Book Review

Remembering Trauma

N Engl J Med 2003; 349:1879-1880November 6, 2003

Article

Remembering Trauma
By Richard J. McNally. 420 pp. Cambridge, Mass., Harvard University Press, 2003. $35. ISBN: 0-674-01082-5

Books with nearly 100 pages of references, not to mention notes, are treasures as resources, even if their content and the discussion they contain require much work of the reader. Remembering Trauma is such a book. It is not, however, about remembering trauma. Rather, it is about the debate over the recall of childhood sexual trauma. It also is not without a point of view of its own.

McNally begins with a useful and dramatic history of the debate about the recall of childhood sexual abuse. In this debate, issues of science, clinical care, and the legal system have come together, often without any acknowledgment of their differences. The failure, inability, unwillingness, or reluctance to recall an event leads to different hypotheses regarding the phenomenon we casually call “forgetting.” To complicate matters further, we know that people often forget the times when they did remember. Evidence, data, methods of obtaining data, and criteria for establishing proof are quite different in the fields of science, clinical care, and the law.

McNally provides a good review of the literature of cognitive psychology on the recall of traumatic events, reminding us that recall is a function of our experience, the neurobiologic limitations of our memory apparatus, and our present context. The process of recall often involves remembering an event that one knows but may not have thought of recently or even for a long time, rather than “remembering” an event of which one was never before aware. The book covers many aspects of this question, from amnesia to belief, perhaps dwelling too much on post-traumatic stress disorder, repression, and dissociation.

Among the studies McNally discusses are two sets that address the specific questions of the recall of sexual abuse particularly well. The first set comprises prospective studies of abused children who were followed as adults. Although McNally tends to interpret these studies as supporting the view that adults nearly always recall documented childhood sexual abuse, the studies also indicate that some adults (10 to 22 percent) do not. Yes, this finding supports the conclusion that forgetting childhood sexual abuse is not the norm. However, it also indicates, within the limits of these studies, that such forgetting does occur.

The second set of studies compares aspects of memory function in three groups of adults: those reporting unconfirmed recovered memories of childhood sexual abuse, those reporting repressed memories of childhood sexual abuse (i.e., they do not recall the sexual abuse, but they think they were abused), and those reporting no history of childhood sexual abuse. The author leads the reader by suggesting that there “should have been” differences in memory function among these groups according to whether the sexual trauma was repressed, dissociated, or forgotten. However, a more neutral interpretation of these studies would be that the null hypothesis was not rejected and that the three groups were therefore surprisingly similar. Interestingly, persons who reported repressed memories were more likely than those in the other groups to score high on tests that measure psychological distress. Either some adults with psychological distress come to believe they have been sexually abused in childhood or, equally possible (although inexplicably demoted to less importance in the book), those who report repressed memories do indeed have more psychological distress. The proverbial chicken-and-egg problem cannot be resolved by these studies.

Is trauma a problem of memory? The recall of traumatic events (and post-traumatic stress disorder) is as much a problem of forgetting as of recalling. The inability to forget and the resultant generalization of the threat result in impairment rather than in protection from danger. The enduring questions regarding memory and traumatic events are not solved in this book, but we are educated about them. The recall of childhood sexual abuse is never established without independent confirmation — a lesson that is taught well in this book and one that our scientists, clinicians, and legal system must not forget.

Robert J. Ursano, M.D.
Uniformed Services University of the Health Sciences, Bethesda, MD 20814