In psychiatry, and in fact for all kinds of counseling, all procedures start with collecting data from the patient. Starting with the individual’s history, finding out what is happening with the patient and learning the psychological background as well as social context, one then attempts to comfort, counsel and heal. This information gathering involves asking some questions but more important is listening to the clients’, and sometimes others’, account of the current and the past situations. Often past trauma is an essential part of the history. Thus, understanding the dynamic of traumatic memory is fundamental to gathering history, just as it is fundamental to proper treatment.
All police officers, judges, counselors, therapists, clinical psychologists, and psychiatrists must at least have some basic knowledge of this dynamic. Without it, grave misunderstandings may arise. The individual’s veracity may be questioned and incorrectly denied. Injustice may be the result based on misunderstanding of the dynamic and demanding a narrative of non-declarative memory. Such a demand simply won’t work. Non-declarative traumatic memory is simply not expressed as a narrative. That doesn’t imply that it is false. It simply means that one has to understand it without the crutch of a conventionally presented storyline.
Often, some past trauma is not remembered. Past trauma is not something anyone really wants to remember, especially if remembering it means, in one’s body, that one re-experiences it.. However, eventually past trauma will resurface. Not too long ago, there was a great deal of furor debating on this topic. The question was posed as to whether or not such “recovered” memory, memories that eventually resurfaced, especially during psychotherapy, can be accepted at face value.
“Repressed memory” is a Freudian term referring to memory that has been unconsciously blocked, due to the memory being associated with a high level of stress or trauma. The theory postulates that even though the individual cannot recall the memory, it may still be affecting them consciously.
A more neutral term, “forgotten or lost memory”, is often used instead. Some studies have shown that forgotten memory can occur in victims of trauma, while others dispute it. According to some psychologists, forgotten memory can be recovered through therapy. Other psychologists argue that this is in fact rather a process through which false memories are created by blending actual memories and outside influences. According to the American Psychological Association, it is not possible to distinguish lost memories from false ones without corroborating evidence.
So, if a patient begins to remember traumatic memories during the process of therapy, how does one know if such memory is accurate or aetrogenic, meaning that the patient has been misled by the therapist into creating a false memory? In psychotherapy, recall of the traumatic past during the process of psychotherapy is commonplace. This includes “dissociative amnesia,” which is defined in the DSM as “an inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness.”
It is well-recognized that “Traumatic Memory”resulting from massive psychic trauma may be associated with amnesia, as well as, paradoxically, hypermnesia. Hypermnesia refers to the unusual power or enhancement of memory, typically under abnormal conditions such as trauma, hypnosis, or narcosis.
A person may be so overwhelmed by a traumatic experience that certain aspect of, or the whole experience may not be registered. For example, many former inmates of Nazi concentration camps could not remember anything of the first days of imprisonment because perception of reality was so overwhelming that it would lead to a mental chaos. [Read Krystal : Massive Psychic Trauma (1968)] At the same time, some part of the traumatic memory may be extremely vivid as if etched in the psyche. An example of this is when a rape victim may retain in great detail the pattern of the curtain behind the abuser at the time of the assault with only the haziest recollection of the appearance of the abuser.
Therapists, police officers and other professionals, unfamiliar with this paradoxical phenomenon, may question the veracity of the victim if the recall of the trauma contains both amnesia and hypermnesia. They presume that, “If the woman was beaten and raped, surely she should remember correctly the color of the car that drove the assailant away.” It is dangerous to use our own ability to access non-traumatic memories as a standard against which we judge a trauma victim’s response.
Fundamentally, there are two kinds of memory: the narrative (explicit memory), and the non-declarative (procedural) memory. The former is involved in the straightforward narrative of an event while the latter is involved in memory that is often unconscious, sub-conscious or simply beyond verbalization. For example, this can refer to recalling an experience such as riding a bicycle (pertaining to motor skill), an emotional response, or a reflex action.
The conversion of the raw data of experience into memory is sifted through different neurological structures such as the amygdala and the hippocampus in the brain. Memory retention is often related to the valence of the emotion associated. Moderate to high activation of the amygdala enhances the long-term potentiation of narrative memory mediated by the hippocampus, while extreme overwhelming arousal disrupts hippocampal functioning, leaving the memories to be stored as affective states or sensori-motor modalities such as somatic sensations or visual images but as not narratives.
One tends to remember something very special, such as the phone number of a person with whom one is very much infatuated. But, in the immediate aftermath of a car accident, the color of the other vehicle may not be registered in one’s narrative memory because of the psychological shock experienced at the time. This is where the therapist (or police officer), in taking a history related to extreme trauma, may find patches of amnesia. One must never jump to hasty conclusions declaring such memory as false just because it has amnestic holes in the narrative. The paradox is that due to the overwhelming arousal, what would ordinarily be stored as narrative memory is instead stored as non-declarative memory.
The above is a gross simplification of the activity of some of the neurological structures that relate to trauma and memory. Because many people are not able to understand or even recognize this complex phenomenon of the impact of trauma on memory, victims are often disbelieved. They are challenged based on their “inadequate” narrative memory of the traumatic experience. But the narrative component of traumatic memory is typically like Swiss cheese, full of holes. It is adding insult to injury to demand a survivor prove his/her case of having been abused in early childhood as a narrative, after they have finally pulled together the courage to come forward to bear witness to their abusive experience. The victim, and their non-declarative memory, are not to blame.
