A second edition allows a second hearing. In the six years or so since the first edition came out there are thousands more graduates in psychology, psychotherapy, medicine, social work, nursing and counselling. There are thousands more volunteers working with rape crisis centres, ChildLine, and the Samaritans. There are more people with DID feeling their society is beginning to consider the reality of their existence. Tragically, there are also new babies born into tramatagenic families who are at risk of developing DID.
However, whilst a reprint alone would answer the needs of some, a second edition with brand new chapters, updated references and ideas, offers something to both old and new readers.
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 Fonagy, Chapter 4; de Zulueta, Chapter 3; Richardson, Chapter 10; Southgate, Chapter 5 and Steele, Chapter 6)?
This book is about one way of surviving. It is about a brilliant piece of creative resilience but it 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
Despite the clear description of what constitutes DID in DSM-IV 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 adequately 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 (Sachs & Galton 2008).
“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 two decades 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 in violence although both sexes (see Bentovim, Chapter 2) use internalising and externalising responses. Cultural issues, as well as gender issues need exploring (see Swartz, Chapter 17).
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 Coleman, Chapter 13) 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 early specialist training on the consequences of abuse, professionals are attacking each other’s contradictory diagnoses without realising the aptness of Walt Whitman’s words “I am large. I contain multitudes”.
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 Midgley, Chapter 1; Bentovim, Chapter 2 and Fonagy, Chapter 4) child patients confirmed that negative responses to their disclosures led to hiding their symptoms (see Sinason, Chapter 8). Children were told they would “grow out of it” or it was “just like an imaginary friend”. Adults report similar past experiences and the pain such misdiagnoses or denial of symptoms causes patients can be seen in the poems on labelling by survivors in this book.
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 two toddled around the kitchen. He put his hand up and almost touched 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.
How do we account for these changed faces and voices? Again, if we go back to our two-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.
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 to her GP 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 brain scans are starting to show. To help Mary regain her spirit that is fragmented into her dissociative states means that she has to 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 lack of specialist resources and disbelieving discrediting staff. Graeme Galton (Chapter 13) examines how language is used as a defence here.
The BACP (British Association for Counselling and Psychotherapy) deserves congratulations as the first major umbrella organisation in the UK taking seriously the ethical difficulties in working in this area where professionals have not been adequately trained.
John Bowlby and DID
In 1988, in a clinical supervision, John Bowlby looked at drawings by a middle aged woman of little children being abused. The artist was being treated by John Southgate,(1996 and Chapter 5) Dr Bowlby mused and finally said “I think this woman is a multiple personality.”
John Bowlby was the world-famous psychoanalyst who created attachment theory and helped to prove 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 in the UK. The Netherlands provides a remarkable alternative vision. Indeed, Ellert Nijenhuis, the distinguished clinician and researcher on this topic, was awarded a knighthood by Queen Juliana of the Netherlands for his services to the country on dissociation.
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 (eg blackouts or chaotic behaviour during alcohol intoxication) or a general medical condition (eg 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 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 Coleman, Chapter 14) offers little understanding both in the past and now (see Whewell, Chapter 11 and Mollon, Chapter 12). This leaves British professionals uniquely vulnerable to emotional stress when encountering such patients despite the increase in neurobiological work (see Moore, Chapter 16) and brain scans.
It could be that our recent social interest in brain research allows a face-saving way of changing our clinical paradigms (see Galton, Chapter 13). 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?
Professor Peter Fonagy has evaluated the aetiology of DID from trauma at 90%. (McQueen, Kennedy, Sinason & Maxted 2008). North et al (1993) found that DID was not only linked to a high childhood sexual abuse rate but also 24%-67% occurrence of rape in adult life, and 60%-81% suicide attempts.. 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 & Sinason 1994) psychotherapists’focus on the internal narrative is a defence against the historic external reality.
However, as de Zulueta (1995) 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”.
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 Leff (1993), Perelberg, Pines (1992) and Orbach; those working with violence and suicide such as Eglé and Moses Laufer (1995), blindness and diabetes (Burlingham, Moran, Fonagy et al at the Anne Freud Centre), perversions and abuse (Glasser, Hale, Campbell, Welldon , Kennedy) and disability, ( Hollins, Kahr, Beail, Banks, Frankish, Cottis, Corbett, Curen).
However, it is important to remember that only thirty 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 was very similar 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.
Perhaps DID raises problematic philosophical and psychological concerns about the nature of the mind itself. As Professor Hinshelwood wrote in the first edition ““truly to understand the nature of DID will include dissolving a whole cultural set of baggage that is deeply invested in the notion of the undivided individual”. 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.
Fragmentation in the team
However, 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) then attacks the other psychiatrist/social worker/psychologist/psychotherapist who points out the fragmentation into states. We are then witnessing the trauma-organised systems (see Bentovim, Chapter 2) that systemically mirror the DID experience.
This polarisation extends to writing on the subject. Some clinicians show a remarkable ignorance of the current state of work in this country. 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 12) 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”.
