DURING MY NINETEEN years of scientific research devoted to dissociation, I have been amazed at the amount of misinformation that has been dispensed to both the public and the professional community. No other field of medicine in modern times has been buried under such a mudslide of misconception, skepticism, and plain ignorance.
Part of the problem lies in the nature of dissociation itself. Dissociative disorders are so fascinating because they express the universal language of pain in an intensely imaginative and metaphorical way, yet at the same time they seem so bizarre and theatrical as to arouse incredulity. Before the SCID-D, diagnosing dissociative disorders was more of an art than a science. With no valid and reliable tool for accurate assessment, wary clinicians tended to shy away from treating dissociative disorders or deny their existence.
Another basis for the skepticism many clinicians have toward dissociative disorders, especially DID, can be found in the philosophical underpinnings of their traditional training. The presence of a variety of personality states that take control of a person’s thoughts and behavior at different times contradicts a long-held assumption. For years the thinking was that we should have one unitary personality, and skeptics are reluctant to question such a fundamental concept.
Yet another reason for clinicians’ skepticism toward dissociation may be their difficulty in accepting a history of trauma in their own lives. A growing number of therapists have acknowledged that they were attracted to the helping professions because as children they learned how to survive abuse or to be caretakers in compromised families. The connection between childhood trauma and dissociative disorders challenges them to look at themselves and their own histories from a potentially painful perspective. Rather than explore such anxiety-provoking issues, they may take cover in a mantle of skeptical “objectivity.”
We all know how nature abhors a vacuum. Unfortunately in the absence of scientific findings about dissociation disseminated to a public largely undiagnosed and untreated for the symptoms, mythology has rushed in to fill the breach. Following are the seven most common myths.
On the contrary, every one of us has probably experienced a perfectly normal dissociative episode any number of times in our lives. These include losing oneself in a novel and completely forgetting where one is; daydreaming while driving a car and arriving somewhere with no idea of how one got there; blanking out and forgetting a familiar name or missing part of a conversation; staring into space and losing track of time; not knowing whether a memory is real or from a dream; not being able to remember what one has just done; feeling as if one were a participant in what is happening and an observer watching it happen; looking in the mirror and seeing oneself as unfamiliar; moving automatically, like a robot; feeling as if one were watching oneself in a movie; having a dreamlike or unreal feeling about other people, objects, or the world around one; feeling that time is standing still.
Most often these symptoms occur as a natural reaction to trauma or stress or having a lot on one’s mind, pass quickly, and do not indicate the presence of a psychiatric disorder. For example, a study of ninety men and women reacting to the 1989 earthquake in the San Francisco area found that two-thirds had some kind of dissociative symptom, such as a distorted sense of time or a perception of the world as dreamlike. One in ten reported having an out-of-body experience, and close to half found themselves staring at an object in space, for example, a tree, and not knowing why.
In all, close to 25 percent of the general population have been found to experience mild to severe episodes of dissociation. If these episodes are short-lived and and do not recur often enough to become a cause of distress or dysfunction, they don’t signify the presence of a disorder. Dissociative symptoms are indicative of a serious disorder only when they have become maladaptive or recur persistently after they are no longer necessary for self-protection and adversely affect a person’s well-being or ability to function in daily life.
Recent studies have shown that far from being rare, dissociative disorders are much more prevalent than previously realized. Multiples, the most seriously affected, number as much as 1 percent of the general population, or more than 2.5 million people. This is a conservative estimate in light of how widely underdiagnosed dissociative disorders are. The true figure for the dissociation disorders is probably closer to 10 percent—as high as the one-year prevalence of major depression or generalized anxiety disorder, for which the dissociative disorders are often mistaken.
Few people make dissociative symptoms their primary complaint, because they are elusive and hard to describe, involving as they do a strange absence of feeling or a curious sense of reality. The symptoms may also remain hidden or silent because people vary greatly in how they experience them—some becoming so acclimated to them that they no longer find them disquieting and assume everyone has them. Sometimes the symptoms have such a demoralizing effect on peoples self-esteem that they develop an attitude of resignation toward them, throwing their hands up in the air and saying, “That’s life.” Actually, this feeling of helplessness is one reason why so many persons with dissociative disorders have been misdiagnosed as depressives.
