An exploration of the relationship between memory, memory formation, and the client’s worldview within a counselling context: A case of posttraumatic stress disorder.

Memory is a complex connective system facilitating the learning and retrieval of behavioural, emotional, and cognitive information. Its multifaceted web design works synergistically to perform numerous tasks, allowing humans to make sense of their experiences (Lynch, 2021). Memories are malleable, factual pieces of information that are processed through a series of mental structures to be stored for retrieval. The first structure, short-term memory, holds limited information (such as the name of the person you just met). Auditory and visual observations in our current environment are evaluated in the working memory but is only available for a short period of time unless it is consciously examined and interpreted. Doing so will store information in the relatively permanent long-term memory (Sigelman et al., 2022). The process of continually recalling information in working memory will enhance the connective pathways in both implicit (non-declarative and non-conscious) and explicit (declarative and conscious) long-term memory. Implicit memory facilitates procedural cognitions, priming of information, and habitual patterns by using past experiences to automize skills without conscious awareness. Explicit memory information is voluntarily retrieved whether it is semantic (factual, general knowledge) or episodic (experiential) (Bouyeure & Noulhiane, 2020). Episodic memories form a person’s interpretation of themselves through their personal schemas. This is a collaboration of past reactions and experiences which operate to form future episodic thoughts in relation to oneself (Rubin, 2014). This can also be conferred as autobiographical memory and it is built on the imagination, socio-cultural expectations, and post-event experiences of someone to form meaning and context to their situations. Subsequently, they are vulnerable to influence from misinformation and false memories, especially for people with posttraumatic stress disorder (Porter et al., 2014; Monds et al., 2016). The counsellor’s role is to interpret the way a person makes sense of these memories to help them detach and heal from the event. A person’s ability to recall information from their memory will directly influence the success of counselling therapy given the specific necessity of a certain degree of self-awareness required to make changes within oneself (Schweizer & Dalgleish, 2016). Using a figurative case study, this essay will explore the aforementioned memory systems and influencers of memory can be interpreted within a counselling context. Further, the implications of memory deficits in a counselling setting and how to adhere to deficit sensitive practices will conclude the body of this essay. The essay will end with a summarised conclusion of memory, memory formation, and the client’s life story in a counselling context.

Adam is a 35-year-old Prison Officer. He is currently on leave from work after having to respond to an incident that has left him feeling easily agitated, unable to sleep, and struggling to concentrate. After being diagnosed with posttraumatic stress disorder (PTSD), Human Resources staff have recommended he seek counselling to assist with working through these atypical behaviours and emotions. Adam has been a Prison Officer for eight years and throughout that time, has been the mediator for a number of disputes between prisoners; having to respond to a variety of prisoner injuries both self-inflicted and inflicted by others. He works a rotating roster with five consecutive overnight shifts every 6-weeks and often stays back for overtime hours, sometimes working a 60-hour week. The prison is understaffed with a high staff turnover, so Adam is congratulated both for his loyalty and for his efforts to assist where possible. However, the most recent incident he responded to has caused Adam to react in a unique way. He has been struggling to fall asleep, though once asleep, he struggles to get out of bed in the morning. His sleep is disrupted by visions of his work life, situations he could have avoided and feelings of guilt for his actions. He has been more reactive to his friends and family, losing his sense of humour and seemingly ‘on guard’, experiencing vivid flashbacks to the incidents at work. His conversations seem to always be about work and the negative impact it is having on his life. He is now on leave from work as he was late three days in a row and forgot to implement integral safety procedures during his shift. Memory is one of the key areas impacted by PTSD, some authors even view PTSD as a disorder of memory (Brewin, 2014). Memory functions such as autobiographical memory retrieval, working memory capacity, and implicit memory networks are hindered by traumatic experiences (Otgaar et al., 2017; Brown et al., 2014). These negative experiences cause overgeneralised and negatively skewed memory recall, deficits in working memory capacity, and overstimulation of emotional reactivity to triggering stimuli. The impact on these areas appear to contribute to the onset and maintenance of PTSD (Schweizer & Dalgleish, 2011).

