Journal of Trauma & Dissociation

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Symptoms of Trauma and Traumatic Memory

Retrieval in Adult Survivors of Childhood Sexual
Abuse

Cheryl Malmo PhD & Toni Suzuki Laidlaw PhD

To cite this article: Cheryl Malmo PhD & Toni Suzuki Laidlaw PhD (2010) Symptoms of Trauma
and Traumatic Memory Retrieval in Adult Survivors of Childhood Sexual Abuse, Journal of Trauma
& Dissociation, 11:1, 22-43, DOI: 10.1080/15299730903318467

To link to this article: https://doi.org/10.1080/15299730903318467

Published online: 07 Jan 2010.

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Journal of Trauma & Dissociation, 11:22–43, 2010
Copyright © Taylor & Francis Group, LLC
ISSN: 1529-9732 print/1529-9740 online
DOI: 10.1080/15299730903318467

ARTICLES
1529-9740
1529-9732
WJTD
Journal of Trauma & Dissociation,
Dissociation Vol. 11, No. 1, Nov 2009: pp. 0–0

Symptoms of Trauma and Traumatic

Memory Retrieval in Adult Survivors
of Childhood Sexual Abuse

CHERYL MALMO, PhD

Symptoms
C. Malmo and
of Trauma
T. S. Laidlaw
and Traumatic Memory Retrieval

Edmonton, Alberta, Canada

TONI SUZUKI LAIDLAW, PhD

Halifax, Nova Scotia, Canada

We examined posttraumatic stress symptoms and the memory

retrieval process in 2 groups of adult survivors of childhood sexual
abuse: 29 participants who reported having memories of their
abuse prior to entering therapy (PM) and 13 who reported no
memories of abuse prior to therapy (NPM). Participants were
asked to indicate on checklists symptoms of constriction, hyper-
arousal, and intrusion experienced (a) prior to entering therapy
and (b) during the surfacing of a memory while in therapy. Over-
all, the findings indicate that for both groups the same cluster of
posttraumatic stress symptoms occurred prior to therapy and
during therapy and that there was a continuity of symptoms over
time. Participants were also asked to fully describe details of their
traumatic memories as these details emerged prior to and/or
during therapy. We determined that (a) there were striking
similarities in the detailed recall of trauma memories for both
groups; (b) memories of abuse emerged in substantial perceptual,
somatic, and emotional detail over time before developing into a
narrative; (c) the amount of detail remembered increased in the
PM group during therapy; (d) members of the NPM group were
more kinesthetic than visual in their orientation to the world and

Received 19 January 2009; accepted 1 April 2009.

Address correspondence to Cheryl Malmo, PhD, 9806 89th Avenue, Edmonton, Alberta,
Canada T6E 2S4. E-mail: cmalmo@shaw.ca

22
 Symptoms of Trauma and Traumatic Memory Retrieval 23

may not have had access to the visual information that would
associate their symptoms to their abuse; and (e) triggers of
traumatic memories were largely the result of internal rather than
external stimuli, and these triggers happened primarily outside of
therapy sessions.

KEYWORDS posttraumatic stress disorder, trauma symptoms,

adult survivors of childhood sexual abuse, traumatic memory
retrieval

INTRODUCTION

To study the consequence of childhood sexual abuse (CSA) and the process
of retrieving traumatic memories, we developed a survey, “Symptoms of
Trauma and the Memory Retrieval Process,” designed for adult survivors in
therapy. Given that retrieved traumatic memory has generated controversy
in the scientific community, we chose to compare results between two
groups: individuals who reported having memories of sexual abuse prior to
entering therapy (PM) and those who reported having no memories of
abuse prior to therapy (NPM). This article describes our findings.
The effects of CSA in adult survivors are reflected in symptoms of post-
traumatic stress disorder (PTSD). The Diagnostic and Statistical Manual of
Mental Disorders (4th ed. [DSM–IV]; American Psychiatric Association, 1994)
outlines the criteria for PTSD as follows: (a) a traumatizing event, usually
involving bodily injury or threat to life; (b) intrusive reexperiencing of symp-
toms; (c) generalized numbing of responsiveness; and (d) physiological reac-
tivity. Herman (1992) identified three types of complex PTSD symptoms:
hyperarousal (the persistent expectation of danger), constriction (the numb-
ing response of surrender), and intrusion (the indelible imprint of the trau-
matic moment). She detailed numerous ways in which each type of symptom
can manifest in cases resulting from continuous and repeated abuse. Explain-
ing that after a traumatic incident, the physiological arousal system of self-
preservation goes into permanent alert, Herman cited Kardiner, who used the
term physioneurosis to describe the psychosomatic complaints that, like other
hyperarousal behaviors, result from chronic arousal of the autonomic nervous
system. When people find themselves completely helpless, the self-preservation
system shuts down entirely—constricts. Escape is experienced by a change in
consciousness, the most severe aspect of which is dissociation, considered to
be a reliable predictor of chronic PTSD (D. Brown, Scheflin, & Hammond,
1998). Intrusion is experienced when constriction fails and aspects of the trau-
matic memory leak into consciousness.
Unlike the DSM–IV, which focuses on single-incident trauma, Herman
(1992) differentiated two types of PTSD: simple (resulting from single-incident
24 C. Malmo and T. S. Laidlaw

