'The rudest awakening'.

I appreciate Dr. Roland Atkinson's perspective on dissociative identity disorder. Not long ago, I would have congratulated him for his courage as well.

Thankfully, one no longer incurs immense risk for speaking out about the characteristics of some practitioners that compel them to seek out the special and important status of having very special and important clients.

In the late 1980s and early '90s, as an early career psychiatrist in rural upstate New York, where I grew up, I was surprised to find myself working with a group of practitioners who were diagnosing multiple personality disorder at an alarming rate. My ignorance led me to believe that open communication, education, and empathic understanding would allow all to slowly transition to a less self-indulgent manner of fulfilling our responsibility to patients and society. That is what I had just learned in my residency. I was in for the rudest awakening and most important lessons about human motivations of my professional career.

Sparing the personal details, I had a front-row seat. I saw what types of people were selected. They were always disempowered women with PTSD/borderline spectrum liabilities or, ideally, some component of autistic spectrum liabilities (mild Asperger's). The therapists could also be characterized as constricted in the manner in which they detected and responded to the suffering of others. Both were chafing more than usual from the constraints of the anonymity of those with uncompensated suffering and/or those delivering thankless caregiving.

Three things really surprised me, however, and for the most part remain a source of deep concern:

1) Sobering was the degree to which certain "compassionate" female therapists invested themselves in the more unhelpful, mind-bending aspects of "therapy" while vehemently condemning the nonbelievers (often male psychiatrists) as unempathic and uncaring. I do believe that this movement is only the latest installment of the age-old disempowering "woman as hysteric" defense of a deeply conflicted male-dominated culture. What societal forces worked this twist to recruit some women to apparently self-relegate the sisterhood?

2) Hospital psychiatrists, while personally appalled at the misuse of psychiatry and innocent patients, turned a blind eye so as not to be cut out of the admission pipeline. It was an "industry," and open nonbelievers were openly shunned.

3) The American Psychiatric Association was likewise tight-lipped. Its silence on the issue of the sudden dramatic change in practice was deafening. The leaders' fear of being politically incorrect led to impotence in the face of direct damage to patients. The corrections of practice had to work their way through the courts. Thankfully, courageous attorneys and judges saved segments of our profession from itself.

Dissociation is common enough. Human motivation is complicated and private, amnestic barriers will always remain mysterious. The bottom line is that the leaders in this area never proved that their approach worked or how to safely administer it. This trickled down to really bad care and clinical disasters. It was about belief--not empirically derived medical care. I suffered some for not admiring the emperor's new clothes, but this pales in comparison to the fate of some of the victims of MPD treatment, once the intrigue had run its course. And yes, it was suggested (in 1997) that I leave the clinic and rural population I had worked with when I refused to administer sodium amytal to help the clinic director communicate with more alters in several of the patients.

Let us not fool ourselves into thinking that this cannot happen again, and let us not again be controlled by fear as we once were.

Stephen Hudyncia, M.D.

Fort Plain, N.Y.