Currents in Affective Illness, XIII (7), July 1994, 5-12
Posted at FMSFonline.org with permission of the publisher
CURRENTS: Dr. Pope, perhaps we can begin with a discussion of the recent Ramona trial in California, including your role in it, to provide context in which to consider your subsequent comments.
POPE: I served as a consultant to Mr. Ramona’s legal team from 1991 to 1994, and also helped to recruit and coordinate expert witnesses and to assist Mr. Ramona’s attorneys in preparing their case.
Mr. Ramona has three daughters. Holly, the oldest, developed symptoms of apparent bulimia nervosa and, subsequently, major depression when she started college. She and her mother found a marital, family, and child counselor (an MFCC) to see Holly, and, at the initial visit, this counselor reportedly told Holly and her mother than 70 to 80 percent of individuals with bulimia had been sexually abused as children. Holly reported that she had no memories of having been abused, but, after having been in therapy for several months, she began to develop what she called "flashbacks" or brief mental images, such as an image of her father’s hand on her abdomen, and became convinced that those images represented memories or fragments of memories of sexual abuse that she had repressed. After six months of therapy, in March of 1990, she requested an amytal interview, apparently hoping that it could confirm the truth of her "memories." The amytal interview was administered, and she reportedly made statements during the course of it that were interpreted as confirming that she had been sexually abused as a child. (Interestingly, even before the amytal interview, arrangements had been made for her to confront her father with her allegations that he had raped her.) The amytal interview was conducted on March 14, 1990, and on the morning of March 15, Mr. Ramona testified that he was invited to come to the hospital, not knowing why; there he was ushered into a room where he found a somnolent Holly along with her counselor and his (Mr. Ramona’s) wife. Holly then confronted him with the allegation that he had raped her between the ages of five and eight. He stated that this was not true, and, he says, Holly’s counselor and Mrs. Ramona immediately exhorted him to confess. He says that he offered to take an amytal interview himself (if in fact amytal was a "truth serum," as they told him), but apparently that was not offered.
He came home feeling devastated. His wife divorced him, and, within a year, he lost his lucrative job as vice president of a winery, which he believes occurred as a result of rumors that he had committed incest with his daughter. He filed suit against Holly’s two therapists and the hospital, and their lawyers challenged his suit on the grounds that since Holly was an adult and was not dissatisfied with her treatment, Mr. Ramona, a third party, had no right to sue. Despite those challenges, the case survived and went to trial in March of this year. Mr. Ramona’s experts argued that it was incorrect to state that bulimia was caused by sexual abuse and to represent amytal as a truth serum or as something that could confirm the validity of memories. The experts also noted that because there was inadequate scientific evidence to claim that someone could "repress" -- that is, have complete amnesia for -- years of trauma, Holly’s "memories" were false. The defense experts claimed that Holly’s therapy was reasonable and proper and that Holly exhibited many signs of having been traumatized as a child. Among the signs cited were the fact that she did not like mayonnaise, that she did not like cream soups or melted cheese, and that she would not eat a banana unless it was cut up. The implication was that these foods reminded Holly of semen or of a penis, and that she did not eat them because she had been forced to perform oral sex. Similarly, her dissatisfaction with her body, her sexual inhibitions, and her depressive symptoms were cited as evidence that her "memories" were real. The jury was instructed to determine whether the defendants had "committed malpractice by implanting and reinforcing false memories of childhood sexual abuse in Mr. Ramona’s daughter, Holly, while she was being treated for bulimia and major depression." The jury found all three defendants (the two therapists and the hospital) guilty and awarded Mr. Ramona approximately half a million dollars.
CURRENTS: Among the issues on trial here, then, was the validity of recovered memories of childhood sexual abuse. What is the evidence for and against recovered memories?
POPE: As you mention, what was on trial here was not just the case of Holly Ramona, but the issue of whether there occurs longstanding repression of major traumatic memories. When I say "repression" here, I mean forgetting something striking, something that no ordinary person would be expected to forget; that is to be distinguished from the ordinary forgetfulness that we all have. For example, you might look at your high school yearbook and see a photograph that reminded you of something that you hadn’t thought about in years -- that your English teacher traumatized you by giving you a bad grade, for example -- but that is not repression; it is ordinary forgetfulness. When I say "repression," I mean a phenomenon in which one experiences severe trauma, such as repeated rape, and then banishes the memory from consciousness and is not able to recall it until many years later. Some call this "strong repression," to distinguish it from ordinary forgetfulness.
