Professional Psychology: Research and Practice 1996, Vol. 27, No. 5, 452-459
Copyright 1996 by the American Psychological Association, Inc. 0735-7028/96/S3.00
Risk Management for Psychologists: Treating Patients Who Recover Lost Memories of Childhood Abuse Samuel Knapp
Leon VandeCreek
Pennsylvania Psychological Association
Wright State University
The mental health community and, in certain respects, society itself have become polarized over the issue of lost and recovered memories of childhood abuse. Psychologists who treat patients who recover lost memories of childhood abuse during psychotherapy may find themselves vulnerable to lawsuits from patients who later recant the memories of abuse or, in unusual circumstances, from family members of the patients. Psychologists can reduce their legal risks by following certain basic precautions, including maintaining appropriate boundaries with their patients, following acceptable procedures in diagnosing and treating patients, obtaining informed consent (especially when using experimental procedures), and showing concern for patients' long-term relationships with their families. Consultation on difficult cases and careful documentation are also indicated.
Psychologists who treat adult survivors of childhood abuse provide a valuable public service. Their patients are often the most needy, vulnerable, and traumatized of all psychotherapy patients. Reports suggest that these survivors do forget and then later recall memories of past abuse (American Psychological Association, 1994; British Psychological Society, 1995). Often, the recall comes through psychotherapy, although other life experiences may prompt recall as well (British Psychological Society, 1995; Feldman-Summers & Pope, 1994). It is unfortunate that many psychologists are becoming reluctant to treat adult survivors of child abuse because of fear of litigation from patients or their parents who claim that the psychologists implanted false memories of childhood abuse (Fox, 1995). Butler (1995) reported that 150 former patients have initiated lawsuits against therapists, and repressed memory complaints accounted for 16% of all claims filed in 1994 against mental health professionals insured by the American Professional Agency ("Repressed Memory Claims," 1995). Furthermore, some parent groups have promoted the Mental Health Consumers Protection Act (an outline of proposed legislation circulated by various false memory syndrome groups), which would place draconian controls over the practice of psychotherapy. In our view, no other area of psychotherapy practice has created such a powerful and organized antagonistic force.
The liability risks are far less when treating patients who have always known that they were abused as children, who have retrieved the memories spontaneously on their own, or who have valid corroborating evidence. In these situations, a reasonable person would not likely accuse the psychotherapist of implanting false memories. Liability risks are slightly higher when the patient retrieves memories through talk therapy and the psychotherapist has documented the content and nature of the treatment sessions. Liability risks are highest when the psychotherapist uses experimental techniques (such as trance work, body memories, or age regression) to retrieve memories. For reasons we describe in this article, malpractice risks greatly increase when psychotherapists encourage patients to confront their alleged perpetrators. Psychologists may believe that these lawsuits are the result of parents denying any wrongdoing or of unstable patients lashing out against innocent psychotherapists. This is true in many situations, but it does not appear to explain the sources of all of the lawsuits. According to victim advocate and trauma expert John Briere( 1992),
SAMUEL KNAPP received his EdD in counseling from Lehigh University in 1982. He is professional affairs officer of the Pennsylvania Psychological Association. His interests are in professional issues and ethics. LEON VANDECREEK received his PhD in clinical psychology from the University of South Dakota in 1972. He is currently dean of the School of Professional Psychology at Wright State University. His clinical and research interests include professional training and professional issues and ethics. THE OPINIONS PRESENTED in this article do not necessarily represent those of the Pennsylvania Psychological Association. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Leon VandeCreek, School of Professional Psychology, Wright State University, Dayton, Ohio 45435. E-mail may be sent via the Internet to
[email protected].
In this article, we describe how psychologists who treat patients with lost and recovered memories of childhood abuse can reduce their risk of being sued for malpractice. Throughout the article, we use the term lost memories in place of repressed memories, which implies the operation of the psychodynamic process of repression that may or may not be responsible for the memory loss. Psychologists can reduce their legal risk to acceptable levels by maintaining appropriate therapeutic boundaries, diagnosing patients carefully, using sound clinical techniques that are based on scientific knowledge, obtaining informed consent for experimental procedures, and showing concern for the patients' future relationships with their families.
