Dissociative Identity Disorder: Adaptive Deception of Self and Others

John 0. Beahrs, MD

Dissociative identity disorder (multiple personality) is increasingly diagnosed, often follows childhood trauma. and is characterized bv riqidification of phenomena that resemble hypnosis. To inteipret dissociated aspeck of selfhood as autonomous entities is a useful heuristic; but when taken too literally, it leads to three kinds of anomaly: (1) legal: dissociators remain culpable for misdeeds carried out beyond apparent awareness or control; (2) clinical: legitimization sometimes leads not to relief, but to escalating cycles of regressive dependency; and (3) scientific: the form of dissociated entities varies with how they are defined, in ways that are intrinsically motivated and clinically manipulable. These anomalies yield to an evolutionary perspective that views dissociative identity disorder as an evolved strategy of adaptive deception of self and others; e.g., a beaten subordinate avoids further retribution by "pleading illness." Such a deceit best avoids detection when fully experienced; through its intensity and persistence, it becomes real at a new level. One's basic competencies remain intact, however, and are the source of the anomalies described. They can be clinically accessed and empowered, providing the key to therapeutic change when dissociative processes are problematic. Overall, despite clear impairment in subjective awareness and volition, dissociative-disor- dered individuals are best held fully accountable for the consequences of their actions.

When deviant behavior becomes unac- ately excused and "treated."' To be held ceptable, society classifies the offending liable for retribution, transgressors must agents in two groups. Those defined as (1) know what they are doing and why, "bad" (culpable, blameworthy) are sub- and (2) be able to choose otherwise. ject to retribution. Others, defined as These attributions correspond to "con- "mad" (sick, insane), are compassion- sciousness" and "volition," the sensory and motor aspects of subjective experi- John 0. Beahrs, MD is associate professor of , ence.* Their absence, by contrast, pro- Oregon Health Sciences University, and staff psychia- trist at the Portland D.V.A. Medical Center, Portland, vides the cognitive and volitional prongs Oregon. This paper was presented at the 24th annual meeting of the American Academy of Psychiatry and of the insanity defen~e,~and also con- the Law, October 24, 1993, San Antonio, TX. The tributes to the defining features of the views represented in this article are the author's own, and not necessarily those of the Department of Veterans dissociative disorders. Affairs. Address correspondence to John 0. Beahrs, Dissociative identity disorder (DID) M.D. (I 16A-OPC), Portland D.V.A. Medical Center, P.O. Box 1036, Portland, Oregon 97207. relabels multiple personality in the new Beahrs DSM-IV.4 Positive criteria are the char- process: real, yet fundamentally decep- acteristic symptom patterns: (a) pres- tive. This further clarifies how excusing ence of two or more "entities" (person- from responsibility paradoxically rein- ality states), which can (b) "take control" forces the condition, whereas accounta- of one's behavior, accompanied by (c) bility, by contrast, can lead to its suc- "inability to recall . . . too extensive to cessful resolution. be explained by ordinary forgetfulness" (). If an alternate personality Multiple Personality as a Useful state takes over and commits a crime Approximation beyond awareness, control, or desire, There is little doubt that DID (multi- three factors provide a prima facie case ple personality) exists as defined by op- that afflicted patients should be excused erational riter ria.^.^^ It is increasingly from criminal retribution. Amnesia, a diagno~ed,~-~and a standard of care has cardinal symptom of DID4 and hypoth- recently been proposed for its treat- esized vehicle for dissociative bameq5, ment.28 Current consensus accepts a negates our usual concept of conscious traumatic etiology, usually catastrophic awareness. Nonvolition is implied when- child abuse or its equivalent. Thus, DID ever an alternate personality (alter) is a variant of posttraumatic dis- "takes over9' beyond a subject's control. order (PTSD).30,31 Although recent data External victimization is believed to be suggest significant differences that re- a primary etiology in more than 95 per- main to be clarified,32posttraumatic dis- cent of cases.7 Eminent treatabilit~~,~sociation remains closely linked with the suggests a practical reason that dissocia- dissociative phenomena of normal hyp- tive-disordered offenders should be n~sis.~,~~Trauma often leads to stable transferred from the criminal justice to increases in hypn~tizability,~~.~~and the system.lO, Predicta- spontaneous hypnosis occurs widely in bly, this occurs from time to time in the patients with DID.21,36 Dissociative bar- lower co~rts.'~-l~ riers are widely believed to be rigidified When such pleas reach the appellate through the aversive push of traumatic level, however, they uniformly affect.37,38 Despite undisputed impairment in con- Regarding other aspects of the disor- sciousness, volition, and recall, higher der, controversy reigns. Among these are courts have consistently ruled that these the questions of re~ponsibility,~~.23 iatro- patients remain legally responsible for genic artifact,39 veracity of traumatic the consequences of their action^.^',^^ mem~ries,~~-~~examiner bias,44and po- Although unfair from an intuitive per- tency of environmental shaping influ- spective, there are also dominating psy- ence~.~~-~~Among experienced practi- chotherapeutic reasons to enforce this tioners there is additional tension be- responsibility rigoro~sly.~~-~~This paper tween whether to emphasize dissociative explicates how such anomalies arise disorder as a pathological ~ondition~-~,48 from the very nature of the dissociative or as residing on a continuum with the

