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Anatomically Correct Dolls: Research vs. Clinical Practice
LETTERS TO THE EDITOR children, it reflects our field's contemporary obsession with "critical scientific documentation.") If we put the child back in child psychiatry, we have to wonder-as man y a child must wonder-why these adults have such strange dolls in their office? What do they do with them after hours? We tacitly assume that children understand the supposed appropriateness ofsuch paraphernalia. This in itself reflects how far we have drifted from an understanding of the experience of children . The child is once again emerging from beneath the trappings of science that have mesmerized the field for two decades. There is hope that our profession will address directly the ethical and technical dilemmas created by the often incompatible roles contemporary society expects of psychiatrists in the protection, care, and treatment of children and adolescents.
Anatomically Correct Dolls: Research vs. Clinical Practice To the Editor: The issues argued in the ongoing debate over the use of anatomically correct dolls in the assessment of sexual abuse in children highlight just how far afield child psychiatry has gone in the last decades. This is reflected in the fact that the primary concern of both sides of this debate appears to be whether or not evidence thus gained will continue to be admissible in court (Yates and Terr, 1988). Terr is concerned-and rightly so-that "Once children's testimony is spoiled by the ignorant, and perhaps unconscionable, use of the anatomically correct dolls, the testimony may not only be useless, it may be dangerous." This is a very real concern and one that needs to be addressed. However, it is already several steps removed from what should be our primary object of concern: the child. The primary concern of child and adolescent psychiatry should be the well-being of children and adolescents . Assessment is a necessary step in the process of assuring their well-being, but it is only a step. Research is a useful tool, but it is only a tool. The primary task of our profession is to respond to the psychiatric needs of our clinical population. Because testimony based on the use of anatomically correct dolls can easily be discredited by a bright, rhetorically apt attorney, this technique should be abandoned. It is as simple as that. However, there are very good reasons to abandon the use of these dolls which are much more relevant to the practice of child and adolescent psychiatry than the admissibility of evidential material in a court setting. Anatomically correct dolls are potentially very countertherapeutic . Those mental health professionals who are committed to meeting the genuine clinical needs of their population will find themselves immediately at odds with the constraints placed on clinical technique by judicial practice and the rules of evidence. The clinician who must second guess the use to which his or her interaction with a hurt child will be put by attorneys is already clinically hamstrung. The hurt child-whether victim of natural catastrophic trauma or human harm-needs and deserves to emerge from a first clinical encounter with a sense of having been genuinely understood and with a genuine sense of relief. The technical means of achieving this are often, if not always, at odds with the "antiseptic" technique required of the potential "expert witness." If the first rule is "Do no harm," the second rule is "Do some good." In those cases where children have been genuinely hurt , not allowing them to express a sense of anger at the cause of their hurt is often interpreted by the child as a form of collusion with the process of harm. On the other hand, it is eminently easy for a clever attorney to make it appear that an appropriate reparative first clinical encounter was calculated to tum the child against the alleged wrongdoer. Even apparently neutral technical approaches such as those of Pynoos and Eth (1986), in which the child is offered an opportunity to change the outcome of the traumatic event through storytelling or drawing, can be construed by intensel y adversarial attorneys as a form of suggestion, mind-control, or purposeful alienation of affection. This places the psychiatrist in a position of potential therapeutic impotence. Having drifted away from our primary role of ministering to the ills of our patients, we are also losing our awareness of the child's position in a live world. (For example, the 1985 edition of the RutterHersov textbook Child and Adolescent Psychiatry-described in this Journal as "a whole new account of the field," and "a point of view that derives solely from data " [Lewis, I986]-contains not one single original case history. A text about psychiatric research, not about
REFERENCES
Lewis, M. (1986), Book review: Child and Adolescent Psychiatry. Modem Approaches, 2nd Ed., ed. M. Rutter & L. Hersov. J. Am. Acad. Child Psychiatry, 25:436-437 . Pynoos, R. s. & Eth, S. (1986), Witness to violence: the child interview. J. Am. Acad. Child Psychiatry, 25:306- 319. Rutter, M. & Hersov, M., eds. (1985), Child and Adolescent Psychiatry. Modern Approaches, 2nd Ed. Oxford: Blackwell Scientific Publications. Yates, A. & Terr, L. (1988), Debate forum. Issue continued: anatomically correct dolls: should they be used as the basis for expert testimony? J. Am. Acad. Child Adolesc. Psychiatry, 27:387-388 . Denis M. Donovan, M.D., M.Ed. Medical Director The Children's Center for Developmental Psychiatry St. Petersburg, Florida Dr. Terr Replies: Although recent California Supreme Court decisions regarding anatomically correct dolls were the impetus for the debate between Dr. Yates and myself, both of us, I thought, went well beyond the legal issues to our concerns for children in general. Both of our main points were the same: that no one will know what these dolls show about children until properly designed scientific studies emerge. Dr. Donovan states his concern about "research" approaches to children . But it is exactly this approach, the scientific one, that I believe will eventually remove doubts and stop any further debates about how children experience the sexually anatomically correct dolls. Lenore C. Terr, M.D. Clinical Professor of Psychiatry University of California San Francisco, California Dr. Yates Replies: Dr. Donovan's letter makes several important points. His major assertion is that we should abandon the use of the anatomically correct dolls because testimony based on the dolls can be discredited in court. He seems to perceive psychiatrists who testify in court as unconcerned about the child's well-being that will not afford the child relief or the sense of being understood. The expert witness is a selfserving individual who devises interview strategies to outsmart (if possible) the attorneys. Generally, the child psychiatrists who testify in court are the same child psychiatrists who practice in the community. Their assessment techniques are pretty much the same whether they expect to go to court or not. When they are secondarily drawn into court proceedings they are ambivalent about testifying because of the stress placed on their patient and themselves and the often insulting tactics of defense
