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Does “Dispelling Confusion About Traumatic Dissociative Amnesia” Dispel Confusion? One Clinician's View

2007; Elsevier BV; Volume: 82; Issue: 9 Linguagem: Inglês

10.4065/82.9.1049

1942-5546

Bennett Simon,

Memory Processes and Influences

It is important that this journal, read by clinicians, has published “Dispelling Confusion About Traumatic Dissociative Amnesia,” an article written by Richard J. McNally,1McNally RJ Dispelling confusion about traumatic dissociative amnesia.Mayo Clin Proc. 2007; 82: 1083-1087Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar a leading researcher on issues of memory and trauma. McNally argues in this issue of Mayo Clinic Proceedings that no pathway has been demonstrated in the laboratory for the complete forgetting and later retrieval of a major traumatic event. He is skeptical of the clinical claims of long inaccessible memories becoming conscious, arguing that “traumatic dissociative amnesia” is a cultural construction. Instead, he argues that instances of “recovered” memory can be explained by “ordinary forgetting,” by the putting of events out of one's mind, and by the receding salience of events with changed circumstances. McNally critiques common clinical concepts such as repression and especially dissociation. Does his article in fact dispel confusion? It does so only partially and only subject to substantial disagreement from clinicians and other researchers on memory processes. His contentions touch on two wars. Citing his own substantial body of research and that of many others, McNally is a formidable partisan in the so-called memory wars about true and false memories of abuse and trauma, including questions of the recall of previously inaccessible memories.2McNally RJ Remembering Trauma. Belknap Press of Harvard University Press, Cambridge, MA2003Google Scholar, 3Putnam F. [Review of the book Remembering Trauma]. Traumatic Stress Points.Bull Int Soc Traumatic Stress Studies. 2003 Fall; 17: 8-9Google Scholar However, McNally and his allies have their articulate critics among clinicians and researchers.4Freyd JJ Betrayal Trauma: The Logic of Forgetting Childhood Abuse. Harvard University Press, Cambridge, MA1996Google Scholar, 5McNally RJ Betrayal trauma theory: a critical appraisal.Memory. 2007; 15: 280-294Crossref PubMed Scopus (20) Google Scholar, 6Freyd JJ DePrince AP Gleaves DH The state of betrayal trauma theory: reply to McNally—conceptual issues and future directions.Memory. 2007; 15: 295-311Crossref Scopus (111) Google Scholar, 7Erdelyi MH The unified theory of repression.Behav Brain Sci. 2006; 29: 499-511PubMed Google Scholar The other conflict, between clinicians and researchers, is a quieter war, and perhaps in the long run more important and more difficult to resolve. An inevitable tension exists between the perspectives and interests of clinicians caring for and worrying about an individual patient and of researchers trying to establish the efficacy or lack thereof of any given treatment. Clinicians mistrust the oversimplification that is inevitable in the laboratory situation, and researchers view the clinical situation as too messy, always needing “controls.” Each “knows” in a way particular to the discipline, and even if the same person is both researcher and clinician, tension may still exist. How can McNally's article be used to enhance understanding between the opposing sides in these conflicts? Despite my reservations as a clinician, I believe his arguments deserve serious consideration by all sides. All can benefit from the healthy debate generated by the controversy. The large body of responsible clinicians who are not involved in “recovered memory therapies” struggle daily with their patients to understand the past and its current import and to work with the inevitable interplay between memories of external events and fantasy elaborations (or other distortions) of those events. Their stake is in helping patients, their families, and other loved ones, and not in scoring points in “the wars.” Indeed, Sigmund Freud considered the distinction between true and false memories of seduction as one of the most difficult in psychoanalysis, and early on wrote that at the end of a day of listening to patients, one could go “meshuggah” [Yiddish for “crazy”] from trying to sort out the truth of their memories.8Blass RB Simon B. Freud on his own mistake(s): the role of seduction in the etiology of neurosis.in: Smith JH Humphrey M. Psychiatry and the Humanities. Vol 13. Johns Hopkins University Press, Baltimore, MD1992: 160-183Google Scholar, 9Good MI The Seduction Theory in its Second Century: Trauma, Fantasy, and Reality Today. International Universities Press, New York, NY2004Google Scholar What have clinicians learned from long-term work with