Title of Course: A Dissociative Identity Disorder Casebook CE Credit



Title of Course: A Dissociative Identity Disorder Casebook CE Credit
 Title of Course: A Dissociative Identity Disorder Casebook CE Credit: 4 Hours (0.4 CEUs) Learning Level: Intermediate Author: Frederick Nolen, PhD Course Abstract: This course details the diagnosis, treatment, and case management of Multiple Personality Disorder, more recently known as Dissociative Identity Disorder. In‐depth discussions include acknowledgement of the confusion and controversies surrounding this relatively rare disorder, rule‐outs and co‐morbid conditions to be considered, and the numerous clinical challenges encountered in treating individuals with multiple personalities. All sections are richly illustrated with case examples from the professional and popular literature, as well as the extensive clinical experiences of the author. Course Objectives: 1.
List the four criteria for diagnosis of Dissociative Identity Disorder (DID) List four aspects of human experience that can be dissociated Name the three most commonly identified psychiatric symptoms in MPD Identify the ultimate goal of therapy with MPD clients Define the concept of “framing” as it applies to the treatment of multiples List the author’s five phases of treatment Posttest: You can access the posttest for this course 24/7 from your personal account on our website. We recommend printing the posttest for use while reading the course materials and then submitting online when ready. 1. Login to your account @ www.pdresources.org 2. Go to My Courses 3. Attend course 4. Click view/print/take test link to open test 5. Click print test link in top right corner to print Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 1 of 50 A Dissociative Identity Disorder Casebook: Diagnosis, Treatment and Case Management Warning 1: As you shall see (or already know), these clients are severely under‐diagnosed, misdiagnosed, ignored, and even ridiculed by their own family and many in the mental health profession. As you shall also see (or already know), therapists who deal with these clients may also be ridiculed and attacked by other mental health professionals and the MPD clients, too. The prognosis for treatment of MPD is still tragically poor. Warning 2: This manual has detailed examples of real physical and sexual traumas. It may trigger your own past abuse memories and feelings. If it does, please get help. Warning 3: I am aware of the controversies past and present that surround debate about the legitimacy of this diagnostic category. Those controversies question the truthfulness of both patient and therapist. The main ones are the following: The patients are mistaken because: 1. They are innocently mistaken. This can happen, and I have seen several instances of this. In one case, I saw a badly physically abused woman who called me for therapy and told me over the phone, before our first session, that she thought she was a multiple personality. She also repeated this assertion to me during our first session. However, I briefly assessed her cognitive processing and found that she had never experienced amnesia for complex activities. She switched from “docile and indecisive” to “wise counselor” but never lost consciousness of the change in her social stance with peers. She had minor episodes of forgetting but they were “normal” forgetfulness (e.g., having coffee burn in the pot because she forgot to turn it off). I communicated this necessary requirement for a diagnosis of MPD, and she understood. 2. They are trying to avoid responsibility for illegal or antisocial activities, infidelity, etc. This might be a possibility, too. There have been many unsuccessful (and some successful) claims for lack of criminal responsibility due to MPD/DID. I will deal further with such issues later in this course. Speaking of trying to avoid responsibility: Ed Norton, Jr. and Richard Gere posted very strong performances (I thought) in a movie called “Primal Fear” that dramatized the possibility of faking DID as an attempt to avoid a murder conviction. In it, Norton played a man who had killed a priest; Gere was his attorney. Norton faked an alter ego to beat the accusation and actually beat the charges. 3. They are simply trying to get attention. This too can happen. I saw examples of this repeatedly during the 1980s when MPD was the “in” diagnosis. The claims I saw were usually made by people who personally knew other “real” multiples and had weak sense of self. They and their claims rapidly subsided with close questioning. 4. They are merely trying to get disability. This also can happen. However, disability claims are adequately evaluated for external confirmation, so claimants would likely receive it if they deserved it no matter what their diagnosis. Most of the individuals I have dealt with were already on disability because they were such low social functioners before they ever came to me. There are also frequent questions and doubts about the integrity of any diagnostician who makes this diagnosis. The criticism, sometimes, is that the diagnosticians are mistaken because 1) they are innocently mistaken and/or 2) are seeking their “15 minutes of fame”. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 2 of 50 I’ll tell you one thing. Openly talking supportively about MPD/DID is not my recommended way of getting your 15 minutes. I did a six‐city, nation‐wide lecture tour on MPD/DID in late 2006 and will never do it again. I have never encountered such disrespect (from mental health professionals) in all my life. All of these errors happen at times…but aren’t the whole story all of the time. These factors involving both patient and therapist also happen with every other “in” diagnosis and treatment. However, all of the clinicians I have met who have actually dealt with multiples to any extent have apparently shared my puzzlement at what was going on with these people (before either of them knew about the dissociations), the patient and therapists’ sense of helplessness, the unpredictability of treatment, and profound sadness about the tragic etiology, painful life courses and chaotic therapeutic courses they all seem to have. I hope every reader of this course will come away with an appreciation of the confusion and suffering experienced by clients with this diagnosis. ON DIAGNOSING The nature of this unusual phenomenon is quite adequately captured by the current DSM‐IV diagnostic criteria for MPD/DID. Diagnostic Criteria for 300.14 Dissociative Identity Disorder from the DSM‐IV‐TR (APA, 2000, p. 529) 1. 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. As we have seen, these personalities are so distinct they claim (and actually feel) they are of different sexes, different races, radically different ages, different sexual identities and anything else that can be different between two physically different people. 2. At least two of these identities or personality states recurrently take control of the person’s behavior. The true level of “taking control” varies from patient to patient. The level of control seems to increase as co‐
consciousness increases through therapy. Conversely, the level of out‐of‐control behavior increases as co‐
consciousness decreases. For some, there is a designated gate‐keeper; for others there is not. 3. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness. The “amnesic barrier” is a crucial component of the level of dissociation and of the diagnosis itself. We all have instances of “normal” forgetting. We all do it everyday since our brains could not possibly store all stimuli we experience in one day, much less for the entire week, much less for all of our lives. Our brain functions on maximum efficiency in so many ways. Storing a bunch of unneeded information reduces the brains computer‐like efficiency for storage, processing and retrieval. So we all forget a lot, every day. However, multiples reported in every medium have forgotten significant hours, days, weeks, even years (as with Eve, to be discussed later). That is not “normal” or “functional,” at any level of social competence. 4. The disturbance is not due to the direct physiological effects of a substance (e.g., blackouts or chaotic behavior during Alcohol Intoxication) or a general medical condition (e.g., complex partial seizures). Note: in children, the symptoms are not attributable to imaginary playmates or other fantasy play. There are many other disorders induced by physiological or psychological events or substances that can create dissociation but aren’t Dissociative Identity Disorder. I developed a diagram of such conditions, which I will present later in the course. I will discuss several of those conditions following that diagram. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 3 of 50 HISTORY OF MULTIPLE PERSONALITY CONCEPT There are numerous Paleolithic cave paintings and historical references to demonic possessions that hint at the existence of dissociative behaviors since the dawn of mankind. The Greek writer, Paracelsus, wrote in the 16th century of a woman who had suffered amnesia and described an alter personality who stole her money (Putnam, 1989; cited by Nancy Burnett: A History of the Study of MPD/DID, in International Society for the Study of Dissociation’s (ISSD) website “Empty Memories” section at http://www.empty‐memories.nl/, accessed Aug 2008. Dr. Jekyll and Mr. Hyde, the book written by Robert Louis Stevenson in 1886, brought the concept of more than one mind in one physical body to the forefront for the popular reader. Stevenson wrote that Dr. Jekyll turned into Mr. Hyde after drinking a potion. Mr. Hyde only turned back into Dr. Jekyll. There were no other personalities in the book. I have heard people described as “Jekyll and Hyde”‐ like ever since I was a child. What’s wrong with this picture? The biggest problem with this picture that faces present‐day mental health professionals (and their patients and their families) is that research data show there are hardly ever just two personalities in an individual with Multiple personality disorder. Some reports place the average number of personalities at four; others say the average number is six. In the cases I saw, the average was about six. There were some clients supposedly with hundreds ‐ or even thousands ‐ of personalities, but I suspect that such high numbers were exaggerated. Why are there rarely just two personalities in a Multiple? The popular literature (e.g., Sybil, Three Faces of Eve, I’m Eve, When Rabbit Howls) and my own clinical encounters indicate that the mental health provider initially interviews the “Host” during therapy. “Host” is a term in the MPD world for the personality who initially presents for therapy. Hosts usually give you their correct legal name and address. They usually (initially) have no idea what is wrong with them. This is Dr./Mrs./Ms. Jekyll. However, therapy in any form always involves asking questions – many personal questions. In the case of multiples, if therapy proceeds for any length of time, the therapist will stumble upon a “touchy” subject during their questioning (unless it’s a three‐session‐and‐we’re‐done‐EAP situation). That “touchy” question may involve sex, sexuality or sexual abuse, although it doesn’t have to be any of those understandably “touchy” topics. Some therapists who are versed in the field of trauma, directly and blatantly ask questions about those sensitive areas. Other therapists don’t ask about abuse. Either way, extended therapy with any patient will eventually “push a button.” The patient explodes and leaves…sometimes for good. Some therapists may perceive the client as merely being “thin‐
skinned” or diagnose her as “Borderline.” You may, in reality, have activated the “protector,” Mr./Mrs./Ms. Hyde. The angry alter egos aren’t simply angry. They are usually created by intense, severe, prolonged sexual and physical abuse. They can be angry, obnoxious and assaultive. They often present a mirror‐image of the abuser(s). However, they aren’t just angry and obnoxious; some or most of them are also defenders. What are they defending? Adults don’t need much defense. Who really needs defending? The helpless and hurt ones are other personalities who function like severely abused little children and adolescents who are petrified and helpless. Some of the adolescent personalities are also angry, rebellious, defiant and dependent…just like real adolescents who were abused as children. Behind Dr./Mrs./Ms. Jekyll and Mr./Mrs./Ms. Hyde are usually the hurt children personalities (plus other adult alter egos developed for various purposes). However, you won’t get to see them if you anger the protector. He or she will take them all away and never let them out for you. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 4 of 50 The second problem with the Jekyll and Hyde process in Mr. Stevenson’s book is that Dr. Jekyll intentionally induced the split (with the potion) and actively evoked the other personality. In comparison, real Multiples don’t seem to have any intentional ability, at least at first, to control shifts. In addition, many of the alter personalities are repulsive and avoided by other alters. The third problem current therapist’s face is that many laypeople mistakenly associate any dramatic change of personality with Jekyll and Hyde and MPD. In reality, most of the people getting the MPD label from laypeople are those who are “nice one moment, and unpredictably angry or mean the next.” These types are more likely to be classic bipolars, borderlines, narcissists and intermittent explosives. You, as a therapist, won’t ever see or knowingly interact with the “hurt children” personalities if you don’t make allies of the aggressive/defender personalities. I believe that the average therapist doesn’t ever make the angry personalities into allies. Rather, they may discharge them as noncompliant, uncooperative, and/or “poor therapy candidates” or, the client leaves therapy, quite upset about what the therapist has done, supposedly has done …or not done. I haven’t found a thorough professional examination of Multiple Personalities before Walter Franklin Prince, MD (Prince, 1916), published his case “The Real Doris” in 1916 (but with initial clinical contact made in 1910). He classically identified different personalities in one body with different names and initial amnesia for each other. Morton Prince, MD (no relation to the aforementioned Walter Franklin Prince), treated a female client and published “Miss Beauchamp: The Psychogenesis of Multiple Personality” in 1920 in the Journal of Abnormal Psychology. His treatment of and articles about Miss Beauchamp are also among the first systematic, scientific examination of the phenomenon. Further information about the topic stayed secluded in the professional domain until Thigpen and Cleckly (1957) worked with and made public “Eve.” Three Faces of Eve was a popular 1957 book and documentary film. The film was much like an army‐training manual of that era: black and white and reducto ad absurdum. “Jane” was the initial host. She had a bland personality, was unremarkable in physical or mental characteristics and initially completely clueless about the existence of the other personalities. This is typical of all hosts when they initially present for therapy. Eve White was a prim and proper female alter ego. She wore a proper, demure dress (always white), sat straight in the chair, placed her hands in her lap, and spoke politely. Eve Black was the naughty one. She always wore black, smoked cigarettes, dressed and acted provocatively, and, I think, swore at times. Thigpen and Cleckly theorized about her cause and cure, and attempted to – or supposedly did – integrate her into one stable personality. Dr. Thigpen basically did this by trying to make Jane go away. She obliged him (temporarily) like any attacked personality does. (I remembered the impermanence of this approach at integration 30 years later when I saw a video tape produced by the University of Missouri. An MPD patient on that tape was speaking confidently that the therapist had cured his multiplicity simply by making the alter personalities “go away”). The biggest problems with the real Eve: she, by her own and her later therapist’s accounts, had a total of 16 personalities and never received any royalties from Thigpen and Cleckly’s book or movie. Also, Thigpen and Cleckly never really integrated her. “Eve” (Christine Sizemore) eventually wrote a book, herself, entitled, I’m Eve (Sizemore, 1977). She repeatedly claimed in her own book to be stably “integrated” after many (18) years of additional therapy. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 5 of 50 She continued to claim successful integration into the late 1990s (in a television documentary about her life). I did meet the lady at an annual meeting of the International Society for the Study of Multiple Personality and Dissociative Disorders in Chicago, Illinois, in 1984 or 1985. She seemed oriented and unremarkable. However, my contact with her was very superficial and very time‐limited. Cornelia Wilbur, MD, contributed a more professionally responsible work related to Multiple Personality Disorder when she co‐wrote Sybil (Schreiber, 1974). It was written to narrate the etiology and treatment of the patient. It was also an excellent book for exemplifying the destructive results possible from attempting the “On Golden Pond” maneuver (trying to resolve it all by getting her parents’ admission of the abuse and enabling by the other spouse). Many therapists apparently didn’t read that part of the book. During the 1980s, I saw and read of many disastrous failed attempts to get abusers to confess and/or seek forgiveness from their victims. Many therapists received complaints against their license and/or were successfully sued for malpractice because they tried a confrontation/reconciliation with the alleged perpetrator…usually without forensic evidence that the abuse really happen. (See my bibliography subsection references regarding “Corroboration”). In Sybil, Dr. Wilbur wrote about a 1957 confrontation she had with Willard Dorsett, Sybil’s father, about his enabling and denial of Hattie Dorsett’s abuse of Sybil. Hattie, Sybil’s mother, had died years before this meeting so she could not be confronted. I remember Sybil’s father’s reactions to her therapist’s confrontations every time I see or hear of more current failed confrontations. Dr. Wilbur was trying to get Mr. Dorsett to admit he had failed to protect Sybil from Hattie’s many abuses. However, his denial and codependence remained active even though Hattie was dead many years ago. Here is the exchange (Schreiber, 1974, pp. 268‐271): “Dr. Wilbur bluntly asked Willard, “Why, Mr. Dorsett, did you entrust the full care and upbringing of Sybil to your wife?” Willard Dorsett was not a man who studies himself or looked at those around him to weigh or measure their moods. In Willow Corners, he had been a busy man, away from home from dawn to sundown. He had felt that he couldn’t have been expected to know them. How, he asked himself, could he possibly answer the doctor’s questions about these details, so far off, so forgotten? Why had he always entrusted to Hattie the full care and upbringing of Sybil? He merely shrugged in reply. The question obviously seemed to him irrelevant. It was like asking a butcher why he sells meat or a farmer why he plants corn. A mother should take care of a child. Had he been aware that Hattie’s behavior was peculiar? He moved jerkily in his chair and became defensive. When he finally spoke, it was to say, “The first Mrs. Dorsett was a wonderful woman, bright, talented.” He hesitated. “And?” the doctor asked. He became flustered. “Well,” he said, “we had a lot of trouble. Financial and otherwise. It was hard on Hattie. At times she was difficult”. “Just difficult?” the doctor asked. “Well, she was nervous.” “Just nervous?” He mopped his forehead, changed his position. “She had some bad spells.” “Is it true that she was in a bad state on the farm when Sybil was six?” Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 6 of 50 He averted his eyes and finally said yes. “Was it true that when she came out of her depression, she tore down the hill on Sybil’s sled?” He squirmed while saying, “Yes, Sybil must have told you it was a big hill. A child’s imagination, you know. But the hill wasn’t really very high.” (He had an almost comic way of wriggling out of facing the real issues.) But your wife came down that hill, large or small, on a child’s sled, laughing? What did you make of her behavior in that instance? The doctor was trapping him into an admission. “Was it safe, Mr. Dorsett, to allow this strange, nervous woman, who had what you call spells, to have the sole responsibility for raising your child?” Instead of answering directly, he murmured non‐responsively, “Hattie was odd.” “It was more than odd, Mr. Dorsett. She was more than nervous if what I’ve been told is true. The bombardment of recollections made the room gyrate. Each recollection, rising from the buried past, reawakened the dull, sad ache of his hands, the after‐image of the neuritis from which he had suffered after he had lost his money. “Well,” Willard explained, “Hattie and Sybil never got along. I thought a mother and daughter should be close, and I was disturbed by their arguments. When they were at each other, I used to say, ‘Hattie, why don’t you rest a while or crack some nuts?’ I used to hope Hattie and Sybil would get over it in time.” “That was when Sybil was a teenager,” the doctor reminded the father. “But weren’t there certain things that occurred when she was a very young child – even an infant – that couldn’t be settled by cracking nuts?” “You must know something I don’t know,” he replied defensively, fiddling with his fingernails. Was he aware that as a child Sybil sustained an unusual number of injuries, the doctor wanted to know. With annoyance he answered quickly, “She had accidents, of course, like any child.” Did he remember any of these accidents? No, he couldn’t say he remembered. Was he aware that Sybil had had a dislocated shoulder, a fractured larynx? “Why, yes,” he replied, screwing up his thin lips. How had they happened? He made no answer, but the involuntary twitching in his face betrayed uneasiness. Flustered, he finally replied, “I never saw Hattie lay a hand on Sybil.” Did he remember the burns on his daughter’s hands, her black eyes? “Yes,” he replied, slowly, remotely. “I seem to recall these things now that you take me back.” He became even more flustered and said, “After all, I didn’t see them happen. They must have taken place when I was away from home.” Did he remember the bead in Sybil’s nose? He replied defensively, “Sybil put the bead in her nose. You know how children are. Always putting things in their noses and ears. Mrs. Dorsett had to take Sybil to Dr. Quinoness. He got the bead out.” And now, the doctor was asking pointedly, “Is that what your wife told you?” Willard Dorsett clasped his hands together to reaffirm his own solidity and put up some resistance, saying, “Yes Hattie told me that. I had no reason to question her.” Dr. Wilbur insisted, “What did your wife tell you about the larynx and the shoulder? Did she say that Sybil had fractured her own larynx, dislocated her own shoulder?” Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 7 of 50 He knew an answer was expected of him, but he took time to think about the doctor’s question. “Well,” he said at last, “I can’t remember exactly what Hattie said. But she was always telling me that Sybil had many falls. I supposed I never really thought abut how these things happened, now that you ask me. Ignorance is one of my failings.” Although Dr. Wilbur cracked and crumbled his defenses with continued aggressive interrogation (I won’t say interview), his second response to her redirected question (why he allowed Hattie to raise Sybil), was “‘it is a mother’s place to raise a child’…and once again his shell closed around him” (page 274). Maybe he was a man of that time, working outside the home from sunrise to sunset. Maybe he was innocent or ignorant because the zeitgeist of that day (Freud’s writings that said children weren’t really abused). Maybe he was just a man of that time because there weren’t even any laws at that time prohibiting physical abuse of children, much less sexual abuse. However, his veneer of innocent ignorance crumbled when Ms. Schreiber reported later in the book that he left Sybil penniless after directly promising her he would leave her a substantial (for that time) sum of money after he died so he could finally provide protection for her. The next great landmark in the history of diagnosis and treatment of Multiple Personality was, unfortunately, a resounding criticism of the treatment of all sexual abuse survivors, much less the treatment of Multiples, the most abused of the abused. (I did six lectures across the country in 2006 on this topic. I was amazed to learn that so many of the therapists in my workshops were actually treating clients they believe to be multiples. I feared the search and treatment of MPDs had been stifled, if not killed by False Memory issues. It has apparently not been killed.) Elizabeth Loftus (1996) published a book about and entitled The Myth of Repressed Memory. She gave many examples of overly zealous “trauma” therapists who were quick to accept that sexual abuse had happened, even with very little substantiation. Sexual abuse wasn’t openly talked about before the 1960s by anyone public or professional. The prevailing attitude of most mental health professionals at that time was driven by the Freudian notion that it was all just part of the Oedipus/Electra Fantasy. Freud and many in the general populace thought that adults didn’t really sexually abuse children. Freud (and therefore, the general populace) thought that children only wanted to have sex with their opposite‐sex parent to psychologically “kill” their same‐sex parent. However, all of those taboos seemed to dissolve in the 1960s. Girls wore pants, shunned their lipstick (and bras), quit shaving their body hair; guys grew their hair long, took up cooking and other “unmanly” activities; drugs, sex and/or rock and roll were out in the open as subjects of social discourse. Sex, in all its facets, became a mater of open discussion. Sexual abuse became openly discussed (and researched), too. Elizabeth Loftus’ book detailed many examples of therapists pressuring clients into talking about “admitting” and “discovering” they had been sexually abused. Many of the examples she gave were blatantly coercive clinical techniques and those therapists, in all probability, caused significant emotional damage to their patients. Their coercive techniques and manners would do damage no matter what the patient’s real issues were. However, the data over many decades continues to indicate the high prevalence of sexual abuse in patients seeking inpatient and outpatient therapy (e.g., Cumella & Kally 2008; Hyman et al, 2008; Dudeck et al, 2007; and Cantor, 1995). Abuse is an issue for many of them. Effective, appropriate, impartial assessment is the therapist’s burden. