Dr. August Piper, Jr.'s columns on a variety of topics have been a
favorite for many newsletter readers. Here is a selection:
"TRUTH SERUM" AND "WHAT REALLY HAPPENED" by August Piper Jr., M.D. Pontius Pilate once asked, "What is truth?" Two thousand years later, plaintiff and defendant, accuser and accused, unfold their versions of truth. In our courtrooms, Pilate's question echoes. A reader of this newsletter inquires: I have heard that sodium Amytal is a truth drug. What does that mean? My lawyer says that taking the drug might help my lawsuit, by helping me and my doctor decide what really happened to me when I was a child. The Amytal interview has been known to American physicians for about half a century. Amytal is the trade name of a drug belonging to the same family as Nembutal, Seconal, and Pentothal. Its generic name is amobarbital (generic names are not capitalized). It is a barbiturate, which means that sufficiently-large doses cause drowsiness and sleep. During an Amytal interview, the physician administers small amounts of the drug, by vein, every few minutes. The procedure usually takes about an hour. The patient is drowsy and slurred of speech, but awake -- the so-called "twilight state" for the duration of the interview. Intravenous Amytal causes a feeling of relaxation, warmth, and closeness to the interviewer; while in this state, the patient is questioned. Other intravenous drugs, like Valium or Ativan, are sometimes used in this kind of procedure. For our purposes, these medicines should be considered essentially identical to IV Amytal, because they produce these same effects on the patient. The amobarbital interview was very popular during the 1930's and 1940's, though at that time it was not usually performed to verify or recover forgotten memories. Rather, doctors employed the procedure to examine the unconscious, or to do psychotherapy (for example, to treat "shell shock"). The dominant theory then, held by many physicians, was that people under Amytal could not possibly lie. This theory was reflected in the colorful name "truth serum" given to the drug. One characteristic of good science is a sincere attempt to disprove its own theories. This principle was applied to the belief that people always tell the truth under Amytal -- that is, patients were tested to see if they could tell falsehoods during Amytal interviews. They could. During such interviews, could people deliberately attempt to deceive an interviewer? They could. Could they report false or exaggerated symptoms of psychological disorders? Again, they could. Withhold information? Yes. In time, other studies revealed more information. They showed that during Amytal administration, patients often demonstrate a distorted sense of time, show memory disturbances, and have difficulty evaluating and selecting thoughts. In addition, under Amytal, patients' claims about details of their histories--events, places, names, dates -- are untrustworthy. Further, these investigations noted that the drug also makes patients vulnerable to either accidental or deliberate suggestions from the interviewer. Finally, and most importantly, patients under Amytal fail to reliably discriminate between reality and fantasy. Now, I bet some readers are thinking: "Hmm. Slurred speech, drowsiness, a feeling of warmth, distorted memory, altered time-sense. Sounds familiar." Cynics would say that those things happen after someone has had "a few too many." And in this case, they would be exactly right: intravenous Amytal creates a state similar to acute alcohol intoxication. So. Having said all that, will I finally answer the reader's question? Courts have long been intensely skeptical of any efforts to "enhance" or "refresh" the memories of participants in trials. The above discussion shows why. The judiciary worries about interviewers contaminating the memories of those they interview, and about the ability of people to misrepresent truth while under Amytal. Then there is the matter of reliability of information obtained from someone who is acutely intoxicated. Thoughtful clinicians, supporting these concerns of the courts, have warned that memories retrieved in an Amytal-induced trance are likely to contain a combination of fact and fantasy, in a mixture that cannot be accurately determined without external verification. This point about external verification is important. It means that statements made under Amytal must be reliably confirmed. If they are not, they cannot be considered more truthful than any other statements. In summary, there's no such thing as "truth serum," and the Amytal interview won't help anybody decide what really happened in your childhood. Waste not your money, dear reader! For more details about Amytal interviews, the reader is invited to consult a forthcoming paper by Dr. Piper entitled "'Truth serum' and 'recovered memories' of sexual abuse: A review of the evidence." It will appear in the summer 1994 issue of The Journal of Psychiatry and Law. August Piper Jr. M.D. is a psychiatrist in private practice in Seattle, Washington. He is a member of the FMSF Scientific and Professional Advisory Board. He has written a chapter in a forthcoming book (Multiple Personality Disorder: Critical Issues and Controversies), as well as several articles on MPD.
