COSA Casualties of Sexual Allegations Newsletter July 1996 Volume 3 No 6
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Editorial: NATO Conference I have just returned from the NATO International Scientific Meeting on ‘Recollections of trauma: Scientific research and clinical practice’ held in Port de Bourgenay, France. This meeting, called an Advanced Study Institute, was organised by psychologists Drs Stephen Lindsay and Don Read, who have published their concerns about "memory work" in therapy including evidence to indicate that large numbers of Americans have been led to create false abuse memories.
Post Traumatic Stress Disorder (PTSD)
Multiple Personality Disorder (MPD)
Overall achievements of the conference
Concerns regarding the conference
I have just returned from the NATO International Scientific Meeting on
Recollections of trauma: Scientific research and clinical practice
Held in Port de Bourgenay, France from 15 to 25 June 1996.
This meeting, called an Advanced Study Institute, was organised by psychologists Drs Stephen Lindsay and Don Read, who have published their concerns about "memory work" in therapy including evidence to indicate that large numbers of Americans have been led to create false abuse memories [‘ "Memory work" and recovered memories of childhood sexual abuse: scientific evidence and public, professional and personal issues’, Psychology, Public Policy and the Law, 1995; 1 (4): 846-908 and ‘Psychotherapy and Memories of childhood sexual abuse: a cognitive perspective’, Applied Cognitive Psychology, 1994; 8: 281-338.]. Their primary agenda for the conference was to convince trauma orientated practitioners of the risks of using techniques to search for suspected forgotten memories, but to do this without undermining sensitivity to and support for trauma victims.
There were approximately 100 participants, mostly psychologists, from the United States, Canada, Britain, Australia, New Zealand, European countries (including Sweden, Denmark, the Netherlands, Belgium, Germany, France, Italy and Spain), and there were also representatives from Turkey and Israel. What was particularly interesting was that adults recovering memories of childhood sexual abuse is largely a phenomenon of the English-speaking world, and has not started to occur with any frequency in the European and Middle Eastern countries represented.
Those attending could be roughly divided into researchers who tend to be sceptical of the validity of recovered memories, and clinicians who work with clients who report childhood trauma, although this is a somewhat arbitrary division and many would not fit comfortably into one camp (for example, clinicians who also do research). This was a scientific meeting, hence the therapists attending were largely those with PhDs who have had some training in critical thinking and the scientific method, whereas a vast number of therapists and counsellors who work in this field do not have this training (some even actively condemn science as a tool of the patriarchy used to keep women oppressed). Many of the clinicians attending, however (for example John Briere and Christine Courtois), have been extremely influential in shaping the beliefs and the work of therapists both in North America and elsewhere, hence the statements they issue after this NATO meeting may be effective in changing the practices of some of their less scientifically qualified colleagues.
The 100-odd participants each gave either a spoken paper or a poster presentation. There were 14 major lectures an hour and a half long with another hour and half for formal commentary by another lecturer and then questions from the floor.
The work day started at 8.30 am and sometimes continued to 8 pm, with 20 poster presentations to view in the two hours before dinner. There was a considerable amount of new and extremely important research presented during the course of the conference. Many of these findings, including those in the posters (many of which would have warranted full papers in their own right) had not been previously published or presented at other forums.
At the very beginning, it was emphasised by organiser Steven Lindsay that this debate had been the arena of much emotional reaction and personal attack in the past. Participants were asked to avoid ad hominem attacks and polemic buzzwords such as "backlash" which tend to polarise the argument. He called for an increasing sensitivity between participants and a readiness to stay open to new evidence.
The conference was deliberately held in an isolated area of the French Atlantic coast, and all those attending were forced to live together, sharing meals and recreation times (walking, swimming, dancing) with each other. This, combined with the beauty of the location, the gourmet French cuisine, the sunshine and the superb service provided by the hotel, made it much harder to vilify each other. Attendees were indeed mostly on their very best behaviour. People were very careful in the way they commented or challenged each other’s work; there was an absence of heated debate, and people maintained a politeness and courtesy in their interactions.
The only paper which included references of a personal nature was in fact that of New Zealand DSAC’s representative, Dr Juliet Broadmore. Broadmore’s paper, entitled "Sexual abuse memories: a medical perspective from NZ", was peppered with both overt and oblique references to myself, including a reference to my book "First Do No Harm" which I considered frankly defamatory (she has agreed to delete that passage from her written version).
