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Dissociative Identity Disorder: a literature review

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 Journal of Psychiatric and Mental Health Nursing, 2000, 7, 25–33

Dissociative identity disorder: a literature review

M. M. McALLISTER rn ed d
School of Nursing, Griffith University, Nathan, Queensland, Australia, 4111

Correspondence: MCALLISTER M. M. (2000) Journal of Psychiatric and Mental Health 7, 25–33

Dr Margaret M. McAllister Dissociative identity disorder: a literature review
School of Nursing
Griffith University This paper presents a review of the literature into dissociative identity disorder. This dis-
Nathan order, previously known as multiple personality disorder, is increasingly diagnozed, in part
Queensland
because of more focused diagnostic tools, but also because people are accessing services to
Australia 4111
assist with the longterm problems of early child abuse and neglect. Dissociative identity
disorder is examined in the literature according to a variety of discourses, each of which
suggest different ways of conceptualizing problems and therapeutic approaches. These dis-
courses reviewed include: psychiatry, psychology, corporeality, feminism, social construc-
tivism, anthropology, and postmodernism. The paper concludes with an examination of
the nursing literature and suggests opportunities for nursing research into this complex
mental health problem.

Keywords: dissociation, dissociative identity disorder, multiple personality disorder, nursing

Accepted for publication: 20 October 1999

post traumatic stress disorder, and multiple personality

Introduction
disorder, or DID.
Child abuse and neglect is common in our society and there
have been suggestions that the incidence is rising because
DID: fact or fiction?
the shroud of shame and secrecy is lifting (Chu 1997).
Although many abused children will recover if placed in a Dissociative identity disorder, while increasingly diag-
nurturing environment, many will suffer serious conse- nozed, remains a controversial diagnosis. Perhaps one
quences. One such consequence is the development of reason for this is that many of the bizarre and painful ex-
dissociative identity disorders (DID), previously called periences of DID are hidden to the observer. Symptoms,
multiple personality disorder. rather than signs, are predominant features of DID. They
Dissociative identity disorders (DID) involve a sudden include headaches, switching, auditory hallucinations and
and temporary alteration in consciousness, identity, or intrusive memories which may not have clear behavioral
behavor (Dallam & Manderino 1997). When a person dis- manifestations and thus are difficult to measure empirically
sociates they may reexperience previous trauma, switch to (Merskey & Piper 1998).
an altered personality, have nightmares or flashbacks. Like Even among mental health professionals opinions are
other coping mechanisms, dissociation can be protective. divided. There are those who believe that the disorder, like
Dissociation allows the person, or host, who may be the child abuse that preceded it, can no longer be denied
unable to deal with an overwhelming stress, to be con- and there are already too many people suffering because
trolled by an alternative personality, the alter. These stres- of a refusal to believe (Middleton 1995). The suffering that
sors or triggers may seem innocuous to others but be people with DID endure includes fear and mistrust of
painful reminders to the person who has been traumatized. others, loneliness, deep insecurity and lack of a coherent
Dissociation is seen in a range of dissociative states: fugue, sense of self, flashbacks, nightmares, insomnia, headaches,

© 2000 Blackwell Science Ltd 25

M. M. McAllister

loss of time and space, fragmented and missing memories, (real or imagined), towards seeing dissociation as a distinct
emotional instability ranging from extremes of rage and disorder.
fear through to numbing and inability to feel at all. If one DSM IV lists the criteria for DID as:
was to suspend disbelief for a moment, one might be able • The presence of two or more distinct identities or per-
to appreciate that DID has similarities to other serious sonality states (each with its own relatively enduring
mental disorders whose symptoms are not clearly mani- pattern of perceiving, relating to and thinking about
fested outwardly, and yet those disorders evoke sympathy the environment and self).
and services. • At least two of these identities or personality states
But there are other mental health professionals who recurrently take control of the person’s behavior:
suspect that symptoms of DID may be invented by people inability to recall important personal information
with personality disorders, or implanted by overzealous that is too extensive to be explained by ordinary
therapists. The idea that repressed memories can be forgetfulness.
elicited, remembered and disclosed within therapy is • The disturbance is not owing to the direct physiologi-
viewed by some with uncertainty, indeed cynicism cal effects of a substance (e.g. blackouts or chaotic
(McHugh in Jaroff 1993). Still others argue that the inci- behaviour during alcohol intoxication) or a general
dence and prevalence of DID is unreliable because research medical condition (e.g. complex partial seizures).
has focused on case studies rather than empirical investi- Note: In children, the symptoms are not attribut-
gations (Aldridge-Morris 1989). able to imaginary playmates or other fantasy play.
The various discourses from which DID has been under- Whilst DSM provides precise descriptions of various
stood, accepted and rejected within mental health will next symptoms of DID, it does not strongly concern itself with
be explored and include: psychiatry, psychology, corpo- causation. Within the discourse of psychology, theories of
reality, feminism, social constructivism, anthropology and aetiology are more commonly found.
postmodernism.

