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Essay review: multiplying the multiplicity: are dissociative identity disorders 'real'?

Psychiatric diagnoses change. This is obvious to anybody who compares different editions of the Diagnostic and statistical manual: Mental disorders (DSM) of the American Psychiatric Association. Multiple personality was recognized in DSM III-R under its traditional name 'multiple personality disorder'. In the latest manual, DSM-IV, it appeared as 'dissociative identity disorder'. Not only has the name changed, but the diagnostic criteria have too. Ian Hacking asks' What is happening?' (Chapter 1). With his customary wit and scholarship, he documents the conflict which accompanied the inclusion of multiple personality into the lexicon of psychiatry. He shows that dissociative identity disorder competes with other diagnoses (e.g. schizophrenia), that it is more popular in some countries (e.g. USA, Netherlands) than in others (e.g. UK, Germany), and that its validity is still a matter of controversy (Chapter 15; see also Aldridge-Morris, 1989; Mollon, 1996; Piper, 1994).

So multiple personality is not yet like 'gravity', universally accepted as a scientific concept. Why? One could ask whether it was 'discovered' or 'constructed'. Dissociative identity disorder may be a useful way to characterize and deal with certain 'problems of living', but is it more than a convenient fiction?

The proponents of dissociative identity disorder argue as follows. It is a real condition. It was discovered and the changes in psychiatric nomenclature reflect our increasing knowledge of that condition. As a phenomenon it is independent of our knowledge of it (Chapters 1 and 3; Ross, 1996). The counter-claim is that multiple personality is a construction of problems in childhood and their consequences in adulthood. But categories which are just constructed carry practical dangers. A traumatized person can become a multiple in therapy, with the concept of dissociative identity disorder resourcing this crystallization as well as the 'cure'! Even more alarmingly, the critics say, memories of sexual trauma are invented in therapy (Chapter 8). They have no grounds in the individual's past, yet they accuse. A mere construction can become a mere pragmatism and tolerate falsehood. That is the fear. From the point of view of a critic, the changes both in the name (i.e. from 'dedoublement' through 'multiple personality' to 'dissociative identity disorder') and also in the diagnostic criteria should warn us of the fictitious nature of the 'phenomenon'.

Hacking raises many issues in his book and we can only discuss some of them. We will argue that posing the question about dissociative identity disorder in a contrastive way - Is it 'real' or is it 'constructed' - is not helpful and leads psychiatrists, psychologists and sometimes even Ian Hacking into confusion, as he himself later recognized in a self-critical article in the London Review of Books. This is the main point of this review article, as well as to recommend the book warmly - though more for its historical case studies than for the persuasiveness of its conceptual arguments. Hacking's book challenges by example those who believe that progress is always to be made through empirical work, rather than through historical reflection upon the formation of psychological concepts and further thought about the consequences of such historical investigation. To anyone firmly of that persuasion, Hacking's case will appear radical indeed. It will appear less so to those who are already familiar with the work of Michel Foucault and of 'social constructionists ', with which Hacking's approach has broad, but sometimes uneasy affinities.

The strong point of Hacking's book is the meticulous and accessible account of the history of multiplicity (Chapters 3, 10, 11, 12), of child abuse (Chapters 4, 13) and of their coming together in dissociative identity disorder. His history-making is not quite what psychologists are used to. In psychology, history is typically used either to provide ideas with a pedigree or to demonstrate scientific progress by belittling the past. Properly drawn history of psychological concepts such as 'trauma' and 'dissociation' is exactly what is needed to put contemporary psychology into perspective.

