Rat ConditioningFor my project I conditioned rats to go through a maze following a certain path. I first let the rats run in the maze without any guidance to where the food was, but they could not seem to find the food within an hour while doing the maze. I then put up a food trial for the rats to follow of the path I wanted them to take, they followed this pretty well. After two days I took the food trial away and the rats continued to follow that trial to where the bulk of the food was at the end. After seven times in the maze the rats memorized the path to the food, so I took them out of the maze for two days. I then tested them on if they still knew the path after the time away, they did the maze without any problem. Then I took them out of the maze for a week and they still had remembered the maze when I put them back in it. This shows that memory does not decay right away and if you repetitively do something the memory will stick.
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I did this project to go more in depth in what I had learned about psychology this year and I was really curious if you could actually train a rat to do something. Also it I wanted to know how you could train a rat to run through a maze and what the procedures were to be able to do that. I am really passionate about this project because I love how the mind works and how we can teach the mind to do something even if the recipients is not aware of it.
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TED TalkAddressing what dissociative identity disorder is and what are the treatments and causes of it.
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Senior thesis paper
What Causes dissociative identity disorder and what is the most effective treatment?
Abstract
Dissociative identity disorder is one of the most misrepresented mental disorders in the media. People with this disorder went through a significant amount of trauma which caused them to have DID. In this paper, I will explore what causes dissociative identity disorder and what the different treatment plans are for this disorder. This research is from primarily from case studies of people who were diagnosed with dissociative identity disorder. In these case studies, there is a substantial correlation between patients who have dissociative identity disorder and childhood trauma. There are two treatment plans for dissociative identity disorder, the Connective Model, and the Trauma Model. The Connective Model tries to connect the identities of the patient, by making the patient aware of their identities. The Trauma Model helps the patient works through the trauma that the patient has most likely endured. The cause of dissociative identity disorder is trauma, usually at a young age, and the best way to treat this disorder is to work through the cause of the disorder which is the trauma.
Part Ⅰ: Introduction
“Had I not been dissociative, I never would have survived.”― Wendy Hoffman, White Witch in a Black Robe: A True Story about Criminal Mind Control.
Dissociative identity disorder (DID) patients have multiple identities that are meant to help the patient, known as the host, in their everyday life. These personality identities, more commonly known as alters, are not people but a fragment of the host’s original personality.DID is a rare disorder that less than 3% of the United States population has, but with the media’s interest in the DID they have created a stereotype for what a DID patient she be. The media takes the little pieces of information they know about DID and twists them to make the patients seem delirious and unstable to fit in their movies. For example, in the movie Split, by M. Night Shyamalan, the main character, Kevin Wendell Crumb (played by James McAvoy) kidnaps three teenage girls due to his evil personality. In the last season of United States of Tara, the title character Tara has an evil alter that goes after her family. The media tells us that people with DID have an “evil” alter and that DID patients could potentially harm you, while most patients are just trying to deal with their disorder and what caused it. DID is widely considered to be caused by traumatic experiences, and while the psychological community is split between two treatment options, treating the underlying trauma appears to be slightly more efficient than treating the symptoms of the disorder. This disorder has been seen throughout history in a multitude of ways.
Part Ⅱ: Historical Context The first sightings of DID were a demon possession and exorcisms where the alters were seen as the demons. One of the first articles that was a clear case of DID was written in 1816, entitled Double Consciousness(Mitchill 19). The Patient, known as Miss R, was described as having switched consciousness after a deep sleep. There were only two consciousness recorded, one being described as very smart, full of ideas, and had great penmanship; while the other was illiterate and had no recollection of the people she had met before her deep sleep. These consciousness would alternate after a profound sleep, the first one was known as old state and the second was known as the new state. Neither consciousness had memories of the others experiences, and at the time they could not diagnosis Miss R’s situation, they just learned to adjust to her states. Now we know Miss R had DID, as she showed signs of amnesia that were far beyond regular forgetfulness, with two identities/states/consciousnesses. From the 1880’s and onward DID was seen as a legitimate disorder instead of a demon possession or phenomenon like in Miss R’s case.
After 1880’s we see the controversies that are going on today in the subject of DID, where the causes are debated and of how should this disorder be treated. One of the most well-known cases of DID was of Sybil/Shirley Isabel Dorsett born in 1923. In 1973, Flora Rheta Schreiber wrote the book titled Sybil that went through the diagnosis and treatment of Mrs. Dorsett. Mrs. Dorsett had a total of sixteen alters documented, Victoria, Peggy Lou, Peggy Ann, Mary, Marcia, Vanessa, Mike, Sid, Nancy, Sybil Ann, Ruthie, Clara, Helen, Marjorie, and The Blonde, all with distinct personalities. Sybil has since been made into a TV show and a movie in 1967 and 2007, respectively. Since Mrs. Dorsett, there have been many more publications of DID case studies.
The diagnosis criteria that is currently being used is that patients must have two or more distinct identities that consistently take control and have the inability to recall important personal information which is beyond regular forgetfulness(DSM-IV). Symptoms of DID include amnesia, headaches, nausea, trouble walking, double vision, depression, anxiety, and hallucinations. DID is usually used as a coping mechanism for children and adults to help them deal with situations that the host feels that they cannot withstand or are not capable of dealing with themselves.
