Towards a theoretical framework
This dissertation is a theoretical exploration of Dissociative Identity Disorder. A feminist and cross-cultural analysis of the embodiment of alternate identities demonstrates that the "illness" of Dissociative Identity Disorder is internalized oppression, not the existence of multiple identities. A proposed stress-related, developmental model, based in neurological and political frameworks, examines abused individual's adaptive responses to violence throughout the life cycle.
Oppression and the social denial of child abuse are necessary contexts for the formation of a multiple identity response, and ongoing traumatization can affect its persistence into adulthood. It is hypothesized that the underlying mechanism of Dissociative Identity Disorder optimizes psychological organization, and can lead to healthy, stabilized structures. The focus is on the abused individual as an active strategist and resistor to ongoing violence and oppression.
This is an academic paper of about 60 pages. I have broken it up into chapters to make it easier to read. Check out chapters 3 and 10 for quick summaries.
I began my research with the basic assumption that if broken bones can knit themselves back together, why can't our minds? Psychology tries so hard to be "scientific", yet ignores some basic biological functions. Therapists are not the heroes of healing -- the clients are. Everyone needs an environment that supports and protects us, yet ultimately, our bones and selves must do the hard work of healing.
I can't see why psychologists expect everyone to be at home in their identities. Women who are expected to change their name when she marries, queers who keep one identity closeted, and anyone who is oppressed will understand that the identity society assigns you, the identity you assume to resist this, and the real you that could exist in the best of all possible worlds are all different things.
Table of Contents
Ch. 1: Intro - redefining the frameworks.
Ch. 2: Background to multiplicity.
Ch. 3: A framework for study (overview).
Ch. 4: Normative (non-pathological) multiplicity.
Ch. 6: The multiple identity response - MIR.
Ch. 8: How the system changes.
Ch. 9: The political act of healing.
Ch. 10: Future research and summary.
This thesis would not have been possible without the assistance of the following people:
A Thesis submitted in conformity with the requirements for the Degree of Master of Arts, Graduate Department of Applied Psychology, in the University of Toronto
Classical Dissociative Identity Disorder
In the last 15 years of research on Dissociative Identity Disorder, a classical characterization has emerged about what is commonly found among clinical cases of Dissociative Identity Disorder. There are many aspects of this characterization that I will question, at length, in the rest of this dissertation, however, for the sake of description, it is important to know what has been understood and described to this point.
The American Psychiatric Association (1994) describes the diagnostic features of Dissociative Identity Disorder in the 4th Edition of the diagnostic and Statistical Manual (DSM IV). The essential features are defined as the:
"presence of two or more distinct identities or personality states (Criterion A) that recurrently take control of behaviour (Criterion B). There is an inability to recall important personal information, the extent of which is too great to be explained by ordinary forgetfulness (Criterion C). The disturbance is not due to the direct physiological effects of a substance or a general medical condition (Criterion D). In children, the symptoms cannot be attributed to imaginary playmates or other fantasy play." (p.484).
The DSM IV also describes Dissociative Identity Disorder as "a failure to integrate various aspects of identity, memory and consciousness" (p.484), and that the amnesia referred to is frequently asymmetrical. Passive identities have fewer memories, while hostile and protecting identities have a complete life history. Switching identities can be triggered by stress, although identities may exert influence by producing visual or auditory hallucinations rather than gaining complete control of the body.
They note that "individuals with Dissociative Identity Disorder frequently report having experienced severe physical and sexual abuse, especially during childhood" and that they may also manifest symptoms of Post-traumatic Stress Disorder, conversion symptoms, substance abuse, headaches, irritable bowel syndrome, asthma, eating and sleep disorders and mood disorders (p. 485).
The DSM IV describes people with multiple identities as more hypnotizable and having a greater capacity for dissociation. Physiological differences may also exist across identity states, including changes in vision, pain tolerance, symptoms of allergies and asthma and response of blood glucose to insulin.
Dissociative Identity Disorder is found in women three to nine times more often than in men, and women tend to have more identities than men, averaging 15 or more, whereas men average 8. "Episodic and continuous courses have both been described. The disorder may become less manifest as individuals age beyond their late 40s, but may reemerge during episodes of stress or trauma or with Substance Abuse." (p. 486).
This description represents a change from the previous Diagnostic and Statistical Manual III Revised Edition (DSM IIIR), which did not include amnesia as a criterion (American Psychiatric Association, 1987). Almost all of the literature of Dissociative Identity Disorder used in this dissertation will have used the DSM IIIR criteria for the research. It is possible that some of the patients studied would be excluded from the current diagnostic category. It also has resulted in some confusing terminology. In the literature on Dissociative Identity Disorder, it is also referred to as Multiple Personality Disorder, sometimes just "multiple personality", and people with Dissociative Identity Disorder are frequently referred to as "multiples." The different identities are at times referred to as personalities, alters, ego states, identity states or alternates.
The evidence that Dissociative Identity Disorder only results as a consequence of ongoing, severe childhood abuse, especially incest, is overwhelming (Briere & Runtz, 1988; Fagan & McMahan, 1984; Kluft, Braun & Sachs, 1984; Wilbur, 1984a; Bliss; 1980; Greaves, 1980; Schultz, Braun & Kluft, 1985; Putnam, 1985; Kluft, 1985b; Ross, Norton & Wozney, 1989). Often, Dissociative Identity Disorder is characterized as a type of posttraumatic stress disorder (Spiegal, 1984; Fike, 1990b; Kluft, 1984; Braun, 1985).
Dissociative Identity Disorder is seen as the most extreme form of dissociation, used as a defensive mechanism to help the child cope with trauma (Braun, 1988).
Ross, Norton & Wozney (1989) reviewed therapists' reports of 236 cases of Dissociative Identity Disorder. The therapists reported that 88.5% of the patients had been either physically or sexually abused, with the majority experiencing both types of abuse. An additional 11.1% of the therapists were uncertain about whether abuse had occurred. The majority of clients had also been raped (Ross, Norton & Wozney, 1989). Putnam et al. (1986) reported that 97% of Dissociative Identity Disorder cases had experienced some form of severe trauma, although this included forms of abuse and neglect not included in the Ross et al. study.
Unfortunately, not enough work has been done to examine child
abuse in a political or feminist framework. Without this framework,
too many researchers approach the issue as a voyeuristic experience
of the "bizarre experiences and symptoms" (Bowers, 1991,
p. 168) of Dissociative Identity Disorders.
My experiences with individuals
with multiple identities
(More alike than different! - Astraea)
I facilitated a support group for lesbian survivors of childhood sexual abuse that was modeled on a lesbian coming-out group. Coming-out groups are possibly the most successful application of feminist group therapy. The purpose of these groups is to provide peer support in facing social oppression, share coming-out stories, end isolation, overcome fear, introduce new members to the existing community and re-frame the heterosexist socialization into a subversive, lesbian-centered framework. The groups are a place to meet friends and lovers and connect with a community that is otherwise hidden and difficult to locate. The groups inherently blend political and personal purposes, and they are an essential aspect of many lesbian communities. The groups are free of charge and collectively facilitated.
This support group was to assist women to come out as lesbians and as survivors of abuse, and explore how those identities and realities intersected. Some of the women in the group also came out as individuals with multiple identities.
The classical model of multiple identities did not seem to fit the lives and experiences of these women. The group dynamic was established to focus on the person as a whole, not a collection of symptoms. Taken in this context, a lesbian with multiple identities did not really stand out in the crowd. All lesbians who live in a patriarchal society, have known what it means to have big and scary secrets. For some lesbians, this goes on throughout their lives, and they live double lives that are carefully separated. They must maintain constant vigilance, self-censorship and create a complex facade to conceal their true life from casual, yet invasively personal, assumptions and inquiries. They keep two wardrobes, two sets of friends and often remark how they feel like a different person when they change identities. Of course, one identity is very ego dystonic - essentially superimposed by the prevailing social structures. However, ego dystonic heterosexuality is not yet recognized as a mental illness in the DSM IV.
The child identities that emerged in the group were not distinctly different from the desire that everyone shared of wanting to curl into the fetal position every so often. The raging, angry identities no different from our anger, and fear of that anger, at our abusers, at society and ourselves. Everyone was familiar with the inner healer, and knew of unbidden strengths that had helped us survive. While we recognized the uniqueness of all of our identities, we also recognized them to be simply aspects of who we are and who we might become.
In this group, we did not follow many of the accepted practices for dealing with individuals with multiple identities. We did not elicit or attempt to control the identities, we believed that they had managed to do by themselves for most of their lives and did not need our help. We had rules for safety that everyone was obliged to follow, and we were provided instructions to contact a "managing" identity who could re-organize the identity system in the case of an emergency. Buried memories came spontaneously, once we were able to provide a safe space to support this intense emotional work. We also used semi-public rituals, field trips and visualizations to release emotions and facilitate healing. We encouraged friendships that maintained contact outside of the group. We went as a group to anti-violence political activities and educational events. We helped women strategize and execute their escapes from current abusive situations. All of the participants expressed delight in meeting and sharing experiences, and knowing that they were not alone.
There were definitely times when some of the women needed
more help than we could provide in weekly group meetings. Several
women were involved in shelters or psychiatric institutions. Unfortunately,
most of these interactions simply re-traumatized the women who
were seeking help. Often, the women were labelled as "high
needs" patients, when in fact their needs were natural, but
the system was not designed to meet them. Some women used these
systems as safe houses to escape unlivable housing conditions
or abusive situations, and attempted to refuse the drugs and ignore
the labels that came with the housing. Others found relief from
their pain, but lost custody of their children. Some lost their
jobs when they came out as lesbians. Some risked their lives escaping
or confronting their abusers. However, we never believed that
we were the "problem" and we never believed that needing
safety and loving support from another human being indicated that
there was something wrong with us.
Purpose of this dissertation
The core of this dissertation is my desire to reframe the investigation into Dissociative Identity Disorder. Multiple identities has been characterized as a debilitating mental illness that results from an adaptation to extreme child abuse. It is an individualized problem that is resolved through private therapy.
I do not believe that multiple identities can ever be truly understood outside of its context; a framework of systematic violence. This violence is not only a dim memory of childhood abuse for many women, but an ongoing threat, or repeated brutality that plays a role in the systemic oppression of women. It is important to give credit to survivors of abuse for coping with the trauma, escaping the abusive situation and finding a path that leads to healing. I see survivors as active participants in responding to violence, strategizing their survival and resisting oppression.
Having multiple identities is not itself debilitating, as cross cultural studies can demonstrate - being brutalized is debilitating. The goal of mobilizing support for survivors of violence is not to label them and file them away, or even to simply anaesthetize the pain. Instead, the appropriate goal for feminist action is to end child abuse and bring respect and understanding to those who have survived it. The forum in which to undertake this work lies not only in individual healing, but in healing as a community.
In most cases of Dissociative Identity Disorder, child abuse is at the core of the dissociative response. Ninety-seven percent of individuals with Dissociative Identity Disorder have a history of child abuse (Putnam et al., 1986), usually incest (68%) (Putnam, 1985). Current studies indicate that one in four girls will be sexually abused before the age of 18 (Briere & Runtz, 1988) and some studies indicate that the rate is closer to one female child in three (Russell, 1986; Finkelhor, 1986). In Russell's study of childhood abuse (1986) 16% of the women interviewed were sexually abused by members of their own families, and the abuse was reported to continue for years.
The mental health profession has been less than supportive in uncovering the incidence of child sexual abuse in our society. When Freud presented a famous paper on the etiology of hysteria that related child sexual abuse to the origin of neurosis, he was not prepared for the disbelief and professional scepticism he would encounter in response to the implication that incest and child abuse was not an uncommon event (Masson, 1984). Freud ultimately retracted his statement, replacing it with the theory of the Oedipal complex. The Oedipal theory explained away disclosures of child abuse as the fantasy longings of female children for their fathers, and denied that the abuse had ever occurred (Masson, 1984). This theory became the foundation of Freud's conceptualization of neurosis, and has been subsequently used for generations of psychiatrists to deny and disbelieve the stories of child sexual abuse reported to them by their clients (Rivera, 1988). The widespread abuses of women and children, in those cases where the proof was indisputable, were viewed as the isolated, individual acts of deviant men (Finkelhor, 1986; Russell, 1986).
The mental health profession reinforced this view. Psychology textbooks cited estimates of incest as occurring in one case per million (Freedman, Kaplan & Sadock, 1975). Later approaches to child abuse also took a "family" oriented perspective to incest; specifically, blaming the mother for her inadequate parenting. Levine (1989) quotes from an article in the Ottawa Citizen in 1978 that states "A local psychiatrist ... believes incest should be seen for what it is - quite literally a family affair. There are always at least three people involved, the mother, the father and the daughter ... usually it is done without violence" (p. 254). This commonly held attitude among mental health professionals reflects the attitude that incest itself is not an act of violence, and either the mother is to blame for not complying with the sexual demands of her husband, or the daughter is to blame for being seductive (Levine, 1989). The violent actions of male perpetrators are often shunted to the sidelines. Outright disbelief of disclosures of child abuse is also common (Goodwin, 1985a).
Interventions by the mental health profession can reflect these victim-blaming attitudes. Even well-meaning interventions into abusive situations can be traumatic to the child because social agencies are established to protect, not empower children. For example Levine (1989) cites a case where in 1980 a girl who was sexually abused by her father was put into a foster home by child welfare workers to study her "sexually provocative" behaviour. Even in cases where the abuser is identified as a threat to the child, the removal of the father often results in a severe drop in the standard of living for the now single-parent family (Ward, 1984).
This can be seen as a form of economic punishment for refusing to accept the rule of the man of the household. Individual intervention has limited effectiveness, because the problem lies in systemic, economically reinforced power relationships.
The focus of psychology is basically the management of mental illness. However, research into the etiology clearly points to the fact that Dissociative Identity Disorder is entirely preventable. Unfortunately, putting research into such a politically applied context is beyond the realm of many researchers. While broadly accepted theories of Dissociative Identity Disorder (Kluft, 1985b; Braun & Sachs, 1985) incorporate an understanding that the abused child is not protected from the abuser, few researchers put this into a social perspective. There is little profit in preventing the abuse of a patriarchal society (Brownmiller, 1975). Psychology remains a culturally bound profession that follows the tenets of the broader culture, and one of the purposes it serves in patriarchy is to privatize and individualize experiences of abuse(Levine, 1989). Defining and creating only individual solutions to the pain and problems of survivors of abuse ignores a political understanding of the larger issues of the oppression of children, especially female children, and the forms of and responses to oppression.
The broader understanding of child abuse emerged out of the Women's Movement of the 1970s and 1980s, not the individualized setting of private therapy (Rivera, 1988). Feminists conceptualized child abuse as a linked aspect of systemic violence against women and children and a tool of patriarchal oppression (Morgan, 1977; Brownmiller, 1975). Once the feminist political activism brought issues of child abuse and violence against women into the public consciousness, the issue was taken up by mental health professionals (Rivera, 1988).
Multiple personality disorder, as indisputably related to child abuse, represents a new opportunity for psychologists to explore the relationships between mental illness and social oppression. To understand Dissociative Identity Disorder as the result of trauma (Ross, 1994) is not enough. Dissociative Identity Disorder must be viewed in the larger social context of the oppression of women and children. Dissociative Identity Disorder is not merely the result of traumatic abuse, it is also the result of the social indifference to this abuse that allows violence against children to continue without intervention, that denies the disclosure of women and children who have experienced abuse and that fails to provide adequate support and care to survivors of abuse.
Part of understanding multiple identities as an adaptation, is understanding the nature of the abuse to which it is adapting. Child sexual abuse is not only an assault on the body of the child. It is an expression of control over the child, teaching the child their status as the sexual private property of men (Brownmiller, 1975). Physical and sexual is an attempt to colonize the mind and body of the child, an expression of the domination and power that adult men hold over women and children in the patriarchal nuclear family unit (Levine, 1989). Training ground for a lifetime of hierarchical oppression, the perpetrator punishes any sign of resistance and anger (Finkelhor, 1986). Child abuse involves a violation of the body which usurps the body from the control and intentions of the child. This leads to ongoing difficulties in "embodiment", or the relationships of the self to the body, in virtually all survivors of childhood abuse (Young, 1992). The body/mind split has little heuristic value when dealing with physical and sexual abuse. The body/mind connection is readily apparent in both the personal response to abuse and the political context in which abuse occurs.
The abuser also assaults the child's self-esteem y blaming the child for their own abuse, in order to displace their own guilt, ensure the child's silence and further dominate the child (Levine, 1989). This also is a divide and conquer strategy, where the child will expend energy blaming and fighting him or herself, rather than resisting the abuser. By examining child abuse as part of a political strategy of oppression that employs such colonizing tactics as "divide and conquer" and "blame the victim" (Hooks, 1981; Davis, 1981; Lorde, 1984), parallels between the response of dissociation and sociopolitical consequences of colonization become more clear. The inner turmoil and conflict of the person with multiple personality is similar to the infighting and internalized oppression of oppressed political groups. The amnesia that prevents even the survivor of child abuse from being aware of their own history is parallel to the silencing of women's voices and realities in a patriarchal system (Levine, 1989).
Modern psychology is predicated on the idea of the divided self.
An awareness of the fundamental divisions of our seemingly unified sense
of self is evident in many investigations into personality structure. Whether
the divisions are seen as ego/id and superego conflicts (Freud, 1893),
Hilgard's "hidden observer" (Hilgard, 1977), the archetypal figures
of Jung (Jung, 1937), ego state theory (Watkins & Watkins, 1979), Beahrs'
argument that multiple consciousness is inevitable in humans (Beahrs, 1983),
or Wolff's (1987) work on infant's states of consciousness; the multiplicity
of the human mind has been noted throughout psychology. There are a number
of proposed model for understanding these divisions; the models that relate
to the study of Dissociative Identity Disorder include a theory of dissociation.
Janet (1889) is credited with conceptualizing the idea of dissociation
as a mechanism, in which systems of thought can be split off from each
other and congeal into a secondary personality that is unconscious, but
can be accessed via hypnosis. In searching for definition to the pattern
of this structure, studies in Dissociative Identity Disorder and other
dissociative states have been ongoing. The clinical history of Dissociative
Identity Disorder extends back into the seventeenth century (Price, 1988).
Joseph Breuer and Sigmund Freud contributed to the conceptualization
of dissociation in their interpretation of the case of "Anna O.",
reported in their "Studies in Hysteria" (Breuer & Freud,
1895). Anna O. was treated for a number of somatic illnesses and dissociative
absences. Breuer regarded these absences as a form of autohypnosis, and
characterized hysteria as an illness with three states of consciousness
- normal waking state, the sleeping state and hypnoid states. He argued
that some form of "double consciousness" was present in every
case of hysteria to some degree. Freud (1893) interpreted the absences
more functionally, as a defensive mechanism. Repression was described as
a "horizontal" split between the conscious and unconscious minds.
