Multiple Identity Enactments and Multiple Personality Disorder: A Socio-cognitive Perspective
Nicholas ‘I’m just a naughty little boy’ Spanos
Psychological Bulletin, 1994, vol. 116, no. 1, ps 143-165.
People who enact multiple identities behave as if they possess 2 or more selves, each with its own characteristic moods, memories, and behavioural repertoire. Under different names, this phenomenon occurs in many cultures; in North American culture, it is frequently labelled multiple personality disorder (MPD). This article reviews experimental, cross-cultural, historical, and clinical findings concerning multiplicity and examines the implications of these findings for an understanding of MPD. Multiplicity is viewed from a socio-cognitive perspective, and it is concluded that MPD, like other forms of multiplicity, is socially constructed. It is context bounded, goal-directed, social behavior geared to the expectations of significant others, and its characteristics have changed over time to meet changing expectations.
People who receive the diagnosis of multiple personality disorder (MPD) behave as if they possess two or more distinct identities. They convey the impression of multiplicity by exhibiting a relatively integrated interpersonal style (i.e., a distinct personality) when calling themselves by one name and different interpersonal styles when calling themselves by other names. Frequently, MPD patients behave as if their different identities have their own unique memories and experiences, and many of the identities claim amnesia for the other personalities with whom they co-reside.
Modern MPD patients are usually women with a wide range of chronic psychiatric problems that predate their MPD diagnosis (Coons, Bowman, & Milstein, 1988; Putnam, Guroff, Silberman, Barban, & Post, 1986; Ross, Norton, & Wozney, 1989). These patients usually claim to have been physically or sexually abused-often horrendously-in childhood (Coons & Milstein, 1986; Ross, Miller, Bjornson, Reagor, Fraser, & Anderson, 199 1; Young, Sachs, Braun, & Watkins, 199 1). Moreover, it is now common for investigators (e.g., Bliss, 1986; Braun, 1990; Kluft, 1993; Putnam, 1989, 1993; Ross, 1989) to argue that MPD is a distinct mental disorder caused by severe childhood abuse. According to this hypothesis, severe trauma during childhood produces a mental splitting or dissociation as a defensive reaction to the trauma. These dissociated "parts" of the person develop into alter identities or personalities that, in adulthood, periodically manifest themselves to help the individual cope with stressful situations, express resentments or other feelings that the primary personality disavows, and so on. The proponents of this perspective have been highly vocal, and, despite much and varied criticism, this view has become highly influential. Thus, from this perspective, displays of multiple identities reflect a mental disorder that "happens" to the person as a result of early traumas and other experiences over which she or he has no control and often no memory rather than something that the person does in response to current contingencies, goals, and understandings.
In this article, I argue that the disease perspective of MPD is fundamentally flawed. Specifically, I use experimental, cross-cultural, and historical findings to argue that (a) multiple identities are usefully conceptualised as rule-governed social constructions, (b) neither childhood trauma nor a history of severe psychopathology is necessary for the development or maintenance of multiple identities, and (c) multiple identities are established, legitimated, maintained, and altered through social interaction.
This socio-cognitive alternative to the disease model suggests that MPD is a socio-historical product (Hacking, 1986, 1992; Kenny, 1986; Shorter, 1992; Spanos, 1989). In the last 2 centuries, a number of psychiatric syndromes (e.g., motor hysteria) have developed, spread, and then all but disappeared as a function of changing conceptions held by both doctors and patients concerning the ways in which distress may be legitimately expressed (Shorter, 1992). In the last 20 years, the notion of multiple personality has become commonplace in North American culture and is now a legitimate way for people to understand and express their failures and frustrations, as well as a covert tactic by which they can manipulate others and attain succour and other rewards. In short, the socio-cognitive perspective suggests that patients learn to construe themselves as possessing multiple selves, learn to present themselves in terms of this construal, and learn to reorganise and elaborate on their personal biography so as to make it congruent with their understanding of what it means to be a multiple. These patients are conceptualised as actively involved in using available information to create a social impression that is congruent with their perception of situational demands and with the interpersonal goals they are attempting to achieve (Spanos, Weekes, & Bertrand, 1985).
According to this perspective, psychotherapists play a particularly important part in the generation and maintenance of MPD. Therapists routinely encourage patients to construe themselves as having multiple selves, provide them with information about how to convincingly enact the role of "multiple personality patient," and provide official legitimation for the different identities that their patients enact.
Identities: Singular and Plural
In all cultures, people exhibit wide variability in their behavior across time and situations. Nevertheless, in North American culture almost all people hold a subjective sense of unitary identity and view their diverse behavior as the product of a single self (Epstein, 1973). The self is a social product, a series of interrelated construals made about the first person singular by the first person singular (Deaux, 1993). These self-construals reflect the categories that each culture uses to describe its members and involve socially derived attributions that people apply to themselves. The way that people view themselves reflects the way that they are viewed by others, and it is others who provide or withhold legitimation for the varied self-presentations that people enact (Goffman, 1959). People typically present themselves as a unitary self enacting different roles because they are reinforced for doing so. In fact, the social, economic, and legal institutions of North American culture are premised on the notion that each person is a unitary self who is accountable for his or her own diverse behaviors, and it is this view of unitary self that is routinely legitimated in social interaction (Halleck, 1990; Mancuso & Sarbin, 1983; M. S. Moore, 1984).
Social products are, of course, subject to social change. There is nothing invariable or inevitable about the notion of a unitary self, and the same social processes that validate the conception people hold of themselves as unitary selves can be used to validate the alternative conceptualisation that people consist of multiple selves.
Hypnosis and Multiple Personality Disorder
In North American culture, those who carry out multiple identity enactments are usually defined by mental health professionals as suffering from MPD. Historically, MPD has been closely tied to hypnotic phenomena. Some modern investigators (e.g., Bliss, 1986; Braun, 1990) have argued that in predisposed children, trauma produces a "hypnotic state" that facilitates the development of alter personalities. Purportedly, these alters remain separated from normal consciousness by a process akin to hypnotic amnesia. In addition, modem experiments aimed at elucidating the nature of multiplicity have been conducted within a hypnotic context. Consequently, background information concerning hypnotic responding in general and hypnotic amnesia in particular may be useful in understanding MPD enactments.
Historically, hypnosis has been viewed as an altered state of consciousness that greatly increases responsiveness to suggestions and that, in highly hypnotisable subjects, produces distortions in memory and perception and facilitates the recall of "hidden" memories. This view of hypnosis is almost always uncritically accepted in the MPD literature (e.g., Bliss, 1986; Ross, 1989). In the last 40 years, however, a great deal of empirical evidence has challenged this view (for reviews, see Spanos, 1986b; Spanos & Chaves, 1989; Wagstaff, 1981). Contrary to the assumption frequently found in the MPD literature, more than a century of research has failed to uncover unambiguous behavioural, physiological, or subjective report criteria for denoting a uniquely hypnotic state (Barber, 1979; Fellows, 1986; Radtke & Spanos, 1981; Sarbin & Coe, 1972). In addition, a large number of studies: indicate that even the seeming dramatic behaviors associated with high hypnotizability (e.g., displays of age regression and amnesia) can be accomplished by motivated control subjects who have not been administered hypnotic induction procedures and who display no signs of being in a "trancelike" condition (Barber, 1969; Diamond, 1974; Wagstaff, 1981). Furthermore, many of these dramatic behaviors have turned out to be much more mundane than they originally appeared. For example, hypnotically age-regressed subjects do not develop the psychological characteristics of actual children; instead, they respond like adults attempting to behave as if they are children. When their expectations of how children behave are inaccurate, their age regression performances are off the mark (Nash, 1987).
MPD theorists frequently imply that hypnosis is a process that happens to a person rather than something that a person does (Bliss, 1986). However, there is much support for the hypothesis that hypnotic behaviors are goal-directed enactments and that highly hypnotisable subjects are cognizing individuals who are attuned to even subtle interpersonal cues and who are invested in meeting the social demands of hypnotic situations to present themselves as "good" subjects (Sarbin & Coe, 1972; Spanos & Coe, 1992). The demands contained in hypnotic suggestions call for particular subjective experiences as well as corresponding overt behaviors. For instance, suggestions for amnesia require not only that subjects fail to report target material but also that they define themselves as having forgotten that material. However, suggested experiences such as temporary forgetting or reduced pain do not occur automatically. Instead, such experiences must be generated by subjects who use their attentional and imaginal abilities in attempting to create these subjective effects. Subjects who are unable to generate the subjective experiences called for by suggestions frequently admit their failures rather than fake their responses. On the other hand, hypnotic responding is exceedingly easy to fake (Orne, 1979), some subjects do purposely describe their experiences inaccurately to meet test demands, and such erroneous descriptions are most likely among highly hypnotisable subjects given difficult suggestions (Burgess, Spanos, Ritt, Hordy, & Brooks, 1993; Spanos, Flynn, & Gabora, 1989; Wagstaff, 198 1).
Amnesia has long been a hallmark of hypnotic responding, and during the 19th century it was thought to occur spontaneously as a function of the transition from being hypnotised to being awake (Sarbin & Coe, 1972). MPD patients frequently behave as if one or more of their alter identities are amnesic for the memories of other alters. MPD theorists typically describe such amnesia as an involuntary and spontaneous occurrence that is akin to hypnotic amnesia (Bliss, 1986; Ross, 1989). Contrary to such descriptions, however, amnesic displays are not a common accompaniment of hypnotic performances unless the amnesia has been suggested explicitly (Coe, 1989). Spontaneous amnesia is a rare occurrence and, when it does occur, may simply reflect subjects' implicit understandings of the hypnotic role. Even highly hypnotisable subjects typically recall the contents of their hypnotic session after its termination unless they are explicitly suggested to do otherwise.
When asked to describe the experience of hypnotic amnesia, subjects proffer a wide range of reports. Contrary to the way in which hypnotic amnesia has been described in the MPD literature (e.g., Bliss, 1986), many subjects describe their forgetting as an active process that involves self-distraction and other strategies aimed at inhibiting recall (Spanos & Bodorik, 1977). Some hypnotic subjects do report that they were unable to recall target material and that they perceived their amnesia as involuntary. Nevertheless, the available experimental data indicate that even these subjects retain rather than lose control of memory processes and guide their recall in terms of the social demands to which they are exposed (Coe, 1989; Spanos & Coe, 1992). For example, in two separate studies (Silva & Kirsch, 1987; Spanos, Radtke, & Bertrand, 1984), highly hypnotisable hypnotic subjects who were displaying amnesia were convinced that they would be able to recall the forgotten information but only under certain conditions. All of the subjects in one study and almost all in the other behaved in terms of the expectations conveyed to them by recalling and failing to recall forgotten material in the appropriate sequences. Relatedly, Coe and Sluis (1989) exposed highly hypnotisable subjects who exhibited posthypnotic amnesia to strong and repeated demands to remember. Under these circumstances, even subjects who had insisted that their amnesia was involuntary showed substantial recovery of the forgotten memories.
MPD patients are frequently described as living for years with alter personalities of which they are unaware (Kluft, 1985). However, hypnotic amnesia is rarely complete even among highly hypnotisable subjects. Moreover, among those few subjects who exhibit total amnesia, more than half report post-experimentally that during the amnesia test period, they consciously remembered but failed to report at least some of the target information (Spanos & Bodorik, 1977).
