Burgus v Braun, Cult Recovery, Cults, DID, Dissociative Identity Disorder, DSM, Ex-Cult Members, Monica Pignotti, Multiple Personality Disorder, Potentially Harmful Therapies, psychiatry, psychology, Scott Lilienfeld, Social Work, Trauma, trauma therapy
Dissociative Identity Disorder, Parts Work and Therapy for Ex-Cult Members
It has come to my attention over the past few months that several different ex-cult members have been receiving diagnoses of Dissociative Identity Disorder (DID, formerly known as multiple personality disorder or MPD) from therapists who are are regarded as and/or proclaim themselves to be “experts” in treating ex-cult members. I have also heard from people who were never in cults and went into therapy for other reasons such as depression or a trauma or loss who have ended up receiving a DID diagnosis and doing “parts” work with therapists who are proponents of DID and now feel that this “parts work” and other DID oriented therapy has greatly harmed them. I am not referring to any one particular therapist, as more than one has been reportedly engaging in this sort of work, so my comments here are not to be taken as a critique of any particular therapist. The purpose of this posting is to provide people with information and an alternative point of view on DID (shared by many well-respected mental health professionals) that they may not be getting from their therapist and in no way should this posting be interpreted as specific advice to anyone. Rather, my purpose here is to make people aware that DID is a highly controversial diagnosis and why.
DID is indeed in the current edition of DSM, DSM IV-TR. However, the DSM has never claimed to be a scientifically based manual. The DSM is based on consensus and inclusion of various disorders can have more to do with politics and consensus than it has to do with actual evidence. This appears to be the case when it comes to DID. Much to the dismay of proponents of DID, there are leading scientific psychologists and psychiatrists who have been attempting to get it removed from future editions of the DSM. The reason for this is that DID is a disorder that has little, if any scientific basis and the claims about it, such as that it comes from severe (usually sexual) abuse in childhood lack sound support. DID proponents will attempt to base their claims on brain scan studies. However, it is common for people to make claims on such studies that are without basis. Just because a person’s brain scan looks different for different alters, that does not mean that this is proof that the separate multiple personalities exist. Brain scans can change for all kinds of reasons and these studies on very small samples really mean very little and are certainly no basis for such a diagnosis.
Another problem is the treatment for DID. There is no evidence that what is currently being done by DID therapists is helpful and some forms of DID therapy have been classified as potentially harmful treatments (see Scott Lilienfeld’s 2007 article) due to multiple, well documented cases of harmful effects, some of them resulting in multimillion dollar lawsuits. Lilienfeld wrote (see p. 60-1):
Proponents of DID-oriented therapy believe that patients with
DID, known formerly as multiple personality disorder, harbor
latent indwelling identities (‘‘alters’’) that must be brought to
light for treatment to progress successfully. Many DID alters are
associated with self-injurious behavior, suicide attempts, and
verbal and physical aggression toward others (American Psychiatric
Association, 2000). Moreover, many of these behaviors
are specific to only one alter (Putnam, Guroff, Silberman, Barban,
& Post, 1986). Although the extant data are strictly correlational,
there is reason to suspect that the presence of alters
can impede treatment progress. In one study of DID patients in
treatment, the number of alters correlated significantly (r5.48)
with the length of time to ‘‘fusion,’’ that is, the reintegration of
alters into a ‘‘single’’ personality (Coons, 1984).
Many advocates of DID-oriented therapy use suggestive
methods, including prompting and contacting purported alters
through hypnosis, introducing alters to one another, and mapping
out the interrelations among alters (Spanos, 1994). Some
also attempt to recover memories of childhood sexual or physical
abuse, which many DID-oriented therapists believe to be a
strong risk factor for DID (but see Lilienfeld & Lynn, 2003, and
Lilienfeld et al., 1999, for challenges to this claim). At least one
prominent DID-oriented therapist advocates the use of a ‘‘bulletin
board’’ in which DID alters can post written messages to
one another (Putnam, 1989); another prominent DID-oriented
therapist encourages the use of ‘‘inner board meetings’’ as ‘‘a
good way to map the system [of alters], resolve issues, and
recover memories’’ (Ross, 1997, p. 351). These and other
suggestive techniques are prevalent in the DID treatment
community (see Piper, 1997, pp. 61–68).
There are numerous reasons to believe that these techniques
can create alters in addition to, or perhaps instead of, discovering
them. Only about 20% of DID patients exhibit clear-cut
alters prior to treatment, and full-blown alters emerge in the
remaining 80% only following psychotherapy (Kluft, 1991).
Moreover, the number of alters tends to increase over the course
of DID-oriented therapy (Piper, 1997; Ross, Norton, & Wozney,
Although DID-oriented therapists typically claim that these
findings reflect the discovery rather than creation of alters,
multiple lines of converging evidence suggest that many and
perhaps most alters are products of inadvertent therapist suggestion
(Lilienfeld & Lynn, 2003). For example, most diagnoses
of DID derive from a relatively small number of therapists, most
of whom are DID specialists (Mai, 1995); therapists who use
hypnosis tend to have more DID patients in their caseloads than
therapists who do not use hypnosis (Powell & Gee, 1999); and
laboratory studies indicate that nonclinical participants provided
with appropriate cues can readily reproduce the core
features of DID (Spanos, Weekes, & Bertrand, 1985).