Although part of the outcry regarding incompetent therapists who "implant" false memories of abuse is undoubtedly specious, it is also true that some very bad "therapy" in this area is being done by individuals with insufficient training, experience, and/or psychological stability, (p. 292)
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Psychologists also need to recognize that this area of clinical work is at high risk for litigation and complaints, even if this risk management advice is followed. Lawsuits may be filed even when the psychologist has not been negligent, and patients may file complaints with ethics committees and licensure boards even when the psychologist has followed the best advice. The impact on the psychologist of these types of investigations may be devastating. Investigations often stretch out for months and years, and the emotional toll on most psychologists is extensive. Even if the psychologist is eventually found innocent, during the period of the investigation, he or she may face the possibility of removal from managed care provider panels and loss of hospital privileges because annual renewal forms often require the disclosure of ongoing investigations and complaints. Liability of Psychologists Persons who file malpractice suits have had the synergistic experience of negative treatment outcomes and ill feelings toward their psychotherapists. The legal requirements of a malpractice suit are that the psychologist owed a duty to the patient, the psychologist deviated from acceptable professional standards, and that deviation directly damaged the patient. The courts will typically ask expert witnesses from the same profession or field as the treating psychotherapist to advise them on the established standard of care. Some memory retrieval techniques, such as age regression and body work, are so controversial that it may be difficult to find expert witnesses who can convince the court that these techniques are accepted within the practice of psychology, especially when patients have not been informed of their experimental and controversial nature. As a consequence, psychologists who practice these techniques without informed consent may be viewed by the courts as violating ethical principles, and courts presume that psychotherapists who violate their professional ethical codes have deviated from acceptable standards of conduct (Stromberg et al., 1988). It has traditionally been difficult for plaintiffs in malpractice suits to prove they have been harmed by psychotherapy, because the damage assessment has depended on the self-reports of persons who have something to gain by falsifying or exaggerating their symptoms. However, courts have been more willing to accept the validity of the complaint when the damage could be assessed more objectively, such as through a suicide attempt, job loss, or when family relationships were disrupted. It has also been difficult for patients to prove the direct link between the behavior of psychotherapists and harm. However, that burden may be easier to meet when psychotherapists assume responsibility for retrieving lost memories of childhood abuse and the patients disrupt their family relationships on the basis of their beliefs in the accuracy of the retrieved information. In addition to malpractice suits, aggrieved patients may present other charges against psychologists, such as complaints to ethics committees and licensure boards, or they may allege other torts, such as defamation (slander or libel). The recent litigation concerning memories of childhood abuse can be placed into two categories of lawsuits: parents' suits against psychotherapists and former patients' suits against psychotherapists.
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Parents' Suits Against Psychotherapists Some parents have initiated lawsuits against psychotherapists who treated their adult children. As noted earlier, a legal duty ordinarily exists only between a therapist and his or her patient, and the psychologist owes no legal duty to any outside party, such as the patient's parents. An exception to this general rule has been the development of a narrowly defined duty to protect (i.e., Tarasoff doctrine) in which the psychotherapist, while treating a potentially dangerous patient, has a legal duty of care toward an identifiable victim of imminent danger of substantial physical harm (VandeCreek & Knapp, 1993). Nevertheless, some parents of patients who claimed to have recovered lost memories of abuse have argued that the duty of the psychotherapists to third parties should extend to them as well. Courts have been split regarding whether to grant parents legal standing to institute a lawsuit against the therapist. In Bird v. W.C.W. (1994), for example, the Texas Supreme Court denied such standing. However, in Ramona v. Ramona (cited in Marine & Caudill, 1994), a California trial court allowed such standing. The court allowed the father to sue because of a California precedent that allows limited status to sue for third parties when they were harmed by the behavior of a health professional (Schneider, 1994). In Sullivan v. Cheshier (1994), a federal court applying Illinois law allowed parents to sue a psychotherapist for "allegedly causing estrangement of patient from her family in connection with patient's memory, under hypnosis, of sexual abuse by sibling" (p. 656). Furthermore, the court noted that the public announcements of the psychotherapist, who had a doctoral degree in psychology, might have violated the Illinois licensing law for psychologists. It is too soon to determine if the Sullivan and Ramona findings are