CURRENTS: Isn’t that a largely subjective distinction? Couldn’t there be children who have been involved in sexual relations with adults who, at the time, did not feel traumatized (in that there was neither pain nor realization that what was occurring was abusive), and then forgot the activity only to remember it later when such activity became more extensively publicized by the media?
POPE: There are sexual acts that everyone would recognize as inappropriate or abusive but which, to a young child, might not be experienced as traumatic and hence might be forgotten via the processes of ordinary forgetfulness. However, most of the proponents of recovered memory therapy would argue that people are capable of a far greater degree of amnesia, and that individuals who have experienced severe, repeated, and unequivocal traumas, extending even into their teenage years, are able to repress the memories of those traumas for years and are able to recover them at a later date. I wouldn’t challenge the notion that someone might forget something because he or she did not perceive it as being particularly memorable at the time. I would grant that a child could have something happen when he or she was four-years-old that would be forgotten as part of the normal process of infantile amnesia. But what I would not grant, and I think this is where the debate is, is that someone could be repeatedly raped over a period of years, as, for example, Holly Ramona alleged, and then completely expunge all of those traumatic memories from consciousness only to recall them years later.
CURRENTS: One must therefore draw a "line in the sand" as to what is unlikely to have been repressed, based on one’s subjective experience at the time.
POPE: True, but in most cases, that line is not too difficult to draw, because many of these patients claim degrees of trauma that are extraordinary by anyone’s standards: they may include sex with animals, satanic rituals, sacrificing of babies, being made pregnant and being taken to an underground abortionist, being shared with other men by their fathers -- events that are so dramatic and striking that everyone would agree that they ought to be remembered.
CURRENTS: Suppose a woman is standing in a crowd, watching a parade, and discovers afterwards that her wallet is missing. At that point, she remembers that someone bumped into her and realizes that she has been pickpocketed by that person (the only person to have bumped into her). At the time, this was not traumatic, but it became so afterwards, the severity of the trauma affected by how much she lost, how much she had in her wallet.
POPE: The traumas described by the majority of patients who have recovered memories of sexual abuse are much more dramatic than in your example. In the wallet example, the woman was not particularly traumatized, and therefore no one would question that she might forget that someone had bumped into her or that she might remember being bumped into only when she discovered her wallet missing and then searched her memory. I would consider that ordinary and normal forgetfulness. On the other hand, if a person claimed that someone violently raped her and that she then got up and went to work the next morning with complete amnesia, I would claim that there is no scientific evidence that that kind of forgetting could occur.
CURRENTS: But if an adult has sex with a child and the child doesn’t know what to call the activity or doesn’t know that the activity is inappropriate -- that is, has no explicit memory of the activity although perhaps has implicit (experiential) memory of it -- then when the child subsequently learns what the activity was, could he or she be said, not so much to have recovered as to have reconsidered the memory? That is, "Oh, is that rape? That happened to me." In that sense, perhaps the person had a "reconsidered" rather than a "recovered" memory.
POPE: Yes, that sounds plausible. I believe that kind of phenomenon could occur.
CURRENTS: So it is conceivable, then, that what is sometimes considered a recovered memory may actually represent learning to label an implicit memory -- "recovering" a memory of an event in the sense of becoming able to make it explicit. And then there may be instances, such as those that you cite, of satanic rituals or sacrifices, for example, in which something that may not have occurred is experienced as if it were being recalled.
POPE: Yes, I believe that all of us would agree that any ordinary person would normally be expected to remember having been forcibly raped at age eight or ten or twelve, and that there would have to be some very special mechanism in the brain to be able to erase from memory something of that magnitude.
CURRENTS: Such a mechanism has been posited by Michela Gallagher at the University of North Carolina; she has concluded, from preclinical findings in rats, that perhaps the release of endogenous opioid compounds during stressful events may inhibit the consolidation into long-term memory of those events.
