Book Review: Recollections of Sexual Abuse, Treatment Principles and Guidelines

Courtois sets out to review the history, research and guidelines for the treatment of cases where memory may be an issue. She is careful to express a "middle ground" approach that neither denies nor confirms the existence of recovered or false memory. The book is ambitious in its format, covering a wealth of material relevant to its subject matter. Clearly written, it links history and research to practice; however, I feel it skims through the historical roots of recovered/false memory and left me wanting a deeper, more considered exploration. Given the extensive nature of the project it is understandable that this is beyond the scope of the book. It is accessibly written, but often from the bias of protecting the practitioner, there is a strong sense in the book that therapists working with recovered/false memories have to protect themselves from prosecution. This stance may be particularly pertinent to an American audience, although it does have some relevance here.

The book follows a sensible structure, is clearly aligned to a psychodynamic model, but stresses the need for cautious, conservative therapeutic approaches with any individual who may suggest that they are recovering memories. Aimed at practitioners who may work with recovered memories, the book deals thoroughly and sensitively with issues surrounding childhood abuse and trauma. It also provides a good introduction to the nature of memory and associated research, stressing that memory is a verb and not a noun. It is dynamic, a non-static entity that reconstructs past events, it does not reproduce them. Guidelines are presented for the diagnosis and treatment of childhood trauma, of recovered/false memories in the light of childhood trauma and post traumatic stress disorder. Similarities and differences between these conditions are outlined and the therapeutic ramifications are explored. The book also covers boundary issues and, as an appendix, offers a detailed example of an information sheet and consent form. This is useful and may benefit trainee therapists learning about the nature of boundaries and contracts as well as revising the issues for experienced therapists.

From an existential point of view the book there are many assumptions made by the book that can be questioned. First, it is written from a psychodynamic orientation, so spends much time and effort considering the accurate diagnosis of childhood abuse and trauma. The importance of diagnosis is considered, again in the light of protecting the therapist in the event of litigation. It never questions the validity of diagnosis as a concept, perhaps this is to be expected in a book which assumes that concepts such as these can be taken as read. It is written very much from the stance of protecting the therapist, hence the emphasis on appropriate diagnoses using DSM IV. Wrongful diagnosis can be used against the therapist if a suit of malpractice/incompetence is brought possibly by the client or by members of the client's family. The whole debate regarding false/recovered memories is highly emotionally charged, and legal proceedings seem to be frequently brought. There are perhaps some grounds for concern inasmuch as the client's needs can be lost in the therapist's desire to protect him/her self; this issue is not discussed.

The terms 'transference' and 'counter-transference' are also employed, but not carefully defined. The reader is left to assume their meaning which can be problematic. They seem to be used in a general sense, particularly counter-transference. No reference is made to the unconscious processes that may be involved and the term could easily be considered to simply refer to the therapist's experience of the client. This subject is given extensive treatment, exploring several possible reactions to difficult scenarios. In each case it is stressed that the therapist must not over- or under- identify with the client, although easily said it is harder to achieve. The complexity of the therapeutic relationship is not addressed other than to stress not over-identifying with a client particularly if the therapist has been through a similar experience. Again caution appears to be the watchword. Courtois stresses that care must be taken not to over or underplay the recovery of memory, the outcome of therapy is not archaeology. Room is also given to the possibility of clients producing false memories. Courtois suggests in all circumstances the client's perceived reality has to be respected even if the narrative of the client is improbable. A skilled clinician should accept the perceived reality of the client while challenging its purpose for the client. This has existential overtones. Indeed although the book adheres to a psychodynamic model, utilising much of the language associated with psychodynamic therapy, there is a sense that it is applicable to many models of therapy.

The lessons to be learnt for existential therapists lie very much around recognising that clients return to a real world and have their own perception of events past and present, which may conflict with the therapist's sedimentations. Although written in a style that is linguistically difficult for existentialism, Courtois frequently refers to the relationship between the therapist and the client and highlights the problems that can be encountered. She attempts to draw a flow chart suggesting therapeutic strategy, which course of action should be taken at which stage and what the therapist is advised to do at various stages of therapy. Several stages of the flow chart refer to the therapist working within their own genre and is, therefore, applicable to an existential therapist.

Existentially speaking one may be wary of diagnosis, treatment strategy and/or technique. Courtois doesn't address concerns regarding these issues other than to suggest that they are utilised with caution in case litigation is brought against the therapist. In a sense the book is grounded in the real world and attempts to address issues that may adversely effect therapy such as the potential for being sued. One existential criticism is the prescriptive nature of the book, although its intention was to produce a set of working guidelines. The prescriptions are tempered with the need to consider the perspective of the client, and are sufficiently broad to be considered as good advice, rather than a step by step guide to therapy. No conclusion to the recovered memory/false memory debated is offered, but a balanced approach to a difficult area is described.

Claire John