CHAPTER 6

Cause

“NEVER in the history of psychiatry have we ever come to know so well the specific etiology of a major illness, its natural course, its treatment.” This remarkable statement was made in 1989 by Richard Loewenstein, when he was president of the ISSMP&D.1 In the course of twenty years an illness had passed from being virtually unknown to being better understood than any other mental malady.

Etiology is defined as that branch of medicine which deals with the causes or origins of disease. Causation matters to the practitioner because the most effective treatment of a disease usually relies on a knowledge of its causes. Knowledge of causes helps us prevent illness. But causation also matters to theory. When we know the causes we feel confident that we have identified a disease entity, something more than a cluster of symptoms. How did the knowledge of the cause of multiple personality come into being? It was not a matter of simple discovery. Since so few people worked in the field in the early days, we can watch the development of this central piece of knowledge about multiplicity.

There are different types of causal knowledge. We know the causes of individual events, and we know general laws of causation. To be totally simplistic, when historians discuss the causes of a historical event—they seldom do—they invoke other individual events. (Parody: the shot at Sarajevo caused the outbreak of the Great War.) When physicists speak of causation—they seldom do—they are usually concerned with causal laws that hold universally or with a definite degree of probability. The simplest statements of an individual cause will be of the form “This event or condition A caused or produced that event or condition B.” Such causal questions interest clinicians and patients: I want to know what made me ill. Philosophers argue that statements of individual causes are warranted only when there is a general causal statement in the background.2 Such a general statement might be nothing more than “Events or conditions like A tend to produce events or conditions like B.”

When we speak of etiology, we mean something more than a clinical judgment that on a certain occasion event A caused event B. Etiology has to do with warranted judgments of causality, and so it demands generality. We ought, however, to be very tolerant about the logical form of such generalizations. Causal generalizations lie between extremes. At one end is the strictly universal: Whenever there is an event or condition of kind K, then there results an event or condition of kind J. Old-fashioned physics preferred laws like that. At the other end are truly modest statements of fairly necessary conditions: Without events or conditions of kind K, events or conditions of kind J are unlikely to occur. In between we have probabilities and tendencies.

“Never in the history of psychiatry,” said Loewenstein, “have we ever come to know so well the specific etiology of a major illness.” His assertion demands that some general causal statement about this major illness be in the background. But it does not demand anything as stringent as strict universality. A fairly necessary condition is sufficient. That is surely what Loewenstein meant. His fairly necessary condition might be this: “Without severe and repeated childhood trauma, typically of a sexual sort, multiple personality is not likely to appear.” The specific etiology of which Loewenstein speaks never goes beyond fairly-necessary-conditions. No one should demand more of psychology. We should, however, be put on our guard against rhetoric. “Specific etiology” sounds very impressive. It sounds as if we are getting to the other extreme of causal statements, to strictly universal statements. Not at all. Loewenstein’s specific etiology is the weakest imaginable etiology.

The fairly-necessary-condition evolved together with the characterization of multiple personality. Consider a careful statement by Cornelia Wilbur and Richard Kluft. “MPD is most parsimoniously understood as a posttraumatic dissociative disorder of childhood onset.”3 Here the childhood onset and the presence of trauma are not parts of an empirical generalization or a statistically checkable fairly-necessary-condition. They are part of the authors’ understanding of multiple personality disorder, part of what they mean by “MPD.” There is nothing methodologically or scientifically wrong with this. I warn only against having it both ways. There is a tendency (a) to define the concept “MPD” (or dissociative identity disorder) in terms of early childhood trauma, and (b) to state, as if it were a discovery, that multiple personality is caused (in the sense of fairly-necessary-condition) by childhood trauma. We should not delude ourselves into thinking that we first defined the disorder and then discovered its cause.

