Recovered memory therapy: a dubious practice technique.
This article examines the validity of memory work as well as the
evidence for the efficacy of therapeutic interventions based in the
recovery of childhood sexual abuse memories. Evidence suggests that both
true and false memories can be recovered using memory work techniques,
and there is no evidence that reliable discriminations can be made
between them. Similarly, there is no empirical evidence to suggest that
recovered memory therapy results in improved outcomes for participating
clients. The article reviews current treatment outcome research and
suggests that participation in recovered memory therapy may be harmful
Key words: child abuse; memory work; psychotherapy; repression; sexual abuse
Sexually abused children
(Care and treatment)
Child psychotherapy (Evaluation)
Recovered memory (Psychology) (Analysis)
Child sexual abuse (Care and treatment)
Child psychiatric services (Evaluation)
|Publication:||Name: Social Work Publisher: National Association of Social Workers Audience: Academic Format: Magazine/Journal Subject: Sociology and social work Copyright: COPYRIGHT 1998 National Association of Social Workers ISSN: 0037-8046|
|Issue:||Date: Sept, 1998 Source Volume: v43 Source Issue: n5|
Throughout most of this century, public response to the sexual abuse
of children had been to disregard, minimize, or deny allegations of
child sexual abuse (Brownmiller, 1975; Finkelhor, 1979; Hechler, 1988).
Incest was said to be a very rare event, involving fewer than two
offenders per million population (Weinberg, 1955). In the 1970s reports
in the clinical and popular literature indicated that child sexual abuse
was more extensive than hitherto accepted (for example, Browning ex
Boatman, 1977; Butler, 1978; Giaretto, 1978; Herman & Hirschman,
1977; Kempe, 1978; Meiselman, 1978). Subsequent survey studies showed
the wide extent of child sexual abuse (for example, Finkelhor, 1979,
1984; Fritz, Stoll, & Wagner, 1981; Russell, 1983, 1984).
In the late 1980s reports of a previously undiscussed sexual abuse phenomenon appeared. Some therapists reported that adult clients had regained formerly lost memories of childhood sexual abuse (Blume, 1990; Courtois, 1988; Olio, 1989). Later survey studies indicated that some individuals forgot being sexually abused (Briere & Conte, 1993; Gold, Hawes, & Hohnecker, 1994; Williams, 1994, 1995). In later studies, Briere and Conte (1993) surveyed 450 adults in therapy who reported sexual abuse histories. Of these, 59 percent reported some period before age 18 when they could not remember their abuse, although there was no independent corroboration of the abuse reports. Gold et al. (1994) surveyed 105 adults in treatment for child sexual abuse issues. About 30 percent of their respondents reported a time period when they completely blocked any recollection of abuse. As was the case previously, there was no independent corroboration of the abuse incident.
Williams (1994, 1995) conducted a longitudinal follow-up study of 206 women who had been treated as girls at a hospital emergency room for sexual abuse. This study, with its prospective design, was an improvement over the previous retrospective studies. Of the 206 women, 129 (63 percent) were interviewed. 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). These reports led many mental health workers to conclude that childhood sexual abuse memories were often repressed. For those clients whom they suspected of being sexually molested in childhood, attempts were made to recover abuse memories - "recovered memory therapy." A recovered memory therapist presumably can identify symptoms of forgotten childhood sexual abuse. The damaging nature of these unavailable memories makes it necessary that they be recovered and addressed in therapy. This is accomplished using memory recovery techniques (Bass &Davis, 1988; Blume, 1990;Courtois, 1988; Frederickson, 1992; Olio, 1989).
However, other clinicians and researchers questioned the validity of some recovered memories (Ceci, Huffman, & Smith, 1994; Ceci & Loftus, 1994; Goldstein & Farmer, 1992; Loftus, 1993; Loftus & Ketcham, 1994; Yapko, 1994). Also, many former memory recovery clients retracted childhood sexual abuse allegations, saying that memory recovery techniques had led to distorted or confabulated recollections (Lief & Fetkewicz, 1995; Merskey, 1996; Seltzer, 1994; Wakefield & Underwager, 1994).
