Working with

Dissociative Identity Disorder                     






            Edited by Valerie Sinason



Reproduction of Introduction Chapter, 18 pages

To begin at the end


How does it begin? ‘Sticks and stones
may break my bones but names will never hurt me’


Dissociation and Fragmentation as a Childhood Defence


Dissociative Identity Disorder


Hiding Selves


What is Dissociative Identity Disorder and How does it Happen?


John Bowlby and DID


DID as a paradigm shift


DSM Criteria


Traumatic Aetiology


Psychoanalysis and the Body


Fragmentation in the Team


The Organisation of the Book


Theoretical Formulations


DID and Ritual Abuse



To begin at the end.

The telephone rings at 10pm. A terrified child voice can be heard on the other end of the phone. There is a train noise in the background and the sound of people talking. ‘Please, please stop her from going back. He’s going to hurt us. He puts stingy stuff in me and I go all sore. Don’t let her go back. I am frightened’.

The voice rises in terror until I remind her that she is not going to be taken back, that her abuser is dead, that she is safe. The voice softens and relaxes. The panic subsides. The 6-year-old voice on the telephone belongs to a professional woman of 40 with Dissociative Identity Disorder.

The woman could not avoid a train journey in order to attend a crucial meeting concerning her new work. At one point on the journey the train was going to stop at the town she had lived in as a child. Rationally she knew her abusers were long since dead. However, the severity of her early abuse had led to fragmentation. Merely stopping at that station was enough to bring back a state of panic.

Instantly, to aid the woman, out of cold storage came the brave 6-year-old friend. Frozen in a terrible state of now-ness that had not changed for over 30 years she emerged. The woman had only just come to therapy. Many of her inside people, alters, self-states, whatever language we wish to use, had autonomous existence. Created to protect her, they hid the discrepancy between the sadism of her attachment figures and her need for love. They came out when she could not manage, to hold the memories of trauma (both actual and corroborated as well as fantasy and flashback – see Jean Goodwin, Chapter 8) and help her survive. Some states were truly frozen – not just in time but in their emotional states, pointing to disorientated disorganised attachments (see Peter Fonagy, Chapter 4) and even earlier infantile trauma.

After two years of treatment they began to thaw, began to grow and discard their old strictures. Some of the frozen friends could then melt into their host bringing their strength, fragments of memory and courage back to the core personality.

How does it begin? ‘Sticks and stones
may break my bones but names will never hurt me’

What happens when a child has to breathe in mocking words each day? What happens when a parent, an attachment figure utters those words: someone the child needs in order to emotionally survive? Sometimes, that mocking voice gets taken inside and finds a home. It then stays hurting and corroding on the inside when the original source of that cruelty might long ago have disappeared or died.

‘You stupid idiot, thick disgusting dunce!’ Ella shouted when she accidentally spilled her tea on the floor. Ella was 60 and had a severe learning disability. Whenever she made any mistake she mocked herself with the words of her sadistic father even though he had died more than 20 years ago. By keeping his angry words she was keeping him alive and sparing herself from the helplessness of being a victim on the receiving end. By shouting at herself she was identifying with him, being him and therefore not having to remember being the frightened unwanted helpless little child. This is not schizophrenia or ‘another person’ inside. This is ordinary development made unpalatable by the toxic nature of what has had to be taken in.

Dissociation and Fragmentation as a Childhood Defence

What happens when the toxic nature of what is poured into the undeveloped vulnerable brain of a small child is so poisonous that it is too much to manage? Little children, who have had poured into them all the human pain and hate adults could not manage, somehow grow up. There is a shadow side to this. Legions of warriors are lost to society through suicide, psychiatric hospitals, addiction and prison. What happens to them, especially when those who hurt them are attachment figures? (See chapters by Fonagy, de Zulueta, Richardson, Mollon, Whewell, Southgate and Steele.)

This book is about one way of surviving. It is about a brilliant piece of creative resilience which comes with a terrible price. It is a way of surviving so difficult to think about and speak about that, like the topic of learning disability, its name changes regularly. Dissociative Identity Disorder is the newest term. Where and in whom the disorder lies, however, is a crucial issue in its own right.

Dissociative Identity Disorder

Dissociative Identity Disorder is the Mad Cow Disease of the mind. Despite the clear description of what constitutes DID in DSM-IV (see p. 10), this condition is still seen by some mental health professionals as a hysterical confabulation. It is 10–20 years too early for it to be picked up and dealt with well. What is it like to be suffering from something that is not yet recognised? And not only is the DID not recognised, but the nature of the sadistic abuse that has caused it in the majority of cases is even less recognised.

‘I’m an attention seeker, don’t you know?’ said one patient bitterly. ‘And I’m hysterical and full of delusions. Amazing isn’t it. My abusers can rape and torture me for years and they are wandering the streets perfectly happy and I am the one with a life sentence, the one who is scared to leave the house, the one who has to apologise for her illness.’

In the last decade I have assessed and treated children and adults, largely female, who have Dissociative Identity Disorder (DID). There is a very significant gender bias in this condition. Indeed, abused boys are far more likely to externalise their trauma although both sexes (see Bentovim, Chapter 1) use internalising and externalising responses. Cultural issues, as well as gender issues, need exploring (see Swartz, Chapter 15).