MORE ON MULTIPLE PERSONALITY DISORDER August Piper Jr., M.D. Two items today about multiple personality disorder. I hope both will stimulate the inquiring minds of this newsletter's readers! The first is from Connecticut, where a reader noticed a newspaper article and was kind enough to bring it to my attention. It says in part If someone has multiple personality disorder, it's not unethical to assume there was abuse, because it's known that this disorder occurs only when there is early, severe abuse. This notion has been indirectly encouraged by the major contributors to the MPD literature. These writers certainly do not come right out and say baldly that "abuse causes MPD." Instead, they say that the condition is "a response to," "arises from" "is linked to," or "is an outcome of" childhood maltreatment. The notion is appealing. It is also badly flawed. Why? First, claiming that MPD occurs only as a result of trauma is like arguing that because stress can cause insomnia, anyone having trouble sleeping must have been under severe pressure, and that such pressure causes every case of insomnia. Such logic ignores other potential explanations for the sleeplessness (like the springtime midnight beer bash and heavy-metal party at the frat house next door). The studies written by the proponents of MPD, claiming to show a link between this condition and childhood sexual abuse, suffer from this defect: they fail to consider other aspects of the child's life that contribute to the difficulties he or she has as an adult. These aspects--for example, absence of one parent from the child's home for extended times, poverty, or parental discord--also contribute heavily to later problems developed by these individuals. I wish to be clear: abuse of children is reprehensible. However, to overstate its importance as a contribution to later problems in life offends the spirit of scholarship and learning. A recent British Journal of Psychiatry study (163:721-732, 1993) concludes that The overlap between the possible effects of sexual abuse and the effects of the matrix of disadvantage from which it so often emerges were...so considerable as to raise doubts about how often, in practice, [the abuse] operates as an independent causal element. The authors of the study also warn that To insist on a process of recalling and reliving...an experience of abuse that a woman has consigned to the past may be damagingly meddlesome. There is another problem with the idea expressed in the newspaper article. The leading proponents of MPD almost invariably approach the subject of mistreatment of children simplistically. Their writings give the impression that "child abuse" is some kind of single, unitary phenomenon leading more or less inevitably to adverse consequences later in life. In contrast, the broader scientific literature recognizes that abuse of children is an enormously complicated subject, one that does not reduce well to simple analysis. For example, merely defining "childhood sexual abuse" is difficult. What age limits are set for childhood? Does the term include or exclude sexual contacts between people of approximately the same age? Another example: the effects of sexual abuse of children differ, depending on a multitude of factors -- the child's age at the time, whether the abuser was a caretaker or not, what the parents' reaction was, whether force was used, whether the abuse was (mis) perceived by the child as an act of caring, the frequency of the behavior, and many others. The third problem with the idea in the newspaper is that the authors of the papers on MPD and sexual abuse almost never take the elementary step of verifying that the assumed abuse actually happened. This is obviously loose scholarship. A final difficulty with the notion expressed in the newspaper: the connection between MPD and abuse is an unproven speculation. Whether MPD is a discrete condition, or simply a collection of symptoms having no intrinsic relationship to each other, is unclear and controversial. Therefore, in view of the amount of knowledge currently available about MPD, sweeping pronouncements about the cause or causes of the condition are simply premature. Reserve, restraint, and tentativeness should be the current watchwords! The second item has to do with the cost of treating MPD. I read that there was a paper written somewhere that said multiple personality disorder patients get better quickly if they are treated in the right way. That isn't happening with my sister. They have been treating her for years and she's not any better. Her treatment is costing a lot of money. My mom thinks she's worse. Do you have any ideas about what's wrong? Gina Without seeing your sister, Gina, I obviously couldn't say what's wrong. However, I can tell you that, contrary to what is so often written about MPD, the published information on how quickly patients improve when they are treated for MPD deserves a healthy dose of skepticism. Example: about a year ago, The American Journal of Psychotherapy (47:103-112, 1993) published a paper in which the authors compared treatment costs before and after the diagnosis of MPD was made. They concluded that treating MPD might be the most cost- effective mental health intervention known. There was just one problem with this conclusion -- it was not well supported by the data. For example, overall treatment costs doubled after the diagnosis was reached, mostly because patients used the hospital much more after finding out they had MPD. I personally know of several patients who have repeatedly spent one or two months or more at a time, several times a year, in the hospital for treatment of this condition. A young woman I recently evaluated told me her mother was in an MPD specialty inpatient unit in another state. At the time of the evaluation, the mother had been there continuously for over four months -- with no indication that she would be leaving any time soon. Two months ago, a patient's father told me that his daughter's therapy had cost $300,000 over the last five years; just this week, an anguished member of the FMSF wrote, saying that in four years, his daughter had spent about three quarters of a million dollars on MPD therapy. The result? "Her original complaint of depression has been exacerbated by her treatment and her overall condition seems to have worsened rather than...improved." In other words, Gina, what is happening to your sister appears to be happening in other places, too. Where will it end? August Piper Jr. M.D. is a psychiatrist in private practice in Seattle, Washington. He is a member of the FMSF Scientific and Professional Advisory Board. He has written a paper discussing the costs of treating MPD that will appear in a 1994 issue of The American Journal of Psychotherapy.
SUGGESTIONS FOR ACCUSED PARENTS: A PROPOSAL AND AN ANALYSIS August Piper Jr., M.D. Could the FMSF do more to help families? That question surfaced after I received several letters and calls from Foundation members whose children had accused them of long-ago abuse. A telephone conversation with Dr. Freyd followed, during which we developed an idea: to compile and publish suggestions for families whose members have been accused of abuse. We hope these suggestions will flow from two sources. First, and most important, we want you, our members, to tell each other what you have learned. Do you have suggestions for other parents who have been similarly accused? What helped you contend with this affliction? If the family ever reunited, what helped bring this about? When parents are confronted with these accusations, is there anything you'd advise them not to do? Being condemned to repeat history is the unhappy fate of those who fail to learn from the past. We hope to avoid this punishment. Therefore, the second source of information for the suggestions will be the thoughts of people who have previously wrestled with and written about the questions that occupy us today. I have begun to review the literature on these subjects to obtain this information. If you wish to contribute to this effort, please send your comments and thoughts to me, in care of the FMSF. One important question is frequently asked of the Foundation: how can parents encourage their children to renounce unfounded abuse accusations? The following analysis may be useful. About twenty years ago, several cults sprang up in the United States. I believe the practices of those groups resembled today's methods of treating multiple personality disorder and satanic ritual abuse, and of performing recovered-memory therapy. Therefore, examining the history of cults should teach some ways that today's families and parents might usefully respond to the problems caused by these three therapies. (Though I am a little uncomfortable with the word "cult, " because of its connotations, it should be pointed out that no disrespect is meant to either religion or to spirituality, and that 'cult" is not used pejoratively. Also, I am not saying that all practitioners who perform these three treatments are members of cults.) What characteristics do recovered-memory therapy, treatment for MPD, and therapy for satanic ritual abuse have in common with the cults of two decades ago? Let's start with a definition. The term "cult" does not have a precise scientific meaning, but as used here, it refers to a group with a "devoted or extreme attachment to or extravagant admiration for a thing or ideal, especially as manifested by a body of admirers; any system for treating human sickness that employs methods regarded as unorthodox or unscientific" (Webster's Unabridged Dictionary; Random House Unabridged Dictionary). According to various references, it is the excessive or extreme attachment formed by members of these groups that is key. This behavior disrupts the lives of involved followers, and therefore causes concern to families and friends of these individuals. Cults typically are