224 Bull Am Acad Psychiatry Law, Vol. 22, No. 2, 1994 Dissociative Identity Disorder complex consciousness of everyday despite appearances of temporal stabil- li~ing.~~-~~ ity, the form of psychological structures However we conceive these dilemmas, varies profoundly with the context in to think of human mentation at least as which they are defined.45Hypnosis re- if comprised of multiple part-selves has search suggests that physiological pa- extensive heuristic value. It helps to rameters may also be context-depend- make sense of otherwise inexplicable ent.60These anomalies will be discussed paradoxes in consciousness and in turn, before a new synthesis that re- volition2.6'2 1'37~49-53 and respects solves them at another level of abstrac- humankind's ubiquitous experience of tion. inner dialogue and conflict. To validate Legal Anomaly: Multiple Personali- part-selves' autonomous identities con- ties are Culpable for their Misdeeds tributes to the efficacy of ego-state ther- Barring major , courts are tra- a~y,'~configurational analysis,54 ges- ditionally reluctant to excuse wrong- talt,j5 and transactional analysis,56 as doers from responsibility because of well as treatment of multiple personali- claimed amnesia or subjective nonvoli- ties per See&9.37.5 1-53 These advantages tion. These are simply too intangible and hold, as long as we consider the concept difficult to validate.27 More important, of mental entities as either a useful ap- if convincing subjective reports could proximation or a he~ristic.~,21, 37 consistently exonerate antisocial of- fenders, this would undermine criminal Reifying Part-Selves: Three law's basic charge for the protection of Anomalies ~ociety.~'Further, such claims are no- When dissociated entities are taken toriously unreliable whenever high literally, reified, or confused with sub- stakes reward skillful de~eit.~~?~~When stantive reality, anomalies arise at legal, being accused, an almost universal hu- clinical, and scientific levels. Because man strategy is to claim lack of there is only one body that others can Surveys of homicide defendants indicate reward or punish, to allocate legal re- that 40 to 70 percent claim amnesia,64 sponsibility among part-selves is enig- and we lack methods to differentiate matic.16 When alters number into the reliably whether this is real or malin- tens or hundreds, it can lead to a reductio gered.65 Interview styles often used to ad absurdum.15When therapists validate uncover multiple dissociative-disordered patients' impair- (MPD) are also known to bias naive ments at the expense of coexisting subjects toward assuming a dissociative strengths, we often see an escalating spi- pattern.45.46 ral of symptomatic distress, destructive These issues led to extensive debate behavior, and regressive unraveling of over the widely publicized "Hillside personality23,25. 263 373 57-59 rather than the Strangler" case. Some experts argued expected relief. Finally, scientific data that the accused committed homicide in from many diverse sources shows that a dissociated state beyond awareness or

