Psychotherapy and the Recovery of Memories of Childhood Sexual Abuse: U.S. and British Practitioners' Opinions, Practices, and Experiences

Transcription

1 Journal of Consulting and Clinical Psychology 1, Vol. 6, No., 46-4 Copyright 1 by the American Psychological Association, Inc. -6X//S. Psychotherapy and the Recovery of Memories of Childhood Sexual Abuse: U.S. and British Practitioners' Opinions, Practices, and Experiences Debra A. Poole Central Michigan University Amina Memon University of Southampton D. Stephen Lindsay University of Victoria Ray Bull University of Portsmouth Licensed U.S. doctoral-level psychotherapists randomly sampled from the National Register of Health Service Providers in Psychology (Surveys 1 and,n= 14; Council for the National Register of Health Service Providers in Psychology, 1) and British psychologists sampled from the Register of Chartered Clinical Psychologists (Survey, n = ; British Psychological Society, 1) were surveyed regarding clients' memories of childhood sexual abuse (CSA). The samples were highly similar on the vast majority of measures. Respondents listed a wide variety of behavioral symptoms as potential indicators of CSA, and 1% indicated that they had used various techniques (e.g., hypnosis, interpretation of dreams) to help clients recover suspected memories of CSA. Across samples, % of the respondents reported a constellation of beliefs and practices suggestive of a focus on memory recovery, and these psychologists reported relatively high rates of memory recovery in their clients. There has been considerable controversy in the past years regarding psychotherapies that emphasize the importance of recovering memories of childhood sexual abuse (CSA). This issue has received extensive (and generally highly polarized) coverage in the media and has inspired the formation of advocacy groups for accused parents (e.g., the False Memory Syndrome Foundation) and for adult children who have retracted allegations against their parents (e.g., Retractions). Professionals have responded by organizing a number of national and international meetings, the American Psychiatric Association (1) and the American Medical Association (14) have released public statements on this issue, and both the British Psychological Society and the American Psychological Association have impaneled groups of experts to produce policy statements. This may well prove to be the most publicly debated and emotionally heated controversy in clinical psychology in the 1s. A number of clinical psychologists (e.g., Claridge, 1; Courtois, 188;Frederickson, 1; Olio, 1 8) and other writ- Debra A. Poole, Department of Psychology, Central Michigan University; D. Stephen Lindsay, Department of Psychology, University of Victoria, Victoria, British Columbia, Canada; Amina Memon, Department of Psychology, University of Southampton, Southampton, England; Ray Bull, Department of Psychology, University of Portsmouth, Portsmouth, England. This work was supported by a Natural Sciences and Engineering Research Council of Canada research grant. We thank Deborah Connolly for comments on an earlier version of the article. Correspondence concerning this article should be addressed to Debra A. Poole, Department of Psychology, Central Michigan University, Mount Pleasant, Michigan ers (e.g., Bass & Davis, 188) have argued, in various ways, that (a) complete amnesia for CSA is fairly common, (b) a wide variety of psychological problems in adulthood are indicators of CSA even in the absence of direct reports of such a history, (c) in such cases recovering memories of CSA is an important part of healing, and (d) various therapeutic techniques and ancillary practices can and should be used to help clients recover suspected memories of CSA. Despite differences across these writers, they share a common emphasis on the importance of helping clients remember suspected CSA, and hence advocate various forms of "memory work" in psychotherapy. Critics of memory work in psychotherapy charge that some therapists use memory recovery techniques in ways that are risky. They claim that some therapists suggest to clients who do not report a history of CSA that their symptoms indicate that they were abused, that survivors often do not remember the abuse, and that healing relies on recovering such memories. According to critics, these therapists use a variety of memory recovery techniques and ancillary practices to help clients remember CSA (e.g., hypnosis, guided imagery, "bibliotherapy" with popular books, "journaling" exercises, interpretation of "body memories" and dreams as evidence of CSA, prescription of workshop and support group exercises, etc.). Although these techniques are intended to help abuse survivors, a growing number of psychologists and sociologists believe that they can also lead nonabused clients to create illusory memories or false beliefs of CSA (see Lindsay & Read, 14;Loftus, 1). Practitioners whose work emphasizes the importance of recovering memories of childhood trauma have countered these claims on several grounds. Some have discounted the criticisms as "backlash" against our culture's recent increase in awareness

2 PSYCHOTHERAPY AND MEMORY RECOVERY 4 of and concern about the sexual abuse of women and children (e.g., Enns, McNeilly, Corkery, & Gilbert, 1; Olio, 14). There is no scientific response that critics of memory work could make to this allegation; they can only protest that, although sexist backlash may contribute to criticisms of the use of memory recovery techniques in therapy, it is not their sole basis. A second ground for rejecting criticisms of memory work in psychotherapy is the claim that memory work could not lead clients to create false beliefs or memories of a history of CSA. For example, in an editorial article in The Networker (a journal for practitioners), Wylie (1) argued that "the unendurable and impossible-to-fake agony of the clients is the most powerful evidence for the truth of their experiences" (p. 6). The claim that memory recovery techniques cannot give rise to illusory memories of CSA in nonabused clients hinges on the rejection of many empirical studies demonstrating that memory is fallible and that people are susceptible to suggestions, on the grounds that those studies cannot be generalized to the case of memories of traumatic life experiences (e.g., Berliner & Williams, 14; Olio, 14; Pezdek, 14). For example, Spanos (14) reported that hypnotic suggestions led some clients to report memories of past lives and that mild prehypnotic suggestions about the nature of past lives affected what clients "remembered" under hypnosis (e.g., telling clients that in earlier times many children were abused increased the likelihood that under hypnosis they reported memories of a past self who was abused). Defenders of memory work in psychotherapy have argued that, because of the differences between research studies and therapy situations, such findings cannot be generalized to memories of CSA recovered in therapy. There are no direct tests of the hypothesis that memory recovery techniques also give rise to illusory memories of CSA, because ethical concerns bar such studies. Thus there is room for debate about the extent to which data on memories of other kinds can be generalized to therapy situations and memories of CSA. Recently, however, even defenders of memory work have acknowledged that highly suggestive approaches to memory recovery may lead some clients to create false beliefs or illusory memories of CSA (e.g., Berliner & Williams, 14; Pezdek, 14). A third argument used to dismiss criticisms of memory work in psychotherapy is that few therapists use the kinds of memory recovery techniques and ancillary practices about which