Conference on Traumatic Memories in Stockholm, September 27-28, 2014

 

Conference on Traumatic Memories in Stockholm, September 27-28, 2014

Written by Hans Peter Söndergaard, MD

Chief psychiatrist, Kris- och Traumacentrum and Associate professor, Karolinska Institutet

From ESTD Newsletter Volume 4 Number 1, March 2015 > read the original article in our newsletter

The title of the conference was “Recovered traumatic memories: Lost and found facts or false inductions?”

Kris- och traumacentrum (Trauma and crisis centre) has for many years arranged conferences each Fall, focusing on important issues in psychotraumatology.  Many outstanding people in the field have made valuable contributions in their particular area(s) of competence.

This year, the theme of the conference was inspired by a specific case that has become a national scandal in Sweden, concerning a person known as Thomas Quick.  He was sentenced to forensic psychiatric care in the early nineties after what, in retrospect, seemed to have been relatively trivial crimes.  As a young person he was sentenced for a sexual crime, and later for a robbery committed under the influence of drugs.  For many years he had been treated with benzodiazepines and had apparently become addicted.

During his stay at the forensic hospital, he became interested in psychotherapy, following the implementation of a new treatment program.  A psychotherapist, Barbro Sandin, had successfully treated a patient diagnosed as schizophrenic during the eighties at the hospital, which led to a book about the case, as well as a doctoral dissertation at the university of Oslo, Norway.  

As far as can be understood, this case inspired the forensic psychiatrists to introduce psychotherapy as a routine treatment for forensic patients at the clinic, where they had formerly received minimal treatment.

According to a book about the case a psychologist, Margit Norell, became a supervisor at the hospital, she was a psychoanalyst.  In reality she was asked to leave the Swedish psychoanalytic society before she was certified, and founded her own society, the society for holistic psychoanalysis, from which she was expelled five years later.  Then she continued on her own. At the time, she was welcomed to the forensic hospital with her radical idea that most people who have committed severe crimes must necessarily have been exposed to early traumatic events that they repeat in their acts.      

Not unexpectedly, after entering psychotherapy, Thomas Quick started to remember horrible early childhood abuse.  After some years, he also started to wonder if he had murdered a young boy, a murder case that had caused a lot of concern because the boy's parents were convinced that they knew who the culprit was, but their information had been disregarded.

At the time, Thomas Quick's recovered memories were welcomed, and prosecutors, defence lawyers, police investigators, and memory experts started to report advances in the case.  At the end of the process, he was sentenced for eight murders, and had confessed to a total of eighteen altogether!

It is not documented, but it can be suspected that his confessions were assisted by anxiolytic drugs given to him after his confessions, helping him to remember the “right” memories.  He stopped remembering imaginary crimes after going through drug detoxification and withdrew all the confessions.

Hannes Råstam, a reporter on the case, was able to demonstrate that Thomas had access to information about the crimes that he shouldn't have had and was asked leading questions during interrogation. First and foremost, he was probably not even near the alleged crime scenes. Hannes Råstam died of cancer in 2012 before his book was finished, and it was completed by a few of his colleagues.  The book is highly recommended to anyone who would like to understand how such a scandal is possible and the problems it poses for forensic psychiatry and the legal system. Thomas Quick has since been cleared of all eight murders but he is still in forensic psychiatric care.  

One of the persons who helped finish the book is the reporter Dan Josefsson, who published another book about the case, “The man who stopped lying”.  He has analysed the case as an example of the creation of false memories, facilitated by a cult-like atmosphere, with messianic hopes, at the forensic hospital.

“The man who stopped lying” was granted a prestigious literary award in 2013, and this moved the focus away from Råstam’s book.  In early 2014, Dan Josefsson was invited to speak at the ”Stockholm Psychiatry Lectures”.  Other presenters at the conference included: a local psychology professor who has focused on the risk of side effects in psychotherapy; Richard McNally, from Harvard talked about his study of “alien abduction” about people who had as strong psychophysiological reactions as PTSD subjects when they talked about their experiences with aliens; and a child psychiatrist who delivered the message that it can be risky to believe everything that patients report.

There was not much time for discussion, and in so far as the people present did understand what the fuss was about, the takeaway message seemed to be: avoid talking to patients about their traumatic experiences.