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 8 of 50 I could never truly empathize with physically or sexually abused people until I saw a documentary somewhere in the 1990s. That documentary involved a different topic (Lesbianism in Denmark in the 1940s), but with the same underlying issue that pre‐1960’s sexual abuse victims had: not being able to talk about it. The woman subject of this documentary made the following statement about her self‐understanding that highlights the personal plight of the abused, too. She said: “I didn’t know what I was until I could talk about it.” The openness of the 1960s let people talk about everything that had been suppressed or forbidden by most cultures in the world up to that time. It let real sexual and physical abuse victims talk about their abuses and pains, get emotional support, get therapy, get better, get protection, get retribution, and get revenge. Unfortunately, as is often the case, the privilege of self‐exploration was abused. These abuses of clinical and professional responsibility appeared to have killed, for a while, the search for the hidden parts of the mind. The best hiders: alter personalities. While Loftus’ work criticized the therapists, she and her foundation (False Memory Foundation) received their own criticisms when several of the foundation board members were exposed as sexual pedophiles, including a Catholic priest who was convicted of pedophilia, incarcerated and defrocked. Two of the board members (Hollida Wakefield and Ralph Underwager) also gave “pro‐pedophilia” interviews in Paidika: The Journal of Pædophilia (Paidika, 1993). Wakefield is quoted as follows: “We can't presume to tell [pedophiles] specific behaviors, but in terms of goals, certainly the goal is that the experience be positive, at the very least not negative, for their partner and partner's family. And nurturing. Even if it were a good relationship with the boy, if the boy was not harmed and perhaps even benefited, if it tore the family of the boy apart, that would be negative. It would be nice if someone could get some kind of big research grant to do a longitudinal study of, let's say, a hundred twelve‐year‐old boys in relationships with loving paedophiles. Whoever was doing the study would have to follow that at five‐year intervals for twenty years. This is impossible in the U.S. right now. We're talking a long time in the future." In the same interview, Underwager said this: "Paedophiles need to become more positive and make the claim that paedophilia is an acceptable expression of God's will for love and unity among human beings. This is the only way the question is going to be answered, of whether or not it is possible. Does it happen? Can it be good? That's what we don't know yet, the ways in which paedophiles can conduct themselves in loving ways. That's what you need to talk about. You need to get involved in discourse, and to do so while acting. Matthew 11 talks about the wisdom of God, and the way in which God's wisdom, like ours, can only follow after. Paedophiles need to become more positive and make the claim that paedophilia is an acceptable expression of God's will for love and unity among human beings." The issue of validity of patient report or diagnosis remains today, regardless of the diagnosis. Children (and some adults) do make false claims of abuse. Those concerns can be effectively handled without “throwing the baby out with the bathwater” or handing the baby over to convicted pedophiles. Hopefully, the pro‐and‐con hysteria has subsided and reason can prevail. The next step in the MPD treatment pathway was the inclusion of posttraumatic stress disorder (PTSD) as a clinical diagnosis in the DSM‐IIIR (APA, 1987). This was accomplished by political pressure of the returning Vietnam War veterans. Until their outspoken pressure, psychological trauma (previously called shell shock, combat fatigue, the 1000‐
yard stare or “the reverie”) was considered to occur only in war and because of war. After PTSD was acknowledged to continue into civilian life for returning soldiers, it was seen to be present in civilians who had never been in war: severely physically and sexually abused civilians. This allowed further understanding and development of the treatment of the most severely abused: the MPDs. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 9 of 50 The final touch was the legislation that made physical and sexual abuse a crime against children. This was done in 1975 in America. There were cruelty‐to‐animal laws before there were cruelty‐to‐children laws. Legislation for child protection was actually modeled from animal abuse statutes (ironically enough) by applying “cruelty to animal laws” to child abuse (Child Abuse Prevention and Treatment Act – CAPTA – 1974). THE DISSOCIATIVE CONTINUUM Multiple Personality Disorder is one example of “dissociation.” Dissociation involves a split of one part of self from other parts of self with partial amnesia for an action or event. Dissociation of behaviors, affects, sensations and knowledge ranges from common, everyday events to the extremes of clinically pathological dissociations. I have developed a partial list, ranging most organic (physical) at top to most nonphysical (psychological) at the bottom. Some of these may be considered as rule‐outs in the assessment process. • Coma Physical • Dementias • Temporal lobe/partial complex/Jacksonian seizure/petit mal epilepsy • Sleep walking/talking • Highway hypnosis • Hypnosis • Daydreaming • “Normal” forgetting • She/He/Sally (third person) • “Blind” rages • Overdose‐induced blackouts • Withdrawal‐induced blackouts • Auditory hallucinations • Psychogenic fugue • Alter egos • Suppression/intentional forgetting • Repression/psychogenic amnesia/automatic forgetting Psychological • Dissociative Identity Disorder: forgetting by splitting My major point about these various types of dissociations that I want you to keep in mind for later is this: All that is divided is not multiplied. Most of the first events at the top of this list are fairly self‐explanatory and organic in nature so I don’t have many comments about them. However, I must remark that it is crucial that you rule out insulin deficiency and temporal lobe epilepsy as the source of the dissociation if you have any indication of diabetes or temporal lobe seizures in the family. I have seen legal convictions for crimes reversed when insulin deficiency‐related amnesia was identified. Regarding epilepsy, there is the spectacular gran mal epileptic seizure (now called tonic/clonic) that is unmistakable. Large voluntary muscles in the arms and/or legs start jerking, loss of bladder control is frequent, and the clonic muscle spasms of gran mal epilepsy can cause injury from falls. Victims are obviously dazed in the postictal state and show full amnesia for the duration of the seizure and some brief period before it. Temporal lobe (also called partial/complex, Jacksonian, or petit mal) epilepsy is much more subtle. It produces some dissociation. The temporal lobe (partial complex/petit mal) seizures are often much less detectable than the gran mal type. The most frequent observable event is the victim staring blankly. However, there is also usually some concomitant muscle twitching, minor spasms and short, sharp noises like growling or whistling. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 10 of 50 Afterr a temporal llobe seizure, victims will reeorient to thee here‐and‐no
ow with variaable ease, durration and efffort. It may appeear as if they w
were just dayydreaming. Ho
owever, they often have lo
oss of memorry for their beehaviors durin
ng the temp
poral lobe seizure even tho
ough they maay engage in ccomplex interractions with you. I had
d an amazing eexample of su
uch a petit mal seizure in 2
2003. I complleted a batterry of psycholo
ogical testingg on an eight‐
year‐‐old male who
o was diagno
osed with ADH
HD, PTSD, Reaactive Attachment Disordeer (RAD), and Pervasive Deevelopmentall Disorrder (PDD). However, I had
d some previo
ous records o
of PET scans aand EEG results. Both of th
hem indicated
d significant prefrrontal lobe su
ubfunction with focal pointts of epileptifform activity in a temporal lobe. I interaacted with th
he child for almo
ost two hours. He was haviing left‐side ““clawing” of h
his hand and aarm during ou
ur time togetther. He madee unusual whisttling noises. H
He completed
d my tests witth varying degrees of focu
us and compliance. I mad
de it a point tto call his fostter mother th
he next day an
nd had her assk him questio
ons to assess his memory of his interactions with me the previo
ous day. He ccould not corrrectly identifyy me as male or female. He could not reemember anyy nly thing he w
was able to reemember accurately was ““drawing circles,” which hee of the tests in whiich he participated. The on
did d
do on one of m
my tests. I believe he was having a petitt mal seizure during the teesting session
n. (An interesting no
ote: he only acted this wayy after he took his stimulan
nt medication
n. I hypothesiized that the stimulant may have been pu
ushing his braain over the seizure thresh
hold. I recomm
mended that they take him
m off the stim
mulant mediication. His ad
doptive moth
her discussed it with the prrescribing phyysician and he discontinueed the medicaation. The boy’ss seizures stopped.) “She//He/Sally:” So
ome individuals refer to th
hemselves in the third person, using a p
pronoun or th
heir own nam
me when referrring to themsselves. This provides somee emotional d
distance but d
does not usuaally indicate aany deeper psych
hopathology (unless the in
ndividual has no memory o
of doing so affterward). “Blind” Rages: Detectives, atto
orneys and co
orrections pro
ofessionals heear many storries of murderers who claim they don’t remeember pullingg the trigger. Most of thosee claims are q
quickly dispelled with morre intense inteerrogation. However, I have seen a couplle of sane and
d sober (at th
he time) civiliaan adults and
d several of m
my adolescent and adult clients who told m
me they becaame so angry that they atttacked someo
one physicallyy and didn’t reemember a thing. Could itt be that somee “blind” ragees are true ph
hysiologically based black o
outs (dissociaative episodess)? Doess the neuroan
natomy of the
e limbic system clue us into
o possible fun
nctional conn
nections betw
ween “blind raage” anger and m
memory lapsees? Maybe. If you
u look at a sch
hematic of th
he Limbic Systtem, it forms a ram’s horn shape as it curvees bilaterally backward, th
hen forward in
n the midbraiin of mammaals. The entire Limbic Systtem is the darrk red loop in the picture tto the right th
hat ends at onversion the top of the blue brainstem. The brain strructures assocciated with co
of short‐term to lo
ong‐term memory (the hip
ppocampus) aare situated n
near the outer tip of each o
of those horn
ns. At the furtthest external tip (see purp
ple tip of pictu
ure below, on each horn lays the amygd
dala, the brain
n structure asssociated with rage (do Amaaral, & Martin
ns de Oliveiraa, 2008). If thatt brain centerr is stimu
ulated to the p
point of “blind
d” rage, does the hippo
ocampus overrload? If it does overload, doees it short‐
circuitt and cease m
memory storagge? Maybe. M
More research is indicateed. Prrofessional Deveelopment Resources | 2008 | ww
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Casebook | Page 11 of 50 Auditory hallucinations: Some consider any hallucination to be a sign of severe insanity, biochemical imbalance in the brain, and nothing more. However, seriously consider the following: the most frequent type of hallucination is auditory. Sixty to seventy percent of schizophrenics have auditory hallucinations (Esposito, 2006). So what? Consider the following: • What kind of messages do the voices communicate? They are usually negative, very hostile and very critical. • The voices may have energy (feelings) that the identified patient doesn’t have. If you ask the patient about childhood abuse, you will often find severe physical abuse (even in those diagnosed as schizophrenic). • The identified patient’s feelings about being abused may have never been taken seriously (by their parents, mental health professionals…or by themselves). So, in a sense, everyone dissociates this part of the individual, who may then be seen as insane. • Ask about the content of the voices and you will definitely find their issues (possibly of abuse and probably denied anger). You may also find the rest of the story, possibly including alter egos. This dissociation list I created is not meant to be exhaustive. I am not suggesting that the sequence is empirically drawn. My main point from this list is, again: all that is divided is not multiplied. Just because you have identified someone who really is psychologically dissociating, it still does not mean you are seeing a genuine case of Multiple Personality Disorder. Consider the other possibilities of psychogenically‐produced subcategories of Dissociative Disorders from the DSM‐IV‐TR (APA, 2000, p. 520). 1. Dissociative Amnesia: forgetting based on emotional (not physical) trauma. These are the classic “suppressed” or repressed memories that surface in therapy all of the time (with or without prompting, with or without prodding, without or without encouraging). They usually have intense negative emotions tied to them. 2. Dissociative Fugue: characterized by “sudden, unexpected travel away from home or one’s customary place of work, accompanied by an inability to recall one’s past and confusion about personal identity or the assumption of a new identity” (p. 532). All of the cases of this category I have seen or heard about I consider to be suspect for the following reasons: a. None of the fugue cases I have heard about had happy homes from which they were fleeing. There were nearly always severe problems like domestic violence, abuse, financial difficulties, and/or impending criminal charges against them. b. None of the subjects were happy when their true identities were discovered. In fact, some of them re‐
experienced their fugue, fleeing to another state with more alleged amnesia after their true identity was discovered in one state. For example, the first fugue case I ever carefully followed happened in Columbia, Missouri in the mid‐70s. A Caucasian female showed up at the Midway Truck Stop just west of Columbia without wallet, purse, money or memory of where she came from or how she got to Columbia. She claimed total amnesia. The case was publicized in the news locally, then nationally, but nobody claimed to know her. At some point, a University of Missouri‐Columbia linguistics professor came forward and declared that some speech characteristics she had indicated she had to have come from one of a few counties in Pennsylvania. The Columbia, Missouri police reactivated their identification efforts in those few counties and her husband identified her within a couple of weeks and agreed to come to Columbia to get her. Unfortunately, he had a record of domestic abuse and she disappeared before he could get back to Missouri. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 12 of 50 Strangely enough, she reappeared at a Florida truck stop claiming no money, no purse, no ID and no memory for where she had come from of how she got to Florida. c. None of the subjects had their amnesias lift in the sequence typically seen in victims of true psychological or physical trauma. That is to say, true amnesias end when memories are recovered. Trauma victims typically remember their most primitive, most basic identification first when their memories return. For example, they remember their names, their family members’ names, pets’ names. Only later do they remember more recent, less personal events (such as what they were doing the hour before they got traumatized, high school classmates’ names; where they were when Kennedy was assassinated or when the 9/11/2001 terrorist attacked the World Trade Towers in New York, etc). d. None of them had reported or demonstrated intense affect to any of the events they claimed to have remembered from their forgotten life. Every true trauma victim I have worked with experienced extreme emotions upon recalling repressed or suppressed memories. They cry, they laugh, they sob, they weep because they have just found something important that they had lost: parts of themselves. Some cry about it for hours; others cry for weeks. They cry some more when they think about it again the next day or talk about it the next week. e. None of the individuals in the fugue cases with which I am familiar were carrying any form of identification when they were found…no wallet, no purse, no driver’s license, no Blockbuster Membership card, no Home Depot discount card…nothing. I believe that this commonality can only be explained as a deliberate maneuver to escape identification. These five observations lead me to suspect that fugue victims are merely consciously running away from bad lives in one place, faking amnesia. EPIDEMIOLOGY Asking about the true prevalence of any mental disorder is akin to opening Pandora’s Box. However, the DSM‐IV‐TR says that the “sharp rise in reported cases of Dissociative Identity Disorder in the United States in recent years has been subject to very different interpretations. Some believe that the greater awareness of the diagnosis among mental health professionals has resulted in the identification of cases that were previously undiagnosed. In contrast, others believe that the syndrome has been overdiagnosed in individuals who are highly suggestible” (APA, 2000, p. 528). James Chu, M.D., wrote: “Clinical studies in North America, Europe, and Turkey have found that between one and twenty percent of patients on general inpatient psychiatric units, adolescent inpatient units, and in substance abuse, eating disorders, and obsessive compulsive disorder treatment may meet DSM‐IV‐TR diagnostic criteria for DID, particularly when evaluated with structured diagnostic instruments (Guidelines for Treating Dissociative Identity Disorder in Adults 2005, http://www.isst‐d.org/education/Adult%20DD%20Treatment%20Guidelines‐ISSTD‐JTD‐
2005.pdf, accessed August2008). Mental health practice has changed so much in my 40 years of study. In earlier versions of the DSM, epidemiology was expressed in terms of percent of inpatient mental hospitalizations. Now that so many inpatient mental facilities have closed compared to the heyday of inpatient hospitalization, we can no longer use that standard. That still leaves us with the interminable question: What is the true prevalence? However, the lack of inpatient facilities now compared to 40 years ago suggests another question of particular relevance to any therapist: where do Multiples go after inpatient placement, since they can’t live in an inpatient facility like they used to? Some multiples may have some high functioning personalities when a high‐functioning personality is out, but a person who functions brilliantly for two days and then doesn’t show up for work for two years probably isn’t going to keep a paycheck coming in. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 13 of 50 Multiples are likely to function at very low socioeconomic levels as they age because society demands more complex and more sustained functioning as we all grow older. Many of them are divorced, under‐employed, low‐salaried when they do work, and probably on disability. Family services will probably have been involved in both the family of origin and the adult family. Long‐term incarceration is so common that it is almost a given. Contacts with multiple, sliding fee scale agencies are most likely. Homelessness is probable. THE DIAGNOSING OF MULTIPLE PERSONALITY DISORDER MPD was introduced into the DSMs in 1980. It continues to be accepted by the American Psychiatric and Psychological associations to this day in spite of the doubters and critics. Below I repeat the four criteria for establishing this diagnosis from the DSM‐IV‐TR (APA, 2000, p. 529): 1. 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). 2. At least two of these identities or personality states recurrently take control of the person’s behavior. 3. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness. 4. The disturbance is not due to the direct physiological effects of a substance (e.g., blackouts or chaotic behavior during Alcohol Intoxication) or a general medical condition (e.g., complex partial seizures). Note: in children, the symptoms are not attributable to imaginary playmates or other fantasy play. Nota bene 1: The standard methods of diagnosing other diagnostic categories are virtually useless for confirming this diagnosis. Standard, generic intake methods such as check sheets, general information sheets, or the Symptom Behavior Check List don’t even ask about dissociative episodes. More pathology‐directed tests like the Minnesota Multiphasic Personality Inventory or Millon Clinical Multiaxial Inventory ask questions about memory lapses but don’t ask enough questions about memory lapses, dissociative episodes, or about hallucinations to differentiate between the schizophrenic‐type auditory hallucinations I talked about previously and the more intra‐psychically interactive mental auditory communications between alter personalities. Nota bene 2: DID is probably the last diagnosis you should expect and will probably be the last diagnosis you consider. The external behaviors and internal experiences of DID are also all manifested in most other true psychological conditions, even the other dissociative disorders. You only know your client is a multiple personality when they are having dissociative episodes and the client or an alter ego, spontaneously names them. I have a personal example of how this doubt about the validity of the DID phenomenon crumbles in the face of object facts. I worked at an outpatient therapy branch of Research Mental Health Services, a large public, non‐profit agency in Kansas City, Missouri, from 1991 to 1993. There were no multiples diagnosed or in treatment at the time I began working there. Then one day my director gave me another therapist’s chart and asked me to evaluate it for a possible diagnosis of MPD. I knew the therapist only by name. I had not heard anything about the client in any form up to the time I was given her chart. The therapist had derived a provisional diagnosis of MPD after working with her for over a year. He and many other clinicians had previously given her many other diagnoses. The director wanted my opinion of the strength of his diagnosis of MPD. I did an hour review of the chart. The therapists notes were behaviorally oriented enough that he included specific statements and observations. I reported that he had written enough about her behaviors and statements that I believed she was a Multiple Personality, even though the therapist himself was completely unfamiliar with many of the nuances of MPDs behaviors. At the time I left that agency in 1993, there were six Multiple Personalities in treatment there, even with exclusions of other possible cases that had some factors of dissociation or multiplicity but weren’t full‐blown Multiples. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 14 of 50 NON‐PRODUCTIVE ASSESSMENT METHODS There are many non‐productive ways to search for and assess the possibilities of multiplicity. The following are likely dead‐ends or wrong‐way streets: • Ask the client if he or she is a multiple. Don’t bother because the data indicate that most of them don’t know they are. The scientific literature (e.g. Putnam, et.al, 1986) and my own experiences indicate that 70% of multiples do not know it when they first present for treatment. They, themselves, can’t be reliable informants at first. • Ask the client’s parents. Again, don’t bother. The may have been involved in the etiology of the client’s pathology and may be even more emotionally troubled than the client. In addition, they are probably in major denial about any problems in their family. Read Sybil (or my excerpt above) again. I think the terms “denial” and “enabler” were developed after therapists dealt with parents of severely mentally ill patients. • Ask the client’s siblings. Still again don’t bother, because they probably have very disturbed relationships with your client, only saw pieces of the puzzle (specific alter egos), didn’t know what to make of them, and may blame the client for being difficult, stubborn or argumentative. • Ask the client’s children. Ditto. They probably have very disturbed relationships with your client, too, and think you are making excuses for what a terrible parent he or she was. • Ask the client’s current friends. They probably won’t or can’t help because they probably aren’t too functional or introspective either. However, they can serve as monitors and witnesses of concrete actions like “we watched a movie last night” or “she left the house last night around 8:00 p.m. and said she was going to meet Tom at the church.” Therefore, they can serve as more reliable informants than the DID clients themselves. • Use general psychological testing such as the MMPI or MCMI. Don’t bother. There are only a few dissociation questions on them, if any. • Use specific dissociation inventories. The only ones I’ve seen are the Dissociative Experience Scale (Bernstein & Putnam, 1986) and Steinberg’s (1994) Structured Clinical Interview for DSM‐IV Dissociative Disorders (SCID‐D‐R). The DES is fast to administer but its scoring is very loose. The SCID is good because it assesses five core areas of DID (amnesia, depersonalization, derealization, identity disturbance and identity confusion) but takes a long time (30‐90 minutes), is “transparent” (obviously asking about memory lapses) and doesn’t ask collateral informants. MOST COMMON PROCEDURAL ERRORS IN DIAGNOSING MPD 1.
