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Sexual assault counsellors' experiences of working with people living with multiplicity.

I first encountered the concept of multiplicity in my work approximately four years ago. Despite my familiarity with dissociation, I had never before (knowingly) met anyone living with multiplicity. I then consulted the available literature on multiplicity and discovered that it was overwhelmingly psychiatrically based. However there is also a substantial amount of literature that suggests that physical, emotional, and in particular sexual abuse, are precipitating factors in the emergence of multiplicity (Kluft 1985; Bliss 1986; Gil 1988; Fleming 1989; Putman 1989; Brown and Anderson 1991; Dunn 1992; Gelb 1992; Halpern 1992; Jackson 1992; Murray 1993; Bloom 1995; Dorahy 1996). More specifically, incest is noted as a predominant feature in the history of adults living with multiplicity (Sgroi 1982; Blake-White & Kline 1985; Briggs 1986; Herman, Russell and Trocki 1986; Ross 1989; Gil 1990; Brown & Anderson 1991; Marmer 1991).

Therefore if one is to accept the aetiology of multiplicity as severe childhood trauma, especially sexual abuse, the absence of the voices of sexual assault counsellors become glaringly apparent. For this reason, together with my personal interest in the area, I was curious to explore the experiences of sexual assault counsellors who have, or had, worked with people living with multiplicity.

As a self-identified feminist I believed it was important for this research to be conducted within a feminist framework. While not necessarily unique to feminism, feminist research is perceived as a two way process between the researcher and those for whom the research is being conducted (Oakley 1981; Stanley and Wise 1983; Finch 1993). Meaning that I considered myself to be a part of the research.

Some feminists suggest the use of qualitative research "in order to better reflect the nature of human experience" (Jayaratne 1993, III). As this study was exploratory a (primarily) qualitative design was decided to be the most suitable. Data was obtained from participants by means of a semi-structured interview which is described by Oakley (1981, 32) as "essentially a conversation" but also an "information gathering tool".

With any research project there are limitations, and this study also had its own constraints. The project had to be completed within one year, there was no budget to cover fieldwork expenses and I alone was responsible for data collection and analysis. Given these restrictions, it was decided that a workable and effective design would be one in which a maximum of ten sexual assault counsellors would be interviewed about their experiences of working with people living with multiplicity. The study area was confined to inner metropolitan Sydney.

Mental Health System

While many important issues were raised by participants during the interviews, about all the different health, welfare and legal services available in our community, the mental health system was overwhelmingly identified as the primary point of contact for multiples. All those interviewed recounted 'horror' stories from clients who had been physically, sexually and emotionally abused within this system.

Initial Contact with the Mental Health System

The claim by one person interviewed that, "all of my clients have had psychiatric histories" represents all participants' comments. The high contact rate with the mental health system was attributed by six participants to suicide attempts. For multiples, attempted suicide was seen as "being very much the norm" and "par for the course". One participant elaborated by saying, "if you have someone that you suspect has DID (multiplicity) then sooner or later there is going to be a crisis that will involve if not a suicide attempt, they will be feeling very, very bad and having suicidal thoughts. I think it goes with the territory".

Kluft (cited in Middleton 1995, 2) asserts that, "there is no condition associated with a higher suicide rate". Putman (1989, 64) also claims that suicidal behaviour is extremely common for multiples, estimating a rate of 75%. Similarly, in his series of 236 cases of multiplicity, Ross (1989, 98) states "72 percent had attempted suicide and 2.1 percent had killed themselves".

Misdiagnoses

All ten people interviewed did not consider it uncommon for multiples to spend a large part of their lives journeying through the mental health system. While one participant did not have a sense of why this phenomenon applies to many multiples, the other nine attributed it to misdiagnoses because generally, the mental health system does not understand, or does not believe in the existence of multiplicity.

According to all ten participants, misdiagnosis can happen again and again. Several of those interviewed commented that it was not unusual for multiples to be diagnosed with schizophrenia and/or borderline personality disorder. All ten referred to major depression as being the most common misdiagnosis that multiples share. Similarly, Putman (1989, 68) claims that, "a past psychiatric history characterised by multiple previous diagnoses such as depression, schizophrenia and borderline personality disorder" is a feature that many multiples share. Within the Australian context, Middleton (1995, 22) informs that 29% of the 58 multiples with whom he has directly worked had previously been diagnosed with schizophrenia.

A major difficulty here is that if people are misdiagnosed then the risk that they may be treated inappropriately is high. For instance, one participant stated, "one of my clients in particular is a traumatic example of this". Apparently the client had been subjected to electroconvulsive therapy (ECT) because she had been diagnosed with major depression. Another participant also referred to a client who had been given ECT because of the same diagnosis and said,
 although it (ECT) is considered effective for treating depression
 it causes confusion, memory loss and headaches. The tragedy is
 that these are the very things that multiples suffer from.


