Evaluation and Treatment of Adults with the Possibility of Recovered Memories of Childhood Sexual Abuse

Introduction

Serious ethical and legal issues have arisen in the clinical literature, courtrooms, and legislatures around the country with regard to the recovering of memories of childhood sexual abuse during the process of treatment. This statement is an effort on the part of the National Association of Social Workers (NASW) National Council on the Practice of Clinical Social Work to provide guidance for clinical social workers as they proceed with the evaluation and treatment of their clients. This guidance is based on the foundation that the clinical social worker's decisions should be clinically sound, ethically based, and legally sanctioned.

The validity of some recovered memories of sexual abuse has been the cause of passionate debate among mental health professionals, attorneys, and the public. In addition to the questions of validity of undocumented reports of sexual abuse and the therapeutic techniques used to elicit these memories have been placed under scrutiny. We will not enter the debate on whether traumatic events are forgotten or how accurately people report their memories. There is ongoing and developing research on memory, including the repressed memory phenomenon. Clinical social workers should be continuously acquainting themselves with this literature. Our concern is for the clients who believe they have been traumatized by childhood sexual abuse as well as the people who believe they have been falsely accused of being a sexual abuser. This statement addresses and reiterates the basic clinical and ethical principles and standards that NASW and the social work profession have followed, applied to the assessment and treatment of clients for whom the possibility of childhood sexual abuse may be present.

Therapeutic Relationship

Establishing and maintaining the appropriate therapeutic relationship is the responsibility of the clinical social worker, not the client. The clinical social worker should:

• establish and maintain an appropriate therapeutic relationship with careful attention to boundary management
• recognize that the client may be influenced by the opinions, conjecture, or suggestions of the therapist
• not minimize the power and influence he or she has on a client's impressions and beliefs
• guard against engaging in self-disclosure and premature interpretations during the treatment process
• guard against using leading questions to recover memories
• be cognizant that disclosure of forgotten experience is a part of the process but not the goal of therapy
• respect the client's right to self-determination.

The clinical social worker's role is to be empathetic, neutral, and non-judgmental. Awareness of one's own attitudes toward repressed memories is crucial. Attitudes of enthusiastic belief or disbelief can and will have an effect on the treatment process. Any predisposition with regard to whether the client's symptoms are related to particular events or circumstances may render the assessment and treatment inappropriate and ineffective. The therapist's responsibility is to maintain the focus of treatment on symptom reduction or elimination and to enhance the ability of the client to function appropriately and comfortably in his or her daily life.

Evaluation and Treatment

A treatment plan should be developed based on a complete psychosocial and diagnostic assessment. Issues related to the client's total clinical picture including symptoms and level of functioning need to be carefully evaluated. All likely medical causes for the client's symptoms need to be identified by referring the client to the appropriate medical personnel before diagnostic conclusions are drawn. Other adjunct services should be made available to the client as needed.

Clinical social workers should explore with the client who reports recovering a memory of childhood abuse the meaning and implication of the memory for the client, rather than focusing solely on the content or veracity of the report. The client who reports recovering a memory of sexual abuse must be informed that it may be an accurate memory of an actual event, an altered or distorted memory of an actual event, or the recounting of an event that did not happen.

The use of therapeutic techniques such as recovered memory groups, guided imagery, and hypnosis for treatment purposes should be limited to clinical social workers with special training, experience, and certification in these modalities.

Clinical social workers need to maintain appropriate skills and knowledge in the area of trauma and memory. They must keep abreast of the evolving relevant scientific examination of the issues and developments in standards of clinical practice. Clinical social workers conducting psychotherapy with clients who have been abused should have adequate training and demonstrated competence and use appropriate and skilled supervision or consultation.

Risk Management

Social workers must maintain an awareness of the effect the treatment may have on people other than the client. Clinical social workers must exercise great caution regarding a client's expressed desire to confront an alleged abuser. The clinical social worker must remain neutral and objective. Although the client has a right to self-determination, the social worker should help the client think through the goals and possible positive and negative outcomes of a confrontation. If a client intends to pursue confrontation the social worker should help the client consider an approach that will maximize the likelihood of a satisfactory result. For example, if clinically indicated, a neutral mediator may be used.

If a client requests the social worker to be present at a meeting with the alleged abuser to discuss the abuse, and if the social worker determines this to be therapeutically indicated and consistent with the treatment plan; the social worker is advised to consider seeking clinical and legal consultation prior to agreeing to such a meeting. It should be understood that if the social worker is present for such a meeting, it will be difficult to argue that this session is not part of the treatment plan. A meeting of this nature may not be essential for a positive treatment outcome, therefore, careful consideration should be made before the client, the alleged abuser and the social worker are placed in a potentially volatile and emotionally charged situation. The purpose of the session should be clarified and all parties should agree to participate. Written consent based on full notice should be obtained from all participating parties before the meeting takes place.