trauma) and complex (resulting from continuous and repeated abuse, such
as often occurs in childhood). With complex PTSD, symptoms can be
chronic and persistent and can involve severe memory disturbance, both
hypermnesic and amnesic (Horowitz & Reidbord, 1992). D. Brown et al.
(1998) outlined research documenting the existence of functional amnesia
in survivors of CSA, including studies by Cameron (1996), Draijer (1990),
Ensink (1992), Herman and Schatzow (1987), and Roe and Schwartz (1996).
Terr (1991) divided childhood trauma into two basic types: Type I includes
full, detailed memories, “omens,” and misperceptions; and Type II includes
denial and numbing, self-hypnosis, dissociation, and rage. Freyd (1996)
proposed a two-dimensional model of trauma in which terror results in the
hyperarousal aspects of PTSD symptoms, and betrayal by a parent or trusted
caregiver results in the amnesia aspect of constriction symptoms.
Critics of the concept of traumatic amnesia have held therapists respon-
sible for implanting memories of abuse in unsuspecting clients. However,
Williams’s (1994) prospective study on memory in survivors of CSA deter-
mined that even in cases when abuse had been documented in medical
records, women had amnesia for their abuse. She concluded, “Having no
memory for childhood sexual abuse is a common occurrence” (p. 1173).
Freyd’s investigation and reanalysis of Williams’s and others’ papers deter-
mined that amnesia rates were higher for survivors who had been abused
by a family member (Sivers, Schooler, & Freyd, 2002). Fergusson, Horwood,
and Woodward (2000) determined that the unreliability of the reporting of
child abuse is due not to false reports by people who were not abused but
to people who were abused often providing false-negative reports.
Although there has been considerable debate regarding amnesia for
CSA, trauma experts agree that memory disturbance resulting from extreme
trauma is best described as dissociation, a concept first used by Janet
(1904). Putnam (1989) defined dissociation as “a normal process that is
initially used defensively by an individual to handle traumatic experiences
and evolves over time into a maladaptive or pathological process” (p. 9).
The DSM–IV (American Psychiatric Association, 1994) defines dissociative
amnesia as “episodes of inability to recall important personal information,
usually of a traumatic or stressful nature, that is too extensive to be
explained by ordinary forgetfulness” (p. 481). Phillips and Frederick (1995)
conjectured that at the extreme end of the dissociation continuum traumatic
memory is not simply forgotten, it does not even register in the conscious
mind because it is stored in a different part of the brain and is assigned to
different aspects of the personality—ego-states.
Current research has explored the different functions of dissociation
(R. J. Brown, 2006; Sar & Ozturk, 2007) and provides new perspectives with
implications for trauma treatment. We have discussed elsewhere how the
natural ability to dissociate, in addition to being a coping strategy, can be
used for healing in psychotherapy, for example when one imagines a safe
 Symptoms of Trauma and Traumatic Memory Retrieval 25