Working memory (WM) is marginally different to short-term memory, though the two work together. Whereas short-term memory holds pieces of information, WM processes and interprets information for future recall (Lynch, 2021).  WM can be divided into a four-component model (Sigelman et al., 2022). Directed by a central executive, attention controls the flow of information through three stages: (1) the phonological loop, (2) the episodic buffer, (3) the visual-spatial scratchpad. The first stage holds auditory information and the second stage links auditory with visual information. The third stage deepens their connection with colours and shapes associated with visual information (Sigelman et al., 2022). The capacity to build these connections, also known as working memory capacity or WMC, influences a person’s ability to regulate expressive and experiential aspects of emotion, and resist emotionally intrusive thoughts (Brewin & Smart, 2005; Schmeichel et al., 2008; Schweizer & Dalgleish, 2011). People with diagnosed mental health problems often have deficits in WMC, partially related to a large portion of cognitive resources being used to decipher and process thoughts, feelings, and behaviours unrelated to their current situation (Mason et al., 2007; Schweizer & Dalgleish, 2011). For example, when a person experiences a highly traumatic event, the emotional impact is not processed at the time of it happening, rather a structural representation of the feared stimuli is stored in memory for later retrieval and processing (Watkins, Sprang, & Rothbaum, 2018). This survival technique protects the individual from reacting in a damaging or life-threatening way, however, also leaves the situation open to interpretation using a potentially biased or misinformed analysis. Treatments such as Prolonged Exposure therapy, Cognitive Processing Therapy, and Cognitive-Behavioural Therapy have shown a significant reduction in symptoms for people with PTSD (Powers et al., 2010; Chard et al., 2012; Watts et al., 2013; Cusack et al., 2016). This type of therapy, which will be discussed later, provides space for the client to process and consolidate information retained from the event, and decipher what is factual, what is influential, and what can be resolved. Consolidation is an important step for storing information in long-term memory because it transforms over time as new information is received (Sigelman et al., 2022).

Procedural memory is an implicit type of long-term memory which governs encoding, storage, and retrieval of information of cognitive and sensorimotor habits. More specifically, it utilises previous experiences to build abilities which require no conscious awareness. The repetition and consolidation of a particular task using procedural memory leads to an automized skill (Bouyeure & Noulhiane, 2020; Sigelman et al., 2022). For example, encoded negative memories from traumatic experiences skew a person’s perspectives in favour of perceived negative outcomes. Participants with PTSD showed greater implicit memory for negative and trauma-relevant pictures compared to neutral pictures (Amir et al., 2010). Without conscious rewiring and cognitive reframing of experiences, irrational thoughts and subjective biases are likely to govern a person’s behaviour (Ackerman, 2018). Adam’s reactivity, distracted awareness, and negative conversation topics are evidence of his implicit memory and subconscious schemas influencing his current reality. Where implicit memory is unintentional and occurs without conscious awareness, explicit memory involves the intentional, conscious recollection of the past.

Semantic and episodic memory are interconnected, where facts and general knowledge are used to link personal experiences with lived reality. However, for the purposes of this essay, only the latter will be discussed. Episodic memory serves to provide information related to experiences and events, a cognitive map of what, when, and where. The ability to recall experiences improves insight and the ability to conceptualise outcomes or consequences of hypothesised future situations. It also enhances safety and flow of experience (Fivush, 2018; Bouyeure & Noulhiane, 2020). These simulations are constructed using the most available information at that time and those who have experienced negative past events, are more likely to construct negatively biased future scenarios (Brown et al., 2013). Within the paradigm of episodic memories are the ever-evolving contents of the autobiographical memory. Repeated personalised narratives of life events add meaning to beliefs, socio-cultural expectations, and personality traits which together integrate the perceptions of oneself (Fivush, 2011). The perspective built from this ‘experiencer of the event’ make up the self-defining concepts that becomes one’s identity. The ability to discern the self (“I”) from the experience but maintaining the self as the thread which connects these experiences over time, is what defines a person’s unique lived experience. And henceforth, the ability to describe these experiences to others allows the sharing of information and builds understanding and connection between people. Since traumatic memories are poorly integrated, they construct strong associations within a person’s autobiographical memory. Recalling details of those traumatic memories are likely to trigger a myriad of other related traumatic experiences (Otgaar et al., 2017). Research has also found that verbal memory specifically, is impacted by traumatic experiences (Petzold & Bunzeck, 2022). Using specific techniques and methodologies, practitioners connect with their clients through conceptualised experiences of themselves as a means to heal and grow. In the case of Adam, his experiences at work have formed a jaded view of himself and others, perceiving them as threatening and untrustworthy. The large influx of negatively skewed events at work have misguided his subconscious thought patterns and behaviours in the community. Working in this environment, he speaks to others with similar experiences and without realising, he has enmeshed his self-concept with the parables of the workplace culture. Once removed from that environment, he is able to redefine himself through a healthier lens and return to work with a strengthened sense of self.

