Brain Stains

A wave of nausea washed over Sheri J. Storm when she opened the Milwaukee Journal Sentinel on a February morning a decade ago and saw the headline: "Malpractice lawsuit: Plaintiff tells horror of memories. Woman emotionally testifies that psychiatrist planted false recollections." The woman in the article shared a lot with Storm--the same psychiatrist, the same memories, the same diagnosis of multiple personality disorder. At that moment, Storm suddenly realized that her own illness and 200-plus personalities, though painfully real to her, were nothing more than a figment of her imagination--created by her trusted therapist, Kenneth Olson.

Storm initially sought treatment from Olson because of insomnia and anxiety associated with divorce proceedings and a new career in radio advertising. She had hoped for an antidepressant prescription or a few relaxation techniques. But after enduring hypnosis sessions, psychotropic medications and mental-ward hospitalizations, Storm had much more to worry about than stress. She had "remembered" being sexually abused by her father at the age of three and forced to engage in bestiality and satanic ritual abuse that included the slaughtering and consumption of human babies. According to her psychiatrist, these traumatic experiences had generated alternative personalities, or alters, within Storm's mind.

Storm is now convinced that her multiple personality disorder was iatrogenic, the product of her "therapy." But years after the psychiatric sessions have ceased, she is still tormented by vivid memories, nightmares and physical reactions to cues from her fictitious past. Although she was told that the false memories would fade over time, she has had a difficult time purging these "brain stains" from the fabric of her mind.

Storm's case is similar to those of many other patients who underwent recovered-memory therapy that revealed sordid histories of sexual abuse and demonic ceremonies. Although the scientific literature suggests that traumatic events are rarely, if ever, repressed or forgotten, this type of therapy was widespread in the 1990s and is still practiced today. Only after several high-profile lawsuits did the American Medical Association issue warnings to patients about the unreliability of recovered memories. Nadean Cool, the patient described in the newspaper story that turned Storm's life upside down, filed one such lawsuit. Cool received a 2.4-million settlement after 15 days of courtroom testimony. Amid the heated controversy, the American Psychiatric Association discontinued the diagnostic category of multiple personality disorder, replacing it with the slightly different diagnosis of dissociative identity disorder.

It seemed that science and the legal system had triumphed over sloppy therapeutic techniques. Some patients received substantial monetary settlements, their therapists were exposed in the media, and scientists produced convincing evidence that false memories could indeed be implanted in the human mind. Case closed. Or was it? For Storm and others like her, bad therapy seems to have altered the brain's emotional circuitry, with lasting effects on memory and mental health. Fortunately, as with most other blemishes, such brain stains may be reversible, though only after considerable effort.

The Fallibility of Memory
In 1949 Canadian psychologist Donald O. Hebb proposed that cellular changes lead to the establishment of "memory circuits" in the brain. Neuroscientists Tim Bliss of the National Institute for Medical Research in London and Terje Lmo of the University of Oslo validated this idea in 1973 by demonstrating that electrical signals delivered to certain brain areas, such as the hippocampus, had long-lasting effects on the connections among nerve cells. Research over the past century has provided unequivocal evidence that the brain's functional structures are continually modified to generate and maintain memories.

The problem with the brain is that it is not a very discriminating processor. It has no spam folder for imaginary or coerced memories. Movie plots, unsubstantiated rumors and images from dreams are stored in our brain alongside memories of our 10th-birthday party, first kiss and high school graduation.

Research by Elizabeth F. Loftus, then at the University of Washington and now at the University of California, Irvine, has shown how difficult it can be to distinguish real memories from fictitious ones. In 1995 she and her research associate Jacqueline E. Pickrell contacted the family members of 24 individuals and, after gathering information about their lives from relatives, constructed memory booklets containing actual childhood events along with a false story of being lost in a mall at five years of age. The researchers found that 29 percent of the subjects "remembered" the false event and were even able to provide details of it.

Recovered-memory therapy relies fundamentally on the notion that some memories are so unspeakable that the mind represses them to protect itself. Decades of research conducted by neurobiologist James L. McGaugh of U.C.I. suggest, however, just the opposite--that one key function of memories is to recall threatening situations so that they can be avoided in the future. Human experiments by McGaugh and neurobiologist Larry Cahill, also at U.C.I., have shown that emotional arousal tends to make memories stronger. Likewise, when animals receive injections of the stress hormone epinephrine (also known as adrenaline), they sail through memory tests. Not only do these experiments run counter to the notion that traumatic memories are repressed routinely, but they also may elucidate why patients such as Storm, whose therapy focused on "guided imagery" and enactments of traumatic scenes, report that these experiences have become fixtures in their memories.