Not assessing for it at all, especially if the client has been in treatment over two years. Directly asking the client if he or she is a multiple personality if you suspect it. Not asking the client about hearing voices. Not getting collateral information. Not immediately asking clients if they’ve been physically abused. Not immediately asking clients if they’ve been sexually abused. Not pursuing the dynamics of auditory hallucinations, if the client admits to them or past records indicate their presence. 8. Not immediately assessing for dissociations. 9. Not immediately assessing for frequency of headaches. 10. Initially asking alter egos for names or “calling out” for alter egos. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 15 of 50 PRODUCTIVE WAYS TO ASSESS FOR MPD 1) Nolen’s Trauma Inventory: I have developed an ever‐ growing list of items that I use for a structured interview. I usually administer this during my first clinical contact. Some therapists have objected to asking about sexual abuse so early in the therapy process because of the lack of a strong therapeutic bond and/or patient fragility that may result in premature termination of treatment. Secondly, there is a greater possibility of conscious denial if the patient does not yet feel comfortable with the therapist. Thirdly, the patient may be too brittle to tolerate that level of stress. I acknowledge all of these concerns. However, I pursue the abuse questions as soon as possible because 1) many patients apparently have never been asked about these issues in their previous therapies and 2) most MPDs have chronic and severe abuse‐related mental illness and 3) chronic and severe abuse usually causes chronic and severe emotional problems. As you will note, these questions are not original. I just haven’t seen them compiled in one place with their anchor to psychopathology. Many of these items are trauma‐based, as you will see. I describe them as a subtle assessment of severe psychopathology. I will also try to explain the implications or application of each area. NOLEN’S TRAUMA INVENTORY (NTI) HEADACHE frequency and severity: I ask this because the number one physical symptom reported by multiples is headaches (Putnam, et. al., 1986). I then follow up positive responses to these items with questions about loss of consciousness during or after the headaches. ALLERGIES: Some allergies are psychophysiological (related to emotional stress or trauma) in nature. Some are specifically trauma‐related. For example: I saw a patient who told me during my first‐session structured assessment that she was allergic to strawberries. Some of her alter personalities started coming out during age‐regression hypnosis and the protector/angry personality terminated therapy. As she went out the door she said, “I’m going to go eat some strawberries.” She wasn’t allergic to them; the host was. ASTHMA: Some asthma is psychophysiological and can be reduced or eliminated during psychotherapy. However, it is advisable to also assess family history and environmental factors (e.g., pollution, insect infestations, etc.). DERMATOLOGICAL PROBLEMS: Many of the old‐time psychosomatic theories (e.g., Graham, 1972; Alexander, 1972) suggested that conditions like eczema and psoriasis were psychosomatically based. They may be, but I haven’t had much positive impact on them with psychotherapy. I have seen a smeared, irregular but distinct blotchy rash on a clients’ throat and chest (like a lupus patch) that may indicate suppressed anger and goes away when hidden anger is released. GASTROINTESTINAL DISORDERS: These may be expressed as frequent diarrhea or constipation. The gastrointestinal system shuts down with chronic or acute stress. It is part of the “flight‐or‐fight” response. The nervous system has the “voluntary” and “involuntary” branches. The involuntary branch (controlling smooth muscles) shuts down blood flow to the vegetative organs during emergency so that full enervation and blood flow can go to the voluntary muscles (for fighting or fleeing). It doesn’t do the body any good to continue spending energy on digesting food if you’re dead. PHOBIAS of ANY TYPE: While any phobia can be trauma‐based, this is not always the case. Many simple phobias (e.g., spiders, snakes, needles) may have little trauma behind them. However, fear of the dark can often be based upon traumatic experiences. I am struck by how common it is for older, abusive siblings to lock their victims in closets, stairwells or clothes trunks. It also surprises many clients when they realize their fear, or their children’s fear, of the dark are due to the domestic violence they saw (and more frequently: heard) between their parents when they were children. Fears of abandonment often get reported in response to this question, too. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 16 of 50 FEAR of ANYBODY: It surprises me how many negative responses I get to this questions even though the patient later tells me about intense, if not horrific, abuse inflicted upon them by a person. I’m not sure of the dynamics of denial here and admission to the more direct abuse questioning later in this inventory. There are probably many dynamics. FIRST MEMORY: What was it and how old were you? I find this clinically interesting if it is significantly past the average range of first memory (between two and five years of age). It can indicate brain damage. It can indicate suppression or repression. However, it may also be that the client 1) does not understand the question or 2) has a recall in the normal range but has trauma issues without forgetting, 3) has normal range first memory and has trauma issues with forgetting. RECURRING DREAMS: These are dreams in which the exact same sequences are repeated over and over again. I don’t mean the same general theme (drowning, flying, driving down a road). I mean the exact, same dream. For example, a young girl I worked with kept dreaming about being trapped under a chair with a beaver sitting on it that was trying to hurt her. She could never escape from it. These may be obvious trauma‐based nightmares of specific abuse episodes or less obvious trauma‐based recollections. NIGHTMARES: Most people have frightening dreams. However, I have found a higher incidence of nightmares in abused people than non‐abused people. ENURESIS: I inquire about any recent occurrences or last known episode in childhood. ENCOPRESIS: Any recent occurrences or last known episode in childhood. SLEEPWALKING/SLEEPTALKING: I usually don’t get much out of this but I ask anyway. SUICIDAL IDEATION/ATTEMPTS: If I get positive responses, I ask what method they used and how they were feeling when they did them. Clients are rarely aware of the dynamics of the thought/attempt at first. They are usually able to tell me about the dynamics (reasons) once I question them in more detail. It is often a surprise to them to realize why they were doing it. HEARING VOICES: I ask if the client has ever heard voices in her head that were not her own thoughts. I’ve had children as young as age five respond positively. I have also had a surprising number of teenagers answer positively. A very large percentage (90% or more) described the voices as a threatening, agitating, angry and male. The majority of those had no other indicators of dissociation, but did have a threatening, abusive, angry male in their real, childhood social sphere. MEMORY LAPSES: I directly ask if clients are aware of having ever done anything complex that they would have enjoyed but didn’t remember afterward (like flying to St. Louis or New York). LISTS/LETTERS/POEMS/SONGS: I ask them if they have ever done any writing that they didn’t remember doing. I get about one patient every 12 months who admits doing this and shows the product to me. FINDING OBJECTS: I ask about finding anything in their pockets or purses that they don’t remember picking up. Most frequently, I get positive responses about small amounts of money, cigarette lighters, or notes. However, I once had a case in which the client found four grams of cocaine in her purse and a pretty bracelet on her wrist that she didn’t remember getting. (She also woke up driving down the road in Arkansas when she last remembered being in her bedroom in central Missouri). FINDING CLOTHES: In your dresser or closet that you don’t remember picking up, that fit you, and that you usually wouldn’t be caught dead wearing. FRIENDS: Having people come up to you, talk to you as if they know you, talk about things you’ve done together…but you don’t remember them. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 17 of 50 BRUXISM: This is nocturnal teeth grinding. It is often a sign of high daytime tension and causes a lot of daytime headaches. It often produces temporomandibular join (TMJ) Syndrome, too ABUSE: As I start asking the questions at the beginning of this inventory, I warn the patient and/or caretaker that I will be finishing at the end with questions about abuse. As interview research literature shows (e.g., Whisman & Snyder, 2007; Duncan, et.al., 1998), when you ask about abuse, you will get what you ask for based on your questions’ transparency, interviewer skill, and the patient’s interpretation of your questions. For example, if you ask “have you been physically abused?” patients may have been slapped, hit, kicked, knocked down and choked but answer “no” because they think they deserved it or that it was just “strict parenting.” Likewise, I’m careful about just asking “have you been sexually abused?” because young victims may have been abused but don’t realize it because the abuse was couched as “love” or “education” or “our special game” by the abuser. With some children, teens, or even adult victims, they may not (ever) recognize it as abuse because it is simply accepted within their subculture. PHYSICAL ABUSE: Have you ever been slapped, hit, kicked, knocked down, pushed down, thrown around, choked…? SEXUAL ABUSE: Have you ever been a victim? Have you ever been a perpetrator? (You will rarely get an honest answer out of anyone) EXAGGERATED STARTLE RESPONSES: May be a sign of hypervigilance 2) Dissociative Experiences Schedule II (DES‐II). This is a 28‐item self‐test that was developed by Carlson and Putnam (1986). It has child, adolescent and adult versions. You can view a copy of it at: http://counsellingresource.com/quizzes/des/index.html (accessed September 2008). I have few comments about it except it asks for more specific examples of dissociation than I do on my Nolen Trauma Inventory. 3) Structured Clinical Interview for DSM‐IV Dissociative Disorders (SCID‐D‐R): nice because it assesses for five subcomponents of dissociation but can take a long time and is self‐reported. In summary, regarding correct detection of DID/ MPD, there are many ways to err and the more avenues you investigate, the more likely you are to get an accurate diagnosis, no matter what it is. It merely takes time and money. The positive and negatives for any assessment are reduced if you use multiple assessment devices. Components of Experience That Get Dissociated (BASK) While we have been talking about dissociations, we haven’t clearly examined all possible components that can and do get dissociated. Bennett Braun, MD, (1984) postulated that all higher‐order activities of the human experience contain four components and each of these components can be split off (dissociated) from the rest: Behavior – motor actions Affect – emotions Sensations – internal and external somatosensory experiences. Knowledge – facts All four of these factors are usually part of any experience. One or more can be dissociated by alter personalities. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 18 of 50 Behavior In my own clients I have seen many cases of dissociating one’s behaviors from knowledge and awareness. Both the popular and the scientific literature are rampant with spectacular examples. They range from the mundane (e.g., forgetting where one’s shoes are because another personality hid them, leaving one’s driver’s license at a gas station because another ego had driven the car without the hosts’ awareness) to the complex (e.g., going to sleep in Missouri, “coming to” driving down the road in Arkansas, or “coming to” on a New York state freeway). Following are a few examples from my own experience. As is typically the case, I did not initially know that the person who turned out to be the first MPD client I ever worked with was actually a multiple. Typically also, she did not know it either. Let’s call her “Jane.” Jane was 21 when I first met her. She initially reported having “headaches the size of Cleveland” and was disturbed by the intensity of the anger she felt at her boyfriend, who used to be her college professor. He had promised to divorce his wife when she graduated and marry her. He never fulfilled that promise. She also reported being gang‐raped by several boys on the football team when she was in high school. She had been in other types of psychotherapy but she wanted hypnosis “to find out what was behind all of her problems.” I was naïve enough as a therapist at that time (1982) to not ask about dissociations. I did a lot of hypnosis back then. I hypnotized her several times. It went very badly, with some hysterical paralysis and other hysterical symptoms. We stopped doing hypnosis. We started more traditional question‐answer type assessment. We weren’t getting anywhere, in the sense that nothing emerged that explained her anger or headaches. Then one Sunday she called me in a panic. She asked me how to get back to her house. I asked her where she was. She said, “Arkansas.” She told me the last thing she remembered was being dressed in her pajamas, sitting on her bed at night in her home in mid‐Missouri. She said the next thing she knew, she “came to” driving down a road in Arkansas in broad daylight. She also said she had a pretty bracelet on her ankle that she didn’t remember buying. She also found four grams of cocaine in her purse that she didn’t remember getting (or what she had to do to get it). This woman did not have a criminal record, was not under indictment for criminal offenses, and did not seem to have any secondary gain to achieve by telling me this. She was experiencing extreme emotional distress about her loss of time on this trip and being in possession of the cocaine. She had clearly dissociated a number of very complex behaviors from her conscious awareness. We eventually determined that she was suffering from multiple personality disorder. Here is another example from Jane, who worked as a secretary. She used an electric typewriter because this was in the days before word processors, desktops or laptop computers even existed. One day, after we had been working about six months, she began finding typed pages stuffed into various folders and drawers in her desk at work. They all had the same phrase typed on them but some were typed forward and some were typed backward; some were typed in lower case and some were all in upper case. Each was typed in a different geometric pattern, yet she didn’t remember typing any of them. Remember she did this with an electric typewriter. She didn’t cut and paste or automatically generate any of it because there were no such capabilities at that time. She had to type every word of every sentence. I include below two copies of the 18 versions she found. I blackened out one word because it is her name. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 19 of 50 Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 20 of 50 Prrofessional Deveelopment Resources | 2008 | ww
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Casebook | Page 21 of 50 A second dramatic example I have of major behavior dissociation involved a 51‐year‐old male I will refer to as “Frank.” He was initially a walk‐in at my office in mid‐Missouri. He was experiencing emotional distress because he had had an affair with a subordinate at his work, his marriage was in trouble, and he was in danger of losing his job. We met for several weeks. His wife was threatening to leave him, and he was eventually terminated from his job due to sexual harassment charges. He then violated an ex parte order secured by the female co‐worker and spent time in prison because of that. We began talking again after he was released from prison. He was having difficulty getting local employment even though he had a college degree in a technical area. Then one day he excitedly told me he had been re‐hired at his previous engineering company back East. I helped him load his furniture and household goods into a U‐Haul trailer and he drove off into the sunrise. I never expected to hear from him again. Two months later, I received a phone call from Frank. He was crying, almost sobbing. He said he had “come to” driving on a major freeway in one of the largest cities on the East coast. He didn’t know how he got there. I asked him if he remembered telling me he had been re‐hired at his old job. He didn’t remember that. I asked him if he remembered me helping him pack up the U‐Haul. He didn’t remember that either. Then he added, very upset, “My car is painted red. I don’t remember getting it painted red. I hate the color red!!!!” He claimed he didn’t remember doing anything that violated his ex parte order, but nobody, including the judge, believed that. However, he also reported that some people in college had called him “Frankie” and told him of unusually aggressive behaviors that he didn’t remember. He never used alcohol and claimed he was not drinking at the times of these blackouts. He was a top‐notch athlete in high school and college. Frank also stated that he did not remember some of the things he was doing in prison – like writing journal notes that were not in his handwriting. This man was a diabetic, but his blood sugar levels were monitored and stable in prison. Something else had to cause the dissociated prison writings. Affect Many therapists have worked with people who have “flat” or “inappropriate” affect. Such clients can tell you about horrendous experiences they have endured without showing any major emotion. However, the dissociation of affect from knowledge in MPDs is much different from that. In some multiples, one personality may initially express no emotion at all when discussing abuse or other events because they believe the abuse happened to one of the other people (alter egos). It is like it truly happened to someone else, because as far as that personality is concerned, it really did happen to someone else. But it gets even more complex in MPDs. Some personalities can have no emotions about an event, others can have negative emotions (fear or anger) while others can even have “positive” emotions (like love or lust). An example of all of this: one personality can have no emotion about abuse that happened, another can be severely traumatized by the memory of it, and still another have the attitude that “they deserved it.” Sensation Individuals typically are able to remember details of things they have done and experiences they have had. They may recall all of the sensory and emotional texture of things that happened to them. However, some personalities in a multiple can have knowledge or memory of an event, but no experience of the physical or emotional experiences during the event or memory of them afterward. Multiples sometimes present as an “observer personality,” who describe witnessing the abuse as an out‐of‐body experience, as if he or she were looking in at or down on the abuser and the abused. The observer personalities feel none of the physical sensations of the abuse. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 22 of 50 If treatment eventually leads to integration, full recall of the traumatic abuse brings back the whole range of abuse sensations, unfortunately as intense as if it were happening again. The therapist must be aware of this and prepare the client for a difficult time. This dissociation of the initial memory and/or sensations of the abuse can create a number of physical symptoms. Note that the seventh most common psychiatric symptom noted in Putnam’s list of psychiatric symptoms, below, is “conversion symptoms.” Conversion symptoms can occur when intense emotions or traumatic memories are repressed. All of the physical conditions on Putnam’s list of medical symptoms can be due to dissociation of the physical feelings of abuse. Knowledge Loss of knowledge by MPDs is not limited to the loss of memory of sensation discussed above. Separate personalities can actually contain completely different knowledge. An example of this is the case of a client who “forgot” the German language one personality studied in High School because her father hated the Germans and didn’t want her to study that language. Another personality in the same client studied and remembered only French, because her father liked the French language. WHAT ELSE TO LOOK FOR IN DIAGNOSING MPD Frank Putnam, MD, and his colleagues (1986) did some benchmark data analysis of published findings on the symptoms of MPDs in several areas. It covered, I believe, NIMH reports from several decades. I present each list below in descending order of the highest and lowest percentages noted. As shown, the most frequent symptom reported by MPDs is depression. It was reported by 90 percent of MPDs upon first contact. Mood swings were noted next most frequently, then suicidality, and so on down the list until the symptom of depersonalization, which was noted in 55 percent of MPDs on first contact. Multiple Personality Disorder Top Ten Psychiatric Symptoms noted on First Contact 6. Sexual dysfunction 1. Depression – 90 Percent 7. Conversion symptoms 2. Mood Swings 8. Fugue Episodes 3. Suicidality 9. Panic attacks 4. Insomnia 10. Depersonalization – 55 Percent 5. Psychogenic amnesia Nota bene: Auditory hallucinations did not even make this top ten list. Why not? Probably because that question was not and still is not a frequently asked assessment question during the initial intake interviews. Multiple Personality Disorder Top Ten Medical Symptoms noted on First Contact 6. Palpitations 1. Headaches – 70 Percent 7. Paresthesias/Analgesias 2. Unexplained Pain 8. Weight Loss 3. Unresponsive Periods 9. Visual Disturbances 4. GI Disturbances 10. Involuntary movements – 20 Percent 5. Nausea and Vomiting My comments: Have you ever heard of “splitting headaches?” Medically, these might be referred to as tension headaches, or migraine or cluster headaches. However, remember that headaches are the most common physical medical symptom reported by multiples. Mindful of this, I always assess for frequency and nature of headaches during the first session in all of my clients. It gives me a general barometer of their level of mental tension. It also gives me a rapid heads‐up to assess for the possibility of dissociation during the headaches. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 23 of 50 The psychological dynamics of headaches in Multiples appear to me to go something like this: most of us get “tension” headaches at one time or another. However, in Multiples, emotional tension builds in one of the personalities to the point at which they can no longer tolerate it, due to the solidly repressed memories and the massive emotions attached to them. The alter with the headache splits out and another personality “switches in” to deal with the problem. Personalities can switch in other ways and can switch without the onset of a headache. However, my own experience with Multiples suggests that headaches usually trigger a switch of personalities. This can serve as a very useful therapeutic tool the patient can use to become aware of imminent switching. I had another strange phone call at my Mid‐Missouri office one time in the mid‐1980s. The caller – who refused to give me her name – immediately asked if I knew anything about Multiple Personality Disorder. I told her that I knew something about the phenomenon. She then said she had been reading the book When Rabbit Howls, but said she couldn’t ever read very much of it without getting a very severe headache. She said she would find it necessary to lie down to sleep off the headache because it was so bad. But she apparently wasn’t sleeping very solidly, she said, because she would always see things that had been done after she woke up that hadn’t been done when she went to sleep. Do you think that sounds like a good deal? It wasn’t for her. She told me she loved houseplants but couldn’t keep any alive because “someone” kept over‐watering them while she was asleep. I asked her if she wanted to make an appointment and come in and talk with me. She declined, stating that she was a nurse and didn’t want any problems with her license. MPD Top Ten Attributes and Behaviors of Alter Personalities Child: 80 Percent. Remember, there are not just Dr. Jekyll and Mr. Hyde. Mr. Hyde is hiding the hurt victim personalities. Those hurt victims are usually children because the intense abuse that created the splitting happened when the patient was a child. The only way they would mentally cope was to “put it on somebody else.” Continuous Awareness: Many of the alter personalities are very aware of and interact with each other. It’s only the host who is (initially) clueless. In my experience, the host is initially unaware of other alter egos in about 70% of cases. The only ones I’ve worked with who were aware of the others at the time of the first session had already received therapy somewhere else. Depressed: MPDs can be very depressed due to the total or impending collapse of all of their adult goals and aspirations. They often have chaotic or abusive marriages, are erratic with their own work and are very emotionally volatile with their children. However, their difficulties encompass far more than just depression. Violent towards other people: A large percentage of male multiples end up in prison or some form of incarceration (personal communication, Ralph Allison, 1986). Most of the people attending my MPD workshops stated that they had seen somewhere between two and ten MPD clients. One woman in Ohio indicated that she had worked with between thirty and forty. When I asked about her work setting, she replied that she worked in a prison. I’ve also done a number of presentations to prison inmates. The concept of MPD often comes up in some way. I once heard from a prisoner that he sometimes heard two men talking to each other in the shower but would find only one in there when he entered the shower himself. He said how this “spooked” him because he was sure he heard two different voices talking to each other. Suicidal: Individuals who are chronically and severely mentally ill (CSMI) are also high risks for suicidality. Mix CSMI with alcohol and drug abuse (as if often seen with MPDs) and the risk is even higher. Serious attempts and completions are very high with Multiples, given they are a) chronically and severely mentally ill with b) high substance abuse problems (Fleischmann, et.al, 2005). Many of them are not simple, straightforward suicidal acts. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 24 of 50 For example, I worked for four years with a woman who had been diagnosed as a multiple by several other therapists. She was 54 when I met her. By the time I started with her, she had one knee implant that was deteriorating (with much pain and degradation), stomach bypass surgery (for obesity), episodes of alcohol abuse, a bladder stimulator (for non‐
obstructive urinary retention problems) and debilitating pain from herniated or slipped discs in her neck. During the four years we worked together, she remembered many aspects of sexual abuse by her father and his friends. We had clearly identified three other personalities besides the host. One of them was an angry little five‐year‐old boy. Some of her personalities were coming out more. Some of them were coming closer to each other. I never talked to the little boy personality. However, the bladder stimulator wasn’t working so she asked for and got a supra‐pubic catheter inserted at a university hospital. I coordinated as much and as often as I could with the attending physician, patient ombudsman, the patient’s husband, granddaughter and best friend. She also had a neck‐stabilization operation to try to alleviate some of the neck pain and reduce her need for pain medications. In spite of it all, the catheter kept getting infected and her neck surgery made her neck and shoulder pain even worse. She fought with all this pain for about two of the four years I worked with her. Then she put a 9mm pistol in her mouth and pulled the trigger. She left a suicide note in a physical‐pain journal she had been keeping. I am including parts of it here. Note the confusing stream of consciousness and the shifting pronouns and genders. “…you were told to shut the suitcase (full of all of her emotional and physical pains) and drive out of town to this field bordering a forest and park. The therapist’s car was already here and she said, ‘Welcome, grab your suitcase and come with me.’ I jerked the case out of the trunk and I swear it weighed twice as heavy (sic) but I followed her down the lane where a path seemed to be leading us. Every few steps I had to stop and take a few breaths as I wiped the sweat from my brow and picked up my suitcase once again. “Up ahead I could hear a gate, and as I got closer I heard the whoosh of a waterfall. As I got closer to the gate, the therapist said, ‘You can go no further with your suitcase.’“ “Where did that voice come from and when/why had she changed clothes?” “She seemed to be surreal and had this light emanating (sic) from all around her. What was happening?…and then I saw people farther down like in a park setting but some were dressed in clothes like the ladies wore in the 1800s. They had on huge hats that tied under their chin and then I noticed the children playing board games in the grass, no yelling, just soft voices and bright green lush grass. Further down some men were playing baseball and I heard the crack of the bat and saw the ball go over my head but when I looked up it was gone and I looked toward my surreal therapist and she saw the question on my face and she kept looking back the way we had come and I noticed the weeds overgrown along the path and dead branches and as I stand she said, ‘You have a choice now. You can pick up you suitcase with all your worries and go back the way you came or you can set your suitcase down and enter through this gate and hear the children’s laughter, be part of the living waterfall, enjoy the smells and leave all your pains behind.’” “His hand (my underline) pulled back from the suitcase and reached for the gate, and as he (my underline) passed through, he (my underline) turned to thank her, and she was gone.” I underlined “his” and “he” for you to note the change of gender in her writing. Remember that this was a 58‐year‐old female. Most females who commit or attempt suicide choose less violent methods, but she committed suicide in a very “male” manner (gun). Did her angry five‐year‐old‐male personality take charge to complete the suicide? Many who had encounters with the five‐year‐old male personality were cowed by his adult‐like fury. He may have been an introjected image of her abusive father who sexually abused her in the basement since she was four years old. His fury was horrible to everyone. I believe she turned it on herself to end her physical and emotional pain. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 25 of 50 Violent toward other alter egos: (i.e., some suicide attempts are actually homicide attempts) Opposite sex alter egos: Note that these occur in over 50% of the reported cases (Putnam, et.al., 1986). Eve was the first reported case of male personalities in a female body. Dr. Wilbur’s conversations with “Mike” and “Sid” (two male personalities within Sybil) serve to illustrate the separation of both individuality and sexuality in this patient’s alter ego’s minds (Schreiber, 1974, p. 283). “I want to ask you something.” states a personality (later identified as Mike). “What would you like to know?” the doctor asked. “How come?” “How come what? “We’re different?” “Different?” the doctor repeated. “Well,” Mike explained, “the others are girls. But I’m a boy, and so is Sid.” “You live in a woman’s body,” the doctor reminded Mike. “Not really,” Mike countered with certainty. “It just looks like it,” Sid added with equal assurance.” Substance abuse: Alcohol and drug abuse are rampant in MPDs. It is interesting that many clients – and even their therapists – initially blame the dissociation on the substance abuse. While that may be true in some cases, dissociation is not always attributable to substance abuse. As an example, I recently saw a patient who dissociated in front of me after being clean and sober for 21 days, having been locked in an inpatient drug detoxification unit for that period of time. After our assessment was finished she swept the floor and then picked up a guitar and played some riffs from heavy metal music. I found those actions curious but did not comment at the time. Two weeks later, I called her to ask a few final assessment questions. When I asked her about her sweeping and guitar playing, she didn’t remember the sweeping or the guitar playing and was quite astonished to hear of it. Sexual Promiscuity. This can be common among Multiples and may take the form of (a) “survival sex” – sex bartered for a roof over one’s head, food in one’s stomach, or a ride to the corner drug store, (b) infidelity – meaningless or revenge sex, or (c) prostitution. Multiple Personality Disorder Top Five Traumas Reported by Clients (Putnam et al 1986) 1. Sexual Abuse – 85‐90 Percent 2. Physical Abuse 3. Physical and sexual abuse 4. Extreme neglect 5. Witness to violent death – 40 Percent My note: Having “imaginary friends” in childhood is NOT a precursor to being MPD in adulthood (Barreda‐Hanson, 2008). “HOW TO MAKE A MULTIPLE PERSONALITY” Putnam’s top five traumas serve to highlight the immense trauma most MPD sufferers have directly experienced or witnessed. Eighty‐five to ninety percent of them have been sexually abused. Many of them have been physically abused. Many of them have been both physically and sexually abused. Most have also suffered extreme neglect, which certainly challenged their survival resources at a very tender age. They had to “grow up” in a hurry and perform incredible feats just to survive or to protect their siblings. Many of them have witnessed the violent deaths of others. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 26 of 50 For many years I have worked with people who have experienced intense childhood physical and sexual abuse or combat trauma. While most of these individuals may have dissociated parts of their experience, they didn’t “split.” What, then, changes dissociation into multiplication? I think what Putnam’s data, above, do not reflect is the intense and prolonged nature of the abuse and neglect suffered by these individuals starting at a very young age. I believe the young age at onset of severe abuse is critical for understanding dissociation and multiplicity. Children who are very young have none of the more sophisticated defense mechanisms adolescents and adults have at their disposal. Such mechanisms include rationalization or intellectualization to help process and diffuse anxiety and fear. Young children naturally learn by internalizing what is placed before them by the actions and words of the adults around them. What is or is not “appropriate” is defined for them by the people around them. If stealing is defined as “bad,” they will probably learn not to steal. If – on the other hand – they are taught how to steal by mother, they may think it is not only all right, but even helpful to mother. To help you appreciate – as an adult – the sponge‐like, automatic learning that is typical of young children, consider the following: You, yourself, speak pretty good English (or Spanish, Mandarin, or whatever dialect you speak). Congratulations. Was it hard to learn? Of course not. You called the furry, four‐legged, warm‐blooded animal that meowed a cat (or “gato” or whatever) without thinking much about it because you heard your parents or caretakers call it something and you automatically imitated them. The abused child is no different from non‐abused child on that count. However, young traumatized children are in an extreme state of emotional arousal during the intense traumas they experience and witness. They are in a reflexive say‐and‐do‐and‐be‐ whatever‐it‐takes mode in order to survive in intellectually insane situations. The risks involved in making a mistake are far greater than in calm, rational family systems. So, they take on personas (the Latin word meaning “mask”) and unconsciously develop multiple personas for handling various people in their lives. For example, the second MPD client (let’s call her Nancy) I ever worked with told me she started cooking for her father when she was three years old. That was bad, right? It was beyond her developmental capabilities for her age. But it wasn’t as bad as what her father did to her when she dropped the pan of spaghetti while trying to drain the water from it in the kitchen sink. He burned her hands in the boiling water as punishment for failing to do what no three year old could successfully do. How complete do you think her attention was from that day on when she dealt with spaghetti? Her mother was a prostitute who “worked” all night and slept all day. This client had to take on the role of adult female when she was three years old, and failure was punished insanely. Two other examples of the intense stress MPDs face in childhood came from the same client. Her mother, being the busy night‐working prostitute, wasn’t available to help take care of her and her brother much during the day. Her mother’s mother, “Grandma H” was pretty erratic and labile herself. One day, Grandma H decided she needed to clean the kitchen floor. However, Nancy and her brother kept getting in the way, as four and three‐year‐olds usually do. Grandma H got quite perturbed by their interference, so she hung Nancy by the back of her blouse on a coat hook and put Bobby in the kitchen gas cooking stove to get them out of the way. Nancy could hear Bobby’s muffled screams. She knew he was in big trouble. She wiggled off the coat hook and rescued Bobby from the stove. When Nancy’s mother returned home she beat Nancy for bothering Grandma H. On another occasion, four‐year‐old Nancy went to a friend’s house to play. When Nancy walked into her friend’s house, her friend’s father was “hurting” (sexually abusing) the child. Nancy was too young to realize anything except that her friend was in terrible pain. One of her alter personalities grabbed a pair of child scissors (the kind with the rounded tips) and stabbed her friend’s father in the back. He made a terrible scream, rolled off his daughter and beat four‐year‐old Nancy up. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 27 of 50 Here is an excerpt of an article published by Ralph Allison, MD. He worked in the California prison system for many years. He became famous for his diagnostic work with the “Hillside Strangler,” the serial killer in the 1980s who claimed to have alter egos. It is titled, “A Guide to Parents: How to Raise Your Daughter to Have Multiple Personalities” (Allison, 1974b). Rule One: Don’t want the child in the first place (My comment: and let the child know that at every opportunity). Rule Two: Create and strengthen polarity between mother and father. All families seem to have “good” and “bad” parents. In MPD families, the child can never tell which is which. (My comment: most of the time, both parents are extremely pathological). Rule Three: Make sure one parent, especially the favored one, disappears before the child is six years old. That parent often returns, but is significantly different/changed. My comment: this makes situations in which the therapist is ill, takes a vacation, goes to a conference, or misses an appointment for any reason extremely tense for both therapist and client. MPD patients are petrified their therapist will leave them and come back…different! Rule Four: Encourage sibling rivalry, or at least don’t recognize it or help your daughter deal with it. This is especially deadly if one or both sexes are stigmatized (Ex., “All men are _____.”, “All women are ____.”, “Men only want one thing, _____.” (Eve’s mother was deadly with these homilies). Rule Five: Be ashamed of your family tree. (More accurately, degrade and castrate the spouse’s family or simply be blatantly honest about their criminal history.) Rule Six: See to it that her first sexual experience is traumatic and that she can’t tell you about it. (Or call her a whore and blame her for it, even if it is her father who rapes her). Rule Seven: Make sure her home life as an adolescent is so miserable she intensely wants to get married to get away. This allows her to marry a violent, sexual deviate that can carry on in your tradition. Women Who Love Too Much (Robin Norwood, 1985) is their case history in a nutshell. These are all intensely negative parent‐child interactions, but they all go no further than describing the sexually abused, non‐MPD female living in a dysfunctional family. None of them alone or in combination can explain why an MPD is created. We still cannot fully explain why some people repress traumas, split, and develop multiple personalities and other traumatized individuals also repress traumas but do not multiply. EFFECTIVE THERAPY WITH MPDs This section will outline the components that I believe comprise the mechanics of effective therapy. Some of these mechanics are general and apply to any effective therapy, while others are more specific to the treatment of MPDs. I will offer a number of considerations that may help keep you out of the quagmire therapy can become. These considerations all fall under the notion of “framing.” Framing is the process of discussing the conduct and potential pitfalls of therapy with your client before actual therapy is initiated. It basically involves putting boundaries (the frame) around the process of therapy (the picture). The process is intended to help both you and the patient set up clear expectations about what will happen in therapy. It can also help the therapeutic process get back on track when (not if) it gets sidetracked by the patient’s or therapist’s issues. Framing As with any therapy, effective treatment of MPDs demands general and unique framework. The general framing for any therapy client/patient minimally involves: 1) Signing of all consent forms and patient rights forms. 2) Establishing mutually agreed upon financial arrangements. 3) Defining boundaries of therapist and patient regarding touch, phone calls, charges for phone calls, appropriate hours of phone calls, after‐hours crises, etc. 4) Discussing the positive and negative aspects of therapy (such as potential negative side effects). Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 28 of 50 5) Discussing issues of transference in terms of how their therapist may hit the client’s “buttons” at various times. 6) Discuss “I Never Promised You a Rose Garden” (the title of a 1960s book). This is to let patients know you won’t be able to solve all of their problems. They will still have to deal with all of the other complications of life we all face once therapy with you is completed. 7) Discuss the First Dictum of trauma therapy: Getting Better Does Not Mean Feeling Better…at First!!!! This communicates the need for the patient to fully process the emotional traumas they’ve experienced, not just mentally run from them as they have done in the past. It also emphasizes to them that they are going to feel uncomfortable – if not horrible – (again) as part of therapy, but it is for a more positive goal this time: the learning in therapy what we therapists call “working through.” Remember; one of the basic subsections of the diagnosis of PTSD is “Persistent avoidance of stimuli associated with the trauma” (APA, 2000, DSM‐IV‐TR, page 468). They’ve either distracted themselves from the trauma clues or not known how to deal with them effectively in the past. They will now be able to defuse the pain and shame with therapy if they quit skimming the surface and going to great lengths to avoid their pain. 8) Discuss with the patient the fact that abused children often become abusive adults. I have found that the abuse‐
