Shareware Overload Trio 2/Shareware Overload Trio Volume 2 (Chestnut CD-ROM).ISO/dir26/ra_mpd.zip/RA-MPD.TXT

Text File | 1994-05-13 | 44KB | 822 lines

                  MULTIPLE PERSONALITY DISORDER

                               AND

                         THE DILEMMA OF

                      RITUAL ABUSE REPORTS




                        COPYRIGHT NOTICE:

                        THIS DOCUMENT IS
               COPYRIGHT 1993 JOHN M. RATHBUN, M.D.

  EXCEPT AS NOTED BELOW, ALL RIGHTS ARE RETAINED BY THE AUTHOR

                            LICENSE:

    YOU MAY MAKE UNLIMITED COPIES OF THIS DOCUMENT AS LONG AS
         EACH COPY SHALL BE A COMPLETE AND UNEDITED COPY
                  OF THE ORIGINAL PUBLICATION.

                  YOU MAY NOT CHARGE FOR COPIES
                      NOR CLAIM AUTHORSHIP.

      THE ORIGINAL COPY OF THIS DOCUMENT IS TO BE FOUND IN
                   COMPUSERVE MEDSIG LIBRARY 1
                         UNDER THE TITLE
                           MPD&RA.EXE


                               MPD




DISSOCIATION:

DISSOCIATION is the name given to a particular method by which
people defend themselves against overwhelming anxiety in dangerous
situations. By reducing anxiety during an acute emergency,
dissociation may enhance the individual's ability to focus on
survival needs. Chronic extreme stress often leads to chronic
dissociation, which engenders major disturbances of memory and
sense of self.

Some people are more likely than others to dissociate under stress.
Factors associated with increased likelihood of dissociation are:

1. Younger age

2. History of extreme trauma in childhood

3. Increased severity of stressor

DSM3R recognizes several distinct DISSOCIATIVE DISORDERS. These
include:

1. Depersonalization Disorder - dreamlike states marked by feeling
unreal, machine-like, dead, or otherwise different from one's
normal self

2. Psychogenic Amnesia - sudden inability to recall important
personal information (beyond ordinary forgetfulness)

3. Psychogenic Fugue - total loss of memory for one's identity
combined with travelling away from one's usual habitat

4. Dissociative Disorder NOS - other stress-induced disturbance of
memory and identity insufficient to be classified as MPD

5. Multiple Personality Disorder - the existence within the person
of two or more distinct personality states which recurrently take
control of the person's behavior.

HISTORY:

MPD has been reported by numerous observers over the past two
centuries. These case reports have been strikingly similar, despite
the cultural differences among the observers, even when the
reporters seemed to have little knowledge of prior reports. The
frequency of these reports has waxed and waned dramatically. There
was a major emphasis on studies of MPD in the late 19th Century,
culminating in the work of the French psychiatrist Pierre Janet,
who described several cases of what he called desaggregation, which
he attributed to childhood sexual trauma and which he treated by
helping his patients to recall what had happened, to re-experience
their natural feelings of fear, rage, shame, and guilt, and to
learn how to accept what had happened to them and then to go on
with their lives.

Sigmund Freud was familiar with Janet's work, and his initial
publications on hysteria followed the same basic premise. His
personal correspondence suggests, however, that Freud felt
overwhelmed by his patients' stories of incestuous child abuse, and
that it was with a considerable sense of relief that he concluded
that these stories were all made up. Freud's theory of repression
proved much more attractive to his (mostly male) colleagues, and
soon displaced Janet's theory from the realm of serious science. In
this atmosphere, the tide of MPD case reports ebbed dramatically
for the next 70 years.

Over the past 20 years, there has been a turn of that tide. The
study of the effects of actual trauma on human development got a
major boost when a large number of soldiers returning from Vietnam
were found to have Post-Traumatic Stress Disorder, and the Women's
Movement raised our consciousness of the realities of child abuse
and the aftermath of rape and incest. In this atmosphere, case
reports of MPD have grown from a trickle to a flood, giving rise to
renewed interest in dissociative defenses and the role of
horrifying trauma during childhood as a major disrupter of the
normal process of identity formation.