isolated findings or whether they will have precedential value. Neither case has yet been heard by an appellate court (Caudill, 1995). A federal court applying Pennsylvania law allowed parents to sue the counselors of their adult daughter for breach of contract and slander (Tuman v. Genesis, 1995). The counselors allegedly convinced the daughter that she had repressed memories that her father had impregnated her, subsequently killed the baby in a satanic ritual, and had also killed her twin brother. It was also alleged that the defendants had solicited money from their other patients to hide the daughter from her parents' cult, which was allegedly intent on harming her. The daughter has assumed a new identity and moved out of the state. Although contract law is not typically applied to psychotherapist-patient relationships, the unique circumstances in the Tuman case allowed courts to apply it there. The parents agreed to the instructions of the therapists in the Genesis Counseling Center: Paying for treatment on a session-by-session basis and detaching themselves from their daughter for 2 years. The explicit relationship between the parents and the psychotherapists, which is atypical among professional relationships, gave support for the theory that contract law should apply here. Furthermore, the Tuman court allowed the parents to sue for slander. The court noted that the daughter made statements alleging incest and murder on the part of her parents to her group therapy members. The court also allowed the parents to charge that their daughter acted as the counselor's mouthpiece by act-
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ing on the memories that they implanted. However, it should be noted that the Tuman case only established the grounds on which a suit could be filed. The actual liability of the counselors in this case has not been established. A Texas court found a psychiatrist liable for slander for telling a patient's family members about the alleged abuse of the patient (Khatian v. Jones, 1994). The facts under which the disclosures were made were especially problematic: The allegations of abuse occurred while the patient was under the influence of sodium amytal; the treating psychiatrist stated in court that he doubted the accuracy of the statements even before he told other family members; and the patient had recanted her allegations before the meeting with the other family members. Nevertheless, the psychiatrist presented the allegations as if they were fact and caused great disruption in the family. The court opined that the presentation of the finding as if it were fact (instead of an allegation) constituted slander. It is unclear whether third-party malpractice suits will become common against the psychotherapists of adult children, because no duty of care exits between the psychologist and the parent of the patient. The breach of contract suit permitted in Tuman was allowed because of the highly unusual circumstances under which the patient received treatment. Slander, however, may become a more common source of complaints against psychologists, especially if family confrontations are encouraged.
Former Patients' Suits Against Psychotherapists The legal standing of patients or former patients to sue their psychotherapists who, for example, allegedly implant false memories of childhood abuse, has never been in question. The allegations have typically included charges that the psychotherapists failed to follow acceptable procedures in their attempts to help patients recover lost memories or to evaluate memories that surfaced spontaneously. The so-called memories may have been retrieved on the basis of techniques that do not have demonstrated scientific usefulness or on the misapplication of otherwise acceptable techniques. As with other malpractice suits, courts will typically rely on the testimony of other psychologists in determining if the accused psychologist has deviated from acceptable professional standards (although some courts have established standards to protect the public in the absence of professional standards; see Helling v. Carey, 1974). In Joyce-Couch v. DeSilva (1991), for example, experts testified that the sodium amytal treatments given to the patient by a psychiatrist were unnecessary and harmful. The facts in Joyce-Couch v. DeSilva were particularly egregious, and liability would probably have been found even if controversial memories of past abuse had not been involved. In that case, a psychiatrist gave a patient 141 injections of sodium pentothal (10 times more than was needed, according to one expert). Furthermore, the court wrote that the psychiatrist "gave [the] patient no feedback and conducted no therapy, that he did not reveal [the] cause of [the] patient's problem to her, despite knowledge that [the] uncertainty caused her severe distress, and that he made improper sexual suggestions" (p. 287). Most of the suits against psychotherapists have been filed recently at the lower trial court levels, and the appellate courts
