Dissociative Identity Disorder exists and it is the result of childhood trauma

In response to a resurgence of "false memory" reporting in Australia, I worked with clinical colleagues Warwick Middleton and Martin Dorahy to write this explanatory piece on Dissociative Identity Disorder for The Conversation.

Once known as multiple personality disorder, dissociative identity disorder remains one of the most intriguing but poorly understood mental illnesses. Research and clinical experience indicate people diagnosed with the condition have been victims of sexual abuse or other forms of criminal mistreatment.

But a vocal group of academics and health professionals have claimed dissociative identity disorder, and reports of trauma associated with it, are created by therapists and the media. They say these don’t reflect genuine symptoms or accurate memories.

Media references to dissociative identity disorder are also often highly stigmatising. The recent movie Split depicted a person with the condition as a psychopathic murderer. Even supposedly factual reporting can present people with dissociative identity disorder as untrustworthy and prone to wild fantasies and false memories.

But research hasn’t found people with the disorder are more prone to “false memories” than others. And brain imaging studies show significant differences in brain activity between people with dissociative identity disorder and other groups, including those who have been trained to mimic the disorder.

What is it?

Dissociative identity disorder has been studied by doctors and scientists for well over 100 years. In 1980, it was called multiple personality disorder in the Diagnostic and Statistical Manual of Mental Disorders(DSM), which outlines the symptoms of psychiatric conditions. Its name was changed in the 1994 edition of the DSM.

Dissociative identity disorder comes about when a child’s psychological development is disrupted by early repetitive trauma that prevents the normal processes of consolidating a core sense of identity. Reports of childhood trauma in people with dissociative identity disorder (that have been substantiated) include burning, mutilation and exploitation. Sexual abuse is also routinely reported, alongside emotional abuse and neglect.

In response to overwhelming trauma, the child develops multiple, often conflicting, states or identities. These mirror the radical contradictions in their early attachments and social and family environments – for instance, a parent who swings unpredictably between aggression and care.

According to the DSM-5, the major characteristic of dissociative identity disorder is a disruption of identity, in which a person experiences two or more distinct personality states (or, in other cultures, experiences of so-called possession).

These states display marked differences in a person’s behaviour, recollections and opinions, and ways of engaging with the world and other people. The person frequently experiences gaps in memory or difficulties recalling events that occurred while they were in other personality states.

The manifestations of these symptoms are subtle and well concealed for most patients. However, overt symptoms tend to surface during times of stress, re-traumatisation or loss.

Media references to dissociative identity disorder, like the lead character in the movie Split, are often highly stigmatising.

People with the condition typically have a number of other problems. These include depression, self-harm, anxiety, suicidal thoughts, and increased susceptibility to physical illness. They frequently have difficulties engaging in daily life, including employment and interactions with family.

This is, perhaps, unsurprising, given people with dissociative identity disorder have experienced more trauma than any other group of patients with psychiatric difficulties.

Dissociative identity disorder is a relatively common psychiatric disorder. Research in multiple countries has found it occurs in around 1% of the general population, and in up to one fifth of patients in inpatient and outpatient treatment programs.

Trauma and dissociation

The link between severe early trauma and dissociative identity has been controversial. Some clinicians have proposed dissociative identity disorder is the result of fantasy and suggestibility rather than abuse and trauma. But the causal relationship between trauma and dissociation(alterations of identity and memory) has been repeatedly shown in a range of studies using different methodologies across cultures.

People with dissociative identity disorder are generally unresponsive to (and may deteriorate under) standard treatment. This may include cognitive behavioural treatment, or exposure therapy for post-traumatic stress disorder.

Phase-orientated treatment has been shown to improve dissociative identity disorder. This involves stages (or phases) of treatment, from an initial focus on safety and stabilisation, through to containment and processing of trauma memories and feelings, to the final phase of integration and rehabilitation. The goal of treatment is for the person to move towards better engaging in life without debilitating symptoms.

An international study that followed 280 patients with dissociative identity disorder (or a variant of it, which is a dissociative disorder not otherwise specified) and 292 therapists over time, found this approach was associated with improvements across a number of psychological and social functioning areas. Patients and therapists reported reduction in dissociation, general distress, depression, self-harm and suicidal thoughts.

