Ascertain personal and professional assumptions and biases and work for a stance
of supportive neutrality
The practitioner must monitor personal and professional
assumptions and biases and avoid leading questions, specific suggestions, prematureclosure
of exploration, and/or the ready acceptance of the individual's recollections
as historical truth. The practitioner should also assess his/her ability to tolerate
and support a patient's uncertainty about the past. An open and nonauthoritarian
perspective is especially important with patients who are excessively dependent
or suggestible or with those who have high hypnotizability. It is advisable to
adopt a neutral therapeutic stance to the possibility of abuse, to ask open rather
than closed or suggestive questions, and to encourage exploration and the cross-referencing
of information without drawing premature conclusions. According to Judith Herman,
M.D., therapists must be technically neutral but be morally cognizant of the prevalence
and possibility of abuse. Being neutral and open-ended in technique does not mean
that the therapist is in denial about abuse as a serious and common occurrence
or about its possibility in the patient's past. Rather, it is the patient who
must come to a understanding of and comfort with his/her personal history. This,
of necessity, may include living with uncertainty, a circumstance that may be
highly distressing, requiring support and empathy (and, at times, empathic confrontation)
on the part of the therapist.
2. Watch assumptions about
incomplete and spotty childhood memory
The practitioner should not assume
that an individual who cannot remember much from childhood is repressing or denying
childhood abuse. Normal memory for childhood is spotty, childhood (infantile)
amnesia generally ends between the ages of 2-1/2 to 3-1/2, and older children
remember more detail and with greater accuracy than younger children. The therapist
should make note of an individual's report of circumscribed time periods in childhood
and/or adolescence with totally absent memory (especially if observed and corroborated
by others and if other signs and symptoms indicative of a possible abuse history
are available, e.g., medical records, outside validation or corroboration, the
client obviously dissociates). Even so, periods of complete amnesia in childhood
or adulthood are not, in and of themselves, enough of a basis on which to make
an exclusive determination of childhood sexual abuse in the absence of other information.
3. Do not automatically assume sexual abuse from a set
No one symptom or set of symptoms (either initially or 1ong-term)
is pathognomonic of childhood sexual abuse, so the practitioner should not automatically
and conclusively assume an abuse history due to particular symptoms, especially
when no memory of abuse is available. The therapist nevertheless needs to be alert
to the emergence of signs and symptoms commonly associated with a trauma history
that are not immediately consciously available to the patient. In such a circumstance,
the therapist needs to encourage exploration of the possibility of abuse or other
trauma because denial and other dynamics may make personal acceptance difficult,
if not impossible, without outside support. A return to more formalized assessment
might also be considered at this point.
4. Be open to the
possibility of other childhood trauma besides sexual abuse
should be open to the possibility that other childhood events and trauma (e.g.,
parental separation and divorce; family violence; significant deaths--including
suicides--and illnesses; medical conditions requiring invasive techniques, pain,
and physical immobility; serious accidents; and natural disasters) might account
for a patient's posttraumatic symptoms. Sexual abuse should not be assumed or
suggested as the only possibility. Most psychological disorders develop from,
and are influenced by, a number of events (as well as other factors, such as the
child's premorbid personality and personal resilience, the nature and severity
of the stressor(s), family functioning, sources of outside support, etc.).
Keep adequately detailed records
The practitioner should keep records
in sufficient detail to document the main issues and events in the therapy, to
articulate and track symptomatology and the treatment plan, and to chronicle all
major communications with the patient. Patient records should be neutral- in tone
and based on fact and behavior rather than on the therapist's speculations. The
chart should include mention of any erroneous expectations and misinformation
regarding abuse and memory held by the patient and should document the provision
of factual and more accurate information and the discussion of process issues
regarding memory retrieval (e.g., information about the delayed memory dispute,
the functioning of human memory, including its reconstructive nature, current
information about memory processes for trauma, the patient's responsibility for
making a determination about his/her own experience, the maintenance of a stance
of therapeutic neutrality, and various techniques and their efficacy and substantiation).