Bull Am Acad Psychiatry Law, Vol. 22, No. 2, 1994 225 Beahrs control66; others, that this was willful incompetency to stand trial. An often- fabrication by an incorrigible psycho- cited law review article noted that "some path.47The intensity of the debate partly amnesia is present in everyone," with reflected the tacit assumption that "real" effects similar to the information gaps implies "not that always complicate jurisprudence; guilty," and the reverse. This assump- thus, amnesia is not a sufficient reason tion does not hold. Even when diagnosis to interrupt the pro~ess.~'In State v. is affirmed, appellate case law holds pa- Badger (1988), a court noted that an tients with dissociative identity disorder MPD claiming incompetency "is only accountable. This applies equally to aware that he has 'lost time.' Yet, when pleas based on impaired consciousness one of his alternate personalities is in (amnesia), nonvolition (alters "taking control, that 'person' can remember, control"), and external victimization quite clearly, what transpired during the (coercion). time that 'person' was in control."72 Amnesia is a known symptom of pri- Each personality state was fully compe- mary organic conditions (e.g., epilepsy, tent, and information sacrificed by dis- Alzheimer's disease), , sociative amnesia for another state could and neurotic process (conversion and be restored adequately with the attor- dissociative disorders), but is "easily fab- ney's help. In summary, we have a par- ricated by a criminal defendant."67 Al- adox: even where global impairment is though in principle it implies diminished undisputed, at other levels the compe- respon~ibility,~~courts usually dismiss it tency remains, and proves definitive. as irrelevant except when it is a symp- Similar results follow claims of non- tom of some other condition.69 Signifi- volition due to contrary alters "taking cant precedents reside in U.S. v. Olvera over" beyond awareness or control. In (1954): "Amnesia is-in and of itself- State v. Grimsley (1982), an Ohio court a relatively neutral circumstance . . . sig- found that "there was only one person nificant only as a symptom confirming driving the car and only one person ac- other evidence that the accused did not cused of drunk driving. It is immaterial know the nature and quality of his acts whether she was in one state of con- during the period for which he lacked sciousness or another, so long as in the recall."70 If epilepsy were established, personality then controlling her behavior, one might be exonerated, but by "the she was conscious and her actions were epilepsy, not the amnesia." If, on the a produc~of her own volition" (emphasis other hand, an intoxicated rapist fled added).73 In Kirkland v. State (1983), a when the victim screamed, this shows Georgia court affirmed conviction for a "that he was conscious of having done robbery committed in a fugue state: "the something wrong." Hence, mens rea is personality, whoever she was, who established. Only this, not the amnesia, robbed the bank did so with rational, is relevant to his guilt. purposeful criminal intent and with Amnesia has also been used to argue knowledge that it was wrong."74

226 Bull Am Acad Psychiatry Law, Vol. 22, No. 2, 1994 Dissociative Identity Disorder A Hawaiian court expanded this rea- has also been used to support pleas for soning in State v. Rodrigues ( l984), mitigati~n.~~ holding that multiple personality "can Two fundamental issues underlie the be examined in a similar fashion as other hard line that courts take in holding defenses of insanity. If a lunatic has lucid multiple personalities responsible. First, intervals of understanding he shall an- for practical reasons, it is only meaning- swer for what he does in those intervals ful to deal with a single body. It is not as if he had no defi~iency."~~And affirm- possible to imprison one part-self while ing earlier decisions, "the law adjudges granting pardon or commendation to criminal liability of the person according another.I6 Second, it is not one's global to the person's state of mind at the time mental state that determines culpability, of the act; we will not begin to parcel but one's state vis-a-vis the offense com- mitted, at the time of the offense. An criminal accountability out among the offender is culpable who knew what he various inhabitants of the mind." or she was doing at that time, and that Similar reasoning applies to crimes others would disapprove. Only this is the committed because of external victimi- mens rea that makes a crime a crime. zation. Discussing Patty Hearst and the Using the multiple consciousness few veterans courtmartialed for anti- model, the impairment to consciousness American actions committed under du- and volition is only partia1;21,22.26it is ress, Lunde and Wilson explored the applicable to perceived selfhood, but not legal ramifications of coercion.76Insan- the level at which an offense is commit- ity is rarely defensible, for similar rea- ted. Only the second level is relevant to sons, and even diminished capacity is mens rea, and here, conscious intention- difficult to argue. They noted that miti- ality is usually evident from the way a gation of sentence is more appropriate, crime is planned and executed. High- based on threefold criteria of a defend- lighting this point are a few contrasting ant's susceptibility, amount of coercion cases in which intentionality is absent relative to severity of crime, and lack of altogether, as in epilepsy. Two patients opportunity to avoid reprisals. with PTSD, for example, charged with Case law variably affirms mitigation excessive use of force in self-defense, of sentence. Death penalty cases are es- were exonerated on testimony that they pecially and some states cur- may have entered dissociative "auto- rently allow varying degrees of compas- matic pilot" when assaulted, truly una- sion for capital offenders who had them- ble to form the requisite intent at any selves been severely abused. In State v. level.80 In DID, however, the fact that Moore (1988), mens rea was affirmed competent awareness and intentionality for a lesser felony. In this case, the vic- remain intact even when concealed tim's death was not intended, but the is fundamental to the nature of the causative brutalizations were.78 Varia- disorder. bly, the pleomorphic diagnosis of PTSD Clinical Anomaly: Iatrogenic Regres-