Psychology
Psychiatry
According to object-relations theory, in times of abuse chil-
Psychiatry is a dominant discourse for discussing dissocia- dren may learn to split off their awareness and memories
tive identity disorder. Janet (1889), a French psychiatrist, from the rest of their identity in order to survive (Braun
was first to emphasize the role of trauma in the genesis of 1987). Two predisposing factors to DID are the psycho-
dissociative symptoms, which at the time were called logical ability to dissociate and repeated physical trauma
hysteria. (Braun 1990).
As a result of various circumstances, Janet’s theory was Bryer et al. (1987) found that abuse has profoundly dele-
quickly eclipsed by Freud’s (1966) sexual theory of hyste- terious effects on the psyche of a child who is forced to
ria, in which he claimed that unacceptable fantasies, not deal with overwhelming emotions and at the same time to
real trauma, led to an unconscious defence mechanism deny that reality. The abused child learns to dissociate, or
called repression, which in turn led to conversion or dis- temporarily leave consciousness, thereby placing the
sociative symptoms. He argued that it was the repressed memory of the trauma into the subconscious, which later
fantasies which were turned into dissociative symptoms. reveals itself as a separate personality. As the child grows
Psychoanalytic theory, which essentially focuses on inter- and experiences repeated abuse, different identities or per-
nal and unconscious affective and psychological processes, sonalities evolve at different times. Each personality holds
dominated clinical practice for the next 50 years. DID, or different memories and feelings and performs different
multiple personality disorder, was seen as an extreme functions (Putnam 1989). The term ‘alter’ or ‘part’ is often
defence mechanism against internal and unconscious used to describe other personalities or identities that reside
conflict. within the body or ‘host’. These alters may be helpful or
In the 1960s, in parallel with the worldwide interest in destructive, and may be of different ages and sexes.
efficiency and measurement, the Diagnostic and Statistical The individual who dissociates has a disturbance in time
Manual of Mental Disorders (DSM) was produced (APA wherein they may have varying kinds of amnesia, as well
1994). The DSM tended to view psychopathology as col- as disturbances in identity, involving fragmented or multi-
lections of symptoms which could be observed and mea- ple identities. Dissociation ceases to be helpful when the
sured with scales and interview schedules. This view took person is unable to use other coping mechanisms to deal
away from the psychoanalytic approach of perceiving DID with stressful, intimate or dangerous situations. Bohn &
as a coping mechanism in response to some inner anxiety Holz (1996) warn that medically intrusive procedures such

26 © 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 25–33
 Dissociative identity order: a review