In light of societal ambivalence toward child maltreatment issues, it is not surprising that many workers equate doubts about memory recovery with doubts about the reality of sexual abuse. Some memory recovery advocates characterized these concerns as denial or minimization or even as "backlash" (Fowler, 1994; Hechler, 1988; Herman & Harvey, 1993). However, skepticism about many claims of recovered memory is not equivalent to skepticism about the reality of sexual abuse. Although child maltreatment and sexual abuse are authentic social and personal problems, it is not clear that memories obtained through memory work are equally authentic. There are grounds for concern about recovered memory therapy that do not involve denial, minimization, or backlash.
This article addresses two areas of research into recovered memory therapy. The first covers research on the validity of memories derived from specific memory recovery techniques. The second entails an examination of recent information on the effects of recovered memory therapy on client outcome.
Memory Recovery Techniques
Sexual Abuse Symptoms
Several authors have suggested a post-sexual abuse syndrome. Briere (1984) proposed a trait cluster associated with sexual abuse including fear, self-injurious feelings, anger problems, chronic muscle tension, and symptoms of dissociation and withdrawal. Bass and Davis (1988) cited eating disorders, drug or alcohol addiction, suicidal feelings, and sexual problems as symptoms of sexual abuse. Blume (1990) described a "post-incest syndrome" (p. vi) and developed an Incest Survivors' Aftereffects Checklist. The checklist includes physical symptoms (for example, arthritis, eating disorders, gynecological disorders, headaches) and psychological signs (for example, phobias, depression, suicidal ideation, low self-esteem, memory gaps).
There is a prevailing belief in a post-sexual abuse syndrome among psychotherapists. Poole, Lindsay, Memon, and Bull (1995) conducted two surveys of U.S. and one of British psychotherapists about recovered memory issues. They found that 36 percent of U.S. respondents and 37 percent of British respondents interpreted physical symptoms in the process of recovering memories of sexual abuse. The Blume (1990) checklist is still widely used and has the endorsement of a prominent therapist who called it a useful "guide for the therapist" (Walker, 1994, p. 114). Despite the belief, there is no empirical evidence for a post-sexual abuse syndrome.
In their extensive review of the sexual abuse literature, Beitchman, Zucker, Hood, daCosta, and Cassavia (1992) found evidence that sexual abuse sequelae may involve a wide array of psychological disorders in adulthood. However, they found no evidence for a post-sexual abuse syndrome. Another review on sexual abuse sequelae for children by Kendall-Tackett, Williams, and Finkelhor (1993) reported similar findings. Although sexually abused children experienced more difficulties than nonabused children, no symptom characterized a majority. The authors concluded that there was no specific syndrome and no single traumatizing process.
Bulimia and other eating disorders are frequently cited as symptoms of childhood sexual abuse (Bass & Davis, 1988; Blume, 1990; Goldfarb, 1987; Poston & Lison, 1989). Pope and Hudson (1992) reviewed the scientific literature on bulimia nervosa and reported that controlled studies generally did not find that bulimic patients showed significantly higher prevalence of childhood sexual abuse than control groups. Neither controlled nor uncontrolled studies found higher rates of childhood sexual abuse than were found in studies of the general population that used comparable methods.
The issue of memory gaps in childhood bears special attention. Blume (1990) alleged that "many incest survivors 'lose' years of their childhood, most frequently ages 1 through 12. In fact, it is a serious 'red flag' to me when a client can't remember much of her childhood. This common occurrence, which psychotherapy has failed to attribute to any specific common theme, generally indicates severe physical or emotional abuse (such as incest)" (p. 108).
Siegel (1995) reviewed the literature on memory development and found that many adults who experienced a nonclinical, normal development reported that they did not recall details from childhood: "Clinical implications of these findings are that therapists should not overzealously interpret lack of recall as a pathognomic indicator of 'repressed' trauma. Also, an increased tendency to recall childhood in midlife may be a normal developmental event and not a sign that something in childhood is 'hidden' and now is intruding on consciousness" (p. 108).