POPE: I find that difficult to accept on intuitive grounds. If, as Gallagher suggests, there were a surge of endogenous opioids that made one amnestic for traumatic events, it would follow that the survivors of disasters, such as the Coconut Grove fire in Boston would remember many other events that year, but would have only a vague memory of the night they spent at the Coconut Grove. We know that the opposite is true. Everyone who was in the Coconut Grove fire will remember the events of November 28, 1942, for as long as they live. There is no one who "woke up" 20 years later and said, "Good God, I was in the Coconut Grove fire and forgot it." Similarly, in a study of 16 children who witnessed a parent murdered, all 16 remember the murder vividly. In studies of children kidnapped on a school bus, children involved in a sniper attack, and in survivors of marine disasters, concentration camps, and war atrocities, all of the individuals remembered the events, often in painful detail. Rather than having amnesia, they seem to have hypermnesia for the events.
CURRENTS: Do you believe, then, that Gallagher’s results in rats are irrelevant to human memory?
POPE: I hesitate to generalize from animals. There have, for decades, been attempts to simulate human repression in the laboratory, and, as David Holmes has discussed in a review of the literature, sixty years of laboratory research have failed to produce a clear demonstration of repression. However, it would be unethical in the laboratory to create terrible, severe traumas comparable to those that occur naturally or those that might be tested in animals. Therefore, even if you had not seen repression in the laboratory, you might still see it in persons who had had terrible real-life traumas. But again, what we find in actual practice is that persons who have experienced terrible real-life traumas remember them in detail.
CURRENTS: What about the work of Judith Herman suggesting that incest survivors may forget incest?
POPE: Let me preface my response to your question with the following observation: In her book, Father-Daughter Incest, published in 1981, Judith Herman describes 40 cases of women who were incest victims, and every one of them appears to have had lasting, clear memories of the abuse. Therefore, it is odd, in my opinion, that only six years later, in a 1987 paper (Psychoanalytic Psychology 4:1-14, 1987), Herman and Schatzow claim that many of their patients displayed amnesia, when Herman did not describe any amnesia in her case series only six years earlier. In the 1987 paper, only 14 of Herman’s and Schatzow’s 53 patients were described a showing "severe amnesia." Later in the course of the paper, they state that 40 percent of the 53 patients obtained corroborating evidence for the trauma and that another 34 percent claimed to have found that a sibling or other individual had been abused by the same perpetrator. The nature of the corroborating evidence is not quantitatively specified, nor is it clear whether the allegedly abused sibling had corroborating evidence that she (the sibling) had been abused. Further, it is not clear whether any of the individuals who obtained corroborating evidence overlapped with the 14 persons who had severe amnesia. That leaves no clear case, among the 53 patients, in which an individual had both clear amnesia and also clearly documented and corroborated trauma. A satisfactory demonstration of repression must involve a series of patients where the trauma is clearly documented and where the patients’ amnesia for it is clearly demonstrated. Herman’s and Schatzow’s study does not provide evidence of that kind.
CURRENTS: Isn’t it true that of the 53 women studied by Dr. Herman (all of them attendees of incest survivor groups), thirty-nine obtained independent corroboration, including admissions by perpetrators, pornographic photographs, or corroboration by family members?
POPE: It is not clear how many obtained corroboration of each kind -- an admission from the perpetrator, for example. Also, although it is stated that 39 obtained independent corroboration, only 21 were said to have obtained corroboration themselves; the other 18 found that a sibling or other individual had been abused. That 18 did not have corroboration that they themselves had been abused. Nor is it clear whether the sibling had corroborated whether she or he had been abused.
CURRENTS: Yet 21 did obtain independent corroboration.
POPE: That’s what was reported, but it is not clear from the authors’ exposition whether that 21 included any of the patients who had severe amnesia. It is possible that none of the 14 patients with amnesia had independent corroboration; it just isn’t clear in their paper. The authors present no data from which the reader can determine the numbers of persons who had both severe amnesia and corroboration. Yet some in the media have repeatedly cited that study as evidence for the plausibility of recovered memory.
CURRENTS: What about the findings of Linda Meyer Williams at the University of New Hampshire, who interviewed 129 women who had been treated for sexual abuse when they were girls, and then found that more than one-third of them subsequently failed to report sexual abuse when questioned?
POPE: While 38 percent of those women did not disclose, on a follow-up interview, that they had been abused, in no case was it confirmed that a woman did not remember that she had been abused. I made that distinction because the interviewers never asked the subjects if they remembered the abuse; the interviewers asked the subjects if they had ever been abused and then recorded their answers. If the subject did not disclose the known episode of abuse, she was not confronted with the evidence that she had been abused. In other words, the interviewer did not say, "I have evidence that you were seen at the hospital when you were eight-years-old for having been sexually abused," and then record whether the interviewee then acknowledged remembering. Therefore, all one can say from that study is that a significant proportion of women may not disclose abuse during an interview -- not that they forget it.