as vaginal or dental examinations may cause the person to Corporeality helps to understand how and why bodily
dissociate. Indeed, any situation which evokes a feeling of experiences for the person with DID can cause so much
powerlessness, loss of control, exposure or intrusion may pain and conflict. First, all experience is an embodied expe-
evoke flashbacks. rience. The experience of love, for example, may be felt by
The amnesia and identity diffusion which occurs when the hand, the heart, the eyes. But in DID, experiences may
a person dissociates can prevent them from relating be linked to the body in skewed ways. A father’s love may
well with others, or impede their performance of daily be linked to genital pain. Love may be linked to loss, shame
activities (Bohn & Holz 1996). Getting close to someone or insecurity. Thus, the meaning of bodily experiences may
may mean getting abused and so the person avoids inti- be confusing and make understanding the mind–body con-
macy, they are unable to trust others, they may be prone nection difficult. Patients may be helped to relearn simple
to being revictimized, they may be antisocial and isolative. links like feeling cool water and feeling calm, looking at a
Low self esteem, self hatred, guilt, a sense of unworthiness, baby’s face and feeling love.
and an inability to trust their own senses and maintain When one speaks to others without hearing one’s own
their own safety may predispose the person to being words, one tends to be cut off from possibilities in the
unsafe. experience. People with DID often feel separated from such
experiences. Therapy can aim to connect people to others
by helping them to appreciate meaning in the words they
Corporeality
use. Therapists often use metaphors to help people think
Psychological understandings of development of self about events in new ways. This play with language opens
involves an awareness of other. One develops a sense of new possibilities of meaning and offers new ways of situ-
self because of an awareness of who others are. This way ating oneself in the world.
of viewing the self sets up a subject–object dichotomy
which can be unhelpful in understanding ways of coping
with trauma. Feminism
For the person with DID, a coherent sense of self may
The increasing exposure and recognition of child sexual
not be possible because they have been grossly objectified.
abuse has been made possible through the feminist move-
The person may not be able to see themselves as a subject,
ment which sought to make public that which was hidden
or one who has worth just because they exist, one who has
in the private world of the family home (Johnstone 1997).
the potential for autonomous existence, who has agency or
Feminism helped to give women a voice in society, in pol-
internal control. The aim of therapy from the corporeal
itics and in health care reform. By encouraging women to
perspective would be to help the person learn to see the
make public their experience of sexual abuse, the systemic
self and colleagues as subjects, not objects.
suffering of many women has at last been acknowledged.
Corporeality understands the body as the site where
And society is under increasing pressure to believe women
cultural experiences are inscribed. The body is an object
and to take action. Thus, therapists have shifted from their
which is always socially influenced, it is marked and
tendency for dispassionate disbelief towards believing
shaped, and yet it is also experienced as unique to the indi-
victims. This willingness to believe may have paradoxically
vidual, the seat of one’s subjectivity and sense of self
spurned the controversy surrounding false memory
(Crowe 1996, Caillois 1984). This paradox is something
syndrome.
that all people must learn when they struggle with the idea
that they can both act, and be acted upon. People can be
subjects and objects at the same time.
False or recovered memory syndrome
Corporeality may see the body as a battleground where
the person acts out this struggle with the self – a self who McHugh in Jaroff (1993) has been quoted as saying that
is unique, personal and subjective and a self who is a social recovered memories of abuse
subject, moulded and constrained by beliefs and practices ‘is the biggest story in psychiatry in a decade. It is a dis-
which have been embedded by society. aster for orthodox psychotherapists who are doing good
For example, when a woman cuts herself, she is the work’.
subject of her bodily experience, not simply the object of Because society, including therapists, is now more willing
other’s experiences of it. She is also acting as the self who to hear victims stories and to believe them, therapists
is personal and who wants to express her internal pain and have been accused of ‘creating’ DID by encouraging their
the self who is a social product who is frustrated with being patients to see themselves as having many parts, or as
treated as an object. having inner children (Ofshe & Waters 1994).

© 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 25–33 27
M. M. McAllister