Controversies and debates

Critics have pointed to poor therapeutic practice causing dissociative symptoms as well as false memories and false allegations of abuse. Some are particularly concerned therapists are focused on recovering memories, or encouraging patients to speculate that they have been abused.

However, a contemporary survey of clinical practice among specialists of dissociative identity found those treating the disorder weren’t focused on retrieving memories at any phase of the treatment.

A recent literature analysis concluded that criticisms of dissociative identity disorder treatment are based on inaccurate assumptions about clinical practice, misunderstandings of symptoms, and an over-reliance on anecdotes and unfounded claims.

Dissociative identity disorder treatment is frequently unavailable in the public health system. This means people with the condition remain at high risk of ongoing illness, disability and re-victimisation.

The underlying cause of the disorder, which is severe trauma, has been largely overlooked, with little discussion of the prevention or early identification of extreme abuse. Future research should not only address treatment outcomes, but also focus on public policy around prevention and detection of extreme trauma.

The continuum of control strategies in organised abuse

Control is one of the central dynamics of organised abuse. Psychologically, perpetrators are often motivated to sexually abuse children by a desire to feel powerful, and displaying control over their victim/s accomplishes this. From a practical point of view, maintaining this control is crucial to ensuring that organised abuse goes undetected. 

In this sense, organised abuse is similar to (and often intersects with) other forms of gender-based violence such as domestic violence, which is also characterised by the use of physical and sexual violence to control and dominate victims. 

However, while the control strategies of domestic violence perpetrators are well documented (although they continue to evolve), the ways in which organised abuse perpetrators control their victims has received considerably less attention.

Over the last twelve months, I've been developing a continuum of control strategies in organised abuse to articulate the degrees of control that abusive groups exert over their victims. The continuum is provided below:

Level 0: Chaotic, disorganised abuse

Mass child abuse occurs due to social disorganisation, such as a breakdown in the social fabric due to factors including cumulative disadvantage, mental illness, intergenerational trauma and geographic/social isolation.

Level 1: Opportunistic or situational organised abuse

Organised abuse occurs due to the convergence of multiple motivated offenders, vulnerable children and a lack of oversight or consequence.

Level 2: Motivated and premeditated organised abuse

Perpetrator groups have a well-developed repertoire of grooming and inducement tactics designed to manipulate and entrap their victims in a culture of abuse and exploitation. Coerced perpetration often begins at this level, in which the child is manipulated or forced into the abuse of other children to engender a sense of complicity and shame.

Level 3: Coercive control in organised abuse

Perpetrators seek control over all aspects of the child’s life, including the child’s body and sexuality, and exchange the child with other perpetrators to demonstrate their ‘ownership’ of the child.

Level 4: Disruption of recall and disclosure

Perpetrator groups use methods such as sedation, drugging and hypnosis to disrupt victim memory and limit their ability to disclose abuse. These strategies result in significant gaps in victim memory, including a partial or total lack of recall for abuse.

Level 5: Deliberate traumatisation

Perpetrator groups orchestrate traumatic ordeals with the intention of terrorising victims, inducing traumatic symptoms such as amnesia and severing the child’s sense of belonging to the social order.

Level 6: Induction and manipulation of dissociation

Perpetrator groups use electroshock, ritual abuse and other forms of torture with the intention of creating dissociative parts, systems and responses.

As the continuum progresses, the likelihood of detection, investigation and prosecution diminishes. Levels one and two describe those cases of organised abuse that are most likely to come to the attention of the authorities. Level three is being occasionally prosecuted, however level four, involving the use of sedatives and other measures to interfere with victim memory and disclosure, is the point beyond which criminal justice sanction rarely occurs.

Levels five and six describe the most destructive and effective control strategies utilised by organised abuse perpetrators. These tactics virtually ensure the impunity of organised abuse perpetrators, since they profoundly compromise the ability of victims to protect themselves or seek help. Most victims subject to these techniques will never disclose, and those that do are likely to be disbelieved or labeled as delusional. 

The full continuum of these control tactics has been well documented by mental health practitioners working with organised abuse victims and survivors for over thirty years. However, the breadth of this continuum is largely unknown to law enforcement, child protection services and most mental health practitioners and agencies.