I have just spoken of definitions. That is not quite right. Very seldom is definition the right concept in psychiatry. The linguists’ idea of a prototype is more serviceable. Child sexual abuse became part of the prototype of multiple personality. That is, if you were giving a best example of a multiple, you would include child abuse as one feature of the example. It is easy to confirm the impression that when clinicians of multiples give an example of a client and cite a causal event, they regularly mention child sexual abuse. People are most revealing when they are very slightly off guard—for instance, when they are not formally discussing causes but mention causes in passing. The way in which a prototype comes into play is striking when an authority is not trying to be scientific, but just lets the common understanding slip out. Here are two examples, chosen from two experts who are not doctrinaire. Both remarks date from 1993, and not from the years of early enthusiasms, the mid-eighties.

A psychologist mentions, in an aside, a thirty-eight-year-old woman who, while in his office, switches into a thirteen-year-old boy who is in her uncle’s house. She then reenacts an anal rape. Or a psychiatrist, describing research on post-traumatic stress disorder in connection with the San Francisco Bay area earthquake of 1991, lets out, as an anecdote, that at the time of the earthquake he was treating a heavy woman. She switched into a six-year-old, thinking the rumble of the quake was the stumbling drunken footsteps of her childhood molesters. He had to get her out of the building, which, in her alter state, was no mean task.4 My two examples are not intended to establish current scientific teaching about multiplicity and abuse. They show how the ideas are associated in the talk of serious contributors to the field. Just as people, at least those who live in Atlanta or the Bay area, do not say “ostrich” when wanting to mention an example of a bird, so it seems that clinicians do not casually give nonabused patients as examples of multiples. Of course ostriches are birds, and known to be so, and there are nonabused multiples, but they are not prototypical.

The connection between abuse and multiplicity became stronger and stronger during the 1970s, just when the meaning of “child abuse” moved from the prototype of battered babies through the full range of physical abuse and gradually centered on sexual abuse. As a point of logic it is useful to see how concepts are used to lift themselves up by their own bootstraps. That sounds highly figurative, but consider this. In a 1986 essay Wilbur wrote, “In discussing the psychoanalysis of MPD, Marmer (1980) pointed out that childhood trauma is central and causal.”5 In fact Steven Marmer had ended his prizewinning essay by posing some questions. He said that in recent previous reports of multiplicity “childhood trauma is central and causal.” He did not “point out” that trauma is, as a sort of law of nature, central and causal; he said that it appeared in previous cases. He proposed as a topic for future research the question of whether this was generally true. And what were the recent cases to which he referred? Wilbur was a primary reference.6 I am not now questioning whether childhood trauma is central and causal. I am making an observation about the use of evidence in the firming up of a conceptual connection. How does it happen? In part, by circular self-support.

Marmer’s psychoanalysis of a multiple is beautifully and simply described. It may also be something of a cautionary tale. His patient was a gifted and artistic Los Angeles woman from a culturally endowed New York family. She saw both of her parents as having two sides to their characters. She was forty-one and had been in therapy when she was much younger, but was now experiencing familial and other crises. Three distinct personalities did emerge in the course of a year or so of intense analysis. The analysis unfolded in a rather classic way, making rich use of dreams, and complete with a primal scene in which the young child interrupts her parents making love. Marmer was careful to enter a caveat that he was not committed to the “historical ‘truth’” of this event. Those are his quotation marks around “truth.”

The central crisis of his patient’s young life was the death of her father when she was eight. At one stage in the analysis she acquired a belief that she had been raped by strange teenagers in the hours after this event. Marmer listened and let the memories work themselves out. As the analysis proceeded, these recollections dissolved into a fantasy that had briefly and conveniently covered over what the woman later came to believe had happened. Immediately after the death she had been forced to be alone in a room with her teddy bear; she had gone out and run through an underground tunnel to an open space. Part of her had been desperately denying her father’s death. She had run screaming up to a stranger in a raincoat, crying, “You’re my daddy, you’re all right, aren’t you,” and had been brusquely turned away. These events—the death of her father, her anguish, loneliness, and temporary abandonment—formed that aspect of her life with which she left analysis.

