Psychiatry has a black spot. A fascinating, controversial and darkly disturbing chapter. A window of time that began in the 1970's with the creation of a hitherto practically unknown psychological disorder, colloquially known as split personality disorder and ended in the 1990's amid a moral panic of epic proportions, involving hundreds of families torn apart by claims of satanic cults that were later refuted. The claims were based on memories implanted in children by psychiatrists using a combination of hypnosis, psychoactive drugs and leading questions. The spate of multiple personality disorder diagnoses and satanic cult claims dissipated almost as quickly as they had begun as patients successfully sued their psychiatrists in the mid 1990's and the position of the media transitioned from frenzied endorsement to skepticism. That's the traditional telling of the story. But did that time really end? That is a question that is now being asked.

In 1973, multiple personality disorder as it was then known, was thrust into public consciousness with the publication of the book Sybil, that went on to sell six million copies and three years later became a feature film. The book and film was based on Shirley Mason, a woman who presented to her psychiatrist, Dr. Cornelia Wilbur with sixteen distinct personalities, which emerged in sessions in which she was given hypnotic drugs such as the infamous Sodium Pentothal, then described as a "truth serum". It is worth reflecting on the fact that this is the same "truth serum" that declassified documents show the CIA has long been interested in for the purposes of interrogation and has been advocated for in the same breath as calls for torture. A short documentary (below) by the New York Times asks the question: "how did a rarely diagnosed psychological disorder turn into a cultural phenomena?" Before Sybil, only 100 cases of multiple personality disorder had ever been reported in the psychological literature. Less than a decade later in 1980, the American Psychiatric Association officially recognized the disorder and the cases rapidly soared into the 1000's. Psychiatrists conducted therapy sessions under hypnotic drugs in which leading questions led to hysterical claims of satanic ritual abuse emerging from patients who before entering therapy had no recollection of the events. Many later recognized the stories they had been led to believe were true, were in fact false, while many of the claims were so implausible that in hindsight it is difficult to understand how anyone ever believed them in the first place.

Last month Pacific Standard magazine published a cover story by Ed Cara definitively titled, The Most Dangerous Idea in Mental Health. Cara looks at how the chapter of memory recovery that should have been shut decades ago, continues - spurned by a minority of therapists who still use questionable techniques. In a sense this shouldn't be surprising: "in the mid-1990s, more than 50,000 U.S. therapists—appeared to accept repressed memories uncritically". Since that time the professional organisations of psychiatry have spoken out against therapies designed to recover memories, but formal guidance in the US has been limited: 

"In 1993, the American Psychiatric Association did issue a cautionary note about the difficulty in distinguishing true memories from false; the next year, the American Medical Association declared recovered memories to be “fraught with problems of potential misapplication.” In 1997, the Royal College of Psychiatrists in Britain, by contrast, explicitly advised against the use of techniques designed to elicit recovered memories of abuse. No such advice was given by either the American Psychological Association or the American Psychiatric Association. The mental health professional organizations, by and large, did not appear interested in calling recovered memory therapists to account."

Cara's extensive account which is well worth reading in full describes a modern day victim's recent recollections of how she lost her sense of "what was and wasn't true" as her therapists encouraged her to name and map out on paper her personalities as she sat in a dark room, disorientated and under hypnosis. This, after the therapists allegedly went as far as assigning her readings of autobiographies of cases of recovered memories and spent time watching movies about cults with her. The therapists even allegedly presented testimonials from their other patients about satanic ritual abuse:

“It was as if someone had reached into my head, pulled out my brain, and replaced it with craziness,” 

There is an alarming distance between the psychological research community and practicing psychologists when it comes to beliefs about the practice of repressed memory retrieval and indeed the very existence of repressed memories as something that can even happen. As demonstrated in a study published this year in Psychological Science: over 43% of practicing clinical psychologists think it is possible to retrieve repressed memories - that figure goes up to 66% among Internal Family Systems therapists. Among the general public in the United States that number is 70%, but this all compares with only 16% of research psychologists who believe the retrieval of repressed memories possible. The story is similar for belief in repressed memories, with 19% of research psychologists believing, compared to 60% of clinical psychologists, 80% of Internal Family Systems therapists and 84% of members of general public in the United States.

