Working (hah, and living) in the field of dissociation, I often come across the popular idea that multiplicity is iatrogenic, that is, caused by well meaning therapists implanting the idea in the minds of vulnerable clients. It’s almost impossible in the clinical sector to have a conversation about DID without someone raising this concern.
What really interests me is the clinical sector only seem to worry about this possibility with DID. I’ve never heard of anyone worrying about iatrogenic Depression or Schizophrenia. Surely people vulnerable enough to be convinced through suggestion that they are multiples could also become convinced of other symptoms? Iatrogenic mental illness should be a huge concern for the psychiatric profession if this is the case: the whole process of assessment and diagnosis should be done in a way that reduces the likelihood of iatrogenic effects, with deep sensitivity to power imbalances, vulnerability, adaptation, and living to labels. So, is this what we’re doing? No, we have collared the word ‘insight’ and changed its meaning to ‘agrees with the doctor’. People are put in situations where to prove sufficient ‘insight’ to be allowed out of hospital they must agree that they have – whatever, lets say Schizophrenia. Two months later a new treating doctor does more tests and changes the diagnosis to PTSD. Where does that leave the ‘insight’? Where does that leave ‘vulnerable people’ and iatrogenesis?
Secondly, when the iatrogenic argument is used as an attempt to explain that DID or multiplicity do not exist, we find ourselves in an unusual situation where apparently a doctor has the power to create a powerful belief and accompanying symptoms in a patient, but it is impossible for highly traumatised people under stress to create this same set of circumstances in themselves. Is the doctor magic? If doctors can do it, why not the rest of us? Of course, this leaves us with old definitions of multiplicity – that the person doesn’t really have parts, merely the delusion of parts – an approach which categorised multiplicity as a form of schizophrenia and led to therapeutic approaches that centred on denying the existence of parts and was generally pretty ineffective. But that’s down to arguments of cause and cure – the iatrogenic argument is still assuming that a ‘multiple state’ can be created in someone vulnerable, but gifting this act of creation as the exclusive domain of therapists and presuming that no one else in any other context might be able to create this state also. Bizarre.
Do I think that everybody diagnosed as multiple must really be a multiple? Of course not. Mis-diagnosis is so rampart within the mental health system that it is actually the norm. It’s laughable to listen to the spin of the mental health sector about science and support and watch someone be given a diagnosis within a 15 minute assessment during high distress on admission to a psych ward, medicated and treated as if that diagnosis has merit over the next few weeks, and then watch it change as the psych on duty changes, and then again when the roster changes in two months, and then again… I’m not making that up, I’ve supported people through that process. The whole idea that someone can sit in a room with you for a few minutes when you’re at your most incoherent (or drugged) and know better than you do what is going on inside you is laughable to me. I have huge issues with the DSM, with our diagnostic entities such as schizophrenia, and with the power imbalance of our process of diagnosis, where an ‘expert’ tells a vulnerable person what is ‘wrong’ with them.
Does my stance on DID (that multiplicity is certainly real and possible) mean I don’t worry about iatrogenic effects? Not at all. I’m very concerned because research consistently shows that people live to their labels – children treated as smart do great in tests, those treated as truants act out, those treated as caring are kind. We know this and have demonstrated the powerful effects of labels, obedience, authority, and adaptation in research over and over again and yet we pay very little attention to the massive risks of diagnosis, particularly being diagnosed with syndromes.
Let’s compare for a minute the diagnostic entity of Dysthymia with that of Schizophrenia. Dysthymia is chronic, low grade depression. Schizophrenia is a syndrome, a cluster of symptoms such as hallucinations, delusions, lack of motivation, lack of emotional expressiveness, and so on.
What are the risks of living to these labels? With both, there is an assumption of duration, that you will be ‘sick’ for a very long time, with schizophrenia most people are told they will be sick for the duration of their lives. How concerned are we that people who might not have struggled with these experiences for their lives will now live to that prophecy and fulfil those expectations? We should be very concerned about this!