Marmer’s description is far richer than my summary and naturally involves the child’s ambivalent love for her parents, their two sides, the primal scene, and so forth. But the father’s death, followed by her abandonment for three hours, was the central trauma. According to Marmer there never was a rape or literal sexual abuse. Why should we believe a Freudian, given Freud’s infamous denial of his own 1893 theory on the cause of hysteria, namely, sexual assault in childhood? We don’t have to believe him: Wilbur cited this case report with apparent approval. Marmer made no assumption about the historical truth of the memories; quite the contrary. Yet his case became part of the evidence that actual historical sexual trauma causes multiple personality.7

The connection between multiple personality and real, not fantasized, child abuse was cemented in clinical journals throughout the 1980s. By 1982 there were vivid musterings of data about the relationship between incest and multiple personality.8 Philip Coons had stated the connection cautiously in a paper of 1980; in his classic 1984 essay on differential diagnosis of multiple personality, he wrote that “the onset of multiple personality is early in childhood, and is often associated with physical and sexual abuse.”9 At that time no child multiples were known—none. But the hunt was on. The first in what is now a long series of books of contributed papers about multiple personality had a fitting title: Childhood Antecedents of Multiple Personality.10

It is worth reading the text, line by line, of Frank Putnam’s exemplary clinical textbook of 1989, Diagnosis and Treatment of Multiple Personality Disorder. Line-by-line readings of any text inevitably make one ask, What did the author mean here? I do not intend to be querulous. This book is universally acknowledged as the best in the field. Putnam begins his chapter on etiology with the words “MPD appears to be a psychobiological response to a relatively specific set of experiences occurring within a circumscribed developmental window.”11 Psychobiological? Thus far, no biological concomitants specific to multiple personality have been sustained. Putnam’s sentence is intended to get at two distinct propositions. First, there is a systematic connection between multiplicity and childhood trauma. But why is that psychobiological?

The answer lies in a second proposition from the traumatic stress literature. Something is known about the brain chemistry of terrified animals. Rats subjected to inescapable electric shocks are paralyzed by fear, and this reaction is correlated with the depletion of important brain chemicals. Moreover, the behavior of the rats is said to resemble that of war veterans diagnosed with post-traumatic stress disorder. From a study of “the psychobiology of the trauma response,” Putnam quotes the assertion that “the symptoms of hyper-reactivity (i.e. startle responses, explosive outbursts, nightmares, and intrusive recollections) in humans resemble those produced by chronic nonadrenergic hypersensitivity following transient catecholamine depletion after acute trauma in animals.”12 It is a reasonable research guess that human hyperreactivity (psychological) is paralleled by chemical changes in traumatized rats. But it is not knowledge.

Putnam did not develop the psychobiology theme in his book. He mentioned a fascinating research program and then turned to clinical experience. “The linkage between childhood trauma and MPD,” he writes, “has slowly emerged in the clinical literature over the last 100 years, although this association is obvious to any clinician who has worked with several cases.” The first part of that statement needs clarification.

The connection between psychological trauma and hysteria had certainly been in place for a century when Putnam wrote his book—almost exactly a century. We find it in the work of Pierre Janet, more famously in Breuer and Freud, and in forgotten predecessors whom I discuss in chapter 13. The linkage of trauma and hysteria became firmly established about 1889. But Putnam was not speaking of that time. Rather, he had in mind the way in which, very occasionally, painful life experiences—such as parental death—occur in some early-twentieth-century reports of multiple personality. Traumatic abuse seems absent until, as Putnam notes, H. H. Goddard’s 1921 patient Bernice R. That young woman had no problem with repressed memories; she spoke directly about incest with her father. But Goddard thought his patient was imagining things, and used hypnotic suggestion to convince her that no such thing had ever happened.13 During the 1920s no one of any influence took actual sexual abuse very seriously, and so it did not figure in the multiple personality case literature. We see sexual trauma in the history of Bernice, but her psychologist did not. Putnam continues, “It was not until the 1970s that the first reports clearly connecting MPD to childhood trauma began to appear in single case histories.” That is, the connection followed in the wake of consciousness-raising about child abuse. The linkage between childhood trauma and multiple personality did not emerge slowly over one hundred years. It came into being almost suddenly, in the 1970s.