A variation on the symptom notion is that of the "body memory" of sexual abuse (Bass & Davis, 1988; Blume, 1990; Courtois, 1992; Frederickson, 1992): "The body stores the memories of incest, and I have heard of dramatic uncovering and recovery of feelings and experiences through body work. This type of therapy includes massage therapy and other traditional forms of body work, as well as newer types or adaptations specifically designed to unlock memories of such childhood traumas as incest" (Blume, 1990, p. 279). In its most common form, the body memory notion is that the body stores memories at the cellular level outside the brain. The body then independently attempts to communicate about abuse through particular somatic illnesses, signs, or stigmata (see, for example, Smith & Pazder, 1980).
There is no evidence that memories are "stored" anywhere but in the brain. However, there are studies suggesting that the brain processes and stores information in more than one way. Two proposed processes are implicit and explicit memory. Implicit memory develops earlier and refers to behavioral memory processes. It also involves emotional and sensory recall. Explicit memory develops later and refers to declarative, narrative memory (Schacter, 1987; Schacter, Chiu, & Ochsner, 1993; Squire, 1992a, 1992b).
"Body work" based in this less extreme notion assumes that implicit memories may be translated into explicit, narrative form. There is no empirical evidence that it can make this translation. Indeed, there is no evidence that such memories are reliable or even that implicit memories themselves are necessarily reliable.
Studies of the development of autobiographical memory indicate that subsequent discussion of early (implicit) memories can change recall of an event (Destun & Kuiper, 1996; Fivush & Hudson, 1990; Nelson, 1993). This opens the door for error and distortion of the implicit memory in the explicit memory system. There is no guarantee that the explanation for the implicit memory will be correct. In her discussion of the development of autobiographical memory, Nelson (1993) noted the separateness of event and autobiographical memory:
The validity of any given memory is not relevant within the present theoretical framework. Although the validity of a memory may be of concern if one is interested in such issues as whether children are reliable witnesses, it is of less concern if one is interested in when they begin to retain memories in the autobiographical memory system. Memories do not need to be true or correct to be part of that system. [italics added] (p. 8)
Whereas the notion of "body memories" is common in the recovered memory literature, Poole et al. (1995) found that fewer than 5 percent in the British and U.S. samples listed body memories as symptoms of childhood sexual abuse.
Hypnosis and hypnotic age regression are often used to recover memories (Claridge, 1992; Courtois, 1988; Feldman, 1993; Gilligan & Kennedy, 1989; Spiegel, 1989). In the Poole et al. (1995) survey, between 29 percent and 34 percent of U.S. respondents, but only 5 percent of British respondents, reported using hypnosis to recover memories.
Many mental health workers in the United States believe that hypnosis is a way of reliably uncovering memories. Yapko (1994) surveyed therapists at psychotherapy conventions about their attitudes toward using hypnosis in memory work. About 47 percent of respondents agreed with the statement that "therapists can have greater faith in details of a traumatic event when obtained hypnotically than otherwise." Also, about 31 percent endorsed the item "When someone has a memory of a trauma while in hypnosis, it objectively must have actually occurred." Over half (54 percent) believed that "hypnosis can be used to recover memories as far back as birth."
Although hypnosis can increase the amount of information and vividness of recall, such information occurs for accurate as well as inaccurate recall. There are many examples of individuals confidently reporting hypnotically induced false memories as real ones (see, for example, Orne, 1959, 1979; Spiegel, 1974). These and other studies (Dywan & Bowers, 1983; Perry & Laurence, 1983; Smith, 1983) demonstrating the limitations of hypnotic memory recovery led the Council on Scientific Affairs of the American Medical Association (1986) to conduct a study of recall during hypnosis. The council reported that such recollections were often less reliable than nonhypnotic recall. Subsequent research has supported the findings that hypnosis is an unreliable memory recovery method (Coons, 1988; Lynn & Nash, 1994; Spanos, Quigley, Gwynn, & Glatt, 1991).
Detailed memories of "past lives" and unidentified flying object abductions have also been recovered under hypnosis (Jacobs, 1992; Kampman, 1976; Klass, 1989; Nash, 1994; Warnbach, 1979). This recovery of such evidently impossible events is compelling evidence that hypnosis can produce powerful but erroneous memories.
