Therapeutic Influence in DID and Recovered Memories of Sexual Abuse

Ralph Underwager & Hollida Wakefield*

(Cite: Issues In Child Abuse Accusations, 8(3/4), 160-169. 1996)

ABSTRACT: Dissociative identity disorder (DID, formerly multiple personality disorder, or MPD) remains highly controversial. Some researchers and clinicians believe DID represents a distinct psychiatric disorder with a unique and stable set of symptoms and behaviors; these professionals see a significant connection between DID and severe childhood abuse. Others maintain DID is an iatrogenic disorder that is heavily dependent upon therapeutic, media, and cultural influences. Despite this debate, there is general agreement that some patients, with the unwitting encouragement of their therapists, can learn to show symptoms of DID. Two case studies are presented that illustrate how therapists can encourage recovered memories of childhood sexual abuse and the development of alter personalities.

The controversies surrounding claims of re-covered memory of childhood sexual abuse continue to rage in the professional community. Along with this debate are disagreements concerning the nature of multiple personality disorder (MPD) (now termed dissociative identity disorder, or DID). Many mental health professionals believe that DID is caused by childhood sexual abuse; therefore adults who recover memories of childhood sexual abuse may also be diagnosed as having DID.

Recovered Memory Therapy

Recovered memory proponents believe that many victims of traumatic and repeated childhood abuse have no memory of their abuse. Along with amnesia for the abuse, they believe that "survivors" have a variety of symptoms and that the patient must be helped to retrieve her memories so she can process the trauma and heal (e.g., Bass & Davis, 1988; Blume, 1990; Courtois, 1992; Dolan, 1991; Fredrickson, 1992). Skeptics, however, believe that such newly recovered memories are actually confabulations created by therapists, survivors' books, or television talk shows (e.g., Loftus & Ketcham, 1994; Ofshe & Watters, 1994; Pendergrast, 1995; Wakefield & Underwager, 1994; Yapko, 1994). This debate has resulted in numerous books, articles, and professional task force reports (e.g., Alpert et al., 1996; British Psychological Society, 1995; Pezdek & Banks, 1996).

Recovered memory proponents refer to various concepts to support their assumptions. The person may have "repressed" the painful memory or "dissociated" during the abuse as protective mechanism. Victims may develop "traumatic amnesia" for the abuse and, if the abuse is severe and repeated, may form "alter personalities" and eventually develop "multiple personality disorder." Proponents believe that the hidden memories of childhood abuse can be observed through psychological symptoms or through "body memories," "flashbacks," or "nightmares."

Techniques used in uncovering sexual abuse memories include direct questioning, hypnosis, age regression, reading survivors' books, attending survivors' groups, free association, massage therapy, dream interpretation, ideomotor signaling with the unconscious, psychodrama, trance writing, and expanding on imagistic memories. Information about this comes from reports of people who have undergone such treatment (Goldstein & Farmer, 1993; Nelson & Simpson, 1994; Wakefield & Underwager, 1994), the therapists themselves (e.g., Bass & Davis, 1988; Blume, 1990; Courtois, 1992; Dolan, 1991; Fredrickson, 1992), journalists or investigators who have joined a survivors' group or gone to a therapist as a pseudopatient (e.g. Nathan, 1992; Wakefield & Underwager, 1994), and some parents whose adult children accused them of abuse based on recovered memories (Freyd, Roth, Wakefield, & Underwager, 1993; Wakefield & Underwager, 1992, 1994).

Memory and Forgetting

Although a common view of memory is that it operates like a videotape in which everything that happens to us is recorded and stored in our brain, this is an erroneous analogy. In reality, what we remember is a combination of the original encoding of the event, everything that happens to us since the event occurred, and our current beliefs and feelings (e.g., Ceci & Bruck, 1995; Dawes, 1988; Goodman & Hahn, 1987; Loftus, Korf, & Schooler, 1989, Loftus & Ketcham, 1991). Reconstructed memories can include detailed and subjectively real false memories of events that never happened (Ceci & Bruck, 1995; Loftus & Ketcham, 1991; Wakefield & Underwager, 1994).

