Who needs repression?

Normal memory processes can explain 'forgetting' of childhood sexual abuse

Susan A. Clancy & Richard J. McNally - Harvard University 
In: The Science Review of Mental health Practice, Vol. 4, Number 2, Fall-winter 2005-2006, pp 66 - 73. 

This research was supported by NIMH grant MH61268 awarded to the second author.

Abstract

Twenty-seven adults reporting "recovered memories" of childhood sexual abuse (CSA) were interviewed to determine 

1. whether they perceived their CSA to be traumatic (e.g., terrifying, life threatening) at the time it occurred,
2. why they believe they "forgot" their CSA memories, and
3. whether they report current psychological symptoms, negative life effects, or both related to their abuse.
    

Data are consistent with the hypothesis that

1. CSA that is "forgotten" and then "remembered" was not necessarily traumatic at the time it occurred,
2. CSA can be forgotten via normal forgetting mechanisms, and
3. it may be the retrospective interpretation of the event as traumatic, rather than the event itself, that mediates any subsequent impact.

Introduction

Some adults report recalling childhood sexual abuse experiences that they had not thought about for many years (colloquially, they "forgot" them). Many trauma theorists explain this forgetting by positing an involuntary, automatic mechanism that renders painful material inaccessible to consciousness

(e.g., Briere & Conte, 1993; Elliot & Briere, 1995; Herman & Schatzow, 1987; Williams, 1995).

Putative mechanisms include repression and dissociation

(Brown, Scheflin, & Hammond, 1998, p. 647; Freyd, 1996; Terr, 1991).

Such mechanisms are proposed because child sexual abuse is invariably understood as a traumatic stressor for the child -- a painful or overwhelming event likely to produce strong adverse emotional responses -- and such events are presumed unlikely to be forgotten in "ordinary" ways.

Other researchers disagree (e.g., Loftus, 1993). They believe that memories of CSA can slip from awareness in the same way that ordinary material can -- due to normal memory processes

(e.g., voluntary suppression, insufficient retrieval cues, avoidance, lack of rehearsal, normal forgetting; McNally, Clancy, Barrett, & Parker, 2004; Schooler & Hyman, 1997).

Further, they do not assume that the CSA memories were inaccessible during the period when the person did not think about them (e.g., Pope & Hudson, 1995).

A failure to think about something is not the same as being unable to remember it (McNally, 2003a, p. 2).

Although trauma theorists are reluctant to invoke "ordinary forgetting" as an explanation for why people might not think about their CSA for long periods of time, survey data do indicate that victims may not think about their CSA for years (i.e., they "forget" it),

Furthermore, experimental data indicate that attempts to forget information -- both neutral and emotional -- can, in some cases, lead to its decreased accessibility on subsequent recall tests

(Anderson & Green, 2001; Rassin, Merckelbach, & Muris, 2000).

To elucidate the phenomenology of "recovered memories" of CSA, we interviewed 27 adults who reported recalling CSA memories after long periods of having not thought about these experiences.

A semi-structured questionnaire, the Childhood Sexual Abuse Interview (CSAI), was developed for this purpose. The interview covers

In addition, subjects were asked why they believe they forgot the abuse and subsequently remembered it years later.

We had three main questions

First, Was the abuse experienced as traumatic (e.g., life threatening, overwhelming, terrifying) at the time it occurred? To date, in no study on people reporting forgetting and remembering of CSA have researchers actually asked subjects this question. Instead, any "forgetting" of CSA experiences reported by subjects

(e.g., Briere & Conte, 1993; Elliot & Briere, 1995; Herman & Schatzow, 1987; Williams, 1995)

is often adduced as support for repression (unconscious, involuntary forgetting) despite the lack of evidence that the memories were, in fact, inaccessible during the period of time when they never came to mind. Whether or not the "forgotten" childhood sexual experiences were experienced as traumatic when they occurred is an empirical question that remains untested.

