Attachment, Trauma and Multiplicity

Working with Dissociative Identity Disorder

Valerie Sinason, Valerie Sinason

• Publisher: Routledge
• Year: 2010
• ISBN:
  9781136827266
• Edition: 2
• Topic: Psychology
• Subtopic: Personality in Psychology
• Index: Psychology

This Revised Edition of Attachment, Trauma and Multiplicity investigates thesubject of Dissociative Identity Disorder. With brand new chapters on police work and attachment theory it has been fully updated to include new research and the latest understanding of patterns of attachment theory that lead to dissociation.

With contributions from psychotherapists, psychiatrists, psychoanalysts and service users this book covers the background history and a description of the condition along with the issues of diagnoses and treatment. It also looks at:

• the phenomenon of DID
• the conflicting models of the human mind that have been found to try and understand DID
• the political conflict over the subject including problems for the police
• clinical accounts and personal writing of people with DID.

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Attachment, Trauma and Multiplicity, Second Edition will prove essential reading for therapists and mental health workers as well as being a valuable resource for graduates and researchers.

Part I
Mapping the territory: childhood aetiology, attachment research, attachment patterns, abuse, dissociation, Dissociative Identity Disorder and culture

Introduction

Valerie Sinason

A second edition allows a second thinking and hearing. In the 6 years or so since the first edition came out, there are more graduates in psychology, psychotherapy, medicine, psychiatry, social work, nursing and counselling wondering why their trainings have failed to equip them for this work. There are more volunteers working with rape crisis centres, Samaritans and other such crucial places, adding to their knowledge on this subject. There are more people with DID educating those they meet and feeling some parts of their society are beginning to consider the reality of their existence. There are also more babies and small children born into trau-matagenic families who are at risk of developing DID or are already developing it.

While a reprint alone would answer the needs of some, a second edition with brand new chapters (Chapters 5, 13 and 15) and updated references and chapters hopefully offers something to both old and new readers.

Let us begin at the end. The telephone rings at 10pm. A terrified child's voice can be heard at the other end of the phone. There is the noise of a train in the background and the sound of people talking. ‘Please, please stop her from going back. He's going to hurt us. He puts stingy stuff in me and I go all sore. Don't let her go back. I am frightened.'

The voice rises in terror until I remind her that she is not going to be taken back, that her abuser is dead, that she is safe. The voice softens and relaxes. The panic subsides. The 6-year-old voice on the telephone belongs to a professional woman of 40 with Dissociative Identity Disorder.

The woman could not avoid a train journey in order to attend a crucial meeting concerning her new work. At one point on the journey the train was going to stop at the town she had lived in as a child. Rationally she knew her abusers were long since dead and impossible to prosecute (see interview with Detective Chief Inspector Clive Driscoll, Chapter 15). However, the severity of her early abuse had led to fragmentation. Merely stopping at that station was enough to bring back a state of panic.

Instantly, to aid the woman, out of cold storage came the brave 6-year-old friend. Frozen in a terrible state of now-ness that had not changed for over 30 years she emerged. The woman had only just come to therapy. Many of her inside people, alters, self-states, whatever language the clients wish to use, had autonomous existence. Created to protect her, they hid the discrepancy between the sadism of her attachment figures and her need for love. They came out when she could not manage, to hold the memories of trauma (both actual and corroborated as well as fantasy and flashashback see Goodwin, Chapter 10) and help her survive. Some states/people were truly frozen - not just in time but in their emotional states, pointing to disorientated disorganised attachments (see Fonagy, Chapter 1; Steele, Chapter 2; Sachs, Chapter 5; Richardson, Chapter 11) and even earlier infantile trauma.

After 2 years of treatment they began to thaw, grow and discard their old strictures. Some of the frozen friends could, in this particular case, then slowly melt into their host, bringing their strength, fragments of memory and courage back to the core personality. Others could state their wish to stay separate. ‘Multigration’(see Southgate, Chapter 6) or cooperation is a matter of choice, not compulsion. Otherwise therapy, in my opinion, becomes a tool of oppression.

How this all starts is a human universal. What happens when a child has to breathe in mocking words each day? Sometimes, that mocking voice gets taken inside and finds a home. It then stays hurting and corroding on the inside when the original source of that cruelty might long ago have disappeared or died.

‘You stupid idiot, thick disgusting dunce!’Ella shouted when she accidentally spilled her tea on the floor. Ella was 60 and had a severe learning disability. Whenever she made any mistake she mocked herself with the words of her sadistic father, even though he had died more than 20 years ago. By keeping his angry words she was keeping him alive and sparing herself from the helplessness of being a victim on the receiving end. By shouting at herself she was identifying with him, being him and therefore not having to remember being the frightened unwanted helpless little child.