concerns have been raised (e.g., Berliner & Williams, 14; Freyd, 1; Olio, 14; Pezdek, 14). We evaluated this claim by conducting two national random surveys in which doctorallevel psychotherapists in the United States (Surveys 1 and ) and chartered clinical psychologists in Great Britain (Survey ) were asked about their opinions, practices, and experiences regarding memories of CSA in their adult female clients. We sampled highly trained clinicians because it has been argued that few of these practitioners focus their therapies on memory recovery (e.g., Pezdek, 14). The questionnaires asked about adult female clients because this group has been the primary focus of popular and professional books and articles on memory recovery. In addition to simple descriptive information about such issues as how often clinicians reported identifying clients as suffering from hidden memories and how many reported using particular memory recovery techniques, we also report analyses of relationships between various measures (e.g., between the use of memory recovery techniques and the clinician's sex and theoretical orientation). Procedure Method For Survey 1, psychotherapists were selected from the National Register of Health Service Providers in Psychology (NRHSPP; Council for the National Register of Health Service Providers in Psychology, 1) by entering the volume haphazardly and selecting approximately every 4th name, with the constraint that all clinicians in the sample reside in the United States and list a doctoral degree. Criteria for admission to the NRHSPP include current state licensing at the independent practice level, and the vast majority of the over 16, members have advanced degrees in clinical psychology. Questionnaires were mailed in July 1, followed by a reminder notice and a second copy of the questionnaire in August. For Survey, a slightly revised questionnaire was mailed in December 1 to another U.S. doctoral-level members of the NRHSPP and to chartered clinical psychologists selected from the 6, listed in the Register of Chartered Clinical Psychologists (RCCP; British Psychological Society, 1).' Unlike the first survey, no reminder followed this initial mailing. The Questionnaire Each clinician received a cover letter and a questionnaire. The first page of the questionnaire asked for demographic and professional characteristics. The remaining pages contained instructions and questions about respondents' experiences with adult female clients, their therapeutic practices, and their opinions regarding memories of CSA. The instructions indicated that, for purposes of the questionnaire, childhood sexual abuse was defined as physical sexual contact perpetrated against someone 16 years of age or younger by a person 6 or more years older than the victim. Most questions asked about adult female clients who had been patients during the past years. Respondents were invited to provide written comments elaborating on or clarifying their responses in a space provided after each question. Questionnaires for the two surveys were similar, but the second was shorter and some questions were clarified. Throughout this article, we report the wording of the second questionnaire whenever responses did not reliably differ across samples. Results We report the results of univariate tests (one-way analyses of variance [ANOVAs] or chi-square tests, as appropriate) of differences between the three samples for questions used in both surveys. Means are presented in the following order: U.S. Survey 1, U.S. Survey, and Great Britain Survey, followed by a grand mean (GM) when differences were nonsignificant. To minimize the likelihood of a Type II error in tests of differences between samples, we did not adjust the alpha level of. for the 1 A chartered clinical psychologist holds the following qualifications: (a) a first degree in a psychology program recognized and approved by the British Psychological Society (BPS), (b) a qualification (master's degree or BPS diploma) from a clinical training program approved by the BPS, and (c) years of supervised practice. Therapists in our British sample with a doctorate (% of respondents) would have entered the master's or BPS program with a research PhD or would have obtained one after qualifying. Copies of the questionnaires are available from Debra A. Poole.

3 48 POOLE, LINDSAY, MEMON, AND BULL large number of tests. Despite this liberal criterion, there were very few significant differences between the samples. Characteristics of the Respondents Total return rates for delivered questionnaires in U.S. Survey 1, U.S. Survey, and Great Britain Survey, across the three samples were 4%, %, and 8%, respectively. These are similar to return rates for other mail surveys of therapists (e.g., Goodman, Qin, Bottoms, & Shaver, 1; Poole & Tapley, 188). Across samples, approximately 8% of the respondents indicated that they were outside of our target population because they had worked with no or few adult female clients in the past years (either because of retirement or nature of position) or they worked in highly specialized areas outside of the domain of interest (e.g., neuropsychology, mental retardation). Analyses were tabulated only for respondents who completed the questionnaire and reported conducting psychotherapy sessions with 1 or more adult female clients in the past years; 14 members ofnrhspp(86 in Survey 1 and in Survey ) and members of RCCP. After our presentation of responses to the questionnaire, we present additional data that address the representativeness of these respondents as a sample ofnrhspp and RCCP members who regularly perform psychotherapy with adult female clients. The U.S. and British respondents differed in several ways. The U.S. respondents were significantly older (Ms = 4., 1., 4. years for U.S. Survey 1, U.S. Survey, and British Survey, respectively) F(, 1) =., p <.1, with a lower percentage of female clients (1%, %, and 61 %, respectively), X () = 1., p <.1. Respondents from the two countries also differed somewhat in theoretical orientation. The percentages of respondents who rated various approaches among their top two were, for the U.S. and Great Britain respectively, behavioral (4% vs. 4%), cognitive (4% vs. 8%), psychoanalytic (% vs. %), gestalt (% vs. %), existential-humanistic (1% vs. %), client-centered (6% vs. 1%), social-learning (6% vs. %), systems oriented (14% vs. 1%), interpersonal relationship (18% vs. %), reality (1% vs. %), and feminist (% vs. %). Compared with the British sample, the two U.S. samples were reliably less likely to rate behavioral among their top two theoretical approaches, x ( 1) = 4.4, p <., but more likely to rate interpersonal relationship among their top two, X ( 1) = 4.6, p <.. The three groups reported seeing a comparable number of adult female clients in the past years (Ms = 84., 84.1, 1., respectively;p =.; GM = 8.1, SD = 8.11). Individual Question Analyses Perceptions of the role of childhood sexual abuse in the presenting problems of adult female clients. The clinicians were instructed to "list the five problems-concerns that your adult female clients reported most frequently." The presenting complaints mentioned by % or more of the respondents in any of the three samples appear in Table 1. By far the most common presenting complaints in all three samples were marital-relationship problems (81%), depression-mood disorder (81%), anxiety (6%), and poor self-esteem (%). Table 1 Percentage of Respondents Listing Various Problems Among the Five Most Frequent Presenting Complaints Encountered in Their Adult Female Clients During the Past Years Problem or concern US-1 US- GB Relationship/intimacy/marital partner Depression/mood disorder Anxiety Self-esteem/identity/autonomy