Wilbur chaired the first panel on MPD at the 1977 meeting of the American Psychiatric Association. Thanks to workshops, meetings, and what was effectively lobbying for the inclusion of an ever more ample diagnostic description in the DSM, multiple personality arrived. It had its own international association, and by 1988 its own journal, owned by therapist Richard Kluft, an advocate of multiples and one of the association’s prime movers. Loosely educated therapists now discovered multiple personalities in growing numbers of patients. Using hypnosis and sodium amytal to unearth the abuse trauma they were convinced lay at the base of the patient’s problems, dissociations appeared and personalities developed. Multiples grew to some twenty thousand and Dr Colin Ross, a leading party in the MPD movement, speculated that over two million Americans ‘fit the criteria for being a multiple personality’.
The therapeutic procedure for diagnosing a patient with MPD is revealing. Frank Putnam, whose 1989 textbook on the subject is the most influential in the field, points out that he begins by taking a full chronology of the patient’s life, and if there are significant gaps or confusions, that is an indication of a possible multiple. Recall is an uncertain function and most people would find this task daunting. Then there are questions about flashbacks, nightmares and intrusive images. Since ‘patients are masters at appearing to say one thing while actually saying another’, it may take some time before memories rise and alters appear. So the clinician can prod, ask questions: for instance, do you ever feel that there is ‘some part of yourself that comes out and does or says things that you would not do or say’?
Being a multiple is a frightening condition. Though its presence in court has most often been in conjunction with cases in which the multiple is accused of committing a crime ‘while in a dissociated state’, in a 1990 trial a diagnosed multiple, Sarah, sued one Mark Peterson, an Oshkosh grocery worker, who she alleged had raped her while she was moving between personalities. Peterson had invited the twenty-six-year-old, who called herself Franny, to go dancing with him, despite the fact that he saw her personality undergo profound shifts even as they sat by a Wisconsin fishing hole, and the group she was with told him she suffered from MPD–or so the prosecution witnesses stated, since Wisconsin law makes it a crime to engage in intercourse with a person you believe to be mentally ill and who cannot assess your conduct.
Peterson rang Franny, took her to a coffee shop where she told him about a personality, Jennifer, who likes to dance and have fun. When, later in the car, he asked ‘Can I love you’, and this Jennifer said OK, he drove her to a park and they had sex, at which point six-year-old Emily intruded, whom he asked to tell Jennifer to keep their tryst a secret. But Franny and Emily told Sarah, and she phoned the police to report an assault.
During the pre-trial hearing, three of Sarah’s twenty-one personalities were sworn in separately. ‘In each instance, she closed her eyes, paused, then opened them to speak and act as different people. At one point, Sarah was given a glass of water by the judge. Later another personality did not remember having taken the drink.’
The increasingly high profile of multiples encouraged the disorder to come out, as anorexia and bulimia had, as a badge of courage. A website called Angel World sets the tone:
Perhaps you are also a Multiple. I hope to be able to show you that there is no need to be frightened. Inner families can learn to work together. Research has shown that multiples are blessed with enormous creativity. Indeed, multiples had to be very creative in the first place to develop such unique solutions to escape the horrors of childhood…The thought I hope you will hold close is that you can lead an extraordinarily productive, creative, and fulfilling life, and that you can do it with abilities which are totally unavailable to singletons.
But the increasing wildness of the disorder made even its original proponents, such as Putnam, issue cautionary warnings. Compliant patients were evidently attempting to satisfy what therapists wanted of them by producing fascinating alters, which were then increasingly difficult to reintegrate into the dominant personality–the ultimate goal of treatment. The psychiatric establishment had always been sceptical about the proliferation of alters. The chair of the dissociative disorders committee for the 1994 DSM-IV noted: ‘there is a widespread misunderstanding of the essential psychopathology in this dissociative disorder which is failure of integration of various aspects of identity, memory and consciousness. The problem is not having more than one personality; it is having less than one personality.’ By 1994 MPD had been reclassified as Dissociative Identity Disorder with an emphasis not on the existence of separate personalities–which suggests distinct people more or less functioning in the world–but rather on the experience by the patient of their presence. The distinction between external and inner, the objective and the psychic realities, indeed between the measurable or evidential and the experienced, has always haunted any classifications the psy professions attempt to make.
Dissociated identity, for the mind doctors’ profession if not necessarily for the multiples of the world, increasingly became a delusional sense of inner disintegration, an uncertainty about who one is, accompanied by varying degrees of amnesia and a sense of severe depersonalization–an experience of feeling out of one’s body. MIND, the leading British mental health charity, often sensible and judicious in its characterizations of illness, notes that the spectrum of dissociative disorders, amongst which it includes PTSD, is most often linked to a history of trauma, usually childhood abuse, since children ‘generally have a greater ability to dissociate’ than adults, unless repeated trauma in childhood has turned it into a habit.
Traditional psychoanalysts found themselves under attack from all sides during this period, as the British analyst Mary Target attests:
On one side, which sees all or most recovered memories of abuse as false (i.e. historically untrue), the accusation is that these ‘memories’ are planted in the minds of suggestible patients by irresponsible therapists. On the other side, there is anger at the thought that survivors can be retraumatised, by therapists who label painfully revived memories as fantasies, and who turn a blind eye, repeating the denial of reality that may at times be the most bitter betrayal in child sexual abuse.