A loved child of 2 toddled around the kitchen. He put his hand up and almost touched the gas heater. ‘Hot!’he shouted. He shouted in the voice of his mother who had been frightened for his safety when she had left the heater unguarded the day before. Like young children all over the world, he was taking in the language and intonation of his attachment figures. When his mother shouts ‘Hot!’in a frightened angry voice her face does not look the same as when she is beaming lovingly at him. Cross Mummy and Loving Mummy are very different people, even though they are Mummy. When all goes well, we take for granted the internal representations of the outside network in each of us. Ironically, it is when things go wrong that we notice the amazing process of what we are made of linguistically. Like Ella, Edward would attack himself verbally.

‘Stupid piece of shit. Edward! Stupid piece of shit. Get under'. This was the verbal calling-card of a severely intellectually disabled man I worked with (Sinason 2010). He was able to show me he was repeating the cruel words said to him by a real external person. I now see them as a verbal flashback. The childhood refrain ‘sticks and stones may break my bones but names will never hurt me’is not true. Names enter us like weapons.

Dissociation and fragmentation as a childhood defence

However, what happens when the toxic nature of what is poured into the undeveloped vulnerable brain of a small child is so poisonous that it is too much to manage? Little children, who have had poured into them all the human pain and hate adults could not manage, somehow grow up. Legions of warriors are lost to society through suicide, psychiatric hospitals, addiction and prison. What happens to them, especially when those who hurt them are attachment figures (see Fonagy, Chapter 1; Steele, Chapter 2; Sachs, Chapter 5)?

This book is about one way of surviving that preserves attachment at all costs. It is about a brilliant piece of creative resilience, but it comes with a terrible price. It is a way of surviving so difficult to think about and speak about that, like the topic of learning disability, its name changes regularly. Dissociative Identity Disorder (DID) is the newest term. Where and in whom the dissociation or the disorder lies, however, is a crucial issue in its own right. My own clinical experience is that everyone with DID is profoundly alert, with a memory like a barrister's. What is fragmented is continuous narrative. People without DID, on the other hand, keep a continuous memory (albeit faulty) but often dissociate by the painful reality of trauma.

As this goes to press, DSM V is being worked out. However, the current DSM IV criteria is that DID is:

The presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self). At least two of these identities or personality states recurrently take control of the person's behaviour. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness and not due to the direct effects of a substance (e.g. blackouts or chaotic behaviour during alcohol intoxication) or a general medical condition (e.g. complex partial seizures).

(American Psychiatric Association 2000)

This is not helpful for where there is DID and alcohol.

Despite the classification, British professionals and their clients remain culturally vulnerable, as DID remains disturbingly under-studied by all professions and both undiagnosed and misdiagnosed. Cultural responses are highly relevant (see Swartz, Chapter 4) as The Netherlands provides a remarkable alternative vision. Indeed, Ellert Nijenuis, the distinguished clinician and researcher on this topic, was awarded a knighthood by Queen Juliana of the Netherlands for his services to the country on dissociation (Van der Hart et al. 2009).

However, what is the emotional experience of children and adults living in our country at a time when the condition that is troubling them (and its traumatic aetiology) is both so misunderstood and little understood? Indeed, where ritual abuse is the cause of DID (Steele, Chapter 2; Sachs, Chapter 5, survivor poems), survivors and those working with them can face dissociation, denial or discrediting in the network. There are no NICE guidelines for DID, although we have requested such an intervention, but we predict instead a rise of manualisation as a means of distancing feelings in the future.

However, as De Zulueta (1995) comments:

a refusal on the part of psychiatrists and therapists to validate the horrors of their patients’tortured past implies a refusal to take seriously the unconscious psychological mechanisms that individuals need to use to protect themselves from the unspeakable. Such a denial is, however, no longer ethical, for it is this human capacity to dissociate that is part of the secret of both childhood abuse and the horrors of Nazi genocide, both forms of human violence, so often carried out by ‘respectable’men and women.

Dissociative identity disorder

What is it like to be suffering from something that is not yet adequately recognised? And not only is the DID not recognised, but the nature of the sadistic abuse that has caused it in the majority of cases is even less recognised (Sachs and Galton 2008). I am repeating this question, as to my mind it is a major source of further societal iatragenic damage to people with DID.

‘I'm an attention seeker, don't you know?’said one patient bitterly (her choice of term). ‘And I'm hysterical and dysfunctional. Amazing isn't it? My abusers can rape and torture me for years and they are wandering the streets perfectly happy and I am the one with a life sentence.'

In the last two decades, colleagues and I have assessed and treated children, adolescents and adults, mostly female, who have Dissociative Identity Disorder (DID). There is a very significant gender bias in this condition. Indeed, abused boys are far more likely to externalise their trauma in violence (see Bentovim, Chapter 3), although both sexes use internalising and externalising responses. Cultural issues as well as gender issues need exploring (see Swartz, Chapter 4).