A study by Femina and colleagues speaks to this issue (D.D. Femina and associates, Child Abuse and Neglect 14: 227-231, 1990). These investigators also conducted follow-up interviews on a group of individuals with documented histories of sexual or physical abuse. Interestingly, precisely 38 percent gave a history on follow-up that was discordant with the documented history. But Femina and colleagues, unlike Williams, went back and found 11 of those patients for a second follow-up interview; in the second interview (which they called the "clarification interview"), they confronted their subjects with their known histories of abuse to find out why their first interviews had been discrepant. Eight of that 11 were known to have been abused and had denied it during the first interview; during the second interview, all eight of those individuals acknowledged that they remembered the abuse but had elected not to tell the interviewer about it the first time. If that is generally true, it suggests that the failure of some of Williams’s patients to disclose the abuse on interview may reflect the fact that the patient elected not to tell the interviewer about it, and, since they were not confronted, it cannot be concluded that they had forgotten the abuse.
In addition, I find it striking that Williams does not discuss in her paper the large literature on non-disclosure. Indeed, a series of Federal Government-sponsored investigations during the 1960s and 1970s looked specifically at why people don’t disclose events on interviews. There were, for example, studies where interviewers went to see people who were known to have been in motor vehicle accidents, and, in the course of interview, asked them about their history of motor vehicle accidents. In one study, thirty percent of the individuals who were known to have been in a motor vehicle accident nine to 12 months earlier did not disclose it on interview. These were people who had not lost consciousness during the accidents and had no biological reasons for having forgotten. In other studies, thirty to 40 percent of people failed to disclose a doctor’s office visit that had occurred just within the preceding few weeks. One wouldn’t claim that they had repressed the memory; they just didn’t tell the interviewer. In other studies in this series, twenty to 50 percent of people failed to disclose to the interviewer a hospitalization they were known to have undergone 10 to 12 months previously. The fact that many people do not disclose life events to interviewers, even when those events have occurred weeks to months earlier, would argue that a 38 percent non-disclosure rate, for an embarrassing event that had occurred 17 years earlier, would be consistent with what one would predict. It is not necessary to posit repression to explain Williams’s finding.
CURRENTS: Did the studies you cite provide explanation concerning the motivations for non-disclosure?
POPE: They did, and the motivations included the degree to which the event had been embarrassing to the subject, the length of the hospitalization, the significance of the hospitalization or doctor’s visit, and the nature of the disease for which the patient saw the doctor or was hospitalized. Also, people of lower socioeconomic classes were more likely to be non-disclosers than were people of upper socioeconomic classes (Williams’s patients came from lower socioeconomic classes).
CURRENTS: There has been reference in the lay media to the findings of Lenore Terr that children who had been subjected to repeated trauma were more likely to forget that trauma than were children who had suffered a single traumatic event. How do you evaluate those findings?
POPE: To my knowledge, Terr has never published a formal study to support this speculation. She has stated that people with so-called Type II traumas (by which she means repeated traumas, as opposed to single traumas, which she calls Type I traumas) may develop amnesia for their traumas. But her evidence for this, as far as I know, is only anecdotal. Again, I find this hypothesis unlikely, given earlier studies of prisoners of war or concentration camp survivors (some having been in the camps as children) who clearly experienced Type II traumas, in that they sustained severe, repeated traumas over time; one does not find reports in the literature of persons who suddenly "woke up" and remembered having been in Auschwitz for two years. That just doesn’t happen.
CURRENTS: And the studies by John Briere at the University of Southern California, suggesting that the earlier and more severe and persistent the trauma, the more likely it is to be repressed?