Another factor that makes it hard to diagnose DID without administering a test like the SCID-D is that people suffering from a dissociative disorder often have a huge amount of denial. The garish stereotype of a multiple that has been implanted in their minds by Sybil and The Three Faces of Eve has had a chilling effect. Their worst fear is that if they talk about their symptoms to a therapist, they’ll immediately be labeled a freak or a crazy person.
Very often people who have separate parts of themselves keep them hidden, because they don’t think of them as well-defined personalities, but more as “aspects” of their own personalities or different internal “voices” or puzzling “sides” of themselves with which they’re not in touch all the time. If they perceive these fragments as vague, amorphous, or shadowy—no matter how troubling—they may dismiss them as simply figments of an overheated imagination. The reason many multiples are misdiagnosed as manic-depressives is that the uncontrollable mood swings and “temper tantrums” they complain of are actually the outbursts of a personality fragment carrying all of the rage associated with childhood abuse.
Although people are rarely quick to complain about their dissociative symptoms to their therapists, the fact is that these episodes occur in many patients who have been diagnosed with other psychiatric problems. They may well indicate a more fundamental dissociative disorder that has to be dealt with before any lasting recovery can be achieved.
The person suffering from a dissociative disorder is a far cry from the distorted image of the bizarre multiple grossly switching from one personality to another on sensationalistic TV talk shows. The fact is that multiples run the gamut from Ph.D.’s to prostitutes and are generally highly intelligent, creative, brave, articulate, and likable. Many are accomplished professionals, married, raising children, and holding down responsible jobs. Most of the time they don’t engage in public displays of shocking, uncontrollable behavior. If they switch at all, it is usually in the privacy of their own home or in confidential sessions with a therapist whom they’ve learned to trust. Otherwise the changes in voice, speech patterns, comportment, and dress signaling that an alter personality has taken control are subtle.
Multiples are able to function at a high level and “pass” as healthy by dint of an elaborate inner world and exhausting always-on-guard compensatory strategies for avoiding detection by others. Tortured by an unspeakable past, they endure the daily agonizing struggles of a present lived in secret shame. The person you’d be least likely to expect—a neighbor, loved one, friend, coworker or boss—might very well be someone secretly struggling with the demons of a dissociative disorder.
The fact is that most abuse survivors seek treatment due to memories of abuse that existed prior to treatment. Though abuse of children is widespread, disbelief about its existence continues. In the United States, close to 1 million children were victims of confirmed child abuse and neglect for each year from 1900 to 1997. Add to that the 4 million women who are victims of severe assaults by boyfriends and husbands each year, as reported by the American Medical Association, and it should come as no surprise that when these people enter treatment, they will report having memories of being abused. Over half of survivors entering therapy report that they have had continuous memories of childhood sexual abuse. Intrusion of traumatic memories often leads people to seek psychotherapy. Because what survivors experienced in childhood was too painful for them to bear, survivors may have partial amnesia for some aspects of their abuse and may not necessarily remember details, such as dates, but will remember the overall gist of their trauma.
In recent years, the controversy over recovered abuse memories has created a groundswell of bias and misunderstanding about trauma and dissociation and is an unfortunate diversion from legitimate claims and treatment. Accusations of therapists’ induction of false memories have magnified limitations in the field that no longer exist. Thanks to advances, clinicians now have the benefit of diagnostic and screening tools, cutting-edge research on the physiological effects of trauma, and specific treatment guidelines. By asking nonleading, open-ended questions that result in spontaneous responses from patients about their traumatic experiences, both in the SCID-D diagnostic process and throughout treatment, therapists can minimize the risk of false memories.
Even “retractors”—people who retrieve memories of abuse, only to claim later on that some memory they retrieved is false—may have some abuse or trauma in their histories. The accuracy of abuse memories has been confirmed in some cases with police or medical reports and by witnesses of the abuse. Today’s more sophisticated and stringent guidelines for assessing and treating dissociative disorders, however, should result in earlier detection of dissociative symptoms and an increasing number of successful outcomes for abuse survivors. Currently, appropriate treatment would focus on helping the patient reduce the severity of dissociative symptoms, alleviate stress associated with whatever memories of abuse he or she has, and restore functioning rather than focusing on identifying specific memories.