Conscious thought can be controlled; conscious awareness can be altered by defenses. But in sleep realities that are carefully masked during wakefulness can leak out. The dreams of many incest survivors are specific versions of the nightmares predicted by posttraumatic distress disorder. Horror-filled, terrifying, full of images of entrapment and violence - they represent the themes of incest. (Blume, 1990, p. 98)
Dream interpretation is often used to retrieve abuse memories (Blume, 1990; Edward, 1987; Frederickson, 1992; Paley, 1992). Between 37 percent and 44 percent of the U.S. therapists and 25 percent of the British therapists surveyed by Poole et al. (1995) reported using dream interpretation as a way of recovering abuse memories. The assumption is that dreams are a gateway to repressed memories. The worker helps the client to recover memories of childhood sexual abuse by using the dream content and associated emotional states as a starting point for the process of developing recollection.
There is no empirical evidence that analysis of dream content (whether by client, worker, or both) leads to accurate memory recovery. The empirical research indicates that dreams tend to incorporate material from the immediately preceding day (Nielsen & Powell, 1992). Thus, a dream about incest could simply reflect the content of a magazine article read in a waiting room.
One chilling scenario could involve a therapist discussing the possibility of incest in a therapy session. The material under discussion would then be reorganized into an incest dream. The next step would be the interpretation of the dream as evidence of past sexual abuse and further discussion of possible incest in therapy. The cycle would continue until a memory of incest was"recovered."
Analysis of flashbacks is similar to dream work. Memory recovery advocates regard them as accurate, intrusive recall of a traumatic experience: "Flashbacks are the re-living of a traumatic experience, or an aspect of a trauma, as if it were happening now. Along with sensory flashes, they are a virtually universal component of Post-Incest Syndrome" (Blume, 1990, p. 100). There is no empirical evidence for the preceding statement. Flashback research suggests that flashback content can be strongly influenced by expectations and context (Grunert, Devine, Matloub, Sanger, & Yousir, 1988; Rainey et al., 1987).
Despite frequent discussion in the recovered memory literature (Bass & Davis, 1988; Blume, 1990), flashback analysis does not appear to be a frequently used technique. Fewer than 5 percent of Poole et al.'s (1995) sample regarded flashbacks as being diagnostic of childhood sexual abuse. Slightly more (U.S. = 7 percent to 9 percent; British = 3 percent) regarded vague, intrusive memories as indicators of sexual abuse.
The term "flashback" came from fictional literature and films. It was later applied to hallucinations and emotional reactions occurring after the use of a psychedelic drug (Matefy, Hayes, & Hirsch, 1978). Flashback seems to have been applied to posttraumatic experiences in the 1980s (Frankel, 1994). Over the next decade, these events were treated as if they were accurate repetitions of trauma, although there were no reports on how to distinguish them from fantasies, hallucinations, illusions, or distorted memories.
Two studies are particularly relevant to the accuracy issue. Grunert et al. (1988) described flashbacks following traumatic hand injuries. In about 60 percent of the individuals, an injury more severe than the one that had occurred was reported under flashback. This occurred even when the recent injury had not been forgotten.
Rainey et al. (1987) induced flashbacks in seven patients with a diagnosis of posttraumatic stress disorder. One reported a vision of watching a surgical operation on himself. Another reported seeing himself strapped down after losing consciousness and having a seizure. A third patient reported seeing himself kill a woman who repeatedly got up to be killed again. None of these incidents actually occurred. These studies demonstrate that, in many cases, the content of a flashback incident may be distorted or manufactured.
Yapko (1994) reported a striking example of totally confabulated flashbacks. It involved an individual diagnosed with posttraumatic stress disorder as a result of prisoner of war experiences in Vietnam. This man, who ultimately committed suicide, displayed the full array of symptoms, including flashbacks. When his wife, with the support of his therapist, attempted to have his name placed on his state's Vietnam memorial, it was discovered that he had never been to Vietnam.
Journals or writing exercises are also used to recover incest memories. Poole et al. (1995) reported that about 32 percent of British therapists and between 29 percent and 50 percent of U.S. therapists reported using journaling or instructions to try to remember sexual abuse.
