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My client has gaps in their memory of the trauma – what do I do?

Gaps in trauma memories are quite common and can occur for several reasons. There may be an obvious reason, for example if your client lost consciousness during the trauma or they were drugged. In other cases, memories may be present but confused, disjointed or fragmented. This could be due to drugs or alcohol, because the client was overwhelmed with what was happening, or because they dissociated during the trauma, which led to the memory not being encoded and stored properly. Another possibility is psychogenic amnesia i.e. where psychological mechanism prevent them consciously recalling some or all of the trauma memories. You and your client may not always know the reason for the memory gaps to start with, but it will often emerge as you work through the stages below.


Be sensitive to concerns that your client has about any gaps. Some will find it very distressing that they cannot remember what happened, and it is important to elicit their concerns. For example, some people will believe that they should be able to remember and feel annoyed with themselves that they cannot, or will have catastrophic beliefs about what it means that they have memory gaps (e.g. that they have brain damage). In such cases, some normalisation and psychoeducation about memory can be helpful, including that our memory systems do not operate like video recorders – memories (even of important events) are typically incomplete and will include inaccuracies.


Others will worry about what happened during the memory gaps, and may have ‘constructed’ ideas and images of what they think happened. Often these images will be of ‘worst-case’ scenarios and can be very distressing. Constructed images from imagination can even become intrusive in their own right and have a similar power to ‘true’ flashbacks.


It is important to discuss the possibility that your client may remember further details about their trauma through memory work, and consider with them whether they want to pursue this. In most cases, the missing content is no worse than what clients imagine, and from a PTSD perspective, it is usually easier to process a complete memory rather than a fragmented or patchy one. However, neither you nor your client will know what they may re-remember, and in some cases it will lead to more distressing recollections being revealed, so some preparation for this possibility is worthwhile.


After these discussions have taken place, the next step is to ‘map the gaps’. Constructing either a detailed timeline or a written narrative of the trauma will allow you to work out where the are gaps in the memory. When you come across a gap in the story, provide some normalisation, mark it on the timeline or written narrative (and leave space where you can add further details later), and then simply ask ‘what’s the next thing you remember?’ to continue the account.


Very jumbled or confused memories will also benefit from this approach. Using a whiteboard, or typing a document, will mean that you can make changes to the narrative if further details emerge, or re-order the account if needed. The aim is to construct as coherent a narrative as possible that flows with from the start to the end and with the gaps joined into the account.


Further information about the gaps can sometimes be accessed through reliving. Asking the client to bring to mind the moments that they do remember, and then trying to run the memory forward, can sometimes elicit further memories. Drawing the trauma may also help, for example drawing a birds-eye view map of the location, to work out some of the details and to prompt for further memories. Re-enacting the trauma using models (for example toy cars for an accident) or walking the trauma through in imagination (Kaur et al., 2016) can also help with memory retrieval. Lastly, revisiting the scene of the trauma often triggers more memories. The therapist and client can do ‘in vivo reliving’ where they reconstruct the trauma narrative at the site, which often helps fill in gaps, either by triggering memories or by working out what must have happened.


Sometimes, information from the gaps will never be retrieved, especially if the client was unconscious. In these situations, it can be most useful to try to estimate what probably happened during the gaps. Further information can sometimes be accessed from other sources, such as police statements, medical records, or from witnesses. Without such information, the therapist and client may just have to make their ‘best guess’ of how long the gap was, and what most likely happened. This can be added into the timeline or narrative (usually in a different colour or font) to help the account to feel more complete. For example:


…and then everything went dark. I know now that I probably lost consciousness at that point because I had lost so much blood. While I was unconscious, I know that I was taken to the hospital in an Ambulance. From my medical records, I know that the Ambulance arrived at 10.38pm, and we arrived at King’s College Hospital at 10.51pm and I was taken into the medical emergency area. My mum arrived at about 11pm and she tells me that I was still unconscious at that time, but the doctors had put me on a drip and put a dressing the wound. They wheeled me upstairs for a head scan not long after she arrived. Mum says I opened my eyes and started trying to talk to her at about 11.30pm, when they I was back in the medical emergency area. The next thing I remember is seeing my mum. She was holding my hand and crying…


Imaginal reliving can still be used when there are memory gaps. Just relive as you usually would up until the gap, and then fast-forward to the next bit that your client remembers.


Occasionally, our clients have no memory at all of their trauma, although they know it happened. This is rare because re-experiencing of memories is part of the PTSD diagnosis, so it’s worth checking those symptoms carefully if your client reports no memory of what happened.


Sometimes there are fragments of memory from before, during or after the trauma which can be worked on with reliving and updating. Otherwise, their only re-experiencing symptom might be reactivity to triggers (e.g. they report no conscious memory of an assault but flinch when something moves close to their head, or feel suddenly scared when they see someone who looks like their assailant). If so, focus on trigger discrimination.


Practice points:

  • Gaps in trauma memories are common and occur for various reasons

  • Eliciting and discussing concerns that your client has about the gaps is important

  • The gap can then be ‘mapped’ using a timeline or written narrative

  • Further details can often be discovered through reliving, drawing or re-enacting the trauma, or revisiting the site of the trauma

  • Some information will not be retrievable, in which case a ‘best guess’ account can be constructed and added to the timeline or narrative

  • Imaginal reliving can still be used when a memory has gaps

  • If there is no or very limited memory, relive what is there, and use trigger discrimination.


Reference:


Kaur, M., Murphy, D., & Smith, K. V. (2016). An adapted imaginal exposure approach to traditional methods used within trauma-focused cognitive behavioural therapy, trialled with a veteran population. The Cognitive Behaviour Therapist, 9.

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