Recovered Memory Therapy: Responses to All.
|Author:||Stocks, J. T.|
|Publication:||Name: Social Work Publisher: National Association of Social Workers Audience: Academic Format: Magazine/Journal Subject: Sociology and social work Copyright: COPYRIGHT 1999 National Association of Social Workers ISSN: 0037-8046|
|Issue:||Date: Sept, 1999 Source Volume: 44 Source Issue: 5|
I am pleased at the extent of response to my article. I believe
that the issue of memory recovery work is an important one that deserves
careful discussion in our profession, and I thank my colleagues who have
replied to this article for their part in further developing this
Lein said that my article should be considered in the context of the positions of an organization not discussed in my article, the False Memory Syndrome Foundation (FMSF). I confess that I do not understand the relevance of Lein's discussion of the FMSF to my discussion. My article was not intended to be reflective of the positions of the FMSF. For the record, I am not now, nor have I ever been, a member of the False Memory Syndrome Foundation. The positions of the FMSF are not relevant to the validity or invalidity of my arguments.
Lein implied that memory research is exclusively used in trials to discredit women who have "recovered" memories of sexual abuse. However, memory research frequently is used in the courts on behalf of women and children who have brought actions against their therapists for professional malpractice (Alkon, 1997; Associated Press, 1996; Gregory, 1997; Gustafson, 1996a, 1996b; Jones, 1997; Yapko, 1994).
Lein implied a straw man argument by asking, "Is a memory false because it is not totally complete, down to the tedious details, or because it contains inaccuracies?" This was not what I said. I said that memory recovery techniques "may lead to recovery of accurate memories, [but] they can also result in the recovery of distorted or wholly constructed memories" (Stocks, 1998, p. 431) and that " there are no procedures that have been demonstrated to reliably distinguish confabulations from accurate memories" (p. 431). Lein was correct that a memory is not necessarily false because of inaccuracies in details. However, it is just as correct that such a memory is not necessarily true either.
Lein missed the point when he characterized my article as advocating the "assiduous avoidance" of abuse memories. I did not take such a position. The well-supported position of my article was that memory recovery techniques recover confabulations as well as accurate memories and that there is no way to distinguish between them. The warning in the article was that memory recovery techniques are procedures that entail documented risks without balancing benefits.
His quotation of LeDoux (1992) was misleading. It did not refer, as Lein states, to "traumatic memories," but rather emotional memories. The entire sentence reads: "These findings suggest that emotional memories are indelible and normally maintained by subcortical circuits involving the amygdala" (p. 280). These are not memories of events, but rather of emotional responses to events. Earlier in the article, LeDoux noted that the amygdala generates emotional responses based on features of the event rather than the total event. "The emotional responses and memories established would therefore not necessarily correspond to the ongoing conscious perceptions of the individual" (p. 277). It is not necessarily the case that an "emotional memory" would lead to a correct narrative memory. As soon as we talk about an emotional memory, it is transcribed into the declarative memory system and is subject to social influence. This opens the door to distortion and confabulation.
Lein ended his reply with a quotation from Karon and Widener (1997) that purported to provide evidence that memory recovery techniques can lead to remission of symptoms. The article dealt with the treatment of war neuroses during World War II. However, an evaluation of Karon and Widener's sources did not support the contention that memory recovery work helped war neurosis patients. Many, if not most, of the cases did not involve "repressed memories" of the traumatic incident. Most of the sources were descriptive of war neuroses rather than evaluative of treatment.
Grinker and Spiegel (1963) carried out the only outcome evaluations. Their results were not supportive of the efficacy of memory recovery. One set of results involved 20 cases of war neurosis treated with sodium amytal narcosis and psychotherapy. Three individuals improved, and the rest did not change or deteriorated. Another evaluation involved 2,780 flying officers and enlistees treated in a hospital. Of these, 1,321 (47.5 percent) were able to return to full flying after treatment for war neurosis. The remainder had to be permanently grounded (33.6 percent), transferred to noncombat flying duties (2.7 percent), or terminated from the service (16.2 percent).
This is scarcely a resounding testimonial for memory recovery work.
