Help for Post Traumatic Stress (PTSD) and dissociation
Sidran.org
1994
Recent debates between differing schools of scientific thought, fueled by the media and by lay organizations with varied political agendas, have left the public confused and misinformed regarding the nature of traumatic memories. This confusion is causing great distress to many people who are survivors of child abuse and those who care about them.
The purpose of this brochure is to reach beyond the hype of popular media and the rhetoric of single-purpose organizations to clarify the issues and to discuss the body of knowledge agreed upon by most mental health professionals about traumatic memories and their retrieval.
There is strong documentation to prove the high incidence of child abuse in the general population. Sexual abuse of children and adolescents is known to cause severe psychological and emotional consequences. Adults who were sexually abused in childhood are at higher risk for developing a variety of psychiatric disorders, including dissociative disorders (such as dissociative identity disorder/multiple personality disorder), anxiety disorders (panic attacks, etc.), personality disorders (borderline personality disorder, etc.), mood disorders (such as depression), PTSD, and addictions.
In order to understand the essential issues about traumatic memory, one must first understand the human mind's response to a traumatic event.
What is trauma, and how do people cope with it?
Psychological "trauma" is defined by the American Psychiatric Association as "an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others." Examples include military combat, violent personal attack, natural or human-made disasters, and torture. For children, sexually traumatic events may include age-inappropriate sexual experiences without violence or injury. (DSM IV, p. 424)
Like adults who experience trauma, children and adolescents who have been abused cope by using a variety of psychological mechanisms. One of the most effective ways people cope with overwhelming trauma is called "dissociation." Dissociation is a complex mental process during which there is a change in a person's consciousness which disturbs the normally connected functions of identity, memory, thoughts, feelings, and experiences (daydreaming during a boring lecture is a good example).
How does trauma affect memory?
People may use their natural ability to dissociate to avoid conscious awareness of a traumatic experience while the trauma is occurring, and for an indefinite time following it. For some people, conscious thoughts and feelings, or "memories," about the overwhelming traumatic circumstance may emerge at a later date. This delayed retrieval of traumatic memories has been written about for nearly 100 years in clinical literature on military veterans who have survived combat.
In fact, in Post Traumatic Stress Disorder (PTSD), a psychiatric diagnosis common among people who have survived horrific events, the defining diagnostic features are memory distortions. People with PTSD inevitably experience extremes of recall regarding traumatic circumstances: intrusive memories of the event (hypernesia) or avoidance of thoughts and feelings about the event (amnesia).
Some people say they are "haunted" by memories of traumatic experiences which intrude on and disrupt their daily lives. They often can't get the "pictures" of the trauma out of their heads. They may have recurring nightmares, "flashbacks," or they may even relive the trauma as if it was happening in present time.
It is also common for traumatized people to make deliberate efforts to avoid thoughts or feelings about the traumatic event and to avoid activities or situations which may remind them of the event. In some severe cases, avoidance of reminders of the trauma may cause a person to have "dissociative amnesia," or memory blanks for important aspects of the trauma.
Why do some people undergoing extreme stress have continuous memory and others have amnesia for all or part of their experience?
There are several factors that influence whether a traumatic experience is remembered or dissociated. The nature and frequency of the traumatic events and the age of the victim seem to be the most important. Single-event traumas (assault, rape, witnessing a murder, etc.) are more likely to be remembered, but repetitive traumas (repeated domestic violence or incest, political torture, prolonged front-line combat, etc.) often result in memory disturbance. The extremely stressful experiences caused by natural or accidental disasters (earthquakes, plane crashes, violent weather, etc.) are more likely to be remembered than traumatic events deliberately caused by humans (i.e. incest, torture, war crimes). People who are adults when they experience traumatic events are less likely to dissociate conscious memories of the events than children who experience trauma. Research shows that the younger the child is at a time of the trauma, the less likely the event will be remembered.
Case studies show that traumatic events in which there is pressure toward secrecy are more likely to induce forgetting as a dissociative defense. For example, a woman who is brutally attacked by a stranger but who receives sympathy, family support, and many opportunities to tell her story, may suffer from PTSD, but is unlikely to develop amnesia for the event. However, a young girl who endures repeated incest with her father and has been sworn to secrecy will more likely have memory impairment for the abuse.