POPE: Briere and Conte (Journal of Traumatic Stress 6:21-31, 1993) conducted a questionnaire survey of a large group of alleged abuse victims who were in the practices of a group of mental health professionals; unfortunately, whether the abuse had occurred was not confirmed. Moreover, the subjects in that study were asked a single question on a written interview, namely, "During the period of time before the first forced sexual experience happened and your eighteenth birthday (sic), was there ever a time when you could not remember the forced sexual experience?" Approximately 60 percent answered "yes." However, there was no follow-up to find out what they meant by "yes." It was not clear whether they preferred not to think about the abuse for a period of time, whether they had a period of time when they may have been occupied with other things and devoted no thought to it, or what else they might have meant by the answer to the question. Nor was the magnitude or the severity or the timing of the abuse clear from the description; one cannot draw the conclusion from that study that someone could be repeatedly raped over a span of a decade and then abolish the memory from consciousness for years.
CURRENTS: So those would be the principal studies or findings -- of Herman, Williams, Terr, and Briere and Conte -- suggesting the validity of recovered memory of traumatic events, and each has significant flaws.
POPE: Yes. What is remarkable is that that is all the evidence there is. You have omitted only one other study that might be cited, and that is a recent study by Loftus and colleagues (Psychology of Women Quarterly 18:67-68, 1994), which resembled that of Briere and Conte. Loftus and colleagues studied 52 women who remembered being abused and found that 10 claimed to have forgotten the abuse for some period of time. Once again, however, this was a simple question on an interview, and no follow-up questioning was conducted to determine the nature or extent of their forgetfulness. That Loftus and colleagues found only a 19-percent rate of temporary forgetfulness as compared with the 60-percent rate reported by Briere and Conte suggests how unreliable a simple question about forgetfulness may be. Again, neither the study by Briere and Conte nor that of Loftus and colleagues provides evidence that someone could forget a series of severe traumas for years, as is claimed in cases like that of Ramona.
CURRENTS: There have been a number of persons who have come forward to testify against Father James Porter, the former Roman Catholic priest who is serving an 18-year sentence in Massachusetts after having been found guilty of criminal charges of sexual abuse against a number of children; some of those persons, including the first person to file suit, have said that they remembered the abuse by Porter after a period of having forgotten it. Don’t the experiences of those persons support the validity of recovered memory?
POPE: I have heard anecdotally about those cases, but I have seen no published data, where someone systematically examined or interviewed the victims. However, if, for argument’s sake, we allow that a certain percentage of those individuals stated that they had forgotten the abuse, the first question would be whether in fact they had forgotten it or whether they were so embarrassed by it that they had chosen not to reveal it until the admissions of other victims made them bold enough to speak out. In a situation like that, it might be embarrassing to admit that one had always known about the abuse, but had said nothing about it; it might be easier to claim that one had repressed it.
CURRENTS: Could that be what has given rise to this phenomenon in some cases -- that some individuals have needed a way to confide childhood sexual abuse and have seized upon "recovered memory" as their instrument?
POPE: It may, but it’s hard to know how frequently that may occur. Something else that might be contributing to assertions of recovered memory is that individuals who are subject to a statute of limitations may make charges of abuse after the statute of limitations have expired; accordingly, they may claim that they have amnesia for several years and have only recently remembered the abuse in order to "toll" (avoid) the statute of limitations.
Overall, there may be a mixture of cases of genuine abuse that was perceived as sufficiently mild to have been forgotten by the processes of ordinary forgetfulness, genuine abuse that was never forgotten but was reported by the individual to have been forgotten, and false memories of abuse than never occurred but apropos of which the individual has developed what he or she believes to be "memories." I believe that all three phenomena occur, although in what prevalences no one is certain. But at this stage, there is no scientific evidence demonstrating that people who genuinely experience severe and protracted abuse can entirely forget it for a period of time and only years later remember it.
CURRENTS: Earlier, you mentioned that among the evidence cited for Holly Ramona’s alleged victimization were her animadversions to mayonnaise, cream soups, melted cheese, and intact bananas. On what basis were those examples advanced as evidence of sexual abuse?
POPE: That opinion was offered by Dr. Terr, who was an expert witness for the defense. Mr. Ramona’s experts countered that a dislike of such things as mayonnaise and cream soups is highly characteristic of bulimic patients. Indeed, if one had a bulimic patient who liked to eat such high-calorie foods as mayonnaise or cream soup, one would be tempted to question the diagnosis of an eating disorder, because avoidance of high-calorie foods is a hallmark of patients with eating disorders. Some patients may binge on high-calorie foods and then vomit, but in the intervals between binges, virtually all bulimic patients abstain from high calorie foods like those that Holly Ramona abstained from.