A function of implicit memory is to use the information of past experiences to predict future expressions of behaviour, cognitions, and emotions. Priming (or perceptual priming) is the process by which previous experiences (or stimuli) influence current and future perceptions of stimuli (Bouyeure & Noulhiane, 2020). This recollection of information may be conscious or sub-conscious, and in the case of people with PTSD, they may be unaware that they are responding to a memory, and instead, are responding to the stimuli as if it were happening to them presently (Michael, Ehlers, & Halligan, 2005). Ehlers and Clark’s (2000) study suggested a strong priming effect which occurs during traumatic events causes the reexperiencing symptoms to be particularly intense in people with PTSD. The greater emotional, behavioural, and cognitive impact caused by an event, the stronger the likelihood of it triggering intrusive memories (Frewen & Lanius, 2010). In the case of Adam, he is confronted at work with numerous cues and new experiences that remind him of his trauma. He is also required to continue the doing the tasks which have cause his PTSD. Due to the specific connections Adam has made between actions within the prison and their consequences, he has begun unintentionally associating normal social behaviours outside of work with untrustworthy and deviant behaviours. Prolonged Exposure therapy is strongly recommended in the treatment of PTSD (Watkins, Sprang, & Rothbaum, 2018). Participants are asked to either confront people, places, and situations that they avoid due to fear or recite the memories of the specific events that cause distress. They are asked to repeat this behaviour until they become desensitised to the situation, person, or place. For Adam, being able to return to work without it eliciting a fear response would be necessary for him to continue his profession and returning to work may also be used as the stimulus for his prolonged exposure therapy.

Another aspect of Adam’s counselling would involve determining whether his experiences have been impacted by personally contrived misinformation. When a person is exposed to a traumatic event, once or multiple times, there is a strong chance of the development of a distortion in cognition. This occurs because the person’s mind is attempting to make sense of what occurred. Porter et al. (2014) found a person’s emotions, especially negative emotions, influences their susceptibility to retaining misinformation or misremembering. This research concluded that when a negative emotion is present at the time of memory encoding, vulnerability to misinformation increases. This is called the misinformation effect and is believed to be caused by the person’s mind attempting to protect the person against distorting influences of their current belief system. As mentioned earlier, memories are malleable and are processed through a series of mental structures before being stored for retrieval (Sigelman et al., 2022). Just as aspects of a memory can be altered to make sense of an experience, some of a particular memory can be misinterpreted or the entire memory could be false. Monds et al. (2016) tested false memory susceptibility in people with a history of trauma using the misinformation effect, and found traumatised participants exhibited greater false recall compared to non-traumatised participants who reported significantly less misinformation. The disruption to memory and awareness from traumatic experiences will increase the susceptibility for retaining false information. It is likely that Adam would use his therapy sessions to seek explanations for his current emotional state. The process of understanding this would involve recall of the events causing his current feelings. By asking Adam to recall these events, the likelihood of false memory recall is increased (Otgaar et al., 2017). Throughout sessions, taking note of Adam’s story recall and confirming discrepancies will highlight where the misinformation effect may have influenced his memory and cause the implementation of false memories.

False memories are distorted recollections of events, either partially or wholly. There are two types of memory distortions: spontaneous false memories that occur without external pressure, and suggestion-induced false memories that are formed by suggestive pressure (Jobson et al., 2022). Some research studies using suggestion-induced false memories have found an increase in false recall by participants with PTSD compared to non-trauma-exposed healthy individuals, however, this was only true for emotionally associative material and not neutral or non-associative material (Goodman et al., 2011; Moradi et al., 2015). These results again suggest the stronger influence of negative emotional memories on implicit and explicit memory structures.

This is called associative activation and occurs because a person’s brain has been developed to activate related nodes and concepts in memory networks. This process occurs automatically and without conscious activation. Research conducted by Otgaar et al. (2017) found people with PTSD are more prone to generating false memories because the key networks associated with processing emotionally related information are more sensitive to activation, therefore inducing false memory recall for emotional material. This susceptibility to misinformation is increased when the event asked to be recalled is negative or disorder-related compared to both positive and neutral events because of the automatic activation of pathology-related emotional experiences (Porter et al., 2010; Hess et al., 2012; Otgaar et al, 2017). Involuntary traumatic intrusions are the most commonly known symptom of PTSD and occurs because of these associative and spreading activations. People with PTSD retain a disproportionate degree of negative psychopathological information and when exposed to stimuli which can be linked to these experiences, they are more likely to make associations to non-present constructs. These associations are what stimulate the development of false memories (Howe et al., 2010). In a counselling setting, people who seek therapy to assist with psychopathological symptoms are more vulnerable to suggestions relating to their experiences and could experience either spontaneous false memories or suggestion-induced false memories.