Factors Influencing continuous memory
What is known about how memories work?
Human memory is a complex operation. Although there is still much to learn about how memories work, scientists generally understand and accept that there are four stages of memory: intake, storage (encoding), rehearsal, and retrieval. Each of these processes can be influenced by many factors such as developmental stage, setting, expectation, post-event questioning, etc. Even the conditions at the time of the telling of a memory can change the form of the memory, influencing its content and belief in the truth of the memory in the future.
Most scientists also agree that there are two identified forms of memory: explicit and implicit. Explicit memory, also called declarative or narrative memory, is the ability to consciously recall facts or events. This is the form of memory used, for example, when a person recounts the events of his or her day at work or school. Implicit memory, also called procedural or sensorimotor memory, refers to behavioral knowledge of an experience without conscious recall. A person who demonstrates proficiency at reading but who cannot remember how he or she learned the skill is an example of implicit memories in the absence of explicit memories.
Why are traumatic memories controversial?
There are differing schools of thought, grounded in solid research and clinical experience, about the reliability of memory. The details of this scientific debate are often obscure, and the subtleties can be confusing to the public.
Some researchers have proven in the laboratory that ordinary or slightly stressful memories are easily distorted. These scientists are concerned that therapists may be unintentionally distorting the memories of people who report histories of traumatic abuse. This is of particular concern to scientists studying the effects of hypnosis on eyewitness testimony because there is laboratory evidence that setting and expectation can "contaminate" a person's memories.
However, this laboratory research on ordinary memory may be irrelevant in regard to memories of traumatic experiences. Scientists argue that traumatic memories are different from ordinary clinical memories in the way they are encoded on the brain. There is evidence that trauma is stored in the part of the brain called the limbic system, which processes emotions and sensations, but not language or speech. For this reason, people who have been traumatized may live with implicit memories of the terror, anger, and sadness generated by the trauma, but with few or no explicit memories to explain the feelings. Trauma clinicians believe that implicit memories are not easily distorted. It would, of course be unethical to create in a laboratory setting the traumatic experiences necessary to study traumatic memories and their ease of contamination or distortion. For this reason, our knowledge of traumatic memories must come from clinical experience. Clinical data since 1919 has shown a direct correlation between trauma and amnesia or other memory disturbance (Van der Kolk, 1994).
What about memory retrieval long after the trauma?
Sometimes a current event or experience may trigger long-forgotten memories of earlier trauma. Often when this happens, the person may be "flooded" with implicit sensorimotor memory: he or she may have just the picture, the feeling, the physiological panic aroused by the memory of the traumatic event without the facts that would explain the meaning of the sensations. Initially, the person may not even be aware of what has triggered the memory, or how the pictures and feelings relate to his or her life.
There is often intense psychological distress when a person is exposed to events which in some way resemble or symbolize the past trauma. These "triggers" may be any sound, smell, or other stimulus such as hot, humid weather which may remind a veteran of his service in southeast Asia, or the smell of a particular cologne which was worn by an abuser.
Can I believe my memories?
At this time, there is no completely accurate way of determining the validity of abuse reports without external corroboration, and that kind of corroboration is often impossible. Many things—questioning (especially of young children), suggestion by a trusted person, even the recounting of a traumatic experience in therapy—may influence the accuracy of abuse memories. Even people who have documented corroboration about their abuse may have inconsistent elements in their stories.
Nevertheless, trauma specialists such as Harvard's Dr. Bessel van der Kolk believe that "the body cannot lie." If a person spontaneously sees a flashback and feels terrified, the feeling can be trusted, especially before an implicit memory has been discussed and possibly contaminated. If the person has the symptoms of PTSD, or a dissociative disorder that is known to be associated with a traumatic history, then it is likely that there are real traumatic experiences in the person's background. Unless one is preparing for a criminal investigation, the exact authenticity of a specific memory may not be important.
It is the job of the individual to figure out his or her own life history. Many people with post-traumatic stress or dissociative disorders have found it helpful to gather information from siblings or other family members to help them understand their memories.
What can I expect from therapy?