Dissociation was conceptualized as a vertical split between separate aspects
of consciousness. Although Freud went on to place greater emphasis on the
mechanism of repression, neo-Freudians have begun to reexamine Freud's
original work and ideas on dissociation. Marmer (1991) adds that the purpose
of the splitting is to preserve the good self and the good object. Marmer
hypothesized that in Dissociative Identity Disorder, the self is split
more than the object, whereas in borderline personality, the object is
more split, with larger swings between idealization and devaluation. Marmer
(1991) argues that the creation of identities is a response to a need for
transitional objects, which fulfill the need for soothers and good objects.
Noll (1989) reviewed Jung's notes regarding dissociation and
argues that Jung is one of the earliest pioneers in the study of dissociation.
Jung's complex theory included a benign concept of dissociation. Jung stated
that dissociation occurs along a continuum from normal mental states to
abnormal states. Dissociation itself was natural and essential to the operation
of the psyche. While contemporaries such as Freud and Breuer focused on
the pathological aspects of dissociation, Jung posited a central and benign
role, fundamental to the processes of the psyche (Jung, 1947). He argues
that the main adaptive benefit of dissociation was that it allowed the
expansion of the personality through greater differentiation of function.
Jung (1937) states:
"As we have seen, the inherent tendency of the psyche to
split means on the one hand dissociation into multiple structural units,
but on the other hand the possibility of change and differentiation. It
allows certain parts of the psychic structure to be singled out so that,
by concentration of the will, they can be trained and brought to their
maximum development. In this way certain capacities, especially those that
promise to be socially useful, can be fostered to the neglect of others.
This produces an unbalanced state similar to that caused by a dominant
complex - a change of personality" (p. 121).
Jung, therefore, saw all of us as essentially multiple, our changes of personality as socially functional, and dissociation as a part of everyday life. Jung hypothesized that two main factors in the development of complexes (or identities) were the environment and the inherent predisposition in the individual. The complexes split off into "psychic fragments" as a result of traumatic influences.
Even moral conflicts can result in tiny psychic fragments that are present in all neurotic and normal individuals (Jung, 1937). Severe trauma leads to deep splinters in the psyche, and alternate personalities develop. This theory is very similar to Kluft's four factor theory of Dissociative Identity Disorder (Kluft, 1985b), except for Kluft's final condition of a hostile or unprotective environment that fails to protect the child from abuse.
Jung followed the philosophical tradition of polypsychism which was common among mesmerists in the 19th century (Noll, 1989). This theory argued that human personality exists in multiplicity. There are many centres of consciousness with varying degrees of control, and they are organized hierarchically. Jung also noted that each fragment has its own character, sets of memories, exists with relative independence from each other and exhibits evidence of amnesiac barriers between personalities. Jung also noted that the healing of neuroses occurred through the "assimilation" of unconscious contents into the ego-complex through an inner dialogue, which brings the fragments under the control of the ego-complex and also expands the functioning capacity of the centre of consciousness (Jung, 1934).
Noll (1989) initially argued that the structure of the identities
commonly found in individuals with Dissociative Identity Disorder reflects
the archetypal characteristics of Jungian analyses. With the centralizing
personality weakened, the unconscious archetypes step forward and act more
directly. Noll believed that archetypes of the child, the shadow, various
aspects of self and anima and animus figures manifested in the identities
of Dissociative Identity Disorder, as the structure of the psyche was laid
bare to witness. However, in a later paper, Noll (1993) corrected his statement
that the identities reflected the collective unconscious, and stated that
their formation was primarily in response to sociocultural influences.
Behavioral state theory
Wolff (1987) conducted research in infant states and hypothesized
that children exist in behavioral states that are self-organizing and self-sustaining.
He drew examples from nonlinear dynamic systems theory to explain the structure
of early developmental states. Children had predictable state fluctuations
anchored around sleeping and eating needs. As development progresses, the
"architecture" of state sequences becomes more complex and more
responsive to the environment. He argued that regulating the behavioral
state is an important task of early development, which includes increased
concentration and attention span, the ability to screen out distractions
and respond to social cues. Putnam (1985) proposed that dissociation represented
a disruption in the development task of learning to generalize across different
states of consciousness. Putnam argued that abused children were unable
to complete these normal developmental tasks in the face of ongoing trauma.
Hilgard (1977) and Bliss (1986) contributed to the understanding of dissociation through their work on hypnosis. They viewed multiple identities as a form of self-hypnosis, also called autohypnosis. Autohypnosis was proposed as the mechanism of how dissociation operates. Hypnosis is an extension of normal processes of dissociation, which allow people to focus attention. The attention mechanism is a network of reticular tissue in the brain (Bliss, 1986). There is natural variation in the population of the degree to which individuals can be hypnotized (Hilgard, 1965; Ross, 1991). Research into the hypnotizability of individuals with Dissociative Identity Disorder found that high levels of hypnotizability were always found in Dissociative Identity Disorder patients (Bliss, 1986). Children are also much more hypnotizable than adults and report more dissociative experiences (London & Cooper, 1969; Ross, 1991; Ross et al., 1989).
State dependent learning theory
State dependent learning is incorporated into a number of models (Braun, 1989; Putnam, 1989; Kluft 1991) as another mechanism of dissociation. The basic concept of state dependent learning is that people experience a variety of states that change according to emotions, behaviours and perceptions of the world. Something learned in one state is best retrieved under a similar state. The closer the state to the original experience, the better the retrieval. This process is thought to include a variety of factors, including learning processes, neurological conditioning processes and methods of encoding information. Ongoing trauma forces dissociative states to reoccur. Personalities are formed and learn through their repeated interactions with the environment. When the states become too disparate, inter-state retrieval becomes nearly impossible, and an amnesiac barrier is said to exist.
Not all trauma results in state-dependent learning effects, however. Braun (1989) notes that although Post Traumatic Stress Disorder is a dissociative disorder, it does not manifest state-dependent learning disruptions evident in Dissociative Identity Disorder.
Kluft (1988a) based his definition of alternate identities on the model of state dependent learning, and states that:
"a disaggregate self state (i.e., personality) is the mental
address of a relatively stable and enduring particular pattern of selective
mobilization of mental contents and functions, which may be behaviourally
enacted with noteworthy role-taking and role-playing dimensions and sensitive
to intrapsychic, interpersonal, and environmental stimuli ... It functions
both as a recipient, processor, and storage center for perceptions, experiences,
and the processing of such in connection with past events and thoughts,
and/or present and anticipated ones as well. It has a sense of its own
identity and ideation, and a capacity for initiating thought processes
and actions." (p. 51)
Ego state theory
Ego state theory extends the argument that the mind is polypsychic with many existing processes and systems throughout life (Kelley & Kodman, 1987). The human personality develops through two different processes, integration and differentiation. Putting common concepts together, through the process of integration, results in more complex concepts, for example the realization that dogs and cats are both animals. By differentiation, the child separates concepts, for example, there are large dogs and small dogs. Dissociation occurs when this separating process becomes excessive and maladaptive (Watkins, 1993). Watkins & Watkins (1990) also argued that pain is eliminated in the primary personality by displacing it into underlying identities, often at their expense. They hypothesize that this process can be a source of internal conflict and further dissociation.
Federn (1952) argued that whether a physical or mental process
was identified as part of the self or something other than the self, was
determined by whether ego or object energy activated it. A personality
is all of one's perceptions and emotions clustered into ego states, to
create "an organized system of behaviour and experience whose elements
are bound together by some common principle" (Watkins, 1993, p. 233).
One state is invested with ego energy, and becomes the "executive
self" (Watkins, 1993; Beahrs, 1983). Other ego states are invested
with object energy and are experienced as "other". Price (1988)
argues that one ego state is perceived as the "real" self because
it is currently cathected and can therefore act as the executive self,
however, this self can change over time. Ego states can be large and include
all work related thoughts and feelings, or they can be related to a single
memory. Everyone has covert ego states, which can be accessed through hypnosis.
In individuals with Dissociative Identity Disorder, however, these covert
states become overt. Price (1988) views the problem with multiple identities
as being the permeability between ego states. The ego states are permeable
to the flow of cathexis (allowing different ego states to assume executive
control), but impermeable to information (causing amnesia). This creates
a discontinuity in the perception of a unified self.
Kluft's Four Factor theory
Kluft (1985b) proposed a four factor theory of the etiology of Dissociative Identity Disorder. In order for Dissociative Identity Disorder to develop, the individual would have to:
The double-bind theory
Braun (1986) suggests that the primary mechanism driving multiple
personality is the contradiction between two primary injunctions from a
parent, in addition to the rule that this contradiction may not be discussed.
For example, if a father who brutalizes his child tells the child that
he is abusing her because he loves her, it combines the need for attention
and loving from the parent with pain and fear. The child is forced to internalize
these contradictions and become one child who is dependent, passive and
eager for attention, and another who is angry and resistant. Repeated abuse
forces the child to protect him or herself from an irrational environment.
Braun's BASK theory
Braun (1984) developed a theory of the structure and etiology of Dissociative Identity Disorder that focused on the forms of dissociation found in Dissociative Identity Disorder. He theorized that:
"in persons with the biopsychophysiologic capacity to dissociate, the predominant defense mechanism may be pathologic dissociation. If the victim suffered childhood incest in the context of an abusive family, the dissociative disorder that develops as its sequel may be seen as complete disruption of behaviour, affect, sensation and knowledge (BASK): that is, multiple personality disorder" (Braun, 1989, p. 307).
Braun argued that behaviour, affect, sensation and knowledge
are processes which function congruently over time. Dissociation can occur
in any of these elements, for example a disruption in sensation results
in hypnotic anaesthesia. A disruption on all BASK elements corresponds
to Dissociative Identity Disorder. Braun believes that awareness and dissociation
occur on a continuum, and that dissociation and Dissociative Identity Disorder
represent the most pathological extremes.
3-P factor theory
Braun & Sach's (1985) 3-P factor theory of etiology is again very similar to Kluft's 4 factor theory. The factors are:
Barach (1991) argues that Dissociative Identity Disorder can also be viewed as an attachment disorder. He uses Bowlby's theory of attachment (1988) to relate to dissociation. This is a variation on the concept of Dissociative Identity Disorder as a developmental disorder, in this case the child abuse interrupts the developmental task of forming secure attachments. Barach argues that detachment (the failure to form attachments) is basically the same thing as dissociation. Barach states when one caretaker is detached or emotionally distant from the child, the child may use dissociation as a defense against the trauma of abuse perpetrated by the other parent. He argues that alternating between assault and abandonment is the core problem. Several studies have confirmed that inconsistent treatment is especially likely to create traumatic dissociation in children (Allison & Schwartz, 1980; Braun & Sachs, 1985; Coons & Milstein, 1986; Kluft, 1982; Wilbur, 1984a). For example, a child might alternately be beaten, ignored or rewarded for the same behaviour on different occasions. Contradictory messages, and alternating patterns of affection and abuse are intermingled. Parental discipline and affection are often unpredictable. There is no one way to respond that will ensure the child's safety or parental approval (Sachs, Frischholz, & Wood, 1988).
Abused children form dysfunctional attachments with their abuser, who hold life and death power over them, and often are in a situation where no one, including the mother, extended family, teachers and so on, believe the child's disclosure of abuse and/or are willing or able to take action to prevent further abuse. Putnam et al. (1986) found that over 60% of patients with Dissociative Identity Disorder reported extreme neglect in childhood. This basic emotional deprivation prevents the child from learning to form trusting relationships, creating anxious attachments later in life.
This is again similar to Kluft's fourth factor of an unsupportive
environment and that fails to protect the abused child.
There are few large, direct studies of individuals with Dissociative Identity Disorder in the literature. Many of the larger studies are actually reports compiled entirely (Ross, Norton & Wozney, 1989; Putnam et al., 1986) or mostly (Rivera, 1991) from therapists' clinical observations. Such indirect data has obvious problems of reliability. Much of data has already been subject to the interpretation of the therapists, who in turn are basing their conclusions on the self-reports of their clients. One of the limitations is that the relative infrequency of Dissociative Identity Disorder makes it difficult to compile large samples.
Although Rivera (1991) found no differences between the reports from individuals with Dissociative Identity Disorder and therapists' reports of clients with Dissociative Identity Disorder in her study, more direct research through multicentre collaborative sampling needs to be done. Many reports are based on small studies from clinical experience (Adityanjee, Raju & Khandelwal, 1989; Kluft, 1991; Young, 1987; Fike, 1990a; Braun, 1989; Dawson, 1990; Dell & Eisenhower, 1990; Angel, 1989; Kluft, 1986b). There are some indications that the clinical population may not be representative to the general population (Ross 1991), which limits the generalizeability of such methods of study.
The lack of longitudinal studies creates further problems of validity, as virtually all the data relies on the self-reporting of patients about events that happened far in their personal past.
The literature also lacks integration with cross cultural data. While some cross cultural studies have documented cases of Dissociative Identity Disorder (Adityanjee, Raju & Khandelwal, 1989; Coons, Milstein & Bowman, 1990; Ensink & van Oterloo, 1989; Malarewicz, 1990; Martinez-Taboas, 1989), the research is limited to urban centres and/or industrialized countries.
The literature is still small, with only a dozen or so researchers
contributing the bulk of the material. Surely, fresh insight would result
from the integration of individuals with multiple identities into the academic
exploration of the phenomena. A less socially dissociated response to child
abuse would include both caregivers and survivors in dialogue. Margo Rivera
(1988) notes a conference she attended where the strongest feminist voices
came from women with multiple identities who presented papers on self-help
groups, social analysis of multiple personality in maintaining societal
norms and cross-cultural and cross-racial issues and problems in therapy.
Rivera comments that "it is significant and not surprising that the
strongest feminist voices at the conference were those of women with multiple
personalities" (p. 39). I can only imagine what it would be like if
all the professionals engaged in research would devote the same time and
effort into providing a forum for individuals with multiple identities
to talk about their experiences and share their theories.
Dissociative Identity Disorder is often described as a stress-related phenomena, specifically an adaptation to the stress of an abusive childhood environment (Spiegal, 1984; Briere & Runtz, 1988; Fagan & McMahan, 1984; Kluft, Braun & Sachs, 1984; Wilbur, 1984a; Bliss; 1980; Greaves, 1980; Schultz, Braun & Kluft, 1985; Putnam, 1985; Kluft, 1985b; Ross, Norton & Wozney, 1989). But what exactly is meant by stress? Often, this term is misinterpreted to refer to an external event, for example, to describe the abused child as being "under stress" or in a "stressful" environment, or to say that Dissociative Identity Disorder is "a response to stress". However, stress was originally conceptualized as an internal state, or specifically as "the state manifested by a pecific syndrome which consists of all the non-specifically induced changes within a biologic system" (Selye, 1978, p. 64).
Understanding stress in this way, instead of as external events,
is a useful heuristic for exploring Dissociative Identity Disorder. Hans
Selye, a well-known endocrinologist, redefined disease and biology with
a radical (at the time) theory about the way human beings adjusted to the
world. Selye (1950, 1967) developed a model called the General Adaptation
Syndrome (GAS) which explains physiological patterns and mechanisms of
adaptation to changes. Before Selye's work, Western medicine defined diseases
as the work of a pathogen, such as a virus or a bacteria that would attack
the body (Hinkle, 1987). Selye redefined these concepts with a more dynamic,
systems model of interactions between the body and the environment.
Selye's dynamic model of stress
Homeostasis is a steady state, waiting for change, that exists before a new stressor is introduced. Adapting to a new environment or new information, involves the process of heterostasis, incorporating these changes into our bodies or lives. After adaptation has occurred, a new state of homeostasis is reached. The process of adaptation has incorporated some degree of change, a new immunity to a pathogen, or a new self-concept. And then another stressor comes along and the process begins all over again.
Selye (1974) believed humans were meant for change, for learning
and growing. He believed that regulating the processes of stress would
result in "dynamic equilibrium". Managing stress is like riding
a bicycle, if we stop we fall over, if we go too fast we break down. We need to keep moving, lack of change can be one of life's most frustrating and stressful situations. However, the changes need to be at a controlled pace that we can adapt to without disturbing the dynamic equilibrium.
Defining stages of stress
Selye defined stress as "the state manifested by a specific syndrome which consists of all the non-specifically-induced changes within a biologic system" (Selye, 1978, p. 64). The process of living involves some level of stress and ongoing changes, for better or for worse. Positive changes can be stressful without causing distress. Selye named this process "eustress", which involved having to make changes for positive stressors in our lives. However, too many positive changes can still be distressing; they still provoke the stress response - increased heart rate, sweating and increased blood pressure.
Stress is the mechanism of heterostasis. The physiological state
of stress can be broken down into three basic phases, also called the General
Adaptation Syndrome - the alarm stage, the resistance stage and the stage
Stage 1: The Alarm Stage
The alarm reaction has hallmark physiological responses, the enlargement of the adrenal cortex, the atrophy of the thymicolymphatic organs, gastrointestinal changes and a variety of chemical changes in the body fluids and tissues. Long-term signs also include loss of weight, changes in the regulation of body temperature and loss of eosinophil cells from the blood. In issues more directly affected by stress, a local adaptation syndrome (LAS) also develops, for example, inflammation where the poison from a bite has entered the body. This is closely coordinated with the GAS. Chemical signals from the directly stressed tissue are sent to the coordinating centres of the nervous system, especially the pituitary and adrenal glands. These glands produce hormones to mobilize the body's defence against the stress, as well as providing specific responses for the directly stressed area. The hormones fall into two categories, anti-inflammatory hormones which prevent the defensive reaction of inflammation (such as ACTH, and cortisone) and proinflammatory hormones which stimulate inflammation (such as STH and aldosterone). Both hormone types help the body cope with the stressor, either by reducing sensitivity to it and making it easier to coexist with it, or by cutting it off from further entry to the body by barricading it within the inflammatory tissue.
These processes all interact with each other, and can be affected by a variety of factors, such as diet, genetic composition and tissue memories of previous exposure to stress. And although the stressor can be non-specific, the stress response can be highly specific.
The overall level of resistance is lowered during the alarm stage.
For example, many of the hormones released during the alarm stage have
deleterious effects on the immune system (Selye, 1978).
Stage 2: The Resistance stage
The resistance stage ensues if continued exposure to the stressor
is compatible with adaptation (i.e. survivable). The body's resistance,
which was lowered during the alarm stage, resumes at a higher level than
normal. Adaptation to the stressor characterizes this process. There are
different types of adaptation; developmental adaptation (where modifications
are required in the current structure and function of a cell or system
in response to a stressor), and re-developmental adaptation (where tissue
which has been organized for one type of action, is forced to readjust
itself completely to an entirely different kind of activity).