Additionally, notes should document memories and events as "reported by"
the patient rather than as historical reality and specifically document any attempts
by the patient to get the therapist to confirm or believe an abuse history based
on recovered memories alone, especially when corroboration is missing. During
sessions when the patient is struggling with issues of unclear memory or reporting
recovered/delayed memories, the therapist might consider taking process notes.
6. Do not use hypnosis (or related techniques) for memory
Hypnosis is one of the most controversial techniques in the delayed/
repressed memory controversy. At present, available research is quite conclusive
that memories that emerge as a result of hypnosis can be compelling yet inaccurate
and that the veridicality of these memories should not be assumed (although some
may well be accurate). The potentially confounding nature of hypnosis (or any
similar technique) makes its use inadvisable to uncover, discover, or rework delayed
memories of abuse. Rather, its use should be restricted to such therapeutic tasks
as ego strengthening, coping, self-soothing, temporizing and pacing, etc. Moreover,
hypnosis should not be used if a patient is involved in any type of legal proceeding
or has any likelihood of taking any legal- action in the future (whether related
to past abuse or not). The use of hypnosis may result in the inadmissibility of
material in any forensic proceeding. Similar to any other specialized technique,
hypnosis should be used only if the therapist has been trained in its use and
with the informed consent of the patient.
the individual's understandings and expectations about memory, therapy, and any
sources of influence and social compliance issues.
If, at the outset or
during the course of treatment, an individual suspects a nonremembered history
of abuse and has unrealistic expectations of therapy and/or misinformation about
abuse, trauma, and memory, the practitioner should inquire about these matters.
In particular, possible sources of influence, social compliance, or misinformation
should be determined. These might include exposure through reading and viewing
biased or overzealous material, participation in abuse-focused self-help activities
and therapy groups (including on the internet and in "chat rooms" devoted
to abuse-related issues and topics) and participation in previous therapy--especially
if unconventional, of the sort that provided or supported erroneous information
or a certain perspective regarding abuse and memory issues, and/or emphasized
the use of hypnosis for memory retrieval. The practitioner must correct specific
misinformation and guide the individual to a broadened understanding of the malleability
and reconstructive nature of memory, the currently unanswered questions about
memory for trauma, and the ways memory issues will be addressed in therapy. Concerning
the latter, the practitioner educates the individual about the sequenced treatment
strategy that is holistic rather than solely focused on abuse and memory retrieval.
Although the clinician is open to the exploration of a patient's
suspicions of abuse, it should be based on open-ended questioning and free narrative
to lessen the possibility of suggestion. A scientific attitude involving the careful
weighing of evidence over time and the avoidance of "jumping to conclusions"
and premature closure is encouraged. It is crucially important that the practitioner
not "fill in," "confirm," or "disconfirm" reported
suspicions of a nonremembered abuse history but rather help the patient explore
the content and its possible meaning while guarding against suggestion, pro or
con. Individuals with positive histories of abuse and trauma often struggle with
differentiating what is real and what is not, experience-strongly ambivalent emotions,
and require a supportive context in which to consider various perspectives. Similarly,
individuals with suspicions but no memories and those with incomplete and reinstated
memories must have the latitude to explore without constraint. Although the clinician
maintains as much neutrality as possible, at times there is a need to educate
or challenge the patient on material that is clearly improbable, seems delusional,
and/or in which the patient is overinvested. As noted in item 10, a return to
more formalized assessment might be in order.
self help books and groups only when familiar with their content and perspective
The practitioner should be cautious in recommending self-help books and
should be familiar with the content of any book that is suggested. In the case
of suspected abuse with no clear memory, a generic book on the effects of a painful
childhood is initially preferable to a book on signs and symptoms of sexual abuse
or a book on repressed memories that offers suggestive methods for retrieving
absent memory. A related issue involves referrals to self-help or therapy groups.