Part Ⅲ: Research and Analysis
Causes
The causes of DID can be considered either iatrogenic based or trauma based. Iatrogenic is defined as an illness that is related to the medical examination and/or treatment of the patient, which is a way of getting the illness by either having been told you have the illness or because you are going through the treatment and your body will make the symptoms appear so that they can be treated. DID can be iatrogenically caused, but that is not considered the only cause for DID. The trauma model claims that patients can be suggested into having DID like any other illness, but that the main cause for DID is traumatic events. They claim that DID is caused by compartmentalizing thoughts and events, such as verbal, sexual, and physical abuse. The patients escape these by becoming a different person and dissociating themselves from what is happening to save them from mental harm. This is why DID patients often have amnesia since the alter consciousness is present during the traumatic event, the patient sometimes never knows they have gone through any trauma at all. Most professionals accept the trauma model as the primary cause for DID, but some say DID is only iatrogenically caused and do not think of trauma as a cause or factor if the patient has DID. Believing that iatrogenic based DID is the only kind is called the socio-cognitive model, where they believe that one can have symptoms of DID but do not actually have DID until they have been told they have DID by a doctor and have started treatment.
In DID is Trauma Based: Further Evidence Supporting the Trauma Model of DID by Brand et al states how DID and post-traumatic stress disorder (PTSD) are similar as both are caused by trauma. “Individuals with DID acknowledge very high levels of childhood and adult trauma…”(Brand et al 561) and that DID patients have “other psychological problems including depression, PTSD, and self-destructiveness…”(Brand et al 561). With the similarities and likelihood of DID patients also having PTSD, Brand states that DID patients must have gone through a traumatic experience at some point in their life, if not more than one traumatic experience. The similarities are the cause of the disorders, which are traumatic events, and this is not the only article that will say the cause of DID is trauma.
In Use of Adlerian Assessment Techniques in the Treatment of Dissociative Identity Disorder: A Case Study by Christopher Allers and Marilyn Snow where they state the cause of DID and show a case study. “Severe and repeated childhood trauma has been demonstrated as a primary factor in the etiology of DID (Allers & Snow 163).” This cause is stated before the case study, and further highlighted with the case of Jon Drake, where “the clinician began attending to the client’s [Drake’s] psychological distress stemming from frightening, painful, and intrusive ‘flashbacks,’ fragmented memories of the abuse-related events (Allers & Snow 169).” Even if trauma does not seem to be the initial cause, later on in therapy trauma will show up even without the patient’s knowledge of the events. Trauma is shown to be the cause in this case study where the clinicians, who were not looking for past trauma, found that a majority of the DID patients they studied had experienced trauma.
In Dissociative Identity Disorder: An Australian Series by Warwick Middleton and Jeremy Butler, it shows how prevalent abuse is in DID patients’ pasts. Childhood abuse is widespread in DID patients and abuse including “sexual relationships with a sibling (31%), involvement in pornographic photography (13%), physical abuse (85%) and emotional abuse (79%) (Middleton & Butler 800).” Middleton & Butler state that of the 63 patients, the number of patients that go through abuse throughout childhood cannot be a coincidence, and trauma must be the primary cause of DID; however, some are skeptical if these traumatic events ever really happened.
Memories
Memory can be a very tricky thing to work with, especially when some people had no memory of a traumatic event and then suddenly remember it. Memories can be unreliable and very susceptible to change and suggestion. When a memory is created, it starts from the senses such as a sight, smell, hearing, etc. The memory will go into short-term memory if enough attention is put on these senses. Once in short-term memory, it’s all up to rehearsal. If the memory is rehearsed, it will go into long-term memory. Then if the memory is retrieved from long-term memory, it goes back into short-term memory to recall the experience, and then will usually go back into long-term memory.
Every time you recall a memory, it will not go back into long-term memory the same that it came out of long-term memory. Memory is not just stored in the brain like a book, memories change every time you think about them. Not only can memories change after they have been recalled, but false memories can also be made and many DID patients are accused of their traumatic memories being false memories. There have been many experiments testing what can and can not make a false memory. The shopping mall experiment of Garry and Loftus was where they “induced detailed memories of an incident… that as a child a person had become lost in a store, while that had never happened in reality (Elzinga et al. 17).” Not all events are easy to make into false memories though, the shopping mall experiment worked because it’s an event that happens to a lot of people when they are young. It’s easy to imagine yourself lost in a store as a child. Pezdek in 1995 tried to induce a false memory of her patients getting a rectal enema and failed on every patient(Elzinga et al. 17). In the iatrogenic based cause of DID, it is stated that patients are suggested into violent false memories, but according to Pezdek, that type of false memory may be difficult to achieve. A memory that has a physical association is usually easier to remember than one that does not, and so it’s hard to convince people of having a false physical memory.With the difficulting of making false memories that have a physical association, DID patient that have such physical memories from trauma can not for certain be accused of their trauma being false. False memories are not the only skeptical thing for DID patients, but also how can someone forget about a traumatic event and then later remember it.
There are multiple reasons why many DID patients may not remember traumatic events that have happened to them. One possible reason is that when children are abused, they often do not entirely understand what is happening to them at the time of the event and only later realize they went through a traumatic event (Myers 362). A second possibility is that they force themselves to forget what has happened, which is called motivated forgetting (Myers 355). Third, they have put the memory into a different alter and the alter’s memories are compartmentalized throughout the brain and only activated once that alter is conscious. During therapy patients will get more connected with their alters, meaning they will find the memories that their alters hold (Elzinga). All in all memories are very key to the state of mind for a DID patient, as their past memories are the cause of their disorder and can be looked evaluated for their treatment.
Treatments
There are two types of primary treatment plans that patients can choose from known as the Connective Model and the Trauma Model. The treatments have the same primary goal of being able to get the patients in a stable state to live their everyday life without trouble from their disorder. The Connective Model goal for treatment explained by Christopher Allers and Marilyn Snow is “to work towards bringing about an increased sense of connectedness or relatedness among the different identity fragments (Allers & Snow 165)”.