place in the mind (Malmo & Laidlaw, 1996). Van der Hart and Nijenhuis (as
cited in D. Brown et al., 1998) identified several types of secondary dissoci-
ation to account for partial amnesia for trauma and for the way in which
traumatic memory can be divided into BASK components (behavior, affect,
somatosensory, kinesthetic). Van der Hart (as cited in Van der Kolk, 1996)
also described tertiary dissociation, which allows people to maintain a sense
of self while separate states of mind process the traumatic event. Nijenhuis,
Van der Hart, and Steele (2004) theorized that structural dissociation is the
phenomenon at the basis of alter personalities in dissociative identity disor-
der. It is generally agreed that traumatic dissociation is an unconscious and
automatic process that disconnects the conscious mind from a traumatic
experience when a person’s cognitions and feelings are overwhelmed,
thereby protecting the individual by causing amnesia. Only when amnestic
persons are safe enough or when a circumstance reminiscent of the trauma
triggers the memory does dissociation begin to break down and memory
begin to return (Grassian & Holtzen, 1996, as cited in D. Brown et al., 1998).
Sivers et al. (2002) defined recovered memory as “the recollection of a
memory that is perceived to have been unavailable for some period of time”
(p. 169). Rossi (1986) proposed that traumatic memory, when dissociated
from consciousness, is state dependent (the origin of symptoms is embedded
in emotional and somatic states), is centralized in the limbic–hypothalmic
system (the link between mind and body), and therefore is often only
retrievable when the person is in the same emotional state as he or she was
when traumatized. Consistent with this theory, Van der Kolk (1996) argued
that traumatic memory is organized differently from ordinary memory as
implicit and perceptual rather than explicit and narrative. D. Brown et al.
(1998) outlined numerous studies (Cameron, 1996; Davies & Frawley, 1994;
Kristiansen, Felton, Hovdestad, & Allard, 1995; Roe & Schwartz, 1996; Van
der Kolk & Fisler, 1995) that have reported the return of traumatic memory
as sensory (flashbacks, somatic experiences, images, dreams, sudden and
intense feelings, fragments, reenactments, avoidant behaviors) rather than
narrative. According to Van der Kolk and Fisler, narrative memory emerges
over time for most people only after the emergence and gradual integration
of sensory memory.
Brewin, Dalgleish, and Joseph (1996) and Brewin (2001) proposed a
dual representation theory of PTSD that involves two separate processing
systems for trauma: (a) verbally accessible memory, which allows for delib-
erate and conscious recall of limited aspects of trauma; and (b) situationally
accessible memory, which involves visual, sensory, physiological, and
motor reenactment of trauma memory. Situationally accessible memory is
accessed spontaneously or unconsciously via external or internal stimuli
and involves far more detailed and extensive memories, with emotions
being reexperienced at their original intensity. Not only do these two systems
result in qualitatively different memories, but situationally accessible memories
26 C. Malmo and T. S. Laidlaw

are more voracious and remain intact because of hormonal effects experi-
enced with acute trauma that diminish neural activity in conscious process-
ing while enhancing nonconscious perceptual and memory processing.

METHOD
Participants
In our previous research (Laidlaw & Malmo, 1995), 143 participants (ages
20–64) from across Canada and the Northwest Territories were identified by
82 therapists as being survivors of CSA. These participants gave multiple
reasons for entering therapy: psychological issues—depression, anxiety, over-
whelming sadness or fear, feeling something was wrong or missing, severe
dissociation, suicidal thoughts or urges, rage, low self-esteem; awareness of
having been sexually abused; relationship issues—marriage problems,
abusive relationship, parenting difficulties; crisis issues—feeling unable to
cope, feeling out of control, problems with school or career, previously failed
treatment, suicide attempt, physical illness, sexual abuse of own child;
seeking support for healing; concerns about possible sexual abuse due to
flashbacks, obsessive thinking, awareness of physical abuse; recommenda-
tions to get help; addiction issues. We contacted the 78 participants who had
agreed to follow-up contact and invited them to take part in this study. Of the
47 who responded, 5 were eliminated because of incomplete surveys, leaving
a total of 42 respondents (41 women, 1 man). Names and identities of partici-
pants were coded to ensure anonymity. All participants gave informed consent.
The project was vetted and approved by the Human Ethics Committee, Faculty
of Graduate Studies, Dalhousie University.
Because traumatic memories retrieved in therapy have been controver-
sial, we compared responses of participants who reported having had
conscious memories of CSA prior to entering therapy (PM; n = 29) with
those of participants who reported having no memories of CSA prior to
therapy (NPM; n = 13).

Survey
The survey consisted of four parts: (a) updated demographic background
and therapeutic experiences of participants; (b) awareness of experiences of
CSA and perpetrators prior to entering therapy; (c) symptoms of trauma
experienced prior to therapy and during the course of memory retrieval in
therapy, details of how traumatic memories emerged during the course of
therapy, and triggers of memories; and (d) the role of the therapist in mem-
ory retrieval. This article focuses on the results obtained from part (c).
Based on Herman’s (1992) descriptions, we developed a checklist of
posttraumatic stress symptoms within three categories: (a) constriction
 Symptoms of Trauma and Traumatic Memory Retrieval 27

(including dissociation), (b) hyperarousal (including medical/physical

symptoms of somatization), and (c) intrusion. Participants indicated which
symptoms they experienced (a) prior to entering therapy and (b) during the
surfacing of a memory while in therapy. In response to a series of open-
ended questions, participants described in detail the emergence of one
traumatic memory recalled prior to entering therapy (if applicable) and one
recalled during the course of therapy. They also described the trigger(s) of
their memory and indicated where the trigger(s) occurred—in a therapy
session, outside of therapy, or both.