The majority of female children and adults I assessed had been diagnosed or misdiagnosed as schizophrenic, borderline, anti-social disorder or psychotic. Despite the fact that anti-psychotic drugs had little or no effect on them, that they experienced their voices as coming from inside and not outside (see Joan Coleman, Chapter 12), and they did not manifest thought disorder or distortions about time and place except when in a trance state, mental health professionals could not perceive flaws in diagnosis. Or rather, and more worryingly, the diagnoses at times were correct but only applied to the ‘state’ that visited them. Hence one psychiatrist assessing ‘Mary’ correctly diagnosed psychosis, and another who assessed the patient a week later correctly disputed that diagnosis and declared ‘Susan’ had borderline personality disorder. Without a holistic approach professionals are attacking each other’s contradictory diagnoses without realising the aptness of Walt Whitman’s words – ‘I am large. I contain multitudes’.

Hiding Selves

In the face of professional confusion and societal denial some patients have managed to hide their multiplicity when told they were making it up. In answer to the key question concerning the small number of children who present in severe dissociative states (see chapters by Arnon Bentovim, Nicholas Midgley and Peter Fonagy) patients confirmed negative responses to their childhood disclosures that led to hiding their symptoms (see Valerie Sinason, Chapter 7). Children were told they ‘would grow out of it’ or ‘it was just like an imaginary friend’. Adults report similar past experiences and these are confirmed by my researching past medical files. The pain such misdiagnoses or denial of symptoms causes patients can be seen in the patients’ poems (pp. 1, 69, 123, 195).

Unfortunately, when practitioners, shocked at the sight of dissociative identity disorder, misuse behavioural techniques without adequate specialist training and give sanctions when ‘alters’ appear, the host personality learns to hide them. This is often perceived as a treatment success. It is not understood that for the patient, who is an expert in learning how to survive denial of DID by clinicians, it is experienced as a psychically annihilating secondary trauma.

To survive, the host incorporates and imprisons within the different states. ‘Don’t you understand’, says Ellen, ‘it is unbearable having to keep everyone imprisoned and not allowed out. But that is what I have to do to survive there. To survive outside I have to let them out so they can get therapy and we can link up. But if I was to show them inside I would just be seen as mad and everything would be ruined. Even though they see that as winning their nasty little behavioural game there is no alternative while my condition is not understood.’

This book, bringing together experienced clinicians, aims to consider the developmental, attachment and adaptive structure of DID as well as the controversy around its aetiology and manifestation.

What is Dissociative Identity Disorder and How does it Happen?

A loved child of 2 toddled around the kitchen. He put his hand up to almost touch the gas heater. ‘Hot!’ he shouted. He shouted in the voice of his mother who had been frightened for his safety when she had left the heater unguarded the day before. He paused. ‘Be careful sweetie’, he added in the voice of his older sister. Like young children all over the world he was taking in the language and intonation of his attachment figures. His family could amusedly point to where his vocabulary, intonation and facial expressions came from. However, just a short time later, in an ordinary developmental process, the words and concepts and gestures and knowledge taken in from the outside became truly his in an apparently seamless way.

When all goes well we take for granted the existence of the outside network in each of us. Ironically, it is when things go wrong and become writ large that we notice the amazing process of what we are linguistically made of.

‘Stupid piece of shit. Edward! Stupid piece of shit. Get under.’ This was the verbal calling-card of a severely learning disabled man I worked with. He said it over and over and because he was learning disabled it was called echollalia. Once I met him and listened he was able to show me he was repeating the cruel words said to him by a real external person. They hurt so much he could not assimilate them except by becoming them and repeating them. I now see them as a verbal flash-back. The childhood refrain ‘sticks and stones may break my bones but names will never hurt me’ is not true. Names enter us like weapons.

How do we account for these changed faces and voices? Again, if we go back to our 2-year-old loved boy we get some answers. When his mother shouts ‘Hot!’ in a frightened angry voice her face does not look the same as when she is beaming lovingly at him. Nor is her voice the same. A baby and a child get used to seeing their primary caretaker’s face change dramatically into something quite different, even though it does not have another name. However, Cross Mummy and Loving Mummy are very different people even though they are Mummy. Hence dissociative mothers with children (see Miki’s description, p. 170) are able to consider their child’s predicament.

Following sadistic abuse Jenny, aged 24 and with Down’s syndrome, developed different ‘states’ to help her survive. ‘I cried in my bed last night. I cried because of those men who hurt me. When I cried and cried I felt hugged in my body. Maggie cuddled me because I was sad and she stroke my hair and help me put my head on pillow. When I wake up I am alright for my day centre.’ ‘How good that Maggie could help you and that you knew she was helping you’, I replied. Jenny’s face changed. It looked older but sweeter. Her voice changed too. ‘Hello love’, she said to me. ‘I am glad you noticed I helped. Poor Jenny had a really hard time last night. A really hard time. I had to help her.’ ‘Thank you, Maggie’, said Jenny, with facial expression and voice returning. Suddenly Jenny’s face became hard and cruel and she smashed at her head with her right arm. ‘Thank you Maggie! Thank you Maggie!’ mimicked a mocking sadistic voice–Myra. ‘Fucking idiots both of you. I will show you what hurts.’