victim part of therapy (I call it “Part A”) is very comforting to the patient because it involves understanding and empathy. However, I also make a point of alerting abuse victims that there is usually a “Part B” of victim therapy, which involves confronting their own abusiveness towards their spouses, children, peers, etc. This Part B is not comforting at all to most abuse victims, who may have viewed themselves only as victims, not perpetrators. Part B is very confrontive and may evoke considerable negative transference because it is ego dystonic to most abuse victims. Their potential to be abusive needs discussing in depth before the first conflict happens. There is a significant risk that patient will abruptly terminate therapy if you don’t caution them about Part B before you turn from the supportive therapist of Part A to the challenger/confronter of Part B. In addition, discuss unique components in the framework of treatment with MPDs, including: 1) Treatment with MPD patients will probably not go smoothly. I discuss with them and their significant others that there will probably be massive emotions triggered, very painful memories surfaced and much resistance aroused – both internally between personalities and externally due to denial, resistance, doubters and critics. 2) The MPD diagnosis is controversial, and they/we will have many doubters, including family members, friends, and even many in the mental health community. 3) Total confidentiality is not guaranteed. During the informed consent process I clearly explain that I will be seeking any collateral informants and information that I can from any valid sources the patient allows. I do get signed permission from the patient before all contact is made or attempted. I do not get information from alleged or suspected perpetrators against the patient without considerable thought, extensive discussion with the patient, full consent of the patient, and a great deal of emotional support before, during and after. 4) Active involvement of collateral reporters and support persons is critical because the true MPD patient is truly unaware of some actions. The collateral observers can serve as my eyes and ears to the patient’s reality. 5) Discussion of integration: a) Explain that integration does not equal death. Many multiples equate integration with death because that is the closest parallel they have experienced. Some of the personalities “go away” or “die” or “go to sleep” during times of abuse or later stress. You have to let them know that it is a coming together and a gaining, not a loss or a death. This is, of course, easier said than done. Patients who persist in therapy eventually learn it first hand and come to trust it as it happens. Some alter‐egos experience it first by getting subtly more aware of and comfortable with other alters, and eventually begin to trust the entire integrating process. Some alter‐egos experience it either much later or never experience it at all. b) I go out of my way to assure all separate personalities that integration doesn’t mean I want any of them to “go away” or “die” because I feel negative about them. Most alter personalities are extremely emotional. They will all emotionally react to the concept of integration within their own substrate and their (mis)understanding of the process. They misinterpret “integration” as the therapist’s desire for them to die or go away because that is how they have understood the temporary or permanent absence of some of their own personalities. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 29 of 50 6)
c) I typically let them know that I have no idea how they are going to turn out post‐integration, except as an intact survivor. It is very important to try not to convey the idea that you have a favorite personality. This is very difficult for most therapists, given the fact that some of the alter personalities are very aggressive, threatening, obnoxious or unpleasant. Keeping the therapeutic ‘mask’ in place is very difficult with these patients. d) I advise patients and families that post‐integration may also involve other work (such as on social skills, assertiveness, and other typical therapy issues). e) I acknowledge that some of the personalities may like me and others may not like me (or even hate me) but that shouldn’t be the real issue. The real issue is for patients make peace within themselves. f) I encourage patients to begin to listen to themselves more (getting co‐conscious). Discourage any hopes for “On Golden Pond” moments with their abusers: i.e., admission of extreme abuse by abusive people is not likely. On Golden Pond (1981) was a movie with Katharine Hepburn, Henry Fonda depicting different generations in a family trying to resolve their conflicts and put them to rest before the family elders died. The inter‐generational conflicts were resolved fully in the movie so the elders could die peacefully. However, none of the conflicts involved abuse of any kind. (See Dr. Wilbur and Sybil’s father’s discussion, above, as the normative experience of victims trying to reconcile with their abusers). Discourage any confrontations with alleged perpetrators due to the high probability of disastrous consequences. I once treated a non‐MPD patient who confronted her physically abusive father, only to hear him reiterate his minimization of his abusiveness with statements like “you deserved it” and “it wasn’t much.” In another case, the patient’s father actually admitted that he sexually abused her in their pickup truck in a farm field and expressed appropriate remorse. However, his daughter – my patient – was extremely disappointed because she had expected more emotional outpouring congruent with her own level of anguish. Discuss and discourage ideas they may have about suing any alleged perpetrators. I recommend they not make their healing dependent on revenge or legal validation of their wounds. In consideration of the unpredictable outcomes of these cases in the courtroom, such proceedings are as likely to do harm as they are to help the victims. Discuss at the onset of therapy that the process is likely to take some time and that the therapist may be absent at times for vacations, conferences, etc. This is a crucial issue for most multiples because, as noted above, Allison (1974a) found that many multiples experienced a caretaker who left and came back significantly changed. Accordingly, multiples have the fear of you leaving and being significantly different (in bad ways) after you come back. I discourage patients from reading any of the popular articles or books about MPD because of the sensationalized, hysterical, undocumented and often inflated events in those writings. The International Society for the Study of Dissociation does have a newsletter called “Many Voices” (at http://www.manyvoicespress.com/subjectindex.html) written by victims for victims. I do endorse it, generally speaking, but have reservations about the inescapable lack of professionalism and lack of objectivity that severely traumatized people have. Treatment Segments Some therapists say you must directly deal with the abuse. Other therapists view it as, “Let the past lie. It’s over. It’s done. Focus on future. Focus on cognitions and behaviors.” I say you must do both. You must approach and deal with the three following segments of dysfunction when working with MPDs: 1) All trauma (sexual, physical, verbal): These are the obvious components – but not the entire set – of issues. It turns out most severely abused people (be they MPD or not) have grown up in extremely dysfunctional families that dysfunction in all areas of life. Therefore, the patient must deal with items 2 and 3 if they are to have a chance of successfully functioning as adults in real life. 2) Self‐Esteem Building: Use any of the multitudes of books on increasing self‐esteem (e.g., Schiraldi, 2001; McKay and Fanning, 2000) 3) Life/Coping Skills: Use any of the multitudes of books on increasing self‐esteem and effective coping (e.g., Kleineke, 1998; Allen, 2005). Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 30 of 50 CASE MANAGEMENT So now you’re sure you’ve got an MPD in front of you. Now what do you do? The first thing I recommend you do – after extensive discussions about the limits of confidentiality in the informed consent process – is warn (frame) everyone else most directly involved with the patient (spouses or significant others, their parents or other caretakers, the judge, the foster parents, the Family Services workers, their kids) that treatment will never go smoothly. Involve others only as necessary and as soon as their cooperation is needed. That involves a clinical judgment on your part that may or may not be correct. Explain to everyone that remembering the causative events will probably be very emotionally difficult for everyone and that the client may need repeated hospitalizations and extensive external monitoring and safeguarding. They all need to be observers and reporters of the client’s behaviors. They will also probably be his or her safety net. In these cases, one cannot rely on the patients, alone for a realistic view of their mental status or behaviors. • Never assume the MPD client is going to act sanely or calmly for any length of time. • Don’t expect that any psychotropic medication is going to be of much help, even if it is given in doses that would be considered excessive in most patients. • Another primary dictum for therapy of any trauma victim is: SAFETY, SAFETY, SAFETY! You must take all possible precautions to assure that any trauma victim is safe from further physical and sexual abuse. That is not as easy as you might hope, even in this day of heightened vigilance by social services, schools, and mental health agencies. The state of affairs – for better or for worse – is that a) parents have complete legal control over the child’s socialization until he/she is of age for first grade, b) many states allow for home‐schooling, potentially further delaying the child’s entry into the mainstream of society, and c) there has to be probable cause for authorities to enter a person’s home. While this privacy is honored in favor of individual rights, good privacy becomes bad secrecy when abuse or neglect of children is occurring. Please be assured I am not casting aspersions on home‐schoolers here. My point is that children who are home‐schooled are relatively isolated within their homes, compared with children who attend public school every day. Isolation is one of the conditions that can help perpetuate abusive situations. However, attending public school may not be much of a protective factor. Some reports of sexual abuse of public school children by teachers and other school personnel suggest that schools can attract sexual perpetrators. Charol Shakeshaft (1994) estimated 6.7 percent of all students in grades 8 to 11 reported sexual contact with an educator. This would translate into more than 4.5 million middle‐ and high‐school students subjected to sexual misconduct by an employee of a public school sometime between kindergarten and 12th grade. That 4.5 million is huge compared to the widely publicized 10,000 cases against Catholic priests (National Review Board for the Protection of Children and Young People, 2004). Safety from further abuse is even problematic when working with adult MPDs. Many marry or cohabit with abusive partners. Some are still in contact with abusive parents. “Jane” (a previously discussed patient) had stopped treatment with me due to many factors. However, by strange coincidence, another patient of mine, “Cat Lady,” was in the same inpatient facility as Jane at the same time. Cat Lady knew Jane was my ex‐client but Jane didn’t know anything about Cat Lady being associated with me. Cat Lady reported to me that Jane went out on weekend leave with her father a couple of times while they were both hospitalized. Jane came back to the hospital badly beaten up by her father both times. Jane had never mentioned abuse by her father to me during any of our therapy sessions. She was still not safe from one of her abusers even in her late twenties. Jane was the one who had told me she had had headaches the “size of Cleveland.” She told me two high school football players had raped her. She did not tell me (or maybe she didn’t remember) anything about her father being angry and abusive. I must warn you, again: there is a lot of case management involved with these patients far beyond the 8‐5, Monday thru Friday job. Be prepared to cover them 24/7/365, or be prepared to fail. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 31 of 50 The Five Treatment Phases I have developed the following five phases of treatment that seem to be common when working with Multiples: 1) Detection: symptoms are noted and expanded. However, can never determine that your patient is a multiple until “someone else” comes around without the other’s consciousness. Caveat 1‐ All that dissociates is not multiplied. Caveat 2 ‐ Never ask any alter ego for the number or names of the other personalities. You are fostering segregation, which is counter‐therapeutic, and asking a leading question to a very suggestible, emotionally fragile person. That leaves you very vulnerable to a lawsuit or complaint against your license. 2) Affection: The MPD client (if no one else) will have an overpowering wave of initial appreciation for your diagnostic and detective skills. They will be thrilled with you and fascinated with the possibility that you are right about them (when nobody else has been for the last __________ (fill in the blank) number of previous therapists over the last _________ (fill in the blank) number of years. Don’t worry, this phase doesn’t last long, because then comes…. 3) Rejection: Denial runs rampant (but, remember, multiples are built on denial and most other defense mechanisms in the first place). Their primary coping mechanisms all of their lives have been denial and avoidance. Denial and defensiveness surge up in both the client and others involved with the client. Denial can be intrinsic within the client (i.e., “everybody forgets”; “forgetting is normal”) or generated by internal, opposing alter egos. Obstructions can be placed in the way by other alters, who may hide journals, bills, and appointment books. They may also break cars, televisions, telephones. Denial can also be extrinsic – generated by external agents (i.e., the abusive or enabling parents, who often say, “I never did that to you,” or the client’s siblings, who often say things like, “You’re just blaming mom/dad for your own problems.” I have also heard of lawyers and even mental health professionals who attempt to convince the client or others that they are “just faking it” in order to avoid going to jail or incurring some other unwanted consequence of their behavior. I once worked with a multiple who stumbled onto a note she didn’t remember writing, which said, “Keep away! Stop talking to her! You don’t know what you are getting into!” 4) Inspection: If you get through the resistance/rejection stage, then you can begin inspection and identification of the internal “family,” in which you do internal group therapy and damage control. The cure (remembering the traumas) is almost as bad as the cause (the traumas). Keep reminding them of the trauma therapy First Dictum: “Getting better does not mean feeling better… at first.” You must explain to MPD clients over and over that they are going to have to deal with some very unpleasant memories and feelings before they can feel better. Some of these traumas, when they surface, are terrifying, and clients can feel as if they are being hurt all over again, even dying. All of those old, very intense feelings surface again. That is probably because the traumas they are remembering did very nearly kill them. Some of the alters may have gone away to keep from dealing with life any longer. The important difference between the original experience of abuse and the therapeutic re‐experiencing is that the therapist is there to 1) give emotional comfort and support to the victim and 2) educate the patient about feelings or beliefs the victim may have that she deserved the abuse, asked for the abuse, could have stopped the abuse, or that the abuse was her fault. This comforting and re‐educating the victim is the core of the healing process of trauma‐based psychotherapy. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 32 of 50 Do: encourage inner group/family therapy. The purpose is to foster increased co‐consciousness. Don’t: call anyone out by name. By doing so you may actually reduce the chances of seeing other personalities and encourage divisiveness and competition between personalities. I was initially trained to construct “family trees” (i.e., do a census of everyone inside) as part of MPD work. However, this may be counter‐therapeutic for a number of reasons. First, any client who is emotionally vulnerable and possibly suggestible, MPD or not, will sometimes tell you things just to please you. This does not advance the therapeutic process. Second, you can easily create inner rivalry if the client really is a multiple and you start trying to get names. The intense inner rivalry and conflict will occur naturally. As noted earlier, asking for names also encourages separation of identities, the very thing you’re trying to avoid. Third, from perspectives of both clinical advisability and risk management, it is important to avoid suggesting the possibility of multiplicity where there is none. What I do now is simply wait to talk to whoever wants to talk to me, usually without asking for names from anyone. This approach is less threatening to the alter egos, makes me less legally liable, and is more in line with the final goal: integration. 5) Integration: This is the final desired objective of merging the various alter egos into one new personality. How many multiples who persist in therapy are able top successfully integrate? Richard Kluft, M.D. (1984b) claimed he had integrated almost 50% of his cases. This sounds high to me. I delivered six national‐level workshops on MPD in 2006. Throughout the tour, I conducted an informal survey of therapists attending my workshops. Among the 71 attendees, polled, they had dealt with an estimated total of 229 different cases of MPD/DID. Only one of the attendees stated that he had ever completely integrated a multiple …and it took him and his patient 11 years to do it. Resistance to integration by the MPD client is incredibly strong. Some of this occurs because many alter egos are highly threatened by the idea of fusion/integration. Some of them will immediately be so upset that they will just “go away” and never talk to you again. You will never be able to be part of the final integration simply because you have scared some of them away by mentioning the final therapeutic goal. They will also initially resist integration because they very often equate integration with death. This is understandably difficult for them (and you) to deal with because many of them have almost been killed by the abuse and neglect they experienced and many of them have witnessed the violent deaths of others. This resistance/fear can also defeat integration. A section of I’m Eve (Sizemore, 1977, p. 425) captures this conflict between personalities regarding their perception of integration quite well. In the following dialogue one of Chris’ alter egos (Turtle Lady) is talking to Chris’ daughter, Taffy, about Chris: “I want to die. Let me die,” begged the suicidal Turtle Lady, as Taffy caught her searching for the hidden pills. “Mother, you can’t feel that way,” the girl pled. “You must live on.” Chris turned on her furiously. “You’re her friend, you’re not my friend!” And later, the conflict between personalities integrating came up: “I’m dying. I don’t want to die.” “But she is going to kill me, she’s pushing me out. I feel myself growing weaker, dying,” Chris professed in despair. “You’ll live on, Mother,” Taffy explained. “Part of you will live on, live out your whole life.” “But I won’t be able to get out!” Panic roughened the voice. “There won’t be any need to get out, Mother,” Taffy soothed. “When you’re well, you won’t need to get out.” Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 33 of 50 In Sybil (Schreiber, 1974, p. 411), Mike expressed “his” anxiety, threat and confusion about integration with the following: “You think the girls are going to kill us?” “Do you think the girls are going to kill you?” the doctor repeated with disbelief. “Yes,” Mike repeated apprehensively. “The girls.” Which girls?” the doctor asked in an attempt to elucidate what Mike really meant. “Marcia and Vanessa,” Mike replied cryptically. “If they kill them, will we die, too?” Sid asked with concern. “I don’t know whom you mean by ‘they,’” the doctor insisted. “There’s a rumor,” Sid explained, “that the girls are going to kill each other, that the time is coming when some of them won’t be.” Some therapists prefer integration “rituals” such as Cornelia Wilbur’s “age progression” (Schreiber, 1974, p328). Others (e.g., Graves, 1988) use “visualization mergers” i.e., having the host imagine fusing different personalities in his or her mind. However, this can only work if the personalities are willing to do it. Graves also had other visualizations like having each ego imagine being on opposite sides of a brick wall and having each one of them in turn take down a brick. Graves also cautioned against trying any of these before all traumas were recalled and processed by each personality. The work I have done suggests that integration is a fairly natural but unpredictable process in which memories and emotions are shared between personalities. This process continues both in and out of the therapy office. Therefore, these times may require hospitalization – or at least constant supervision by their support system – since the patient can be in a very confused and disorganized state. Graves (1988) suggested that this post‐