The Connective Model uses a series of instruments to help assess the personality type and roles of the different alters in the system. The assessments that are used are the Kern Lifestyle Scale (Kern and Cummins) and the System Constellation Assessment. Early recollections will also be talked about to assess the different alters. Early recollections defined by Allers and Snow is the memories of early childhood events before the age of eight. When looking at early recollections, the clinician is looking at the amount of involvement, either active or passive, that the identity will take. This reveals how that identity deals with interpersonal conflict. The Lifestyle Scale is precisely what it sounds like, it assess the patient's lifestyle through levels of control, pleasing and discouragement. This helps the therapist understand how the patient and their alters interact within different intimate social settings. Next is the System Constellation Assessment, which is a questionnaire that examines the system of alters in the patient and how the interrelationships and influence of each alter affects the psychological development of the patient as described by Dinkmeyer et al. All these assessments help the clinician understand the personality type of each alter, and are then used in treatment where each alter is taught about the personality of the other alters in the system in order for the host to better understand the purpose of each alter. Through this, the patient is more aware of their psychological condition and why they have alters. After treatment, patients “reported that a number of his identities had lost their ‘separateness’ and that most were coconsious, coexistent, or both with at least one other identity (Aller & Snow 174).” This treatment does not help the patient’s dealing with past trauma or going over the cause of their disorder.
Some of the benefits of the Connective Model are that the patients learn how to deal with their disorder in a positive way after treatment. Alters will often merge by the end of the therapy making the disorder easier to manage, but because the point is to educate the patient on how their alter system works, even if alters do not merge, it still makes the disorder easier to manage even if they have the same amount of alters after treatment. Being able to understand their disorder helps the patient understand why they have alters and what the alters are doing for them psychology.
One of the cons of the Connective Model is that the patient never processes the traumatic events they have gone through and when their alters are merging with them, the patient will discover the traumatic memories of those alters. This can cause great stress for the patient having never processed or learned how to process the emotions of those traumatic event. The ability to fully merge with all the patient’s alters is low because without going through the cause of why those alters are there, and what the alters struggle through, it limits the chances of all the alters merging. The patient will never fully understand each alter if they do not understand the traumatic memories that these alters hold.
The Trauma Model which is referenced by Warwick Middleton and Richard Horevitz is where the clinician’s goal is to work through the trauma the patient has experienced in order to understand the most likely cause of their disorder. The Trauma Model focuses on dealing with the traumatic events that the patient has gone through with the side effect of the treatment being that the alters merge. The only assessments that are used during this treatment are the ones used for diagnosis. During therapy, the patients will go through each of their traumatic experiences and process the events with the therapist. Usually patients have therapy sessions four times a week for as little as six months, but often treatment can last for years. Soon the reason for the alters starts to go away, as the alters job was to console the host of their traumatic past that haunts them(Aller & Snow). The alters that are similar and hold many of the same traumatic memories usually merge first. As the patient deals with the traumatic events, the other alters start to merge until there is only the host left. The host will usually still hear the voices of the different alters in their head, but they are much less prominent than they were before treatment. Once the alters are fully merged, the patient will often continue to attend therapy to keep processing trauma, until the therapist believes the patient can process trauma on their own without further assistance. Once the sessions stop, the therapist will often check in on the patient about every six months to make sure they are not reverting back and using their disorder to deal with situations they are uncomfortable in.
Some of pros of the Trauma Model are that going through the trauma that caused the patient’s disorder will help the patient understand how they came to have their disorder and how to handle trauma in the future. This could keep them from dissociating in the future which would be what they used to process their emotions before treatment. Since the patient is going through each traumatic event that their alters hold, they learn how their alter system worked and why they had each alter. This lets them understand each alter which enabled them to merge with their alters making it very likely that the patient will merge with all their alters through the Trauma Model.
Some of the downsides are that the patient does have to deal with new memories of past traumatic events that they did not even know happened to them. Finding these memories in itself is a traumatic experience, and there is no guarantee that the patient will be able to be able to process this trauma, which is why the patient built their alter system. After treatment and learning about all these traumatic events, the patient can develop post-traumatic stress disorder where the patient will have to continue to be checked on how well they are processing the trauma they have gone through.
Hypnotic Aid in Treatment
Hypnosis is when someone is put in a state of consciousness in which the person loses the power of voluntary action and is responsive to suggestion and/or direction. Hypnotic aid, can be used in any treatment plan of DID for a multitude of reasons. The three main reasons that hypnosis is used is for being able to process emotions, to find repressed memories, and to make a safe place in the patient’s mind. The other reasons that it could be used is to repress emotion, to merge alters, and to age alters that are stuck at a certain age(Spanos).
In therapy, the patient needs a safe place where they can talk to their alters and understand why they are there and what purpose they serve. Through hypnosis, this can be achieved through bringing the patient into their mind and creating a place that they feel safe in for all the alters. Every time the patient would like to talk to an alter, they can go to this place in their mind and this allows for the patient to understand why they have certain alters and help them understand their past better with the memories these alters hold. Alters hold different memories from the host’s past so that the host does not have to deal with a certain traumatic event, this is also where hypnosis can come into play. In order for the patient to process the trauma they have gone through, they first need to know all the trauma they have gone through. The therapist will put the patient into a hypnotic state and continue to ask patients questions making sure to keep from suggesting the patient into a false memory. These questions will start to be answered by other alters that have these memories. Once a new memory is found the therapist will first help the alter process the trauma then move on to telling the host and have the host process the trauma as well. During this time the host will most likely talk to the alter that has now already processed this trauma and will help the host in doing the same thing. During the process the host and that alter might merge, but that is not always the case(Horevitz). The last main reason that hypnosis would be used is to process the emotions of finding out about a repressed memory which can be a traumatic event in itself. Hypnosis would be used to calm down the patient and reassure them that they are in a safe place. This, in the end, will help the patient process the traumatic events with a more relaxed head being able to think more clearly and see that the event was not under their control and not their fault.