established by strong or charismatic leaders who control power hierarchies and material resources. Cults possess some revealed "word" in the form of a book or doctrine. Also, they confine their membership in various ways -- for example, by bringing people into controlled environments where they are bombarded with strange new ideas (Streiker, Mindbending; Kaplan, Freedman, and Sadock, Comprehensive Textbook of Psychiatry). Group membership is contingent on accepting the doctrines and dogma of the leader. Joining the group brings two powerful reinforcements into play. First, rather than being encouraged to discover their own responses to the complexities of modern life, cult members learn a seemingly coherent system of ideas providing simple, "cookie-cutter" answers. For example, many in to- day's cult-like groups are told that past sexual abuse is responsible for all their current problems. Second, members develop a sense of being part of a group that shares their feelings and aspirations. These two forces produce a third vital effect -- a significant increase in self-esteem (Canadian Journal of Psychiatry 24:593-602, 1979). Above all, cults employ systematic forms of consciousness-altering practices (chanting, spending long hours reciting memorized material); they encourage their members to remove themselves from greater society so as to devote more time to the cult; they discourage critical thinking and suppress alternative views of social reality; and they strongly encourage members to cut off communication with families, often by inducing fears and phobias -- "Your father raped you when you were a helpless child," (Pavlos, The Cult Experience; Streiker). To a greater or lesser extent, the three kinds of treatments under discussion here share these characteristics. For example, in my experience, many patients who become involved with these therapies do so excessively. Treatment becomes the focus of their lives. They spend tens of hours each week in therapy and therapy-related activities. One teenager I evaluated was seeing her therapist at least six or seven hours a week for months. In addition, the therapist encouraged her to devote several hours each day to writing down ever-more-fantastic "memories" of rapes by her father and episodes of satanic abuse by her parents and grandparents. Mainstream clinicians and scholars regard the theories supporting these three treatments as unorthodox and unscientific. For example, the idea of "repressing" a whole series of memories, and then accurately recovering them after years or decades, is now considered to be without foundation. Science encourages critical evaluation of ideas. Cults, on the other hand, tend to regard books like The Courage to Heal as exactly and timelessly true. Because such texts rest on faith, rather than on the strength of supporting evidence, they admit of no doubt, require no proof. Controlled environments? Bombarding people with strange ideas? These phrases exactly describe hospitals where patients are encouraged to search for "buried memories" of sex abuse and for "hidden alter personalities." The facilities often employ systematic forms of consciousness-altering practices, like hypnosis and Amytal interviews, in such quests. Influential clinicians encourage patients to remain in these hospitals for weeks or months. during this time patients withdraw from the larger world in order to undergo the inward-directed rituals of recovered-memory or satanic-abuse treatment. It should be acknowledged that almost all the above characteristics of cults could be applied to both legitimate psychotherapies and to mainstream religions. However, two of them cannot be: no conventionally oriented western religion, nor any standard psychotherapy, isolates the bulk of its adherents from the outside world, or urges general severance of family contacts. I have set out, perhaps at immoderate length, the analysis. Does it help those asking for advice on how to heal their families, and how to talk to accusing children? I believe it does. Some advice that follows from the analysis: First, each family's situation is obviously different; there is no one "procedure" that works for all. Second, I have recently heard of parents who are considering kidnaping their children and "deprogramming" them, just as was done two decades ago. The literature of the time indicates that such drastic methods worked poorly then; they would probably fare no better now. In addition, they are almost certainly legally and ethically indefensible, because they violate freedoms guaranteed by the Bill of Rights. Finally, techniques of coercive persuasion strengthen the hand of cult-like groups: these procedures show cult members that parents and friends are not to be trusted. Thus, not only does "deprogramming" anger those on whom it is attempted, but it also risks driving other members deeper into the cult (American Journal of Psychiatry 136: 279-282, 1979). Third, families should remain optimistic about the likelihood that loved ones will renounce their accusations. Several literature sources claim that about nine of ten members of cults eventually leave them. Do any Foundation members have figures on the present rate of recantations of accusations? The key word in the previous paragraph is "eventually": healing from accusations should be considered a marathon run, not a sprint. One father and mother to whom I recently spoke had just been accused of years-ago sexual abuse by their grown son (whose therapist had apparently "discovered' the abuse); after accusing them, he had refused to even talk to them. Nonetheless, these devastated and panicked parents were set to take a two-thousand-mile airplane trip to try to talk him into retracting his allegations. I wondered if they might better avoid reacting when the adrenalin was pumping, and take a little time to make a reasoned response. (They canceled the trip.) The older literature advises against trying to argue accusers out of their beliefs. One modern commentator echoed this. If the accusations really are untrue, "Family members should deny, deny, deny -- but arguing with the accuser is a waste of time." The theory behind this, of course, is that it truly is difficult for just one person to have a successful argument. Instead of debating, parents might simply continue quietly saying, "We'll always be your parents, and we'll always be ready to welcome you back," or something to that effect. In such a way, the children hear every day a still, small voice of their own, asking if they really know what they are doing. Parents might remember: "The drop maketh a hole in the stone, not by violence, but by oft falling." If the child insists on talking about the alleged abuse, parents may have to be firm and simply refuse to discuss the matter, to change the subject, or use other tactics to avoid entering into a debate about truth or falsity of the accusations. These tactics force accusing children to examine their own consciences, to listen to the inner voice that asks if they really know what they are doing. What about arguing with therapists? The FMSF working paper, Meeting your Accusing Child's Therapist, offers good thoughts. Streiker advises that friends of the family, and non-accused siblings, have important roles to play. Their task is to make consistent efforts to establish and maintain contact with the accusing child, to develop his or her trust, and to create opportunities for dialogue. Obviously, they too should avoid arguing with the estranged family member. Equally obviously, guilt-tripping ("Do you know what you're doing to us? How can you do this to us?") and insults ("How can you be so stupid?") seldom lead to reconciliation. The papers warn parents against developing an obsession with the cult and the apparent loss of their child. The importance of parents carrying on with other aspects of their lives and those of their other children is also stressed. A support group or formal counseling might help. Halperin's book, Psychodynamic Perspectives on Religion, Sect, and Cult, has some interesting comments on these points. Several writers urge families to look honestly at the accumulated misunderstandings, poor communications, and hostilities that have contributed to the present difficulties: neither accepting an excessive amount of blame for the problems, nor minimizing responsibility for them. The literature warns; no matter how attractive the ideas of "mind- control" or "brainwashing" are, these notions are oversimplified and almost certainly inaccurate as well. See Cults, Converts, and Charisma: The Sociology of New Religious Movements by Robbins. I found interesting the articles that talk of difficulties experienced by people who leave cults. They are beset with guilt and shame: for turning their backs on their belief system, for letting down or deserting their friends in the cult, and, of course, for hurting their families in the first place. For weeks or months, recanters may be disoriented, isolated, angry, embarrassed, and depressed, or may have 'dissociative" experiences. They will need understanding and nurturing and support -- at exactly the time when the family's own reserves may be depleted. Several writers make what I consider a good case for a brief course of professional counseling at the time of reentry to the family. It hardly seems necessary to say -- but I will -- that the chosen therapist should not be one who will practice what one commentator called "hokum therapy": no alters, no rooting around for buried abuse. The goal of the counseling should be simply to help the family and the child rejoin. Finally, parents may have to face and accept the terrible truth; they may, after all, be powerless to stop the child from worshiping false gods. Let us know your thoughts! August Piper Jr. M.D. a psychiatrist in private practice in Seattle, is a member of the FMSF Scientific and Professional Advisory Board.