The gap between the beliefs of research psychologists, practicing psychologists and the general public should be cause for concern. It seems the dark age of repressed memory recovery is sadly not ready to be consigned to the history books. The debate regarding repressed memories and claims of satanic ritual abuse causes very strong feelings on both sides and the sensitivity of the topic is one reason it is so rarely discussed publicly. Last year Psychiatric Times ran a cover story on the topic by Richard Noll PhD, but shortly after publication the online version of the article silently disappeared. After a fair bit of outcry the disturbing account of the history of satanic ritual abuse claims was republished along with public responses from those involved, including from Al Frances MD, former chair of the American Psychiatric Association's Diagnostic and Statistical Manual task force. The DSM is essentially the psychiatrist's bible, listing all mental illnesses. The quote below is from Al Frances MD:

"I have been so vocal in warning about DSM-5 partly because I'm ashamed of my silence in the face of a previous outrage that cried out for similar whistle blowing. The episode is recalled in this wonderful piece by Richard Noll that brings the history vividly back to life.

The time was between 20 and 25 years ago. The outrage that needed exposing was the sudden epidemic of prosecutions of daycare workers for the alleged sexual and satanic ritual abuse of the children under their care. The place was all over the U.S. -- this was a nationwide craze that focused suspicion on more than 100 daycare centers. The victims were the completely innocent daycare workers who were indicted and often convicted of ridiculous charges that could not possibly have any foundation in reality. Many were pressured, threatened, and/or tortured into false confessions, and some, under great duress, were forced into making false charges implicating co-workers. Dozens have served prison sentences, and some are still in jail -- an injustice of shocking proportions.

The initial accusers were usually mentally unbalanced parents harboring weird imaginings or an ax to grind, or both. The first-responder enablers were gullible police detectives who spread panic from household to household. Next came ambitious prosecutors who used the cases to make a name for themselves (one became Attorney General of the United States; another governor of North Carolina). Most inexcusable were the self-appointed "expert" therapists with their anatomically correct dolls and their leading and bullying suggestions. The children were seduced and brow beaten into confirming wild stories of horrible but totally implausible, sexual and/or satanic experiences. Parents, police, prosecutors, and therapists who theoretically were there to protect the kids from abuse instead themselves became their abusers.

The charges were farce, but the impact on those involved was tragedy. Never was there a single shred of physical evidence that any of the crimes had ever occurred. It was a modern witch hunt, no better than the Salem trials occurring 300 years before, or the Spanish Inquisition 400 years ago. In the interim, modern man has acquired remarkable knowledge but is still capable of remarkably primitive thinking and cruel action.

I stayed silent on the sidelines, observing all this foolishness but displaying a cowardly distaste for controversy. As Chair of the DSM IV Task Force, I had a bully pulpit to point out the utter craziness of the fad. Instead, I justified my passivity on the grounds that it was not really my fight and that getting involved might compromise my neutrality as DSM IV Chair. These were lousy excuses considering that innocent people were going to jail and kids were being traumatized by fake therapists who professed to be experts in childhood trauma. My priorities were all screwed up.

Anyone who thinks it improbable that anything so dumb and destructive could ever happen again need only google "satanic ritual abuse." You will find a wealth of reckless and nutty how-to guides ready to lure the gullible into a new round of similar primitive thinking and witch hunts. And there is no shortage of gullible people -- a recent survey indicates that a majority of Americans still believe in demonic possession. The percentages would be even higher in many parts of the world that are even less developed than we are.

If we don't recall this disaster and learn from its lessons, we are likely to repeat it -- possibly in the near future.