The "memory deficits" displayed by hypnotically amnesic subjects vary dramatically as a function of the expectations to which they are exposed. Thus, depending on the suggestions they are given, these subjects behave as if they have forgotten an entire list or only a subset of the list; all of the concrete words on a list but none of the abstract words, and vice versa; the number 4 while recalling all remaining numbers; and so on (Coe, 1989). Exhibiting the wide range of memory performance changes called for in these different experiments requires that hypnotic subjects retain rather than lose control of memory processes and guide their amnesic displays in terms of their understanding of what is called for by the amnesia test situation.
MPD patients also exhibit a wide range of amnesic deficits that are difficult to explain in terms of involuntary memory dysfunction. Some report a one-way amnesia between alter identities, whereas others report a two-way amnesia. When switching alter identities, most such patients retain basic skills such as reading and writing. In some early cases, however, these abilities were purportedly lost and had to be relearned by the new identity (Hacking, 1991; Kenny, 1986). In many modern cases, MPD patients switch back and forth between alters (and thereby between sets of supposedly segregated memories) very quickly. However, in a series of 19th-century British cases described by Hacking (1991), these kinds of switches between alters frequently involved a period of transitional sleep. Nineteenth-century and early-20th-century MPD patients rarely displayed more than two or three alter identities (Bowman, 1990). Modern patients, on the other hand, display an average of 15 or more alters, and some of these patients exhibit more than 100 alters (Ross, Norton, & Fraser, 1989). In other words, the number of dissociated memory systems supposedly possessed by MPD patients has grown exponentially since the beginning of this century. These kinds of differences in amnesic displays over time and across patients suggest that MPD patients, like hypnotically amnesic subjects, alter their patterns of recall as a function of their understanding of what is expected. As the expectations of therapists concerning the amnesia of their patients change, patients change their amnesic displays to meet the new expectations.
Work with non-MPD psychiatric patients also indicates that psychogenic amnesia is a goal-directed achievement influenced by subjects' understandings and by legitimation received from others rather than an involuntary occurrence (Kirshner, 1973). For instance, Parfitt and Gall (1944) worked with combat veterans whose reports of amnesia prevented their return to active service. Rather than legitimating these amnesic displays, Parfitt and Gall informed the patients that their memory would return and continued to convey this expectation in their interactions with the patients. Parfitt and Gall did not use any treatment to lift patients' amnesia other than telling them that they could remember. Exposure to these consistent demands to recall rather than to continue forgetting led most subjects to recover their memories. On the basis of these and other clinical findings, Kirshner (1973) suggested that psychogenic amnesia can be construed as a transitional social role that is adopted to deal with conflict and stress. Such an analysis may be useful for explaining how hypnotic interventions that legitimate remembering can often induce a "sharing" of memories among the several identities enacted by multiples (R. B. Allison & Schwarz, 1980; Bliss, 1980; Ross, 1989). The available evidence indicates that hypnotic procedures do not possess intrinsic properties that enhance recall (Smith, 1983; Wagstaff, 1989). However, such interventions may provide a legitimating context for redefining the situation as one in which displays of cross-identity remembering are considered role appropriate.
In summary, MPD theorists may well be correct when they contend that the amnesia of MPD patients resembles hypnotic amnesia. However, the descriptions of hypnotic amnesia given by these theorists are often misleading (e.g., Bliss, 1980, 1986). Contrary to these descriptions, the available data indicate that hypnotic amnesia does not involve an automatic and complete forgetting of events. Instead, hypnotic amnesia (and most likely much of MPD amnesia as well) involves goal-directed enactment aimed at meeting social expectations. Such amnesia is frequently defined by subjects as involving voluntary self-distraction, it is rarely complete even in highly hypnotisable subjects, and, when it is complete, it frequently involves conscious withholding and is typically of short duration. Hypnotic subjects retain rather than lose control of memory processes and, in that way, display the particular memory deficits called for by the test situation (Coe, 1989; Spanos, 1986b).
Braun (1990) suggested that the segregated memories displayed by different alters reflect state-specific recall. Application of this idea to the amnesia seen in MPD patients suggests that experiences acquired in one psychological state (i.e., Identity A) will not be remembered when the person is in a different state (i.e., Identity B). However, these experiences will be easily remembered when the person is again in the first state (i.e., Identity A). This formulation cannot account for the one-way amnesia that is commonly reported by MPD patients (e.g., Identity A is aware of its own memories and those of Identity B, but Identity B is aware only of its own memories). In addition, this hypothesis cannot explain cases in which people who display distinct identities show no cross-identity amnesia.
Heterosexual male transvestites in North American culture alternate between a male and female identity. When enacting their female identity, they typically dress as women, act as women, and refer to themselves with a woman's name (Talamini, 1982). Nevertheless, transvestites do not display between-identities amnesia. While enacting their female self, they recall and discuss their masculine self, and vice versa (Docter, 1988). These findings indicate that amnesia between identities does not arise automatically as a function of the differences in psychological functioning that are involved in enacting one identity as opposed to another. Instead, whether or not amnesia is associated with alter identity enactments appears to depend on the expectations and purposes associated with those enactments.
Experimental Creation of Multiplicity
In the last 20 years, two lines of experimental research have examined variables that influence the development of multiplicity. The first was initiated by Hilgard (1979) and revolved around his notion of a hidden observer or hidden self. The second research line has dealt with the phenomenon of past-life hypnotic regression.
Hidden Observer Experiments
Hilgard (1979, 1991) conducted a series of studies that led to the elicitation of "hidden selves" in highly hypnotisable college students. In a typical experiment, subjects were exposed to Pain stimulation trials before and after administration of a hypnotic procedure and suggestions for analgesia. Subjects were also given instructions that implied that a hidden part of them remained aware of all they experienced during the analgesia period. During hypnotic analgesia testing, these subjects gave two types of pain reports. Verbal (overt) reports purportedly from their hypnotised self usually indicated relatively low levels of pain, and covert reports (numbers tapped out in a previously taught keypressing code) supposedly from their hidden self usually indicated high levels of pain.
Hilgard (1979, 1991) argued that the hidden self instructions used in these studies did not provide subjects with the idea that they had a hidden self or with the idea that hidden and overt reports should be different. Instead, the hidden self was supposedly an unsuggested accompaniment of hypnotic analgesia that remained separated from normal consciousness by an "amnesic barrier" unless and until it was contacted by the hypnotist. Contrary to this view, a number of studies (Spanos, Flynn, & Gwynn, 1988; Spanos, Gwynn, & Stam, 1983; Spanos & Hewitt, 1980) demonstrated that the direction of hidden reports varied with the expectations conveyed by hidden self instructions. Thus, depending on the implications contained in their instructions, subjects exhibited hidden selves that reported less pain than, more pain than, or an amount of pain equal to that of their hypnotised selves.
The creation of hidden selves that respond to instruction by behaving as if they possess information of which the person's "normal self " is unaware has been documented in studies on hypnotic age regression, blindness, eye-witness recall, and amnesia as well as pain reduction (Spanos et al., 1988; Spanos, Gwynn, Corner, Baltruweit, & deGroh, 1989; Spanos & Mclain, 1986; Spanos et al., 1984). Moreover, hypnotic procedures are not required to produce hidden selves. Two studies (Spanos & Bures, 1993; Spanos, deGroot, Tiller, Weekes, & Bertrand, 1985) found that nonhypnotic high hypnotizables reported experiencing hidden selves as frequently as did corresponding hypnotic subjects.
In summary, the enactment of hidden or dissociated selves. by hypnotic and nonhypnotic subjects involves strategic, rule-governed self-presentation. In these studies, information about the characteristics of the hidden selves was provided by experimental instructions, and subjects guided their experiences and behaviors in terms of these role prescriptions. Thus, the characteristics of hidden self enactments varied as a function of the performance expectations transmitted to subjects.
Past-Life Regression Experiments
Several studies have examined factors that influence the formation of multiple selves by using the phenomenon of past-life hypnotic regression. Although some believers in reincarnation hold that people can be hypnotically regressed back to previous lives (e.g., Wambaugh, 1979), the available evidence suggests instead that past-life experiences are fantasy constructions (Baker, 1992; Spanos, Menary, Gabora, DuBreuil, & Dewhirst, 199 1). These experiences are important because they shed light on the processes by which people come to treat their fantasies as real and because past-life identities are similar in many respects to the multiple identities of MPD patients. Like MPD patients, subjects who exhibit past-life identities behave as if they are inhabited by more than one self. Like the secondary selves of MPD patients, those exhibited by past-life responders often display moods and personality characteristics that are different from the person's primary self, have a different name than the primary self, and report memories of which the primary self was previously unaware. Just as MPD patients come to believe that their alter identities are real personalities rather than self-generated fantasies, many of the subjects who enact past lives continue to believe in the reality of their past lives after termination of the hypnotic procedures.
Kampman (1976) found that 41% of highly hypnotisable subjects manifested evidence of a new identity and called themselves by different names when hypnotically regressed beyond their birth. Contrary to the notion that the development of multiple identities is a sign of mental illness, Kampman's past life responders scored higher on measures of psychological health than did subjects who failed to exhibit a past life.
In a series of experiments, Spanos, Menary, et al. (1991) also obtained past-life identity enactments after hypnotic regression suggestions. Frequently, the past-life identities were elaborate, had their own names, and described their lives in great detail. Subjects who reported past lives scored higher on indexes of hypnotizability and fantasy proneness, but no higher on indexes of psychopathology, than those who did not exhibit a past life.
The characteristics that subjects attributed to their past lives were influenced by experimenter-transmitted expectations. For instance, subjects provided with prehypnotic information about the likely characteristics of their identities were much more likely than controls to incorporate these characteristics into their descriptions of their past-life selves (Spanos, Menary, et al., 1991, Experiment 2). In a different study (Spanos, Menary, et al., 1991, Experiment 3), some subjects were informed prehypnotically that children in past eras were frequently abused, whereas those in the other condition were given no information about abuse. The past-life identities of subjects given abuse information reported significantly higher levels of childhood abuse than did the past-life identities of control subjects. In summary, these studies indicate that the personal attributes and memory reports elicited from subjects who enact past-life identities are influenced by the beliefs and expectations conveyed by the experimenter/hypnotist. Subjects shape the attributes and biographies attributed to their past-life identities to correspond to their understandings of what significant others believe these characteristics to be.
The extent to which subjects assigned credibility to their past life identities correlated significantly with the degree to which they placed credence in reincarnation before the experiment and the extent to which they expected to experience a real past life. However, subjects' beliefs in the reality of their past lives were also influenced by information from the experimenter. Spanos, Menary, et al. (1991, Experiment 4) informed subjects in one condition that past-life identities were interesting fantasies but were certainly not evidence of real past lives. Those in another condition were informed that reincarnation was a scientifically credible notion. Subjects in the two conditions were equally likely to enact past-life identities, but those assigned to the imaginary creation condition assigned significantly less credibility to these identities than did those told that reincarnation was scientifically credible. In short, prior information from authority figures influences not only the characteristics and memories that people attribute to their multiple identities but also the degree to which they come to believe in the reality of these identities.
