Disturbed patient, disturbing therapy by St. Cloud psychologist | StarTribune.com

Somebody on Twitter alerted me to this story. Briefly, a therapist got over-involved with two of her clients and was disciplined for it. The problem, at least as it is framed by the local newspaper, is that she has poor boundaries and poorer reality testing: As they so cutely put it, she believed the client's delusions more than the client did.

The line between a memory and a delusion is a fine one, especially in Dissociative Identity Disorder (DID). DID occurs in people who have suffered especially severe and often bizarre, but quite real, abuses while at the same time there is an unreal quality to the disorder itself. Real memories, in other words, quite commonly exist side-by-side with unrealistic beliefs in DID.

Therapists are not, and cannot be, in the business of validating clients' memories. However, when a client questions her/his own memories, we can encourage reality-testing by the client. In doing so we must not forget that perpetrators of abuse quite naturally go to great lengths to hide what they are doing, so that validating a specific memory may simply not be possible. We also need to caution clients against attempts to validate that may be dangerous, such as directly confronting perpetrators.

Sometimes the only validation available is indirect: We are working on a dysfunctional behavior in therapy, a memory surfaces, and the behavior “spontaneously” clears up. Other examples of indirect validation that come to mind include addicted and sexually-acting-out siblings (possible co-victims) and an arrest of a relative for a related crime. None of these things proves the validity of a specific memory, but it does lend credence to the client’s family portrait.

It is a myth, by the way, that a person has to remember in order to heal. Or that survivors have to remember more: To quote the late Ann D. McAllister, Ph.D., "What [they] already remember is more than enough." Digging for additional memories runs the risk of (a) producing "memories" that aren't, and (b) completely unraveling the client's ability to function in the present.

Since disbelieving real abuse can be as harmful as becoming part of a delusional system, the therapist serves the client best by focusing on current functioning. The focus of treatment becomes teaching the client to manage flashbacks, switching between alters, emotions, appropriate boundaries, insomnia, self-harm, addictions, self-image, etc. And the key phrase here is “teaching the client to manage,” not managing it for the client. Treatment for DID is emotionally intense, and it’s not going to happen without a degree of dependency developing. But throughout the therapy, the therapist maintains the boundaries of the working relationship and encourages the client’s independence.

Blackout

Just finished reading John Lescroart's Betrayal (at 1 a.m. this morning, but compulsive reading is another subject for another day). In it, a defendant has no memory for the time of the crime. The defense attorney's handling of this problem is a bit muddled.

He hopes to get in Posttraumatic Stress Syndrome (PTSD) as the explanation for the gap in memory. In a preliminary hearing, a psychiatrist with expertise in PTSD testifies that flashback-related blackouts last only a few minutes (pp. 211-217). My quibble with this is that these experiences are not technically "blackouts" at all, but dissociative episodes. The person is fully conscious, but not really present because they are re-experiencing events from another time and another place. Most likely, they will remember the content of the flashback, but not necessarily what they said or did, or what other people said or did, while they were having it. It is in that sense that it is a blackout, in that the information they forgot was never recorded in the first place, and this is why it cannot be recalled.

During the trial, the evidence proffered is that an old head injury is the cause (pp. 274-279). Unfortunately for the defense, a neurologist testifies that brain injuries do not account for extended periods of unconsciousness (after the initial trauma, that is) and the defendant has four days to account for. Not to mention that his blood alcohol at the time of his arrest shows clearly that he'd been wide awake and drinking like a fish for goodly portions of the days in question. Here the problem is that, once again, "blackout" as a term is being used by the attorney to mean one thing, and by the expert to mean another.

The defense attorney recognizes this little problem in mid-testimony and gives up on this witness, when another question or two would have established that "blackout" is not synonymous with "unconsciousness." Indeed, testimony from a VA staffer is available to show that, while still in the hospital, the defendant had experienced an episode during which he was fully awake but thought he was still in Iraq: He remembered nothing of this afterward (pp. 226-228).

And then I must have had some kind of blackout, because I started this blog entry over two months ago and never published it. I found it when I decided to write a little scribble on memory in general, and was checking to see if I'd done that already!

I have no idea any more how I intended to finish it, so here it is, as is. Scary.