Response to the Canadian Psychiatric Association
Harvey Armstrong, U. Toronto
Elliot Barker, Penetang
Bergljot Bright, UBC
Patrick G. Coll, Calgary
John C. Curtis, Halifax
Margaret S. Dean, Toronto
George Fraser, U. Ottawa
Arthur P. Froese, Queen's U.|
W. D. Gutowski, Chilliwack
Marlene Hunter, West Vancouver
Marilyn Korzekwa, McMaster U.
John A. O'Neil, McGill U.
Clare Pain, Ottawa
Georges Robitaille, Montreal
David Wheelwright, Kelowna
Members, Education Council, CPA:
Stella Blackshaw. MD, FRCPC
Praful Chandarana, MBChB, ABPN, FRCPC
Yvon Garneau, MD, FRCPC
Harold Merskey, DM, FRCPC
Rebeka Moscarello, MD, FRCPC
Re: POSITION STATEMENT
Adult Recovered Memories of Childhood Sexual Abuse
prepared by the Education Council and approved by the Board of Directors of the Canadian Psychiatric Association on March 25, 1996
We, the undersigned, are psychiatrists (and one family practitioner, associate member of CPA) with significant past and on-going experience in the treatment of those psychiatric conditions (disorders of anxiety, mood, dissociation, personality, and substance abuse) which the Position Statement correctly identifies as having childhood sexual abuse as a nonspecific risk factor.
The Position Statement is timely and important. We note in our Membership Directory the number of psychiatrists with related Areas of Interest: Adult Survivors of Child Abuse (85), Child Abuse (49), Dissociative Disorders (63), Hypnosis (59), Sexual Abuse (57), and Trauma Victims (34). The Position Statement is well-intentioned and largely appropriate. There are, however, a number of serious shortcomings which ought to be addressed, as these will likely mislead the membership and the public. Such shortcomings were perhaps unavoidable in that only one of you (Rebeka Moscarello) lists an Area of Interest which is directly pertinent to the field: Trauma Victims. Thus, it would seem that you were all operating largely outside of your areas of greatest interest and experience.
Please find appended a suggested editing of the Position Statement which we believe maintains its original intent while avoiding all the shortcomings outlined below.
The following are the shortcomings:
1. The terminology "false memory syndrome" and "recovered memory therapy" were coined by the so-called "False Memory Syndrome Foundation", headquartered in Philadelphia, PA. The terminology has not independently occurred in the scientific literature. The FMSF is not a professional medical body, but a lay organisation and legal defense lobby. It is professionally and scientifically inappropriate and misleading for the Canadian Psychiatric Association to incorporate nonprofessional, nonscientific nomenclature into an official Position Statement without accurately putting such nomenclature into its proper socio-legal context. The CPA ought not to act, nor seem to act, as a client organisation of an American legal defence lobby.
2. The Position Statement follows too closely the FMSF agenda, which is narrowly preoccupied with the purported manufacture of false memories, and confrontation or legal pursuit of alleged perpetrators. The vast majority of cases that are of clinical relevance, however, are those where memories of childhood sexual abuse are first experienced in adulthood, but which involve no confrontation or legal pursuit of alleged perpetrators. The two issues are separate, and ought to be better teased out one from the other. In addition, the Position Statement contains valuable passages on memory in general and on diagnosis. The more rational agenda would be to deal first with memory in general, then with diagnosis, then with memory in therapy, and lastly with confrontation and accusation of alleged perpetrators.
3. The Position Statement neglects the following clinically significant groups of survivors of childhood sexual abuse: those who deny memories of ill-treatment, despite corroboration; those who experience memory of childhood sexual abuse spontaneously in adulthood; those with fluctuating awareness, who oscillate between clinical pictures of acute PTSD symptoms on the one hand, and amnesia with emotional blunting on the other.
4. There is some incoherence in the section on normal memory. The Position Statement says: "Cognitive psychology further finds that memory is an active process of reconstruction that is susceptible to fluctuating external events and to internal efforts or drives." This implies that memories which were not susceptible to such fluctuating, such as repressed or dissociated memories, would be less reconstructed (edited) than normal continuous memories, the opposite of what the Position Statement wishes to say. It immediately goes on to state: "If memories of events have not been revisited and cognitively rehearsed in the interval between the occurrence of the events and attention being paid to them some years later, it is not clear that such memories can endure, be accessible, or be reliable." This statement implies the opposite of the previous: that repressed or dissociated memories would be lost or less reliable than those undergoing continuous reconstruction. In addition, the scientific literature does include papers supporting the hypothesis that recovered recollections can endure, be accessible, and be corroborated, so that "it is not clear" rather overstates the case.
5. The Position Statement rightly alerts to gross therapeutic errors by misguided therapists. Psychiatrists who work in the area also commonly encounter patients seeking misguided therapy or with covert hidden agendas to confront or accuse. The Position Statement ought to alert psychiatrists to this.