Ann W. Aukamp
Aukamp placed skepticism about memory recovery in the context of a supposed right-wing attack on certain types of therapies. She presented no evidence to support this assertion. However, within the context of a Fundamentalist "Religious Right" promotion of a Satanism threat (Richardson, Best, & Bromley, 1991), memory recovery work has been used to "uncover" supposed memories of satanic ritual abuse (Loftus & Ketcham, 1994; Parr, 1996; Yapko, 1994). Certain Christian mental health clinics have used memory techniques routinely to "recover" satanic abuse memories (Loftus & Ketcham, 1994). Some Fundamentalist churches even have used retreats as the occasion for "memory work" aimed at excavating abuse memories (Alkon, 1997; Loftus & Ketcham, 1994; Yapko, 1994).
Does the foregoing mean that there is a link between right-wing politics and advocacy of memory work? Of course not. Rather, it demonstrates that there is no connection between attitude toward memory work and any political position.
Aukamp cites Brown, Scheftin, and Hammond (1998), arguing that there is research showing that "recovered memories are as likely to be accurate as those never forgotten." The research cited by Brown et al. consists of several studies (Coons, 1994; Coons & Milstein, 1986; Dalenberg, 1996; Kluft, 1997; Martinez-Taboas, 1996; Williams, 1995) that deserve close scrutiny.
Coons (1994) investigated abuse histories for 21 children with diagnoses of multiple personality disorder, dissociative disorder not otherwise specified, and factitious dissociative disorder, as well as nine children with nondissociative disorder diagnoses. Apparently, only one case (factitious dissociative disorder) involved recovered memory of abuse, and this memory was unconfirmed. Coons and Milstein (1986) reported on 20 patients with multiple personality disorder. The article did not mention recovered memories at all.
The Dalenberg (1996, 1997) study involved 17 people recruited after therapy with the author was completed. Dalenberg (1997) reported that "all subjects had some continuous memories of child abuse" (p. 450). Because all subjects had continuous memory of abuse, there were no individuals with recovered memories to act as a comparison group.
Kluft (1997) likewise evaluated his own patients. There were 34 patients, 19 (56 percent) of whom were able to obtain confirmation of the abuse. Of the 19 individuals who were able to confirm abuse, 10 had always remembered the abuse and nine had recovered the memory in therapy. However, Kluft did not present information on the frequency of those subjects who were not able to confirm abuse. This is important because, lacking this information, we cannot know if there was a differential rate of confirmation for those who had always remembered abuse compared with those who recovered memory of abuse. The confirmation methodology was itself flawed. Some of the "confirmations" were memories recovered in therapy. Thus, there was a circular process whereby memory recovery techniques "validated" memory recovery techniques.
The Martinez-Taboas (1996) study consisted of two case studies involving sexual abuse memories uncovered in therapy. There was no comparison with individuals with continuous memories of abuse.
The Williams (1995) study was discussed in my article. This was a longitudinal follow-up study of 129 women who had been treated for sexual abuse in an emergency room when they were children (17 years previously). Forty-nine (38 percent) did not report recall of the specific sexual abuse incident (although 33 of these 49 did recall other incidents of sexual abuse). Of the 75 women who remembered the documented abuse, 12 (16 percent) reported forgetting and then remembering the abuse. Although this study demonstrates that individuals report forgetting and remembering sexual abuse that actually occurred, it provides no information about the likelihood that individuals who have never been abused may recover distorted or confabulated memories.
To sum up, none of these studies showed what Aukamp said they did. They do not show that recovered memories are as accurate as continuous memories.
Aukamp cited Roth and Fonagy's (1996) meta-analysis of psychotherapies to support a contention that memory recovery work is a useful practice technique. She quoted the authors to the effect that "psychological therapy techniques appear to be valuable in reducing the intensity of PTSD symptoms in a substantial proportion of patients" (p. 169). However, "psychological therapy techniques" (p. 169) did not refer to memory recovery work. They referred to interventions other than pharmacological ones. The majority of the so-called psychology therapy techniques reviewed were cognitive-behavioral interventions.