Confusion, memory loss and headaches are well documented as common features of multiplicity (Bliss 1986; Putman 1989; Ross 1989; Middleton 1995; Schneider 1996; Van der Volk et al 1996).

The Misuse of Medication

Prescription of inappropriate medication was cited by participants as one of the consequences of misdiagnosis. A concern for four participants was the emphasis placed on medications for multiples. This was expressed as "psychiatrists not seeming to understand multiplicity". One participant conveyed a case where a client had been misdiagnosed and given "a lot of anti-psychotic medication". Apparently the client found that this "scrambled her brain completely and left her feeling like she had no control over anything in her life". This is a matter for concern, especially when other psychiatrists (Bliss 1986; Kluft 1985; Ross 1989) working in the area claim a diagnostic clue for multiplicity is failure to respond to conventional drug therapy.

Scheff (1984, 163) comments on the overuse of psychiatric medications and says some he has witnessed include such physical side effects as "irreversible brain damage from overuse of sedatives". Scheff further asserts that because medication does not remove the source of the so-called disorder, psychiatrists are strongly tempted to resort to maintenance therapy because he claims that this acts as a "chemical straitjacket" (Scheff 1984, 171).

Other Forms of Abuse

All but one of those interviewed mentioned that many of their clients living with multiplicity had been mistreated and/or exploited within the mental health system. One of the participants said that the mental health system is "at best punitive and at worst re-abusive". This echoes the general view of participants.

Known instances of sexual assault were reported by three participants with one stating, "I do not think it is at all uncommon for people to have been sexually assaulted within the mental health system". Another revealed that all of her clients with multiplicity had been "terribly abused by the psychiatric system, let alone how many have been raped within that system". Previous research affirms this. Middleton (1995, 23) informs that thirty three percent of his 58 clients living with multiplicity have "reported past sexual abuse involving a doctor or other therapist".

Irwin and Thorpe (1996, 11) alert us to the situation where "professionals in the human services can be perpetrators of violence, albeit unintentional". This is well illustrated by one participant who invites us to 'imagine' being a multiple with a history of childhood sexual abuse:
 imagine being a woman in a psychiatric unit and as you come to
 admission your clothes are taken away from you and you are given
 a nightgown. You may or you may not be allowed to wear
 underpants. Not only do you risk being molested by other residents
 but imagine being triggered in some way and you experience a
 flashback. The nurses respond, not just one, it is more like four.
 They push you to the ground, your nightgown is pulled up, your
 underpants are pulled off, if you are wearing any. You are then
 given a big injection in the bum and are dragged off. What would
 that be like?


As well as sexual violence, claims are made by participants that physical violence is also perpetrated against people in the mental health system. Two of the people interviewed referred to "cold bath treatments". This was described by one as: "taking what was considered to be severely psychotic patients and placing them in a bath full of cold water. Once they were in the bath there was a cover placed around them which was zipped up to the neck so that the person had no way of getting out. They were often left in there for hours."

Most (nine) participants reported that the multiples they have worked with are very bitter about their experiences in the mental health system. This was partly attributed to the fact that "a lot of mental health workers know nothing about dissociation", therefore it was argued, they do not know how to work with multiples.

Medicalisation of Violence

Placing the issue of sexual violence within a medical context effectively invalidates 'victims' experiences and problematised them in terms of a serious mental health issue. One participant's statement that "I have an issue with the whole psychiatric ownership around normal reactions to trauma and how that becomes medicalised", summarises the view of half (5) of those participants interviewed. Medical ownership of sexual violence means that the effects are pathologised and individualised. Rather than acknowledging responses as a sexual violence issue, they are problematised within the person and seen as an 'illness'. Not only does the meaning a person attributes to their experience change, but medical expertise is then required to 'cure' the person.

Psychiatric Dominance

Several participants referred to the dominance of psychiatry in the area of multiplicity. When asked the reasons for this, one participant stated that, "the fact that multiplicity has been described as a mental health problem. I guess that is where psychiatry had owned it". Yet, this was not necessarily a negative situation for another participant who said,
 if someone fronts up and says I have been diagnosed by a
 psychiatrist then it is nameable and the person is naming it. So,
 you can name it as well and then that gives a frame of reference to
 what you are doing. I do not know why but if it is not named by a
 psychiatrist then it is nerve wracking because you know, therapists
 are supposed to implant those sorts of things. It does not seem to
 have that same sort of sense and credibility, whether that is real
 or imagined.