ETIOLOGY:

The most satisfactory explanation of the phenomena of MPD is known
as ego states theory. It has been suggested that we all start out
life as a collection of unintegrated ego states, such as "Happy
baby", "Hungry baby", "Scared baby", "Mad baby", and "Sleepy baby".
We observe normal infants making abrupt switches between these ego
states according to current circumstances, and there seems to be
little continuity of memory from one such ego state to the next. We
observe normal parents sponsoring integration of ego states in
normal youngsters. The pre-schooler who falls and hurts himself
while playing undergoes a switch from the "Happy child" ego state
to the "Scared and painful" ego state, and seems to have no concept
that his suffering is a temporary condition. Mother provides
reassurance along the following lines: "You're OK now, even though
it hurts; you were happy a few moments ago, and you'll be happy
again in another few minutes!" The child takes it all in, and we
can later observe the same child as a grade-schooler getting hurt,
starting to switch ego states, and then reassuring himself that
he'll feel better soon, thereby maintaining his own ego
integration. In adulthood, the fabric of ego integration is usually
so tightly woven that it takes a catastrophe to cause dissociation.


Some children, however, don't have a "normal" childhood with the
support of well-integrated parents. Suppose father is alcoholic; he
may have one ego state that comes home late and rapes the little
girl, and another that is acutely remorseful the next day and tries
to make it up to her. Mother may be physically or psychologically
absent from what's going on with her daughter, so father is the
only source of comfort in her life. The child may be unable to get
help for a variety of reasons, including her fear of the father,
fear of losing her father, and a sense that what's happening is
inevitable. She faces an endless series of irreconcilable realities
which she is incapable of integrating; her most useful defense may
be to maintain two distinct ego systems, one of which deals as best
she can with father the rapist, and the other of which functions
the rest of the time, and functions better if she knows nothing of
what happens after dark. How can you look normal in school all day
if you have to remember your father raping you the night before?

When this sort of childhood starts early and goes on a long time,
the two ego states may accumulate very different memories,
emotions, and behaviors. They may even have different names if, for
example, an abusive parent calls her "Sallie" when in a good mood
and "Sarah" when angry. A child growing up in a very sick family
system faces a large number of very difficult conflicts, and
dissociation may become the preferred way to deal with virtually
every problem the child faces. Thus, a system of dissociated ego
states may arise, one of which does well in school, another is very
athletic, a third feels a great deal of rage, a fourth can function
sexually, and the fifth goes to church and prays a lot - thus fully
expressing all the family values in one person without having to
resolve any of the conflicts that divide the family.

DIAGNOSIS:

The typical presentation of the patient with MPD is a female in her
twenties who has been under mental health treatment for the past
five to ten years under a wide variety of diagnoses, and who has
not benefitted from the application of standard treatments for
those diagnoses. She may be of above average intellect, although
this will seldom be apparent to the examiner in the initial
interview. Her achievement in life will be far below the level
expected for her intelligence.

She will sit passively with the interviewer and will give short
answers to direct questions. The initial impression may be of
retarded depression. It will become apparent that she feels anxiety
about almost everything most of the time, and that she feels quite
hopeless and helpless about herself and her life.

She may present an impressive array of physical symptoms suggesting
conversion disorder. She will often admit to traumatic nightmares,
self-mutilation, panic attacks, substance abuse, and hearing
conversations in her head in which she is harshly criticized.

This broad array of symptoms almost guarantees that the clinician
who hastily pursues the first symptom offered and omits to inquire
about symptoms suggesting other diagnoses will be led to an
incomplete understanding of this patient's problem. It is in taking
a complete history of the person's symptoms and personal
development that the alert clinician may realize that there is a
major dissociative process at work.