Stage 3: The Exhaustion stage
The exhaustion stage follows long-continued exposure to a stressor
that the body has become adapted to. The signs of the alarm reaction may
reappear if the stressor is still present, and the individual may die.
The capacity for adaptation, which Selye believed was finite, has been
exhausted at this point.
The Process of Adaptation
Selye (1978) defines adaptation as the "balanced blend of defense and submission" (p.169). Adaptation is the blending of life and death, resistance and submission, composition and decomposition, as every manifestation of growth necessitates destruction. Every time a muscle is flexed, stressed and developed; destruction and "wear and tear" occurs at the same time.
Adaptive does not always mean healthy. Selye's model challenges the definition of health, as much as it challenges the concept of disease. Adaptation occurs only relative to the environment, what is adaptive in one environment is not adaptive in another. Rapidly changing environments, that require ongoing, rapid internal changes, result in a high state of stress. Even though successful adaptations are produced in response to each stressor, the cumulative effects of stress can be detrimental and will eventually diminish the adaptive energy.
Selye hypothesized that adaptive energy, the capacity to respond to the environment, was finite. Adaptability is not simply a matter of calories, but a different kind of energy, similar to the concept of vitality or vital energy.
The non-specificity of the stress response
The state of stress is generalized throughout the body's systems.
A LAS does not occur in isolation, but in conjunction with a general mobilization
of the body's defenses. Often, the process and degree of the GAS depend
on the type of stressor. It can be more effective to localize the response
as much as possible. When there are a limited number of effector mechanisms
or a limited success with which they can respond to the stressor that the
state of stress becomes more systemic and the response is non-specific.
Diseases of adaptation
Some stressors can directly cause disease. For example, if you put the hand of a corpse into acid it would cause burning regardless of the fact that the corpse showed no adaptive responses to the stressor. However, more complex, long-term syndromes and cumulative environmental responses are the result of diseases of adaptation.
A disease of adaptation occurs when the adaptive responses of the GAS produce damaging effects (Selye, 1978). The external agent is not the (direct) cause of the disease, just the stressor, and possibly one of many factors. For example, consuming fat in one's diet is a stressor. In order to transport the fat through the bloodstream, the liver produces cholesterol. Large amounts of dietary fat leads to a large stress response (more cholesterol) which can be trapped in the lining of the arteries. This begins to limit the blood supply to the organs. According to Selye, it is the adaptation to the stressor (the production of cholesterol) that creates the manifestation of disease.
Using this analysis, a multifactorial approach can be used to understand disease syndromes, not related to a direct cause and effect relationship. For example, seemingly unrelated factors such as a sedentary lifestyle, certain chemicals inhaled in tobacco smoke and a variety of other stressors can also affect the response of cholesterol levels. These different factors can have complicated relationships, for example chemicals in tobacco damage the lining of the arteries and increase the likelihood that cholesterol will be trapped in them.
The generalized response of the individual includes intellectual and emotional aspects. The body responds to intellectual demands, and the intellect responds to physical demands. Therefore, in studying the GAS, the entire body-mind system must be examined. The artificial separation between the physical and mental is not a useful heuristic in this context. The GAS includes changes in gross motor behaviour, patterns of activity that change exposure to stressors and other behaviours, ideations and affects that mediate the impact of a physical stressor.
In some way, many diseases can be understood to be diseases of adaptation. However, the meaning of disease is changed. The linear concept of pathogen and illness, stimulus and response, need to be redefined to accommodate more complex realities. If diseases occur as a result of adaptation, we need to rethink the relationship of illness and health. For example, we get sick as a result of immunization, yet being immunized is a healthful process. Chicken pox is a dangerous disease in adulthood, and contracting the illness is considered a normative, healthy aspect of childhood to prevent future damage (Selye, 1978). We think of disease as something bad that we should try and eliminate, rather than examining the complex interrelationships of our environments and our responses to these environments. Disease is rarely a passive experience of something that happens to us, it is a dynamic and interactive relationship we have with our environment. Often, the immediate signs of disease, are really the results of adaptations to the environment. Intervention in the environment will naturally reduce the signs of disease, as the adaptive responses are no longer elicited. Complex, adaptive responses, such as Dissociative Identity Disorder, need to be analyzed by examining GAS effects.
One example that clarifies the implications of the GAS, is weightlifting. In weightlifting, it has always been assumed that by lifting weights, and forcing the muscles in the body into a state of stress, that they would adapt to this stressor by increasing in strength. However, weightlifters, who regularly seek to maximize this state of stress, also know that at some point in intensive training, long plateaus of weeks or years can result in no change to the muscles, despite continuing stressors (Garhammer, 1986).
This is the result of the body reaching a level of homeostasis that incorporates the regular activity. It has entered the resistance stage, where the system is accommodating the current level of stress without making further responses to the stressor. The plateau experience is the conservation of adaptive energy, your body is reluctant to begin a new cycle of heterostasis. Overtraining can also lead to the exhaustion stage, where new adaptive responses simply cannot be activated by that specific stressor. Exposing the system to stress at this stage damages the muscles and joints instead of strengthening them.
Weightlifters also discovered that lifting more poundage does
not always lead to the fastest improvements. For example, lifting 20 pounds
ten times a session, three times a week equals a total amount of 600 pounds.
Lifting 20 pounds in a sequence of 8, 10 and 12 times over the course of
the week will result in faster improvement, even though the total remains
600 pounds (Garhammer, 1986). Not training can improve performance as well.
Regular breaks during training are needed to keep improving, even though
the muscles are being subjected to less stress (Garhammer, 1986). Selye
(1978) explains that the body adjusts to the pattern of the stressor, as
well as each individual period of exposure. Constant variations in the
type of stressor will stimulate new cycles of the heterostasis to adapt
to the new changes. Many weightlifters advise beginning with a simple exercise
routine and then adding variations to the workout. If too many variations
are introduced all at once, the initial rapid improvement will quickly
lead to long plateaus.
Psychological stress is often defined in a relatively mechanistic way, in analogy to the body's GAS. This is partly because psychological stressors and biological ones usually produce overlapping stress responses. The generalization of the stress response is critical in expanding the model for psychological and sociological applications. Hinkle (1987) states that psychological stress has an obvious effect on the central nervous system, and produces changes in moods, thoughts and behaviours. Hinkle (1987) also states that:
"information acquired from the social and interpersonal
environment and mediated by the central nervous system through its control
of internal regulatory processes, is able to produce alterations of internal
functions down to the biochemical level" (p. 562).
Social stress occurs for a person when "he [sic] is faced with a situation that implies for him two or more different kinds of behaviour, based on two or more different set of guidelines and values, which are in conflict and not readily reconcilable" (Hinkle, 1987, p.562).
Selye's model of stress can be applied to Dissociative Identity Disorder, in examining the etiology, stages and structures through a dynamic model. The model implies that it is possible to trace a life history of the course of Dissociative Identity Disorder, and examine the impact of different stressors affecting the individual. Examining Dissociative Identity Disorder as not only a defensive response for survival, but a reactive and proactive adaptation, implies that the individual is not merely fleeing from pain but heading towards something else; that they are not merely coping with abuse, but resisting it.
Overview of the theory
Multiplicity can exist in non-pathological states in adulthood, and dissociative personality structures naturally occur in the general population. Neurological models provide a concrete theoretical background to study this normative multiplicity (NM) as well as multiple identities that result from childhood abuse.
I find the best way to conceptualize identity, is as a dynamic consciousness system (DCS) that corresponds to a neurological framework. Several theories of dissociation use a model of either the executive self (Watkins & Watkins, 1979) or a host personality that is the central self, while the other identities are peripheral (Putnam, 1985). Using the term DCS emphasizes that the system as a whole is organizing the responses to abuse, not just one aspect of consciousness.
Dissociative Identity Disorder is a result of an adaptive response, which I refer to as the Multiple Identity Response (MIR). The MIR is not static, but is constantly changing over time. For most of its cycle, the MIR does not result in a state that could be termed Dissociative Identity Disorder. Eventually, the MIR can resolve itself to a stable, adaptive and productive system.
The criteria for examining Dissociative Identity Disorder are too narrow to understand the life history and developmental aspects of the MIR, resulting in rigidly defined models of dissociation that reflect culturally-bound assumptions of the nature of self.
To summarize my theory:
1. The embodiment of alternate identities is an acceptable principle of psychological organizing, that can exist without the presence of pathology. This is called normative multiplicity (NM).
The model for basic psychological structure, which can develop into a variety of organizational patterns, is called the dynamic consciousness system (DCS).
2. The DCS forms a response to abuse, called the multiple identity response (MIR), which has definite stages and follows a developmental history. The MIR is a constant blend of resistance and submission to stressors. Factors in adulthood affect the course of the MIR.
3. The MIR is an adaptive response to social oppression and cultural demands, as well as to the individual abuse. The individual experience of abuse is a necessary but not sufficient condition for the formation of the MIR.
4. The diseases of adaptation present in the MIR include internalized oppression and amnesia. Multiplicity itself is not a disease of adaptation, but a normative condition.
5. The diseases of adaptation can be resolved outside the context of therapy. The MIR is an adaptive response that changes with time, and can result in healthy, stabilized structures.
6. The appropriate response to abuse is both personal and political.
I propose that the basic personality system is more of an organized, self-regulated body of operations that together form the dynamic consciousness system (DCS). The system is dynamic because of its changing, adaptive nature. Varying levels of awareness and consciousness exist within the system, which is organized on a modular, decentralized basis.
By multiplicity, I am referring to the embodiment of alternate identities, not just "covert ego states" (Watkins, 1993) or "subpersonalitites" (Rowan, 1990) but the actual experience of a highly dissociative psychological organization. This challenges the "humanist notion of the coherent, essentially rational individual who is the author of her own meanings and the agent of her own productions" (Rivera, 1988, p. 40).
There is a wide range of natural variation in the forms of
psychological organization, although this is likely to be developmentally
skewed in North American culture. If the embodiment of multiple
identities is a natural aspect of psychological organizing for
some people, this criteria for Dissociative Identity Disorder
needs to be re-evaluated. The definition of the "disease"
of Dissociative Identity Disorder may ultimately be highly culturally-specific
and ultimately fallacious.
In North American culture, we are trained to respond to the world in linear, singular thinking. We create hierarchies and use models of the "executive personality" which controls the other ego states (Watkins, 1993; Braun, 1986, Kluft, 1991), rather than acknowledging the biochemical multiplicity, modularity and decentralization of our central nervous system.
Recent theories in physics, such as Quantum theory and fractal theory (Briggs, 1992; Peitgen, 1992a; Peitgen, 1992b; Bohm, 1980,Davies, 1980), imply that multiplicity is an organizing principle of much of the physical and biological world, ecosystems, matter and energy and spacetime.
Modern psychology has been predicated on the principle of the divided self, but this divisiveness is cast as a struggle for dominance with only one self being able to rule at any given time.
In Civilization and Its Discontents, Freud (1963) argued that this struggle for a rational, unified self was ongoing. Subjugating the irrationality, destructiveness, lust and forbidden thoughts of the unconscious mind was necessary for maintaining civilization. Failure to do so would result in the descent of our selves and societies into barbarity.
This linear, hierarchical thinking is also reflected in concepts of monotheism, Newtonian and reductionist thinking, colonization, mind/body dualism with the body being properly subjugated to the mind, human/animal dualism with the animal being properly subjugated to the human and the lack of willingness to acknowledge and understand our other identities (Ross, 1991). The need for structure, reason and law in order to prevent barbarity, chaos and anarchy from overwhelming and destroying humanity is a common theme. Western psychology has acknowledged that children experience discrete, distinct and discontinuous states of consciousness, and they argue that learning to integrate these states is a crucial part of the maturation process (Wolff, 1987). However, deconstructing the social context of this theory leads to reinterpreting these findings as meaning that children initially experience the world as it is, rather than cognitively processing it. As children begin the process of perception, and the concomitant construction of a world view, socialization plays a large part in determining how this world view will develop. The act of perception, which involves superimposing abstract concepts and relational patterns, involves interpreting how the world is patterned. The end result of this process, a world view, varies widely from culture to culture. In Western culture, children are socialized to believe that reality is unified, continuous and organized, and that the inner reflection of this world, the identity, is also unified, continuous and organized.
A number of research findings support the hypothesis of normative multiplicity. There is already evidence that children have more dissociative experiences and are more hypnotizable than adults (Ross, 1991). Both hypnotizability and dissociative experiences peak in late childhood and early adolescence, and then drop quickly as the individual progresses into adulthood (Ross, 1991). The normative multiplicity hypothesis also predicts that level of dissociation and hypnotizability in children of different cultures would be more similar than adults across cultures, and that levels and types of dissociation in the general population are likely to vary widely across cultures and individuals, with more dissociative experiences occurring in cultures that have polytheistic religions, trance and possession ceremonies and nonindustrial economic bases.
We are socialized to repress, deny and dissociate from our "unacceptable" thoughts and feelings on a daily basis (Rivera, 1988). We create the illusion of singularity (Watkins & Watkins, 1979). Many of us present a unified response to situations, without acknowledging the complexity of our lives and our selves (Beahrs, 1982; Watkins & Watkins, 1990; Braun, 1989). Often, it takes therapy or dream work to access the responses deemed unfit and suppressed from our consciousness - anger, fear, resentment, self-blame, blaming others, hope - all these responses can be discovered in layers of feeling, thoughts and selves (Rowan, 1990). Sometimes it is astonishing how many and how different thoughts and feelings can be elicited in response to a single situation.
The irony of the Executive Self model is that we change roles,
or identities, all the time. It's just that all these changes
are supposed to happen under the auspices and regulation of the
Executive Self (Watkins, 1993). Conscious awareness of these everyday
internal conflicts has sparked much of the scepticism of Dissociative
Identity Disorder, after all most people experience states of
"I don't know what possessed me" and "I just wasn't
feeling myself" at some point or another (Kelley & Kodman,
1987). In order to overcome the socialization that only one response
is allowed to exist within each person, family therapy models
use the analogy of a cast of characters who represent different
needs, moods, beliefs and social identities (Kramer, 1968; Watanabee,
1986; Watanabee-Hammond, 1987). The feeling that other people
are living inside us, marginalized and unacknowledged, appears
to be very common. John Rowan (1990) details a number of common
"subpersonalities" that he believes exist in everyone.
Common subpersonalities include an inner child, a critical self,
a protector for the child, a working or intellectual persona and
other aspects that represent all the selves that are needed to
function in modern society. Not surprisingly, these are the identities
most commonly found in individuals with Dissociative Identity
Disorder (Ross, Norton & Wozney, 1989).
The cultural continuum of dissociation
Dissociation is not a pathological state, but a natural function of the human brain which is present in all stages of life (Jung, 1934). Degrees of dissociation form a part of our everyday lives, in fact, if we did not have the ability to dissociate, and respond to our environment at a level below the consciousness awareness, our lives would be very difficult (Hilgard, 1977). Physical reflexes rely on dissociation to function rapidly, dissociation is what makes typing or driving a car possible (Hilgard, 1977). Even reading involves deciphering the letters and words faster than would be possible if full attention was needed to think through the meaning of each letter (Hilgard, 1977). These descriptions of everyday dissociation imply that dissociation is commonly used in Western societies in making boring or repetitious tasks go easier and faster. The relative ease of learned dissociated processes makes our conscious minds able to function on more complex tasks.
Dissociative experiences happen to everyone, in dreams, in fantasies, trance states, driving and meaningful religious experiences (Rivera, 1988). Dissociation is also used in hypnosis as a tool in therapy. Of course, this list of everyday dissociations may be commonplace only in industrialized societies. One problem with rapid industrialization in some countries is the unsuccessful adaptation of the people to the repetitious, mind-numbing nature of work in an industrialized environment (Stavrianos, 1981; Elliot, 1989; Beckford, 1972) and comprehending the apparent obsessive-compulsive relationship to tiny increments of time (Stavrianos, 1981). While Westerners develop a high dissociative capacity to endure a lifetime of alienated labour, it cannot be assumed that this is the same in all cultures. In North America, attention deficit "disorder" is used to describe children who cannot sit still for the required length of time and focus on one task (Levinson, 1990).
The process of focusing attention in this way is a basic form of autohypnosis, and involves a certain capacity for dissociation. This may be further indication of the wide natural variation in dissociative capacity, as well as testimony of how well this capacity can be developed with practice. On the other hand, certain types of dissociation that are regarded as commonplace in some cultures, such as having spirits take control of the body or channelling the presence of dead ancestors, is regarded with singular dismay in Western psychology (Mulhern, 1991). The Western tradition, both religious and psychological, are strongly negative with regard to possession and trance states. Often, such states are equated with Satanic possession or medical pathology (Leavitt, 1993). However, in many parts of the world, possession is considered a normal aspect of religious life and a psychologically and medically healing activity (Bourguignon, 1973).
The same types of dissociation as in Dissociative Identity Disorder, including the embodiment of an alternate identity, are not considered an illness (Leavitt, 1993; Mulhern, 1991) when they take the culturally appropriate form of shamanic visions (which do not involve any loss of memory or consciousness) or an external entity possessing the body (usually leaving the host with no recollection of the specific event). Within the same culture, one can find cases of unwanted possession, for which the best cure is often divine possession to cast out the other spirits, often as part of the same religious ceremony (Leavitt, 1993).
Few cultures would perceive the embodiment of the divine as an illness or pathology (Ward, 1989; Obeyesetere, 1977; Mulhern, 1991; Leavitt, 1993). Bourguignon's (1973) cross-cultural sampling found that possession was seen in the public, religious experiences of 251 out of 488 societies. Leavitt (1993) provocatively proposes a "Trance and Possession Suppression Disorder", often suffered in Western society, which involves the inability to lose oneself and become someone else for even a little while. He argues that the over-emphasis on rigid personal control and guilt is the root of the Western "allergy to dissociation."
Multiplicity in any cultural context, even the context of Western society, belies the view that multiplicity itself is an appropriate criteria for mental illness. Kluft (1991) observed in a study of individuals with high numbers of identities, that it is the degree of conflict between identities, not the state of multiplicity, that is at the root of pathology. Ross (1991) studied the general population of Winnipeg searching for an indication of Dissociative Identity Disorder in the general population. He found 3.1% of respondents to an interview could fit the criteria of Dissociative Identity Disorder. However, of these 14 individuals (out of 454 participants), the majority (8) seemed to be radically different from Dissociative Identity Disorder patients in therapy. These individuals often did not report abuse history and often reported experiencing little psychopathology. In a test of the Dissociative Experiences Scale (DES), all but one had scores of less than 20. The DES has a scale out of 100, with the mean score of a person with Dissociative Identity Disorder was 41.4 with a standard deviation of 20. The mean score in the general population is 10.1 (Ross, 1991), meaning that the scores of this subgroup were above average for the general population, but well below average for clinical cases of Dissociative Identity Disorder. Only 6 individuals in the general population appeared to have what Ross described as "pathologic posttraumatic MPD," which was 1.3% of the entire sample. These individuals had abuse histories and reported difficulties in functioning.
