What did that monster do to you?!!" - Joanne Woodward as Comelia Wilbur, MD, referring to the mother of "Sibyl" (Sally Field) in the movie of the same name.
In this example, our sympathies as audience with the outrage of the therapist on behalf of her beleaguered patient might well lead us to gloss over the former's rather evident breach of therapeutic neutrality. But note that the story of Sibyl differs in one extremely important respect from many clinical vignettes: this therapist left her therapeutic chair and donned the mantle of investigator and, in that role, corroborated her patient's story, down to the purple chalk marks on the inside of a chest. Such validation of actual monsterhood is rare.
Our field is at present engaged in a debate about such historical memories of childhood abuse recovered in the course of psychotherapy of adults. With our growing awareness of the important role of childhood trauma in adult psychopathology, appropriate attention is given to such memories. According to some theorists, however, inappropriate attention is being accorded as well.
To briefly summarize a complex debate, recent evidence has been revealed as to the unreliability of the process of memory generally and of the particularly suspect validity of memories recovered under certain circumstances. Some scholars, including Loftus1,2 and others3,4 have demonstrated that memories are easily contaminated; that false memories can be experimentally implanted; and that memories can be produced - perhaps as fabrications - in response to therapist pressures and expectations. This literature has recently received an excellent and comprehensive review by Wakefield and Underwager.4 Other dimensions of this problem are addressed in an excellent succinct discussion by Appelbaum.5
So widespread is the problem of possible false accusations that a group of accused parents (survivors?) who claim the accusations against them are false have formed the False Memory Syndrome Foundation (3508 Market St., Suite 128, Philadelphia, PA 19104), a tax-exempt research and educational institute that disseminates data with which to challenge allegedly recovered memories of alleged abuse.
Other scholars6 have countered that patient memories should be trusted in the service of empathie understanding of victims and validation of their traumas in the service of healing. They suggest that experimental study of memory fails to capture the reality of memory of trauma in clinical, as opposed to laboratory, settings. They suggest that the appearance of such research is part of a defensive backlash against increasing awareness of the widespread occurrence of sexual abuse.
A forensic perspective (in this instance, drawing on my own experience with such cases) may be necessary because of the frequency with which the question of recovered memories of child sexual abuse is examined, not in clinicians' offices or memory researchers' experimental sites, but in the courtrooms.
I have found it useful to begin such an inquiry with some axioms:
* Child sexual abuse is an evil that is real, underreported, and very harmful.
* Like most human phenomena, memories may range from utterly true to utterly false and everything in between.
* Courtrooms, though striving for justice, can almost always attain at best an adversarialized approximation of the truth, based on evidence that may, indeed, be ruled inadmissible in some situations and admissible in others. But if a matter is brought to the courtroom for resolution, then courtroom rules will prevail, including rules of evidence and an adversary context that requires two sides to every case.
* This adversarial context contrasts sharply with the alliance-based relationship and atmosphere of therapy.
To orient ourselves for this discussion, let us distinguish the true and the real. Something may be true for a person, in the sense of deeply held, strongly believed, and expressed with conviction; yet that very thing may not be real, in the sense of objectively determined and available for empirical proof or consensual validation. A paranoid individual may be conveying, through his delusions of persecution, some essential truth about his early life experience (his relationships with his parents, for example) but this does not mean that his present persecutors are real, that is, really out there in the world at this time. In another conceptual frame, "true" as I use it corresponds to "narrative truth" and "real" to "historical truth."
As therapists we hear much truth in our offices, especially if we listen closely and with the third ear. Patients feel joined when we can see the world empathically through their eyes and adopt their truth as our own. Such listening and joining can be healing and helpful. However, they also contaminate us in one sense: they distort inevitably the objectivity needed to testify to "reasonable medical certainty," the standard for experts in court. "Reasonable medical certainty" means that something is more likely or more probable than not.7 This level of probability in forensic practice is attained by painstaking and comprehensive review of all available elements of data in a given case-all elements on both sides, because the situation is adversarial. For example, in a daughter's allegation of sexual abuse by a father, a forensic witness would want to examine both parties, or at least read both depositions.
Perhaps more importantly, a forensic witness brings a balanced skepticism to the task, based on the human tendency of individuals in an adversarial struggle to act self-servingly. Hence, little is taken at face value; external corroboration is sought, ideally from neutral, unbiased sources, disinterested in the case outcome. Under some circumstances, memory researchers might or might not fit into this category.
This necessary forensic skepticism in the legal setting contrasts with the equally necessary credulousness of the therapist in the clinical setting. Immersion in the patient's world view is good therapy but bad forensic expertise if not balanced by the necessary objectivity. What galls us in the forensic community is the therapist testifying in court to reasonable medical certainty that something really happened, a conclusion based solely on what the patient said. This confounds the true with the real. It does not matter that the patient is convincing or resembles others who have had real experiences. Persons laboring in honest error may be convincing and resemblances are not proof When asked if they have interviewed the accused or read his/her deposition, such treating therapists often state (and with some justice) that this is outside their therapeutic purview, that they are not interested in what abusers have to say, or that their patients will begrudge them this diversion of attention away from them to a hated other.
Another difficulty in this area bears some relationship to the common finding of dissociative states resulting from childhood sexual abuse. Among other qualities, such states appear to produce an increased suggestibility in victims.8 There are two regrettable implications of this fact.