However, another participant claimed:
 there are implications around believing somebody who was not
 psychiatrically assessed because of the mythology surrounding
 psychiatry. I think that out there, there is real pressure that
 no-one can be multiple unless a psychiatrist has diagnosed them
 in the same way.


Scheff (1984, 172) argues that psychiatric dominance is "largely a result of legal and social definitions". He argues that Mental Health Acts usually require psychiatrists to be in dominant positions within mental health institutions. Their decisions are socially sanctioned and reinforced by law endowing psychiatrists with 'expert' authority in what is perceived as the mental health area.

Psychiatric Labelling

Labelling multiplicity as a psychiatric disorder was also raised as a major concern by participants. Five of the ten people interviewed expressed unease at attaching a psychiatric label to multiplicity, viewing it as a creative coping mechanism rather than a disorder. One participant portrayed multiplicity thus:
 it shows the strength of the human psyche, the spirit and the spark,
 and the intelligence that is there for the child to survive. I do
 not like to call that a disorder. It is not at all disorderly.


One person interviewed believed that:
 people have always been labelled by the medical profession
 depending on a certain behaviour. I think it is historical, since
 Freud. I guess it has just been a way that the medical profession
 has been able to box people and therefore define the treatment.


One participant thought it was curious that:
 if we talk about this whole thing of being ascribed a label and
 therefore there is some sort of medication that comes with that
 label, but they [psychiatrists] are still not picking up on the
 issue of the sexual assault.


Rummery (1996, 157) suggests that labelling people who report histories of childhood sexual abuse as "crazy" allows professionals to "dismiss disclosures about CSA as imagined or exaggerated". This effectively silences victims and provides professionals with an 'out' by hiding behind a veil of denial.

Psychiatric labelling also has the potential to marginalise people because of the social stigma attached to 'mental illness'. They often wear a 'mad' or 'bad' label which dictates their role within the family system and society. Being labelled deviant in this sense isolates people even further, a situation which is often exacerbated by the lack of support services in the community. It also precludes many from obtaining employment and, therefore, they are denied the opportunity to 'live' as other citizens within their community.

Psychiatric Denial

Psychiatry's denial of childhood sexual abuse, and therefore of multiplicity, was cited as a primary concern by those interviewed. In fact, one participant deemed the 'divided camp' in working with multiplicity to be a major issue; "I struggle with the fact that even though it is recognised in the DSM-IV many psychiatrists do not believe in its existence".

Middleton (1995) argues it is not by chance that psychiatric acknowledgment of the trauma from intra familial abuse has lagged behind its acceptance of other victims of trauma. He claims that it is easy to "write editorials based on rhetoric, collude with the person's own defence mechanism of denial, or by being the expert" (1). Whereas, he argues, acknowledging widespread existence of trauma confronts the "darker" side of our society.

Bloom (1995, 15) also suggests that recognising childhood sexual abuse has been "an enigma to modern psychiatry and the culture it represents throughout its existence". In her training as a psychiatrist, Bloom says she was taught that incest was rare and that she would never see a case of "the so-called condition, MPD" (Bloom 1995, 21). How then can the existence of multiplicity ever be established if professionals are not even open to the possibility. It is assumed that even sceptics have debated the arguments to arise at the conclusion that it does not exist.

Training

All ten participants raised appropriate education and training as an essential issue. One participant referred to the danger of unqualified people "like social workers and occupational therapists working with multiplicity", deeming psychiatrists and psychologists as the only professions competent enough to do so. However, another participant stated, "if you do not work in a particular framework then you are made to feel not good enough".

Five participants thought that in order to work with multiplicity, "training is vital for all people regardless of professional background". One stated,
 I think training is really important, like training that tells
 people that you have got the skills and also training that says
 this is the dynamics. Training that actually promotes people to
 think about what are the dynamics, what is MPD about, how do
 people develop MPD, and training that encourages people to
 listen to what women's experiences are.


Gil (1988, 152) also argues that there is a lack of appropriate training in relation to multiplicity, claiming that "in graduate schools across the United States students of mental health have been consistently taught that MP is extremely rare". It would seem then that validation and understanding of multiplicity requires education for all professionals on the reality and impact of sexual violence.

Conclusion

Many important issues were raised by participants during the interviews. Severe childhood sexual abuse was identified by all those interviewed as the primary element in the creation of multiplicity. Although participants were divided on the issue of diagnosis, all ten described multiplicity as a dissociative process. A lack of appropriate services for all survivors of sexual violence was pinpointed as a major social issue requiring urgent attention. The impact of working with multiples who have been abused by satanic cults was raised as an issue by five people interviewed. Society's denial of the existence of multiplicity, and the extent of childhood abuse, were raised as key issues.