Claims of false memories and retractions of abuse have to be seen in the context in which they are made. Even when there are confessions by perpetrators and substantial physical evidence of abuse, children can retract their disclosures as a way of dealing with their confusion and psychological pain. Adult victims who confront their families about the abuse are often met with denial and coercion to retract their allegations. Parents, siblings or grandparents who have abused a child in the family may be so ashamed of what they’ve done that they cannot admit it to themselves. Clinical experience shows that perpetrators are far more likely to suppress the truth about their abuse than their victims are to fabricate it.
Pressure to remain silent about traumatic events plays a significant role in provoking amnesia for them. When a father repeatedly forces his young daughter to have sex and warns her, “If you talk about this, I’ll kill you,” or the girl reports the abuse and is told, “You’re lying,” the girl is prompted to split the memory of the trauma off from consciousness. She forgets it, because she fears being driven crazy by acts of betrayal too painful to bear. Forced to live with a terrible secret and made mute by the fear of reprisal, she is unable to find comfort or enlist anyone to come to her rescue.
The failure to report abuse does not mean that people have forgotten it. The fact is that most victims do not report abuse at all. In a study conducted at the University of Colorado at Boulder in 1995, researchers found that only 8 percent of men and 22 percent of women who described experiencing sexually abusive events in childhood identified themselves as “abused.” Of those who described experiencing physical abuse, including being beaten, punched, kicked, and threatened with a weapon by a parent, only 5 percent of men and 9 percent of women identified themselves as “abused.” A 1994 study of 129 women with sexual abuse histories (documented by ER visits) found that when they were interviewed seventeen years later, 38 percent of these women did not recall their abuse. These were women whose abuse was so severe that it necessitated visits to hospital emergency rooms. We can only imagine how many others suffered in silence at home.
People with histories of childhood abuse are not eager to talk about it. Or they can’t. For every person who has a supposedly false memory of abuse, there are millions of people who’ve been so debilitated by childhood abuse, whether they are mentally impaired, in chronic psychiatric institutions, or homeless on the street, that they will never speak a word of it to anyone.
Ironically, researchers’ findings that people forget the details of a traumatic event but not that it happened best answers the question so often asked by skeptics: How can a person completely forget something as outrageous as sexual abuse and then suddenly remember it years later? The point is, the person doesn’t forget it completely. Many adults with histories of childhood abuse have times during their lives when they’ve forgotten or nearly forgotten the abuse, but very few have consistently forgotten about it throughout their lives. What generally happens is that they experience a breakthrough of intrusive but fragmented impressions of the abuse with intermittent periods of forgetting. Most disclosures of sexual abuse are not based on “recovered” memories magically pulled from storage like rabbits out of hats, but on a process of remembering, forgetting, and remembering that is customary for recalling traumatic memories.
Memories like those of sexual abuse have a life of their own. As fear-imprinted memories, they are not recorded coherently on a mental “videotape,” as factual memories are encoded by the thinking part of the brain. Incapable of thought, the tiny mass of gray matter called the amygdala shapes and stores traumatic memories in the limbic part of the brain, which processes emotions and sensations, but not language or speech. As a result, survivors of childhood abuse may carry implicit physiological memories of the terror, pain, and sadness generated by the abuse but may have few or no explicit factual memories to explain their flashbacks and the feelings and sensations they arouse. They live with the repercussions of the event without having a narrative—this is what happened at this time at such-and-such a place—to provide a back story. Memories of traumatic experiences are not retrieved so much as they intrude. They pop up in jagged impressionistic fragments overloaded with sensations and emotions that can distort the details. The memory that abuse occurred usually remains intact over time—and is real.
Another question often heard from people who doubt the veracity of abuse disclosures is, Why do some trauma survivors remember their experience without any blanks at all, and others have amnesia for it? In other words, why doesn’t everyone dissociate the memories of trauma? Obviously those who are more driven to avoid the stressful thoughts and feelings related to the trauma are more likely to have memory blanks for the event or its most threatening aspects. There are three main factors that influence this propensity toward dissociative amnesia: the nature of the traumatic events, their frequency, and the age of the person experiencing them.