New legislation, particularly in the United States of standing until the 1980s. The reason for this, Hartcollis
America, written to protect the rights of victims of abuse, suggests, lies in society’s slow, but eventual willingness to
enabled victims to sue the accused perpetrator long after acknowledge and expose the taboo of child abuse and rec-
the crime. A few court cases ensued, taken out by alleged ognize its impact on victims.
victims whose abuse was remembered during therapy.
These cases achieved public notoriety when the allegations
were vigorously denied by the abusers, and later retracted Anthropology
by the prosecutor. Cynics have taken this as evidence to
An anthropological view of DID asserts that the way the
suggest that many troubled people, encouraged by their
phenomenon has been constructed differs across time and
therapists to reach deeper into the recesses of their memo-
cultures. In India, for example, DID is a rare diagnosis but
ries, conjure up detailed recollections of sexual abuse
possession syndrome is quite common. In cultures which
which never happened (Aldridge-Morris 1989). Further-
believe in the supernatural there may be a tendency to
more, publicity about multiple personality disorder in
accept even, expect possession-type experiences and
popular media may have led to a kind of copycat phe-
expression.
nomenon and thus a surge in the number of people claim-
Until recently, DID appeared to be occurring mainly in
ing to experience dissociation.
the United States, and there were some thoughts that this
Thus, repressed memories have come to be seen as false
was because life was more traumatic, child abuse was more
memories, and thus the legitimacy and trustworthiness of
common, or that the DSM-IV tool was used more readily.
childhood memories of abuse is questioned. While trau-
Middleton & Butler (1998) explain that these myths are
matic abuse of children is widespread, the controversial
being dispelled as countries like Australia and the UK are
recovered memory phenomenon may trigger a backlash
increasingly diagnozing DID, and finding very similar links
against legitimate charges of abuse (Aldridge-Morris 1989;
to abuse and neglect.
McHugh in Jaroff 1993). Still others argue that the literal
Across time DID symptoms have also varied from the
truth of memories is irrelevant when the fact is that people
dual person such as that portrayed in Dr Jekyll and Mr
experiencing DID are suffering anxiety, terror, intrusive
Hyde (Stevenson 1886) in the 19th century to the multiple
ideas and emotions and therefore they need help. Rossel
personalities portrayed in such novels as Sybil (Schreiber
(1998) argues that the important issue is how people go
1974) and The Flock (Casey 1992). In the later parts of
about finding meaning in their stories, true or otherwise.
the 20th century Kenny (1986) suggests that this mirrors
For him, the central task of therapy is to assist patients in
the change in ways of thinking about the world from
learning how to play with meaning in experience, and to
modernist dualistic thinking towards post modernist
resist the temptation to jump prematurely into literalizing
diversity.
their stories.
Kenny (1986) also suggests that ways of expressing
distress have changed over time. From the fainting
Social constructivism Victorian woman expressing her anxiety, society has
moved to accepting the expression of distress through
The social constructivist position is less concerned with
perceiving the self as fractured and multiple. Society
trying to prove the genuineness of DID, and more inter-
today also tends to accept that the world is a traumatic
ested in explaining why the diagnosis of DID is rising, how
place and thus to accept the trauma-dissociation theory as
society responds to the diagnosis, and how the controversy
valid.
gets played out. Hartcollis (1998) points out that while
DID was once thought of as an extremely rare phenome-
non, it has gained notoriety and become a fairly common,
The postmodern world
perhaps fashionable, diagnosis.
A metareview of the literature conducted by Gotteman, Rossel (1998) argues that the ambiguity and the absence
Greaves, & Coons (1992) showed that reports about DID of a moral centre is a reality of contemporary life. Tradi-
have grown from about one citation a year in the 1970s to tional assumptions about identity – that it is strong,
60 citations a year in the early 1990s. Hartcollis (1998) natural, unitary, stable, rational, or knowable are now
also points out that DID has made its way into popular questioned. His view is that it is possible that DID is not
culture, being presented in movies, soaps, novels, biogra- always caused from sexual trauma or abuse, but may also
phies, talk shows, and celebrity confessionals. But she goes come about through living in a world of fluidity, where
on to argue that while stories about DID have been around identity is diffuse and impoverished and where people are
since the 1950s, the label didn’t reach common under- required to develop an ‘abundance of selves’.

28 © 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 25–33
 Dissociative identity order: a review