Ross describes a number of possibilities that explain these findings. He contemplates that the non-pathological group could be false positives, that the individuals could be amnesiac for abuse, that the Dissociative Identity Disorder could be in remission or that:
"multiplicity exists in a non-pathological endogenous form in the general population. About 2% of people may be natural multiples who do not have dysfunctional posttraumatic MPD. They may simply have a highly dissociative psychic organization" (Ross, 1991, p. 510).
I would add that this sub-population in this study are individuals who maintained this structure despite years of socialization. I would predict that the size of this subgroup would be much higher in other cultures. Ross went on to state that "simply having distinct personality states that feel subjectively like separate people may not in itself be a mental illness" (p.511).
Hughes (1992) described 10 trance channelers who scored comparably to individuals with Dissociative Identity Disorder on the DES (i.e. reported high levels of dissociative experiences). The dissociative processes underlying Dissociative Identity Disorder and trance channelling seemed to be similar, yet the trance channels exhibited none of the secondary features of Dissociative Identity Disorder, had little evidence of childhood abuse or pathological profiles.
Krippner (1987) reported on Brazilian approaches to Dissociative Identity Disorder, which integrate traditional concepts of spiritism and Western psychology. A local physician, Eliezer Mendes, is a follower of the Kardec spiritist movement and works with Dissociative Identity Disorder patients. He views the phenomenon as either dissociation resulting from child abuse, or the intrusion of spirits and past lives into the psyche of the individual, depending on the results of a differential diagnosis process. Mediums are used as diagnosticians because individuals with multiple identities are often found to have mediumistic abilities. Training as a medium involves learning to set aside spirits and past life identities into the parallel universe where such spirits live, until it is time to call on them during a seance or for healing and other practices. The explicit goals of such therapy is to move from involuntary possession to a voluntary incorporation of an embodied alternate identity. Traditional Brazilian practices, which incorporate the concept of embodying alternate identities, make a smooth link between traditional views of spirit possession and Dissociative Identity Disorder. Again, multiplicity is considered normative, even a necessary requirement for working as a medium, the pathology results from ego-dystonic intrusion of the spirits and/or trauma resulting from child abuse.
This cross-cultural investigation gives a very different picture
than the one currently held in the North American study of Dissociative
Identity Disorder, which implies that multiplicity represents
the "extreme point on the dissociation/association continuum"
(Rivera, 1988, p. 22) on a scale where increased dissociation
becomes "increasingly pathologic, terminating in the severe
dissociative disorders" (Braun, 1990, p. 973). It is clear
that although the embodiment of alternate identities represents
a radical departure from socially expected behaviour in Western
societies, it is not in and of itself a pathological state of
being. Leavitt (1993) concludes in his article on involuntary
possession and Dissociative Identity Disorder, if "dissociation
is not in itself a disorder, then cases of negatively-valued trance
and possession represent a symptom of something else ... a culturally
mediated distress whose expression through dissociation is part
of a cultural complex that itself very likely holds the key to
resolution" (p. 56).
Division versus multiplication
The often used heuristic model in dealing with dissociation is a form of "division" that occurs in the personality, resulting in a "divided consciousness" (Rivera, 1988; Jung, 1937; Marmer, 1991; Braun, 1990). However, this heuristic has limited applicability and does not adequately describe certain phenomena, such as polyfragmented Dissociative Identity Disorder. Kluft (1988) described several cases of polyfragmented Dissociative Identity Disorder, where more than 26 personalities existed in a variety of identities. One patient was reported as having 4,500 identities. However, despite the high number of identities and identity fragments, most of the time a core of one to six identities were present and performing ongoing roles. Kluft noted that the degree of conflict, rather than the number of identities, determined the level of pathology and the ability to function. In individuals with many identities, each identity spent less time in open manifestation. Polyfragmented patients presented little of the classical symptomology of Dissociative Identity Disorder, such as overt switching and clearly defined identities.
The concept of "divided" consciousness has little meaning in the context of the complexity of Dissociative Identity Disorder. It conveys the sense of cutting up a pie into pieces, with the resulting effect of having fewer and fewer resources for each identity. The term implies that the original self, sometimes called the "host" personality (Braun, 1986), is diminished as a result of its loss, and that what was once unified is now broken.
A better heuristic to use is that of a multiplied consciousness, where the individual creates an isomorphic self (Kluft, 1988a). Kluft stated that "the mind, rather than dividing itself, rather multiplies itself, recopies itself selectively, or rearranges a finite number of elements in patterns of great potential variety (Kluft, 1988a, p. 57). Kluft (1991) reported, in his presentation of atypical forms of Dissociative Identity Disorder, a category of "isomorphic" multiple personality, where a group of very similar identities are in control and try to pass as one. The traumatized child creates another version of him or herself to store the memory.
This concept is supported by a neurological model of multiplicity. Substructures in the brain can operate differently when they function in the context of different modules or relays. The neurology is not limited or finite, because the basis for identity alternates comes from shifting existing patterns, not developing new components.
The dynamic consciousness
system metaphor is a reflection of how the central nervous system is actually
functioning. By grounding a model of identity in a neurological theory,
I hope to build connections between the understanding and interface of
the mind and body. It is important to make this link in order to understand
the full systemic impact of child abuse and the development of multiple
The Role of Neurology
Neurological research implies that the brain functions as a fairly decentralized set of subsystems that mutually inhibit and self-regulate their processes. Grigsby, Schneiders & Kaye (1991) argue that there is a "strong case for the brain as a distributed, massively parallel, self-organized, modular system. The brain is comprised of myriad heterarchically organized structural-functional units (modules), operating in parallel and in series. These modules influence and are affected by one another at nearly every level of integration (p.39)"
The brain is a distributed system, not a hierarchically organized unit. The modules operate relatively independently, but are interconnected through re-entrant signals (Edelman, 1987) which give the brain an incredible capacity for synthesis.
Early studies of commisurotomy
suggest that all people have parallel multiple selves, differentially inhibited
through the process of hemispheric "dominance" (Gazzaniga et
al., 1977). Further research clearly indicates that "each self-representation
which is mediated by a neural network is in essence a modular component
of the self, and each neural network is comprised in turn of a number of
modular units (e.g. affect, perception, cognition), each of which is itself
a modular system" (Grigsby, Schneiders & Kaye, 1991, p.42). There
is no differentiation between the physical and mental structures and processes
in this model. The traditional idea of the body/mind split fails to account
for the myriad of ways that the mind-body system interacts. Modern neurological
models include nervous system components that regulate somatic operations.
Hemispheric "dominance" is really the inhibition of one hemisphere
from the awareness of the other. The various chemical inhibitions existing
between modules change depending on the circumstance and in response to
a variety of stressors. Disinihibited neural processes involved in "switching"
identities may account for the headaches reported in 78.7% of Dissociative
Identity Disorder patients (Ross, Norton & Wozney, 1989). These headaches
are commonly reported to accompany dissociative episodes. Hemispheric inhibition
normally prevents simultaneous awareness of both hemispheres. However,
disinhibition can lead to the awareness of "other" thoughts and
emotions, which come from the other hemisphere. The "executive personality,"
therefore, is only a temporary status of the identity currently responding
to the environment. The interactions between the dynamic consciousness
system and the environment are a dialogue, as the central nervous system
continually responds to new stimuli.
Theoretical framework for relating brain structures to multiplicity
Little research has been done on brain structure and multiplicity since early experiments that investigated an apparent relationship between Dissociative Identity Disorder and epilepsy (Mesulam, 1981; Schenk & Bear, 1981; Drake, 1986). Changes in identity have been observed in patients with seizure disorders following a seizure, and the patient was amnesiac for the changes, however these patients did not really meet the criteria for Dissociative Identity Disorder. Coons, Bowman & Milstein (1987) reported a 14% incidence of psychogenic seizures and 10% incidence of organic seizures in Dissociative Identity Disorder patients, and concluded that although epilepsy occurs in a small number of Dissociative Identity Disorder patients, it does not cause the dissociation. However, it is possible that these seizures are a result of the disinhibition of the parallel modular systems of individuals with multiple identities.
The neurological map of the DCS is a modular system, with both parallel modules that are vertically integrated, and networks between modules that produces lateral integration. Each module is capable of inhibiting within its own structure as well as being capable of inhibiting parallel relays. In normative multiplicity, there is a moderate and frequently uneven degree of inhibition occurring between parallel relays. For example, the "dominant" hemisphere may not be fully inhibiting the impulses from the other hemisphere, but picks up thoughts, images and other input. The thoughts, feeling and so on may or may not be experienced as "self" or "parts of the self" (Kelley & Kodman, 1987), but are experienced as emerging from "inside the head" (Ross et al. 1990).
Hypothesizing the development
of multiple identities within this framework, multiplicity may result from
a strong inhibition of re-entrant signals between modules. At the same
time, a number of modules would be disinhibited, and new modular systems
formed. They could overlap to varying degrees with existing modules and
vary in size. Thus, while the modules (which are the basis of the identities)
experience developmental growth and are activated when cued by different
circumstances, they are also not communicating with each other.
Early research into Dissociative Identity Disorder reported "double consciousness" as a common phenomenon (Janet, 1889; Breuer, 1893). A report of Dissociative Identity Disorder occurring in adulthood as a result of combat trauma, also reported only two personalities (Young, 1987). Three case studies in India (Adityanjee, Raju & Khandelwal, 1989) were reported as Dissociative Identity Disorder although there were only two personalities and the authors indicated no history of childhood abuse. While these are too few cases to draw any firm conclusions, it would be worthwhile to examine if there is a subgroup of Dissociative Identity Disorder patients whose alternate identities emerge in adulthood, who never develop more than two identities.
A pattern of dual personalities
in adult onset may be a result of the fact that no matter what socialization
exists to produce the unified self, the hemispheres of the brain represent
two major modular systems with radically different functions (Grigsby,
Schneiders & Kaye, 1991). Because of the channelling effect between
hemispheres, they may be more likely to become dissociated from each other
than other brain subsystems. In adulthood, when the modular patterns and
interrelationships are fairly well established (Grigsby, Schneiders &
Kaye, 1991), a shift in the dominant self-representations located in different
hemispheres may be possible through a relatively simple disinhibition.
Such a disinhibition in other parts of the brain, would involve complicated
processes because of the extensive network of interrelationships established
between modules. Further research into Dissociative Identity Disorder in
adults could explore this possible connection.
Neurology and multiple identities
Some of the physiological studies of Dissociative Identity Disorder report a variety of indications that electrochemical changes in the brain, and changes in hemispheric dominance, are occurring when identities change. Coons (1988) reviewed studies indicating changes in brain electrical activity, regional cerebral blood flow, seizures, changes in handedness and visual evoked potentials (changes in the brain's response to light stimulation). Other physiological changes (such as sensitivity to pain, vision, handwriting changes, blood pressure, heart rate and palpitations, galvanic skin response, allergies, different responses to medication, dermatitis, genitourinary pains and gastrointestinal disturbances) likely reflect variations in sensitization and conditioning processes, as well as emotional states (Coons, 1988).
There is no indication to support the hypothesis that neurological dysfunction is at the root of Dissociative Identity Disorder. While drug therapy has been used in the treatment of Dissociative Identity Disorder, its role is limited to controlling sudden mood swings as the process of therapy continues, not acting as a cure itself (Loewenstein, 1991). Miller & Triggiano (1992) reported on insomnia in multiple personality patients, but found no evidence of temporal lobe dysfunction, and attributed the insomnia to post-traumatic emotional states. This indicates that emotional shifts and conditioned responses that are the consequences of abuse are responsible for the corresponding physical changes.
>Coons (1988) noted that
physiological studies have used small samples or single case designs, and
that further research is needed to understand the physiological relationship
between alternate identities and their physiological states. Miller &
Triggiano (1992) also noted that some findings have been contradictory,
and that many of the studies suffer from methodological flaws that make
Models for the DCS
One way to conceptualize the DCS is to imagine the cast of characters representing different modules or identities. Each has an individual role, but they also create something different than the sum of the parts, they create an overall posture or interrelationship (DCS). Different functions are heterarchically organized, with vast parallel systems and decentralized and mutually inhibiting processes determining the outcome of responses, conflicting emotions and thoughts. The power is not exactly collectively shared, but it is decentralized and modular in nature. Some states have executive control for some aspects of behaviour, but little say in other systems.
The unifying quality of
the DCS is the structure created by the modules, the shape of the interrelations
between modules is the shape and boundaries of the psychological structure.
The DCS, as an entity, is more than the sum of its parts, just as the brain
is more than a sum of neurons.
The following model describes a simplified system of modules and submodules. It uses the BASK dimensions, which integrates somatic, cognitive, intellectual and emotional functions (Braun, 1988). [My HTML skills completely fail me here. Until I convert my nice model into a gif file, you'll just have to imagine these points being connected. For example, M1 (Module 1, is connected to B1, K1, A1 and S1. Module 2 is connected to B2, K2 and so on. M3 is the system connected to all others and M4 is connected to B4 - S4 and also overlaps with parts of M2. Won't you be happy when I draw this!]
M1 M2 M3 M4 Module
B1 B2 B3
K1 K2 K3
A3 A4 Affect
S1 S2 S3
Parallel systems are labelled M1 and M2. M3 contained more submodules than the other modules, to demonstrate the modules can vary in size and components. These parallel systems are only heuristic in value. They are not limited in number, because they can overlap with each other. For example, suppose that S2 and S3 actually represented the same component, that functioned differently in the context of different relays. One could conceptualize the potentiality of a virtually unlimited number of parallel systems. Using the BASK dimensions (Braun, 1988), this model shows that each parallel module is made of submodules. Theoretically, submodules are also modular. For example, S1 may be composed of a number of related cellular and tissue structures, which can be further broken down into intracellular chemical processes and so on (Grigsby, Schneiders & Kaye, 1991).
Re-entrant signals integrate information and stimulations throughout the system. Different disruptions in integration of information lead to different forms within the DCS. For example, learning to suppress sensations of hunger, hypothetically processed by M3, involves suppressing somatic indications, in this case hypothalamic neurons stimulate the sensation of hunger. In suppressing these sensations, the link between S3 and K3 is suppressed. Awareness of hunger only occurs when insistent signals from S3 are being transmitted. However, the cells still need nutrients and stimulation of the conscious awareness of hunger can come from other submodules. Perhaps S2 represents balance, and the person begins to feel dizzy after long periods without food. S2 might then stimulate K3 of the awareness of hunger. Each person's patterns become relatively idiosyncratic, and can also change over time.
Dissociation also takes place on a more horizontal axis, for example, if M4 is functioning as a self-contained system. This vertical "splitting" is a common conceptualization of multiple personality (Marmer, 1991). However, this is oversimplified. The isolated module did not previously exist and then was split off, the splitting simply refers to the inhibition of re-entrant signals between modules and strengthening integration of signals within the module. As the system is heterarchically organized, some modules and submodules may receive input without sending it. A possible example of the Executive Self model would be a central module that sent information to all other modules, but did not readily receive input.
The important aspect that this model does not adequately demonstrate is that none of these relationships are mutually exclusive. The spatial representation of parallel modules refers to their mutually inhibitive capacity. However, submodules can function in two different systems. For example, the identity of one identity still has access to memories and learned behaviours of how to dress, technical skills and other information, thoughts and feelings. Amnesia is often asymmetric (American Psychiatric Association, 1994), indicating that some modular systems are much larger than others, cross over in different ways and generally do not conform to the linear, singular operations that would make it easy to draw. Also, some submodules serve a collating function, and process signals from a number of related submodules. The one-to-one relationship of various components depicted here is oversimplified.
Before the MIR is activated, the abused child undergoes a
number of other stress responses to the abuse. These responses
are often present at the beginning of the MIR. The MIR takes its
place in a spectrum of general responses to pain and shock.
The stress response to abuse
The responses to abuse follow the stages of the stress response - alarm, resistance and exhaustion. However, the cycles are layered. There are responses to individual acts of abuse, generalized stress as a result from ongoing oppression and adaptive responses to the social environment. There are also simultaneous levels of the GAS taking place. For example, physiological processes may reach exhaustion quite early on, and damage is done to the body that is irreparable, while other responses are only beginning.
The strategy to survive severe stress is to avoid using up adaptation energy before one escapes the stressor (Selye, 1978). Therefore we can predict that:
Survivors of abuse report a wide variety of responses to their trauma as well as effects from the abuse. They include minimizing the effects of abuse, leaving the body during the abuse, repressing all memories of abuse or denying some aspects of abuse, forgetting the abuse even as it happens, feeling depressed, spacing out, keeping oneself busy, drinking or abusing drugs, escaping through fantasy or television, self-mutilation, attempting suicide, lying, stealing, gambling, workaholism and developing low self-esteem, compulsive behaviours and eating difficulties (Bass & Davis, 1988). Sometimes conditioning effects are evident, such as in the well-developed startle reflex exhibited by many survivors of abuse, and the critical inner self.
The model predicts that it would be rare that a survivor of abuse would have only one response to abuse. Each coping strategy has only a limited effectiveness. The DCS will naturally use responses that take the least effort, and vary the responses, seeking a homeostasis that accommodates the level of abuse and requires no further adaptation.
Unfortunately, there seems to be little systematic research into examining what types of responses emerge first, how rapidly sequential responses are employed and how these responses change over time. There is considerable evidence that individuals with Dissociative Identity Disorder also have a plethora of other difficulties, possible testimony to the variety of responses that have all been employed in surviving ongoing abuse. Some studies have indicated that 60% (Ross et al., 1990) to 70% (Horevitz & Braun, 1984) of Dissociative Identity Disorder patients also met the criteria for borderline personality disorder. Others suggest that 80% of Dissociative Identity Disorder patients have a co-morbidity for Post Traumatic Stress Disorder, and that the remainder are likely have some symptoms of Post Traumatic Stress Disorder (Armstrong & Loewenstein, 1990; Dell & Eisenhower, 1990; Kluft, 1988a).
The GAS model predicts that responses will generalize and
become systemic as they accumulate over time. For example, the
difficulties in staying in one's body during sexual abuse may
lead to broader disruptions in embodiment, such as eating disorders
Mechanisms of dissociation
High hypnotizability is consistently mentioned as a factor in Dissociative Identity Disorder (Marmer, 1991; Watkins, 1993; Hilgard, 1977; Bliss, 1986). However, because of the dearth of longitudinal studies, it can be difficult to tell whether the high abilities of autohypnosis and capacity for dissociation are inherent and somehow genetically predetermined, or if long practice has developed this skill.
