Memory expert Elizabeth Loftus, Ph.D., warns that psychiatrist Marlene Steinberg, M.D., in her new book Stranger in the Mirror, is trying to breathe new life into a form of therapy that once destroyed thousands of lives. Dr. Steinberg responds.
When you look into a mirror, who looks back? If you sometimes have the eerie feeling that you don't really know who that is in the looking glass, then you may be one of the 30 million Americans who suffer from Dissociative Identity Disorder (DID). Such is the extraordinary claim of psychiatrist Marlene Steinberg.
Steinberg, with the help of writer Maxine Schnall, makes her case in Stranger in the Mirror: Dissociation: The Secret Epidemic of Our Time (Cliff Street Books, 2000). In it, she states that DID is due to traumatic experiences, typically childhood sexual abuse. According to the theory, the traumatic experiences are too horrendous to contemplate, so the victim forces them into a dark corner of psychic inner space, where they nevertheless chafe the unknowing ego, eventually splitting it into fragments that later manifest themselves as alternate personalities. This is one reason why when a DID victim looks in the mirror, she may see a stranger staring back.
Steinberg thinks this is what happened to many of her patients. She goes into detail about three in particular, including Nancy, who supposedly experienced abuse by her father, mother and grandfather. When discussing this abuse, she would abruptly switch personalities, from the mother of teenagers that her friends and family knew, to an anguished 8-year-old child. When in "child mode," Nancy would slip into grade-school speech, saying "skeered" and "veery," for example, as in, "I'm veery skeered."
Then there was Jean, the 40-year-old mother of two pursuing a college degree. Jean didn't buy the DID diagnosis at first: "When I tell Jean that I have diagnosed her with DID," Steinberg writes, "she becomes defensive." Jean apparently insisted that she came to therapy because of panic attacks, anxiety and poor school performance; couldn't they just deal with those problems?
Apparently not. Once the diagnosis of DID is made, therapy must focus on dredging up those repressed memories of abuse; there is no time to waste talking about anxiety or how to improve a "D-" in American History. Important, long-buried memories must be brought to light.
Steinberg claims a high success rate for which, unfortunately, she provides no documentation. In evaluating her claim, consider how she defines success. In the manuscript version of her book, she writes, "I consider achieving functional cooperation among a person's alternate personalities a successful outcome of therapy... " In other words, if you and your 37 selves are all getting along with one another, Steinberg will pronounce you cured!
To make a diagnosis of DID, Steinberg uses a test she developed called the Steinberg Clinical Interview for DSM-IV Dissociative Disorders, (SCID-D, for short). She modestly characterizes the test as a "breakthrough diagnostic tool," but offers no scientific evidence for its validity. Nevertheless, her confidence in the instrument knows no bounds: If the test says you have DID, then you have DID.
Steinberg's faith in her "breakthrough" tool may have prompted her to include in her book a series of questionnaires, adapted from the SCID-D, that readers can use to determine whether they, too, are in need of treatment for dissociative disorder. I sat down one day and took these tests. To my dismay, I found that I had amnesia and suffered from "mild identify confusion."
Identity confusion? I thought I was a college professor, a researcher in the field of memory, sister to two wonderful brothers, aunt to adorable nieces and nephews. While I admit I occasionally wonder what I want to do next in life, this hardly seems to qualify as identity confusion.
The test includes items such as, "I have a critical commentary in my head about things I do," and, "Who I am can change from day to day." I had the choice of checking these and similar items "never, .... once or twice," "sometimes," "many times," or "almost all the time." It seems likely that most people would admit to having these experiences now and then, but it turns out that the only way you can avoid a diagnosis of identify confusion is to check "never" to all the items. Steinberg admits that mild or short-lived episodes of dissociative feelings are normal, but her test makes it hard for people to escape a diagnosis.
It doesn't take a crystal ball to foresee thousands of people finding themselves described in the pages of Steinberg's book and having their fears confirmed by its tests. Nor will it be very surprising if many of these people go to therapists who, wittingly or unwittingly, implant memories of childhood cruelty that never happened. No doubt some innocent people (especially parents, grandparents and siblings) will be accused of the "remembered" abuse, and some may be sued or prosecuted. Some may even go to prison.
This is not just exaggerated speculation; indeed, it has already happened. In the 1980s and '90s, thousands of people, most of them women, entered psychotherapy for treatment of depression, anxiety, eating disorders, sexual dysfunction and other problems, and were told that their troubles were due to repressed memories of childhood sexual abuse. These painful memories, they were told, lay festering in their subconscious, causing their symptoms. It would be necessary for the patient to "recover" the memories in order to heal their current ailment.
There was no credible scientific evidence for any of this: no evidence that people who had experienced years of abuse ever repressed it; no evidence that forgotten memories caused the symptoms experienced; no evidence that "recovering" memories relieved symptoms. Nevertheless, during the course of therapy many of the patients came to believe that they had repressed memories of abuse. On the basis of these memories, many of the accused found themselves facing criminal or civil charges for child abuse, and some of them went to jail. But it turned out that in most of these cases, the events people "recovered" during therapy never actually happened. How could people remember events that hadn't occurred?