Analysis
The quantitative component of the study focused on the symptoms experi-
enced by participants prior to and during therapy. Because numbers were
small, no significant differences were found using standard methods of
statistical analysis. Therefore, we used only percentages to compare symp-
toms of constriction, hyperarousal, and intrusion.
The qualitative component provided for an in-depth examination of the
emergence of participants’ traumatic memories. We categorized responses
according to the kind of sensory material that was reported:

1. Context—aspects of the environment in which the abuse occurred.

2. Images—visual pictures in the mind.
3. Sensations—all sensory information other than images or sounds.
4. Feelings—emotional state of the survivor and perpetrator.
5. Behaviors—actions, words, or sounds of the survivor and perpetrator.
6. Cognitions—recollections of thoughts, meanings, intentions, intuitions.
7. Narratives—descriptions of what happened over time, including events
preceding the abusive incident, the abusive experience itself, and events
following the abusive incident.

We also analyzed triggers that precipitated the emergence of a memory,

categorizing them as internal (originating inside the participant) or external
(originating outside in the environment) and as simple (single) or complex
(multiple). We compared the results between groups for details of traumatic
memory and triggers of them, and we compared the memories of the PM
group prior to and during therapy.

RESULTS
Demographic Information
Certain differences were noted between the NPM group (n = 13) and PM
group (n = 29). Specifically, 54% of the NPM group had received a graduate
28 C. Malmo and T. S. Laidlaw

degree compared to 21% of the PM group, 62% of the NPM group had full-
time employment outside the home compared to 28% of the PM group, and
8% of the NPM group made less than $20,000 per year compared to 41% of
the PM group.

Complex Posttraumatic Stress Symptoms

Constriction. Large numbers of participants in both groups indicated
that they experienced constriction symptoms prior to as well as after enter-
ing therapy (see Figure 1). The most obvious difference between the
groups was that all members of the NPM group reported total amnesia
before therapy, whereas almost two thirds of the PM group reported partial
amnesia for details related to sexual abuse and for associated feelings. In
the NPM group, total amnesia completely disappeared during therapy; in
the PM group, amnesia for memory details dropped dramatically (from 62%
to 2%), but amnesia for feelings remained relatively high (41%). Approxi-
mately half of participants in both groups reported generalized amnesia for
childhood prior to therapy that decreased during therapy. Experiences
related to dissociation were consistently reported in greater numbers by the
NPM group before therapy. An altered sense of time was reported in greater
numbers by both groups during therapy compared to prior to therapy, and
this increase was most dramatic for the NPM group. Although there was a
decrease in the reporting of emotional constriction for both groups, the
decrease was greater for the PM group.
Hyperarousal. Large numbers of participants in both groups reported
many hyperarousal symptoms—including anxiety, hyperalertness, startle
responses, extreme reactivity, medical/physical symptoms, sleep problems,
panic attacks, phobias, and explosive anger—both before entering therapy
and during the surfacing of traumatic memories in therapy (see Figure 2).
Anxiety was consistently reported by a greater percentage of participants in
the PM group than in the NPM group at both time periods—83% compared
to 62% prior to therapy and 86% compared to 69% during therapy, respec-
tively. Medical/physical symptoms included a variety of gastrointestinal
problems (nausea, gagging, choking, stomach pains, rectal bleeding) as well
as psychogenic, muscular, neurological, gynecological, respiratory, and
cardiovascular problems. Changes in medical/physical symptoms during
therapy were noteworthy: Symptoms decreased in the PM group (from 72%
to 59%) but doubled in the NPM group (from 46% to 92%). Another
noteworthy change was the reduced reporting of phobias by the PM group
during therapy compared to prior to therapy.
Intrusion. Large numbers of participants in both groups for both time
periods indicated numerous symptoms of intrusion, including overwhelming
feelings of sadness or pain, fear or terror, guilt or shame, and anger or rage;
visual intrusions—flashbacks, dreams, nightmares; intrusive thoughts and
 Symptoms of Trauma and Traumatic Memory Retrieval 29

FIGURE 1 Complex posttraumatic stress symptoms: constriction. PM, n = 29; NPM, n = 13.
PM = participants who reported memories of abuse prior to entering therapy; NPM = partici-
pants who reported no memories of abuse prior to entering therapy.

words; kinesthetic intrusions—body sensations and intrusive smells, tastes,

and sounds; and compulsive urges, compulsive reenacting, and risk-taking
behaviors (see Figure 3). A notable difference was the decreased reporting
of overwhelming sadness or pain in the NPM group after entering therapy
(from 62% to 38%) and the increased reporting of overwhelming fear or
terror (from 46% to 85%). The number of participants in the PM group who
reported these symptoms remained constant at about 66%. A notable
increase for both groups was the increased reporting during the surfacing of
memories in therapy of intrusive images (NPM: from 23% to 69%; PM: from
30 C. Malmo and T. S. Laidlaw

FIGURE 2 Complex posttraumatic stress symptoms: hyperarousal. PM, n = 29; NPM, n = 13.
PM = participants who reported memories of abuse prior to entering therapy; NPM = partici-
pants who reported no memories of abuse prior to entering therapy.