We do know that only individuals who are highly hypnotizable
are more effective in reducing the sensation of pain (Bowers,
1991). In the DCS, autohypnosis is a preferred method of pain
reduction because it requires little effort to maintain once it
has been established (Bowers, 1991). While cognitive strategies
can reduce pain, they impair cognitive function and are effortful
to maintain (Miller, 1986). Conserving adaptive energy is essential
in surviving ongoing abuse.
State dependent learning
Once dissociation of any type has begun, the phenomenon of
state dependent learning must be taken into account. As the identities
diverge, their learning curves also differentiate. The changing
states of inhibition and disinhibition provide divergent chemical
and electrical sensitivities between identities. For example,
in treating Dissociative Identity Disorder, frequent state-dependent
medication effects have been reported (Loewenstein, 1991). This
effect is not limited to Dissociative Identity Disorder patients.
Individuals in extreme states of mania and with delirium tremens
have also demonstrated high medication tolerances that are state
dependent (Loewenstein, 1991). The state dependent effects could
be the result of "altered peripheral metabolism or clearance
alone, or the varying activation or deactivation of neuroendocrine
aggregates in different behavioral states; variation in the neuroendocrine
environment of the drug receptors in the central nervous system
(CNS); state-dependent changes in drug receptor number, receptor
conformation or binding ability; alterations in second messenger
function; or more than one of these processes (Loewenstein, 1991,
p. 724)." These physiological markers for state-dependent
effects are the same as the responses of the GAS to a stressor.
Body memories of pain
There is some debate about how dissociation exactly manages to inhibit the sensation of pain. Some theorists have suggested that the pain is displaced into underlying ego states or the hidden observer, but it does not just "go away" (Watkins & Watkins, 1990). In a neurological model, pain is an internally produced experience, a response to stimuli. Dissociating from pain is the process of selectively inhibiting pain receptors below the conscious levels of the central nervous system, so the chemical and electrical responses to pain is localized in the part of the body where the direct pain is occurring. This model predicts that only "memory" or chemical and electrical responsiveness to similar stimuli, would occur directly in this region. Selye (1978) frequently reported such conditioned responses to stressors occurring on a cellular level. This may account for the high rates of somatization disorders in Dissociative Identity Disorder patients (Coons, 1988).
The body literally holds the memories of the painful experience at the cellular level (Selye, 1978). A specific area might be sensitized to certain stimuli, for example the arthritic swelling of ankles and wrists that have been chained during abuse (Frank, 1990) or unexplained pelvic pain (Coons, 1988).
In the MIR, the sensitization process can be limited to a
specific identity. In this sense, it appears that Watkins &
Watkins are correct that the pain does not simply disappear. The
MIR encapsulates the pain response. Anecdotal evidence indicates
that physical stigmata can be associated with the emergence of
alternate identities, such as welts and marks emerging upon transition
to a child identity (Miller & Triggiano, 1992). Asthma, a
stress related illness, is found in some alternate identities
(American Psychiatric Association, 1994). Abreacting the memories
can relieve the somatic diseases of adaptation (Coons, 1988).
Abreaction is the process of reliving the experience, often under
hypnosis, where the patient is encouraged to break the amnesiac
barrier and allows the DCS to re-establish integrative functions
(Fike, 1990b). The fact that emotional catharsis can relieve physical
illnesses is yet another indication of the importance of bridging
the gap of the mind/body split when examining the MIR.
The stages of the MIR
The stages of the MIR follow the three stages of the GAS - alarm, adaptation and exhaustion. Within each of these stages, are the two interconnected aspects of submission and resistance. Resistance is lowered during the initial alarm stage and the stage of exhaustion.
Resistance is at its height during the adaptation stage. This
cycle is ongoing throughout the life history of the MIR, with
different levels and cycles building cumulative responses. The
developmental aspects of this cumulative response will be discussed
in the next chapter, here the mechanisms of adaptation in childhood
and adulthood are outlined.
Stage 1 Alarm
The first stage takes place during each incident of trauma.
At this point, the identities that characterize the MIR are not
entirely formed. The gradual sensitization effects of different
modules will create dissociative relationships in the DCS. The
alarm stage involves a lowered level of resistance, a state of
shock that largely accommodates the trauma. Although there are
elements of resistance, they are mostly passive and focus on making
the shock bearable.
The child must present a submissive response to the abuse - compliance to the stressor in order to survive. Sensitization and conditioning effects are likely to have already developed in some modules in the DCS. For example, if the abuser demands the child act as if the abuse is enjoyable, carrying out this behaviour involves inhibiting emotions and thoughts that contradict this behaviour. This results in a shifting relationship between modules.
With the continuing presence of certain stimuli (such as the demands of the abuser), some modules become more developed and capable of inhibiting other modules. As time progresses, these modules must begin to function more independently and on a wider range of behaviour. During the abuse, the child must still respond to demands for sleep, food and other behaviours that may be elicited during the abuse. The module becomes more complex over time until is has its own integrated and coherent structure.
Identities created at this time are the nearly ubiquitous
child identities, found in 86% (Ross, Norton & Wozney, 1989)
of all cases of multiple personality. They are frequently without
awareness of feeling and unable to experience pleasure (Fike,
1990b). Clinical observations of child identities characterize
them as "shy and withdrawn and have difficulty coming out
except when the patient is alone or in psychotherapy" (Fike,
1990b, p. 1003).
Even such apparently submissive behaviour has elements of resistance. The creation of identities is a form of diversion, like the opposum that plays dead when attacked, presenting this compliant appearance confuses the abuser into thinking their control is complete and their assault has worked. This may prevent the abuser from attempting further and more damaging techniques to dominate the child.
The child also resists the conditioning effects of abuse, by inhibiting the re-entrant signals between parallel modules that allow information to be integrated throughout the DCS. This isolates the conditioning effect to only one module. The process is gradual and incomplete, survivors of shock frequently report feeling distanced from their memories, forgetting them at times or finding them easy to "put out of mind" (Bass & Davis, 1988). This inhibitory process strengthens with repetition and gradually forms the MIR. Initial identities are likely to be limited and fragmentary in nature. Children have fewer identities, and the identities are less defined than adolescents or adults (Baldwin, 1990).
By the time the MIR is fully developed, the inhibition of re-entrant signals is virtually complete. Even when amnesia was not a criteria for Dissociative Identity Disorder, amnesia between personalities occurred in 94.9% (Ross, Norton & Wozney, 1989) to 98% (Putnam, 1986) of cases reported. The amnesia is similar to the inflammation that occurs during a physiological GAS, its purpose is to localize the stressor by putting a barrier around it (such as that of inflamed tissue). This amnesiac barrier prevents the spread of the irritant into the system. It represents fight, not flight, and is an attempt to inactivate the aggressor and protect the surrounding dynamic consciousness system. The MIR is an attempt to adapt to the trauma by isolating parts of the modular system and at the same time providing appropriate responses to ensure survival. The sensitizing effects of the trauma on one module is deepened, but isolated from the rest of the DCS.
The capacities of the DCS are expanded by the MIR. The MIR
multiplies the number of times some basic responses can be used
before exhaustion sets in, because the effects of such trauma
are limited from doing systemic damage. Putnam et al. (1984) observed
that several disorders could be sequestered in specific identities,
but not across the dynamic consciousness system. The DCS survives
by avoiding the cumulative effects of the trauma.
Stage 2 Adaptation
In this stage, most of adaptive energy still goes to creating
new identities. However, the focus is now on resisting the influence
of the stressor. The role of amnesia is also changed.
As the abuse continues, the stages of the GAS repeat themselves
over time. However, the DCS is now affected by the ongoing development
of alternate identities. The function of the identities created
directly in response to the abuser's demands are frequently compliant
or passive. The stability of the DCS is affected by increasingly
conditioned identities. Once the alarm stage has passed, increased
resistance resumes in the DCS in an attempt to resume a heterostasis.
The next step of the DCS is to form counter identities to stabilize the adaptations. For example, where the abusive experiences are stored in a passive, child identity (the submission), the DCS creates a protector identity (resistance) to balance the system. Where one identity is conditioned to present sexual submissiveness, another identity will express the suppressed rage. This stage is cumulative to the initial changes that took place during the alarm stage. The basic structures created during the alarm stage cannot be disturbed, but new developments can take place. For example, creating a protective identity involves resisting abuse, yet this resistance is encapsulated. In the abusive situation, resistance is not tolerated, and the child must control the resistance and anger as long as the abuser is present.Consequently, the resistance is contained as much as the submission is contained, but the system is now balanced. This represents the cumulative processes involved in the GAS. For example, the four most common identities are the child (or victim) personalities and protector (or rescuer) identities, persecuting identities and inner healers (Price, 1988; Ross, Norton & Wozney, 1989). They often are found in exact balance to each other. For example, persecuting and healing identities are both found in 84% of patients (Ross, Norton & Wozney, 1989).
The amnesia at this stage also functions to reduce conflict
between identities, as well as isolate the specific effects of
the abuse (Berman, 1981). Kluft (1984) reports that as the amnesiac
barriers begin to fall during therapy, the MIR loses some of its
functioning effectiveness. Social skills, self-care skills, the
ability to keep a job, maintain relationships and care for their
children diminish, especially during difficult stages of therapy.
Stage 3 Exhaustion
In the exhaustion stage, adaptive responses, of either submission or resistance, no longer take place. It is the end of the GAS. The stressor is no longer contained, and its effects become systemic. In most cases, exhaustion does not occur. Preventing exhaustion is that main function of the MIR. Although individual strategies may be exhausted and no longer able to maintain the adaptive resistance, systemic exhaustion occurs when the individual has no more strategies. Hopefully, systemic exhaustion is never reached while the individual is still in the control of the perpetrator. Once the adaptive energy is consumed, the child would have no defenses against the trauma. The fact that 72% of patients with Dissociative Identity Disorder attempted suicide at some point in their life (Ross & Norton, 1989) indicates how ongoing abuse truly taxes the limited resources of the child. The rapid deterioration in physical health that can occur in older patients also indicates the rapid progression of stress related diseases that can occur during decompensation (Kluft, 1988c).
Stages of exhaustion are seen in clinical studies with adult clients. The early stages of exhaustion are similar to the initial alarm stages, with a lowering of resistance, as the adaptive functions lose their ability to respond. Decompensation is sometimes seen in patients during therapy where new identities emerge as the layers of defense are peeled away (Kluft, 1986). It could be that individuals who seek therapy are aware that their responses are nearing exhaustion and/or that the re-traumatizing process of therapy leads to decompensation. Often, Post Traumatic Stress Disorder emerges in 80% or more of the patients in intense therapy (Loewenstein, 1991). Horevitz & Braun (1984) also reported that the co-occurrence of other indices of discomfort and pathology is correlated with overall difficulties in functioning. This may indicate that individuals who have survived extreme abuse, and used many different strategies to survive over time, have reached the limit of their adaptive energy and now have difficulty simply adapting to more common stressors in life.
Awareness of the developmental nature of the MIR should alert therapists to this type of client. In such cases, the therapy should proceed with caution. In the case of older clients, whose adaptive energy is limited, therapists recognize that treatment needs to proceed more slowly than usual, avoiding dramatic changes that might initiate decompensation (Kluft, 1988c).
The number of identities is determined by several factors. The first is the relative difficulty of different forms of adaptation. Selye (1978) termed redevelopment adaptation as any response which required a system to undertake a completely new response or activity. Development adaptation involves the further development of a similar activity as the one the system is currently performing. Redevelopment adaptation is much more difficult than development adaptation. For example, if you have never acted like a seductive 6 year old, it is hard to do it the first time. However, if you already have an identity that is a seductive six year old, some basic modifications might make it a suitable seductive adult that can handle adult dating experiences. The adaptive energy involved in redevelopment adaptation means that the process of developing new identities is used only when necessary.
Strong systemic inhibitions against using the MIR for minor stressors would be expected. This model also predicts that the more inconsistent the behaviour of the abuser or the more varied the trauma, the more identities will emerge as a result, which concurs with Braun's (1986) double-bind theory. Also, identities would emerge slowly at first, being present mostly as fragmented aspects that would follow a developmental path. In adulthood, the DCS is predicted to produce identities more easily, by blending existing identities.
If our personality develops over time as a result of shared
memories and common constitution, the same process should occur
for identities. In most individuals with Dissociative Identity
Disorder, only a handful of identities are well defined (Dell
& Eisenhower, 1990; Kluft, 1991). Often, there are several
fragmented and less developed identities. Kluft (1988) observed
that in individuals with many identities, only a few were ever
fully developed, and individuals with extremely high numbers of
identities often had no single identity that was ever particularly
well developed. Alternate identities seem to develop by interacting
with their environment and building integrative processes within
their own functions. Many identities, however, can be related
to a single trauma or event that appears to be their point of
origin (Dell & Eisenhower, 1990). Presumably, all identities
begin in less differentiated form, and a handful go on to develop
more fully in order to carry out specific functions.
Social and cultural contexts
In 62.6% of individuals with Dissociative Identity Disorder, there are identities who are male and identities who are female (Ross, Norton & Wozney, 1989). Rivera (1989) discusses the ways that the identities act out the sex roles and power dynamics that mirror the social construction of gender. By using a social constructionist viewpoint, Rivera expands the concept of gender as more than the physical aspects of the individual, but sees gender as a referent contained within a social context of classification. Gender can be applied to objects, inanimate forces in nature and many types of polarities and complementary aspects of a variety of phenomena.
Rivera comments that in her work she finds that women with multiple personality "it is very common for their vulnerable child personalities and their seductive and/or compliant personalities to be female and their aggressive protector personalities to be male" (Rivera, 1988, p. 43). The conflicts within the DCS closely resemble the gender conflicts in society at large (Rivera, 1989). This is an example of how social constructs determine the shape of the multiple identity response within the appropriate social context. If 38% of girls are sexually abused by the age of 18 (Russell, 1986) and over one million women a year in Canada are assaulted by their partners (MacLeod, 1987), it is obvious why women who have survived this abuse would be torn between their identification as a woman, and at the same time create an identity in response to the desire for some of the seemingly powerful aggressiveness of the masculine gender role. Women may find their anger too frightening or unacceptable to deal with. It is common for survivors of abuse to have powerful fantasies of revenge or torturing their perpetrators (Bass & Davis, 1988). Having suffered at the hands of abusive rage, such feelings will conflict with a traditional feminine self image. Some aspect of the stereotypical role is simply learned behaviour. If no model of constructive anger exists, then abused children learn that anger is released through rage and destruction. Differentiating abusiveness and anger is a difficult task for many women (Bass & Davis, 1988). One individual describes how the fear of vulnerability triggered her defensive identities, which were modeled on stereotypically male, abusively-modeled notions of strength.
"I could be trying to argue, pursing my lips and trying
to keep from shaking, until they come up to me. Sometimes they
stood behind me, sometimes in front of me, and they'd say cold,
colder than Clint Eastwood, colder than my Dad, 'Fuck you pig.
Don't fuck with me. You don't know who you're talking to' in a
voice that did not sound very much like mine and scared the shit
out of people. I would be inside thinking 'Excuse me? Are you
sure this is a good idea?' but they would curse and swear and
bang the table. It worked. Scared the hell out of everyone, scared
the hell out of me. I hated them. I thought I could use them,
but all those years they watched my Dad and learned a lot"
(Whyte Ravyn, 1990).
Little exploration has been done in deconstructing the cross race identities found in individuals with Dissociative Identity Disorder. Anecdotal evidence indicates that it follows similar lines as the stereotyping process that produces cross gendered identities. Caucasian, Western individuals can have identities that reflect the evil, aggressive, sexualized or tough stereotypical identities who are represented as people of colour. For example, The Troops for Truddi Chase (1987) describe the protector "Mean Joe" as a large Black man who was capable of great physical strength. Naming identities as "Black" and "White" also represents good and evil conflicts, regardless of their perceived race, but in accordance to the racist linguistic icons of Western society, such as White Catherine and Black Catherine (Chase, 1987) and Eve White and Eve Black from the Three Faces of Eve (Sizemore & Huber, 1988).
Adityanjee, Raju & Khandelwal (1989) also describe the
"glamorized", Westernized identities that emerged in
Indian cases of Dissociative Identity Disorder. The identities
preferred to speak English rather than Hindi and adopted Westernized
manners. Wilbur (1984b) reported on a Caucasian patient who had
a Native American identity who represented spirituality and other-worldliness.
Although Ross, Norton & Wozney (1989) report that 21.1% of
identities are cross-racial, little systematic research has been
conducted on determining what social constructs and purposes these
identities have in common. Part of the relative rarity of cross-racial
identities may be due to the racial segregation in society (Lorde,
1984). A Caucasian child may have little access to other children
or adults of colour, whereas many significant others are likely
to be of different genders. Fike (1990b) reports two cases of
Black and Hispanic identities in Caucasian children, who represented
childhood friends that were seen as either "tough" or
provided comfort and friendship to the child. I would predict
that people of colour would be more likely to have Caucasian-identified
identities, as part of the racial oppression includes greater
contact with the dominant Caucasian culture and the necessity
of learning to adapt to the Caucasian dominated society in a way
that Caucasian children would not be required to interact with
or learn the social values and mores of marginalized cultures
The cultural manifestation of the MIR
A study by Adityanjee, Raju & Khandelwal (1989) details 3 cases of Dissociative Identity Disorder encountered by the authors in three years of work in psychiatric clinics. In each case there were only 2 personalities, one primary personality and an identity that emerged in an episodic fashion, usually after an overnight sleep. The alternate identities were more glamorized self-images of the adolescents, who often spoke English rather than Hindi, were more Westernized and otherwise led more glamorous lives.
The authors report that one girl "behaved very formally, as if she were a guest, and spoke in English, addressing her family members by their names. She expressed a desire to wear jeans and wanted to play badminton. She also complained that the food was not to her taste" (p. 1608)
They frequently denied knowing their families, and in one case, claimed that the parents of a friend were really her parents. The authors note that the Hindi cinema frequently portrays a dramatic change in behaviour after a sleep or an accident, which is how the transition occurred in all of the teenagers. In all cases, the individuals had desires which conflicted with those of their families, either in terms of school expectations or sexual desires.
Kleinmann (1977) notes that a person labelled mentally ill would be strongly stigmatized in traditional Indian families and the person would essentially be unmarriageable. Because marriage is the only means of leaving the family of origin and economically necessary for survival (especially for girls), one would expect that the MIR would adapt itself to dealing with this situation. The MIR would not be effective as a survival mechanism if it resulted in remaining in the family of origin indefinitely or in destroying the means necessary for economic survival.
This may explain why possession states are more common as
a release or means of restitution (Adityanjee, Raju & Khandelwal,
1989). It may also explain why Adityanjee, Raju & Khandelwal's
patients were all middle-class Westernized individuals, who's
families had few of the traditional stigmas about mental illness
and brought their children to the psychiatric clinic immediately
for treatment. In such as family, Dissociative Identity Disorder
would be an effective form of adaptation.
