Introduction, Valerie Sinason
A
second edition allows a second hearing. In the six years or so since the first
edition came out there are thousands more graduates in psychology,
psychotherapy, medicine, social work, nursing and counselling. There are
thousands more volunteers working with rape crisis centres, ChildLine, and the
Samaritans. There are more people with DID feeling their society is beginning
to consider the reality of their existence. Tragically, there are also new
babies born into tramatagenic families who are at risk of developing DID.
However,
whilst a reprint alone would answer the needs of some, a second edition with
brand new chapters, updated references and ideas, offers something to both old
and new readers.
……………………………….
What happens when the toxic
nature of what is poured into the undeveloped vulnerable brain of a small child
is so poisonous that it is too much to manage? Little children, who have had
poured into them all the human pain and hate adults could not manage, somehow
grow up. There is a shadow-side to this. Legions of warriors are lost to society
through suicide, psychiatric hospitals, addiction and prison. What happens to
them, especially when those who hurt them are attachment figures (see Fonagy,
Chapter 4; de Zulueta, Chapter 3; Richardson, Chapter 10; Southgate, Chapter 5
and Steele, Chapter 6)?
This book is about one way of surviving. It
is about a brilliant piece of creative resilience but it comes with a terrible
price. It is a way of surviving so
difficult to think about and speak about that, like the topic of learning
disability, its name changes regularly. Dissociative Identity Disorder is the
newest term. Where and in whom the disorder lies, however, is a crucial issue
in its own right.
Dissociative Identity Disorder
Despite the clear
description of what constitutes DID in DSM-IV (see page xx – Routledge to add page number; later in this introduction)
this condition is still seen by some mental health professionals as a
hysterical confabulation. It is 10-20
years too early for it to be picked up and dealt with well. What is it like to
be suffering from something that is not yet adequately recognised? And not only
is the DID not recognised, but the nature of the sadistic abuse that has caused
it in the majority of cases is even less recognised (Sachs & Galton 2008).
“I’m an attention seeker,
don’t you know?” said one patient bitterly. “And I’m hysterical and full of
delusions. Amazing isn’t it? My abusers can rape and torture me for years and
they are wandering the streets perfectly happy and I am the one with a life
sentence, the one who is scared to leave the house, the one who has to
apologise for her illness”.
In the last two decades I
have assessed and treated children and adults, largely female, who have
Dissociative Identity Disorder (DID). There is a very significant gender bias
in this condition. Indeed, abused boys are far more likely to externalise their
trauma in violence although both sexes (see Bentovim, Chapter 2) use
internalising and externalising responses. Cultural issues, as well as gender
issues need exploring (see Swartz, Chapter 17).
The majority of female
children and adults I assessed had been diagnosed or misdiagnosed as
schizophrenic, borderline, anti-social disorder or psychotic. Despite the fact that anti-psychotic drugs
had little or no effect on them, that they experienced their voices as coming
from inside and not outside, (see Coleman, Chapter 13) and they did not
manifest thought disorder or distortions about time and place except when in a
trance state, mental health professionals could not perceive flaws in
diagnosis. Or rather, and more
worryingly, the diagnoses at times were correct but only applied to the ‘state’
that visited them. Hence one psychiatrist assessing ‘Mary’ correctly diagnosed
psychosis, and another who assessed the patient a week later correctly disputed
that diagnosis and declared ‘Susan’ had borderline personality disorder.
Without early specialist training on the consequences of abuse, professionals
are attacking each other’s contradictory diagnoses without realising the aptness
of Walt Whitman’s words “I am large. I contain multitudes”.
In the face of professional
confusion and societal denial some patients have managed to hide their
multiplicity when told they were making it up. In answer to the key question
concerning the small number of children who present in severe dissociative
states (see Midgley, Chapter 1; Bentovim, Chapter 2 and Fonagy, Chapter 4)
child patients confirmed that negative
responses to their disclosures led to
hiding their symptoms (see Sinason,
Chapter 8). Children were told they would “grow out of it” or it was
“just like an imaginary friend”. Adults report similar past experiences and the
pain such misdiagnoses or denial of symptoms causes patients can be seen in the poems on labelling by survivors in this book.