integration instability usually settled down after two or three days. Kluft (1984b) reported several factors in failed integrations. He suggested that integrations that dissolved within the first week were probably due to the integration being unwelcome in the first place and material getting re‐
repressed. He further stated that integrations that failed within the first three months may have occurred because of “layering” (a known personality hiding an unknown personality). Finally, he reported that integrations that lasted as long as 27 months could still dissolve due to the death of an abuser, becoming terminally ill, some ego withholding memories, or severe loss or threat of loss. Trauma Therapy There are two aspects of trauma therapy that must be accomplished with trauma victims in general, and multiples, in specific: their “Triggers” and a “Coping Chart.” Triggers are events in the present world that activate old emotions and memories. All external events occur and are perceived in the five domains we all have for external perception: sight, sound, taste, smell and touch. All traumas have components in several of those five domains. It is useful to start very early in treatment teaching patients to identify those events that trigger intense emotions and to have them fill out a trigger chart on an ongoing basis. Warning: working on this chart can trigger intense emotions because you will be reactivating the source(s) of the emotions as you process the “why this upset me” part of it. Take it slow, at the patient’s pace. It may be necessary to alert the patient’s support systems that they might be incredibly activated for some time. TRACING “TRIGGERS” Basically the patient has to identify, “When I _____________________, I _______________________.” (fill in the sensory mode) (fill in the feeling or action) Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 34 of 50 When I: See/saw a. b. c. d. e. f. I Feel/thought _______about… a. b. c. d. e. f. Hear/heard: a. b. c. d. e. f. I Feel/thought______ about: a. b. c. d. e. f. Taste(d): a. b. c. d. e. f.. I Feel/thought _______about: a. b. c. d. e. f. Smell(ed): a. b. c. d. e. f. I Feel/thought __________ about: a. b. c. d. e. f. Feel/felt (touch/touched): a. b. c. d. e. f. I Feel/thought ______about: a. b. c. d. e. f. Note (again): working on this list will probably trigger intense feelings. You might be able to start to process only one event at a session (much less finish it). Make sure you have a support system for him/her when he/she leaves the office. Even consider having someone drive them to and from each session, especially when working on triggers. For example, let’s imagine an MPD sees a person on the street who looks like their worst abuser. They initially may unconsciously shift personalities but have enormous emotional surges and act out their feelings. They may then go home and take it out on a child or a pet (as a symbolic or random victim of their anger at the abuser). Unfortunately, the initial acting out will be very emotional with possibly high injury or lethality for someone. What you have to do eventually is get the patient (and the alter egos) to realize that a) seeing something or someone, b) triggered great feelings of ____ and c) they expressed those feelings by hurting something or someone else. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 35 of 50 I treated a female MPD who dissociated at the sound of a jack‐in‐the‐box. She performed many extreme dissociated behaviors after hearing this auditory trigger. She did this for decades before she finally became conscious of the memory of her father cranking a jack‐in‐the‐box as he sexually molested her and reaching orgasm when it popped out of the box. Another more subtle example of a tactile trigger: I treated a non‐multiple, eight‐ year‐old girl who was sexually abused when she was four. Her mother’s boyfriend had raped her. The patient and I took walks to the park as part of our therapy time. As the months passed, cool and crisp springtime turned to warm and humid Missouri summer. We both began to sweat on our outside walks. She repeatedly reacted to her sweat with aversion, stating, “I hate sweat.” I initially missed the clinical implication of her reaction and lectured her about the positive functions sweat serves. I realized I was missing her point when she kept bringing it up. When I finally “got it,” I asked her why sweat upset her. She astutely told me that her rapist (her mother’s 28‐year‐old boyfriend) was sweating while he raped her, and his sweat dropped on her as he hung over her. The sweat was connected in her mind with the rape. The experience of sweating in the present triggered the feelings of the sweat of the rapist and of the rape. Emotional Tsunamis The other case‐management issue is trying to help clients and their support persons to start coping more effectively with “Emotional Tsunamis.” These are immense waves of emotion set off by some event. The triggered emotions surge upon the victims with little warning, like the ocean Tsunami surges upon the shoreline of land with small waves at first. By the time the victim is aware of what is really happening, they have been swept off their feet, are out of control of their bodies and their minds, and have few alternatives to cope with the wave besides just “riding it out” and trying keep from drowning. This is often the time when the host gets thrown into the “driver’s seat” (sometimes literally speaking) and has to deal with being some place miles away from their last known location. Learning to cope effectively with those tsunamis is a lengthy, touch‐and‐go process. Typically, patients react to the initial surge of feelings blindly, with little or no consciousness (especially on the part of the Host). However, it is often the host who has to cope with the aftermath. If the personality working with you doesn’t know the trigger, ask: “then who does know?” Be ready for someone to threaten the others or actually punish them if they tell secrets too fast. Does this sound like a double bind? It is! In addition to working on triggers, you can also use the following chart to help patients become conscious of how they can react when they are triggered in the daytime vs. nighttime, when alone vs. with others. You can cut and paste it and make as many copies as you need. COPING METHODS WHEN TRIGGERED When Alone With Others a. Daytime a. b. b. c. c. d. d. e. e. a. Nighttime a. b. b. c. c. d. d. e. e. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 36 of 50 These coping mechanisms involve what most healthy people are able to do automatically all day every day as competent adults: respond to stimuli (mostly cognitively): • act on the basis of our past experiences • consider our options • think about where we can go to learn more options • respond to the problem without emotional surging • evaluate the outcomes of our chosen actions • get more information if it seems to be a novel situation Unfortunately, most MPDs did not have the advantages of growing up around mentally healthy, competent, functional adults. In addition, they may have been judged a complete failure by somebody (and punished “fittingly”). Remember the punishment the three‐year‐old alter personality got for dropping daddy’s spaghetti noodles? He scalded her hands in the boiling spaghetti water! The Business of Living a Functional Life For sexual abuse victims who would like to do some reading, I strongly suggest the newer version of The Courage to Heal by Ellen Davis and Laura Bass (1988). I think it is excellent for covering both trauma work and the other two segments: coping skills and esteem building. The first version of the book was criticized for being too extreme in terms of the early over‐enthusiasm with finding sexual abuse victims (i.e., “if you think you were sexually abused, you were abused”). The authors modified later editions to be more cautious and less zealous. Coping/Life Skills: These skills involve effectively dealing with normal day‐to‐day demands that include assertiveness, conflict resolution, effective parenting, budgeting, job interviewing (if you ever get them that far), etc. For lower‐
functioning individuals, this effort can include activities of daily living (ADLs) like brushing teeth, etc. Remember that many traumatized individuals grew up in extreme emotional chaos and interpersonal dysfunction, so they may have never learned any effective coping or problem solving information. Esteem Building: There are many techniques that can be used to build or repair self esteem (e.g., Schiraldi, 2001; McKay and Fanning, 2000). However, I think true self‐esteem is developed by effectively handling life. Therefore, I recommend you focus much more on the previous segment, Coping/Life Skills. External Family Therapy: I recommended using as many collateral informants and external supporters as possible. Such individuals can be an important source of information and support. They can also be another great bundle of “issues.” It is important for the therapist to remain aware that – while the patient’s family and friends may present themselves as rescuers/support systems – they may have been the enablers and co‐dependents ( and even the abusers) who contributed greatly to the patient’s difficulties in the first place. For examples of such dynamics, see The Games People Play (Berne, 1966) or The Games Alcoholics Play (Steiner, 1971). I have worked with about one MPD client per year over the 30 years I have knowingly worked with this disorder. I have never, to my knowledge, full integrated any of them. Factors contributing to this include the prevalence of denial and rejection by the client and those around the client (including many mental health professionals). The second MPD client I worked with (Nancy) died from lung cancer after I had worked with her for four years. However, she reported to me on several occasions that some of her alter personalities were “coming together.” She and other MPDs in the literature (e.g., Sybil, I’m Eve) all report that integration is a strange and frightening process. So, what can you do to foster the process of integrating the various alter egos? That depends on whom you ask. There are some therapists who have developed visual imagery‐type procedures, but I don’t particularly like those. In my estimation, they can actually inhibit integration by pushing the patient before the time at which he or she is ready to begin the difficult and lengthy process of integration. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 37 of 50 I have also seen videotaped “h
high‐powered,” forced inteegrations thatt supposedly overcome resistance. How
wever, I doub
bt if those were truly succe
essful, due to the intense eemotional preessure involved by the pattient. It seemed like another form of aabuse. I preffer simply to deal methodically with paatients wherever they are on that day, lletting them ttalk about wh
hatever they wantt to discuss, p
past, present o
or future. Eveerything goess “sideways” b
badly enough
h anyway. I haave found it n
necessary to repeaat and review
w the same trauma by five separate perrsonalities before affect drrains away. Th
hat, I believe,, is what is truly required to aaccomplish trrue integratio
on. It cannot b
be forced or h
hurried. Affecct Containme
ent Th
hroughout all of these stagges, everyonee involved is ggoing to have to walk the ttightrope of aff
ffect containm
ment. As I havve previously mentioned (N
Nolen, 2002 aand earlier in this course), an
ny trauma treatment facess the little‐reccognized task of coping witth the highly charged em
motions released when traauma memories are recalleed or unknow
wingly triggereed. The client’s nervouss system reaccts “as if” the trauma is happening again. That mean
ns it goes into
o a sstate of “fightt or flight” or “kill or be killed” with adrrenaline‐driveen arousal thaat can go on for weeks afterr a trauma meemory is recalled or stimulated by something in the current nvironment. M
Multiply that emotional arousal by the number of peersonalities in
nvolved, and en
ou can apprecciate how imp
portant it is fo
or everyone in
nvolved with the client to be vigilant bee for emotional vollatility and accting out. How
w long can thee client be in this fight‐or‐flight state? II have seen m
many Vietnam
m War combat veterrans go back into combat patrol‐level vvigilance (“Full Metal Jackeet”) triggered by personal and national events. One of tho
ose was when
n the World TTrade Towerss were attackeed on 9/11/2001. Some o
of those Vietn
nam vets weree in Full Metal Jackeet from that ttime until we invaded Afgh
hanistan and Iraq (around 2003). They could only “stand down” when
n someone ellse picked up their fight. I have heard of a W
World War II veteran who
o flashed backk to the Battlee of the Bulgee when he waas caught in a snowstorm in Mo
ontana in abo
out 1998. 199
98 minus 1944 equals fifty four years!
The eemotional tsu
unamis discusssed earlier are a constantt part life for m
multiples. On
ne of the MPD
D clients I treaated (Janie) reenaacted one event for aroun
nd six monthss. The trauma event involvved her fatherr and her dow
wn in the baseement of their house when she was about four. He w
was a WWII veeteran of the Navy. His ship was bombeed or torpedo
oed by the nese in the Paacific Ocean, and one of his shipmates was trapped under some fallen debris.. The ship wass ablaze. Japan
Theree were explossions, fires, heat, sprayingg water and people scream
ming everywhere. Her fatheer was unablee to free his budd
dy from the burning debriss under which
h he was trapped. His budd
dy told him to
o shoot him sso he would n
not suffer the agon
ny of burning to death. All sailors know the horrors o
of burning to death on a sh
hip. It’s a horrrible choice b
between beingg burned by tthe fire and ju
umping into the water and
d dying by shaark bite, drow
wning or dehyydration. To ““help” his budd
dy avoid burning to death, her father sh
hot and killed him. Howeever, like many combat ve
ets, he felt guilty about it aafterwards an
nd suffered th
he effects of tthe trauma. FFor years, he reenaacted that WWII incident downstairs in
n the basement of the fam
mily home with
h my patient when she waas a little girl besid
de him. He wo
ould open the
e door to their coal furnacce and furioussly shovel in tthe coal to geet the furnacee roaring hot.
She d
did not remem
mber if he did
d anything to re‐create thee spraying waater. He madee her stay dow
wn there with
h him. Duringg thesee frightening episodes she
e huddled in the corner behind boxes, thinking the w
world was com
ming to an end. Durin
ng my therapy with her, on
ne of her personalities started indirectlly hinting to m
me (as is often the case at first) that another personaliity was building a barricade because she was scared of something. I had not yyet heard the whole story nd the reenacctment, and sso I was unab
ble to interven
ne before shee was evicted for flooding her apartmen
nt. The behin
wateer, of course, also drained into her neighbors’ apartm
ments, floodin
ng theirs, too
o. That caused
d a life‐managgement crisis that set therapy b
back a month or two as wee looked for (aand found) diifferent, low‐income housing for her. G
Getting her packed and moved was no eassy process eith
her. Her few friends were not very help
pful. Prrofessional Deveelopment Resources | 2008 | ww
ww.pdresourcess.org | #40‐14 A Dissociative Ideentity Disorder C
Casebook | Page 38 of 50 Only then could we process the real‐life events that were the source of the reenactment. The reenactment involved her building a box barricade and turning on all of the hot water faucets in the house full‐blast until the house was full of steam, the rooms were as hot as she could get them, and the walls were dripping water. She had reenacted the terrifying scenario re‐created by her traumatized father as he was unconsciously reenacting the WWII mercy killing of his shipmate on the blazing ship in WWII. Did I get her integrated? No. She got oat‐cell lung cancer and died within six months of detection in spite of aggressive chemotherapy. I had worked with her without payment for five years. She was going to pay me back when she got better. She didn’t get better. Post‐Integration Caveats Even after you achieve integration or get reports of integration from the patient, concerns still remain. Caveat One: Don’t bet that your patient is really, fully, permanently integrated. My experiences match other seasoned veterans of MPD treatment (e.g., Caul, 1984; Graves, 1988), who report that one therapist is usually not sufficient to complete all of the work required. This is because there are so many unexpected and unavoidable events that occur during therapy with these clients. The sheer volume of work can prevent any one therapist from being shown all of the alter egos, much less dealing with all of each ego’s issues. Some of the alters may love males; some of them may hate males. Some of them may love females; some of them may hate females. You, as a therapist, are either physically male or female. It’s unavoidable. You are more likely than not to be a source of intense ambivalence to any patient for any number of other reasons over which you have no control. All of your other attributes and characteristics like age, race, religion, etc. can engender strong reactions on the part of the various personalities. There is probably something about any therapist that is going to scare or drive away some of the client’s alter egos. Integration can even be prevented due to that trigger of intense emotion in the client based on the therapist’s characteristics. I’ll give you some examples: Nancy (the second MPD I worked with) had worked with a therapist for six years after he accurately diagnosed her as a multiple. Prior to that, she had been in therapy for many years, with all of the usual misdiagnoses. When he thought he had met all of the personalities and worked through all of their issues, he did imagery‐type integration. Following this work, he believed they had achieved integration. Nancy also thought she was integrated. However, she came apart four years later and came to me for further therapy after clients at the nursing home where she worked began suspiciously dying. She “came apart” because one of her personalities had hidden from her prior therapist because she thought he made fun of her. That alter‐ego’s name was “Cat Lady,” referred to earlier in this course. She was a nine‐year‐old, female personality. She was the one who had stabbed her friend’s sexually‐molesting father in the back with the scissors. Cat Lady dressed in a very peculiar way and wore unusual glasses. Do you remember the up‐sweep glasses that Lilly Tomlin used to wear when she was playing the Telephone Lady? Well, Cat Lady wore that same style of glasses with sparkles on the front and side frames, and she looked as silly as Lilly Tomlin did. Maybe her prior therapist did have an amused reaction when Cat Lady “came out.” I was able to keep a poker face when Cat Lady first came out only because some of the other child alter egos inside Nancy had warned me that Cat Lady was very sensitive to rejection. I had to repeatedly reassure them all that I wouldn’t laugh at her if she came out. I probably would have not been able to hide my amusement if I hadn’t been warned. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 39 of 50 Another factor that can impede therapy and integration is that some egos of MPDs are so sensitive to rejection that they persistently hide from the therapist as a form of self‐defense. Cat Lady (above) was one example. Here is another. I had only a single session with a 10‐year‐old boy whose mother thought he was a multiple. He showed me a book about which he was very enthusiastic. I reacted sincerely, but apparently did not express enough interest or enthusiasm for him. He refused to come back and talk further with me because of my inadequate interest in his book. I am not sure he was a multiple because I did not get past the first session. Caveat Two: It is very important that you not terminate treatment immediately after integration. You are not yet finished. Most multiples will still need a great deal more work on social skills, self‐esteem, assertiveness, abstinence, etc., because 1) the social environments in which they grew up were likely pathological and 2) their developmental processes were probably impaired by the difficulties imposed by the disorder itself. Caveat Three: Encourage patients to avoid watching television and using alcohol for a long period of time after achieving integration. Television and alcohol can induce a sense of unreality that can be a threat to someone with a fragile sense of self. Alcohol is, of course, potent in reducing impulse control. Traumatized individuals frequently use alcohol to dissociate themselves from troublesome thoughts and memories (Savitz, et.al, 2008; Widom, et.al., 2007). Caveat Four: Hope and pray that your integrated patient does not get physically or sexually abused again. Such a trauma is likely to trigger the old memories and cause the individual to split again, not necessarily back into the same personalities as before. However, the literature does suggest that multiples who were able to integrate may be able to do so again in a somewhat shorter period of time. Other Considerations In addition to the straightforward issues of diagnosis and integration, it is useful to be aware of the following, more exotic considerations: Animal Alters: I have not encountered any of this type of alter ego, but Hendrickson, McCarty, & Goodwin (1990) reported five cases of MPDs with animal alter egos. They stated the development of the animal alter could be traced to childhood traumata involving (1) being forced to act or live like an animal, (2) witnessing animal mutilation, (3) being forced to engage in or witness bestiality, or (4) experiencing the traumatic loss of or killing of an animal. Smith (1989) also reported snake and wolf alter egos in a Native American MPD who also had alter personalities representing other Native American myths and spirits. They all were created by trauma and wanted to tell their stories. Past Life Alters: I have worked with one MPD patient (Janie, above) who had originally had one personality – Cat Lady – who claimed to be from a prior life. Although she wore the funny glasses, she claimed her name was from her previous life as an Inca Indian. She claimed she was a healer of those times and was very attuned to panthers. She claimed she had developed special medicinal uses for panther urine. I was careful not to confront or challenge her. I did not laugh at her. Eventually, she felt safe enough to tell me her story of stabbing her girlfriend’s rapist father. Once she was able to share that memory, I could help her process her guilt and horror about his raping his daughter and her own aggression in an attempt to save her friend. Little four‐year‐old girls can’t understand and cope with all that complexity. Four‐year‐
old Cat Lady could finally work through it with me...because I didn’t laugh at her. Internal Self‐Helpers (ISH): This phenomenon was first reported in the literature by Allison (1974), and subsequently by others (e.g., Comstock, 1991; Gunn, 1995). ISHs are theorized to be, and seem to act as “detached knowers” (my term) or objective observers. They usually act very aloof, detached, and intellectual. They can be of help giving “the others” structure and moral guidance. They can also give the therapist an intellectualized view of the patient. I first heard of ISHs during an ISSMPDD workshop presented by Dr. Allison. However, I think I met my first ISH during work with my first multiple (“Jane”) about two years before I ever heard of the concept of ISH. Jane was the patient who “came to” driving in Arkansas. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 40 of 50 Jane always came to therapy in blue jeans and a white blouse. She usually acted anxious and nervous. Her skin was blotchy and patchy. Our therapy hadn’t been going very well. The hypnosis had been unproductive, if not counter‐
therapeutic. Then, one night she came in wearing a Victorian‐era dress. It was floor‐length with a stiff, lacy collar that reached up toward her chin instead of lying flat as most collars do. Her dress was an earthy brown color, nothing fancy or garish. She walked fluidly and gracefully, sat properly, erect and refined, and behaved and talked in a very dignified fashion. Her complexion was smooth and even. She never told me her name or referred to herself with any identity. She talked distantly but academically about Jane, as if Jane were an object of observation and analysis. She was quite proper in posture and speech. She explained Jane’s problems in simplistic terms but without emotion. Then she left and I never saw her again. Other writers on MPD state that the ISHs can be more actively recruited to be involved in the therapy. I leave you to read more about them and make up your own mind. I do know that some therapists actively call for the ISH. I am leery of doing so because I am careful to avoid creating anything in the patient’s mind that isn’t already there. I think the less threatening the therapist and the therapeutic process, the safer the patient will feel to reveal their personal hurts and pains. Gatekeepers appear to control who is “out.” Gatekeepers may not always be present in all MPD clients at all times. One writer (Chase, 1987) suggests that the therapist actively work with the Gatekeepers. I generally do not unless they present themselves and also have issues. When a perpetrator dies: Contrary to popular expectation, the death of an abuse perpetrator can be a heart‐wrenching experience for the MPD client. This because of the intense and conflicting feelings and attitudes various personalities can have about the abuser and the abuse. If a perpetrator dies during your therapy with the victim, be ready for many extra sessions and activate your client’s entire support network. Grief: Like other abuse survivors, MPD clients often grieve over the loss of the innocent childhood that everyone is supposed to have. They also grieve over the loss of the wild and crazy explorations of adolescence we are all supposed to get. Besides helping them through the normal grieving, I also try to get my clients to understand that they will be more advanced in wisdom about life than their non‐abused, non‐split peers because of the insight that intense pain often provides. Most of them understand this and it provides them with some sense of serenity and actual meaning for their suffering. CAN CHILDREN BE MULTIPLES? The literature (e.g., Barreda‐Hanson, 2008; ISSD, 2003) and my own experience suggest that children can be multiple personalities. I, myself, have worked with three children ages 9, 11 and 14 whom I diagnosed as MPD. One of my seminar attendees once told she had seen a six‐year‐old girl who had been extensively abused and had a sexually‐active adolescent female alter personality. The nine‐year‐old I worked with was a “maybe,” since he discontinued therapy with me before I could do a thorough assessment of him. His mother wouldn’t bring him back. I also saw the 14‐year‐old only very briefly. She was the second oldest child in a family of five children who were all severely physically and/or sexually abused by their stepfather and/or their mother’s teen‐age lovers. Some of the mother’s boyfriends were also her teenage daughters’ boyfriends. She presented at least three personalities. One was the host, one was an “evil old woman” and one we called “Sickly Sweet.” Her acting out in her foster home and at school was so and aggressive and sexual that she was quickly placed in a girls’ treatment center. After that I received only occasional feedback about her. However, I did hear that she told the staff at the group home that the “evil old woman” had gone away. My bet is that the “evil old woman” will be back at some point. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 41 of 50 The third child I saw, the 11‐year‐old, was a biracial female. Let’s call her “Alice.” Alice had been having severe emotional and behavioral problems since she was five years old. She never knew her father. Her mother had been a methamphetamine addict but had been reportedly clean for four years. Alice was referred to me for therapy after her mother caught her sexually acting out with her two younger stepbrothers. During my first assessment session, Alice reported that she had been having auditory hallucinations since she was about five or six years old. She showed me a card she had made about a year earlier. She knew that she had made it, but did not remember doing so. She repeatedly expressed great fear about “the others” being mad at her if she told me about them. We identified three other personalities. One of them was a 9‐year‐old African‐American girl, one an angry adult male, and one of them a nice, adult female. In addition, her mother reported observing her playing with a cousin’s doll, sitting on the floor like a baby, babbling incoherently. I suspected she also had a toddler personality. Alice’s behavior when she “told” me about the other three personalities was very interesting. She didn’t tell me using words. In fact, she covered her mouth with one hand and wrote the ages and races of the others in the air, using the fingers of her other hand. It appeared she used this method of communication so that the others wouldn’t know she was telling me about them. Her tricky communication didn’t work. After she had spelled out some of this information, she got a very frightened look on her face, hid her eyes with her hand, and then pulled her shirt up over her face as silent tears streamed down her face. I asked her if she was feeling a lot of emotion. She nodded her head “yes” and said “they” were mad at her because she was telling me about them. I only worked with Alice for about two months. However, her parents told me she had been more emotionally stable for a longer time than they had ever seen before. They also told me they understand some of her “weird” behaviors better in light of my MPD diagnosis than they ever had before. However, the family eventually disintegrated over day‐to‐day stresses, and social services placed her back with a known methamphetamine‐abusing grandmother. That grandmother and social services terminated my therapy with her. Post‐script: I saw Alice in a local restaurant a few months later, but didn’t talk to her. She did not recognize me, since I was so far away from her location in the restaurant. She appeared to have gained 50 pounds. She didn’t walk or act like the anxious, insecure 11‐year‐old I had worked with. She was now acting more like a super‐confident, adult man. She had her backpack slung over her shoulder and was walking with a swagger. She had a “kick‐your‐butt” kind of energy. People she talked with appeared to treat her with a great deal of deference. ALL THAT IS DIVIDED IS NOT MULTIPLIED! This dictum is also relevant – maybe particularly so – when working with children. I worked with another young girl, 11 years of age, who was dissociating. Let’s call her “Cathy.” Her biological brother – four years older – had physically and sexually abused her for many years. The abuse started when she was about five years old and continued until her biological mother won custody of her when Cathy was about 10. Her biological mother was unaware of the severity and extent of the abuse Cathy had experienced, since her mother had not lived with Cathy or her father for many years. Cathy was referred because she had killed some kittens and was masturbating in class at school. She was also doing some things that she truly didn’t remember doing, like playing cards or writing certain homework assignments. She had told a previous psychologist that she heard voices in her head. One of those voices was of a “mean, white‐
haired old lady” and the other voice was of her abusive brother. She also saw faces attached to the voices. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 42 of 50 Afterr I questioned
d Cathy aboutt the mean, w
white‐haired o
old lady, she q
quickly told m
me that she had driveen the old lady away by plaacing a preten
nd spider neaar her, becausse she had leaarned that sh
he feared spideers. I didn’t th
hink we would
d be rid of thee mean old laady that easilyy. I was right.. The mean old lady re‐ap
ppeared abou
ut three montths later when stresses occcurred, apparrently brough
ht about when Cathy’s biolo
ogical father ggave her some
e pictures and birthday prresents. She aassociated her father with her abusive brother. A
At that time, I asked Cathyy if she really knew any meean old ladiess. She denied it, at first. Ho
owever, her moth
her reminded
d Cathy that h
her biological father’s moth
her was a meean, old lady w
with faded blo
onde hair. Th
his helped Cathyy understand
d the source o
of her inner vo
oice and men
ntal picture off the mean olld lady. We w
worked directtly on the phyysical and meental abuse byy her brother. He caused p
part of her disssociations byy telling her he w
would always kknow where sshe was and ccome to her iin her dreamss and hurt heer. He has lostt much of his mental hold on heer since we taalked about h
him and his brrutality. She h
had dissociateed (divided) p
parts of herseelf but hadn’t multiplied. I have seen more cases of psych
hogenic amneesia than I havve MPD, by faar. DID//MDP, HYPN
CS, and SOD
AL Hypn
nosis: During tthe 1970’ and
d 80’s I did a lot of age‐reggression hypn
nosis. That is w
when I found
d most of my MPD/DID clientts. However, opening them
m up in that w
way left them
m in a mass off emotional ch
haos. Case management w
was very difficcult if not imp
possible. I then developed the Nolen Trauma Invento
ory, which I sttill use to try to detect dissociative tendencies. Todayy I avoid usingg any type of hypnosis on someone who has strong dissociative ttendencies. Foren
nsics: I have h
had little positive experien
nce convincin
ng the courts tthat anyone II thought wass a multiple o
or severely disso
ociated was geenuine. Howe
ever, I have h
heard of a num
mber of casess (e.g., Billy M
Milligan, Juaniita Maxwell and others; in Saks,, 1997) in whiich the courtss did accept M
MPD as a genuine phenom
menon and maade rulings deeclaring that the “Host” lackeed responsibillity for the be
ehaviors of altter egos. How
wever, you wo
on’t win them
m all. I once heard an attorrney ask an MPD
D if she ever to
ook drama claass in high school. Foren
nsics, Part 2: The latest Am
merican Psych
hological Asso
ociation data (APA‐sponso
ored ethics work, Springfieeld, Missouri, 2003
3) I have on m
malpractice law
wsuits and co
omplaints to eethics boardss shows that ttherapists wh
ho 1) treat sexxual abuse victim
ms, 2) work w
with PTSD or B
Borderline patients, or 3) d
do “recovered
d memories” work tend to
o get sued or have ethics comp
plaints filed against their liicenses moree frequently th
han those wh
ho do not worrk with such ccases. Foren
nsics, Part 3: Doing hypno
osis can be hard on your m
malpractice ratte. Some MPDs have claim
med that hypn
nosis “made” them
m multiples. N
Not that it is p
possible, but yyou would bee dealing with
h ethics board
ds, judges, and attorneys, w
who may have agendas of ttheir own. The
ere are even mental health providers w
who might sugggest that someone createed MPD in their clients, because they never saw any evvidence of mu
ultiplicity wheen they treated the patien
nt. I am frequently assked if combaat trauma can
n be a cause o
of MPD. Comb
bat veterans can – and freequently do –– develop PTSD
D, they can haave psychogen
nic amnesia, but they don’t tend to mu
ultiply. I have never heard of a case of ccombat PTSD beco
oming a case o
of multiple pe
ersonality disorder. Why is that? Heree is what I thin
nk: while young children w
who are expossed to trauma have little in the way of effective copin
ng mechanism
ms, adults havve many more cognitive ab
bilities and co
oping skills to
o deal with inttensely emotional events before, during, an
nd after the trrauma. They aare always filtering and evvaluating the event througgh the cognitive and copin
ng mechanism
ms available tto most adults. So, even th
hough they m
may suffer severe PTSD sym
mptoms, they do not geneerally develop
p MPD unless they were alsso trauma vicctims early in their lives. Psych
hotropics: I d
defer specificss to psychiatrrists or neurologists on what and how m
much. However, I strongly caution theraapists to havee some reliable adult be reesponsible forr administerin
ng and monitoring all presscribed psychotropic mediications given
n to MPD patiients. Doing o
otherwise is inviting trouble. Prrofessional Deveelopment Resources | 2008 | ww
ww.pdresourcess.org | #40‐14 A Dissociative Ideentity Disorder C
Casebook | Page 43 of 50 Sodium Amytal: This is the drug that has been labeled “truth serum.” I once had an experience that induced me to caution against its use with MPDs. I was seeing an MPD client who was prescribed sodium amytal by a psychiatrist after we had many problems doing hypnosis. She thought it might be a painless shortcut. After he administered the drug, one of her other personalities exploded out when he had only counted down to “7.” It took five hospital aides to subdue her, one of whom received a broken collarbone in the fracas. My patient’s left arm ended up in a cast. The drug produced an intolerable state of helplessness in my patient who equated helplessness with abuse. An aggressive alter ego came out and took charge in an effort to protect the weaker alter egos by the only means he knew: aggression. MEDICAL CASE MANAGEMENT Some multiples have many physical health problems or complaints. They may be somaticization disorders or they can be truly physical problems. Many of their real physical problems are due to the chronic stress caused by their abuse and adrenaline hyper‐reactivity. Unfortunately, they tend to be very poor communicators when they try to explain things to health professionals. They also tend to be overly emotional under stress. Obviously, undergoing invasive medical procedures is stressful. These characteristics often result in catastrophes when they deal with medical health care providers. Simple misunderstandings can be the start of massive negative transference, whether they are correct or not. I have become more active over the years trying to offer myself as an interface with medical professionals dealing with my MPD clients. My efforts have been more or less successful. I recommend (again, after appropriate informed consent’ protection of privacy, and need‐to‐know) the following steps: 1) Let the medical staff know your patient is under treatment and has problems with comprehension and emotional instability. (I don’t mention MPD unless I consider it necessary, because medical staff may have negative opinions about MPD. 2) Offer daily telephone consults with patient, partners and medical staff if the procedure requires inpatient care. 3) Try to visit in person at least once a week if at all possible. NEVER TREAT A MULTIPLE BY YOURSELF Always consult with someone else. I say this for several reasons: 1) Multiples are mentally exhausting. Let others share the burden. 2) Multiples will push your limits and boundaries. Let someone else check your boundaries and keep you in the proper zone. 3) What if you die, quit the agency, move away or get fired? Who will take over? This abandonment will be another example of severe loss of a safety net for the client. Therapy is further delayed, thwarted or circumvented. Get Plenty of Reality Checks: Confirm as much as you can about what the multiples are telling you. I know of one tragic case in which a therapist was consulting on a woman who claimed she had had one personality who had murdered and cannibalized over a hundred people around her town. He never checked on any of this. It turned out there were no people murdered in her area, let alone a hundred. Unfortunately, he failed to get reality checks and paid for it with his licenses and positions at prestigious hospitals and universities after she claimed he planted those false memories in her head. Lastly: Never promise an MPD patient complete confidentiality. Use all of the collateral support, witnesses and observers you can from those around the client. You and the client will need them, for better or for worse. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 44 of 50 In spite of all of the possibilities for error, misperception, and misrepresentation, I (and apparently many other practicing clinicians) have repeatedly seen first‐hand the emotional agony, decompensation, and unimaginable transformations that multiples endure before and during therapy. I have also seen and experienced first‐hand the bewilderment and befuddlement therapists can experience when dealing with a multiple. I was aware of the problems with suggestion and false memory in 1968, well before I encountered my first MPD client and long before I started doing any age‐regression hypnosis (in 1975) and encountering my first MPD (in 1982). I genuinely believe the MPDs I have worked with were not a product of any suggestion on my part. I write this course for the sake of the patients and the therapists dealing with this disorder. My hope has been to do what I can to help them through their incredible, fascinating and tortured process. References APA ‐ American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental Disorder, Third Edition ‐ Revised (DSM‐III). Washington, DC: American Psychiatric Association. APA ‐ American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders, Version Four (DSM‐