45% to 76%) and intrusive body sensations (NPM: from 15% to 69%; PM:
from 38% to 66%). A somewhat decreased reporting of compulsive urges
and behaviors was seen for both groups during therapy.

Memory Content
Comparisons of memory detail (context, images, sensations, feelings,
behaviors, cognitions, narratives) revealed that a great amount of detail was
 Symptoms of Trauma and Traumatic Memory Retrieval 31

FIGURE 3 Complex posttraumatic stress symptoms: intrusion. PM, n = 29; NPM, n = 13.
PM = participants who reported memories of abuse prior to entering therapy; NPM = partici-
pants who reported no memories of abuse prior to entering therapy.

recalled by the PM group before entering therapy and by both groups dur-
ing therapy. A comparison of the PM group’s memories before and during
therapy revealed an overall increase in details remembered during therapy.
A comparison between the PM and NPM groups’ memories during therapy
revealed a similar pattern of reporting numerous details for memory content
in all categories, with little variation.
Context. The place or environment in which the abuse occurred was
the aspect of context most often recalled (by more than four fifths of both
groups during therapy), followed by the time of day or year, clothing of self
32 C. Malmo and T. S. Laidlaw

FIGURE 4 Details of memory content: context. PM, n = 29; NPM, n = 13. PM = participants
who reported memories of abuse prior to entering therapy; NPM = participants who reported
no memories of abuse prior to entering therapy.

and of the perpetrator, awareness of others, voices of others, and sounds

from the environment (see Figure 4).
Images. The majority of participants reported seeing images of them-
selves, followed by images of the perpetrator, body parts, the perpetrator’s
facial expression, themselves naked, the perpetrator naked, and symbolic
images (such as a snake representing a penis; see Figure 5).
 Symptoms of Trauma and Traumatic Memory Retrieval 33

FIGURE 5 Details of memory content: images. PM, n = 29; NPM, n = 13. PM = participants
who reported memories of abuse prior to entering therapy; NPM = participants who reported
no memories of abuse prior to entering therapy.

Sensations. Relational position (such as whether the perpetrator was

approaching from the left or right side or was experienced as being above
or beside) was consistently reported by about three fourths of participants
across groups. However, there was a striking difference in the reporting of
kinesthetic memory. For the PM group, reporting of kinesthetic memory
34 C. Malmo and T. S. Laidlaw

FIGURE 6 Details of memory content: sensations. PM, n = 29; NPM, n = 13. PM = partici-
pants who reported memories of abuse prior to entering therapy; NPM = participants who
reported no memories of abuse prior to entering therapy.

doubled from 38% prior to therapy to 76% during therapy, whereas 100% of
the NPM group reported kinesthetic memory. The reporting of sense of size
of self and smell followed a similar pattern of increased reporting. Only a
small number of the PM group reported remembering taste and only during
therapy (see Figure 6).
Feelings. There was an almost identical reporting of feelings by both
groups at both time periods: More than four fifths of participants reported
their own feelings (“fear,” “terror,” “pain,” “confusion,” “guilt,” “shame,”
“sadness,” etc.), and one fifth reported their perpetrator’s feelings (“anger,”
“hate,” “friendly,” “loving”).
Behaviors. The behavior of the perpetrator was consistently reported
by more than three fourths of participants in all cases, and the voice of
 Symptoms of Trauma and Traumatic Memory Retrieval 35

FIGURE 7 Details of memory content: behaviors. PM, n = 29; NPM, n = 13. PM = partici-
pants who reported memories of abuse prior to entering therapy; NPM = participants who
reported no memories of abuse prior to entering therapy.