False memory research
In his opening lecture, Steve Lindsay emphasised that criticism of memory recovery work should in no way be seen as minimising the occurrence or potential effects of real child sexual abuse (CSA), but that research does indicate that exposure to prolonged and multifaceted suggestive influences can result in illusionary memories.
He identified some of the arguments regarding the generalisability of laboratory experiments to situations involving real life trauma victims. Firstly the reasoning is given that experimental subjects are not trauma survivors, but he countered that there is little reason to suggest that trauma victims might be less suggestible than normal subjects, and that the main concern was in fact not about those genuine victims but the therapy clients who are not survivors but who come to believe they are. Secondly it is argued that the subjects in laboratory experiments are not people in psychotherapy, but again it can be countered that there is little evidence to believe clients will be less suggestible than the normal population. Thirdly it is said that the false memories induced in research are not memories of sexual abuse, and hence cannot be generalised. Clearly ethics bar research which would deliberately implant false memories of serious childhood trauma such as CSA, but recent studies have achieved some fairly close parallels.
Some researchers expressed deep concerns that much of clinical practice (not necessarily of the conference attendees but of many clinicians practising in the USA and elsewhere) is not grounded in science but based on clinical intuition, and that experimentalists and therapists operate from very different underlying ideologies and assumptions.
Experimental researchers Professor Elizabeth Loftus and Dr Maggie Bruck presented papers outlining the malleability of memory. Loftus described experiments which indicate that it is possible to create entire false memories. She emphasised that this did not mean that all these memories produced in experimental situations were entirely false memories, and that sometimes there is a source misattribution and a memory fragment from a different source (for example, something seen in a movie or read about) becomes incorporated into the reconstructed memory.
Bruck, a leading researcher (who has published extensively with Stephen Ceci, another world renowned expert) into the suggestibility of children, reported studies which demonstrate the ease with which false memories can sometimes be created in children, and which indicate that there are no markers to distinguish false memories from true.
One of the points made repeatedly by researchers was that we lose source memory very quickly, and whilst we may remember something as familiar we may easily attribute the wrong source to our memory (for example, incorrectly remember that something we read about actually happened to us).
There was some impatience and disquiet to be noticed amongst the clinicians whenever studies indicating the implanting of false memories was reported. Trauma researcher Rachel Yehuda responded that there is a redundancy in demonstrating that errors can occur with suggestion. Distortion of reporting does not mean we cannot believe children who are telling the truth. Research, she claimed, is for traumatised children who need us to advocate for them. Sadly lacking, I felt at times, was acknowledgement that research should be for everyone, and should also especially be for children who come to believe in false memories, and their families who suffer the consequences of this.
The clinical argument
There was considerable difference in the way many of the clinicians viewed the problem compared to many of the academic researchers. The former emphasised the fact that whilst it was concerning that a few poorly trained therapists might have been using such techniques and aggressively searching for memories in their clients, these were isolated incidents – most clinicians were competent, and most clients reporting abuse were genuine victims. At times it was expressed that laboratory situations where someone could be manipulated to believe something happened which had never occurred could not be equated with the clinical situation where the profound pain and distress of the client was manifest. Clinicians continued to warn about the dangers of generalising experimental results to the therapeutic situation, although ethical constraints invariably mean that at best research can only approximate therapy situations.
John Briere presented a lecture entitled "Integrated clinical approach to self-reported memories of abuse in adults with reference to recovered memories". A major proponent of recovered memories in the past, Briere made some very valuable contributions to the debate. Whilst he feels it important to take a detailed trauma history from clients, he advocated asking this by behaviour rather than by name (for example, ask about a client’s first sexual experience, rather than ask directly whether she has been sexual abused as a child).
He says that it is not appropriate for therapists to go looking for a history of CSA if a client had not disclosed one. Therapists must accept a client may have said no even if it has occurred, or may have confabulated.
He also stated that therapists should never say in court that abuse in childhood has caused a particular problem in an adult, because this is something you just cannot know.
He then went on to talk about the treatment of adults who have suffered childhood trauma. Throughout this discussion there was an assumption that once a client has disclosed, this means that they definitely did experience the trauma and need therapy to get over it. One of the goals of therapy is to increase a client’s "internal resources" by teaching such skills as relaxation and stress management. Whilst he advises against memory recovery techniques which seek inaccessible memories, he advocates the processing of available painful memories using a process of desensitisation. Clients are progressively exposed to amounts of stress that they can handle. They start with gradual exposure to painful memories (less detailed and vague, such as feeling in danger and unsafe as a child) and gradually increase to more detailed memories and associate feelings. He says that it is important that this progressive exposure to painful stimuli has to stay within therapeutic window.