Sexual abuse Parenting Eating disorders Career/vocational Sexuality Abuse/psychological abuse Pain/adjustment to physical problem Addiction/drugs Phobias/panic Anger control/explosiveness Psychotic episodes/hallucinations Grief/separation/loss Personal growth/performance/role conflicts Personality integration/disorder Adjustment disorder Self-abuse Stress Family discord" Family of origin Obsessive-compulsive Psychosomatic/somatoform Posttraumatic stress disorder Behavioral disturbance/acting out Early life trauma/trauma Offending/sex offending , 4 1 Note. Problems are listed in order of decreasing frequency for the three samples combined. US-1 = U.S. Survey 1; US- = U.S. Survey ; GB = Great Britain Survey. " Listed separately by respondents who also listed relationship or intimacy problems. The respondents estimated the percentage of their clients who had reported each of several types of CSA. Table lists the weighted mean percentage for each type of abuse (calculated by multiplying each clinician's frequency estimate by the reported number of clients treated). The three samples indicated similar rates of various types of abuse among their clients. (Only two types of CSA, "genital touch" and "stimulate abuser manually," yielded significant differences for the unweighted means, ps <., but even for these the weighted means were comparable.) These prevalence estimates are not as high as one might have suspected, in that many of them do not differ markedly from those obtained in retrospective self-report surveys of the general population. For example, the clinicians indicated, on average, that 1.6% of their women clients reported penile penetration before age 16 years. Wyatt's (18) study of 48 Los Angeles women found that 1% reported sexual intercourse before age 18 years, and Finkelhor, Hotaling, Lewis, and Smith (1) reported that 1% of the 1,481 women in their sample reported intercourse by age 18 years. However, for some types of abuse, respondents' prevalence estimates were greater than those reported in surveys of the general population. For example, the

4 PSYCHOTHERAPY AND MEMORY RECOVERY 4 Table Respondents' Estimates of the Percentage of Female Clients Who Report Sexual Abuse Type of abuse US-1 US- GB Noncontact psychological abuse Witnessing exposure/masturbation by abuser Forced to expose themselves to abuser Nongenital sexual touching by abuser Genital touching by abuser Asked to stimulate abuser manually Genital sex without penetration (between legs, etc.) Forced fellatio Vaginal/anal penetration by penis Vaginal/anal penetration with objects Forced to witness killing/mutilation of animals Forced to witness killing/mutilation of people Note. Percentages are weighted means, calculated by multiplying each clinician's estimated percentage by the number of clients seen in the past years. Blank cells indicate questions asked in Survey 1 that were not included in Survey. US-1 = U.S. Survey 1; US- = U.S. Survey ; GB = Great Britain Survey. mean estimate of the percentage of clients reporting forced fellatio (.4%) was higher than in prevalence studies (e.g., Finkelhor et al., 1, found that.1% of the women in their sample reported childhood oral sex or sodomy). The majority of respondents indicated that they encountered relatively few reports of CSA from their adult female clients. For example, % of them said that no adult female client in the past years had reported having experienced penile penetration as a child, and 6% said such reports had been made by 1% or fewer of their clients. Some respondents, in contrast, indicated very high rates of reported CSA (e.g., 1% said that % or more of their adult female clients had reported childhood penile penetration, and 1% said that half or more had made such reports). Because there is currently heated debate about the validity of claims of ritualistic (e.g., satanic) abuse (e.g., Rogers, 1), two questions asked about the percentage of clients who had reported kinds of abuse associated with satanic cults (e.g., forced to witness killing or mutilation of animals and forced to witness killing or mutilation of people). Most of the clinicians (%) indicated that no client had reported such abuse in the past years. Nineteen percent of the clinicians reported that between.% and % of their clients had reported such events, % of the clinicians reported that 1% of their clients had reported such abuse, and one therapist reported that % of his 6 clients had reported childhood events involving the killing or mutilation of both animals and people. In response to the question, "How many cases of ritualistic-satanic abuse have you treated during all of your years of practice?" the three samples reported comparable, and low, numbers of cases (Ms =.1, 1.6, and. for U.S. Survey 1, U.S. Survey, and British Survey, respectively; p =.1, GM = 1., SD =.6). Over half (8%) indicated that they had no experience with reports of this type of abuse, and most of the remainder indicated that they had encountered only one or two such cases during their careers. Some clinicians did report multiple cases, however, with the number of clients reporting satanic ritualistic abuse ranging as high as 6. The top % of clinicians (ranked by number of satanic abuse cases encountered) accounted for 8% of the cases reported by all clinicians. This is consistent with Goodman et al.'s (1) finding that a very small percentage of therapists account for most reports of satanic ritual abuse. In response to the question, "Which of the following best describes your opinion about the existence of ritualistic-satanic abuse?" the clinicians gave comparable responses across samples, p =.1. They generally indicated that they believe that ritualistic abuse does exist but do not accept all reports as true: Only 8% checked that ritualistic abuse "probably does not occur," 6% checked "a small subset of reports are based on actual cult-satanic experiences," % checked "most reports" (Survey 1) or "half or more" (Survey ) are "based on actual cult-satanic experiences," and % checked "all" (Survey 1) or "virtually all reports are valid" (Survey ). Finally, the respondents in the three samples estimated that comparable percentages of their female clients suffered from sequelae of CSA, with estimates ranging from % to 1% (Ms =.%, 4.1%, and.4% for the three surveys, respectively; p =., GM = 8.1%, SD = 8.8; weighted GM =.8%). The majority of the clinicians indicated that CSA played an important role in the psychological problems of only a minority of their adult female clients. For example, % said that CSA played an important role in 1% or fewer of their clients. However, a substantial minority of the respondents reported that CSA was an important psychopathogenic factor for many of their clients. For example, % said that such abuse was an important etiological factor in at least half of their clients. Our data on respondents' estimates of the percentage of their clients reporting various kinds of CSA, and their opinions concerning the role of CSA in contributing to their clients' problems, do not support the notion that there is a widespread tendency for doctoral-level practitioners to focus their therapies on CSA. A substantial minority of the clinicians, however, did indicate a focus on CSA. These respondents reported rates of CSA far greater than those found in studies of the general population and indicated that CSA played an important role in causing the psychological problems of many or even most of their clients. Clinical judgments concerning hidden memories and the importance of memory recovery. Four questions addressed the