Possession as a form of restitution
Although practices vary widely, Mulhern (1991) describes common patterns in possession. Possession often involves an ailment or the fear of an ailment that brings a person into the cult. The individual is absolved of all blame for her suffering, and her ailments are understood as a spirit demanding recognition. In order for the spirit to stop interfering in her life, she must accede to its demands. Relatives and friends are expected to assist her in pursing whatever is necessary to appease the spirit, or else they assume blame for her continuing illness. This can include material gifts, payment for ritual, seclusion, time allowed away from duties to travel to possession rituals and so forth (Mulhern, 1991).
Possession occurs far more frequently than Dissociative Identity
Disorder in India, but not in North America (Adityanjee, Raju
& Khandelwal, 1989). Possession occurs almost exclusively
among women and in the poorer classes (Akhtar, 1988). Adityanjee,
Raju & Khandelwal (1989) describe their interactions with
possessed individuals, and remark that "the `possessing spirit',
through the patient, makes various demands on the surroundings,
usually on close relatives who humbly comply with them" (p.
1609). The main difference, which is significant, is that unlike
in Dissociative Identity Disorder where the identities are concealed
from observers, possession is a public event, acknowledged and
witnessed by the community (Mulhern, 1991). This witnessing is
part of what makes the possession so therapeutic, although therapy
is not its only purpose. Possession is a much more public process
than "going crazy" in North America (Levine, 1989),
however, it exists within the defined social norms just the same.
Mulhern (1991) argues that although possession beliefs and practices
vary from culture to culture, in many cultures the reason for
the spirit being angry at the family is not mentioned, only that
the spirit needs care and attention. Although the spirits unmask
the potential consciousnesses of the individual and expose the
social order, they do so through symbolic representation. A violent
male spirit may embody an impoverished woman who threatens the
crowd, a child spirit may smear food over the body of its socially
rigid host (Mulhern, 1991). Although the ceremony turns the social
order on its head, it does not threaten to disrupt the prevailing
social order (Mulhern, 1991). Possession does differ from Dissociative
Identity Disorder in that it is experienced by a much larger portion
of the population, and is regarded as a fairly normal part of
religious life (Leavitt, 1993).
Relationships to animals
Another cultural determinant of the structure of the Dissociative Identity Disorder is evident in the portrayal of animals in the MIR. Among Western individuals living in urban areas, relationships with and understanding of animals develop largely from dealing with pets, zoos or the media. Hendrickson, McCarty & Goodwin (1990) reported on 5 cases of Dissociative Identity Disorder with animal identities. The animals named were either familiar pets, such as domestic cats, dogs and birds and in one case a panther. One woman's identities emerged from ritualized abuse which involved a wider variety, including a snake, dolphin, owl, hawk, large and domestic cats and dogs. They re-emerged when she began to explore New Age religion that encourages spiritual imagery of animal medicines. All of the identities could be traced back to witnessing the abuse or animals, participating or witnessing in the abuse of animals or bestiality, being forced to live or act like an animal or experiencing the traumatic loss of a pet.
The role of animals in society is reflected clearly. Animals are one of the few things lower in status than children and can be destroyed or tortured by an abuser with little risk of retribution. Torturing animals has been used by the abusers as a form of threat against the child, to demonstrate their fate, or as a form of punishment, to remove a loved ally from the child's life (Hendrickson, McCarty, & Goodwin, 1990). The abused individuals frequently identified with the animal, and perceived animals as helpless or innocent. Animals can also be used to displace rage at the abuser, if the abused child in turn abuses the perpetrators favoured pet (Bass & Davis, 1988).
Contrast these findings with the case of a Native American man who had several identities who were animals or spirits. Smith (1989) reported that the majority of identities were not human (7 out of 11 identities). The MIR emerged out of child abuse, but was informed by cultural values and beliefs. The animal identities represented medicines or powers consistent with traditional beliefs about the nature of the animals. Unlike the animal identities reported by Hendrickson, McCarty & Goodwin (1990), these identities represented wild animals common in Native religions, including the snake, wolf, bear, panther, turtle, owl and hawk. It is quite likely that in cultures where animals have a larger symbolic significance, or where contact with animals is more common, more animal identities will be found.
The MIR is the process and mechanism that underlies the development of Dissociative Identity Disorder. However, Dissociative Identity Disorder is only one element of the MIR. The MIR is actually a much broader cycle that goes through many stages. It is not an illness of disorder, it is an adaptive strategy. The purpose of the MIR is to adapt and survive. As a response to a divide and conquer strategy of oppression, its response has been to divide and survive. One of the prime functions of the MIR is to respond to the abuser's insistence that the abuse be kept secret, usually on pain of death or torture (Ward, 1984). Abused children are frequently also told that if they reveal their abuse, they will be called crazy (Bass & Davis, 1988).
As such, most forms of MIR are covert and subtle, and present a very different picture than the stereotypical forms that are so commonly portrayed. Kluft (1991) estimates that about 80% of individuals with Dissociative Identity Disorder do not spend the majority of their adult life in an overtly Dissociative Identity Disorder adaptation. Only 1.2% of Dissociative Identity Disorder patients make an "overt and florid" appearance that would easily be recognized. Eight percent could be recognized by a clinician with a "high index of suspicion", 2.8% are overtly Dissociative Identity Disorder for long periods, but they do not seek attention and try to "pass", and another 8% are "very highly disguised indeed, and are usually found only if efforts are made to explore for MPD even in a patient who offers no strong suggestive signs, or as defenses are eroded in the course of therapy" (Kluft, 1991, p.620).
Kluft (1991) described a number of different forms of Dissociative Identity Disorder, viewing them as "atypical" presentations, rather than developmental stages. He used the DSM IIIR criteria, which did not include amnesia. This is helpful because many of these individuals would have been excluded from study under the DSM IV, being classified as Dissociative Disorder Not Otherwise Specified. One of the problems of the rigidity of psychiatric classification systems is that little attention is paid to developmental aspects. Individuals are seen as dropping and out of categories, or going into remission and then re-manifesting symptoms, but longitudinal examination of a life process is rarely described.
In the cycle of the MIR, the stage of alarm involves the creation of new identities. The stage of resistance involves the adaptation of the identities to the external environment and the homeostasis of the MIR. The exhaustion stage would take the form of decompensation and/or death through suicide or stress related illnesses. There is a rough correspondence between these stages and the life cycle. In childhood, identities are simplified, mostly emotionally based states with less definition (Baldwin, 1990). Complex cognitions, internalized oppression, greater resistance to the influence of the abuser and subsystems of identities begin to develop in adolescence (Dell & Eisenhower, 1990). In adulthood, the resistance stage is maintained in homeostasis for decades, but heterostasis can bring on new adaptations, for better or for worse.
The exhaustion phase is more common in older patients, who are more prone to decompensation as adaptive energy is drained (Kluft, 1985b).
Much of the clinical work on Dissociative Identity Disorder
revolves around the developmental time frame of early adulthood.
For example, the average age for Ross, Norton & Wozney's (1989)
study was 31 years old. Some work on Dissociative Identity Disorder
in childhood and adolescence has explored the early stages of
developing the MIR. However, very little has been done to examine
the MIR throughout adulthood. Using a developmental model, I will
work through some likely stages in the development of the MIR.
At times, it will reflect the elements of Dissociative Identity
Disorder that are so familiar, at other times, the MIR takes forms
that barely resemble the classical model of Dissociative Identity
Disorder. In particular, I hypothesize that the function of healing
and reintegration becomes dominant when the individual has left
the abusive situation. I also believe that traumatization in adulthood
plays a major role in the ongoing presence of the MIR throughout
the life cycle. Without ongoing traumatization, the MIR will ultimately
result in a healthy, stabilized psychological organization, possibly
normative multiplicity or more common forms of psychological systems.
The average age at which children first report developing a distinct alternate identity varies from 3 to 6 years of age (Dell & Eisenhower, 1990; Kluft, 1985a; Bliss, 1980; Coons, 1988; Putnam et al., 1986). The MIR in children is less noticeable than in adults. The change is more subtle and may be attributed to the child's changing moods or impulsiveness. Children tend to have fewer identities than adults, averaging about 4 identities, with a range of 2 to 6 (Baldwin, 1990). By comparison, adults have a range of 2 to 100 identities, with an average of 13 (Coons, 1986). Very young children, are less likely to verbally express themselves, but may injure small animals or their dolls, or complain of pain in their bodies. Older children are more likely to verbalize the abuse, but often without the emotions one would expect, sometimes in a lighthearted or joking manner, or with a completely flat affect. It often takes only a few months for children to reintegrate in therapy, while it can take years for adults to do so. However, the abusive situation must end in order for reintegration to take place at all. (Baldwin, 1990).
Depression and somatic complaints are less common in children than adults diagnosed with Dissociative Identity Disorder (Baldwin, 1990), possibly due to fewer total years experiencing abuse (not as many responses to abuse have been used and adaptive energy is not depleted). Baldwin (1990) also reports that children with Dissociative Identity Disorder experience about the same amount of amnesia, indicating this is a process of MIR established early on in life.
The definition of these identities is not a conscious process, but emerges out of the natural emotions responses to the trauma, for example, being scared and angry are both natural responses to abuse. However, while the abuser may permit the fear to show, or even demand it, the anger is punished. The identities in children mostly represent direct emotional states. Dell & Eisenhower (1990) in their study of adolescents with Dissociative Identity Disorder, reported that 82% reported that their first alternate identity emerged as a response to the abuse.
Many identity types found in adulthood are not present in childhood cases. Kluft (1985a) clinical sampling of children found that the children had "no inner persecutors, classic inner self helpers (ISHs), special purpose fragments, or systems of personalities. The identities who expressed either repressed or forbidden impulses rarely were overt about their differences" (p. 214).
Fike (1990a) described child identities as frequently aware of traumatic memories for which other identities are amnesiac. Often, they are shy, sometimes incapable of experiencing pleasure and unable to play. They tend to be compliant and withdrawn. Sometimes specialized child identities are present (Fike, 1990a). These are identities that are presented as children, and possess the cognitive capacity of children, but have specific roles, such as being sexual, performing certain tasks, keeping a lookout for other identities about when it is safe to come out and other functions.
Sometimes angry child identities manifest as persecuting identities (Price, 1988). Often, they are convinced that by punishing the other identities, the abuser will stop hurting them, or that the other identities deserve to be punished.
Self destroying identities are found in cases of ritual abuse. A specific identity may be created to report back to the cult, sabotage therapy, or to injure the body if the secret is revealed.Self-destroyer identities whose only purpose is to kill the body if the secrets are revealed are also only found in survivors of ritual abuse (Braun, 1986).
As childhood progresses, and the abuse continues, identities that have emerged directly on demand to the abuser, or as passive, submissive elements will be balanced by identities which represent resistance. For example, protector identities perform rescuing functions and are conciliatory and nurturing. They provide self-care and even first-aid (Price, 1988).
Kluft (1985a) noted that identity systems (groups of similar identities) are seen in children but are often unsuccessful, however, the systems reported in adulthood are very adaptive. Presumably, developing more complex systems somehow makes resisting the abuse easier, but the response is difficult to develop.
Identities quickly begin to reflect cultural norms and values.
Sometimes, the identities begin to take on the characteristics
of former imaginary companions. For example, one boy had an identity
named Martin who was a fearless and adventurous spaceman (Bliss,
1984). Also, some of the early cross-racial identities are based
on the stereotypical or imaginary characteristics of individuals
the child has come into contact with. Fike (1990a) describes one
woman with a Black identity that was based on a classmate who
was described as the toughest child in the school. Wanting the
apparent fearlessness of this child, she modeled an identity after
her. Gender roles are also assumed early in life, and identities
reflect basic gender stereotypes (Rivera, 1989).
The MIR in Adolescence
Identities become more complex and differentiated with subsequent interactions with their environment (Dell & Eisenhower, 1990). Their experiences reinforce their identities, because they are selectively activated to deal with specific situations. Thus, the identity that deals with anger, is always encountering anger. To them, the world is a hostile place, and each experience confirms their preconceptions. This can result in the high degree of conflict between identities, as each identity develops very different world views and has different response to one situation.
The identities also begin to reflect a more cognitive understanding of their abusive situation and social demands. On the whole, the identities of adolescents are very like the ones found in adults. The adolescent patients in Dell & Eisenhower's (1990) study had a high number of alternate identities (24 on average), but only a core group of identities was well defined. Other identities were less defined, came out less frequently and tended to have relatively little knowledge of the patient's life. Complex subsystems and groupings of identities sometimes found in adults were not present in adolescents. The average length of time for reintegration to occur was 29 months. This is significantly more time than for children, who often spontaneously abreact and integrate in a matter of months, yet less than the years of therapy required for adults (Baldwin, 1990).
Dell & Eisenhower (1990) reported that all patients had child identities, scared identities, depressed identities and angry protector identities. More adult-like identities were also found, particularly persecutors and internal helpers were found in 82% of the cases. Violent identities were also present in 64% of the cases, sexualized identities in 55% of the cases and suicidal identities in 50% of the cases.
Persecuting identities can be critical, verbally abusive and physically abusive identities (Fike, 1990a). Sometimes they are manifested as copies of the abusive parent, coming back to punish the child (Price, 1988). These identities tend to have internalized a number of blaming or self-hating cognitions of their abuser (Ross & Gahan, 1988). In 28% of cases, persecuting identities take the form of a demon (Ross et al. 1989). Demonic identities are most common among survivors of ritual abuse in Satanic cults, although mythological gods are sometimes found among individuals from strongly religious backgrounds (Ross & Gahan, 1988; Wilbur, 1984b). In Christian religious traditions, it seems that such identities are more likely to be described as saintly or evil, godlike or demonic (Bowman, et al., 1987), than in cultures where spirit possession is thought to occur by neutral ancestral spirits, reincarnated selves or mischievous spirits (Mulhern, 1991).
The increasing cognitive complexity of the adolescent often results in the internalization of the negative and blaming messages of the abuser. Ross & Gahan (1988) describe some of the common cognitions that emerge out of adolescence, many of which are contradictory and include such messages as:
"I am responsible for the abuse"
"I deserve punishment"
"It is wrong to show anger"
"I can't trust myself or others"
"Good children should love their parents, I don't therefore
I must be bad. I'm bad, which is why I am being punished."
It is likely that these cognitions result from a shifting strategy of the abuser. As the child ages, and the likelihood of exposure of or rebellion against the abuser increases, the abuser will turn to emotional manipulation to control the child (Ward, 1984). Abused children internalize these messages and blame themselves for their abuse, believing it is wrong to express anger, or defiance, criticism, fear...(Ross & Gahan, 1988).
These messages also increase the level of conflict in the DCS. For example, the belief that one identity loves her parents, but the other doesn't; the belief that one identity must protect the others who can't handle the memories, attempts to punish other identities or release them from their misery may result in self abuse (Ross & Gahan, 1988). As the identities have greater cognitive abilities, obvious problems begin to occur. If one identity has no recollection of the abuse, yet is aware of pregnancy resulting from the abuse, how will this identity view or rationalize this event? Isolating ongoing memories of abuse in different identities is a difficult task. The MIR attempts to manage this through maintaining amnesia, however, some conflicts are bound to arise. The level of stress in the DCS is expected to be very high in adolescence, because the abuse is cumulative and ongoing. The stress model predicts that the majority of suicide attempts will occur during adolescence. Further research into suicide and parasuicide may indicate whether or not abused adolescents are particularly at risk for suicidal behaviour.
Inner Self Helpers (ISHs) emerge in adolescence, these identities are sometimes viewed as detached, problem-solving entities who can relate information and give guidance within the system (Price, 1988). Sometimes, they are experienced as divine aspects that have come to help (Comstock, 1991).
Lying about the abuse is more common in adolescence, as the individuals respond to the social demands that they conceal the abuse (Kluft, 1985a). Often, the children are threatened not to reveal the abuse, or they are told that no one will believe them (Herman & Hirschman, 1981). Consequently, many abused individuals lie compulsively, with the untold reality of their abuse being the biggest lie of all (Bass & Davis, 1988). Sometimes this faculty is developed as a form of internal security, to cover over amnesias or inexplicable behaviours. Lying is a presenting symptom in 82% of adolescents with Dissociative Identity Disorder (Dell & Eisenhower, 1990). This contrasts with the behaviour of children, who openly ask to be addressed by a different name and readily admit they are hearing voices (Baldwin, 1990) and adults, who are extremely covert and cautious about revealing their alternate identities to anyone (Kluft, 1985b).
Leaving the abusive situation is an act of resistance with a goal of eliminating the stressor, not just a simple event that happens in the individual's life. A new stage of heterostasis for the DCS is sparked when the individual leaves the initial abusive situation, or the abuser is removed from them. It would not be enough to simply have the abuse end, if it was never discussed or resolved, the initial threats of retribution make the presence of the abuser(s) a continuing danger.
The ending of the abuse is an important stage in the life cycle of the MIR. Unless the abuse is ended, therapeutic attempts at reintegration will inevitably fail (Dell & Eisenhower, 1990; Baldwin, 1990). In Dell & Eisenhower's study of adolescents, detoxifying the home environment was the first step in therapy. Often, even getting the adolescent and the family to agree to therapy involved long negotiations. Sometimes, patients left or were removed from therapy. Only once these terms of safety had been established was it safe enough for therapy to proceed.
Researchers should also not assume that the abuse simply stopped,
in many cases leaving the abusive situation is an event planned
for and executed by the DCS as an act of resistance. Leaving any
kind of abusive situation is difficult, and frequently involves
conflict with the abuser(s) who wish to continue their domination
(Ward, 1984). More research into the acts of planning and leaving
may reveal information about how abused children managed to leave
MIR developments in adulthood
This aspect of development in the MIR seems to be largely neglected in the study of Dissociative Identity Disorder. This stage of life offers new opportunities for healing, or new threats of re-traumatization. Once the individual has left the abusive situation, a number of divergent paths can occur in the next stages of development. Leaving the control of the perpetrator weakens their abusive influence. Identities created for resistance can act more openly. Submissive identities will not be elicited as frequently. As the level of stressors drop, the focus of adaptation can shift from maintaining heterostasis and conserving adaptive energy, to a new heterostasis that incorporates changes in the individual's life.
The individual also experiences a change in status from child to adult. More options are available. The shift for males into positions of relative power is greater than that for females upon reaching adulthood (Ward, 1984). New roles have to be assumed to take on this new status, this could lead to the development of new identities or the developmental adaptation of existing ones.
The individual could also be re-traumatized. Many women experience
rape and assault in their adult lives (MacLeod, 1987). Even the
threat of such brutality may be enough to maintain some of the
resistance structures of the MIR throughout adulthood.