6. The Position Statement correctly invokes "well-conducted psychotherapy" as a general model for handling memory. This model can be profitably extended to related therapeutic questions, such as the appropriate use of hypnosis (also see [illegible]) and the general attitude to adopt when faced by a patient who considers confrontating and accusing alleged perpetrators. This approach would lend more stylistic and conceptual coherence to the Statement.
7. The Position Statement neglects the direct dangers to the patient of decompensation, suicidal gestures and rehospitalization that are often associated with planned or anticipated confrontation or accusation of alleged perpetrators. Clinically, such decompensation is more often encountered than disruption of family relationships, either because family relationships are already significantly disrupted, or because the decompensation prevents the confrontation from occurring.
8. The Position Statement is inconsistent on memory when it states: "When recovered memories are found to be false, family relationships are unnecessarily and often permanently disrupted." Just as we ought not to conclude that so-called "recovered memories" are true, we ought not to conclude that recantations or legal decisions are true. Furthermore, even when so-called "recovered memories" are true, family relationships need not be disrupted, and may be improved, as may occur when the accused perpetrator confesses, corrects or embellishes an accusation and an estranged family relationship is mutually mourned and healed.
9. Hypnosis is mentioned twice, both times as a "memory recovery technique" (again borrowing from the FMSF) and lumped with narcoanalysis as well as with specific psychotherapeutic technical errors such as leading questions, pressure to recall and suggestions of abuse. In the Conclusions and Recommendations, it states "Psychiatrists should take particular care, however, to avoid inappropriate use of leading questions, hypnosis, narcoanalysis, or other memory enhancement techniques directed at the production of hypothesised hidden or lost material." There are the following objections to this:
9a. hypnosis is generally disparaged in being linked with specific technical errors.
9b. it is unclear if the CPA is recommending that psychiatrists avoid inappropriate use of hypnosis, or rather recommending that it be avoided altogether.
9c. much psychiatric hypnosis has nothing to do with survivors of child sexual abuse, nor with enhancing memory. Even in patients who are, or who may be, survivors of child sexual abuse, much hypnosis still has little to do with enhancing memory, but rather with intrapsychic restructuring for the purpose of symptom control and the management of behaviour, such as suicidality and self-mutilation, and the interruption of general decompensation that would otherwise require hospitalization.
Committee members ought to reflect that their lack of interest or experience in hypnosis may have led them to inadvertently impugn as many as 59 of their fellow CPA members for whom Hypnosis is a professed Area of Interest. The Position Statement should not, under any circumstances, condemn, nor seem to condemn, this useful medical modality. The Statement needs to accommodate the appropriate psychotherapeutic use of hypnosis, which according to the practice of many CPA members may constitute an essential therapeutic adjunct in the treatment of certain patients.
As a general concluding comment, it might be wise for the CPA Education Council to make a general policy of consulting more widely with CPA members who have interest and experience that is pertinent to the question at issue. The "Areas of Interest" section of our Membership Directory is useful for this. Imagine if the Position Statement on Clozapine had been prepared by members none of whose interests included Biological Psychiatry, Chronic Care, Psychopharmacology or Schizophrenic Disorders!
We urge you to study the appended revision carefully, and, if you agree with it, to resubmit it to the Board of Directors for reconsideration.
Harvey Armstrong, MD, FRCPC
Associate Prof. of Psychiatry, U. Toronto
Staff Psychiatrist, Hospital for Sick
Elliot Barker, MD, FRCPC
Psychiatrist and Consultant, Mental Health
Centre, Penetang, ON
Bergljot Bright, MD, FRCPC
Clin Assoc. Prof. of Psychiatry, UBC;
Consultant, Ridge Meadows Hospital, Maple
Patrick G. Coll, MB, FRCPC
Psychiatrist, Calgary General Hospital
John Curtis, MD, FRCPC
XMargaret S. Dean, MBBS, FRCPC
Arhur P. Froese, MD, MPA, FRCPC
Assoc. Prof. of Psychiatry and Pediatrics,
Director of Child and Family Unit, Kingston
W. D. Gutowski, MD, Bsc, FRCPC,
Psychiatrist, Chilliwack, BC
Marlene Hunter, MD, FCFPC
Family Practitioner, CPA Assoc. member,
Marilyn Korzekwa, MD, FRCPC
Asst. Prof. of Psychiatry, McMaster U.
John O"Neil, MD, CM, FRCPC,
Asst. Prof. of Psychiatry, McGill U.,
Service Chief, Eating Disorders Unit,
Douglas Hosp., Montreal
George Fraser, MD, FRCPC,
Asst. Prof. of Psychiatry, U. of Ottawa
Director, Anxiety and Phobic Disorders
Clinic, Royal Ottawa Hosp.
Clare Pain, MD, FRCPC,
Georges Robitaille, MD, FRCPC
Psychiatre, Hopital Charles Lemoyne
Greenfield Park, QC
David Wheelwright, MA, BM, FRCPC,
Psychiatrist, Kelowna, BC
C.C.: Members, Board of Directors, CPA
Chairs of CPA Sections and Committees