Multiple Personalities
Storm's relationship with her psychiatrist was based on trust. She knew that he had professional credentials and a prestigious reputation at the local hospital. Once she was diagnosed with multiple personality disorder, she received official-looking publications that seemed to confirm the surprising judgment. Storm reports that over time, her "memories" were fabricated and consolidated by a multitude of techniques--long hypnotherapy sessions, multiple psychotropic medications, sodium amytal (purportedly a truth serum), isolation from family members and mental-ward hospitalizations.

Transcripts of Storm's sessions with Olson reveal that he did most of the talking [see box on page 52]. Although Storm provided no initial information about the alters, Olson identified and conversed with them. When she repeated and responded to the terrifying accusations revealed during her sessions, she was videotaped so that her alters could be validated once the sessions were over. As the sessions progressed, the acts Storm described became more horrific, and the alters became active even when she was not in her therapist's office.

"I felt absolutely stark-raving mad," Storm later wrote. "Under Olson's tutelage, dissociation became second nature to me. I randomly switched from alter to alter so frequently that I lost time or forgot how to perform even simple, routine daily functions."

The idea that emotionally laden memories can be induced in a clinical setting dates back to experiments conducted nearly a century ago. Famed behaviorist James B. Watson "conditioned" an 11-month-old infant, known in every introductory psychology text as Little Albert, to fear a white rat. The infant showed no sign of fear toward the furry creature in the first session, but after the white rat was paired with a very loud noise, Albert responded with tears. Later, Albert cried when he was presented with a variety of stimuli that resembled the rat. This early case suggested that a therapist (or experimental psychologist, in this case) could easily create emotional associations and that these mental connections could be so powerful that they generalized to similar stimuli. In the case of Little Albert, the memories were "implicit"--that is, not consciously recalled--but Watson's findings remind us that powerful emotional memories can be enduring.

In Storm's case, a technique called abreactive therapy helped to create these emotional associations. Storm was told that abreactions were total-body "flashback" reactions that would enable her to relive the traumatic events in her life, complete with the sounds, smells, sights and tactile experiences of these events. Olson instructed Storm to allow her alters to come forward and share their participation in unthinkable acts such as eating babies. For Storm, this therapy was physically, mentally and emotionally grueling. Years later the conditioned associations remain strong. Storm is plagued not only by her explicit memories of the disturbing scenes brought to life in her therapist's office but also by implicit memories that provoke reflexive physical reactions.

When Storm found a hair in her pizza at a local restaurant, it triggered visual and emotional memories of gagging, eating babies and cult activity. Cigar smoke brought up memories of cigar burns and subsequent rapes by her uncle. The cries of a baby provoked an intense desire to "save" the child. And the list goes on: stale air in the car made her recall sensations of being buried alive; dead animals on the road awakened grief and dread associated with satanic ritual abuse; and any form of anxiety or stress led to stuttering, crying hysterically and choking sensations. Worst of all, Storm became convinced that her parents--the people previously associated with nurture, safety and love--had tortured her in unimaginable ways.

Long-Term Impacts
Before she began therapy, Storm's symptoms consisted of minor insomnia and mild anxiety. After Olson's therapy commenced, she experienced migraines, dizziness, backaches, nausea, bowel disturbances and severe insomnia. Olson prescribed lithium, Prozac, Desyrel, Tegretol, Xanax and several migraine medications to address these new symptoms. A decade later Storm reports continued use of psychotropic medications--Prozac, Xanax, Cytomel and a rotation of sleep medications. She continues to experience intrusive images and thoughts and remains unemployed and socially isolated.

