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Ethical Boundary Considerations and Repressed Memories of Sexual Abuse
4 CEUs Ethical Boundary Considerations and Repressed Memories of Sexual Abuse

Section 14
Boundary Treatment Guidelines:
Issues Pertaining to Memories of Sexual Abuse

Ethics CEU Question 14 | Ethics CEU Answer Booklet | Table of Contents | Boundaries CEU Courses
Counselor CEUs, Psychologist CEs, Social Worker CEUs, MFT CEUs

1. Ascertain personal and professional assumptions and biases and work for a stance of supportive neutrality
The practitioner must monitor personal and professional assumptions and biases and avoid leading questions, specific suggestions, prematureclosure of exploration, and/or the ready acceptance of the individual's recollections as historical truth. The practitioner should also assess his/her ability to tolerate and support a patient's uncertainty about the past. An open and nonauthoritarian perspective is especially important with patients who are excessively dependent or suggestible or with those who have high hypnotizability. It is advisable to adopt a neutral therapeutic stance to the possibility of abuse, to ask open rather than closed or suggestive questions, and to encourage exploration and the cross-referencing of information without drawing premature conclusions. According to Judith Herman, M.D., therapists must be technically neutral but be morally cognizant of the prevalence and possibility of abuse. Being neutral and open-ended in technique does not mean that the therapist is in denial about abuse as a serious and common occurrence or about its possibility in the patient's past. Rather, it is the patient who must come to a understanding of and comfort with his/her personal history. This, of necessity, may include living with uncertainty, a circumstance that may be highly distressing, requiring support and empathy (and, at times, empathic confrontation) on the part of the therapist.

2. Watch assumptions about incomplete and spotty childhood memory
The practitioner should not assume that an individual who cannot remember much from childhood is repressing or denying childhood abuse. Normal memory for childhood is spotty, childhood (infantile) amnesia generally ends between the ages of 2-1/2 to 3-1/2, and older children remember more detail and with greater accuracy than younger children. The therapist should make note of an individual's report of circumscribed time periods in childhood and/or adolescence with totally absent memory (especially if observed and corroborated by others and if other signs and symptoms indicative of a possible abuse history are available, e.g., medical records, outside validation or corroboration, the client obviously dissociates). Even so, periods of complete amnesia in childhood or adulthood are not, in and of themselves, enough of a basis on which to make an exclusive determination of childhood sexual abuse in the absence of other information.

3. Do not automatically assume sexual abuse from a set of symptoms
No one symptom or set of symptoms (either initially or 1ong-term) is pathognomonic of childhood sexual abuse, so the practitioner should not automatically and conclusively assume an abuse history due to particular symptoms, especially when no memory of abuse is available. The therapist nevertheless needs to be alert to the emergence of signs and symptoms commonly associated with a trauma history that are not immediately consciously available to the patient. In such a circumstance, the therapist needs to encourage exploration of the possibility of abuse or other trauma because denial and other dynamics may make personal acceptance difficult, if not impossible, without outside support. A return to more formalized assessment might also be considered at this point.

4. Be open to the possibility of other childhood trauma besides sexual abuse
The practitioner should be open to the possibility that other childhood events and trauma (e.g., parental separation and divorce; family violence; significant deaths--including suicides--and illnesses; medical conditions requiring invasive techniques, pain, and physical immobility; serious accidents; and natural disasters) might account for a patient's posttraumatic symptoms. Sexual abuse should not be assumed or suggested as the only possibility. Most psychological disorders develop from, and are influenced by, a number of events (as well as other factors, such as the child's premorbid personality and personal resilience, the nature and severity of the stressor(s), family functioning, sources of outside support, etc.).

