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Dissociative identity disorder and the sociocognitive model: Recalling the lessons of the past

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Abstract

In a recent article in this journal, D. H. Gleaves (1996) criticized the sociocognitive model (SCM; N. P. Spanos, 1994) of dissociative identity disorder (DID) and argued in favor of a posttraumatic model (PTM) in which DID is conceptualized as a consequence of childhood abuse and other traumatic events. The present authors demonstrate that (a) many of Gleaves's arguments were predicated on misunderstandings of the SCM, (b) scrutiny of the evidence regarding the psychopathology and assessment of DID raises questions concerning the PTM's conceptual and empirical underpinnings, (c) the treatment literature suggests that iatrogenic factors play an important role in the etiology of DID, and (d) the evidence linking child abuse to DID is more problematic than implied by Gleaves. The present authors conclude that Gleaves's analysis underemphasized the cultural manifestations of multiple role enactments and that the history of DID imparts a valuable lesson to contemporary psychotherapists.
Psychological
Bulletin
1999,
Vol. 125,
No. 5,
507-523
Copyright
1999
by the
American Psychological Association, Inc.
0033-2909/99/S3.00
Dissociative Identity Disorder
and the
Sociocognitive Model:
Recalling
the
Lessons
of the
Past
Scott
O.
Lilienfeld
Emory University
Steven
Jay
Lynn
Binghamton
University
Irving
Kirsch
University
of
Connecticut
John
F.
Chaves
Indiana
University School
of
Dentistry
Theodore
R.
Sarbin
University
of
California,
Santa
Cruz
George
K.
Ganaway
Emory
University School
of
Medicine
Russell
A.
Powell
Grant
MacEwan
College
In
a
recent article
in
this journal,
D. H.
Cleaves
(1996) criticized
the
Sociocognitive model (SCM;
N. P.
Spanos, 1994)
of
dissociative identity disorder (DID)
and
argued
in
favor
of a
posttraumatic
model
(PTM)
in
which
DID is
conceptualized
as a
consequence
of
childhood abuse
and
other traumatic events.
The
present authors demonstrate that
(a)
many
of
Gleaves's arguments were predicated
on
misunder-
standings
of the
SCM,
(b)
scrutiny
of the
evidence regarding
the
psychopathology
and
assessment
of DID
raises
questions concerning
the
PTM's
conceptual
and
empirical underpinnings,
(c) the
treatment
literature suggests that
iatrogenic
factors play
an
important role
in the
etiology
of
DID,
and (d) the
evidence linking child abuse
to DID is
more problematic than implied
by
Cleaves.
The
present authors
conclude
that
Gleaves's
analysis
underemphasized
the
cultural manifestations
of
multiple role enact-
ments
and
that
the
history
of DID
imparts
a
valuable lesson
to
contemporary psychotherapists.
The
etiology
and
nosological status
of
dissociative identity
disorder
(DID),
formerly known
as
multiple
personality
disorder
(MPD),
are
among
the
most controversial issues
in
contemporary
Editor's Note.
Cleaves
(1996),
discussed
in
this article,
was
deemed
a
commentary
on
Spanos (1994). Nicholas Spanos died
in
1994,
and the
present
article
was
written
as a
reply
to
Cleaves
(1996)
in
Spanos's
stead.
Because
Cleaves
(1996)
was
considered
a
commentary
and the
present
article
was
considered
a
reply
to
that commentary,
no
additional commen-
taries
or
replies were
solicited.—NE
Scott
O.
Lilienfeld, Department
of
Psychology, Emory University;
Steven
Jay
Lynn,
Department
of
Psychology, Binghamton University;
Irving
Kirsch, Department
of
Psychology, University
of
Connecticut; John
F.
Chaves, Indiana University School
of
Dentistry;
Theodore
R.
Sarbin,
Department
of
Psychology, University
of
California, Santa Cruz; George
K.
Ganaway, Department
of
Psychiatry, Emory University School
of
Medicine; Russell
A.
Powell, Department
of
Social
Sciences,
Grant
MacEwan
College, Edmonton, Alberta, Canada.
This article
was
inspired
by the
work
of
Nicholas Spanos, whose tragic
death
in
1994
was a
great loss
to the
field
of
psychology
in
general
and to
the
fields of
hypnosis
and
dissociative identity disorder
in
particular.
In
addition,
we
thank
Eric
Vanman,
Richard McNally,
and
several
others
for
their
extremely
helpful
comments
on
drafts
of
this
article.
Correspondence concerning this article should
be
addressed
to
Scott
O.
Lilienfeld,
Department
of
Psychology, Room 206, Emory University,
Atlanta,
Georgia 30322. Electronic mail
may be
sent
to
slilien@emory.edu.
clinical
psychology
(L.
Cohen, Berzoff,
&
Elin,
1995; Cormier
&
Thelen,
1998;
Pope,
Oliva,
Hudson,
Bodkin,
&
Gruber,
1999).
Over
the
past decade,
two
competing views concerning
the
genesis
and
nature
of DID
have emerged.
One
perspective,
referred
to by
Cleaves
(1996)
as the
posttraumatic model (PTM; called
the
"disease
model"
by
Spanos, 1994), maintains that
DID is an
etiologically
distinct condition that
is
best conceptualized
as a
defensive
response
to
childhood trauma, particularly severe sexual
and
physical abuse. Proponents
of
this view hold that
DID is
most
typically
a
form
or
variant
of
posttraumatic stress disorder
(PTSD)
and
that
the
features
of
most cases
of DID can be
conceptualized
as
coping responses
to
early trauma.
Specifically,
advocates
of the
PTM
contend
that
following severe abuse
or
other traumatic
events, individuals dissociate
or
"compartmentalize" their subjec-
tive experience into alternate personalities
("alters")
as a
means
of
coping with
the
emotional pain
of the
trauma.
As
Ross (1997),
a
proponent
of the
PTM, argued, "MPD
is a
little girl imagining
that
the
abuse
is
happening
to
someone
else"
(p.
59).
An
alternative perspective
on DID is
afforded
by the
Sociocog-
nitive model (SCM; Spanos, 1994, 1996;
for
related views,
see
Aldridge-Morris,
1989; Ganaway, 1995; Merskey, 1992; Sarbin,
1995;
and
Simpson, 1989).
The SCM
conceptualizes
DID as a
syndrome that consists
of
rule-governed
and
goal-directed experi-
ences
and
displays
of
multiple role enactments that have been
created,
legitimized,
and
maintained
by
social reinforcement.
Pa-
tients with
DID
synthesize these
role
enactments
by
drawing
on a
wide
variety
of
sources
of
information,
including
the
print
and
507
508
LILIENFELD
ET AL.
broadcast media, cues provided
by
therapists, personal experi-
ences,
and
observations
of
individuals
who
have enacted multiple
identities.
By
role
enactment, proponents
of the SCM
(see
Sarbin
&
Coe,
1972; Spanos, 1996) mean that
DID
patients adopt
and
enact social
roles geared
to
their aspirations
and the
demand characteristics
of
varied social contexts. According
to
this view,
the
metaphor
or
concept
of
role
does
not
imply that role-related behaviors
are the
products
of
conscious deception. Instead, role enactments tend
to
flow
spontaneously
and are
carried
out
with
little
or no
conscious
awareness
and
with
a
high degree
of
"organismic
involvement"
(Sarbin
&
Coe, 1972) such
that
the
role
and
"self"
(or
"multiple
selves"
as the
case
may be)
coalesce
so as to
become essentially
indistinguishable.
According
to the
SCM, iatrogenic
and
sociocultural
factors play
a
substantial etiological
role
in DID and
account largely
for the
recent
and
dramatic upsurge
in
reports
of
this condition
(Aldridge-
Morris,
1989). Some authors (e.g., Boor, 1982) have argued that
the
term epidemic best describes this secular increase, because
the
number
of
reported cases
of DID in the
world literature increased
from
79 as of
1970
to
approximately
6,000
by
1986
(Elzinga,
van
Dyck,
&
Spinhoven, 1998).
The
number
of
reported cases
at the
close
of the
20th century
is
difficult
to
estimate
but
appears
to be
in
the
tens
of
thousands (Acocella, 1998).
The SCM
further posits
that
DID is one
variant
of a
broader constellation
of
multiple
identity
enactments, including demonic possession, mass hysteria,
transvestism,
and
glossolalia, that traverse cultural
and
historical
boundaries. Although
the
protean manifestations
of
these enact-
ments have been shaped by cultural and historical expectations,
their underlying commonalities
are
suggestive
of
shared origins.
In
a
recent article
in
this journal,
Cleaves
(1996) criticized
a
review
by
Spanos
(1994)
that
presented
a
large body
of
scientific
and
historical evidence
in
support
of the
SCM. Gleaves
further
argued that
the
PTM
provides
a
superior account
of the
etiology
of
DID. Because Nicholas Spanos
was
tragically killed
in a
plane
crash
in
1994, Gleaves's criticisms
of the SCM
have gone unan-
swered.
We
believe that
careful
scrutiny
of
Gleaves's assertions
is
warranted
for two
reasons. First,
the
arguments raised
by
Gleaves,
although
not
new, have gained acceptance among
a
large segment
of
the
therapeutic community (e.g.,
Bloch,
1991;
Ross, 1997)
and
general public (e.g., Steinem, 1992;
see
Acocella, 1998,
and
Sho-
walter,
1997,
for
discussions)
and
have exerted
a
substantial
in-
fluence
on the
conceptualization
and
treatment
of
DID.
Moreover,
they
have been referred
to
frequently
by
proponents
of the PTM
(e.g.,
Kluft,
1993; Ross, 1997). Second, Gleaves's article
has
already been heralded
by
some authors
as
providing
a
convincing,
if
not
definitive,
refutation
of the
SCM.
Scheflin
(1997),
for
example, described Gleaves's critique
as "a
masterful article
ar-
ticulating,
and
then
refuting,
the
premises
of the
iatrogenic posi-
tion"
(p.
253).
Although
some
of the
presuppositions
of the PTM and SCM
may
not be
mutually
exclusive
or
logically inconsistent, these
models
differ
substantially
in
emphasis
and
engender quite
differ-
ent
expectations
concerning
the
etiology
and
correlates
of
DID.
These
two
models diverge most sharply
in
their explanations
for
the
emergence
of
alters. Specifically, whereas
the PTM
posits that
alters
are a
naturally occurring result
of
severe child abuse
and
other traumatic events,
the SCM
posits that alters arise
as a
consequence
of
therapist influences, media portrayals,
and
socio-
cultural
expectations. Although
the SCM is not
inconsistent with
the
possibility that childhood trauma might produce
a
predisposi-
tion
toward certain psychological traits
(e.g.,
fantasy proneness;
Lynn,
Rhue,
&
Green, 1988) that
in
turn increase individuals'
receptivity
to
therapist cues, this model does
not
posit that
the
creation
of
alters
is a
defensive reaction
to
trauma.
In
addition,
the
two
models
differ
markedly
in
their views
of the
relative impor-
tance
of
iatrogenic
and
other sociocultural influences
in the
etiol-
ogy
of
DID. Whereas proponents
of the PTM
have typically
maintained that such influences
are of
relatively minor importance
in
the
genesis
of DID (or
that they
account
for a
relatively
small
minority
of DID
cases;
see
Ross, 1997), proponents
of the SCM
have typically maintained that such influences play
a
substantial
role
in
DID's
etiology (Spanos, 1994).
Finding
evidence that would unambiguously
falsify
either
or
both models
is
difficult,
largely because
(a)
direct experimental
manipulation
of the
crucial etiological agents posited
by
each
model (i.e., childhood trauma
in the
case
of the
PTM, iatrogenic
and
sociocultural expectations regarding multiple identity enact-
ments
in the
case
of the
SCM)
is
impossible
for
obvious ethical
and
practical reasons (although,
as we
discuss later, analogue
studies
of the
etiological
agents
posited
by the SCM
have
been
conducted);
(b)
many
of the
putative etiological agents posited
by
the
PTM, particularly child sexual
and
physical abuse,
are
some-
times
difficult
to
operationalize
in a
standardized fashion across
investigations (Rind, Tromovitch,
&
Bauserman,
1998);
(c)
many
of
the
putative etiological agents posited
by the SCM
(e.g., socio-
cultural expectations)
are
difficult
to
assess objectively;
and (d)
prospective, rather than retrospective, data
would
ideally
be re-
quired
to
test
the
central hypothesis
of the
PTM, namely, that
severe childhood trauma
is a
necessary precursor
of
most cases
of
DID.
Nevertheless,
the SCM
would
be
falsified
or at
least
strongly
called into question
by
data demonstrating that
a
large proportion
of
clear-cut
DID
cases emerged
in
childhood prior
to
therapy
and
prior
to
exposure
to
widely available knowledge concerning
the
expected features
of
DID.
The
PTM,
in
turn, would
be
falsified
by
data demonstrating that
the
majority
of
cases
of DID
were
not
preceded
by
severe child abuse
or
other trauma. Alternatively,
the
PTM
would
be
called into question
by
data indicating that most
individuals
ultimately diagnosed
with
DID
begin therapy with
few
or no
detectable features
of
this condition, particularly multiple
identity
enactments,
and
develop these features only
after
thera-
peutic
intervention.
Although
we do not
believe that
the
extant data
on DID are
sufficient
to
permit
a
definitive
refutation
of
either model,
we
contend that adequate data
are now
available
to
accept many
of the
major
premises
of the SCM and to
raise important questions
concerning
a
number
of the
central tenets
of the
PTM.
In the
remainder
of
this article,
we
argue that
(a)
Gleaves's
(1996) article
contained
serious misinterpretations
of the SCM and
dismissed
this model
on the
basis
of
inadequate data,
(b) the
research support
for
the PTM
presented
by
Gleaves
was
problematic
and in
many
cases
flawed,
and (c)
Gleaves's analysis neglected
or
underem-
phasized
the
historical
and
cultural
manifestations
of
multiple
role
enactments.
In
addition,
we aim to
update important developments
in
the DID
literature since
the
reviews
of
Spanos (1994)
and
Gleaves, sharpen several conceptual distinctions that have some-
times been blurred
in
debates concerning DID,
offer
a
number
of
suggestions
for
methodological improvements
in
this area,
and
attempt
to
foster
a
more constructive dialogue among proponents
DID
AND THE
LESSONS
OF THE
PAST
509
of
both
the SCM and the
PTM.
We
organize
our
review around
three broad issues:
(a) the
psychopathology
and
assessment
of
DID,
(b) the
treatment
of
DID,
and (c) the
etiology
of
DID. Before
addressing these issues, however,
it is first
necessary
to
examine
Cleaves's
exegesis
of the
SCM.
Assumptions
of the SCM
Early
on in his
article,
Cleaves
(1996)
called
into
question
a
number
of the
assumptions
of the
SCM. Several
of the
assumptions
criticized
by
Cleaves,
however, appear
to be
misrepresentations
or
misunderstandings
of the
SCM.