It can be difficult to distinguish a memory for a real event from one that was imagined after reading a survivors' book, hearing abuse discussed in a survivors' group, or being given suggestions by a therapist. The type of error where people mistake memories of events they have only imagined, dreamed, or talked about for memories of real events that have happened is known as a source monitoring error (see Johnson, Hashtroudi, & Lindsay, 1993). Such source monitoring errors can occur in psycho-therapy since the process of talking about memories to a therapist makes it hard to differentiate memories for real events from memories of events that have only been imagined (Suengas & Johnson, 1988). In therapy, the patient talks about past experiences and the therapist selectively reinforces and validates the patient's memories (Lynn & Nash, 1994). A patient who encounters a therapist who believes that repressed sexual abuse is common and that these repressed memories must be recovered for healing to occur is at risk of developing a false memory of abuse. This is especially true if abuse is discussed in every session or when the client is placed in a survivors' group.

Many childhood events, even important ones, can be forgotten (e.g. Loftus, 1993; Raphael, Cloitre, & Dohrenwend, 1991; Rettig, 1993). Such forgotten events are usually easily remembered when there are cues. Even with cues, however, people are seldom able to remember incidents from before the age of 3 or 4 because of the phenomenon of infant amnesia (e.g., Fivush & Hamond, 1990; Howe & Courage, 1993; Loftus, 1993; Nelson, 1993; Pillemer & White, 1989; Wetzler & Sweeney, 1986). Infant amnesia is part of the normal process of memory development and has nothing to do with dissociation, repression, or traumatic amnesia. No researchers report reliable memories in adults for events that occurred before the age of two.

Therefore, sexual abuse may be simply forgotten. Studies on the effects of sexual abuse indicate that many victims show little or no symptomology (Finkelhor, 1990). They may not have seen their abuse as terribly traumatic or they may have been too young at the time to fully understand what was happening, especially if the abuse consisted only of fondling. The abuse may have been perceived as unpleasant, but relatively unimportant, in the same category as many other childhood events (Spence, 1993). It is therefore not surprising that some people forget their abuse until they are reminded in some way. A mechanism of repression, dissociation, or traumatic amnesia should not be hypothesized for this.

Persons for whom their sexual abuse was traumatic are unlikely to forget it. The literature on people who have undergone documented trauma (such as fires, airplane crashes, terrorist attacks, automobile accidents, hurricanes, being held hostage) suggests that, although survivors may report fragmented and impaired memories, they are not likely to develop total amnesia for the entire incident (e.g., Eth & Pynoos, 1985; Spiegel, 1991; Wilson & Raphael, 1993). Terr's (1988, 1990) studies of children who have experienced verified trauma indicate that children over the age of infant amnesia invariably have some memories of their trauma. These findings are consistent with studies where children witnessed acts of personal violence such as homicide, rape, or suicide (e.g., Black, Kaplan, & Hendricks, 1993; Gordon & Wraith, 1993; Malmquist, 1986; Pynoos & Eth, 1985). We were unable to discover any studies on children and documented trauma where the children were described as developing amnesia for the entire incident.

Repression and Dissociation

Repression has been used to explain how people with no memories of sexual abuse can later recover these memories in accurate detail. Repression is conceptualized as a psychological defense that results in the person losing all memory for traumatic events and is usually differentiated from dissociation and traumatic amnesia, although sometimes these concepts are used interchangeably. Repression that involves the removal from consciousness of a series of traumatic events over a number of years has been termed "robust repression" by Ofshe and Watters (1994).

Despite its popularity in psychoanalytic theory, the only support for the concept of repression comes from impressionistic clinical case studies and anecdotal reports. None of the hundreds of studies testing repression (Hoch, 1982; Holmes, 1974, 1990, 1994; Hornstein, 1992) have found convincing support for the concept of repression. In addition, traditional psychodynamic theorists are concerned with the patient's perceptions of reality and do not assume that childhood memories retrieved in therapy are historically truthful (Hedges, 1994; Nash, 1992). There is no support for the belief that repeated episodes of intrusive sexual abuse can be "repressed" and banished from memory, only to be remembered years later.