PSYCHOTHERAPIES: VALIDATED AND UN August Piper, M.D. The False Memory Syndrome Foundation has recently begun to note that recovered-memory therapy is an unvalidated form of psychotherapy, implying that such therapy is experimental (see page one of the October Newsletter). Though the concerns leading to these criticisms are understandable, attempts to make such implications oversimplify a complicated problem. In scientific terminology, if something is valid, it does what it is supposed to do. Thus, a validated therapy effectively treats the condition it is intended to treat. As correctly noted in the October newsletter, investigators have measured the effectiveness of various talk therapies. However, such measurement is extraordinarily difficult, for several reasons. Psychotherapy is severely hobbled by a distressing lack of agreement among its practitioners on the answers to several critical questions. First is the question of what the goals of treatment are. Does the therapist intend simple symptom relief, recovery and reliving of past stressors, insight into the causes of the patient's problems, change in maladaptive behaviors, a thorough remaking of the personality, or what? Second, what criteria should be used to measure improvement? Measuring psychotherapy-induced change is a minefield of difficulty. Third, how much time should treatment require? Some therapists seriously recommend compressing an entire treatment course into a single session, whereas at the other extreme, treatment has endured in some cases for years. I have even heard of one patient who was in analysis for thirty (!) years. Another difficulty is that psychotherapy has failed to adopt a uniformly-accepted method of classifying and designating the conditions it is concerned with. Such a system of classifying and arranging disorders is called a nosology. The Diagnostic and Statistical Manual, now in its fourth edition (DSM-IV), represents a good start toward such a nosology. However, it is only a start; DSM shows particular problems in classifying disorders that are treated by psychotherapeutic methods (as opposed to pharmacological ones). In the absence of a good nosology, attempting to do psychotherapy research becomes an arduous, frustrating undertaking. This is true because the symptoms of psychological conditions overlap so much. For example, depression is a very common symptom of all psychological disorders. In some, depression is the legitimate focus of therapy: it is the problem. In others, however, the very same symptom picture results from any or all of a host of other conditions: drug or alcohol use; marital, social, or economic problems; medical conditions; other psychiatric disorders; childhood stressors; etc. Determining the "real" cause of the depression can be nearly impossible -- witness the acrimonious debate over those therapists who claim that childhood sexual abuse is the real cause of many, if not all, adult psychiatric problems, including depression. This overlap, in turn, means that researchers can never be sure that their study groups differ only in the variable under study. With so many problems and so much disagreement within the field, and with no formal arrangements for those outside the discipline to establish standards for psychotherapy, no one should be surprised that poorly-validated treatments for psychological problems periodically, like locusts, overrun psychotherapy. Counting the protuberances of a patient's head (phrenology); believing that runaway black slaves have a disease (drapetomania); passing magnets over the body (mesmerism); spraying patients with water, or putting them in wet packs or rapidly-rotating chairs; believing that a woman can have excessive envy of the penis, or develop a wandering uterus (hysteria); surgically attacking the brain (lobotomies) -- all have had their days in the sunlight. My purpose here is neither to make excuses for psychotherapy's problems, nor to attack the discipline, but rather to point out how difficult it is to validate therapies. The reader who recognizes this will not think an unvalidated therapy is necessarily a bad therapy: because it is so difficult to prove that a given psychological treatment is effective, many commonly-used psychotherapies are unvalidated. Nor will the reader fail to realize that saying a therapy is valid does not go far enough: the question should be, "For which conditions is it valid?" After all the above is said, however, the essential points made in last month's newsletter article remain correct: many investigators have carefully gathered evidence documenting that one or another treatment, if performed properly, helps patients. In other words, these psychotherapies have been validated. Also, instruction manuals for several different types of psychotherapy are available to practitioners. The manuals are intended to insure that the therapy is performed properly. Many patients, who have disorders treatable by validated psychotherapies, see recovered-memory practitioners instead. These practitioners have recently come under increasing fire because of the harm their treatments can do. Therefore, the question must indeed be asked: with so many better choices available, why would anyone see therapists who practice a form of treatment that can do such harm? People considering psychotherapy are well advised to spend a few minutes, either on the telephone or in person, to find out whether the clinician utilizes a kind of therapy that has reasonable evidence for efficacy. The list in last month's newsletter might be helpful. August Piper Jr. M.D. is a psychiatrist in private practice in Seattle, Washington. He is a member of the FMSF Scientific and Professional Advisory Board.