Journaling involves having the client start with a central detail such as a feeling or idea and record in words the sensations and thoughts that arise (Frederickson, 1992). The client is instructed to attempt nonevaluative stream-of-consciousness writing. Bass and Davis (1988) advised: "If you don't remember what happened to you, write about what you do remember. Re-create the context in which the abuse happened, even if you don't remember the specifics of the abuse yet" (p. 83).
Journaling is also used to strengthen and allow for elaboration of a recently recovered memory. Courtois (1988) wrote, "Writing a detailed autobiography can help the survivor acknowledge details about the past and works against "reformatting," a not uncommon occurrence. Even when repression is strong and memories sketchy, the survivor can be encouraged to write what she does remember. This can serve as a general framework for additional memories" (p, 195).
There is no empirical evidence that journaling leads to accurate memory recovery. There is, however, evidence that repeatedly thinking about a fictitious event can lead an individual to believe that he or she actually experienced it (Ceci et al., 1994; Roediger, Jacoby, & McDermott, 1996).
Destun and Kuiper (1996) observed that because
techniques such as journaling encourage clients to rehearse versions of childhood memories that are often deliberately embellished in therapy, it is possible that this rehearsal could lead to clients' increased acceptance and belief in these memories. By the same token, the passage of time between the episode being remembered and therapy, in combination with the fact that the therapist might be perceived by the client to be in a position of relative authority, might serve to increase the client's acceptance of a memory that is, at least in part, a product of therapist suggestions. (p. 426)
Guided imagery is a form of psychodrama in which the client achieves a relaxed state and then pictures scenarios suggested by the therapist. The starting point is an intuition from which the client and worker try to uncover emotionally charged early memories (Edwards, 1990). Between 26 percent and 32 percent of U.S. therapists and 14 percent of British therapists reported using guided imagery in memory work (Poole et al., 1995).
There is no evidence that guided imagery results in the recovery of accurate memories as opposed to confabulations. Several forensic psychologists (for example, Gudjonsson, 1985; Perry & Nogrady, 1985) have concluded that guided imagery promotes a state similar to that of hypnosis and is equally unreliable.
Task-motivated respondents (having a strong desire to accede to the desires of the researcher) have been found to be as open to an inserted memory as hypnotized respondents (Weekes, Lynn, Green, & Brentar, 1992). Hyman and Pentland (1996) found that respondents in a guided imagery condition were more likely than controls to remember true events from their pasts (based on parental reports) as well as false events (created by the researchers).
Of course, people who seek therapy are highly task motivated. Because the therapist is a significant figure to most clients, they have a desire to be evaluated by their therapist as "good." This desire creates a powerful incentive to tailor memories to the therapist's pattern.
Sodium amytal (amobarbitol), the so-called truth serum, is a barbiturate. Its effects include drowsiness, feelings of inebriation, relaxation, a sense of well-being, and a willingness to discuss things one usually would not discuss with strangers (Naples & Hackett, 1978). Amytal is sometimes used to enhance recall. Other sedatives have also been used in memory recovery interviews - barbiturates (for example, Brevital, Nembutal, and Pentothal) and benzodiazepines (for example, Ativan and Valium). These drugs have similar effects to amytal (Piper, 1993).
The amytal interviewer begins by telling the client that he or she is receiving a drug that will cause relaxation and create a desire to talk. Clients are to be reassured that they are not receiving a "truth serum." The interviewer begins discussing neutral topics and gradually moves on to more threatening issues as the drug takes effect. Periodically, small amounts of amytal are injected to keep the individual in a drowsy but awake state (twilight state) until the interview is completed. An interview usually lasts about an hour (Piper, 1993). Its proponents (for example, Herman, 1992; Terr, 1994) assert that it is sometimes useful in detecting deception and recovering memories. Presumably, amytal weakens "repressive ego forces" (Whiskin, 1974, p. 199) so that unconscious content can surface.