Our second main question was, Why do the subjects believe that they "forgot" their abuse? Although research on qualitative differences in victims' perceptions of their forgetting is scarce, three studies show that victims seldom characterize their forgetting as unconscious and automatic

(Epstein & Bottoms, 2002; Melchert, 1996; Melchert & Parker, 1997).

Instead, most victims thought their forgetting resulted from ordinary mechanisms (e.g., lack of rehearsal, avoidance, and retrieval failure).

If subjects retrospectively report that the abuse was experienced as non-traumatic (albeit uncomfortable, embarrassing, and shameful) at the time it occurred, and if subjects report consciously trying not to think about it, this provides support for the hypothesis that CSA may be forgotten and then remembered in the same way that other unpleasant experiences can be -- due to ordinary memory processes.

Third, the CSAI asks subjects how they perceive the abuse today and how they believe it may have affected their lives

(e.g., Was it traumatic? Do you think that it affected your life?).

Related to this, we assessed for current symptoms of depression, dissociation, and posttraumatic stress disorder (PTSD).

Even if subjects did not experience the CSA as traumatic at the time of its occurrence, they may retrospectively appraise it as a traumatic stressor -- one that they report had a negative impact on their lives and resulted in symptoms of PTSD.

The potential of CSA to adversely affect some victims' emotional and behavioral development and adjustment has been demonstrated in the literature. However, research also indicates that CSA does not inevitably cause a specific profile of emotional responses

(e.g., Kendall-Tackett, Williams, & Finkelhor, 1993;' Rind, Tromovitch, & Bauserman, 1998).

What factors mediate any link between CSA and outcome?

Twenty years of research on objective characteristics of the abuse (e.g., severity, duration, identify of perpetrator) has yielded inconsistent results

(e.g., Kendall-Tacket et al., 1993; Lauman, Gagnon, Michael, & Michaels, 1994; Rind et al., 1998).

If victims do not report the abuse as "traumatic at the time it occurs" but still report social, psychological, and occupational dysfunction in the aftermath, this would suggest that factors other than objective characteristics of the abuse mediate the link between CSA and adjustment

(e.g., Holman & Silver, 1996; Kolko, Brown, & Berliner, 2002).

Method

Recovered memory subjects were recruited through advertisements placed in newspapers that read:

Entry into the study was contingent upon the subjects

1. having experienced an episode of sexual abuse ranging from fondling to penetration (e.g., anal, oral, vaginal) prior to the age of 15 with a perpetrator who was at least 5 years older than the participant and
2. having a period of time in which they repressed, forgot, or otherwise were not aware of their abuse histories.

Consistent with how forgetting has been assessed in previous studies

(e.g., Briere & Conte, 1993; Elliot & Briere, 1995; Herman & Schatzow, 1987),

subjects in the "recovered memory group" reported at least one autobiographical memory of CSA that came to mind after many years of having not thought about it.

Again, in accordance with previous studies, we did not require that the abuse be traumatic (i.e., overwhelmingly terrifying or perceived as life threatening) at the time it occurred. Respondents received a phone screen (conducted by the first author) that determined their eligibility for the study. Subjects who met criteria were scheduled for an interview at our laboratory.

The recovered memory group consisted of 27 adults (17 female, 10 male). The average age of the subjects was 41.1, and the average years of education completed was 14.9.

During the subjects' visit to our laboratory, the first author fully explained the study and obtained written informed consent before administering the Structured Clinical Interview for DSM-IV

(SCID; First, Spitzer, Gibbon, & Williams, 1995).

Current Axis I diagnoses included

Following completion of the SCID, subjects were administered the Post-traumatic Stress Symptoms Inventory (PSS; Foa, Riggs, Dancu, & Rothbaum, 1993).

Nine subjects met criteria for PTSD:

Subjects then received the CSAI. Interviews were audio-taped and transcribed. For those that requested it (n = 5), treatment options were discussed.

To characterize our subjects further, we asked them to complete

Mean Scores and standard deviations on these instruments were

respectively.

