DISSOCIATIVE IDENTITY DISORDER: THE RELEVANCE OF BEHAVIOR ANALYSIS.
When behavior analytic accounts of abnormal behavior are presented in textbooks, the discussion is usually brief, with references to faulty learning, inadvertent conditioning experiences, or aberrant behavior models. The brevity is to be admired, as it shows the behavior analyst or therapist's hesitation to speculate in the absence of data as to how a particular behavior may have developed (Thompson & Williams, 1985). Further, behavioral theorists are reluctant to attribute explanatory or causal status to intrapyschic or other variables relating to the individual as a cause of their behavior (Skinner, 1974). Nevertheless, this hesitation to speculate has led many writers to conclude that because behavior analysts have little to say or they say the same things repeatedly about different behaviors, behavior analytic contributions are irrelevant. This paper offers a behavior analytic account of personality and relates this to Multiple Personality Disorder (American Psychiatric Association, 1987), now called Dis sociative Identity Disorder or DID (American Psychiatric Association, 1994). The intent here is to point out the misunderstood relevance of behavioral theory to this disorder.
What Is Personality in Behavioral Terms?
There are over fifty definitions of personality most refer to internal variables that somehow cause a person's behavior but do not refer to personality as being behavior (Hayes, Follette, & Follette, 1995; Pronko, 1988). Relatively few behavior analytic or otherwise behavioral theorists have addressed or defined the behaviors of personality. For instance, Skinner (1953) argued that personalities represent "topographical subdivisions of behavior" and that a particular personality was "tied to a particular type of occasion [ldots] a given discriminative stimulus" (p. 285). Twenty years later, Skinner echoed his earlier argument with "a self or personality is at best a repertoire of behavior imparted by an organized set of contingencies" (Skinner, 1974, p. 149). In a similar vein Eysenck (1959) stated his position as "personality as the sum total of actual or potential behaviour patterns of the person, as determined by heredity and environment" (as cited in Chesser, 1976, p. 291). Bijou and Baer (1966) referred to personality as the development of contingencies between "social reinforcement for social behavior, under social SOs" (p. 721). Harzem (1984) defined a personality (characteristic) as being "a cluster of functional relations between (1) a set of variables and (2) the already-established behavior patterns of an individual" (p. 391). In more general terms, Staats (1993) gave his definition of personality as "personality is composed of specifiable, learned behaviors" (p. 10).
Interbehaviorial psychologists have defined personality as Kantor (1924) wrote, "we cannot consider personality to be anything more than the individual's particular series of reaction systems to specific stimuli" (p. 75). Similarly, Pronko (1980) defined personality as "the total series of a given individual's interactions with the relevant stimulus objects" (p. 201). In analogous terms, Keller and Schoenfeld (1950) and Kohlenberg and Tsai (1991) addressed the term "self" much as others above addressed personality. Keller and Schoenfeld (1950) defined self as "a word that is meant to designate the ability to speak of (be 'aware' of) one's own behavior, or the ability to use one's own behavior as the SD for further behavior, verbal or otherwise" (p. 369) and "the 'Self' in short is the person, his body and behavior and characteristic interactions with the environment, taken as the discriminative objects of his own verbal behavior" (p. 369). Likewise, Kohlenberg and Tsai (1991) discussed self from the individu al's point of view, as one who reports self-observations of their specific personality, "the experience of the self lies in specification of the stimuli controlling the verbal response 'I' "(pp. 128-129). Lastly, Hayes (1984) and Hayes, Kohlenberg, and Melancon (1989) discussed how our verbal environment teaches us to have a sense of self or to see our experiencing of the world (seeing, feeling, hearing, etc.) from a distinct perspective of "you."
Here, it is elucidated that the people in our lives refer to us with the term "you" used in different ways; on some occasions, you is used to refer merely to us as a physical body or structure, as a person may say to us, "I saw you unconscious in the hospital"; in other instances, our verbal environment teaches us to see ourselves seeing from our own perspective, that is, from a perspective of you, where seeing refers to experiencing and interacting with the world (feeling, hearing, moving, etc.). Now consider the following question from different perspectives, "If you lost your arms and legs, would you still be you?" (Hayes, 1984. p. 103). From the perspective of one as physical body, or "My body is me," the answer would be no. The answer, from the perspective of one with a perspective of you, is yes; you could still envision yourself seeing yourself as you. That is, our verbal environment teaches us a general tendency to respond to our own observations of our own behavior verbally and give us "a sense of s elf" or to "have" self-knowledge as a result.
