Recovered memory debate revisited: practice implications for mental health counselors.

With the high incidence of childhood sexual abuse and the attendant serious negative consequences resulting from it clearly documented, there is a high probability that many mental health counselors will at some point in their career provide treatment to members of this population. Since memory retrieval is an integral part of the treatment protocol when working with such clients, it is imperative that clinicians have a good understanding of the controversy over recovered memories of childhood sexual abuse. This article revisits the controversy, provides a detailed discussion of the issues involved, and offers practice implications for mental health counselors.

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Since the early 1990s there has been a great deal of controversy within the mental health community over the recovery of previously repressed or dissociated memories of childhood sexual abuse. There were a number of factors contributing to the increased interest in this psychological phenomenon, beginning with a tremendous increase in cases where individuals reported the recovery of such forgotten memories after a period of many years. The memories were allegedly repressed or dissociated and subsequently recovered, often when the individual began therapy (Baker, 1998; Courtois, 1999; Loftus & Ketcham, 1994; Lynn & McConkey, 1998; Pendergast, 1995; Pope & Brown, 1996; Whitfield, 1995).

State legislative changes allowing victims to prosecute perpetrators many years after the events had occurred added momentum to the controversy resulting in numerous lawsuits filed against parents. The central component and catalyst for the controversy were claims made by alleged perpetrators that accusations made were false and based on memories often induced, or suggested, by the victims' psychotherapists. Often such claims were substantiated when individuals who had recovered memories in therapy recanted, reporting that they were actually false and implanted by their therapists' suggestion (Magner & Parkinson, 2001; Wakefield & Underwager, 1992).

The major mental health organizations responded by initiating task forces to examine the controversy. This resulted in guidelines for treating clients claiming recovery of memories of childhood sexual abuse during therapy (Courtois, 1999). While the current trend is towards a more balanced perspective and the extreme positions of the past have been modified, there still is disagreement within the mental health community over the veracity of such memories (Brown, 2004; Davies & Dalgleish, 2001).

Given the documented incidence of childhood sexual abuse there is high probability that mental health counselors will encounter clients who present with this problem or who suspect they may have been sexually abused and seek treatment in uncovering memories related to this suspicion. Therefore, it is critical that mental health counselors have a clear understanding of this ongoing controversy and, more importantly, of how to effectively treat clients with such backgrounds. This article presents a discussion of the contributing factors in the longstanding debate. It also provides suggestions for mental health counselors to consider when treating clients who claim to have recovered memories of sexual abuse or who want to retrieve such memories because they believe they were sexually abused.

PREVALENCE AND IMPACT OF CHILDHOOD SEXUAL ABUSE

Numerous studies have substantiated a history of childhood sexual abuse among adults seeking therapeutic services. Finkelhor (1994) noted prevalence rates ranging from 7% to 36% for women and from 3% to 29% for men, while Gorey and Leslie (1997) reported prevalence rates of 22% for women and 9% for men. In a study conducted of U.S. women, Consentino and Collins (1996) reported that 25% to 33% revealed sexual abuse before age 18. Jones and Finkelhor (2001), citing data from the National Child Abuse and Neglect Data System, found a prevalence rate of 32.8%.

More recently, documented evidence of the prevalence of childhood sexual abuse for women revealed a low range of 10.9% to 13% (Oaksford & Frude, 2001; Plant, Miller, & Plant, 2004; Sidebotham, 2000) to a high range of 27.2% to 33% (Boles, Joshi, Grella, & Wellisch, 2005; Feerick & Snow, 2005; Freeman, Parillo, Collier, & Rusek, 2001; Hawke, Jainchill, & DeLeon, 2000). The prevalence rate for men ranged from a low of 4% to 5% (Dunne, Purdie, Cook, Boyle, & Najam, 2003; King, Coxell, & Mezey, 2000) to a high of 9.2% to 11.7% (Boles et al., 2005; Plant et al., 2004).

Further, the long-term negative effects of childhood sexual abuse have been amply documented as follows: development of adult mental disorders (Katerndahl, Burge, & Kellogg, 2005); disordered eating behaviors and clinical eating disorders (Ackard, Neumark-Sztainer, Hannan, French, & Story, 2001; Hund & Espelage, 2005; Johnson, Cohen, Kasen, & Brook, 2002; Romans, Gendall, Martin, & Mullen, 2005); greater marital dissatisfaction (Liang, Willaims, & Diegel, 2006); disturbed interpersonal relationships (DiLillo, 2001); post-traumatic stress disorder (Feerick & Snow, 2005; McDonagh et al., 2005); risk for greater suicidal behavior (Martin, Bergen, Richardson, Roeger, & Allison, 2004; Oates, 2004); adolescent pregnancy and sexual problems (Noll, Trickett, & Putnam, 2003); engaging in high risk sexual behaviors (Cinq-Mars, Wright, Cyr, & McDuff, 2003; Testa, VanZele-Tamsen, & Livingston, 2005); use of illicit drugs and substance use disorders (Hawke, Jainchill, & DeLeon, 2000; Plant et al., 2004; Rodriguez-Srednicki, 2001); alcohol abuse (Dube, Anda, Felitti, Edwards, & Croft, 2002; Horwitz, Widom, McLaughlin, & White, 2001); depression (Hill et al., 2000); childhood onset depression (Hill, Pickles, Rollinson, Davies, & Byatt, 2004); and anxiety (Roberts, O'Connor, Dunn, & Golding, 2004).