have not yet had an opportunity to review them. Consequently, these cases have not yet been published in the legal digest system and will not be available for common distribution for several years. However, the self-reported stories of retractors or recanters (former patients who have claimed that their psychotherapists implanted false memories of abuse) provide evidence of some of the actions that could precipitate lawsuits against psychologists. Although we found no independent verification of the accuracy of these allegations, they are an important source of information on the nature of the charges that could be made against psychologists. Some recanters have described harmful boundary violations, such as a patient promoting a workshop for her psychotherapist, a psychotherapist attending a party at a patient's house (Goldstein & Farmer, 1993), or a psychotherapist inviting a patient over for coffee and taking her for rides in the country (Pendergast, 1995). Other alleged boundary violations were more subtle and have included prohibiting an adult child from receiving letters from her parents ("Parents Tell Us," 1993) and pressuring patients to write angry letters to their parents (Goldstein & Farmer, 1993). Recanters also have described psychotherapists who appeared to focus more on the identification of childhood sexual abuse than on treating the patient's presenting problem. Private investigators hired by disgruntled parents and posing as patients also have reported on the apparent exclusive preoccupation of some psychotherapists with childhood sexual abuse (Loftus, 1995). The accusations of recanters have often been combined with allegations that the psychotherapists attempted to create excessive dependency on the psychotherapists or a group therapy family and refused to change treatment plans despite substantial deterioration in the overall functioning of the patients. Memories of abuse have allegedly been retrieved through the misapplication of hypnotherapy and through the interpretation of body memories, coercive group therapy, or trance writing (Goldstein & Farmer, 1993). Also, some recanters have alleged that they were discharged from hospitals prematurely, allowed to have their insurance benefits run out without concern for extended coverage, or given referrals to incompetent practitioners or high-pressure survivor groups (Goldstein & Farmer, 1993). A family member stated that a counselor told her sister with schizophrenia that "psychiatry was a conspiracy of the 'patriarchy' to take power away from women," and that all the symptoms of her alleged schizophrenia "were caused by a person's mind trying to blot out memories of sexual abuse" ("My Sister's Story," 1993, p. 8). An informal review of the recanter literature suggests that many of the offending psychotherapists were unlicensed and practicing without state certification or licensure. However, these accusations would, if true, represent breaches in the fiduciary relationships to which psychologists are held. Practices That Reduce Risks of Legal Liability Professional psychologists can greatly minimize their legal risks by taking basic precautions when treating patients who recover lost memories of childhood abuse. The same attitudes and behaviors on the part of psychologists that lead to quality
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patient care in general (and deter against malpractice suits) apply in the treatment of patients when forgotten, recovered, or implanted memories are suspected. Effective treatment includes maintaining appropriate professional boundaries, developing an accurate diagnosis that is based on a collaborative relationship with the patient, using intervention techniques that have been empirically derived or in other ways have received the profession's endorsement, obtaining informed consent from patients when using experimental techniques, and showing concern for the patients' long-term relationship with their families of origin. Consultation in difficult cases and careful documentation are also essential. Maintain Boundaries
By the nature of our ethical principles, we psychologists are encouraged to avoid multiple relationships (boundary violations) with patients. Psychologists who violate the ethical standards of their profession could be found to have automatically violated the practice standards of their profession (Strombergetal., 1988). As noted earlier, some recanters have reported boundary crossings, such as therapists socializing with patients at a party or having a patient recruit registrants for a workshop. For some patients, these boundary crossings would be harmless, but in the instances reported by recanters, such boundary crossings were perceived by the patients as examples of reinforcing dependency on the therapist. Other reported examples of boundary crossings may be more egregious, such as encouraging patients to contact their families, pressuring patients to confront their perpetrators publicly, or in other ways aligning too closely with the patients. Psychotherapists who become strong advocates for the rights of victims risk losing their objectivity and critical judgment, two traits necessary for successful treatment, and they may be at high risk of being sued. As we document in following sections, boundary violations appear to be a variable in other problem areas of work with these patients as well, such as faulty diagnoses and selecting improper treatment techniques. Psychotherapists should be especially alert to maintaining boundaries with patients who may have been abused, because these patients have already been victims of boundary violations. Many such patients can be expected to reenact boundary problems in their relationships with their psychotherapists. The report of the American Psychiatric Association (1993) on memories of sexual abuse stated the following: Psychiatrists should vigilantly assess the impact of their conduct on the boundaries of the doctor/patient relationship. This is especially critical when treating patients who are seeking care for conditions that are associated with boundary violations in the past. (p. 5)