Aukamp continued with another quotation: "Effective treatments appear to involve relatively complex combinations of treatment methods, which may be best administered at service units specializing in this type of disorder" (Roth & Fonagy, 1996, p. 169). Again, this did not refer to memory work. In fact, memory recovery work was absent from the list of effective treatment methods. On the facing page, Roth et al. (1996) stated, "The current treatment of choice appears to be a combination of cognitive techniques (S[tress] I[noculation] T[herapy] and cognitive restructuring) and exposure" (p. 168).
Robert R. Fournier
Fournier said that problem resolution involves "suffering." I agree that individuals often experience discomfort as part of the problem-solving process. Where I part with Fournier is the belief that memory recovery work is a practice technique in which the benefits justify the extreme suffering experienced by many clients.
Fournier argued that improvement shown by individuals after withdrawing from memory therapy was an expectable result of the therapy itself. There are two reasons why such an interpretation is unlikely. The first relates to the studies (Pendergrast, 1995; Seltzer, 1994) reporting on client status before and after treatment involving memory work. No individuals showed improvement during memory therapy. All showed improvement after leaving such therapy. Although it is remotely possible that the benefits of memory work only manifest when an individual leaves therapy, it is not really credible. An analogous situation would be that of people losing no weight or even gaining weight while participating in a weight reduction program and losing weight after leaving it. Would it truly be credible that the weight loss was a delayed effect of the program?
The second reason Fournier's argument is implausible may be found in the Washington Department of Labor and Industries study (Parr, 1996). This was not a study of individuals who dropped out of memory recovery therapies. It was a longitudinal study of individuals involved in memory recovery work.
Presumably, the "fruits of the labor of therapy" would be due for harvest at three-year evaluation. However, these "fruits" included loss of job (73 percent of clients), separation or divorce (64 percent), loss of custody of children (33 percent), and self-mutilating behavior (27 percent) (Loftus, 1997; Parr, 1996).
Fournier asked where the hope for recovery was. It is a legitimate question that he did not address. He gave no evidence that memory recovery work resulted in improved outcomes. Where is the hope to balance the documented harm experienced by individuals participating in "therapeutic" attempts to recover abuse memories? Until he (or someone else) provides evidence that there are actual benefits that outweigh the harm associated with memory recovery work, the conclusion that these techniques should be avoided is, in my opinion, appropriate.
Barbara L. Weeks
Weeks argued that "recovered memories do not have to be completely accurate. They merely have to help survivors break through the cloak of denial that keeps them from accepting and facing the truth - that they were abused by the very people in their childhood who should have been protecting them and loving them in an appropriate way." Weeks also equated retracting abuse accusations with a "return to denial and repression . . ." Her argument rests on the questionable assumption that any person who recovers a memory of sexual abuse was, ipso facto, sexually abused.
There are many instances of recovered memories that have later been proven to be false (for example, Alkon, 1997; Yapko, 1994). Perhaps the best-known validated retraction involved Beth Rutherford. Ms. Rutherford entered counseling for sleep problems. Under her therapist's supervision, she recovered memories of being repeatedly raped by her father resulting in pregnancy and a coat-hanger abortion. Ms. Rutherford later retracted. A medical examination revealed not only that she had never been pregnant, but that she was a virgin. Furthermore, her father had obtained a vasectomy when she was four (Alkon, 1997; Associated Press, 1996).
Weeks expressed concern that my "attitudes" could lead insurers to stop coverage for interventions involving memory recovery. The concern is not one of "attitude" but of evidence. There are well-documented risks to the practice of memory work (Stocks, 1998). Dismissing these real risks as denial and repression will not help to make a reasonable case that insurers should pay for this work. Insurers have sufficient other reasons to be concerned about memory recovery. Many former clients are successfully suing memory recovery therapists for malpractice. For example, Beth Rutherford and her family received a settlement of $1 million after suing her therapist (Alkon, 1997; Associated Press, 1996).
Psychiatrist Kenneth Olson helped Nadean Cool "recover" memories of satanic abuse. He paid a settlement of $2.5 million. In a previous case Olson was ordered to pay total damages of $204,000 to another recovered memory patient (Jones, 1997).