The
latrogenesis
of DID
One
of
Cleaves's
(1996)
initial arguments
was
that "the all-or-
nothing
assumption
of the
iatrogenic model
is
false because
no
disorder
can be
entirely iatrogenic
or
entirely
noniatrogenic"
(p.
42).
The SCM
does not, however, posit that
the
etiology
of DID is
completely
iatrogenic. Instead,
as
already noted, this model pro-
poses that
the
features
of DID can be
constructed
from
a
variety
of
sources
in
addition
to
unintentional
prompting
from
therapists,
including
memories
of
one's
past behavior, observations
of
other
individuals,
and
media portrayals
of DID
(Spanos,
1994). Thus,
it
is
relevant that
the
current dramatic increase
in the
prevalence
of
DID
cases (Boor, 1982) began shortly
after
the
release
of the
popular book
and
television
film
Sybil
(book:
Schreiber,
1973;
film:
Petrie,
1976). Furthermore,
the SCM
posits that multiple
identity
enactments transcend societal
and
historical boundaries
and
can be
found
even among cultures
in
which
the
involvement
of
mental health professionals
is
minimal.
Nor
does
the SCM
imply that social
influences
are the
only
causal variables relevant
to
DID, because this model suggests that
individual
differences
in
personality
or
psychopathology,
in
con-
junction with iatrogenic
and
sociocultural
influences,
can
predis-
pose certain individuals
to DID
(see
the
section below entitled
The
Psychopathology
and
Assessment
of
DID). Thus,
the SCM is
consistent
with
the
possibility that certain traits, such
as
absorption
(Tellegen
&
Atkinson, 1974)
and
fantasy
proneness (Lynn
et
al.,
1988), play
an
etiological role
in at
least some cases
of DID
(Spanos, 1996;
see
Bowers, 1991,
for a
related view). Fantasy
proneness,
for
example, correlates moderately with indexes
of
dissociation (Rauschenberger
&
Lynn, 1995)
and may
place indi-
viduals
at
heightened
risk for
enacting
imaginary
identities
in
response
to
therapeutic
and
sociocultural cues (Lynn
et
al.,
1988).
Moreover, Spanos (1996) argued that
DID
overlaps substantially
with
several psychopathological conditions, including borderline
personality disorder (BPD)
and
somatization disorder. Thus,
the
SCM
does
not
deny that much
of the
psychopathological
raw
material from which
DID is
sculpted exists prior
to
professional
intervention.
The
Simulation
of DID
Cleaves
(1996)
asserted that
a key
assumption
of the SCM is
"that there
is
something unique about
DID
that would make
it
rewarding
to
simulate
the
disorder"
(p.
43). This statement repre-
sents
a
widespread misunderstanding
of the
SCM, which
is
careful
to
distinguish
role enactment
from
simulation. This distinction
is
not
semantic.
As
noted earlier, role enactment, unlike simulation,
typically occurs
in a
seemingly spontaneous
fashion,
with little
or
no
conscious
effort
or
planning. Spanos
and
other proponents
of
the SCM do not
maintain that most individuals with
DID are
consciously dissimulating, although
in
rare cases (see, e.g.,
Orne,
Dinges,
&
Orne, 1984) certain individuals
may
feign
DID to
avoid
culpability
for
criminal actions
or to
obtain attention.
The
Pseudoissue
of
DID's
"Existence
"
Contrary
to
Gleaves's (1996) claims (see
pp.
43-44),
the SCM
does
not
take issue with
findings
that
(a)
certain individuals
consistently
present with
the
clinical features
of DID and (b) the
characteristics
of DID can be
reliably differentiated
from
those
of
other diagnoses.
Cleaves
committed
a
similar error later
in the
article when
he
confused
the
question
of
DID's
existence with
the
question
of its
etiology.
For
example,
he
contended that studies
demonstrating that many
of the
features
of DID can be
readily
induced
in
normal
participants
provided
with instructions
to
role-
play
multiple identities (see, e.g., Spanos, Weekes,
&
Bertrand,
1985)
do not
call into question
the
existence
of
DID.
He
cited
Carson
and
Butcher's
(1992)
opinion that
such
role playing demonstrations
do not
answer,
let
alone convinc-
ingly
address,
the
question
of the
reality
of
MPD. That college
students might
be
able
to
give
a
convincing portrayal
of a
person with
a
broken
leg
would
not
establish
the
nonexistence
of
broken
legs,
(p.
209)
But
the SCM
does
not
maintain that
DID is
"not
real"
or
does "not
exist" (see
Arrigo
&
Pezdek, 1998; Dunn, Paolo, Ryan,
& van
Fleet, 1994;
and
Elzinga
et
al.,
1998,
for
similar
errors).1
The
crucial
question
concerns
not
DID's
existence—the
fact that cer-
tain individuals exhibit
the
features
of DID is not in
dispute—but
rather
its
origins
and
maintenance (McHugh, 1993).
Is DID
best
conceptualized
as a
naturally occurring response
to
early trauma
or
as a
socially influenced product that unfolds largely
in
response
to
the
shaping influences
of
therapeutic practices,
culturally
based
scripts,
and
societal expectations?
Multiple
Identity
Enactments
and DID
Cleaves
criticized
Spanos's
(1994) purported contention
that
"multiple identity enactment
and DID are
equivalent phenomenon
[sic]"
(Cleaves,
1996,
p. 43) and
took issue with Spanos
for
equating
one
diagnostic feature (i.e., multiple identity enactment)
with
one
disorder
(i.e.,
DID).
Yet
Spanos (1994) never equated
multiple identity enactment with DID. Instead,
he
emphasized
multiple identity enactment
as the
principal feature
of DID
(Amer-
ican
Psychiatric Association
[APA],
1994)
and
argued that
DID is
one
prominent
contemporary
manifestation
of
multiple identity
enactment.
The
notion
of
multiple identity enactment
as the
essential char-
acteristic
of DID did not
originate with Spanos. Both
the PTM and
the
current Diagnostic
and
Statistical Manual
of
Mental Disorders
(fourth
ed.,
DSM-IV;
APA, 1994) conceptualize multiple identity
enactment
as the
essential feature
of
DID.
For
example, Ross
(1997)
asserted that
all of the
features
of DID
"follow logically
1
We
acknowledge, however, that some skeptics
of the DID
diagnosis
have
in
fact framed
the DID
debate
in
terms
of
this
condition's
existence
(see, e.g., Mai, 1995,
p.
157).
510
LILffiNFELD
ET
AL.
from
the
existence
of
alter personalities that take control
of the
body"
(p.
136)
and
contended
that
multiple
role
enactments,
in
addition
to
amnesia,
are the
essential
characteristics
of
DID.
Ac-
cording
to
Ross,
the
other symptoms
of
DID, including blank
spells
and
flashbacks,
are
"secondary
features" that "are
evidence
of
the
existence, activity,
and
influence
of the
alters"
(p.
136).
DSM-IV
noted that
the
"essential feature
of DID is the
presence
of
two
or
more distinct identities
or
personality
states
...
that recur-
rently
take control
of
behavior"
(p.
484). Thus,
Cleaves
(1996)
was
at
odds with other proponents
of the
PTM
and
with
DSM-IV
in
arguing
that "the core
psychopathology
of
DID"
(p. 43)
includes
such symptoms
as
identity disturbance,
depersonalization,
and
Schneiderian
symptoms (e.g., voices arguing with
one
another)
and
that multiple identity enactment
is
merely
one
symptom
among many
of
those
exhibited
by DID
patients.
Cleaves
(1996)
further
maintained that
these
dissociative fea-
tures
are
rarely observed
in
other
conditions,
then used this
finding
to
call
the SCM
into question
(p.
43).
In
fact,
this finding
is
consistent with
the
SCM, which represents
an
attempt
to
address
the
question
of why
individuals exhibit precisely this constellation
of
characteristics. Specifically, this model posits that many
or
most
of
the
features
of DID can be
explained
by the
fact that
these
features
derive
from
culturally based scripts
and
expectations
regarding
the
typical manifestations
of
multiple
role
enactments
in
Western
culture.
Because
the
features
of DID
have
become
widely
disseminated throughout
the
culture
via the
media
and
other
sources,
it is not
surprising that individuals
who
exhibit multiple
identities
often
display such features.
That
being said, however, some
of the
purportedly distinctive
clinical features
of DID
cited
by
Cleaves
are
questionable.
For
example,
"lack
of
autobiographical memory
for
childhood"
(Cleaves,
1996,
p. 43) may not be
specific
to DID or
other
dissociative disorders. Read (1997)
found
that
20% of a
commu-
nity
sample
of
adults reported significant gaps
in
memory
after
age 3, and we are
unaware
of any
controlled
studies
demonstrating
that
individuals
with
DID
exhibit poorer recall
of
childhood mem-
ories than
do
other psychiatric patients
or
individuals without
psychopathology.
In
addition, individuals
who
obtained high
scores
on the
Dissociative Experiences Scale (DES; Bernstein
&
Putnam,
1986),
a
commonly used self-report measure
of
dissocia-
tive
tendencies, reported
the
same ages
for
their earliest memories
as
did
individuals
who
obtained
low
scores (Lynn,
Malinoski,
Aronoff,
&
Zelikovsky, 1998), although
the
relation between
DES
scores
and
early memory gaps
has not
been examined empirically.
Moreover,
case
studies
have yielded conflicting
findings
regarding
whether
DID
patients date their earliest memory later than
do
individuals without psychopathology (Bryant, 1995; Schacter,
Kihlstrom,
Kihlstrom,
&
Berren,
1989). Finally,
the
findings, cited
by
Cleaves,
of
Coons, Bowman,
and
Milstein (1988), which
re-
vealed that virtually
all DID
patients reported
a
history
of
amnesia
in
early childhood,
are
open
to
alternative explanations. Many
therapists
may
either presume
or
attempt
to
elicit
a
history
of DID
based
on the
absence
of
certain memories
and
thereby
use
amnesia
as a
scaffolding
on
which
to
construct
a DID
diagnosis. Because
a
large proportion
of
adults report memory
gaps
for
childhood
(Read,
1997), Coon
et
al.'s
failure
to (a)
include either
a
psychi-
atric
or
normal comparison group
and (b)
specify
how
amnesia
was
operationalized
(e.g.,
isolated memory gaps
vs.
long periods
of
missing time) renders their
findings
difficult
to
interpret.
The
Psychopathology
and
Assessment
of DID
The
Overlap
of DID
With
Other Conditions
In
his
evaluation
of the
literature concerning
the
psychopathol-
ogy
of
individuals with DID,
Cleaves
(1996)
made
the
same error
he
accused
Spanos
of
having made
in the
case
of
multiple identity
enactments
and
DID: equating
one
diagnostic feature with
one
disorder.
Specifically,
Cleaves
equated
attention
seeking
with his-
trionic personality disorder (HPD)
and
argued that because
the
SCM
posits that gaining attention
is an
important motivation
for
DID
patients,
this model predicts that
these
patients should exhibit
higher rates
of HPD
than other patients (see also Dell, 1998).
Gleaves's
review
of the
literature indicated, however, that
DID
patients
do not
exhibit markedly elevated rates
of
HPD.
Nevertheless, attention seeking
is
only
one
characteristic
of
HPD and is
found
in a
number
of
conditions other than HPD.
Moreover, Spanos
(1994)
never used
the
terms histrionic person-
ality
disorder
or
hysteria
in his
review,
and his
description
of the
modal
DID
patient
as
exhibiting "mood swings,
shameful
or un-
representative behaviors, ambivalent feelings, hostile fantasies,
forgetfulness,
guilt-inducing sexual fantasies,
and bad
habits"
(p.
155) does
not
appear prototypal
of
patients with HPD.
As a
consequence,
it is not
clear that
the
data presented
by
Cleaves
(1996,
pp.
44-45)
regarding
the
relatively
low
rates
of HPD
among
DID
patients
are
directly relevant
to the SCM or to
Spa-
nos's (1994) exposition
of
it.2
Although
Cleaves
(1996)
reviewed evidence
from
studies
by
Ellason,
Ross,
and
Fuchs
(1996)
and
Lauer,
Black,
and
Keen
(1993) indicating that many
DID
patients meet criteria
for
avoidant
personality
disorder (APD)
and are
thus presumably unlikely
to be
strongly
motivated
by a
need
for
attention,
the findings of
these
two
studies
are
difficult
to
interpret.
The
study
by
Ellason
et
al.
did
not
include either
a
psychiatric
or
normal comparison group,
and
the
study
by
Lauer
et al.
reported
no
significant
differences
in the
rates
of APD
between small samples
of DID
patients
(N
= 14) and
BPD
patients
(N =
13).3
Moreover,
the finding
that
DID
covaries
with
APD,
if
demonstrated
in
studies with appropriate comparison
groups,
does
not
contradict
the
SCM.
DSM-IV
(APA,
1994) noted
that
individuals with
APD
"desire
affection
and
acceptance
and
may
fantasize about idealized relationships
with
others"
(p.
663)
and
are
characterized
by "a
need
for
reassurance"
(p.
664).
In
addition,
individuals with
APD
tend
to be
overly dependent
on
others
for
approval (Trull, Widiger,
&
Frances, 1987). Thus,
APD
is
associated
with
several traits that would
be
expected
to
increase
the
seeking
of
approval
from
authority
figures and
perhaps
foster
receptivity
to
therapist suggestions.
Furthermore, many
of the
clinical features
Cleaves
(1996)
de-
scribed
may be
associated with BPD, which
Cleaves
largely
ig-
nored
in his
review. BPD, like HPD,
is
characterized
by
attention
2
Cleaves
(1996)
asserted
that among individuals with DID, "the prev-
alence
of
histrionic personality disorder appears
to be no
higher and,
in
actuality,
lower than
in
other general
or
specific clinical
and
nonclinical
samples"
(p. 44;
emphasis added). Inspection
of
Gleaves's Table
1 (p.
45),
however, clearly reveals that
HPD is
more prevalent among
DID
patients
than
among patients
in
nonclinical samples.
3
Although
not
calculated
by
Ellason
et al.
(1996),
the 95%
confidence
interval surrounding
the
proportion
of
patients with
DID who met
criteria
for
APD
(50%) ranges
from
24% to
76%.
DID AND THE
LESSONS
OF THE
PAST
511
seeking (APA, 1994,
p.
657).
In
addition,
BPD has
been
found
to
co-occur extensively with DID. Across
a
number
of
studies (Boon
&
Draijer, 1993; Dell, 1998; Ellason
et
al.,
1996; Horevitz
&
Braun,
1984; Lauer
et
al.,
1993; Ross
et
al.,
1990; Scroppo, Drob,
Weinberger,
&
Eagle,
1998; Tutkun
et
al.,
1998;
Yargic,
Sar,
Tutkun,
&
Alyanak, 1998),
the
proportion
of DID
patients
fulfill-
ing
diagnostic criteria
for BPD has
ranged
from
35% to
71%.
