“a Critical Examination of the Models of Dissociative Identity Disorder: a Synthesis of the Posttraumatic Model and the Sociocognitive Model”

Introduction Theories are used to define and explain the world around us. In essence, theories are frameworks for explaining various events or processes. (Baron & Byrne, 2003). Claude Levi Strauss (as cited in Fourie, 2001) maintained that a single logic underlies the structure of all theories. Seemingly contradictions between theories can be reduced to binary oppositions. Theories can thus be reduced to oppositional pairs that produce meaning. Therefore, according to Strauss, society can only understand and give meaning to processes through the contradictionary theories from which they emerge.

Fundamentally then, a thesis is always followed by an antithesis, and at best, a synthesis of the thesis and the antithesis would result in the best theory of a phenomenon (Sternberg, 2003). Dissociative identity disorder (DID), formerly known as multiple personality disorder, is a dramatic condition in which two or more relatively independent personalities appear to exist in one person (Sue, Sue & Sue, 2003). Because of the complexity of the disorder, many theories have been developed to offer explanations for the cause of the disorder.

As with most explanations for complex phenomena, these theories often clash or offer contrasting rationalizations. Controversy also surrounds the disorder because when the disorder became popularised in the 1970’s, the number of cases of DID rose from less than two hundred cases reported worldwide a year to six thousand cases reported each year (Milstone, 1997; as cited in Sue et al, 2003). Some clinicians believe that DID is relatively common but is underreported because of misdiagnosis, others believe that the prevalence of DID is overestimated because of reliance on questionable self-report measures (Sue et al, 2003).

In a survey of psychologists conducted by Cormier and Thelen (1998; as cited by Sue et al, 2003), most psychologists believed DID to be a rare but valid diagnosis. Fifty three percent said they did not think the disorder was due to iatrogenic factors (unintended effects of some action by the therapist), whereas one third believed the condition was produced by the use of a technique such as suggestion or hypnosis.

This essay does not aim at arguing whether DID exists or not, but rather, looks at two contrasting models of DID, the posttraumatic and sociocognitive models, and attempts a synthesis of the two to offer a more complex and rounded explanation for the causes of DID. The crucial question is not concerned with the existence of DID, but rather on its origins and maintenance. Is DID best conceptualised as a naturally occurring response to early trauma, or as a socially influenced product that unfolds largely in response to the shaping influences of therapeutic practices, culturally based scripts, and societal expectations?

The Elements of DID Dissociative disorders involve some sort of dissociation, or separation, of a part of a person’s consciousness, memory, or identity (Sue et al, 2003). DID is a rare, severe dissociative disorder, characterised by the presence of two or more distinct personalities within an individual. Each personality is a complex, integrated being with its own name, memories, behavioural traits, emotional characteristics, social relations, employment histories, mental and physical disorders, and psychological test responses (Maxmen, 1986).

Another key diagnostic criterion of DID is amnesia, described in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV, 1994; as cited in Huntjens, Postma, Peters, Woertman, & Van der Hart, 2003), as “the inability to recall important personal information that is too extensive to be explained by forgetfulness”. Common to most DID patients is the frequent reporting of episodes of interidentity amnesia, in which an identity claims amnesia for events experienced by another identity (Huntjens, Postma, Peters, Woertman, & Van der Hart, 2003).

Not all dissociative identities within a patient are considered to be totally amnesic for each other’s memories. Some identities experience total amnesia, some partial amnesia, and some no amnesia at all. Interidentity amnesia may be symmetrical (both identities claiming amnesia for each other’s experiences), or asymmetrical (one identity claiming amnesia and the other not). (Huntjens, Postma, Peters, Woertman, & Van der Hart, 2003). The relationships between personalities within the individual are often complex, and diametrically opposed pairs of personalities are common in DID patients.

Three types of personalities have been noted in DID patients. The host personality, which usually retains the patient’s legal name and assists in everyday normal functioning, persecutory personalities, which act out aggressive and hostile impulses, and protector personalities, which usually work to avoid dangerous situations. (Sue et al, 2003). DID is much more prevalent in women, and appears to originate in childhood years. The etiology of DID has been linked to severe childhood physical and sexual abuse. (Sue et al, 2003).