Research suggests that Storm's case is not unique. According to a 1996 report of the Crime Victims Compensation Program in Washington State, recovered-memory therapy may have unwanted negative effects on many patients. In this survey of 183 claims of repressed memories of childhood abuse, 30 cases were randomly selected for further profiling. Interestingly, this sample was almost exclusively Caucasian (97 percent) and female (97 percent). The following information was gleaned:

• 100 percent of the patients reported torture or mutilation, although no medical exams corroborated these claims

• 97 percent recovered memories of satanic ritual abuse

• 76 percent remembered infant cannibalism

• 69 percent remembered being tortured with spiders

• 100 percent remained in therapy three years after their first memory surfaced in therapy, and more than half were still in therapy five years later

• 10 percent indicated that they had thoughts of suicide prior to therapy; this level increased to 67 percent following therapy

• Hospitalizations increased from 7 percent prior to memory recovery to 37 percent following therapy

• Self-mutilations increased from 3 to 27 percent

• 83 percent of the patients were employed prior to therapy; only 10 percent were employed three years into therapy

• 77 percent were married prior to therapy; 48 percent of those were separated or divorced after three years of therapy

• 23 percent of patients who had children lost parental custody

• 100 percent were estranged from extended families

Although there is no way to know whether recovered-memory techniques were the sole cause of these negative outcomes, these findings raise profoundly troubling questions about the widespread use of such techniques.

Whereas traditional therapeutic approaches are designed to reduce problematic symptoms, recovered-memory therapy exacerbates symptoms, sometimes intentionally. In a 1993 article, Paul R. McHugh, former director of the psychiatry department at Johns Hopkins University, noted that most patients later diagnosed with multiple personality disorder (MPD) had come to therapists with ordinary psychological symptoms such as problems with relationships or feelings of depression. The therapists, according to McHugh, suggested that there was a deep emotional root for these symptoms and that they were caused by alternative personalities.

After viewing their problems in this new and perhaps interesting way, some patients display repeated shifts of demeanor and deportment on command. Eventually these patients are diagnosed with dissociative identity disorder (DID). In the most recent (2000) version of the American Psychiatric Association's Diagnostic and Statistical Manual, the diagnostic criteria for DID include the presence of at least two distinct identities that frequently take control of a person's behavior. The DSM also states that the average time between the appearance of the first symptom and the diagnosis is six to seven years. Most patients begin therapy with no clear signs of DID, and determination of the disorder comes mostly from a small number of DID "specialists."

In 2004 August Piper, a Seattle psychiatrist in private practice, and Harold Merskey, a professor emeritus of psychiatry at the University of Western Ontario, examined the scientific literature and concluded that there was no compelling evidence that DID is caused by childhood trauma. They reported that the disorder is not reliably diagnosed, that DID cases in children are practically never reported and that recurring evidence of blatant iatrogenesis is seen in the practices of some therapists utilizing recovered-memory methods--for example, calling out alters by name and referring to them as different people. Piper and Merskey concluded that DID "is best understood as a culture-bound and often iatrogenic condition."

In popular culture, books and films may have played a role in turning MPD, and later DID, into a fad. The 1976 made-for-television movie Sybil portrayed the life of a shy graduate student, Shirley Ardell Mason, who was diagnosed with MPD. This compelling movie, based on a 1973 book, won Sally Field an Emmy. Further confirmation of the power of Field's performance may be found in the sharp increase in MPD diagnoses after the release of the book and movie. Before 1973 fewer than 50 cases of MPD associated with child abuse had been reported, but by 1994 the number had soared to more than 40,000.

Mason herself may have been a victim of iatrogenic practices. In 1997 Herbert Spiegel, a psychiatrist who worked with Mason for four years, told an interviewer that Mason's behavior was induced by the suggestive therapeutic techniques of her primary psychiatrist. That revelation has not stopped CBS from producing a remake of the film starring Jessica Lange as Sybil's psychiatrist, which has not yet been scheduled for broadcast.

Neural Restructuring
Decades of behavioral neuroscience experiments using animal models have consistently suggested that trauma and fear can change the architecture of the brain. For example, neuroscientist Bruce McEwen's group at the Rockefeller University has shown that chronic stress alters neuronal complexity in three key areas: the medial prefrontal cortex (involved in working memory and executive function), the hippocampus (involved in learning, memory and emotional processing) and the amygdala (involved in fear and intense emotions) [see box on preceding page].

McEwen found that chronic stress reduces length and branching of dendrites in the brain's medial prefrontal cortex by about 20 percent. This reduction is associated with an impaired ability to shift attention while learning new tasks. In contrast, neurons in the amygdala grow in response to fear. The functions of the brain areas that are affected by fear and stress in animal studies are closely aligned with the symptoms exhibited by recovered-memory patients. Compromised functioning of the prefrontal cortex may be associated with a patient's inability to distinguish reality from fiction, whereas growth of neurons in the amygdala may lead to hypervigilance and suspiciousness. Animal research also suggests that once therapy sessions cease, compromised prefrontal cortex functioning may diminish the ability to inhibit fearful memories.