The commonalities in these definitions are obvious. Personality consists of behavior-environment relations and is subject to control and modification by the environment. Further, personality or the self cannot be given explanatory or causal status of other behaviors, except as part of a behavioral chain or as discriminative stimuli for behavior. Instead, the terms personality and self are behavior in need of explanation and identification of their causal variables (Skinner, 1974). Finally, each of these definitions points to personality as being highly consistent yet still malleable, within limits imposed by the environment and the individual's heredity. As Pronko put it "everything is in a state of flux; so is personality. An inventory of one's personality would stop only with the death of the individual" (Pronko, 1980, p. 201). Our personalities are consistent and variable as a function of past or present environmental factors and the concept of any individual having multiple personalities is implicit in b ehavioral definitions of personality (Kantor, 1924; Skinner, 1953). Skinner (1957, 1989) also discussed different repertoires of personality or selves observable either by other individuals or the person so behaving, traceable to environmental contingencies. Although in the above definitions only Eysenck explicitly acknowledges the role of genetic variables, other behavioral writers do not dismiss hereditary factors as being a distal variable in determining behavior (Skinner, 1974). Some may not be inclined to include Eysenck as being a behavioral theorist but the definition of personality given by Eysenck is a definition of personality as behavior.
What Is Multiple Personality?
The syndrome commonly known as Multiple Personality Disorder but now called Dissociative Identity Disorder (American Psychiatric Association, 1994) might be thought of as a recent phenomenon. This behavior, however, was described in every DSM system since its inception (American Psychiatric Association, 1952, 1968, 1980, 1987, 1994); in addition, Flournoy (1900) described similar behaviors at the turn of the century. With a stretch, the report of the Biblical demoniac in Mark appears as a self-report of multiple personalities: "my name is legion, for we are many," indicating this condition is ancient.
The diagnostic literature shows the definition of multiple personality as evolving significantly over the editions of the Diagnostic and Statistical Manual of Mental Disorders. In the DSM-1, these behaviors were called dissociative reaction, (American Psychiatric Association, 1952), which came to be called hysterical neurosis, dissociative type in the DSM-II (American Psychiatric Association, 1968). In each of these, multiple personality was not seen as a distinct disorder but was grouped with somnambulism, amnesia, and fugue states. Only in the DSM-III does Multiple Personality Disorder appear as a separate diagnostic category, with a definition of this behavior. This disorder's defining features were argued to be "the existence within the individual of two or more distinct personalities, each of which is dominant at a particular time" (American Psychiatric Association, 1980, p. 257). The DSM-IIIR of 1987 gave nearly identical defining features as "the existence within the individual of two or more distinct personalities or personality states" (American Psychiatric Association, 1987, p. 269). The defining features evolved further in the DSM-IV where this behavior pattern came to be termed Dissociative Identity Disorder. Its features became "the presence of two or more distinct identities or personality states that recurrently take control of behavior" (American Psychiatric Association, 1994, p. 484).
This subtle change is significant; distinct personalities were no longer seen as existing within the person or as a part of the person, but the behaviors displayed different states or identities. This definition is less organismic and more behavioral-environmental in theory than earlier versions. With the readers' extrapolation, the personality is variable behavior or as "topographical subdivisions of behavior, occasioned by discriminative stimuli and controlled by reinforcement contingencies." Here, the personality is showing more variability than that of the "average or normal" individual; the individual lacking one coherent personality displays a personal repertoire of behaviors which is very diverse, with large variability in the relationship between antecedents and responses. The antecedents, that is, people, places, events, and so forth, of the individual in question occasion more responses of an idiosyncratic nature which are maintained by reinforcement contingencies unique to that individual. Along t his approach, one writer took the new definition to mean that the individual displaying these behaviors could no longer be described as having more than one personality. Instead, the person should be viewed as having less than one whole, coherent personality (Sapulsky, 1995). Similarly, Kohlenberg and Tsai (1991) observed that these individuals may have not developed all the characteristics of a stable, single personality.
How Common Are These Behaviors?
The frequency of multiple personality has been debated over time. There were some descriptions of these behaviors early in this century, but from the 1920s to the early 1970s, there was a surprising dearth of cases (Spanos, 1994). Kohlenberg (1973) termed it relatively rare as did Caddy (1985), while other reports saw it as very numerous in number; more cases were reported from the mid-1970s to the mid-1980s than in the previous two-hundred years (Orne, Dinges, & Orne, 1984). The tremendous increase in reported cases has occurred almost exclusively in North America (Spanos, 1994). This behavior pattern is rarely reported in Great Britain, France, and Russia; no case has ever been reported in Japan (Spanos, 1994). In both North America and Switzerland, most diagnoses are made by a small minority of professionals while the vast majority of professionals rarely if ever see such a case (Mersky, 1992; Modestin, 1992; Spanos, 1994).
The dramatic increase in the reported numbers of cases has been attributed to differing factors. Possibly, cases which were undiagnosed in previous decades are now being diagnosed because of greater awareness of this condition; it has also been proposed that the condition is now being overdiagnosed in individuals whose behaviors are readily suggestible (American Psychiatric Association, 1994). It is probably safe to conclude that the prevalence of Dissociative Identity Disorder is in dispute at this time; some may also dispute the validity of this diagnosis as the DSM-IV, unlike earlier versions of the DSM, does not provide any diagnostic reliability information (American Psychiatric Association, 1994).