The question of what analytic stance to take in such cases is tricky. There is the danger of the patient’s compliance and suggestibility, which may create the very memories the therapist, let alone the culture as a whole, implies are present. On the other side there is the fear that if the analyst doesn’t ally herself with that part of the patient that is trying to overcome denial and repression, then the patient may experience the whole therapy as a repetition of an earlier failure to perceive and protect. The image of Freud pursuing Dora’s seduction, perhaps a little too relentlessly, haunts the profession.
Another matter underlies the wary psychoanalyst’s hesitation over recovered memory. Why all these years on, and sexual revolutions later, is it only memories of abuse that recovered memory therapists, not to mention patients, insist need ‘validation’? After all, if it were a fundamental question of the status of the ‘real’ and the ‘fantasized’ throughout a patient’s therapy, or indeed of ‘trust’, then many other aspects of life would have to be put in the ‘reality’ scales:
the analyst is not seen as having to say whether a patient’s mother was really depressed, whether the patient was really left alone too much in hospital, whether she was really very close to her grandmother who died when she was small; these things are worked on as the patient’s reality, which is not to dismiss them as fantasy. It is the expression of her current internal world, or present unconscious.
Whatever the more wary of the European psychoanalysts’ responses to the status of trauma and recovered memories of abuse, child abuse itself remained a central social preoccupation and a continuing problem in the therapeutic and care sectors. Sometimes it also expressed itself, with the help of a goading popular press, in a mass hysteria about paedophiles and child sex rings, which from ti
me to time throughout this period rocked Britain, France and Belgium. At other times, it found its focus in frantic attempts to repress or criminalize Web porn sites. In New York, where a licensed registration system has been put in place for psychoanalysts and therapists, they are now asked, in addition to the ‘professional education requirement’, to ‘complete coursework or training in the identification and reporting of child abuse’.
THE SCIENCE OF TRAUMA
Throughout the 1980s and ’90s, research in adjacent fields brought a boost to theories which postulated that childhood trauma, even of the neglectful rather than abusive kind, affected later behaviour, as well as stress levels and neurochemical activity. Mother–child relations, it now seemed clear, were imprinted on the physiology, the very chemistry of body and brain, and not only on the psyche. Earlier theorists might not have presumed that there could be a clear-cut difference, but now in any case it was eroded. Neurochemistry could chart the evidence.
Harry Harlow’s student, the psychologist Stephen J. Suomi, conducted a subtle experiment with infant monkeys. The monkeys were reared by humans in the presence of inanimate surrogate ‘mothers’ for the first thirty days of their lives, then put in a group of peers and then into a larger mixed troop. Apart from thumb-sucking, these ‘peer-reared’ monkeys behaved normally, unlike Harlow’s own sad, mad, monkeys raised in isolation. Their only irregularity was that they clung longer to other monkeys, and were rather more timid and slow to explore. In yearly periods of social separation from their group, the peer-reared monkeys showed significant signs of distress and withdrawal–signs which are linked to depression–such as huddling, rocking, passivity, and anxiety evidenced in increased grooming and picking. Monitored over time, these same monkeys showed a marked abnormality in their biochemical distress indicators. Their cortisol levels were high and their norepinephrine activity abnormal, compared with monkeys raised by their mums. Cortisol and epinephrine, or adrenaline, the fight-or-flight substance, are the two hormones responsible for regulating stress in the body. They have also been found to be related to mood regulation.
The conclusion drawn from these experiments was that disruption of social bonds affects the physiology and neurochemistry of stress, leaving the monkeys more neurochemically sensitive to stress even much later in life. Their condition deteriorates with time, each separation from the group bringing greater signs of depression and anxiety, with its attendant change in hormone and neurotransmitter systems.
Monkeys may not be humans, but a 1991 NIMH-funded study found similar physiological abnormalities in stress hormones following what this time was abuse, rather than what might be termed neglect. Here 160 girls from the ages of six to fifteen were followed from six months after they had experienced documented sexual assault by a family member for a period of four to five years. Compared to a control group, the girls were found to have consistently above normal cortisol levels and disruptions in the rise and fall of their stress hormone system. This was later correlated to high levels of depression in the girls some years after the abuse.
PTSD as a diagnosis in America received a new boost and new research monies with each ‘traumatic’ social event–from scares of child abuse in schools to shootings, to the attack on New York’s Twin Towers, when the trauma therapists came out in full force. Increasingly, American trauma therapists travelled the world of crises and offered psychiatric services to hurricane and war survivors. With the rise of brain imaging and the neurosciences, a whole new set of ‘scientific’ descriptions came into place to bolster diagnosis and further research. Trauma, it now seemed to be clear, altered the chemistry of the brain for life–though it was possible that talk, and more certainly–or so it seemed–drugs, could have a therapeutic effect. Even the psychoanalysts and therapists who had been trained to think in terms of unconscious conflicts were drawn into the new trauma science.
