STATEMENT OF AMERICAN PSYCHIATRIC ASSOCIATION REGARDING MEMORIES OF SEXUAL ABUSE

 

This Statement is in response to the growing concern regarding memories of sexual abuse. The rise in reports of documented
cases of child sexual abuse has been accompanied by a rise in reports of sexual abuse that cannot be documented. Members
of the public, as well as members of mental health and other professions, have debated the validity of some memories of sexual
abuse, as well as some of the therapeutic techniques which have  been used. The American Psychiatric Association has been
concerned that the passionate debates about these issues have obscured the recognition of a body of scientific evidence
that underlies widespread agreement among psychiatrists regarding psychiatric treatment in this area. We are especially
concerned with the public confusion and dismay over this issue and the possibility of false accusations not discredit the
reports of patients who have indeed been traumatized by actual previous abuse. While much more needs to be known,
this Statement summarizes information about this topic that is  important for psychiatrists in their work with patients for
whom sexual abuse is an issue.

Sexual abuse of children and adolescents leads to severe negative consequences. Child sexual abuse is a risk factor for many
classes of psychiatric disorders, including anxiety disorders, affective disorders, dissociative disorders and personality
disorders.

Children and adolescents may be abused by family members, including parents and siblings, and by individuals outside
of their families, including adults in trusted positions (e.g. teachers, clergy, camp counselors). Abusers come
from all walks of life. There is no uniform "profile" or other method to accurately distinguish those who have sexually
abused children from those who have not.

Children and adolescents who have been abused cope with the trauma by using a variety of psychological mechanisms. In some
instances these coping mechanisms result in a lack of conscious awareness of the abuse for varying periods of time. Conscious
thoughts and feelings stemming from the abuse may emerge at a later date.

It is not known how to distinguish, with complete accuracy, memories based on true events from those derived from other
sources. The following observations have been made:

Human memory is a complex process about which there is a substantial base of scientific knowledge. Memory can be
divided into four stages: input (encoding), storage, retrieval, and recounting. All of these processes can
be influenced by a variety of factors, including developmental stage, expectations and knowledge base prior to an event; stress
and bodily sensations experienced during an event; post-event questioning; and the experience and context of the recounting of
the event. In addition, the retrieval and recounting of the memory can modify the form of the memory, which may influence the content
and the conviction about the veracity of the memory in the future.  Scientific knowledge is not yet precise enough to predict how a
certain experience or factor will influence a memory in a given person.

Implicit and explicit memory are two different forms of memory that have been identified. Explicit memory (also termed declarative
memory) refers to the ability to consciously recall facts or events. Implicit memory (also termed procedural memory) refers
to behavioral knowledge of an experience without conscious recall.  A child who demonstrates knowledge of a skill (e.g. bicycle riding)
without recalling how he/she learned it, or an adult who has an affective reaction to an event without understanding the basis for
that reaction (e.g. a combat veteran who panics when he hears the sound of a helicopter, but cannot remember that he was in a
helicopter crash which killed his best friend) are demonstrating implicit memories in the absence of explicit recall.

This distinction between explicit and implicit memory is fundamental because they have been shown to be supported by different brain
systems, and because their differentiation and identification may have important clinical implications.  Some individuals who have
experienced documented traumatic events may nevertheless include some false or inconsistent elements in their reports. In addition,
hesitancy in making a report, and recanting following the report can occur in victims of documented abuse. Therefore, these seemingly
contradictory findings do not  exclude the possibility that the report is based on a true event.

Memories can be significantly influenced by questioning, especially in young children. Memories can also be significantly influenced
by a trusted person (e.g. therapist, parent involved in a custody dispute) who suggests abuse as an explanation for symptoms/problems,
despite initial lack of memory of such abuse. It has also been  shown that repeated questioning may lead individuals to report
"memories" of events that never occurred.

It is not known what proportion of adults who report memories of  sexual abuse were actually abused. Many individuals who recover
memories of abuse have been able to find corroborating information about their memories. However, no such information can be found,
or is possible to obtain, in some situations. While aspects of the alleged abuse situation, as well as the context in which the memories
emerge, can contribute to the assessment, there is no completely accurate way of determining the validity of reports in the absence
of corroborating information.

Psychiatrists are often consulted in situations in which memories of sexual abuse are critical issues. Psychiatrists may be involved in
a variety of capacities, including as the treating clinician for the alleged victim, for the alleged abuser, or for other family member(s);
as a school consultant, or in a forensic capacity. Basic clinical and ethical principles should guide the psychiatrist's
work in this difficult area. These include the need for role clarity. It is essential that the psychiatrist and the other involved parties
understand and agree on the psychiatrist's role.

Psychiatrists should maintain an empathic, non-judgmental, neutral stance towards reported memories of sexual abuse. As in the treatment
of all patients, care must be taken to avoid prejudging the cause of the patient's difficulties, or the veracity of the patient's reports.
A strong prior belief by the psychiatrist that sexual abuse, or other factors, are or are not the cause of the patient's problems is likely
to interfere with appropriate assessment and treatment. Many individuals who have experienced sexual abuse have a history of not being believed
by their parents, or others in whom they have put their trust. Expression of disbelief is likely to cause the patient further pain and decrease
his/her willingness to seek needed psychiatric treatment.  Similarly, clinicians should not exert pressure on patients to believe in events
that may not have occurred, or to prematurely disrupt important relationships or make other important decisions based on these speculations.
Clinicians who have not had the training necessary to evaluate and treat patients with a broad range of psychiatric disorders are at risk
of causing harm by increasing the patient's resistance to obtaining and responding to appropriate treatment in the future. In addition,
special knowledge and experience are necessary to properly evaluate and/or treat patients who report the emergence of memories
during the use of specialized interview techniques (e.g., the use of hypnosis or amytal), or during the course of litigation.

The treatment plan should be based on a complete psychiatric assessment, and should address the full range of the patient's clinical needs. In
addition to specific treatments for any primary psychiatric condition, the patient may need help recognizing and integrating data that informs
and defines the issues related to the memories of abuse. As in the treatment of patients with any psychiatric disorder, it may be important
to caution the patient against making major life decisions during the acute phase of treatment. During the acute and later phases of treatment,
the issues of breaking off relationships with important attachment figures, of pursuing legal actions, and of making public disclosures
may need to be addressed. The psychiatrist should help the patient assess the likely impact (including emotional) of such decisions, given
the patient's overall clinical and social situation. Some patients will be left with unclear memories of abuse and no corroborating information.
Psychiatric treatment may help these patients adapt to the uncertainty regarding such emotionally important issues.

The intensity of public interest and debate about these topics should not influence psychiatrists to abandon their commitment to the basic
principles of ethical practice, delineated in _The Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry_. The
following concerns are of particular relevance:

Psychiatrists should refrain from making public statements about the veracity or other features of individual reports of sexual abuse.

Psychiatrists should vigilantly assess the impact of their conduct on the boundaries of the doctor/patient relationship. This is
especially critical when treating patients who are seeking care for conditions that are associated with boundary violations in their
past.

The APA will continue to monitor developments in this area in an effort to help psychiatrists provide the best possible care for their patients.