Hypnosis can also be used to repress emotions, merge alters and to age alters that are stuck at a certain age. Not all patients will need this hypnotic aid. The therapist will only use hypnosis to repress emotions during a session if the patient is overwhelmed by emotions. The therapist will suppress the negative emotions of the patient at the end of the session until next session. To merge alters the patient will go to the safe place created earlier in therapy. During this time the therapist will start trying to get the patient to see the similarities between them and their alter which will get the patient to think that their alter is them (which is true). The patient will then start merging with that alter, some alters will automatically merge with the patient, but for patients who are struggling to merge with an alter that is ready, hypnosis will often be used to do so. Next is aging alters as some alters do not age as the patient ages. For example, alters can be ten years old and stay that age while the patient continues to age. Not all DID patients have an alter that does not age, but for those who do, hypnosis is usually used to merge and age the alter. This is usually done by having the alter imagining themselves growing up as is seen in Horevitz case study of Foster The Treatment of a Case of Dissociative Identity Disorder. This leads to the alter actually growing up because as they imagine themselves aging in the mind of the patient they are able to psychologically visualize themselves aging and growing up. Since the alter is usually made in the image of the patient as a child, when the alter does age they look exactly like the patient. Alters often see themselves differently, and when the alter’s self image looks like the patient’s image, this alone can make the newly aged alter and the patient merge. Hypnosis is not always used in treatment, but when a therapist deems it necessary it can also be an effective aid. Only a trained professional should be putting patients under hypnosis.
Part Ⅳ: Conclusion
With everything that has been discussed for causes of either trauma or iatrogenic, treatments based on the Trauma Model or Connective Model, and hypnotic aid for treatment, trauma looks to be the cause of DID in most cases. While people can be suggested into having DID, they are few and far between. Therefore, the best treatment plan would be to process the trauma that has been done to the patients that have DID and have them be able to function in society while taking care of the overall mental health that the trauma has caused. Hypnotic aid can be very useful in processing emotions and allowing for one’s alters to be able to talk in a safe place.
The Trauma Model treatment plan is best because it treats the cause of the disorder and the systems of the disorder. The Connective Model treatment plan does not intentionally go over any trauma that the patient has endured and risks that the patient may not fully merge with all their alters. In the Trauma Model treatment, the patients can learn to cope with trauma that they have gone through and now have the knowledge on how to deal with traumatic events that could happen in the future. This will decrease their chances of dissociating and creating new alters again, as shown in the case study in Hypnosis in the Treatment of Multiple Personality Disorder by Richard Horevitz, which was the patient’s original coping mechanism for dealing with trauma. Patients could still end up dissociating after treatment, but now that they know what treatment is like and have merged with an alter before, the process becomes shorter, especially if the patient is dealing with recent trauma instead of old trauma. Hypnotic aid going through new and recent trauma would also be easier to process emotionally. Hypnotic aid is not advised for finding repressed memories because it is easy to suggest the patient into a false memory of trauma, but hypnosis should be used for processing emotions, repressing emotions (only if they are repressed until the next therapy session), and aging alters.
Treatment for DID should be to treat the cause that will inevitably treat the symptoms as well as help the patient to better process emotion and events in their life. While the Trauma Model has been shown to work in some individual case studies, there have been no mass studies of this treatment, which leaves some questions if this would work for a majority of people who have DID. Because there is no clear research on how multiple patients react to certain treatment plans, it would be helpful for a mass treatment study. You could measure this mass study’s success by seeing how well the patients are doing in society and personal life and looking at how they are able to deal with stressful events and their overall feelings in day to day life.
We have learned that traumatic events will cause DID. While their can be other factors that cause DID, they are rare and do not cause as severe symptoms as trauma based DID. The best treatment for DID is through the Trauma Model plan, where the trauma behind the disorder is treated and processed which will then cause DID symptoms to resolve themselves. Hypnosis also helps with treatment in processing emotions during therapy sessions about traumatic events. With the misconception of DID patients being unstable and having some evil personality that could harm others, the findings show that these are just people that are creating ways of dealing with traumatic events. Now research needs to be done in order to help these people even more during treatment.
Work Cited
"A Double Consciousness, or a Duality of Person in the Same Individual: From a Communication of Dr. Mitchill to the Rev. Dr. Nott, President of Union College. Dated January 16, 1816." National Register, vol. 1, no. 2, 09 Mar. 1816, p. 19. EBSCOhost,
Allers, Christopher T. and Marilyn Snow. "Use of Adlerian Assessment Techniques in the Treatment of Dissociative Identity Disorder: A Case Study." Journal of Individual Psychology, vol. 55, no. 2, Summer99, p. 162. EBSCOhost, search.ebscohost.com/login.aspx?direct=true&db=aph&AN=9054899&site=ehost-live.
Brand, B. L., et al. "DID Is Trauma Based: Further Evidence Supporting the Trauma Model of DID." Acta Psychiatrica Scandinavica, vol. 134, no. 6, Dec. 2016, pp. 560-563. EBSCOhost, doi:10.1111/acps.12653.
“DID Research.” DID in History, did-research.org/did/history/index.html.