Although
several
of
these studies lacked comparison groups (and
the
study
by
Lauer
et
al.,
1993, included only
a
comparison group
of
BPD
patients),
the
study
by
Scroppo
et al.
(1998)
found
statis-
tically
significant
and
large (Cohen's
d =
1.52) differences
in the
rates
of BPD
between
DID
patients
and
nondissociative psychiat-
ric
patients.
In
addition, Yargic
et al.
(1998) reported significantly
higher
rates
of BPD
among
a
group
of DID
patients than among
three groups
of
patients with schizophrenia, panic disorder,
and
partial complex seizure disorder, respectively,
and
Dell
(1998)
reported
significantly
higher rates
of BPD
among
DID
patients
than
among patients
with
a
diagnosis
of
dissociative disorder
not
otherwise specified.
Gleaves
(1996)
sidestepped
the
issue
of the
extensive overlap
between
DID and BPD by
stating that
"to
thoroughly discuss
the
connection
between borderline personality disorder
and DID
would
be
beyond
the
scope
of
this
article"
(p. 44) and
noting that
the
overlap between these
two
conditions
is not
surprising given
their
association with child abuse
and
PTSD.
Nevertheless,
Gleaves
did not
address
the
possibility that both
the
history
of
abuse
and
PTSD symptoms
may be
seized upon
as
evidence
of
potential
DID by
therapists
who
seek
to
explain many
of the
puzzling
features
of
BPD, such
as
identity disturbance, dramatic
changes
in
mood,
and
marked instability
in
interpersonal relation-
ships,
in
terms
of DID
(Ganaway, 1995;
see
Piper, 1997,
for a
discussion
of the
potential
"elasticity"
of the DID
diagnostic
criteria
in the
hands
of
some clinicians). Because
a
number
of the
signs
and
symptoms
of BPD
resemble those
of
DID,
the
possibility
that
these
two
conditions
are
readily confused with
one
another
merits systematic examination
in
studies
of
diagnosticians'
judgments.
The
Assessment
and
Diagnosis
of DID
Gleaves
(1996)
reviewed
a
large body
of
evidence indicating
that
the
diagnosis
of DID can be
made reliably
and
validly
using
self-report
and
structured interview measures.
It is
unclear, how-
ever,
how
this literature
is
relevant
to the
validity
of the
SCM.
As
noted earlier, this model does
not
take issue with
the
claim that
individuals
with
DID
display relatively distinctive features that
are
rarely
found
in
other conditions.
As
useful
as the
measures
of DID
and
dissociation reviewed
by
Gleaves might
be for
diagnostic
purposes, they
are not
designed
to
differentiate conditions that
are
largely iatrogenic
(or
otherwise influenced
by
social expectancies)
from
other conditions.
Gleaves's
(1996) conclusions concerning
the
convergent
and
discriminant
relations
of the
DBS
with various
psychopathological
conditions
are
similarly open
to
alternative explanations. Many
DBS
items (e.g.,
"Some
people
find
that
in one
situation they
may
act
so
differently compared with another situation that they feel
almost
as if
they were
two
different
people")
refer explicitly
to
common signs
and
symptoms
of DID
(Spanos,
1996).
As a
con-
sequence,
the finding
that
the DES
consistently distinguishes
DID
from
other conditions
is
neither surprising
nor
informative
and
might
instead
by
attributed
to the
largely tautological overlap
between
the
content
of DES
items
and the
symptoms
of
DID.
Although
this problem
of
content overlap
is not
unique
to the
literature
on DID and
probably accounts partly
for a
number
of
commonly
reported correlations among measures
of
psychopathol-
ogy
(see Nicholls, Licht,
&
Pearl,
1982,
for a
general discussion
of
this
problem
in the
self-report assessment
of
personality
and
psy-
chopathology),
it is
important
to
note that Gleaves invoked
the
correlation between
the DES and DID as
evidence against
the
claim
that
the
features
of DID are
largely iatrogenic
(p.
46).4
However, this correlation
is
equally consistent with both
an
iatro-
genic
and
noniatrogenic hypothesis, because
it can
more parsimo-
niously
be
explained
by
content overlap.
The
Treatment
of DID
The
Clinical Presentation
of DID
Before
and
After
Treatment
Although
proponents
of the
PTM
have sometimes been hard-
pressed
to
address
the
question
of why the DID
diagnosis
was
rarely made prior
to
1970 (Piper, 1997), they have typically
responded
by
contending that
the
signs
and
symptoms
of DID are
subtle,
covert,
and
easily
missed.
Moreover, they have contended
that
individuals
with
DID
often
hide
or
minimize their symptoms
(Ross,
1997).
As a
consequence,
these
authors
have
suggested,
the
diagnosis
of DID was
frequently
overlooked
by
clinicians
of
previous
generations, because these clinicians
(a)
were often
un-
aware
of the
features
of DID or (b)
neglected
to
probe
sufficiently
for
these features.
Gleaves's arguments
are
similar.
He
asserted that
Spanos's
(1994)
description
of
many
DID
patients, namely, "that
of
some-
one who
openly calls herself
or
himself
by
different
names
and
behaves like
different
people
on
different
occasions"
(Gleaves,
1996,
p.
44),
is at
variance with what
is
reported
in the DID
literature.
He
further
argued that
DID
often
goes unrecognized
for
many
years
and
that
"a
florid, obvious presentation
of the
disorder
is
atypical"
(p.
45).
It
is
unclear, however,
how
these
findings are
best interpreted.
On
the one
hand, they
may
help
to
explain
why DID was
presum-
ably
underdiagnosed
for
many decades (Ross, 1997).
On the
other
hand,
if a florid and
obvious presentation
is
atypical prior
to
therapy
and
becomes typical only during therapy, these
findings
raise
the
possibility that iatrogenic factors play
an
important role
in
DID.
Kluft
(1991) estimated that only
20% of DID
patients exhibit
clear-cut
indications
of
this condition
at the
beginning
of
therapy
and
that
the
remaining
80%
exhibit only specific "windows
of
diagnosability,"
namely,
transient
periods
during which
the
classic
features
of DID are
evident. Although there
is
disagreement con-
cerning
the
exact percentages, virtually
all
authors
in
this
literature
have concurred that
a
large
proportion—perhaps
a
majority—of
DID
patients
in
their samples exhibit
few or no
unambiguous signs
of
this condition prior
to
therapy
(Kluft,
1984; Putnam,
Guroff,
Silberman,
Barban,
&
Post, 1986; Ross,
1997).
4
Gleaves
(1996)
cited studies
on the
relation between
the DES and DID
in
a
section entitled Creating Multiplicity
(p. 46) and
concluded this section
by
asserting that "the data
do not
support
the
hypothesis that assessment
or
treatment
procedures
are
responsible
for the
creation
of
DID"
(p.
49).
512
LILIENFELD
ET AL.
Moreover, although systematic data
are
lacking, numerous
ad-
vocates
of the
PTM
(e.g.,
Kluft,
1984; Ross, 1997;
Schafer,
1986)
have
contended that
DID
patients themselves
are
frequently
un-
aware
of
their alters prior
to
therapy.
This
is a
point
that
Cleaves
(1996)
did not
clearly acknowledge
and
that
is
consistent
with
an
iatrogenic
explanation. Putnam
(1989)
estimated that
80% of DID
patients
possess
no
knowledge
of
their multiplicity before begin-
ning
treatment,
and
Dell
and
Eisenhower
(1990)
reported
that
all
11
of
their adolescent patients with
DID
professed
no
aware-
ness
of
their alters
at the
time
of
diagnosis. Lewis, Yeager, Swica,
Pincus,
and
Lewis (1997) similarly
reported
that none
of the 12
murderers with
DID in
their sample reported
any
awareness
of the
existence
of
their multiple personalities. Although Gleaves main-
tained
that
DID
patients
"appear
to
have experienced their symp-
toms most
of
their lives, well before they were ever
in
treatment
for
a
dissociative disorder"
(p.
49),
the
only published evidence
he
offered
for
this assertion
was the
reports
of
Coons
et
al.
(1988)
and
Fahy,
Abas,
and
Brown (1989), both
of
which
are
uncontrolled
studies that
did not
provide either
(a)
evidence
of
alters prior
to
treatment
or (b)
external
corroboration
for the
patient's
pretreat-
ment
DID
symptoms. Moreover,
the
pretreatment
symptoms
re-
ported
by the
patient
in
Fahy
et
al.,
which included "blackouts,"
seizures
of
apparent psychogenic origin, depersonalization, mem-
ory
gaps, auditory hallucinations, depression,
and
anxiety, were
nonspecific
and
consistent
with
a
number
of
diagnoses other than
DID, including somatization disorder (which
is
sometimes char-
acterized
by
both unexplained physical symptoms
and
amnestic
periods; APA,
1994,
p.
449)
and
BPD.
Although
proponents
of the PTM
(e.g., Ross, 1997) have
often
maintained
that
the
essential features
of DID are
frequently
"la-
tent"
and
therefore
difficult
to
detect prior
to
therapy (see Piper,
1997,
for a
discussion), this proposition raises important concerns
regarding
the
falsifiability
of the
PTM. When confronted with
evidence that
DID
patients
often
exhibit
few
clear indications
of
multiple
identity
enactments prior
to
therapy, advocates
of the
PTM
could argue that these features were present
but had not yet
been elicited. Without independent evidence
of the
existence
of
these features, however, this assertion
is
difficult
to
refute.
Several authors have also reported that
the
number
of
alters
tends
to
increase over
the
course
of
treatment (see, e.g.,
Kluft,
1988; Ross, Norton,
&
Wozney, 1989).
In
addition, although
the
number
of
alters
per DID
case
at the
time
of
initial diagnosis
has
apparently
remained constant over time (Ross, Norton,
&
Wozney,
1989),
the
number
of
alters
per DID
case
in
treatment
has in-
creased (North,
Ryall,
Ricci,
&
Wetzel, 1993). Although these
findings
are
consistent with
Gleaves's
hypothesis that
DID
patients
tend
to
hide their dissociative symptoms prior
to
treatment, they
are
also consistent with
an
iatrogenic hypothesis. Moreover, pro-
ponents
of the PTM
will
again need
to
make explicit what data
could
potentially
falsify
the
former hypothesis.
We are
hard-pressed
to
identify
another
DSM-IV
disorder
whose essential
feature
(viz., multiple identity enactment)
(a) is
often
or
usually
unobservable
prior
to
treatment
and (b)
tends
to
emerge
and
become considerably more
florid
during treatment.
These
two
observations probably help explain
why
iatrogenesis
has
long been
a
serious concern
in the DID
literature (e.g.,
Aldridge-Morris,
1989). Although Gleaves (1996) acknowledged
that
"additional alters
can be
iatrogenically
created"
(p. 54)
once
the
disorder
has
begun,
he
denied that iatrogenic influences play
a
role
in
DID's
onset. Although
it is
difficult
to
refute
this hypothesis
given
the
absence
of
relevant data, Gleaves's argument hinges
on
the
critical assumption that iatrogenic factors
can
lead patients
with
one or
more alters
to
develop additional alters
but
cannot lead
patients without alters
to
develop
one or
more alters. Although
the
theoretical basis underlying this assumption
was not
articulated
by
Gleaves,
a
clear explication
of the
grounds
for
this assumption
appears necessary
for
evaluating
the
assertions
of the
PTM's
proponents.
Hypnosis
and the
Creation
of
Multiplicity
Gleaves
(1996)
took issue with
the
claim that hypnosis plays
a
causal
role
in a
number
of
cases
of
DID.
He
cited studies (Coons
et
al.,
1988; Ross, Norton,
&
Wozney, 1989) indicating that most
DID
patients have never been hypnotized,
as
well
as
studies that
reported
no
differences
in the
diagnostic features
of DID
patients
(e.g.,
number
of
alters, number
of
diagnostic criteria)
who had and
had
not
been hypnotized (see, e.g., Putnam
et
al.,
1986; Ross
&
Norton,
1989).
According
to
Gleaves, these results
refute
predic-
tions derived
from
the
SCM. Nevertheless,
the SCM
does
not
maintain
that hypnosis
is
necessary
for the
creation
of
DID,
be-
cause hypnotic procedures
do not
possess
any
inherent
or
unique
features
that
are
necessary
to
facilitate responsivity
to
suggestion
(Barber, Spanos,
&
Chaves, 1974; Spanos
&
Chaves, 1989). Other
methods, such
as
leading interviews
and
suggestive questions,
may
be
equally likely
to
induce clients' adoption
of
multiple
roles
(Barber, 1979; Spanos, 1996). Moreover, many
of the
features
of
DID may
derive
from
widely available societal scripts concerning
the
characteristics
of
this
condition. Thus,
the SCM
would
not
necessarily predict
differences
between hypnotized
and
nonhyp-
notized individuals
in
their rates
of DID or DID
symptoms, par-
ticularly
if
both groups were subjected
to
suggestive therapeutic
procedures.
It
might nonetheless
be
argued that
(a)
hypnosis
is one
technique
among
many that
can
facilitate responsivity
to
suggestion,
(b)
therapists
who use
hypnosis
may be
especially likely
to
utilize
potentially
suggestive techniques (e.g., guided imagery)
in
general,
and
(c)
because hypnosis
is
widely viewed
as a
technique that
can
penetrate defensive barriers,
the use of
this technique
may
help
to
legitimize
the
emergence
of
alters
(Stafford
&
Lynn,
1998).
If so,
the
findings of
Putnam
et al.
(1986)
and
Ross
and
Norton (1989)
may
warrant closer examination.
Nevertheless,
for two
reasons, these
two
studies
do
not,
as
argued
by
Gleaves, provide evidence against iatrogenesis. First,
because
all
patients
in
these studies
had
DID,
the
finding
that
hypnotized
and
nonhypnotized patients
did not
differ
in the
num-
ber of
diagnostic criteria
for DID is
difficult
to
interpret
in
light
of
ceiling
effects
(see also Powell
&
Gee,
in
press).
For
example,
all
of
Ross
and
Norton's (1989) patients
met the
criteria
for DID
given
in the
revised third edition
of the
Diagnostic
and
Statistical
Manual
of
Mental Disorders (APA, 1987),
and the
percentages
of
these patients
who met the
three additional
DID
criteria
from
the
third
edition
(DSM-HI;
APA, 1980)
and the
National
Institute
of
Mental
Health criterion sets ranged
from
94.4%
to
95.7% (Putnam
et
al.,
1986,
did not
report descriptive statistics
for the
number
of
DID
criteria
met in
their sample).
A
more relevant question, which
has
yet to be
examined,
is
whether patients
who
initially present
without
symptoms
of DID and are
then hypnotized subsequently
exhibit
more symptoms
of DID
than
do
comparable patients
who
are not
hypnotized.