Bull Am Acad Psychiatry Law, Vol. 22, No. 2, 1994 227 Beahrs sion Dissociative-disordered patients tients' autonomy. How this is problem- often present as living in constant fear atic can be understood by again viewing of imminent catastrophe from within, patients' impairment as only partial. due to overpowering traumatic affect Concurrent with seemingly insatiable and dyscontrol of dissociated alters, im- dependency needs is an inviolable de- plying that, being so impaired, only a mand for autonomy:37 the former, a therapist can assume responsibility for probable manifestation of traumatic af- their safety. To reify this implication as fect; the latter, an antithesis to the utter if objective truth is highly problematic helplessness that many consider the from a therapeutic standpoint. most aversive aspect of trauma.85Ther- Facing such a patient can feel like apeutic nurturance provides relief at the seeing an abandoned baby in the street. first level and impetus to continue in Basic human instinct cries out to rescue treatment. At the level of the already and provide emotional nurturance. suppressed autonomous strengths, how- There is also real concern over the pa- ever, the dependency is perceived as a tient's safety, feared liability for failing threat, increasing the perceived helpless- to protect, and a prevailing ethic of play- ness and leading to an escalating cycle. ing safe. When a therapist does reach Acting out with transient tension relief out to rescue or nurture, however, the can be seen as a misdirected assertion of patient is often not functionally relieved, autonomy,25.37 or in biochemical terms but may enter a pattern of regressive like endogenous addi~tion.'~Either way, dependency with increased emotional the autonomous coping most needed for distress, ever more desperate pleas for health is undermined. rescue, and escalating invasion of the The regressive cycle can be avoided in therapist's boundaries that can worsen part by selectively reinforcing and build- the patient's condition, make treatment ing on the impressive autonomous untenable, and/or aggravate the ulti- strengths that virtually all dissociating mate risk of tragedy.25,267 373 57-59 patients possess but disavow.25.j13 59 This Experienced MPD therapists attribute can be facilitated by therapists' explicitly iatrogenic regression to excessively nur- renouncing the role of indispensable turant co~ntertransferance;~~*" others, agent of change,87which keeps the inter- to therapists' implying their own omnis- personal boundary rigorously correct. cience or omnipotence, treating patients Such treatment could not be conceived as "special," or gratifying patients' de- were we to take the impairment literally penden~y.~~.~~Halleck sees failing to as the truth, the whole truth, and noth- hold patients responsible as a primary ing but the truth. Thus, to optimize factor leading those with dissociative treatment requires that we look beneath disorder23and other "disorders of surface appearances to validate and chal- to regress rather than improve in treat- lenge the underlying competency, not ment. All these factors share a common threaten it. This is the same hidden com- denominator: an implied threat to pa- petency that renders dissociators legally

