Bad Men Do What Good Men Dream: A Forensic Psychiatrist Illuminates the Darker Side of Human Behavior (25 page)

More than the memories themselves, patients are very frightened and are loathe to reexperience the death-gripping terror and paralytic feelings that accompany memories of sexual abuse. If the right combination of thoughts, feelings, or situations is struck, terrifying memories of abuse long forgotten can be unlocked.

Sarah, whose story introduced this chapter, was a victim of extensive child abuse, a fact brought out at the time of the trial of Mark Peterson. Born and orphaned in Seoul, Korea, she was adopted at the age of 8 months by American parents, who raised her in Iowa City, Iowa. At the trial, Sarah testified that she had difficulty remembering her childhood, but that she did recall physical abuse from her father and mental abuse from her mother. Since age 4, she had heard “babbling” voices in her head, and as an adolescent she experienced severe mood swings and amnesia. Often, she felt compelled to place a blanket over her head and to hide in dark places. Her already compromised mental condition worsened at age 21, when she found her adoptive father crushed under a van.

The medications she received for severe anxiety and depression did not seem to help. With her mother, she moved to Oshkosh, Wisconsin, but was unable to keep her jobs as a dishwasher and a bakery sales clerk. Because of her illness, it was determined that she was unable to work, and she began to receive income from Social Security. She moved into her own apartment with her poodle, P.J., and her cat, Monster, though she maintained a friendly relationship with her mother. Sarah’s illness was finally identified as M PD. Her rape occurred shortly thereafter.

At her trial, a psychiatric expert on MPD testified to the authenticity of Sarah’s mental illness. In many ways, her disorder was typical, the expert noted, with the six main personalities exhibiting a full range of consistent behavior and memories, from the self-destructiveness of Ginger, Shadow, Patty, and Justin, to the protectiveness of Franny.

If her disorder was typical, however, her involvement with the law was atypical. Most often, when MPD cases reach the courts, it is because the destructive personalities of an individual with MPD have caused harm to others by committing assault, rape, or murder. The actual incidence of criminal acts perpetrated by persons with M PD appears to be quite small. Most of the time, the victims harm themselves in various ways.

Multiple Personality Disorder: A Controversial Diagnosis

Although the history of M PD runs parallel to the history of modern psychiatry, the diagnosis of MPD was first officially recognized by the American Psychiatric Association in 1980, as one of a group of stressinduced disorders that also now includes posttraumatic stress disorder, dissociative disorders, and somatization disorders. In the latest version of the official American Psychiatric Association diagnostic manual, the MPD diagnosis has been renamed
dissociative identity disorder
. Except when making a formal diagnosis, most clinicians use M PD as the preferred diagnostic term.

The clinical syndrome of dissociation into multiple personalities has been known about since the nineteenth century, and was noted in the work of Jean-Martin Charcot and Pierre Janet in Europe. In the United States, since the time of Benjamin Rush, the father of American psychiatry, eminent clinicians have had to deal with the complex issues now associated with the diagnosis of M PD. One source estimates that 1% of the U.S. population has some form of M PD. In psychiatric hospitals, the percentage of inpatients with M PD is thought to be about 20%, although MPD is often misdiagnosed as anxiety, depression, or schizophrenia. There are, however, well-qualified, experienced psychiatrists who doubt its existence. In Sarah’s case, Dr. Harold Treffert, director of the Fond du Lac County Health Care Center in Wisconsin, testifying as an expert for the prosecution, said that “Multiple personality disorder is a very, very rare condition. Because of TV talk shows, it has become the disease of the month and plea of the year. It’s a condition that’s fairly easily induced in a very suggestible patient.”

Such doubts are also expressed by juries and judges in court cases in which the victim or, more often, the accused claims to have MPD. Disbelievers in the MPD diagnosis maintain that the disorder is a fiction that has been created by zealous, trauma-seeking therapists who play upon the naïveté of suggestible, hysterical patients. On the other hand, proponents of the MPD diagnosis point out that it is a psychiatric entity noted by doctors for hundreds of years, which cannot be suggested to individuals because it is too complex and multifaceted to be induced by mere suggestion. They assert that mental health professionals who doubt the existence of M PD are resistant to recognizing the presence of severe childhood abuse in the backgrounds of M PD patients and the specific kinds of psychological damage that abuse can cause in adulthood.