Faced with memories of unbearable helplessness and shame (see Peter Whewell, Chapter 10) Myra represented the identification with the abuser as a defence against pain, leaving Maggie to represent the loving caretaking self and Jenny the vulnerable victim.

Such sights and sounds provide painful visual re-enactments of past trauma. ‘Sibyl’ and ‘The Three Faces of Eve’, however dated, remain the main public image (see Brett Kahr, Chapter 16) of dissociation. Somehow it has remained easier to consider the subject safely contained in a Hollywood film or a book rather than on the street and in the homes, schools, universities, workplaces and psychiatric hospitals of the country. DID (Dissociative Identity Disorder) people become successful professionals, writers, dancers, artists, scientists, shopworkers, singers (like Joan Baez) and parents. They also become prostitutes, drug addicts, criminals and pornstars. They also die. Sometimes they cover the range of possibilities within their one frame. Jane, for example, was a successful part-time university lecturer but dissociatively, as Enya, ran a sado-masochistic brothel, as Mel was involved in small-time theft, as Janet was a computer programmer and as Annette was a drug addict. Each had their own friendships, clothes and homes.

How do we make sense of the paradox of this mental position? At one level the idea that five different people could all have timeshares in one body seems absurd. And yet, it is both delusional and real and all at the same time. (See R.D. Hinshelwood, Chapter 14).

To understand this paradox takes us into a new way of conceptualising the human mind, the resilience of the human spirit and the profound need to find defences that can protect against unbearable events.

As an intellectual defence measure some professionals use diagnostic concepts to avoid considering traumatic aetiology. Border-line personality disorder, a description that applies to many such patients has an 81 per cent chance of major trauma (Herman 1992). Indeed, Professor Jean Goodwin (personal communication 2000) informs me that worn out American workers in some states are trying to treat symptoms and bypass aetiology to avoid controversy and political conflict. This is similar to the legal situation in the UK where evidence of ritual abuse can be removed in court cases because a jury is seen as more likely to take the evidence seriously if it is confined to the sexual aspects of abuse.

Can we ever really manage to consider the meaning of trauma – something that breaks through our defences and cannot be properly processed? Think of the way someone breaks their leg and talks of ‘the leg’. It is not ‘my leg’. It is dissociated from as it has felt pain and caused pain. Think too of the encouragement offered by society to ‘think about something else’ – sometimes helpfully – to the hurt person.

Now think of a child being bullied in a school playground. Everything goes into slow motion. The child feels it is not happening to them. That too is dissociation. Take it further. The child is an 8-year-old called Mary. She is being kicked and feels she is watching from a great height. It is not her. The person kicking her is an attachment figure, her father. She cannot see this properly because she needs the support of her father to survive. The only way she can manage this inescapable experience it is to dissociate further. She is 8 whereas that girl being kicked cannot be her because that girl is only 5. What’s more, as the kicking goes on and turns into rape, her name is Mary and she has a father who loves her while that girl on the floor is only 5 and her name is Jane and she does not feel anything. Gradually the story becomes more fleshed out as the dissociation provides her with means of survival. If the abuse turns into torture it might be that even with ‘Jane’ Mary cannot psychically survive and a further ‘state’ is created. Jane, who appears when Mary cannot manage, then creates a big brother who is tall and strong and will protect her, called Peter.

This brilliant survival mechanism helped when facing the trauma of the abuse but it is maladaptive when the trauma is over. Mary aged 25 presents at her GP’s surgery with terrible memory loss and signs of self-injury. Sometimes she does not know where she is when she wakes up. Jane and Peter are still appearing in Mary’s life because no new way has been found for the system’s survival. The multiplicity is hardwired, as brainscans are starting to show. To help Mary regain her spirit that is fragmented into her dissociative states means that she had to cognitively take on board her past. Without a safe environment and skilled staff how is it possible to re-experience the very trauma that led to fragmentation? And yet all over the UK these heroic and troubled survivors – mainly women – have to deal with a lack of specialist resources and disbelieving discrediting staff. It is hard to underestimate the impact on vulnerable people of facing the disbelief and even attack of professional staff when trying to have their problems heard.

John Bowlby and DID

In 1988, in a clinical supervision, John Bowlby looked at drawings of little children being abused and pictorially delineating terrible stories. The artist was a middle-aged female patient who was being treated by John Southgate, the founder and former Chair of the Bowlby Centre for Attachment-based Psychoanalytic Psychotherapy. The patient had been feeling that her therapist did not understand the drawings. Dr Bowlby mused and finally said – ‘I think this woman is a multiple personality.’ Southgate commented, ‘He said there was a lot of work in the US on Dissociation and proposed that I should talk to these children and listen to the story they were trying to tell me’ (see Southgate 1996 and Chapter 5).

John Bowlby was the world-famous psychoanalyst who created attachment theory (see chapters by Felicity de Zulueta, Sue Richardson, Peter Fonagy, Howard Steele and John Southgate) and proved to the western world that separation of young children from their attachment figures was psychically damaging (whether in hospital or in evacuation) in proportion to the nature of their attachments, age and degree of separation.

Bowlby’s work on separation and attachment did not find an immediate positive response. Indeed, upper class English Christian psychiatrists, doctors and psychoanalysts who had been sent away to boarding school found his ideas as disturbing as their Jewish counterparts who had lost their safe family links through the holocaust.

