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Chapter 1

Introduction: Redefining the Frameworks

The last decade in North America has seen an explosion in interest in a formerly obscure mental illness, Multiple Personality Disorder, recently renamed Dissociative Identity Disorder (American Psychiatric Association, 1994). Up until 1980 only about 200 cases had been reported in the world literature (Ross, Norton & Wozney, 1989). Since the official recognition of Multiple Personality Disorder as a psychiatric diagnosis in 1980, an estimated 6000 cases have been diagnosed in North America (Coons, 1986). Estimates of the prevalence of Dissociative Identity Disorder in the general population vary from 0.1% (Braun, 1990), 1.2% (Loewenstein, 1988) and 1.3% (Ross, 1991).

Classical Dissociative Identity Disorder

In the last 15 years of research on Dissociative Identity Disorder, a classical characterization has emerged about what is commonly found among clinical cases of Dissociative Identity Disorder. There are many aspects of this characterization that I will question, at length, in the rest of this dissertation, however, for the sake of description, it is important to know what has been understood and described to this point.

The American Psychiatric Association (1994) describes the diagnostic features of Dissociative Identity Disorder in the 4th Edition of the diagnostic and Statistical Manual (DSM IV). The essential features are defined as the:

"presence of two or more distinct identities or personality states (Criterion A) that recurrently take control of behaviour (Criterion B). There is an inability to recall important personal information, the extent of which is too great to be explained by ordinary forgetfulness (Criterion C). The disturbance is not due to the direct physiological effects of a substance or a general medical condition (Criterion D). In children, the symptoms cannot be attributed to imaginary playmates or other fantasy play." (p.484).

The DSM IV also describes Dissociative Identity Disorder as "a failure to integrate various aspects of identity, memory and consciousness" (p.484), and that the amnesia referred to is frequently asymmetrical. Passive identities have fewer memories, while hostile and protecting identities have a complete life history. Switching identities can be triggered by stress, although identities may exert influence by producing visual or auditory hallucinations rather than gaining complete control of the body.

They note that "individuals with Dissociative Identity Disorder frequently report having experienced severe physical and sexual abuse, especially during childhood" and that they may also manifest symptoms of Post-traumatic Stress Disorder, conversion symptoms, substance abuse, headaches, irritable bowel syndrome, asthma, eating and sleep disorders and mood disorders (p. 485).

The DSM IV describes people with multiple identities as more hypnotizable and having a greater capacity for dissociation. Physiological differences may also exist across identity states, including changes in vision, pain tolerance, symptoms of allergies and asthma and response of blood glucose to insulin.

Dissociative Identity Disorder is found in women three to nine times more often than in men, and women tend to have more identities than men, averaging 15 or more, whereas men average 8. "Episodic and continuous courses have both been described. The disorder may become less manifest as individuals age beyond their late 40s, but may reemerge during episodes of stress or trauma or with Substance Abuse." (p. 486).

This description represents a change from the previous Diagnostic and Statistical Manual III Revised Edition (DSM IIIR), which did not include amnesia as a criterion (American Psychiatric Association, 1987). Almost all of the literature of Dissociative Identity Disorder used in this dissertation will have used the DSM IIIR criteria for the research. It is possible that some of the patients studied would be excluded from the current diagnostic category. It also has resulted in some confusing terminology. In the literature on Dissociative Identity Disorder, it is also referred to as Multiple Personality Disorder, sometimes just "multiple personality", and people with Dissociative Identity Disorder are frequently referred to as "multiples." The different identities are at times referred to as personalities, alters, ego states, identity states or alternates.

The evidence that Dissociative Identity Disorder only results as a consequence of ongoing, severe childhood abuse, especially incest, is overwhelming (Briere & Runtz, 1988; Fagan & McMahan, 1984; Kluft, Braun & Sachs, 1984; Wilbur, 1984a; Bliss; 1980; Greaves, 1980; Schultz, Braun & Kluft, 1985; Putnam, 1985; Kluft, 1985b; Ross, Norton & Wozney, 1989). Often, Dissociative Identity Disorder is characterized as a type of posttraumatic stress disorder (Spiegal, 1984; Fike, 1990b; Kluft, 1984; Braun, 1985).

Dissociative Identity Disorder is seen as the most extreme form of dissociation, used as a defensive mechanism to help the child cope with trauma (Braun, 1988).

Ross, Norton & Wozney (1989) reviewed therapists' reports of 236 cases of Dissociative Identity Disorder. The therapists reported that 88.5% of the patients had been either physically or sexually abused, with the majority experiencing both types of abuse. An additional 11.1% of the therapists were uncertain about whether abuse had occurred. The majority of clients had also been raped (Ross, Norton & Wozney, 1989). Putnam et al. (1986) reported that 97% of Dissociative Identity Disorder cases had experienced some form of severe trauma, although this included forms of abuse and neglect not included in the Ross et al. study.