Amytal interviews are similar to hypnotic interviews (Kwentus, 1981). Lack of attention to the environment, suggestibility, suspension of critical judgment, a sense of lethargy, and the willingness to focus attention on command are typical of amytal and hypnotic interviews (Beahrs, 1989; Kraines, 1967). Thus, it should not be surprising that amytal and hypnotic interviews are similarly problematic.
Furthermore, amytal interviews are not always conducted according to the protocol described by Piper (1993). In 1994, Gary Ramona sued two therapists and a medical center for allegedly creating false memories of him sexually abusing his daughter. In the trial, it was established that Ramona's daughter was told that a memory of abuse recovered under sodium amytal would be true. Ramona received a $500,000 jury award (Slovenko, 1995).
Dysken, Kooser, Haraszti, and Davis (1979) carried out a double-blind, randomized, placebo-controlled study on the utility of amytal interviews. The individuals studied were 20 hospitalized patients with varied diagnoses (about half were schizophrenic). Both amytal and placebo injections were found to be moderately useful in obtaining new information, although no statistically significant differences were found between placebo and amytal patients with respect to the primary therapists' ratings of clinical usefulness of the interview results.
Kwentus (1981) evaluated the clinical usefulness of intravenous drugs in psychiatric interviews. It was noted that barbiturates depress cerebral cortex functioning, making people more suggestible and less observant. Kwentus raised the concern that drug-assisted suggestion could be akin to brainwashing. Kraines (1967) observed that although intravenous sodium amytal provided immediate relief from tension and enhanced rapport, it produced a state in which the patient was less resistant and more willing to accept the therapist's suggestions.
Piper's (1993) review of the medical literature did not encourage use of amytal interviews:
The degree of agreement in the literature is striking: numerous studies were reviewed for the present article, but not a single investigator who had actually conducted Amytal interviews endorsed this procedure as a means of recovering accurate memories of past events. Barbiturate-facilitated interviews intended to recover memories of childhood sexual abuse may be worse than useless, because they may encourage patients' beliefs in completely mythical events. (p. 465)
Participation in an incest therapy group usually stimulates the memory recovery as members "chain" from each other's experiences. Group further allows the validation of memories and support in expression, since other members have had similar experiences. In fact, a group can be such a powerful catalyst to recall that it is sometimes necessary for the leaders to slow the process to avoid flooding of memories and emotions and to allow time for reintegration. (Courtois, 1988, p. 299)
Some therapists regard participation in incest survivors' groups to be "a powerful stimulus for recovery of memory in patients with severe amnesia" (Herman & Schatzow, 1987, p. 9). Herman and Schatzow's study of clients in their incest survivor groups is sometimes cited as showing that incest group work is a way of regaining reliable memories of childhood sexual abuse. The authors reported that 39 (74 percent) clients in their groups were able to obtain proof of sexual abuse. This group consisted of 20 women with no amnesia (38 percent), 19 women with moderate (some recall) amnesia (36 percent), and 14 women with severe amnesia (26 percent). However, the authors never computed what percentages of clients within each of the amnesia conditions were able to obtain confirmation of their memories (J. L. Herman, personal communication, September 6, 1996). This raises the prospect that virtually no confirmations were obtained from clients who had no prior memory of sexual abuse.
Another serious problem is the nature of proof. The confirmation of a memory was based on the clients' reports that the clients themselves had obtained proof. There was no indication that the authors cross-checked these reports. This lack of confirmation is problematic because the desire to please the therapist may influence clients' reports (Spence, 1982; Weekes et al, 1992).
Finally, a group itself is a powerful controller of behavior. Forty years ago, Asch (1956) demonstrated how groups can enforce conformity to the extent that members will make statements that are inconsistent with observable fact. This should lead to extreme caution in evaluation of memories "uncovered" in survivors' groups.
Disputing Client Doubts
"You must believe that your client was sexually abused, even if she sometimes doubts it herself. Doubting is part of the process of coming to terms with abuse. Your client needs you to stay steady in the belief that she was abused. Joining a client in doubt would be like joining a suicidal client in her belief that suicide is the best way out" (Bass & Davis, 1988, p. 347). However, there are many examples of memories of traumatic incidents that are not true (Ceci & Loftus, 1994; Goldstein & Farmer, 1992; Hilts, 1995; Lief& Fetkewicz, 1995; Loftus, 1993; Loftus & Ketcham, 1994; Terr, 1994; Wakefield & Underwager, 1992, 1994; Yapko, 1994).