DID AND THE
LESSONS
OF THE
PAST
513
Second,
contrary
to
Gleaves's
claims,
the
results
of
Ross
and
Norton
(1989)
did
reveal differences between hypnotized
and
nonhypnotized
patients with
DID.
In a
reanalysis
of
Ross
and
Norton's data, Powell
and Gee (in
press)
found
that hypnotized
patients
exhibited greater variance
in the
number
of
alters
at the
time
of
diagnosis
and in
subsequent treatment. Although
the
mean-
ing
of
this
finding is not
entirely clear,
the
authors conjectured that
this
finding
might reflect bimodal attitudes regarding iatrogenesis
among
practitioners
who use
hypnosis, with some practitioners
(i.e., those
who
believe that hypnosis
is
potentially
iatrogenic)
using
hypnosis
with
caution
and
others (i.e., those
who
believe that
hypnosis
is not
iatrogenic) using hypnosis relatively indiscrimi-
nately
and
producing
a
large number
of
alters.
In
addition, Powell
and
Gee
reported that practitioners
who
used hypnosis reported
a
significantly
higher number
of DID
patients
in
their caseloads than
did
practitioners
who did not use
hypnosis. Although this finding
is
correlational
and
open
to
multiple interpretations
(e.g.,
special-
ists
in DID may be
more likely
to use
hypnosis),
it is
potentially
consistent
with
iatrogenesis. Thus, Ross
and
Norton's (1989) data
do not
argue against
an
iatrogenic hypothesis
and may in
fact
provide suggestive evidence
for
this hypothesis.
Current Treatment Methods
for
DID
Gleaves criticized
Spanos's
(1994)
characterizations
of the DID
treatment
literature
as "at
best, lacking
in
support" (Gleaves,
1996,
p.
47).
He
contended that Spanos's assertions that "therapists routinely
encourage patients
to
construe themselves
as
having multiple identi-
ties, provide them with information about
how to
convincingly enact
the
role
of
'multiple
personality
patient,'
and
provide
official
legiti-
mization
for the
different
identities that patients
enact"
(Spanos,
1994,
p.
144)
are not
borne
out by an
examination
of the DID
treatment
literature.
Instead, Gleaves claimed, this literature discourages thera-
pists
from
treating
DID
patients
as
though they
possessed
genuine
personalities
and
encourages them
to
treat patients' alters
as
self-
generated.
He
contended that "skeptics
of the
reality
of DID
seem
to
assume
that therapists
who
treat people with
DID
conceptualize alters
as
different
people
or
entities
or
conceptualize patients with
DID as
having
more than
one
personality" (Gleaves,
1996,
p. 48; see
also
Ross, 1990).
Nevertheless,
an
examination
of the
widely available treatment
literature
on DID
reveals that much,
and
arguably most,
of
this
literature
is
oriented around such techniques
as
mapping
the
system
of
alter personalities
and
establishing direct contact with alters
(e.g.,
see
Ross,
1997,
pp.
305-315).
These
"reifying" techniques appear
to be
especially common
in the
early phases
of
therapy, although
the
later
phases
of
therapy
often
focus
on
unreifying
alters
and
achieving
integration among them (Ross, 1997). Moreover, many prominent
authors
do in
fact
appear
to
treat
DID
patients
as
harboring multiple
discrete
personality-like
entities,
if not
fully
developed personalities
(Piper, 1997).
A
sampling
of
quotations
from
five of the
most
influ-
ential
and
widely cited proponents
of
mainstream treatment methods
for
DID
illustrates this point.
Kluft
(1993)
argued that "when information suggestive
of MPD
is
available,
but an
alter
has not
emerged spontaneously, asking
to
meet
an
alter directly
is an
increasingly
accepted
intervention"
(p.
29).
Kluft
further acknowledged that
his
most frequent hypnotic
instruction
to DID
patients
was
"Everybody
listen"
(see
Ganaway,
1995). Braun (1980) wrote that "after inducing hypnosis,
the
therapist
asks
the
patient
'if
there
is
another thought process, part
of
the
mind,
part,
person
or
force that
exists
in the
body'"
(p.
213).
Bliss
(1980) noted that
in the
treatment
of
DID,
"alter egos
are
summoned,
and
usually
asked
to
speak
freely.
.
..
When they
appear,
the
subject
is
asked
to
listen.
[The
subject]
is
then intro-
duced
to
some
of the
personalities"
(p.
1393). Putnam (1989)
advocated
the use of a
technique known
as the
"bulletin board,"
which
permits
DID
patients
to
have
a
"place
where personalities
can
'post'
messages
to
each
other....
I
suggest that
the
patient
buy
a
small notebook
in
which personalities
may
write messages
to
each
other"
(p.
154).
Finally, Ross (1997;
see
also Putnam, 1989),
recommended giving names
to
alters
and
stated that "giving
an
alter
a
name
may
'crystallize'
it and
make
it
more distinct" (Ross,
1997,
p.
311).
According
to
Ross, this technique
is
used primarily
among patients with possible
DID as a
means
of
clarifying
the
individual's personality system.
In
addition, Ross advocated
the
use
of
"inner
board meetings"
as a
"good
way to map the
system,
resolve issues,
and
recover
memories"
(p.
350).
He
described this
method
as
follows:
The
patient relaxes with
a
brief hypnotic induction,
and the
host
personality walks into
the
boardroom.
The
patient
is
instructed
that
there
will
be one
chair
for
every personality
in the
system.
. . .
Often
there
are
empty chairs because some alters
are not
ready
to
enter
therapy.
The
empty chairs provide
useful
information,
and
those
present
can be
asked what they know about
the
missing
people,
(p.
351)
An
inspection
of the
mainstream
DID
treatment literature
re-
veals that these quotations
are
representative
of
those
of
many
other authors
(see
Piper,
1997,
pp.
61-68,
for
similar examples).
These
quotations
appear
to
contradict
Gleaves's
(1996)
assertions
that
"alters
are
explained
and
conceptualized
as
part
of a
whole
person,
not as
separate
people
or
entities"
and
that
the
"general
recommendation
is
that
one
speaks with alters
to
understand
all
parts
of the
person
in
therapy
but not as if
they were
different
people"
(p.
48).
As is
evident from
the
preceding quotations, many
or
most influential authors
in the DID
treatment literature treat
alters
as
independent entities
or
even personalities,
at
least
in the
early phases
of
treatment, although systematic data
are
needed
to
ascertain
the
prevalence
of
these practices among therapists
in the
community.
Moreover, although Gleaves (1996) described
the
therapeutic practices
of
most
DID
clinicians
as a
relatively passive
process
of
"acknowledging [that]
a
patient
with
DID
[has the]
genuine experience
of
alters
or
real people
or
entities"
(p. 48;
emphasis
in
original), many
of
these practices (e.g., summoning
alters that have
not yet
appeared,
naming
alters)
appear
to be
quite
active
or
potentially suggestive, particularly
if, as
noted earlier,
many
DID
patients have
no
conscious awareness
of
multiple
identity
enactments prior
to
therapy. From
a
behavioral
or
social
learning perspective, this
reification
of
alters
may
adventitiously
reinforce
DID
patients' displays
of
multiplicity.5
5
We
should note that
the
process
of
mapping
and
communicating with
alters
differs substantially
from
the
process
of
mapping
and
communicating
with
the
voices
of a
psychotic patient
(cf.
Ross,
1997).
Although clinicians
often
inquire about auditory hallucinations
in
order
to
better understand
their patients' phenomenology
or
establish
a
diagnosis, they rarely encour-
age
patients
to
elaborate
in
great detail
on the
content
of
these voices,
summon these voices repeatedly over
the
course
of
treatment, refer
to
these
voices
by
name,
or
attempt
to
elicit reports
of new
voices
for
which
the
patient
has no
recollection.
514
LILIENFELD
ET
AL.
Gleaves
(1996)
also
committed
a
logical
error
by
confusing
the
absence
of
appropriate treatment ("benign
neglect")
with
the be-
havioral technique
of
extinction.
The
potential utility
of
extinction
techniques
in the
treatment
of DID was
illustrated
by
Kohlenberg
(1973) using
a
single-subject design. Kohlenberg
found
that sys-
tematically ignoring
and
attending
to a DID
patient's
behavioral
expressions
of
multiplicity reduced
and
increased, respectively,
the
frequency
with which
this
patient presented with
an
alter person-
ality.
To
argue against
the
efficacy
of
extinction, Gleaves cited
reports (e.g., Ross, Norton,
&
Wozney,
1989) indicating that many
patients
with
DID
whose condition went unrecognized (and whose
DID was
presumably
not
addressed
in
treatment)
for
many years
exhibited
little improvement.
He
then used this evidence
to
con-
tend
that
the
approach advocated
by
proponents
of the
SCM—not
attending
to or
otherwise reinforcing
the
patient's displays
of
multiplicity—is
countertherapeutic.
Gleaves
(1996)
asserted that
"of
these hundreds
of
patients with DID,
not
addressing
and
treating
the
dissociative condition
did not
lead
to
clinical improve-
ment"
(p.
49).
For
three reasons, however, these data
do not
provide evi-
dence
against
the
SCM. First,
the
evidence cited
by
Gleaves
derives exclusively
from
uncontrolled studies
and
anecdotal
reports
by DID
patients (see, e.g.,
B. M.
Cohen, Giller,
& W.,
1991)
and
therefore does
not
provide
a
stringent test
of the
SCM. Second, these data
are
subject
to a
potentially serious
selection bias, because those patients
who
remained
in
non-
DID-oriented
treatment
for
many years
are
presumably those
who
failed
to
benefit
from
this treatment.
It
remains possible
that
the
majority
of DID
patients benefited
from
such treatment.
Third
and
most
important,
the
absence
of
appropriate such
treatment
is not
synonymous with
the use of
extinction tech-
niques advocated
by
behaviorists (e.g., Kohlenberg, 1973).
To
the
contrary,
the
behaviors
of
untreated patients with
DID may
have been intermittently reinforced
by
others, including mental
health
staff,
relatives,
and
friends,
in the
absence
of
explicit
treatment
for
DID. Gleaves
in
effect
equated
a
systematic
psychological
treatment (viz., extinction) with
the
absence
of
psychological treatment
and
then erroneously extrapolated
from
the
literature
on the
latter
to
evaluate
the
effectiveness
of the
former.
As an
analogy, Patterson (1982) would
not
equate
the
absence
of
adequate treatment
for a
child with conduct disorder
(CD) with extinction. Instead,
he
would almost certainly con-
tend that
the
antisocial behaviors
of an
untreated child with
CD
were being intermittently reinforced
by
parental attention
and
submission
to the
child's actions
and
that extinction
of
such
behaviors
by
eliminating this pattern
of
reinforcement
was
necessary
for
behavior change.
As
Gleaves noted
(1996,
p.
54), there exist
no
controlled studies
on
the
treatment
of
DID. Ellason
and
Ross (1997) reported
that
a
sample
of
hospitalized patients with
DID
showed improvement
after
a
2-year period following discharge,
but
this study
did not
include
either
a
randomized
or a
matched group
of DID
patients
who
received either
no
treatment
or an
alternative treatment.
Nor
was
the
nature
of the
treatment received
by DID
patients made
explicit.
Further complicating
the
interpretation
of
Ellason
and
Ross's
findings
is the
fact
that their original sample comprised
135
patients,
of
whom only
54
(40%) were located
and
reassessed
at
follow-up
(see Powell
&
Howell, 1998a, 1998b,
for
additional
methodological criticisms
of
Ellason
and
Ross's
design). Con-
trolled treatment studies
of DID
will
be
necessary
to
better eval-
uate
the
relative
merits
of
competing therapeutic approaches (e.g.,
extinction, traditional treatment methods emphasizing integration
among alters).
The
Distribution
of
DID
Diagnoses
Across
Clinicians
To
address
the
SCM's
assertion
that
iatrogenesis
is an
important
factor
in the
etiology
of
DID, Gleaves (1996) disputed Spanos's
(1994)
claim that
a
disproportionate number
of DID
diagnoses
are
made
by a
small number
of
therapists. Gleaves cited data indicat-
ing
that
the DID
cases
described
by
three investigative teams were
referred
by a
large number
of
different
clinicians.
Careful
inspec-
tion
of
these
studies, however, reveals serious
selection
biases.
Putnam
et
al.
(1986) distributed
400
questionnaires
to
"clinicians
.
..
who had
previously indicated
an
interest
in
multiple personal-
ity
disorder"
(p.
291)
and
received responses
from
92
individuals.
Schultz,
Braun,
and
Kluft
(1989) mailed questionnaires
"to 676
clinicians
who had
indicated
an
interest
in
MPD"
(p. 47) and
received
355
responses.
The
mean number
of DID
patients seen
by
each
of the
responding clinicians ranged
from
1 to
over 100. Ross,
Norton,
and
Wozney (1989) mailed questionnaires
to 515
mem-
bers
of the
International Society
for the
Study
of
Multiple Person-
ality
and
Dissociation
(ISSMD)
and to
1729 members
of the
Canadian
Psychiatric Association
(CPA).
The 236
cases
of DID
examined
by
Ross, Norton,
and
Wozney were referred
by 154
members
of
ISSMD
and 49
members
of
CPA. Thus, members
of
ISSMD were between
10 and
11
times more likely
to
report having
seen
a
case
of DID
than were members
of
CPA.
Thus,
the
results
of
these studies
do not
refute
Spanos's (1994)
contention
that
a
disproportionate
number
of DID
diagnoses
are
made
by a
small number
of
therapists, because
(a) in all
three
studies, many
or all or the
questionnaires were mailed
to
clinicians
with
specialized interests
in
DID,
who
make
up a
small proportion
of
all
therapists,
and (b)
therapists
with
interests
in DID are
much
more likely than other therapists
to
report
cases
of
DID. Along
similar lines,
Mai
(1995)
found
evidence
for
considerable variabil-
ity
in the
number
of DID
diagnoses across psychiatrists
and
concluded
that
diagnoses
of DID
derive mostly
from
a
relatively
small number
of
psychiatrists. These
findings
dovetail with those
of
Qin, Goodman, Bottoms,
and
Shaver (1998),
who
found
that
reports
of
satanic
ritual
abuse (which
are
closely associated
with
DID;
Mulhern,
1991) derive primarily
from
a
small number
of
therapists.
Contrary
to
Gleaves's (1996) claims,
the
results
of
these studies
are
thus consistent
with
the
possibility that iatrogenesis
is a key
factor
in the
genesis
of
DID. Moreover, they provide
one
important
test
of the
SCM, because
if DID
diagnoses were
not
made dispro-
portionately
by a
subset
of
therapists—namely,
those
who are
ardent
proponents
of the DID
diagnosis—the
iatrogenic hypothesis
would
be
called into question. Nevertheless, these findings
are
causally
indeterminate
and do not
prove iatrogenesis, because they
are
also
consistent
with
the
hypothesis that specialists
in DID
receive referrals
for a
disproportionate number
of DID
cases.
