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Dissociative Identity Disorder
(a) many of Gleaves's arguments were predicated on misunderstandings of the SCM,
(b) scrutiny of the evidence regarding the psychopathology and assessment of DID raises questions concerning the PTM's conceptual and empirical underpinnings,
(c) the treatment literature suggests that iatrogenic factors play an important role in the etiology of DID, and
(d) the evidence linking child abuse to DID is more problematic than implied by Gleaves.
The present authors conclude that Gleaves's analysis underemphasized the cultural manifestations of multiple role enactments and that the history of DID imparts a valuable lesson to contemporary psychotherapists.
Gleaves (1996), discussed in this article, was deemed a commentary on Spanos (1994). Nicholas Spanos died in 1994, and the present article was written as a reply to Gleaves (1996) in Spanos's stead. Because Gleaves (1996) was considered a commentary and the present article was considered a reply to that commentary , no additional commentaries or replies were solicited.-NE
This article was inspired by the work of Nicholas Spanos, whose tragic death in 1994 was a great loss to the field of psychology in general and to the fields of hypnosis and dissociative identity disorder in particular. In addition, we thank Eric Vanman, Richard McNally. and several others for their extremely helpful comments on drafts of this article.
Correspondence concerning this article should be addressed to Scott O. Lilienfeld, Department of Psychology, Room 206, Emory University, Atlanta, Georgia 30322. Electronic mail may be sent to firstname.lastname@example.org.
|APD||Avoidant Personality Disorder|
|DDIS||Dissociative Disorders Interview Schedule|
|DES||Dissociative Experiences Scale|
|BPD||Borderline Personality Disorder|
|DID||Dissociative Identity Disorder|
|HPD||Histrionic Personality Disorder [Hysteria]|
|MPD||Multiple Personality Disorder|
|PTSD||Post Traumatic Stress Disorder|
Assumptions of the SCM
The Iatrogenesis of DID
The Simulation of DID
The Pseudo-issue of DID's "Existence"
Multiple Identity Enactments and DID
The Psychopathology and Assessment of
The Overlap of DID With Other Conditions
The Assessment and Diagnosis of DID
The Treatment of DID
The Clinical Presentation of DID Before and After Treatment
Hypnosis and the Creation of Multiplicity
Current Treatment Methods for DID
The Distribution of DID Diagnoses Across Clinicians
The Epidemiology of DID in Adulthood and Childhood: Implications for Iatrogenesis
The Etiology of DID
Motivations for Developing DID
Child Abuse and DID:
- The corroboration of child abuse reports among DID patients
- Interpretation of the child abuse-DID association
Summary of the DID literature: The SCM Reappraised
Discussion: Recalling the Lessons of the Past
The etiology and nosological status of dissociative identity disorder (DID), formerly known as multiple personality disorder (MPD), are among the most controversial issues in contemporary clinical psychology (L. Cohen. Berzoff. & Elin. 1995; Connier & Thelen. 1998; Pope, Oliva. Hudson, Bodkin. & Gmber. 1999).
Over the past decade, two competing views concerning the genesis and nature of DID have emerged.
One perspective. referred to by Gleaves (1996) as the posttraumatic model (PTM; called the "disease model" by Spanos, 1994), maintains that DID is an etiologically distinct condition that is best conceptualized as a defensive response to childhood trauma, particularly severe sexual and physical abuse. Proponents of this view hold that DID is most typically a form or variant of posttraumatic stress disorder (PTSD) and that the features of most cases of DID can be conceptualized as coping responses to early trauma. Specifically, advocates of the PTM contend that following severe abuse or other traumatic events, individuals dissociate or "compartmentalize" their subjective experience into alternate personalities ("alters") as a means of coping with the emotional pain of the trauma. As Ross (1997), a proponent of the PTM, argued. "MPD is a little girl imagining that the abuse is happening to someone else" (p. 59).
An alternative perspective on DID is afforded by the sociocognitive model (SCM; Spanos, 1994, 1996; for related views, see Aldridge-Morris. 1989; Ganaway, 1995; Merskey, 1992; Sarbin, 1995; and Simpson. 1989). The SCM conceptualizes DID as a syndrome that consists of rule-governed and goal-directed experiences and displays of multiple role enactments that have been created. legitimized, and maintained by social reinforcement. Patients with DID synthesize these role enactments by drawing on a wide variety of sources of information, including the print and
broadcast media, cues provided by therapists, personal experiences, and observations of individuals who have enacted multiple identities.
By role enactment, proponents of the SCM (see Sarbin & Coe, 1972; Spanos, 1996) mean that DID patients adopt and enact social roles geared to their aspirations and the demand characteristics of varied social contexts. According to this view, the metaphor or concept of role does not imply that role-related behaviors are the products of conscious deception. Instead, role enactments tend to flow spontaneously and are carried out with little or no conscious awareness and with a high degree of "organismic involvement" (Sarbin & Coe. 1972) such that the role and "self" (or "multiple selves" as the case may be) coalesce so as to become essentially indistinguishable.