Records should be maintained that reflect the clinical activity with the client from the initial appointment to termination of treatment. The recorded information should be objective and clinically relevant. The documentation should reflect the process related to assessment and ongoing treatment and should document facts and descriptions about what takes place in the therapeutic setting. It should reflect how the memories surfaced and how the client arrived at the conclusion that he or she was the victim of childhood sexual abuse. The social worker must remember that the record is a treatment tool and potentially a legal document.

Clinical social workers should be knowledgeable of state and federal laws regarding disclosure, reporting of abuse, privileged communications, and release of records. Both the obligations and/or lack of protections for the client or social worker may pose clinical and ethical challenges for the social worker. Some circumstances may stimulate requests by clients or other parties for access to the records.

Summary

Clinical social workers who practice in the area of recovered memories should be mindful that this is a high-risk area of practice in an environment of intense controversy. Individuals who report childhood sexual abuse and trauma must receive expert care. The clinician must carefully evaluate theories and techniques used in the care of this very vulnerable client group. The application of sound clinical judgment in the midst of conflicting beliefs and evolving knowledge is the best course to follow on behalf of both the client and the social worker. The clinical social worker needs to conscientiously adhere to principles such as currency of knowledge, comprehensive treatment planning, use of consultation, maintenance of clear boundaries, and careful documentation as described in the NASW Code of Ethics and NASW Standards for the Practice of Clinical Social Work. ð

NASW National Council on the Practice of Clinical Social Work, 1995-96

Mary Jo Monahan, ACSW, LCSW,Chair
Patricia M. DeLorme, MSW, ACSW, LICSW, Immediate Past Chair
Veronica Coleman, ACSW, LCSW, National Board Representative
Jeannie Krause-Taylor, ACSW, LCSW
Sonja Berry, ACSW
Kathryn Koos-Lee, ACSW

References and Suggested Readings

American Medical Association Report of the Council of Scientific Affairs. (1994). Memories of childhood abuse. Washington, DC: Author.

American Psychiatric Association. (1993). Statement on memories of sexual abuse. Washington, DC: Author.

American Psychiatric Association. (1994, April). Fact sheet on memories of sexual abuse. Washington, DC: Author.

American Psychological Association. (1994). Working group on investigation of memories of childhood abuse. Interim report. Washington, DC: Author.

Australian Psychological Society Limited Board of Directors. (1994). Guidelines relating to the reporting of recovered memories. Carlton, South Victoria: Author.

Barlas, S. (1995, March). Psychiatrist unraveling memories of abuse walk on tenuous ground. Psychiatric Times, p. 44.

Bolker, J. (1995). Forgetting ourselves. Readings, 10, 12-15.

British Psychological Society. (1995). Report of the working party of the British Psychological Society on recovered memories. (Available from the British Psychological Society, St. Andrew House 48, Princess Road, East Leicester LE 1 7DR United Kingdom).

Butler, K. (1995a). Caught in the cross fire. Family Therapy Networker, 19, 24-79.

Butler, K. (1995b). Like herding cats. Family Therapy Networker, 19, 35.

Butler, K. (1995c). Marshaling the media. Family Therapy Networker, 19, 36.

Canadian Psychiatric Association. (1996). Position statement on adult recovered memories of childhood sexual abuse. Ottawa, Canada: Author.

Cornell, W. F. (1995). A plea for a measure of ambiguity. Readings, 10, 4-10.

Gardner, R. A. (1995). Protocols for the sex-abuse evaluation. Kreskill, NJ: Creative Therapeutics.

Garry, M., & Loftus, E. F. (1994). Pseudomemories without hypnosis. International Journal of Clinical and Experimental Hypnosis, 13, 363-378.

Herman, J. L. (1992). Trauma and recovery. New York: Basic Books.

International Society for the Study of Dissociation. (1994). Guidelines for treating dissociative identity disorders (multiple personality disorder) in adults. Skokie, IL: Author.

McHugh, P. R. (1992). Psychiatric misadventures. American Scholar, 61, 497-510.

McHugh, P. R. (1994). Psychotherapy awry. American Scholar, 63, 17-30.

National Association of Social Workers. (1989). NASW standards for the practice of clinical social work. Washington, DC: Author.

National Association of Social Workers. (1991). NASW guidelines on the private practice of clinical social work. Washington, DC: Author.

National Association of Social Workers. (1994a). NASW code of ethics. Washington, DC: Author.

National Association of Social Workers. (1994b, August). Recovered memories. Need for action (Report to the NASW National Council on the Practice of Clinical Social Work). Washington, DC: Author.

Peterson, M. R. (1992). At personal risk. Boundary violations in professional-client relationships. New York: W. W. Norton.