5 4 POOLE, LINDSAY, MEMON, AND BULL willingness of clinicians to identify CSA in clients who do not report abuse histories, as well as their perceptions of the frequency of memory recovery during therapy. Eighty clinicians in Survey 1 responded to the question, "Of the adult female clients whom you suspected were sexually abused as children, what percentage initially denied any memory of childhood sexual abuse?" (The six answers of "not applicable" came from clinicians who had no clients who reported sexual abuse or who did not make judgments of abuse without direct client report.) Of those who gave an estimate, % reported that at least some of the clients they had suspected of having been abused had initially denied memories of such abuse, and responses ranged as high as 1% (M = 6.%, SD =.4%). This question was reworded and moved in Survey, such that it served as a leadin for a question about how often this opinion was formed during the initial session with a client. Comparable percentages of U.S. clinicians in Survey and British clinicians in Survey indicated that they had sometimes "suspected that a client had been abused although the client did not explicitly report any abuse" (% vs. %, p= 1.). The three samples gave similar estimates of the percentage of such cases in which they were "fairly certain about this abuse diagnosis after the initial session with the client" (Ms =.4%, 1.8%, and.% for the three surveys, respectively; p =.8, GM = 1.%, SD =.1), with 1% of those who had formed this judgment indicating that at least half of the time they were certain after the initial session. We also asked the clinicians to "list the indicators that lead you to suspect childhood sexual abuse." The three samples did not differ significantly in the number of indicators of abuse listed (Ms =.1,., and.64, for U.S. Survey 1, U.S. Survey, and British Survey, respectively; p =.14), with the total sample generating 8 different indicators (GM =.16, SD =.4; maximum per clinician = 14). Only 18% listed no indicators. Table lists the percentage of respondents who reported each indicator mentioned by at least % of the clinicians across the two studies (remaining indicators are simply listed). Two aspects of these data are worthy of comment. One is the wide range of complaints that are taken as indicators of CSA by some clinicians. Indeed, comparing Tables 1 and, all but a few of the listed presenting problems were also listed as indicators of CSA by at least some clinicians. Another interesting point is the general lack of agreement across respondents only one indicator (sexual dysfunction) was listed by more than 14% of the clinicians across all samples. The clinicians rated, on a scale ranging from 1 (not very important) to (very important), how important it is "that a client who was sexually abused acknowledges or remembers that abuse in order for therapy to be effective." The three groups gave comparable ratings of the importance of remembering abuse (Ms =.6,., and.86 for the three surveys, respectively; p =., GM =.6, SD = 1.1). Responses ranged from 1 to and, across samples, 6% of the clinicians judged the importance of remembering abuse as being above the midpoint of the scale. Written explanations of these ratings, requested in a follow-up question, were provided by 18 clinicians; of these, 6 (4%) commented on the importance of memory recovery (e.g., "if experience is not consciously integrated, it continues to surface pathologically"). The remaining clinicians who wrote comments indicated that they did not believe remembering abuse is always necessary (e.g., "useful but not always essential, depending on stated initial problem"), with 1(% of the clinicians who commented) expressing criticism of the emphasis on memories (e.g., "obsessive concern about sexual abuse can be untherapeutic"). In a summary of this section, most clinicians indicated that they had at least sometimes formed the opinion that a client who denied a history of CSA had indeed been abused. A substantial minority of the clinicians indicated that they made this assessment quite frequently and that they sometimes did so very quickly. The clinicians produced a large list of potential indicators of CSA, with different clinicians listing different indicators. Finally, although the responses of most clinicians suggest that they do not have a central focus on helping clients recover memories of CSA, the majority indicated that it is important for clients with such histories to remember the abuse. Use of memory recovery techniques. Table 4 lists the percentage of clinicians who reported that they used each of eight techniques that are considered suggestive by many cognitive psychologists (see Lindsay & Read, 14; Loftus, 1). The questionnaire used in Survey 1 stated, "Some therapists use special techniques to help clients remember childhood sexual abuse. Check any technique that you have used with abuse victims in the past two years." Because the respondents reported using these techniques with surprising frequency, the question was revised for Survey to make it completely clear that a technique was to be reported only if it had been used explicitly to help clients recall memories of sexual abuse ("Check ["tick" for the British survey] on the left any technique that you have used in the past two years to help clients remember childhood sexual abuse"). Table 4 also lists the percentage of clinicians who indicated that each of these techniques was inappropriate for use with suspected abuse victims ("On the list above, draw a line through any technique that you believe should not be used to help clients remember sexual abuse"). Comparing the first and second U.S. samples, the wording change did not affect the mean reported number of techniques used (Ms =.6 vs.., p =.1) or disapproved of (Ms =.). However, the U.S. clinicians in Survey 1 were less likely than those in the first to check that they used "instructions to work at remembering," x ( 1) =.46, p <., and more likely to disapprove of "instructions to work at remembering," x ( 1) = 4.1, p <.. Altering the wording of "instructions to let the imagination run wild" (Survey 1) to "instructions to give free rein to the imagination" (Survey ) resulted in lower ratings of disapproving of this technique in Survey, x (O = 4., p <.. Despite these minor differences, the two U.S. samples concurred in indicating that use of special techniques to recover memories is widespread. Comparing the U.S. and British respondents in Survey, a comparable percentage of clinicians in the two samples reported using at least one technique, p =., but the U.S. clinicians reported using more of the listed techniques (Ms =. vs for U.S. and British respondents, respectively, t( 11) =.1, p <., with the difference attributable to greater use of hypnosis, x O) = 1.,p<.1, and guided imagery, x (l) = 4.1, p <.. There was no difference, however, in the number of techniques that the two groups indicated should "not be used