After that time multiple personality became very firmly associated with childhood trauma, but association is not causation. Putnam offers “a developmental model of multiple personality.” Models are to be welcomed: often, in the natural sciences, it is in simplified models of reality that we get the clearest grasp of causal laws.14 Perhaps the very word “model” implicitly carries the cachet, if not of models in physics and cosmology, at least of statistical or economic models. But Putnam’s model is not like physics or economics. It is a story. It is a story in a time-honored tradition, a story that explains by telling how things originated. Like Genesis, the first book of the Bible.

“The evidence suggests” to Putnam “that we are all born with the potential for multiple personalities and over the course of normal development we more or less succeed in consolidating an integrated sense of self.” What evidence? Putnam refers to one important school of “infant-consciousness researchers [who] have evolved an agreed-upon taxonomy of newborn infant behavioral states.” He finds that the ways in which infants change states exhibit “psychophysiological properties” that resemble those which occur when alters switch personalities.15 Psychophysiology is more directly observable than the psychobiology alluded to earlier. It means change in facial expression, demeanor, muscle tension, and the like.

Putnam has an eminently plausible story of growing up. The baby, then the child, manages to “consolidate self and identity.” Multiple personality is proposed as failure at this “developmental task.” Putnam then turns to a “second normative process”—the first one, presumably, being the process of consolidating self. The word “normative” is not used in the dictionary meaning, “Of, relating to, or prescribing a norm or standard.” Since Putnam uses the word in contrast to “pathological” he must mean not “normative,” but “normal,” viz. “conforming with, adhering to, or constituting a norm, standard, pattern, level or type; typical.”16 What Putnam calls the second normative process is the “propensity of the child to enter into a specific kind of state of consciousness, the dissociative state.” He is saying that this is normal, ordinary, but can become pathological. Such states are characterized by “significant alterations in the integrative functions of memory for thoughts, feelings or actions, and significant alterations in the sense of self.” Thus far they are ordinary and healthy (not pathological, anyway). Adults who spontaneously dissociate tend to have a capacity “to enter voluntary hypnotic states.” Children are more readily hypnotized than adults and are most hypnotizable around nine or ten years of age. Hence if children make use of ordinary and commonplace dissociation to cope with stress, they may do it best at that time in their lives.

The third “normative development substrate” is the ability of children to fantasize. Some children invent imaginary playmates or companions (most recently immortalized in the comic strip Calvin and Hobbes). In the early eighties the imaginary playmate who stayed on was proposed as a source of an alter personality. The suggestion seems to have been too benign to account for the horror in the lives of multiples, and this conjecture has been largely discarded. Putnam still had to discuss it when he was writing his textbook, published in 1989, where he calls the idea “tantalizing but ambiguous.”

With this story of development in place, we have room for a relation between multiple personality and overwhelming trauma. A child copes by heightening the separation between behavioral states “in order to compartmentalize overwhelming affects and memories generated by the trauma.” Children may in a sense deliberately enter into dissociative states. In addition, parents and caretakers play an active role in helping their child “enter and sustain appropriate behavioral states.” The child abuse that is prototypically associated with multiples comes from people who ought to have been caring for the child, and ought to be deserving of trust. “It is easy to speculate that the bad parenting accompanying abuse fails to aid the child in learning to modulate behavioral states.” Finally, the dissociated states get firmed up and take on their own characters. “One can easily conceive of these dissociated states, each imbued with a specific sense of self, being elaborated over time as a child repeatedly re-enters a given state to escape from trauma.” This may be the only way in which the child can carry on; it may be “life-saving,” says Putnam. “It becomes maladaptive, however, in an adult world that stresses continuity of memory, behavior, and sense of self.”