Elzinga, Bernet M., et al. "Three Controversies about Dissociative Identity Disorder." Clinical Psychology & Psychotherapy, vol. 5, no. 1, Mar. 1998, pp. 13-23. EBSCOhost, search.ebscohost.com/login.aspx?direct=true&db=aph&AN=11820222&site=ehost-live.
Gleaves, David H., et al. "The Etiology of Dissociative Identity Disorder: Reply to Gee, Allen, and Powell (2003)." Professional Psychology: Research & Practice, vol. 34, no. 1, Feb. 2003, p. 116. EBSCOhost, search.ebscohost.com/login.aspx?direct=true&db=aph&AN=9039493&site=ehost-live.
Horevitz, Richard. "Hypnosis in the Treatment of Multiple Personality Disorder." Handbook of Clinical Hypnosis., Judith W. Rhue, et al., American Psychological Association, 1993, pp. 395-424. EBSCOhost, doi:10.1037/10274-032.
Horevitz, Richard. "The Treatment of a Case of Dissociative Identity Disorder." Casebook of Clinical Hypnosis., Steven Jay Lynn, et al., American Psychological Association, 1996, pp. 193-222. EBSCOhost, doi:10.1037/11090-010.
“Memory.” Psychology, by David G. Myers and C. Nathan DeWall, Worth Publishers, 2018, pp. 327–365.
Middleton, Warwick. "Owning the Past, Claiming the Present: Perspectives on the Treatment of Dissociative Patients." Australasian Psychiatry, vol. 13, no. 1, Mar. 2005, pp. 40-49. EBSCOhost, doi:10.1111/j.1440-1665.2004.02148.x.
Middleton, Warwick and Jeremy Butler. "Dissociative Identity Disorder: An Australian Series." Australian & New Zealand Journal of Psychiatry, vol. 32, no. 6, Dec. 1998, p. 794. EBSCOhost, search.ebscohost.com/login.aspx?direct=true&db=aph&AN=5910711&site=ehost-live.
Spanos, Nicholas P. "Complex False Memories, Body Memories, and Hypnosis." Multiple Identities & False Memories: A Sociocognitive Perspective., American Psychological Association, 1996, pp. 105-115. EBSCOhost, doi:10.1037/10216-008.
Dissociative identity disorder is one of the most misrepresented mental disorders in the media. People with this disorder went through a significant amount of trauma which caused them to have DID. In this paper, I will explore what causes dissociative identity disorder and what the different treatment plans are for this disorder. This research is from primarily from case studies of people who were diagnosed with dissociative identity disorder. In these case studies, there is a substantial correlation between patients who have dissociative identity disorder and childhood trauma. There are two treatment plans for dissociative identity disorder, the Connective Model, and the Trauma Model. The Connective Model tries to connect the identities of the patient, by making the patient aware of their identities. The Trauma Model helps the patient works through the trauma that the patient has most likely endured. The cause of dissociative identity disorder is trauma, usually at a young age, and the best way to treat this disorder is to work through the cause of the disorder which is the trauma.
Part Ⅰ: Introduction
“Had I not been dissociative, I never would have survived.”― Wendy Hoffman, White Witch in a Black Robe: A True Story about Criminal Mind Control.
Dissociative identity disorder (DID) patients have multiple identities that are meant to help the patient, known as the host, in their everyday life. These personality identities, more commonly known as alters, are not people but a fragment of the host’s original personality.DID is a rare disorder that less than 3% of the United States population has, but with the media’s interest in the DID they have created a stereotype for what a DID patient she be. The media takes the little pieces of information they know about DID and twists them to make the patients seem delirious and unstable to fit in their movies. For example, in the movie Split, by M. Night Shyamalan, the main character, Kevin Wendell Crumb (played by James McAvoy) kidnaps three teenage girls due to his evil personality. In the last season of United States of Tara, the title character Tara has an evil alter that goes after her family. The media tells us that people with DID have an “evil” alter and that DID patients could potentially harm you, while most patients are just trying to deal with their disorder and what caused it. DID is widely considered to be caused by traumatic experiences, and while the psychological community is split between two treatment options, treating the underlying trauma appears to be slightly more efficient than treating the symptoms of the disorder. This disorder has been seen throughout history in a multitude of ways.
Part Ⅱ: Historical Context The first sightings of DID were a demon possession and exorcisms where the alters were seen as the demons. One of the first articles that was a clear case of DID was written in 1816, entitled Double Consciousness(Mitchill 19). The Patient, known as Miss R, was described as having switched consciousness after a deep sleep. There were only two consciousness recorded, one being described as very smart, full of ideas, and had great penmanship; while the other was illiterate and had no recollection of the people she had met before her deep sleep. These consciousness would alternate after a profound sleep, the first one was known as old state and the second was known as the new state. Neither consciousness had memories of the others experiences, and at the time they could not diagnosis Miss R’s situation, they just learned to adjust to her states. Now we know Miss R had DID, as she showed signs of amnesia that were far beyond regular forgetfulness, with two identities/states/consciousnesses. From the 1880’s and onward DID was seen as a legitimate disorder instead of a demon possession or phenomenon like in Miss R’s case.
After 1880’s we see the controversies that are going on today in the subject of DID, where the causes are debated and of how should this disorder be treated. One of the most well-known cases of DID was of Sybil/Shirley Isabel Dorsett born in 1923. In 1973, Flora Rheta Schreiber wrote the book titled Sybil that went through the diagnosis and treatment of Mrs. Dorsett. Mrs. Dorsett had a total of sixteen alters documented, Victoria, Peggy Lou, Peggy Ann, Mary, Marcia, Vanessa, Mike, Sid, Nancy, Sybil Ann, Ruthie, Clara, Helen, Marjorie, and The Blonde, all with distinct personalities. Sybil has since been made into a TV show and a movie in 1967 and 2007, respectively. Since Mrs. Dorsett, there have been many more publications of DID case studies.