This book, bringing together
experienced clinicians, aims to consider the developmental, attachment and
adaptive structure of DID as well as the controversy around its aetiology and
manifestation.
What is Dissociative Identity Disorder and How does it Happen?
A loved child of two toddled
around the kitchen. He put his hand up and almost touched the gas heater.
“Hot!” he shouted. He shouted in the voice of his mother who had been
frightened for his safety when she had left the heater unguarded the day
before. He paused. “Be careful sweetie”, he added in the voice of his older
sister. Like young children all over
the world he was taking in the language and intonation of his attachment figures.
His family could amusedly point to where his vocabulary, intonation and facial
expressions came from. However, just a short time later, in an ordinary
developmental process, the words and concepts and gestures and knowledge taken
in from the outside became truly his in an apparently seamless way.
When all goes well we take
for granted the existence of the outside network in each of us. Ironically, it
is when things go wrong and become writ large that we notice the amazing
process of what we are linguistically made of.
………………………………………
How do we account for these changed faces and
voices? Again, if we go back to our two-year-old loved boy we get some answers.
When his mother shouts “Hot!” in a frightened angry voice her face does not
look the same as when she is beaming lovingly at him. Nor is her voice the
same. A baby and a child get used to seeing their primary caretaker’s face
change dramatically into something quite different, even though it does not
have another name. However, Cross Mummy and Loving Mummy are very different people
even though they are Mummy.
………………………………………..
This brilliant survival
mechanism helped when facing the trauma of the abuse but it is maladaptive when
the trauma is over. Mary aged 25
presents to her GP with terrible memory loss and signs of self-injury.
Sometimes she does not know where she is when she wakes up. Jane and Peter are
still appearing in Mary’s life because no new way has been found for the
system’s survival. The multiplicity is hardwired as brain scans are starting to
show. To help Mary regain her spirit
that is fragmented into her dissociative states means that she has to take on
board her past. Without a safe environment and skilled staff, how is it possible
to re-experience the very trauma that led to fragmentation? And yet all over
the UK these heroic and troubled survivors – mainly women – have to deal with
lack of specialist resources and disbelieving discrediting staff. Graeme Galton
(Chapter 13) examines how language is used as a defence here.
In 1988, in a clinical
supervision, John Bowlby looked at drawings by a middle aged woman of little
children being abused. The artist was being treated by John Southgate,(1996 and
Chapter 5) Dr Bowlby mused and finally
said "I think this woman is a multiple personality."
John Bowlby was the
world-famous psychoanalyst who created attachment theory and helped to prove to
the Western world that separation of young children from their attachment
figures was psychically damaging (whether in hospital or in evacuation) in
proportion to the nature of their attachments, age and degree of separation.
Bowlby’s work on separation
and attachment did not find an immediate positive response. Indeed, upper class
English Christian psychiatrists, doctors and psychoanalysts who had been sent
away to boarding school found his ideas as disturbing as their Jewish
counterparts who had lost their safe family links through the holocaust.
As Bowlby himself tells us,
we cannot see what we cannot bear to see.
How then do we best educate each other and tolerate the conceptual and
clinical gaps? Kuhn’s work shows us how, when an older paradigm cannot account
adequately for a subject we find it problematic. Multiple Personality Disorder
(MPD) or the newer term Dissociative Identity Disorder (DID) is such a subject
in the UK. The Netherlands provides a remarkable alternative vision. Indeed,
Ellert Nijenhuis, the distinguished clinician and researcher on this topic, was
awarded a knighthood by Queen Juliana of the Netherlands for his services to
the country on dissociation.
The DSM IV criteria specify
that DID is:
The presence of two or more
distinct identities or personality states (each with its own relatively enduring
pattern of perceiving, relating to, and thinking about the environment and
self).
At least two of these
identities or personality states recurrently take control of the person's
behaviour.