Rind, Tromovitch and Bauserman's (1998) meta-analysis on the long-term effects of childhood sexual abuse set off a controversy in the U.S. media that reached the halls of Congress. They concluded that the harmful effects of childhood sexual abuse were greatly overstated by mental health researchers, and indicated that willing encounters should no longer be classified as childhood sexual abuse, but rather, as adult-child sex. Their findings were disputed, severely criticized and found invalid by subsequent reviewers (Dallam et al., 2001; Lilienfeld, 2002; Whittenburg, Tice, Baker, & Lemmey, 2001; Speigel, 2001).

Thus, it is apparent that not only will mental health counselors come into contact with individuals sexually abused in childhood, but also that individuals from this population are in dire need of therapeutic services to address the issues and circumstances surrounding their abuse.

RECOVERED MEMORY CONTROVERSY

The Beginning

The recovered memory controversy began in the late 1980s and early 1990s and centered on whether traumatic experiences, such as childhood sexual abuse, could be completely forgotten and recovered years later. Not only were numerous families split over accusations of sexual abuse but the controversy over the reliability and veracity of such memories also caused a significant split within the mental health profession (Davies & Dalgleish, 2001; Schacter, 1996). Besides the question of whether the mechanism of repression actually existed, issues involved in the hotly debated topic included how memory is formed, encoded and retrieved, the effect of trauma on memory, the accuracy and credibility of memories of childhood sexual abuse, and the role of therapeutic influence on memory retrieval (Davis, 2005; McNally, 2003; Mollon, 2002).

Courtois (1999) indicated there were three issues involved in the recovered memory controversy: "(1) whether trauma can be forgotten and then remembered, (2) the accuracy and credibility of memories of childhood sexual abuse, and (3) the role of therapeutic influence on memories" (p. 31). Brown (2004) agreed but suggested the early debate focused basically on two areas: (1) was it scientifically possible for someone to remember sexual abuse trauma after many years of not knowing and (2) was it possible for someone to develop false beliefs about prior life experiences, specifically about having been sexually abused in childhood, in response to suggestions from therapists, books and other sources.

The False Memory Perspective

The False Memory Syndrome Foundation (FMSF) was founded in 1992 by Pamela and Peter Freyd, after Peter was accused of sexually molesting their daughter Jennifer, a professor of psychology. Its purpose was to assist individuals claiming to be falsely accused of, or charged with sexual abuse. After gathering together a small group of academics who believed that memories of abused were often false and implanted by psychotherapists, the FMSF began a media campaign against what they referred to as recovered memory therapy (Whitfield, 1995).

False memory (FM) advocates took the extreme stance that all denials by alleged perpetrators and any recantations on the part of victims were truthful and to be believed even without investigation, while all abuse memories discussed or recovered during therapy were false, and should not be believed. They claimed that recovered memories were untrue, that substantial numbers of people were falsely accused and that those who say they are survivors have often been misled, or even brainwashed by naive or manipulative therapists, authors, and book publishers. They pointed out that research studies had not found many cases in which sexual abuse events were completely wiped from memory and that most victims remembered all too well, rather than forgot the sexual abuse (McNally, 2003; Pope & Brown, 1996).

According to Davis (2005), "the FMS Foundation and other critics have largely framed the memory wars as a battle between empirical science and therapeutic romanticism" (p. 231). He described it as a polarization between psychiatrists and academic psychologists defining their discipline as one of rigorous scientific observation and methodology against therapeutic practitioners relying heavily on insights gathered from the treatment of individual cases. It was a rejection of the trauma model and the mental mechanisms of repression and dissociation.

Strongly based on Holmes' (1990) research on repression, the FM position argued against the existence of repression, dissociation, and recovered memory. This perspective found support among many mental health professionals (Loftus, 1993; Loftus & Ketcham, 1994; Ofshe & Watters, 1994; Pendergast, 1995; Pope & Hudson, 1995, Thomas & Loftus, 2002; Yapko, 1994) who suggested that certain biased therapeutic techniques used to assist in memory recall, such as hypnosis, and self-help strategies for survivors of childhood trauma fostered in self-help books ran the risk of implanting memories in vulnerable individuals (Draucker & Martsolf, 2006). Furthermore, they warned that the creation of false memories in legal proceedings was also associated with specific therapeutic techniques such as guided imagery, age regression, journaling, dream work and interpretation, EMDR, art therapy, feelings/emotional release work, group therapy, and bibliotherapy (Madden, 1998). The FMSF influenced the development of similar organizations in the United Kingdom, Australia, New Zealand, and elsewhere making the controversy an international one (Davies & Dalgleish, 2001).

