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Dr. Bob is Robert Hsiung, MD,
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Posted by alexandra_k on March 28, 2005, at 22:04:05
(ix) Descriptive Adequacy, Aetiology, and Treatment Success
While Dennett, (1998 p.51) maintains that
>Carcot himself demonstrated only too convincingly, a woman who feels no pain when a pin is stuck into her arm feels no pain – and calling her lack of reaction a “hysterical symptom” does not make it any the less remarkable. Likewise a woman who at the age of thirty is now living the life of several different selves is now living the life of several different selves – and any doubts we might have about how she came to be that way should not blind us to the fact that such is now the way she is.Dennett is primarily considering the florid cases that have been diagnosed. Sceptics maintain that the predictive success that is gained by the adoption of what I have called multiple systems theory is one that is a matter of self fulfilling prophecy, as clinicians legitimate and sustain the behaviours they have predicted as a confirmation bias. Dennett’s emphasis, though, would seem to suggest that in the florid cases there is predictive leverage to be had, and I have considered that it is not only the sceptics who resist the multiple systems version of the intentional stance in theory.
While treatment outcomes are obviously an empirical matter it seems plausible to me at least that those with merely a ‘window of diagnosability’ may be more amenable to alterations in reinforcement contingencies which serve to shape behaviours towards an unambiguous, single systems view. The more florid cases would seem to result from the subject having adopted multiple systems theory regarding their own behaviours. Shaping such behaviours away would seem to lapse into ‘punishment’ both in the technical, and non-technical sense. Spanos considers a case where a hospitalised subject was ignored and placed in isolation when he switched into alters that the staff had decided to ‘shape away’. Over time he did indeed switch less frequently and this is considered a prime example of how such behaviours may be ‘shaped away’ by sceptics. Such ‘shaping’ would seem to me to be questionable on ethical grounds – who gets to decide which alter will be reinforced, and which should be ‘punished for existing’? Supporters maintain that they treat many such subjects who have been punished in the above fashion for 7-10 years and the subjects came to maintain that the alters did not disappear, they just felt unwanted and chose to come out at different times or mimic more closely the behaviour of the ‘acceptable’ personality. Such ‘shaping’ would also seem to be counter-productive with respect to establishing and maintaining a healthy rapport and therapeutic relationship.
With respect to the question of when the disorder emerged one might consider that alters emerged at the point where the multiple systems interpretation of their behaviour became a viable option. While the disagreement seems to centre on whether they were present from childhood or not, we may consider that alters emerged whenever the stance was adopted. If alters are best construed as intentional systems, as I have maintained, then clinicians can expect to find ‘windows of diagnosability’ in children should they seek them out with the multiple systems interpretation in mind. Whether alters have been present since childhood or not would thus not seem to be either confirmed or disconfirmed by finding it in children despite some theorists considering this to be crucial data. Dennett, (1998) considered a subject who claimed that her alters originated in childhood when her father would call her by a different name and pretend to abuse someone else. He considers that whether this interpretation is offered by an abuser when the subject was a child, or years later when the subject is an adult and the interpretation is offered by a clinician would seem to be fairly arbitrary. To consider that the case of childhood origin was somehow legitimate, while the case of adult origin was an artefact of treatment would also seem somewhat arbitrary.
The other point of controversy is something that I will just touch on briefly. There is dispute as to whether the disorder is necessarily traumatic in origin, or whether Spanos account of multiple identity enactment shows us that trauma need not be a requisite for alters. There is a danger in considering a history of severe abuse to be a causative factor in the development of any disorder lest clinicians and clients both consider that it is the only rationally acceptable explanation for their behaviour. Hopefully we have learned something about memory as a constructive process so that the Freudian error is not repeated;
>I no longer accepted her declaration that nothing had occurred to her, but assured her that something must have occurred to her… Finally I declared that I knew very well that something had occurred to her and that she was concealing it from me; but that she would never be free of her pains so long as she concealed anything. By thus insisting I brought it about that from that time forward my pressure on her head never failed in its effect (Freud, 1953-74 p. 154 in Webster, 2003 p. 11).
It may turn out that the majority of subjects with the disorder do indeed have a history of severe child-hood abuse. With respect to explanation, however it would seem to me that diathesis could go a long way. Surely all that is required for the post-traumatic account is that the child perceived a great trauma. For an extremely sensitive child (or indeed an adult) circumstances may not have to be considered as objectively of ‘sickening severity’ for the individual to feel traumatised. Perhaps trauma is not a requisite and there may be other explanations for the emergence of alters, as Spanos has indicated.
Spanos maintains that the issue is not the existence of the phenomena, rather it is the origin and maintenance of the phenomena (thus the controversy is over aetiology and treatment). I think, though, that by recasting the problem of alters as to whether one adopts a single or multiple systems theory to explain and predict these subjects behaviour a new light is cast on aetiology and treatment. If there is a degree of indeterminacy as to whether the single or multiple systems stance is appropriate, then perhaps it is too much to expect empirical facts of the matter to determine which interpretation we should adopt. While there may be facts of the matter with respect to subjects’ histories (which are inaccessible) and treatment outcomes there would seem to still be a genuine indeterminacy as to whether some subjects are best predicted and explained by multiple systems theory or single systems theory.
These subjects present with unintegrated memories, desires, beliefs, and goals and thus treatment consists in integrating them. The role of reinforcement contingencies clearly plays an important role in the establishment and maintenance of any intentional system, no matter how many we have associated with a single body. A re-conceptualisation of alters may thus be able to cut through both of the extreme views on offer. The views reflect quite distinct treatment approaches and theoretical frameworks in that the socio-cognitive model is fairly behaviourist and the post-traumatic model is fairly psychodynamic. While cognitive-behaviour theorists seem to have largely side-stepped the disorder, trusting its conceptualisation to the behaviourists, perhaps a middle ground could be reached by a tradition that in practice seems to take from both psychodynamic and behaviourist traditions. Perhaps there could be a re-conceptualisation of the disorder in a way that is moderate and demystifying; though it would seem that any theorist needs to take a stance on whether the subject is best viewed as a multiple or single system. To realise that this is a matter of interpretation (and thus is amenable to reinterpretation) is to demystify the decision either way while taking seriously the phenomenon of the alters that are the distinctive feature of this diagnosis.
This is the end of the thread.
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