As a consequence, we decided that our Fall conference would take a closer look at the issues from a more clinical as well as a scientific perspective.  For instance, what are the possible explanations of memories being present or inaccessible during psychotherapy?  What do traumatic memories that are corroborated by independent proof look like as they arise during psychotherapy treatment of PTSD?  What does memory research in forensic psychology tell us about the fallibility of human memory?

The first presenter was Ellert Nijenhuis, who talked about structural dissociation and its consequences for memory functions.  The main goals of his and his colleagues’ research included studying whether 1) trained actors can mimic crucial features of dissociative parts of the personality?, 2) individuals with dissociative disorders are “fantasy-prone”?, and 3) different types of dissociative parts of individuals with a complex dissociative disorder have  unique patterns of subjective, psychophysiological and neural activation.  His findings are that neither high fantasy-prone, mentally healthy individuals nor actors who were instructed and motivated to simulate different prototypical dissociative parts of the personality were able to do this in psychophysiological and neural respects.  

Ellert also mentioned studies showing abnormal, and in many cases smaller, brain structures in traumatized individuals, including individuals with dissociative disorders.  For example, hippocampal volume is negatively associated with the degree of traumatization and with the complexity of the dissociative disorder.  Other studies suggest that hippocampal volume of traumatized and dissociative individuals may increase with effective treatment.  The importance of these findings is that the hippocampal formation contributes to the ability to integrate the spatiotemporal context of traumatic experiences.   This enables the individual to turn their traumatic memories—i.e., bodily, emotional, and behavioural re-enactments of traumatic experiences—into symbols, into narratives, that is, into autobiographical semantic memories.

Ellert  Nijenhuis also presented his model according to which memories of trauma must necessarily be interpreted with regard to the first, second, or third person perspective.  The first person perspective pertains to the raw subjective experience, the second involves the interpersonal experience, and the third person perspective denotes “facts”.   Whereas the first and second person perspectives concern phenomenal (subjective) experiences and phenomenal judgments of these experiences, the third person perspective involves physical judgments, that is, judgments of physical facts.  This latter perspective does not allow a judgment of “what it is like” to have an experience.

In summary, Ellert Nijenhuis’ main point was that a great deal of the confusion surrounding “false memories” can be explained by the fact that dissociative disorders are under-recognised and poorly understood in general psychiatry.  He also pointed out that there are occasional examples of inadequate assessment and therapy, but these should not be confused with state-of-the-art treatment of traumatized individuals.  Adequate treatment includes reflective evaluation of the veracity of continuous and delayed traumatic memories.

Chris Brewin focused on memories of trauma in PTSD or complex PTSD, and the diversity of memory mechanisms.  He pointed out that most of the research on the creation of false memories builds on the Deese-Roedinger-McDermott paradigm, in which subjects, mostly healthy college students, are read a word series and subsequently report how many words they remember and then are suggested words that are plausible, but not actually present in the series. These are then summed up as correct memory and false recall.

He covered the different memory mechanisms, and then proceeded to address specific memories of trauma, mechanisms of forgetting, and remembering in different modalities, with reference to the brain systems involved.

The next part of the talk mentioned how traumatic memories can be forgotten and retrieved, and how this would present in therapy.  The neurobiological and psychological research behind this part of the presentation concluded that memories of trauma are simultaneously stored as verbally accessible memories (VAM) in the brain, roughly semantic memory; and as situationally accessible memories (SAM) of a more visual character.  Traumatic memories are more often accessible after situational cues or reminders, or as flashbulb memories.  Studies of VAM and SAM memories have shown that they can be interfered with by specific tasks, such as verbal memory tasks or tapping tasks (visuospatial), respectively.     

Brewin’s research is a highly recommended read.  It is beyond the scope of this text and impossible to condense into a few words.  From the point of view of this text, the take-home message is that traumatic memories are very complicated, and that there is no easy way to discern traumatic memories from false memories that might be induced by suggestion.  However true this is, most research that has actually focused on traumatic memories in PTSD clients contradicts the claim that false memories are prevalent; more often, fragmented memories or flashbulb memories are signs of actual traumatic memories.  First and foremost, in the absence of manipulation, memories of trauma are remarkably stable over time.  What might differ a great deal, however, is whether they can be readily accessed or not, is dependent on factors such as identity fragmentation. 