The Recovered Memory Perspective

Contradicting the FM position were many mental health professionals convinced of the reality of repression and recovered memory (Courtois, 1999; Freyd, 1996; Reisner, 1998; Terr, 1994: Whitfield, 1995). Proponents stressed that the notion of hidden memory was not foreign to the clinical field as the defense mechanism of repression had been at the center of psychodynamic explanations and treatment for decades. They cited the category of dissociative amnesia listed in the DSM-IV (1994) as formal acknowledgment of the phenomenon of repression. They argued it was not unreasonable to expect that some children might totally repress their painful sexual trauma until discussion in therapy, or life events later triggered memories. In addition, they asserted there was substantive research literature supporting the contention that repressed or recovered memories of abuse can be accurate (Reisner, 1998; Whitfield, 1995).

Olio (1992) strongly disputed the FM position stipulating there were no appropriate scientific studies or clinical trails to substantiate a diagnosis of false memory syndrome, and that nearly all delayed memories of child sexual abuse were true. He asserted that appropriate scientific studies on repression would be difficult to conduct due to ethical concerns in trying to duplicate traumatic experiences in a laboratory setting. Pope (1994) agreed citing a coauthored statement signed by 17 researchers objecting that the term false memory syndrome was a non-psychological term originated by a private foundation whose stated purpose was to support accused parents. Furthermore, there was no scientific evidence supporting it, and they urged, for the sake of intellectual honesty, that the term false memory syndrome be left to the popular press to use.

Davis (2005) reported that survivor therapists responded to the accusations of the FMSF by emphasizing that clinical issues belonged in the hands of clinicians who had specialized training and expertise. The survivor therapists strongly affirmed the empirical foundations of the trauma model and rejected the implication by FM advocates, also on empirical grounds, that therapists routinely implanted memories of abuse and post-traumatic reactions in clients.

Conte (1999), disputing the accusation there was no scientific evidence for the existence of repression, reported that Holmes' (1990) review of the literature related only to laboratory research and that Holmes himself pointed out that any lack of empirical evidence for repression did not mean repression does not exist, only that it had not been proven in the laboratory.

Response by Professional Organizations

Responding to the escalating controversy, mental health organizations established taskforces to study the issues involved and make recommendations for clinical, research and forensic practice (American Psychiatric Association, 1993; American Psychological Association, 1994; British Psychological Society, 1995; Canadian Psychiatric Association, 1996; National Association of Social Work, 1996). The final recommendations of the Working Group on Investigation of Memories of Child Abuse of the American Psychological Association presented findings mirroring those of the other professional organizations: (1) controversies regarding adult recollections should not be allowed to obscure the fact that child sexual abuse is a complex and pervasive problem in America that has historically gone unacknowledged; (2) most people who were sexually abused as children remember all or part of what happened to them; (3) it is possible for memories of abuse that have been forgotten for a long time to be remembered; (4) it is also possible to construct convincing pseudo-memories for events that never occurred; and (5) there are gaps in our knowledge about the processes that lead to accurate and inaccurate recollections of childhood abuse (APA Working Group, 1998, p. 933).

Each group strongly advocated for a more balanced perspective. They concluded there should be a more dispassionate approach taken to the issues involved as both sides were guilty of making pronouncements and taking action based on anecdotes and impressions rather than on systematic empirical evidence. They stressed that professional wisdom required a more restrained, tolerant and sensitive approach by all sides. They also advocated for greater effort by all to establish points of commonality and much more study made on the part of all professionals involved in this area (Courtois, 1999).

Current Perspective

After publication of the task forces findings the radical positions originally staked out, with the accompanying inflammatory rhetoric, were condemned openly and publicly by moderates within the profession (Allen, 2005; Brown, 2004, Courtois, 1999; Davis, 2005, Mollon, 2002; Pope & Brown, 1996; Power, 2001; Yapko, 2003). These moderate professionals searched for common ground, areas of agreement and ways to be more collaborative and less adversarial. The middle ground position was articulated succinctly by Davies and Dalgleish (2001), as well as Allen (2005) who summarized the current situation within the field as one in which, "clinicians, researchers and professional organizations have managed to transcend acrimonious debate to arrive at a well-informed middle ground that can guide clinical practice" (p. 90). Power (2001) concluded there was evidence strongly suggesting that everyone had been on target regarding the controversies surrounding memory: memories can be forgotten and then recovered and they can also be false.

Enough research has been accumulated supporting the position that traumatic memory is different from ordinary event memory and that recovered memories are possible while not necessarily accurate in their entirety (Allen, 2005; Courtois, 1999; Davis, 2005; McNally, 2003; Mollon, 2002). In reviewing scientific developments related to the delayed recall of memory, Brown (2004) found support for the belief that traumatic memories are processed differently than memories for ordinary events. Areas of research highlighted by Brown were van der Kolk's (1996) research on the somatosensory modalities of processing information, the betrayal trauma model developed by Freyd and colleagues (2001), and Anderson's (1998) inhibitory memory model.