228 Bull Am Acad Psychiatry Law, Vol. 22, No. 2, 1994 Dissociative Identity Disorder responsible for the consequences of their their focus in a context of enhanced actions. affiliative bonding known as "rap- Scientific Anomaly: Context-Depend- p~rt."~',~~When a hypnotic "state" is ency of Psychological Structures From achieved, subjects experience new inner a purely scientific perspective, viewing realities in response to suggestion, while dissociated part-selves as truly autono- hypnotists enjoy a corresponding illu- mous entities is also profoundly anom- sion of control. Similar processes are alous. Social psychological data show widely believed to occur within psycho- that although dissociative structures are therapy.37. 43.5 1.92.93 Each party's experi- found, their form varies with their psy- ence validates and reinforces the other's, chosocial context far more than com- much like a folie a deux. monly believed. Spanos and colleagues The quasi-contractual nature of these replicated many earlier studies that had transactions is betrayed by the fact that identified dissociated en ti tie^,^.^^ but each party is often partially aware of an found that if they altered the subtle con- "as if' quality. The psychoanalytic inter- textual cues in an otherwise unchanged pretation of hypnotic phenomena as al- design, the nature of the entities changed tered psycho!ogical str~cture~~,~~be- a~cordingly.~~.~~Reviewing many such comes increasingly problematic, as new studies led Spanos to conclude that research refutes the validity of "trance" whenever the predictions of objective as a separable ~tate.~~.~'An alternative entity and context-dependency models model is to view them as an experienced conflict, the latter always prevail.45Like reification of a covert contract for recip- earlier skeptical investigator^,^^,^^ he af- rocally reinforcing illusions. These are firmed that dissociative phenomena like then experienced so vividly that they involuntary action are valid, subjec- become real, at a new le~el.~,~' tively, but must be intrinsically decep- tive. Only through actions consciously Adaptive Deception of Self and planned and voluntarily implemented, Others at some level, can one create the (real These anomalies yield to another level but illusory) experience of subjective of abstraction: the adaptive point of non~olition.~~ view, i.e., distinctions like conscious ver- Strategic therapists report successfully sus unconscious, voluntary versus invol- revising their patients' inner realities by untary, and defining boundaries of psy- skillfully redefining their interpersonal chological entities are all inherently de- ont text.^',^^,^^ With dissociative phe- ceptive, having been shaped through nomena so closely linked to hypnosis, natural selection both to avoid retribu- we must keep in mind their enhanced tion and to promote social cooperation potential for modulation through hyp- in the face of conflicting interest^.^^-^^ notic-like transactions in the interper- Like hypnotic phenomena, these decep- sonal en~ironmental.~',~'Hypnotists tions become real by virtue of how viv- channel subjects' attention and redefine idly they are experienced, stubbornly

Bull Am Acad Psychiatry Law, Vol. 22, No. 2, 1994 229 Beahrs maintained, and legitimized by signifi- avoid betraying the lie by nonverbal cant others. They are real, but are not slips, one must actually experience the what they seem. Psychological structures impairment. One deceives oneself in or- masquerade as if substantive entities, der to protect adaptive deception of oth- but they follow the rules of motivated ers from detection. This process is de- intentionality rather than those of phys- fended both internally and externally by ical substance.loOUnlike objects, they traumatic affect, whose coercive force vary with how they are defined and are both protects against corrective self-scru- validated by social consensus-the "rea- tiny and helps to secure legitimization sonable person" test of common la^.^.^' from significant others.lo2 When these Their inherent intentionality has sev- processes are vividly experienced, main- eral important implications. In science, tained over extended time, and socially it contributes to the fundamental uncer- validated, they become real at a new tainty that accompanies any attempt to level: "psychological realities" that can apply the rules of physical causation.)' even acquire their own physiological In psychotherapy, the resulting context- substrates. By this means, a is dependence permits the therapeutic use born. of "reframing," in which an otherwise At the same time, it remains in trau- invariant reality is simply redefined and matized organisms' interest to retain the reality then change^.^' In social in- maximum coping skill, as long as this is tercourse, by tacit contract, what is hid- hidden from dominants. Autonomous den by self-deception as "unconscious" competencies are preserved but "go un- and "involuntary" is relatively off limits, derground," into an "unconscious" from reinforcing these deceptive attributes which their actions are experienced as and providing coherence to what society 599 91,98 One now controls rewards and pun is he^.^.^^ In social pol- others indirectly, through psychological icy, what is excluded as "taboo" often "gamesws6or "symptoms as a power tac- returns to cause paradoxical effects.lOl Supporting this hypothesis is that subjective impairment usually far out- Posttraumatic Deception: The weighs any objective limitations in DID. Root of Dissociative Identity Most patients experience their impair- Disorder ment as real, and their basic competency Deceptive elements are intensified as but a "front," in ironic contrast with and rigidified by psychological trauma. the deeper truth that the competency is An evolutionary theory of neurosis pos- more real, but concealed. tulates that traumatized individuals Others are led to accept a patient's avoid further retribution by convincing self-definiti~n,~'in part through the dominants that they are ill, thus no coercive effect of traumatic affect,Io2and threat.59,99If this charade is respected, it also through the benefits of re~iprocity.~~ ensures both survival and face-saving Legitimization helps to support a thera- with peers and intimates. Further, to pist's own relative dominance, self-im-

