Working with Clients who have Recovered Memories

Susan P. Robbins, Ph.D., LMSW-ACP
susanrobbins.com

One of the most controversial and divisive issues among mental health professionals and researchers in the past two decades has been the delayed recovery of memories of traumatic events. Although the major social work journals carried only a handful of articles on this topic (see Benatar, 1995; Robbins, 1995; Stocks, 1998), well-respected journals in psychology, psychiatry, and law published numerous articles and special issues dedicated to the debate about the nature, veracity, and accuracy of recovered memories, particularly memories of childhood sexual abuse (CSA).

At the heart of this debate is whether it is possible to repress or dissociate all memory of CSA and later accurately recall the trauma as an adult. Two related questions pertain to the actual prevalence of abused children who completely forget their early abuse and the specific mechanisms responsible for the absence of memory. These became contentious issues because some believe that early memories of traumatic events that are inaccessible to the conscious mind can nonetheless affect one's social and psychological functioning throughout life.

During the 1980s and 90s, thousands of people, primarily white middle class women, were diagnosed by mental health practitioners such as social workers, psychologists, psychiatrists, and substance abuse and other counselors as having been victims of sexual abuse in their childhood, despite a total lack of recall of any such event. Others, who had continuous memories of early abuse, were told that they were victims of additional episodes of CSA, often horrific in nature, that they did not recall, such as satanic ritual abuse (SRA). Recovered memories of SRA most typically included being drugged, brainwashed, and forced to watch or participate in satanic rituals that often included murder or rape by multiple perpetrators. Seeking mental health and counseling services for a broad array of problems that included depression, eating disorders, marital difficulties, substance abuse, and bereavement (among others), clients began to allegedly “recover” memories of CSA and SRA with the help of their therapists, spontaneously, or upon reading books for sexual abuse survivors and attending self-help groups.

Clinicians who strongly advocated the use of memory recovery techniques believed that it was necessary for their clients to retrieve their previously forgotten memories of CSA in order to heal and recover from what they believed to be a forgotten but unresolved trauma. Concepts such as repression, dissociation, traumatic amnesia, and multiple personality disorder (later renamed dissociative identity disorder) were used to explain why memory of the alleged trauma was not available to the conscious mind. In the quest to assist clients in recovering these memories a variety of therapeutic techniques were used that included, but were not limited to, hypnosis, truth serum, guided imagery, dream interpretation, age regression, free association, journaling, psychodrama, reflexology, massage and other forms of “body work” to recover “body memories,” primal scream therapy, attending survivor's groups and reading books on recovering from sexual abuse. Clients were often encouraged by their therapists and self-help groups to believe in the veracity of their newly recovered memories, define themselves as “survivors,” and interpret their current day problems and symptoms in terms of their early unresolved trauma.

Therapy of this sort had consequences not only for the clients, but for their families as well. As the retrieval of recovered memories came to be seen as the path to healing, many clients were also encouraged to confront their alleged perpetrators and break off all contact with anyone in the family who questioned the veracity of their newly recalled memories. Further complicating this issue were criminal and civil charges that clients were encouraged to file against family members as part of their recovery process. According to Underwager and Wakefield (1998), approximately 200 cases involving claims of recovered memory have reached the appellate courts and raised serious issues related to discovery rules, statutory limitations, and rules of scientific evidence.

By 1992, a small group of parents who claimed to have been falsely accused joined together with sympathetic professionals to form a support and advocacy organization, the False Memory Syndrome Foundation (FMSF). In addition to sponsoring scientific and medical research on memory, suggestibility, and repression, the FMSF disseminates research to legal and mental health professions as well as to the general public and the media. A growing number of people have since recanted their accusations of abuse, accusing their therapists of pressure, suggestion, and coercion. Although this has strongly bolstered the position of the FMSF that such memories are the product of unethical therapy rather than events rooted in reality, recovered memory advocates have been unrelenting in their attack of this organization, its founders and scientific advisory board. To date, there are no accepted standards for determining the veracity of reports of abuse that are based solely on recovered memories and most agree that it is impossible to determine the validity of recovered memories without external corroboration.

In a thorough review of the literature on recovered memory therapy (RMT), Stocks (1998) examined the various techniques and therapeutic interventions that were commonly used to assist in the recovery of abuse memories as well as the impact of such therapy on client outcomes. Noting the historical ambivalence towards sexual abuse that was prevalent until the latter part of the twentieth century, Stocks also provided a discussion and critique of the initial studies that led some clinicians and researchers to conclude that CSA memories were frequently repressed. In doing so, he cautioned that the reality of abuse should not be confused with skepticism about recovered memories of abuse. This echoed Loftus and Ketcham's earlier position (1994) that the disagreement about memory is not a debate about childhood sexual abuse.