Mollon (2002), articulating on the research gathered over the years with respect to trauma and memory, indicated the following consistent themes that had emerged: (1) while memory may often be essentially accurate, it is uncertain and prone to error, (2) memory may be disturbed in various ways because of trauma; (3) in any particular case, absent corroborative evidence, there may be no way of knowing whether a particular memory of a childhood event is essentially true or essentially false; and (4) many of the dogmatic statements and generalizations found in the recovered memory dispute were spurious and misleading.

In support of recovered memory, Stoler, Quina, DePrince, and Freyd (2001) reported there were at least 30 peer-reviewed retrospective studies of adult survivors of child sexual abuse which documented that between 19 and 59% of the subjects forgot and later recalled some or all of the abuse. Brown (2004) citing the above studies concluded that, "the overwhelming weight of the data argues for the reality of delayed recall in the lives of many adults who were sexually abused as children" (p. 197). Further support is offered by Cheit (1998) who founded the Recovered Memory Archive containing detailed information on 101 well-corroborated cases of delayed recall, the majority involving allegations of childhood sexual abuse. Referring to the evidence supporting the forgetting or blocking out of traumatic experiences with recall at a later date, Ainscough and Toon (2000) stated, "survivors sometimes recover memories of abuse while in therapy, perhaps because their memories are triggered by talking about their lives or because they feel safe enough to allow the memories back into awareness" (p. 268).

Skinner (2001) also disputed the argument that it is not possible to forget something as traumatic as sexual abuse. He presented case examples of individuals who gained access to previously unaware material outside of treatment and without specific prompting of "memory recovery" techniques such as hypnosis. He stated:

   These subjects had good reason not to remember, and there is a
   variety of scientific psychological explanations for the process. It
   is likely that different mechanisms are responsible for different
   forgetting--repression, dissociation and ordinary forgetting. The
   view that it is not possible to forget something as traumatic as
   sexual abuse does not stand up to examination." (p. 48)

More recently Brown (2004) refuted allegations made by the FM advocates stating, "the assertions made in the early 1990s by individuals in the false memory movement that it is impossible for reasonably accurate memories to be experienced in this delayed fashion has been well refuted by the data" (p. 202).

PRACTICE IMPLICATIONS FOR MENTAL HEALTH COUNSELORS

Memory retrieval continues to be an important component in treating individuals who were traumatized by childhood sexual abuse. Even though it is not necessary for sexually abused clients to recall every episode of abuse in exact detail, clinicians working with survivors tend to agree that to process the trauma some memories of the abuse must be recalled along with any associated affective symptoms. This process is considered necessary for recovery (Allen, 2005; Bass & Davis, 1994; Brown, Scheflin, & Hammond, 1998; Courtois, 1999; Davis, 2005; Draucker & Martsolf, 2006; McNally, 2003; Mollon, 2002; Roland, 1993).

Yapko's (1998, 2003) position that it is the responsibility of the therapist to discern true from false memories places the mental health counselor in the role of investigator and judge. He indicated that whenever a client reports a sudden recovery of memories of sexual abuse, either in therapy or after reading recovery literature, the therapist should find corroborating evidence for such ambiguous revelations. This evidence can be confirmed through medical and school records from the client's childhood, and by interviewing family and friends about the reported incidents. According to Yapko, the more external the evidence, the better.

Earlier, Davies and Frawley (1991), when addressing transference and counter-transference issues, suggested that therapists might become anxious when hearing of sexual abuse if they feel they have to determine fact from fantasy. They indicated it is the client's, and not the therapist's task, to define their own personal history. Matsakis (1994) supported this position stressing that what matters most is what the client believes occurred, not what the therapist believes, and the therapist is not the judge of whether or not an event actually took place or whether memories are 100 percent accurate. McDonald (1995) agreed when she stated, "the therapist's role is not one of fact-finding, but one of support and encouragement" (p. 21). Pope and Brown (1996) also asserted that therapists are not in a position to ultimately validate or reject anything clients say about their lives. They pointed to the extreme difficulty survivors have believing they were abused, even when details of the abuse have never left their memories and stressed that questions of validity, reality and corroboration become even more complex when the memory has been delayed, or out of consciousness for many years. Additionally, Ganaway (1995) stressed that part of the clinician's responsibility to the client is to offer psychological understanding and support while not actually adopting or promoting the client's point of view.

Promoting the awareness of the controversy is vitally important in preparing mental health counselors to treat individuals who have a history of childhood sexual abuse and those who suspect they may have been victimized. Mental health counselors need to exercise sound clinical judgment when treating this population and having an understanding of both treatment concerns and recommendations gleamed from the literature will help them do so.

Treatment Recommendations

Given the high probability that mental health counselors will encounter clients with histories of childhood sexual abuse it is important for them to be aware of treatment concerns when dealing with survivors. The following treatment recommendations are offered for mental health counselors to consider when working with survivors of childhood sexual abuse:

* Avoid memory retrieval techniques that have been shown to foster the creation of false memories.