Posttraumatic stress disorder causes deficits in all aspects of memory (Brewin, 2014). Working memory capacity in people with PTSD lacks sufficient ability to regulate expressive and experiential aspects of emotion and are less able to resist emotionally intrusive thoughts compared to healthy non-traumatised individuals. It is most commonly seen as triggered flashbacks of the traumatic event which cause the individual to react in an outward behavioural manner to a perceived, but non-evident stimulus (Schweizer & Dalgleish, 2011; Watkins, Sprang, & Rothbaum, 2018). Memories not sufficiently processed during a highly traumatic experience are vulnerable to suggestibility during later retrieval. These encoded negative stimuli consolidate into reactive emotional and behavioural tendencies as implicit procedural memories (Amir et al., 2010; Bouyeure & Noulhiane, 2020). Counsellors must be mindful of the strong associative and spreading activations during counselling whilst discussing emotional topics otherwise their client may become unintentionally volatile. PTSD appears to be mostly characterised by episodic long-term memory impairment (Petzold & Bunzeck, 2022). In explicit episodic and autobiographical memory, PTSD symptoms are displayed as strongly associated, poorly integrated trauma-related memories which expresses as reactivity to the external environment and potential disassociation from one’s current reality (Mason et al., 2007; Otgaar et al., 2017). A person with PTSD will be limited in their therapeutic capacity because their verbal memory and ability to encode, consolidate, and retrieve information is hindered. It is therefore recommended that prior to any treatment, assessments for memory deficits should be conducted (Petzold & Bunzeck, 2022).

A variety of treatment options are available for people experiencing symptoms of PTSD.  Eye movement desensitisation and reprocessing (EMDR) is a commonly recommended intervention strategy when dealing with trauma. This particular process uses working memory to recall the traumatic event whilst moving their eyes bilaterally. The process of focusing on an external stimulus whilst recalling an event or personal belief enables the thought to be stored appropriately within memory, without strong emotional associations. It is also successful for PTSD clients because it doesn’t necessarily require the person to speak about the trauma incident (Discovery Mood & Anxiety Program, 2021). Cognitive Behavioural therapies such as Prolonged Exposure therapy, and Cognitive Processing therapy are also strongly recommended in the treatment of PTSD (Powers et al., 2010; Chard et al., 2012; Cusack et al., 2016; Watts et al., 2013; Watkins, Sprang, & Rothbaum, 2018). It is suggested that gradual exposure to the trauma will reprogram the thoughts, feelings, and emotions towards the stimuli and the client will learn that anxiety and fear resolves eventually. It should be noted that though research has found evidence for deficits in working memory and episodic memory in people with PTSD, it may be likely that those deficits existed prior to the PTSD and increased the likelihood of PTSD formation. It could be concluded that memory deficits increase a person’s vulnerability to the development of this disorder (Petzold & Bunzeck, 2022). More research in this area needs to be conducted to determine the validity of this suggestion.

In conclusion, not only does memory play a critical role in counselling therapy, but it also has a crucial role in allowing people to make sense of their lived experiences. Each component, from receiving auditory and visual information, connecting data for memory formation, and stimulating memory recall, all serve to develop a complete perception of one’s internal and external reality (Sigelman et al., 2022). Moreso, the personalised narratives created by this cognitive loop are what give people their sense of self and what add meaning to these constructed realities (Fivush, 2011; Brown et al., 2013). These personalised narratives are malleable, shifting and evolving over time as a person continues to create new experiences. This is both a strength and detriment. Though some experiences serve to advance a person, just as many can become a hindrance, causing negative biases and misinformed judgements which can be externalised without conscious knowing. The consequences of continual traumatic experiences are what lead to PTSD, where triggers occur from everyday experience and impact both the individual and those around them. Therapy which aims to alleviate the constraints of these symptoms focus centrally on both reducing emotional reactivity to perceived, illusory threats and on improving mindful awareness of one’s thoughts, feelings, and behaviours. Though it is unclear whether retrieving information about the event is helping or hindering the process of healing, it is understood that on an individual basis, the many types of therapies available to work towards deconstructing these memory associations will provide some relief. Memory is an ever-evolving construct that builds the structural schemas of a person’s lived experience. Without healthy input, the output is unpredictable.  

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