Dissociation is now often used to explain how traumatic memories are banished from consciousness. There is no controversy about dissociation comparable to that about repression. We are all familiar with spacing out while driving or reading, and trauma victims may report dissociating while in the midst of an accident, fire, rape, terrorist attack, or other trauma. Dissociative disorders are described in the DSM-IV (American Psychiatric Association, 1994).

Recovered memory therapists assume that a child experiencing repeated trauma learns to dissociate so that the abusive experiences are banished from conscious awareness. They believe a child subjected to repeated abuse may eventually develop alter personalities and dissociative identity disorder. But there are problems with these assumptions. If countless women had been abused but forgotten it because of dissociation, dissociation should be commonly found in childhood. But review articles (e.g., Lahey & Kazdin, 1988, 1989, 1990) on childhood disorders do not mention dissociative disorders. Also, the research claiming a link between trauma and dissociation has many shortcomings (Tillman, Nash, & Lerner, in press).

Dissociative amnesia (psychogenic amnesia in the DSM-III-R), defined as "an inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by normal forgetfulness" (American Psychiatric Association, 1994, p. 478), is used to explain how memories for abuse are lost. Loewenstein (1991) has expanded the concept of dissociative amnesia to include a group of events so it can be used to explain the absence of memories for repeated instances of sexual abuse. But there are no empirical data sup-porting a concept of dissociative amnesia for a category of events stretching across several years. Literature reviews on the effects of sexual abuse (e.g., Beitchman, Zucker, Hood, daCosta, & Akman, 1991; Beitchman, Zucker, Hood, daCosta, Akman, & Cassavia, 1992; Cole & Putnam, 1992) do not include dissociative or psychogenic amnesia as a consequence of sexual abuse.

No one has ever explained just how repression or dissociation or dissociative amnesia are actually supposed to work in removing sexual abuse memories from conscious awareness. Does the person develop amnesia immediately following each abusive event? If so, each new instance of abuse would be like the very first time since there would be no memories of any of the previous incidents. Or, does the person, after years of abuse, suddenly develop total amnesia for all memories of all of the abuse incidents which had previously been remembered? This question has not been answered. Also, a person with traumatic amnesia is usually aware of having a memory gap. Although there may be loss of memory for a specified time period, there is memory for events before and after the gap. It is not likely that a person would have total amnesia for a series of events along with no awareness of these memory gaps until a therapist helps him or her recover the lost memories.

Ceci (1995) notes the problem of translating the memories of a very young child into the later interpretations of an adult:

[O]ne possible means of reconnecting with early experiences would be to retrieve the uninterpreted perceptual details as an adult and reinterpret these perceptions in light of their adult meaning. To do this would require that the original perceptions be vivid and accessible. But if they were not originally interpreted as assaultive by the infant, then how could they be the source of subsequent clinical problems? And if they were simply stored as startling images that created some intrapsychic turmoil for the infant, then why should not the same be true (actually, even more true) of a host of startling nonsexual experiences such as genital catheterizations, circumcisions, insertion of suppositories, repeated enemas, and so forth? . . . For these experiences to be sources of adult psychopathology, they would have had to have been experienced as traumatic (e.g., because of their assaultive nature or their betrayal of trust) when they first occurred; if they were not, then nonsexual events that can claim to be at least as traumatic (e.g., genital catheterizations) would also be a basis for similar psychopathology" (p. 97).

Corroboration is seldom found when dissociative amnesia is claimed in cases of recovered memory. In contrast, people who have experienced documented trauma rarely develop total amnesia for the event unless they are physically injured. With the exception of dissociative identity disorder (discussed below), there is nothing in the literature on dissociation that describes selective amnesia for a series of traumatic events which occur at different ages and at different times and places.