Longitudinal
studies examining whether patients tend
to
experi-
ence
the
symptoms
of
DID, particularly multiple identity enact-
ments, before
or
after
referrals
to
specialists
would
help
to
deter-
mine
whether these data speak primarily
to
iatrogenesis
or to
differential
referral patterns.
DID
AND THE
LESSONS
OF THE
PAST
515
The
Epidemiology
of DID in
Adulthood
and
Childhood:
Implications
for
latrogenesis
One set of
findings that
is
sometimes invoked
as
evidence
against
the SCM is the
literature
on the
prevalence
of DID in
community
and
clinical samples (see, e.g., Ross, 1997).
If it
could
be
shown that
a
large number
of
individuals
in the
general
popu-
lation,
for
example,
met
criteria
for DID
prior
to
treatment
and to
extensive
exposure
to
information concerning
the
signs
and
symp-
toms
of
DID, this finding would provide evidence against
iatro-
genesis
and the SCM
more generally.
The
study
by
Ross (1991)
represents
the
only published study
on the
epidemiology
of DID in
the
general population (see
Cleaves,
1996,
p.
50).
Ross
(1991)
used
a
structured interview,
the
Dissociative Disorders Interview
Schedule
(DDIS;
Ross, Heber,
et
al.,
1989),
to
establish diagnoses
of
DID and
conducted interviews with
454
community residents
in
Winnipeg, Canada.
These
residents formed
a
subset
of an
initial
sample
of
1,055 respondents identified
by a
stratified cluster
sampling method. Ross (1991) reported that
14
individuals (3.1%)
met
criteria
for DID
according
to the
DDIS,
6 of
whom reported
histories
of
child abuse.
Nevertheless, these findings
are
difficult
to
interpret
for
several
reasons. First,
the
DDIS
has not
been validated
for use in
non-
clinical
(e.g., community)
samples
(Ross,
1991),
and its
false-
positive rate
in
such samples
is
unknown. This issue
is of
particular
concern because diagnostic measures developed
for use in
clinical
samples
often
yield high false-positive rates when applied
to
samples
with
low
base rates
of the
diagnosis (Finn
&
Kamphuis,
1995). This concern
is
heightened
by the
finding (Ross, 1991)
that
13
out of the 14
respondents
who met
DDIS criteria
for DID
scored
in the
average range
(10 to 20) on the
DBS.
Because Ross
(1991)
did not
follow
up
positive DDIS diagnoses
of DID
with
blind diagnostic interviews
by an
independent assessor,
the
issue
of
false
positives
is
difficult
to
evaluate.
Second,
because
there
is no
information
on
whether
the 14
individuals
who met
criteria
for DID had
received psychotherapy,
the
possibility
of
iatrogenesis
cannot
be
excluded. Perhaps more
important,
Ross
did not
report data
on the
extent
of
respondents'
exposure
to
explicit information concerning
the
features
of DID
(e.g.,
media coverage
of
DID). Such data would
be
helpful
in
evaluating
the
extent
to
which
the SCM
could account
for
these
cases
of
DID. Similar problems apply
to
studies
of the
prevalence
of
DID in
clinical samples (e.g., Ross, Anderson,
Fleisher,
&
Norton,
1991),
which
do not
provide data
on the
exposure
of DID
patients
either
to
potentially suggestive treatment practices (e.g.,
repeated
probing regarding
the
existence
of
potential
alters)
or to
explicit information regarding
the
expected features
of
DID.
A
second source
of
data potentially relevant
to
evaluating
the
SCM is
findings
on the
prevalence
of DID in
children.
As
noted
earlier, data indicating that unambiguous cases
of DID
emerge
in
childhood
prior
to
either treatment
or
extensive exposure
to
infor-
mation
regarding
the
features
of DID
would call
the SCM
into
question.
Although cases
of DID
have been reported
in
children
(Putnam,
1997), there
are no
large-scale systematic studies
of the
prevalence
of
childhood
DID in the
general population (Ross,
1996).
In
addition, studies
of the
prevalence
of
childhood
DID in
psychiatric
samples
(e.g.,
Waterbury,
1991)
have
not
provided
data
on
the
exposure
of
participants
to
either
(a)
potentially suggestive
diagnostic
and
treatment practices
or (b)
information regarding
the
expected features
of
DID.
The
former issue
is of
particular impor-
tance given research demonstrating
the
heightened suggestibility
of
children
compared
with adults
(Ceci
&
Brack,
1993),
although
this literature focuses primarily
on
children's
episodic memory
rather than
on
their willingness
to
endorse
the
presence
of
latent
personality structures
(e.g.,
alters). Moreover,
it is not
known
whether
cases
of DID in
children tend
to
persist into adulthood.
Such
information would
be
helpful
in
evaluating whether such
cases
represent stable syndromes that
are
etiologically
related
to
adult
DID or
instead represent transient conditions that
differ
qualitatively
from
adult DID. More detailed information concern-
ing
both
the
antecedents
and the
course
of
childhood
DID
should
prove
useful
in
testing
the
predictions
of
both
the SCM and the
PTM.
The
Etiology
of DID
Analogue Studies
Cleaves
(1996)
was
correct that role-playing studies (e.g., Spa-
nos et
al.,
1985;
Spanos,
Weekes,
Menary,
&
Bertrand,
1986)
do
not
by
themselves demonstrate that
DID is
produced
iatrogeni-
cally.
Nevertheless,
his
assertion that
"to
conclude that these
studies
prove that
DID is
simply
a
form
of
role-playing
is
unwar-
ranted"
(Cleaves,
1996,
p. 47)
represented
a
misreading
of
these
studies' purpose.
These
studies were designed
not to
reproduce
the
full
range
or
subjective experience
of DID
symptoms, including
multiple identity enactments,
but
rather
to
demonstrate
the
ease
with
which cues
and
prompts
can
trigger participants without
DID
to
display
the
overt characteristics
of
this condition.
The SCM
asserts that
(a) the
experiences
and
behaviors
of DID
patients
are
substantially culturally influenced
and (b)
data demon-
strating
that
simulators
accurately reproduce some
of the
critical
features
of DID
indicate that
the
culture contains
sufficient
cues
for
individuals
to
learn
what
kinds
of
experiences
and
behaviors
are
typical
of
this disorder.
As a
consequence,
the
findings
of
role-playing
studies
provide
a
sufficiency
proof that
many
of the
overt features
of
DID can be
reproduced following interviewer prompting.
For
exam-
ple, Spanos
et al.
(1985) reported that most participants provided
with
suggestions
for DID
(e.g.,
"I
think perhaps there might
be
another part
of
[you] that
I
haven't talked to") spontaneously reported amnesia
for
their alters following hypnosis, whereas
no
control participants
did so.
hi
addition, Spanos
et al.
found
that many role-playing participants
spontaneously
adopted
a
different
name, referred
to
their primary
personality
in the
third person,
and
exhibited striking differences
between
their primary
and
alter
"personalities"
on
self-report mea-
sures.
All of
these characteristics
are
commonly exhibited
by DID
patients (Ross, 1997). When
situational
demands
are
conducive, nor-
mal
participants
can
readily role-play
a
number
of
characteristics
of
DID, including reports
of
physical, sexual,
and
satanic
ritual
abuse
(Stafford
&
Lynn, 1998).
These findings demonstrate that
the
behaviors
and
reported
experiences
of DID
patients
are
familiar
to
many members
of the
general
population.
Were
this
not the
case,
the SCM
would
not be
able
to
account
for a
number
of the
features
of
DID. Analogue
studies thus provide
corroboration
for one
important
and
poten-
tially
falsifiable
precondition
of the
SCM, although they
do not
provide dispositive evidence
for
this model.
Motivations
for
Developing
DID
Cleaves
(1996)
asserted that
an
assumption
of the SCM is
that
patients
with
DID
enjoy
having this disorder. According
to
516
LILIENFELD
ET
AL.
Gleaves, this assumption stems
from
the
SCM's proposition that
DID is
largely maintained
and in
some cases partly caused
by
social reinforcement, such
as
attention
from
others. Nowhere,
however, have
Spanos
(1994)
or
other proponents
of the SCM
posited that patients with
DID
"find having
DID
enjoyable
or
rewarding" (Gleaves, 1996,
p.
45).
To the
contrary, proponents
of
the
SCM
emphasize that patients with
DID
often experience pro-
found
suffering.
Spanos
(1996),
for
example, described patients
with
DID as
"chronically disturbed, unhappy,
polysymptomatic
.
. .
people
who are
emotionally
needy"
(p.
259).
Gleaves
(1996)
further
maintained that
the
intense
suffering
expe-
rienced
by
many
or
most individuals with
DID
implies
that reinforce-
ment
processes
are
largely irrelevant
to the
etiology
and
maintenance
of
this condition. Both behavioral
and
social learning theorists, how-
ever, have long recognized
that
individuals
often
engage
in
patholog-
ical
and
psychologically
painful
behaviors
as a
consequence
of
rein-
forcement
(e.g.,
see
Hayes, Wilson,
Gifford,
Follette,
&
Strosahl,
1996,
and
Mowrer's [1948] classic discussion
of the
"neurotic para-
dox").
For
example, many theorists have argued that
a
variety
of
forms
of
psychopathology
can be
conceptualized
as
resulting
from
short-term reinforcement
at the
expense
of
long-term
suffering
(see,
e.g.,
Ullman
&
Krasner,
1975).
To
contend
that
reinforcement plays
little
or no
role
in the
genesis
of DID
because
the
symptoms
of DID
are
deeply distressing
is no
more logically defensible than
to
contend
that
the
etiology
of
obsessive-compulsive
disorder
(OCD)
is
inde-
pendent
of
reinforcement because
OCD is
intensely
painful
to its
sufferers.
In
fact,
there
is
compelling evidence
that
OCD is
maintained
and
perhaps partly caused
by
reinforcement
processes
(Rachman
&
Hodgson, 1980).
Gleaves
(1996)
also
did not
discuss
the
hypothesis
that
much
of the
suffering
of DID
patients
is
iatrogenically
induced. Indeed,
a
number
of
individuals
who
retracted reports
of
child abuse have reported that
their condition deteriorated
as
they became increasingly dependent
on
their therapists
and
alienated
from
friends
and
relatives
(de
Rivera,
1997; Lief
&
Fetkowitz,
1995). Gleaves's analysis overlooked
the
possibility that
maladaptive
and
even subjectively distressing behav-
iors
that
might
not
appear
to be
reinforcing
from
the
perspective
of
outside
observers (e.g., displays
of
multiplicity) might nonetheless
be
reinforcing
to
clients
with
weak social support systems
who
have
become intensely dependent
on
their therapists. Indeed, there
is
evi-
dence that
socially
deprived individuals tend
to find
negative
social
attention
more reinforcing
than
no
attention
at all
(see, e.g.,
Gallimore,
Tharp,
&
Kemp, 1969).
Child
Abuse
and DID
In
his
analysis
of the
literature linking child abuse
to
DID,
Gleaves (1996) again cited Carson
and
Butcher's (1992) opinion:
"while
it is
somewhat amazing that this connection [between
DID
and
child abuse]
was not
generally recognized until 1984, there
is
now
no
reasonable doubt about
the
reality
of
this
association"
(p.
208). Scrutiny
of the
literature reviewed
by
Gleaves, however,
calls this conclusion into question.
Before
we
examine
the
child
abuse-DID
link,
it is
important
to
note that recent quantitative reviews raise questions concerning
the
magnitude
of the
association
between
child sexual abuse
and
later
psychopathology.
Specifically,
the
meta-analysis
of
Rind
et
al.
(1998) suggests that
the
association between child sexual abuse
and
psychopathology
may be (a)
considerably weaker than previ-
ously
believed (see also
Tillman,
Nash,
&
Lerner,
1994)
and (b) at
least partly mediated
by
dysfunctional
family
environment. More-
over, Rind
et al.
reported
a low
effect
size (.09)
for the
association
between child sexual abuse
and
self-reported dissociative symp-
toms across eight studies
(N =
1,324).
The
interpretation
of
Rind
et
al.'s
findings and
conclusions
is
potentially complicated, how-
ever,
by the
fact
that their analyses were based
on
college samples,
which
were
found
by
Jumper
(1995)
to
yield smaller
effect
sizes
for
the
relation between child abuse
and
psychopathology than
did
either community
or
clinical samples.
In
contrast,
a
separate meta-
analysis
by
Rind
and
Tromovitch
(1997)
found
comparably
low
effect
sizes
for
this
association
in
college
and
community samples.
Despite
the findings of
Rind
et al.
(1998),
we
believe
for at
least
two
reasons that
the
issue
of
whether child abuse predisposes
to
DID
remains
an
open question that merits
further
investigation.
First,
it is
conceivable that
the
relation between child abuse
and
psychopathology
is
pronounced
in
magnitude only among individ-
uals
who
have experienced abuse that
is
severe, repeated,
or
both,
although Rind
et al.
found
that
the
frequency,
duration,
and
force
of
sexual
abuse
did not
moderate
the
association
between
early
abuse
and
later psychopathology. Second, there
is
some evidence
that
self-reports
of
physical
and
sexual abuse
may
underestimate
actual abuse rates
(Widom
&
Morris, 1997;
Widom
&
Shepard,
1996).
A
nontrivial
rate
of
false negatives
for
child abuse might
have attenuated
the
reported relations between child abuse
and
psychopathology
in a
number
of
studies. Nevertheless,
the
formi-
dable
methodological
difficulties
involved
in
operationalizing
and
assessing child abuse when
it is
mild
or
moderate
in
severity (see
Rind
et
al.,
1998),
in
corroborating abuse reports (e.g.,
see
Schooler, Bendiksen,
&
Ambadar,
1997,
for an
illustration
of
some
of
the
methodological complexities involved
in
corroborating child
abuse reports),
and in
determining whether child
abuse-
psychopathology correlations imply causation (DiLalla
&
Gottes-
man,
1991)
demand
a
circumspect analysis
of the
evidence regard-
ing
the
association between child abuse
and
DID.
In the
following
section,
we
separate
our
evaluation
of the
literature concerning
the
child
abuse-DID
link into
two
major
issues:
(a) the
corroboration
of
child abuse reports among
DID
patients
and (b) the
interpreta-
tion
of the
child
abuse-DID
association.
The
corroboration
of
child
abuse
reports
among
DID
patients.
Although
Gleaves reviewed
a
number
of
studies suggesting
a
high
prevalence
of
child abuse among
DID
patients (see Gleaves, 1996,
Table
3, p.
53),
in
none
of
these studies
was the
abuse corroborated
by
independent sources.
In
Coons
et al.
(1988), Ross
et al.
(1990),
Boon
and
Draijer
(1993),
and
Ellason
et al.
(1996),
the
abuse
reports were based exclusively
on
patient interviews,
and in
Put-
nam
et al.
(1986), Ross, Norton,
and
Wozney (1989),
and
Schultz
et
al.