Taken together, the experimental data indicate that multiple identities are social creations that can be elicited easily from many normal people. When the identity to be constructed is relatively complex, as in past-life regression studies, subjects draw on information from a wide array of sources (e.g., TV shows, historical novels, aspects of their own past, and wish-fulfilling daydreams) to flesh out the newly constructed identity and to provide it with the history and characteristics that are called for by their understanding of the current task demands. These studies indicate that the development of multiple identities is not related to psychopathology and that men are as adept as women at creating such identities. Although none of these studies obtained information about whether subjects had been abused as children, the fact that psychopathology failed to predict either the development of these identities or the extent to which subjects construed them to be real rather than imagined makes it unlikely that early abuse played an important role in these regards.
Cross-Cultural Studies on Spirit Possession
Multiple self enactments occur in most but not all cultures (Bourguignon, 1976). In many traditional societies and in some subcultural contexts in North American society, multiple self enactments take the form of spirit possession. In these cases, it is believed that the human occupant of the body is temporarily displaced by another self or selves that are defined as spirits who temporarily take over control of the body. Frequently, the human self claims amnesia for the periods during which the spirit selves are in control (Bourguignon, 1976; Lewis, 1987).
The frequency with which possession occurs varies greatly from one society to another. In some societies that hold possession beliefs, only a relatively small percentage of the population is ever defined as actually possessed. For instance, Wijesinghe, Dissanayake, and Mendis (1 976) reported an incidence of 0.5% for a semiurban population in Sri Lanka; Carstairs and Kapur (1976) found a period prevalence rate in a rural population on the west coast of South India of 2.8%; and Venkataramaiah, Mallikadunaiah, Chandra, Rao, and Reddy (1981) reported a prevalence of 3.7% in a different South Indian rural population. In other societies, the rates of possession are extremely high. For instance, in the villages of the Malagasy, speakers of Mayotte, Lambek (1980) reported that 39% of the adult women and 8% of the adult men were considered to be possessed. Relatedly, Harper (1963) reported that 20% of the women among the Havik Brahmins in Mysore, India, experienced possession, and Boddy (1988) found that in different years 42% and 47% of ever-married women more than 15 years of age in the village of Hofriyat in Northern Sudan had succumbed to possession. When considering only women between the ages of 35 and 55 years, Boddy (1988) reported that 66.6% bad experienced possession.
In most traditional societies that hold possession beliefs, possession occurs much more frequently in females than in males. This, however, is not invariably the case, and in some societies possession occurs with equal or almost equal frequency in the two sexes (Lewis, 1987). If nothing else, the marked differences between societies in rates of possession, coupled with the very high rates of possession in some societies, should make one wary of explanations of multiple identity development that emphasize the importance of stable personality or cognitive characteristics (such as high fantasy proneness or high hypnotizability) as necessary predisposing factors. Sex ratios and the proportion of community members affected also vary widely in some North American groups that display spirit possession.
Two North American Examples of Spirit Possession
One relatively common form of possession experience in North American society is religious glossolalia (Hine, 1969). Glossolalia involves semantically meaningless vocal utterances that sound language-like and that are sometimes mistaken by naive listeners as a foreign language. Glossolalia is frequently spoken in certain Christian religious settings. It may be accompanied by dramatic behaviors including convulsions, profuse sweating, eye closure, and an apparent loss of consciousness, but it often occurs in the absence of all such dramatic accompaniments (Spanos & Hewitt, 1979). Whether or not glossolalia is accompanied by dramatic displays appears to depend on the expectations of the glossolalics and their audience and the norms of the particular setting in which it is displayed. Traditionally, glossolalia has been interpreted in Christian circles as possession by the Holy Spirit, who speaks his own language (the glossolalia) through the possessed person.
Glossolalia is learned behavior, and rates of glossolalia differ dramatically across different religious groups as a function of expectations concerning who will and will not manifest the phenomenon. In some congregations, glossolalia is encouraged and occurs in all or almost all members. In other congregations, it is relatively rare (Samarin, 1972). Glossolalia can be easily learned through modelling and practice (Spanos, Cross, Lepage, & Coristine, 1986), and congregations that encourage glossolalia typically provide the novice with much encouragement and coaching and multiple opportunities to closely observe other glossolalics (Maloney & Lovekin, 1985). Glossolalics do not score higher than nonglossolalics on measures of hypnotizability, imaginative activity, or psychopathology (Richardson, 197 3; Spanos & Hewitt, 1979), and the ability to learn glossolalia is unrelated to either hypnotizability or imaginative activity (Spanos, Cross, et al., 1986). Glossolalia can occur with equal frequency in men and women, and when sex differences do occur they reflect local custom rather than intrinsic gender differences (Samarin, 1972).
In some religious communities, the first manifestation of glossolalia is interpreted as a sign of salvation that signals full acceptance into the religious group. In describing their conversion, new members typically draw a sharp distinction between their new (post-conversion) identity and their old life of sin.
These members frequently reconstruct their biographies to accentuate differences between their pre-conversion and post-conversion identities, In so doing, they emphasize their first glossolalic experience as a marker of what they and their community view as a critical transition point between a discarded sinful identity and a new consecrated identity (Hine, 1970; Maloney & Lovekin, 1985).
Another form of possession with a long history in Western societies is spirit mediumship (R. L. Moore, 1977). During the late 19th century, at the height of interest in mediumship in America, spirit mediums were often female, and adoption of the medium role was a vehicle through which women could circumvent some of the restrictions associated with the female role and earn an independent living. North American mediums usually became possessed by a control spirit who served as an intermediary to the spirit world and who summoned the spirits of departed relatives, who in turn possessed and spoke through the medium. Typically mediums reported amnesia for the period during which the spirits occupied their bodies.
Although less common than previously, spirit mediums continue to operate in many North American cities. Biscop (1981, 1985) conducted a participant observation study of a spiritist church in Canada and documented the process by which novices were socialised into the role of medium. Part of this process involved formal teaching, but much of it involved repeated opportunities to observe more experienced mediums, coupled with encouragement in small-group settings in which novices were provided with helpful feedback. Mediumship involves learning how to "read" the client to obtain information about the deceased that can then be fed back to the client as proof of the deceased's survival. At times, mediums go to great lengths and use much trickery to obtain information and provide convincing performances (Keene, 1976). Biscop (1981) interviewed six North American mediums at length. Most reported relatively happy childhoods, and, in marked contrast to MPD patients, only one reported that she had been sexually abused as a child.
The characteristics of possession displays in other cultures also vary greatly both between societies and within societies. Possession is not a unitary phenomenon; it differs dramatically depending on the status of the possessed person, the context in which the possession occurs, and the meaning attributed to the possession both by the possessed individual and by his or her audience (Krippner, in press; Lewis, 1987).
In many societies, spirit possession occurs as part of helping rituals. The medium becomes possessed by a spirit or by successive spirits, and it is the spirits who diagnose the client, prescribe treatments, or offer advice for problems in living. The rituals can be private consultations involving only the medium and client or public ceremonies involving one or more mediums and large audiences (Lee, 1989; Lewis, 1987). The structure of these rituals illustrates the social nature of multiple identity enactments and the dependence of such enactments on social validation. The medium and the audience hold complementary expectations concerning the behaviors that define the medium as possessed by a particular spirit and the behaviors that define members of the audience as validating the spirit presentations. The medium presents as a specific spirit by enacting the behavioural displays that the audience identifies with that spirit. The audience, in turn, validates the medium's presentation by responding in a manner that is congruent with the particular spirit identity being presented (Firth, 1967; Lambek, 1988; Lee, 1989).
For instance, the transition from the medium's human personality to that of a spirit is marked by readily identifiable signs (e.g., shaking and eye closure) that the audience has learned to interpret in terms of spirit possession. Similarly, the transition from one spirit identity to another is marked by recognisable changes in behavior such as changes in voice, personality, and dress. In some cultures, particular spirits dance to some tunes but not others; in others, each change in spirit identity is marked by replacing a scarf of one colour with a scarf of another. When behaving as a warrior spirit, the medium struts to and fro in an aggressive and threatening manner and the audience responds accordingly by being quiet and respectful. When presenting as a tiger spirit, the medium may walk on all fours and growl while the audience backs away. When presenting as a risqué spirit, the medium jokes with the audience, which responds with relaxation and laughter (Krippner, 1989; Lambek, 1989; Lee, 1989; Saunders, 1977). The result of these mutually supporting interactions is the construction of spirit possession as a social reality (Schieffelin, 1985).
Often, ritual possession ceremonies involve a number of people who are possessed simultaneously (Lewis, 1987). Furthermore, in some ceremonies, a single spirit can move from possessing one person to possessing another. However, the same spirit cannot possess two people simultaneously. Thus, ceremonies that involve the simultaneous possession of several people by spirits that move between mediums involve a good deal of co-ordination. The various mediums must be aware of their own performances as well as those of other mediums to keep their changing roles distinct (Lambek, 1988; Lee, 1989).
The rule-governed nature of ritual possession is also illustrated by the preparation required for a convincing performance. The props for differentiating spirit identities must be readily available. For instance, when presenting as a tiger spirit, one medium would bite and suck at the patient's body until he produced from his mouth a black substance that he called black pus and blood. The blood he probably produced by biting his own cheek, and the "black pus" he produced by putting ashes into his mouth before the ceremony and before becoming possessed (Peters, 1981).
Becoming a spirit medium usually involves an extensive socialisation process, and once an individual becomes a medium periodic possession may be a lifelong occurrence. In some societies, mediumship runs in families, and particular spirits move from possessing a parent to possessing one of his or her children. In other cases, mediums are former patients who apprentice with their healer. Frequently, there are a number of different paths into mediumship within the same society. Regardless of the path taken, however, the medium must learn the rules required to give convincing performances that meet the expectations of clients and other audience members (Krippner, 1989; Morton, 1977; Peters, 1981).
Becoming a spirit medium, like becoming a glossolalic, sometimes involves the possessed organising their biographies to correspond with implicit societal conceptions concerning the meaning of possession. In some societies, for instance, the possession careers of mediums are described in highly stereotyped fashion and include a series of stock background events (e.g., fleeing into the wilderness) that explain why they were singled out by the spirits for possession (Morton, 1977). Investigators of mediums in traditional cultures (Krippner, 1989; Leacock & Leacock, 1972) have often commented that these individuals usually appear to be well adjusted, mentally healthy, and competent.
The spirit possession enactments of mediums are responsive to sociocultural changes, and in some circumstances possession becomes a vehicle for expressing resistance to externally imposed authority (Stoller, 1989). For instance, during the French colonial period, native African mediums among the Songhay became possessed by a new group of spirits that aped colonial officials and burlesqued French colonial society with displays of exaggerated and satiric behavior. Later, when French rule was replaced by a puritanical Islamic state, mediums expressed their resistance by enacting scatological and overtly sexual possession displays that violated the official Islamic moral code (Stoller, 1989). The responsiveness of possession displays to cultural changes illustrates the constructive and goal-directed nature of possession and the importance of ongoing situational factors (as opposed to idiosyncratic psychological ones) in determining both the character of possession displays and the historical changes that occur in the nature of those displays.