NON-SCIENCE AND REAL SCIENCE August Piper Jr., M.D. In a staff meeting four years ago, a fellow psychotherapist proposed treating a patient by "realigning his life-energy forces." On hearing this, the fires of indignation roared up within me. I thought: how dare this therapist speak of such plans here? Doesn't she know we are meeting to discuss scientific treatments? Perhaps the smoke billowing from the fires of indignation slowed the thought's movement from brain to tongue -- I don't know. In any case, for whatever reason, just as I was about to make the above inquiries, the Voice of Humility posed two questions that turned the fires of indignation to embers. This voice whispered in my mind's ear: "Yo, Piper. What distinguishes your brand of 'scientific' psychotherapy from your colleague's 'unscientific' brand?" And just what, exactly, does 'scientific' mean, anyway?" I thereupon closed my mouth (with as much dignity as the moment allowed) then began a search for answers to Humility's questions, a search preoccupying and troubling me ever since. Over the years, the questions evolved into larger concerns: What are the hallmarks of good science? How does one distinguish science from matters that are not science -- say, matters of faith? Worries about these questions become acutely painful for me in several settings. First, in writing books or papers: Is this writing based on anything sound? Does this paper say anything that needs saying? Second, in reading books like Peter Huber's Galileo's Revenge: Junk Science in the Courtroom -- an unsettling but delightful book that should be on lots of must-read lists. Third, and most troubling, in testifying at trials where questions of psychiatric malpractice are raised. The expert witness in such trials requires some map, however torn, sun-bleached, or water-stained, of the border separating the land of science from the land of non-science. These questions have also troubled no less a body than the United States Supreme Court, which has attempted to provide such a map. In drawing this map, the Court relied on four benchmarks that, among others, are hallmarks of good science. The following discussion is based largely on two thoughtful papers, cited below. * First, is the technique or theory falsifiable? This question simply asks if a serious attempt, based on scientifically valid reasoning, has been made, or can be made, to prove that a given idea is false. * Second, what is the technique's known or potential error rate? In other words, the Court wants the following questions answered: How prone to errors are the measurements used in examining this technique? * Third, how widely has the theory or technique been exposed to rigorous and critical scrutiny by publication and dissemination in the scientific community? * Finally, is the technique or theory generally accepted by the relevant body of scientists? Scientific theories or procedures become accepted because they have been published, scrutinized, and replicated, and thereby ultimately found trustworthy. In summary, the Court's map concerns itself less with what experts conclude than it does with how those experts reach their conclusions. These criteria have come under some attack from critics. However, the Court has drawn a reasonably good map, one that will help delineate the border between science and not-science: say astrology, fortunetelling, or religion. Listing these three examples does not signify antipathy toward practitioners of, or believers in, astrology or religion -- after all, I know that much psychotherapy sits uncomfortably near the border mentioned above. The issue is not that of an antipathy toward astrology or religion, but rather, of a concern that many have raised over the years: that wrapping unscientific beliefs in the cloaks of science, and then allowing courtroom testimony from those wearing such garb, risks shredding the fabric of the law: Good science is defined not by credentials but by consensus. Whatever her resume may say, an expert who reports on views held by no one but herself, or on symptoms experienced by no one but one of her patients, is not reporting anything that can properly be called science. And the judge who welcomes her to court is allowing the pursuit of speculation and superstition to replace the pursuit of truth (Galileo's Revenge, p. 226). Concerns about these risks are well-founded: recall the witchcraft horror that swept the world three centuries ago. However, in the last decade of the twentieth century, nonscientist judges and juries are demonstrating that they can distinguish between good science and junk science. They have learned that some psychiatric treatments are reasonable, and others are not. A trial that ended last month in Minnesota demonstrated, with notable power, judges' and juries' abilities to distinguish between good and bad treatment. The psychiatrist in the case was sued for spending several years convincing the patient that the patient, years ago, had participated in, and repressed all memory of, the all-too- familiar litany of ghoulishness: dead babies, cannibalism, assorted mutilations, hooded figures dancing around campfires, multiple episodes of forced sex with her parents, etc., etc. No evidence at trial showed that any of it had really happened. Two aspects of this trial are noteworthy. First, the judge concluded that recovered-memory therapy flunks the test of science; therefore, he reasoned, those wishing to testify about this kind of therapy fall into the category of the expert in the Galileo's Revenge quote above. The other aspect of this verdict deserving mention is that the damages assessed against the psychiatrist were five times greater than in any previous repressed-memory case. Here are the two references mentioned above. 1) C.T. Hutchinson and D.S. Ashby. Daubert v. Merrell Dow Pharmaceuticals, Inc.: Redefining the bases for admissibility of expert scientific testimony. 15 Cardoso Law Review, 1875 (1994). 2) R.N. Jonakait. The meaning of Daubert and what that means for forensic science. 15 Cardozo Law Review, 2103 (1994). * * * I will close by looking both back and ahead. In looking back, the last column is found to contain an error. A reference was given there for a paper by Campbell on "tolling" the statute of limitations in sexual-abuse cases. Though the paper was cited as appearing in the American Journal of Forensic Psychology, it actually appears in the American Journal of Forensic Psychiatry (16:25-81, 1995). Looking ahead: A response to the lengthy but kind comments by Thomas Griffin that just came the other day. Finally, once again, to those readers who write pleasant things: These comments invigorate writers: thank you, thank you! Dr. Piper is in private practice in Seattle, Washington and is currently writing a book on Multiple Personality Disorder. He is a member of the FMSF Scientific and Professional Advisory Board.
