Charles A. Benincasa, MA & Tyson D. Bailey, PsyD, ABPP
Narratives emerging from the #MeToo movement have illuminated the pervasiveness of sexual assault and positioned the associated psychological impacts within a broader sociopolitical discourse. The eruption of #MeToo anecdotes has also provided a commentary on the ways that social, legal, political, and cultural systems coalesce to protect individuals in positions of power and privilege. Research exploring the reasons that sexual violence goes underreported substantiates these anecdotes (Bergman, Langhout, Palmieri, Cortina, & Fitzgerald, 2002; Kaiser & Miller, 2001). Reporters of sexual harassment, assault, and abuse are often discredited, accused of misperceiving intentions, blamed for their supposed role, and/or alleged to have made up false claims (Ahrens, 2006; Du Mont, Miller & Myhr, 2003). Some literature refers to these sociocultural biases as “rape myths” (Suarez & Gadalla, 2010). Negative encounters with social systems, including experiences of being blamed or not being believed, have been shown to be associated with significant increases in posttraumatic stress symptoms (Campbell et al., 1999).
For individuals who have experienced multiple or repeated traumas, the deleterious effects of traumatic stress compound with the re-traumatizing effects of biases and myths that still pervade legal, medical, and mental health systems. One population for whom this is particularly true includes individuals with the neurobiological organization of Dissociative Identity Disorder (DID). Providers who regularly work with individuals with DID are accustomed to hearing stories of not being believed, being accused of malingering or factitiousness, or being told that DID is not a legitimate psychiatric construct (Dalenberg et al., 2014). In addition to the myths associated with assault and abuse, individuals with DID are also subjected to unsubstantiated myths (Brand et al., 2016). The prevalence and pervasiveness of such myths results in the ascription of excessive pathology, rendering of misdiagnosis, and subjection to contraindicated treatments (Hodas, 2006).
Authors who dispute the legitimacy of DID often rely on myths, debunked literature, and personal skepticism. It is reasonable to question the degree to which this skepticism is emboldened by subtle forms of neurological privilege; i.e. the existence of autonomous identity states may seem incomprehensible for those who have not needed to rely upon dissociative survival strategies. Yet, the features of dissociated identity states, as included in scientific literature, have represented a theoretically consistent construct for over 200 years (for a thorough overview, see Dell & O’Neil, 2010). Dissociation, generally, is an adaptive, hardwired neurobiological survival strategy that exists in other mammals, not just humans (for a review of the neurobiology of dissociation, see Lanius, Paulsen, & Corrigan, 2014). With the contemporary advancements of neuroimaging technology, DID has been further validated as a neurobiological organization that develops when children repeatedly rely on dissociation to tolerate overwhelming life-threat states.
Of the most persistent and harmful myths about DID are that this neurobiological adaptation to extreme stress is an iatrogenic disorder and that treatment for DID is harmful (e.g., Lilienfeld, 2007). Although authors who discuss the Fantasy Model (FM) have made numerous claims that dissociative disorders (DD), particularly DID, are fabricated by individuals who are prone to engage in fantasy and susceptible to influence from powerful others—such as a therapist (Giesbrecht, Lynn, Lilienfeld, & Merckelbach, 2008; Lynn et al., 2014)—other researchers have convincingly demonstrated how individuals with authentic DID are distinguishable from simulators, including those with high fantasy-proneness, along objective personality, neurological, and physiological metrics (Brand, & Chasson, 2015; Reinders et al., 2018; Reinders, Willemsen, Vos, den Boer, & Nijenhuis, 2012). Additionally, when considering the available research evidence, antecedent trauma remains associated with the development of dissociation and various DDs as a strategy for mediating extreme, persistent stress (Dalenberg et al., 2012; Dalenberg et al., 2014; Dorahy et al., 2014).
In a study comparing responses to neutral and trauma-related stimuli among individuals with DID, high fantasy-prone non-dissociative controls, and low fantasy-prone non-dissociative controls, Reinders, Willemsen, Vos, den Boer, and Nijenhuis (2012) found that the DID group was distinguishable with statistical significance across multiple physiological and neurological metrics, including regional cerebral blood flow in multiple brain regions, heart rate frequency, and blood pressure. Additionally, Reinders et al. (2018) established a neuroimaging classification that can identify DID using individual neuroanatomical biomarkers with 71.88% sensitivity and 73.81% specificity. As DID continues to be validated through the use of neuroimaging technology, scientific evidence suggests that DID is not a disorder of sociocultural or iatrogenic origin. Unfortunately, FM tenants are often presented in psychology textbooks as verified theories, which can perpetuate the harmful myths that further invalidate individuals living with the experience of DID (Wilgus, Packer, Lile-King, Miller-Perrin, & Brand, 2015).