Lewis (1987) distinguished between central and peripheral possession. In central possession, the medium is possessed by the major deities of the society, and the possession performances serve to publicly reaffirm and support the central values of the society. Typically the medium in central possession is a respected member of the community. In contrast, peripheral possession afflicts socially marginal and oppressed members of the community. In this case, the possessing spirits are capricious and often amoral members of the pantheon, and possession is associated with illness, emotional distress, or both.
Lewis (1987) hypothesised that peripheral possession often constitutes a strategy used by the socially powerless to manipulate their social superiors. Typically, peripheral possession occurs in people low in the social hierarchy who are experiencing high levels of psychological or interpersonal stress. The stress is often manifested in psychophysiological symptoms (e.g., headaches) that are interpreted as initial manifestations of possession. The possessing spirit makes numerous demands that must be met by the family of the possessed. Possession is considered involuntary, and the disruptive behavior and unusual demands are attributed to the possessing spirit rather than the possessed person. Frequently, peripheral possession is chronic, and new or recurring stresses lead to a recurrence of symptoms (Saunders, 1977; Ward, 1989).
Many traditional societies are strongly patriarchal, and the women in these societies often have few rights and are hemmed in by many social restrictions. Consequently, in most of these societies it is women rather then men who resort to peripheral possession as an interpersonal strategy for improving their lot. For example, a woman who is in an unhappy marriage to an inattentive or brutal husband and lives in a culture that restricts married women almost exclusively to the home may become possessed by a spirit who demands an expensive public ceremony that includes rich delicacies, new clothing, and interaction with other women. Moreover, when enacting the spirit role, the woman can voice unflattering and insulting remarks to her husband that would not be tolerated if they were defined as coming from her rather than from her spirit (Constantinides, 1977). Possession is a public event, and the norms of the community may demand that the husband abide by the requests of the spirit despite his personal feelings toward his wife and despite the substantial expense involved.
In many societies where peripheral possession occurs, the aim of treatment is not to expel the spirit but to bring it under control. Frequently, this taming process is accomplished by the possessed joining a possession cult (Lewis, 1987). Here the possessed individual joins with other possessed individuals under the tutelage of a shaman. The shaman is herself possessed but has learned to control her possessing spirits and use them as spiritual advisors. The women in the cult meet regularly to hold feasts and dances in honour of the spirits and to seek spiritual advice from the spirits of the shaman (Lewis, 1987; Morton, 1977). Frequently, these cult groups foster a high level of cohesiveness and appear to provide tangible psychological benefits for their adherents (Galanter, 1990; Morton, 1977).
Rates of peripheral possession can change within a culture. In societies that condone possession beliefs, cultural changes that increase stress levels often produce increased rates of possession (Ackerman & Lee, 1981; Phoon, 1982; Sharp, 1990; Teoh, Soewondo, & Sidharta, 1975). For instance, several investigators (Ackerman & Lee, 1981; Ong, 1988; Phoon, 1982) have described small epidemics of possession in female Malaysian factory workers. These women frequently carry out boring, repetitive work for very low wages under poor working conditions. The anti-union policies of the factories effectively prevent organised protest. Under these circumstances, epidemics of spirit possession that involve convulsions and bizarre behavior become a way of venting distress and frustration, obtaining time off from work, and rebelling against authority. Because the spirits rather than the possessed women are blamed for the disturbances, possession displays are a safe, albeit indirect, way of expressing grievances. In a factory studied by Ackerman and Lee (1981), increases in the frequency of possession episodes followed a change from relaxed to stricter management. Moreover, the possession displays occurred only among the Malaysian workers whose cultural beliefs made possession an acceptable vehicle for the expression of dissatisfaction. Chinese and Indian workers in the same factory never exhibited displays of possession.
Epidemic possession affects numerous people in close proximity within a short period of time and, therefore, cannot be accounted for by theories of multiplicity that emphasize idiosyncratic psychological causes. The contagion that occurs in these cases results from social factors, from the common understandings held by participants about what constitute legitimate means of expressing dissatisfaction, and from the effects of observing displays of possession and the consequences of those displays.
In summary, possession phenomena underscore the rule-governed and social nature of multiple identity displays. Enactments of spirit possession are learned patterns of social responding. Possessed individuals enact spirit identities that correspond to their understandings and expectations of possession. Possession enactments are public and involve interaction with an audience that legitimates the enactments. These enactments occur in a wide range of circumstances, are carried out by very different kinds of people, and serve a number of different social functions. Possession is sometimes symptomatic of severe stress and accompanied by symptoms of psychopathology. At other times, however, it is enacted by well-adjusted individuals who do not manifest high levels of psychopathology.
Historical Manifestations of Demonic Possession
The idea that demons can enter into people and take over their functioning entered Western European history as an accompaniment of Christianity (Spanos, 1983a). Although information concerning the rate of possession in earlier centuries is sparse, it seems clear that this rate varied dramatically in different historical eras (Oesterreich, 1966). Possession and exorcism were frequently used as proselytising tools to impress and convert unbelievers. Consequently, possession appears to have been a relatively common occurrence in the early church while Christianity struggled for supremacy among numerous competing religions. After Christianity became th,- state religion of the Roman Empire, the frequency of possession and exorcisms appears to have waned.
Beginning in the 11th. century with the gradual breakdown of feudalism, Western Europe experienced increased politico-religious turmoil that, in the 16th century, culminated in the Reformation and in the break-up of Western Christianity into competing sects (Russell, 1980). This period also saw the development and elaboration of the mythology of Satanism. According to the tenets of this mythology, there existed an international satanic conspiracy bent on destroying Christianity. The agents of this conspiracy were witches who supposedly worshipped Satan at secret meetings where they desecrated the symbols of Christian worship and engaged in cannibalism, murder, and sexual orgies (Cohn, 1975). Modern historians have rejected the notion that there actually was a satanic conspiracy or that those accused of witchcraft belonged to a large-scale conspiracy. Instead, the idea of a satanic conspiracy existed only in the imagination. It existed first in the imagination of cultural elites who established the administrative machinery and legal categories that made satanic witchcraft a crime and then spread down the social scale to become part of the taken-for-granted belief system of much of the populous (Cohn, 1975; Larner, 198 1; Russell, 1980; Spanos, 1978).
Possession and exorcism again became common between the 15th and 17th centuries because, during this period, possession became associated with witchcraft. Both Catholics and Protestants believed that witches, through Satan's intercession, could send demons to possess people. However, the indwelling demons could be coerced by authorities to name the witch that sent them. The accused witch could then be arrested, tortured into confessing her involvement in a non-existent satanic conspiracy, and, in many cases, executed. Thus, during this period demoniacs frequently functioned as witch finders, and those who controlled the demoniacs had a powerful weapon to use against political, social, or personal rivals (Spanos, 1978).
The Socialization of Demoniacs
The idea of demon possession was taken for granted in early modern Europe, and the major components of that role were well-known (Thomas, 1971). The subtle aspects of the role were transmitted through the demoniac's exposure to clerical experts. Demonic possession was used as one explanation for certain physical symptoms or for behavior that was socially disruptive or considered abnormal. During the initial stages of possession, the demoniac's symptoms were often ambiguous. Frequently, these symptoms began to correspond to "official" stereotypes of demonic possession as the demoniac gained information about those stereotypes (Spanos, 1983b; Spanos & Gottlieb, 1976; Walker, 1981).
The symptom displays of the possessed sometimes varied with local beliefs and practices, and these variations demonstrate the social and rule-governed nature of possession. For instance, both Catholic and Protestant demoniacs regularly convulsed and displayed a variety of sensory-motor deficits. In addition, Catholic demoniacs invariably exhibited direct evidence of indwelling demon selves. These demon selves spoke in voices different from that of the possessed person, had their own names, and displayed their own unique demonic personalities. Protestant demoniacs of the same period rarely displayed demon selves (Walker, 1981).
Protestant-Catholic variation in the frequency of demon self enactments reflected the different practices toward the possessed adopted by these religions. During Catholic exorcisms, the priest communicated directly with the indwelling demon. The priest made a clear distinction between the possessing demons and the person possessed. When questioning a demon, the exorcist expected to be answered by the demon and not by the person possessed (Oesterreich, 1966). Before beginning the exorcism rite, the priest contacted and questioned the demons to obtain their names, number, reasons for possessing the person, hour they entered the body, and length of time they proposed to stay (Kelly, 1974; "The Roman Ritual of Exorcism;' 1614/ 1976). During the exorcism, the demons were often questioned repeatedly and at great length about their motives, earthly accomplices, status in the social structure of hell, and so forth (e.g., Michaelis, 1613). In short, Catholic exorcism procedures strongly cued demon self enactments as a central component of the demonic role. In contrast, Protestants rarely used formal exorcism procedures because direct communication with demons was shunned as sinful (Thomas, 1971). In place of exorcism, Protestant demoniacs were treated with prayer and fasting, procedures that were much less likely to elicit demon self enactments.
Detailed information concerning role prescriptions was conveyed to both Catholic and Protestant demoniacs outside of the exorcism situation. The sources of this information could include explicit coaching by parties who held a vested interest in the demoniacs giving convincing performances, exposure to other more practised demoniacs, and conversations about the occurrence and timing of symptoms that were held in the demoniac's presence (Harsnett, 1599, 1603; Thomas, 1971; Walker, 1981).
A number of potent social psychological factors converged in leading potential demoniacs to define themselves as possessed., These individuals shared the same belief system as the community that labelled them and, therefore, tended to interpret their own illness of behavioural deviations in the same terms as their neighbours and clerical superiors (Thomas, 1971). In some cases, demoniacs were made dependent for the satisfaction of their physical and social needs on those who labelled them. The labellers consistently interpreted the experiences of demoniacs in terms of possession and isolated the demoniacs from others who might offer nondemonic interpretations of these events (Spanos, 1983a).
Individuals sometimes denied that they were possessed; however, these denials were routinely construed by authorities as indications of a wily demon attempting to escape divine punishment. Continued refusal to define oneself as possessed and act accordingly frequently led to threats of perpetual damnation and sometimes to punishment administered in the guise of benevolently motivated attempts to free hapless victims from demonic control (Harsnett, 1599; Spanos, 1983a).
Reasons for Adopting the Possessed Role
People did not always avoid being labelled demonically possessed. Like sufferers of peripheral possession in other cultures, the demonically possessed could use their enactments strategically. Those who became demoniacs usually had little social power, were hemmed in by social restrictions, and had few sanctioned avenues for protesting or improving on their situations. Given the patriarchal and misogynistic culture of early modem Europe, it is not surprising that adult demoniacs were much more frequently women than men (Oesterreich, 1966). Child demoniacs, on the other hand, were frequently of both sexes (Spanos, 1983a).
For the socially powerless, demonic possession offered numerous advantages. Its adoption could lead to a dramatic rise in social status. On one hand, demoniacs were viewed as the helpless victims of satanic influence and consequently received sympathetic attention and a reduced workload. On the other hand, they were sometimes treated as awesome seers whose affliction placed them in direct contact with the supernatural and whose performances commanded fearful respect and attention. Demoniacs sometimes became the star attractions in what the community considered a deadly serious combat between the forces of heaven and hell (Spanos, 1983a; Walker, 1981). Like peripheral possession in other cultures and MPD in North American culture, demonic possession was often chronic. Frequently, these individuals were possessed by many demons that had to be individually exorcised over a long period of time. Moreover, even the successful exorcism of all the demons was no guarantee that they would not return. Thus, once possession had been legitimated, it remained an option that could be used as the situation required.