patients? Memory processes are ongoing, active, and interactive; they involve family, social environment, and the therapist.10Haaken J Pillar of Salt: Gender, Memory and the Perils of Looking Back. Rutgers University Press, New Brunswick, NJ1998Google Scholar, 11Praeger J. Presenting the Past: Psychoanalysis and the Sociology of Misremembering. Harvard University Press, Cambridge, MA1998Google Scholar The encoding of experiences, their accessibility and inaccessibility, and the processes of retrieval are powerfully influenced by relational contexts, including the patient's relationship with the therapist. Patients know and remember or fail to know and remember in a variety of ways. They have distinctive styles and mixtures of cognitive styles and defenses that shape their memories. For example, patients differ in whether they remember and how they recall dreams and the memories encoded therein. Dreams may take the form of linear narratives, images, delusions, or somatic sensations. Similarly, patients may “forget” in multiple ways. Examples include a conscious decision not to think about something; a style of “when in doubt, shut it out”; or a parent or authority figure's command, possibly associated with coercion, not to discuss an inappropriate incident and hence not to remember.7Erdelyi MH The unified theory of repression.Behav Brain Sci. 2006; 29: 499-511PubMed Google Scholar, 12Lunbeck E Simon B. Family Romance, Family Secrets: Case Notes of an American Psychoanalysis, 1912. Yale University Press, New Haven, CT2003Google Scholar Furthermore, developmental considerations enter into whether events are encoded—children are rarely able to retrieve memories from before the age of 3 or 4 years. Then there is “ordinary forgetting,” the mechanisms of which are certainly not completely clear. Notably, the importance assigned to certain events—and hence the drive to recall them—changes with the patient's age and time of life (as McNally suggests). Clinicians realize that processes of recall and retrieval of forgotten or seemingly inaccessible memories can yield admixtures of memories that may be veridically accurate, embellished, overly vivid (hypermnesia), heavily edited, or fantasied. McNally's presentation of the many ways in which events may be rendered temporarily or chronically inaccessible to consciousness overlaps with what clinicians encounter. However, many clinicians would disagree with McNally on the role of dissociation in making memories inaccessible. In sitting with patients who are dissociating, clinicians are reminded of how much patients can block out events occurring during the session, not to mention events that occurred a day, a week, or years ago. Furthermore, some researchers strongly disagree with McNally's claims that there is no demonstrable mechanism of late retrieval of trauma from long ago.4Freyd JJ Betrayal Trauma: The Logic of Forgetting Childhood Abuse. Harvard University Press, Cambridge, MA1996Google Scholar, 13DePrince AP Freyd JJ Forgetting trauma stimuli.Psychol Sci. 2004; 15: 488-492Crossref PubMed Scopus (123) Google Scholar Recognizing these multiple modalities for remembering and forgetting offers a fertile meeting ground for clinicians and researchers, including those who disagree with McNally.3Putnam F. [Review of the book Remembering Trauma]. Traumatic Stress Points.Bull Int Soc Traumatic Stress Studies. 2003 Fall; 17: 8-9Google Scholar, 6Freyd JJ DePrince AP Gleaves DH The state of betrayal trauma theory: reply to McNally—conceptual issues and future directions.Memory. 2007; 15: 295-311Crossref Scopus (111) Google Scholar, 7Erdelyi MH The unified theory of repression.Behav Brain Sci. 2006; 29: 499-511PubMed Google Scholar If they are to take advantage of this meeting ground, clinicians must pay closer attention to the details of how patients remember and forget and publish those observations. McNally's article might thus motivate clinicians to report what they see in therapy. Researchers in turn can benefit from immersing themselves in the enormous complexity of the clinical situation, thereby coming to appreciate how one theory is not likely to explain all examples of dissociative phenomena. By reading McNally's piece and learning more about the controversies in the research literature, I have come to better understand some of my own clinical experiences. The following examples, taken from those experiences, will lend support to the need for more detailed and open-ended clinical inquiry. Early in psychoanalysis, a young married woman reported that she had detailed memories of her mother's pregnancy with her sister aged 3 years younger and of that baby sister's homecoming, but virtually no memory of her mother's pregnancy with her sister aged 8 years younger and of that sister's homecoming. Several years later, she painfully