This concern is at the very heart of the memory debate and clinicians have been severely criticized for using methods that may be misleading and result in false memories and false accusations (Reisner, 1998). Many therapists have incorporated into treatment a variety of memory recovery techniques that have been called into question, such as hypnosis, age regression, guided imagery, journal writing, dream interpretation, interpretation of body symptoms, or identification of sexual abuse from a set profile in the form of a symptom checklist (Yapko, 1994). Brainerd and Reyna (2005) have identified certain therapeutic techniques shown to be fertile ground for fostering false memories including: hypnosis, guided imagery, memory work, interpretation of the meaning of behavioral symptoms, dream interpretation, age regression, the use of family photographs and giving free rein to the imagination to stimulate memory recovery. The authors implied that using such methods to recover memories of sexual abuse often was a powerful case of suggestibility.

Lindsay and Read (1994) reported several factors contributing to the creation of false memories: suggestions by a respected authority figure, long delays between the purported event and the surfacing of the memory, the plausibility of the events, and the repetitive discussions in therapy of the alleged abusive events. Thus, recovered memories may be iatrogenic (i.e., unintentionally caused by the therapist). Yapko (1994) places the responsibility to sort out true from false reports of childhood traumatic abuse on the mental health professional. However, acknowledging the difficulty of doing so, he insisted that, at the least, clinicians should be extremely cautious that, in their effort to heal, they do not create memories of abuse which did not occur. Gafner (2004) recommended informing clients that a memory recalled or retrieved through hypnotic techniques may be valid, but it also may be fantasy, distortion, or confabulation.

The caution for clinicians to be careful not to create false memories is meaningful and important. Mental health counselors must be careful during assessment to insure an accurate diagnosis, and cautious when using certain therapeutic techniques during treatment so as to avoid pitfalls leading to inappropriate outcomes. Yapko (2003) reported that memory is not reliable and if one is looking for truth it would not be found in memory. Recalled memories may be entirely accurate, partly accurate, partly inaccurate, and entirely inaccurate. Sivers, Schooler, and Freyd (2002) agreed stating that, "recovered memories may vary in their degree of accuracy, ranging from largely accurate to entirely false, with many gradations of gray in between" (p. 183).

Furthermore, Yapko (2003) stated that "without objective evidence to corroborate a memory, there is no known technology for determining its veracity. Hypnosis does not reveal the truth" (p. 335). Garner (2004) and McDonald (1995) also agreed indicating that memories recovered or recalled under hypnosis are suspect in that any such memories may be true or false, or may be a combination of true and false. Brainerd and Reyna (2005) have reported that hypnotic retrieval is not more accurate than conscious retrieval, and it is more likely that false memories will occur during hypnotic retrieval than during conscious retrieval. An approach that clinicians might adopt is one previously articulated by Yapko (1990): "If you are interested in how someone represents and accesses past experience, which is essential in psychotherapy, then appreciating that the memory seems 'real' to the person is the main point" (p. 45). As with all memories, ideally verification should be sought.

Perhaps the best approach to utilize in cases of suspected sexual abuse with no clear recollection of events is offered by Brown et al. (1998) who stated that the best technique for recall is no technique at all other then free recall. Clinicians should begin with what is available and encouraged free recall. Degun-Mather (2006) agreed stating, "in order to help the client recover memories, it is best to use free recall rather than hypnosis and guided imagery, or structural inquiry or leading questions" (p. 32). Kluft (1996) suggested therapists work with memory from the "top on down", from what is available first, with details perhaps emerging later. He recommended therapists follow a hierarchy of interventions beginning with those having a low degree of risk for suggestion moving step-wise to those with greater intensity and suggestibility only when clinically warranted and possibly only after consultation, supervision and/or peer review.

Finally, recent experiments have demonstrated that guided imagery, like hypnotic retrieval, can result in the formation of false memories of childhood experiences (Arbuthnott, Arbuthnott, & Rossiter, 2001; Arbuthnott, Geelen, & Kealy, 2002; Clancy, McNally, & Schacter, 1999). As with hypnosis it is evident that clinicians should be careful when using techniques, such as guided imagery, age regression and memory retrieval. Mental health counselors must recognize that memories retrieved with such techniques may be totally accurate, partially accurate and partly imagined, or completely imagined. Without independent verification, there is no way for the clinician to know if a client's report is accurate (Yapko, 2003). Therefore, with hypnosis and other memory retrieval techniques, extreme caution is needed because of a greater possibility of memory contamination due to suggestion.

* Discuss the legal ramifications of specific memory retrieval strategies with the client.

Because the memory retrieval techniques mentioned above may foster the creation of false or inaccurate memories mental health counselors need to be aware of the legal ramifications of using these techniques. Orne, Whitehouse, Dinges, and Orne (1988) expressed concern about hypnosis being used in a forensic setting when they concluded that the basis for testimony by witnesses or victims in a court of law should never be permitted if memories were hypnotically induced. Yapko (2003) more recently reported that, "experts are at odds over the issue of whether hypnotically obtained testimony is valid because of the potentially detrimental effects of hypnosis on memory e.g., intentionally or unintentionally suggested misrememberings" (p. 113).