the perpetrator was consistently reported by more than half in all cases.
The most notable differences were in the PM group’s increased reporting
of their own behavior, dissociation, resistance, and vocalizations during
therapy compared to prior to therapy and the NPM group’s even greater
reporting of their own resistance and verbalizations/vocalizations (see
Figure 7).
Cognitions. More than four fifths of the NPM group and the PM
group before therapy reported the identity of the perpetrator. There was
a slight drop in awareness of the abuser’s identity for the PM group after
entering therapy, reflecting the awareness of additional perpetrators.
Their own age at the time of the abusive incident was reported by two
thirds or more of the participants in all cases. Other aspects of cognitions
reported in similar numbers were beliefs, intentions, intuitions, an
36 C. Malmo and T. S. Laidlaw

FIGURE 8 Details of memory content: cognitions. PM, n = 29; NPM, n = 13. PM = partici-
pants who reported memories of abuse prior to entering therapy; NPM = participants who
reported no memories of abuse prior to entering therapy.

awareness of power difference, and threats and intimidation by perpetra-

tors (see Figure 8).
Narratives. More than half of participants recalled the beginning of the
narrative in all cases. The middle of the story—the abusive incident itself—
was recalled by 79% of the PM group before therapy, which increased to
88% during therapy, compared to 92% of the NPM group. Although only
28% of the PM group described the end of the incident in the memory
recalled prior to therapy, their reporting increased to 64% during therapy
compared to a similar reporting of 62% by the NPM group.
 Symptoms of Trauma and Traumatic Memory Retrieval 37

Triggers
Triggers of memories of abuse were categorized as internal (kinesthetic,
images, repetitive thoughts, dreams, nightmares, spontaneous) or external
(context, talking about abuse, hearing about abuse in media, seeing the
perpetrator, being touched, being raped) and as single or multiple.
Although some categories are self-explanatory, others require explanation.
A kinesthetic trigger refers to body sensations or experiences such as bleed-
ing, bruising, legs twitching, throat filled with phlegm, chest constricted,
feeling cold, and other similar experiences. A context trigger refers to envi-
ronmental factors, such as time of day or year, quality of the light, details of
a particular room, or an object or an animal related to the abuse.
For the PM group prior to therapy, triggers were largely external
(talking about abuse, context, perpetrator, media), and during therapy they
were largely internal (kinesthetic, dreams, nightmares, and relaxation with
image or kinesthetic sensations). Single and multiple triggers were reported
about equally by the PM group, and multiple triggers most often involved
context. In the NPM group, the majority of participants reported single inter-
nal triggers (kinesthetic), and when multiple triggers were reported they
included kinesthetic sensations.
Finally, for the time period during therapy, 85% of the PM group indi-
cated that their memory was triggered outside of therapy, 7% indicated that
triggers occurred during therapy, and another 7% indicated that triggers
occurred both outside of and during therapy. A similar finding for the NPM
group was even more dramatic: 92% indicated that their memory trigger
was located outside of therapy.

DISCUSSION
Posttraumatic Stress Symptoms
This article has presented the results of a study that examined symptoms of
complex posttraumatic stress. Participants who reported memories of abuse
prior to entering therapy (PM group) and those who reported no conscious
memory of abuse prior to entering therapy (NPM group) experienced many
similar complex posttraumatic stress symptoms of three types—constriction,
hyperarousal, and intrusion—before entering therapy. These numerous sim-
ilarities indicate that regardless of whether survivors of CSA had conscious
memories of having been abused prior to entering therapy (i.e., whether
they were amnestic for the abuse incidents), they have experienced many of
the same kinds of symptoms.
After entering therapy, both the PM and NPM groups continued to
experience the same symptoms during the surfacing of traumatic memory,
with anxiety remaining high for both groups. This suggests that particular
38 C. Malmo and T. S. Laidlaw