For some individuals, they have little energy left for further adaptations. They may find the world a confusing and unfriendly place (Fike 1990). Threats from the abuser prevent them from telling anyone about the abuse for a long period of time, or when they attempt to disclose the abuse, their stories may be discounted (Bass & Davis, 1988; Herman & Hirschman, 1981).
The colonization process of abuse means that they have internalized the abuser, often in the form of a persecuting or critical identity (Price, 1988). Although the perpetrator is not present, they may have formed identities that are self-destructive and self-critical. As the environment is still neglectful of their situation, little changes are needed in the MIR.
For these individuals, what changes are made are directed
at accommodating to the demands of their new life. New identities
may be needed for coping with adulthood. A working identity is
found especially in high functioning adults, the working identity
takes care of all employment related tasks (Kluft, 1986b). Taking
emotional refuge in staying busy is a richly rewarded pursuit.
This may be a development of some children's intellectualized
identities who function in school (Kluft, 1985b), have few personal
feelings and little awareness of a personal life. Using previously
existing identities is easier than creating new ones (Selye, 1978),
and this process would be typical in these individuals.
For individuals with a more robust MIR, they face new developmental challenges. Resistance-oriented identities can act more overtly. As the presence of the pathogen diminishes, the intensity of the GAS response can also be reduced. This will automatically result in the reduction and eventual elimination of the diseases of adaptation (amnesia and internalized oppression), which are a result of the adaptive process in the presence of the pathogen (abuse).
The changes brought about by leaving the immediately abusive
situation call upon the MIR to produce new adaptive responses.
The tasks include minimizing conflict within the DCS, reducing
the amnesiac barrier, dealing with self destructive behaviour,
addressing issues of internalized oppression and allowing awareness
of the abuse to surface.
The logical place to first begin reducing amnesia and internal conflict is to make the identities aware of each other. This forces them to begin to interact with each other and work out compromises of behaviour. It also is the beginning stages of abreacting the trauma, as initial clues about the abuse are uncovered. Identities such as the ISH and protector identities are expected to play a large role in determining the pace of the reintegration and seeking support.
The person may slowly become more aware of their inner conflicts and feel deeply divided about their self-concept or paralysed in making decisions (Ross & Gahan, 1988). Abusive incidents will spark old memories and feelings, and these will not be suppressed but come into consciousness (Price, 1988). Flashbacks, body memories, nightmares and other disturbances (Fike, 1990a) result from the increased awareness of the childhood abuse. This may be subjectively disturbing to the individual, but they are part of the healing and reintegration process. Kluft (1991) describes patients "whose alters are generally inactive but are triggered to emerge infrequently by intercurrent stressors, many of which are analogous to, symbolic of or trigger memories of childhood traumata." (p.621)
The signs of this initial healing may not always be experienced in a positive way. More Schneiderian first rank symptoms (such as hearing voices, passive somatic influences and visual hallucinations) may resume, as the blending identities are heard as voices or visual hallucinations. The identities are attempting to influence the DCS without taking full control of the body. Ross et al. (1990) report that in a study of Dissociative Identity Disorder patients in therapy, the average patient experienced 6.4 Schneiderian symptoms, as compared with an average of 1.3 symptoms acknowledged by schizophrenics reported in other studies. The most common Schneiderian symptoms were voices commenting, voices arguing, thoughts ascribed to others, made feelings, acts and impulses. These findings support the hypothesis that the amnesiac barriers between identities are weakening and the DCS is moving towards normative multiplicity. In the Ross et al. study (1990), 94.4% of the patients said they recognized the voices as coming from inside the head, as opposed to schizophrenic voices coming from outside the head.
Kluft (1991) described several "forms" of Dissociative Identity Disorder that seem to represent this stage of reintegration. Covert Dissociative Identity Disorder is a stage where entities contend for control and influence without assuming full executive control.
Passive influence experiences are common. Individuals at this
stage are described as experiencing identities who rarely fully
emerge, body memories of painful events, intrusive traumatic memories,
unexplained strong emotions, sudden inexplicable pains or a sense
of unwilled motor acts. This is the beginning stage of reintegration,
often experienced as unpleasant. This form of the MIR can be expected
to emerge at different times during the reintegration process,
and will wax and wane over time. It seems more likely that people
will seek out therapy at this stage of the MIR because the symptoms
of recovery are so unpleasant. The average age of Dissociative
Identity Disorder patients in clinical studies is 31 years old
(Ross, Norton & Wozney, 1989) which is an age range that is
compatible with this hypothesis. If so, the clinical research
may be reflecting larger levels of this stage of MIR than exists
in the general population.
Partially integrated MIR
The MIR at this stage can function almost invisibly. High functioning individuals will show less internal conflict, fewer gaps in their recall, more subtle influences of identities and a greater ability to voluntarily manage the MIR (Kluft, 1986b). The MIR at this stage strongly resembles the functioning of the Executive Self, separating personal and public roles, repressing unacceptable memories and generally acting in a manner highly adaptive to the alienated, fragmented and identity-constricting structure of North American society.
Kluft (1991) describes a form of isomorphic Dissociative Identity
Disorder, in which a group of identities who are very similar
are mainly in control and try to pass as one. Slight unevenness
of memory and some skills are the only indications. This indicates
that the levels of internal conflict have been greatly reduced
as the adaptive responses (both submissive and resistant) are
normalizing. It is unclear from Kluft's description, but it is
likely that amnesia is still present and may be concealing a fair
degree of conflict.
This stage represents integration that is almost complete,
but a protecting identity is maintained for defensive or nurturing
purposes. Most importantly, conflict has been reduced significantly
among the identities. Amnesia is limited to childhood events,
if it exists at all. The individual is not "losing time"
in their daily life. As the identities are quite ego syntonic,
they may remain present for a long time without a concomitant
pathology. These stages essentially reflect normative multiplicity,
with effective integrative processes and the embodiment of ego
syntonic alternative identities.
Adult Imaginary companions
Kluft (1991) describes this as a friendly entity that is co-conscious
and co-present, often being supportive and caring. The remnants
of the MIR appear to be maintained to assist with self-parenting.
This is basically a state of normative multiplicity where the
person continues to utilize autohypnosis.
Kluft (1991) describes this as a system where the identities know about each other and have worked out some type of arrangement.
Whatever amnesia exists becomes apparent only in therapy and
is largely related to events in the distant past. It is possible
that the amnesia that Kluft found in some of these individuals
is simply amnesia, and not related to the existence of a hidden
identity. The fact that amnesia for current events is not present
indicates an effective reduction of internal conflict and internalized
oppression. This is a pragmatic and adaptive mental state. It
may be that the individual suffers only from a lack of supportive
resources (including time and money) to deal with deep traumas.
Private and Secret MIR
Private MIR is when the identities are aware of each other,
and consciously pass as one. Secret MIR is when identities emerge
only when the individual is alone. Often, these are found together
(Kluft, 1991) in individuals who experience their multiplicity,
but like to let everyone out to play once in a while. This basically
reflects normative multiplicity. Sometimes there are identities
unknown to the rest of the system, which represents a hidden level
of amnesia, probably for traumatic past events, that have not
Fully reintegrated MIR
Although many of the defensive forms of reintegration are adaptive in a threatening society and can exist without any evidence of pathology, with support and resources a complete reintegration is possible. Believing this can happen involves challenging some commonly held assumptions. There is a persistent unwillingness to believe that mental illness is ever healed, it only ever seems to go into remission (Finkler, 1994). Kluft notes that "at times the alters do little more than persist, having minimal or no appreciable impact on the flow of experience" (Kluft, 1991, p. 609). Kluft (1985b) also says that "most patients who satisfy DSM III criteria for multiple personality disorder at some points in time do not satisfy such criteria at others." However, Kluft does not believe that Dissociative Identity Disorder can ever be cured without therapy, and that this therapy must specifically addresses the issues of Dissociative Identity Disorder to be effective. He states that "the manifest symptoms may wax and wane and appear to be absent, but a diathesis remains and the potential for the recapitulation of the overt pathology persists" (Kluft, 1991, p.610). In examining physical illnesses, physicians recognize that the process of healing is inherent in the body; a broken bone will knit itself together, the immune system can overcome a virus. There is no reason to ignore or deny similarly inherent healing processes in the psyche.
In Selye's model (1978), healing is defined as an internal
process, not something that can be externally imposed. Support
for healing can help this process take place, but healing itself
is the final stage of adaptation that represents successful resistance
to the stressor. Acknowledging the strength of resistance and
potential for healing in survivors of child abuse is an important
step in understanding the complete cycle of the MIR.
What is illness and what is healing? In adaptive terms, it depends on the purpose. In Selye's (1978) classic example, the body responds to infection by increasing body temperature. This is an (often very effective) attempt to resist the invasion of the pathogen. But this process of healing, is experienced as uncomfortable. In some cases, it may result in a disease of adaptation, where the fever threatens life. Because an excessive fever is a disease of adaptation, medical interventions focus mostly on changing the stressor or the environment. Using penicillin to reduce the presence of the stressor allows the fever response to diminish. In some cases, the fever response can be deliberately suppressed for short periods of time, but it is an essential defense and a part of the body's healing. The appropriate response is to change the environment, not attempt to interfere with a perfectly adaptive response. Suppressing the adaptive response is only necessary in times of crisis, when diseases of adaptation are threatening the life or long-term health of the patient. Early intervention, which is ideal, focuses solely on changing the environment.
Another example of painful healing is the process of abreaction during therapy. Often experienced as extremely painful, and it can disrupt the patient's life and threaten functioning (Fike, 1990b). In therapy, many identities that the person is never aware of in their daily functioning, emerge as a result of the process of uncovering the defensive layers (Kluft, 1991). New identities can develop to cope with the trauma of therapy (Kluft, 1982; Braun, 1984). Yet this manifestation of illness is part of the healing process. A change in environment results in a change in the MIR.
The process of healing in the MIR can take place outside of therapeutic support. Healing is often uncomfortable, everyday functioning seems to be at its lowest point. The process of uncovering memories of abuse and integrating identities is often viewed as evidence of pathology. However, it is a healing process, and just one aspect of a continued response to abuse. The resistance to the abuser, the multiple identity response, is the process of healing. This process will constantly adapt to optimum psychological functioning within the context of the environment.
If the MIR is a consequence of abuse and oppression, survivors of childhood abuse should be recognized as more than victims. The individual with multiple identities has already done the hardest work, surviving the abuse, often with little help from anyone. It does not seem so unlikely to me that such individuals are also capable of healing themselves on their own. However hard the therapist works, it is ultimately the client who is doing the hardest work, reliving their trauma, working through their relationships, facing their fears.
It is unfortunate that little research appears to be carried
out to study the potential of self-healing. While studies regularly
report a "placebo effect", when the mind heals physical
and/or psychological problems, this data is routinely discarded
as "noise" that confuses the real purpose of the study.
What needs to be acknowledged is that people always heal themselves.
To believe that therapy is what is doing the healing is an illusion.
It is true that some kind of support, including therapy, is a
necessary but not sufficient condition of healing. But, the support
for this healing, doesn't have to come from therapy. It can come
from other individuals, religious communities and supportive peer
Healing outside the context of therapy
Studies on individuals with Dissociative Identity Disorder are based on clinical populations. Therefore, there is limited evidence to explore whether or not individuals who experience dissociation as a result of childhood abuse are capable of healing independently of therapy. However, there is some anecdotal evidence to indicate this.
Kluft (1986b) notes that the "overt expression of the classic phenomena of MPD is not consistent longitudinally over time" (p. 722). Kluft reports on 12 individuals who fulfilled the diagnostic criteria of Dissociative Identity Disorder according to the DSM III, but had histories of superior social functioning, including uninterrupted work, no evidence of major life disruptions, medical problems, seizure disorders or severe psychopathology. All pursued successful careers, the identities influenced each other subtly, leaving no recall gaps. The MIR functioned like an internal society or family. In all these cases, these relationships were cooperative and complementary. Conflict was negotiated, or behaviours served different purposes for the different identities.
Kluft (1986) presented three case studies that all reported a common reason for seeking therapy, problems with their relationships with men. In one case a woman had "failed to change masochistic tendencies in her relationships with men" [in other words, she was being continually traumatized in an abusive relationship (Caplan, 1985)], another was going through a traumatic divorce and the third had unspecified "problems". The MIR functioned well for these individuals, and no significant pathology was present. The women appear to have survived and essentially recovered from the trauma of childhood abuse. When the need arose to deal with trauma in adult life, the MIR was reactivated to deal with the situation.
Individuals with Dissociative Identity Disorder can also remove
identities using self-hypnosis. Kluft (1988b) describes one client
who used autohypnosis to prevent a new identity from emerging.
An upsetting incident had triggered the recall of some traumatic
memories and an incipient, nameless identity was formed to cope
with these events. Using autohypnosis she contacted the identity
to assure her that the memories and the new identity were welcome
to her, and prevented the split from occurring. In the same article,
Kluft describes another case of a man who could not find sufficient
help and integrated his identities using autohypnotic techniques.
He concludes that the case "illustrates that the applications
of autohypnosis in motivated MPD patients may be far wider than
generally assumed." (p. 92).
The inner healer
The inner healer, also called the inner self helper (ISH), has been seen by mystics as spirits possessing the body, by clergy as the presence of the divine, by philosophers as a representation of our higher selves and by therapists as a therapist's assistant (Allison, 1974).
Few things are as indicative of the inner power to heal oneself as the presence of the inner healer in the DCS. Allison (1974) describes the Inner Self Helper (ISH) as a source of wisdom, self preservation, perspective and understanding that appeared to be unique to Dissociative Identity Disorder patients and people with other dissociative disorders.
However, the concept of inner guidance is ancient. Some early conceptualizations of the unconscious mind did not perceive as the Freudian repository of animalistic lusts and irrationalities, but as a source of peace, sustaining energy and inborn wisdom (Comstock, 1991). Ross (1989) argues that Breuer's patient Anna O. had a ISH that Breuer did not use sufficiently in his treatment.
Jung viewed the unconscious mind as a source of wisdom, and encouraged listening to this inner voice (Comstock, 1991). Hilgard (1977) named it the "hidden observer", but saw it as less emotional, more analytical and mature. He characterized it as distant from the functioning of the psyche, observing all that happened but not interfering. Allison (1974) viewed the ISH as presenting itself as emotionally subdued, but would eventually express a full range of human emotion.
Other psychologists studying Dissociative Identity Disorder have viewed the ISH as a central, unifying force (Beahrs, 1986; Allison, 1974; Putnam, 1989; Comstock, 1991). Several therapists believe that the ISH is often or always present in individuals who do not have multiple identities as well as in a multiple identity response (Allison, 1974; Beahrs, 1986; Putnam, 1989).
In a study by Adams (1989) of therapists working with Dissociative Identity Disorder clients, over half reported that they believed every Dissociative Identity Disorder patient had a ISH, and 90% of therapists reported contact with at least one ISH in their practice.
Comstock (1991) believes that a person can have more than one ISH, sometimes spiralling upward to higher Higher Selves that superseded the body, and are rarely called on but available if needed. Comstock reports that communicating with the ISH has been reported to occur through a sudden insight or knowing, possibly through some process of projective identification. Also, he comments that the strong spiritual ties of the ISH makes some psychologists uncomfortable. The ISH can communicate directly with the therapist about missing time and forgotten events, interpret somatic symptoms, give advice on the course of therapy, assist with integrating identities, bring the individual into therapy and seek help on behalf of the DCS, crisis management and prevention and other self-preserving functions (Comstock, 1991). After integration has occurred, the ISH remains intact to regulate internal communication, and is accessible only through hypnosis (Watkins, 1982). It stands to reason that the ISH can function outside of the context of therapy, and would be the prime mechanism for self-preservation and healing.
The presence of the ISH displays the adaptivity of the MIR.
By encapsulating the influence of the abuser, the individual has
managed to sustain a sense of self-love and inner peace that is
intact. At some deep level, the abuser failed to extinguish the
sense of self-love and self-preservation in the child. This is
a strategic victory for the MIR, that despite the ravages of annihilation
and psychological colonization, essential parts of the DCS that
are necessary for eventual healing were preserved intact.
The role of ongoing traumatization in adulthood
Unfortunately, leaving the family of origin is not always
the same as beginning an abuse-free life, especially for women.
In a society that was supportive of survivors of abuse, simply
leaving the abuser would be enough. However, it is clear that
society plays an important role in not only the creation but the
maintenance of the MIR. Therapeutic interventions with children
with MIR demonstrate that unless the abuse is ended and the child
is in a relatively safe environment, the MIR will continue (Dell
& Eisenhower, 1990).
The oppression of children
Running away from home is one of the few ways possible to escape the abusive family, unfortunately this act of resistance is not encouraged by society. Economic dependence on the family of origin is one of the cornerstones of the oppression of children. Many abused children run away from home, only to be brought back by the police and into the hands of the abuser again (Webber, 1991).
Others find their way to the streets, unable to find adequate
shelter or employment because of their age. Many of these individuals
are re-traumatized through repeated abuse (Webber, 1991). Ross,
Norton & Wozney (1989) reported that 19% of individuals with
Dissociative Identity Disorder had worked as prostitutes. The
patriarchal system moves them from the individuals abuse and degradation
of their family of origin into the class of general sexual property
of men (Brownmiller, 1975).
The oppression of women
The gender ratio of children with Dissociative Identity Disorder is about 3 girls for every 2 boys, by adolescence the proportion of females to males has widened to 4:1 (Dell & Eisenhower, 1990). In adulthood the ratio is approximately 9:1 (Putnam et al., 1986; Ross et al. 1989b). There are a number of theories to account for this.
One is the finding that boy children are not abused as often as girl children (Finkelhor, 1986). Another theory is that males with Dissociative Identity Disorder end up in prison rather than therapy (Allison, 1980; Bliss & Larson, 1985; Kluft, 1988a; Putnam, 1989; Ross & Norton, 1989). This speculation is based largely on the fact that males with multiple personality exhibit more antisocial and aggressive tendencies than females (Loewenstein & Putnam, 1990).
However, as the study of the literature on child abuse demonstrates, there is little correlation between men who rape and assault their girlfriends, wives and children and their tendency to be incarcerated (Finkelhor, 1986). Male individuals with multiple identities are provided with socially acceptable outlets for their behaviours. Ross & Norton (1989) noted that males were more likely to go to jail than females, however, there were very few males in the study. Also, 70% of males had neither been convicted of a crime or gone to jail.