As with any other clinical concern, it is important to properly assess for dissociation and rule out other potential disorders before rendering a diagnosis of DID. Methods for trauma-informed psychological assessment have expanded significantly over the past two decades with notable advancements in the comprehensive understanding of dissociative experiences (for a review, see Brand, Webermann, & Frankel, 2016). Consequently, there are well-validated methods for accurately assessing and diagnosing DID (as well as ruling out DID) that are, unfortunately, not common in mainstream clinical and forensic assessment. Structured interviews, such as the Structured Clinical Interview of Dissociative Disorders-Revised (Steinberg, 1994)provide a guided format for gathering information about symptoms in a standardized manner. Further, objective measures including the Multiscale Dissociation Inventory (MDI; Briere, Weathers, & Runtz, 2005)and the Multidimensional Inventory of Dissociation (MID; Dell, 2006)provide comprehensive information about the presence of multiple forms of dissociative sequalae. Validity indicators on the MID also assess for conditions such as psychosis, rare symptoms, and borderline personality features to aid in diagnostic accuracy.
Objective personality measures have also been shown to adequately distinguish individuals with DID from simulating controls; however, it is critical to understand how the presence of dissociative symptoms may impact validity scales of commonly used measures. For instance, Brand and colleagues found particular profiles associated with individuals diagnosed with DID, including elevated validity scales on the Minnesota Multiphasic Personality Inventory-2 and Personality Assessment Inventory (Brand & Chasson, 2015; Stadnik, Brand, & Savoca, 2013). Further, the Structured Interview of Reported Symptoms-2 has been shown to potentially misclassify DDs as feigning if the Trauma Index is not utilized in conjunction with the overall scores (Brand, Tursich, Tzall, & Loewenstein, 2014). When considering this body of work, it is critical to note how these measures have been found to clearly differentiate simulated from genuine DID utilizing well-validated assessment measures. The comprehensive nature of these scales provides an important comparison to screeningmeasures, such as the Structured Inventory of Malingered Symptomatology (Widows & Smith, 2005), which are supposed to be utilized as a precursor to more comprehensive analysis of symptom feigning when elevated.
All healthcare providers are tasked with the ethical imperative to avoid inflicting harm. Yet, unsubstantiated bias and myth often define the perspectives of providers who would deny the existence of DID in opposition to rigorously developed scientific evidence. Dissociative Identity Disorder continues to be an internationally accepted medical diagnosis within both the International Classification of Diseases (ICD) and Diagnostic and Statistical Manual of Mental Disorders (DSM) classification systems. Yet, some providers discourage assessing dissociation because of personal beliefs that DID does not exist. When health care providers allow myths to permeate the ways in which social systems interface with individuals who have experienced various forms of psychological trauma, they allow for the perpetuation of re-traumatization and replication of damaging dynamics of abuse (Burke, 2019). Trauma Psychologists have a unique opportunity to take a definitive stance that dispels harmful myths, repudiates debunked literature, affirms DID as a well-validated construct, acknowledges the influence of privilege on skepticism, and advocates for the ethical assessment, diagnosis, and treatment of individuals with DID.
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Chuck is a doctoral candidate in counseling psychologyat Saint Mary’s University of Minnesota. He will be beginning his pre-doctoral internship in the fall at The Carson Center in Westfield, Massachusetts. His dissertation examines the relationship between the Dissociation scale of the TSI-2 and select scales of the MMPI-2. His clinical focus includes the comprehensive assessment and treatment of complex trauma anddissociation and he has received advanced training inEMDR and the AIR Network Model.
Tyson is a board certified clinical psychologist whospecializes in treating and assessing individuals whohave experienced developmental trauma. He is a partnerin a group practice that provides trauma-informed clinical and forensic services in the Seattle area. He is an associate editor for Psychological Trauma: Theory, Research, Practice, and Policy and an action editor forPsychological Injury & Law. Tyson is also an author of the upcoming APA Guidelines for Psychologists Regarding the Assessment of Psychological Trauma in Adults.