I was still left with concerns that a therapist whose client discloses abuse has no way of knowing whether these memories are real or illusionary, and this treatment was working on the assumption that the remembered trauma events must be real.
Does repression exist?
Clearly before this question can be addressed, we must define what we mean by repression. This is also true of a number of words used in this field, which have very different meanings and definitions to different people – words such as trauma, amnesia, and dissociation.
Generally, it is accepted that repression involves the unconscious blocking of recall of memories of severe and ongoing childhood trauma, until these memories are made accessible to conscious memory in adulthood, usually but not exclusively through processes of psychotherapy, where the person now feels safe to remember and deal with the trauma.
Whether or not such a mechanism of memory repression exists, is actually inaccessible to science. Repression theory hypothesises that for some period, a recovered memory was not available to conscious recall. However, because unconscious memory is a subjective experience; no-one but the individual can know if memory was truly out of consciousness. Verifying must be based on a belief that an individual is truthful when he or she is saying whether or not the memory has been accessible to consciousness. Science cannot determine with certainty whether such reports truly involve loss of conscious memory.
Suppression is usually the term used to refer to the conscious or semiconscious decision to put out of mind unpleasant experiences and feelings. However, there is no clear demarcation between the conscious and the unconscious avoidance of memory. Furthermore, the distinction between a continuous and a recovered memory is arbitrary. On occasion, someone who has recovered a memory in therapy may later come to believe that somewhere she actually always remembered it; there are also cases where someone has recovered a memory thought to be buried since childhood, only to be told by someone close to her that she has already shared that memory several years before.
Clinician Constance Dalenberg presented case studies of 17 women she had treated. Some had continuous memory of abuse and others had recovered memory elements in therapy which worsened the severity. She looked for corroboration from her clients’ families. She reported that in 4 cases of recovered memories she had found corroborative evidence, such as confession by the accused offender or witness of the event by a sibling.
Researcher Jonathon Schooler also reported several case stories where there appeared to be corroborative evidence to support recovered memories. In general these were one-off traumatic events, for example someone who had found the dead body of a suicided parent later remembering that she had been told about the death at camp, but then in therapy recovering the memory of being the one to find the body (which was then corroborated by her family).
What this indicates is that it is possible to forget traumatic events that occurred in childhood and then later have these memories triggered during psychotherapy or elsewhere. There is a danger that these case studies will be used to support the theory of repression and subsequent accurate memory recovery. However given all that is currently known about memory, research indicates that adult memories of childhood events are extremely fallible and malleable, and in the absence of corroboration, therapists and others have no way to determine whether their client’s’ recollections represent actual and accurate events, distorted versions or complete fabrications. It should of course also be noted that corroboration of part of a story does not mean that all the story is necessarily true.
Post Traumatic Stress Disorder (PTSD)
In her paper "Hormones, memory and PTSD", Dr Rachel Yehuda discussed research into whether there are biological changes related to trauma which can be measured.
The diagnosis of post-traumatic stress disorder (PTSD) was developed after psychological problems were seen in war veterans. The diagnosis of PTSD is therefore not based on science but on patients’ histories. Classed as a psychiatric condition caused by exposure to extreme trauma, the diagnosis requires:
- exposure to a traumatic event involving subjective response of fear, helplessness, horror (actual or threatened bodily harm)
- event persistently re-experienced (intrusive memories, nightmares)
- avoidance of situations reminiscent of the trauma and emotional numbing
- hyperarousal (insomnia, hyper-vigilance)
In order to get PTSD included as a diagnosis in the DSM (the Diagnostic and Statistical Manual on which American psychiatric diagnoses are based), it was argued that stress is different to trauma and that almost anyone would succumb to effects of trauma and develop the symptoms of PTSD.
Yehuda has measured some hormone levels in people with this diagnosis and found that they appear to be unusually responsive to stress and external environmental stimuli (for example, they have lower Cortisol levels, higher and more responsive Glucocorticoid levels, and an enhanced response to Dexamethasone). People with a CSA PTSD diagnosis have also been shown to have small hippocampal findings in the brain.
There are some major problems with the PTSD diagnosis however. Firstly only a small percentage of trauma victims develop chronic PTSD, which suggests that PTSD is not the normal stress reaction to extreme trauma that DSM IV states.