Putnam has carefully hedged his discussion with such qualifiers as “it is easy to speculate,” “one can easily conceive of,” and “one can postulate.” Yet the reader tends to discard these phrases and the innumerable “may”s and “possibly”s. This is how it is—without qualification. This is how the child dissociates. This is the causal effect of trauma. In a book published the next year Denis Donovan and Deborah McIntyre quote and paraphrase Putnam’s discussion at length, but manage to omit every single qualifier. Within one year speculation and postulation had come to be cited as fact.17

Thus Loewenstein’s “specific etiology” is a self-sustaining and self-confirming etiology. A certain picture of origins is imparted to disturbed and unhappy people, who then use it to reorder or reorganize their conception of their past. It becomes their past. I am not saying that their past is directly created by doctors. I am saying that this picture becomes disseminated as a way of thinking of what it was like to be a child and to grow up. There is no canonical way to think of our own past. In the endless quest for order and structure, we grasp at whatever picture is floating by and put our past into its frame.

There is an abbreviated version of this account of development and the past, Kluft’s Four-Factor Model of Multiple Personality Disorder. Instead of one fairly necessary causal condition, we get four. According to Kluft, multiple personality “begins in childhood and occurs when (1) a child able to dissociate is exposed to overwhelming stimuli; (2) these cannot be managed by less drastic defenses; (3) dissociated contents become linked to underlying substrates for personality organization; and (4) there are no restorative influences, or there are too many ‘double-binds.’”18

We should notice the phrase “a child able to dissociate.” There are many suggestions, in the literature, that degrees of this ability are innate, inherited. There are two parts to this suggestion. The first is that dissociation comes in degrees, as if everyone could be arranged in a line, with the most dissociation-prone at one end, and the least dissociation-prone at the other. This proposition is defended by work on the measurement of dissociation. I discuss that in the next chapter, and show how measurement and causation support each other. Once the assumption is made that dissociation is linear, a matter of more or less, there appears the second part of the suggestion, that these degrees can be inherited. That is interesting, but such genetically oriented claims are extraordinarily difficult to substantiate. We must be very careful about spurious correlations. For example, one might find that multiple personality runs in families. But the explanation might be that members of a family go to the same group of therapists who specialize in multiples.

What evidence might bear on the models of Putnam or Kluft? One kind would be very general. Childhood trauma, and particularly repeated sexual abuse, might be shown to have specific psychiatric sequelae in adulthood. There is an immense amount of folklore on this issue, but my survey in chapter 4 suggests that there is very little agreed stable and specific knowledge about such effects. The most promising venue is current research on post-traumatic stress disorder. This approach was favored by David Spiegel from the beginning, and it is not at all clear that it leads us in the direction of understanding multiple personality. It is no accident that Spiegel himself helped rename multiple personality, or that he discounts the idea of fully rounded alters. He sees the problem as one of integrating a person who has broken down; the breakdown is connected with a terrible early life. That may well be the future of multiple personality. But whereas the florid multiple personality of the 1980s seemed to demand something like the models of Kluft or Putnam, Spiegel’s potential future for the disorder may not need anything of the sort.

A second type of evidence for models like those of Putnam and Kluft is based on clinical experience. Clinicians find it absolutely compelling. As Putnam wrote, “this association is obvious to any clinician who has worked with several cases.” Patients themselves come, in therapy, to describe their dissociation in ways that conform to these pictures. A therapist can hardly resist such evidence, and yet there is reason to worry that the process of therapy and healing concretizes a story into a fact.