Results 

The mean number of abuse episodes reported by subjects was 1. 7. Thirteen subjects reported that they were abused multiple times, but were unsure of the exact number. The average age at which victims were abused was 7.7 years.

In every case the victim knew the perpetrator (n=27). Perpetrators included: 

Only one person (female) reported more than one perpetrator (mother and father). In all but two cases the alleged perpetrators were male.

The type of abuse reported ranged 

On average, subjects were 29 years old when they recovered their memories and the mean number of years between the CSA and memory recovery was 21.5. 

Recall reminders were 

Twenty-one out of 27 subjects (78%) reported seeking therapy at some point in their lives. Reasons for therapy were as follows: 

Subjects were confident about the accuracy of their memories. On a 10-point confidence scale (10 = extremely confident, 1 =not confident at all) the average confidence rating was 9.4. 

Only two subjects reported experiencing their abuse as terrifying, life threatening, or overwhelming (i.e., as traumatic) at the time it occurred. 

In one case the memories were so bizarre that we question their authenticity

(“My mother was twisting my nipples and yanking my
pubic hair . . . it would go on for hours . . .”). 

In the other case, the subject reported, 

“My grandfather raped me. He was on top of me, moving . . . pain . . . there was blood on my sheet.” 

In all other cases (n=25, 93%) the CSA was described as unpleasant or distressing, but not traumatic. Terms such as “confusing,” “weird,” and
“uncomfortable” were consistently used by these subjects to describe their experience.

Subjects' abuse descriptions included the following:

Of the four victims who reported penetration,

In the words of one of the victims, 

"He would always say if you love me you'll do it. It hurt, and after a while I knew it was wrong, but not at the beginning." 

The other victim of penetration reported, 

"I didn't like it -- I knew it was wrong -- but it was better than having to go back to DYS [Department of Youth Services custody]."

Although subjects were asked to describe their abuse experiences in their own words, they were also specifically asked 

As most were unaware that it was sexual, these subjects inferred it was wrong based on the following types of responses:

[Traumatic?]

Subjects were asked to rate their CSA on a 10-point scale (10 = extremely traumatic, 1 = not traumatic at all). Although only 2 subjects reported abuse descriptions consistent with the definition of a traumatic event, the average trauma rating was 7.5.

[Effects?]

All 27 subjects (100%) reported multiple adverse effects from the abuse.

Finally, subjects were asked why they believe that they forgot their abuse. 

[* Because we conducted the memory interview with each participant only once, we did not obtain an estimate of the reliability of participants' beliefs regarding why they believed they had not thought about their abuse in years. It is possible that some participants might have given different responses if they had been re-interviewed on a second occasion. Because of the length of the memory interview, we opted not to administer it twice in an effort to gauge reliability of their responses.]

Discussion

The results of this study are threefold. 

First, 

most of the recovered memory subjects (93%) report that their
CSA experiences were unpleasant, distressing, or confusing, but not traumatic (e.g., terrifying) at the time they occurred. 

This is consistent with the research on both children's recall of their experiences 

(e.g., Finkelhor, 1979; Kendall-Tackett et al., 1993) 

and adults' retrospective recall of their abuse experiences as children 

(Finkelhor, 1979; Long & Jackson, 1993; Nash & West, 1985; Okami, 1991; Russell, 1986). 

Second, 

consistent with the three previous studies on this topic 

(Melchert, 1996; Melchert & Parker, 1997; Epstein & Bottoms, 2002)

more than half of the subjects report that they actively tried to forget their experiences after they happened. 

These findings are consistent with the hypothesis that CSA experiences may be forgotten due to normal memory processes, such as voluntary suppression and absent retrieval cues. One need not posit any automatic, unconscious repression or dissociation mechanism to explain why some subjects do not think about their abuse for many years. 

Trauma theorists who postulate dissociative mechanisms to explain why CSA victims might not think of their abuse for many years presuppose that overwhelming terror activated the defensive mechanism. But if the abuse were not experienced as traumatic at the time it occurred, then the motive for repression or dissociation would not be present. 