The failure to maintain appropriate boundaries not only can undermine therapeutic effectiveness, but also can anger the patient enough to precipitate a lawsuit. Many patients with an apparent history of abuse enter therapy with a background of unstable interpersonal relationships, sometimes varying between idealization and vilification of others, including their therapists. One recanter wrote about her idolization of her ther-
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apist, "I believed in him so deeply I began telling other people, Trust him, believe in him, he will make you whole.' . . . If Steve said it, I believed it" (Goldstein & Farmer, 1993, p. 353). Later, she sued Steve and others whom she believed had implanted false memories of child abuse. Diagnose Carefully As noted previously, in a malpractice suit, psychologists are judged according to the extent that their diagnoses or treatments deviated from established professional standards. It is unfortunate that some psychotherapists use unacceptable methods to diagnose childhood sexual abuse. One psychologist claimed that she could identify an abused person just by talking with him or her casually for 10 minutes (Yapko, 1994). In some cases, patients with suggestive symptom profiles have been informed, after a single consultation, that they were undoubtedly victims of abuse (Loftus, 1995). One patient stated the following: My therapist's conjecture of incest became a recurring mental boxing match because of its very nature. I believe it was preposterous, yet one of the hallmarks of such abuse is supposed to be denial. Was I sure it never happened? (Overstreet, 1993, p. 6)
A determination of childhood abuse should never be made on the basis of a cluster of symptoms alone. Depression, suspiciousness, anxiety, or other symptoms can be caused by several variables, of which childhood sexual abuse is only one. Being too quick to identify childhood sexual abuse does a disservice to the patient and may reflect a bias on the part of the psychotherapist. Guthiel (1993) warned that "a facile formulation of 'child sexual abuse' may replace a careful clinical assessment of a complex history" (p. 529). As the media popularizes the possibility of recovering memories through hypnosis and other techniques, prospective patients may ask psychologists to diagnose them as survivors of childhood abuse by helping them reawaken childhood events or verifying vague recollections or feelings. Although the attribution of such power is flattering, the prudent psychologist acknowledges the limitations of psychological techniques and will disavow any such infallible power, noting that memory is a reconstructive process and that no truth serum, be it hypnosis or drugs, is without shortcomings. Although patients may become angry with a therapist who expresses uncertainty about the literal truth of their childhood memories, the patients are better off with a therapist who honestly holds judgment in abeyance. Clinical skill is required to balance the patients' need for emotional support with their need to remain open to alternative explanations in the presence of ambiguous or conflicting evidence. Humility and caution are needed here, as with any patient. Psychologists should not be afraid to express uncertainty about the etiology of a particular problem. Symptomatology can be multidetermined, and it should not be presumed that similar symptoms in different patients have the same etiology. Some patients may not be able to confirm their inklings or suspicion of past abuse. Treatment may help these patients adjust to this unresolved area of their lives.
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Choose Acceptable Interventions As with improper diagnoses, courts are more likely to find psychotherapists liable for choosing unacceptable intervention techniques when the harm has been obvious, such as when patients act on suicidal or homicidal tendencies or disrupt family relationships. For example, a psychiatrist was sued for malpractice when she allegedly helped a patient recover lost memories of sexual abuse and the patient later killed himself. The experimental reparenting treatment procedure was allegedly inappropriate for the patient, whom other experts claimed was suffering from a psychotic depression (McNamara, 1991). If it is necessary to attempt to retrieve memories of past abuse, then psychologists should rely on their scientific heritage to guide their choice of procedures. A court is more likely to reject a charge of negligent psychotherapy if the psychologist used professionally acceptable techniques that are based on scientific research. Basics of memory retrieval. Psychologists who treat patients with reawakened memories of past traumas should select treatments that are consistent with what psychological science knows about memory creation and reconstruction. Some psychotherapists mistakenly believe that memory works like a video recorder and accurately records all the events that occurred during a life. According to this popular theory, patients should be able to retrieve all experiences that they endured during their lives if they are only given the appropriate retrieval cues. As a consequence, the uninformed psychotherapist may believe that hypnotic age regression, body work, trance writing, or some other technique will provide the cue necessary to elicit accurate memories of past events. One therapist who did body work stated the following: When I'm working with someone and their body tells the story and their feelings are so connected with their body—I believe them strongly . . . My gut knows truth. I know when someone is bull. . .