READERS' RESPONSES TO "FOOD FOR THOUGHT" August Piper, Jr., M.D. The February edition of this column was entitled "A special delivery of some food for thought." Apparently the article provided food energy for writing as well as thinking, because it generated several letters. Today, we sample readers' responses. We will continue next month. * * * * A question in the February column asked why therapists treat patients in ways that promote false memories. This question intrigued a reader from Washington state, who wrote a dignified but provocative reply. She says the field of psychotherapy in general has contributed to the false memory syndrome phenomenon because of: 1) the lack of objective, scientific research-based diagnostic and treatment guidelines and standards. Because of this deficiency, the kind of therapy a patient receives depends less on the patient's diagnosis than it does on the psychotherapist's theoretical orientation; 2) the lack of educational and training standards for practitioners and the lack of education in salient other fields such as social psychology; 3) the lack of objective documentation of therapy sessions. This results in therapists being able to claim credit for any benefits of the treatment, with- out needing to be concerned about being required to produce concrete evidence (such as audiotapes) to provide proof of what really took place in the ses- sions; 4) the apathy and tolerance of many professionals toward colleagues' incompetence and improprieties, combined with the lack of external social controls on the profession; and 5) the attitude of many mental health proessionals toward patients that, because they are patients, everything they feel, say, or do is explainable by the patient's pathology. These statements answer the question of how a therapist _could_ treat patients in ways that are harmful. However, the real spirit of the February question seemed to be why _would_ a therapist do so. The writer from Washington also described some goings-on at a well-known mental health center in the Seattle area: at this center, we were specifically told (in addition to other nonsense) that there are several satanic cults and witches' covens in our area where infants are being murdered and children horribly abused. She enclosed 26 pages from a social psychology textbook. Among other fascinating points, the book warned about "Barnum Descriptions" -- named for P.T. Barnum, who believed "there's a sucker born every minute." Such descriptions are recipes for impressing patients: * give people a subjective test; * make them think that its interpretation is unique to them; * and, drawing upon things true of most people, tell them something that is ambiguous. Here's an example: You have a strong need for other people to like you and for them to admire you. You tend to be critical of yourself, and have a great deal of unused energy that you have not turned to your advantage. At times you seriously doubt whether you have made the right decision or done the right thing. You have found it unwise to be too frank in revealing yourself to others. Research shows that if people are told that descriptions like the above are designed, on the basis of psychological tests or astrological data, specifically for them, they will say the description is very accurate. (In fact, given a choice between a fake "Barnum description" and a real personality description based on a bona fide test, people tend to say that the phony description is more accurate!) The textbook also warns that people can easily be induced to give information that fulfills the expectations of the treating clinician. This "confirmatory bias" is responsible for many self- confirming beliefs in psychotherapy. For example, consider a therapist who strongly believes that gay adult males had poor relationships with their mothers. Studies show that such practitioners may meticulously probe for recalled -- or fabricated -- signs of tension between gay patients and their mothers, but neglect to perform a similarly-careful review of their heterosexual patients' relationships with their mothers. This material has obvious relevance to concerns of the FMSF. Barnum descriptions play a significant role in the current overdiagnosis of multiple personality disorder cases. That is, proponents of MPD actually say that having significant mood swings, speaking in a childlike voice during therapy sessions, or sometimes dressing in bright colors may signal MPD. Barnum descriptions also play a significant role in the current overdiagnosis of sexual abuse based on "repressed memories." That is, trauma-search therapists actually say that being unable to remember what happened in the fifth grade, experiencing discomfort when using public bathrooms, or not liking to have water on your face when swimming or bathing may signal past sexual mistreatment. Before closing, I thought it would be good to acknowledge the compliments from a California reader. He thought this column was as pleasurable to read as his favorite (but now defunct) comic strip, "Calvin and Hobbes." Because I too used to wait every day to see what Calvin and his funny stuffed tiger would do, I consider this quite a compliment! August Piper, M.D. is in private practice in Seattle, Washington. His book on multiple personality disorder will be published in the summer of 1996. He is a member of the FMSF Scientific and Professional Advisory Board.
A WAY TO HELP SOMEONE WHO BELIEVES IN THE IRRATIONAL August Piper Jr., M.D. The masses think it is easy to flee from reality, when actually, it is the most difficult thing in the world. Ortega y Gasset, 1948 A woman -- who lives in Philadelphia, oddly enough -- wrote last month to say that she had heard the False Memory Syndrome Foundation had gone out of existence. I called her to say that although probably any number of people most ardently wished this were indeed the case, the rumor contained neither jot nor tittle of the truth. A phone call to the FMSF office assured her that I had spoken correctly. The main reason for the letter, however, was to ask a question about her 26-year-old daughter, Linda, who has become convinced that she is a victim of sexual abuse (she is not sure by whom) and satanic ritual abuse. "And in the past few years," the mother's letter continues, "with the help of two therapists, she has discovered she has some seventy different personalities." The mother said that she had half believed Linda's story as it evolved. Though she had never seen evidence that her husband had improperly touched her daughter, it was hard to argue with the therapist. For one reason, she claimed to be an expert. For another, she refused to meet with Linda's mother or to even talk to her on the phone. Over the years, Linda's memories became more and more incredible. Finally, she came to remember being sexually molested in a ceremony in her parents' house -- while her mother watched, doing nothing to assist Linda. The mother's letter says, "This accusation, though painful, nonetheless brought me an odd kind of relief. Whereas I didn't know whether or not my daughter's earlier claims were based in reality, I knew beyond any doubt that this one was absolutely false. So this preposterous accusation helped me see that my daughter had fallen victim to a cruel delusion; it helped me finally realize that her memories were unreliable." She has told her daughter of this realization -- to no avail: "Linda continues to cling firmly to all her beliefs, including that her brother is part of a huge cult." This story, in all its dismal sordidness, must smell depressingly familiar to many of us: Childhood maltreatment that is remembered for the first time during psychotherapy. The ubiquitous "cult" -- for which no one can ever seem to produce evidence. The expert therapist, so confident of his or her ability to unearth the truth buried in the past. Multiplication of "personalities," as far as the eye can see. Ever-more fantastic memories of evermore fantastic mistreatment. The dreary features of this story are staples of the lawsuits, now blossoming all over the country, against both major and minor practitioners of recovered-memory psychotherapy. In her letter, the mother asks the impassioned question voiced by so many FMSF members:"What can I do to help my daughter?" Some research, based on sound cognitive-behavioral principles, might help answer this question. In treating patients who have delusions -- that is, beliefs that are held firmly, despite a lack of evidence to support them, and in the face of evidence against them -- psychiatrists have found that attempting to argue against the delusional belief usually accomplishes little. Rather, the research indicates a better course: simply ask the patient to generate his or her own alternative hypothesis for the phenomenon under discussion. After such explanations come forth, therapist and patient rationally discuss and weigh the merits and demerits of the various alternative explanations. Beauty and elegance lie in this admittedly rather passive approach: in essence, patients are asked to argue against their own beliefs. It avoids the struggle that occurs when one side attempts to press its beliefs on the other. The therapist might offer an hypothesis, but only as something that the patient might -- or might not -- want to examine; the therapist is not passionately invested in one position or another. So Linda's mother might say something like this: "Yes, dear, I understand you believe you were raped on an altar in our living room by the pastor and assistant pastor of our neighborhood Lutheran church while I watched. But is there any other hypothesis we might want to consider here?" She then refuses to discuss the matter further until daughter does the work of generating another theory that, one hopes, would conform more closely to the reality that most of us hold close. Yes -- the problems of this approach are many. It's slow. The accusing family member may never develop an alternative theory. It requires conveying the message that a delusional belief deserves the same credence as a reality-based belief. It requires cool, rational discussion of a hot, emotional issue. But I don't know any other research-validated method that tackles the vexing problem of therapy- induced false memories. Let me hear from all you wise readers who have other suggestions for Linda's mother!