We reproduce here a fragment of Hacking's genealogy of multiplicity. He shows that it is steeped in controversy. According to him, the most famous early English-speaking case was noted in Pennsylvania in 1815-1816 (p. 150). Mary Reynolds came from a strictly religious family, and was described as 'normally shy, melancholic, and given to religious devotions'. Aged 18 she started to have severe 'hysterical fits' - she went blind and deaf for five weeks. Aged 19 she slept for almost a whole day, and when she woke up she knew hardly anything of what 'she has learned in the past'. But within a few weeks she relearned to read, write and count. She was buoyant, witty, fond of company and nature. Unfortunately, after about five weeks of this new and presumably better life, she slept again and awoke as her 'normal' self, with no memory of what she had experienced since the lapse. She started alternating between the two identities but the second state eventually became permanent, and that's how Miss Reynolds died (Greaves, 1980; Taylor & Martin, 1944). S. Weir Mitchell presented her case as that of 'double consciousness, or a duality of person in the same individual', distinguishing the alternating states in terms of character, knowledge and skill but being relatively insensitive to memory.

In France, according to Hacking, the concept of double consciousness came to be used only somewhat later. The crucial case was Felida X, brought to fame by the French physician, Azam. When he examined her in 1858 he saw 'catalepsy', 'anaesthesia' and 'hypersthesia' and 'lesions of memory', declared her a 'complete somnambulist', and accounted for her problems in terms of 'hypnotism'. In 1875, however, Azam was inspired by a report of the Belgian Medical Academy about a woman, Louise Lateau, who was famous in Catholic circles for devotional trances and miraculous stigmata, which appeared on her hands, feet and side every Friday (pp. 165-166). The Academy report presented her problems using concepts of doublement de la vie and condition second. Azam re-examined Felida X and reinterpreted her problem as doubling of personality. According to Hacking, Azam established a prototype of double consciousness - a woman with a childhood trauma (not necessarily involving sexual abuse), with an early onset of problems, with one- or two-way amnesia, with alternation between two personality states, and with the second one possibly being an improvement (cf. Hacking, 1995, p. 169). The case of Felida X became influential. Pierre Janet re-presented Despine's case of Estelle as 'an undoubling [dedoublement] of personality' (Janet, 1901, p. 491). But, according to Janet 'the second group of psychological phenomena, instead of alternating with the first, developed simultaneously below and outside of the normal thought of the subject. ... These personalities are not content merely to alternate, to succeed each other; they can coexist in a way more or less complete' (Janet, 1901, p. 492). Once double consciousness became dissociation (desagregation) it could extend from full-blown doubling of personality to isolated fixed ideas. Moreover, fixed ideas could be used to explain, for instance, hyperaesthesias, disturbances of movement and hallucinations. But these were the symptoms of hysteria. Doubling of personality was thus bound to hysteria as its symptom and dissociated fixed ideas came to figure in explanations of hysteria. Hacking commented that 'French multiple personality was born under the sign of hysteria' (p. 132; cf. Micale, 1995). Multiple personality possibly has a longer history than Hacking allows - his own comments on Lateau indicate that prior to hysteria, multiplicity was associated with religious trance possessions and hallucinatory psychosis diagnosed by alienists (cf. James, 1995; Chapter 9).

According to Hacking, the concept of dissociation fell into a temporary disuse (cf. Greaves, 1980) only to reappear as 'multiple personality'. But it had also changed. Eve started with three alters (Thigpen & Cleckley, 1957), Sibyl had 16 (Schreiber, 1973), and with Billy Milligan one stops counting at 20 (Keyes, 1981). The alters now could be of opposite sex and of different race and the important alters were children. The most important feature of the 'new wave' multiplicity was that sexual abuse had become an aspect of dissociative identity disorder (Chapter 4).

So there was a change in multiplicity, but what sort of change was it? Did people dissociate in a different way in the 19th century and in the second half of the 20th century? Or was there a change in the professional conception of multiplicity and therapists started noticing something which was always there? Hacking raises the possibility that both the concept and the practice of multiplicity changed and they did so contingently. One interesting point is that most of the individuals with a diagnosis of dissociative identity disorder report child sexual abuse, but dissociative identity disorder rarely figures as a sequel of established sexual abuse. This could mean that dissociative identity disorder is very rare and sexual abuse is maybe not sufficient to produce it. But it could also mean that dissociative identity disorder and the memories of sexual abuse are jointly established in therapy by therapists and patients working with the concept of multiple personality. Hacking discusses the controversy surrounding this latter possibility in some detail in Chapters 8 and 15.