According to Stocks (1998), the research on RMT shows that such techniques are not reliable in recovering valid memories. Although some recovered memories may be accurate, many are partly or totally confabulated, and there is no way to reliably distinguish between those that are real and those that are not. Further, he found no conclusive evidence that memories of this sort have any clinical utility. In fact, the few existing outcome studies suggest that RMT is likely to lead to deterioration rather than improved functioning. Based on this, Stocks warned that the risks of RMT far outweigh the perceived benefits, discussed the necessity of informed consent for therapy that is unreliable and potentially harmful, and concluded that social workers should avoid using such techniques in their practice.

Subsequent letters to the editor in response to his article (see Lein, 1999; Social Work, September, 1999) reflect the ongoing professional division concerning the nature of recovered memories and the utility of RMT. A similar split can be seen in the final report of the American Psychological Association Working Group on Investigation of Memories of Childhood Abuse (1996). The three clinicians in the group differed from the three researchers on several points including the mechanisms that are responsible for delayed recall, the frequency of the creation of false memories, and the rules of evidence for testing hypotheses about memory and the consequences of trauma. They concluded that their failure to reach consensus was due in part to “profound epistemological differences” between the researchers and the clinicians. This basic disagreement is reflected in the field of social work as well.

There is, however, an underlying professional consensus in four basic areas as summarized in Table 1. (Knapp and VanderCreek, 2000, p. 336; APA, 1996).

Table 1: Consensus on Recovered and False Memories

Child Abuse Child abuse is harmful and prevalent.
Satanic or ritual abuse is rare.
Memory and the Creation of Memories Most people who were sexually abused remember all or part of what happened to them.
Adults with continuous memories of being abused are likely to have accurate memories.br>Although it is rare, some memories of past traumas can be forgotten and later remembered.
Memories from infancy are highly unreliable.
False or pseudo-memories memories can be created.
Magnification and minimization are better ways to conceptualize memories than the dichotomy of "true" or "false."
It is difficult to ascertain the accuracy of memories recovered by suggestive "memory recovery" techniques.
It is impossible to distinguish a true memory from a false one without other corroborative evidence.
Diagnosis of and Psychotherapy with Patients with Memories of Abuse Child abuse, in and of itself, is not a diagnosis.
Child abuse cannot be assessed from a set of current symptoms or a checklist of symptoms.
Mental illness and mental disorders have many causes.
Psychotherapists should ask patients about past childhood abuse if it is clinically indicated.
Memory recall of abuse is not necessary for effective therapy to occur.
The focus of treatment should be on the current functioning of the patient.
Treatments should be tailored to the individual needs of each patient.
At times, patients may need to learn to live with ambiguity about the veracity of memory or memory fragments.
Role of Psychotherapists Psychotherapists need to respect and promote patient autonomy.
Psychotherapists need to scrupulously maintain professional boundaries.
Psychotherapists need to maintain therapeutic neutrality on the issues of litigation and confrontation.
Even though psychotherapists have no primary legal duty to third parties, they should not be oblivious to the impact of their actions on those third parties.

        Despite these significant areas of consensus, it is the ongoing areas of disagreement that continue to divide professionals in the field. This division is not merely an academic debate inasmuch as it directly affects the practice techniques that are used with clients. By the mid 1990s most of the major professional organizations issued warnings concerning suggestibility and false memories (APA, 1993; AMA, 1994). One of the strongest cautionary statements came from the AMA in its position that "The AMA considers recovered memories of childhood sexual abuse to be of uncertain authenticity, which should be subject to external verification. The use of recovered memories is fraught with problems of potential misapplication." (AMA, 1994, p. 4).

Most early organizational statements on recovered memory therapy urged the use of caution, with the acknowledgement that recovered memories may or may not be true. Many of the later statements more explicitly warn against the use of memory recovery techniques as a method or focus of practice. A good chronology of statements and positions on RMT made by professional organizations can be found on the Internet at: http://www.religioustolerance.org/rmt_prof.htm.