SUPPORT GROUPS: VIPERS' NESTS? by August Piper, Jr., M.D. From A.G. in California comes a letter enclosing and discussing an article in McCall's magazine (September 1996). The article concerns Leslie, an overweight woman whose physicians had been unable to find a biological cause for her weight problem. To a psychotherapist, Leslie revealed that she had difficulty sleeping, "felt uncomfortable in closed spaces, and had recurrent nightmares about being attacked." In the article, the therapist noted that these symptoms "can be indications of post-traumatic stress disorder, a psychiatric illness that sometimes occurs [after] a traumatic event." Indeed, Leslie did have such a history; an accidental death of a dearly-loved sister, sexual mistreatment at the hands of an uncle, and an alcoholic father who, when drunk, physically and verbally abused family members. All these events had taken place at least twenty years before Leslie consulted the therapist. After several months of individual psychotherapy, the therapist referred the patient to a "long-term group for survivors of sexual abuse." Since then, the therapist says, "Leslie's PTSD symptoms have improved and she has been gradually losing weight through exercise and by reducing the fat content in her diet." A.G. and I both wish to raise a few concerns about Leslie's treatment. But first, we want to commend the therapist for what didn't take place during that treatment. As A.G. notes, the therapist makes no mention of confrontations, threats of lawsuits, discontinuation of family contacts, demands for monetary remuneration, or any of the other tiresome impediments of what A.G. calls "hate therapy." (I wish I had coined that phrase!) Having said that, now let us examine a few concerns about the article. The therapist assumes that Leslie has PTSD -- that the patient's symptoms result from past trauma. Although they may, they also may not, and it is difficult in the extreme to be confident that anyone's present difficulties stem from events occurring two decades ago. The other concern with Leslie's PTSD diagnosis is one of definition. Originally, the diagnosis was intended for people who had suffered events not only truly beyond ordinary human experience, but also ones that provoked extreme fear and terror about threats to one's life or limb. But clinicians proved unable to agree on exactly what kinds of events should be considered to satisfy these criteria. The result? PTSD diagnoses began to be given to people with less severe and even trivial traumas: one case where two men engaged in a fistfight in which perhaps six punches in all were thrown; another in which a woman's shampoo dramatically changed her hair color; a third where a supermarket patron was asked -- politely -- if he had taken a pack of cigarettes without paying for them. The point of all this: the term "PTSD" is now being bandied about so casually that it is in danger of becoming trivialized to death (Remember "hypoglycemia" of a few years ago? For a while, it seemed that every second person who came into the office claimed to be suffering from that quite uncommon disorder). If any diagnosis is stretched so widely that it applies to every event, it ceases to mean anything at all. Specifically, in Leslie's case, it seems reasonable to at least ask one question: Were her stressors, although admittedly unfortunate, so "beyond ordinary human experiences" as to warrant a PTSD diagnosis? It also seems reasonable to wonder whether the symptoms' very long persistenceQ twenty years -- should raise a question about the accuracy of the PTSD diagnosis. The question is warranted because according to the DSM-IV, about half of those suffering from this condition recover completely within three months. This discussion is relevant to FMSF members because many members' relatives receive this diagnosis. Surprisingly, a significant number of people so diagnosed do not develop any post-traumatic symptoms until after they have contacted a therapist. This, of course, strongly suggests that the therapist's interactions with the patient trigger the manifestations of PTSD. For example, as FMSF members know only too well, such manifestations can be triggered by psychotherapists who overzealously try to convince a patient that he or she has been sexually mistreated as a youngster. A.G. has another concern. She says: Before our experience with a false accusation of sexual mistreatment, and the resulting destruction of my family, I wouldn't have thought anything about a therapist referring a patient to a support group for survivors of sexual abuse. Now I cringe at this "help," because such a group fueled the beliefs of my sister-in-law and encouraged her lawsuit. A.G. does not trust any of these groups because she now believes that even if they are well-meaning, they are wellsprings of the false memory syndrome cult. Her question: are there any guidelines that good therapists follow to ensure that the groups to which they refer are not breeding grounds for the destructive Courage to Heal type of therapy? To guard against therapist misconduct like that mentioned by A.G., two lines of defense exist. The first is the referring professional's knowledge of the group leader's qualifications, skills, and practices. But this defense is rather porous: if you are seeking a good auto mechanic, roofer, or surgeon, for example, rarely does anyone have extensive intimate knowledge of how that mechanic or surgeon actually works. Thus, the referral may well rest mostly on the person's reputation -- sometimes a frail and vaporous thing. The most important defense, rather, lies in the hands of the individual seeking help. If, on the basis of what you know, you think something a little quirky is going on in your treatment, simply ask the professional to explain his or her practices. A good practitioner should not object to this opportunity to educate his or her patient (Remember, the word "doctor" comes from the Latin word meaning "to teach"). If you still feel uncomfortable, get a second opinion--or just get a new therapist. Trust your intuition. Finally, A.G., I refer patients to support groups; not all are nests of vipers. Beware of criticizing all because of misdeeds of a few! August Piper, M.D. is in private practice in Seattle, Washington. He is a member of the FMSF Scientific and Professional Advisory Board. His new book, HOAX AND REALITY: THE BIZARRE WORLD OF MULTIPLE PERSONALITY DISORDER, published by Jason Aronson Inc. will be available in January 1997. "By encouraging a more critical evaluation of what is called MPD, this book will help clinicians in their efforts to help those rare patients who truly should be given that diagnosis, as well as the much larger number who might otherwise be incorrectly diagnosed."