First, such individuals may pick up and respond to expectational cues from the therapist. These can be subtle or extremely crude as in this example from an article in the Boston Globe:
Gavigan, a 38-year-old computer operator, was hospitalized in 1989 for depression. Within three days, she says, her therapist told her that her father had sexually abused her. When Gavigan disagreed, he suggested she read The Courage to Heal, a popular but controversial handbook for incest survivors. Questioned daily about abuse by her therapist, Gavigan says, she began to wonder if she had indeed repressed traumatic memories.9
As implied in the quotation, this problem is intensified by an apparent tendency of numbers of poorly trained counselors from various disciplines to seize upon childhood sexual abuse as a single cause for all adult psychopathology and then to follow a well-worn trail of "therapy" - acknowledgement of abuse, acceptance of victimhood, confrontation of alleged abusers, and assignment to support groups of like-minded individuals. The situation has been described in a New York Times article as the "incest-survivor machine."10 It is often difficult to avoid the inference that a facile formulation of "child sexual abuse* may replace a careful clinical assessment of a complex history.
Second, in the attempt to bring the child sexual abuse/incest survivor issue into the open, some sources, like The Courage to Heal11 intentionally maintain an extremely low credibility threshold with the avowed purpose of making memory retrieval easier. Some representative language from that text includes:
If you are unable to remember any specific instances . . . but still have a feeling that something abusive happened to you, it probably did (p. 21).
If you think you were abused and your life shows the symptoms, then you were (p. 22).
If you don't remember your abuse, you are not alone. Many women don't have memories and some never get memories. This doesn't mean they weren't abused (p. 81).
You are not responsible for proving that you were abused (p. 137).
While debatably valuable for therapeutic facilitation, such a manifestly low reliability threshold cannot produce evidence suitable to a court of law.
Another way to conceptualize the problem is to understand the difference between a fact witness and an expert witness.12 A fact witness testifies to direct observations through the senses (e.g., what one saw in or heard from a patient) and what one did (e.g., explored an issue). An expert, once qualified by the court, may testify to conclusions to the previously described reasonable degree of medical certainty. Note that the license to testify in this way derives in part from the assumption that the expert has objectively examined the entire database in a given case, including both sides of the matter, and that the expert is willing to acknowledge honestly the limits of the data. For example, an expert may find a patient credible, but the expert does not confuse this subjective reaction with proof that the events described actually occurred. The expert, after all, was not there at the time.
Hence the treating therapist can serve ethically only as a fact witness, for the reasons noted above. Unfortunately, this rule is violated all too often in two common scenarios: 1) therapists embarking on a well-meaning but misguided advocacy for their patients - misguided because they are now supposedly functioning as experts; 2) attorneys trying to save money by not hiring an expert and instead thrusting the treating therapist into a totally inappropriate "expert" role.
How shall we answer the objection that even to discuss false accusations or false memories is politically incorrect since it may deter victims from revelation of abuse, especially since victims of such abuse are usually already reluctant to come forward for obvious reasons of guilt, shame - and fear of disbelief? Certainly the treating therapist has every right to look to the patient's protection and support, discounting data from the alleged abuser, but the courtroom has different and more egalitarian rules that protect both plaintiff and defendant. A treating therapist who, on the witness stand, posits that all allegations are true does his/ her own patient a disservice by decreasing credibility. One may believe one's own patient, but one did not witness his/her childhood and cannot testify authoritatively as to what happened.
In conclusion, note that a simplistic view is dangerous; a complex grasp is the valid one. To claim that some abuse memories are false is not to dismiss all abuse memories as false. The adversary method that courts have always used is not a ploy designed to harass victims but a means to protect the falsely accused - a protection that is essential since, in this emotionally charged area, being accused, even falsely, is as destructive as being convicted.
It is, alas, possible that some victims may be deterred from coming forward because of these realities. But we must clearly understand that poor contaminated evidence or even iatrogenic memories, and litigation based on these, have the inarguable effect of biasing future fact-finders against those true victims who have been genuinely abused, have repressed the memory, and have come forward belatedly. Those victims are entitled to a fair hearing; we do them no service by suppressing a balanced discussion of the issues here reviewed.
1. Loftus EF, Ketcham K. Witness for the Defense. New York, NY: St. Martin's Press; 1991.
2. Loftus EF. Repressed memories of childhood trauma: are they genuine? Harvard Medical School Mental Health Letter. 1993; 9(9):4-5.
3. Dawes RM. Biases of retrospection. In: Rational Choices in an Uncertain World. San Diego: Harcourt Brace Jovanovich; 1988.
4. Wakefield H, Underwager R. Recovered memories of alleged sexual abuse: lawsuits against parents. Behavioral Science and the Lam 1992; 10:483-507.
5. Appelbaum PS. Memories and murder. Hosp Community Psychiatry. 1992; 43:679-680.
6. Herman JL, Harvey MR. The false memory debate: social science or social backlash? Harvard Medical School Mental Health Letter. 1993; 9(10):4-6.
7. Rappeport JR. Reasonable medical certainty. Bull Am Acad Psychiatry Lam 1985; 13:5-16.
8. Kluft RP (ed). Incest-Related Syndromes of Adult Psychopathology. Washington, DC: American Psychiatric Press Ine; 1990.
9. Jacobs S. Sex abuse memories in question. Boston Globe. April 5, 1993:1.
10. Tavris C. Beware the incest-survivor machine. New York Times. January 3, 1993; 1.
11. Bass E, Davis L. The Courage to Heal. New York, NY: Harper and Row; 1988.
12. Appelbaum PS, Gutheil TG. Clinical Handbook of Psychiatry and the Law. Baltimore; Williams & Wilkins; 1991.