More recently, professional concerns have focused on informed consent and, as noted by the American Academy of Psychiatry and the Law (1999, p. 2), in light of the warnings given by most professional organizations, “Few would currently argue against informing patients about the fallibility of memory and the dangers involved with recovering memories of sexual abuse.” Given the unproven clinical utility of RMT, coupled with the lack of evidence that the benefits of such therapy outweighs the risks, the issue of informed consent is critical for social workers inasmuch as this is also mandated by the National Association of Social Workers' (NASW) Code of Ethics (NASW, 1996a).

A specific practice statement addressing the evaluation and treatment of adults with the possibility of recovered memories of childhood sexual abuse, developed by the NASW National Council on the Practice of Clinical Social Work, was published in June, 1996. In this statement social workers are cautioned to: a) establish and maintain an appropriate therapeutic relationship with careful attention to boundary management; b) recognize that the client may be influenced by the opinions, conjecture, or suggestions of the therapist; c) not minimize the power and influence he or she has on a client's impressions and beliefs; d) guard against engaging in self-disclosure and premature interpretations during the treatment process; e) guard against using leading questions to recover memories f) be cognizant that disclosure of forgotten experience is a part of the process but not the goal of therapy g) respect the client's right to self-determination (NASW, 1996b, p. 2).

Due to the prevalence of RMT during the 1980s and 90s and the sensationalized media coverage of recovered memories, social workers are likely to encounter clients who were previously subjected to a variety of RMT techniques, abuse survivor groups and literature, or who spontaneously recovered abuse memories. Some clients may still believe in the veracity of these memories, while others may have come to question them. Others may have fully recanted their abuse allegations upon realizing that their memories were inaccurate or iatrogenically induced in therapy. Working with such clients can prove to be a challenge for social workers, as most typically receive little or no formal education regarding the nature of memory or the suggestive techniques that can create false memories.

As noted elsewhere (Robbins, 1997), it is critical that social workers adhere to NASW guidelines when working with clients who have possibly recovered memories of childhood sexual abuse. Neutrality about the veracity of such memories is critical because it is impossible to determine the accuracy of memories without external corroboration. This is especially true when RMT techniques have been used. The NASW guidelines caution that “enthusiastic belief or disbelief can and will have an effect on the treatment process” (NASW, 1996b, p. 2). Personal biases may result in incorrect diagnosis and inadequate or inappropriate treatment.

Social workers should always follow accepted professional standards when diagnosing and treating clients. Information about abuse and other negative childhood experiences should be gathered in the course of obtaining a complete psychosocial history, but this should only be one part of a holistic assessment that includes an evaluation of the client's "total clinical picture including symptoms and level of functioning" (NASW, 1996, p. 2).

It is also important to remember that CSA is an event in a person's life; it is not a diagnosis and should not be treated as such. In addition, CSA should not be inferred from any specific symptoms or cluster of symptoms (APA Working Group, 1996). Social workers should also be cognizant of the fact that most victims of CSA either completely or partially remember their abuse. Although delayed recall is possible, the frequency of abuse memories that are forgotten and later recalled is not known (Knapp & VandeCreek, 2000).

Treatment should always be based on a complete assessment, informed by the scientific literature, designed to meet the individual client's needs, and the emphasis should be on the client's current functioning (Knapp & VandeCreek, 2000). According to NASW (1996b, p. 2), the social worker's responsibility is to “maintain the focus of treatment on symptom reduction or elimination and to enhance the ability of the client to function appropriately and comfortably in his or her daily life.”

In accordance with this, archeological reconstruction of one's past and placing a focus on working through painful emotions should not be the primary goal of treatment. As Littrell (2000) has pointed out, the failure to express emotions is not necessarily responsible for poor health and impaired functioning. According to Littrell, current research indicates that expressing emotions related to trauma may be helpful if the client is then able to reframe the experience and develop a new attitude towards it. She noted, however, that “Recasting thoughts about the trauma is the goal, but we know too little about how to reach it” (p. 8)

If a client enters treatment with the desire to discuss or examine recovered memories, NASW (1996b, p. 2) recommends that social workers “explore the meaning and implication of the memory for the client, rather than focusing solely on the content or veracity of the report.” In addition, it is the responsibility of the social worker to inform the client that their memory may be “an accurate memory of an actual event, an altered or distorted memory of an actual event, or the recounting of an event that did not happen.”