and poignantly recalled vivid details of the terrible family strife that was taking place during the pregnancy with the sister aged 8 years younger, and many details were later verified by her parents. The confluence of these hitherto unremembered events and of developmentally appropriate conflicts helped account for the amnesia and the drama of its lifting. Was the story never remembered in the 20-year interval? At that time, unfortunately, I did not attend carefully to that question, nor was I distinguishing between repression and dissociation. Even for this woman, who characteristically disposed of unpleasant memories in a wide variety of ways, this particular patch of amnesia seemed unique and was perhaps associated much more with dissociation than I recognized. For details on this case, see previously published information.14Simon B. Recognition in Greek tragedy: psychoanalytic on Aristotelean perspectives.in: Rudnytsky P Spitz EH Freud and Forbidden Knowledge. New York University Press, New York, NY1994: 109-127Google Scholar McNally cites an important laboratory exploration of this phenomenon.15Geraerts E Arnold MM Lindsay DS Merckelbach H Jelicic M Hauer B. Forgetting of prior remembering in persons reporting recovered memories of childhood sexual abuse.Psychol Sci. 2006; 17: 1002-1008Crossref PubMed Scopus (39) Google Scholar I have elsewhere reported the details of how a woman in her fifties, painfully facing her denial of her parents' malevolent behavior toward her, was slowly piecing together the story of her adolescence.16Simon B It's really more complicated than you imagine.in: Rudnytsky PL Charon R Psychoanalysis and Narrative Medicine. State University of New York Press, Albany, NY2008: 119-136Google Scholar She used a variety of ways to not know that she knew and to not remember that she remembered, including not remembering that she had her adolescent diaries that contained much of this information. She did not look at them until reminded of their existence by her husband, and even then she did so reluctantly. In another instance, a patient, several years into his analysis, dramatically recovered the memory of a traumatic sexual seduction that occurred when he was aged approximately 7 years. He forgot—several times—that I knew about this incident because he had alluded to it early in treatment. A man in his fifties had been in psychotherapy continuously, seeing a number of therapists sequentially, since a psychotic episode in his early twenties. A crippling limitation became increasingly salient: an extraordinary poverty of ordinary memories not just of his early years but also of events that occurred well into his adult life. Personal memories (eg, family mealtimes, morning routines as the children prepared for school, a sexual relationship [or lack thereof] with a high school girlfriend) were scarce and sparse. We arranged for comprehensive evaluation at a clinical research center devoted to memory issues. The researchers, who were unable to match his constellation of symptoms to any recognizable pattern of memory disorder due to brain disorder, speculated (as did the patient) that a history of severe and chronic trauma within the family was the basis of the memory deficit. Undoubtedly, family interactions were often pathological, but traumatic dissociative amnesia did not seem to me to offer an adequate explanation of his disability. Fortunately, the process of investigation was helpful to him and to me, and he gradually recovered and discovered more memories from those “blank” years. In summary, I suggest that we are not currently in a position to dispel all confusion about traumatic dissociative amnesia but instead should be willing to live with some confusion, acknowledge it, and devise collaborative ways to address it. To paraphrase Mephistopheles in Goethe's Faust, life is green and all our theories are gray, a claim that will certainly resonate with clinicians and researchers alike. I am grateful to Roberta Apfel, MD, for editorial advice and to Frank Putnam, MD, and Mieke Verfaellie, PhD, for bibliographic advice. Dispelling Confusion About Traumatic Dissociative AmnesiaMayo Clinic ProceedingsVol. 82Issue 9PreviewHow survivors of trauma remember—or forget—their most terrifying experiences lies at the core of one of the most bitter controversies in psychiatry and psychology: the debate regarding repressed memories of childhood sexual abuse. Most experts hold that traumatic events—those experienced as overwhelmingly terrifying and often life-threatening—are remembered very well; however, traumatic dissociative amnesia theorists disagree. Although acknowledging that traumatic events are usually memorable, these theorists nevertheless claim that a sizable minority of survivors are incapable of remembering their trauma. Full-Text PDF