Controversies Over Dissociative Identity Disorder

Dissociative identity disorder (DID) (formerly called multiple personality disorder, or MPD in the DSM-III-R) is defined as the presence of two or more distinct identities or personality states. But, although MPD and DID appear in the DSM-III-R and the DSM-IV (American Psychiatric Association, 1987, 1994), the disorder itself is extremely controversial (Dunn, 1992; North, Ryall, Ricci, & Wetzel, 1993). This controversy has increased as this diagnosis has been given to people claiming recovered memories of child sexual abuse.

On one side of the debate is the claim that DID represents a psychiatric disorder with a unique and stable set of symptoms and behaviors. It is believed that DID mainly affects women and begins early in life in children who are subjected to severe physical and sexual abuse (Coons, 1986; Kluft, 1991; Gleaves, 1996; Putnam, Guroff, Silberman, Barban, & Post, 1986; Ross, Norton, & Wozney, 1989). The theory is that a "protector" personality develops, allowing the child to escape psychologically from the abuse (Spiegel, 1991). It is claimed that clinicians often misdiagnose patients who have DID and, because the presentation of DID is often subtle and covert, clinicians must work hard to elicit a history that will permit the correct diagnosis (Bliss, 1988; North, et al., 1993). Hypnosis is often used to elicit signs of DID, to regress to earlier ages, and to trigger the emergence of the alter personalities.

In opposition to this view are researchers and clinicians who maintain that DID is heavily dependent upon cultural influences for both its emergence and its diagnosis (Aldridge-Morris, 1989; Fahy, 1988; Frankel, 1993; McHugh, 1993, 1995; Merskey, 1992, 1995; Sarbin, 1995; Spanos, 1994, 1996; Thigpen & Cleckley, 1984; Wakefield & Underwager, 1994, Weissberg, 1993). The skeptics note that at the time of the publication of The Three Faces of Eve by Thigpen and Cleckley in 1957, MPD was considered an extremely rare disorder. However, there was a great increase in the number of reported cases in the 1980s (Goff & Simms, 1993). Although some clinicians working on dissociative disorder patients report "inordinate numbers" of MPD patients, others report none (Merskey, 1992). In addition, the majority of therapists reporting MPD patients are in the United States (Aldridge-Morris, 1989). The nature of the cases has also changed: Goff and Simms compared 52 case histories of MPD patients published between 1800 and 1965 to 54 reports published in the 1980s. The mean number of personalities in the recent cases was much greater (12 vs. 3), the age of onset was younger (11 vs. 20), there were fewer males (24% vs. 44%), and there was a greater prevalence of reported childhood abuse in the histories (81% vs. 29%).

Many skeptics doubt whether DID/MPD exists at all except as a media or therapist-induced disorder. McHugh (1993) believes MPD is an "iatrogenic behavioral syndrome, promoted by suggestion and maintained by clinical attention, social consequences, and group loyalties" (p. 2). Merskey (1992) reports he was unable to find a case in which MPD emerged spontaneously in the absence of shaping by physicians or preparation through the media. Weissberg (1993) describes the way alter personalities are often elicited by the MPD therapists — highly suggestive instructions, 8-hour interviews, refusal to allow breaks — and he notes that dissociative states resembling MPD may be shaped into multiple personality states. He states that, especially when hypnosis is used, there are significant problems with confabulation and pseudomemories.

Spanos and his colleagues (Spanos, 1994, 1996; Spanos, Burgess, & Burgess, 1994; Spanos, Weekes, & Bertrand, 1985; Spanos, Weekes, Menary, & Bertrand, 1986) performed a series of experiments on what they call the "social psychological" model of MPD. Spanos (1994, 1996) believes that people may combine what they know about MPD from the media with the information provided by the therapist to learn the "symptoms" of multiple personality. The therapists, through encouragement, shaping, and reinforcement, generate and maintain the signs of MPD. Spanos reports that subjects in role playing experiments displayed the major signs of a multiple personality, including adopting a differently named identity, reporting amnesia, using the third person in self-reference, responding differently to psychological tests, and giving different accounts of childhood relationships and current relationships to others. Spanos observes that similar factors are operating in people who report encounters with UFO aliens, in those who uncover memories of ritual satanic abuse, and in those who develop symptoms of multiple personality disorder.

