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Updated 04/16/2007

Reasons for Caution about Diagnosis of MPD/DID

by Russ Dewey

In researching the section on MPD and DID for the Self-Help pages on Psych Web, I discovered a disturbing fact. The vast majority of web sites about multiple personality seem to be gullible and unscientific in their attitudes toward the disorder. Moreover, the people involved seem happy to have this diagnosis; they celebrate it. That is not true of any other disorder listed on these self-help pages, with the possible exception of autism. High-functioning autistics are often proud of their special talents, as they should be. But autism is genetic. MPD (at least, the form of MPD celebrated on web pages) is far too often iatrogenic. In other words, it is often generated by interaction with a therapist or other charismatic figure who elicits the syndrome in a suggestible person. As with religious discoveries facilitated by an evangelistic figure, these therapist-assisted "discoveries" of DID are often accompanied by an enthusiasm for the newly discovered solution and, in some cases, a desire to spread the word and make converts.

By contrast, people who come to their DID diagnosis independently, as the result of evidence they cannot ignore, seem far less inclined to celebrate it. Often they bring it to the attention of a therapist only reluctantly if at all. Several have written to me, pointing out that their case was neither iatrogenic nor a cause for celebration. These individuals said they wish they could be rid of the disorder. They could use some web sites specifically devoted to non-iatrogenic DID!

After reading several of those e-mails, I have revised this page to make clear I am not trying to deny that genuine DID exists. A 1940s survey of the literature found cases of multiple personality going back to the early 1800s, so clearly the syndrome is not a modern invention, and it can emerge spontaneously in a person who has not read books or seen movies about it. However, I think cases of DID that emerge because a therapist is looking for it are more likely to be iatrogenic.

Iatrogenic means "therapist-created" but it does not mean "willfully deceiving." The creation of MPD need not be a conscious intention of a therapist. Freud was probably not intending to persuade his first 18 patients in a row that they suffered sexual abuse in childhood; he discovered this because he was looking for it. Only later did he decide some of the stories were not true (incurring the wrath of recovered memory advocates to this day).

Mere expectation is enough to elicit patterns of behavior. Even lab researchers using rats tend to elict the results they expect to find. In fact, this happens as a rule, unless careful precautions are taken. Robert Rosenthal is famous for over 20 years of research on expectancy. His most famous demonstration involved self-fulfilling prophecies of academic achievement or underachievement in school children (the "Pygmalian Effect"). However, Rosenthal found many other situations in which expectancy effects are powerful. For example, graduate students told that certain rats are bred to be more intelligent will find that these rats are quicker to run through mazes than other rats...even though (unknown to the students) the rats were assigned at random to the two groups. The only difference between them was that graduate students carrying out the measurements expected one group to be faster learners. Rosenthal showed that expectancy is powerful in schools, courtrooms...almost every setting in which human belief can influence events. Similarly, if a therapist expects to find that a client has MPD/DID, that therapist is more likely to create conditions in which the client acts out the role of a person with MPD/DID.

Normally, in therapy, the patient expects to get better. The therapist expects the patient to get better. All of this helps create a self-fulfilling prophecy. This is a desirable form of expectancy: if it comes true, everybody wins. So expectancy is usually a positive factor in therapy.

However, patients diagnosed with MPD typically do not get better. They often descend into a confusing belief system in which their different roles, inclinations, emotions, or modes of thinking are assigned names and treated as individuals, with the result that troublesome behavior patterns are actually strengthened. This is consistent with the principle of expectancy. If a client finds a therapist who perks up and pays attention to every appearance of an "alter," the message is clear enough. Keep producing alters.

People with MPD often do not get better until they stop acting multiple. An excellent illustration of this can be found in the final five minutes of the Frontline documentary The Search for Satan. It focuses on the alleged (and, as it turns out, non-existent) tie between MPD and satanic ritual abuse. The title is a pun. By the end of the documentary, it is clear that if anybody is "satanic" in the sense of being morally corrupt, it is the therapists. The modus operandi of the therapists was to convince depressed or confused clients that they had MPD stemming from previously unremembered Satanic ritual abuse in childhood. The patients were then hospitalized while the doctors billed their health insurance for intensive care treatment. The therapists, led by Dr. Bennett Braun, Dr. Roberta Sacks, and associates, appear to have targeted patients with generous policies for mental health treatment. Once the patients hit their limits for insurance coverage (typically $1,000,000) the treatment ended. Then the patients checked out of the hospital, found new therapists, removed the prescription drugs from their systems, and (at the urging of their new therapists) resumed critical thinking. The "multiple personalities" promptly vanished.