Clients who have recanted memories of abuse may need assistance in understanding the dynamics that led them to believe in recovered memories of events that never happened. A psychoeducational approach can assist them in understanding the nature of memory, memory reconstruction, and the specific techniques that can lead to false memories. They may also need help in resolving issues of guilt and self-blame and in reestablishing relationships within their families. This is particularly true if their abuse memories resulted in accusations, angry confrontation, legal action, or alienation among family members.

Social workers should also be cognizant of legal issues related to recovered memories and be fully informed about issues related to risk management. Although the social worker's primary responsibility is to the client, she or he should also be concerned about the effect of false allegations on the accused, many of whom are family members. The guidelines developed by NASW (1996b) discuss this in detail, with specific recommendations related to record keeping, informed consent, client self-determination, and requisite knowledge of state and federal laws.

Finally, it is incumbent on social workers to have adequate training, and maintain current skills and knowledge in the areas of trauma and memory if they are working with clients who have histories of abuse or recovered memories of abuse. Scientific research in this area is constantly emerging and social workers must be able to critically assess new findings and be open to incorporating new knowledge into practice (NASW, 1996b).

References and Readings

American Academy of Psychiatry and the Law. (1999, April). Recovered memories of sexual abuse: informed consent. American Academy of Psychiatry and the Law Newsletter, 24 (2), 5-6

American Medical Association. (1994, July 14). Report of the Council on Scientific Affairs (CSA Report 5-A-94). Chicago: Author.

American Psychiatric Association. (1993). Statement on Memories of Sexual Abuse. Washington, DC: Author

American Psychological Association Working Group on Investigation of Memories of Childhood Abuse. (1996). Final report. Washington DC: Author.

Benatar, M. (1995). Running Away from Sexual Abuse: Denial Revisited. Families in Society, 76 (5).

Knapp, S. and VandeCreek, L. (2000). Recovered memories of childhood abuse: Is there an underlying professional consensus? Professional Psychology: Research and Practice, 31 (4), 365-371.

Lein, J. (1999). Points and Viewpoints: Recovered memories: Context and controvery. Social Work , 44 (5), 481-484.

Littrell, J. (2000). Should the expression of emotional memories be a goal of therapy? The Harvard Mental Health Letter, 16 (12), 8.

Loftus, E.F. and Ketcham, K.K. (1994). The myth of repressed memory: False memories and accusations of sexual abuse. New York: St. Martin's Press.

National Association of Social Workers. (1996a). National Association of Social Workers Code of Ethics. NASW News, 41 (10), Insert 1-4. (Also available at http://www.socialworkers.org/Code/ethics.htm)

National Association of Social Workers. (1996b). Practice statement on the evaluation and treatment of adults with the possibility of recovered memories of childhood sexual abuse. Washington DC: NASW Office of Policy and Practice.

Robbins, S. P. (1995). Wading through the muddy waters of recovered memory. Families in Society, 76, 478-489.

Robbins, S. P. (1997). Cults (update). Encyclopedia of Social Work, 19th Edition on CD ROM. Washington DC: National Association of Social Workers Press.

Social Work (September, 1999). Letters: Recovered Memories, 44 (5), 484-490.

Stocks, J.T. (1998). Recovered memory therapy: A dubious practice technique. Social Work, 43 (5), 423-436.

Underwager, R. and Wakefield, H. (1998). Recovered memories in the courtroom. In S. J. Lynn & K. M. McConkey (Eds.), Truth in Memory. New York: The Guilford Press.

Glossary

False memory syndrome: A lay term used to describe memories of events that did not happen. Such memories are confabulated or fabricated, usually, but not exclusively, in the course of therapy aimed at retrieving early childhood memories of abuse.

Recovered memory: A memory of a past traumatic event, believed to have been concealed from consciousness by repression or dissociation, but retrieved or recovered intact at a later point in time. See also recovered memory therapy and false memory syndrome.

Recovered memory therapy: A controversial form of psychotherapy aimed at retrieving traumatic memories that are believed to be repressed or dissociated. Although there is no one method for this, the techniques used most typically include hypnosis, truth serum, guided imagery, dream interpretation, age regression, free association, journaling, psychodrama, primal scream therapy, reflexology, massage and other forms of “body work” to recover “body memories.”

Satanic ritual abuse: A form of child abuse by widespread, organized, underground satanic cults that engage in horrifying rituals including ritualistic torture, sexual abuse, and human sacrifice. To date, no physical evidence has been found to support the claims of ritual abuse survivors who recovered memories of satanic murder and ritualistic human sacrifice, and neither the FBI nor the police have been able to document even one organized satanic cult murder in the United States.