This interpretation of DID as an artifact of psychotherapy is criticized by researchers and clinicians who see DID as a distinct mental disorder and who maintain that, although some of the symptoms of DID can be created by therapists, there is no evidence that the disorder itself can be created. Spiegel and Cardeña (1991) state, "although it is possible that the inappropriate handling by a therapist of a highly suggestible person may give rise to inaccurate reports of early abuse and MPD-like symptomatology, this mechanism does not seem sufficient to explain all or even most of the cases of MPD" (pp. 371-372). Gleaves (1996) maintains that Spanos (1994) makes "numerous false assumptions about the psycho-pathology, assessment, and treatment of DID" (p. 42). He believes that treatment recommendations arising from such assumptions may be harmful to patients, since posttraumatic symptoms will not be addressed.

But, although the existence of DID as a distinct mental disorder is debated, there is agreement that suggestible patients, with unwitting encouragement from their therapists, can learn to show symptoms of DID (e.g., North et al., 1993). The patient may initially show symptoms hesitantly, but with encouragement and guidance from the therapist, DID symptoms emerge and become more complex (Bliss, 1980; Kluft, 1989). Some patients, eager to please the therapist, may develop more alternate personalities (Kluft, 1989). Decker (quoted in North et al., 1993, p. 35) notes that cases of DID "often started out as descriptions of short fugue states followed by amnesia; they ended up as prolonged, complicated, and mysterious cases of multiple personalities."

Several writers (see North et al., 1993, for a summary) observe that DID can provide benefits to patients. The most obvious of these is that DID symptoms are a highly effective way of gaining attention-both to patients and to the therapist diagnosing the disorder. The diagnosis can allow the patient a means of avoiding responsibility for certain behaviors. It can also serve as an outlet for expressing impulses and behaviors that would otherwise be considered unacceptable, such as aggression and sexual acting out. It can provide a face-saving explanation for personal inadequacies and failures. In addition, some criminal offenders have attempted to escape responsibility by using a DID defense (Orne, Dinges, & Orne, 1984).

One therefore does not have to take a position in the debate as to whether DID exists as a valid disorder existing outside of therapist and social influences in order to recognize that symptoms of the condition can be created iatrogenically. We present here two case histories. In both, new memories of sexual abuse were also elicited in therapy. For "Elisa," we suspect that the abuse never occurred. "Belinda,"1 on the other hand, had a well-documented history of sexual abuse by her father which she had always remembered. But her newly recovered memories of sadistic and bizarre abuse were most likely pseudomemories. Both of these cases illustrate how DID symptoms can be created by a therapist.

Case Example 1: Elisa

Elisa claimed to have been sexually victimized by a neighbor when she was between 14 and 18 years of age. She maintained she repressed all memories of this abuse until her therapist questioned her about the possibility. After developing the memories, she sued the neighbor, who denied the abuse.

Elisa came from a troubled and conflicted family and perceived her family as nonsupportive. After high school she worked as a secretary and attended community college part time. She met her future husband when she was 18 and they were married two years later. Her life was complicated by rheumatoid arthritis which, although not life-threatening, was painful and difficult, and she was eventually hospitalized for depression. At the time we saw her she had had a total of five hospitalizations for emotional problems. The hospital records mention her anger and frustration over the chronic pain along with problems with her marriage and with her family, particularly her mother. But until three years ago she was employed and going to school part time.

Elisa began seeing Dr. Smith three years ago. Dr. Smith's case notes indicate that he questioned her a number of times about abuse and that she initially denied it. But he believed she had the symptoms of sexual abuse, so he persisted questioning her until she eventually agreed that her neighbor had "touched" her. She didn't have many memories of this at first, but after a few months she had "flashbacks," and "frightening things" came into her mind. She eventually recovered memories of her neighbor regularly grabbing her and kissing and fondling her when her parents were at work. She claimed that the abuse went on for four years until shortly before she met her future husband, but she claimed to have no memory of it until Dr. Smith began questioning her.