6 PSYCHOTHERAPY AND MEMORY RECOVERY 41 Table Reported Indicators of Childhood Sexual Abuse in Adult Female Clients Indicator US-1 US- GB Sex dysfunction Poor relationships Low self-esteem/distorted self-image/identity Depression Memories amnesia for childhood Dreams/nightmares/sleep disorder Eating disorder/overweight Dissociative symptoms Self-multilation/masochism Anxiety Sex current promiscuity /preoccupation Chemical dependency Lack of trust Memories vague, intrusive Difficulty with intimacy/withdrawal Physical symptoms Panic/fear Abusive spouse/choice of partners Family of origin dysfunction Behavioral signs/current pathology Men fear of Posttraumatic stress disorder Note. The data in this table refer to the indicators mentioned by at least % of the respondents. Indicators are listed in order of decreasing frequency for the three samples combined. The following 6 indicators (listed alphabetically) were mentioned by less than % of the respondents: Abreactions under hypnosis, acting out as a teen, alcoholic dad/parent, anger at specific child behavior, anger at dad/parent, atypical psychotic presentation, avoidance/guardedness, avoidance to talk about childhood/comments about childhood, borderline features/personality disorder, (born-again) Christianity, boundary problems, child perpetrated, children abused, constriction, controlling, current family/marital dysfunction, dad strict, delusional ideas of reference, dependent/passive, desire to alter gender, devaluation of women, difficulty with affection/ touch, drawings, failure to respond to treatment, feeling "different," feeling overpowered/victimized, feelings of derealization, guilt/shame, hostility, hypervigilance, idealization of parent/idealization by parent, inappropriate hygiene/dressing, inhibition discussing sex, memories body, memories flashbacks, memories other types of abuse, memories sleeping with dad, men anger at, no boyfriend or dating, not expressing emotions, multiple personality disorder, multiple suicide attempts, mutism/areas of silence, obsessive-compulsive, parental overprotectiveness, parenting problems, perfectionism, poor bonding with children, poor resistance to stress, possessive behavior/unusual relationship with a relative, preoccupation with body/poor body image, reactions to medical exams, repression, "rosy" childhood that doesn't ring true, self-defeating behavior, sex precocious, sexualized presentation, shyness, siblings abused, unable to control emotions/general emotional problems, underachiever, unexplained sexual knowledge, wanting to please others. US-1 = U.S. Survey 1; US- = U.S. Survey ; GB = Breat Britain Survey. to help clients remember childhood sexual abuse" (Ms =. vs..4 for the U.S. and British Survey respondents, respectively, p =.). Two points are worthy of emphasis. First, most clinicians reported using memory recovery techniques (e.g., 1 % of the 1 interpretable responses reported using at least one of the listed alternatives, and 8% reported using two or more techniques). Second, there was a surprising lack of agreement among these highly trained clinicians as to which techniques are and are not appropriate. For example, more than one fourth of the U.S. respondents reported using hypnosis to help clients remember CSA, and more than one fourth indicated that hypnosis should not be used to help clients remember CSA. Because the popular book The Courage to Heal (Bass & Davis, 188) has been a major focus of critics of memory work in psychotherapy, we asked U.S. clinicians in Survey 1 to comment on their familiarity with and use of this book. Half reported that they had read the book, and 44% said they had recommended it to clients. Only 8% of the respondents reported that they never currently recommend it to clients with a history of CSA, % recommended the book occasionally, 16% frequently, and % always or almost always. Survey asked respondents to list any books related to sexual abuse that they had recommended to clients in the past years; approximately half in each country reported recommending such books (4% vs. 46%,p =.46). Some questions dealing with memory recovery were modified for the second survey. In Survey 1, we asked clinicians the question, "Of the adult female clients whom you suspected were sexually abused as children, what percentage initially denied any memory of childhood sexual abuse?" followed by the question, "Of the adult female clients who initially denied any memory of sexual abuse, what percentage came to remember childhood sexual abuse during the course of therapy?" The vast majority of respondents (8%) reported at least some cases of memory recovery among clients who initially claimed to have no history

7 4 POOLE, LINDSAY, MEMON, AND BULL Table 4 Percentage of Respondents Reporting Use of Various Memory Recovery Techniques and Percentage Indicating That These Techniques Should Not Be Used Respondents using Respondents disapproving Technique US-1 US- GB US-1 US- GB Hypnosis Age regression Dream interpretation Guided imagery related to abuse situations Instructions to give free rein to the imagination' Use of family photographs as memory cues Instructions to work at remembering/journaling Interpreting physical symptoms Note. US-1 = U.S. Survey 1; US- = U.S. Survey ; GB = Great Britain Survey. ' In Survey 1, this technique was worded as "instructions to let the imagination run wild.' of abuse, and estimates of the percentage of women clients recovery memories of CSA were as high as 1% (M = 4.%, SD =.88%). This question sequence may have resulted in a high mean estimate for delayed recall and reporting of abuse because the first question may have led clinicians to estimate, on the second question, memory recovery only for the subset of women they had suspected of abuse. As noted earlier, in Survey the first question was rephrased and moved, and the second was worded as, "Of the adult female clients who initially indicated that they did not remember any childhood sexual abuse, what percentage eventually came to remember childhood sexual abuse during the course of therapy?" This revision yielded significantly lower estimates of memory recovery in Survey for both the U.S. clinicians (M = 1.16%, SD =.6), /(1) =.8, p <.1, and the British clinicians (M = 18.%, SD =.61), t( 114) =.84, p <.1, with these two groups not reliably differing (p =.). Nonetheless, 1% of the respondents in Survey reported memory recovery in at least some clients, with rates as high as 1%. The U.S. Survey 1, U.S. Survey, and British Survey samples also agreed on the percentage of those women who initially reported abuse who remembered more about the abuse during therapy, with estimates ranging from % to 1% (Ms = 6.8%, 4.%, and 64.8%, respectively; GM = 6.1%, SD = 6.6%, p =. 1). Clients' identification of and reactions to perpetrators of newly remembered abuse. Retrospective self-report studies of the prevalence of CSA indicate that only a minority of such abuse is perpetrated by fathers. For example, of the women interviewed in Russell's (188) carefully conducted study, 4% reported some type of sexual abuse before age 18 years, but only 4.% reported actual or attempted sexual contact by their fathers or stepfathers. In contrast, proponents of memory work in psychotherapy have emphasized paternal abuse (e.g., Courtois, 11). In Survey 1, respondents estimated that, of the female clients who came to remember previously unavailable memories of CSA, the client's father was the perpetrator in 4.8% of the cases (SD =.8%). In Survey, we modified the question to read "biological father." This resulted in lower (but still quite high) estimates by U.S. respondents (M =.%, SD =.),f( 11) =., p<., with the British clinicians concurring(m =.81%, SD= 6.1 ),p =. 86. In Survey 1, we asked respondents to report the percentage of clients, among those who through therapy remembered abuse, who confronted their abuser (M =.%, SD =.