protects the ego in times of stress, actually work? Does dis-

The trauma–dissociation link
sociation exist on a continuum ranging from simple day
Despite the prevalence of the DSM, and its emphasis dreaming in times of boredom, through to the development
on measuring symptoms, clinicians are moving back to of alter personalities in times of terror? Are some children
trying to understand causation and are reconsidering the constitutionally predisposed to defend against trauma by
trauma–dissociation link originally put forward by Janet splitting off or dissociating memories from consciousness?
(Janet 1889; Ross 1997, Middleton 1995). DID is being
recognized increasingly as a relatively common posttrau-
Assessment
matic syndrome.
According to Braun (1987), Coons (1994), Putnam Various rating and observational scales exist for differen-
(1989) and Ross (1997), individuals with DID almost uni- tiating patients with DID from those with similar symp-
formly report a history of severe abuse usually beginning toms. Alpher (1996) found the Structural Analysis of Social
in early childhood. They experience complex posttrau- Behavior (SASB) to be effective in discriminating DID from
matic and dissociative symptoms such as flashbacks, other mental disorders.
intense affect, altered states of consciousness, and self- The Dissociative Disorders Interview Schedule (DDIS) is
destructive impulses (Herman 1992). The prevalence of a structured interview schedule which promotes the differ-
DID ranges from 0.1% to 5% of the population (Ross ential diagnosis of DSM-IV mental disorders including:
1997, Wing 1997). somatization disorder, borderline personality disorder,
DID also commonly involves the development of con- major depressive disorder and all of the dissociative disor-
current disorders such as alcohol abuse and obsessive ders. The Dissociation Experiences Survey is a question-
compulsive disorder believed to occur because of the deep naire which consists of 28 questions about the degree to
emotional pain experienced by the patient. which dissociative experiences occur in the person’s daily
According to a psychobiological view, the trauma life (Van der Kolk 1998).
response alters the central nervous system in five ways:
• intrusive symptoms such as flashbacks, nightmares; Symptoms
• avoidance symptoms such as avoiding thinking of
events; DID is easily misdiagnozed because its signs and symptoms
• hyperautonomic arousal symptoms such as heightened are readily attributed to other more familiar psychiatric
startle reflex, vigilance, increased heart rate, sleep dis- disorders. Headaches, mood swings, time lapses, auditory
ruption, alterations in pain response; hallucinations and anxiety may lead to diagnoses such as
• numbing symptoms such as detachment from sur- schizophrenia, mood disorder, anxiety disorder (Wing
roundings, memory lapses and 1997).
• distortions of the selfsystem such as lack of cohesion Three distinct symptoms of DID which require explana-
with multiple personalities, inability to monitor self, tion are dissociation, fragmented memories and abreac-
or sustain selfesteem (Hartman 1995). tion. Dissociation is a selfhypnotic state in which thought
These changes which are linked to limbic functioning are processes and current experiences are separated from the
central to memory, learning and emotional control. mainstream of consciousness (Stafford 1993). Common
triggers for dissociation include remembering early trauma,
associations such as colors, touches, sounds or pictures.
Cognitive mechanisms
Dissociation is a necessary coping mechanism which allows
Currently, there is an increasing interest in understanding the patient (host), who is unable to deal with the current
the cognitive mechanisms for dissociation. Sel (1997) sug- stress, to be controlled by an alternate personality (alter).
gests the theory of dissociation as a complex adaptation, After the dissociation, the host may have no recollection
which sees the patient with DID as an ecosystem of alters of the event and may lose time. Dissociation occurs on a
who compete with each other to gain control over the continuum from mild, such as daydreaming, to the emer-
output channels. The alter that most successfully maintains gence of an alter, through to the severe abreaction.
an emotional equilibrium is most likely to be the best Despite the suspicion that repressed memories may be
adapted. When the patient moves to a different context, false, there is no doubt that memories can be patchy and
different cognitive schemata will be more adaptive and the forgotten. Nor is there doubt that in extreme trauma,
alters will switch. memory is stored in fragmented ways (Van der Kolk &
Other questions of interest are: How does the autohyp- Fisler 1996). A simple way to explain fragmented memory
nosis, which leads to amnesia or switching and effectively is to recall what happened to your body the last time the