Cognitive development theorist Jean Piaget (1951/1962) reported on what may be the most famous example of an erroneous memory. When Piaget was two, his governess reported that she had thwarted an attempt to kidnap young Jean. Piaget had vivid memories of the incident until he was 15. At this time, the governess sent the parents a letter saying that she wished to confess and return the watch she had been given as a reward. She had made up the entire story.
Terr (1994) reported an incident involving a 32-year-old woman who "saw" her grandfather "standing at her feet and putting something painful into her vagina. Her therapist advised [the client] to tell her mother at once, and to consider revealing publicly what her famous grandfather had done" (p. 162). Terr asked the mother about the client's childhood medical history. An alternative explanation emerged. When the daughter was three, she underwent a painful medical procedure for treatment of "giggle bladder." The urologist was a tall, bearded, dignified man who looked almost exactly like the grandfather.
The consequences of uncritically affirming abuse are obvious. In the preceding case, what might have occurred had the advice of Bass and Davis (1988) been followed and alternative explanations been rejected?
Outcome of Recovered Memory Therapy
Studies of individuals who have retracted abuse claims have found deterioration rather than improvement under recovered memory therapy (Lief & Fetkewicz, 1995; Loftus & Ketcham, 1994; Pendergrast, 1995; Seltzer, 1994). Loftus (in press) noted that as of 1994, about 300 individuals had retracted allegations of sexual abuse based on recovered memories. A number of these successfully sued their former therapists for malpractice (Lief & Fetkewicz, 1995; Merskey, 1996; Slovenko, 1995).
Seltzer (1994) found deterioration for four of five individuals during recovered memory therapy. Problems emerging during therapy included self-mutilation, suicidality, amnesic episodes, and loss of custody of children. All five study participants showed improvement following cessation of recovered memory therapy.
Pendergrast (1995) reported on seven former recovered memory patients, including two individuals who became suicidal after beginning recovered memory therapy, and an additional two who began self-mutilation. Four people reported onset of sleep disorders and nightmares, and two were hospitalized in psychiatric facilities after starting therapy. All seven reported deterioration after beginning and improvement after terminating recovered memory therapy.
Lief and Fetkewicz (1995) reported on 40 individuals who had retracted allegations based on recovered memories. Thirty-three of these reported that their therapists suggested that they had been sexually abused before recovery of memories. After entering recovered memory therapy, all 40 showed deterioration including increases in self-mutilation, suicidal ideation, and frequency of suicide attempts.
More recently, a study by the Washington State Crime Victims Compensation Program (Parr, 1996) raised serious questions about the appropriateness of recovered memory treatment. Under the Crime Victims Act (1990), individuals had been allowed to seek compensation from the State of Washington for prior abuse if their memories of the abuse had been repressed but then returned. Between 1991 and 1995, 325 claims received some compensation under the repressed memory provision of the act. In 1995 staff from the Department of Labor and Industries analyzed 132 of these cases. From the analysis group, 30 cases were selected for intensive study (Loftus, in press; Parr, 1996).
The 30 cases involved 29 females and one male with ages ranging from 15 to 67. Memories emerged during therapy for 26 (87 percent) of the individuals. All individuals were receiving therapy three years after the first recovered memory, and 18 (60 percent) were still in therapy after five years (Parr, 1996).
Overall, the status of the individuals in the sample deteriorated during treatment. Before memory recovery, three (10 percent) of the sample had attempted or thought of suicide. After the emergence of memories, 20 (67 percent) had attempted or considered suicide, Before memories appeared, one individual had engaged in self-mutilation; afterward, eight (27 percent) had. Two (7 percent) were hospitalized before memory recovery; afterward, 11 (37 percent) were hospitalized (Loftus, in press).