The mental health system was cited by participants as the primary, and often the first point of contact, for those living with multiplicity. Prolonged contact with the mental health system was argued on the grounds of a lack of understanding of multiplicity, often resulting in misdiagnoses and the prescription of inappropriate medication. The dominance of psychiatry in the area of multiplicity was questioned by participants, particularly in light of the widespread denial of its existence by the psychiatric profession. The labelling of multiplicity as a psychiatric illness was deemed by participants to be particularly problematic and was seen as contributing to it being misunderstood. Thus, appropriate training was seen as crucial to work in the area of multiplicity.

The existence, and therefore the aetiology, of multiplicity has long been controversial. Surely, after almost 100 years of debate, it is time to set aside the argument about the existence of multiplicity and turn our attention to ways of assisting people to overcome their trauma. As unpleasant as it may be, society needs to hear the plea of abused children, and focus on ways of preventing the enormity of this tragedy from marring any more lives.

References

Blake-White J. & Kline C. (1985) 'Treating the Dissociative Process in Adult Victims of Childhood Incest,' The Journal of Contemporary Social Work, America, September, 394-402.

Bliss E. (1986) Multiple Personality, Allied Disorders and Hypnosis, Oxford University Press, New York.

Bloom S. (1995) 'Child Sexual Abuse--Does it Really Exist: The Issue of False Memory', The ISA Journal, October 14-24.

Briggs F. (1986) Child Sexual Abuse: Confronting the Problem, Pitman Publishing, Australia.

Brown G.R. & Anderson, B. (1991) 'Psychiatry Morbidity in Adult Inpatients with Childhood Histories of Sexual Abuse and Physical Abuse', American Journal of Psychiatry, 148, 55-61.

Dorahy M. (1996) 'Dissociation', Beyond Survival, 16, 4-5.

Dunn G. (1992) 'Multiple Pnersonality Disorder: A New Challenge for Psychology', Professional Psychology, Research and Practice 23 (1), 1823.

Finch J. (1993) 'It's Great to have Someone to Talk to: Ethics and Politics of Interviewing Women', in C. Bell and H. Roberts (eds), Social Researching: Politics, Problems, Practice, Routledge, London.

Fleming, J. (1989) 'Multiple Personality Disorder', British Journal of Psychiatry 154, 877.

Gelb J. (1992) 'Current Research on Multiple Personality Disorder', paper presented at the 1st Australian Association of Multiple Personality & Dissociation Conference, A Multi-Disciplinary Perspective on Satanic Ritual Abuse, Melbourne.

Gil E. (1988) Treatment of Adult Survivors of Childhood Abuse, Launch Press, California. Gil E. (1990) United We Stand, Launch Press, California.

Herman J., Russell D. & Trocki K. (1986) 'Long-term Effects of Incestuous Abuse in Childhood', American Journal of Psychiatry, 143, 1293-1296.

Jackson C. (1992) 'Multiple Personality Disorder: An Overview', paper presented at 1st Australian Association of Multiple Personality & Dissociation Conference, A Multi-Disciplinary Perspective on Satanic Ritual Abuse, Melbourne.

Jayaratne T. (1993) 'The Value of Quantitative Methodology for Feminist Research', in M. Hammersley (ed), Social Research, Philosophy, Politics and Practice, Sage, London.

Kluft R.P. (1985) 'Childhood Multiple Personality Disorder: Predictors, Clinical Findings and Treatment Results', in R. Kluft (ed), Childhood Antecedents of Multiple Personality Disorder, Guilford Press, Washington.

Marmer S. (1991) 'Multiple Personality Disorder: A Psychoanalytic Perspective', Psychiatric Clinics of North America 14 (3), 677-693.

Murray J. (1993) 'Relationship of Childhood Sexual Abuse to Borderline Personality Disorder, Posttraumatic Stress Disorder and Multiple Personality Disorder', The Journal of Psychology, 127(6), 657-676.

Oakley A. (1981) 'Interviewing Women: A Contradiction in Terms', in H. Roberts (ed), Feminist Research, Routledge and Kegan Paul, London.

Putman F. (1989) Diagnosis and Treatment of MPD, Guilford Press, New York.

Ross C.A. (1989) Multiple Personality Disorder, John Wiley & Sons, Canada.

Stanley L. and Wise, S. (1983) Breaking Out: Feminist Consciousness and Feminist Research, Routledge and Kegan Paul, London.

Susan Neighbour (1) (1) At the time of writing this article Susan Neighbour was a social worker in a sexual assault service in Sydney.
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Title Annotation:RESEARCH FORUM
Author:Neighbour, Susan
Publication:Women in Welfare Education
Article Type:Report
Geographic Code:8AUST
Date:Jan 1, 1998
Words:3449
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