The key to the controversy may lie in the fact, noted previously in this chapter, that severe childhood abuse or trauma is invariably found in the backgrounds of M PD patients. To some people in psychiatry, the epidemic of child abuse is also a fiction. Dr. Paul R. McHugh, emeritus chairman of the Department of Psychiatry at Johns Hopkins University, is a persistent critic of the plethora of child abuse allegations and the overuse of the M PD diagnosis. His critiques are worth exploring. Dr. McHugh claims that the flood of MPD cases reflects a prevailing social trend based on political hot buttons of the 1980s and 1990s, “particularly those connected with sexual oppression and victimization. Just as an epidemic of bewitchment served to prove the arrival of Satan in Salem, so in our day an epidemic of MPD is used to confirm that a vast number of adults were sexually abused…during their childhood.”

Dr. McHugh has used polygraphs and extensive interviews with self-reported victims of child abuse and other informants to disprove allegations of child abuse. Both the symptoms that surfaced in the women of Salem 300 years ago and those today associated with M PD patients, Dr. McHugh argues, are really manifestations of hysteria, but not of a distinct psychiatric disorder. He believes that the symptoms of MPD can be explained by reference to hypnosis because “they are generated in a therapeutic, suggestive way, and they are eliminated in a way that shows their hysterical nature.” Dr. McHugh is concerned because so often when a diagnosis of MPD is made, child abuse is then asserted, and soon afterward family members “are being accused of the worst kinds of sexual perversions with little children.” To buttress his allegation, he points out that statistics show true abusers to be more commonly stepfathers than biological fathers, which is just the opposite of the patterns of abuse reported by MPD patients.

A second critic of the M PD diagnosis was Dr. Martin Orne. Until his death in 2000, he was a professor of psychiatry at the Institute of the Pennsylvania Hospital and an internationally recognized expert on hypnosis. Dr. Orne believed that the eliciting of childhood memories of sexual abuse in the treatment of MPD patients ruined the lives of people accused of having molested these patients. This ruination took place without any separate validation or evidence to support the allegation of abuse.

On the other hand, proponents of the MPD diagnosis point out that the diagnosis is based on established criteria developed over time by the American Psychiatric Association. Its existence has been discussed by many prominent and highly credible psychiatrists, among them Drs. Richard J. Lowenstein and Richard P. Kluft.

Dr. Lowenstein is medical director of trauma disorders services at Sheppard and Enoch Pratt Hospital in Towson, Maryland. He charges that the original nineteenth-century concept of hysteria was sexist and reflective of a male view of female personalities, and that to call all symptoms hysteria is to fall into an old trap. Furthermore, Lowenstein writes, “there isn’t any evidence that the full syndrome of M PD can be created by suggestion.” If there is some question about the ways in which childhood abuse is remembered and dissociated, he points out that this, not the existence of MPD, is still the area of ongoing research. He believes that those who oppose the M PD diagnosis and seek to discredit it are doing so to minimize the extent and damage done by child abuse in our society.

Dr. Kluft, clinical professor of psychiatry at Temple University School of Medicine, argues that “a therapist who dismisses the [alternate] personalities as unworthy of attention is avoiding serious scrutiny of much of the patient’s mental life. It is a mistake to be preoccupied with alters as entities in themselves…but it is an equally serious error to suppose that engaging the alters reinforces the patient’s psychopathology.”

My own sense of the truth is that MPD is underdiagnosed, not overdiagnosed. As a psychiatrist, I have treated a number of patients with MPD and have spoken with many colleagues who have themselves seen many MPD cases. But I have also spoken with many colleagues who have never seen a case of M PD and who remain skeptical of its existence. In fact, MPD is hard, not easy, to diagnose accurately, and its existence may only be recognized in a patient years after that patient’s treatment has begun. Several reasons can lead to the delay. According to Dr. Kluft, only about 20% of M PD patients spend the main part of their lives in an open MPD state. Another 40% may present signs that suggest M PD to the alert clinician but that may be missed by many therapists. The remaining 40% of patients diagnosed with M PD are so designated only after exploration done in the absence of signs that would strongly suggest it.