Before going into therapy, 25 (83 percent) had jobs. After three years, only three (10 percent) had jobs. Twenty-eight (93 percent) were married when entering therapy. At three years, 18 of the 28 (64 percent) were separated or divorced. Twenty-one patients had children, and seven (33 percent) subsequently lost custody during therapy (Loftus, in press; Parr, 1996). Twenty-nine of the 30 said that they had been abused in the context of satanic rituals. Reported experiences included torture and mutilation. Medical examination did not reveal any evidence of mutilation (Loftus, in press; Parr, 1996).
The Parr (1996) report concluded that the data indicated that patients in
therapy designed to excavate memories experience an unusually high incidence of serious symptoms that include self-mutilation, suicidal ideation, the loss of family, friends and other meaningful relationships. Some patients become agoraphobic while others require inpatient hospitalization. Many require medications. Usually these symptoms were either not in evidence at the time therapy is initiated, or were mild and unremarkable. [italics added] (p. 18)
This article has addressed two areas of research about recovered memory therapy: the evidence for the validity of recollections derived from specific memory recovery techniques and recent information on the impact of recovered memory therapy on client outcome. A review of the literature on memory recovery techniques supports the conclusion that such techniques do not reliably recover valid memories. Although each of the techniques may lead to recovery of accurate memories, they can also result in the recovery of distorted or wholly constructed memories.
Furthermore, there are no procedures that have been demonstrated to reliably distinguish confabulations from accurate memories. Similarly, no symptom cluster has been demonstrated to reliably identify individuals who have "repressed" memories of abuse. Aside from direct historical evidence, there are no empirical criteria for reliably determining whether a recovered memory conforms to an actual occurrence or is an iatrogenic mirage.
Although recovered memories may not be accurate, it has been argued that they still have clinical utility (compare Fowler, 1994). Currently, the outcome research on use of recovered memories in therapy is thin. As of this writing, four studies were found that systematically evaluated outcomes of clients who had received recovered memory therapy. None of them supported the notion that recovered memories had clinical utility. In fact, each study demonstrated deterioration for clients while in recovered memory therapy.
Three of the four outcome studies (Lief & Fetkewicz, 1995; Pendergrast, 1995; Seltzer, 1994) involved individuals who had retracted allegations based on recovered memories and had left recovered memory therapy because of dissatisfaction with treatment. These individuals may have been from atypical populations for whom recovered memory therapy leads to deterioration. However, the Washington Crime Victims Compensation Program sample (Parr, 1996) were not self-selected from dropouts or retractors. That they also showed deterioration does not support a "special population" explanation of poor outcome.
Another explanation for the decline during therapy is that the abuse trauma was so severe that the clients would have shown deterioration without recovered memory therapy. However, deterioration stopped and was even reversed when individuals left recovered memory therapy (Pendergrast, 1995; Seltzer, 1994). Such findings are more indicative of iatrogenically induced deterioration than a delayed or ongoing response to sexual trauma.
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.
There is no reasonable dispute as to the seriousness of child sexual abuse. There is likewise no reasonable dispute that many childhood sexual abuse survivors experience difficulties as a result of their abuse experiences. Appropriate therapeutic intervention can he helpful for abuse survivors.
The primary responsibility of social workers is to promote the well-being of clients. Currently, there is no evidence that the benefits of recovered memory therapy outweigh its risks. This raises serious questions about the appropriateness of memory recovery work in therapy.
Social workers also have an obligation to inform clients of the purposes of and risks related to the services they provide. Social workers providing memory recovery services have an ethical obligation to inform their clients that the reliability of recovered memories is questionable and that there is no empirical evidence that the benefits of participation in recovered memory therapy outweigh its risks.
Clearly, more research needs to be carried out with respect to the effects of recovered memory therapy. However, until evidence is presented demonstrating that the benefits of recovered memory therapy exceed its risks, social workers should seriously consider avoiding the use of this practice technique.
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J. T. Stocks, MSW, PhD, is assistant professor, School of Social Work, Michigan State University, Baker Hall, East Lansing, M148824-1118; e-mail: firstname.lastname@example.org. The author thanks Diane Levande, Rena Harold, Mary Hilliard, and an anonymous reviewer for their critical comments on an earlier draft of this article.
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