662
Anatomically Correct Dolls: Research vs. Clinical Practice To the Editor: The issues argued in the ongoing debate over the use of anatomically correct dolls in the assessment of sexual abuse in children highlight just how far afield child psychiatry has gone in the last decades. This is reflected in the fact that the primary concern of both sides of this debate appears to be whether or not evidence thus gained will continue to be admissible in court (Yates and Terr, 1988). Terr is concerned-and rightly so-that "Once children's testimony is spoiled by the ignorant, and perhaps unconscionable, use of the anatomically correct dolls, the testimony may not only be useless, it may be dangerous." This is a very real concern and one that needs to be addressed. However, it is already several steps removed from what should be our primary object of concern: the child. The primary concern of child and adolescent psychiatry should be the well-being of children and adolescents . Assessment is a necessary step in the process of assuring their well-being, but it is only a step. Research is a useful tool, but it is only a tool. The primary task of our profession is to respond to the psychiatric needs of our clinical population. Because testimony based on the use of anatomically correct dolls can easily be discredited by a bright, rhetorically apt attorney, this technique should be abandoned. It is as simple as that. However, there are very good reasons to abandon the use of these dolls which are much more relevant to the practice of child and adolescent psychiatry than the admissibility of evidential material in a court setting. Anatomically correct dolls are potentially very countertherapeutic . Those mental health professionals who are committed to meeting the genuine clinical needs of their population will find themselves immediately at odds with the constraints placed on clinical technique by judicial practice and the rules of evidence. The clinician who must second guess the use to which his or her interaction with a hurt child will be put by attorneys is already clinically hamstrung. The hurt child-whether victim of natural catastrophic trauma or human harm-needs and deserves to emerge from a first clinical encounter with a sense of having been genuinely understood and with a genuine sense of relief. The technical means of achieving this are often, if not always, at odds with the "antiseptic" technique required of the potential "expert witness." If the first rule is "Do no harm," the second rule is "Do some good." In those cases where children have been genuinely hurt , not allowing them to express a sense of anger at the cause of their hurt is often interpreted by the child as a form of collusion with the process of harm. On the other hand, it is eminently easy for a clever attorney to make it appear that an appropriate reparative first clinical encounter was calculated to tum the child against the alleged wrongdoer. Even apparently neutral technical approaches such as those of Pynoos and Eth (1986), in which the child is offered an opportunity to change the outcome of the traumatic event through storytelling or drawing, can be construed by intensel y adversarial attorneys as a form of suggestion, mind-control, or purposeful alienation of affection. This places the psychiatrist in a position of potential therapeutic impotence. Having drifted away from our primary role of ministering to the ills of our patients, we are also losing our awareness of the child's position in a live world. (For example, the 1985 edition of the RutterHersov textbook Child and Adolescent Psychiatry-described in this Journal as "a whole new account of the field," and "a point of view that derives solely from data " [Lewis, I986]-contains not one single original case history. A text about psychiatric research, not about
REFERENCES
Lewis, M. (1986), Book review: Child and Adolescent Psychiatry. Modem Approaches, 2nd Ed., ed. M. Rutter & L. Hersov. J. Am. Acad. Child Psychiatry, 25:436-437 . Pynoos, R. s. & Eth, S. (1986), Witness to violence: the child interview. J. Am. Acad. Child Psychiatry, 25:306- 319. Rutter, M. & Hersov, M., eds. (1985), Child and Adolescent Psychiatry. Modern Approaches, 2nd Ed. Oxford: Blackwell Scientific Publications. Yates, A. & Terr, L. (1988), Debate forum. Issue continued: anatomically correct dolls: should they be used as the basis for expert testimony? J. Am. Acad. Child Adolesc. Psychiatry, 27:387-388 . Denis M. Donovan, M.D., M.Ed. Medical Director The Children's Center for Developmental Psychiatry St. Petersburg, Florida Dr. Terr Replies: Although recent California Supreme Court decisions regarding anatomically correct dolls were the impetus for the debate between Dr. Yates and myself, both of us, I thought, went well beyond the legal issues to our concerns for children in general. Both of our main points were the same: that no one will know what these dolls show about children until properly designed scientific studies emerge. Dr. Donovan states his concern about "research" approaches to children . But it is exactly this approach, the scientific one, that I believe will eventually remove doubts and stop any further debates about how children experience the sexually anatomically correct dolls. Lenore C. Terr, M.D. Clinical Professor of Psychiatry University of California San Francisco, California Dr. Yates Replies: Dr. Donovan's letter makes several important points. His major assertion is that we should abandon the use of the anatomically correct dolls because testimony based on the dolls can be discredited in court. He seems to perceive psychiatrists who testify in court as unconcerned about the child's well-being that will not afford the child relief or the sense of being understood. The expert witness is a selfserving individual who devises interview strategies to outsmart (if possible) the attorneys. Generally, the child psychiatrists who testify in court are the same child psychiatrists who practice in the community. Their assessment techniques are pretty much the same whether they expect to go to court or not. When they are secondarily drawn into court proceedings they are ambivalent about testifying because of the stress placed on their patient and themselves and the often insulting tactics of defense
662