5. Keep adequately detailed records
The practitioner should keep records in sufficient detail to document the main issues and events in the therapy, to articulate and track symptomatology and the treatment plan, and to chronicle all major communications with the patient. Patient records should be neutral- in tone and based on fact and behavior rather than on the therapist's speculations. The chart should include mention of any erroneous expectations and misinformation regarding abuse and memory held by the patient and should document the provision of factual and more accurate information and the discussion of process issues regarding memory retrieval (e.g., information about the delayed memory dispute, the functioning of human memory, including its reconstructive nature, current information about memory processes for trauma, the patient's responsibility for making a determination about his/her own experience, the maintenance of a stance of therapeutic neutrality, and various techniques and their efficacy and substantiation). Additionally, notes should document memories and events as "reported by" the patient rather than as historical reality and specifically document any attempts by the patient to get the therapist to confirm or believe an abuse history based on recovered memories alone, especially when corroboration is missing. During sessions when the patient is struggling with issues of unclear memory or reporting recovered/delayed memories, the therapist might consider taking process notes.

6. Do not use hypnosis (or related techniques) for memory retrieval
Hypnosis is one of the most controversial techniques in the delayed/ repressed memory controversy. At present, available research is quite conclusive that memories that emerge as a result of hypnosis can be compelling yet inaccurate and that the veridicality of these memories should not be assumed (although some may well be accurate). The potentially confounding nature of hypnosis (or any similar technique) makes its use inadvisable to uncover, discover, or rework delayed memories of abuse. Rather, its use should be restricted to such therapeutic tasks as ego strengthening, coping, self-soothing, temporizing and pacing, etc. Moreover, hypnosis should not be used if a patient is involved in any type of legal proceeding or has any likelihood of taking any legal- action in the future (whether related to past abuse or not). The use of hypnosis may result in the inadmissibility of material in any forensic proceeding. Similar to any other specialized technique, hypnosis should be used only if the therapist has been trained in its use and with the informed consent of the patient.

7. Ascertain the individual's understandings and expectations about memory, therapy, and any sources of influence and social compliance issues.
If, at the outset or during the course of treatment, an individual suspects a nonremembered history of abuse and has unrealistic expectations of therapy and/or misinformation about abuse, trauma, and memory, the practitioner should inquire about these matters. In particular, possible sources of influence, social compliance, or misinformation should be determined. These might include exposure through reading and viewing biased or overzealous material, participation in abuse-focused self-help activities and therapy groups (including on the internet and in "chat rooms" devoted to abuse-related issues and topics) and participation in previous therapy--especially if unconventional, of the sort that provided or supported erroneous information or a certain perspective regarding abuse and memory issues, and/or emphasized the use of hypnosis for memory retrieval. The practitioner must correct specific misinformation and guide the individual to a broadened understanding of the malleability and reconstructive nature of memory, the currently unanswered questions about memory for trauma, and the ways memory issues will be addressed in therapy. Concerning the latter, the practitioner educates the individual about the sequenced treatment strategy that is holistic rather than solely focused on abuse and memory retrieval.

Although the clinician is open to the exploration of a patient's suspicions of abuse, it should be based on open-ended questioning and free narrative to lessen the possibility of suggestion. A scientific attitude involving the careful weighing of evidence over time and the avoidance of "jumping to conclusions" and premature closure is encouraged. It is crucially important that the practitioner not "fill in," "confirm," or "disconfirm" reported suspicions of a nonremembered abuse history but rather help the patient explore the content and its possible meaning while guarding against suggestion, pro or con. Individuals with positive histories of abuse and trauma often struggle with differentiating what is real and what is not, experience-strongly ambivalent emotions, and require a supportive context in which to consider various perspectives. Similarly, individuals with suspicions but no memories and those with incomplete and reinstated memories must have the latitude to explore without constraint. Although the clinician maintains as much neutrality as possible, at times there is a need to educate or challenge the patient on material that is clearly improbable, seems delusional, and/or in which the patient is overinvested. As noted in item 10, a return to more formalized assessment might be in order.

