orlando Sentinel, October 11, 1992.
  11. Willwerth, James: Dubious Memories, Time, May 23, 1994, pg. 51.
  12. Grinfeld, MJ and Duffy, JF: Jury Awards Father $500,000 in Recovered Memories Trial. Psychiatric Times, June 1994.
  13. Meadow, R: False allegations of abuse and Munchausen syndrome by proxy. Arch Dis Child 1993; 68:444-447.
  14. Myers, JEB: Allegations of child sexual abuse in custody and visitation litigation: recommendations for improved fact finding and child protection. J Fam Law; 1989-90; 28:1-41.
  15. Lewis, DO; Bard, JS: Multiple Personality and Forensic Issues. Psychiatric Clinics of North America; Sept. 1991; 14(13):741-756.
  16. Knight, B: Simpson's Forensic Medicine, 11th edition. Oxford University Press, New York, NY; 1991; p134.

Factors To Be Considered

  1. Is accuser creditable?
  2. Is story consistent and believable?
  3. Is there a motive for revenge or mischief?
  4. Have other allegations been made previously? Does a pattern of allegations exist?
  5. Has the patient been counseled in their charges by some professional who has vested interest?
  6. Is there any physical evidence of misdeed?
  7. What is the reputation of the accused?
  8. How does the accused respond to the charges?
  9. Are there issues of custody, property settlement, divorce, or suit involved?
  10. Is there a history of personality disorder - antisocial, narcissistic, borderline - in either party?
  11. Is there a history of alcohol or substance abuse in either party?

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