The diagnosis criteria that is currently being used is that patients must have two or more distinct identities that consistently take control and have the inability to recall important personal information which is beyond regular forgetfulness(DSM-IV). Symptoms of DID include amnesia, headaches, nausea, trouble walking, double vision, depression, anxiety, and hallucinations. DID is usually used as a coping mechanism for children and adults to help them deal with situations that the host feels that they cannot withstand or are not capable of dealing with themselves.
Part Ⅲ: Research and Analysis
Causes
The causes of DID can be considered either iatrogenic based or trauma based. Iatrogenic is defined as an illness that is related to the medical examination and/or treatment of the patient, which is a way of getting the illness by either having been told you have the illness or because you are going through the treatment and your body will make the symptoms appear so that they can be treated. DID can be iatrogenically caused, but that is not considered the only cause for DID. The trauma model claims that patients can be suggested into having DID like any other illness, but that the main cause for DID is traumatic events. They claim that DID is caused by compartmentalizing thoughts and events, such as verbal, sexual, and physical abuse. The patients escape these by becoming a different person and dissociating themselves from what is happening to save them from mental harm. This is why DID patients often have amnesia since the alter consciousness is present during the traumatic event, the patient sometimes never knows they have gone through any trauma at all. Most professionals accept the trauma model as the primary cause for DID, but some say DID is only iatrogenically caused and do not think of trauma as a cause or factor if the patient has DID. Believing that iatrogenic based DID is the only kind is called the socio-cognitive model, where they believe that one can have symptoms of DID but do not actually have DID until they have been told they have DID by a doctor and have started treatment.
In DID is Trauma Based: Further Evidence Supporting the Trauma Model of DID by Brand et al states how DID and post-traumatic stress disorder (PTSD) are similar as both are caused by trauma. “Individuals with DID acknowledge very high levels of childhood and adult trauma…”(Brand et al 561) and that DID patients have “other psychological problems including depression, PTSD, and self-destructiveness…”(Brand et al 561). With the similarities and likelihood of DID patients also having PTSD, Brand states that DID patients must have gone through a traumatic experience at some point in their life, if not more than one traumatic experience. The similarities are the cause of the disorders, which are traumatic events, and this is not the only article that will say the cause of DID is trauma.
In Use of Adlerian Assessment Techniques in the Treatment of Dissociative Identity Disorder: A Case Study by Christopher Allers and Marilyn Snow where they state the cause of DID and show a case study. “Severe and repeated childhood trauma has been demonstrated as a primary factor in the etiology of DID (Allers & Snow 163).” This cause is stated before the case study, and further highlighted with the case of Jon Drake, where “the clinician began attending to the client’s [Drake’s] psychological distress stemming from frightening, painful, and intrusive ‘flashbacks,’ fragmented memories of the abuse-related events (Allers & Snow 169).” Even if trauma does not seem to be the initial cause, later on in therapy trauma will show up even without the patient’s knowledge of the events. Trauma is shown to be the cause in this case study where the clinicians, who were not looking for past trauma, found that a majority of the DID patients they studied had experienced trauma.
In Dissociative Identity Disorder: An Australian Series by Warwick Middleton and Jeremy Butler, it shows how prevalent abuse is in DID patients’ pasts. Childhood abuse is widespread in DID patients and abuse including “sexual relationships with a sibling (31%), involvement in pornographic photography (13%), physical abuse (85%) and emotional abuse (79%) (Middleton & Butler 800).” Middleton & Butler state that of the 63 patients, the number of patients that go through abuse throughout childhood cannot be a coincidence, and trauma must be the primary cause of DID; however, some are skeptical if these traumatic events ever really happened.
Memories
Memory can be a very tricky thing to work with, especially when some people had no memory of a traumatic event and then suddenly remember it. Memories can be unreliable and very susceptible to change and suggestion. When a memory is created, it starts from the senses such as a sight, smell, hearing, etc. The memory will go into short-term memory if enough attention is put on these senses. Once in short-term memory, it’s all up to rehearsal. If the memory is rehearsed, it will go into long-term memory. Then if the memory is retrieved from long-term memory, it goes back into short-term memory to recall the experience, and then will usually go back into long-term memory.
Every time you recall a memory, it will not go back into long-term memory the same that it came out of long-term memory. Memory is not just stored in the brain like a book, memories change every time you think about them. Not only can memories change after they have been recalled, but false memories can also be made and many DID patients are accused of their traumatic memories being false memories. There have been many experiments testing what can and can not make a false memory. The shopping mall experiment of Garry and Loftus was where they “induced detailed memories of an incident… that as a child a person had become lost in a store, while that had never happened in reality (Elzinga et al. 17).” Not all events are easy to make into false memories though, the shopping mall experiment worked because it’s an event that happens to a lot of people when they are young. It’s easy to imagine yourself lost in a store as a child. Pezdek in 1995 tried to induce a false memory of her patients getting a rectal enema and failed on every patient(Elzinga et al. 17). In the iatrogenic based cause of DID, it is stated that patients are suggested into violent false memories, but according to Pezdek, that type of false memory may be difficult to achieve. A memory that has a physical association is usually easier to remember than one that does not, and so it’s hard to convince people of having a false physical memory.With the difficulting of making false memories that have a physical association, DID patient that have such physical memories from trauma can not for certain be accused of their trauma being false. False memories are not the only skeptical thing for DID patients, but also how can someone forget about a traumatic event and then later remember it.