230 Bull Am Acad Psychiatry Law, Vol. 22, No. 2, 1994 Dissociative Identity Disorder age as a beneffective healer, and eco- forcement and rehearsal of defensive nomic li~elihood.~~~',~~-'03 As in hypno- skills needed for emergencies likely to sis, this leads to "rapport."91992By these recur regularly but infrequently. The interdependent processes, patients' com- overall patterns are hypothesized to have petencies are successfully concealed but been adaptive in the dangerous but sta- continue to exert their effects, manifest ble environment of evolutionary adap- in the legal, therapeutic, and scientific tation, but progressively dysfunctional anomalies described. in a rapidly challenging milieu like the This is compatible with recent trauma technological societies of today.lo4 research. Catastrophic stressors lead to lrnplications for Mental Health predictable psychological effects that in- Practice clude dissociation; blurred interpersonal boundaries; and a variety of changes in Although inherently deceptive, disso- cognition, perception, and recallg5 that ciated part-selves are not fraudulent in closely resemble the hypn~tic.~'.~'The the sense of a willful lie. Through their resulting patterns are rigidified and many interdependent reinforcers, they driven by traumatic affect in two oppos- have become real at a new level. Thus, ing directions, avoidance and re-enact- multiple consciousness can still provide ment.85,86This model may also help to a useful approximation or heuristic, val- clarify the .affect-laden controversy uable in many circumstances if not about the veracity of traumatic recall. taken too literally. When problematic, The indelible quality of posttraumatic anomalies can be avoided by returning images may partly follow the rigidifying to a unitary "whole person" perspective, effect of traumatic affect, and its ability but in a way that fully validates the to evoke uncritical acceptance by so subjective reality of psychological enti- many significant ~thers.~O-~'At the same ties and their profound roIe in the regu- time, their more fundamentally trans- lation of interpersonal behavior. Which actional essence is reflected in the many approach or what combination will case reports that illustrate their mallea- prove most fruitful will vary for different bility to therapeutic suggestion and con- clinical situations. textual influence.43DID is one of several Traditional "MPD therapyv8,9. 283 36 possible ways that these processes be- can be interpreted in these terms9' come manife~t.~' Achieving a shared diagnosis, e.g., the The trauma response probably number of alters, relative permeability evolved to serve as "learned instinct" for of amnesic barriers, and subjective levels adaptation to a particular ecological of control, is interpreted not as a sub- niche. Legitimization by others provided stantive truth, but a quasi-contractual external reinforcement, and also served agreement on how reality is to be de- to promote interpersonal bonding in fined-one that validates the patient's the face of outside common threats. pre-existing reality, but has already Re-enactment provided internal rein- changed it in a direction of greater spec-