A third type of evidence would come from examining multiple personality as it develops in children. If multiple personality has its onset in childhood, then it should be possible to elicit it at that time. Treatment should be easier, and adult disintegration could be precluded. It becomes an obligation—indeed a therapeutic imperative—for therapists to seek multiplicity in children, where the alters or personality fragments will not be so entrenched. There is also a great theoretical incentive for finding child multiples, for they would confirm the models of how multiple personality originates. The hunt was on for child multiples. One leader in this field has been Gary Peterson, who proposed the first diagnostic guidelines.19 Peterson is chair of the ISSMP&D committee on child multiple personality disorder and is leading the campaign to have the disorder introduced into the next Diagnostic and Statistical Manual, DSM-V. The campaign failed for DSM-IV, although that volume does contain a passing acknowledgment of the possibility of such a condition.

A skeptic will observe that throughout the twentieth century, child multiple personality disorder was absolutely unknown until a certain account of multiple personality emerged in the 1980s. Such a skeptic could well be picking up the wrong end of the stick. The physical sciences abound with examples of phenomena that no one noticed until there was a theory to make one look. It could be one of the strengths of Putnam’s account that it makes us examine disturbed children more closely, to see if they are nascent multiples.

So let us look at two different views about whether some disturbed and suffering children should be treated as if they had alter personalities. One clinician respects indications that the child may have a dissociated side of herself, and makes use of that in the treatment. Another pair of clinicians discourages the appearance of alters. I do not wish to imply that one approach is more clinically sound than the other. The first example is a girl of nine named “Jane.”20 Her parents were appalled by her grossly aggressive behavior. They alleged that she had multiple food allergies. In fact, however, she appeared to have been starved. The family environment was not a happy one, with a deserting father, a stepfather, and plenty of indifference and cruelty. Her school did not regard her as having the behavior problems complained of by her parents, but instead reported her to be withdrawn and isolative. When she was treated after being placed in a foster home, her reported eating problems and food allergies disappeared. Her therapist asked Jane if she had been abused. No. But she played knowingly with anatomically correct dolls. She came to speak of a Bad Sister who did bad things. Then Jane spoke in the voice of the Bad Sister; yes, she had indeed had sex and enjoyed it thoroughly. The therapist read stories about a girl who had used the help of “invisible friends” to deal with bad things. Jane listened attentively. She acknowledged that she too employed such a strategy. Soon after, she was able to abandon the dissociative defenses and was better able to interact normally with children her own age.

Jane’s therapist evidently helped Jane heal. “Bad Sister,” on this view, indicated a part of Jane that had dissociated. The therapist worked with Jane to make her conscious of this part of herself and the memories and experiences associated with it. When the girl was able to face these events as having occurred to her, and to bring the dissociated Bad Sister to the surface, she was able to accept her own abuse and was no longer isolated and withdrawn at school nor violent and aggressive in her new stable home environment. Now consider another approach. Twelve-year-old “Sally Brown” was viciously aggressive and exhibited uncontrollable switching and other dissociative behavior. She was adopted by the Browns from a foster home, where she had been placed because her mother, father, and mother’s boyfriends abused her both physically and sexually. For well over a year an enormous sum had been spent on testing, hospitalization, and treatment. She was repeatedly diagnosed with multiple personality disorder. Because she did not respond to any type of therapy, the Browns called a number of experts on multiple personality. They were eventually referred to Donovan and McIntyre, a psychiatrist and a psychotherapist.

Donovan and McIntyre hold that the usual process of confirming a diagnosis of child multiple personality strongly reinforces dissociation. They do not attempt to elicit any kind of pathological behavior. Instead they try, as they put it, “to mobilize learning, growth, adaptation, health, and change.” Whenever Sally answered a question with “I don’t know” when they were taking her history, Donovan or McIntyre replied, “You’re kidding!” As a result Sally cheerfully answered most of the questions and displayed none of her usual abrupt changes in consciousness. When Mrs. Brown discussed Sally’s life in school, she said, “We’re not doing too well in that area,” Donovan and McIntyre made fun of the “we” because it muddles how many people there are, and who. When Mrs. Brown referred to herself as “Mommy” in the third person, as if that were another person, they pointed out the equation this suggested: Mrs. Brown = Mommy = Sally’s biological mother (far away, who had beaten Sally). Mrs. Brown thereby invited Sally to punish Mrs. Brown for the biological mother’s behavior. When Mrs. Brown spoke of “the real mother,” one of the therapists remarked, in Sally’s presence, that real mothers protect their children. In short, Donovan and McIntyre redefined Sally’s relations to her adoptive mother and blocked dissociative behavior.