There are multiple reasons why many DID patients may not remember traumatic events that have happened to them. One possible reason is that when children are abused, they often do not entirely understand what is happening to them at the time of the event and only later realize they went through a traumatic event (Myers 362). A second possibility is that they force themselves to forget what has happened, which is called motivated forgetting (Myers 355). Third, they have put the memory into a different alter and the alter’s memories are compartmentalized throughout the brain and only activated once that alter is conscious. During therapy patients will get more connected with their alters, meaning they will find the memories that their alters hold (Elzinga). All in all memories are very key to the state of mind for a DID patient, as their past memories are the cause of their disorder and can be looked evaluated for their treatment.
Treatments
There are two types of primary treatment plans that patients can choose from known as the Connective Model and the Trauma Model. The treatments have the same primary goal of being able to get the patients in a stable state to live their everyday life without trouble from their disorder. The Connective Model goal for treatment explained by Christopher Allers and Marilyn Snow is “to work towards bringing about an increased sense of connectedness or relatedness among the different identity fragments (Allers & Snow 165)”.
The Connective Model uses a series of instruments to help assess the personality type and roles of the different alters in the system. The assessments that are used are the Kern Lifestyle Scale (Kern and Cummins) and the System Constellation Assessment. Early recollections will also be talked about to assess the different alters. Early recollections defined by Allers and Snow is the memories of early childhood events before the age of eight. When looking at early recollections, the clinician is looking at the amount of involvement, either active or passive, that the identity will take. This reveals how that identity deals with interpersonal conflict. The Lifestyle Scale is precisely what it sounds like, it assess the patient's lifestyle through levels of control, pleasing and discouragement. This helps the therapist understand how the patient and their alters interact within different intimate social settings. Next is the System Constellation Assessment, which is a questionnaire that examines the system of alters in the patient and how the interrelationships and influence of each alter affects the psychological development of the patient as described by Dinkmeyer et al. All these assessments help the clinician understand the personality type of each alter, and are then used in treatment where each alter is taught about the personality of the other alters in the system in order for the host to better understand the purpose of each alter. Through this, the patient is more aware of their psychological condition and why they have alters. After treatment, patients “reported that a number of his identities had lost their ‘separateness’ and that most were coconsious, coexistent, or both with at least one other identity (Aller & Snow 174).” This treatment does not help the patient’s dealing with past trauma or going over the cause of their disorder.
Some of the benefits of the Connective Model are that the patients learn how to deal with their disorder in a positive way after treatment. Alters will often merge by the end of the therapy making the disorder easier to manage, but because the point is to educate the patient on how their alter system works, even if alters do not merge, it still makes the disorder easier to manage even if they have the same amount of alters after treatment. Being able to understand their disorder helps the patient understand why they have alters and what the alters are doing for them psychology.
One of the cons of the Connective Model is that the patient never processes the traumatic events they have gone through and when their alters are merging with them, the patient will discover the traumatic memories of those alters. This can cause great stress for the patient having never processed or learned how to process the emotions of those traumatic event. The ability to fully merge with all the patient’s alters is low because without going through the cause of why those alters are there, and what the alters struggle through, it limits the chances of all the alters merging. The patient will never fully understand each alter if they do not understand the traumatic memories that these alters hold.
The Trauma Model which is referenced by Warwick Middleton and Richard Horevitz is where the clinician’s goal is to work through the trauma the patient has experienced in order to understand the most likely cause of their disorder. The Trauma Model focuses on dealing with the traumatic events that the patient has gone through with the side effect of the treatment being that the alters merge. The only assessments that are used during this treatment are the ones used for diagnosis. During therapy, the patients will go through each of their traumatic experiences and process the events with the therapist. Usually patients have therapy sessions four times a week for as little as six months, but often treatment can last for years. Soon the reason for the alters starts to go away, as the alters job was to console the host of their traumatic past that haunts them(Aller & Snow). The alters that are similar and hold many of the same traumatic memories usually merge first. As the patient deals with the traumatic events, the other alters start to merge until there is only the host left. The host will usually still hear the voices of the different alters in their head, but they are much less prominent than they were before treatment. Once the alters are fully merged, the patient will often continue to attend therapy to keep processing trauma, until the therapist believes the patient can process trauma on their own without further assistance. Once the sessions stop, the therapist will often check in on the patient about every six months to make sure they are not reverting back and using their disorder to deal with situations they are uncomfortable in.
Some of pros of the Trauma Model are that going through the trauma that caused the patient’s disorder will help the patient understand how they came to have their disorder and how to handle trauma in the future. This could keep them from dissociating in the future which would be what they used to process their emotions before treatment. Since the patient is going through each traumatic event that their alters hold, they learn how their alter system worked and why they had each alter. This lets them understand each alter which enabled them to merge with their alters making it very likely that the patient will merge with all their alters through the Trauma Model.
Some of the downsides are that the patient does have to deal with new memories of past traumatic events that they did not even know happened to them. Finding these memories in itself is a traumatic experience, and there is no guarantee that the patient will be able to be able to process this trauma, which is why the patient built their alter system. After treatment and learning about all these traumatic events, the patient can develop post-traumatic stress disorder where the patient will have to continue to be checked on how well they are processing the trauma they have gone through.
Hypnotic Aid in Treatment
Hypnosis is when someone is put in a state of consciousness in which the person loses the power of voluntary action and is responsive to suggestion and/or direction. Hypnotic aid, can be used in any treatment plan of DID for a multitude of reasons. The three main reasons that hypnosis is used is for being able to process emotions, to find repressed memories, and to make a safe place in the patient’s mind. The other reasons that it could be used is to repress emotion, to merge alters, and to age alters that are stuck at a certain age(Spanos).