Several multi-million dollar lawsuits against the therapists resulted from these cases. Therapists should think twice before giving people a "treatment" that makes them worse instead of better.

What is the scientifically defensible truth about DID/MPD? The history of multiple personality disorder suggests that in the years before Three Faces of Eve this disorder occurred very rarely, perhaps several times per year in a country the size of the United States. Its modern frequency of diagnosis in the U.S. and Canada is a direct result of popular movies like Sybil and HBO's gullible production about MPD (which listed Dr. Braun as a consultant). These video productions instructed millions of people about how to act if you believe you have MPD. They no doubt increased the frequency with which genuine or non-iatrogenic MPD was diagnosed, as well, by familiarizing people with the syndrome.

Sybil herself may have been imitating a previous case of MPD. A New York Review of Books article featuring an interview with Dr. Herbert Spiegel, a colleague of Dr. Wilber's who was trusted with transcripts of the Wilber/Sybil sessions, revealed that Sybil herself had read The Three Faces of Eve and was fascinated by it. In essence, she was taught the part! (And note that Sally Field, who played Sybil in the movie, also learned how to simulate the disorder very realistically. Clearly this is possible.) This evidence that even Sybil was "contaminated" by mass media coverage of the disorder is in an interview with Spiegel here. It is a "must read" for those interested in the Sybil case.

I met the Three Faces of Eve lady, Chris Sizemore, after she re-integrated in mid-life. I think her case was genuine. In her case, the emergence of multiple personalities was not prompted by any therapist. It occurred before there were any popular movies or books about multiple personalities. Her therapists (Thigpen and Cleckley) saw hundreds of other people with supposed multiple personalities after they published The Three Faces of Eve. They said almost all the cases presented to them were the result of expectation and therapists' suggestions.

The Sybil case was different from the Eve case in many ways. As you will see if you read the Spiegel interview, there is good reason to doubt the authenticity of the Sybil case. Her alters were drawn out by a therapist who was eager to find multiple personalities.

Most modern cases are a lot like Sybil. A person with psychological problems stemming from childhood encounters a therapist alert for the signs of MPD. The rest, hypnosis and the elicitation of alters, follows as if written into a script understood by all.

The Sybil movie is quite deceptive in creating evidence for Sybil's Dissociative Identity Disorder. In the movie, Dr. Wilber finds physical evidence to validate Sybil's memories (purple crayon markings inside a wooden box). No such passage appears in the book. The movie changes the relationship between Dr. Wilber and Sybil in ways that (in every case) make the diagnosis of MPD more plausible. For example, in the movie, Dr. Wilber's first contact with Sybil is in an Emergency Room where Sybil has dissociated into a child personality. Several other spontaneous dissociations occur in the following days, so Dr. Wilber is forced despite herself to recognize her patient has multiple personalities. None of that actually happened.

In reality, Dr. Wilber treated Sybil for an entire decade, diagnosing her as schizophrenic, and only then used hypnosis to elicit different personalities. Little details like that make all the difference. Spiegel's article also reveals that Wilber's co-author insisted Sybil be cured before the book was written...and Sybil was promised a third of the book's royalties if she cooperated! Talk about an incentive to integrate. It makes the whole enterprise seem utterly corrupt.

However, Sybil changed the landscape for mental health professionals. Diagnoses of MPD went from 1-2 per year before The Three Faces of Eve was published to about 50 per year afterwards, then to over 2,000 per year after the book Sybil became a best-seller in 1973. After the epic (4 hour) made-for-TV Sybil movie, the Sybil scenario became part of our culture. As with UFO kidnappings, everybody knows the "script." That makes it difficult for therapists to distinguish culturally-suggested MPD from authentic cases (if by authentic we mean a case that would have manifested spontaneously). Nobody can know which cases would have emerged spontaneously, when everybody in our culture is familiar with MPD and knows how to act the part. Hypnosis is not necessary, as Spiegel points out; some people are highly suggestible and can replicate the phenomena of hypnosis without an induction procedure.

Those who claim to suffer from MPD may indeed have a "post-traumatic stress disorder of childhood origin" as MPD is sometimes described. Such people should be treated as seriously as any PTSD patient. However, if I was a therapist, I would not attempt to encourage MPD under hypnosis-like conditions. If I was a person with MPD-like symptoms, I would be skeptical of the whole thing if the MPD was discovered during therapy rather than manifesting itself pre-therapy. I do believe genuine cases of DID exist, and apparently they can resolve over time. Therapy may be helpful when it is aimed at restoring peace and harmony to the overall psychological system, and the most effective therapies seem to be those aimed at ending the dissociation, not encouraging it.

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