Could it be that diagnostic concepts in psychiatry are not historically fixed, and this is so because they do not follow naturally and inevitably from the objects which they represent? Even this claim would be anathema to an empiricist, but Hacking goes further. He argues, effectively in our view, that concepts may influence the phenomena that they represent. If we understand his position correctly, Hacking holds in Rewriting the soul that the influence of concepts on experiences is not cognitive (as in linguistic relativism), but mediated by the work of concepts in practices. If concepts operate solely at the level of cognition (i.e. as mental representations) how could they materially affect their referents? Rewriting the soul argues in places that concepts are social tools which resource practices in which experiences are formed and situated, including the experiences of mental illness. The lesson for psychologists could be to remember the advice of the philosopher, J. L. Austin, and pay attention to the pragmatics of concepts and not just to their syntax and semantics.

Hacking does, however, find himself in a quandary. Does everything change historically? No, Hacking maintains that sexual abuse has appalling effects on children however we describe it, and we agree. The claim is, however, difficult to warrant within social constructionism. Had Hacking not spared us the trouble, we would, at this point, have argued that there are serious problems at the very heart of his arguments. These become very obvious in Chapter 17, where Hacking is forced to argue for the indeterminacy of the past, but also to maintain that sexual abuse of children was always sexual abuse. Hacking's case for the indeterminacy of the past draws on the philosophical theory that a single action can be known under different descriptions which in part determine what it is. This theory of action, proposed by Anscombe, has much to recommend it but we are not convinced that Hacking can weld its theme effectively to his main preoccupation with the historical change in our categories for describing the treatment of children. His difficulty arises because he is drawn toward making a transhistorical judgment on what he has done his best to persuade us is an historically changing thing. What, he wants to know, are we now to say about what people did then, given that we can now say things that they could not have said (because the concepts to say, think or intend such things were not then formed)? But the question partly answers itself: the idea of child sexual abuse that we now have would have been meaningless to those in the past - given the concepts available to them they could not have understood, let alone accepted, the suggestion that what they were doing was child sexual abuse. It is Hacking's determination to push the issue to the point of asking of some incident in the past: but was it or was it not sexual harassment then given that people in, say, the 1950s just did not have the contemporary concept of 'sexual harassment'? This is a question too far. It is obviated by the fact that in the 1950s no one could have thought it sexual harassment since the very expression was unintelligible and the concept could not have resourced social activities. Retrospectively, the condemnation of the past is not only that people then behaved in the ways we now reject, but that no one thought anything of such conduct. It was precisely to change that latter fact, to change the standards of what is acceptable and so to discourage or inhibit people inclined to act in such a fashion - that the contemporary idea of sexual harassment was formulated. There is no historical indeterminacy involved, for it is quite determinate that the concepts available then did not include straightforward equivalents to our contemporary concepts. What is involved is a difference between contemporary and the present-day descriptions of past deeds.

The retrospective identification of something in the past as (what we now call) sexual harassment or child abuse is possible because these categories are not entirely, nor necessarily even primarily, intentional ones. Some difficulties one has in making retrospective judgments of child abuse, sexual harassment or multiple personality can arise from the projection onto the past of the irresolution of our present disagreements. There is no settled standard for identifying, and therefore enumerating, for example, multiples even amongst those who accept that the concept is authentic. We regard Hacking's position here as resulting in important respects more from a failure to align his tenses and voices, than from any genuine necessity to contemplate an indeterminacy of the past. The problem may be Hacking's movement between impartially describing the historical development of concepts, and entering into the fray over the applicability of those concepts in other cultures and times.