© 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 25–33 29
M. M. McAllister

stress response was triggered. You may have a memory of a situation which reminds them of the original trauma,
a particular sight or smell, or feel that time slowed down. they do not respond in the damaging way and develop
You may be surprised that you have a clear memory of resilience to the damaging effect of the memory.
some detail of that event, but no memory at all of other
things. In the stress response, memory is stored in frag-
Learning to live with many selves
mented ways.
Abreaction is the reliving of earlier trauma on a physi- Rossel’s (1998) postmodern therapeutic approach is to help
cal and emotional level as if it were happening now. An patients find new ways to live in a rapidly disintegrating
environmental trigger elicits the trauma neurophysiologi- social context, to help them situate themselves in their
cal response, and the person relives the physical and emo- experience. Rossel sees it as pointless to aim to achieve a
tional experience to the extent that they experience stable, unitary self, when there may be no such thing in
derealization and depersonalization and require assistance contemporary life. A happy person may be one who is able
to regain contact with reality. to take a playful and open attitude towards experiences
and be comfortable with shifting back and forth among a
large number of selves. He argues that just as there are
Treatment and therapy
many ways to fracture personality, through accidental
Simply put, treatment for dissociation is reassociation, or trauma, through environmental and social trauma,
putting consciousness back together. through intentional abuse or neglect, so there are also
Reassociation may be also known as gaining insight many ways to reassociate, or put the personality back
(Freud 1966), transformation (Erickson 1980), or invent- together.
ing realities that work (Gilligan 1993). The International Oke & Kanigsberg (1991) take a more specific occupa-
Society for the Study of Dissociation (ISSD) recommends tional view and suggest that common skill deficits for the
that treatment should move the patient towards a sense of person with DID include: sensory integration, cognitive,
integrated functioning and that generally a two year out- dyadic interaction, group interaction, self identity and
patient treatment is successful in helping the person process sexual identity. These skills are commonly deficient because
their traumatic memories and overcome intercurrent prob- past trauma may have occurred during crucial develop-
lems such as depression and anxiety. mental stages. Although authors may each have distinct
Traumatic memories which are reexperienced over deficits depending on their experience of trauma. These
and over again tend to be retraumatizing. In order for the authors advocate the use of techniques such as; play,
trauma to cease, these memories need to be processed, guided imagery, life skills teaching, projective techniques
understood, contextualized and then stored safely away. and group therapy to help bring awareness, understanding
Because these memories may have been pushed into the and eventually cohesion to all alters.
unconscious, or only partially remembered various tech- Hospitalization is recommended to be used only for the
niques for maximizing safe recall may be utilized (Ross achievement of specific goals such as restoring the person
1997). to a stable level of functioning so that they can resume out-
Hypnosis, deep muscle relaxation and eye movement patient treatment (ISSD 1997).
desensitisation and reprocessing (EMDR) may be useful to
aid in recall. EMDR involves the movement of a finger in
Models for nursing care
front of the patient’s eyes 20 or 30 times in succession to
encourage left–right brain connection and assist the patient Riggs & Bright (1997) applied Jean Baker Miller’s Rela-
to recall traumatic experiences without the full blown emo- tional Model (1986) as a framework for inpatient treat-
tional effects. By neutralizing the pain of memories, EMDR ment for female DID patients. They argue that because
allows the trauma to be viewed more dispassionately, Miller’s model focuses on the importance and ability of
remembered fully and thus eliminate the tendency for women to create and maintain successful relationships, the
intrusive fragmented memories to recur. dissociation from self and colleagues felt by DID patients
EMDR may also be useful in preventing the neurophys- can be alleviated through the use of this model. Riggs and
iology of the trauma–memory–retrauma cycle. Chauvin Bright describe a combination of individual and group
(1999) explains that whenever a person remembers their therapies, art and movement activities as well as psychoe-
trauma the physiological stress response is reactivated ducational sessions which aim to foster good relationships
which elicits dissociative symptoms and damages the body. between patients, and between the patient and staff. The
EMDR may help to interrupt that cycle and prevent the authors suggest that the same sex requirement in the unit
corticosteroid flooding. Thus, even when the person is in facilitates a sense of belonging to a group, and promotes