Secondly, the finding of a difference in neuro-biological findings in patients with this diagnosis has several interpretations. Although this could possibly assist in diagnosis, biological markers have had a difficult history in psychiatry. It is well established that our experience and environment alters our brain function and morphology (neurobiology). There is difficulty in demonstrating that a particular finding is caused by a previous episode of trauma however. The changes measured might be due to subsequent experiences in adulthood; or the problems demonstrated in the person regulating his or her stress response might be induced by exposure to trauma but also it is possible that he or she has always had these responses (ie it was pre-existing) and it was not induced by the trauma.
Thirdly, unlike most diagnoses, PTSD requires a documented traumatic event prior to the development of the symptoms. The symptoms experienced are not specific to PTSD and may be also present in other psychiatric conditions, such as depression and obsessive-compulsive disorder. What may happen, however, is that the symptom cluster is diagnosed, a history of CSA is later disclosed during therapy, and the diagnosis is made without any clear documentation of previous trauma (the clinician assumes that because the patient has these symptoms, she or her must have suffered severe trauma in the past). There is a lack of recognition that causality can only go in one direction.
Multiple Personality Disorder (MPD)
An anthropologist, Professor Sherrill Mulhern discussed how the MPD diagnosis frames the recovered memory debate. She presented an overview of the phenomenon, identifying many threads which had come together to lead to these diagnoses. She drew parallels to cultures which have spiritual embodying of identities (spiritual possession), and discussed the influences of Freud and Janet. Other issues she identified were the medicalization of child abuse; the social revolution of the 1980s leading to an alliance between radical therapists and feminists; the return of the use of hypnosis in the 1970s; and the emergence of the diagnosis of MPD because of the perception of a social group suffering childhood trauma whose redress was under negotiation in 1970s and 1980s.
She emphasised that this was not a discussion of iatrogenesis (which places all responsibility for the phenomenon on the clinician); rather it is a diagnosis which fills a need for many people who feel marginalised by society. The actions and beliefs of therapists; the contribution of clients themselves, and the social cultural environment in which the diagnosis has occurred, all need to be recognised as factors leading to this diagnosis.
The apparent common ground
There was apparent consensus amongst the clinicians and researchers attending the conference that it is possible to implant false memories through suggestive interview and therapy techniques. It was considered inappropriate therapy for therapists to use techniques such as hypnosis, age regression or guided imagery to go looking for memories of childhood trauma which clients have not already remembered.
The final lecture, given by Dr Christine Courtois, was entitled "Informed clinical practice and the standard of care: guide-lines for treating adults who report delayed memory for past trauma". In the past Courtois has advocated a treatment process which includes an initial validation that abuse has occurred, memory retrieval of childhood abuse using techniques such as guided imagery, hypnotic age regression and guided imagery, and assisting the client to believe her memories are real (overcoming denial) [Courtois, Christine. ‘Theory, sequencing and strategy in treating adult survivors’]. The recommendations she gave at this conference therefore represented a very major shift in her perspective in the past few years. She listed the following points:
- The majority of adults who seek treatment have retained memory
- Some may recall more during therapy
- Memories can be recalled after a period of total lack of recall (but this is not the norm)
- Some memories reflect narrative rather than historical truth and pseudomemories are possible
- Without evidence, a therapist has no way to distinguish between true and false memories.
She also acknowledged that therapists should not be simultaneously working through their own trauma issues.
She identified a number of important issues with respect to client’s memories:
- There is a fine line between suggesting and dismissing
- Be neutral but supportive
- It is better to use a free-recall strategy
- Tolerate uncertainty and ambiguity
- Avoid an authoritarian closed-ended relationship
- Avoid close-ended questioning
- Keep any memory focus only a part of the treatment
- Educate patients about memory
- Avoid problematic methods [such as hypnosis and age regression]
Should Courtois’ standards be widely disseminated to psychologists, psychotherapists and counsellors, hopefully some of the more dangerous practices of therapists actively seeking trauma memories would wane.
Overall achievements of the conference
There was immense benefit to be gained by people who had previously been in two polarised camps living together for eleven days, sharing meals and recreation times. It is much harder to vilify someone with whom you have shared breakfast and laughed together over a joke at dinner. Don Read and Steve Lindsay, assisted by Sherrill Mulhern, cannot be highly commended enough for the sensitive and sincerely caring manner with which they organised this conference. They offered an opportunity for people to lay down their weapons and try to view the world from their opponents’ perspectives. They managed to maintain a friendly atmosphere, soothe ruffled feathers, and take care of people’s personal needs in the most hospitable manner possible.