With the advent of concern about the boundary between raw memory and distortions (which have been exploited by various false memory exponents) there has been more room for minority views like Merskey’s that DID is an iatrogenic disease created and instantly implanted by naive therapists who expect to see it (Mollon).
Whilst rigorously trained professionals are well aware of the suggestibility of traumatised clients, especially those who have been hypnotised, it is worth noting that virtually all the patients who came to the Clinic for Dissociative Studies (and before that to the Portman Clinic project on ritual abuse) had long been aware of their own dissociation. 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.
Psychotherapists have negligible training in brainwashing, forcing of alien memories, military mind control or distorted ideas (Sachs and Galton 2008). These are not areas of mainstream professional training despite the profound influence such practices have on vulnerable minds (Sinason 2008). Mental health professionals also do not have any basic grounding in this subject.
This book aims to redress that balance and provide basic clinical and theoretical information for the mental health professional and the interested layman. It is of concern to all because whilst 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.
The Organisation of the Book
To understand the process and aetiology the first part of the book deals with origins in childhood and developmental issues. How does dissociation begin? Nick Midgeley of the Anna Freud clinic looks at the lack of focus on the childhood roots of dissocation whilst Dr Arnon Bentovim examines developmental precursors in multi-abused offending boys. Dr Felicity de Zulueta of the Maudsley Hospital Traumatic Stress Service describes the dissociative continuum and treatment options.
Part Two takes a theoretical focus. Professor Peter Fonagy provides a conceptual overview of the origins of dissociation. John Southgate offers a model that combines his work with Bowlby and his interest in Bion. Professor Howard Steele updates us on theresearch potential of the Adult Attachment Interview. In a new chapter, Consultant Psychotherapist Adah Sachs provides her crucial theoretical understanding on the nature of infanticidal attachments.
Part Three looks at clinical practice. It includes leading psychoanalysts and psychotherapists from the public sector Dr Peter Whewell, Dr Alison Cookson, Dr Phil Mollon and Professor Jean Goodwin. Attachment-based psychoanalytic psychotherapist Sue Richardson describes her way of working clinically. I provide a first meeting with a patient in which the story of The Shoemaker and the Elves provided powerful therapeutic aid.
In Part Four we look at linguistic, diagnostic and forensic issues. In a new chapter, Consultant psychotherapist Graeme Galton takes us through the linguistic defences involved in this work, Dr Joan Coleman speaks of the lack of psychiatric training in this subject, and in another new chapter Detective Chief Inspector Clive Driscoll of the Metropolitan Police speaks of his work in this area.
In Part Five a new chapter by Dr Mary Sue Moore provides understanding of how a child’s drawings provides neurobiological evidence of attachment patterns and dissociation; Professor Leslie Swartz offers an anthropological South African cultural experience and Professor Brett Kahr concludes with an interview with a pioneer on this subject, Flora Rheta Schreiber.
The beginning of each new section is heralded by poems and statements from survivors including, Cuckoo, Beverley, Beverley’s mother, David, Joanna, Mary Bach-Loreaux, Miki and Toisin. Finally, there is an updated information section.
It was Charcot, the great nineteenth century neurologist, who first brought the concepts of hysteria and its symptoms of neurological damage and amnesia to public attention. Whilst 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’ whilst Freud underpinned the concept of traumatic repetition as a way of working through. Breuer andFreud coined the term ‘double-consciousness’. Breuer and Freud (1895) wrote that “hysterics suffered from reminiscences” (Studies on Hysteria 2) and Janet (1891) also 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 many professionals 100 years later than Freud to accept the extent of middle class as opposed to working-class abuse. In fact, Freud never gave up entirely on the significance of the abuse of early seduction.
DID and Ritual Abuse
In America the largest amount of DID is diagnosed in connection with allegations of ritual Satanist abuse. 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 as issues in those alleging this kind of abuse. Indeed, the pilot study on patients alleging ritual abuse that Dr Robert Hale, then 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 made contact with them after disclosing ritual Satanist abuse, and only because no-one else would listen to them.
Although our established religions find the cruel personal Satan of fundamentalists unpalatable or irrelevant, when it comes to examining abuse carried out by Satanist paedophiles (or those who draw on the frightening power of occult paraphernalia to hurt their victims more), nursery memories of harsh religious teaching can reappear and cause fear and confusion. 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 and practice a legally accepted belief system are increasingly concerned at the way criminal groups closely related to the drug and pornographic industries abuse their rituals.
One courageous ritual abuse survivor, on being told by the team psychiatrist that her behaviour and disclosures were upsetting the nurses, commented:
“What do you expect me to say? I am the patient. That is why I am here in this case conference. I am sorry the nurses are upset. But I tell you. I would rather be the nurses who are upset than be me and have to deal with in my head what I have gone through”.
I am first and foremost grateful to all the patients/clients with DID who have worked with me and it is to them the book is dedicated. I am also grateful to all those with DID who wrote to me or met me informally. Organisations and conferences that chose to include these topics are also to be thanked for helping to change the emotional climate.