Multiple Personality Disorder (aka Dissociative Identity Disorder) has always been controversial and contagious. We are lucky that MPD is now in one of its quiescent phases, but it will almost certainly make a comeback before very long. Recurrent false epidemics have occurred several different times during the last century. The trigger is usually either the widespread copy-catting of a popular movie or book, or the fevered preachings of a charismatic MPD guru--or both.

MPD was an extremely popular diagnosis when hypnosis was in vogue 130 years ago; then emerged again 60 years ago when The Three Faces Of Eve became a best selling book and hit movie; was revived 40 years ago following the vogue of the movie Sybil, and its many imitators; and reached a peak 30 years ago when several 'thought leaders' started conducting weekend workshops all over the country minting an army of poorly trained MPD therapists who suddenly diagnosed and treated it in all their patients.

Having seen hundreds of patients who claimed to house multiple personalities, I have concluded that the diagnosis is always (or at least almost always) a fake, even though the patients claiming it are usually (but not always) sincere.

In every single instance, I discovered that the alternate personalities had been born under the tutelage of an enthusiastic and naive therapist, or in imitation of a friend, or after seeing a movie, or upon joining a multiples' chat group -- or some combination. It was most commonly a case of a suggestible and gullible therapist and a suggestible and gullible patient influencing each other in the creation of new personalities. None of the purported cases had had a spontaneous onset and none was the least bit convincing.

Why does MPD keep making its periodic comebacks, despite not being a verifiable or clinically useful mental disorder? My best guess is that the labeling of 'alters' offers an appealing and dramatic metaphor, an idiom of distress. Under the influence, pressure, guidance, and modelling of external authority, suggestible individuals find in MPD a convenient way to describe, explain, and express their conflicting feelings and thoughts. But the metaphor often takes on a dangerous and impairing life of its own, feels all too real to the patient, and contributes to regression, invalidism, and a negative treatment response. And many who present with MPD have a real and treatable psychiatric disorder that is masked by it.

At the height of the most recent fad in the '90s, it seemed that every third or fourth patient was presenting with a long list of newly developed multiple personalities. The modal number of personalities per patient started multiplying exponentially from just two to 16. The champion in my experience was a middle aged woman who managed to embody 162 distinct alters- including representatives of both genders, all ages, a wide variety of personality types, and some leftovers from previous lives.

MPD presented an insoluble conundrum for me as Chair of the DSM-IV Task Force. I was convinced that it was an iatrogenically inspired diagnosis inappropriately inflicted on vulnerable patients by the poorly trained therapists who came away from their silly weekend workshops armed with an MPD hammer that seemed to fit every patient nail. My own inclination was to wise up dumb therapists and protect vulnerable patients by simply omitting MPD from the DSM.

But my hands were tied. We had laid down strict rules requiring high evidentiary standards before any change could be made in DSM-IV. This was intended to prevent arbitrary changes by containing the diagnostic exuberance that typified the experts who were engaged in revising the manual. Any suggestion to expand the system required compelling evidence. But this sword cut both ways. Any change to reduce the system -- like eliminating MPD -- required equally compelling evidence. I couldn't rid DSM-IV of MPD because I had to follow my own rules and there was no compelling proof that MPD didn't exist as a meaningful clinical entity. It was only my personal opinion-- however certain I was. The best we could do to reduce the popularity of MPD and inspire caution in its diagnosis was to fill its text description with all the cogent arguments against it.

MPD disappeared in the mid-'90s because of its own failures and dangers, not because of anything we did in DSM-IV. It was doomed when insurance companies stopped paying for MPD treatments and patients started suing MPD therapists for malpractice.

I have no doubt that MPD will rise again -- it always has. Forgetting the past MPD follies is a proven guarantee we will repeat them."

It would seem Dr Frances' fears have been realized. It is important to clarify that the history of satanic ritual sexual abuse claims dubiously recovered from allegedly repressed memories should not be confused with the cases of sexual abuse that have come to light over recent years within the Catholic Church, amongst celebrities and elsewhere. Sexual abuse is real, widespread and deserves our full attention and thorough investigation, but to do this properly we mustn't forget the dark and disturbing history of witch hunts run amok. 

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