Bull Am Acad Psychiatry Law, Vol. 22, No. 2, 1994 23 1 Beahrs ificity. Concretization allows one to bet- tive consequences can threaten society's ter grasp and gain control of processes fundamental charge for the protection otherwise too diffuse. Like Erickson's of its citi~ens.~'All lead to iatrogenic famous case of experimental neurosisg0 reinforcement. and Freud's transference neurosis,'05 to Alternative treatment recommenda- resolve the newly modified condition tions can minimize these problems. It is then pulls the other one along with it safer and more effective to hold patients toward therapeutic cure by transferential to their own essential d~ties,~','~chal- mechanisms not yet understood. lenging their autonomous strengths and What is known as the "working thereby empowering rather than under- through" of objective content is viewed mining their mastery and competency. as the renegotiating over de$nition of Appreciating the context-dependence of "seg " a superordinate structure best dissociated structures also cames the po- understood in terms of its impact with tential to alter them at the very outset what is beyond.49 Successful "integra- by how they are defined.59 tion" represents the patient's having The disorder must be validated as real, agreed to a new covert contract, in which both to gain rapport and respect the fact case failure to subsequently uncover al- that dissociative processes had long been ters by hypnotic e~ploration~~reflects present, rigidified by traumatic affect the subject's steadfast commitment to and hypnotic-like transactions with nu- adhere to his or her new self-definition. merous others. This does not require Without reifying the constructs, anom- taking the disorder too literally, how- aly is avoided, and as long as there is a ever. How therapists interpret it with shift toward increased expectation of a their patients may well influence such patient's re~ponsibility,~~a therapeutic parameters as number of alters, perme- outcome is likely. ability to information flow, and patients' Shared reifications become problem- ability to control and redirect their im- atic, however, when therapists even cov- pulses.' This confers an obligation to de- ertly undermine patients' autonomous fine these parameters so as to imply strengths. This leads to peril in both maximum health to begin with-specif- clinical and legal spheres. Clinically, to ically, to imply maximum internal in- reinforce perceived impairments at the formation flow, and to hold patients expense of already suppressed autono- fully responsible for what they can lit- mous strengths can fuel the regressive erally do only for themselves. cycle described earlier. Legally, to accept The therapeutic "fine art" is how to excessive responsibility for another's validate the emotional pain, symptom- state of being may also have contractual atology, and subjective impairment in implications with heightened liability ways that lead patients to feel under- risk whenever illusory expectations can stood and respected, while at the same no longer be fulfilled. In addition, to time reframing their essential responsi- grant violators exemption from retribu- bilities so that they appear self-evident.

232 Bull Am Acad Psychiatry Law, Vol. 22, No. 2, 1994 Dissociative Identity Disorder It often helps to clarify what the therapist also less need for the external reinforcers cannot do: provide global nurturance or of dissociation, i.e., being treated as spe- reparenting, or usurp patients' ultimate cial and avoiding responsibility. Toward responsibility for their safety and life this goal, patients are encouraged to en- priorities. This boundary-setting avoids hance coping skills at all levels including contextually reinforcing the impairment maintaining health, learning useful in- and respects patients' personal space. formation, and applying new strategies Unitary "whole person" language also for personal advancement in the real helps to ensure that contextual reinfor- world. Dissociation can also be used in- cers operate in the desired direction. The tentionally as an adaptive skill rather new label of "dissociative identity dis- than a ~yrnptom.~'Attention shifts to- order"4 facilitates this by accurately im- ward more unitary issues like defining plying disordered personal identity with who one is, value priorities, goals, per- dissociative pathology, and no more. ceived roadblocks, and plans for over- Knowing that hidden aspects remain coming them in the context of everyday aware (co-conscious) enables patients to life. Self-acceptance and confidence in work with them without abdicating ex- one's mastery then become reciprocally ecutive ~ontrol.~~,~~Patients can hold self-reinforcing. "internal board meetings" to hear out Within these parameters, patients' de- inner strivings, address inner discord, fining and redefining of their conflicted and establish common purpose. In es- sense of personal identity can be used as sence, alters are treated as the potentially the primary vehicle for therapeutic discordant aspects of selfhood that all change.25Regressive dependency is min- humans possess. imized by defining a therapist as a con- Patients are expected to interdict their sultant expert, rather than a primary own destructive impulses voluntarily agent of change. Pilot data confirm the rather than shift this burden to others, utility, safety, and cost-efficiency of and, if in danger of dyscontrol, to seek holding dissociative-disordered patients and accept emergency protection via solely responsible for their essential tasks known crisis resources. Violation can of safety from destructive impulses and lead to temporary transfer to a more the direction and pace of therapeutic secure facility elsewhere, defined as pro- tection rather than treatment. When the In summary, despite severe degrees of patient is once again able and willing to subjective impairment and nonvolition, accept his or her primary responsibility, patients with DID retain their basic treatment per se can resume. In a similar competencies at levels that are hidden, vein, patients are also encouraged to but accessible. Hence, they remain fun- identify and abstain from the quasi-ad- damentally accountable for their ac- dictive re-enactment behaviors that in- tions. To hold them responsible has the ternally reinforce the disorder.85.86 threefold advantage of better protecting With increasing confidence, there is society's citizens from offending behav-

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