What Causes These Behaviors?
Theories attempting to describe these behaviors are as diverse as the paradigms that frame them. Psychoanalytical theory argues these behaviors as being motivational (Sackeim & Devanand, 1991) driven by a defective or unsatisfactory identification with the same-sex parent and the abrupt loss of a substitute model (Horton & Miller, 1972). Bowers, Brecher-Marer, Newton, Piotrowski, Spyer, Taylor, and Watkins (1971) argued that a sense of self-contempt and self-alienation leads to the development of multiple personality. Dissociation has also tentatively been attributed to self-hypnosis (Bliss, 1980, 1984; Hilgard, 1977) and neurological dysfunction or epileptic seizure-related activity (Gur, 1982; Schenk & Bear, 1981).
How Does Behavioral Theory Account for These Behaviors?
Although Skinner (1953) had suggested we all might display multiple personalities, Kohlenberg (1973) first proposed a learning theory account for a disorder of multiple personality. It can be argued that each of us has differing amounts of variance in our repertoires to the point that a common question may arise: "How many personalities do we actually have?" The question isn't how many personalities does each of us have, but, how many behavioral repertoires are each of us capable of performing or exhibiting?
Viewing personality this way, it is obvious that we all perform many personalities, with differing degrees of behavioral excesses and deficits, beyond what is "normal." These variations are caused by differential stimulus control, reinforcement, and punishment contingencies. That is to say, we may behave very differently in a lecture hall than in a church or synagogue. Any individual no doubt behaves very differently when with one's mother than when with friends at a convention. Despite the variability, an observer would still see "It's still Joe" or that there was enough stability or generalization in Joe's personalities across all contexts for Joe to be recognized as the same person.
The Control of Self-Report
On balance, with the behaviors labeled Dissociative Identity Disorder or DID hereafter, the variability between behavioral repertoires is very high, possibly so extreme that the repertoires do not compose one stable personality (Sapulsky, 1995). The person himself or herself may even report being a different person, complete with a different name or "identity." Although the behavioral variability is more extreme here, it is still on a continuum with the average person; we all can exhibit several personalities and there are circumstances under which any person might claim to be a different person (Sackeim & Devanand, 1991). Among the behaviors correlated with a diagnosis of DID, self-report is less controlled by public, environmental events and more controlled by events which are private to the person providing the self-report (Kohlenberg & Tsai, 1991). The most apparent question is: What type of experiences could account for this extreme behavioral variability, in the self-report of being a different person, with differences in sex, age, race, physical appearance, and so forth.
As is commonly known, these individuals frequently report having suffered extreme neglect or abuse as a child (American Psychiatric Association, 1994; Murray, 1994). Reports of a history of childhood abuse are no doubt seen as the defining feature of DID in the minds of many clinicians, as individuals with DID-like behaviors may also display posttraumatic symptoms (American Psychiatric Association, 1994). These reports do not enlighten much because abuse is not rare but the prevalence of these behaviors, while in dispute (American Psychiatric Association, 1994) is not nearly as common as abuse. Some accounts of abuse have been considered suspect because individuals who exhibit these behaviors give highly variable self-reports, and some of these reports of abuse may have been suggested by overzealous therapists (Spanos, 1994).
In relating variations in self-observations and self-reports to the influence of others, the behavior analyst sees the two being related as a straight-forward conclusion. Much self-observation and resultant self-report comes from experiences with, observations of, and inquiries from others (Skinner, 1974). Conceptually, a person with behavior so labeled has had experiences, probably social, that have resulted in extreme behavioral variance as well as self-reports of their behaviors. The behavioral variances are not as readily related to obvious environmental stimuli, however, as they are in the person who does not exhibit the behaviors labeled as being DID (Kohlenberg &Tsai, 1991).
Kohlenberg and Tsai argue that any individual has the experience of "being someone else" as a normal part of a child's imaginary play and these behaviors can be occasioned and reinforced by the public environment. Having different aspects of one's self or "being someone else," accompanied by different subjective states of memory and emotion, because of so behaving, can become a very adaptive behavior, under certain circumstances. When experiencing repeated physical or emotional trauma, being somebody else could provide means of escape or avoidance when no other means of escape or avoidance is attainable (Kohlenberg & Tsai, 1991). The child cannot be unaware of the horrible things happening, but the child can be unaware that it is happening to them. By being someone else who needn't remember the trauma, the child can distance himself or herself from the trauma and still maintain some semblance of a normal emotional relationship with the abuser. From the perspective of the person with the history of being abus ed, "My dad does bad things to that other little girl, but only because she is so naughty, but my dad loves me and has never done anything bad to me."