Like the ritual ceremonies conducted by spirit mediums in other cultures, the performances of demoniacs often required forethought and the judicious use of props. For instance, the spitting up of pins or nails that were supposedly used by indwelling demons to torture the demoniac internally was a fairly regular feature of English and Continental possession cases (Notestein, 1911; Oesterreich, 1966). Obviously, the demoniacs had to place the pins in their mouths before their performance in anticipation of spitting them out later and in anticipation of the effect that such displays would produce in their audience.
In summary, demonic enactments constituted co-ordinated, goal-directed self-presentations aimed at conveying and sustaining the impression that the actors were possessed by evil spirits. As in cross-cultural manifestations of spirit possession, a major feature of the demonic role involved conveying the impression that behaviors were no longer governed by the actor. However, conveying this impression convincingly required that demoniacs retain behavioural control and gear their enactments to contextual demands in a manner consistent with their audience's conception of what constituted possession.
Multiple Personality Disorder
Cases that today would be labelled as MPD were reported infrequently during the first three quarters of the 19th century. An increase in the number of cases was reported in the last quarter of the 19th and the early years of the 20th century, and most of these were from either France or the United States (Hacking, 1986). By the end of the first 2 decades of the 20th century, the number of cases had dropped substantially, and from the 1920s to 1970 only a handful were reported world-wide. Since 1970, the number of cases reported has increased astronomically, and thousands have now been reported (Putnam, 1989). Investigators who are sympathetic to the MPD diagnosis are particularly likely to find high rates of occurrence of the disorder. For instance, Bliss, Larson, and Nakashima (1983) reported that 60% of the 45 patients admitted to a single inpatient ward with auditory hallucinations were actually suffering from MPD. Bliss and Jeppsen (1985) reported that approximately 8 of 50 (16%) sequentially admitted inpatients on an acute psychiatric ward and 9 of 100 (9%) private psychiatric outpatients suffered from MPD. Ross, Anderson, Fleisher, and Norton (1991) diagnosed 3.3% of a sample of 299 psychiatric inpatients as suffering from MPD. Despite the high rates of occurrence found in these studies and the high rates reported more informally by numerous other clinicians who are strong supporters of the MPD diagnosis (e.g., R. B. Allison & Schwarz, 1980; Braun, 1984; Kluft, 1982), some studies have reported very low rates of occurrence. Thus, Merskey and Buhrich (1975) found no MPD among 89 patients diagnosed with dissociative or conversion disorders. In addition, a number of highly experienced clinicians with many years of practice report never having seen a case of MPD (Chordoff, 1987; Merskey, 1992).
At present, MPD appears to be a culture-bound syndrome. The explosion of cases since 1970 has been largely restricted to North America. Despite its turn-of-the-century prominence as a center for the study of MPD, the diagnosis is very rarely made in modern France. It is also very rare in Great Britain (Aldridge-Morris, 1989; Fahy, 1988), Russia (R. M. Allison, 1991), and India (Adityhanjee & Khandelwal, 1989), and a recent survey in Japan failed to uncover even a single case (Takahashi, 1990).
Modestin (1992) surveyed all of the psychiatrists in Switzerland concerning the frequency with which they had seen patients with MPD. Depending on how it was calculated, the prevalence rate ranged between 0.5% and 1.0%. More Interesting, Modestin noted that 90% of the respondents had never seen a case of MPD, whereas 3 psychiatrists had each seen more than 20 MPD patients. From the data presented in this article, it appears that 66% of the MPD diagnoses were made by only 6 of 655 (0.09%) psychiatrists. Unlike North American samples in which women are at least three times more likely than men to receive an MPD diagnosis, Modestin found that 51% of the MPD diagnoses were given to men.
The historical changes in the prevalence of MPD, the substantial national differences in prevalence and in gender ratios, and the large differences in the frequency with which different clinicians make the diagnosis are difficult to account for parsimoniously in terms of a disease perspective. They are, however, reminiscent of the historical changes in the prevalence of demonic possession, the large cross-cultural differences in the prevalence of spirit possession, and the large differences in rates of glossolalia seen between different churches in North America. In short, the prevalence data for MPD suggest that MPD, like possession phenomena, is a social creation that varies in frequency as a function of the expectations for its occurrence that are transmitted to patients. The most important sources of such expectations are therapists committed to the MPD diagnosis, but other sources (e.g., media) have become increasingly important as information about MPD has infused into the wider culture.
An alternative to the social creation hypothesis holds that the incidence of MPD has not really increased. According to this view, MPD was previously (and often continues to be) misdiagnosed as schizophrenia, psychopathy, and various other disorders (R. B. Allison & Schwarz, 1980; Rosenbaum, 1980; Ross, Norton, & Wozney, 1989). Purportedly, the current increased prevalence of the disorder is apparent rather than real and reflects the fact that actual MPD cases are incorrectly diagnosed less frequently than previously. This account is also sometimes used to explain national differences in MPD rates (Altrocchi, 1992). According to this view, psychiatrists in other countries have not yet developed the diagnostic acumen required to recognise MPD.
A major problem with this account is that the symptoms of MPD are, in fact, quite distinctive. A patient who calls herself Mary on one day and Jane on another and who behaves very differently as Mary than as Jane is unlikely to go unrecognised as a candidate for an MPD diagnosis by even an inexperienced clinician. To deal with this difficulty, proponents of the disease model argue that such patients are skilled at hiding their multiplicity and reveal it only when those with acumen enough to correctly interpret the subtle signs use diagnostic procedures that bring forth the multiple identities. In fact, the proponents of the MPD diagnosis agree that most patients who eventually receive this diagnosis do not enter therapy complaining about multiple personalities, do not exhibit clear-cut evidence of multiplicity, and do not know that they possess alter identities (R. B. Allison, 1978; Franklin, 1988; Wilbur, 1984). These investigators regard MPD as a "hidden syndrome" in which 80% of such patients were unaware of the existence of alters before entering treatment with the therapist who uncovered their multiplicity (Kluft, 1985). From a socio-cognitive perspective, these data suggest instead that the procedures used to diagnose MPD often create rather than discover multiplicity.
Proponents of the MPD diagnosis have described a large and diverse number of signs that supposedly might indicate this disorder and that can be used to justify probing for confirmation. Some of these signs include depression, somatoform symptoms, headaches, periods of missing time, impaired concentration, hallucinations, sexual dysfunctions, fatigue, and drug abuse (Coons et al., 1988; Ross, Norton, & Wozney, 1989). There are many more. R. B. Allison (1978) even suggested that a smooth complexion might indicate MPD because the regular switching of alter personalities supposedly prevents the formation of wrinkles. Even this truncated list makes it clear that a large set of presenting symptoms can be used as possible indicators of MPD.
Once the diagnosis is suspected, it is common practice to ask leading and explicit questions in an attempt to confirm it. Putnam (1989), for example, asked such questions as "Do you ever feel as if you are not alone, as if there is someone else or some other part watching you?" (p. 90). Others apply stronger pressure. Merskey (1992) recently reviewed a large number of MPD cases from the 20th century and earlier that provided information about treatment procedures and symptomatology. His review included well-known cases such as those of Sally Beauchamp (Prince, 1908), The Three Faces of Eve (Thigpen & Cleckley, 1957), and Sybil (Schreiber, 1973), as well as many lesser known ones. Merskey (1992) found that highly leading and suggestive procedures have long been routine in the diagnosis of MPD. In some cases, therapists insisted to doubting patients that they were multiples and even supplied the patients with names for their alters. Along these lines, it is worth noting that Allison and Schwarz (1980) contended that patients are frequently reluctant to accept that they are multiples and, under these circumstances, should be actively persuaded by their therapist.
Perhaps the most common procedure used to elicit evidence of multiplicity is the use of highly leading hypnotic interviews during which alter personalities are explicitly suggested and explicitly asked to "come forth" and talk with the therapist (Allison & Schwarz, 1980; Bliss, 1980, 1986; Brandsma & Ludwig, 1974). In fact, R. B. Allison (1978) stated that the major difference between therapists who diagnose MPD and those who do not is the use by the former of hypnotic procedures for uncovering hidden memories. Wilbur (1984) described the process: "The patient is hypnotised and each alternate, in turn, is asked to tell what precipitated it into the life of the birth personality" (p. 28). Bliss (1986) elaborated on the procedure:
“I then suggest that the [hypnotised] patient look into her mind to see if there is anyone or anything there. If anything or a person is identified I want to know who it is. [Once an alter has been identified] I then make a rapid survey by asking the personality . . . if she has a name; how long she has been there; the patient's age when she [the alter] came; whether the patient knows her; whether she ever takes over the body; whether she ever directs or influences the patient when the patient has the body; her mission or function; and whether there are other people back there.” (pp. 196-197)
Given the highly leading nature of these procedures, it comes as no surprise that there often are "other people back there," and they are identified and surveyed in the same manner. The flavour of such interviews is conveyed in the following verbatim excerpt from a hypnotic interview with a suspected murderer named Ken Bianchi. Because it was conducted in a forensic context, Bianchi's interview was videotaped. After a hypnotic induction procedure, the clinician proceeded as follows:
“I've talked a bit to Ken but I think that perhaps there might be another part of Ken that I haven't talked to. And I would like to communicate with that part. And I would like that other part to come and talk to me. . . . And when you are here, lift the left hand off the chair to signal to me that you are here. Would you please come part so I can talk to you. . . . Part would you come and lift Ken's hand to indicate to me that you are here? . . . Would you talk to me part by saying "I'm here."“ (Schwarz, 1981, pp. 142-143)
During this interview, Bianchi displayed a second personality named Steve who confessed to the murders with which Ken had been charged. The clinician who conducted this interview pointed out that he did nothing unusual in this case and used such interview procedures regularly to diagnose MPD (Watkins, 1984). In other words, leading hypnotic interviews that repeatedly inform the patient that he or she has other parts that can be addressed and communicated with as if they were separate people are used routinely when diagnosing MPD.
Spanos, Weekes, and Bertrand (1985) used the hypnotic interview that was employed with Bianchi to test the hypothesis that such procedures can provide even naive subjects with the information required to enact multiple identities. The subjects were college students asked to pretend that they were in Bianchi's situation, had been accused of committing a series of murders, and had been remanded for a psychiatric interview. Subjects were told nothing about multiple personality. They were simply instructed to use whatever background information they possessed and whatever they could glean from their interview to behave the way they believed an accused in that situation would behave.
Subjects in one group were administered an interview modelled closely on the one used with Bianchi. Role-playing control subjects were also interviewed. These subjects were told that personality was complex and involved walled-off thoughts and feelings, but the interviewing "psychiatrist" never informed the controls that they possessed another part that could be communicated with directly.
Most of the role players given the Bianchi interview enacted symptoms of MPD by (a) adopting a different name, (b) referring to their primary personality in the third person, and (c) displaying amnesia for their alter personalities after termination of the hypnotic interview. None of the role-playing controls displayed any of these symptoms.