This has paved the way for theory-building by psychoanalysists, and most literature on DID is confined to theory of dissociation within an individual due to intense trauma in childhood. This is the foundation of the posttraumatic model. However, controversy has surrounded the issue of the etiology of DID in that, historically, very few cases of DID were reported, but by the 1970’s and 1980’s, an epidemic of DID cases emerged (Kilhstrom, 2005). Critics regard this as being due to the oversensationalism of the disorder through the media and journals reported, which lead to the increase in the diagnosis of the disorder.

Interestingly enough, not only was there an increase in the number of DID cases reported, but also in the number of alter egos (personalities) reported per case. (Kilhstrom, 2005). The diagnosis of DID is an extremely difficult task, this being due to overlapping symptoms with other disorders (borderline personality disorder, schizophrenia, bipolar disorder), and the fact that many DID patients are unaware of altering identities prior to diagnosis due to interidentity amnesia (Powell & Gee, 1999). A substantial amount of research has been conducted on whether the diagnosis of DID is perhaps iatrogenic in nature.

The use of hypnosis in psychotherapy when treating DID patients has particularly brought about a flurry of accusations of iatrogenic inducement of the disorder (Powell & Gee, 1999). The sociocognitive model of DID examines the possible social construction of the disorder through the media, psychosocial expectations, and iatrogenic inducement (Gleaves, 1996). The Posttraumatic Model Psychodynamic theory views dissociative disorders as the result of the person’s use of repression to block traumatic events from consciousness.

When complete repression of the events are not possible, dissociation of mental processes occurs. DID, in this view, is seen as an extreme dissociation where the splits in mental processes are so profound that independent personalities are formed. (Sue et al, 2003). The posttraumatic model (PTM) built on this theory and maintains that DID is an etiologically discrete condition that results from a defense response to childhood trauma, particularly severe sexual and physical abuse. (Powell & Gee, 1999).

Thus, the condition can be seen as a variant of posttraumatic stress disorder (PTSD) in that it acts as a coping mechanism for early trauma (Micale & Lerner, 2001). Advocates of this view will highlight the many cases of sexual and physical abuse in childhood reported by DID patients. In fact, a study by Draijer and Langeland (1999) reported that the severity of the sexual abuse (involving penetration, several perpetrators, lasting more than one year) correlated positively with the severity of the dissociation.

Thus, the development of DID stems from childhood trauma where the child faced with overwhelming traumatic situations resorts to “going away” in his or her head. Children typically use this ability as an extremely effective defense against acute physical and emotional pain. By this dissociative process, thoughts, feelings, memories, and perceptions of traumatic experiences can be separated off psychologically, allowing the child to function as if the trauma had not occurred. Memory and other aspects of consciousness are then said to be divided up among “alters”.

The number of “alters” identified by various therapists range from several to tens to hundreds. (McHugh, n. d. ). Defenders of the PTM of DID will point to the numerous studies that link DID to traumatic abuse in childhood. The vast majority of individuals who develop dissociative disorders (as many as 98 to 99%) have documented histories of repetitive, overwhelming, and often life-threatening trauma at a sensitive age (usually before the age of nine), and they may possess an inherited biological predisposition to the disorder (Sidran Institute, 2003).

The prevalence of DID in women also point to childhood trauma as women are more likely to be sexually abused as children. The Sociocognitve Model According to the sociocognitive model (SCM), iatrogenic and sociocultural factors play a substantial role in DID and account largely for the recent and dramatic rise in reports of this condition (Aldridge-Morris, 1989; as cited in Chaves, Ganaway, Kirsch, Lilienfeld, Lynn, Powel & Sarbin, 1999). The SCM emphasises that through role enactment, DID patients adopt and enact social roles geared to their aspirations and the demand characteristics of varied social contexts.