—I can feel it. \bu can't fake feelings really well when they are deep down. It's really hard to fake it because people go back to being children. (Goldstein & Farmer, 1994, p. 197) However, intense emotions and intuition are not adequate to corroborate past events. Memories are not always accurate. Instead, memories can be altered by the way in which they are retrieved. That is not to say that they are always entirely false; there may be elements of truth contained with some generally inaccurate memories. However, the very process of retrieving a memory often involves some distortions. It is not the purpose of this article to review the scientific literature on reconstructive memory (see British Psychological Society, 1995;Loftus, 1993;Yapko, 1994). However, responsible psychotherapists who work with these patients know the limitations and potential problems associated with memory retrieval techniques. Retrieving lost memories. The optimal manner of retrieving past events involves talking with patients, eliciting their feelings, helping them to understand the impact of past traumas on their present lives, and teaching them how to make their everyday functioning more productive (Herman, 1992). Some questionable techniques used to retrieve lost memories include age regression, body memory interpretation, suggestive questioning,
guided visualization, sexualized dream interpretation, highpressure survivor groups, aggressive sodium amytal interviews, and misleading bibliotherapy. We were unable to find controlled outcome studies that demonstrate their effectiveness in treating Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) disorders. The accuracy of these techniques in retrieving childhood events is questionable, and they have the potential for creating false memories (Lindsay & Read, 1995). Unless patients have been advised of these techniques' limitations, their use will be difficult to support in the event of litigation. For example, evidence suggests that age regression does not help patients recall past events accurately. Nash's (1987) review of age regression studies found that "there is no evidence for the idea that hypnosis enables subjects to accurately re-experience the events of childhood or to return to developmentally previous modes of functioning" (p. 49). Although hypnotized participants typically act more child-like, so can adequately motivated control participants. "Hypnotic age regression . . . elicits a profoundly believed in experience that may have important diagnostic and therapeutic properties . . . but it does not seem to involve a bona fide return to or reinstatement of childhood functioning" (Nash, 1987, p. 50). Many experienced clinicians believe that it is therapeutically indicated, under certain circumstances, to seek to retrieve (or "de-repress") memories of abuse through hypnotherapy or sodium amytal interviews. According to Gold, Hughes, and Hohnecker (1994); Terr (1994); and Herman (1992), these techniques may be justified when hidden trauma is strongly suspected on the basis of objective criteria and the patient's suffering is severe. We would add that they are justified only when more prosaic techniques of memory recovery (e.g., talking) have failed and the patient has been informed of the limitations of these techniques and their potential for creating false memories. To minimize the possibility that therapist bias could influence the content of the memory, contextual cues should be kept as neutral as possible. Psychologists should record in detail the patient's statements about possible past abuse ahead of time and should video- or audiotape the sessions to protect against possible allegations that they, the psychologists, implanted false memories. Each venture must be preceded by careful preparation and allow for an adequate period of reintegration of the new knowledge. "Premature conclusions can bias the subsequent direction of the search. . . . As the patient accumulates memory traces without contextual biasing, the process of event reconstruction becomes less like a projective test being administered to the therapist" (Byrd, 1994, p. 439). The nature of the debriefing should be recorded in detail. Informed consent. The American Psychological Association (APA) ethics code (APA, 1992) requires that patients be informed of the general nature and content of the psychotherapy procedures in which they participate: The content of informed consent will vary depending on many circumstances; however, informed consent generally implies that the person ( 1 ) has the capacity to consent, (2) has been informed of significant information concerning the procedure, (3) has freely
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A general rule is to ask what the average person would want to know about the procedure. Previous courts dealing with informed consent have ruled that patients should have the opportunity to learn the risks and benefits of treatment procedures. According to Canterbury v. Spence (1972), informed consent "means generally informing patients in nontechnical terms as to what is at stake, i.e., the therapy alternatives open to him, goals expected or believed to be achieved, and risks which may ensue from particular treatment and no treatment" (p. 773). The informed consent process should include statements about the general nature of therapy, the role of the memory retrieval techniques (if used at all) in meeting the overall goals of therapy and an explanation of the benefits and risks of those procedures. A brief printed brochure on the memory retrieval procedure may reinforce what the patient is told verbally. The brochure should indicate the limitations to and benefits of the memory retrieval technique. Care