Elisa saw Dr. Smith, who also managed her medications, three times a week and was on a large number of mood-altering drugs. She became progressively more dysfunctional until she was unable to work. She spent most days in bed, except when she was at therapy, while her husband did the house cleaning, shopping, cooking, and laundry. Her inability to cope with these tasks was due to her emotional problems rather than her physical ones, which were currently under control.

Dr. Smith diagnosed her as multiple personality disorder and had this diagnosis confirmed by an MPD "expert" in a nearby city. It was hard for Elisa to accept that she had MPD and she denied it until Dr. Smith told her, "there was no doubt that I had multiple personalities." Eventually she developed seven different personalities and believed that her MPD resulted from the abuse by her neighbor.

Elisa reported that she screams, shouts and throws and breaks things when she is angry and that she has one personality who is very violent. She said that the multiple personalities were a coping mechanism for when she is in a difficult or stressful situation. Dr. Smith's case notes indicate that the alters appeared regularly in their therapy sessions. She hallucinated monsters in the form of a man who was following her. She became frightened and hid and then "Chrissy" came out. She also heard voices that said bad things about her. When this happened, "Judy" came out and punished her by cutting her arms and her legs. She said, "I don't cut, Judy cuts."

During our evaluation, Elisa was appropriate and cooperative. RU spoke to her for four hours and at no time did she display any sign of cognitive slippage, delusions or hallucinations, irrational behavior, or changing personalities. This was despite the stress of the evaluation. She also reported seeing the neighbor in a parking lot at lunch time, but no alters emerged to protect her from either RU or the neighbor.

Elisa's psychological test results indicated significant exaggeration of problems. We interpreted this as a learned response to therapy and her hospitalizations rather than deliberate malingering. She was told that she had severe psychological problems, including MPD, and she learned to play the role of a disturbed and dysfunctional MPD patient, especially when around people who expected this from her. After therapy three times a week, several hospitalizations, and constant talking about how the personalities helped her cope and how the abuse damaged her permanently, this became her reality.

Case Example 2: Belinda

Belinda is the oldest of three children. Her father, a dairy farmer, ruled the household and subjected the children to frequent temper outbursts and harsh punishment when he was displeased with them. Her mother was insecure and extremely passive. As the oldest child, Belinda was expected to spend each day helping with chores. When she was 7 or 8 her father began sexually abusing her; the abuse progressed to regular episodes of sexual intercourse. Belinda did not tell anyone and planned to wait until she graduated from high school to escape, but, when she was 15, her younger sister said she was also being abused by the father. Therefore, in order to protect her sister, Belinda disclosed her abuse to her pastor, who notified the police. The father, who admitted the abuse but maintained it was his prerogative, spent three years in prison. Belinda was blamed by both parents for disrupting the family. She was placed in foster care for the remainder of her high school years where she had several months of therapy.

After high school, Belinda began to work her way through college. While in college, she met her future husband, a bookkeeper who was taking classes towards an accounting degree. He helped her finish college after they were married but she became a stay-at-home mother after their two children, a boy and a girl, were born.

While the children were still preschoolers, Belinda had an episode that was described as an "anxiety attack and dissociative experience" and was diagnosed as "atypical anxiety disorder with hysterical features." Belinda's husband had found her standing in a corner screaming and crying, saying that she was fearful that her father was coming to get her. He took her to the mental health clinic where she was evaluated and given medication. Therapy was recommended but she did not pursue this.

Belinda's next encounter with the mental health system occurred several years later. Her son and daughter were now in school full time. She and her husband, who were having marriage difficulties, each sought individual therapy with the understanding that joint counseling might also occur. Belinda told her therapist, an MSW, about the abuse, but said she felt she had dealt with this. The therapist, however, who believed Belinda had unresolved issues from her childhood abuse, gave her self-help books to read, placed her in a sexual abuse survivors' group (led by the therapist), and asked her to keep a journal of her feelings.

The therapist's case notes for individual therapy, which lasted for two years, contain no mention of dissociative experiences or multiple personalities. However, Belinda eventually began to have "flashbacks," dreams, and new memories of her childhood sexual abuse. These new memories were of violent, bizarre abuse and included others in addition to her father. The journal entries, which are voluminous, focus on her feelings about her father's abuse of her, her mother's passivity, and her needy, inner child that wanted to be held and comforted.