There is a clear need for comprehensive training in the control tactics of perpetrator groups to ensure that organised abuse is being adequately investigated, disrupted and prosecuted, and victims and survivors are being identified and supported.  

Canadian survey finds child pornography often manufactured in organised groups by the parents of victims

A recently published survey by the Canadian Centre for Child Protection found that over 50% of adult survivors of child abuse imagery (“child porn”) were victimised in organised abuse. Importantly, the survey found that they were usually trafficked into organised abuse by their own parents.

Those of us who work with organised abuse survivors will not be surprised to hear this. Since the 1980s, clinicians and researchers have warned that parents are major players in organised abuse and the global production of child abuse material.

This is a message that many have been unable to hear. A number of journalists and academics claimed that these reports are evidence of “moral panic” and an epidemic of “false memories”.

There is now an extensive body of literature claiming that state authorities and other groups exaggerated allegations of organised abuse to expand their control and execute an ideological agenda.

This was a largely confected controversy. There is no evidence of an upsurge of baseless or rash prosecutions for child sexual abuse. Prosecutions rates or child sex offences remain low across all jurisdictions.

However, the debate over “false memories” effectively forestalled the development of any specialised response to organised sexual abuse.

The data has remained the same for almost thirty years now. The overlap between incest, organised abuse and the manufacture of child abuse material is undeniable.

The research by the Canadian Centre for Child Protection suggests that agencies are starting to pay attention to complex trauma and the extremes of sexual violence against children.

Addressing this problem will require us to move beyond disbelief and begin to interrogate the contexts and power dynamics that make the production of child abuse material possible.

Behind every child abuse image there is a story of a severely abused child. It's about time we started listening to those stories. 

Doing trauma research in a sustainable way

I’ve been researching organised abuse for about ten years. Whether I’m in a professional or social setting, one of the most common questions that I’m asked is how I ‘cope’ with or ‘manage’ with emotional impacts of the research, particularly since I’ve been interviewing organised abuse survivors for a long time.

In this post, I want to reflect on how to make trauma-intensive research a sustainable professional practice. The available guidance on the conduct of trauma research is focused on minimising risk to research participants in accordance with overarching principles of human research ethics.

Working to ensure that research participants are not harmed in the course of the study is, of course, crucially important. However, for researchers who are committed to the study of trauma, the question of how to craft a larger program of trauma research (beyond a single study) is largely ignored.

Interpersonal trauma and violation are, necessarily, challenges to widely held assumptions about the orderliness of the world and the predictability of other human beings. How can researchers expose themselves to traumatic material over weeks, months and years without coming to experience the suffering reported by the people that we interview? 

In my experience, making trauma-intensive research sustainable is not solely a methodological issue. Rather, it is an ethical undertaking, in which the research process involves the development and disclosure of clearly articulated frameworks of understanding and meaning that are capable of holding, and making sense out of, traumatic material and affect.

Self-reflection

This involves, first and foremost, a process of self-reflection on behalf of the interviewer. We need to be clear to ourselves about why we are doing the research, and what we expect to get out of it. Trauma researchers may well find that they have developed outsized expectations of what research can accomplish for them, their participants or society at large.

A mismatch between what we want research to accomplish, and what it can reasonably achieve, will only lead to burnout. When I first started doing this work, I was given advice that I've never forgotten: 'This is a marathon, not a sprint'.

As difficult as it may be, particularly when faced with grievous injustice, we need to accept that change is often slow and incremental, and our work is just one small part of a much larger picture. At the same time, we should recognise and value the contribution that we are making.

Ethical commitment

Trauma fragments and disrupts systems of meaning, leading to feelings of nihilism and emptiness. This is true for witnesses, including researchers, as well as those more directly impacted. To counterbalance this, it's important that we, as trauma researchers, are clear to ourselves about the ethical commitments that underlie our research practice. We should continually renew those commitments against the potentially corrosive effects of trauma exposure.

These commitments will vary from person to person, and may be sourced from diverse philosophical, cultural or religious traditions. Personally, I've found the Buddhist understanding of compassion to be compelling, where compassion is defined as a wish to relieve suffering.

In the Buddhist tradition, this wish is formulated in a way that recognises our practical limitations (we are often unable to relieve the suffering we witness) but also exceeds those limitations, in the sense that we can still wish for others to be free from suffering even where we cannot accomplish this ourselves.