A therapist can help by showing a person how to put these memories in the context of other psychological symptoms, and guide them in the process of getting on with their lives. A good therapy situation is a collaborative effort in which the client can feel comfortable taking the lead; a competent therapist may inquire about but generally does not suggest an abuse history. Uncovering memories is only one step in the process of healing from trauma. Other therapy goals may include learning to live with feelings, handling anger, dealing with cognitive distortions, ending a cycle of repeated victimization, etc.
A client should feel comfortable about the relationship with a therapist and feel free to make decisions about the direction and pacing of treatment. A good therapist is willing to be flexible. Ultimately, the decision about whether or not specific memories are valid is the responsibility of the client.
If you have been diagnosed with a dissociative disorder or PTSD, it would be most helpful to see a therapist with a specialty in these areas. Names of therapists who have experience treating trauma survivors are available through the Sidran Institute Help Desk (email help@sidran.org).To practice their specialty, therapists should have a license from the state in which they work. If you have doubts about the progress of your therapy, seek a second opinion from a well-credentialed expert.
What about hypnosis?
The use of hypnosis in trauma therapy is quite common, and careful use of hypnotherapy can be helpful but it also can be problematic if used imprudently. Many people think that memories recovered while under hypnosis are more valid than memories retrieved under other circumstances. However, research has shown that hypnotically retrieved memories may be more prone to distortion.
One of the best uses of hypnosis in trauma therapy is for stabilization: to help a person focus on tasks of daily functioning, and to manage the pain of traumatic memories. People with dissociative disorders often find hypnotherapy helpful in fostering cooperation between dissociated parts or alters.
The uncovering of forgotten memories needs to occur in the larger context of treatment for psychiatric distress or disability. For some people, hypnosis may not be necessary at all. It is, however, generally not appropriate to use hypnotherapy as a "digging tool" to find out if a person has been traumatized.
Any client whose therapist suggests the use of hypnosis should be an informed consumer and ask about the purposes of this type of therapy. A good therapist will get informed consent (preferably in writing) from a client before beginning any course of treatment, including hypnotherapy. This means that before hypnosis is used, the client will be informed of the purposes, benefits, and risks of, and alternatives to this type of treatment, and will (without coercion) agree to its use.
What do I do if I can't remember?
Not all abuse or trauma survivors can clearly remember their traumatic experience/s. Some individuals have only a vague recollection of "something" happening; others can't recall anything traumatic occurring in their lives at all.
Even before you begin to tackle the issue of traumatic memories, the first critical aspect of your therapeutic work will be to stabilize your current functioning. Memory loss related to traumatic experiences may serve as a protective function, which should be respected. "Digging up" the past will not alleviate your current difficulties. There is no such thing as a "quick fix" or "skipping steps" when it comes to healing from trauma. Without first establishing the necessary framework for a healthy lifestyle and level of functioning in the present, the challenges of coping with and integrating memories of past trauma may further add to your current difficulties and symptoms. Therefore, it is highly valuable to first work on your present life issues, the problems that you can more readily identify and address.
This will provide you with a solid foundation for further therapeutic work dealing with possible traumatic memories. If you are struggling with memory disturbances related to trauma or abuse, it is important for you to know you are not alone in this experience and you are not "going crazy."
Here are some helpful things to keep in mind:
Sidran.org
1994
Recent debates between differing schools of scientific thought, fueled by the media and by lay organizations with varied political agendas, have left the public confused and misinformed regarding the nature of traumatic memories. This confusion is causing great distress to many people who are survivors of child abuse and those who care about them.
The purpose of this brochure is to reach beyond the hype of popular media and the rhetoric of single-purpose organizations to clarify the issues and to discuss the body of knowledge agreed upon by most mental health professionals about traumatic memories and their retrieval.
There is strong documentation to prove the high incidence of child abuse in the general population. Sexual abuse of children and adolescents is known to cause severe psychological and emotional consequences. Adults who were sexually abused in childhood are at higher risk for developing a variety of psychiatric disorders, including dissociative disorders (such as dissociative identity disorder/multiple personality disorder), anxiety disorders (panic attacks, etc.), personality disorders (borderline personality disorder, etc.), mood disorders (such as depression), PTSD, and addictions.