In a second session, the "psychiatrist" again contacted the alter personalities of the role-playing multiples. These subjects maintained their role successfully in the second session by exhibiting marked and consistent differences between their primary and alter personalities on a variety of psychological tests. Role-playing controls performed similarly on the two administrations of the test. A replication of this study by Rabinowitz (1989) yielded similar findings.
Spanos, Weekes, Menary, and Bertrand (1986) extended the findings of Spanos, Weekes, and Bertrand (1985) and Rabinowitz (1989) by exposing role-playing multiples to interviews that focused on their childhood experiences. The task of the role players was not, of course, to describe their actual childhoods but, to use cues gleaned from the interviews to present themselves as actual patients. Like the histories given by actual MPD patients, the role-playing multiples gave negatively toned descriptions of childhood, described their parents as punitive and rejecting, described an early onset (before 10 years of age) for their alter personalities, and described their alters as "taking over" to handle difficult situations and express strong emotions. The findings of these studies are straightforward. They demonstrate that the interviewing procedures used routinely to diagnose MPD convey all of the information required to allow even psychiatrically unsophisticated subjects to enact the cardinal symptoms of multiplicity.
All of the subjects in these studies had been explicitly asked to fake their responses, and, consequently, it can be argued that people who were not faking would be unlikely to develop multiple identities after exposure to leading hypnotic interviews. This argument is contradicted by the evidence described earlier that demonstrated that hypnotic procedures that were less leading than the one used with Bianchi led regularly to enactments of hidden selves and past-life personalities in nonsimulating college students (Spanos & Hewitt, 1980; Spanos, Menary, et al., 1991).
Hypnotic interviews used to diagnose MPD are highly reminiscent of Catholic exorcism procedures. They have, of course, been secularised to meet the materialist assumptions of 20th century psychiatry, but the major components are the same. The hypnotist has replaced the priest, and he or she searches out and obtains the names of alters rather than demons. The priest "discovered" when the demons entered the body; the hypnotist "discovers" when each alter split from the "birth personality." The priest discovered why each demon entered the person; the hypnotist discovers the supposed trauma that led to the formation of each alter. The priest discovered the number of indwelling demons; the hypnotist discovers the number of alters, and so on. Exorcisms led regularly to the production of multiple indwelling demons, and hypnotic interviews appear to produce their secular counterparts: multiple indwelling personalities.
Motivations, Legitimation, and Multiple Personality Disorder
Information about MPD is widespread in North American culture, and the major components of the role are now well known to the general public. Popular TV movies like Sybil and popular biographies like The Minds of Billy Milligan (Keyes, 1981) provide extensive information about the symptoms of MPD, and MPD patients, along with their psychiatrists, are sometimes even featured on popular TV talk shows. In all of these sources, MPD patients are shown in an attractive light as people with dramatic symptoms who, with the help of devoted and empathic therapists, surmount numerous obstacles to eventually gain self-esteem, dignity, health, happiness, and much sympathetic attention from high-status others. In short, the idea of being a multiple, like the idea of suffering from peripheral possession or demonic possession, may provide some people with a viable and face-saving way to account for personal problems as well as a dramatic means for gaining concern and attention from significant others. The role of the media in fostering MPD was evident in a report by Gruenwald (1971) concerning a 17-year-old, hospitalised female patient. This patient's first enactment of an alter personality occurred the day after seeing the movie The Three Faces of Eve on television. Relatedly, Fahy, Abas, and Brown (1989) reported on a patient who presented symptoms of MPD and who had seen the movie The Three Faces of Eve and read the book Sybil (Schreiber, 1973).
Thigpen and Cleckley (1957), the authors of The Three Faces of Eve, commented on the attractions of an MPD diagnosis. After publication of their famous book, they were frequently contacted by people who displayed symptoms similar to those reported in the book for Eve and who sought out the authors to legitimate their self-diagnosis of multiplicity:
“[Many of these patients] appeared to be motivated (either consciously or unconsciously) by a desire to draw attention to themselves. Certainly a diagnosis of multiple personality attracts a good deal more attention than most other diagnoses. Some patients appear to be motivated by secondary gain associated with avoiding responsibility for certain actions.” (Thigpen & Cleckley, 1984, p. 64)
Given the attractions of the MPD diagnosis and the widespread knowledge of its symptoms, it is not surprising that patients sometimes present such symptoms in the absence of cueing from therapists. Nevertheless, people are unlikely to sustain enactment of such a role in the absence of legitimation. For instance, the therapist who treated the case described by Fahy et al. (1989) directed attention away from the patient's alters and focused on her other problems in living. In the absence of the therapist's legitimation, the patient's MPD enactments went into sharp decline.
The importance of interpersonal legitimation in the maintenance of alter identity enactments was demonstrated by Kohlenberg (1973). Kohlenberg described how the psychiatric staff of a ward that housed a multiple were sensitised to his three different personality enactments and interacted with each personality in a different manner. To demonstrate the importance of contextual variables in maintaining multiple identity enactments, baseline rates of occurrence were assessed for the behaviors associated with each of the patient's three personalities. Afterward, the behaviors associated with only one of the personalities were selectively reinforced. The behaviors associated with the reinforced personality increased dramatically in frequency. In later extinction trials, the frequency of occurrence of these behaviors decreased to baseline levels.
Currently, the legitimation of MPD often involves a social dimension that transcends patient-therapist interactions that occur in the consulting room. In some respects, advocacy of the MPD diagnosis has taken on the characteristics of a social movement (Mulhern, 1991b, in press). MPD patients, along with therapists, participate regularly in MPD workshops and conferences, and both patients and therapists frequently have access to national newsletters that provide updated information about the syndrome (Victor, 1993). Along with their individual therapy, many patients participate in MPD self-help and therapy groups that provide ongoing legitimation for their multiple self enactments. Patients in one highly vocal subset who appear to enjoy their MPD status have even asserted their right to remain multiples (Mulhern, 1991b, in press). Some therapists employ MPD patients as co-therapists to help convince sceptical new patients that their MPD diagnosis is accurate (Allison & Schwarz, 1980). Perry (1992) estimated that 17% of the therapists treating MPD are themselves patients or former patients diagnosed with MPD or other dissociative disorders (see also Mulhern, in press). These therapists, who help to socialise new patient recruits into the MPD role, are reminiscent of those in traditional cultures who, after their own possession, join and sometimes become leaders of the possession cults that shape and legitimate the spirit possession enactments of new members.
In summary, the importance of psychotherapy and therapy-related social supports in the genesis and maintenance of MPD would be hard to overemphasise. Therapists are, after all, typically viewed by their clients as competent experts whose opinions are highly valued and whose suggestions are treated seriously. In addition, psychotherapy clients are often insecure, unhappy people with a strong investment in winning the concern, interest, and approval of their therapist. This is likely to be particularly true of the polysymptomatic, chronically disturbed women with a long history of psychiatric involvement who are typically diagnosed as MPD sufferers. Given these circumstances, mutual shaping between therapists "on the lookout" for signs of MPD and clients involved in creating an impression that will elicit approval is likely to lead to enactments of multiple personality that confirm the initial suspicions of the therapist and, in turn, lead the therapist to encourage and validate more elaborate displays of the disorder (Sutcliffe & Jones, 1962). In addition, the newsletters, therapy groups, workshops, and informal interactions with other multiples that have become an important part of the social life of many MPD patients serve to continually shape and legitimate multiple self enactments.
This analysis does not imply that MPD patients are typically faking their multiplicity. Instead, it suggests that patients come to adopt a view of themselves that is congruent with the view conveyed to them by their therapist. Adoption of this view involves clients coming to construe their various "symptoms" (e.g., mood swings, shameful or unrepresentative behaviors, ambivalent feelings, hostile fantasies, forgetfulness, guilt-inducing sexual feelings, and bad habits) as the results of personified alter selves. In North American culture, it is common for people to describe uncharacteristic or ambivalent feelings and behaviors metaphorically as resulting from different parts of themselves (e.g., "One part of me wanted to do it but another part said no" or "I'm of two minds about the issue"). A socio-cognitive analysis suggests that the development of MPD involves a reification of such metaphors that leads both the client and the therapist to construe the client as possessing multiple selves (Sarbin, in press).
Child Abuse and Multiple Personality Disorder
Most studies find that MPD patients report extremely high rates of childhood sexual or physical abuse, or both (e.g., Coons et al., 1988; Ross, Miller, et al., 199 1; Ross, Norton, & Wozney, 1989). These findings are the major source of empirical support for the hypothesis that MPD results from early trauma. As described earlier, however, data obtained from North American spirit mediums, as well as from experimental subjects who report past-life identities, indicate that multiplicity can occur in the absence of early child abuse. In addition, the correlational nature of the MPD/child abuse findings precludes their establishing a causal relationship between abuse and MPD. Moreover, the frequent reports of child abuse from MPD patients can be accounted for without positing that abuse causes MPD.
The sexual abuse of children appears to be a relatively common occurrence in North American culture, and such abuse occurs more frequently in girls than in boys (Finkelhor, 1979). For instance, depending on the criteria for defining abuse and the characteristics of the samples assessed, rates of reported childhood sexual abuse in women ranged from a low of 27% to a high of 62% in a series of studies reviewed by Pope and Hudson (1992). Even higher rates have been reported in some clinical samples. Briere and Zaidi (1989) found that 70% of 50 consecutive female patients visiting an urban emergency room reported a history of child sexual abuse. The short-term and long-term psychological effects of child sexual abuse are by no means clear because of serious methodological problems in the studies that have addressed these issues (Beitchman, Zucker, Hood, DaCosta, & Akman, 1991; Beitchman et al., 1992). Nevertheless, people who were abused as children often report a range of psychiatric symptoms and undoubtedly come to the attention of mental health professionals at least as frequently as the nonabused. Consequently, the high rate of abuse in MPD patients can be partly explained by the fact that a substantial proportion of chronically disturbed people who seek psychiatric help (particularly women) are likely to report a history of child abuse. In addition, because some clinicians consider a history of abuse to be a possible sign of MPD, they may be more likely to expose abused than nonabused patients to leading hypnotic interviews and other "diagnostic" procedures that generate displays of multiplicity. To the extent that this occurs, the idea that early abuse is associated with MPD becomes a self-fulfilling prophecy.
Some patients who receive an MPD diagnosis do not remember having been abused in childhood until their multiplicity is "discovered" in therapy. In these cases, the patient's alter personalities report abuse that had purportedly been dissociated from the memory of the presenting personality. Under these circumstances, there is reason to believe that such newly "remembered" abuse is often fabricated. In other words, patients who develop the expectation that they must have been abused may construct fantasies of such abuse. Given their expectations and the validation of these fantasies as memories by their therapists, the fantasies are experienced as real memories of abuse (Loftus, 1993b; Spanos, Burgess, & Burgess, in press).
