Controversies about dissociation and the dissociative disorders
Authored by Henry Strick van Linschoten
Over almost 40 years during which dissociation has been rediscovered and much clinical work and research has taken place with people with dissociative disorders, a number of controversies have developed, which are summarised here.
What is the main aetiology of the dissociative disorders?
Opinions about the aetiology of the dissociative disorders, and dissociative identity disorder (DID) in particular, can be divided in two main groups. One set of views proposes that in its severe form, pathological dissociation can affect functioning and quality of life substantially; that it is linked to chronic, usually developmental trauma leading to a disorganised attachment style. Another set of views is termed sociocognitive theory. This perspective supports the idea that most dissociative symptoms, and especially DID, are not caused by trauma but are iatrogenically induced – that is, caused by psychotherapists – and that cultural influences provide models and behaviours that are imitated. ‘False memory syndrome foundations’ started in the 1990s in a number of countries, claiming the existence of false memory syndrome. They assert that people diagnosed with DID suffer from false memories that they thought had been recovered, but in fact were induced by the psychotherapist.
The trauma-originated model is described in these recent books and articles: Spiegel et al. (2011); Gold & Seibel (2009); Sar (2011); Howell (2010). Two interesting sources from the time when the controversy between the models was at its height are Brown et al. (1998) and Mollon (1996).
Lilienfeld & Lynn (2003) give this description of the sociocognitive model:
“DID is a socially constructed condition that results from the therapist’s cueing (e.g., suggestive questioning regarding the existence of possible alternate personalities), media influences (e.g., film and television portrayals of DID), and broader sociocultural expectations regarding the presumed clinical features of DID. For example, some proponents of the sociocognitive model believe that the release of the book and film Sybil in the 1970s played a substantial role in shaping conceptions of DID in the minds of the general public and psychotherapists […] Many proponents [of the model] contend that individuals with DID are engaged in a form of ‘role playing’ that is similar in some ways to the intense sense of imaginative involvement that some actors report when playing a part. (2003: 117).”
Piper & Merskey wrote: ‘The unsatisfactory, vague, and elastic definition of “alter personality” makes a reliable diagnosis of DID impossible’ (2004b: 678).
The ideas can be found more fully in the articles and book of Harold Merskey and August Piper (Piper, 1996; Piper & Merskey, 2004a, 2004b). Other recent sources describing sociocognitive theory are Cardeña & Gleaves (2007), Boysen (2011) and Lynn et al. (2012).
The ISSTD Guidelines (2011) mention sociocognitive and iatrogenic theories, but come down against their credibility. Brown et al. (1999), Gleaves (1996), Reinders et al. (2012), Ross (2009) and Loewenstein (2007) are other sources critiquing sociocognitive theory: they maintain that sociocognitive theory lacks coherence, is not based on clinical evidence, ignores or misrepresents extensive amounts of research evidence, uses invalid theories of memory, believes in unrealistic models of psychotherapeutic practice and fails a carefully designed psychobiological verification test. Another account is offered by Kihlstrom (2005).
One result of criticism of early practices of psychotherapy with dissociative disorders was to make practitioners sensitive to certain risks or weaknesses in their way of working. These criticisms were reviewed by most major psychotherapy organisations and teaching institutes, which led to a number of recommendations for good practice. These include the avoidance of suggesting ideas or memories, and the importance of maintaining good-quality process notes in order to avoid exposure to lawsuits and role contamination with legal professionals involved in divorce and custody actions. Two sources containing such guidance are Sandler & Fonagy (1997) and Brown et al. (1998).
Adaptations to psychotherapy methods in working with dissociative disorders
Since the 1970s, it has been increasingly argued that adaptations are necessary to the standard psychotherapies in working with dissociative disorders. First, recognition of dissociation as central to a range of problems has led to an approach that places dissociation as a central focus of therapy. Second, there is a view that phased working is essential for effective treatment of dissociative disorders. The generally three-phased method received shape in the early 1990s, and is described in Herman (1992), Howell (2011: chapter 9), Sanderson (2006: chapter 4) and Chu (2011). The need for adaptation and the three phases are integral parts of the ISSTD Guidelines (2011).
The main goal of psychotherapy with a fragmented personality
For a long time the idea was held that fragmentation, a frequent feature of DID, was the major symptom. Hence, a major goal of psychotherapy has focused on ending this fragmentation, eliminating the ‘alters’, and achieving ‘integration’, ‘unification’ or ‘fusion’ of the personality. There is another position, that suggests that multiple personalities or parts can be lived with; that the dissociation itself may need to be accepted and adapted to; and that the client’s overall preferences on the matter of integration should be taken into account and respected.
The problem is discussed in Kluft & Fine (1993) and in the ISSTD Guidelines (2011), which both conclude with a cautious bias towards integration. Rivera (1996) is an advocate of the other view: that quality of life comes first, and that this can be achieved by adapting to fragmentation. One of her chapters is entitled ‘Multiplicity is the solution, not the problem’.
Different views about ritual abuse and mind control
Beyond the main forms of child abuse – sexual, physical, emotional and neglect – a number of professionals working with dissociative disorders believe that they have encountered what they call ritual (sometimes satanic) abuse and mind control. This involves exploitation of a different order of severity which, it is proposed by these professionals, is designed to destroy a child’s developmental process and ensure their long-term submission to the will and ideology of the perpetrator(s). In the case of mind control, this might involve organs of the state. This is controversial, with some people doubting that ritual abuse or mind control exist at all, others believing that instances are extremely rare. Some experts believe that occurrences are more common than is assumed, but are well-hidden and rarely discovered or understood.
Some sceptical or negative sources are La Fontaine (1998), McHugh (2008), McNally (2005) and De Young (2004). Some sources on the positive but not uncritical side are Badouk Epstein et al. (2011); Miller (2011); Noblitt & Perskin (2000, 2008); Ross (1995); Sinason (1994, 2011). A popular book that gives a feel for the issues around mind control is Streatfeild (2006).
Bibliography
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