8. Recommend self help books and groups only when familiar with their content and perspective
The practitioner should be cautious in recommending self-help books and should be familiar with the content of any book that is suggested. In the case of suspected abuse with no clear memory, a generic book on the effects of a painful childhood is initially preferable to a book on signs and symptoms of sexual abuse or a book on repressed memories that offers suggestive methods for retrieving absent memory. A related issue involves referrals to self-help or therapy groups. The patient with absent autobiographical memory for abuse is best referred to a heterogeneous group for general mental health concerns rather than a homogeneous abuse focused one. A difficult circumstance arises when a patient with suspicions of abuse and sketchy memory has read books, viewed media presentations, or participated in groups that push a certain perspective or that offer erroneous information. The clinician must re-educate the patient and correct skewed content.

9. Support a patient's search for corroboration after adequate exploration and preparation in therapy
Some patients decide they want to seek outside sources of information regarding possible childhood abuse (e.g., medical and school records, witnesses, other victims, etc). The clinician can support a search as a means of gaining potential material to be assessed and weighed in the course of therapy. It is advisable, however, that the patient first explore the ramifications of such a search with the therapist and take action only after having achieved a relative degree of life and symptom stabih'ty and after adequate preparation. The patient should consider the range of possible consequences of a search, from positive to negative, and the relative probability of each. Possible responses should also be anticipated and prepared for finding or not finding evidence and corroboration can be very unsettling. Optimally, a support system is in place to assist the patient with the results and the emotional consequences of a search.

10. Do not recommend family cut-offs on the basis of recovered memory
The practitioner should also be cautious in suggesting that the patient limit or cut off contact with family, especially when recovered memories form the basis for abuse suspicions or beliefs; however, in cases of a positive abuse history and reports of ongoing abuse or other clear and present danger, the practitioner is responsible for helping the patient assess the cost/danger in continuing contact (and may further have a duty to report). The therapist must keep the patient's safety paramount while helping him/her to recognize ongoing danger and learn assertive and self-protective strategies with unsafe or abusive others.

11. Contract for no unplanned/impulsive disclosures, confrontations, or legal initiatives
The practitioner should have a collaborative agreement with the patient that unplanned/impulsive disclosures, confrontations, or legal initiatives not be undertaken without extensive discussion in therapy. These actions are quite risky even when the patient has clear memory and some corroboration; when abuse is suspected or believed on the basis of recovered memory without corroboration, they are even riskier (for both patient and therapist). The cost benefits of these actions are best considered when the patient's symptoms and life circumstance are stabilized and, in the case of known abuse, after the bulk of trauma-resolution work has been completed. They should only be undertaken following a period of careful planning and assessment of possible consequences, including family estrangement, threats and violence, legal initiatives, etc. Consideration should also be given to whether they should be done within or outside of the therapy. In either event, thorough preparation is recommended.

12. Do not encourage or suggest a lawsuit
It is not the practitioner's role to suggest a lawsuit. If the patient chooses to investigate this option, the therapist should encourage the gathering of comprehensive information on which to base decision-making. Litigation is enormously stressful and requires an extensive time commitment as well as the allocation of significant personal and financial resources. The plaintiff in a legal proceeding must meet a standard of proof that is not found as a patient in a clinical setting. Also, since the advent of the memory controversy, plaintiffs seeking damages for past abuse have been challenged on the basis of false-memory production, a challenge that has made the process even more difficult. Should a patient opt to initiate a lawsuit, the practitioner must keep the treatment and legal action separate and insist that the patient get a separate psychological expert; otherwise, the practitioner becomes engaged in a dual role relationship with the patient and therapy becomes derailed.
- Courtois PhD, Christine A, "Guidelines for the treatment of adults abused or possibly abused as children"; American Journal of Psychotherapy; Fall 1997, Vol. 51 Issue 4, p497
The article above contains foundational information. Articles below contain optional updates.

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Personal Reflection Exercise #7
The preceding section contained information about treatment guidelines regarding issues pertaining to memories of sexual abuse. Write three case study examples regarding how you might use the content of this section in your practice.

Ethics CEU QUESTION 14
Why should sexual abuse not be assumed or suggested as the only possible explanation of a client's posttrauma symptoms? Record the letter of the correct answer the Ethics CEU Answer Booklet.

 
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