%) and who cut off relations with the abuser (M =.61%, SD =.1%). On average, the clinicians reported that only.8% (SD = 1.1%) of clients who had come to remember childhood abuse during therapy took legal action against their abusers. Sensitivity to the possibility of memory reconstruction during therapy. Several questions assessed respondents' beliefs about memory reconstruction and illusory memories. In both countries, the majority of clinicians indicated that it is possible for a client to come to "believe that she was sexually abused as a child if no abuse had actually occurred" (1%, %, and 88% for the U.S. Survey 1, U.S. Survey, and British Survey respondents, respectively,/) =.64; total sample = 1%). Of the clinicians who commented on this question, (61%) indicated that this is an unlikely event (e.g., "Anything is possible, but why?"), and only 6(18%) indicated that illusory memories are common or stem from previous therapy or leading questions (e.g., "easily, especially with zealous prior therapist"). In Survey 1, clinicians who indicated that illusory memories are possible were asked how often they had suspected that one of their own clients had "experienced such illusory beliefs or memories about childhood sexual abuse": 18% circled "never," % circled "very rarely" or "rarely," and % circled "fairly often" or "often." In Survey, respondents were asked to estimate the percentage of their clients who "had come to believe in or remember instances of childhood sexual abuse that you suspect did not occur." The U.S. and British samples indicated that similarly low percentages of their clients had experienced such illusory beliefs (.1% vs. 1.1%, p=.1; GM =.61, SD =.). We also asked the clinicians to estimate what percentage of their clients "who came to remember being sexually abused during the course of therapy later denied the validity of those memories." Compared with those in Survey 1, Survey clinicians estimated that fewer women retracted memories recalled

8 PSYCHOTHERAPY AND MEMORY RECOVERY 4 during therapy (Ms = 4.48%,.%,.41%) F(, 18) = 4.18, p <.. It is likely that the lower estimates of retraction in the Survey stemmed from the aforementioned wording change that asked Survey respondents to base estimates of memory recovery on all female clients who initially denied CSA histories, not only on those whom the clinicians suspected had been abused (i.e., some clients not suspected of hidden memories may nonetheless recover memories during therapy, and such clients may be less likely to retract reports of abuse). Seven clinicians commented on retracted allegations, indicating that vacillation is not uncommon in cases of sexual abuse (e.g., "% but this was only a temporary phase... they later accepted the memories as accurate"). Thus, although some respondents indicated that their clients sometimes deny the validity of newfound abuse memories, the vast majority did not, and even those who did deny validity often indicated that questioning the validity of recovered memories was a transient phenomenon. These findings suggest a widespread acceptance of the possibility of illusory memories and an equally widespread belief that most memories of CSA recovered in therapy are accurate, especially those of one's own clients. Summary. The two U.S. samples were virtually identical except in responses to questions that had been substantially reworded in Survey. Despite some differences in the characteristics of the U.S. and British samples, their responses to questions about memories of CSA were very similar. Although on average the British clinicians reported using a smaller number of memory recovery techniques than their U.S. counterparts, approximately two thirds of the respondents from each country reported using at least one memory recovery technique to help clients remember CSA. British and U.S. respondents gave similar estimates of the percentage of women clients reporting CSA, generated a comparable (and large) number of indicators of sexual abuse, gave similar ratings of the importance of remembering abuse, and reported comparable rates of memory recovery. These findings argue against suggestions that clinicians who focus on memory recovery represent a minority culture within the United States that is populated primarily by clinicians with little or no formal training (e.g., Gardner, 1). Responses by Sex and Theoretical Orientation The responses of male and female clinicians were very similar across the three samples. Male and female clinicians did not differ in the number of adult female clients served in the last years (p =.16), the percentage of their women clients for whom they believed sexual abuse played an important role in causing psychological problems (p =.), ratings of how important it is to remember abuse (p =.), the percentage of their clients who initially denied abuse but came to remember it during therapy (p =. for Survey!,/>=.61 for Survey ), or the number of memory recovery techniques used with suspected abuse victims during the past years (p =.6 for the U.S. samples and p =.1 for the British sample). Female respondents listed more indicators of abuse (Ms =.86 vs..66), /(1) =., p <.1, but male and female respondents alike listed multiple indicators. We explored relationships between opinions and theoretical orientations by conducting / tests on mean differences for five selected questions, comparing clinicians who ranked each of the three most frequently selected orientations (behavioral, cognitive, and psychodynamic) among their top two choices with clinicians who assigned lower ranks to these approaches. With regard to the percentage of female clients for whom sexual abuse played an important role in causing the client's psychological problems, there were significant differences in the estimates of behavioral clinicians versus others (Ms = 18.4% vs..68%), t( 1) = -., p <.1, cognitive clinicians versus others (Ms =.% vs..4%), /(188) = -.4, p <., and psychodynamic clinicians versus others (Ms = 8.81% vs..%), t( 1) =., p <.1. Note that behavioral and cognitive approaches were associated with lower estimates of sequelae of abuse, whereas a psychodynamic approach was associated with higher estimates. However, it is not possible to determine whether these trends reflect different attitudes about the frequency and impact of childhood trauma or different client populations (e.g., some behavioral clinicians indicated that they worked primarily with focused interventions, such as smoking cessation). Behavioral clinicians also indicated that it is less important to remember abuse (Ms =.44 vs..), /(1) = -.1, p <., and psychodynamic clinicians that it was more important to remember abuse (A/s =.88 vs..), /(1) =.8, p <., with no significant difference in ratings associated with checking a cognitive approach. Analyses of (a) the reported percentage of women who come to remember abuse during therapy (calculated separately for Survey 1 vs. Survey because of changes in the wording of the question), (b) the number of indicators of abuse mentioned, and (c) the number of memory recovery techniques used (analyzed separately for U.S. and British clinicians) revealed no influence of theoretical approach on responses. It is clear from the number of orientations checked per respondent (GM = 4., SD =.) that most clinicians view themselves as eclectic, and therefore expressions of theoretical orientation are generally poor predictors of attitudes and practices related to memory recovery. Response Patterns Critics of memory work in psychotherapy have focused on approaches that combine several potentially suggestive practices (e.g., suspecting hidden memories in clients who report no history of abuse, communicating to clients that recovering memories of sexual abuse is important for the success of therapy, and using multiple memory recovery techniques and ancillary practices to promote memory recovery). Some psychologists (e.g., Berliner & Williams, 14;Freyd, 1; Olio, 14; Pezdek, 14) have argued that few, if any, clinicians use such approaches. Our findings challenge this claim. For all three samples, there was a significant correlation between the number of memory recovery techniques used and estimates of the percentage of women who recalled sexual abuse during therapy (rs =.1,.4,.1, ps <.). We estimated the percentage of the Results from the separate variance formula are reported whenever the F test for homogeneity of variance indicated significantly different variances between the two groups.