The culmination is an individual who never attains a complete personality, self, or an experience of being one coherent "I" controlled by public and private events. Instead, the individual who experienced the history of abuse has more than one personality or self, controlled by a host of private events (Kohlenberg & Tsai, 1991). In contrast during more normal development, an individual will increasingly engage in being the same person, with these behaviors occasioned and maintained by public and private events; being someone else does not have significant adaptive value.
Besides engaging in different personalities, another aspect of the extreme behavioral variance in this disorder is that of amnesia, or an inability to remember beyond what is considered average (American Psychiatric Association, 1994). In other words, besides extreme variability in behavior and self-report of identity, the self-reports of experiences the person has had also varies widely (Coons, 1994). When exhibiting some personalities, the person reports past abuse but not necessarily all the present circumstances. When another behavioral repertoire is exhibited, past abuse may not be reported but the present is reported clearly. It is this behavior that intrigues many. Clinicians and the lay public alike seem to want to know "Is it all in there?". That is, are all the memories and experiences stored somewhere in the mind or brain of this person? From the behavior analytic point of view, remembering (or forgetting) is a behavior, more or less likely to occur as a function of its consequences (Grant, 1982; Grant & Barnet, 1991; Kohlenberg & Tsai, 1991; Skinner, 1974); storage and accessibility are replaced with probability of remembering. With that clarified, one could say that some or most real experiences can be remembered (potentially) and reported; to remember we must arrange the environment to increase the probability that we will behave in the future as we are now behaving (Skinner, 1989). But in these cases, the person is unwilling or unable to remember or report some experiences until that person is in a different situation or the reinforcement contingencies change. Then, the person may change personality repertoires and can remember and report different experiences.
The vivid imagery of the past that is reported by these persons when displaying differential personalities corresponds with Skinner's "conditioned seeing" (Skinner, 1953). A person may come to see stimulus Z, not just when Z is in fact present, but also when other stimuli that have frequently accompanied Z are present. That is, if I can remember and have the emotions of my past, I can come to see aspects of my past; if I do not remember how I felt in the past, I am less likely to see the past again.
This differential remembering/reporting is also on a continuum in degree, not in kind, from the average person's behavior. We all remember, or fail to remember, as a function of discriminative stimuli. These discriminative stimuli, some of which are self-produced in our verbal behavior, and the reinforcement and punishment contingencies in effect at a given time enable our remembering behavior; stimuli guide or facilitate remembering just as stimuli guide or facilitate other behaviors (Donahoe & Palmer, 1994; Grant, 1982; Grant & Barnet, 1991; Skinner, 1974). But these individuals show behavioral variance in remembering and personality in response to highly specific and subtle stimuli, probably more in response to covert behaviors called moods, thoughts, and so forth, than the average person. This difference in controlling factors of these persons' verbal behavior is the key to conceptualizing this behavior pattern (Kohlenberg & Tsai, 1991).
Self-Observation and Controlling Events
To this point, a few of the typical behaviors labeled as DID have been described in behavior analytic terms. While a complete account of the behaviors conceptualized under the DID label is not likely, a probable accounting of most of these behaviors can be framed, using established and understood behavioral processes.
To pursue this further, the variance in self-report of identity and experience by individuals whose behaviors have been labeled as DID may be based disproportionately on inaccurate self-observations made without seeking verification from the social environment. Simply put, such individuals may attend more to their own observations expressed in their own verbal behavior and less upon the observations and reports of others. That is to say, when in Rome and unsure of what to do, persons with DID-like behaviors may not attend to or imitate the behavior of other Romans. Instead, these persons may arrive at an inflexible self-instruction (Fine, 1992) by which to behave or they may attempt to engage in what they judge to be appropriate behavior by trying to observe their own behavior without using social comparisons. Keller and Schoenfeld (1950) described the person as having "the ability to use one's own behavior as the SD for further behavior, verbal or otherwise" (p. 369); here, the person uses his or her own be havior as a guide presumably to a greater extent than the normal individual.
Because abnormality is defined by its context, and because we are frequently less adept at self-observation than we are at observing the behavior of others (Skinner, 1974), this in and of itself could lead to aberrant behavior. But individuals with DID-like behaviors persist in their self-observations and reports, even in the face of contradicting public observations. They claim to be different persons when in fact there is only one and the same person (or body) present. These individuals have dissociated their self-observations and resulting reports from the reports of others. As a result, they have observations that are not as controlled by the public environment but are instead a function of their own distorted verbal governances (Fine, 1992).
Such inaccurate self-observations may be under the control of reinforcement contingencies other than those exerted by other individuals. In the past, the person with the present DID-like behaviors learned to attend to and rely more heavily upon his own observations of how he felt, what he needed, whether he was "good" or "bad," and so forth, (Fine, 1992; Keller & Schoenfeld, 1950). This behavior may have been caused by either neglect or abuse, both of which were possibly delivered without regard to what the child did. The behavior might also have been present before the abuse but only emerged as adaptive responses while the child experienced the abuse (Kohlenberg & Tsai, 1991).