According to the SCM, iatrogenic and sociocultural factors play a substantial etiological role in DID and account largely for the recent and dramatic upsurge in reports of this condition (Aldridge-Morris, 1989). Some authors (e.g., Boor, 1982) have argued that the term epidemic best describes this secular increase, because the number of reported cases of DID in the world literature increased from 79 as of 1970 to approximately 6,000 by 1986 (Elzinga, van Dyck, & Spinhoven, 1998). The number of reported cases at the close of the 20th century is difficult to estimate but appears to be in the tens of thousands (Acocella, 1998). The SCM further posits that DID is one variant of a broader constellation of multiple identity enactments, including demonic possession, mass hysteria, transvestism, and glossolalia, that traverse cultural and historical boundaries. Although the protean manifestations of these enactments have been shaped by cultural and historical expectations, their underlying commonalities are suggestive of shared origins.
In a recent article in this journal, Gleaves (1996) criticized a review by Spanos (1994) that presented a large body of scientific and historical evidence in support of the SCM. Gleaves further argued that the PTM provides a superior account of the etiology of DID. Because Nicholas Spanos was tragically killed in a plane crash in 1994, Gleaves's criticisms of the SCM have gone unanswered. We believe that careful scrutiny of Gleaves's assertions is warranted for two reasons.
First, the arguments raised by Gleaves, although not new, have gained acceptance among a large segment of the therapeutic community (e.g., Bloch, 1991; Ross, 1997) and general public (e.g., Steinem, 1992; see Acocella, 1998, and Sho- walter, 1997, for discussions) and have exerted a substantial influence on the conceptualization and treatment of DID. Moreover, they have been referred to frequently by proponents of the PTM (e.g., Kluft, 1993; Ross, 1997).
Second, Gleaves's article has already been heralded by some authors as providing a convincing, if not definitive, refutation of the SCM. Scheflin ( 1997), for example, described Gleaves's critique as "a masterful article articulating, and then refuting, the premises of the iatrogenic position" (p. 253).
Although some of the presuppositions of the PTM and SCM may not be mutually exclusive or logically inconsistent, these models differ substantially in emphasis and engender quite different expectations concerning the etiology and correlates of DID. These two models diverge most sharply in their explanations for the emergence of alters. Specifically, whereas the PTM posits that alters are a naturally occurring result of severe child abuse and other traumatic events, the SCM posits that alters arise as a consequence of therapist influences, media portrayals, and socio- cultural expectations.
Although the SCM is not inconsistent with the possibility that childhood trauma might produce a predisposition toward certain psychological traits (e.g., fantasy proneness; Lynn, Rhue, & Green, 1988) that in turn increase individuals' receptivity to therapist cues, this model does not posit that the creation of alters is a defensive reaction to trauma.
In addition, the two models differ markedly in their views of the relative importance of iatrogenic and other sociocultural influences in the etiology of DID. Whereas proponents of the PTM have typically maintained that such influences are of relatively minor importance in the genesis of DID (or that they account for a relatively small minority of DID cases; see Ross, 1997), proponents of the SCM have typically maintained that such influences playa substantial role in DID's etiology (Spanos, 1994).
Finding evidence that would unambiguously falsify either or both models is difficult, largely because
(a) direct experimental manipulation of the crucial etiological agents posited by each model (i.e., childhood trauma in the case of the PTM, iatrogenic and sociocultural expectations regarding multiple identity enactments in the case of the SCM) is impossible for obvious ethical and practical reasons (although, as we discuss later, analogue studies of the etiological agents posited by the SCM have been conducted);
(b) many of the putative etiological agents posited by the PTM, particularly child sexual and physical abuse, are sometimes difficult to operationalize in a standardized fashion across investigations (Rind, Tromovitch, & Bauserman, 1998);
(c) many of the putative etiological agents posited by the SCM (e.g., socio- cultural expectations) are difficult to assess objectively; and
(d) prospective, rather than retrospective, data would ideally be required to test the central hypothesis of the PTM, namely, that severe childhood trauma is a necessary precursor of most cases of DID.
Nevertheless, the SCM would be falsified or at least strongly called into question by data demonstrating that a large proportion of clear-cut DID cases emerged in childhood prior to therapy and prior to exposure to widely available knowledge concerning the expected features of DID. The PTM, in turn, would be falsified by data demonstrating that the majority of cases of DID were not preceded by severe child abuse or other trauma. Alternatively, the PTM would be called into question by data indicating that most individuals ultimately diagnosed with DID begin therapy with few or no detectable features of this condition, particularly multiple identity enactments, and develop these features only after therapeutic intervention.
Although we do not believe that the extant data on DID are sufficient to permit a definitive refutation of either model, we contend that adequate data are now available to accept many of the major premises of the SCM and to raise important questions concerning a number of the central tenets of the PTM. In the remainder of this article, we argue that
(a) Gleaves's (1996) article contained serious misinterpretations of the SCM and dismissed this model on the basis of inadequate data,
(b) the research support for the PTM presented by Gleaves was problematic and in many cases flawed, and
(c) Gleaves's analysis neglected or underemphasized the historical and cultural manifestations of multiple role enactments.
In addition, we aim to update important developments in the DID literature since the reviews of Spanos (1994) and Gleaves. sharpen several conceptual distinctions that have some- times been blurred in debates concerning DID, offer a number of suggestions for methodological improvements in this area, and attempt to foster a more constructive dialogue among proponents
of both the SCM and the PTM. We organize our review around three broad issues:
(a) the psychopathology and assessment of DID,
(b) the treatment of DID, and
(c) the etiology of DID.
Before addressing these issues, however, it is first necessary to examine Gleaves's exegesis of the SCM.
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