Hacking, however, did get in before us with his own self-criticism in the London Review of Books (1997). There he lays out what he now sees as a major problem with Rewriting the soul. The problem concerns the notion of 'social construction' (which is not a term that he uses in the book, though the concept is certainly present there) and it is not new. Having declined to affiliate the arguments in his book to those of a 'social constructionist' kind, Hacking subsequently came to recognize in his own book a parallel with the difficulty that typically confronts constructionists. He says: 'There is a felt tension between the notion that something is real and the notion that it is constructed', and he also says that, therefore, 'Whenever someone talks about "construction" it is important to be clear about just what is supposed to be constructed.' His diagnosis is that the problem with Rewriting the soul was the indiscriminate constructionism which, according to him, involved conflating 'the object' and 'the concept'.

The 'concept' is the way in which we think about something, and the 'object' is the something that we think about. Schizophrenia, for instance, is a real illness (the object) but it may be presented differently in different countries, cultures and historical periods (the concept). The distinction between 'concepts' and 'objects' enables Hacking to ask a supposedly clarifying question: 'What is it that is socially constructed, the concept or the object?' In the London Review of Books, Hacking answers that it is the concept, and not the object, that is socially constructed. This allows him to maintain both the permanence (and invariable wrongfulness) of the suffering of children who have been abused and the historical variation in how we think about their abuse ('trauma', 'battered child syndrome', 'child sexual abuse').

Distinguishing between objects and concepts does not mean one has to accept that the two are always mutually inert, or that the influence always flows from the object to the concept. In Rewriting the soul, Hacking provides nice instances of how new concepts can resource new ways of being 'mentally ill'. In the London Review of Books article, however, Hacking limits the 'looping' of concepts onto their objects: the phenomena of social sciences (their objects) are not 'indifferent' to the concepts whereas, according to Hacking, the phenomena in the natural sciences are 'indifferent'. In effect, Hacking rediscovers a traditional and a rather worn distinction between the natural and the social sciences (and a rather traditional explanation for the 'undeveloped' state of the latter: that the phenomena of natural science remain invariant across changing theories, whilst those of the social sciences may respond to, and be changed by, the succeeding theories).

We are not sure that Hacking's London Review reflections correctly diagnose the problem with Rewriting the soul, nor that the arguments elaborated in the London Review of Books improve the situation. First, we are not satisfied that Hacking has put his finger precisely upon his problem with the notion of social construction. The question 'What is it that is socially constructed?' (e.g. about multiple personality) may indeed be a helpful one in clarifying the arguments, but the options to which Hacking restricts the answers are not.

First, the 'real' and the 'socially constructed' are not always exclusive alternatives. For instance, the controversy between those in psychiatry who deny and those who assert the reality of dissociative identity disorder is not an argument about whether or not it is a 'social construction'. Arguing that dissociative identity disorder is not real does not commit one to holding that it is constructed (some would say, for instance, that dissociative identify disorder is not an authentic mental disorder but a matter of people 'faking it' or living our fantasies). The converse is even more obvious: arguing that dissociative identity disorder is socially constructed does not mean that one holds that it is therefore unreal.

'Social construction' is nowadays something of a promiscuous expression (as the term ' representation' has become) and we cannot elaborate in a review on all the confusions it generates. But a blunt way to answer the question 'what is socially constructed?' is thus: 'It is the accepted reality of the phenomenon.' But what does this mean? With respect to the dispute between psychiatrists over the reality of dissociative identity disorder, it is the dispute itself which is the matter of 'social construction', rather than any single position within the dispute. Even if consensus were to emerge that dissociative identity disorder is a biologically based phenomenon, this would not in any way diminish its status as a 'social construction.' Nor, we hasten to add, should this latter identification detract from this 'reality', implying that it is 'only' or 'merely' a social construction. The continuing irresolution about the reality of dissociative identity disorder is a matter of organized professional activities, practices and relationships. The analysis of the way in which through these the reality or otherwise of dissociative identity disorder is adjudicated provides the material for analyses of 'social construction.'