Emotional Behaviors and Controlling Contingencies
During abuse, emotional outbursts such as crying and responses to pain, which were originally respondent behaviors (Fordyce, 1976; Turk & Rudy, 1990), caused still more abuse and therefore came under control of avoidance and escape contingencies (Kohlenberg & Tsai, 1991). Pain-inflicted crying led to more pain being inflicted. Crying, smiling, and other emotional displays could come to be more under the control of operant stimuli and contingencies, or in the vernacular, became more voluntary, in an attempt to avoid further punishment. In addition, the care giver's abuse may have been erratic and difficult to predict but was still the focus of attempts by the abused person to predict and avoid further abuse; as a result, the abuse victim may have come to exhibit behaviors and emotions capriciously and histrionically; at other times, virtually no effect or behaviors would be exhibited. These attempts at self-control from the erratic stimulus events and draconian contingencies were probably not often successful in avoiding abuse. The person being abused could never learn to predict what produced or avoided abuse or reinforcement (love) and came to increasingly attend to himself or herself since other individuals provided unreliable discriminative stimuli as to how to behave.
In the present, however, the former victim has potentially "heightened" operant control of emotions and personalities when confronted with uncertainty or stimulus conditions reminiscent of the past. These individuals are often very skilled at altering their presentations of their self to manipulate others (Spanos, 1994). Kohlenberg and Tsai (1991) explained that these individuals are vigilant and attentive to the therapist's discriminative stimuli as to how to behave. At the same time, different personalities may be displayed with no obvious change in any public, environmental stimuli.
Some writers report that this disorder may only become apparent to a professional or others when "different people" attend meetings, interviews, or therapy; that is, the same individual attends but with a different self-report of identity, memories, and personality (Sackeim & Devanand, 1991). In so doing, individuals displaying these behaviors can receive a great deal of reinforcing attention from professionals for engaging in these behaviors. Individuals displaying behaviors correlated with a diagnosis of DID may be reassured of no further abuse and may be encouraged to try to "be themselves" in as many ways as they can. The different self-reports and personalities become a source of gratification (self-reinforcement) for the formerly abused victims and the professional alike (Spanos, 1994). The danger here is that a person with degrees of behavioral variability could be shaped iatrogenically to reporting to be a divergent person by professionals zealously looking for this disorder (Fahy, 1988; Merskey, 199 2). To quote one skeptic, "the procedures used to diagnose MPD often create rather than discover multiplicity" (Spanos, 1994, p. 153).
Differential "Intelligence" and Physical Symptoms
This behavior pattern has been conceptualized as being largely a difference in verbal behavior, but other differences are reported to exist and are marshaled as evidence for this disorder. That is, the individuals who exhibit these behaviors are reported to be different in intelligence, medical prescription needs, different corrective prescriptions for vision, allergies, and so on (American Psychiatric Association, 1994). Some of these reported differences are explainable in the analysis presented here. For instance, a person's intelligence quotient score consists of his or her ability to answer specific types of questions and his or her attempts to perform some nonverbal tasks. Some of these are a person's learned verbal behaviors (Staats, 1963), in that the person, when displaying some personalities, does not "know as much" as other personalities. The person answers fewer questions correctly. In terms of nonverbal tasks, "I can't figure this one out" or "I don't know what to do here" can end the trial, jus t as performing slower or faster can alter the score. The score is taken as a measure of intelligence when all that are being measured are test-taking skills (Staats, 1993), which are largely self-reports. The reported differences in corrective lenses are explainable by self-report but the differences in medical conditions may be more difficult to explain.
Pain complaints, paralysis, blindness, and so forth, also consist of a self-report of a private event. Each of these may be accompanied by publicly observable events such as wincing, reluctantly moving, reporting or appearing to be unable to move or see (Fordyce, 1976; Skinner, 1974). Both the self-reports and the public evidence for these differences are under stimulus control of the different personality repertoires in cases of these behaviors. When such an individual displays a specific personality, the self-report of pain or other symptom comes or goes with the other behaviors. Originally, the public signs of pain were authentic afflictions in the past as the result of abuse; months or years later, such indications could be self-produced, rule-governed behavior as part of the personality repertoire. These pains and related behaviors could be reinforced and shaped into a "real" affliction by well-meaning others as the verbal behavior acquired differential stimulus control of operant pain behavior. The rep orts of pain and related behaviors can persist as operant behavior maintained by its consequences in the absence of the original painful stimuli (Bonica & Chapman, 1986; Fordyce, 1976).