DID as a paradigm shift

As Bowlby himself tells us, we cannot see what we cannot bear to see. How then do we best educate each other and tolerate the conceptual and clinical gaps? Kuhn’s work shows us how, when an older paradigm cannot account adequately for a subject, we find it problematic. Multiple Personality Disorder (MPD) or the newer term Dissociative Identity Disorder (DID) is such a subject.

The impact on professionals of extreme childhood trauma and multiplicity is far more severe than the impact of childhood separation was and so the response to this subject has been even less positive than to Bowlby’s words of almost half a century ago. It remains disturbingly under-studied by all professions and both undiagnosed and misdiagnosed in this country (see Joan Coleman, Chapter 12) and a continued object of controversy in the USA.

DSM Criteria

The DSM-IV criteria specify that DID is

The presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self).

At least two of these identities or personality states recurrently take control of the person’s behaviour.

Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness and not due to the direct effects of a substance (e.g. blackouts or chaotic behaviour during alcohol intoxication) or a general medical condition (e.g. complex partial seizures).

Although the international psychiatric criteria in DSM-IV describe very clearly what constitutes this condition, British clinicians have on the whole ignored or condemned both the condition and the clinicians who recognise it and offer treatment. Indeed, the British Journal of Psychiatry has published only five papers on DID since 1989, all of which are unanimously critical. Psychiatric training (see Joan Coleman Chapter 12) offers little understanding both in the past and now (see Peter Whewell, Chapter 10; Phil Mollon, Chapter 11). This leaves British professionals uniquely vulnerable to emotional stress when encountering such patients.

A curious small ray of light appeared on the British television programme Tomorrow’s World in 1999 when the Maudsley Psychiatrist Dr Raj Persaud declared that psychiatrists would now have to recognise DID because brainscan research at Harvard had proven its existence. Dr Persaud, who, like many of his psychiatric colleagues, did not consider DID could exist, changed his mind because of brain research results rather than the direct clinical experience of being with such patients. It could be that our recent social interest in brain research allows a face-saving way of changing our clinical paradigms. However, what is the emotional experience of children and adults living in a country at a time where the condition that is troubling them (and its traumatic aetiology) is linked to a paradigm shift rather than an area of clinical resourcefulness?

Traumatic Aetiology

North et al. (1983) found that this condition was not only linked to a high childhood sexual abuse rate but also to a 24–67 per cent occurrence rate of rape in adult life, and to a 60–81 per cent rate of suicide attempts. Thus it is clear that DID is part of a substantial grouping of trauma-based conditions. Putnam et al. (1986) in the USA, looking at 100 DID patients, found that 97 of the hundred had experienced major early trauma with almost half having witnessed the violent death of someone close to them. Compared with Freud’s ability to recognise the traumatic aetiology of hysteria one hundred years ago (Freud 1896), contemporary clinicians have found it extremely hard to bear the horrors of patients’ objective lives. Sometimes (Hale and Sinason 1994) psychotherapists’ focus on the internal narrative is a defence against the historic external reality.

However, as de Zulueta (1993; see also Chapter 3) comments:

A refusal on the part of psychiatrists and therapists to validate the horrors of their patients’ tortured past implies a refusal to take seriously the unconscious psychological mechanisms that individuals need to use to protect themselves from the unspeakable. Such a denial is, however, no longer ethical, for it is this human capacity to dissociate that is part of the secret of both childhood abuse and the horrors of Nazi genocide, both forms of human violence, so often carried out by ‘respectable’ men and women. (p. 190)

Psychoanalysis and the Body

In the adolescent and adult psychoanalytic field there is relatively little published work involving the physical body as opposed to the metaphoric or fantasy body. Exceptions include those who have to acknowledge the physical body through working on pregnancy and gender body issues, such as Raphael-Leff (1993), Perelberg, Pines (1982) and Susie Orbach; those working with violence and suicide, such as Eglé and Moses Laufer (1995); blindness and diabetes (Burlingham, Moran and Fonagy et al. from the Anna Freud Centre); as well as those who have worked with perversions and abuse, such as Glasser, Hale, Campbell, Welldon (at the Portman Clinic), Mario Marrone, Nicola Diamond, R.D. Hinshelwood, Roger Kennedy; plus colleagues Sheila Hollins, Brett Kahr, Nigel Beail, Pat Frankish, Sophie Thompson, Nicola Chad, Tamsin Cottis, Al Corbett and others working with disability.

Within the child field, in the last decade, by contrast, there has been a significant increase in writing about physical trauma. This is partly due to protective feelings for children who are not responsible for their external environment and partly as a result of health service statutory requirements since the existence of sexual abuse was accepted. Within the psychoanalytic community from the 1980s clinicians such as John Bowlby, Brendan MacCarthy, Judith Trowell, Juliet Hopkins, Arnon Bentovim (see Chapter 1), Eileen Vizard, Peter Fonagy (see Chapter 4) and Mary Target have been essential here in changing social views with their research as well as providing more focused case studies.

However, it is important to remember that only 15 years ago most major training schools did not accept the existence of child abuse and condemned what they saw as the unhealthy excitement that was considered to emanate from the earliest exponents. The language of their criticism is very similar (see R.D. Hinshelwood, Chapter 14) to what greets the clinician of today who speaks of DID. It has been a later knowledge that understands the way the shame and trauma of abuse become projected into the professional network leading to splitting and blame.