Dr. Diane Humenansky was ordered to pay $2.3 million to a client who became suicidal after sexual abuse memories were "recovered." She also had to pay $150,000 to the plaintiffs husband for loss of companionship. Another of Humenansky's recovered memory patients received a $2.6 million award (Gustafson, 1996a, 1996b). Therapists using memory recovery techniques continue to be sued with awards ranging up to $10.6 million (Gregory, 1997).
In addition to civil lawsuits, memory recovery practitioners have had their licenses to practice suspended or removed (for example, Grumman, 1998; Gustafson, 1997). Currently, an administrator and four therapists from Spring Shadows Glen Hospital in Texas are facing federal criminal charges in connection with memory recovery work. The five are charged with collecting fraudulent insurance payments after convincing patients that they had been involved in a satanic cult (Smith, 1997b). One of the indicted therapists has already been ordered to pay $5.8 million in damages to a former Spring Shadows Glen patient who had recovered memories of murder, cannibalism, sexual abuse, and incest (Smith, 1997a).
Although Weeks has argued that there are benefits of recovered memory therapy, she has presented no evidence as to what these benefits might be or that they outweigh the documented risks of memory recovery work. This writer believes that it is her obligation to submit such evidence.
Boumgarden raises a number of interesting questions and issues with respect to assessment to identify clients appropriate for memory recovery work, identifying appropriate outcomes for participants in memory recovery work, and establishing the clinical skills necessary to engage in memory recovery work. However, these questions seem to be based in a number of questionable assumptions. If special clinical expertise is needed to engage in memory recovery work, then lack of expertise must be what accounts for the negative results experienced by many clients and their families. Nonetheless, expertise does not appear relevant to outcome in memory recovery work.
Dr. Renee Fredrickson is a recognized expert on repressed memories of sexual abuse. Her book, Repressed Memories: A Journey to Recovery from Sexual Abuse (Fredrickson, 1992), is a frequently cited work on recovered memories. Nevertheless, in 1997 Fredrickson was sued by a former patient who charged that Fredrickson used hypnosis, guided imagery, dream interpretation, automatic writing, body memories, and other memory recovery techniques to convince the patient that she had been a ritual abuse victim (Howatt, 1997). Dr. Fredrickson paid a settlement of $175,000. The patient has filed a complaint against Dr. Fredrickson with the Minnesota Board of Psychology that is currently under investigation by the Minnesota Attorney General's Office.
Dr. Bennet Braun is a well-known expert on multiple personality disorders (MPD). His publications on MPD include many articles, an edited symposium (1984) for the prestigious Psychiatric Clinics of North America as well as a book (1986) on treatment of multiple personality disorder published by the American Psychiatric Association's press. He is one of the founders of the International Society for the Study of Multiple Personality, the precursor organization to the International Society for the Study of Dissociation (ISSD). The ISSD has been cited as an accurate source of information about "the complexities and precautions about working with memories, recovered or otherwise" (see Ann W. Aukamp's response, this issue).
Dr. Braun helped Patricia Burgus "recover" memories of cannibalizing children, taking part in the kidnapping of children, sexually abusing her sons, and being sexually abused. Dr. Braun also admitted her four- and five-year-old sons to Rush-Presbyterian-St. Luke's Medical Center in Chicago for inpatient treatment that lasted from 1986 to 1989. Treatment of the children included receiving stickers for telling "yucky" stories about participation in ritual sacrifice and human torture (Gregory, 1997; Grumman, 1998).
After her medication levels were lowered, Ms. Burgus realized that her memories could not be true. She subsequently sued Dr. Braun for implanting false memories and received a $10.6 million dollar settlement. Currently, the Illinois Department of Professional Regulation is pursuing action to remove Dr. Braun's medical license (Gregory, 1997; Grumman, 1998). In both these instances, the therapists were not untrained nor were they inexpert. They were the trainers and the experts.