As for the reports in the literature of allergic and other responses being present in some personalities and not others, these too can potentially be accounted for via verbal behavior mechanisms. There are reports that individuals can develop rashes, a wound or a burn or other physiological symptoms in response to another's verbal suggestions, that is, under hypnosis, although it has been argued that many of these symptoms are likely self-inflicted when observers are not present (Johnson, 1989). Actual reports of hypnotically induced dermatological changes are difficult to substantiate; such effects are difficult to produce and are not as common an occurrence as often reported (Johnson, 1989). These reports are not all due to the acts of the person showing the symptoms; instead, these symptoms may be due to an interaction of verbal behavior and conditioning mechanisms. Verbal behavior can also facilitate the development of stimulus control via respondent or operant conditioning (Skinner, 1957). If an experim enter were to flash a light in your eyes and then shock you, the experimenter would expect you to come to recoil to the light after some number of such pairings. If the experimenter were to tell you that he or she was going to shock you after every light flash, then it would be expected for you to recoil to the light sooner.
Relating this to the differential presence of symptoms is not a big leap. Here, the individuals who display the divergent personalities have self-instructed and subsequently conditioned themselves to display symptoms when performing different behavioral repertories. Over time, the symptoms may come under the stimulus control of the emotions displayed, in addition to the person's verbal behavior, and appear spontaneous to the person himself or herself. To support the argument for conditioning mechanisms producing somatic symptoms, Smith and McDaniel (1983) showed that a hypersensitive cellular response to tuberculin was modulated by respondent conditioning. Individuals can also exert control over a variety of autonomic functions as diverse as dysmenorrhea to seizure activity, via biofeedback (Adler & Adler, 1989).
How Should Therapy Address These Behaviors?
From the foregoing assumptions, therapy for persons displaying the behaviors in question must consist of extinguishing a reasonable share of the behavioral variability in the repertoire and reinforcing behavioral stability and generalization; literally, to shape one personality. Kohlenberg (1973) reported being able to increase the frequency of specific behaviors composing one personality of an individual who exhibited DID-like behaviors by differential reinforcement of that personality. When placed on extinction, these behaviors returned to baseline frequencies. Other techniques might involve the client role-playing and rehearsing several social interactions and experiencing some situations expected to produce "normal" emotional behaviors. Price and Hess (1979) reported success at "reintegrating" the personalities in a dual personality individual by teaching assertiveness skills via role playing. Caddy (1985) also used assertiveness training and shaping in reintegration. The therapist might videotape client s as they behave, to use for feedback and in shaping and instructing more "cohesive" behavior. There might also have to be a way of teaching the client to engage in more "social-referencing," or seeking public feedback in more instances of what is acceptable behavior. Whereas you or I might ask, "Did you see (or hear) something?" when we are unsure of seeing or hearing, individuals whose behaviors are consistent with the label of DID may have to learn to ask, "Am I still behaving as me?" The therapist could not answer this question alone but family members and significant others could. This process would have to continue until the person reports being the same individual with the same experiences, and has less observable variability in his or her personal repertoire.
Even if a therapist were to try to undertake such an intervention, and most would probably not, this process could be long and arduous, due to the multiple sources of control that would require adjustment, and the possibly well-meaning sabotage by those who attend to and reinforce the variability. Indeed, based on this account, control of the behaviors in this pattern would be difficult for anyone to establish. Even the therapist who encourages variance is not exerting control unless unpredictable behavior is the target behavior. As a result, these individuals may have been and will likely be in therapy for years (American Psychiatric Association, 1994).
This paper has attempted to apply a behavioral analysis to Dissociative Identity Disorder. Why should anyone conclude that a behavioral analysis of this disorder offers any more than other theoretical positions? Behavioral theory treats personality as behavior and identifies the known environmental variables that determine behavior; other paradigms either reject personality as behavior or defer causation to inaccessible, internal, and often ill-defined variables (Bliss, 1980, 1984; Bowers et al., 1971; Gur, 1982; Hilgard, 1977; Horton & Miller, 1972; Schenk & Bear, 1981). The same environmental variables that influence personality no doubt have a significant role in Dissociative Identity Disorder. As an alternative to the "ill-defined" variables criticized above, behavioral theory would argue that the person's verbal behavior (overt and covert) and the basis for some of the person's relevant verbal behavior, their self-observations, are variables to be functionally analyzed and possibly manipulated as a fact or underlying the behaviors labeled DID. No claim is being made here that the person's verbal behavior is the functional variable behind dissociative behaviors. As Beck stated, "To conclude that cognitions cause depression is analogous to asserting that delusions cause schizophrenia" (Beck, 1991, p. 371). A person's verbal behavior can play multiple roles in interacting with other behaviors, as antecedent stimuli, as concurrent behavior, or as stimuli that have acquired reinforcing or aversive properties (Skinner, 1957) or as functional variables that either "complement" or override control by other operant contingencies (Catania, Matthews, & Shimoff, 1982, 1990).