A child sexually abused by a parent who warns that disclosure means death has good reason to develop amnesia for the trauma. By comparison, a woman raped by a stranger who slips into her apartment and assaults her at knife point may suffer severe posttraumatic stress, but if her family and friends rally around her and offer sympathy and support as she recounts the dreadful experience, she has no need to dismiss it from memory.
Random disasters, like earthquakes or plane crashes, are impersonal in nature and less likely to be dissociated than trauma inflicted on someone willfully by another human being, such as sexual abuse or torture. A traumatic single event, such as a rape or witnessing of a violent death, or narrowly escaping the loss of one’s own life in an accident, is less likely to be dissociated than repetitive traumas, such as ongoing physical or sexual abuse or lengthy military combat, which often result in amnesia. Adults who experience traumatic events are not as likely to dissociate memories of them as are children who experience trauma. Since a child’s brain and central nervous system are too immature to process the overwhelming fear, pain, and excitement that repeated sexual trauma engenders, the younger a child is when the trauma occurs, the more likely it is that the event will be dissociated.
All scientific investigations support the fact that DID is a real illness with a consistent pattern of symptoms, a characteristic course, and chronic impairment if untreated. The SCID-D field trials provided evidence that DID is a real illness with clinically measurable symptoms. Subjects gave elaborate descriptions to substantiate all dissociative symptoms they claimed to have. Independent researchers around the world, using the SCID-D and a variety of other measures, have documented virtually identical symptom profiles in people with DID. On the other hand, the myth that DID is not a real illness is based on anecdotal information or misinformation as well as unjustified conclusions by investigators who do laboratory research on college student volunteers rather than psychiatric patients. Although these experiments show that isolated symptoms, like using an alternate name, can be shaped by asking leading questions, they offer no proof that the full clinical syndrome of DID can be faked.
The idea that people can successfully fake or exaggerate multiple personalities was soundly disproved by Dr. George Fraser, M.D., and associates in a 1999 study. Using the SCID-D and other psychological tests, the research project detected individuals asked to fake multiple personalities in a group consisting of the pretenders, DID patients, schizophrenics, and normal people. On the SCID-D 100 percent of the true DID patients were diagnosed with DID, and none of the pretenders or the normals was.
People who are now professing that “Sybil” was not a real multiple, but a highly suggestible person who was faking her symptoms to please her therapist, are guilty of hearsay and pseudoscience posing as authentic research. Her psychiatrist, Dr. Cornelia B. Wilbur, M.D., former professor of psychiatry at the Medical School of the University of Kentucky, has since died and is unable to defend her diagnosis and treatment of her famous patient. Sybil’s therapy took place in the days before we had modern tests that would have proven whether she was a real multiple or not. However, her symptoms described in the book based on her case are typical of patients who have been accurately diagnosed with DID.
DID patients have a good prognosis for recovery once they are accurately diagnosed and treated appropriately. The problem has been the failure of many clinicians to make an accurate diagnosis. Now, with the SCID-D, this problem can be eliminated. The questionnaires in this book will make it possible for you to identify symptoms in yourself or in a loved one that might have been unnamed or unnoticed before and were therefore untreatable.
The most effective treatment for DID is a combination of highly specialized psychotherapy and drug therapy. Antidepressants and antianxiety medication are frequently used to help alleviate the emotional numbness, depression, or turmoil associated with the disorder. The psychotherapy, contrary to a popular misconception, is not concentrated on recovering memories of abuse. It isn’t necessary for a person to dredge up more memories than she is prepared to handle, nor to remember all the details. What is necessary is knowing how to comfort oneself when distressing memories or emotions emerge.
Recovery is a challenging process that takes time—an average of three to five years of weekly sessions. The results can be enormously gratifying and transformative, especially when you consider that many people with DID spend long years of their lives in treatment for panic attacks, OCD, depression, anxiety disorders, bipolar disorder, ADHD, and even schizophrenia without this kind of progress.
The in-depth case histories of three of my patients that appear later in the book are enlightening examples of how people with a dissociative disorder can recover. They’re proof of the extraordinary power of the human mind both to defend itself against inhumanity and to recover from the wounds sustained in that life-or-death battle.