CURRENTS: We talked about the evidence for recovered memory; let’s talk now about the evidence against it. Perhaps we can start with the findings of Elizabeth Loftus and those of Richard Ofshe.
POPE: Both have demonstrated that it is possible to "implant" false memories. Loftus was able to convince a group of persons that, as children, they had become lost in a shopping mall, when in fact that had not happened. Ofshe was able to convince a man who had been accused of satanic ritual abuse that he had forced his son and daughter to have sex with one another.
CURRENTS: That was the Ingram case.
POPE: Yes. And within a couple of sessions, I am told, Ingram came to believe the charges against him, even though it was something that Ofshe had made up.
One of the striking findings in psychological research over the last fifty years is that even intelligent and sophisticated people can be highly suggestible. The now classic experiments in social psychology, such as the Asch experiment, the Milgram experiment, and Rosenthal experiments, have demonstrated that, regardless of intelligence or education, people can be extraordinarily vulnerable to suggestion under the pressure of peers or authority.
In the classic type of Asch experiment, you come into a room and are asked to estimate the lengths of two line segments on a screen. At first, the other members of your group agree with you -- that line A, for example, is longer than line B. But then, all at once, the other group members (who are, unbeknownst to you, paid stooges), begin to say that line A is shorter than line B, even though your eyes tell you the opposite. Many people in that situation will bow to group pressure and see the shorter line as the longer one, even though it contradicts the evidence of their senses.
The Milgram experiment is even more dramatic. In that experiment, each subject was induced to deliver what he or she thought were electric shocks to another subject in a "learning" experiment. The intensity of the "electric shocks" gradually increased to the point where the "learner" was screaming in pain. After the "300-volt" level, the "learner" (who was on the other side of an opaque screen) stopped responding entirely; yet, when told by the experimenter that "the experiment requires you to continue," many subjects continued to deliver "450-volt shocks" to another person under the experimenter’s authority. The finding was so striking that Milgram and colleagues thought it might be due to the influence of the prestige of the setting (Yale University); yet, when they moved their offices to a building in Bridgeport, Connecticut, where there were not trappings of academia, they replicated their findings.
Rosenthal found that an investigator could bias other investigators who were working for him to produce results that were congruent with his expectations; he found that even the subtlest of cues could alter his subjects’ responses. The findings of these and other experiments in social psychology suggest that we humans have an almost humiliating degree of suggestibility, and that the forces of suggestion, of peer pressure, and of authority -- all of which occur in individual psychotherapy and in group psychotherapy -- may have profound influences, or at least influences that are greater than most of us would like to believe. In my opinion, the rise and fall of various cults and their adherents’ willingness to die for what appear to be preposterous beliefs -- from Jonestown to Waco -- are examples of this suggestibility.
CURRENTS: Do we know what makes one person more or less suggestible than another?
POPE: That goes beyond my area of expertise, but is seems to me that if someone is suffering from depression or from an eating disorder, it is only human to seek an explanation for that suffering. Some have called this kind of seeking "effort after meaning." If I became profoundly depressed today, I’m sure I could come up with an explanation for why it happened today rather than last month or next year. In our efforts after meaning, we perhaps become too ready to latch on to any reasonable explanation that seems to account for our suffering. Forgotten childhood sexual abuse is appealing because it is so simple -- that is, maybe my problem with depression is due to the fact that I was sexually abused as a child, and if I recover and work through the memories of that abuse, maybe my depression will disappear.
CURRENTS: What are the symptoms or signs that have been claimed to indicate that someone has been sexually abused in childhood?
POPE: My understanding, from popular magazine articles and books as well as from scientific articles, is that few symptoms have been spared; the list of symptoms that have been claimed to be sequelae of sexual abuse has become so vast that virtually anyone could be found to have them.
CURRENTS: Can some pharmacologic agents conduce to suggestibility or confabulation?
POPE: There is literature linking some sedative compounds with development of false beliefs of having been sexually abused. This has been known since the nineteenth century. When my father went to medical school in the early 1930s, he was admonished never to administer nitrous oxide or other anesthetic agent without a chaperone in the room because of the risk that a female patient might wake up and claim that she had been sexually abused. Recently, in the U.K. there have been a number of cases with midazolam (Versed) and other sedative-hypnotic drugs, where women have claimed that they were sexually abused by a physician, even in situations where it was physically impossible -- such as where there were instruments in their mouths at the times that they claimed they were forced to have oral sex, or when they claimed that they had been forced to masturbate the doctor when, in fact, the doctor was asking them to squeeze his fingers to test for strength of grip in both hands, or where women believed that they were sexually abused when there were several persons present in the room. That sedative-hypnotic drugs can cause confabulations of sexual abuse has been known for a long time.