Unless a reader is willing to look at the evidence for the effectiveness of behavior analysis, the arguments made here are moot. Some readers, behavioral or otherwise, may consider any discussion of this disorder to be a waste of time or even an indulgence in "pop psychology" but it gets a great deal of attention from the media and in clinical training programs. Therefore, behavior analysts should take the time to explain their analysis of the condition; after all, Skinner (1945) spent considerable time analyzing psychological terms. It is not, however, productive to discuss this behavior pattern as a unique condition as it is merely an instance of behavioral variability.
Although behavior analysts are hesitant to address this and similar behavior problems, other explanations are being proposed and widely read. The behavior analysts have been reluctant too long.
ADLER, C. S., & ADLER, S. M.(1989). A psychodynamic perspective on self-regulation in the treatment of psychosomatic disorders. In S. Cheren (Ed.), Psychosomatic medicine: Theory, physiology and practice (Vol. II, pp. 841-897). Madison, CT: International Universities Press, Inc.
AMERICAN PSYCHIATRIC ASSOCIATION. Diagnostic and statistical manual of mental disorders. First edition, 1952; Second edition, 1968; Third edition, 1980; revised, 1987; Fourth edition, 1994. Washington, D.C.: Author.
BECK, A. T.(1991). Cognitive therapy: A 30 year retrospective. American Psychologist, 46, 1368-1375.
BIJOU, S. W., & BAER, D. M. (1966). Operant methods in child behavior and development. In W. K. Honig (Ed.), Operant behavior: Areas of research and application. New York: Appleton Century Croft.
BLISS, E. (1980). Multiple personalities: A report of 14 cases with implications for schizophrenia and hysteria. Archives of General Psychiatry, 37, 1388-1397.
BLISS, E. (1984). A symptom profile of patients with multiple personalities, including MMPI results. Journal of Nervous and Mental Disease, 1172, 197-201.
BONICA, J. J., & CHAPMAN, C. R. (1986). Biology, pathophysiology, and treatment of chronic pain. In P. A. Berger & H. K. H. Brodie (Eds.), American handbook of psychiatry (2nd ed.), Vol. VII: Biological Psychiatry (pp. 711-761). New York: Basic Books.
BOWERS, M. K., BRECHER-MARER, S., NEWTON, B. W., PIOTROWSKI, Z., SPYER, T. C., TAYLOR, W. S., & WATKINS, J. G. (1971). Therapy of multiple personality. International Journal of Clinical and Experimental Hypnosis, 19, 57-65.
CADDY, G. R. (1985). Cognitive behavior therapy in the treatment of multiple personality. Behavior Modification, 9, 267-292.
CATANIA, A. C., MATTHEWS, B. A., & SHIMOFF, E. H. (1982). Instructed versus shaped human verbal behavior: Interactions with nonverbal responding. Journal of the Experimental Analysis of Behavior, 38, 233-248.
CATANIA, A. C., MATTHEWS, B. A., & SHIMOFF, E. H. (1990). Properties of rulegoverned behaviour and their implications. In D. E. Blackman & H. Lejeune (Eds.). Behavior analysis in theory and practice. Hillsdale, NJ: Eribaum.
CHESSER, E. S. (1976). Behavior therapy: Recent trends and current practice. British Journal of Psychiatry, 129, 289-307.
COONS, P. M. (1994). Multiple personality disorder. In M. Hersen & R. T. Ammerman (Eds.), Handbook of prescriptive treatments for adults (pp. 297315). New York: Plenum.
DONAHOE, J. W., & PALMER, D. C. (1994). Learning and complex behavior. Boston: Allyn & Bacon.
EYSENCK, H. J. (1959). Learning theory and behavior therapy. Journal of Mental Science, 105, 61-75.
FAHY, T. A. (1988). The diagnosis of multiple personality disorder. British Journal of Psychiatry, 153, 597-606.
FINE, C. G. (1992). Multiple personality disorder. In A. Freeman & F. M. Datillio (Eds.), Comprehensive casebook of cognitive therapy (pp. 347-360). New York: Plenum.
FLOURNOY, T. (1900). From India to the planet Mars. New York: Harper Row.
FORDYCE, W. E. (1976). Behavioral methods for chronic pain and illness. St. Louis: Mosby.
GRANT, D. S. (1982). Stimulus control of information processing in rat short-term memory. Journal of Experimental Psychology: Animal Behavior Processes, 14, 368-375.
GRANT, D. S., & BARN ET, R. C. (1991). Irrelevance of sample stimuli and directed forgetting in pigeons. Journal of the Experimental Analysis of Behavior, 55, 97-108.
GUR, R. C. (1982). Measurement and imaging of regional brain function: Implications for neuropsychiatry. In J. Gruzelier & P. Flor-Henry (Eds.), Hemispheric asymmetries of function in psychopathology, Vol. II (pp. 589-616). New York: Oxford University Press.
HARZEM, P. (1984). Experimental analysis of individual differences and personality. Journal of the Experimental Analysis of Behavior, 42, 385-396.
HAYES, S. C. (1984). Making sense of spirituality. Behaviorism, 12, 99-110.