Courtois (1999) indicated that courts have been fairly consistent in disqualifying testimony based on hypnotically refreshed memories. She reported that therapists have been sued because testimony was disqualified through the use of hypnosis even when it was not used for purposes of memory retrieval or refreshment. In situations where clients are involved in any type of litigation Courtois recommended that therapists not use hypnosis or any other similar techniques. Magner and Parkinson (2001) reported that courts have adopted a variety of approaches in dealing with this issue. They stated:

   One solution has been to hold that the hypnotic session was
   irrelevant on basis that if the witness would otherwise have
   been competent, the witness remains competent. On the other
   end of the spectrum, it has been held that the hypnotic session
   makes the evidence completely inadmissible. The preferable approach
   appears to be a case-by-case assessment in which the exercise of
   certain precautions is relevant and the failure to exercise such
   precautions leads to the exclusion of the evidence as inadmissible
   (p. 57).

Brown (2004) addressing the ambiguity of testimony based on recovered memory indicated that testimony based on hypnotic memory retrieval continues to be admissible in states that have statutorily defined memories as capable of being lost and then recovered. However, in other states trail judges, on a case-by-case basis, have ruled both to admit and exclude such testimony. It is important for mental health counselors to discuss with clients contemplating any sort of legal action the possible ramifications of using memory retrieval techniques with respect to the admissibility of such testimony in a court of law. Courts have become extremely skeptical that an accurate and objective accounting of past events can be provided by a hypnotized witness. In New York state, the Court of Appeals precluded an individual from testifying to memories that arose following hypnosis when these memories were offered as direct evidence to demonstrate the truth of the matter in question. The Court declared that hypnosis was an inherently suggestive procedure affecting the subject in three primary respects: (1) increasing susceptibility to suggestions, (2) confabulation by the subject, and (3) the subject will experience an increased confidence in subsequent recollections of a recalled incident (Behnke, Perklin, & Bernstein, 2003).

Some experts have indicated it is inappropriate for clinicians to recommend litigation to clients. However, should a client decide to pursue such a course of action it is critical that the therapist help the client examine his or her thoughts and feelings regarding the decision to initiate a lawsuit. Clients need to clearly understand and be aware of all the legalities of any action brought before the court and it is imperative to assist the client in researching the legal process in their local jurisdictions regarding the admissibility of testimony (Brown et al., 1998; Courtois, 1999).

* Avoid interpreting behavioral symptoms alone as an indication of sexual abuse without other supporting documentation

A main criticism rendered by the FM advocates was that therapists were diagnosing a history of sexual abuse based on symptoms a client manifested at intake without additional assessment or any memory of past abuse (Courtois, 1999). Many of the self-help books identified by FM advocates as fostering the creation of false memories included lists of specific symptoms the authors claimed were indicative of childhood sexual abuse (Bass & Davis, 1994; Blume, 1990; Frederickson, 1992). These authors offered symptom checklists for self-diagnosis which included a host of characteristics associated with sexual abuse. However, they did not indicate how the lists were constructed or developed. Yapko (1998) asserted that although these authors and some therapists believe symptoms connected with sexual abuse indicate that the abuse happened, in actuality the symptoms do not provide evidence of sexual abuse. McDonald (1995) agreed with Ainscough and Toon (2000) who stated therapists "cannot diagnose sexual abuse from a person's symptoms" (p. 268).

The attributes on such lists are broad and general and could apply to any number of psychological disorders. It may be true that abuse victims manifest the signs and symptoms appearing on these lists, but it can not be stated that everyone who displays such attributes is a victim of sexual abuse. Briere (1997) cautioned that because the long-term effects of childhood sexual abuse are so variable it is not sufficient to make a definite determination of abuse based on symptom checklists alone. Similarly, McDonald (1995) warned that symptoms alone do not necessarily identify childhood abuse and cautioned clinicians against using any list of presenting symptoms purporting to identify childhood sexual abuse in assessing whether or not abuse actually occurred.

With respect to the utilization of abuse and trauma symptoms scales, Courtois (1999) has indicated that such scales have psychometric limitations, including a lack of scientific validity. She stated, "they cannot and should not be used to assume past abuse or trauma in the absence of memory" (p. 240). Courtois suggested using such scales for screening purposes and as a reference point for additional inquiry. The Working Group of the American Psychological Association (Alpert, Brown, & Courtois, 1996) provided guidance in this area when they indicated that no one symptom or set of symptoms was pathonomic of sexual abuse or trauma. Brainerd and Reyna (2005) reported that, "the statements of professional organizations indicate there is no scientific basis for such readings of behavioral signs" (p. 395).