The suggestion that tools be developed to identify individuals appropriate for memory recovery work assumes that recovered memories have unique features requiring new ways of assessment. Similarly, the supposed need for identification of appropriate outcomes for individuals who have recovered abuse memories, presumes that they all experience the same concerns. However, there is no evidence for this. With respect to sexual abuse, there is no single syndrome (Beitchman, Zucker, Hood, daCosta, & Cassavia, 1992; Kendall-Tackett, Williams, & Finkelhor, 1993). Although adults who were sexually abused as children are more likely to experience difficulties in adulthood, not all do. Each adult encountering difficulties does not encounter the same ones, although commonly occurring problems include anxiety, depression, posttraumatic stress disorder, and sexual dysfunction (Beitchman et al., 1992).
The issue of identifying appropriate outcomes for memory recovery work participants seems to me to be a nonissue. There does not seem to be any difficulty establishing what are appropriate outcomes for anxiety, depression, posttraumatic stress disorder, and sexual dysfunction. There is already an extensive evaluation literature on these problems (Nathan & Gorman, 1998; Roth & Fonagy, 1996).
The identification of clients appropriate for memory recovery work presupposes that memory work is an effective technique for helping clients to reach their goals. However, there is no evidence to suggest this. It is putting the cart before the horse to propose that we develop instruments to find out which clients would benefit from memory recovery work before demonstrating that there is any benefit at all.
Snyder also seemed to miss the point of my article. I never said that memories are irrelevant to treatment. I said that we cannot distinguish between totally confabulated memories and recovered memories that are accurate representations of actual events.
Snyder mentioned the work of Bessel van der Kolk, although she did not discuss the relevance of the work nor provide any references. In fact, van der Kolk's research (for example, Rauch et al., 1996; van der Kolk, Burbridge, & Suzuki, 1997) does not address the accuracy of narratives based on recovered memories. In a nutshell, van der Kolk has suggested that, for individuals with posttraumatic stress disorder, "traumatic experiences initially are imprinted as sensations or feeling states and are not collated and transcribed into personal narratives" (van der Kolk et al., 1997, p. 110).
However, Christianson, Saisa, and Silfvenius (1995) found similar results that did not involve traumatic experiences. They used intercranoid sedation to inactivate the left or right brain hemispheres of patients with epilepsy. After sedation, the patients were shown pictures of ordinary faces along with short fictional biographies. The biographies depicted the person in pleasant, unpleasant, or neutral terms.
When left hemisphere sedation occurred, patients correctly classified the faces associated with negative biographies at a higher rate than faces associated with neutral or positive biographies. Although they could not recognize the biography content, faces associated with negative biographies were rated as more unpleasant than faces associated with neutral or positive biographies. These results suggest that different systems are involved in the memory of emotional components of an event and specific details of an event even when the event is not traumatic.
These findings provide an explanation for the creation of misleading memories in memory recovery work. "Emotional memories" may not be associated with any recoverable narrative memory. Because individuals tend to prefer to find explanations for feelings, they may construct explanations in the absence of any "real memory." This would account for the distortion and outright confabulation that occasionally occurs in flashback experiences (for example, Grunert, Devine, Matloub, Sanger, & Yousif, 1988; Rainey et al., 1987; Yapko, 1994) as well as in memories recovered in therapy.
Sandgrund identified some risks of memory recovery work. However, I am concerned that some parts of his reply could be interpreted as implying that all "recovered" memories are based in a traumatic past. "Traumatic memories" are not equivalent to recovered memories. Whereas the recovered memories discussed in my article were of purported traumatic incidents, not all recovered memories are of traumatic events. Furthermore, there are documented instances of recovered memories of trauma in the absence of any trauma (for example, Alkon, 1997; Associated Press, 1996; Gregory, 1997; Grumman, 1998).
It makes a difference whether a memory is accurate or not. People live within a network of social relationships. If a confabulation is accepted as "truth," it can needlessly disrupt important supportive relationships. Because no procedures can reliably distinguish confabulations from accurate memories, it is imperative that social workers inform clients of this.
In this context Sandgrund's caution that uncritical validation of recovered memories can be retraumatizing is well taken. As he notes, forceful pursuit of validation may create substitution of therapist suggestion for therapeutic work.
Hardwick objected to my use of the terms "recovered memory therapy" and "recovered memory techniques." She noted that these "labels do not describe the professional therapeutic practices traditionally taught at schools of social work, nor are they part of the Council on Social Work Education's curricular standards."