This part of the presentation was an important contribution in summing up how much knowledge there actually is about subjects forgetting well-documented childhood traumas and how traumatic memories can reappear.  It is impossible to summarize the research studies he presented in a few words, but it was impressive and is worth following up. .

On day two of the conference, Elizabeth Loftus presented her research on forensic psychology/witness psychology.  As mentioned, there are many studies that are similar to the DRM paradigm, but also of how it is possible to “implant false memories” with additional suggestive techniques.  These studies range from how you can make people believe something that is plausible, for instance to “remember” that you got lost as a small child in a shopping mall, or that you got sick from eating something, with subjects subsequently changing their eating patterns.  Elizabeth Loftus explained that realistic studies that could show that memories of trauma could become implanted would never be accepted by an institutional review board, a common problem in psychotraumatology.

She then expressed her main concern.  She showed material concerning subjects who had been sentenced for rape and who were later proven innocent after a reassessment of the evidence, after DNA proof had become accessible and another perpetrator was convicted.  Thus the proof based on earlier witness testimony, in front of a jury, was turned around completely.  She also cited examples showing that legislation and changes in practice can have grotesque consequences.

The afternoon session on day two started with a discussion among the presenters that summed up the clinical and legal consequences of what had been discussed so far. The discussion was fair and correct.

A series of short video excerpts were then presented, showing two clients undergoing a treatment where eye movements were used to focus on bodily sensations/medically unexplained symptoms.  Due to the extraordinary reactions that might or might not be seen as recovered or, on the contrary, false memories, each case was recorded on video in order to make it accessible to experts and had English subtitles

The first case that was presented concerned a woman who had been incarcerated as a young adult in a Latin American country, where at the time thousands of people who were opposed to the regime were tortured or “disappeared”, a euphemism for political murder.  During her time in prison, she gave birth to her first child in dire circumstances.  She and the child survived, and she was functioning well, when suddenly she developed a painful paralysis of her right arm after a flashback experience that was triggered by seeing several policemen approaching.  Her memories of the time in prison were more or less continuous, with a lot of independent corroboration.  However, there was amnesia for certain episodes.  During the therapy that consisted of five treatment sessions, very traumatic torture experiences became accessible and were processed, with no residual symptoms.

The second example was a patient who had been in therapy previously with the same therapist (LRR).  The initial therapy focused on refugee trauma and how to function in the here and now, as a parent and as a professional, in spite of PTSD.  The therapy had been successful, but the patient returned 10 years later because of psychosomatic problems.  Now, the therapist focused on the somatic experience and for a number of sessions, she suddenly, and to the great confusion of her therapist and herself, remembered several very upsetting early memories of sexual abuse by the father, and even emotional and physical abuse at the hands of her mother.

The material was very upsetting and emotional. However, both clients were functioning well after therapy and still are.

In the discussion, Chris Brewin emphasised first that the material was upsetting, but that there was nothing about the way the memories manifested themselves that was different from subjects processing traumatic memories of a continuous nature, e.g. the knowledge about the trauma had been there all the time.

Ellert Nijenhuis commented on the excerpts from the point of view of dissociation and possible suggestions from the therapist.  It was obvious that even if some of the questions that the therapist posed might have been suggestive, the patient did not respond to the potential suggestions but continued to experience flashbulb memories.

Elizabeth Loftus remarked firstly that she did not know what to say, and later that she now realized what therapists' encounters with recovered memories might be like.  Then, “I wonder what you (the audience) would say if she became a retractor?”

At this point, the audience was invited to comment. Dan Josefsson, the author of the book about Thomas Quick, remarked that the videos were very convincing, but equally so were Thomas Quick’s memories as they appeared during therapy.  Loftus and Brewin both expressed their interest in reviewing the material, but Josefsson had to explain that there were no videos, only written records.

At the end of the conference, one would have liked to have a recipe for differentiating false and true memories of trauma.  This was not achieved, but what we witnessed was a meeting where proponents of very differing theories from differing clinical and research backgrounds came together and generously shared their knowledge and engaged in an earnest discussion, using concrete clinical examples.