(1989),
the
abuse reports were based exclusively
on
clinician
questionnaires.
The
absence
of
corroboration
for
reported abuse
in
these studies (see also Scroppo
et
al.,
1998)
is
problematic
in
view
of
recent
findings
indicating that memory
is
considerably more
malleable, reconstructive,
and
vulnerable
to
suggestion than pre-
viously
believed
(Loftus,
1993, 1997a;
Malinoski
&
Lynn,
1995).6
6
Gleaves
(1996)
dismissed this problem
by
citing
the
review
by
Brewin,
Andrews,
and
Gotlib
(1993),
who
concluded that
the
evidence regarding
the
validity
of
retrospective reports
did not
support
an
extreme reconstruc-
tive model
of
memory. Nevertheless,
the
data reviewed
by
Brewin
et al.
dealt
with
the
retrospective assessment
of
events
by
means
of
standardized
questionnaires, interviews,
and
other methods
of
assessment
in
which
(a)
DID
AND THE
LESSONS
OF THE
PAST
517
Moreover, recent evidence suggests that memories
of
traumatic
events
(e.g.,
combat experiences)
may not be
immune
to
this
problem (Southwick, Morgan, Nicolaou,
&
Charney,
1997).
Although
the
research
of
Pezdek, Finger,
and
Hodge
(1997)
indicated
that memory implantation
may be
likely
to
occur only
when
the
event being implanted
is
plausible
and
accords with
script-relevant knowledge existing
in
memory,
the
relevance
of
their findings
to
early abuse reports requires clarification.
Pezdek
et
al.'s
findings
might suggest that unintentional implantation
of
child abuse memories
in DID
patients
can
occur only when these
patients
possess
implicit causal theories regarding
the
association
between early abuse
and
DID, although this possibility
has not
been examined.
In
addition, abuse memories
recovered
in
therapy
may
be
less likely
to be
veridical than abuse memories recalled
continuously
since childhood
(Loftus,
1993), although there
is
little
empirical evidence directly relevant
to
this assertion. Because
none
of the
studies cited
by
Gleaves
(1996,
p. 53)
provided
information
on
whether
the
reported
abuse
was
recalled continu-
ously
or
recovered
in
treatment, this potentially important distinc-
tion cannot presently
be
addressed.
In
addition,
the
phenomenon
of
"effort
after
meaning," whereby
individuals
interpret potentially ambiguous events
(e.g.,
hitting,
fondling)
in
accord with their implicit theories regarding
the
causes
of
their disorders,
further
renders some reports
of
relatively
mild
or
moderate physical
and
sexual child abuse
difficult
to
interpret
without independent
corroboration
(Rind
et
al.,
1998).
Finally,
it is
difficult
to
exclude
the
possibility that
the
same
unintentional
cues emitted
by
therapists that
may
promote
the
creation
of
alters
might also promote
the
creation
of
false memo-
ries
of
abuse (Spanos, 1994), although little
is
known about
the
prevalence
of
suggestive practices among
DID
practitioners.
As a
consequence,
it is not
known whether
the
reported association
between child abuse
and DID
might
be at
least partly spurious
and
contaminated
by
therapists' methods
of
ascertaining information.
Several
investigators have, however, attempted
to
corroborate
the
retrospective abuse reports
of DID
patients. Gleaves (1996)
cited
the
findings
of
Coons
and
Milstein
(1986)
and
Coons
(1994),
who
claimed
to
provide objective documentation
for the
abuse
reports
of a
number
of DID
patients,
as
offering
especially com-
pelling support
for the
child
abuse-DID
link.
Close
inspection
of
these studies, however, reveals various methodological shortcom-
ings.
In
neither study were diagnoses
of DID
made blindly
of
previous
abuse reports. This methodological shortcoming
is
prob-
lematic
because
certain therapists might
be
especially likely
to
attempt
to
elicit features
of DID
among patients with
a
history
of
severe abuse.
In the
Coons (1994) study,
DID
diagnoses were
made only
after
medical histories
and
psychiatric records (many
of
which
may
have contained information regarding abuse histories)
had
been reviewed. Moreover, because standardized interviews
were
not
administered
in
Coons
and
Milstein (1986)
and
were
administered only
to an
unknown number
of
participants
in
Coons
(1994),
the
possibility
of
diagnostic bias
is
heightened. Finally,
the
patients
in
Coons
(1994)
"were
diagnosed personally
by the
first
the
opportunity
for
unintentional prompting
was
minimal
and (b)
events
were typically
assessed
on
only
one
occasion.
In the
therapeutic
context,
in
which
clinicians have ample
and
repeated opportunities
to cue the
emer-
gence
of
abuse histories,
the
possibility
of
false memories
is
considerably
more problematic.
author
over
an 11
year
period"
(p.
106). Because there
is no
evidence concerning whether these patients
had DID
prior
to
treatment,
the
possibility
of
iatrogenic
influence
is
difficult
to
exclude.7
Gleaves
(1996)
neglected
or
underemphasized several pieces
of
data
that appear
to
call into question
the
veracity
of
some reports
of
child abuse
in
studies
of DID and
that underscore
the
impor-
tance
of
corroborating these reports.
In the
study
by
Ross
et al.
(1991),
26% of DID
patients
reported
being abused prior
to age 3,
and
10.6% reported being abused prior
to age 1.
Similarly, Dell
and
Eisenhower
(1990)
noted that
4 of
11
adolescent patients
with
DID
reported
that their
first
alter emerged
at age 2 or
earlier,
and 2
of
these patients reported that their
first
alter emerged between
the
ages
1 of 2.
Memories reported prior
to age 3 are of
extremely
questionable validity,
and it is
almost universally accepted that
adults
and
adolescents
are
unable
to
remember events
that
oc-
curred
prior
to age 1
(Fivush
&
Hudson,
1990).
It is
possible
that
the
memories reported
in
these studies were accurate
but
that they
were dated incorrectly. Nonetheless,
the
nontrivial
percentages
of
individuals
in
Ross
et al.
(1991)
and
Dell
and
Eisenhower (1990)
who
reported abuse
and the
emergence
of
alters
at
very
young
ages
raise
concerns regarding
the
accuracy
of
these memories.
In
this context,
it is
worth noting that Ross
and
Norton (1989)
found
that
DID
patients
who had
been hypnotized reported
signif-
icantly
higher rates
of
sexual
and
physical abuse than
DID
patients
who had not
been hypnotized. Because there
is
little
evidence
that
hypnosis enhances memory (Lynn, Lock, Myers,
&
Payne, 1997),
this
finding is
consistent
with
the
possibility that hypnosis pro-
duces
an
increased rate
of
false abuse reports. Nevertheless, this
conclusion must remain tentative
in
view
of the
absence
of
inde-
pendent
corroboration
of the
abuse reports
and the
correlational
nature
of
Ross
and
Norton's
data.8
'Lewis
et al.
(1997) recently reported
findings
from
a
study
of 12
murderers with
DID
that,
in the
authors' words, "establishes, once
and for
all,
the
linkage between early severe child abuse
and
dissociative
identity
disorder"
(p.
1703). Nevertheless, close inspection
of
their results reveals
six
problems:
(a)
Because violent
individuals
tend
to
have high rates
of
abuse
in
childhood (Widom, 1988), Lewis
et
al.'s
findings are
potentially
attributable
to the
confounding
of DID
with violence;
(b) the
objective
documentation
of
abuse provided
by
Lewis
et al. was
often
quite vague
(in
several cases, there were indications only that
the
"mother [was] charged
as
unfit"
or
that "emergency room records
report[ed]
severe
headaches");
(c) the
objective documentation
of
childhood
DID
symptoms
was
similarly
vague
in
many
cases
and was
often
based
on the
presence
of
imaginary
playmates
and
other features (e.g., marked mood changes) that
are ex-
tremely common
in
childhood;
(d)
diagnoses
of DID
were
not
performed
blindly
with respect
to
knowledge
of
reported abuse history;
(e) the
murderers' handwriting samples, which
differed
over time
and
were used
by
Lewis
et al. to
buttress
the
claim that these individuals
had
DID, were
not
systematically evaluated
by
graphoanalysts
or
compared
with
the
handwriting samples
of
normals over time;
and (f) the
possibility
of
malingering (which
may be a
particular problem among criminals)
was not
systematically evaluated
with
psychometric indexes.
8
Another reason
for
emphasizing
the
importance
of
corroborating
the
child
abuse reports
of DID
patients
is
recent
findings
that high
DBS
scorers
(a)
exhibited
a
response bias toward endorsing
a
large number
of
autobio-
graphical memories
on
life
events questionnaires, including memories
of
both negative
and
neutral
life
events (Merckelbach,
Muris,
Horselenberg,
&
Stougie,
in
press),
and (b)
were
especially
likely
to
accept misleading
statements,
including
those dealing
with
autobiographical events
(Ost,
518
LILIENFELD
ET
AL.
Cleaves
(1996)
contended that
"there
have been
no
cases
in the
scientific
literature where
the
alleged abuse
in a
patient with
DID
was
found
to be
totally fabricated"
(p.
54).
To
maintain this
position, Gleaves would
be
forced
to
argue that most
or all of the
memories
of
satanic
ritual
abuse that have been recovered
by a
large proportion
of DID
patients (estimated
by
Mulhern,
1991,
to
be
25% as of the
mid-1980s)
are
veridical. Nevertheless, federal
law
enforcement officials have been unable
to
detect
the
existence
of
satanic cults (whose purported crimes involve multiple murders,
cannibalism,
and
bizarre
human
sacrifices)
despite
years
of
inten-
sive investigation (Bottoms, Shaver,
&
Goodman, 1996; Hicks,
1991;
Lanning,
1989).
Although
it is
conceivable that
a
subset
of
satanic
ritual
abuse reports represent
the
memory overlay
of
actual
abuse incidents
(Loftus,
1997b),
the
burden
of
proof would appear
to
rest
on
Gleaves
and
others, rather than
on
critics
of the
PTM,
to
provide documentation
of
such incidents.
Interpretation
of
the
child
abuse-DID
association. Even
if the
child abuse reports
of
most
DID
patients could
be
corroborated,
several important questions arise concerning
the
interpretation
of
these reports.
In
particular,
it
remains
to be
determined whether
a
history
of
child
abuse
is (a)
more
common among
DID
patients
than
among psychiatric patients
in
general
and (b)
causally asso-
ciated with
risk for
subsequent DID.
With
respect
to the first
issue, base rates
and
referral biases pose
potential
difficulties
for
Gleaves's interpretation
of the
abuse data.
Because
the
prevalence
of
reported child abuse among psychiatric
patients
in
general tends
to be
high (see, e.g.,
Pope
&
Hudson,
1992), these data
are
difficult
to
interpret without
a
psychiatric
comparison group. Moreover,
the
co-occurrence between reported
abuse
and DID
could
be a
consequence
of
several selection arti-
facts
that increase
the
probability that individuals with multiple
problems
seek
treatment. Berksonian
bias
(Berkson, 1946)
is a
mathematical
effect
that results
from
the
fact
that
an
individual
with
two
problems
can
seek treatment
for
either problem. Clinical
selection bias (see
du
Fort, Newman,
&
Bland, 1993) reflects
the
increased likelihood that patients
with
one
problem will seek
treatment
if
they subsequently develop another problem. Either
or
both
of
these artifacts could lead
to the
apparent relation between
child
abuse
and DID
discussed
by
Gleaves. Indeed, Ross (1991)
found
that
nonclinical
participants with
DID
reported substantially
lower
rates
of
child abuse than
did
patients with
DID
recruited
from
a
clinical population. This
finding is
consistent with
the
hypothesis
that
selection
biases
account
at
least
partly
for the
high
levels
of
co-occurrence between reported child abuse
and
DID.
Moreover, Ross, Norton,
and
Fraser (1989) reported that American
psychiatrists
reported
a
substantially higher prevalence
of
child
abuse among
DID
patients
(81.2%)
than
did
Canadian psychiatrists
(45.5%). This
finding
suggests
the
possibility
of
biases
in the
assessment
or
elicitation
of
child abuse reports
and
raises questions
concerning
the
claim
that
child abuse
is
necessary
for
most cases
of
DID
(Spanos, 1994).
Gleaves
(1996)
dismissed3
Spanos's (1994) argument that
the
relation between child abuse
and
DID, even
if
shown
to be
genu-
ine,
is
correlational
in
nature
and
could
be a
product
of
unidentified
third
variables, such
as
adverse
family
environment. Gleaves
lik-
Fellows,
&
Bull,
1997). Nevertheless, because
the
relevance
of
this liter-
ature
to
child
abuse
and to DID per se has yet to be
established,
it is not
reviewed
further
here.
ened
the
literature concerning
the
relation
of
child abuse
and DID
to
the
literature concerning
the
relation
of
trauma
to
PTSD:
"the
empirical support
for the
relationship between PTSD
and
trauma
is
also correlational. However, such
a
state
of
affairs
would
not
seem
to be a
convincing argument that PTSD
is not a
posttraumatic
condition" (Gleaves, 1996,
p.
53).
But
this analogy
is
questionable.
Many
studies have revealed dramatically increased rates
of
PTSD
shortly
after
objectively documented events, such
as
Hurricane
Andrew
(Garrison, Bryant, Addy,
&
Spurrier, 1995)
and the
1988
Armenian earthquake
(Goenjian
et
al.,
1994).
Thus, although
the
relation between trauma
and
PTSD
is
correlational,
the (a)
objec-
tive
nature
of the
traumatic event,
(b)
immediacy
of
many indi-
viduals' reaction
to
this event,
and (c)
clear-cut link between
the
nature
of the
stressor
and
individuals' intrusive imagery provide
compelling support
for the
assertion that this relation
is
causal
in
at
least some cases.
The
relation between child abuse
and DID is
markedly
different:
the
traumatic event
is
often
neither clear-cut
nor
readily corroborated
by
objective evidence.
Nor are
there data
demonstrating that this event
is
unambiguously followed almost
immediately
by the
signs
and
symptoms
of
DID. Moreover,
Gleaves's
assertion
(1996,
p. 55)
that
most
patients
with
DID
meet
criteria
for
PTSD borders
on
being tautological
and
begs
the
very
question
that
is at
issue:
Is the
child abuse genuine?
If
not,
the
diagnostic criteria
for
PTSD would
not be
satisfied,
as
this diag-
nosis
requires exposure
to a
life-threatening
or
otherwise
ex-
tremely
dangerous event
(APA,
1994).
Summary
of the DID
Literature:
The SCM
Reappraised
Gleaves
(1996)
concluded
by
recommending that "the sociocog-
nitive
model
be
abandoned
as an
etiological
explanation
of
DID"
(p.
54).
Careful
scrutiny
of his
central arguments, however, reveals
that
this conclusion
is
premature
and
unwarranted. Although
Gleaves arrived
at
strong conclusions regarding
the
psychopathol-
ogy
of
DID,
the
motivations
of DID
patients,
and the
efficacy
of
extinction treatments
for
DID, these conclusions appear
to be
based largely
on
uncontrolled and,
in
some cases, anecdotal
evidence.