Reluctance to diagnose MPD is understandable. After all, the idea that numerous personalities can exist in one individual smacks of demonology and witchcraft. It also challenges the therapist’s own sense of wholeness. Although most people are aware that there are many of us inside our heads, as mentally stable people we are able to maintain the unity of personality and memory. The notion that we may have dark, destructive personalities lurking in our minds (but beyond our awareness), and that these personalities could take control of us, is tremendously threatening. In a therapeutic situation, it can even threaten the therapist’s equilibrium to listen as a patient’s voice changes to that of a little girl and to see the patient then want to sit on the floor and play. It is as if a sudden time warp has occurred when an adult patient is psychologically transformed, before the therapist’s very eyes, into a 3-year-old child. A profound sense of the uncanny may grip the therapist. At this point, even a good therapist may wonder if he or she is being conned. A more frightening facial transformation is a change from a normal visage to that typical of a psychopathic murderous personality; visions of Dr. Jekyll and Mr. Hyde dance in one’s head. This is unnerving to the clinician. He or she must also realize that the transformation is extraordinarily frightening to the patient as well. In some instances, it can even lead to the patient fleeing the treatment or to an inexperienced clinician abandoning the patient. The clinician must always be aware that the patient is one person; alternate personalities do not exist separately from the patient.

The treatment of M PD is a complex, difficult, often daunting task. However, the results of achieving a reasonably integrated personality in the patient are extremely gratifying, both to patient and therapist alike. Because of the split-off personalities in MPD, the sum of the parts add up to one personality. It is a camp divided. The goal of treatment is to integrate the disparate personality elements. The patient’s internal integration of personalities may take the form of a board meeting (with the host personality as chairman), a town meeting, a dictatorship, or some other form of processing internal communications, like a therapy group. Some patients achieve near total integration and oneness with the alternate personalities, a desirable result for both patient and therapist. In fact, a good deal of what happens to M PD patients has that quality of astonishing both the therapist and the patient. To observe the mind’s adaptive ability to create various personalities in the effort to cope with overwhelming trauma is an amazing experience. The final creation appears as a brilliant piece of baroque art work, one that leaves both doctor and patient with a profound sense of awe and humility.

Multiple Personality Disorder and the Courts

Controversy among mental health professionals about the very existence of MPD, the fascinating and often dramatic nature of the disorder, the ease with which the disorder can be faked, and the natural disbelief of jurors make MPD a difficult legal defense to pursue in the courts. Nevertheless, in a number of cases, ranging from forgery and drunk driving all the way up to the more heinous crimes of robbery, rape, and murder, M PD has been raised as a legal defense and, on rare occasions, has been used successfully in an insanity defense.

Courts have generally taken the position that the mere presence of M PD does not relieve the patient of responsibility for his or her acts. In each case, a judge or jury must decide whether a person’s disease affects his or her ability to stand trial and to assume responsibility for the crime in the eyes of the law.

Lewis and Bard (1991) described four major defenses presented at trial for crimes committed by alternate personalities:

1. The person had no control over the alternate personality committing the crime.
2. The person cannot remember the acts of the alternate personalities, and therefore cannot assist in his or her own defense and is incompetent to stand trial.
3. Because of the MPD, the person could not conform his or her behaviors to the law or tell right from wrong.
4. Like a sleepwalker, the accused person was unconscious of the alternate personality’s behavior and thus cannot be held accountable for it.

The most often cited case on judicial theory having to do with MPD is
State v. Grimsley
. In this case, one of Ms. Grimsley’s secondary personalities, named Jennifer, was arrested for drunk driving. Ms. Grimsley contended that her primary personality, Robin, “was not conscious of what was happening and lacked voluntary control over Jennifer’s actions.” The court rejected Jennifer’s insanity defense on the grounds that “the evidence fails to establish by a preponderance that Ms. Grimsley’s mental disorder so impaired her reason that she, as Robin or as Jennifer or as both, either did not know that her drunken driving was wrong or did not have the ability to refrain from driving while drunk.” This argument upheld the long legal tradition in which the law judges a person’s criminal liability according to his or her mental state at the time of the act. That is, in
Grimsley
, the court determined that both Robin and Jennifer knew better than to drive while drunk.
Three other cases are also noteworthy because of their judicial reasoning. In
Kirkland v. State
, in which a woman with M PD robbed a bank, the court agreed with the findings in
Grimsley
, echoing that “we will not begin to parcel criminal accountability out among the various inhabitants of the mind.”