symptoms that may have brought people into therapy may continue to
occur during the therapeutic process while trauma memories are entering
consciousness and being worked through. The decreased reporting of
amnesia and other constriction symptoms is consistent with the increased
reporting by both groups of intrusive symptoms. This change is to be
expected, given that a goal of therapy is to reconnect people to their disso-
ciated memories. These results are consistent with the findings of Cameron
(1996) that many symptoms of trauma increase with memory recovery.
The reporting of total amnesia for CSA prior to therapy by the NPM
group and partial amnesia by the PM group supports findings (Draijer, 1990;
Ensink, 1992; Harvey & Herman, 1994; Herman & Schatzow, 1987) that
amnesia for abuse is not an either/or phenomenon and can involve partial
amnesia. That amnesia for details of the abuse dropped dramatically but
amnesia for feelings remained high in the PM group suggests that connecting
to feelings associated to CSA is more difficult than knowing cognitively that
abuse has occurred.
Being aware of their sexual abuse and being generally more symptomatic
may have interfered with achievement in the PM group, whose members
reported a lower level of education and income than those of the NPM
group. This result supports the findings of Grassian and Holtzen (1996; as
cited in D. Brown et al., 1998), who determined that dissociation could
provide for a higher level of functioning in those survivors of abuse who
coped by internalizing their trauma compared to those who externalized,
remembered, and consistently experienced problems, including conduct
and addictive behaviors as well as lower grades in school. About those
people who successfully dissociate their memories from consciousness for a
period of time, Grassian and Holtzen concluded, “We are able to view both
the adaptive function of the failure to remember—the avoidance of
overwhelming, disorganizing affect—and also the heavy price the individual
pays for such a defensive adaptation—emotional constriction, numbing, and
compulsivity” (as cited in D. Brown et al., 1998, p. 174).
Once in therapy, the NPM group reported more changes in symptoms
than the PM group—a decrease in emotional numbing, a sense of some-
thing missing, and generalized amnesia for childhood—which suggests that
in therapy they were reconnecting with their past experiences. There was
also a decreased reporting of dangerous, risk-taking behavior, suggesting
that during therapy they were learning to take care of themselves and to
express feelings and needs appropriately. At the same time, certain negative
symptoms increased dramatically for this group, including medical/physical
symptoms, overwhelming fear and terror, intrusive images and flashbacks,
and intrusive body sensations. These findings suggest that for those trauma
survivors who are most dissociative, particular symptoms may increase as
the trauma is reassociated. This result supports the findings of Grassian and
Holtzen (1996; as cited in D. Brown et al., 1998) that for severely amnestic
 Symptoms of Trauma and Traumatic Memory Retrieval 39

people, remembering trauma can precipitate an emotional crisis that results

in those people becoming more symptomatic.
Almost three quarters of the PM group reported medical/physical
symptoms prior to entering therapy, and this number decreased a little after
groups entered therapy, whereas in the NPM group the numbers doubled
from 46% to 92%. The high reporting of medical/physical symptoms high-
lights the prevalence of somatization, which has long been understood to
be an indicator of posttraumatic stress. Van der Kolk, McFarlane, and Weisaeth
(1996) identified numerous studies that have linked somatization to childhood
sexual or physical abuse, dissociation, and PTSD. They concluded,

Traumatized patients come to experience emotional reactions merely

as somatic states, without being able to interpret the meaning of what
they are feeling. Unable to “know” what they feel, they become prone
to undifferentiated affect storms and psychosomatic reactions which
are devoid of personal meaning and cannot lead to adaptive
responses. (p. 60)

It would appear that the group with no conscious memory of having been
abused prior to therapy became overwhelmed by the realization that they
had been abused (and, according to Freyd, 1996, that they had been
betrayed) and that their distress was converted into physical pain and
medical problems.

Traumatic Memory Retrieval

The most striking aspect of the participants’ descriptions of their abuse
memories was the amount and quality of detail that was remembered.
Participants in both groups were able to recall a great deal of detail in every
category, with the amount of detail increasing for the PM group once partic-
ipants were in therapy. The vast majority of memory detail described by
participants in all cases was perceptual. These results support the position
of Van der Kolk and Fisler (1995) that trauma is initially remembered as
somatosensory information and emotional flashbacks—that traumatic
experiences are remembered intrinsically in the body. The results are also
consistent with the view that traumatic memory is organized differently
from ordinary memory as implicit and perceptual rather than explicit and
narrative (Van der Kolk, 1996).
Somatosensory memory is primal and is typical of infants and young
children who do not yet have the cognitive structures with which to contex-
tualize their experiences. That the majority of participants in all cases
recalled their relational position with respect to the perpetrator is not
surprising, then, because differentiating the self in relation to others is one
of the earliest developmental tasks of an infant. Our results support
40 C. Malmo and T. S. Laidlaw

