Some years ago, I had been working in psychotherapy with a woman artist, Natasha, for a couple of years or so. Her paintings displayed vivid abstract images of violent intrusions, explosions of red engulfed by a menacing black. From the beginning, she had presented narratives of sexual and other forms of abuse by her father, a senior manager in public services. She appeared to have a confused perception of her father, perceiving him at one moment as a monstrous perpetrator of crimes against her, and at other times believing that he was the only one who loved her.
These conflict-laden perspectives were also at times expressed in the transference. For example, she once tearfully exclaimed that I obviously did not care about her because I did not abuse her. Do you think I'm making all this up? It is my experience that people with DID are likely to describe having experienced severe and ongoing emotional, physical, and sexual abuse from an early age, and it will be extremely important to them that we believe their account. They may also describe committing such abuse themselves.
It is possible that these accounts will not be presented until several years of psychotherapy have established sufficient trust that the therapist will take them seriously. The memories of these experiences may be divided between different personalities, with amnesic barriers keeping certain memories from the awareness of other personalities.
This means that a memory of an experience may be held by a particular personality and may not be available to a patient's other personalities, leaving those personalities with no knowledge of the experience, or several personalities may remember an experience but the main personality may know nothing of the event. One of the difficulties that can face us as psychotherapists when a patient describes traumatic experiences of emotional, physical, and sexual abuse is the challenge of believing the reality of what the patient is saying, especially if the memories have not been held continuously in the patient's conscious memory.
This chapter explores some of the clinical implications of a psychotherapist either believing or not believing a DID patient's memories of extreme abuse and the effect that the therapist's response may have on the patient. Ross describes a deliberate creation of DID through government-sponsored mind-control programs. Van der Hart, Nijenhuis, and Steele coin and describe structural dissociation as the result of chronic, especially but not only early, traumatization.
Liotti , Southgate , Sinason , and others have written about the link between trauma and dissociation from an attachment perspective, focusing on disorganized attachment as the almost inevitable sequel of severe relational trauma. I would appreciate the opportunity to share my thoughts about some clinical issues regarding the treatment of the patient that we share, who has dissociative identity disorder.
Perhaps it would be helpful if I gave you some of the background. I had been Katie's GP for several years and had known her as a quite regular attender—an unhappy woman of about 40, with recurrent depression and intermittent contact with the Community Mental Health Team. There had been a few attempted overdoses in the past, and a suggestion of some sort of personality disorder, never finalized. And so I entered into the confusing world of DID. At times it feels like a Hitchcock story rather than an actual medical condition, and, for the GP, the almost constant underlying feeling is that you are joining and possibly increasing your patient's delusion, rather than helping and treating a very difficult psychological condition.
Forensic Aspects of Dissociative Identity Disorder
This is largely because DID is barely mentioned in medical school, and I have never read an article on it in the usual GP journals. Most GPs, when confronted with such a diagnosis, have very little recourse to informed colleagues, and very few have even heard about it, let alone understand the condition. Before training in osteopathy, I obtained a degree in physiology, then trained and worked for 12 years in general nursing.
I have been a qualified osteopath for 22 years, and in my work as an osteopath I have treated 10 patients with dissociative identity disorder. All my patients with DID reported injuries of various kinds that were inflicted by others. Some of these were physical injuries, including many childhood injuries, such as being picked up and thrown across a room, having their head banged against a wall, or being held by one arm and swung against a wall.
Other injuries were current and were the result of ongoing abuse. These injuries included being hit hard over the vertex of the head with a heavy object, leaving a tissue memory of impaction of the upper cervical spine into its articulation close to the anterior margin of the foramen magnum, and being kicked in the lower posterior rib cage with resulting haematuria and hospitalization due to puncture of the kidney by fractured eleventh and twelfth ribs and crush fractures of the vertebral bodies at the thoraco-lumbar junction, necessitating hospitalization and fitting of a spinal brace.
One patient reported being kept in extreme confinement locked in a cage, unable to stand up straight, or lie down, or stretch their limbs to full length.
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At some point in their treatment, all these patients reported sexual abuse. In Greek mythology there is a famous tale about a woman, Pandora, who was entrusted with a special box and the safe keeping of its contents by the god Zeus.
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She had no idea that inside was every imaginable evil and sorrow that could afflict mankind. She was simply told never to open the lid. She forgot about this box for many years, until one day, coming across it, innocent curiosity overcame her and she lifted the lid, releasing its deadly contents throughout the world.
When she realized what was happening, she slammed the lid shut, trapping at the bottom of the box the very thing that could save mankind from endless torment and despair. The world remained an extremely bleak place until one day Pandora chanced to revisit the box again, and, lifting the lid a second time, the box's remaining occupant—hope—flew out in the form of a dove, thus making life in the world worthwhile and bearable even in the face of horror and tragedy.
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As with Pandora's box, hope is often the last—but the saving—grace to emerge. Once these horrors and their effects have surfaced, they can never be pushed back inside—and, indeed, one would not want them to remain hidden, as they need to be worked with and resolved. Even with hope this is an incredibly difficult and bewildering process, not only for the individual with DID but also for the therapist, support workers, friends, and family who accompany the sufferer on his or her courageous journey to recovery.
This kind of liberal orientation has great appeal. We must electrically control the brain. Some day armies and generals will be controlled by electric stimulation of the brain. Moreover, even when the destructive effects of their work become patently clear, and they are asked to carry out actions incompatible with fundamental standards of morality, relatively few people have the resources needed to resist authority. The year was The former military American man was lying on the London hospital bed in a state of terror. He did not know why he had flown to England when he had no friends or family here, but he knew he had to kill someone.
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