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memories.nl. 2008. Berne, E. The Games People Play: the psychology of human relationships, 1966, Deutch, London. Bernstein, E.M., & Putnam, F.W. Development, reliability and validity of a dissociation scale. J. Nervous and Mental Disease, 174, 727‐735, 1986. Branscomb, L. Dissociation in combat‐related post‐traumatic stress disorder. Ridgeview Institute and the International Society for the Study of Multiple Personality and Dissociation, March, 1991, @Https://scholarsbank.uoregon.edu/dspace/handle/1794/1732. Braun. B. What gets Dissociated: BASK. Presidential address of the International Society for the Study of Multiple Personality Disorder, 1984. Cantor, S. Inpatient treatment of adolescent survivors of sexual abuse. In: Child survivors and perpetrators of sexual abuse: Treatment innovations. Hunter, Mich; Thousand Oaks, CA, US: Sage Publications, Inc, 1995. pp. 24‐49 Caul, D. Team Treatment. First International Conference on Multiple Personality and Dissociative States, Chicago, Il., 1984 Chase, T. When Rabbit Howls, E.P. Dutton, 1987. Comstock, C.M. The Inner Self Helper and Concepts of Inner Guidance: Historical Antecedents, Its Role within Dissociation and Clinical Utilization. Dissociation, 4(3), 1991. Cumella, E. J.& Kally, Z, Profile of 50 women with midlife‐onset eating disorders. Eating Disorders: The Journal of Treatment & Prevention, Vol. 16(3), May 2008. pp. 193‐203. Davis, E. & Bass, L. The Courage To Heal, Harper and Row, 1988 Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 45 of 50 do Amaral, J.R., M.D, & Martins de Oliveira, J., MD, PhD. Limbic System: The Center of Emotions. The Healing Center Online, http://www.healing‐arts.org/n‐r‐limbic.htm, 2008. Dorlands' Illustrated Medical Dictionary, 28th Edition WB Sounders Company, 1994. Dudeck, M; Spitzer, C. & Stopsack, M. 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Handbook of Psychophysiology, Holt, Rinehart and Winston, USA, p 839‐917, 1972. Graves, G. Common Errors in the Treatment of Multiple Personality Disorder. Dissociation, 1(1), pp. 61‐66, 1988. Greenberg, J. I Never Promised You A Rose Garden. Signet, 1989. Guidelines for Treating Dissociative Identity Disorder in Adults. American Psychiatric Association, 2005, at http://www.issd.org/indexpage/treatguide1.htm#epidemiology, 2007) Guidelines for the Evaluation and Treatment of Dissociative Symptoms in Children and Adolescents. ISSD Task Force on Children and Adolescents, [email protected] http://www.issd.org/indexpage/ChildGuidelinesFinal.pdfs Gunn, J.P. The Inner Self Helper in Multiple Personality Disorder: Angel or Artifact? Unpublished Dissertation, 1995. Hendrickson, K. M., McCarty, T., & Goodwin, J. Animal alters: case reports, Dissociation : Vol. 3 (4), 1990. Hyman, S. M., Paliwal, P., & Chaplin, T. M. Severity of childhood trauma is predictive of cocaine relapse outcomes in women but not men. Drug and Alcohol Dependence, Vol 92(1‐3), Jan 2008. pp. 208‐216. ISSD ‐ International Society for the Study of Dissociative Disorder’s Bibliography @ http://www.empty‐memories.nl Keyes, D. The Minds of Billy Milligan. Bantam Press/Random House, 1981 Kleineke, C.L. Coping With Life Challenges. Brooks/Cole, 1998. Kluft, R. P. An introduction to multiple personality disorder. Psychiatric Annals, 14, 19‐24, 1984a. Kluft, R.P. The Phenomenology & Treatment of Highly Complex MPD, First International Conference on Multiple Personality and Dissociative States, Chicago, Il., 1984b. Kluft, R.P. (Ed.) . Childhood Antecedents of Multiple Personality, American Psychiatric Press, Washington DC, 1985. Loftus, E., & Ketcham, K. The Myth of Repressed Memories, St. Martin’s Press, NYNY, 1996. Many Voices: Words of Hope for People Recovering From Trauma and Dissociation @ http://www.manyvoicespress.com/subjectindex.html McKay, M. & Fanning, P. Self‐esteem. New Harbinger, Oakland. CA, 2000. Nasar., S. A Beautiful Mind: A biography of John Forbes Nash, Jr., winner of the Nobel prize in economics, 1994, Faber and Faber, 1999. National Review Board for the Protection of Children and Young People. A Report on the Crisis in the Catholic Church in the United States. Washington, DC (2004). Nolen, F. Public Health, Private Grief: Child Sexual Abuse, Victim and Perpetrators. AMAS Publishing, 2002. Norwood, R. Women Who Love Too Much. St. Martin’s Press, 1985. Osgood, C. The nature and measurement of meaning. Psychological Bulletin, 49, 197, 237, 1952. Osgood C., Sucy, G., & Tannenbaum , P. The Measurement of Meaning, Urbana, 1957 Oxnam, Robert. A Fractured Mind: My Life with Multiple Personality Disorder, Copyright © Reed Business Information, a division of Reed Elsevier, Inc. "Paidika Interview: Hollida Wakefield and Ralph Underwager. Paidika: The Journal of Pædophilia, Stichting Paidika Foundation, the Netherlands, Winter 1993. Prince, M. Some of the revelations of hypnotism. Boston Medical Surgery J., 122: 463‐467, 1890. Prince, M. Miss Beauchamp: The Psychogenesis of Multiple Personality. J. Abnormal Psychology, 16, 67‐135. 1920. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 46 of 50 Prince, Walter Franklin. The Doris case of multiple personality, Proceedings of the American Society for Psychical Research, 10, 701‐ 1419, 1916. Putnam, F.W., Guroff, J.J., Silberman, E.K. Barban, L. & Post, R.M. The Clinical Phenomenology of Multiple Personality Disorder: Review of 100 Recent Cases, Journal of Clinical Psychiatry, 47: 285‐293, 1986. Saks, E. Jekyll on Trial: Multiple Personality Disorder and the Law. New York University Press, NYNY, 1997. Satanic Ritual Abuse (SRA) @http://www.religioustolerance.org/sra.htm, 2008. Savitz, J. B., van der Merwe, L., & Stein, D. J. Neuropsychological task performance in bipolar spectrum illness: Genetics, alcohol abuse, medication and childhood trauma. Bipolar Disorders, Vol 10(4), Jun 2008. Schiraldi, G.R. The Self‐Esteem Workbook, Harbinger Press, Oakland, CA., 2001. Schreiber, F.R. Sybil, Werner Press, 1974. Shakeshaft, C. Educator Sexual Misconduct: A Synthesis of Existing Literature, US Department of Education, 1994. Sizemore, C. I’m Eve, Doubleday, Garden City, NY, 1977 Smith, S.G. Multiple Personality Disorder With Human and Non‐Human Subpersonality Components. Dissociation, 2(1), 1989. Steiner, Claude, M. The Games Alcoholics Play; the analysis of life scripts, 1971, Grove Press, NY. Steinberg, M. Structured Clinical Interview for DSM‐IV Dissociative Disorders (SCID‐D‐R), 1994, appi.org Stevenson, R. L. Dr. Jekyll and Mr. Hyde, 1886. Thigpen, C., & Cleckley, H. The Three Faces of Eve, Popular Library, NYNY, 1957 Weiten, W. Psychology: Themes and Variations, 7th Ed, 2007, Thomson/ Wadsworth. Whisman, M.A. & Snyder, D.K. Sexual infidelity in a nation survey of American women: Differences in prevalence and correlates as a function of method of assessment. Journal of Family Psychology, 21(2), 2007, (147‐154). Widom, C. S., White, H. R. & Czaja, S. J. Long‐term effects of child abuse and neglect on alcohol use and excessive drinking in middle adulthood. Journal of Studies on Alcohol and Drugs, Vol. 68(3), May 2007. See International Society for the Study of Dissociative Disorder’s Bibliography @ http://www.empty‐memories.nl Other Relevant Readings (May be some duplication across topics) Giving Legal Testimony Albert, S., Fox, H. M., & Kahn, M. W. (1980). Faking psychosis on the Rorschach: Can expert judges detect malingering? Journal of Personality Assessment, 44, 115–119. Aldridge‐Morris, R. (1989). Multiple personality: An exercise in deception. London: Erlbaum. American Psychological Association Division 41 and American Psychology‐Law Society. (1991). Specialty guidelines for forensic psychologists. Law and Human Behavior, 15, 655–665. Barach, P. (1999). President’s message. ISSD News, 17, 1. Barrett v. Hyldburg, Super. Ct., Buncombe Co., North Carolina, No. 94‐CVS‐0793 (January 23, 1996) Beitchman, J. H., Zucker, K. J., Hood, J. E., daCosta, G. A., Ackman, D., & Cassavia, E. (1992). A review of the long‐term effects of child sexual abuse. Child Abuse and Neglect, 16, 101–118. Bersoff, D. N., Glass, D. J., Dodds, L. D., Eckl, L., & Peters, L. M. (1999). The admissibility of forensic psychological and social science evidence. Unpublished list of cases. Blackowiak v. Kemp, 546 N.W. 2d 1, Minn. (April 19, 1996) Bliss, E. L. (1986). Multiple personality, allied disorders, and hypnosis. New York: Oxford University Press. Borawick v. Shay, 68 F. 3d 597, 2nd Cir., Conn., cert. denied (October 17, 1995) Bowman, M. (1997). Individual differences in post traumatic response: Problems with the adversity‐distress connection. Mahwah, NJ: Erlbaum. Butcher, J. N., Dahlstrom, W. G., Graham, J. R., Tellegen, A., & Kaemmer, B. (1989). Manual for administration and scoring of the MMPI–2. Minneapolis: University of Minnesota Press. Carlson v. Humenansky, No. CX‐93‐7260, 2nd Dist., Ramsey Co., Minn. (December 29, 1995) Comm. of Pennsylvania v. Crawford, 682 A. 2d 323, Pa. Super. (July 30, 1996) Commonwealth v. Kater, 447 N.E. 2d 1190 (Mass. 1983) Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 47 of 50 Coons, P. M., Bowman, E. S., & Milstein, V. (1988). Multiple personality disorder: A clinical investigation of fifty cases. Journal of Nervous and Mental Disease, 176, 519–527. Cronbach, L. J. (1949). Statistical methods applied to Rorschach scores: A review. Psychological Bulletin, 46, 393–429. Dalrymple v.Brown WL 499945, Pa., Aug. 25(1997) Daubert v.Merrell Dow Pharmaceuticals, Inc. 509 U.S., 113 S. Ct. 2786(1999) Dell, P. (1988). Professional skepticism about multiple personality. The Journal of Nervous and Mental Disease, 176, 528–
531. Doe v.Maskell 679 A. 2d 1087 Md., July 29, 1996, cert. denied 117 S.Ct. 770(1997) Engdahl, B., Dikel, T. N., Eberly, R., & Blank, A., Jr. (1997). Post traumatic stress disorder in a community group of former prisoners of war: A normative response to severe trauma. American Journal of Psychiatry, 154, 1576–1581. Engstrom v. Engstrom, No. B098146, Cal. App., 2nd App. Dist., Div. 2, June 18, 1997,unpublished, cert. denied Cal. (September 3, 1997). Exner, J. E., Jr. (1980). But it’s only an. inkblot. Journal of Personality Assessment, 44, 563–577. Exner, J. E., Jr. (1993). The Rorschach: A comprehensive system: Vol. 1. Basic foundations (3rd ed.). New York: Wiley. Frye v. United States, 293 F. 1013 (D.C. Cir. 1923) Galante, R., & Foa, D. (1987). An epidemiological study of psychic trauma and treatment effectiveness for children after a natural disaster. Journal of the American Academy of Child Psychiatry, 25, 357–363. Garb, H. N. (1985). The incremental validity of information used in personality assessment. Clinical Psychology Review, 4, 641–655. Garb, H. N., Florio, C. M., & Grove, W. M. (1998). The validity of the Rorschach and the MMPI. Psychological Science, 9, 402–404. Garb, H. N., Wood, J. M., Nezworski, M. T., Grove, W. M., & Stejskal, W. J.Towards a resolution of the Rorschach controversy. Psychological Assessment. (in press). General Electric Co.v. Joiner, 118 S. Ct. 512(1997) Gianelli, P. C. (1980). The admissibility of novel scientific evidence: Frye v. United States, a half‐century later. Columbia Law Review, 1197, 1223–1224. Grove, W. M., Zald, D. H., Hallberg, A. M., Lebow, B., Snitz, E., & Nelson, C. Clinical versus mechanical prediction: A meta‐
analysis. Psychological Assessment. (in press) Hagen, M. A. (1997). Whores of the court: The fraud of psychiatric testimony and the rape of American justice. New York: Harper Collins. Hammane v.Humenansky No. C4‐94‐203, 2nd Dist., Ramsey Co., Minn.(1995) Hammond, C. (1992, June). Hypnosis in MPD and ritual abuse. Paper presented at the Fourth Annual Eastern Regional Conference on Abuse and Multiple Personality, Alexandria, VA. Hiller, J. B., Rosenthal, R., Bornstein, R. F., Berry, D. T. R., & Brunell‐Neuleib, S. (1999). A comparative meta‐analysis of Rorschach and MMPI validity. Psychological Assessment, 11, 278–296. Hunter v. Brown, 1996 WL 57944, Tenn. App., slip copy (February 13, 1996) Corroboration of Accusations Barach, P. M. M. (1991). Multiple personality disorder as an attachment disorder. Dissociation, 4, 117–123. Beahrs, J. O. (1982). Unity and multiplicity: Multilevel consciousness of self in hypnosis, psychiatric disorder, and mental health. New York: Brunner‐Mazel. Bernstein, E. M., & Putnam, F. W. (1986). Development, reliability, and validity of a dissociation scale. Journal of Nervous and Mental Disease, 174, 727–735. Bliss, E. L. (1983). Multiple personalities, related disorders and hypnosis. American Journal of Clinical Hypnosis, 26, 114–
123. Bliss, E. L., & Larson, E. M. (1985). Sexual criminality and hypnotizability. Journal of Nervous and Mental Disease, 173, 522–526. Boon, S., & Draijer, N. (1993). Multiple personality disorder in the Netherlands. A study on reliability and validity of the diagnosis. Lisse, the Netherlands: Swets & Zeitlinger. Brown, D. P. (1995). Pseudo‐memories: The standard of science and the standard of care. American Journal of Clinical Hypnosis, 37, 1–24. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 48 of 50 Brown, D., Scheflin, A. W., & Hammond, D. C. (1998). Memory, trauma treatment, and the law. New York: Norton. Chu, J. A. M.D., Frey, L.M., Psy.D., Ganzel, B.L., Ed.M., M.A. and Matthews, B.A., Ph.D., M.D. Memories of Childhood Abuse: Dissociation, Amnesia, and Corroboration . American Journal of Psychiatry, 156: 749‐755, (1999). Coons, P. M. (1994). Confirmation of childhood abuse in child and adolescent cases of multiple disorder and dissociative disorder not otherwise specified. Journal of Nervous and Mental Disease, 182, 461–464. Coons, P. M., Bowman, E. S., & Milstein, V. (1988). Multiple personality disorder: A clinical investigation of 50 cases. The Journal of Nervous and Mental Disease, 176, 519–527. Courtois, C. A. (1995). Scientist–practitioners and the delayed memory controversy: Scientific standards and the need for collaboration. The Counseling Psychologist, 23, 294–299. Courtois, C. A. (1996). Informed clinical practice and the delayed memory controversy. In K.Pezdek & W. P.Banks (Eds.), The recovered memory/false memory debate (pp. 355–370). San Diego, CA: Academic Press. Courtois, C. A. (1997). Delayed memories of child sexual abuse: Critique of the controversy and clinical guidelines. In M. A.Conway (Ed.), Recovered memories and false memories (pp. 206–229). New York: Oxford University Press. Dalenberg, C. J. (1996). Accuracy, timing and circumstances of disclosure in therapy of recovered and continuous memories of abuse. Journal of Psychiatry and Law, 24, 229–275. Elliott, D. M., & Briere, J. (1994). Forensic sexual abuse evaluations of older children: Disclosures and symptomatology. Behavioral Sciences and the Law, 12, 261–277. Frankel, F. H. (1993). Adult reconstruction of childhood events in the multiple personality literature. American Journal of Psychiatry, 150, 954–958. Fredrickson, R. (1992). Repressed memories: A journey to recover from sexual abuse. New York: Simon & Schuster. Freyd, J. J. (1996). Betrayal trauma: The logic of forgetting childhood trauma. Cambridge, MA: Harvard University Press. Gutheil, T. G., & Simon, R. I. (1997). Clinically based risk management principles for recovered memory cases. Psychiatric Services, 48, 1403–1407. Harvey, M. R., & Herman, J. L. (1994). Amnesia, partial amnesia and delayed recall among adult survivors of childhood trauma. Consciousness and Cognition, 3, 295–306. Hayes, J. A., & Mitchell, J. C. (1994). Mental health professionals’ skepticism about multiple personality disorder. Professional Psychology: Research and Practice, 25, 410–415. Kluft, R. P. (1995). The confirmation and disconfirmation of memories of abuse in dissociative identity disorder patients: A naturalistic clinical study. Dissociation, 8, 253–258. Kluft, R. P. (1995b). Current controversies surrounding dissociative identity disorder. In L.Cohen, J.Berzoff, & M.Elin (Eds.), Dissociative identity disorder (pp. 347–377). Northvale, NJ: Jason Aronson Laub, D. (1995). Truth and testimony: The process and the struggle. In C.Caruth (Ed.), Trauma: Explorations in memory (pp. 61–75). Baltimore: Johns Hopkins University Press. .Lewis, D. O., Yeager, C. A., Swica, Y., Pincus, J. H., & Lewis, M. (1997). Objective documentation of child abuse and dissociation in 12 murderers with dissociative identity disorder. American Journal of Psychiatry, 154, 1703–1710. Martínez‐Taboas, A. (1996). Repressed memories: Some clinical data contributing towards its elucidation. American Journal of Psychotherapy, 50, 217–230. McHugh, P. (1993b, December19). Viewpoints—Do patients’ memories of sexual abuse constitute a “false memory syndrome”? Psychiatric News. P. 18. Ross, C. A., Norton, G. R., & Fraser, G. A. (1989). Evidence against the iatrogenesis of multiple personality disorder. Dissociation, 2, 61–65. Phelps, S. A., Friedlander, M. L., & Enns, C. Z. (1997). Psychotherapy process variables associated with the retrieval of memories of childhood sexual abuse: A qualitative study. Journal of Counseling Psychology, 3, 321–332. Pope, K. S., & Brown, L. S. (1996). Recovered memories of abuse: Assessment, therapy, forensics. Washington, DC: American Psychological Association. Rogers, M. L. (1994). Factors to consider in assessing adult litigants’ complaints of childhood sexual abuse. Behavioral Sciences and the Law, 12, 279–298. Sar, V., Tutkun, H., & Yargic, L. I. (1997, November). Confirmation of childhood sexual abuse in chronic complex dissociative disorder.Paper presented at the 13th annual meeting of the International Society for Traumatic Stress Studies, Montreal, Quebec, Canada. Sauzier, M. C. (1997). Memories of trauma in the treatment of children. In P. S.Appelbaum, L. A.Uyehara, & M. R.Elin (Eds.), Trauma and memory (pp. 378–393). New York: Oxford University Press. Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 49 of 50 Simon, R. I., & Gutheil, T. G. (1997). Ethical and clinical risk management principles in recovered memory cases: Maintaining therapist neutrality. In P. S.Appelbaum, L. A.Uyehara, & M. R.Elin (Eds.), Trauma and memory (pp. 477–
498). New York: Oxford University Press. Swica, Y., Lewis, D. O., & Lewis, M. (1996). Child abuse and dissociative identity disorder/multiple personality disorder: The documentation of childhood maltreatment and the corroboration of symptoms. Child and Adolescent Psychiatric Clinics of North America, 5, 431–447. Van der Hart, O., & Nijenhuis, E. (1995). Amnesia for traumatic experiences. HYPNOS, 22, 73–86. Viederman, M. (1995). The reconstruction of a repressed sexual molestation fifty years later. Journal of American Psychoanalytic Association, 43, 1169–1195.Waller, N. G., Putnam, F. W., & Carlson, E. B. (1996). Types of dissociation and dissociative types: A taxometric analysis of dissociative experiences. Psychological Methods, 1, 300–321. Whitfield, C. L. (1995). Memory and abuse. Deerfield Beach, FL: Health Communications Goodwin, J. (1985). Credibility problems in multiple personality disorder patients and abused children. In R. P.Kluft (Ed.), Childhood antecedents of multiple personality (pp. 21–35). Washington, DC: American Psychiatric Press. Merskey, H. (1992). The manufacture of personalities: The production of multiple personality disorder. British Journal of Psychiatry, 160, 327–340. Recovered Memories See Recovered Memory [email protected] http://www.brown.edu/Departments/Taubman_Center/Recovmem/index.html And http://www.brown.edu/Departments/Taubman_Center/Recovmem/archive.html False Memory Foundation False Memory Syndrome Website: http://www.fmsfonline.org/ Professional Development Resources | 2008 | www.pdresources.org | #40‐14 A Dissociative Identity Disorder Casebook | Page 50 of 50 

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