The patient with absent autobiographical memory for abuse is best referred to
a heterogeneous group for general mental health concerns rather than a homogeneous
abuse focused one. A difficult circumstance arises when a patient with suspicions
of abuse and sketchy memory has read books, viewed media presentations, or participated
in groups that push a certain perspective or that offer erroneous information.
The clinician must re-educate the patient and correct skewed content.
Support a patient's search for corroboration after adequate exploration and preparation
Some patients decide they want to seek outside sources of information
regarding possible childhood abuse (e.g., medical and school records, witnesses,
other victims, etc). The clinician can support a search as a means of gaining
potential material to be assessed and weighed in the course of therapy. It is
advisable, however, that the patient first explore the ramifications of such a
search with the therapist and take action only after having achieved a relative
degree of life and symptom stabih'ty and after adequate preparation. The patient
should consider the range of possible consequences of a search, from positive
to negative, and the relative probability of each. Possible responses should also
be anticipated and prepared for finding or not finding evidence and corroboration
can be very unsettling. Optimally, a support system is in place to assist the
patient with the results and the emotional consequences of a search.
Do not recommend family cut-offs on the basis of recovered memory
practitioner should also be cautious in suggesting that the patient limit or cut
off contact with family, especially when recovered memories form the basis for
abuse suspicions or beliefs; however, in cases of a positive abuse history and
reports of ongoing abuse or other clear and present danger, the practitioner is
responsible for helping the patient assess the cost/danger in continuing contact
(and may further have a duty to report). The therapist must keep the patient's
safety paramount while helping him/her to recognize ongoing danger and learn assertive
and self-protective strategies with unsafe or abusive others.
Contract for no unplanned/impulsive disclosures, confrontations, or legal initiatives
The practitioner should have a collaborative agreement with the patient
that unplanned/impulsive disclosures, confrontations, or legal initiatives not
be undertaken without extensive discussion in therapy. These actions are quite
risky even when the patient has clear memory and some corroboration; when abuse
is suspected or believed on the basis of recovered memory without corroboration,
they are even riskier (for both patient and therapist). The cost benefits of these
actions are best considered when the patient's symptoms and life circumstance
are stabilized and, in the case of known abuse, after the bulk of trauma-resolution
work has been completed. They should only be undertaken following a period of
careful planning and assessment of possible consequences, including family estrangement,
threats and violence, legal initiatives, etc. Consideration should also be given
to whether they should be done within or outside of the therapy. In either event,
thorough preparation is recommended.
12. Do not encourage
or suggest a lawsuit
It is not the practitioner's role to suggest a lawsuit.
If the patient chooses to investigate this option, the therapist should encourage
the gathering of comprehensive information on which to base decision-making. Litigation
is enormously stressful and requires an extensive time commitment as well as the
allocation of significant personal and financial resources. The plaintiff in a
legal proceeding must meet a standard of proof that is not found as a patient
in a clinical setting. Also, since the advent of the memory controversy, plaintiffs
seeking damages for past abuse have been challenged on the basis of false-memory
production, a challenge that has made the process even more difficult. Should
a patient opt to initiate a lawsuit, the practitioner must keep the treatment
and legal action separate and insist that the patient get a separate psychological
expert; otherwise, the practitioner becomes engaged in a dual role relationship
with the patient and therapy becomes derailed.
- Courtois PhD, Christine A,
"Guidelines for the treatment of adults abused or possibly abused as children";
American Journal of Psychotherapy; Fall 1997, Vol. 51 Issue 4, p497
The article above contains foundational information. Articles below contain optional updates.
Reflection Exercise #7
The preceding section contained information
about treatment guidelines regarding issues pertaining to memories of sexual abuse.
Write three case study examples regarding how you might use the content of this
section in your practice.
Ethics CEU QUESTION
Why should sexual abuse not be assumed or suggested as the only possible
explanation of a client's posttrauma symptoms? Record the letter of the correct
answer the .