Inability to recall important
personal information that is too extensive to be explained by ordinary
forgetfulness and not due to the direct effects of a substance (eg blackouts or
chaotic behaviour during alcohol intoxication) or a general medical condition
(eg complex partial seizures).
Although the international
psychiatric criteria in DSM-IV describe very clearly what constitutes this
condition, British clinicians have on the whole ignored or condemned the
condition and the clinicians who recognise it and offer treatment. Indeed, the
British Journal of Psychiatry has published only five papers on DID since 1989,
all of which are unanimously critical.
Psychiatric training (see
Coleman, Chapter 14) offers little understanding both in the past and
now (see Whewell, Chapter 11 and
Mollon, Chapter 12). This leaves British professionals uniquely
vulnerable to emotional stress when encountering such patients despite the
increase in neurobiological work (see Moore, Chapter 16) and brain scans.
It could be that our recent
social interest in brain research allows a face-saving way of changing our
clinical paradigms (see Galton, Chapter 13).
However, what is the emotional experience of children and adults living
in a country at a time where the condition that is troubling them (and its
traumatic aetiology) is linked to a paradigm shift rather than an area of
clinical resourcefulness?
Professor Peter Fonagy has evaluated the
aetiology of DID from trauma at 90%. (McQueen, Kennedy, Sinason & Maxted
2008). North et al (1993) found that DID was not only linked to a high
childhood sexual abuse rate but also 24%-67% occurrence of rape in adult life,
and 60%-81% suicide attempts.. Putnam et al (1986) in the USA looking at 100
DID patients found that 97 of the hundred had experienced major early trauma,
with almost half having witnessed the violent death of someone close to them.
Compared with Freud's ability to recognise the traumatic aetiology of hysteria
one hundred years ago (Freud, 1896), contemporary clinicians have found it
extremely hard to bear the horrors of patients' objective lives. Sometimes
(Hale & Sinason 1994) psychotherapists’ focus on the internal narrative
is a defence against the historic external reality.
However, as de Zulueta (1995) comments: "a refusal on
the part of psychiatrists and therapists to validate the horrors of their
patients' tortured past implies a refusal to take seriously the unconscious
psychological mechanisms that individuals need to use to protect themselves
from the unspeakable. Such a denial is, however, no longer ethical, for it is
this human capacity to dissociate that is part of the secret of both childhood
abuse and the horrors of Nazi genocide, both forms of human violence, so often
carried out by ‘respectable’ men and women”.
In the adolescent and adult
psychoanalytic field there is relatively little published work involving the
physical body as opposed to the metaphoric or fantasy body. Exceptions include
those who have to acknowledge the physical body through working on pregnancy and
gender body issues such as Leff (1993), Perelberg, Pines (1992) and Orbach;
those working with violence and suicide such as Eglé and Moses Laufer (1995),
blindness and diabetes (Burlingham, Moran, Fonagy et al at the Anne Freud
Centre), perversions and abuse (Glasser, Hale, Campbell, Welldon , Kennedy) and
disability, ( Hollins, Kahr, Beail, Banks, Frankish, Cottis, Corbett, Curen).
…………………………………
However, it is important to
remember that only thirty years ago most major training schools did not accept
the existence of child abuse and condemned what they saw as the unhealthy
excitement that was considered to emanate from the earliest exponents. The
language of their criticism was very similar to what greets the clinician of today who speaks of DID. It has been a later
knowledge that understands the way the shame and trauma of abuse become
projected into the professional network leading to splitting and blame.
………………………………………..
Perhaps DID raises problematic philosophical and psychological
concerns about the nature of the mind itself. As Professor Hinshelwood wrote in
the first edition ““truly to understand the nature of DID will include
dissolving a whole cultural set of baggage that is deeply invested in the
notion of the undivided individual”. Ideas of a unitary ego would incline
professionals to see multiplicity as a behavioural disturbance. However, if the
mind is seen as a seamless collaboration between multiple selves, a kind of
‘trade union agreement’ for co-existence, it is less threatening to face this
subject.