This is a good point. These are not typically taught in schools of social work nor are they part of the curricular standards. However, this raises the question of whether these procedures should be part of the curriculum. There is no systematic evidence that "recovered memories" are reliable. There is no systematic evidence that interventions based in the recovery of memories are helpful. On the basis of the currently available evidence, I conclude that we should not recommend these techniques.
Hardwick raised the issue of the accuracy of prevalence estimates for use of memory recovery techniques. This is a diversion from the point of contention. Whereas a dangerous intervention is of greater concern if more people use it, it does not follow that it is permissible if only a few people do it. The prevalence and incidence of recovered memory therapy is completely irrelevant to the issue of appropriateness.
An attempt at more substantive criticism involved the validity of the outcome studies for clients receiving recovered memory treatments. Hardwick proposed that my "failure to clarify the limitations of these studies leads the uncritical and untrained reader to assume unfounded ecological validity and generalizability of findings." There are three points I should like to make in response.
First, I reviewed some of the limitations of these studies on page 432 of my article. This section ended with this statement: "The outcomes of four studies do not in themselves constitute definitive proof that use of recovered memories in therapy is always to be avoided. The documentation of the effects of recovered memory therapy is incomplete. Further research in this area is indicated and is being conducted. Nonetheless, the available evidence indicates that individuals in recovered memory therapy are more likely to deteriorate than improve" (Stocks, 1998, p. 432). It strikes me that this reasonably addressed the contingent nature of the findings about the effects of recovered memory therapy.
Second, my remarks were within the context of the risks and benefits of recovered memory therapy. Hardwick did not address this issue. She did not present evidence as to whether benefits of memory work for individuals suspected of being sexually abused outweighed the documented harm. In fact, she presented no evidence of any benefit accruing as the result of recovered memory therapy.
Third, Social Work is a professional journal whose readers are professional social workers. I do not believe that professional social workers are, as Hardwick implied, "uncritical and untrained readers." I think our colleagues have the competence to critically evaluate the evidence presented in my article and in the responses to my article. I believe that our colleagues can reach valid conclusions from this evidence.
Hardwick portrayed my article as consisting of "gross innuendo rather than rigorous critique supported by recognized forms of evidence." I hope to be forgiven if I say that this seems more characteristic of her letter than my article. She has presented no evidence (of any recognizable form) that the benefits of memory work outweigh the risks. The burden of proof rests on the partisans of a practice technique to prove its efficacy. Hardwick is trying to shift this burden off her shoulders and onto mine. It is not my burden to bear; it is hers.
I am concerned by a veiled call for censorship at the end of Hardwick's letter. This is improper. If Hardwick disagrees with my conclusions, then let her show how to distinguish true from false recovered memories. Let her demonstrate that the benefits of memory work for suspected sexual abuse survivors outweigh the risks.
True and false memories can be obtained using memory recovery techniques. There is no reliable way to discriminate between true and false recovered memories. There is no empirical evidence to suggest that memory recovery therapy results in improved outcomes for clients. There is evidence that indicates that individuals deteriorate while receiving therapy involving memory recovery.
Section 1.03(a) of the NASW Code of Ethics (1996) reads: "Social workers should provide services to clients only in the context of a professional relationship based, when appropriate, on valid informed consent. Social workers should use clear and understandable language to inform clients of the purpose of the services, risks related to the services, limits to services because of the requirements of a third-party payer, relevant costs, reasonable alternatives, clients' right to refuse or withdraw consent, and the time frame covered by the consent. Social workers should provide clients with an opportunity to ask questions."
If a social worker decides to use memory recovery techniques, the client must be informed of the specific risks associated with memory recovery work. The decision rests with the client as to whether he or she would choose to participate in a program where there is documented risk and no evidence of benefit or in another program were there is evidence for benefit and minimal risk. Only by giving the client this information do we fulfill our ethical responsibility to protect our client from harm and to enhance his or her right to self-determination.
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J. T. Stocks, MSW, PhD, is assistant professor, School of Social Work, Michigan State University, Baker Hall, East Lansing, MI 48824-1118; e-mail: firstname.lastname@example.org.
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