It has been found, for instance, that when patients suffering from PTSD are confronted with a number of sensations that match the initial traumatizing experience–such as being touched in a particular way, or finding themselves exposed to smells or visual reminders–their biological systems make them react with fight-or-flight responses, as if they were being traumatized all over again. Studies have shown that this is to do with abnormalities in the neurotransmitters that regulate arousal and attention. Sufferers from PTSD or indeed from depression have low levels of the stress hormone cortisol and secrete too much norepinephrine. Their continuously high physiological arousal engenders a tendency to call up emotional memories that were laid down during past states of arousal, resulting in the flashbacks and nightmares which are part of the condition’s description.
Brain imaging has shown that when people are frightened or aroused, the frontal areas of the brain which control analysis and language are cut off in favour of the more primitive parts, the limbic system and the brain stem, not under conscious control. The amygdala, responsible for creating emotional memories, interprets the threat level of incoming information: once it has been imprinted with the memory that particular sensations are dangers, it triggers fight-flight reactions, and indeed behaviour that might look irrational.
According to Bessel van der Kolk, Director of the Boston Trauma Clinic and, along with Judith Herman, a leading medic and researcher in the field, the difficulty of traditional talk therapies with patients who suffer from PTSD is that not only does their traumatizing experience happen upon them, but it overcomes them with sensation. They cannot talk about it to a therapist. Nor do they want to confront the experience. How, then, to help patients process traumatic memories? Van der Kolk recommends the use of SSRIs amongst which are antidepressants such as Prozac, Paxil, etc.), which have been shown to allow patients some emotional distance from the traumatizing stimuli. Eye movement desensitization and reprocessing (EMDR), has a similar effect, though no one seems to understand quite why following the therapist’s hand while remembering trauma should have any calming impact, unless one hazards the notion that it might have something in common with mild hypnosis.
Only in their newly found calm can patients begin to make sense of the intrusive memories. With the therapist they find a language in which to communicate the worst in all its detail, encoding it in time, overcoming their helplessness. In that way it can become the past, while the patient emerges into a potential future. Achieving perspective, realizing that remembering is not reliving, can result in symptom reduction. However, van der Kolk warns, the fall-out rate with PTSD sufferers is high.
The fall-out rate of those wanting trauma therapy seems to be high outside the USA as well. Predictions after the Bosnian War, for example, that everyone there was traumatized and would need help in dealing with it, were not met. Recent advice from WHO to NGOs was that the world’s one billion victims of war, torture and terrorism needed less therapy and more compassion and assurance that their basic physical needs would be met. After the tsunami disaster in Sri Lanka, the chief of their psychosocial services dealing with the aftermath told the New York Times, ‘We believe the most important thing is to strengthen local coping mechanisms rather than imposing counselling.’ Therapists were criticized for rushing in to impose Western-style group therapy and ‘debriefing’ techniques in which victims are meant to express their feelings and relive the traumatizing event as vividly as possible. Little attention was paid to local healing systems and conceptions of what mental illness might be, let alone to current needs. From Beirut to Bosnia, what refugees want far more than trauma therapy is help in rebuilding their lives through training or education.
PERSONALITY DISORDERS
Josetta is an attractive thirty-five-year-old Hispanic woman, separated from her husband, mother of a twelve-year-old girl and a nine-year-old boy. After a suicide threat in the midst of depression, she was admitted to the psychiatric unit of a New York hospital. There had been two previous attempts at suicide, the first having taken place just after her daughter’s birth, the second three years before her current admis
sion to hospital.
Josetta lives in an area where drugs and violence are an everyday part of the life of the streets. She herself has a history of on-and-off drug use and heavy drinking, though until six months ago she was fairly regularly employed as a nurse. The drug-taking varies in seriousness, depending on how ‘worthless’ and ‘helpless’ she feels. The two drug treatment programmes she has been on seem to have had little permanent effect. Most recently, the patient said she had been taking drugs to ‘numb the pain’. Josetta is highly sensitive to pain and to slights. In her time, she has left various jobs where she felt she wasn’t treated with sufficient respect. She has also found herself fired from them.
For the last six months Josetta has been unemployed. Seven months ago she kicked out her boyfriend, who the daughter had told child protection services was molesting her. Though her mother didn’t believe her and the boyfriend denied the charge, Josetta threw him out after one of their repeated violent rows. The children’s biological father disappeared for good when the children were small and Josetta thinks he might be in prison. Since then she has engaged in any number of stormy sexual liaisons. These inevitably prove harmful to her, often physically as well as emotionally, but she is incapable of being alone for any length of time.
Since her first suicide attempt, Josetta has had a history of diverse symptoms ranging from depression, to insomnia, to weight loss; in addition to hospitalization, there has been a long pattern of outpatient treatment with various therapists. She does not follow up treatment recommendations, and has abruptly terminated two therapies. With her therapists she is alternately suicidal and seductive, hostile and dependent. Various medications have been prescribed over time: antidepressants, anxiolytics and neuroleptics. None have had any long-term benefit.
Mad, Bad, and Sad: A History of Women and the Mind Doctors Page 52