It is a general strategy of Donovan and McIntyre’s Healing the Hurt Child to use straight talk. When Mrs. Brown said to Sally, “Can you tell them …” (suggesting that maybe Sally could not tell them), the two clinicians insisted on “Tell them….” It was made plain that Sally’s previous therapies did not have to be accepted, and that she could carry on in the new straightforward way outside the office, at home. This made it increasingly hard for Sally to forget, space out, or blur boundaries within or between persons.

Donovan and McIntyre use their sense of how a child, not an adult, thinks, finds out, and behaves; they rely on what they call the normal “childhood capacity for adaptive-integrative-transformative change.” This approach is altogether different from identifying, meeting, and negotiating with child alters, or bargaining with them to get along with each other. After a second two-hour session on the first afternoon, Sally found it hard to dissociate. By the end of the final hour-and-a-half session the next day, she could no longer dissociate. Donovan and McIntyre argue that their child-centered approach allows them to start healing during the very first encounter. Their refusal to support any type of dissociation very often at once reduces the number and intensity of symptoms.21

Donovan and McIntyre have not taken a public position on the causes of adult multiple personality. In practice they say that children should not be treated as if they were miniature adult multiples enduring classical therapy for their disorder. From the point of view of the theory of trauma and multiplicity, there are at least two ways to react to stories like that of Sally. One is to say that childhood multiplicity can be treated very easily. It becomes pathological in adulthood precisely when it has gone underground. Childhood and adult multiple personality are nevertheless one and the same illness. But there is a very different inference to draw from the case of Sally Brown: Childhood and adult multiplicity and dissociation are different kinds of things. One cannot use observed multiplicity in some children, given certain types of therapy, to conclude that one is watching, in miniature, the very same illness as troubles adults. Hence child multiplicity, such as it is, is not evidence that childhood trauma causes adult multiple personality.

Clinicians committed to the diagnosis and treatment of multiple personality do see a continuum connecting child, adolescent, and adult multiple personality. This continuum is not merely clinical. It furnishes part of the basis for the current etiology of multiple personality. The same dissociative phenomena are said to be at work with nine-year-olds as we find in thirty-nine-year-olds. It is asserted that the dissociation in the woman of thirty-nine began when she was nine, or three. There is an implied contrary-to-fact conditional here; if the nine-year-old had not been treated, then even if she were to mature into a relatively stable adult, we would expect manifestations of multiple personality to emerge later. Bad Sister would become an alter, perhaps forever locked into the age of nine. Conversely, if we find a patient who has Bad Sister as an alter, then that alter was formed when the patient was nine, and had the patient had the good fortune to enter into therapy at nine, then she would have behaved like Jane. That is the theory underlying my first example of successful child therapy.

My second example takes another route. The therapy of Donovan and McIntyre presumes that even if there is such a thing as multiple personality in childhood, it is not a childhood version of the adult syndrome. That calls in question the causal story of multiple personality discussed in this chapter. For the specific etiology of multiple personality—the discovery announced by Lowenstein—is that splitting occurred during childhood, as a coping response. Donovan and McIntyre maintain that what we find in childhood is something else. Hence we are led to a quite different version of multiple personality. The disorder becomes a way of seeing childhood and its terrors. It is not that one split early in life in order to cope. Rather, in therapy, one begins to see oneself as having split at that time in order to cope.