Draucker and Martsolf (2006) also stressed there was no specific profile for sexual abuse identified for any standardized personality instrument. Problems occur when well intentioned therapists conclude from their clients' symptoms alone that they were victims of abuse. Therefore, mental health counselors should not utilize symptom checklists or symptom scales for diagnostic purposes. When treating individuals manifesting symptoms suggestive of childhood sexual abuse it is important that mental health counselors not make assumptions regarding causality. Careful inquiry will help to ascertain if the individual has recollections of whether or not abuse occurred. If the client has clear memories, treatment is geared towards helping the individual deal with the symptoms and the related trauma. When there is no recall of sexual abuse having occurred, the mental health counselor must be extremely careful not to suggest to the client that the symptoms are the result of having been sexually abused.

* Attempt to verify the veracity of any recovered or recalled memory whenever possible, provided it is the desire of the client to do so.

Kluft (1996) reported in a study of individuals with Dissociative Identity Disorder that a significant number of clients with histories of sexual abuse were able to obtain independent corroboration of their recovered memories. There is considerable research evidence indicating clients can corroborate recovered memories or delayed recall of childhood sexual abuse (Brewin & Andrews, 1998; Fivush & Edwards, 2004; Pope & Tabachnick, 1995; Widom, 1997). However, clinicians must bear in mind that not everyone will be able to access outside confirmation of their delayed recall of abuse. If memories surface during the course of therapy it is preferable, but not always possible, that some sort of independent verification be made. Without some kind of independent verification there is no way to ascertain definitively if a client's report of memories is accurate. In the absence of independent corroboration, there are no criteria that can readily distinguish between accurate recollections and inaccurate or false memories (Barber, 1997). Mental health counselors should be very aware of not pushing or pressing clients to do more than they are ready, or willing to do. Clinicians may empower clients by reminding them that they are free to determine for themselves what appears in their images, dreams or flashbacks and that they will not be pushed in any particular direction. Clients should be supported regarding their wishes in terms of seeking out corroborating evidence and if they choose to pursue corroborating evidence from independent sources they should be supported in their decision to do so (Pope & Brown, 1996).

In addition, when dealing with human memory it is important to keep in mind the distinction between narrative truth and historical truth. The latter refers to events that actually occurred in the person's past, whereas narrative truth refers to events that either may or may not have actually happened in the (historical) past, but are believed to be true (in the psychological sense) by the person. Narrative truth refers to our life story as we remember it; the historical accuracy of such narrative truth is often indeterminate (Ganaway, 1989; Howard, 1991). Therapists need to be cautious when the individual recovers memories of having been sexually abused while in treatment as what is presented might be narrative truth, not necessarily historical truth. To determine the historical truth would by necessity require independent verification (Allen, 2005).

* Always educate clients to the pitfalls of memory work

Mental health counselors are strongly urged to be diligent in educating clients to the reality of memory work. Clients must be made aware that memories recovered during treatment or after reading certain literature may or may not be accurate. Gafner (2004) stressed that memories recovered under hypnosis are not reliable. They may be valid, but they may also be fantasy, distortion, or confabulation and he recommended that therapists make certain clients are aware of such unreliability. The only definitive way of ascertaining the historical veracity of a memory is to seek outside verification, which as previously discussed, should only be undertaken with the expressed consent of the client. Both the mental health counselor and the client must also accept the possible outcome that they may never actually know whether any particular memory is true or not true. Barber (1997) challenges the clinician to be intellectually and emotionally open to the possibility of no resolution regarding the veracity of a client's report. He stated that without independent verification:

   It may be that the client was abused; it may also be that the client
   was not abused. It may be that the client's sense of having been
   abused is an accurate reflection of how the client felt as a
   child--not physically or sexually abused, necessarily, but not well
   cared for, either. It is likely that there is no way to know. We may
   need to help the client accept this openness to interpretation, as
   well. (p. 314)

Pope and Brown (1996) have stressed the importance of supporting clients in the realization they may never know with absolute certainty what actually happened to them. Mental health counselors can empower clients to be the ultimate expert regarding what is real for them. This would include the real possibility they may never know. Pope and Brown recommend aiding clients in the process of informed exploration by providing information to clients on how memory works and how children's heightened suggestibility can be used to create recollections or perceptions that are inaccurate content-wise, but contain valuable information about what may have happened to them.

Mental health counselors must provide clients with accurate and detailed information regarding the nature of memory and memory retrieval. Clients should be advised that memories consists of a blend of accurate and inaccurate information and that with respect to historical truth even emotionally compelling memories may be inaccurate. Common memory errors, such as detailed reconstruction, source misattribution and confabulation need to be discussed with clients (Brown et al., 1998).

* Avoid recommending confrontation of perpetrators or family members by clients.

The numerous lawsuits and counter lawsuits initiated against clients, family members and therapists during the height of the controversy, in many cases, caused irreparable damage and harm to both clients and third parties involved in the adversarial legal proceedings. While confrontation can be a very powerful opportunity for survivors to foster resolution of their traumatic experiences it may also evoke strong affective responses and possible manifestation of trauma symptomatology. Clients should be advised that confrontation is not a prerequisite for healing, nor is it necessary for healing to occur. Whether to confront or not should always be the client's decision. Also, it should only be considered after careful evaluation of the client's expectations and reasons for wanting a confrontation and a thorough examination of the potential negative consequences of such an undertaken (Draucker & Martsolf, 2006; McDonald, 1996).