The subjects themselves were quite explicit in stating 

-- all findings strikingly consistent with 

Pinker (2005) has lamented that certain topics of vital social relevance have become taboo, frightening scientists away from studying them. Indeed, the emotions provoked by controversial issues such as CSA can lead to misunderstanding about what the research says or does not say.

In the spirit of preventing misunderstandings, we address several possible criticisms of our study.

One possible criticism of this data is that our subjects are not representative of the populations of victims of CSA who recovered their memories. 

Indeed, without corroboration we cannot even be certain that our subjects are abuse survivors. By assuming they were abused, we can only say that they might be representative of those willing to volunteer for studies on this topic. Furthermore, we did not draw subjects from clinical settings, and so they may be less impaired than many abuse survivors. However, there is no reason to believe that those seeking treatment are more representative of the population of abuse survivors than ours, who were at least recruited from the general population.

Another possible criticism of this study is that the abuse experienced by our subjects was less traumatic than the abuse experienced by those in clinical CSA populations of people reporting recovered memories. 

This seems unlikely for a number of reasons. 

First, most of our subjects report that today they view the abuse as a traumatic event -- one that resulted in multiple symptoms of psychosocial distress. 

Second, many of our subjects do report current symptoms of PTSD and depression. 

Third, although recruited from the community, 94% sought therapy for their problems at various points in their lives. 

In short, our subjects resemble other CSA survivors 

(i.e.,

Had we not specifically asked how their abuse was retrospectively perceived, there would be no reason to suspect that the abuse was not traumatic at the time it occurred.

Another possible criticism of our data is that that the reason subjects did not report the abuse as being traumatic at the time it occurred is due to "defenses of denial and repression." 

Although, theoretically possible, a more probable and parsimonious account for the data is that the subjects are "telling the truth" and that the abuse was not particularly traumatic (painful, terrifying) at the time it occurred.

The notion that the mind protects itself by sealing off memories of the most terrifying events comes partly from 

(forgetting that, as discussed earlier, could be the result of normal memory process), 

For corroborated traumatic events, reviews indicate that the more terrifying the event, the more likely it is to be remembered 

(e.g., Holocaust trauma; Pope, Oliva, & Hudson, 1999, for a review, see McNally, 2003a). 

That being said, even traumatic events are not recalled completely or flawlessly -- memory does not operate like a videotape machine. But the essence of a truly horrific event is seldom, if ever, inaccessible to recall. 

A fourth possible criticism of our data is that, in general, retrospective accounts are not reliable. 

A limitation to our research is that it relies on victims' self-reports of 
the severity of the abuse at the time it occurred. This presupposes that people can accurately and objectively recall their stressful experiences.

Self-reports of adverse events that happened long ago can be unreliable 

(Southwick, Morgan, Nicolaou, & Charney, 1997). 

However, research indicates that subjects' clinical state strongly predicts the degree and direction of memory distortion 

(Harvey & Bryant, 2000; Schwarz, Kowalski, & McNally, 1993). 

All of our subjects 

1. had either symptoms or diagnoses of PTSD and 
2. reported negative life effects from the abuse. 

Therefore, if memory for the CSA were being distorted, it should be in the direction of remembering the event as more traumatic than it was, not less traumatic.

Asking participants to speculate about why they believe they had not thought about their abuse in years has the additional complication, underscored by Nisbett and Wilson (1977), that people often do not have access to the cognitive mechanisms underlying conscious mentation, but that they nevertheless often generate seemingly plausible explanations based on available "folk psychology" accounts (e.g., "I repressed the memory"). 

[About PTSD]

For three decades, CSA has been seen through the lens of a traumato-genic framework -- perceived of as an almost invariably traumatic event that causes negative psychosocial outcomes. 

Although PTSD has served as a focal point for the analysis of sexual abuse trauma 

(in part because it is a well-developed generalized theory of traumatic processes) 

some theorists 

(Finkelhor, 1986; McNally, 2004) 

have raised questions about how well the model accounts for CSA experiences. 