Practical guidelines to follow when one suspects a patient history that includes trauma:
1. Avoid obsessive digging at the past. Do not interrogate a patient before a therapeutic relationship has been established. Even after establishing such a relationship, avoid demanding details. Remember that every question telegraph’s the questioner’s bias to the patient. By the choice of words and the affect associated with the question, one’s bias is revealed in the tone of voice, in body language, etc. Limit your presentation of bias to the extent you can. It takes special effort to phrase a question – including one’s own body language – in a neutral way. Make the effort. The goal is to permit the patient to allow traumatic memories, if they do exist, to arise in their own time and in their own manner of presentation. If you do this and such memories arise, they will arise with authenticity and be far more available to healing.
2. The less interrogation, the easier to establish a therapeutic alliance. In the absence of interrogation, in a container of stable warmth, it is far more likely that trust can be rapidly established. With that trust, trauma information will be forthcoming when and as needed. Usually, it is presented by the patient without any need for prodding by the therapist.
3. It not important to know all the details. The task of the therapist is to help patients deal with the psychological and the physiological effects of past trauma. For example, is the patient able to bring her mind and body back to the here and now, or is she stuck in the past? Successful therapy doesn’t mean the patient must learn and acknowledges all the details of the past trauma. Success is demonstrated when the patient is able to live in the present experiencing safety unencumbered by the past trauma. The patient’s ability to control the disturbance of the memory of the past, to be able come back to enjoy the present moment of safety and peace, is the hallmark of recovery. The patient will tell you what is important to work on.
4. You are not preparing a police report. The central issue is whether the patient is able to develop some detachment and objectivity of the experience. This means that the patient no longer experiences retraumatization, no longer becoming overwhelmed and re-living the trauma when the memory arises. As a therapist, the goal is healing – not building a court case. Neither you as the therapist nor the patient needs to prove the dotting of every “i” and the crossing of every “t”.
5. Understand Traumatic Memory. Traumatic memory consists of images, sensorial and affective states, and behaviors that are invariably consistent over time. These memories are highly state-dependent and cannot be evoked at will. They are not condensed to fit social expectations. Narrative memory is social and adaptable to the needs of both the narrator and the listener. As such, it can be expanded or contracted according to social demands.
Survivors of early childhood trauma are usually left with non-declarative memories of horrific past experiences that are locked in somatic and sensorial memories. These are usually terrifying as they survivors lack a narrative memory to help conceptualize frightening visual imageries. It is common that people are unable to accept these thoughts and feelings.
Once people become conscious of the intrusive qualities of the trauma memory, they are likely to try to fill in the blanks and complete the picture. The stories that people tell about their trauma are as vulnerable to distortion as are people’s stories about anything else. As a result, trauma history may be distorted when it is subjected to misguided leading questions from the therapist. However, just because trauma history may be distortable by its lack of narrative memory or by leading questions, does not mean that trauma did not occur. Let me reiterate the point – human memories are simply not 100% accurate. We are not computers or digital cameras playing back a recording.
6. Truth and Non-Declarative Memory. With non-declarative memory, accuracy to a third party’s conceptual (narrative) understanding of “truth” is not the point. Just as the host in a DID system may simply refuse to believe the truth of the non-declarative memory, that memory is accurate in its context. As I have mentioned repeatedly, the details are not necessary to the therapy. Once the therapist has determined that trauma did occur, let the patient assess the right time to disclose an abusive history in a form and context of their choosing. This is far more likely to produce benefits in therapy as compared to an interrogation based data collection that seeks to determine “exactly” what happened. For the therapist, it is preferable to simply accept the truth that when trauma occurs, details of the traumatic experience may not be recalled in exactly accurate narrative detail.
It is more important for the therapist (and the patient) to know whether or not trauma did occur, rather than the details of who did what when and to whom. There are some specific instances where some of the details may be critical, for example when the abuser is a primary caretaker of the patient and remains in a position to further abuse the patient or others.
7. Memories Held by Alters. Joan, my patient mentioned in Chapter 1 of my book Engaging Multiple Personalities, Volume 1, came to see me complaining of visual imageries and memories of her father abusing her – even though she did not believe it had ever happened. She was afraid she was going out of her mind, that she might be locked up as a crazy person for having such thoughts. Such amnesia, which in this case included the refusal to accept that abuse had happened, is typical of abuse memories when they are being held and expressed only by an alter. The inaccessibility of such memories to the host is exactly the safety dynamic that enabled the individual to survive the abuse at the time it was happening.
The function of such an alter is to spare other parts of the personality the burden/pain of the abuse. This is an example of true dissociated memory. Despite many papers which have argued against “repressed memory,” I have seen it vividly during direct interactions with patients. People who have been traumatized as young children will almost never be able to tell you about it when they first come to see you as your patient. Information gathered through some compulsory interrogation on the first patient’s first visit must be viewed with caution.
8. Genuine Therapeutic Alliance is Key. Those who deny repressed memory claim that to do otherwise invites false positives, abuse memories being presented because the patient thinks that is what you want to hear or that you have “implanted” such memories because of your own confused issues as a therapist. In other words, you have not established a genuine therapeutic alliance and therefore the idea of repressed memories is a vehicle for mutual delusion. The real issue to be concerned with is that one runs a far greater risk of getting false negatives because the patient simply cannot access the non-declarative memories in front of a stranger – which is what you are until a genuine therapeutic alliance has been established.
[This post contains paraphrased material from Bessel A.van der Kolk’s book <Traumatic Stress> (1996)]