Courtois (1999) stressed the importance of not advising clients to undertake any action with a potential to harm others, such as confrontation, but to explore the advantages and disadvantages of any such action. Courtois even requires as a condition of treatment that clients agree not to make any impulsive or unplanned disclosure of abuse either known or suspected, especially to the alleged perpetrator or other family members. Brown et al. (1998) expressed similar concern regarding confrontation and stressed that any confrontation decided on by the client not create any kind of therapeutic relationship between the therapist and alleged abuser. They recommended that this clarification be discussed with the client and documented in writing in the case file.

Draucker and Martsolf (2006) stipulated that mental health counselors can assist clients in preparation of a confrontation if the client, after careful consideration of all possible consequences continues to express a desire to do so. They cautioned that the therapist should only proceed if: (1) the client insists upon it, (2) the client has made significant progress with issues of denial, minimization and self blame, and (3) the client's motivation to confront is not predicated on the hope and desire the offender will express remorse and contrition for the offense.

* Focus the use of hypnosis with clients to more supportive areas

Conte (1999) challenged the assertion that certain techniques created false memories. He cautioned there was no research supporting the claim that therapeutic techniques, such as guided imagery, journaling, dream interpretation work, and survivor groups created false memories of childhood sexual abuse. He indicated the criticism of such techniques was unfounded even though research has clearly demonstrated that there are no reliable methods, hypnotic or otherwise, that can be used to recover forgotten memories. Barber (1997) asserted, "there is no evidence that hypnotic methods should be generally abandoned in the therapeutic enterprise" (p. 315). More recently, Gafner (2004) expressed agreement with Barber.

Besides assisting in the recapturing of lost memories, Courtois (1999) lists other useful purposes in using hypnosis including the abreaction of the trauma, in the identification of and reconnection with disowned parts of the self, in pain management and substance control, and as a means of relaxation and self management. Davies and Frawley (1994) did not advocate the use of hypnosis in the disclosure of traumatic memories with clients who may view it as a form of therapeutic domination and invasive control, but cited beneficial aspects of hypnotic work specifically when used with clients to enhance their experience of control and containment. They stated, "the patient is taught any of a number of deep-relaxation exercises, processes akin to self-hypnotic techniques, that promote a form of physical and mental self-control and a sense of well-being and can be used before, during, and after the disclosure of traumatic memories" (p. 205-206).

Yapko (2003) identified numerous areas where hypnosis could be utilized to assist clients in dealing with problems emanating from the trauma of childhood sexual abuse including reduction of anxiety and stress, depression, relationship issues, self-esteem issues, substance abuse, and sexual dysfunctions. Hypnosis also has tremendous therapeutic value in assisting clients to reconnect with lost memories and emotions as well as minimizing the pain, through relaxation, normally experienced by clients when recalling traumatic events. The release of emotions facilitated through hypnosis is a major benefit for the client. In the therapeutic setting the accuracy of a memory is not as important as it would need to be in a court of law. The historical accuracy of an event is not as important as the manner in which the client expresses, understands and deals with it (Degun-Mather, 2006). Therefore, mental health counselors should certainly consider using hypnosis as an adjunct to therapy in providing supportive services to the client and helping them deal more effectively with any trauma symptoms they may be experience.

CONCLUSION

I believe it is vitally important that mental health counselors, when working with sexual abuse survivors, achieve a balance between supporting them and adhering to the ethical and moral responsibility to "do no harm." This can be done by judicious use of memory retrieval techniques such as hypnosis, age regression, automatic writing, guided imagery, memory recall, dream work and journal writing. It also requires awareness of the research on memory which indicates that any memories recovered may or may not be accurate. While memory retrieval work is important and a necessary part of the treatment of sexually abused clients, the clinician must be conscious of two concerns: (1) that there is a greater possibility of the formation of false memories and (2) that relentlessly pursuing the recovery of abuse memories may do more harm than good as it forces clients to deal with affect they may already feel unable to handle.

Yapko (2003) succinctly summarized what mental health counselors need to do to avoid making mistakes when engaging in memory work with clients:

   Don't infer a history of abuse where none is stated, don't offer
   leading suggestions to a client in hypnosis about what and how to
   remember, don't assume a "root cause" for every problem, do know
   the workings of human memory, do know the limits of hypnosis, do
   know that memories can be detailed and emotional and still be
   wrong, and be clear about the distinction between supporting
   versus validating your client's memories (p. 546).

Lastly, I believe it is critical for mental health counselors to remember that we help clients deal with the inner images and feelings they may be experiencing, not necessarily with what historically may or may not have happened to them.

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James J. Colangelo is an assistant professor of education in the Department of Counseling and Development at Long Island University/C. W. Post Center. Correspondence regarding this article should be sent to [e-mail].