Formulated in this way, compassion provides an active way of being present with someone who is describing violence and grief that remains focused on the wellbeing of that person, while listening and responding to their testimony without being overwhelmed by it.

After interview work has taken place, compassion provides a structure of feeling and thinking that affirms the importance of that work, while still holding onto the recognition of the harm that has been inflicted on others. 

Self-care

There are a number of practical measures that we can put in place to ensure the sustainability of trauma-intensive research. Some trauma-exposed researchers are lucky enough to work in a trauma-informed workplaces, where the management of vicarious trauma is built into the institution, but most do not. Trauma researchers generally need to take responsibility for their own self-care. Below are four key points of advice:

  1. Get professional supervision: I personally pay for monthly supervision sessions from a clinical psychologist. This gives me an hour in which to discuss what’s happening in the research and how it is impacting on my life.

  2. Mindfulness practice: There is no escaping the fact that trauma research has enduring effects on how we think and feel. It’s important to develop a mindfulness practice that assists in re-regulating your nervous system and promoting of a sense of emotional and physical wellbeing. This can include practices such as yoga, tai chi or meditation.
  3. Accept mistakes: Trauma research involves encounters with people and material that can be challenging and unexpected. It's healthy to recognise, and accept, that we will make mistakes as trauma researchers. At those times, we can take responsibility and try to learn from our mistakes without blaming or shaming ourselves.
  4. Connection: The experience of trauma is characterised by feelings of isolation and the severing of relations with others. Working with others in the trauma field opposes these feelings and creates a context of safety and connection. Join organisations or professional networks in the trauma field. 

Finally, make sure that your life outside work feels more substantive and weighty to you than your life inside work. The ultimate goal of recovery from trauma is, in the words of Marsha Linehan, to find a ‘life worth living’. Researchers into trauma should make sure they are not compromising their own quality of life while they are helping trauma survivors to find theirs. 

Recommended organised abuse bibliography

In my research on organised abuse, there are certain books and papers that have stood out to me. They strike a chord in terms of the depth of their scholarship and their commitment to preventing abuse and advancing the well-being of victims and survivors. Below is a list of books on organised abuse and related issues that have made an impact on me. I'll keep updating it over time.

Cheit R. (2014) The witch-hunt narrative: Politics, psychology and the sexual abuse of children, Oxford: Oxford University Press.

Professor Ross Cheit provides a forensic analysis of early organised abuse cases in the United States. In unparalleled detail, he traces the progression of infamous organised abuse investigations through the courts, and identifies significant disparities between the facts of these cases and their coverage in the mass media. The book is a scathing indictment of those journalists who claimed that organised and ritual abuse investigations were nothing more than a modern 'witch hunt'. It also calls into question the credibility of those academics who framed their research into sexual abuse in these terms.

Freyd JJ. (1996) Betrayal trauma: The logic of forgetting child abuse, Cambridge, MA: Harvard University Press.

Freyd JJ and Birrell P. (2013) Blind to betrayal: Why we fool ourselves we aren't being fooled. Wiley.

Professor Jennifer Freyd's research into the dynamics of remembering in the context of abuse and trauma has been highly influential. Through a program of rigorous empirical research, she has established that particular subjective dimensions to abuse, such as betrayal and powerlessness, have a determinative impact on how and whether abuse is remembered. Her more recent work has examined how betrayal trauma operates as the collective and social level, blinding whole communities and societies to the prevalence and impact of perpetration and violation.

Gallagher B, Hughes B and Parker H. (1996) The nature and extent of known cases of organised child sexual abuse in England and Wales. In: Bibby P (ed) Organised abuse: The current debate. London: Arena, 215–230.

Gallagher B. (1998) Grappling with smoke: Investigating and managing organised child sexual abuse - A good practice guide. Policy, Practice, Research. London: National Society for the Prevention of Cruelty to Children.

Dr Bernard Gallagher's research in the 1990s on organised abuse stands out in terms of his commitment to empirical rigor and the development of best practice standards. His 1996 chapter, written with colleagues, offers the most comprehensive analysis of child protection case files on organised abuse to date, and highlights the tendencies of child protection workers to over-report some forms of organised abuse and under-report others. Interestingly, this data set formed the basis of Professor Jean LaFontaine's publications on organised and ritual abuse although her conclusions were somewhat different, perhaps because, as an anthropologist, she did not share Dr Gallagher's background in child protection practice. 

