Selected Columns of August Piper, Jr., M.D.

from the FMSF Newsletter

Dr. August Piper, Jr.'s columns on a variety of topics have been a favorite for many newsletter readers. Here is a selection:


Other columns by Dr. Piper may be found in the Newsletter Archives:

               "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.