must be taken that the brochure does not guarantee results, create unrealistic expectations, or minimize the risk of creating false memories. The brochure should supplement, not replace, ongoing conversations between the psychologist and patient as treatment progresses. By itself, the brochure is meaningless unless given in the context of discussion and understanding on the part of the patient. Survivor bibliotherapy. It is very unlikely that a psychologist would be held liable, in and of itself, for recommending a particular book. However, the recommendation of a book written specifically for survivors may, along with other actions, imply a diagnosis of childhood abuse for the patient. Bibliotherapy should be accompanied by discussion of the reading material in therapy. Survivor groups. Self-help groups have been of great value to many patients, and no doubt many patients with backgrounds of abuse have benefited from self-help groups. At the same time, the literature on this area suggests that there have been many instances in which survivor self-help groups have been destructive. Psychologists and other health professionals could be held liable for negligent referral or for referral to practitioners whom they knew, or should have known, were not competent or appropriate for specific patients. The decision to refer to a survivor-oriented adjunctive therapy group depends on the individual needs of the patient and the nature of the group. In some self-help groups, the sharing of memories by some survivors may influence the memories of others who were not certain whether they were abused (Rogers, 1994). Without professional leaders who have a scientific background and who are trained in professional ethics, self-help groups are vulnerable to developing (a) a zealous leadership that insists on pseudoscientific explanations or (b) a grandiose leadership that has an intrusive impact on their members. An example of pseudoscience includes the dedication to which some members of Schizophrenics Anonymous held on to the megavitamin theory of treating schizophrenia (Galanter, 1988). Intense dependency within the group may discourage persons from graduating from the group—some patients are told that the group represents their "new family" (Goldstein & Farmer, 1994).
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Show concern for family relationships. Interventions should show concern for the future of the patients' relationships with their families. It is not always responsible for a psychologist to say, "I only respond to what my patient says, I do not concern myself with the objective accuracy of her report." If patients intend to detach themselves from their families or to initiate a lawsuit against parents, then they deserve the benefit of an informed opinion concerning the veracity of their perceptions or the scientific basis of the techniques used to retrieve their memories. Courts may doubt the accuracy of bizarre accusations in the absence of corroborating evidence. A higher threshold of skepticism should occur when patients retrieve memories of past abuse that occurred in their very early lives, involved satanic rituals, or occurred under other highly unusual circumstances. Childhood amnesia. A psychologist who is aware of the phenomenon of childhood amnesia would have reservations about accepting the validity of a recollection of an event that, for example, occurred before the child reached the age of 2 years and certainly before the age of 1 year. Everyone suffers from childhood amnesia, the inability to recall experiences from the first years of life. "Nothing can be recalled accurately from before the first birthday and little from before the second. Poor memory from before the fourth birthday is normal" (British Psychological Society, 1995, p. 29). Of course, the remembered event may have been a reconstruction that was based on descriptions of the event given by parents, siblings, or other witnesses. A survey by the False Memory Syndrome Foundation in the United States showed that 33% of the accusing children reported uncovering memories of abuse that occurred before the age of 2 years ("The Accusations," 1993). However, the survey asked when the abuse first began. It is possible that the patient accurately remembered later events, although the veracity of the early events remains more questionable. These reports suggest that patients are either entering therapy with preconceived and false notions of very early childhood memories or are acquiring those memories during psychotherapy. Satanic rituals. The evidence for satanic ritualistic abuse is controversial, but part of the problem may rest in its definition. Although about one third of psychotherapists have claimed that they have treated at least one patient reporting satanic or religiously motivated abuse, very few psychotherapists have reported treating dozens or even hundreds of cases (Bottoms, as cited in Schneider, 1994). This fact is consistent with the theory that the identification of satanic ritualistic abuse depends more on the bias of the treating psychotherapist than on the objective circumstances of the patient. This is not to say that all reports of satanic ritual abuse are false. However, greater skepticism must be given to such reports in the absence of corroborating evidence, especially if patients are considering confronting or detaching themselves from their families of origin. For example, one adult child accused her parents of using her as a breeder (impregnating her to obtain babies who were later killed in sacrificial rituals) in her early adolescence. However, the parents obtained a physician's report that she was a virgin at the age of 19 (Goldstein & Farmer, 1994). Family confrontations. A child abuse accusation can create lifelong anger and alienation among family members. The problem is exacerbated when the accusations are based on memories