In therapy, the patient needs a safe place where they can talk to their alters and understand why they are there and what purpose they serve. Through hypnosis, this can be achieved through bringing the patient into their mind and creating a place that they feel safe in for all the alters. Every time the patient would like to talk to an alter, they can go to this place in their mind and this allows for the patient to understand why they have certain alters and help them understand their past better with the memories these alters hold. Alters hold different memories from the host’s past so that the host does not have to deal with a certain traumatic event, this is also where hypnosis can come into play. In order for the patient to process the trauma they have gone through, they first need to know all the trauma they have gone through. The therapist will put the patient into a hypnotic state and continue to ask patients questions making sure to keep from suggesting the patient into a false memory. These questions will start to be answered by other alters that have these memories. Once a new memory is found the therapist will first help the alter process the trauma then move on to telling the host and have the host process the trauma as well. During this time the host will most likely talk to the alter that has now already processed this trauma and will help the host in doing the same thing. During the process the host and that alter might merge, but that is not always the case(Horevitz). The last main reason that hypnosis would be used is to process the emotions of finding out about a repressed memory which can be a traumatic event in itself. Hypnosis would be used to calm down the patient and reassure them that they are in a safe place. This, in the end, will help the patient process the traumatic events with a more relaxed head being able to think more clearly and see that the event was not under their control and not their fault.
Hypnosis can also be used to repress emotions, merge alters and to age alters that are stuck at a certain age. Not all patients will need this hypnotic aid. The therapist will only use hypnosis to repress emotions during a session if the patient is overwhelmed by emotions. The therapist will suppress the negative emotions of the patient at the end of the session until next session. To merge alters the patient will go to the safe place created earlier in therapy. During this time the therapist will start trying to get the patient to see the similarities between them and their alter which will get the patient to think that their alter is them (which is true). The patient will then start merging with that alter, some alters will automatically merge with the patient, but for patients who are struggling to merge with an alter that is ready, hypnosis will often be used to do so. Next is aging alters as some alters do not age as the patient ages. For example, alters can be ten years old and stay that age while the patient continues to age. Not all DID patients have an alter that does not age, but for those who do, hypnosis is usually used to merge and age the alter. This is usually done by having the alter imagining themselves growing up as is seen in Horevitz case study of Foster The Treatment of a Case of Dissociative Identity Disorder. This leads to the alter actually growing up because as they imagine themselves aging in the mind of the patient they are able to psychologically visualize themselves aging and growing up. Since the alter is usually made in the image of the patient as a child, when the alter does age they look exactly like the patient. Alters often see themselves differently, and when the alter’s self image looks like the patient’s image, this alone can make the newly aged alter and the patient merge. Hypnosis is not always used in treatment, but when a therapist deems it necessary it can also be an effective aid. Only a trained professional should be putting patients under hypnosis.
Part Ⅳ: Conclusion
With everything that has been discussed for causes of either trauma or iatrogenic, treatments based on the Trauma Model or Connective Model, and hypnotic aid for treatment, trauma looks to be the cause of DID in most cases. While people can be suggested into having DID, they are few and far between. Therefore, the best treatment plan would be to process the trauma that has been done to the patients that have DID and have them be able to function in society while taking care of the overall mental health that the trauma has caused. Hypnotic aid can be very useful in processing emotions and allowing for one’s alters to be able to talk in a safe place.
The Trauma Model treatment plan is best because it treats the cause of the disorder and the systems of the disorder. The Connective Model treatment plan does not intentionally go over any trauma that the patient has endured and risks that the patient may not fully merge with all their alters. In the Trauma Model treatment, the patients can learn to cope with trauma that they have gone through and now have the knowledge on how to deal with traumatic events that could happen in the future. This will decrease their chances of dissociating and creating new alters again, as shown in the case study in Hypnosis in the Treatment of Multiple Personality Disorder by Richard Horevitz, which was the patient’s original coping mechanism for dealing with trauma. Patients could still end up dissociating after treatment, but now that they know what treatment is like and have merged with an alter before, the process becomes shorter, especially if the patient is dealing with recent trauma instead of old trauma. Hypnotic aid going through new and recent trauma would also be easier to process emotionally. Hypnotic aid is not advised for finding repressed memories because it is easy to suggest the patient into a false memory of trauma, but hypnosis should be used for processing emotions, repressing emotions (only if they are repressed until the next therapy session), and aging alters.
Treatment for DID should be to treat the cause that will inevitably treat the symptoms as well as help the patient to better process emotion and events in their life. While the Trauma Model has been shown to work in some individual case studies, there have been no mass studies of this treatment, which leaves some questions if this would work for a majority of people who have DID. Because there is no clear research on how multiple patients react to certain treatment plans, it would be helpful for a mass treatment study. You could measure this mass study’s success by seeing how well the patients are doing in society and personal life and looking at how they are able to deal with stressful events and their overall feelings in day to day life.
We have learned that traumatic events will cause DID. While their can be other factors that cause DID, they are rare and do not cause as severe symptoms as trauma based DID. The best treatment for DID is through the Trauma Model plan, where the trauma behind the disorder is treated and processed which will then cause DID symptoms to resolve themselves. Hypnosis also helps with treatment in processing emotions during therapy sessions about traumatic events. With the misconception of DID patients being unstable and having some evil personality that could harm others, the findings show that these are just people that are creating ways of dealing with traumatic events. Now research needs to be done in order to help these people even more during treatment.
Work Cited
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