Goodwin JM. (1994) Credibility problems in sadistic abuse. The Journal of Psychohistory 21: 479–496.

Goodwin JM. (1994) Sadistic abuse: Definition, recognition and treatment. In: Sinason V (ed) Treating survivors of satanist abuse. London; New York: Routledge, 33–44.

I've always admired Professor Jean Goodwin's publications on extreme trauma. Her written work combines clinical experience with survivors with historical analysis and useful theory-building. In the 1990s, Professor Goodwin defined sadistic abuse as the intentional and deliberative infliction of pain, and made a convincing argument that sadistic abuse was a subterranean tradition within Western culture with roots in Enlightenment thought (particularly the writings of Sade). Her position is that organised abuse should be analysed in terms of power relations rather than the "cult" paradigm that was dominant at the time.

Itzin C. (2001) Incest, paedophilia, pornography and prostitution: Making familial abusers more visible as the abusers. Child Abuse Review 10: 35–48.

This is one of a number of papers published by the late Dr Catherine Itzin that foregrounded the role of familial abusers in organised forms of sexual abuse, such as child prostitution and the manufacture of child abuse material. During the 1990s, it was typically assumed that most child sexual exploitation was being perpetrated by extra-familial perpetrators outside the home. The work of Dr Itzin drew on the testimony of survivors to emphasise the central role of incestuous fathers in facilitating the production of child abuse material and exchanging children with other men and groups. We now know that a significant amount of child abuse material is produced by fathers and other incestuous abusers. This is a very prescient paper in that regard.

Kelly L. (1998) Confronting an atrocity: The Dutroux case. Trouble and Strife 36: 16–22.

During the "memory wars" of the 1990s, Professor Liz Kelly was one of the few people willing to contest the hegemonic position that there is "no evidence" for organised and ritual abuse. As she points out in this paper, the crimes of the infamous Belgian sex offender and murderer Marc Dutroux as well as Rosemary and Fred West in the United Kingdom closely parallel the testimony of organised and ritual abuse survivors. Professor Kelly observes that very few journalists or academics were willing to make this connection, nor did policy-makers respond to the extremes of maltreatment revealed in these cases. This paper is a powerful critique of the depths of denial that persisted throughout the 1990s and to the present day.

Kitzinger J. (2004) Framing abuse: Media influence and public understanding of sexual violence against children, London; Ann Arbor, MI: Pluto Press.

Professor Jenny Kitzinger provides a detailed account of the social construction of contentious organised and ritual abuse cases in the United Kingdom by journalists, editors and social movements. Her work is grounded in interviews with journalists and editors working in the mass media who were grappling with how to cover contentious child protection cases, as well as interviews with members of the 'false memory' movement in the United Kingdom. Her research demonstrates the formative role that the culture of news production played in shaping a largely skeptical narrative around these cases. Her focus group research with news consumers suggests that mass media audiences interpret and rework news coverage in creative ways, drawing upon their own lived experience to make sense out of coverage on child sexual abuse.

Middleton W. (2013) Ongoing incestuous abuse during adulthood. Journal of Trauma & Dissociation 14: 251-272.

Middleton W. (2013) Parent–Child Incest That Extends Into Adulthood: A Survey of International Press Reports, 2007–2011. Journal of Trauma & Dissociation 14: 184-197.

Middleton W. (2015) Tipping points and the accommodation of the abuser: The case of ongoing incestuous abuse during adulthood. International Journal of Crime, Justice and Social Democracy 4: 4-17.

Recently, Professor Warwick Middleton has published a series of articles highlighting the overlap between incestuous abuse and organised abuse from childhood into adulthood. His work combines an acute political and historical sensitivity with his clinical experience as the long-standing director of Australia's only specialist dissociation inpatient unit. Emerging from Professor Middleton's work is a renewed focus on incestuous abuse as a major locus point for organised abuse and the sadistic maltreatment of children and women. His work has major implications for the prevention and detection of violence against children and women that has yet to be fully appreciated.

Schwartz HL. (2000) Dialogues with forgotten voices: Relational perspectives on child abuse trauma and treatment of dissociative disorders. New York: Basic Books.