The most likely explanation for this increasing gender difference is the role of ongoing traumatization in adulthood. Over 1 million Canadian women are assaulted each year by their partners (MacLeod, 1987). Approximately 98% of the perpetrators of these assaults are male (Russell, 1986). There is some evidence that survivors of childhood abuse are raped and assaulted in adulthood more often (Kluft, 1985b). While this is sometimes attributed to their "masochistic tendencies" (Kluft, 1986b; Caplan, 1985), little research is done to determine exactly why this happens. Unfortunately, investigating whether these individuals are in precarious economic or social situations that makes them less able to respond to dangerous situations, or that the ongoing violence contributes to the MIR (while non-abused women drop out of the statistics) has not been explored. Loewenstein & Putnam (1990) reported that 57.7% of female patients reported being sexually assaulted in adulthood. While males in this study reported being raped 16.7% of the time, males in the Ross, Norton & Wozney (1989) study reported similar rates of physical and sexual abuse and rape as those for females, 64% to 67% respectively.
It may be that individuals who are otherwise recuperated from their childhood traumas, re-emerge as individuals with multiple identities after being re-traumatized in adulthood. For some, the abuse is simply unending. Such ongoing violence is far more likely to happen to women than men in a patriarchal society (Brownmiller, 1975; Levine, 1989). The ever widening gap between females and males with multiple identities is not simply that women are more likely to seek therapy or that men are more likely to be incarcerated for their abusive behaviour. Men have more opportunities, by virtue of their privileged position in patriarchy, to reintegrate than women.
Although Kluft (1991) recognizes that the "presence of trauma and stress" contribute to manifestations of overtness in adult individuals with multiple identities, he does not consider that this could play a primary role in perpetuating Dissociative Identity Disorder for decades after leaving the abusive situation.
Note the following stages that Kluft (1991) identities as forms of Dissociative Identity Disorder. In each of the stages, the MIR re-emerges after a traumatic incident. "Latent" MIR is described by Kluft (1991) as when the identities are inactive but can emerge when triggered by a stressor, especially re-traumatization or other events that are symbolic of or remind the individual of their childhood traumas. Kluft describes this as latent, however, I would say the initial MIR has been resolved. Sensitization to brutality would trigger the well-developed MIR in the DCS.
Posttraumatic MIR is described as clandestine until the individual
is re-traumatized through rape, violence or betrayal, or experiences
a head trauma. Ad hoc MIR is when a single helper identity emerges
to create a number of short lived identities that cope with a
crisis. The identity function briefly and then cease to exist,
but the helper identity persists (but rarely emerges). This is
probably a response by the MIR to dealing with systems that have
been oversensitized by abuse. It may be that some basic damage
has resulted and a crisis management team is necessary to maintain
mental health. I would regard this as a health preserving stage
of MIR. It is possible that after sequential re-traumatization
as an adult, the MIR would be maintained as a defense against
the future fear of assault, rape and other brutalities.
Therapy as a form of trauma
There are numerous reports that individuals with multiple personality will produce new identities during treatment if the therapist makes technical mistakes or otherwise re-traumatizes the client (Kluft, 1982; Braun, 1984). There are also a number of studies that indicate that therapy which misdiagnoses individuals with Dissociative Identity Disorder will result in little, if any long term gain. The suicide and parasuicide rates for individuals with multiple identities is positively correlated with the length of time they have spent in the psychiatric profession (Ross & Norton, 1989). Longitudinal follow up studies can help determine whether this is due to a higher rate of active suicidal intention in individuals with multiple identities who seek psychiatric care, or if spending 7 years (Rivera, 1991) to 10 years (Ross & Norton, 1989) being misdiagnosed was ultimately a destabilizing influence for these individuals.
Firsten's (1990) study on female psychiatric patients found that women were at high risk for sexual and physical abuse during their hospitalization. The vulnerability of female psychiatric patients, whom no one will believe and who may be heavily drugged, places them in further danger of abuse. Obviously, psychiatric settings are not the safe haven needed to facilitate healing. From a feminist perspective, treatment in psychiatric facilities often serves only to isolate and pathologize the individual (Finkler, 1994). In one study (Rivera, 1991) individuals with Dissociative Identity Disorder received a total of 46 different diagnoses, the most common being depression (46%), borderline personality disorder (37%) and schizophrenia (33%). The treatment for these disorders is often inappropriate for individuals with multiple identities. Parasuicidal individuals reported receiving 4 different types of psychotropic drugs more frequently than other patients, and 12% reported receiving electroshock treatments (Ross & Norton, 1989). Studies on the effects of pharmacology in the treatment of Dissociative Identity Disorder have shown it has limited success, largely as an adjunct to therapy (Loewenstein, 1991), and electroshock is rarely indicated as an appropriate treatment for Dissociative Identity Disorder. Aside from the unpleasant effects of these treatments, the fact that these individuals probably never received in-depth counselling constitutes a form of re-traumatization. The lack of recognition of the impact of abuse in their lives is a form of silencing and discrediting these experiences. By pathologizing the individual, rather than examining the social situations they face, psychiatry often simply reinforces the messages that the "problem" is defined as the person (Levine, 1989).
When therapy does work, it uses the strengths of the MIR and gives support for the inherent process of healing. Hypnosis is an excellent use of the MIR, because it can utilize the developed abilities of dissociation to abreact, control pain, slow-leak overwhelming memories, perform fusion rituals, cognitive restructuring and positive dreamwork (Shapiro, 1991; Salley, 1988).
Play therapy, contracting, age regression, abreaction and other eclectic techniques are used successfully (Rivera, 1988). Kluft (1986) notes that the key to successful therapy is to establish trust, express support for the client and use a variety of techniques.
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Dissociation from the reality of child abuse is a socially congruent choice of defense for an abused child, because of society's persistent desire to dis/associate itself from the oppressed child's experiences (Rush, 1980). Accepting the fact of child abuse would threaten the patriarchal, child oppressive and heterosexist structures of the social order, beginning with the nuclear family as its point of indoctrination and socialization in lessons of oppression (Rush, 1980; Rivera, 1988). The colonization of the mind and body, are the heaviest weight of oppression. In a society that refuses to acknowledge child abuse, the survivors of this abuse come to doubt their sanity, disbelieve their own realities and blame themselves for their "problems." (Levine, 1989.
Currently, it takes three decades or more for the MIR to run its course (Ross, Norton & Wozney, 1989). This could happen within months with timely intervention in child abuse (Coons, 1986). The individual with Dissociative Identity Disorder did not "fail to" integrate (American Psychiatric Association, 1994), they have been actively prevented from doing so. Our society labels Dissociative Identity Disorder a dis/order because it challenges the social order, especially myths that dis/associate from the realities of childhood, child oppression, the family dysfunction and male domination (Foucault, 1972). However, by understanding MIR as a response to the demands of an oppressive family, which is the locus of an oppressive system, we can learn about resisting and surviving oppression.
Kluft (1985b) and Braun & Sachs (1985) noted than Dissociative Identity Disorder develops in the context of an unsupportive environment. Put another way, ongoing abuse can only occur in the context of an environment that supports such behaviour covertly or overtly. This social support for violence can also be named as oppression. If a child experienced trauma, but received immediate help from a supportive environment, the MIR would never emerge.
Further brutality and neglect in adulthood help maintain Dissociative Identity Disorder, despite the tremendous self-nurturing potential of the MIR. Carmen, Reiker and Mills (1984) studied 180 psychiatric patients and found that 43% had histories of physical and/or sexual abuse. Other studies targeting women in psychiatric populations, found that 72% (Bryer et al., 1987) to over 80% (Firsten, 1990) of women reported a history of abuse at some time in their lives. While the debate over the differential diagnosis of Borderline Personality Disorder and Dissociative Identity Disorder continues (Fink & Golinkoff, 1990), some research indicates that 86% of individuals with Borderline Personality Disorder experience childhood sexual abuse (Bryer et al., 1987). Rather than spending time classifying survivors of abuse, psychiatry (and its users) would benefit more from recognizing the links between oppression and psychiatric diagnosis. It may be that Dissociative Identity disorder has been recognized as an outcome of childhood abuse because it is particularly resistant toward pharmacological masking of its presence. While depression can be anaesthetized, although the depressing situation remains, multiple identities have proven resistant to the usually vigorous application of pharmaceutical intervention.
Therapy and crisis management is only one aspect of dealing with Dissociative Identity Disorder. The internalization of sexist and racist stereotypes, the internalization of violence, the lack of constructive models of anger, the widespread reality of child abuse and oppression and the continuing abuse women face as adults at the hands of male violence are all parts of the issue of Dissociative Identity Disorder that demand a political response. Amnesia about one's personal history of child abuse serves only the abuser and the society that prefers to ignore abuse. Many women have not had their first recollection of child abuse in the therapist's office, but in a political context, surrounded by other women unearthing their experience and sharing their stories (Rivera, 1988).
Political action is therapeutic, and it is quite likely that it is the locus of healing and support that some individuals with multiple identities need. Feminist politics has also been essential in recognizing the strength and courage it involves to survive abuse. Recognizing people as "survivors" as well as "victims" of abuse helps them put their experiences into perspective (Bass & Davis; 1988; Lew, 1988). A political understanding of child oppression and violence can help in dealing with issues of shame and low self-esteem. Reclaiming the concept of the victim may also be important, to overcome society's contempt for those who "allow" themselves to be violated. People who are seen as helpless may be pitied, but they are rarely respected. Recognizing that even such seemingly passive acts as submitting to the rape without a struggle is an act of strategy that may involve great courage and endurance, but was needed to avoid losing one's life, has helped many abuse survivors see themselves in a new light (Bass & Davis, 1988). One social aspect often internalized by the DCS is the social contempt and blame for the victim who "allows" the abuse, or even "asks for it." (Ross & Gahan, 1988) Challenging this myth is necessary in reducing the conflict evident between the child identities and other identities that adopt roles which are compliant with the abuse, and the identities which reflect the internalized oppression, such as internal persecutors. Such divide and conquer strategies are evident in broader forms of colonization, where degrees of affiliation with the oppressor create conflicts that serve to weaken direct resistance (Davis, 1981; Hooks, 1984). Recasting the behaviours as forms of resistance allows the disparate elements to unify and identify their oppression more clearly. Ross describes his view of the role of a therapist:
"The Osiris complex designates what I believe is the most important motif in psychopathology: the fragmentation of the self in response to external trauma. In the Isis-Osiris myth from ancient Egypt, Osiris is murdered by his jealous brother Set, who cuts him into pieces and scatters them far and wide. Isis then gathers them, and resurrects Osiris in a new form: this healing of the traumatized self is my task as a therapist" (Ross,1994, p.xiv)
Such as view reinforces the concept of the therapist repairing the inert victim. The role of abuse survivors in enduring and escaping abuse and participating in their own healing process is not acknowledged in this image. Just as the move from victim to survivor is empowering, so is the move from survivor to resistor. The pathology identified in individuals who have experienced abuse needs to be recognized as more than a consequence of abuse, but as a consequence of social oppression. To not acknowledge the mobilization of resource in individuals with Dissociative Identity Disorder is to undermine the strength and strategies used. The therapist is not the saviour of the helpless victim, but an ally in the struggle of resistance.
Feminist political methodologies can be used in dealing with Dissociative Identity Disorder. For example, the process and goal of therapy can be examined in a political light. Fusion implies that singularity is the ideal state of selfhood and integration infers that identities should be subject to a hierarchical "executive self". Is there another model? What about co-consciousness, a collectively oriented, cooperatively negotiated structure? How do people negotiate the embodiment of alternate identities? We can predict that individuals struggling to use this model of self-organization will face the same strengths and weaknesses that feminist collectives face. For example, the greater the differences between the identities, the more conflict they will face. Learning methods of conflict resolution and establishing covenants of trust between identities would be one of the first tasks. Some individuals may choose this system because of the insights it offers. Fusion, or singularity, implies a certain degree of illusion, that hides many aspects from the self awareness (Watkins, 1993). Similarly, the concept of the executive self also involve inhibiting "inappropriate" responses from awareness (Watkins, 1993). Taking on the challenge of full awareness of one's selfhood, and the selves that we can be under a wide variety of circumstances, is a daunting task.
Joesph Campbell (1968) argues that religion, philosophy and cultural myths tell a single, basic story of the search for our self. Our true identity is often hidden from view under the social constructions and roles we are trained to adopt. Searching for what lies underneath, exploring the fullness of what it means to live a human life, is a common core of religion and myth throughout societies. Choosing to remain in awareness of human multiplicity, refusing to live divided and alienated roles and trying to keep in touch with all of the selves is a valid personal and political choice for some individuals with MIR. The act of remembering abuse and maintaining conscious connections with all aspects of our selves is a political action.
"We are often forced to hide parts we would like to be free to express. With freedom to express, freedom to live as you choose to live, you gain your freedom to be whole. When you are whole, you can let your voice be heard. Let all your voices be heard." (E.B.,1990).
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The model of the DCS is eminently suited for computer generated modelling. Although neurology is a science in its infancy, developing advanced models for understanding psychological processes will have many benefits to medicine and psychology alike.
Creating neurological models that integrate the entire body as part of its systemic functioning is long overdue in neurology. Further understanding of the nature and limitations of neurology and its impact on physical and mental health is an appropriate goal for future research.
The diagnostic criteria of Dissociative Identity Disorder and Dissociative Disorder Not Otherwise Specified are likely catching a very large population, including people who exhibit few signs of pathology. The cross cultural perspective on possession and trance states makes it clear that embodying an alternate identity is not necessarily an unwelcome or pathological event. The evidence on multiplicity points out that if we all live in multiplicity, it is not inherently destructive. The criteria should be adapted to include an ego dystonic requirement for such a diagnosis. This would be more cross culturally appropriate and accommodate individuals who have embodied ego syntonic alternate identities, both people with spontaneously occurring multiplicity and reintegrated abuse survivors who choose to retain multiple consciousnesses.
The whole concept of pathologizing the survivors of abuse is questionable. Defining the survivor as the problem stigmatizes the abused, not the abusers. In seeking help, individuals with multiple identities may find themselves re-traumatized by unwanted interventions. The creation of safe houses, where healing can take place in safety, and where people can go to escape abusive situations, would be an important step in assisting the healing of abuse survivors. Further research into the feasibility of such projects would greatly benefit individuals with multiple identities. It is important to remember that we, as a society, do not simply want to assist survivors in adapting to their abuse, but actually work towards ending child abuse and violence in our society.
Dissociative Identity Disorder should be regarded as not only
a disease that responds well to appropriate treatment, but an
entirely preventable difficulty of living with an unlivable environment.
More research on early intervention techniques, and further political
actions to prevent child abuse are essential. Further research
into the developmental aspects of psychological responses to trauma
are necessary to test the hypotheses put forward in this dissertation.
By examining the environmental and social influences on mental
adaptations, the developmental processes of resisting oppression
may be further uncovered and elaborated. Early intervention with
abused children before the age of 3 years could provide insight
into the earliest developmental stages. This model of research
would also be useful in examining other psychiatric diagnoses
for the contribution of social factors in their etiology and maintenance.
Dissociative Identity Disorder can only be understood within its social and cultural context. Specifically the integral role of oppression in child abuse and ongoing violence indicates that Dissociative Identity Disorder is not a result of isolated situations of abuse, but part of the systemic violence against children and women.
The embodiment of alternate identities is a normative state for some individuals, although cultural socialization can have a large impact on defining "appropriate" forms of dissociation and autohypnosis, the two mechanisms that underlie the process of embodying alternate identities. Neurological frameworks clearly point to the existence of decentralized, modular processes the define our psychological organization, and plausible neurological mechanisms for embodying alternate identities support the hypothesis that multiplicity is a normative process.
This leads to the need to re-define the "disease" of Dissociative Identity Disorder. Internalized oppression, including self-abuse, forgetting the personal history of abuse, and internalized messages of self-hate and self-destruction, are the true cause of pathology and discomfort among abuse survivors. These negative messages are internalized as a consequence of the abuser colonizing the mind of the child. Dissociative Identity Disorder is a label that pathologizes these effects of abuse. In fact, the underlying mechanism of the multiple identity response, is a coping and healing strategy that optimizes psychological organization to the environment. Changes in the environment allow the multiple identity response to complete its cycle, and activate its capacity to resist internalized oppression.
The common conception of multiple identities as a form of extreme pathology that takes on classical symptomology is false. In fact, the multiple identity response produces a variety of responses throughout its cycle, and takes a wide variety of forms.
Clinically-based studies, which likely represent a narrow
sampling of the total population of individuals with multiple
identities, have probably contributed to this misconception. Survivors
of abuse must be given credit as strategists, working proactively
as well as reactively to escape pain, escape the abuser, provide
self-nurturing and find a path to healing. A political, community
based response to child abuse is needed to truly address the issues
and difficulties of individuals with multiple identities.
The question that I could not resolve, for myself, throughout this dissertation was the basic paradox - how can we be healthy in an unhealthy world? The General Adaptation Syndrome is a model of adaptation, not a clear, philosophical definition of mental illness and mental wellness. Further research into the developmental stages of psychological adaptations may help to bring a greater feminist understanding to mental health. Researching the processes of adaptation, the role of social supports and the search for mentalwellness among abused and oppressed individuals could illuminate some aspect of this question. It may be that the desired goal of healing, and the definition of mental wellness differ from person to person. How different individuals defined and pursued this goal would be instructive.
This is an uncommon approach if one believes the model of "pathogen and disease". There is little choice involved in being sick or not. However, through understanding the nature of adaptation, we can clarify what choices people do have about their health. By knowing what aspects of health are prioritized, what struggles are endured to pursue the goal of health and what support is needed to accomplish these goals, the mental health profession can learn to be more responsive to the needs of the system users.
Making the link between the body and mind is also an important step for analyzing abuse. Often, the feminist praxis is that "every woman owns her body". Actually, every woman (and person) is their body - what happens to the body happens to the self. The body/mind dichotomy is a heuristic that has long outlived its usefulness. Understanding physical and sexual abuse involves recognizing the complex interactions between the body and the rest of the self. The way physical and sexual abuse use the physical form to colonize the self is a profound violation, which often results in difficulties of embodiment. Further exploration of our physical relationships with ourselves could help explore this complex process.
In developing an understanding of child abuse as an element of systemic violence, it raises the issue of redefining oppression as abuse. For example, the hate-motivated violence of racism needs to be understood as a form of abuse. Systemic discrimination against lesbians and gay men needs to be examined as a form of abuse. What impact does this impersonal, yet systemic and profound violence, isolation, social ostracism and socialized self-hatred have on the mental health of oppressed groups? Understanding how the impersonal systems of oppression create personal experiences of abuse is an important contribution to developing a theoretical nexus of personal and political realities.
The other outstanding question I am left with is what happens to severely abused children who do not have a naturally high dissociative ability? The endemic nature of child abuse, as well as ongoing brutality in adulthood, necessitates an investigation into the role of oppression in all forms of mental functioning, whether they are labelled as illnesses or not. How does violence, or even the everyday fear of violence, influence our mental health? Hopefully, using a developmental model of adaptation will help illuminate the etiology and structure of other outcomes of violence and provide some insight on how social systems can be most responsive to these needs.
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