CURRENTS: Is this related to the development of "multiple personality disorder?"
POPE: Many question the validity of that diagnosis. It was hardly heard of a decade ago, whereas now we see it diagnosed frequently, and we see patients diagnosed as having not two or three but sometimes 30 or 40 personalities; in my opinion, this rapid change in the frequency of diagnosis compromises the credibility of it as a "legitimate" disorder. My hunch is that we are seeing individuals who develop and exhibit beliefs or behaviors in response to their doctors’ conscious or unconscious wishes or suggestions.
CURRENTS: If we assume that individuals who report sexual abuse after having a "recovered memory" are exhibiting a confabulatory phenomenon, might that sometimes resemble what we see in the context of "legitimate" disorders -- in bipolar disorder, for example, where a hypomanic or manic patient may embellish or fictionalize biographical or other historical information that family or friends later reveal to be embellishments or fictions? Could a phenomenon occur in persons with "recovered memories," where what is or was true becomes for them what "feels right" to have been, with remembering no longer a mimetic, but a creative process?
POPE: Most of the patients I have been consulted about were not in the midst of psychotic or manic episodes, nor did it appear that they were confabulating events out of frank malingering or sociopathic motivations; rather, it appeared that they were victims of suggestion, and were already vulnerable as a result of suffering -- the phenomenon of "effort after meaning" I alluded to earlier.
CURRENTS: What is the significance of the Ramona verdict and others that have preceded it, where recovered memories have been rejected as evidence of childhood sexual abuse?
POPE: It seems to me that the significance of the Ramona verdict is this: there are no methodologically sound studies demonstrating the efficacy of recovered memory therapy, and, as we have discussed, there are no convincing data to indicate the existence of strong repression. However, because a therapy has not been proven to work and because the therapy does not have a proven theoretical basis, that perforce does not mean that physicians should never use it. If one has a suffering patient, one may want to use a therapy before its efficacy has been proven, in the hope that it will help the patient. However, if the therapy has potentially destructive effects, such as that it may induce false memory and shatter a family, that is a different situation. In my opinion, it is reasonable to try unproven therapies that have a low risk of harm, but not reasonable to try unproved therapies that have a high risk of harm. One should not use a potentially dangerous therapy unless one has evidence to suggest that its benefits outweigh its risks. The message of Ramona is that recovered memory therapy has clearer risks than benefits.
CURRENTS: Would recovered memory therapy have been justified had Ms. Ramona said that she had been raped by persons unknown?
POPE: I’m not sure that would be without risk, insofar as it might become a distractor. When someone develops a fixed, false belief that becomes a principal reason for living or a principal focus for activity, he or she may be diverted from finding more effective strategies for coping or solving problems.
CURRENTS: The Ramona trial also seems to relate to how we establish what is true, as well as how we come to believe that something is true.
POPE: It does go to those issues, but I believe that we do not need to determine whether sexual abuse causes bulimia or whether it is possible to repress a series of traumas. What I believe we must determine before we initiate a therapy is whether its benefits outweigh its risks. The lesson of the Ramona verdict is that recovered memory therapy has risks that outweigh its benefits. In my opinion, everything else becomes moot.
CURRENTS: The risk, in the Ramona case, that a person’s reputation was damaged and his life disrupted.
POPE: Yes, and that Ms. Ramona may have been harmed by becoming fixated on her "memories" rather than on other, potentially more effective strategies for dealing with her problems.
CURRENTS: Would you agree that incest is more common than previously suspected?
POPE: I would, and what I have said earlier should not be construed to challenge that or to question the fact that when sexual abuse occurs it can be extremely damaging. No one questions that patients who have suffered sexual abuse deserve intervention; that is not a matter of debate. However, we should be aware that there are persons with false memories of sexual abuse, and that those persons may divert attention and resources from persons who in fact have suffered sexual abuse.
CURRENTS: What effects has the controversy about recovered memories had on psychiatry?