Schwartz HL. (2013) The alchemy of wolves and sheep: A relational approach to internalized perpetration in complex trauma survivors. New York and London: Routledge.

This two volumes should be widely read by practitioners and researchers in the field of trauma, abuse and dissociation. His first book provides one of the most comprehensive accounts of organised abuse to date, drawing on clinical experience as well as sociological and philosophical frameworks. In his second book, Dr Schwartz describes how chaotic social, political and interpersonal forces are internalised and replicated in the inner worlds of victimised individuals, generating persecutory psychological states and structures. This includes a detailed account of the deliberate production and manipulation of dissociation within criminal subcultures and networks. Through case examples and clinical reflections, Dr Schwartz provides a range of suggestions to improve the treatment trajectory of severely traumatised and dissociative survivors, including those who are enmeshed within abusive familial and criminal groups.

Scott S. (2001) Beyond disbelief: The politics and experience of ritual abuse, Buckingham: Open University Press.

Throughout the 1990s, sociological accounts of ritual abuse were based on mass media reports rather than fieldwork or empirical research, and tended to adopt the skeptical tone and argument prevalent in the mass media at the time. Dr Scott's book signals a major break with this approach. She presents the first search research-informed sociological account of ritual abuse that draws directly on interviews with adult survivors of ritual abuse, as well as Dr Scott's own history as a sexual assault counselor and foster mother to a ritually abused child. She makes important links between ritual abuse and more common forms of violence against children and women, positioning ritual abuse on the broader spectrum of gendered violence.

Survey for adult survivors of child sexual abuse imagery

I'm in the early stages of partnering with the Canadian Centre for Child Protection, who are keen to do more work around organised abuse.

They are currently running a survey for adult survivors of child sexual abuse imagery (what used to be called 'child pornography').

If you've survived abuse that included the manufacture of child abuse material, you may want to fill out the survey - click here.

There's lots of information at the link on the Centre and their survey. They are keeping the survey open indefinitely to capture as much information as possible.

Interview on organised abuse

A few years ago, I was interviewed by my friend (and incredible artist) Lynn Schirmer about my work on organised abuse.

We discuss my particular approach to the topic of organised abuse, my work with survivors and survivor movements, and compare the situation facing survivors in Australia and North America.

You can read more here. An excerpt is below.

LS: Over the past two decades, survivors of extreme and/or organized abuse have attempted many programs of advocacy to change the status quo. Although these efforts may have had a profound effect on the lives of individual survivors, they have yet to substantially impact the views of society at large, and its institutions. Do you have any special advice about how survivors might advocate for themselves in more effective ways?

Michael Salter: In my experience, social movements of trauma survivors can find it difficult to tolerate ambiguity. What I mean by this is that there can be a predominance of black-and-white, us-vs-them thinking rather than an appreciation of the grey areas and a more constructive interest in opposing arguments. While black-and-white thinking helps people feel confident and validated in a group environment (which is of course very important for survivors) it can also push survivor groups into positions of false certainty in which a strong stance is taken on an issue where the evidence is weak or unclear. This position is of course vulnerable to being discredited or attacked by others.

I think it’s really important for survivor groups and movements to find ways of validating and supporting one another that includes a space for uncertainty. This allows survivor groups to engage with, for example, evidence around the unreliability of memory while still asserting that memories of abuse are very likely to be accurate. This disempowers critics who like to malign survivor groups as one-note or simplistic, and it enables survivor representatives to speak in a clear and authoritative way about the issues that affect them. It also helps survivor groups to move beyond null-sum competitions over whether severe abuse “exists” or not. The evidence clearly shows that organised, ritual and sadistic abuse has occurred and is occurring, and my view is that people who deny it are not serious commentators and should be ignored at this point.

When it comes to advocacy, it’s important to think practically and act strategically. While there are particular challenges that are specific to organised abuse, many of the obstacles faced by survivors are shared with other people impacted by abuse and violence. A lack of health services and limited access to the criminal justice system are common to victims of child sexual abuse, rape and domestic violence. These are indicative of major systemic failings that can only be changed slowly, over time, through collective social and political pressure. I know many survivors of organised abuse are working within organisations that aim to address these problems and I’d encourage others to think about the kinds of partnerships they can strike up with like-minded social movements.