The majority of children and adults we assessed had been diagnosed or misdiagnosed as schizophrenic (Leevers 2009), borderline, anti-social disorder or psychotic. Sometimes the diagnoses were correct but only applied to the alter-personality who visited them. Hence one psychiatrist assessing ‘Mary’correctly diagnosed psychosis, and another who assessed the patient a week later correctly disputed that diagnosis and declared ‘Susan’had borderline personality disorder. Without early specialist training on the consequences of abuse, some professionals attack each other's contradictory diagnoses without realising the aptness of Walt Whitman's words ‘I am large. I contain multitudes.'

I am including myself here. In 1988 I published a paper on the sig-ni ficance of different play material for sexually abused children. One of the clinical vignettes was about a girl of 11 who I called Anne. She had a psychotic mother who was frequently hospitalised and an alcoholic father. They separated while she was still a baby. Anne was often left with the maternal grandmother when her mother was hospitalised or an aunt and uncle. Her father reappeared when she was 2, stating that an uncle had oral intercourse with her. This was acknowledged and she was placed into care where the same situation occurred. She was then moved into a residential home, where she lived from the age of 5 to 11 until finally an adoptive family was found.

In my published vignette (Sinason 1988), I wrote that Anne ‘spoke in three distinct voices; a harsh moving voice, a prissy voice and a shy childish voice'. In the classroom she kept to one voice, but whenever she was distressed or stressed the voices would alternate. I spoke about her fragmentation and what exacerbated or ameliorated it, but I had no idea whatsoever about dissociation or dissociative disorders. It was a tribute to Anne and Co. that they took the best of what I could give them to grow from, rather than focus on my incapacities.

It is worth mentioning here that there are other ‘invisible’DID patients in treatment without their therapists knowing that is what they have and, again, many have found a way of taking nourishment however incomplete it might be.

Anne had a mild dissociative disorder rather than a full-blown DID. She had been removed from florid abuse from the age of 5. Nevertheless, in witnessing the way she made use of large toys to reveal her abuse and her multiplicity, I was able to comment ‘it seemed that the actual concrete physical presence of the dolls that stood for her fragmented experiences kept the different voices and meanings inside their own physical entities, freeing her to return to the outside with one voice’(p. 353).

It was to take 22 years for me to consciously note the same process with a young woman with a severe learning disability who on projecting her alters into soft toys was more able to maintain a consistent voice! Dissociative disorders, as we show, cover a wide spectrum and the ‘mild’ end requires proper attention too.

Hiding selves

In the face of professional confusion and societal denial, some patients have managed to hide their multiplicity when told they were making it up. Nicholas Midgeley, in the first edition, asked the key question concerning why such small numbers of children present with severe dissociative states. Our patients have almost all spoken of the negative responses to their childhood disclosures, which led to hiding their symptoms (see Sinason, Chapter 9). Children were told they would ‘grow out of it’or it was ‘just like an imaginary friend'. The pain such misdiagnoses cause can be seen in the poems by survivors in this book. It says a lot for Anne's capacity that she coped with my incapacity to truly recognise her others.

Unfortunately, when some practitioners penalise the host when ‘alters’appear and will only refer to the biological name, the host personality learns not to speak of fragmentation, and, at the same time, some alters learn to be silent or respond to the host's name. This is often misperceived as a treatment success. It is not understood that for the patient it is experienced as a psychically annihilating secondary trauma. Indeed, Kluft, a pioneering American clinician, predicted such attitudes led to long-term therapeutic failure.

‘Outside of hospital I am still being abused', says Ellen, ‘but I can at least choose my own personal therapist. All my alters like that. But if they came out inside the hospital I would just be seen as mad and for me the psychological abuse that comes from that is worse than the cult.'

What is dissociative identity disorder and how does it happen?

‘Sybil’and ‘The Three Faces of Eve', however dated, remain the main public image (see Kahr, Chapter 16) of dissociation. Somehow it has remained easier to consider the subject safely contained in a Hollywood film or a book rather than on the street and in the homes, schools, universities, workplaces and psychiatric hospitals of the country. DID people become successful professionals, writers, dancers, artists, scientists, shop-workers, singers and parents. They also become prostitutes, drug addicts, criminals and pornstars. Sometimes they cover the range of possibilities within their one frame.

Jane, for example, was a successful part-time university lecturer, but Enya, one of her alters, ran a sado-masochistic brothel, while Mel was involved in small-time theft. Each had their own friendships, clothes and homes. Some are intellectually brilliant and some are severely intellectually disabled (Sinason 2010).

How do we make sense of this?

We cannot reach the place to make sense of that without following through the continuum of...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Notes on contributors
• Part I: Mapping the territory: childhood aetiology, attachment research, attachment patterns, abuse, dissociation, Dissociative Identity Disorder and culture
• Part II: Attachment Focus: Mainly Theory
• Part III: Attachment focus: mainly practice
• Part IV: Other Frames of Reference: Linguistic, Diagnostic, Forensic and Historic Issues
• Information for People with DID and Professionals Working with them