According to MPD proponents, abuse that occurs during childhood is often so traumatic that it is forgotten (i.e., dissociated from the primary personality). This hypothesis predicts that children who have suffered documented psychological trauma will later be unable to recall that trauma. However, the available data gathered in prospective studies of traumatised children suggest instead that children who are more than 4 or 5 years of age at the time that they are traumatised usually remember rather than forget the traumatic events years after their occurrence (Femina, Yeager, & Lewis, 1990; Terr, 1988, 1990). Femina et al. (1990) found that people who were abused as children sometimes denied the abuse when interviewed years later. In a second interview, however, these subjects invariably acknowledged remembering the abuse and described their earlier denials as due to factors such as embarrassment about what had occurred rather than memory loss. Obviously, the findings of these studies do not demonstrate that people never forget early abuse. Nevertheless, they suggest that reports of previously forgotten childhood trauma that emerge for the first time during therapy should be treated cautiously rather than accepted as accurate descriptions of early events.
It is now generally acknowledged that memory involves reconstructive elements and is strongly influenced by current beliefs and expectations (Friedman, 1993; Loftus, 1979). People typically organise their recall of past events in a way that makes sense of their present situation and is congruent with their current expectations. The specifics of what they recall are frequently in error and involve a mixture of correctly remembered and misremembered information that is often impossible to disentangle. Frequently, there is little or no correlation between the accuracy of recall and the confidence that people place in their recall. It is not unusual for people to be convinced about the accuracy of a remembrance that turns out to be false (Loftus, 1979; Wells, Ferguson, & Lindsay, 1981). In addition, leading questions and other suggestive interview procedures can produce a substantial deterioration in recall accuracy even when subjects remain highly confident of their inaccurate remembrances (Spanos, Gwynn, et al., 1989). Contrary to popular belief, hypnotic procedures do not reliably enhance the accuracy of recall and, at least under some circumstances, may lead subjects to become even more overconfident than usual in their inaccurate recall (Smith, 1983; Spanos, Quigley, Gwynn, Glatt, & Perlini, 1991). The fallibility of memory should be kept in mind when examining reports of child abuse that emerge for the first time during therapy (Loftus, 1993b; Wakefield & Underwager, 1992).
The strong connection between child abuse and MPD is of recent origin. Cases reported in the early part of the 20th century and before were much less likely than modern cases to be associated with reports of child abuse (Bowman, 1990; Kenny, 1986). Moreover, the abuse that was reported in these early cases lacked the lurid ritualistic elements that are becoming an increasingly prominent characteristic of the abuse memories proffered by modem MPD patients. An association between MPD and child abuse first came to prominence in the 1970s with the concurrent rise in public interest in child sexual abuse. In the early 1970s, the book Sybil (Schreiber, 1973) described the sadistic childhood abuse purportedly suffered by an MPD patient. The book and later television movie were exceedingly popular and Sybil, even more than Eve (Thigpen & Cleckley, 1957) in the previous decade, became a model of the MPD survivor that greatly influenced the expectations of therapists and patients alike (Putnam, 1989). Consequently, when MPD patients claim that they cannot remember having been abused, therapists tend to disbelieve them (Bliss, 1986). Instead, therapists may prod them repeatedly in an attempt to unearth such memories. When patients believe they may be fantasizing rather than remembering abuse, their uncertainty may be presented to them as evidence that they are unwilling to face the fact of their abuse (Bliss, 1986). In short, MPD therapists appear to frequently use leading and suggestive procedures to elicit abuse memories from their patients (Mulhern, 1991a).
A number of years after the publication of Sybil, a book titled Michelle Remembers (Smith & Pazder, 1980) reported on ritual satanic tortures that a woman had purportedly experienced during childhood and then forgotten until they were recovered during therapy. Michelle's story became a part of the propaganda used by the evangelical Christian movement that became increasingly prominent in many facets of American social and political life during the 1980s. This movement reinvigorated the mythology of Satanism. Like its 16th- and 17th-century predecessor, this reinvigorated mythology holds that there exists a powerful but secret international satanic conspiracy that carries out heinous crimes. These crimes supposedly include the kidnapping, torture, and sexual abuse of countless children as well as murder, forced pregnancies, and cannibalism (Bromley, 1991; Hicks, 1991; Lyons, 1988).
Large numbers of therapists who identified themselves as active Christians joined the MPD movement in the 1980s (Mulhern, in press), and soon accounts like those of Michelle began to be reported by the alters of MPD patients (Fraser, 1990; Young et al., 1991). By the mid- 1980s, 25% of MPD patients in therapy had recovered memories of ritual satanic abuse, and, by 1992, the percentage of patients recovering such memories was as high as 80% in some treatment facilities (Mulhern, in press).
If the ritual satanic crimes "remembered" by MPD patients actually occurred, it would necessitate the existence of a monumental criminal conspiracy that has been in existence for at least 50 years and has been responsible for the murder of thousands of people (Hicks, 1991). Law enforcement agencies throughout North America have investigated numerous allegations of satanic abuse made by MPD patients but have been unable to substantiate the existence of the requisite criminal conspiracy (Lanning, 1989). It is important to understand that criminal conspiracies are very difficult to hide. This, of course, is particularly true when large numbers of conspirators are involved and the crimes include murder and cannibalism, which leave physical evidence that is difficult to eliminate (Lanning, 1989). Thus, the repeated failure of law enforcement agencies to obtain support for the satanic abuse allegations of MPD patients constitutes strong evidence that the vast majority of these allegations are false and that the "memories" on which they are based are fantasies rather than remembrances of actual events (Hicks, 1991). Like the satanic conspiracy of the 16th and 17th centuries, the modern conspiracy exists only in the imaginations of its propagators.
Recently, Bottoms, Shaver, and Goodman (1991) surveyed psychologists across the United States about the frequency with which they had seen patients who reported ritual abuse memories. Seventy percent of the respondents reported that they had never seen such patients. A small minority, however, reported having seen large numbers of patients who reported ritual abuse. This pattern of findings suggests that therapists who obtain such reports regularly may play an active role in shaping the ritual abuse memories of their patients.
Mulhern (1991a) described the hypnotic procedures sometimes used to elicit satanic ritual abuse memories in MPD patients:
“During hypnotic interviews clinicians explicitly described satanic ritual scenes or displayed pictures of satanic symbols to a patient; then addressed "all parts of the patient's mind" or "everyone inside," requesting that any part who recognised the satanic material so indicate either by a nod of the head or by prearranged yes, no and stop ideomotor signals . . . is it possible that these clinicians never paused to consider just what kind of message a patient would receive from a clinician who is holding up snapshots and asking if the patient can identify people as leaders of a group of cannibalistic devil worshippers.” (p. 610)
The importance of leading interrogations in obtaining memories of ritual abuse was underscored in the case of a suspect described by Ofshe (1992) who confessed to raping and ritually abusing his own children as part of a satanic cult. None of the satanic elements of his story could be confirmed by police investigation, and many of the events to which he confessed were suggested to him by the police officers and psychologist who interrogated him. The events to which he confessed were legitimised as memories rather than fantasies by his fundamentalist minister. Ofshe interrogated the suspect with the leading questions and guided fantasy procedures used by the police and suggested to him that he had committed a set of abuse events that the police agreed had not occurred. The suspect readily confessed to the false events and, after the interrogation, insisted that those events had really occurred. Although the suspect had no psychiatric history before his arrest, he was diagnosed by one psychologist involved in the case as suffering from MPD.
Whitley (1992) described several former patients from the same psychiatric clinic who reported ritual abuse memories during their therapy but later disavowed the reality of these reports. The patients (some of whom were diagnosed as multiples) described their reports of early abuse as fantasies that were suggested and encouraged by their therapists and by copatients in psychotherapy groups. These patients reported a great deal of interpersonal pressure to generate reports of severe abuse and to define those reports as memories as opposed to fantasies.
Some patients report memory fragments or dreams with satanic content and only afterward are exposed to hypnotic interviews aimed at confirming such abuse. However, because many MPD patients are enmeshed in a social network in which they hear about satanic abuse from other patients, therapists, and shared newsletters and in which they or their fellow patients attend workshops devoted to such abuse, "spontaneous" dreams and memories of this kind are hardly surprising and do not provide serious evidence of actual ritual abuse. In this context, it is worth recalling the ease with which highly hypnotisable college students were induced to enact past-life personalities who "remembered" that they had been abused as children when the expectation of such abuse had been conveyed to them before their hypnotic regression (Spanos, Menary, et al., 1991). Also relevant are the reports of glossolalics in some congregations and spirit mediums in some cultures who reorganise their biographies to bring them into line with cultural expectations concerning the past histories of possessed people.
The reporting of ritual satanic abuse is not the only unusual characteristic of the child abuse reported by MPD patients. For instance, some evidence suggests that the populations from which subjects are selected influence the incidence with which MPD patients report child abuse histories. Ross, Norton, and Fraser (1989) found that a sample of American psychiatrists reported a much higher prevalence of child sexual abuse in their MPD patients (81.2%) than did Canadian psychiatrists (45.5%). Relatedly, Ross (1991) reported that subjects drawn from a non-clinical population and diagnosed with MPD reported much lower rates of child abuse than MPD patients drawn from clinical populations. The findings of these studies challenge the idea of a causal relationship between child abuse and MPD.
Studies on the sexual abuse of children (reviewed by Wakefield & Underwager, 1991) indicate that the abusers are very unlikely to be female and that this is particularly true when the victim is female. Some studies of hospitalised adolescents who had been sexually abused as children reported that the perpetrators were never female (e.g., Sansonnet-Hayden, Haley, Marriage, & Fine, 1987). Given the consistency of these findings, those reported by Ross, Miller, et al. (1 99 1) for MPD patients raise suspicions about validity. These investigators reported that 15.7% of their MPD patients had been sexually abused by their mothers; 2.9%, 10.8%, and 21.6%, respectively, had been so abused by their stepmothers, other female relatives, and other females. Unfortunately, Ross, Miller, et al. (1991) did not provide the total percentage of patients abused by a female; however, that total obviously must have been quite substantial and well above what would be expected on the basis of other studies of child abuse. Ross, Miller, et al. (1991) also reported on the age of earliest sexual abuse for their subjects. A substantial 26.6% reported being sexually abused before 3 years of age, and 10.6% reported being sexually abused before their first birthday. The fact that these ages are much younger than the age at which abuse typically begins (see Wakefield & Underwager, 1992) is problematic. More troubling is that these data were based entirely on the retrospective reports of the patients. Studies on recall of early memories have usually indicated that people are unable to recall events that occurred before 3 years of age, and these studies have reported uniformly that subjects are unable to recall events before their first birthday (Howe & Courage, 1993; Loftus, 1993a). Ross, Miller, et al. (1991) said nothing about corroboration of their patients' early memories, and one is left wondering how these patients were able to remember what happened to them before the age of I or 2 years.
In summary, the high rates of child abuse reported by MPD patients do not constitute good evidence that such abuse causes multiplicity. A number of different non-causal factors probably contribute to the high rates of child abuse reported by these patients (e.g., high base rates for abuse in chronic psychiatric populations, the use of abuse histories as a criterion for conducting MPD-eliciting hypnotic interviews, and treatment-induced fabrication). No doubt, many people who become MPD patients were abused during childhood. Nevertheless, most people who suffer even severe child abuse do not exhibit MPD, and many people who have not been abused can easily and quickly be induced to display multiplicity (e.g., college students given past-life regression suggestions and mentally healthy spirit mediums). Taken together, these findings argue against a causal relationship between child abuse and later displays of multiplicity.