Moreover, several
of the
central premises
of the
PTM, such
as
the
assumption that
the
prevalence
of
child abuse
is
substantially
elevated among
DID
patients compared with other psychiatric
patients,
require
more
compelling
data
before they
can be ac-
cepted.
In
particular,
Gleaves's
(1996) conclusion that
"there
does
not
appear
to be any
convincing reason
to
doubt
the
association
between
DID and
childhood trauma"
(p. 54) is not
borne
out by a
careful
examination
of the
evidence. Although
a
causal link
be-
tween
early abuse
and DID
cannot
be
excluded, studies that
provide corroborated abuse reports, distinctions between continu-
ally
recalled
and
recovered memories
of
abuse,
and
psychiatric
comparison groups
are
needed
to
bring clarity
to
this methodolog-
ically complex area.
In
addition, causal modeling studies
may
help
to
rule
out
competing hypotheses
for the
high levels
of co-
occurrence
between
reports
of
early trauma
and
later
DID and
thereby
provide more compelling support
for the
claims
of the
proponents
of the
PTM.
If
such abuse
can be
corroborated
and
shown
to be
correlated
with
risk for
subsequent DID, such studies
will
be
especially informative
if
they incorporate potential third
variables that might account
for
this correlation,
such
as
adverse
early
home environment.
DID
AND THE
LESSONS
OF THE
PAST
519
Although
the
relative paucity
of
data
on the
role
of
iatrogenic
factors
in DID
renders
a
definitive verdict premature, several lines
of
evidence converge upon
the
conclusion that
iatrogenesis
plays
an
important, although
not
exclusive, role
in the
etiology
of
DID:
(a) The
number
of
patients with diagnosed
DID has
increased
dramatically over
the
past several
decades
(Elzinga
et
al.,
1998);
(b)
the
number
of
alters
per DID
case
has
increased over
the
same
time period (North
et
al.,
1993), although
the
number
of
alters
at
the
time
of
initial diagnosis appears
to
have remained constant
(Ross,
Norton,
&
Wozney, 1989);
(c)
both
of
these increases
coincide with dramatically increased therapist awareness
of the
diagnostic features
of DID
(Fahy,
1988);
(d) a
large proportion
or
majority
of DID
patients show
few or no
clear-cut signs
of
this
condition, including multiple identity enactments, prior
to
therapy
(Kluft,
1984);
(e)
mainstream treatment practices
for DID
patients
appear
to
verbally reinforce patients' displays
of
multiplicity
and
often
encourage patients
to
establish
further
contact with alters
(Ross, 1997);
(f)
the
number
of
alters
per DID
case tends
to
increase over
the
course
of
DID-oriented
therapy (Piper, 1997);
(g)
therapists
who use
hypnosis appear
to
have more
DID
patients
in
their
caseloads
than
do
therapists
who do not use
hypnosis (Powell
&
Gee,
in
press);
(h) the
majority
of DID
diagnoses derive
from
a
relatively small number
of
therapists (Mai, 1995);
and (i)
labora-
tory studies demonstrate that nonclinical participants provided
with
appropriate cues
can
successfully reproduce many
of the
overt features
of DID
(Spanos
et
al.,
1985). Given
the
high rates
of
preexisting mental conditions among
DID
patients (Spanos, 1996),
however,
it
seems likely that iatrogenic factors
do not
typically
create
DID in
vacua
but
instead operate
in
many cases
on a
preexisting substrate
of
psychopathology, such
as
BPD.
We
believe that each
of
these nine sources
of
evidence
is
fallible
and
that several (e.g.,
a, b, f, g, and h) are
open
to
multiple causal
interpretations.
For
example,
the
finding
that
the
number
of
alters
per
case
tends
to
increase over
the
course
of
therapy
is
potentially
consistent with
the
assertion (Ross, 1997) that therapy
for DID is
often
accompanied
by the
progressive uncovering
of
previously
latent
alters.
Moreover,
as
Ross (1997) noted, several
of
these
arguments
are
probably applicable
to
psychological disorders other
than
DID; diagnoses
of
PTSD,
for
example, have increased dra-
matically
over
the
past
two
decades
(Zohar,
1998). Nevertheless,
the
consilience
of
evidence across these nine quite diverse sources
of
data appears
to
provide
an
impressive,
if not
compelling, cir-
cumstantial
case
for the
role
of
iatrogenic factors
in
DID. More-
over,
Cleaves
(1996) acknowledged that iatrogenic factors
can
produce additional
alters,
and
Ross (1997) estimated that approx-
imately
17% of DID
cases
are
predominantly iatrogenic (see also
Coons, 1989). Thus,
the
principal unresolved question appears
to
be not
whether iatrogenesis sometimes plays
a
role
in
either
the
etiology
or
maintenance
of DID but
rather
its
relative importance
compared
with other potential causal variables, such
as
media
influences,
widely available cultural scripts regarding
the
expected
features
of
DID, individual differences
in
personality
and
psycho-
pathology,
and
perhaps early trauma. Further
research
examining
the
symptomatic characteristics
of DID
patients before
and
after
treatment
is
needed
to
clarify this issue.
Nevertheless,
because
proponents
of the
PTM,
including
Cleaves,
have typically con-
tended that
the
multiple identity enactments
of DID
patients typ-
ically remain hidden prior
to
treatment, they need
to
explicate
what
findings
could potentially
falsify
the
assertion
(Cleaves,
1996,
p.
42)
that
DID
cannot
be
iatrogenically
created.
Discussion:
Recalling
the
Lessons
of the
Past
The
diagnosis
of DID has a
short history
but a
long ancestry.
Historically, dissociative
and
somatoform
disorders were grouped
together
as
subtypes
of
hysteria. Beginning with
DSM-III
(APA,
1980), these conditions were dissociated
from
each other,
and the
overarching construct
of
hysteria
was
eliminated entirely
(Hyler
&
Spitzer, 1978). This decision
was
understandable, largely because
the
concept
of
hysteria
was
imprecise
and ill
defined. Neverthe-
less,
the SCM
suggests that
the
dissociation
of
dissociative
and
somatoform
disorders
may
have been
an
error (see also
Kihlstrom,
1994). These superficially
different
groups
of
disorders
may
reflect
phenotypically
different
expressions
of a
shared diathesis (Good-
win
&
Guze, 1996; Lilienfeld, 1992).
The
underlying nature
of
this
diathesis
(e.g.,
fantasy
proneness, absorption), however, remains
to
be
determined. Slater (1965) similarly noted that many conditions
that
would today
be
subsumed under
the
rubric
of
somatoform
and
dissociative disorders
can
assume
a
variety
of
superficially
differ-
ent
manifestations across individuals.
Moreover,
the
behavioral expression
of
these conditions
may be
shaped substantially
by
cultural
and
historical
factors.9
For
exam-
ple,
latah,
a
condition characterized
by
sudden
and
transient epi-
sodes
of
profanity, command obedience, trancelike states,
and
amnesia,
is
limited primarily
to
women
in
Malaysia
and
Indonesia
(Bartholomew, 1994). Conversion disorders were prevalent
at the
end of the
19th
century
but are
apparently much rarer
now
(Jones,
1980).
In
moving
from
one fin de
siecle
to the
next,
DID may
have
replaced conversion disorders
as the
disorder
in
vogue (see Hack-
ing,
1995). Although
further
research
using
external validating
variables
(e.g.,
family
history, course
and
outcome, biological
variables)
is
necessary
to
corroborate
the
hypothesis that DID,
latah,
and
conversion disorders
are
expressions
of the
same under-
lying
etiology, this hypothesis
has the
potential
to
unify
a
large
number
of
disparate observations.
Veith
(1965) argued that
the
manifestations
of
somatoform
and
dissociative conditions have changed dramatically over time
in
accord
with
prevailing cultural conceptions.
For
example,
she
observed that Victorian England
in the
19th century experienced
a
marked increase
in the
prevalence
of
dramatic
and
unexplained
somatic symptoms (e.g., paralyses, aphasias), which were subse-
quently
displaced
by
less florid episodes
of
fainting
("the vapors").
Veith
pointed
out
that
the
manifestations
of
[these
conditions] tended
to
change
from
era to
era
much
as did the
beliefs
as to
etiology
and the
methods
of
treatment.
The
symptoms,
it
seems, were conditioned
by
social
ex-
pectancy, tastes, mores,
and
religion,
and
were further shaped
by the
state
of
medicine
in
general
and the
knowledge
of the
public about
medical matters.
. . .
Thus
we
have seen departures
from
and
returns
to the
generalized convulsion,
the
globus
hystericus,
the
loss
of
consciousness,
the
cessation
of
breathing.
We
have watched
the
9
Cleaves
(1996)
cited data indicating that
DID had
recently been
diagnosed
in the
Netherlands
and
other European countries
and
invoked
these data
to
dispute Spanos's (1994) contention that
DID is a
culture-
bound
condition. Nevertheless, without additional information regarding
the
accessibility
of
information about
DID to the
general public
in
such
countries, these
findings
are
difficult
to
interpret.
In the
Netherlands,
for
example,
the
writings
of
several well-known
researchers
(e.g.,
van der
Hart, 1993;
van der
Kolk,
van der
Hart,
&
Marmar,
1996) have resulted
in
greatly
increased media
and
professional
attention
to
DID.
520
LILIENFELD
ET AL.
acting-out
of
demonic posession
and the
vast variety
of
delusions
related
to it. (p.
209)
Most proponents
of the
PTM
have
not
explicitly attempted
to
explain
the
cross-cultural
and
cross-historical manifestations
of
multiple
role enactments
and
have instead focused primarily
or
exclusively
on the
etiology
of DID per se.
This
is
especially
true
of
Gleaves's (1996) exposition
of the
PTM, which dethrones
multiple
identity enactment
as the
essential feature
of DID and
instead largely emphasizes secondary features
(e.g.,
Schneiderian
symptoms,
depersonalization)
not
commonly
found
in
other con-
ditions
characterized
by
multiple role enactments (e.g., transves-
tism, glossolalia;
see
Spanos,
1994).
The
existence
of
social, cross-cultural,
and
historical influences
on
the
manifestations
of
multiple role enactments
may not in
principle
be
incompatible
with
the PTM
(Castillo, 1994)
and may
in
fact
represent
one
potential area
of
common ground between
the
PTM and the
SCM. Ross
(1997),
for
example, acknowledged that
social psychological factors (e.g., therapist expectations)
often
play
a
role
in the
etiology
and
maintenance
of DID
(e.g.,
p. 81) and
suggested that demonic
possession
may be a
culture-bound variant
of
DID.
In
contrast,
Gleaves's
(1996) categorical rejection
of the
SCM (p. 54)
leaves little room
for the
incorporation
of
sociocul-
tural
and
historical
influences into
the
PTM.
To
integrate
such
influences
into
the
PTM, proponents
of
this model need
to
clearly
articulate
how the
etiological variables
(e.g.,
iatrogenesis,
media
influences)
postulated
by the SCM
could interact with childhood
trauma
to
produce DID,
as
well
as how
cultural
and
historical
factors
might
differentially
shape
the
phenotypic expression
of
multiple
role enactments.
As
Bronowski
(1978) noted,
a
number
of
the
most
significant
advances
in
science stem
from
the
demonstra-
tion
that
phenomena previously believed
to be
distinct
are in
fact
interrelated. From this perspective,
the SCM
represents
a
step
forward
in the
effort
to
address
the
puzzling question
of why
certain individuals display markedly
different
identities
at
different
times.
By
focusing primarily
or
almost exclusively
on the
overt man-
ifestations
of DID
rather than
on its
commonalities with other
conditions, many modern
DID
practitioners
may
unwittingly
be
repeating many
of the
errors
of the
past.
For
example,
in the
1880s,
Charcot
believed
that
he had
identified
a new
disease,
"hystero-
epilepsy,"
characterized
by fluctuations in
consciousness, seizures,
and
fainting
spells. Charcot
frequently
displayed
hystero-epileptics
at
conferences
and
accorded them special attention. Nevertheless,
one
of
Charcot's
students, Joseph
Babinski,
convinced Charcot
that
hystero-epilepsy
was the
inadvertent product
of his
mentor's
creation.
He
persuaded Charcot
to
isolate hystero-epileptics
from
each other
and
from
epileptics (they
had
originally been housed
with
epileptics
and had
begun
to
mimic their seizures)
and to
withhold attention
from
their dramatic symptomatic displays. Bab-
inski's
prescription worked
(McHugh,
1993).
By
reinforcing
the
multiplicity
of DID
patients, many modern
therapists
may be
recapitulating
Charcot's
error. Moreover,
by
underemphasizing
the
possibility
that
DID is
aformefruste
of the
same psychological disposition underlying other multiple role
en-
actments,
Gleaves
and
some other proponents
of the PTM may
have
erroneously
reified
one
variant
of a
broader constellation
of
multiple
role enactments
into
a
distinct nosological entity
(Fahy,
1988).
When viewed
in
historical
context,
the
current epidemic
of DID
cases (Boor, 1982)
may be
neither
as
inexplicable
nor as
surprising
as
it
appears.
This
epidemic
does,
however, impart
a
valuable
lesson
to
today's
psychotherapists.
The
well-replicated
finding
that
psychotherapy, although generally
effective
(Wampold
et
al.,
1997),
can be
harmful
in a
select number
of
cases
(Strupp,
Hadley,
&
Gomes-Schwartz, 1978) serves
as a
needed reminder that
the
clinician
qua
diagnostician
and
treatment provider
can be the
creator
as
well
as the
discoverer
of
psychopathology.
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... Le modè le socio-cognitif (MSC) rassemble les thé ories expliquant ce « pré tendu » TDI. Le MSC explique le TDI comme un syndrome qui consiste en l'affichage de multiples rô les qui ont é té cré é s, lé gitimé s et maintenus par le renforcement social [53]. Le MSC propose que l'apparition du trouble serait due à des influences socioculturelles (mé dias ou religions) [53,103], à des psychothé rapies suggestives, à des tendances à l'affabulation, des dysfonctionnements cognitifs, et/ou à un haut niveau de suggestibilité [34,65]. ...
... Le MSC explique le TDI comme un syndrome qui consiste en l'affichage de multiples rô les qui ont é té cré é s, lé gitimé s et maintenus par le renforcement social [53]. Le MSC propose que l'apparition du trouble serait due à des influences socioculturelles (mé dias ou religions) [53,103], à des psychothé rapies suggestives, à des tendances à l'affabulation, des dysfonctionnements cognitifs, et/ou à un haut niveau de suggestibilité [34,65]. ...