While professionals and patients can be blamed for ‘believing’ in an illness or having one, patients also report problems when they are believed. Some professionals, they commented, have worryingly simplistic ideas of ‘integration’. Ignoring the separately named alters in effect offers a psychic death sentence rather than aiding integration. If anything it can create a compliant false-self ‘main person’ who answers to her name and keeps all other ‘states’ in silent terror internally. This iatrogenic damage is inevitable where professionals have a unitary model of the mind theories. Perhaps DID raises problematic philosophical and psychological concerns about the nature of the mind itself (see R.D. Hinshelwood, Chapter 14). Ideas of a unitary ego would incline professionals to see multiplicity as a behavioural disturbance. However, if the mind is seen as a seamless collaboration between multiple selves – a kind of trade union agreement for co-existence – it is less threatening to face this subject. This is an issue that continues to be debated internationally (see chapters by Southgate and Hinshelwood) and is crucial in considering many psychological problems.

The psychoanalyst Bion took great care to differentiate psychotic from non-psychotic personalities. New work on the changing roles between brain stem, left brain and right brain during infancy may soon clarify these issues without threatening established concepts of mind (Mary Sue Moore personal communication 2000).

Whatever the theory, it is important to note that clinicians such as Kluft draw attention to the clinical error of insisting that all alters talk as one or that only the alter with the legal name should be validated. ‘Such stances are commonly associated with therapeutic failure.’

Fragmentation in the Team

The primary split of DID creates a curious secondary splitting between staff. The psychiatrist who meets a frozen DID patient who shows only one state (as a result of correctly assessing their psychiatrist’s inability to deal with the subject) and proclaims it is borderline personality disorder then attacks the other psychiatrist/social worker/psychologist/psychotherapist who points out the fragmentation into states. In having one professional pronounce that a condition does not exist versus another who does we are witnessing the trauma-organised systems (see Bentovim, Chapter 1) that systemically mirror the DID experience. The conflict between states is accurately and ironically mirrored in the conflicts between professionals. One state cannot believe that another exists, disputes its sense of reality and at times wishes to destroy it.

This polarisation extends to writing on the subject. Some clinicians show a remarkable ignorance of the current state of work in this country and the relative lack of interest by psychoanalytic practitioners. Aldridge-Morris (1989) sees those of us who are dealing with the reality of this condition as ‘practitioners who generally favour hypnotherapeutic techniques, are psychoanalytic or neopsychoanalytic in orientation’. As Mollon (1996 and Chapter 11) points out: ‘In fact most contemporary writers on the treatment of MPD favour techniques derived from cognitive-behavioural approaches. The concept of MPD is not part of the psychoanalytic tradition. Relatively few psychoanalysts make use of the concept of dissociation.’ Yet at the same time others are arguing that psychoanalysts and therapists are projecting dissociation onto the patients. Merskey (1992), in a review of past cases of DID, states that: ‘suggestion and prior preparation of the patients are at the root of this condition’.

With the advent of concern about the boundary between true memory and false extrapolations (which has been exploited by various false memory exponents) there has been more room for views like Merskey’s that DID is an iatrogenic disease created and instantly implanted by naïve therapists who expect to see it (see Mollon, Chapter 11).

While rigorously trained professionals are well aware of the suggestibility of traumatised clients, especially those who have been hypnotised, it is worth noting that all the patients who came to the Clinic for Dissociative Studies had already got a long knowledge of their own dissociation. Similarly, those alleging ritual abuse as a trigger for fragmentation had never lost such memories and had expressed them to other professionals long before attending the clinic.

It is worth noting that, in this subject, becoming more experienced by seeing several people with the same condition is highlighted as a matter of concern rather than a useful building of knowledge. There is perhaps a wish to consider that the therapist is the toxic agent spreading this unbearable narrative. That would spare us all the pain of having to consider it might be true.

Whether fortunately or unfortunately, psychotherapists have negligible training in brainwashing, forcing of alien memories or distorted ideas. Military mind control experiments, brainwashing within religious cults and government programmes are not areas of mainstream professional training despite the profound influence such practices have on vulnerable minds. Thus psychotherapists do not have the competence to project states or traumatic narratives into their patients. Mental health professionals also do not have any basic grounding in this subject.

This book aims to redress that balance and to provide basic clinical and theoretical information for the mental health professional and the interested layman. It is of concern to all because while we consider that this brilliant but tragic adaptation to trauma is as rare as the torture it stands witness to, extreme states show us writ large the stresses and responses of ordinary life.

There are many fearful societal templates about this subject. But I would like to consider it through fairytale – ‘The Shoemaker and the Elves’. The link (see Sinason, Chapter 7) came to me in the first meeting with a patient and helped to transform the session. As you may recall there was a poor shoemaker facing eviction and poverty and yet because he was hardworking he worked to the very end, leaving out the last two shapes of leather to make into shoes for the morning. In the morning, to his shock, there are two perfectly made pairs of shoes. They catch the eye of a rich customer and the money paid allows the shoemaker to buy leather for four pairs of shoes. These too appear perfectly made in the morning, are sold and bring in money for eight pairs of shoes. It carries on and on with the elves completing whatever the shoemaker leaves out for them.