Hypnotizability and Multiple Personality Disorder
MPD patients frequently attain high scores on standardised hypnotizability scales (Bliss, 1980, 1986; Bliss & Larson, 1985). The suggestions included on these scales are communications that call for the construction of "as if" situations (Bertrand, 1989). Thus, suggestions for arm levitation, hallucination, and amnesia are, in effect, tacit requests to use imaginative and other cognitive abilities to behave as if one's arm is rising by itself, as if one is unable to remember, and so forth. Behaving as if an imaginary scenario is true involves creating the requisite subjective experiences as well as generating the requisite behaviors (Sarbin & Coe, 1972; Spanos, Rivers, & Ross, 1977). The hypnotic interviews typically used to "call up" alter personalities, like the standardised suggestions on hypnotizability scales, also include requests to construct an as if scenario: to behave and experience as if one has alter identities.
MPD proponents interpret the finding that MPD patients frequently attain high hypnotizability to mean that hypnotizability scores reflect individual differences in the capacity for dissociation (Putnam, 1993). This hypothesis predicts a substantial correlation between hypnotizability and independent indexes of dissociation. Stava and Jaffa (1988) developed several objective indexes of dissociative capacity (e.g., degree of success at dividing attention and performing two tasks simultaneously). None of these correlated significantly with hypnotizability. Bernstein and Putnam (1 986) developed a questionnaire index of dissociation, and Putnam (1989) reported that it correlated significantly with hypnotizability. However, two studies (Nadon, Hoyt, Register, & Kihlstrom, 1991; Spanos, Arango, & de Groot, 1993) found that dissociation scores correlated significantly with hypnotizability only when both indexes were assessed in the same context. When dissociation was assessed in a context that subjects did not associate with their hypnotizability testing, it failed to correlate significantly with hypnotizability. These findings indicate a lack of any intrinsic relationship between dissociation scores and hypnotizability. Whether or not these dimensions are found to be related appears to be dependent on expectations generated by testing both dimensions in the same context.
Most studies report no differences between the sexes in hypnotizability (for a review, see deGroot, 1989). In North American studies, however, women are assigned the MPD diagnosis much more frequently than men, whereas the one Swiss study (Modestin, 1992) found that men were assigned the diagnosis slightly more frequently than women. These findings indicate that the relationship between MPD and hypnotizability must be moderated by other variables. The hypothesis that this moderator is early child abuse requires that child abuse occur at least three times more frequently in girls than in boys in North America but with about equal frequency in boys and girls in Switzerland. This hypothesis further suggests that the combination of high hypnotizability and early child abuse is much rarer in Great Britain and in other societies with very low rates of MPD than it is in North America. The available evidence does not indicate that high hypnotizability is more common in North America than in Great Britain, nor does the evidence indicate very low rates of child abuse in Great Britain (La Fontaine, 1990).
An alternative hypothesis holds that high hypnotizables are particularly likely to respond with displays of multiplicity to the cueing contained in leading interviews. This hypothesis holds that hypnotizability is a stable, trait-like index of suggestibility and that high hypnotizables constitute only about 10% of the population. Because high hypnotizables are more suggestible than moderate or low hypnotizables, they are particularly likely to respond to the strong cueing for MPD contained in leading diagnostic interviews (Ganaway, 1989; Mulhern, 1991b).
This suggestibility trait hypothesis accounts for why MPD patients typically score as high hypnotizables. Moreover, it can account for different cross-national gender ratios and incidence rates by suggesting that they reflect the expectations of therapists who use leading hypnotic procedures. Those who believe that MPD is relatively common will use such procedures frequently, those who believe that it is more common in women than men will use such procedures more frequently with women than with men, and so on. However, the suggestibility trait hypothesis cannot account parsimoniously for the very high rates of multiplicity seen in some traditional cultures (e.g., 47% of the women in some villages) or for the very high rates of demonic possession seen in some group possession cases (e.g., the case in which all or almost all of the nuns in a particular convent displayed possession simultaneously; Huxley, 1952). This hypothesis also has difficulty with the findings that glossolalics do not exhibit particularly high hypnotizability (Spanos & Hewitt, 1979) and that, in some congregations, glossolalia occurs in all or almost all members (Goodman, 1972).
An alternative to the suggestibility trait hypothesis holds that a great many people who do not typically attain high hypnotizability scores possess the cognitive abilities required to enact the as if scenarios contained in hypnotic suggestions and in hypnotic interviews that call for multiplicity (Spanos, 1986a). Along these lines, a number of recent studies have demonstrated that short training procedures aimed at altering subjects' interpretations and attitudes produce large gains in hypnotizability (e.g., Gorassini, Sowerby, Creighton, & Fry, 1991; Spanos, Gabora, Jarrett, & Gwynn, 1989; Spanos, Lush, & Gwynn, 1989). Thus, a much greater proportion of people than indicated by conventional hypnotizability testing possess the cognitive abilities required to experience the as if scenarios traditionally associated with hypnotic suggestions.
The leading interviews used to diagnose MPD are frequently conducted in a hypnotic context, and the psychotherapeutic procedures used with these patients almost always make use of hypnotic procedures. In other words, almost all MPD patients have been repeatedly administered hypnotic procedures and have responded repeatedly to these procedures by displaying alter personalities. Given this, MPD patients are very likely to construe themselves as highly hypnotisable and are likely to be motivated to respond to communications delivered in a hypnotic context. Consequently, when they are tested for hypnotizability, they tend to respond in terms of the motivations and expectations derived from their earlier hypnotic experiences and, therefore, attain high hypnotizability scores.
This contextualist hypothesis does not deny that individual differences on some cognitive or interactional style dimensions may influence the ease with which people carry out multiple identity enactments. For example, some clinical reports describe MPD patients as highly imaginative people with rich fantasy lives who have spent much time covertly rehearsing and becoming absorbed in a range of "make believe" activities (e.g., Keyes, 1981). Given appropriate motivations, it is easy to understand that such people might be particularly adept at enacting multiple identities when contextual inducements call for such enactments.
Relatedly, some clinical studies describe many MPD patients as exhibiting symptoms of borderline personality disorder (e.g., Horevitz & Braun, 1984). Borderlines are described as displaying sudden mood shifts; rapid, marked changes in attitude; impulsivity; and sudden, inappropriate anger. When provided with the idea of MPD, such people may find it particularly easy to conceptualise their rapid shifts in mood and behavior as stemming from different selves at war with one another.
Many MPD patients are diagnosed as psychopaths at some point in their careers (Bliss, 1986). In short, they are often adept at altering their self-presentations to manipulate others. Given that they see it in their best interests, such people may be particularly adept at enacting multiplicity.
In summary, there may be numerous cognitive propensities and interactional styles that influence the ease with which individuals carry out multiplicity enactments. On the other hand, motivational and contextual demand variables will undoubtedly interact with and may at times even override the effects of such individual difference variables. In addition, it is important to keep in mind that individual difference variables that might facilitate multiple identity enactments in one cultural context may be unimportant or even a hindrance to such enactments in other cultures. For example, borderline characteristics might facilitate a self-definition of multiplicity when multiplicity is defined as a pathology and when erratic and unpredictable behaviors are congruent with the multiple identity role. However, the same characteristics might well hinder displays of multiplicity in a shaman who is required to display restraint and good judgement and whose multiple identity enactments entail regular conformance with ritual requirements.
In summary, cross-cultural differences in the rates with which multiplicity is displayed are very large, and in some cultures substantial proportions of the population display multiplicity at some point in their lives. These considerations suggest that the cognitive abilities required to experience and enact multiplicity are fairly common and that the frequency of such enactments is limited as much, and perhaps more, by contextual considerations (e.g., the practices of different therapists and the opportunity to observe more practised demoniacs) as by stable individual differences in cognitive abilities.
Multiple identity enactments occur in most human societies. Nevertheless, the frequency of these enactments, their behavioural components, the conditions under which they occur, and the characteristics of those who display them differ dramatically between cultures and sometimes within cultures as well. When examined across cultures and historical eras, the rule-governed nature of multiple identity enactments and their embeddedness within a legitimising social matrix become clear.
Each culture develops its own indigenous theory of multiple identity enactments. These local theories reflect local social structures and institutions, and they translate into culturally specific expectations that guide both the performance of multiple identity enactments and the reactions of audiences to these enactments. Thus, the theory that the Holy Ghost speaks through people and, in so doing, endorses them spiritually provides a local explanation for glossolalia and helps to establish motivations and expectations for its perpetuation. However, local theories of multiplicity are designed to explain only local displays, and their deficiencies as general theories of multiplicity become obvious when these enactments are compared across historical and cultural contexts.
The disease theory of MPD is a local theory. Because the proponents of this theory are invariably mental health professionals, the displays of multiplicity that they observe are usually limited to those distressed people who go to them for help. This limitation profoundly influences the manner in which these investigators conceptualise multiplicity. The disease theory of MPD is based on the idea that unhappiness or behavioural deviance in adulthood stems from particular traumatic events occurring in childhood. The particular childhood traumas on which modern MPD proponents focus are physical abuse and, especially, sexual abuse. Because of its emphasis on childhood antecedents and on the notion that "symptoms" reflect unconscious defences, this approach tends to greatly de-emphasize the social and strategic nature of multiple identity enactments and the roles played by the institutionalised contexts that encourage, shape, and legitimise these enactments. In particular, this emphasis deflects attention away from the role clinicians themselves play in cueing and legitimising manifestations of multiplicity. It also deflects attention from the marked changes in symptomatology that have occurred in MPD over the years, changes that illustrate the role of social factors in shaping MPD displays. Since the 19th century, for example, the number of personalities per patient has jumped from 2 or 3 to often more than 20 and sometimes into the hundreds. Early cases were marked by transitional periods of sleep and convulsions, which are uncommon today. The alters of early patients were human. Recently, however, scholarly articles have been devoted to animal alters (e.g., Hendrickson, McCarty, & Goodwin, 1990), and the alters "discovered" by some clinicians now exhibit the characteristics of semi-spiritual self helpers (R. B. Allison & Schwarz, 1980) or reincarnated past lives (Krippner, 1986). Reports of child abuse have gone from occasional accompaniments of early cases to the ritual satanic abuse of today.
Changes of these kinds are difficult to deal with from a perspective that explains identity enactments as symptoms caused by past traumas rather than as expectancy-guided displays that change with new information concerning role demands. As indicated earlier, role changes of this kind are commonly seen in historical and cross-cultural displays of possession. Songhay mediums, for example, changed the characteristics of their possession displays in response to changes among the ruling elites (Stoller, 1989), and the characteristics of demonic possession changed to meet the different requirements of particular religious communities (Spanos, 1983a; Walker, 1981). Relatedly, the recent association of MPD with reports of ritual satanic abuse is much more likely to reflect therapy-induced fabrications generated by the infusion of evangelical Christian ideology into the MPD movement than the existence of a 50-year-old secret conspiracy that has been responsible for the murder of thousands without leaving a trace of evidence.
Like other local theories, the disease theory fails to provide a general account of multiplicity that takes into consideration its cross-cultural and transhistorical manifestations. I suggest that the local theory of MPD be abandoned and the phenomenon of multiplicity viewed from a socio-cognitive and historical perspective.
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