Although investigations of brain responsiveness in MPD-DID patients are lacking, striking similarities to brain areas known to be affected by fear and stress in animals are found in neuroimaging studies of humans experiencing post-traumatic stress disorder (PTSD). PTSD is classified as an anxiety disorder characterized by recurrent intrusive memories of a past traumatic event; behavioral and cognitive avoidance; and psychophysiological arousal leading to mood disturbances and sleep disturbances--all resulting in functional impairment. Research on PTSD patients has shown diminished responsiveness in the medial prefrontal cortex and heightened activity in the amygdala proportional to the severity of PTSD symptoms.

Guided imagery and reenactments used in recovered-memory therapy may produce PTSD-like symptoms. Harvard University psychologist Stephen M. Kosslyn has found evidence that the same areas of the brain activated when we see an object are activated when we close our eyes and imagine seeing the object. From the brain's perspective, guided imagery could be just as powerful as viewing home movies of abusive events.

The feelings of helplessness associated with recovered-memory therapy may increase the likelihood of negative effects. In animal research conducted in 1967 at the University of Pennsylvania, psychologists Martin Seligman and Steven Maier (Maier is now at the University of Colorado at Boulder) found that when dogs were allowed to escape an aversive shock stimulus, they continued to show motivation to escape in the future. But when dogs were not given an opportunity to escape the traumatic experience, many of them just gave up when exposed to the shock the second time, even when an escape route was provided.

It is difficult to imagine a context in which one would feel more helpless than that of MPD-DID patients learning that alternative personalities, including demonic ones, could emerge at any time. Yet the notion of demonic possession persists to this day among a handful of psychiatrists. Olson conducted an exorcism in the hospital on his patient Cool--complete with a fire extinguisher because he had read that patients sometimes self-combust in these circumstances.

Recovering from Recovered Memories
Storm initially fought her diagnosis of MPD but eventually came to believe it. She was convinced that if she did not continue therapy and accept her "history," her illness would worsen and one of her satanic alters would harm her children. When she finally realized that she had been misdiagnosed, she had nowhere to turn. There are no formal programs or clinics for "deprogramming" the victims of bad psychotherapy, and these victims often find it difficult to trust any potential new therapies.

Although research evidence is lacking, some patients might find relief through antianxiety medications that mitigate intense emotional responses. Others have been helped by behavioral conditioning designed to extinguish alters by ignoring them. These therapies have not been systematically assessed for MPD-DID in large-scale studies, however. McEwen's studies of animals exposed to chronic stress suggest that brain alterations, though physical in nature, could be reversed by medications or by living in a stress-free, enriched environment.

Harvard psychologist Richard McNally suggests that the malleability of memories is a product of the most prized aspects of human intelligence: inference, imagination and prediction. MPD-DID patients exhibit impressive abilities to weave the fragments of fiction and reality revealed in their therapists' offices into the neurobiological fabric of their minds. The development of MPD-DID symptoms appears to be the result of a highly functioning but misdirected mind.

Understanding the science of memory formation and the impacts that emotional experiences have on the brain is critical for refining mental-health therapies. Some long-standing therapeutic practices may need to be reconsidered. For example, research reviewed comprehensively in 2003 by psychologists McNally, Richard Bryant of the University of New South Wales in Australia and Anke Ehlers of King's College London has shown that reliving traumatic memories shortly after a terrifying event--performed in a popular therapeutic technique called crisis debriefing--may cause unnecessary stress and impede recovery.

Columbia University psychologist George Bonanno suggests that it is time to take a fresh look at the different ways individuals adapt to and flourish in the midst of traumatic events. After focusing throughout most of the history of psychology and psychiatry on individuals who do not exhibit natural resilience, it is time to learn more about effective coping strategies. Such endeavors will determine when it is beneficial and when it is harmful for individuals to engage in therapies that provide a constant reminder of traumatic events.

In the case of Storm and patients like her, "forgetting" traumatic events--whether they happened or not--may offer the best chance for regaining mental health. But forgetting may be especially difficult when a legal case remains unresolved. Storm filed a malpractice suit in September 1997. A decade later her case has not gone to trial.