Saturday, May 7, 2016

Trauma and Recovered Memories

The American Psychological Association defines trauma as an emotional response to a terrible event like an accident, rape or natural disaster. Immediately after the event, shock and denial are typical. Longer term reactions include unpredictable emotions, flashbacks, nightmares, strained relationships and even physical symptoms like headaches or nausea. There is no doubt that many survivors of trauma suffer terribly due to the after effects of events that are beyond the capacity of the human mind and body to absorb overwhelming physical and emotional stimuli.

Today, many patients come to us with trauma histories, and seek relief from the aftereffects. Here I’ll discuss a particular type of trauma experience, the recovered memory. A recovered memory is a recollection of a traumatic event that the patient was unaware of until it was uncovered during the psychotherapeutic process. Once uncovered, the memory may become the focus of a lengthy therapeutic process often lasting years in which the patient is helped to come to terms with the event.

How is it possible that a traumatic event could not be remembered? It would seem that an event of overwhelming emotional or physical (or both) intensity would be impossible to forget. The rationale involves repression, a concept promoted by Sigmund Freud and others who believe in the psychoanalytic theory of the mind. In repression, traumatic thoughts, impulses, and experiences pass out of consciousness because the conscious mind cannot cope with them. However, Freud believed the events did not disappear from the psyche, but rather remained active in the unconscious mind, where they could still play havoc by resulting in all sorts of emotional disabilities such as anxiety, or even physical symptoms. This concept is so engrained culturally that we may hear in everyday conversation a person with peculiar behaviors referred to in a pejorative manner as “really repressed”.

In medical school, nascent doctors are taught about differential diagnosis, which is basically the process of formulating a list of possible etiologies for a patient’s particular suite of clinical signs and symptoms. So, for example, shortness of breath might be due to lung, heart, or even central nervous system disorders. Medications can also contribute to shortness of breath. Similarly, from a differential diagnosis perspective, psychiatric symptoms like anxiety and depression can have many causes. For some people, there appears to be an inherited, genetic predisposition to these disorders. For others, physical illness can bring on anxious and depressed feelings. Still others experience these emotions when life stressors such as family, job, or financial stressors increase. Finally, for many depression and anxiety appear to arise out of the blue without a clear familial, physical, psychosocial basis.

It is important in approaching any patient in emotional distress that the differential diagnosis be open. If the clinician has the belief that certain mental symptoms are the result of trauma, then by necessity the trauma must be identified. If the patient cannot recall trauma, the clinician who is a believer in repressed memories will search for trauma in therapy using techniques such as hypnosis, guided imagery, and frank suggestion. These approaches have been shown over and over to be highly unreliable and many cases of false recovered memories have been documented. During the 1980’s and 1990’s, there was a veritable explosion in patients who reported that memories of past trauma had been recovered in therapy. Perhaps one of the most tragic cases of recovered memories is discussed in Pulitzer Prize winning author Lawrence Wright’s book “Remembering Satan”. Many other accounts of negative outcomes from recovered memories therapy have been published. Some clinicians practicing recovered memories therapy ended up facing malpractice litigation.

In fact, the scientific study of recovered memories, pioneered by the psychologist Elizabeth Loftus (co-author of “The Myth of Repressed Memory”), has demonstrated that memories are malleable, often unreliable, and subject to change over time. Experiments in the laboratory reveal that in psychologically normal individuals, memories may arise that seem real, but are in fact not based in actual experience (for example, see Patihis and colleagues, PNAS, 110:20947–20952, 2013). Longitudinal studies of those exposed to a single, well documented traumatic event have found that memories of the degree of threat posed by the event become amplified over time (Heir and colleagues, Br J Psychiatry 194:510-514, 2009). Finally, convincing evidence that repressed memories lead to emotional or physical illness has never emerged, despite widespread acceptance of this notion by the psychoanalytic community for over 100 years. Although the mind and body are closely interconnected, there are no scientific data to support memories hidden in the unconscious mind as a source of bodily distress.

In recent years, most therapists have come to recognize that recovered memories are often distorted or false, and the popularity of this psychotherapeutic approach has declined significantly from its peak around 1990. Still, the practice lives on. I recently cared for a hospitalized patient who experienced suicidal thoughts after his psychotherapist guided him in recovering memories of childhood sexual abuse. Until the therapy, the patient never had any recollection of abuse. However, the therapist had decided that the patient’s symptoms must be due to repressed memories, and hence patient was guided toward remembering things that he had never before remembered. In the hospital, the patient improved dramatically without any specific treatment other than standard daily cognitive behavioral group therapy. At discharge, the patient revealed that the recovered memories therapy itself had been traumatic and that he now realized the therapy provoked his suicidal thoughts.

When approaching any new patient reporting a history of trauma, it is worth asking if the memory of trauma was elicited during therapy. It is often difficult to obtain independent verification of events from the distant past, but given the unreliability of therapy-recovered memories, the clinician should at entertain alternative hypotheses about the psychological basis for the patient’s distress. Sadly, recovered false memories can often form the basis for a lasting sense of victimization, which can seriously impede opportunities for personal growth and fulfillment. Recovered memories therapy is a failed method from the 1980’s that has not been verified through scientific investigation, and hence has no place in modern, evidence-based psychotherapy. Since the 1980’s there have been significant advances in psychotherapy and medications for anxiety, depression, and other mental conditions that do not involve searching for repressed memories of trauma, and have solid scientific evidence for their efficacy.

But what of the many patients who have truly experienced devastating trauma in the past and seek guidance in coping with their emotions, and moving forward? There are a number of evidence-based psychotherapeutic and medication-based treatments for post-traumatic stress disorder (PTSD) that can readily be utilized by the skilled clinician to ease the suffering of these patients (for example, see Greenberg and colleagues, Br Med Bulletin 114:147-155, 2015; Cusack and colleagues, Clinical Psychology Rev 43:128-141, 2016). Cognitive behavioral therapy is an excellent starting point, with a modern antidepressant such as an SSRI added if need be. In addition, many up-to-date clinicians are incorporating new scientific findings and techniques from the field of Positive Psychology that focus on human resiliency and growth after trauma, rather than on victimization and disability (for example, see the findings of Tsai and colleagues, Psychological Med 45:165-179, 2015).

Over 25 years after the recovered memories heyday, the concept still elicits strong opinions among clinicians and patients. However, there is little rationale for employing this technique in clinical practice, and working with the assumption that certain symptoms by definition must be due to a repressed memories is very poor medicine.