He is shocked at first but then grateful and finally decides to stay up to meet his benefactors. When he spies the elves, who don’t see him, he sees they are in rags and poorly fed. He and his wife then make lovely sets of clothes and shoes for them all and leave out food and, as they can see he is now rich and successful, the elves happily go away. He carries on making his excellent shoes.

The point of the story I want to illustrate is that the shoemaker did know how to make good shoes. His success was not fake. He was able to acknowledge the secret night-time help he got. When people with DID acknowledge their night-time help, they can then at some point be happy with the shared gifts they had and that helps them deal with the pain of their situation.

The Organisation of the Book

To understand the process and aetiology of DID Part I deals with origins in childhood and developmental issues. How does dissociation begin? Arnon Bentovim looks at the developmental precursors and gender issues followed by Nicholas Midgley of Great Ormond Street and the Anna Freud Clinic. Felicity de Zulueta of the Maudsley Hospital Traumatic Stress Service describes the continuum from dissociation to Post-traumatic Stress Disorder to full-blown Dissociative Identity Disorder.

Part II takes an attachment theory focus. Peter Fonagy provides a conceptual overview of the origins of dissociation. He sees the deactivation of attempts to understand the world as a defence from trauma. John Southgate offers an attachment-based model that combines his work with Bowlby and his interest in Bion. Leading University College London and Anna Freud Clinic researcher Howard Steele discusses the research potential of the Adult Attachment Interview in his work with patients from the Clinic for Dissociative Studies.

Part III looks at clinical practice. It includes leading psychoanalysts from the public sector Peter Whewell, Phil Mollon and Jean Goodwin. Peter Whewell describes both theoretically (especially using the work of Fairbairn) and clinically the work of the Newcastle NHS specialist team in dealing with clients. Phil Mollon provides a theoretical assessment of the nature of memory and assessment and the dangers of taking on this work. He provides many important cautions. Psychoanalytic therapist Sue Richardson provides an attachment theory method of working clinically. I provide a first meeting with a patient in which the story of the shoemaker and the elves provided a powerful therapeutic aid.

In Part IV we look at practical issues. Joan Coleman speaks of the lack of psychiatric training in this subject, Patricia Pitchon looks at how a telephone can offer help, and Claire Usiskin highlights administrative issues. Some legal pointers are also provided.

In Part V Bob Hinshelwood provides a thoughtfully sceptical look at the theoretical issues and social debate, Leslie Swartz offers an anthropological South African cultural experience, and Brett Kahr concludes with an interview with a pioneer on this subject – Flora Rheta Schreiber.

Poems by survivors also feature in the book, and at the end there is a brief information section.

Theoretical Formulations

Many of the authors provide particular reviews of literature that influence their understanding so I shall only provide a brief historical summary here.

There are many shades of dissociation that lead all the way to full-blown DID. It was Charcot, the great nineteenth-century neurologist who first brought the concept of hysteria and its symptoms of neurological damage and amnesia to public attention. While he demonstrated the psychological aetiology of hysteria as opposed to an organic aetiology, he was not particularly interested in the meaning, and it was Janet and Freud who became interested in taking the work further. By the mid-1880s (Herman 1992) both recognised that altered states came from trauma and that somatic symptoms represented disguised representations of events repressed from memory. Janet produced the term ‘idée fixe’ while Freud underpinned the concept of traumatic repetition as a way of working through. Breuer and Freud coined the term ‘double-consciousness’. Breuer and Freud (1895) wrote that ‘hysterics suffered from reminiscences’ and Janet (1891) too described how one patient improved when, after removing the superficial layer of delusions, he realised the fixed ideas at the bottom of her mind.

However, it was Freud (1896) who in ‘The aetiology of hysteria’ firmly based the origins of hysteria in traumatic sexuality. He saw this as the key issue, the ‘caput Nili’. Freud’s shock at his own findings and his inability to conceive that abuse in his own social class was so widespread is not surprising. As I have written elsewhere (Sinason 1993), it is hard enough for professionals 100 years later than Freud to accept the extent of middle-class abuse. It is far easier to pick up the signs of abuse in working-class or ‘underclass’ children. In fact, Freud never gave up entirely on the significance of the abuse of early seduction.

However, Freud’s modification and transforming of his clinical views came at a significant moment in European history. Charcot, before his death in 1893, was coming under attack concerning the scientific validity of his public demonstrations. There were rumours that the women were actresses pretending to go into trances; and Janet, who stayed faithful to the traumatic origins of hysteria, was not successful in having his ideas passed on. Breuer collaborated with Freud in publishing the case of ‘Anna O’ but did not like Freud’s finding concerning early sexual trauma. After ‘The aetiology of hysteria’ was published, Freud wrote to Fliess: ‘I am as isolated as you could wish me to be; the word has been given out to abandon me, and a void is forming around me’ (4 May 1896).

The void that always forms around messengers with unwanted news was spreading and sadly returned the study of hysteria, hypnosis and altered states in Europe ‘into the realms of the occult’ (Herman 1992).

