Recovered Memories
Harold J. Bursztajn, M.D.
Psychiatr Serv 49:699-700, May 1998
To the Editor: In their article on risk management
principles for recovered memory cases in the November 1997 issue, Drs.
Gutheil and Simon [1] conclude by advising that "if
the patient persists with the intention to sue, the clinician should
refer the patient to another therapist, if necessary, and terminate therapeutic
work with that patient." Such a recommendation, unless used with
caution, can create clinical or iatrogenic harms even as the therapist
seeks specifically to avoid such harms.
First, it is important to keep in mind that clinicians often resort to
recommendations to terminate treatment when feeling frightened, pressured
by time, or otherwise constrained. Although the authors qualify their
fundamental recommendation to terminate treatment and refer to another
therapist, the danger remains that uncritical application of such
a principle will encourage treating clinicians to shed responsibility
in order to appear beyond reproach, while leaving the patient, family,
and subsequent clinician with the risk for escalation of the patient's
harmful behavior as a reaction to an experienced abandonment.
Just as we clinicians must not jump to conclusions about intersubjective
reality, we must avoid threatening to conclude our work with our
patients when they act disagreeably [2]. We can
set reasonable limits with the patient on the scope of our work by
paying careful attention to maintaining our own neutrality between
external and internal—objective and subjective—reality rather than
run the risk of rationalizing a countertransferential wish to have
the patient conform to our view of reality by threatening termination.
Second, as always, a therapeutic impasse is most likely to be resolved
when the treating clinician takes responsibility for self-analysis
of how countertransference issues may be impinging on the creation
of a therapeutic alliance and its maintenance and re-creation as
work proceeds [3]. Often the background for childhood
abuse is childhood neglect. A premature termination, while avoiding
exploration of the former, may lead to a reenactment of the latter.
When a therapeutic impasse is reached, a psychoanalytically informed
consultation may be a useful tool for the treating clinician. The
focus of such a consultation may be on the alliance and on how patient
transference and clinician countertransference may be distorting
the frame of the alliance.
Footnotes
Dr. Bursztajn is associate clinical professor in the department of psychiatry
at Harvard Medical School in Boston.
References
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Gutheil TG, Simon RI: Clinically based risk management principles
for recovered memory cases. Psychiatric Services 48:1403-1407,
1997
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Bursztajn HJ: Traumatic Memories as evidence: true or false? Journal
of the Massachusetts Academy of Trial Attorneys 2:77-80, Mar
15, 1994
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Bursztajn HJ, Feinbloom RI, Hamm RM, et al: Medical
Choices, Medical Chances: How Patients, Families, and Physicians
Can Cope With Uncertainty. New York, Routledge, Chapman & Hall,
1990