Herman’s (1992) supposition that “in their predominance of imagery and

bodily sensation, and in their absence of verbal narrative, traumatic memo-
ries resemble the memories of young children” (p. 38).
That traumatic memory is different from ordinary memory is substanti-
ated by research that used mental imaging to demonstrate that different
parts of the brain fire during the recalling of autobiographical narratives
than fire during the experiencing of traumatic flashbacks (Ogden, Minton, &
Pain, 2006; Van der Kolk & Fisler, 1995; Van der Kolk et al., 1996).1 This is
significant because research that claims that false memories can be
suggested has demonstrated only that narrative memory, not traumatic
memory, can be manipulated (D. Brown et al., 1998).
It has already been established that adults who have experienced more
severe trauma and who possess a greater ability to dissociate have less
conscious awareness of having been abused in childhood (Brown et al.,
1998). Chu, Frey, Ganzel, and Mathews (1999) found that being abused at
an early age and being abused frequently was associated with higher levels
of dissociation. Freyd determined that the element of betrayal is another fac-
tor affecting level of amnesia (Sivers et al., 2002). Our research may have
uncovered another factor that can assist in understanding why some people
are aware of having been sexually abused in their childhoods whereas
others remain largely dissociated from their traumas. The 100% reporting of
kinesthetic memory detail by the NPM group suggests that people with no
conscious memories of having been abused prior to entering therapy (but
with numerous other trauma symptoms similar to those experienced by
people with conscious memories) may be more kinesthetic in their orienta-
tion to the world. This group’s dramatic increased reporting (92%) of
medical/physical symptoms during therapy as dissociation was reversed
seems to be congruent with this interpretation—traumatic memories were
experienced physically, and unresolved trauma manifested somatically.
Conversely, it may be that participants with conscious awareness of their
abuse prior to therapy are more visual. Perhaps the PM group was aware of
having been abused because they had images of their trauma and thus
“knew” what had happened to them. During memory retrieval in therapy,
most participants in both groups reported the perpetrator’s facial expres-
sion, body parts, voice, behaviors, and identity. It is this crucial information
that the NPM group members did not have prior to entering therapy in
order to conclude that they had been abused.
Participants generally explained that their memory detail emerged as
symptoms and fragments over long periods of time, from days to months
(and for initial memories even years), and only became a narrative at the end
of the remembering process when fragments merged. There was a dramatic
increase in reporting of the end of the narrative in memories described dur-
ing therapy compared to prior to therapy for the PM group. This suggests
that safety and support in the therapeutic relationship enables people to stay
 Symptoms of Trauma and Traumatic Memory Retrieval 41

with or tolerate the recollection of a traumatic memory to its completion, that

is, through the process of gathering together fragments of emotional and
sensory material until a complete narrative emerges into consciousness.
The differing nature of memory triggers for the groups is interesting.
For the PM group, the movement from primarily multiple to single triggers
suggests that once in therapy these participants were working more quickly
with their initial memory indicators. The movement from primarily external
to internal triggers in this group suggests that participants were in the
process of learning to work with the emerging material from their uncon-
scious minds and bodies rather than simply reacting to events from the
environment, as they had done prior to therapy.
That the members of the NPM group primarily indicated single triggers
suggests that they may be less likely to be flooded with intrusive symptoms, or
that they were continuing to dissociate, or that their greater kinesthetic aware-
ness allowed for keener focus. Their reporting of primarily internal triggers
(arising from their own somatic and affective experience) is consistent with
their 100% reporting of kinesthetic memory during traumatic memory retrieval
in therapy and their 92% reporting of somatic symptoms during therapy.
Finally, the vast majority of participants in both groups reported that trig-
gers of their memory occurred outside of therapy, challenging those who
claim that retrieval of traumatic memory is the result of suggestions by thera-
pists. This finding supports Chu et al. (1999), whose participants generally
reported recovering their memories at home, alone, or with family or friends.

CONCLUSION

Our findings indicate that the same cluster of posttraumatic stress symptoms
occurs in adult survivors of CSA prior to therapy and during the course of
therapy whether they report having awareness of their abuse prior to therapy
or no awareness of abuse. In other words, psychological consequences of
abuse are evidenced prior to as well as during therapy whether or not the
survivors are aware of the origin of their symptoms. Although the numbers
are too small to draw any definitive conclusions, the results also suggest
that people with no conscious awareness of having been abused prior to
therapy, despite exhibiting numerous severe PTSD symptoms, may be more
kinesthetic than visual in their perceptual orientation and may be missing
the visual memory fragments that would provide them with knowledge of
having been abused.
For both those people who had memories of abuse prior to entering
therapy and those who reported none, memories of abuse emerged in
substantial perceptual, somatic, and emotional detail over time before devel-
oping into a narrative. Greater detail and a more complete narrative were
reported by the PM group after entering therapy compared to before. Triggers
42 C. Malmo and T. S. Laidlaw

for memories were more internal than external for both groups, demonstrat-
ing that retrieved memories of abuse emerge primarily from the mind–body
of survivors of abuse and not from the environment. This is especially the
case for individuals with no conscious memories of their abuse before ther-
apy, who appear to be largely kinesthetic in their perceptual orientation. This
result challenges the position of critics who argue that retrieved memories are
necessarily suspect and arise from suggestions by the therapist.

NOTE

1. Traumatic flashbacks involve emotional and sensory aspects of the traumatic experience,
including visual images and auditory, olfactory, and kinesthetic sensations.

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