Unfortunately, not enough work has been done to examine child abuse in a political or feminist framework. Without this framework, too many researchers approach the issue as a voyeuristic experience of the "bizarre experiences and symptoms" (Bowers, 1991, p. 168) of Dissociative Identity Disorders.

My experiences with individuals with multiple identities

I facilitated a support group for lesbian survivors of childhood sexual abuse that was modeled on a lesbian coming-out group. Coming-out groups are possibly the most successful application of feminist group therapy. The purpose of these groups is to provide peer support in facing social oppression, share coming-out stories, end isolation, overcome fear, introduce new members to the existing community and re-frame the heterosexist socialization into a subversive, lesbian-centered framework. The groups are a place to meet friends and lovers and connect with a community that is otherwise hidden and difficult to locate. The groups inherently blend political and personal purposes, and they are an essential aspect of many lesbian communities. The groups are free of charge and collectively facilitated.

This support group was to assist women to come out as lesbians and as survivors of abuse, and explore how those identities and realities intersected. Some of the women in the group also came out as individuals with multiple identities.

The classical model of multiple identities did not seem to fit the lives and experiences of these women. The group dynamic was established to focus on the person as a whole, not a collection of symptoms. Taken in this context, a lesbian with multiple identities did not really stand out in the crowd. All lesbians who live in a patriarchal society, have known what it means to have big and scary secrets. For some lesbians, this goes on throughout their lives, and they live double lives that are carefully separated. They must maintain constant vigilance, self-censorship and create a complex facade to conceal their true life from casual, yet invasively personal, assumptions and inquiries. They keep two wardrobes, two sets of friends and often remark how they feel like a different person when they change identities. Of course, one identity is very ego dystonic - essentially superimposed by the prevailing social structures. However, ego dystonic heterosexuality is not yet recognized as a mental illness in the DSM IV.

The child identities that emerged in the group were not distinctly different from the desire that everyone shared of wanting to curl into the fetal position every so often. The raging, angry identities no different from our anger, and fear of that anger, at our abusers, at society and ourselves. Everyone was familiar with the inner healer, and knew of unbidden strengths that had helped us survive. While we recognized the uniqueness of all of our identities, we also recognized them to be simply aspects of who we are and who we might become.

In this group, we did not follow many of the accepted practices for dealing with individuals with multiple identities. We did not elicit or attempt to control the identities, we believed that they had managed to do by themselves for most of their lives and did not need our help. We had rules for safety that everyone was obliged to follow, and we were provided instructions to contact a "managing" identity who could re-organize the identity system in the case of an emergency. Buried memories came spontaneously, once we were able to provide a safe space to support this intense emotional work. We also used semi-public rituals, field trips and visualizations to release emotions and facilitate healing. We encouraged friendships that maintained contact outside of the group. We went as a group to anti-violence political activities and educational events. We helped women strategize and execute their escapes from current abusive situations. All of the participants expressed delight in meeting and sharing experiences, and knowing that they were not alone.

There were definitely times when some of the women needed more help than we could provide in weekly group meetings. Several women were involved in shelters or psychiatric institutions. Unfortunately, most of these interactions simply re-traumatized the women who were seeking help. Often, the women were labelled as "high needs" patients, when in fact their needs were natural, but the system was not designed to meet them. Some women used these systems as safe houses to escape unlivable housing conditions or abusive situations, and attempted to refuse the drugs and ignore the labels that came with the housing. Others found relief from their pain, but lost custody of their children. Some lost their jobs when they came out as lesbians. Some risked their lives escaping or confronting their abusers. However, we never believed that we were the "problem" and we never believed that needing safety and loving support from another human being indicated that there was something wrong with us.

Purpose of this dissertation

The core of this dissertation is my desire to reframe the investigation into Dissociative Identity Disorder. Multiple identities has been characterized as a debilitating mental illness that results from an adaptation to extreme child abuse. It is an individualized problem that is resolved through private therapy.

I do not believe that multiple identities can ever be truly understood outside of its context; a framework of systematic violence. This violence is not only a dim memory of childhood abuse for many women, but an ongoing threat, or repeated brutality that plays a role in the systemic oppression of women. It is important to give credit to survivors of abuse for coping with the trauma, escaping the abusive situation and finding a path that leads to healing. I see survivors as active participants in responding to violence, strategizing their survival and resisting oppression.

Having multiple identities is not itself debilitating, as cross cultural studies can demonstrate - being brutalized is debilitating. The goal of mobilizing support for survivors of violence is not to label them and file them away, or even to simply anaesthetize the pain. Instead, the appropriate goal for feminist action is to end child abuse and bring respect and understanding to those who have survived it. The forum in which to undertake this work lies not only in individual healing, but in healing as a community.

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