These role enactments are not products of conscious deception, rather they tend to flow spontaneously with no conscious awareness and a high level of “organismic involvement” such that the role and the self (multiple selves) coalesce so as to become essentially indistinguishable. The media then serves as a tool for reinforcing role enactment. Thus the SCM model proposes that many of the features of DID are derived from culturally based scripts and expectations regarding the typical manifestations of multiple role enactments in Western culture. Chaves et al, 1999). Furthermore, Spanos (1994; as cited in Gleaves, 1996) stressed that treatment literature suggests that iatrogenic factors play an important role in the etiology of DID. This suggestion emerged from the question of why DID diagnosis was rarely made prior to 1970. Advocates of the PTM have counteracted this claim by responding that DID individuals often hide or minimise their symptoms and that clinicians of previous generations were often unaware of DID features or neglected to probe sufficiently for DID features.

However, the SCM maintains that if obvious features of DID are unclear prior to therapy and are illuminated only during therapy, then the possibility that iatrogenic factors play an important role in DID are high. (Chaves et al, 1999). In essence, the SCM posits that alters (personalities) arise in DID patients as a consequence of therapist influences, media portrayals, and socio-cultural expectations. Synthesis The models described above in essence propose a psychodynamic versus social constructionism debate.

Though some of the presuppositions of the PTM and SCM may not be mutually exclusive or logically inconsistent, they differ substantially in emphasis on the etiology and correlates of DID. Specifically, whereas the PTM posits that alters are a naturally occurring result of severe child abuse and trauma, the SCM posits that alters arise as a consequence of therapist influences, media portrayals, and socio-cultural expectations. (Chaves et al, 1999). Given the high rate of child abuse reported in DID cases (98 to 99%), a synthesis of the two models will assume that childhood trauma plays a substantial role in the occurrence of DID.

Thus childhood trauma might produce a predisposition toward certain psychological states (e. g. fantasy proneness and absorption) which in turn increase individuals’ receptivity to suggestion, therapist cues, and role enactment demands in various social contexts. This accounts for the typical manifestations of the disorder only emerging in therapy and not prior to therapy. The media may also be responsible for the types of alters that emerge in DID patients. The sensationalism of DID through the media could be highly suggestive to individuals who have a predisposition to dissociation.

Also, the media plays an important role in setting role behaviours in various social contexts, and this could influence the types of alters that emerge in various social settings. Several authors have also reported that the number of alters tend to increase over the course of therapy (Chaves et al, 1999). A disposition toward dissociation, even if alters already exist, may be increased and expanded through the iatrogenic influences of therapist cues and techniques. Consequently, the SCM could be used to support the PTM.

Dissociation, or a predisposition to dissociation, may arise in childhood as a defense mechanism for traumatic events, but dissociation is maintained and increased through media influences, iatrogenic therapy, and socio-cultural expectations. Conclusion A review of the models of DID does not lead to any substantial evidence to support either model. Finding evidence that would unambiguously falsify either or both models is difficult for several reasons. Firstly, direct experimental manipulation of the crucial etiological agents posited by each model (i. e. childhood trauma in the case of the PTM, iatrogenic and sociocultural expectations regarding multiple identity enactment in the case of the SCM) is impossible for obvious ethical and practical reasons. Secondly, many of the accepted etiological agents posited by the PTM, particularly child sexual and physical abuse, are difficult to operationalise across investigations. Thirdly, many of the accepted etiological agents posited by the SCM, such as sociocultural expectations, are difficult to assess objectively. (Chaves et al, 1999). However, it is difficult to refute either model.

Although the PTM is the most widely accepted and supported model, research has shown that it is possible to iatrogenically create more alters through therapy (Powel & Gee, 1999). Moreover, the research on childhood trauma that supports the PTM is reliant on retrospective information (Chaves et al, 1999). This essay has proposed a synthesis of the two models in an attempt to “see the forest in spite of the trees”. Human phenomena have continuously been found to be produced by an interconnected complexity of agents, and no less should be thought in the case of DID.

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