PTSD is described as resulting from experiences that are objectively traumatic (ones that result in overwhelming fear and horror) -- and much sexual abuse lacks these components (e.g., Laumann et aI., 1994).

Clinical and non-clinical data consistently indicate that 

Thus, it is likely that, beyond a sense of shamefulness or "wrongfulness," many victims do not understand that what is happening to them is sexual or wrong at the time it occurs. 

Life threat was integral to the original concept of PTSD. The point was to demarcate traumatic stressors from severe, but more mundane stressors. Yet ever since DSM-IV, the concept of traumatic stressor has undergone a kind of bracket creep where stressors that are not life threatening are certified as qualifying as traumatic (McNally, 2003b).

Recollecting having been fondled by one's stepfather is now bracketed with rape, combat, confinement to a concentration camp, and so forth as stressors deemed sufficient to produce PTSD. 

Nearly a third of our subjects did qualify for PTSD. This raises the issue of whether individuals who affirm enough symptoms to qualify for PTSD from stressors as diverse as fondling to the Holocaust are, in fact, experiencing and suffering from the same illness. 

Hence, although many adult victims of CSA may suffer symptoms that appear to be explained by the PTSD model (i.e., cognitive avoidance, re-experiencing, hyper-arousal), the mechanisms underlying them are unclear. 

[About CSA]

Due to the morally reprehensible nature of CSA, there is an understandable tendency to project our adult fears, repulsion, and horror onto child victims, who, in many cases, may simply not understand the nature of what is happening to them until years later. 

However, researchers and clinicians are dealing with children's sexual experience, not adults', and we may need a framework other than the trauma paradigm to understand them 

(e.g., Browning & Laumann, J.997; Burkhardt & Rotatori, 1995). 

As far back as 1979, a pioneer in the field decried the adult-centric focus of much of the reason on the topic of CSA. 

"Kids have only a dim sense of adult sexuality. The child, as a newcomer to the vocabulary of sexual gestures, is likely to fail to recognize sexual action and intention on the part of others or to interpret them as something else" (Finkelhor, 1979, p. 47). 

What may seem like a horrible violation of social taboos from an adult perspective may not be so to a child (p. 31).

This is the first study concerning ...

... retrospective perceptions of trauma in people reporting recovered memories of sexual abuse and only the third to examine why subjects report they forgot their abuse. 

The data are consistent with the hypothesis that 

1. CSA is not necessarily traumatic at the time it occurs, 
2. CSA can be forgotten via normal forgetting mechanisms, and 
3. it may be the retrospective interpretation of the event, rather than the event itself, that mediates its subsequent impact.

These findings ...

... have the potential to begin to quell some of the controversy surrounding temporarily forgotten and recovered memory, most of which is fueled by those who do and do not accept the mechanism of repression. 

To date, no research convincingly supports this hypothesis. Instead, a growing body of data shows that such forgetting is most likely the consequence of either normal forgetting mechanisms or subjects experiencing a time when they failed to understand the experience

(e.g., Epstein & Bottoms, 2002; Finkelhor, 1979)

Future research needs to explore further 

1. the mechanisms underlying "forgetting and remembering" o fCSA and 
2. the cognitive and social characteristics of the types of abuse that do report getting forgotten.

The lack of attention to retrospectively reported assessments of the CSA abuse experience is unfortunate. How children understand abuse at the time it occurs is one cognitive factor likely related to future symptoms 

(e.g., Burkhardt & Rotatori, 1995; Finkelhor, 1979; Holman & Silver, 1996; Kolko et aI., 2002).

In conclusion [*], regardless of whether a subject experienced the abuse as traumatic, the sexual exploitation of children remains morally reprehensible. Sexual abuse calls for condemnation regardless of whether a victim experienced it as traumatic, and regardless of whether a victim develops psychiatric disease as a consequence.