Most people think of memories as photographs in an album or files in a computer. They see remembering as a matter of opening the album or calling up a file. But six or seven decades of research has shown that this is not the way memory works. Remembering is an unreliable process that is greatly influenced by, among other things, the contexts in which remembering occurs, the kinds of questions asked, and the status of the person asking the questions. The American Psychiatric Association recently posted a fact sheet on its Web site (www.psych.org) that warns mental health professionals against leading or pressuring patients into accusing people of sexual abuse. Doctors who ask leading questions in the midst of therapy are especially likely to influence the nature of events recalled. In these circumstances, perfectly normal people can be induced to remember things that never happened. Many distinguished mental health professionals believe this is exactly what has occurred in most, if not all, cases of recovered memories.
The many people who came to realize that their "recovered memories of abuse" were false then had to seek treatment for their new symptoms, including guilt, anxiety and disrupted family relationships, that were a direct result of their "therapy." The phenomenon was so common that therapists and researchers began to speak of the "false memory syndrome." The next wave of litigation turned patient against therapist as woman after woman saw through the fabricated memories, planted in part by suggestive and sometimes downright coercive psychotherapy. Therapists had a hard time defending their techniques. Court judgments and settlements were in the millions, with one exceeding $10 million.
That super award went to Patricia Burgus, one of the first patients admitted to the Dissociative Disorders Unit of a major Chicago hospital. She endured six years of treatment, including hypnosis and powerful medication, and at one point became convinced that she had over 300 alternate personalities that purportedly arose as a direct result of extended childhood abuse. Burgus believed she had experienced cannibalism, ritual murder and torture at the hands of her own family. Her two young sons were also hospitalized for years on the dubious theory that dissociative disorder tends to be genetically predisposed.
Burgus finally realized that her memories were untrue, and she filed suit. When she and her family received the $10.6 million settlement, R. Christopher Barden, a psychologist and attorney in the case, said: "This is the end of the controversy regarding recovered memories .... This is its death knell."
But Barden's eulogy was premature. Steinberg and others -- including Cameron West, Ph.D., author of First Person Plural: My Life As A Multiple (Hyperion, 1999) and a soon-to-be-published multiple-personality memoir by China-relations expert and novelist Robert B. Oxnam -- are attempting to breathe new life into the concept of recovered memories. West even appeared on "Oprah" to tell how he developed 24 distinct personalities after suppressing memories of childhood abuse.
Many people actually experience the symptoms ascribed to DID: memory lapses and distortions, confusion, a sense of unreality, and mood swings. But most experts now agree that there can be many reasons a person would experience such symptoms. Canadian psychiatrist Harold Merskey says people with DID symptoms might be suffering from depression, anxiety, adjustment disorders or severe stress-from the death of a spouse, loss of a job, the end of a relationship, or audits by the IRS. Even migraine headaches and mild epileptic seizures are known to produce symptoms, akin to dissociation. Neurological and neuropsychological testing can often reveal which of these or other disorders are at the root of the problem. Identifying the real source of symptoms -- whether organic or situational -- is important because the person then has an excellent chance of receiving effective treatment.
For over 2,000 years, health professionals have been guided by the Hippocratic principle, "First, do no harm." Psychotherapists violated this principle when they created an epidemic of false memories. DID therapists may be about to repeat the performance. Many people reading Steinberg's book, and others like it, will seek and receive therapy for a disorder they don't have. If, in the course of therapy, they "recover" memories of abuse that never occurred, if innocent people are then accused of these horrendous crimes, and if the patients themselves are denied treatment for real problems, then the therapists will not have alleviated suffering, but will have caused it.
Dr. Marlene Steinberg Respond
"IT'S THE 'GOLD STANDARD'"
Elizabeth Loftus' commentary on Stranger in the Mirror: Dissociation: The Hidden Epidemic illustrates the elaborate mythology and misrepresentations surrounding the field of dissociation. As many people are aware, Loftus is not a licensed clinical psychologist and has never diagnosed or treated a single person through psychotherapy. In addition, respected professionals have documented misrepresentations, scientific errors, erroneous conclusions and ethical breaches in regard to her research.
Like all myths, however, Loftus' assertions fall to stand up when compared to the facts. Indeed, there are hundreds of scientific publications documenting advances in the field of dissociation. These articles validate the Steinberg Test (SCID-D) and other screening tools, and also confirm the precise nature and high prevalence of dissociative symptoms and disorders in the general population. Based on the highest standards of psychiatry, the SCID-D is now considered the "gold standard" for identifying dissociative symptoms and disorders. Its reliability for detecting and distinguishing patients suffering from dissociation from those with anxiety, depression, and other disorders has been documented, replicated, published and presented by many clinical investigators around the world. Readers who wish to learn more about the recent advances in diagnosis and scientific evidence for dissociation are invited to review Stranger in the Mirror's detailed annotated bibliography.
Unfortunately, myths about dissociation that ignore scientific evidence to the contrary are still being perpetuated, delaying accurate diagnosis and treatment for survivors of abuse or trauma. One such myth suggests that treatment of dissociative disorders is focused on eliciting memories of abuse from the patient, regardless of whether such memories exist. Another myth suggests that a dissociative disorder can be magically created after reading an informative book. Stranger in the Mirror shatters these and other myths by presenting the scientific truth about this hidden epidemic. In fact, reading the book can help you determine whether you or someone you love can benefit from the recent advances in the field of dissociation with the help of a trained professional.
Marlene Steinberg, M.D., is an associate professor of psychiatry at the University of Massachusetts Medical Center, and has private practices in Connecticut and Massachusetts.
Adapted by Ph.D.
Elizabeth Loftus, Ph.D., is a psychology professor at the University of Washington in Seattle.