Attendees had the opportunity to meet with leading researchers and clinicians in their fields, and were presented with a wealth of new and important information in this field. This was a wonderful opportunity for clinicians to inform their experimental colleagues of specific issues they would like to see researched, and for researchers and therapists to form collaborative arrangements to work jointly on some of these issues in the future.
Concerns regarding the conference
The amount of material presented and the different belief systems and epistemologies of those attending means that various aspects of the conference could be used to support a variety of stands on this debate.
It should be acknowledged that what I have presented here is my own interpretation and version of what I heard and understood. I have only reported details that had particular reference to my attitudes and views on this issue. It is inevitable that anyone else making a report will choose a different points to highlight, and will make different evaluations of what he or she has learnt. We take what we want and reject that which we don’t like. In about 6 months, a book will be published containing the lectures with commentaries, some of the discussion questions; the short papers and abstracts of the posters, and this will be more representative of the conference content.
One concern I do have is that the politeness and the sincere desire not to offend other participants meant that many points went unchallenged. From my perspective, clinicians presenting case studies and self-reports from "trauma victims" were seldom challenged to the effect that these are mostly alleged rather than established trauma events.
There was very little acknowledgement of the extent of the problem, the possible number of families involved or the effect of these false memories on the client and her extended family. No-one really discussed the issue of what can be done to help these people. A number of clinicians expressed the view that they believed that the problem had been grossly over-stated by the media and by organisations such as the FMS Foundation. Even when it was acknowledged that maybe clients had come up with stories of CSA that were not historically accurate, it was expressed that clients would not come up with feelings of severe childhood trauma unless they had experienced abuse as children. These were parents who traumatised their children, even if the actual details were sometimes inaccurate.
The pivotal role of the self-help book Courage to Heal (and similar books published soon after) in shaping the belief of therapists and the general public in the value of searching for and validating buried memories of CSA was never really identified. The fact that the phenomenon of thousands of adults only began recovering CSA memories following the publishing of this book and the dissemination of this theory in the psychological literature, was never really addressed, and the dangers of therapists recommending this book to their clients not clearly stated during the conference.
My major concern was that there were accusations that the FMS Foundation and other FMS groups are organisations which harbour pedophils. In many ways, FMS groups (and therefore COSA by proxy) replaced individuals previously named on either side of the debate as the villains of the course. Several people advised strongly that professionals should not associate themselves with such organisations. Elizabeth Loftus was the only member of the FMSF Scientific and Professional Advisory Board to attend, and largely the Board was painted as a group of extremists, rather than concerned professionals who had perceived a serious problem in our society and had set about trying to rectify it by disseminating accurate scientific information. As the President of COSA, I clearly did not find this argument comfortable.
In her anthropological overview of the development of MPD and SRA, Professor Sherrill Mulhern described how in the 1980s therapists had stood up for sexual abuse victims who could not speak for themselves. She identified the very real phenomenon of a social group (sexual abuse victims) experiencing distress and injustice, with no way to get redress. The position of professionals taking up the cause of those suffering from childhood trauma, was applauded.
From my perspective, society now has a new group who are undergoing distress and injustice. These are all those whose lives are damaged by false allegations, including those adults and children who come to believe in trauma memories of events which never happened. There are currently few professionals available to speak up for those in our society who are damaged in this way. Denying those affected a voice cannot help rectify the problem, and hence I feel I must ignore my colleagues’ warnings. I will not disassociate myself from COSA nor stop speaking out professionally or publicly about my grave concerns.
Please notify COSA if you know of any recent or coming workshops, seminars and other relevant events.
International conference "Narrative and Metaphor across the Disciplines
Auckland University, 8-10 July 1996
I will be presenting a paper at this conference entitled "Clinical use of narrative to harm or heal".
Children’s Issues Centre ‘Investing in Children’ Conference
Dunedin, 10-13 July 1996
I will be presenting a paper at this conference on 11 July entitled "Child sexual abuse prevention programmes: cautions and pitfalls".
Bessell van der Kolk
Seminar on trauma memory sponsored by DSAC
12 Sep 1996 Auckland Medical School
13 Sep 1996 Wellington Medial School
Professor van der Kolk recently persuaded a US judge that memory repression and recovery is accepted as a valid theory by American professionals.