A New Day Dawning? August Piper Jr., M.D. A recent curious little debate has merrily bubbled and squeaked along in obscure corners of the media. The question: does the 21st century begin in the year 2000 or 2001? Though the weight of logic supports the latter, this seems to count for nothing, because at least in the United States, it appears that the new age will be embraced 365 days early. Many American psychotherapists are not waiting until 2000 to embrace and welcome another kind of new age. I refer to what might be called the age of dissociation. To satisfy yourselves, dear readers, that this age is upon us, merely open a recent issue of almost any psychiatry or psychological journal. Difficult it is, you will find, to avoid seeing one paper after another on this subject. The prestigious American Journal of Psychiatry, for example, is quite enamored of such papers; it published 11 in 1996 alone. Yes, dissociation is sexy now. But before getting too cozy with this notion, we should become better acquainted with it. "Dissociation" is defined as a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment (DSM-IV). Five manifestations of dissociation are said to exist: amnesia (a specific segment of time that cannot be accounted for by memory); depersonalization (detachment of consciousness from the body); derealization (a sense that one's surroundings are unreal); identity confusion (a subjective feeling of uncertainty, puzzlement, or conflict about one's identity); and identity alteration (evidence of actions of different identities or ego states). These definitions are beset by vagueness and excessive dependence on interpretation. Consider amnesia, for instance. How can an outside observer ever evaluate the genuineness of a claim of amnesia? One writer has noted that even from its earliest history, dissociation has always been a concept in need of restraint. But the restraints came off a few years ago, and now this nebulous concept runs wildly around everywhere. Examples: If you don't remember parts of conversations, that's dissociation. Do you become so involved in a book or movie or other experience that your surroundings fade away? You guessed it: dissociation. Unable to recall parts of a long, boring freeway ride? Right again! -- dissociation. And if you fail to remember large blocks of your childhood, dissociative disorder proponents can tell you why. Some proponents go so far as to imply that commonplace experiences like these indicate significant psychiatric disorders, or a repressed history of childhood maltreatment. The definitions' ambiguity and subjectivity allow "dissociation" to be defined in nearly any way people want. I recently interviewed a woman who actually claimed she was "dissociated 100 percent of the time" -- even while she was talking to me (and, I might add, not only following the conversation, but also making perfect sense). The concept is all-explaining. Thus, one dissociative disorders expert says that mania, panic attacks, mood swings, obsessive- compulsive symptoms, self-mutilation, drug abuse, phobias, hallucinations, eating disorders, suicidality, depression, sexual dysfunction, bodily aches and pains, insomnia, and several other psychiatric difficulties may occur in patients who have dissociative disorders. This expert implies that dissociation causes all these difficulties. One can only wonder if there is any psychiatric problem that fails to make this list. Yet another problem is that the concept of dissociation directly leads to intractable logical contradictions about responsibility for one's actions. Two legal cases in which I recently consulted provide examples. In the first, the patient in question was hospitalized to treat dissociative identity disorder (formerly multiple personality disorder). The patient, and the staff as well, believed she had an alter that periodically assumed control of her body. Though she feared this entity would compel her to harm herself or someone else, she refused to take any responsibility for such actions. Instead, she adopted the dissociative disorder party line: "I have no control over my dissociation. It just happens to me, and then the alter takes over." The treating clinicians endorsed this regressive stance of nonresponsibility. Unfortunately, this endorsement left them with just one exceedingly unpalatable treatment choice: to assume more and more responsibility for the patient's life. But the more they took control, the worse she became. The staff finally decided -- unilaterally -- that, "for her own good," they would move the patient to another state, far from her home city. They did this because they were firmly convinced that "The Cult" was after her. In the second case, a defendant who claims to have MPD faces charges of misappropriating a small mountain of money from a financial institution. She asks the court to agree that she is not criminally responsible for this behavior. Why? Because, she claims, she had dissociated at those times when the funds vanished. In other words, she didn't take the money -- her alters did. This argument apparently exerts a compelling attraction for one well-known university professor. He will testify that neither the defendant, nor any of her alters, deserves so much as even a glimpse of the inside of a prison. Finally, see what a reader in Ohio says: In 1992, my 34-year-old daughter wrote me, saying that her therapy had revealed that something might have happened to her when she was a child. Although she never accused me directly in person, by phone, or by letter, she would tell her brothers and mother that I had committed incest with her. All these people turned against me; I tried to reason with them but they wouldn't listen. Now my daughter tells me she should not be held responsible for these comments, because one of her alter personalities made them. My question is: Should she? These questions of responsibility revolve around two articles of faith passionately endorsed by many MPD proponents. First, that at least some barriers between patients' personalities are impermeable -- that is, information does not leak between alters. Second, that patients suffering from dissociative disorders cannot control the conditions' phenomena. If these claims are true, then neither the main personality, nor any of the subpersonalities, can reasonably be held responsible for what any other personality does. According to this logic, the hospitalized patient described above could indeed not avoid killing herself, the defendant should not go to prison, and the daughter should be free to make all manner of accusations against her father. No one, I suspect, would want to live in such a world, where any responsibility could be lightly evaded by easy appeal to invisible alters. Interestingly enough, some MPD-focused therapists seem to agree. For example, one such therapist explicitly tells MPD patients to behave responsibly -- as by demanding, under threat of legal sanctions, that they exert sufficient control over their behavior to keep away from his home and family. How obvious it is that this demand contradicts the above articles of faith! Though the Ohio reader asks a moral, rather than clinical, question, his question challenges those MPD proponents who urge that more people be so diagnosed. What happens to the concept of responsibility in a society where scores of thousands of people receive this diagnosis? Frankel (Am J Psychiatry July 1996 supplement) wisely warns against premature cozy embrace of a new age centered on "unbridled versions of the concept of dissociation" -- a concept that, he notes, has recently been "projected as larger than life." He says although some evidence for dissociation's existence may eventually appear, at this point in the old millennium, it is largely just an hypothesis. August Piper, Jr. M.D. is in private practice in Seattle. He is a member of the FMSF Scientific Advisory Board and the author of the just-released book Hoax & Reality: The Bizarre World of Multiple Personality Disorder, Northvale, NJ: Jason Aronson, Inc.