9 44 POOLE, LINDSAY, MEMON, AND BULL sample whose responses suggested a focus on memory recovery by identifying respondents who indicated that (a) it is important for abused clients to acknowledge or remember the abuse for therapy to be effective, (b) they sometimes formed the opinion that clients who denied any abuse history had been abused, and were sometimes "fairly certain" about this judgment after the initial session, and (c) they used two or more different techniques to help clients remember CSA. There was no significant difference between samples in the percentage of respondents (with sufficient valid answers to be categorized) who met these criteria, p =.4, with % falling into this category. These clinicians reported working with a total of,4 adult female clients in the past years. For Survey 1, clinicians who met these criteria reported that, on average, 6.1% of the clients they suspected of abuse but who initially denied abuse eventually came to remember CSA during therapy (as opposed to 4.% for other respondents),?(6) =., p <.1. For Survey, clinicians who met these criteria estimated that, of all female clients who initially indicated that they did not remember any childhood abuse, 4.% came to remember such abuse (as opposed to.% for other respondents), f(1) =., p<.\. On the opposite end of the spectrum, we calculated the percentage of respondents who (a) did not rate memory as an important therapeutic goal, (b) reported that they never formed the opinion that clients who denied an abuse history had been abused after an initial session, and (c) reported that they used none of the listed techniques to help clients remember CSA. There was no difference between samples in the frequency of these "cautious" clinicians, p =., with 8% meeting these criteria. Reported rates of clients recovering memories of CSA for this subgroup were lower than estimates by respondents who did not fit these "cautious" criteria: 6.6% in Survey 1, compared with 4.8% for other respondents, p =.8; 1.% in Survey compared with 1.66% for other respondents, /() =.4, Representativeness of Sample It might be argued that these data overestimate the population's focus on memory recovery because of the relatively small sample sizes and the possibility that clinicians who emphasize memory recovery may have been more likely to return the survey. The high level of agreement between the two NRHSPP samples demonstrates that our samples were sufficiently large to yield stable data, and the total U.S. sample size ( 14 ) is certainly large enough to justify confidence. Regarding representativeness, it should first be noted that even if the sample is assumed to be maximally nonrepresentative (i.e., even if no nonreturners use memory recovery techniques), the results would still indicate that a substantial number of clinicians use such techniques. Furthermore, there are grounds to argue that the sample is not grossly nonrepresentative. Our return rates were similar to those of other mail surveys of therapists (e.g., Goodman et al., 1; Poole & Tapley, 188), and the proportion of male to female respondents ( 4% ) was virtually identical to the proportion in the total random sample (4%). In addition, analyses of questionnaires that were returned promptly in the first survey ( n = 8) versus those returned only after the second mailing (n = 4), suggest that clinicians' beliefs about memories of CSA did not operate as a powerful self-selection factor. Late returns were more often from clinicians outside of the target population of those who regularly do psychotherapy with adult female clients (44% vs. 1% among prompt returns). However, of those in the target population, there were no reliable differences between early and late returns in estimates of the percentage of clients for whom abuse played a significant role in causing psychological problems (Ms =.% vs. 8.1 %, p =.8), rated importance of remembering abuse (Ms =.6 vs.., p =.6), estimates of the percentage of clients who initially denied abuse but came to report abuse during therapy (Ms = 4.41% vs. 41.%, p =.8), or the number of techniques used to recover memories of abuse (Ms =. vs.., p =.). These similarities between early and late returners provide evidence for the representative of the sample, because if memory-focused clinicians were self-selecting, one would expect more such clinicians in the early than the late groups. Nonetheless, our findings are best viewed as illustrating the variability that exists among highly trained psychotherapists, rather than as definitive estimates of the proportion of all practitioners who endorse particular beliefs and practices. Discussion Our survey of highly trained practitioners in the United States and Great Britain indicates that (a) some clinicians believe they can identify clients who were sexually abused as children even when those clients deny abuse histories, (b) some clinicians use a variety of techniques to help clients recover suspected memories of CSA, (c) such clinicians are often successful in these attempts, and (d) these interventions can have serious implications for clients (e.g., lead some clients to terminate relations with their fathers). The responses also indicate that a wide range of presenting complaints have the potential of being viewed as indicators of CSA. Our data do not indicate whether therapy-induced illusory memories contributed to the high rates of memory recovery reported by memory-focused respondents, because these clinicians may have uncovered accurate memories of abuse. The findings do, however, indicate an urgent need to investigate the safety of memory-focused therapy. In our sample, only a minority of clinicians indicated a strong focus on helping clients recover suspected memories of CSA. However, this translates into a large number of practitioners. For example, if our sample is representative of clinicians listed in the NRHSPP and RCCP, then % of the members of those organizations who conduct psychotherapy with adult female clients believe that recovering memories is an important part of therapy, think they can identify clients with hidden memories during the initial session, and use two or more techniques to help such clients recover suspected memories of CSA. Given the large number of practitioners in these organizations, and given that respondents reported working with an average of 81 women in the last years, then hundreds of thousands of women worked with such NRHSPP and RCCP clinicians during the - year interval addressed by the questionnaires. Even if none of the nonrespondents focus on memory recovery, the number of clients working with memory-focused NRHSPP or RCCP cli-

10 PSYCHOTHERAPY AND MEMORY RECOVERY 4 nicians during the time covered by the survey would still be over 1,. Furthermore, many practitioners do not belong to NRHSPP or RCCP(e.g., Baker, 14, estimated that there are some, registered mental health care providers in the United States), and there is evidence that memory-focused approaches to therapy may be more common among non-doctoral-level clinicians (Yapko, 14). These statistics suggest that a very large number of women have worked with memoryfocused practitioners in the past few years. If a fraction of clients who receive such therapy come falsely to believe that they had been sexually abused as children, this would amount to a substantial number of cases of false beliefs. Thus, to some extent the results of this survey are consistent with the concerns expressed by critics of memory work. It should be emphasized, however, that our results are inconsistent with the idea that a large percentage of psychotherapists have a single-minded focus on getting their clients to remember CSA. On the contrary, the majority of the respondents indicated that relatively few of their clients reported CSA during therapy and that, in their opinion, CSA played an important role in the psychological problems of a relatively small percentage of their clients. Furthermore, our data do not directly indicate whether the clinicians who used memory recovery techniques did so in single-minded and highly suggestive ways, in open-minded and cautious ways, or somewhere between these extremes. Finally, the questionnaire