Many people believe that DID therapy is only an embarrassing part of the mental health profession’s past and that it went away after a number of successful lawsuits. However, based on a number of reports I and others have received, some from people who believe they have been severely damaged by DID therapy or so-called “parts” work, this is not the case. Even though it is not the same as the recovered memory therapy of the 1990s, it appears to have morphed into other forms of questionable and potentially harmful therapies. There are several different forms of DID therapy or “parts” work that are currently being done and were discussed in a recent book entitled Trauma Treatment Handbook: Protocols Across the Spectrum (2010, W. W. Norton). Amazingly, this author also references the work of psychiatrist Bennett Braun, as if he were a credible source on DID. Braun was sued by a client who won a $10.6 million settlement against him (see Burgus v Braun) resulting in the surrender of his Illinois license following a complaint by the State of Illinois due to this case. If this is someone currently practicing DID therapists consider a credible source to be cited in a handbook for clinicians, the profession is in trouble!
Since these approaches do not appear to meet the standard to be classified as empirically supported, this raises serious concerns about not only their effectiveness but also about whether they may do more harm than good. I predict that some supporters of DID therapy will protest that the harm comes when people practice illegitimate forms of the therapy or in some way do something incorrectly. However standards for what is or what is not legitimate become moot when the so-called legitimate forms of the therapy lack sound evidence to support their safety and efficacy. Most of the therapists who were sued and the ones who are now being complained about are licensed mental health professionals and in some cases state boards appear to be turning a blind eye to attempts by some patients to complain, which for some have been to no avail.
One might wonder whether therapy clients can just use their own experience in therapy to judge whether this type of approach is helping. Why not just continue if they are doing better and stop if they aren’t? While this seems to make good common sense, the problem with this is that typically, DID therapists warn their patients/clients that they are going to initially feel worse, that the therapy takes many years and that they will feel worse, possibly for long periods of time, before they get better. Again, note that there is no scientific/research evidence to support this claim, only anecdotes, but it keeps the client coming back, even while further deteriorating. Typically the therapist will focus on positive anecdotes of clients who claim to have ultimately benefited from such therapy while ignoring or explaining away anecdotes from clients who they feel they have been tremendously harmed by such approaches. The bottom line is that if there are no well-designed, scientific studies to show that this approach is truly helpful, the burden of proof is on the people making these claims and given that anecdotes are both positive and negative, we need to take the negative anecdotes very seriously. Since the first mandate of a mental health professional is to do no harm, it is better to err on the side of caution in these matters.
If you are an ex-cult member or anyone else who is receiving therapy that has involved a diagnosis of DID or parts work, while I cannot offer you specific advice, you would do well to make sure you have engaged in a thoughtful examination of both sides of this controversy. There is a tight-knit community of therapists who like to think of themselves as “trauma therapists” who use this approach and who have launched vicious attacks on any critics. For those of you who have been in a cult, these tactics will look all too familiar.
Just remember that people who are undergoing psychotherapy of any kind should expect to be feeling better and to be making progress, functioning better in their relationships, work and lives, not worse. There have been a number of reports of people who initially came into therapy with a problem such as depression or dealing with the aftereffects of a trauma, who during the course of therapy became less functional, became unable to work or began to have serious relationship problems. This should not be happening in legitimate therapy. If someone has told you that you need to get worse before you get better, that is a time to be very skeptical. Unless the person can show you published, controlled studies that document that people who get worse actually do eventually get better, if I were a client in that position or anyone in my family was, I would get them out of that situation as quickly as possible. That’s what I would do and it is up to each individual to decide what he or she would do.
As I have mentioned elsewhere, I also have serious concerns about some of the ways in which post-cult therapy is promoted. Statements have been made, without sound basis that everyone who has been in a cult needs therapy to recover or they will not be able to successfully move on. Again, there is no evidence that this is the case. Many people who leave cults have gone on to live happy and productive lives without any therapy whatsoever and many who were having difficulty, recovered within a short period of time just by having supportive therapy, not any kind of therapy that dwelled on treating DID, dissociation or “”cult selves” or “parts”. There are people who have been away from the cults they were in for years or even decades and literally for years run from one cult recovery group, therapy or conference to the next and do not appear to be getting better, but instead are endlessly dwelling on their cult experience. Again, I have to question the helpfulness of such “experts”.
DID can seem credible to people because we all do have different aspects to our personalities. There is nothing abnormal about this at all. Social psychologists call this role identity. We behave differently when we are in different life roles. For example, a mother who is also an executive would be behaving very differently in each role and may even seem or feel like a different person in each role. That, however, does not mean that she has DID or any kind of disorder. Applying this to cults, people would indeed behave very differently as cult members in that role identity than they would in situations outside the cult but again, that doesn’t mean that the person has a dissociative disorder. I have to say that having seen the kind of struggle ex-cult members who seek help are going through, I really have to question and wonder whether many of these post-cult therapists are doing them any good, especially when I have seen so many other people walk out of cults, initially go through a period of confusion and distress and then move on to live happy, productive lives without the help of any “experts”. I’m not saying that no one should ever seek therapy for their cult experience. Sometimes, for some people it can be helpful but I would be careful about getting into yet another “identity” of the ex-cult member poster child. The fact is that current post-cult therapy really has no evidence that it helps so all people can do is to monitor themselves and truly examine whether they are feeling and functioning better in their lives or not and be very skeptical of anyone who tells you that you have to get worse before you get better. Again, these are my opinions, not meant to be any kind of specific advice.