However, the primary split
of DID creates a curious secondary splitting between staff. The psychiatrist
who meets a frozen DID patient who shows only one state (as a result of
correctly assessing their psychiatrist’s inability to deal with the subject)
then attacks the other psychiatrist/social worker/psychologist/psychotherapist
who points out the fragmentation into states. We are then witnessing the
trauma-organised systems (see Bentovim,
Chapter 2) that systemically mirror the DID experience.
This polarisation extends to
writing on the subject. Some clinicians show a remarkable ignorance of the
current state of work in this country. Aldridge-Morris (1989) sees those of us
who are dealing with the reality of this condition as "practitioners who
generally favour hypnotherapeutic techniques, are psychoanalytic or
neopsychoanalytic in orientation". As
Mollon (1996 and Chapter 12)
points out: "in fact most
contemporary writers on the treatment of MPD favour techniques derived from
cognitive-behavioural approaches. The concept of MPD is not part of the
psychoanalytic tradition. Relatively few psychoanalysts make use of the concept
of dissociation".
With the advent of concern
about the boundary between raw memory and distortions (which have been exploited by various false memory exponents)
there has been more room for minority views like Merskey’s that DID is an
iatrogenic disease created and instantly implanted by naive therapists who
expect to see it (Mollon).
Whilst rigorously trained
professionals are well aware of the suggestibility of traumatised clients,
especially those who have been hypnotised, it is worth noting that virtually
all the patients who came to the Clinic for Dissociative Studies (and before
that to the Portman Clinic project on ritual abuse) had long been aware of
their own dissociation. Those alleging ritual abuse as a trigger for
fragmentation had never lost such memories and had expressed them to other
professionals long before attending the Clinic.
………………………………………………
Psychotherapists have negligible
training in brainwashing, forcing of alien memories, military mind control or
distorted ideas (Sachs and Galton 2008). These are not areas of mainstream
professional training despite the profound influence such practices have on
vulnerable minds (Sinason 2008). Mental health professionals also do not have
any basic grounding in this subject.
This book aims to redress that balance and
provide basic clinical and theoretical information for the mental health
professional and the interested layman. It is of concern to all because whilst
we consider that this brilliant but tragic adaptation to trauma is as rare as
the torture it stands witness to, extreme states show us writ large the
stresses and responses of ordinary life.
………………………………………………….
To understand
the process and aetiology the first part of the book deals with origins in
childhood and developmental issues. How does dissociation begin? Nick Midgeley of the Anna Freud clinic looks at the lack of focus on the
childhood roots of dissocation whilst Dr Arnon Bentovim examines
developmental precursors in multi-abused offending boys. Dr Felicity de Zulueta of the Maudsley Hospital Traumatic Stress
Service describes the dissociative continuum and treatment options.
Part Three looks at clinical
practice. It includes leading psychoanalysts and psychotherapists from the
public sector Dr Peter Whewell,
Dr Alison Cookson, Dr Phil Mollon and Professor Jean Goodwin.
Attachment-based psychoanalytic psychotherapist Sue Richardson describes her way of
working clinically. I provide a first
meeting with a patient in which the story of The Shoemaker and the Elves provided powerful therapeutic aid.
In Part Four we look at
linguistic, diagnostic and forensic issues. In a new chapter, Consultant
psychotherapist Graeme Galton takes
us through the linguistic defences involved in this work, Dr Joan Coleman speaks of the lack of psychiatric
training in this subject, and in another new chapter Detective Chief Inspector Clive Driscoll of the Metropolitan Police
speaks of his work in this area.
In
Part Five a new chapter by Dr Mary Sue Moore
provides understanding of how a child’s drawings provides neurobiological
evidence of attachment patterns and dissociation; Professor Leslie Swartz offers
an anthropological South African cultural experience and Professor Brett Kahr concludes
with an interview with a pioneer on this subject, Flora Rheta Schreiber.
The beginning of each new
section is heralded by poems and statements from survivors including, Cuckoo,
Beverley, Beverley’s mother, David, Joanna, Mary Bach-Loreaux, Miki and
Toisin. Finally, there is an updated
information section.
……………..