DID and Ritual Abuse

In America the largest amount of DID is diagnosed in connection with allegations of ritual satanist abuse, hence the discrediting of or inability to perceive the possibility of the one existing automatically precludes rational thinking about the other. Hacking (1995) is concerned about this combination as well as the lack of external corroboration of ritual abuse. ‘It would be a grave mistake for any therapist to believe memories of such events without conclusive independent corroboration’ (p. 118). He adds, ‘Ganaway thought that uncritical acceptance of memories of satanic abuse not only imperilled the credibility of multiple personality but put research on child abuse in general at risk’.

It is worth noting that both at the Portman Clinic and in the Clinic for Dissociative Studies we have not found evidence of fundamentalist religious beliefs, recovered memory or Munchhausen’s Syndrome as issues in those alleging this kind of abuse. Indeed, the pilot study on patients alleging ritual abuse that Dr Rob Hale, Director of the Portman Clinic, and I submitted in July 2000 included the finding that the only two out of 51 subjects who had any link with evangelist religious groups did this after disclosing ritual satanist abuse because no one else would listen to them.

In our far more secular society with established churches in which leading members do not believe in a personal God, a personal Satan is incomprehensible. This leads the majority to conflate satanist abuse with Satan rather than with sadistic paedophilia carried out either by Satanists – people who do believe in Satan (Satanist paedophiles) – or those who draw on the frightening power of occult paraphernalia. To the child victim it is irrelevant which group carried out the abuse.

Van Benschoten (1990) comments that ‘The issue of credibility is the first hurdle professionals and the public must confront when dealing with MPD patients’ reports of satanic ritual abuse. Survivors’ accounts reveal activities which are not only criminal but deliberately and brutally sadistic almost beyond belief.’

I have stated elsewhere (Sinason 1994) that the number of children and adults tortured in the name of mainstream religious and racial orthodoxy outweighs any onslaught by satanist abusers. Wiccans, witches, warlocks, pagans and Satanists who are not abusive are increasingly concerned at the way criminal groups closely related to the drug and pornographic industries conflate their rituals.

In trying to deal with worrying patients who have to be treated regardless of the doubts around their disclosures, mental health professionals often have to face these contentious issues. This makes it much harder for a proper considered response because professionals, like everyone else, are affected by the consensus. In my past work at the Portman Clinic and in my clinic I have noted the secondary traumatisation of professionals caused both by the impact of the patients’ narrative and then by the disbelieving stance of colleagues. Indeed, both professionals and, more importantly, patients, suffer from societal discrediting processes (including the media) in addition to their primary trauma. This applies to lawyers and police officers as well as mental health professionals.

On the influential Today programme on 9 February 2000 I spoke of a clinic database of 76 children and adults who alleged to have witnessed appalling crimes within the context of ritual abuse. The programme correctly commented that I would separately be sending a pilot study report co-written with Dr Robert Hale to the Department of Health. I mentioned that some patients coming to the Clinic for Dissociative Studies brought proof that they had not been registered as children. This is a shocking fact and not surprisingly caused shock. Also included in the programme was a woman survivor with whom I have no connection who described seeing children kept in a cage. The Daily Mail provided a banner headline conflating these two episodes. ‘Do Satanists really keep babies in cages in modern Britain – or has this woman [me] duped the BBC’s most prestigious news programmes?’

In a curious process of Chinese whispers they then quoted Professor Sydney Brandon as saying that I had spoken of 12-year-old girls being kept in a cage, ‘the proof being droppings under the cage. Words fail me. The terrible thing is that therapists influence people’s lives and they can do harm as well as good.’

The media response to this topic with concerning distortions even, apparently, from mental health professionals, inhibits some colleagues from taking on this work. This also impacts on the police.

The public often fail to understand the difference between clinical concerns of what is heard in a session and the amount of proof necessary to prove beyond reasonable doubt in a criminal court. Only 2 per cent of rape cases even get to court. The Today programme interviewer was shocked to hear that photographic evidence of sites with mutilated animals, injuries that could not be self-inflicted, and remains of ceremonies do not lead to successful prosecutions.

However, the increase in referrals from worried clinicians and families all over the UK is moving towards the critical mass that is required to implement proper provision and treatment strategy.

In 1999 the Institute for Psychotherapy and Disability was launched at St George’s Hospital Medical School under the mission statement ‘Treating with Respect’. Professors Bicknell and Hollins, Dr Pat Frankish, Dr Nigel Beail, Brett Kahr and myself all declared that one essential pre-requisite for a specialist learning disability therapist was treating the client with respect. We found ourselves shocked by the lack of respect accorded to many adults in the mental health services and the dynamic of ‘blaming the patient for their illness’. Sadly it has to be mentioned that learning-disabled patients with dissociative identity disorder have also been significantly represented. This concerns organisations such as RESPOND and VOICE.

Secondary traumatisation is a real danger in facing this work. I have found it essential to have weekly supervision from a senior training analyst as well as a long personal psychoanalysis. Additionally, I have benefited from the Psychoanalytic Study Group on Ritual Abuse and Dissociation and the support of clinic staff and consultants.

The clinical needs of this patient group are very different and it requires careful thought when considering where the frame needs altering to provide the adequate conditions of safety (see chapters by Mollon and Whewell). Sessions that last double time (100 minutes) with face-to-face patients who are too terrified to lie down on a couch are a very different experience for the average psychodynamic practitioner. Considering the clinical and technical issues of using emails and telephone calls to provide extra support at different times also takes a great deal of thinking. Many psychodynamic practitioners find they are using cognitive elements too.