30 © 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 25–33
 Dissociative identity order: a review

relationship building as well as safe disclosure and to listen and hear the stories of abuse so frequently as they
selfanalysis. are relived by patient after patient. Hartman suggests that
O’Reilly Knapp (1996) provides another model for responses range from avoiding patients, to overidentifica-
nursing therapy that focuses on three goals: first to build tion, neither of which are conducive to a useful therapeu-
ego strength, then to modulate affect and finally to support tic relationship. Hartman advocates improved staff
abreaction. She explains that ego strength can be built by cohesion through support groups, personal reflection and
reassuring present safety, by legitimizing all emotions, and staff education programmes.
by encouragement to confront the past. The second phase Hall (1997) argues that the termination of therapy for
of treatment involves the modulating affect, or the regula- victims of childhood abuse is as important as the begin-
tion of important memory emotion associations. Here, the ning and course of therapy. Because poor closure of
therapist must appear confident and nonfragile against the therapy can potentially overshadow any progress of
potentially explosive traumatic memories, so as to build therapy for the patient, certain steps must be taken to
patient confidence and self efficacy. The final process of ensure that no harm is done to the patient at the end of
supporting or fractionating abreactions has the therapist treatment. She advocates both foreshadowing the ending
become a container for emotions by listening, applying from the onset of therapy, as well as a degree of selfdis-
meaning to feelings, and sharing the interpretation which closure from the caregiver to facilitate the patient’s under-
the patient can either accept or reject. standing of closure in general. A type of closure is possible
(and desirable) that involves an individualized mutual
transformation of the therapeutic relationship into a ‘real
Nursing and a milieu for safe disclosure
relationship’, free of the power disparities of the therapist-
Bohn & Holz (1996) suggest that a forum in which the patient relationship.
person can safely disclose their abuse history is very impor-
tant because often the person has been forced to keep the
Summary
abuse secret, or when they have dared to speak, they may
have not been believed. Indeed, an abuser may try to wear DID is a controversial diagnosis which evokes powerful
the victim down by controlling their thoughts and percep- reactions from outrage about the effects of childhood
tions so that over time, the person comes to believe the abuse, fervent advocacy for victims of abuse, fascination at
abuser’s version of reality. Thus, their own ability to per- such bizarre experiences, through to cynical condemnation
ceive reality, and remember events accurately may be of fantastic thinking and mass hysteria. Despite the con-
doubted and confusing. troversy, the disorder is increasingly diagnozed for various
Therefore, the person needs to be assured that whatever reasons: a better informed and more articulate public who
feelings they have are legitimate, that they are believed, and now voice their health needs; increased selfreporting of dis-
that they are not judged. The authors recommend that turbing symptoms, childhood abuse and trauma; a shifting
telling a person that they are worthwhile and did not social world which is now willing to acknowledge that
deserve to be abused can be very powerful. Other goals child abuse has serious long term sequelae; a paradigm
include helping them to understand that their behaviour shift in therapy which now values the subjective experience
did not cause the abuse and that their feelings and thoughts of patients as well as focused techniques to assist healing.
are normal reactions to the abnormal abusive behavior of Freud’s theory of repressed sexual fantasies leading to
another person. dissocation has lost ground and been replaced with
Bohn & Holz (1996) also state that health carers need Janet’s (1889) earlier theory that real trauma can cause
to be comfortable with the issue of abuse. They need to see dissociation.
abuse as a public health issue not a private problem. They Therapeutic approaches aim for reassociation of the
need to overcome biases, prejudices or myths about vio- fragmented self by: encouraging disclosure of the earlier
lence against women. Such myths include that the woman and repeating trauma; finding meaning in the experiences
provoked the abuser, that the story is fictional or that the of flashbacks and body memories; learning to place mem-
behaviors are malingering or factitious rather than the con- ories of the past into context; learning to relate with others
sequence of abuse. as both subjects and objects; becoming more resilient to
Hartman (1995) raises the notion of vicarious trauma the traumatic effects of remembering, and learning to
for carers. Vicarious traumatization is the exposure of develop more life skills to promote a happy life and avoid
persons other than the victim to either the re-enactment of further trauma.
the original trauma, or to the behavioral side effects of the Two nursing models were discussed – one which focuses
original trauma. It must be horrific, and stressful to have on establishing a milieu which makes possible safe disclo-

© 2000 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 7, 25–33 31
M. M. McAllister

sure and social connections; and another which focuses on Freud S. (1966) The future prospects of psychoanalytic therapy.
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