HAYES, S. C., FOLLETTE, W. C., & FOLLETTE, V. M. (1995). Behavior therapy. In A. S. Gurman & S. B. Messer (Eds.), Essential psychotherapies: Theory and practice (pp. 128-181). New York: Guilford.
HAYES, S. C., KOHLENBERG, B. S., & MELANCON, S. M. (1989). Avoiding and altering rule-control as a strategy of clinical intervention. In S. C. Hayes (Ed.), Rule-governed behavior: Cognition, contingencies, and instructional control (pp. 359-385). New York: Plenum.
HILGARD, E. R. (1977). Divided consciousness: Multiple controls in human thought and action. New York: John Wiley.
HORTON, P., & MILLER, D. (1972). The etiology of multiple personality. Comparative Psychiatry, 13,151-159.
JOHNSON, R. F Q. (1989). Hypnosis, suggestion, and dermatological changes: A consideration of the production and diminution of dermatological entities. In N. F Spanos & J. F Chaves (Eds.), Hypnosis: The cognitive-behavioral perspective (pp. 297-31 2). Buffalo, NY: Prometheus.
KANTOR, J. R. (1924). Principles of psychology New York: Knopf.
KELLER, F S., & SCHOENFELD, W. N. (1950). Principles of psychology. New York: Appleton Century Croft.
KOHLENBERG, R. J. (1973). Behavioristic approach to multiple personality disorder: A case study. Behavior Therapy, 4, 137-140.
KOHLENBERG, R. J., & TSAI, M. (1991). Functional analytical psychotherapy: Creating intense and curative therapeutic relationships. New York: Plenum.
MERSKEY, H. (1992). The manufacture of personalities: The production of multiple personality disorder. British Journal of Psychiatry, 160, 327-340.
MODESTIN, J. (1992). Multiple personality in Switzerland. American Journal of Psychiatry, 149, 88-92.
MURRAY, J. B. (1994). Dimensions of multiple personality. Journal of Genetic Psychology, 155, 233-246.
ORNE, M. T., DINGES, D. F., & ORNE, E. C. (1984). On the differential diagnosis of multiple personality in the forensic context. International Journal of Clinical and Experimental Hypnosis, 32, 118-169.
PRICE, J., & HESS, N. C. (1979). Behavior therapy as precipitant and treatment in a case of dual personality. Australian and New Zealand Journal of Psychiatry, 13, 63-66.
PRONKO, N. H. (1980). Psychology from the standpoint of an interbehaviorist. Monterey, CA: Brooks/Cole.
PRONKO, N. H. (1988). From Al to zeitgeist: A philosophical guide for the skeptical psychologist. New York: Greenwood Press.
SACKEIM, H. A., & DEVANAND, D. P. (1991). Dissociative disorders. In M. Hersen & S. M. Turner (Eds.), Adult psychopathology and diagnosis (2nd ed.). New York: Wiley.
SAPULSKY, R. (1995, November). Ego boundaries, or the fit of my father's shirt. Discover, 16, 62-67.
SCHENK, L., & BEAR, D. (1981). Multiple personality and related dissociative phenomena in patients with temporal lobe epilepsy. American Journal of Psychiatry, 138, 1311-1316.
SKINNER, B. F. (1945). An operational analysis of psychological terms. Psychological Review, 52, 270-277.
SKINNER, B. F. (1953). Science and human behavior. New York: Free Press.
SKINNER, B. F. (1957). Verbal behavior. New York: Appleton Century Croft.
SKINNER, B. F. (1974). About behaviorism. New York: Random.
SKINNER, B. F. (1989). Recent issues in the analysis of behavior. Columbus, Ohio: Merrill.
SMITH, G. R., & MCDANIEL, S. M. (1983). Psychologically mediated effect on the delayed hypersensitivity reaction to tuberculin in humans. Psychosomatic Medicine, 45, 65-70.
SPANOS, N. P. (1994). Multiple identity enactments and multiple personality disorder: A sociocognitive perspective. Psychological Bulletin, 116, 143-165.
STAATS, A. W. (1963). Complex human behavior. New York: Holt, Rinehart, & Winston.
STAATS, A. W. (1993). Personality theory, abnormal psychology, and psychological measurement: A psychological behaviorism. Behavior Modification, 17, 8-42.
THOMPSON, J. K., & WILLIAMS, D. E. (1985). Behavior therapy in the 1980's: Evolution, exploitation, and the existential issue. The Behavior Therapist, 8, 47-50.
TURK, D. C.,& RUDY, T. E. (1990). Pain. In A. S. Bellack, M. Hersen, & A. E. Kazdin (Eds.), International handbook of behavior modification and therapy (2nd ed., pp. 399-413). New York: Plenum.
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|Author:||PHELPS, BRADY J.|
|Publication:||The Psychological Record|
|Date:||Mar 22, 2000|
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