One way of further clarifying our meaning is to suggest some analogy between our analysis of 'social construction' and the phenomenological practice of 'bracketing', insofar as the latter device was intended to disentangle the business of analysis from engagement in the 'ground-level' affirmation and rejection of truth claims. By this analogy, the characterization of something as a 'social construction' does not stand at the same level as the assertions and denials made by disputing parties as to the actuality or otherwise of a given phenomenon, or with respect to the proper identification of the purported phenomenon. Far from aligning itself with either of those standing on different sides of a controversy, it should encompass them both in its depictions, treating them as jointly engaged in the work of 'social construction', i.e. of either endowing the status of 'real' upon, or withholding it, from some phenomenon.

Some sociologists and social psychologists have inflated the notion of 'social construction' out of control. It was originally contrived for sociological purposes, which means that the contrastive category for 'social construction' should include neither philosophical positions such as 'realism', nor other scientific conceptions such as 'the biological', but instead, other sociological standpoints, such as functionalism. Talk of 'social construction' should not be thought of as posing new epistemological and ontological issues but as offering rather a new range of sociological topics. The study of practices for adjudicating whether something is real or not could be added to the study of religious, martial, agricultural, industrial, educational and other practices in which people engaged.

The claim that 'reality is a social construct' may, then, provide no more than a license to engage in the study of the assorted practices whereby persons determine the reality or otherwise of specific phenomena. Assertions about the socially constructed character of psychiatric phenomena would not then be 'ground-floor' contentions about whether or not these phenomena 'really exist', but only about the form of those social practices involved in the conduct, promotion and criticism of various contending approaches to psychiatry (including anti-psychiatric ones). On this view, there is absolutely no need to exempt 'natural' phenomena from the contention that they are socially constructed, nor for those who engage in the investigation of such natural phenomena to feel anxiety on hearing that they are 'constructing' their phenomena. The notion of social construction, so construed, is ontologically and epistemologically innocuous. All the paper expended on arguments over these matters might prove to involve much ado about not very much.

We recommend Rewriting the soul to readers. The book is a very useful resource for anybody interested in multiple personality and its history. They should, however, be aware that even Hacking is not necessarily clear about what his book has actually achieved in broader terms, and has himself voiced serious reservations.

IVAN LEUDAR and WES SHARROCK (Department of Psychology and Sociology, University of Manchester)

Aldridge-Morris, R. (1989). Multiple personality: An exercise in deception. Hove: Erlbaum.

Greaves, G. (1980). Multiple personality 165 years after Mary Reynolds. Journal of Nervous and Mental Disease, 168, 577-596.

Hacking, I. (1997). Taking bad argument seriously. London Review of Books, 21 August, 14-16.

Janet, P. (1901). Mental state of hystericals. New York: Putnam.

James, A. (1995). Dream, creativity and madness in nineteenth-century France. Oxford: Clarendon Press.

Keyes, D. (1981). The minds of Billy Milligan. London: Penguin Books.

Micale, M. S. (1995). Approaching hysteria: Disease and its interpretations. Princeton, NJ: Princeton University Press.

Mollon, P. (1996). Multiple selves, multiple voices. Chichester: Wiley.

Piper, A. (1994). Multiple personality disorder. British Journal of Psychiatry, 164, 600-612.

Ross, C. A. (1996). Dissociative identity disorder. New York: Wiley.

Schreiber, F. (1973). Sibyl. Chicago: Henry Regency.

Taylor, W. S. & Martin, M. F. (1944). Multiple personality. Journal of Abnormal and Social Psychology, 39, 281-300.

Thigpen, C. H. & Cleckley, H. (1957). Three faces of Eve. New York: McGraw Hill.
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Author:Leudar, Ivan; Sharrock, Wes
Publication:British Journal of Psychology
Date:Aug 1, 1999
Words:3783
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