In the instance of schizophrenia however, the labelling risk goes further. You can be diagnosed on the basis of a single experience such as hearing voices. On the basis of that ONE experience, people are told they have a condition that includes many other debilitating symptoms. We have just increased the likelihood that the person will experience all the rest of the cluster, and that when they do they will attribute them to the illness. It’s no surprise to me that many people with schizophrenia lack motivation, between the stigma, disruption, loneliness, and low expectations isn’t it the slightest bit reasonable that lack of motivation might occur? Is that really an ‘illness symptom’ or a reaction to circumstances?
Diagnoses often cluster many different symptoms and also make predictions about duration of experiences. My experience has been that while certain clusters are more common than others, we each of us have our own personal unique cluster. We should never ever be set up to expect that we will develop a whole range of other crippling symptoms if we don’t already have them! And I believe it is appallingly irresponsible to make miserable predictions about duration or quality of life when we have such an excellent evidence base that tells us people are vulnerable to making prophecies come true, however ill-founded they are.
So yes, I consider that DID is both over and under diagnosed. That in no way means that I assess people to try and determine if they are a ‘real’ multiple – it means I take your word for what is going on with you. I believe you are the expert in your own experience. I don’t care what your diagnoses are, if you tell me you’re not a multiple, that’s cool. Right up to the point where you switch and introduce yourself as George anyway. 🙂 I think it is unhelpful when people are not dealing with multiplicity to have therapists trying to frame everything in that way – but not more so than therapists framing experiences as psychotic when they’re not or borderline when they’re not. All frameworks have limitations and that of multiplicity is no exception. It’s only valid if it’s helpful! I find it useful, and I find the notion of ‘healthy multiplicity’ useful and the idea that all of us have ‘parts’, that multiplicity is normal and healthy, merely the dissociative barriers are unusual. I’ve known people who needed to be more multiple, who had lost so many of their parts that they had become less then who they really were, shut down and limited and struggling. I’ve talked with people like this about Jungian archetypes, about the tremendous wealth of information and resources within us, about the need to react to life with a full deck of cards to play, not the same two cards over and over. But part of what makes these frameworks useful is that I have explored and adapted them to myself, not had them imposed on me from outside. (That’s not to say I haven’t been diagnosed, I was, but for me I went through a lengthy diagnosis process for myself to be satisfied that the language was accurate, useful, and not iatrogenic – see How do I know I’m multiple?)
For myself, like many other people, the simplest rebuttal to the iatrogenic argument is that my life, experiences, and journals all evidence significant signs of major dissociation and multiplicity long before I ever sat in a therapists office or came across the concept of DID. Not every multiple has this – and lack of it is not proof of iatrogenesis! Many people do have this; journals with different handwriting, different names used in different social networks, chronic amnesia, voices, and internal wars that predate contact with the mental health system. In some cases, a person’s medical notes carry all the evidence of distinct multiplicity documented many years prior to anyone considering a dissociative diagnosis, even noting the different names, ages, and functioning of parts but failing to consider multiplicity and conceptualising the observed behaviour as psychotic, borderline, or bipolar instead. Iatrogenesis is not a reasonable alternative to the possibility that multiplicity really exists. It is often framed in different ways, outside the west cultures may talk about people being possessed by demons or in touch with spirit guides, or speaking to to their ancestors, but the basic underlying experience of separate parts are what we have termed multiplicity and they certainly exist all over the world.
Oh how I envy you,
who have nothing to suppress
but who are whole;
in this world.
What is this, that cries so plaintively, arcing wings within me?
Whose voice do I hear when the darkness descends?
If you put your head beneath the water, you can hear the screaming.
In dark mirrors my reflection is a strangers face
I cannot remember the sky or the feel of the rain.
For more information see articles listed on Multiplicity Links, scroll through posts in the category of Multiplicity, or explore my Network The Dissociative Initiative.