It is easy to be misconstrued here, in two different ways. First, theory and practice are different. In is a familiar fact in clinical practice that gifted individual therapists with very different theoretical assumptions and practical guidelines can help patients heal. It would be absurd for me to take a position on which types of clinical practice are best for any particular therapist and client. Second, in following up the practice of Donovan and McIntyre, in which splitting of childhood personalities is discouraged, we do not deny the horror in the lives of many children who become disturbed. There are some people who still want to argue that the terrors of awful childhood do not occur in the lives of many children. That is not only ludicrous but vile, exculpatory. I suggest something entirely different. It is far more complex, and at odds with our ordinary sense of causation. I want to express the paradoxical idea in terms most favorable to the recent styles of diagnosis and treatment of multiple personality. Contrary to Loewenstein, I suggest that we have not found any ordinary etiology of this illness. We should not think of multiplicity as being strictly caused by child abuse. It is rather that the multiple finds or sees the cause of her condition in what she comes to remember about her childhood, and is thereby helped. This is passed off as a specific etiology, but what is happening is more extraordinary than that. It is a way of explaining oneself, not by recovering the past, but by redescribing it, rethinking it, refeeling it.

It is tempting to say that a new past comes into being once events are recalled and described within a new structure of causation and explanation. It need not be a false past, in the sense that it is at odds with, inconsistent with, what would have been recorded if everything had been overseen by a great camcorder in the sky. But the permanent videotape thus imagined gives pictures of events, not descriptions of them. The past becomes rewritten in memory, with new kinds of descriptions, new words, new ways of feeling, such as those grouped under the general heading of child abuse. The events as described, which the multiple in therapy comes to feel as the cause of her illness, did not produce her present state. Instead, redescriptions of the past are caused by the present. Nevertheless, the patient feels that events as newly described do produce her present state. She feels that way because of the kinds of knowledge about memory that are current. She may not be healthy enough or educated enough to use words such as “etiology,” but this causal story has become part of the conceptual space in which she lives, thinks, feels, and talks.

In this chapter I have described how the causation of multiple personality became an item of knowledge. Psychiatry did not discover that early and repeated child abuse causes multiple personality. It forged that connection, in the way that a blacksmith turns formless molten metal into tempered steel. I have traced the lines of development, using the best textbook in the field in conjunction with the standard research papers. A disturbed type of behavior has been joined to events in early childhood that may surface in memory. Cynics about the multiple movement argue that both the behavior and the memories are cultivated by therapists. That is not my argument. I am pursuing a far more profound concern, namely, the way in which the very idea of the cause was forged. Once we have that idea, we have a very powerful tool for making up people, or, indeed, for making up ourselves. The soul that we are constantly constructing we construct according to an explanatory model of how we came to be the way we are.

It follows that this chapter has not been concerned with an empirical question: Does early and repeated child abuse cause, under the right conditions, adult multiple personality? I have been discussing a reformulation of how we can come to be the way we are, and of how we come to view our own nature. A seemingly innocent theory on causation (which might as a matter of empirical fact be true or false) becomes formative and regulatory. And of course multiple personality is only a tiny microcosm used to illustrate this phenomenon. The theory of multiple personality has the virtue, for exposition and study, of being incredibly simple. I hope it is obvious by now that the recent theory of multiple personality, as opposed to clinical practice, is the most elementary psychological theory that has ever existed.

Multiple personality disorder illustrates, in a heightened way, a completely general phenomenon about memory, description, the past, and the soul. Such difficult matters are the topics of my last two chapters. I believe that the causal theory about dissociative disorders cannot be understood on its own. For we must come to see how it became obvious, inevitable, the sort of thing that nobody even asks about. It did so because memory became the way to have knowledge of the soul. I shall presently turn to that, but first we should examine another way in which knowledge about multiple personality became objective. The measurement of dissociation supports the simple theory of multiple personality because it became an item of knowledge that all people dissociate to some degree. There is just one kind of thing, “dissociation,” and we all dissociate. There are two parts to the causal theory of multiplicity. There is the occasioning cause, child abuse. And there is the innate tendency of some children to dissociate to a great degree and thereby have a special way of coping with trauma. We know about these degrees of dissociation because we can measure them. I shall now describe how this knowledge came into being.