It
was Charcot, the great nineteenth century neurologist, who first brought the
concepts of hysteria and its symptoms of neurological damage and amnesia to
public attention. Whilst he demonstrated the psychological aetiology of
hysteria as opposed to an organic aetiology, he was not particularly interested
in the meaning, and it was Janet and Freud who became interested in taking the
work further. By the mid 1880s (Herman
1992) both recognised that altered states came from trauma and that somatic
symptoms represented disguised representations of events repressed from
memory. Janet produced the term ‘idée
fixe’ whilst Freud underpinned the concept of traumatic repetition as a way of
working through. Breuer and Freud coined the term ‘double-consciousness’. Breuer and Freud (1895)
wrote that "hysterics suffered from reminiscences" (Studies on
Hysteria 2) and Janet (1891) also described how one patient improved when,
after removing the superficial layer of delusions, he realised the fixed ideas
at the bottom of her mind.
However, it was Freud (1896)
who in The Aetiology of Hysteria
firmly based the origins of hysteria in traumatic sexuality. He saw this as the
key issue, the ‘caput Nili’. Freud's
shock at his own findings and his inability to conceive that abuse in his own
social class was so widespread is not surprising. As I have written elsewhere (Sinason 1993), it is hard enough for
many professionals 100 years later than Freud to accept the extent of middle
class as opposed to working-class abuse. In fact, Freud never gave up entirely
on the significance of the abuse of early seduction.
…………………………………..
In America the largest
amount of DID is diagnosed in connection with allegations of ritual Satanist
abuse. Hacking (1995) is concerned about this combination as well as the lack
of external corroboration of ritual abuse.
"It would be a grave
mistake for any therapist to believe memories of such events without conclusive
independent corroboration" (p.118). He adds, "Ganaway thought that
uncritical acceptance of memories of satanic abuse not only imperilled the
credibility of multiple personality but put research on child abuse in general
at risk".
It is worth noting that both
at the Portman Clinic and in the Clinic for Dissociative Studies we have not
found evidence of fundamentalist religious beliefs, recovered memory or
Munchhausen’s as issues in those alleging this kind of abuse. Indeed, the pilot study on patients alleging
ritual abuse that Dr Robert Hale, then Director of the Portman Clinic and I
submitted in July 2000 included the finding that the only two out of 51
subjects who had any link with evangelist religious groups made contact with
them after disclosing ritual Satanist abuse, and only because no-one else would
listen to them.
Although our established
religions find the cruel personal Satan of fundamentalists unpalatable or
irrelevant, when it comes to examining abuse carried out by Satanist
paedophiles (or those who draw on the frightening power of occult paraphernalia
to hurt their victims more), nursery memories of harsh religious teaching can
reappear and cause fear and confusion. Van Benschoten (1990) comments that:
"the issue of
credibility is the first hurdle professionals and the public must confront when
dealing with MPD patients' reports of satanic ritual abuse. Survivors' accounts
reveal activities which are not only criminal but deliberately and brutally sadistic
almost beyond belief".
I have stated elsewhere
(Sinason, 1994) that the number of children and adults tortured in the name of
mainstream religious and racial orthodoxy outweighs any onslaught by Satanist
abusers. Wiccans, witches, warlocks, pagans and Satanists who are not abusive
and practice a legally accepted belief system are increasingly concerned at the
way criminal groups closely related to the drug and pornographic industries
abuse their rituals.
…………………………………………….
One courageous ritual abuse
survivor, on being told by the team psychiatrist that her behaviour and
disclosures were upsetting the nurses, commented:
“What do you expect me to
say? I am the patient. That is why I am here in this case conference. I am
sorry the nurses are upset. But I tell you. I would rather be the nurses who
are upset than be me and have to deal with in my head what I have gone
through”.
I am first and foremost
grateful to all the patients/clients with DID who have worked with me and it is
to them the book is dedicated. I am also grateful to all those with DID who
wrote to me or met me informally. Organisations and conferences that chose to
include these topics are also to be thanked for helping to change the emotional
climate.
…………………………………………….