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that were recovered through experimental interventions. When patients want to go public with their accusations, they should consider asking for impartial sources of verification, such as hospital or physician records, recollections of other family members, or other sources. A high threshold should be required before a memory fragment or an inkling is turned into a belief. Although Herman (1992) believes that family confrontations can be therapeutic and empowering, she noted that they are not without problems. Traditional family dynamics of dominance and submission may make the confrontation difficult; some family members may deny the events or become alienated from the accuser. Their symptoms may become worse as patients disclose their abusive experiences. This may be, at least in part, because patients lose their traditional support systems (McNulty & Wardle, 1994). The decision about whether to detach from a family or to confront the alleged perpetrator should be made only after careful evaluation of the consequences for the patient. As with other patients, it is advisable to refrain from making important decisions about family confrontation or detachment during the acute phase of a disorder. Psychotherapists should help patients clarify their goals in light of their unique life circumstances. Direct contact between the patient's psychologist and her or his parents may be risky from a risk management perspective. The direct contact may be construed as a professional relationship between the parents and the psychologist, thus providing the parents with the necessary fiduciary relationship in order to sue for malpractice. If patients are uncertain about their memories, then it may be prudent to involve the parents in a nonconfrontational mediation process (London, 1995). The goals of this process could be to help obtain background information on the suspicions or inklings of the patient and to build or rebuild family relationships. Encouraging confrontations with alleged perpetrators, out of a concern for the so-called silent victims who are afraid to come forth, risks a boundary violation where the therapist's allegiance shifts from the patient to nonpatients. Although it is highly desirable for all persons to work to reduce childhood sexual abuse, using the dependence engendered in psychotherapy to enlist a patient to help redress this social wrong may violate appropriate boundaries.
Document Carefully As with the treatment of any patient, psychologists should document what they are doing and why they are doing it. A well-written document recording treatment decisions and procedures is a powerful defense in court (Soisson, VandeCreek, & Knapp, 1987). An axiom among malpractice defense attorneys is "If it isn't written down, it didn't occur." Psychologists should record the presenting problems and diagnosis, the methods used to obtain it, the treatment plan and its relationship to the presenting problems or diagnosis, and all consultations. If experimental techniques are used to de-repress memories, then the psychologist should record why these techniques were needed to help the patient. Documentation of what the patient said before, during, and after the de-repression session is indicated. A video- or audiotape of the de-repression session can help to defuse later accusations of suggestive question-
ing or misleading contextual cues. Documentation of informed consent for experimental procedures should be made. If the patient decides to detach from or confront his or her family, psychotherapists should record their neutrality in reaching this decision and should document their discussions about the inherent risks.
Consult With Other Professionals Psychologists should consult with other psychotherapists as part of the larger process of self-monitoring and self-improvement of their professional services. When challenged in court, psychologists will be evaluated on the extent to which they adhered to the standards of their profession. Seeking consultation helps to ensure that psychologists are providing good treatment to their patients. At times, it may be desirable to seek consultation with an expert who has a different perspective on the nature and frequency with which memories are lost and recovered. The consultation should be documented and include responses to specific questions, including, but not limited to, the diagnosis or presenting problem, specific treatment plans, and alternative treatment strategies.
Conclusion The antitherapy rhetoric in the repressed memory war has often been outlandish, unjustified, and needlessly offensive. However, part of the controversy is fueled by substandard practices on the part of some psychotherapists. Skilled professionals agree on the need to adhere to appropriate professional boundaries and to rely on accepted methods of diagnosing and treating patients. Psychologists who adhere to these standards will provide better treatment to their patients and substantially reduce the legal risks to themselves. As a profession, we psychologists have a responsibility to help the survivors of childhood traumas. We also have a responsibility to avoid false accusations of parents that are inherently harmful and that weaken the credibility of the true victims of child abuse.
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