In order to understand the essential issues about traumatic memory, one must first understand the human mind's response to a traumatic event.
What is trauma, and how do people cope with it?
Psychological "trauma" is defined by the American Psychiatric Association as "an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others." Examples include military combat, violent personal attack, natural or human-made disasters, and torture. For children, sexually traumatic events may include age-inappropriate sexual experiences without violence or injury. (DSM IV, p. 424)
Like adults who experience trauma, children and adolescents who have been abused cope by using a variety of psychological mechanisms. One of the most effective ways people cope with overwhelming trauma is called "dissociation." Dissociation is a complex mental process during which there is a change in a person's consciousness which disturbs the normally connected functions of identity, memory, thoughts, feelings, and experiences (daydreaming during a boring lecture is a good example).
How does trauma affect memory?
People may use their natural ability to dissociate to avoid conscious awareness of a traumatic experience while the trauma is occurring, and for an indefinite time following it. For some people, conscious thoughts and feelings, or "memories," about the overwhelming traumatic circumstance may emerge at a later date. This delayed retrieval of traumatic memories has been written about for nearly 100 years in clinical literature on military veterans who have survived combat.
In fact, in Post Traumatic Stress Disorder (PTSD), a psychiatric diagnosis common among people who have survived horrific events, the defining diagnostic features are memory distortions. People with PTSD inevitably experience extremes of recall regarding traumatic circumstances: intrusive memories of the event (hypernesia) or avoidance of thoughts and feelings about the event (amnesia).
Some people say they are "haunted" by memories of traumatic experiences which intrude on and disrupt their daily lives. They often can't get the "pictures" of the trauma out of their heads. They may have recurring nightmares, "flashbacks," or they may even relive the trauma as if it was happening in present time.
It is also common for traumatized people to make deliberate efforts to avoid thoughts or feelings about the traumatic event and to avoid activities or situations which may remind them of the event. In some severe cases, avoidance of reminders of the trauma may cause a person to have "dissociative amnesia," or memory blanks for important aspects of the trauma.
Why do some people undergoing extreme stress have continuous memory and others have amnesia for all or part of their experience?
There are several factors that influence whether a traumatic experience is remembered or dissociated. The nature and frequency of the traumatic events and the age of the victim seem to be the most important. Single-event traumas (assault, rape, witnessing a murder, etc.) are more likely to be remembered, but repetitive traumas (repeated domestic violence or incest, political torture, prolonged front-line combat, etc.) often result in memory disturbance. The extremely stressful experiences caused by natural or accidental disasters (earthquakes, plane crashes, violent weather, etc.) are more likely to be remembered than traumatic events deliberately caused by humans (i.e. incest, torture, war crimes). People who are adults when they experience traumatic events are less likely to dissociate conscious memories of the events than children who experience trauma. Research shows that the younger the child is at a time of the trauma, the less likely the event will be remembered.
Case studies show that traumatic events in which there is pressure toward secrecy are more likely to induce forgetting as a dissociative defense. For example, a woman who is brutally attacked by a stranger but who receives sympathy, family support, and many opportunities to tell her story, may suffer from PTSD, but is unlikely to develop amnesia for the event. However, a young girl who endures repeated incest with her father and has been sworn to secrecy will more likely have memory impairment for the abuse.
Factors Influencing continuous memory
- Single traumatic event
- Natural or accidental cause
- Adult victim
- Validation and support
- multi-event / repetitive
- deliberate human cause
- child victim
- denial and secrecy
What is known about how memories work?
Human memory is a complex operation. Although there is still much to learn about how memories work, scientists generally understand and accept that there are four stages of memory: intake, storage (encoding), rehearsal, and retrieval. Each of these processes can be influenced by many factors such as developmental stage, setting, expectation, post-event questioning, etc. Even the conditions at the time of the telling of a memory can change the form of the memory, influencing its content and belief in the truth of the memory in the future.
Most scientists also agree that there are two identified forms of memory: explicit and implicit. Explicit memory, also called declarative or narrative memory, is the ability to consciously recall facts or events. This is the form of memory used, for example, when a person recounts the events of his or her day at work or school. Implicit memory, also called procedural or sensorimotor memory, refers to behavioral knowledge of an experience without conscious recall. A person who demonstrates proficiency at reading but who cannot remember how he or she learned the skill is an example of implicit memories in the absence of explicit memories.