In the meantime, Belinda's marriage continued to deteriorate and she and her husband separated. They had joint custody of the children. During this period, she took a job as a secretary, at which she performed very well (Belinda is of superior intelligence). But she had several "dissociative events" at work where she would have a fixed gaze and wouldn't respond when spoken to. She was not referred to a doctor for these.

After three years, Belinda stopped attending the survivors' group, and four months later she attended the funeral of a relative. She had not seen her family for some time before this and the interactions with the family resulted in depression and suicidality. She wrote a suicide note to her former therapist, who arranged for emergency hospitalization. While in the hospital, she was assigned to a clinical psychologist, Dr. Jones. The hospital records indicate that her history focused on the childhood abuse. Dr. Jones diagnosed her as a borderline personality disorder but also saw her as having a possible multiple personality disorder. Psychological testing during this hospitalization indicated significant distress.

Belinda then began regular sessions of therapy with Dr. Jones. At the beginning he saw her every day in the hospital and then once a week on an outpatient basis. But these visits increased in frequency until she had three to four sessions a week. Over the next three years she was hospitalized 11 more times.

Therapy techniques used by Dr. Jones included yoga and meditation, dream analysis, visualization, automatic writing, analysis of images in dissociative states, and hypnosis. Several times in therapy, Belinda reported new memories of abuse by her father but doubted whether the memories were true. She recovered memories of her father tying her to a mattress, raping her, and sticking a wrench into her vagina; inserting a rifle barrel into her vagina and threatening to pull the trigger; inserting a cross into her vagina as retribution for her religious beliefs; pulling the head off a chicken, sticking his penis into the chicken and making her lick it off; and raping her in a ritualistic abuse ceremony with sacrificed animals and stone circles with fire. Belinda also recalled abuse by others in addition to her father. But whenever she expressed doubt about the veracity of the new memories, Dr. Jones told her that her memories were truthful and that she must accept them as reflecting actual events. Dr. Jones also spent a great deal of time on interpretations of transference and resistance. Belinda saw a psychiatrist for medication, but Dr. Jones was very active in this.

Dr. Jones gradually encouraged the emergence of Belinda's alter personalities. He began by telling her that her conscious mind tries to keep itself separate from the unconscious and that she learned to do this a long time ago for self-protection. He said that when the sadistic abuse occurred she dissociated. He introduced the concept of an "internal self-helper" that was involved in her memories and that tried to communicate directly to her unconscious mind. He taught her that she separated her life experiences into two or more realities and dissociated when she could find no way to deny what was happening.

As Dr. Jones attended to her dissociation, her dissociative episodes increased in frequency over what they had been before. He talked about her false self and her real self. He hypnotized her and used "archetypes" and visualizations to retrieve memories. He taught her about her internal system, her internal self-helper, and her archetypes and the various parts of herself. He named the archetypes and used them to explore issues in therapy. He told her about ego states that were separate from her and encouraged her to ask her arguing ego states to sit down and talk over conflicts. They named the ego states.

More and more ego states appeared and were named until there were over 20. Now most of the sessions were spent talking to the various alters; Belinda had to take her turn to talk to Dr. Jones. Some sessions were spent playing checkers with the boy alter. A promiscuous teenage alter was held responsible for a bar fight. When decisions were to be made, the alters were summoned for a conference and a consensus was taken. Belinda was regularly hypnotized. Eventually, Dr. Jones began fusing the alters after processing this with each of the individual alters; each alter had to give permission before he or she could be fused with Belinda.

Belinda was now unable to care for her children, so her husband, from whom she eventually divorced, received physical custody of them. Despite her good job performance as a secretary and her superior intelligence, she was now unable to work and was placed on social security disability.


1 Names and identifying details are changed in both cases. [Back]

* Ralph Underwager and Hollida Wakefield are psychologists at the Institute for Psychological Therapies, 5263 130th Street East, Northfield, MN 55057-4880[Back]

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