Memories formed very early in life are often unclear or fragmentary, not least because our autobiographical memory system is still developing at that time. Under the age of two years, most events are not stored as explicit verbal memories; although there is evidence that behavioural, or implicit ways of remembering start at a very young age. Childhood trauma memories are no less disturbing for their lack of clarity. They may also consist of apparently unremarkable snapshots, but accompanied by a strong sense of something being wrong. Sometimes very clear memories exist, but lack context in terms of age or location. Other people have sensory or affective memories with little visual content, like the feeling of a heavy body pressing down on them or fear associated with a certain sound or smell. For others, there is no clear memory content but other re-experiencing symptoms that are thematically related to a known trauma, such as nightmares of a figure standing over their bed.
As usual, when memories are unclear, just double-check that there is some form of re-experiencing (intrusive memories, flashbacks, nightmares, emotional and/or physical reactivity to reminders of the trauma) before you progress with PTSD treatment. Childhood traumatic events will certainly be important to any formulation, but if the main presenting problem is something other than PTSD, our treatment approach may differ (for example, it may be the meaning of the events rather than the incomplete memory processing which is more important if memories aren’t re-experienced).
Where there is some trauma memory content that is re-experienced, however fragmentary, this can still be relived and updated as usual. Remember that any updates need to make sense to the person as they were at the time of the trauma, so for early childhood trauma memories these need to be clear and simple, usually accompanied with actions. For example, an abuse memory from the age of four may not benefit from detailed cognitive updates, but a simple message to combat peritraumatic emotions like fear and shame e.g. “I am safe now, I did nothing wrong” accompanied by physical gestures such as a hug (either in imagery or by the client giving themselves a ‘butterfly hug’ while updating).
Memories which are unclear or blurry, or which appear to be composite memories of multiple traumatic events can be worked on by reliving a ‘representative memory’. Exact details of time, place, order of events etc are not important; the key is just to access the important meanings and emotions associated with the memory. For example, a client who was repeatedly locked in a cupboard as a child had intrusive images of being cold and frightened and knocking on the door to be let out. This happened numerous times, so the memory we worked on was not a specific event but one which represented this experience. Reliving this representative memory meant that the feelings of fear and loneliness could be accessed and updated.
Another option is imagery rescripting. This can be particularly helpful for clients who struggle to put words to their experience (perhaps because they were so young at the time or feel too ashamed to articulate what happened – see also this blog post). Again, we bring to mind whatever memory the client can access and then change what happens in ‘the story’. For example, for the client who was locked in the cupboard, he could have grown big and strong and smashed his way out of the cupboard or had a fantastical or real figure come to rescue him. As before, the rescript ideally addresses the need that the client had at the time, like to be safe or comforted. They can also enter the scene as their adult self and intervene as in the classic Arntz and Weertman (1999) protocol, with the help of the therapist or another trusted person as desired. There is evidence that rescripting trauma memories can be effective even if the story changes before the main hotspot; the key is that the relevant emotions have been accessed, so it doesn’t matter if the client has a very limited or unclear memory of what happened.
These various techniques are not mutually exclusive; some combination of them can be used depending on what works for an individual client. Similarly, you may need various attempts at updating or rescripting to address their different needs at the time. If so, don’t worry that you are doing this wrong as a therapist – sometimes it is an important part of processing the trauma memory and all its associated layers of meaning. Just stay curious, collaborative and patient.
Practice points
· Memories from early childhood can be fragmentary, blurred, primarily sensory and/or hard to place in time or location
· To meet criteria for PTSD and be suitable for trauma-focused therapies, memories must be re-experienced in some way so this should be checked
· Early memories, however fragmentary, can still be relived and updated
· Updates should make sense to the person at the age they were at the time of the trauma
· Unclear or composite memories can be relived and updated using a ‘representative’ memory
· Imagery rescripting can be used as an alternative or addition to reliving
References
Arntz, A., & Weertman, A. (1999). Treatment of childhood memories: Theory and practice. Behaviour research and therapy, 37(8), 715-740.