If a lucky enough professional needs a multiplicity of supports to manage this subject we need to think very hard about the level of trauma the actual patient feels. Whatever we feel is only a shadow of that. If we cannot manage to bear the pain of these individuals what does that say about the level of pain that was forced into them at an early age?

The views expressed by any of the contributors, including myself as editor and chapter-writer, are individual opinions. Inclusion in this collection does not imply theoretical or clinical agreement.

With thanks to the following for crucial support in this work: to Pearl King for weekly supervision, clinical and ethical guidance and unwavering support, to the memory of Mervin Glasser, my psychoanalyst, who died in November 2000 for making the unbearable manageable, to the memory of my father Professor S.S. Segal whose steadfast pioneering led to the inclusion of disabled children within the education system and whose motto in standing up for stigmatised individuals was ‘and shall not pass them by nor throw them crumbs’, to David Leevers for personal, editorial and conceptual support, Tina Carlile, Joan Coleman, Carole Mallard, Peter Fonagy, Richard and Xenia Bowlby, Howard and Miriam Steele, Marcus and Jennifer Johns, Moira Walker, D.I. Clive Driscoll, D.C.I. Chris Healy, D.C.I. John Welch, D.C.I. Kate Halpin, Sarah Gordon, Rob Hale, Ainsley Gray, Jeremy Glyde, Harry Grant, Michael Curtis, Nancy Dunlop, Anthony Lee, Lee Moore and ACAL, Jeni Couzyn, Lynda Rycraft, Eddy and Heather Rowarth, John and Hazel Silverstone, Tamar and Alan Segal, Marek and Marsha, Patricia and Eduardo Pitchon, Susie Orbach and Joe Schwarz, LASA, Llin Golding MP, Lord Alton, Sheila Hollins, Arnon Bentovim and Marianne Tranter, Estela Welldon, Liz Lloyd, Shahnawz Haque and Respond, Lloyd de Mause, the Psychoanalytic Study Group on Ritual Abuse and Dissociation including Phil Mollon, Mario Marrone, Nicola Diamond, Elizabeth Campbell, Peter Whelan, John Southgate, Kate White, Liz London. Particular thanks for editorial assistance work from Claire Usiskin and Jill Duncan, the former and current Clinic Administrators. Thanks to all the contributors for both their written chapters and their many other emotional contributions, to Joanne Forshaw at Routledge for her patience and care and to Kristin Susser for production.

Thanks to all those with DID who have dared to face yet another professional with their gifts, their hurt and their courage.



Aldridge-Morris, R. (1989) Multiple Personality, An Exercise in Deception. Hove: Erlbaum.

Breuer, J. and Freud, S. (1893–5) ‘Studies on hysteria’, in The Standard Edition of the Complete Psychological Works of Sigmund Freud, vol. 2. London: Hogarth Press.

de Zulueta, F. (1993) From Pain to Violence: The Traumatic Roots of Destructiveness. London: Whurr Publishers.

Freud, S. (1896) ‘The aetiology of hysteria’, in The Standard Edition of the Complete Psychological Works of Sigmund Freud, vol. 3, p. 203. London: Hogarth Press.

Hacking, I. (1995) Rewriting the Soul: Multiple Personality and the Sciences of Memory. London: Princeton University Press.

Hale, R. and Sinason, V. (1994) In Valerie Sinason (ed.) Treating Survivors of Satanist Abuse. London: Routledge.

Herman, J.L. (1992) Trauma and Recovery. New York: Basic Books.

Janet, P. (1891) Néuroses et idées fixes. Paris: J. Rueff.

Laufer, M. (ed.) (1995) The Suicidal Adolescent, for Brent Adolescent Centre, Centre for Research into Adolescent Breakdown. London: Karnac Books.

Merskey, H. (1992) ‘The manufacture of personalities. The production of multiple personality disorder’, British Journal of Psychiatry 160: 327–40.

Mollon, P. (1996) Multiple Selves, Multiple Voices. Chichester: John Wiley & Sons.

North, C.S., Ryall, J.-Em., Ricci, D.A. and Wetzel, R.D. (1983) Multiple Personalities, Multiple Disorders, Psychiatric Classification and Media Influence. New York: Oxford University Press.

Pines, D. (1982) ‘The relevance of early psychic development to pregnancy and abortion’, International Journal of Psychoanalysis 63: 311–320.

Putnam, F.W., Guroff, J.J., Silberman, E.K. et al. (1986) ‘The clinical phenomenology of multiple personality disorder: Review of 100 recent cases’, J. of Clinical Psychiatry 47: 285–93.

Raphael-Leff, J. (1993) Pregnancy: The Inside Story. London: Sheldon Press.

Sinason, M. (1993) ‘Who is the mad voice inside?’, Psychoanalytic Psychotherapy 7: 207–21.

Sinason, V. (ed.) (1994) Treating Survivors of Satanist Abuse. London: Routledge.

Southgate, J. (1996) ‘An attachment approach to dissociation and multiplicity’, paper presented at the Third John Bowlby Memorial Lecture, Centre for Attachment-based Psychoanalytic Psychotherapy, London.

Van Benschoten, S. (1990) ‘Multiple personality disorder and satanic ritual abuse: the issue of credibility’, Dissociation 3(1) March.