POPE: It has polarized us. My impression is that there is more skepticism about recovered memory therapy among psychiatrists than among non-psychiatrists. That may be because physicians have been trained more extensively in the risk-benefit paradigm.
CURRENTS: In a letter published last year in the APS Observer, a publication of the American Psychological Association, seventeen well-known psychologists, some of them experts on memory, objected to the use of the term "false memory syndrome." How do you feel about that term?
POPE: I don’t object to it, because I believe that there are individuals who have a syndrome characterized by false memories of sexual abuse. I doubt that anyone would question that that entity exists, although there is a range of estimates as to how common it may be, with some who believe that it is very rare and others, such as myself, who believe that it may be common.
CURRENTS: How common might it be?
POPE: The False Memory Syndrome Foundation has received inquiries from some thirteen thousand families. How many of those families have been victims of false accusations I don’t know. Nor can we know how many families have been victims of false accusations and have not reported them. A number of thousands of cases does not seem unreasonable, and I believe that many people who have had experience with this phenomenon might give a higher estimate.
CURRENTS: There seems to be a great deal of defensiveness on the part of those who have had recovered memories when the validity of those memories is broached. What is the best way to respond to a patient who confides a recovered memory of sexual abuse?
POPE: Persons who have been victims of suggestion and who are already subject to some of the pressures I alluded to earlier (like those in the social psychological experiments) may already have begun to develop their "memories" into a central organizing theme that they do not wish to relinquish. In a patient who suspects that he or she has memories, it is important to inquire how the patient acquired his or her beliefs and to assess the extent to which suggestion or the effects of peer pressure or authority may have contributed to them. If a patient has been a victim of suggestion or of authoritarian or peer pressure influences, it should be addressed, but it should be addressed in a cautious and caring way. If a patient describes images or "flashbacks," whether or not derivative from suggestion, it seems to me unwise to simply agree with the patient that those experiences represent memories of events. Nor would it be wise, in my opinion, to tell the patient flat-out that those experiences are false (as we would not [tell] the patient with a symptom such as pain, that he or she attributed to a specific event). One should explore the issue with the patient, being careful not to jump to a conclusion one way or the other, in order to determine the nature of the experiences. If, after careful evaluation, those experiences do not appear to be what the patient believes them to be, the patient must be gently confronted with that and helped to examine the underlying or associated issues.
For example, if an anorexic patient who weighs 70 pounds comes to you and says, "Doctor, don’t you think I’m too fat?", no reasonable physician would answer, "Yes, you are too fat." Nor would a reasonable physician say, "You’re so thin you look ugly." The reasonable physician would say, "No, I do not believe that you are too fat and I wonder why you do; I believe we need to talk about this." That approach, which we take every day in psychiatry in dealing with patients who have illogical beliefs, or seemingly illogical beliefs, is the kind of approach that one would take with any kind of image or flashback or apparent "memory" of uncertain origin.
CURRENTS: What about the credibility of the False Memory Syndrome Foundation? There have been allegations that that organization is a haven for pedophiles.
POPE: I am a member of the scientific advisory board of the False Memory Syndrome Foundation, and all of the other members of the advisory board whom I have met appear to me to be responsible scientists who rely upon acceptable scientific evidence to make reasonable judgments and have built reputations doing that. To claim that such people are perpetrators or that they provide a haven for perpetrators has no factual basis.
CURRENTS: In what direction is this area of investigation likely to proceed, given the Ramona verdict?
POPE: Recovered memory therapy should be greatly reduced or put on hold until such time as we have reliable and methodologically sound evidence that (1) "strong" repression can occur, (2) that childhood sexual abuse actually produces DSM-IV Axis I disorders in adulthood or contributes substantially to DSM-IV Axis I disorders in adulthood, and (3) that therapy directed toward recovering memories can be effective. The Food and Drug Administration would not approve a drug if there were no published studies to suggest that it was effective and if thirteen thousand families were to come forward claiming that the drug had harmed them; why apply such a different standard to a therapy? I’m being a bit factious here, but the analogy is relevant: we need a better determination of the risk-benefit ratio of recovered memory therapy, in accord with the venerable medical principle of primum non nocere.
CURRENTS: Perhaps we also want to redouble our efforts to identify child abuse when it is occurring.
POPE: Yes; we must never ignore real child abuse, but we must confront the issue of what to do when the memories of child abuse are false.