The Iatrogenesis of DID
Early on in his article, Gleaves ( 1996) called into question a number of the assumptions of the SCM. Several of the assumptions criticized by Gleaves, however, appear to be misrepresentations or misunderstandings of the SCM.
The Iatrogenesis of DID
One of Gleaves' s ( 1996) initial arguments was that "the all-or-nothing assumption of the iatrogenic model is false because no disorder can be entirely iatrogenic or entirely noniatrogenic" (p. 42). The SCM does not, however, posit that the etiology of DID is completely iatrogenic. Instead, as already noted, this model proposes that the features of DID can be constructed from a variety of sources in addition to unintentional prompting from therapists, including memories of one's past behavior, observations of other individuals, and media portrayals of DID (Spanos, 1994). Thus, it is relevant that the current dramatic increase in the prevalence of DID cases (Boor, 1982) began shortly after the release of the popular book and television film Sybil (book: Schreiber, 1973; film: Petrie, 1976). Furthermore, the SCM posits that multiple identity enactments transcend societal and historical boundaries and can be found even among cultures in which the involvement of mental health professionals is minimal.
Nor does the SCM imply that social influences are the only causal variables relevant to DID, because this model suggests that individual differences in personality or psychopathology, in conjunction with iatrogenic and sociocultural influences, can predispose certain individuals to DID (see the section below entitled The Psychopathology and Assessment of DID). Thus, the SCM is consistent with the possibility that certain traits, such as absorption (Tellegen & Atkinson, 1974) and fantasy proneness (Lynn et al., 1988), play an etiological role in at least some cases of DID (Spanos, 1996; see Bowers, 1991, for a related view). Fantasy proneness, for example, correlates moderately with indexes of dissociation (Rauschenberger & Lynn, 1995) and may place individuals at heightened risk for enacting imaginary identities in response to therapeutic and sociocultural cues (Lynn et al., 1988). Moreover, Spanos (1996) argued that DID overlaps substantially with several psychopathological conditions, including borderline personality disorder (BPD) and somatization disorder. Thus, the SCM does not deny that much of the psychopathological raw material from which DID is sculpted exists prior to professional intervention.
The Simulation of DID
Gleaves ( 1996) asserted that a key assumption of the SCM is "that there is something unique about DID that would make it rewarding to simulate the disorder" (p. 43). This statement represents a widespread misunderstanding of the SCM, which is careful to distinguish role enactment from simulation. This distinction is, not semantic. As noted earlier, role enactment, unlike simulation, typically occurs in a seemingly spontaneous fashion, with little or no conscious effort or planning. Spanos and other proponents of the SCM do not maintain that most individuals with DID are consciously dissimulating, although in rare cases (see, e.g., Orne, Dinges, & Orne, 1984) certain individuals may feign DID to avoid culpability for criminal actions or to obtain attention.
The Pseudo-issue of DID's "Existence"
Contrary to Gleaves's (1996) claims (see pp. 43-44), the SCM does not take issue with findings that
Gleaves committed a similar error later in the article when he confused the question of DID's existence with the question of its etiology. For example, he contended that studies demonstrating that many of the features of DID can be readily induced in normal participants provided with instructions to role-play multiple identities (see, e.g., Spanos, Weekes, & Bertrand, 1985) do not call into question the existence of DID. He cited Carson and Butcher's (1992) opinion that
But the SCM does not maintain that DID is "not real" or does "not exist" (see Arrigo & Pezdek, 1998; Dunn, Paolo, Ryan, & van Fleet, 1994; and Elzinga et al., 1998, for similar errors). [*1] The crucial question concerns not DID's existence - the fact that certain individuals exhibit the features of DID is not in dispute - but rather its origins and maintenance (McHugh, 1993). Is DID best conceptualized as a naturally occurring response to early trauma or as a socially influenced product that unfolds largely in response to the shaping influences of therapeutic practices, culturally based scripts, and societal expectations?
Multiple Identity Enactments and DID
Gleaves criticized Spanos's (1994) purported contention that "multiple identity enactment and DID are equivalent phenomenon [sic]" (Gleaves, 1996, p. 43) and took issue with Spanos for equating one diagnostic feature (i.e., multiple identity enactment) with one disorder (i.e., DID). Yet Spanos (1994) never equated multiple identity enactment with DID. Instead, he emphasized multiple identity enactment as the principal feature of DID (AmericanPsychiatric Association [APA], 1994) and argued that DID is one prominent contemporary manifestation of multiple identity enactment.
The notion of multiple identity enactment as the essential characteristic of DID did not originate with Spanos. Both the PTM and the current Diagnostic and Statistical Manual of Mental Disorders (fourth ed., DSM-IV; APA, 1994) conceptualize multiple identity enactment as the essential feature of DID. For example, Ross (1997) asserted that all of the features of DID "follow logically
from the existence of alter personalities that take control of the body" (p. 136) and contended that multiple role enactments, in addition to amnesia, are the essential characteristics of DID. Ac- cording to Ross, the other symptoms of DID, including blank spells and flashbacks, are "secondary features" that "are evidence of the existence, activity, and influence of the alters" (p. 136). DSM-IV noted that the "essential feature of DID is the presence of two or more distinct identities or personality states ... that recurrently take control of behavior" (p. 484). Thus, Gleaves (1996) was at odds with other proponents of the PTM and with DSM-IV in arguing that "the core psychopathology of DID" (p. 43) includes such symptoms as identity disturbance, depersonalization, and Schneiderian symptoms (e.g., voices arguing with one another) and that multiple identity enactment is merely one symptom among many of those exhibited by DID patients.
Gleaves (1996) further maintained that these dissociative features are rarely observed in other conditions, then used this finding to call the SCM into question (p. 43). In fact, this finding is consistent with the SCM, which represents an attempt to address the question of why individuals exhibit precisely this constellation of characteristics. Specifically, this model posits that many or most of the features of DID can be explained by the fact that these features derive from culturally based scripts and expectations regarding the typical manifestations of multiple role enactments in Western culture. Because the features of DID have become widely disseminated throughout the culture via the media and other sources, it is not surprising that individuals who exhibit multiple identities often display such features.
That being said, however, some of the purportedly distinctive clinical features of DID cited by Gleaves are questionable. For example. "lack of autobiographical memory for childhood" (Gleaves. 1996, p. 43) may not be specific to DID or other dissociative disorders. Read (1997) found that 20% of a community sample of adults reported significant gaps in memory after age 3, and we are unaware of any controlled studies demonstrating that individuals with DID exhibit poorer recall of childhood memories than do other psychiatric patients or individuals without psychopathology.
In addition, individuals who obtained high scores on the Dissociative Experiences Scale (DES; Bernstein & Putnam, 1986), a commonly used self-report measure of dissociative tendencies, reported the same ages for their earliest memories as did individuals who obtained low scores (Lynn, Malinoski, Aronoff, & Zelikovsky, 1998), although the relation between DES scores and early memory gaps has not been examined empirically. Moreover, case studies have yielded conflicting findings regarding whether DID patients date their earliest memory later than do individuals without psychopathology (Bryant, 1995; Schacter, Kihlstrom. Kihlstrom, & Herren, 1989). Finally, the findings, cited by Gleaves, of Coons, Bowman, and Milstein (1988), which revealed that virtually all DID patients reported a history of amnesia in early childhood, are open to alternative explanations.
Many therapists may either presume or attempt to elicit a history of DID based on the absence of certain memories and thereby use amnesia as a scaffolding on which to construct a DID diagnosis. Because a large proportion of adults report memory gaps for childhood (Read, 1997), Coon et al.'s failure to
renders their findings difficult to interpret.