revealed widespread concern about the potential for leading clients to create illusory beliefs or memories, although this concern was often juxtaposed with reported use of techniques considered risky by many psychologists and with statements to the effect that most or all memories recovered by the respondent's clients were accurate. There are two ways of thinking about this tension between the respondents' expressions of concern about the risks of leading clients, on the one hand, and their expressions of belief that the memory recovery techniques they use rarely if ever lead their clients to create illusory memories or beliefs, on the other. One possibility is that they use memory recovery techniques only in very cautious ways, such that their clients rarely develop illusory beliefs or memories. We suspect that, although this is probably an accurate description of some clinicians who use memory recovery techniques, it is not an accurate description of all of them. Instead, we believe that the therapeutic community is in a state of transition, in which enthusiasm for memory recovery techniques is giving way to concerns about their potentially suggestive nature. Converging support for this view comes from Yapko's (14) survey of 86 therapists attending conventions and workshops: % indicated that clients can come to believe false memories suggested by others, and 1% reported cases in which they believed a client had developed illusory memories suggested by another therapist, yet 1% agreed that "when someone has a memory of a trauma while in hypnosis, it objectively must actually have occurred" and 4% said that hypnosis enables clients to remember actual events "as far back as birth." This faith in hypnosis as a tool for recovering memories is opposed by research evidence (e.g., American Medical Association Council on Scientific Affairs, 18). Yapko's findings illustrate the tension between memory-focused clinicians' awareness of the possibility of illusory memories and their confidence that their own clients rarely if ever develop illusory memories. What are the bases of clinicians' confidence in the memory recovery techniques they use, belief in their ability to detect clients with hidden memories, and trust that their own clients rarely or never develop false memories or beliefs during therapy? For some therapists, these beliefs may be well-founded (i.e., they may only use such techniques in cautious and minimally suggestive ways and with clients who really were abused as children). However, there are well-established cognitive biases that can distort human judgment, and these may contribute to ill-founded confidence in some clinicians who use memory recovery techniques (see Lindsay & Read, 14; Nezu & Nezu, 18). For example, many clinicians reported making clinical judgments concerning CSA based on clients' behavioral symptoms and the indicators they listed included many of the common presenting complaints of adult female clients. Confidence in the reliability of such indicators is in sharp contrast to clinical research, which indicates that CSA accounts for a relatively small portion of the variance in adulthood symptoms and that there is as yet no well-defined post-csa syndrome (e.g., Beitchman, Zucker, Hood, dacosta, Cassiva, 1). Cognitive decision biases may contribute to this discrepancy between clinicians' intuitions and the research evidence. For example, "confirmatory bias," a tendency to focus on expectation-confirming cases, can give rise to "illusory correlations" between symptoms and diagnostic categories (Chapman & Chapman, 16; Dawes, 18, 14; Dowling & Graham, 16). In this case, confirmatory bias may give rise to compelling illusory correlations between presenting problems and a forgotten history of CSA. Another cognitive bias that may lead to mistaken beliefs about the predictive value of presenting symptoms is the "representativeness heuristic" (Tversky & Kahneman, 14). The representativeness heuristic is a tendency to assess the probability that A is associated with B on the basis of the perceived similarity between A and B. For example, the only indicator of CSA mentioned by more than 14% of the respondents in each sample was adulthood sexual dysfunction. Although clinical studies have found higher rates of sexual dysfunction among abuse survivors than control groups (Briere & Elliott, 1), many abuse survivors do not report sexual dysfunction, and sexual dysfunction is also associated with a variety of other background factors (Sutker & Adams, 1). Because of the surface similarity between adulthood sexual dysfunction and CSA, the representativeness heuristic may lead some clinicians to exaggerate the strength of the relationship between the two or to explore the possibility of CSA as an explanation for sexual dysfunction before considering other etiological factors that have a higher base rate of occurrence. Other factors may contribute to skepticism regarding the claim that memory work can lead clients to develop illusory memories. One such factor may be lack of familiarity with the literature on the fallibility and suggestibility of human memory, which demonstrates that people sometimes experience compelling illusory memories and indicates that several factors typically present in therapy situations likely enhance clients' suggestibility (Lindsay & Read, 14;Loftus, 1). Furthermore, even clinicians who are aware of and accept the evidence of the

11 46 POOLE, LINDSAY, MEMON, AND BULL fallibility and suggestibility of memory may underestimate the extent to which they influence their clients. Research demonstrates that people especially authority figures can profoundly influence the behavior of others with whom they interact (e.g., Rosenthal & Jacobson, 168; Snyder, Tanke, & Berschied, 1), even when they are unaware of wielding that influence (e.g., Wheeler, Jacobson, Paglieri, & Schwartz, 1) and even when those whose behavior they affect are unaware of the influence (e.g., Bowers, 184). In summary, we believe that many psychotherapists who use memory recovery techniques to help clients remember suspected histories of CSA are in a state of transition characterized by concern about the suggestibility of human memory, on the one hand, and confidence that their clinical judgments are accurate and that their clients rarely if ever develop false memories, on the other. To the extent that clinicians are correct in their intuitions and use memory recovery techniques in minimally suggestive ways, these beliefs may be well founded, but, as briefly reviewed earlier, various biases of human judgment may lead some clinicians to hold undue confidence in the safety of these practices. Our results indicate an urgent need for research on three major issues. First, given the concern that memory recovery techniques may inadvertently lead some nonabused clients to come to believe that they were abused as children, it seems important to demonstrate that memory work is indeed helpful for clients who were abused. At present, the only evidence supporting attempts to help clients recover suspected memories of CSA comes from clinicians' case studies (e.g., Courtois, 11) and from anecdotes in popular books (e.g., Bass & Davis, 188). This is a weak foundation for the use of potentially risky therapeutic techniques (cf. Beutler & Hill, 1; Haaken & Schlaps, 11). Second, if clinicians do continue to use such techniques, it is important that researchers redouble their efforts to improve practitioners' ability to discriminate between clients who were sexually abused as children and those whose psychological problems have other etiologies. Current mandatory reporting laws for CSA, coupled with increased efforts to prosecute perpetrators in some locations, may make it possible to conduct better longitudinal follow-up research on the behavioral sequelae of CSA and the availability of memories of abuse, research that could improve prediction and produce greater consensus among the clinical community. Finally, there is need for research to assess the riskiness of particular memory recovery techniques and the ways these techniques interact with one another and with client characteristics. 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