Why are traumatic memories controversial?
There are differing schools of thought, grounded in solid research and clinical experience, about the reliability of memory. The details of this scientific debate are often obscure, and the subtleties can be confusing to the public.
Some researchers have proven in the laboratory that ordinary or slightly stressful memories are easily distorted. These scientists are concerned that therapists may be unintentionally distorting the memories of people who report histories of traumatic abuse. This is of particular concern to scientists studying the effects of hypnosis on eyewitness testimony because there is laboratory evidence that setting and expectation can "contaminate" a person's memories.
However, this laboratory research on ordinary memory may be irrelevant in regard to memories of traumatic experiences. Scientists argue that traumatic memories are different from ordinary clinical memories in the way they are encoded on the brain. There is evidence that trauma is stored in the part of the brain called the limbic system, which processes emotions and sensations, but not language or speech. For this reason, people who have been traumatized may live with implicit memories of the terror, anger, and sadness generated by the trauma, but with few or no explicit memories to explain the feelings. Trauma clinicians believe that implicit memories are not easily distorted. It would, of course be unethical to create in a laboratory setting the traumatic experiences necessary to study traumatic memories and their ease of contamination or distortion. For this reason, our knowledge of traumatic memories must come from clinical experience. Clinical data since 1919 has shown a direct correlation between trauma and amnesia or other memory disturbance (Van der Kolk, 1994).
What about memory retrieval long after the trauma?
Sometimes a current event or experience may trigger long-forgotten memories of earlier trauma. Often when this happens, the person may be "flooded" with implicit sensorimotor memory: he or she may have just the picture, the feeling, the physiological panic aroused by the memory of the traumatic event without the facts that would explain the meaning of the sensations. Initially, the person may not even be aware of what has triggered the memory, or how the pictures and feelings relate to his or her life.
There is often intense psychological distress when a person is exposed to events which in some way resemble or symbolize the past trauma. These "triggers" may be any sound, smell, or other stimulus such as hot, humid weather which may remind a veteran of his service in southeast Asia, or the smell of a particular cologne which was worn by an abuser.
Can I believe my memories?
At this time, there is no completely accurate way of determining the validity of abuse reports without external corroboration, and that kind of corroboration is often impossible. Many things—questioning (especially of young children), suggestion by a trusted person, even the recounting of a traumatic experience in therapy—may influence the accuracy of abuse memories. Even people who have documented corroboration about their abuse may have inconsistent elements in their stories.
Nevertheless, trauma specialists such as Harvard's Dr. Bessel van der Kolk believe that "the body cannot lie." If a person spontaneously sees a flashback and feels terrified, the feeling can be trusted, especially before an implicit memory has been discussed and possibly contaminated. If the person has the symptoms of PTSD, or a dissociative disorder that is known to be associated with a traumatic history, then it is likely that there are real traumatic experiences in the person's background. Unless one is preparing for a criminal investigation, the exact authenticity of a specific memory may not be important.
It is the job of the individual to figure out his or her own life history. Many people with post-traumatic stress or dissociative disorders have found it helpful to gather information from siblings or other family members to help them understand their memories.
What can I expect from therapy?
A therapist can help by showing a person how to put these memories in the context of other psychological symptoms, and guide them in the process of getting on with their lives. A good therapy situation is a collaborative effort in which the client can feel comfortable taking the lead; a competent therapist may inquire about but generally does not suggest an abuse history. Uncovering memories is only one step in the process of healing from trauma. Other therapy goals may include learning to live with feelings, handling anger, dealing with cognitive distortions, ending a cycle of repeated victimization, etc.
A client should feel comfortable about the relationship with a therapist and feel free to make decisions about the direction and pacing of treatment. A good therapist is willing to be flexible. Ultimately, the decision about whether or not specific memories are valid is the responsibility of the client.