... Certains [73,78] en concluent que le TDI ne fut qu'une mode pendant une pé riode de temps relativement restreinte avant que le TDI ne dé cline dans les anné es 1990. Né anmoins, on observe la pré sence de TDI dans des pays ou ré gions où la litté rature dans ce domaine est inexistante [53,118]. Il est probable que des patients atteints de TDI aient toujours existé , parfois sous d'autres dé nominations diagnostiques, comme en té moignent des descriptions rapporté es depuis plusieurs siè cles, comme le cas d'Anna O. [31]. ...
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Résumé Le trouble dissociatif de l’identité (TDI) fait l’objet de controverses dans la littérature scientifique et dans la pratique clinique. Cet article relève les principales croyances des cliniciens et les confronte aux études scientifiques sur ce sujet par une présentation des principales recherches des spécialistes du TDI et des opposants à ce trouble. Il résulte de cette revue de la littérature que (1) le TDI est un trouble différent de la schizophrénie ; (2) qu’il existe en dehors de toute influence iatrogène du thérapeute ou des médias ; (3) ces patients ne sont pas particulièrement sujets à la suggestibilité ni à la tendance à l’affabulation ; (4) le TDI apparaît en dehors de tout traitement hypnothérapeutique ; (5) il est le plus sévère des troubles d’origine traumatique ; (6) l’amnésie de traumas de l’enfance est un phénomène démontré ; (7) l’étendue des violences physiques et sexuelles extrêmes réalisées par des individus ou des groupes organisés sur des enfants, parfois des bébés, est connue des instances policières et judiciaires.
... Some researchers have proposed that DID might not be entirely due to traumarelated dissociations (Dalenberg et al., 2012), but rather, to social learning, media influence, and cultural expectations (Spanos, 1994). Suggestive individuals could be predisposed to exhibit dissociative identities, willingly (Boysen & VanBergen, 2014) or unwillingly (Lilienfeld et al., 1999;Lynn et al., 2012;Spanos, 1996), thus begging the question of whether IIA is due to simulation. Huntjens et al. (2006) tested this -while they did not find evidence of IIA in a memory recognition test, they did find that both DID individuals and simulators selected incorrect answers above chance performance, thus suggesting that DID individuals may have simulated too. ...
... DID is characterised by two or more identities that control a person's behaviour and self-awareness. DID is believed to be the product of traumainduced dissociations that typically occur during childhood (Dalenberg et al., 2012), although this is not a unanimous view -many researchers have proposed that DID may also be (totally or partially) due to social learning, media influence, and cultural expectations (Lilienfeld et al., 1999;Spanos, 1994). On top of this ongoing debate about the nature of DID, there is also the problem of malingering (Brand & Chasson, 2015;Drob et al., 2009): how can clinicians discriminate genuine DID individuals from those who simulate? ...
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Dissociative identity disorder (DID), formerly known as multiple personality disorder, is characterised by two or more identities that control a patient's actions, each typically with a distinct personal history, self-awareness, and name. They are believed to be the result of trauma-related dissociative defence mechanisms. Substantial progress has been made to determine the cognitive, neural, and psychometric signatures of dissociative identities. However, tools to discriminate genuine DID individuals from malingerers are still lacking. Here, we review the empirical attempts that have been made to detect malingerers of DID. Additionally, we present the case of a DID patient who exhibited nine different identities. After clinically ruling out malingering and factitious behaviour, we assessed her primary identity and two alternate identities (a trauma identity and an avoidant identity) using the Millon Index of Personality Styles. We found three very distinct personality profiles, with evident differences between primary and trauma identities. The profiles had high consistency scores and moderate to low negative and positive impression scores, respectively, thus supporting the profile's validity for interpretation. Future studies should employ personality inventories that go beyond psychopathological symptoms to describe the consistency and adaptation style of dissociative identities when assessing malingering.
... Critics contend that DID and dissociative amnesia may be fuelled, perhaps even iatrogenically created by social pressure originating from books, media, and therapists (e.g., Lilienfeld et al., 1999; see also Pope et al., 2006). ...
Article
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Dissociative amnesia, defined as an inability to remember important autobiographical experiences usually of a stressful nature, is a controversial phenomenon. We systematically reviewed 128 case studies of dissociative amnesia reported in 60 papers that appeared in peer-reviewed journals in English over the past 20 years (2000-2020). Our aim was to examine to what extent these cases met core features of dissociative amnesia. All cases were about reports of autobiographical memory loss, but the evidence offered in support of a dissociative amnesia interpretation was often weak and plagued by an ambiguous heterogeneity with respect to nature, aetiology, and differential diagnoses of alleged memory loss. Most case studies failed to rule out plausible alternative explanations of dissociative amnesia, such as ordinary forgetting and malingering. We encourage clinicians and researchers to more critically investigate alleged cases of dissociative amnesia and provide criteria for how a dissociative amnesia case ideally would look like.
... In an earlier study in an adolescent school population in Nepal, Sapkota et al. (30) examined if factors associated with the two most widely used etiological models of dissociation (i.e., trauma and socio-cognitive models) [e.g., see (31)(32)(33)(34)(35)(36)] and other measures of distress (i.e., current psychological distress, quality of life, PTSD symptoms, and depressive symptoms) could predict the level of dissociative experiences (30). The current study extended this research by examining an adolescent population affected by MPI. ...
Article
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This paper presents the first systematic case-control study of correlates of mass psychogenic illness (MPI) in an adolescent school population. MPI is generally construed as a dissociative phenomenon spread by social contagion to individuals who are prone to dissociation. We sought to test if the correlates of dissociative experiences most commonly proposed in the literature could predict caseness among students affected by episodes of mass psychogenic illness occurring in schools in Nepal. We assessed 194 cases and 190 controls (N = 384) of ages 11–18 years from 12 public schools. Cases and controls were comparable on all demographic variables, except for family configuration, with nuclear families more common among those affected. In bivariate comparisons, caseness was associated with childhood physical neglect and abuse, as well as living in nuclear families, peritraumatic dissociation, dissociative tendencies, and depressive and post-traumatic stress symptoms. Hypnotizability emerged as the strongest correlate of psychogenic illness among the cognitive and personality trait variables. However, in multivariable logistic regression, the correlates of dissociation did not predict caseness, suggesting that they do not adequately account for the phenomenon of mass psychogenic illness. An ad-hoc Classification and Regression Trees analysis showed that if an adolescent was highly hypnotizable and reported high rates of peritraumatic dissociative experiences, then there was a 73% probability of being a case in a mass psychogenic illness episode. Future studies involving other psychological, social and cultural factors, as well as school- and family-related factors are needed to understand the correlates of mass psychogenic illness and guide prevention and intervention.
... Despite the drawbacks of the study, the current data attested to the crucial relations between dissociative symptomatology and sleep by means of pathological worry. Trauma model is the prevailing notion considering the etiology of dissociative disorders that a more profound understanding of the relationships with sleep will contribute to further refinements regarding nontraumatic etiology of dissociative experiences (Butler, Duran, Jasiukaitis, Koopman, & Spiegel, 1996;Lilienfeld et al., 1999;Watson, 2003). The current results may be interpreted in a way that both pathological worry and dissociative amnesia may play role in the cognitive suppression of negative content arising from stressful life events at the expense of normal sleep-wake cycle. ...
... The intersection between the diagnosis of DID and the courts has been complex, difficult, and controversial Brand et al., 2018;Lewis & Bard, 1991;Orne et al., 1984;Watkins, 1984). Some forensic experts do not view the disorder as an authentic psychiatric condition (Coons, 1991;Lilienfeld et al., 1999;McHugh, 1995;Merckelbach & Patihis, 2018). In civil/administrative litigation, individuals with DID-or purported DID-may be involved as plaintiffs or defendants in a variety of cases where the DID diagnosis is material to the case. ...
Article
Full-text available
Courts struggle with questions of how to assess competency to stand trial (CTS) and not guilty by reason of insanity (NGRI) in dissociative identity disorder (DID). Concerns about CTS include dissociative amnesia and unpredictable switching behaviors that could cause inconsistent information transfer across self states, with the defendant unable to access important legal information about his/her defense and to collaborate with his/her attorney; DID defendants could not conform their conduct to the law or know right from wrong due to dissociative amnesia, the seemingly independent actions of self states, and the disruption of reality testing by switching. The author presents the case of a woman charged with both a witnessed and an unwitnessed burglary and arson, the latter at the home of her former therapist. The author was the fourth forensic evaluator in the case. Disagreements included whether the defendant met diagnostic criteria for DID or was malingering, and whether she was CTS and/or NGRI. In clinical work with DID, “the whole human being” is held responsible for all behavior, despite reported amnesia or lack of subjective agency. The Discrete Behavioral States (DBS) model of DID avoids reification of the DID self states and their conflation as separate “people.” This model supports evaluating the defendant at the level of specific self states, the self-state system, and that of the whole human being. The author concluded that the defendant met diagnostic criteria for DID and also was malingering its severity. She was competent to stand trial and legally sane.
Thesis
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Cette thèse sur travaux aborde les troubles dissociatifs tels que décrits par les classifications internationales DSM et CIM à travers dix articles. Dans ce domaine une définition claire de la dissociation s’impose et nous suivons en cela la théorie de la dissociation structurelle de la personnalité. Celle-ci propose que, dans les suites d’une situation traumatisante et par un échec d’intégration, la personnalité d’un sujet peut se diviser (se dissocier), en plusieurs parties dissociatives : une partie dite ‘partie apparemment normale’ continue de s’engager dans des actions de la vie quotidienne et évite une ou plusieurs parties dissociatives dites ‘parties émotionnelles’ restées fixées sur la situation traumatique et qui s’engagent dans des actions ressemblant aux défenses animales face à une menace. La première partie de cette thèse se concentre sur la reconnaissance de ces troubles, en particulier du trouble dissociatif de l’identité qui est sans doute le trouble psychiatrique le plus controversé. Puis nous détaillons la conceptualisation des troubles dissociatifs selon la théorie de la dissociation structurelle de la personnalité. La deuxième partie de la thèse s’intéresse aux procédés diagnostiques des troubles dissociatifs. Un article présente l’étude de validité et de fiabilité du SCID-D, entretien semi-structuré pour le diagnostic des symptômes et troubles dissociatifs selon le DSM-5 et la CIM-11. Nous abordons aussi des procédés diagnostiques plus adaptés à des cas de trouble dissociatif nécessitant une approche au plus près de la singularité du patient. La troisième partie s’intéresse aux principes et moyens thérapeutiques utiles pour surmonter ces troubles sévères. Plusieurs articles sont présentés, en particulier sur le thème de l’intégration des souvenirs traumatiques et des parties dissociatives. Nous y décrivons dans le détail ces interventions thérapeutiques. Nous prenons également en compte les aspects relationnels complexes de ces situations cliniques, en particulier les aspects contre-transférentiels. Reconnaître, diagnostiquer et surmonter les troubles dissociatifs est un défi majeur pour les patients mais aussi pour les professionnels qui doivent souvent dépasser leurs fondamentaux théoriques pour rencontrer le patient dans une singularité inattendue. Il s’agit également d’un défi en termes de politique de santé publique et de formation des professionnels, puisque les troubles dissociatifs s’avèrent être des troubles fréquents et fortement invalidants.
Article
Background and Objectives Anecdotal and research evidence suggests that individuals with dissociative symptoms exhibit hyperassociativity, which might explain several key features of their condition. The aim of our study was to investigate the link between dissociative tendencies and hyperassociativity among college students. Methods The study (n = 118) entailed various measures of hyperassociativity, measures of dissociative tendencies, depressive experiences, unusual sleep experiences, cognitive failures, and alexithymia. Results We found a positive association between dissociative experiences (i.e., depersonalization) and hyperassociativity specific for associative fluency and associative flexibility tasks (including neutral and valenced material), but not for a remote association task. We also found tentative evidence for cognitive failures and alexithymia explaining the link between hyperassociativity and daytime dissociation and nighttime unusual sleep experiences. Limitations Limitations include the use of hyperassociation tasks limited to verbal associations vs. imagistic associations, the lack of a measure of trauma history, and a sample limited to college students. Conclusion Our study reports a link between depersonalization and hyperassociativity on tasks that allow for free associations across different semantic domains, potentially explained by alexithymia and cognitive failures. This finding may, with replication, open the pathway to applied intervention studies.
Article
Land use, woodland and forestry policy continues to evolve in response to unfolding economic, social and environmental challenges and opportunities. Concerns about integration across the stakeholder landscape impacting delivery and implementation of policy are common. Competing public and private sector stakeholder goals, narratives and actions are problematic. Developing insights from a recent case study, we uncover fragmentation in narratives, tensions in priorities, and misunderstandings at multiple levels between stakeholders. We identify the corrective influence of ‘dissociative jolts’ to trigger stakeholder's self-realisation of the extent of their unintentionally diverse interpretations of policy. These ‘dissociative jolts’ moments triggered open discussion, debate and reflexive questioning by the participants, enabling them to constructively contest their differences. In doing so, the participants were able to challenge and deconstruct their assumptions, reconstruct and develop new, shared understanding without trauma or denial. The structured mechanisms and formalisms of the intuitive-logics scenario planning approach provided a psychologically safe space with openness and equality of input to surface, explore, question and defragment stakeholder assumptions and narratives. The outcome of this defragmentation process was the collective recognition of failure, if the situation did not change, the dissolution of observed tensions conflicts and dilemmas, and the negotiated agreement for future action by the diverse stakeholder group.
Chapter
Ideas about dissociation—the causes, including its role as sequelae of trauma—are viewed very differently by some clinicians and researchers. Yet, dissociation is a common symptom among trauma survivors. Like the theoretical camps in psychotherapy approaches, there are strong views on why some people develop problematic dissociation. I will discuss some of these controversies and will speak to research which suggests that dissociation can occur on a continuum of normal to excessive. I’ll provide some context for theoretical disagreements, which may stem from cultural and some mental health clinician’s and researcher’s historical tendency to disavow aspects of trauma, particularly childhood trauma. Finally, I will discuss treatment approaches for people with excessive dissociation.
Article
Study of the epidemiology of dissociation in children and adolescents is in its infancy. Extrapolation from existing data on adults and those studies done to date in adolescents leads to the conclusion that dissociative disorders may affect 5% to 10% of children and adolescents in the general population, with higher rates in a variety of high-risk populations. DID may affect 1% of adolescents in the general population and 5% of children and adolescents receiving psychiatric care for severe emotional disturbance. If these estimates are approximately accurate, it is evident that the vast majority of children and adolescents with dissociative disorders go undiagnosed when they receive mental health services.
Article
The Dissociative Disorders Interview Schedule (DDIS), a structured interview, has been developed to make DSM-IU diagnoses of the dissociative disorders, somatization disorder, major depressive episode, and borderline personality disorder. Additional items provide information about substance abuse, childhood physical and sexual abuse, and secondary features of multiple personality disorder, These items provide information useful in the differential diagnosis of dissociative disorders. The DDIS has an overall inter-rater reliability of 0.68, For the diagnosis of multiple personality disorder it has a specifity of 100% and a sensitivity of 90%.