If you have been diagnosed with a dissociative disorder or PTSD, it would be most helpful to see a therapist with a specialty in these areas. Names of therapists who have experience treating trauma survivors are available through the Sidran Institute Help Desk (email help@sidran.org).To practice their specialty, therapists should have a license from the state in which they work. If you have doubts about the progress of your therapy, seek a second opinion from a well-credentialed expert.
What about hypnosis?
The use of hypnosis in trauma therapy is quite common, and careful use of hypnotherapy can be helpful but it also can be problematic if used imprudently. Many people think that memories recovered while under hypnosis are more valid than memories retrieved under other circumstances. However, research has shown that hypnotically retrieved memories may be more prone to distortion.
One of the best uses of hypnosis in trauma therapy is for stabilization: to help a person focus on tasks of daily functioning, and to manage the pain of traumatic memories. People with dissociative disorders often find hypnotherapy helpful in fostering cooperation between dissociated parts or alters.
The uncovering of forgotten memories needs to occur in the larger context of treatment for psychiatric distress or disability. For some people, hypnosis may not be necessary at all. It is, however, generally not appropriate to use hypnotherapy as a "digging tool" to find out if a person has been traumatized.
Any client whose therapist suggests the use of hypnosis should be an informed consumer and ask about the purposes of this type of therapy. A good therapist will get informed consent (preferably in writing) from a client before beginning any course of treatment, including hypnotherapy. This means that before hypnosis is used, the client will be informed of the purposes, benefits, and risks of, and alternatives to this type of treatment, and will (without coercion) agree to its use.
What do I do if I can't remember?
Not all abuse or trauma survivors can clearly remember their traumatic experience/s. Some individuals have only a vague recollection of "something" happening; others can't recall anything traumatic occurring in their lives at all.
Even before you begin to tackle the issue of traumatic memories, the first critical aspect of your therapeutic work will be to stabilize your current functioning. Memory loss related to traumatic experiences may serve as a protective function, which should be respected. "Digging up" the past will not alleviate your current difficulties. There is no such thing as a "quick fix" or "skipping steps" when it comes to healing from trauma. Without first establishing the necessary framework for a healthy lifestyle and level of functioning in the present, the challenges of coping with and integrating memories of past trauma may further add to your current difficulties and symptoms. Therefore, it is highly valuable to first work on your present life issues, the problems that you can more readily identify and address.
This will provide you with a solid foundation for further therapeutic work dealing with possible traumatic memories. If you are struggling with memory disturbances related to trauma or abuse, it is important for you to know you are not alone in this experience and you are not "going crazy."
Here are some helpful things to keep in mind:
- Recognize that there is a reason for your current difficulties; your "symptoms" are meaningful. They did not come from nowhere.
- Trust in your own process and timing.
- Find a treatment provider with whom you can establish a safe and trusting therapeutic relationship.
- Just as it takes time to build strong foundations of trust and deep roots of connection in relationships with others, so too must you establish these elements internally to strengthen an inner connection within yourself. This will greatly support the work you do both therapeutically and individually.
- American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.
- American Psychiatric Association (1993). Statement on Memories of Sexual Abuse.
- Briere, J., and Conte, J. (1993). Self-reported amnesia for abuse in adults molested as children. Journal of Traumatic Stress, 6: 21–31.
- Freyd, J. (1993). Theoretical & Personal Perspectives on the Delayed Memory Debate. Moving Forward 2, no. 4.
- Family Therapy Networker, September/October 1993. Special Feature: The False Memory Debate. vol. 17, no. 5.
- Herman, J. L. (1993). False memory debate: Social science for social backlash. Harvard Mental Health Letter. 9, no. 10.
- Herman, J. L., and Schatzow, E. (1987). Recovery and verification of memories of childhood sexual trauma. Psychoanalytic Psychology, 4: 1–14.
- Loftus, E.F. (1993). The Reality of Repressed Memories. American Psychologist 48, 518–537.
- Perry, N. E., (1993). Memory Research: A Complete Bibliography.
- Van der Kolk, B. (1994). The Body Keeps the Score: Memory and the evolving psychobiology of post traumatic stress. Harvard Review of Psychiatry. 1, no. 5.
- Williams, L. M. (1992). Adult survivors of childhood abuse: preliminary findings from a longitudinal study. The Advisor 5, 19–20.