These patients are very frustrating and time-consuming to
interview, and several hours of hard work may be necessary before
the matter becomes clear. They are commonly unable to remember much
about their childhood, and what they do remember may be bland,
idealized, and empty of emotional content. You may notice that the
patient is attempting to distract you from certain lines of
inquiry, and it is common for a dissociating patient to complain of
severe headache during an interview.

If you persist, you will come to recognize that this patient has
gross memory failure about important events throughout her past,
and that she may be unable to recall things from one session to the
next. Even within the same session, you may see her seem to "space
out" of a conversation and then find that she has no recall of what
you were talking about. Neurological investigations for seizures or
dementia may be necessary, but there will be a lack of confirmatory
findings. As you come to know this patient better, you'll recognize
gross inconsistencies in affect, appearance, cognitive style, and
tone of voice.

While you may develop a high index of suspicion about the
possibility of multiplicity in such a patient, I don't recommend
that you make a firm diagnosis or discuss your ideas with the
patient (or the patient's relatives) until the patient has
developed sufficient trust to let you see the extent of her
problem. Gentle probing, combined with much supportive counseling,
is the key to engaging these patients in therapy. When the patient
is ready to deal openly with her dissociation, you'll be confronted
by one or more of her alternative ego states, and the diagnosis
will be made for you. There are quicker ways to get to a diagnosis
of MPD, but then you have to live with the uncertainty about how
your activities may have influenced the form of the patient's
pathology. These patients are experts at getting you to lead them;
the trick is to get the patient to lead you, and herself, to the
diagnosis.

TALKING TO THE ALTERS:

The short term for an alternative ego state is alter. It is
confusing and anti-therapeutic to refer to alters as
"personalities". Alters usually have a strongly over-valued sense
of their own separateness, and it is very inappropriate to
reinforce this. The modal intervention in the psychotherapy of MPD
is, "You're all parts of the same person, what affects one affects
all, and you have a joint responsibility to solve this problem!" It takes a
lot
of preliminary work with the alters to develop
sufficient trust for them to be able to hear this without
unbearable anxiety, but it's important throughout the rapport-
building phase of therapy to subtly reinforce the idea of oneness.
We do this by referring to the "system of alters" as the focus of
therapy. The system originally presents itself as a collection of
unintegrated ego states that are in constant conflict and whose
attempts at communication are limited to an exchange of ritualized
insults. In this, the system of alters reflects the family system
in which the patent grew up.

If you know a lot about family systems theory, the psychotherapy of
MPD becomes easy to conceptualize. Think of your patient as a
large, intensely schismatic family with zero conflict-resolution
skills. You'll need to remain sympathetically connected to
everybody in the system, especially the ones who are scapegoated,
while helping them to negotiate compromises that will make life
easier for everybody.

It becomes essential, in this model of therapy, to fully understand
the characteristics and motivations of each family member. Such
knowledge comes gradually, and the total amount of data to be
managed is often overwhelming.

The experienced family therapist will quickly recognize certain
constellations of family pathology. Similarly, the experienced
therapist working with MPD will recognize certain alters as proto-
typical "old friends", and will often be able to save time by
intuitive understanding of each alter's needs.

The alter that initially presents for therapy, seeming profoundly
overwhelmed and passive, is called the "host". Her primary need is
to understand what has happened to her and how to deal with her
dissociated memories and feelings.

Some of the earliest recognizable alters to greet the therapist
have the mannerisms of fearful young children; they will contain
the memories and feelings connected with abuse. They need to feel
safe and to understand that they are not to blame for what
happened.

You'll soon hear about the internal persecutors, gigantic,
powerful, and malevolent monsters representing the child's view of
those who abused her. These hostile alters will not be slow to
greet you if invited to do so, and the more quickly you can
establish rapport with them, the safer will be the therapy for the
patient and for the therapist. It is a major challenge for the
therapist to avoid taking sides with those darling little child
alters and the poor, pathetic host against these dreadful ogres
that seem determined to prevent the therapy from continuing, even
if it costs the patient her life. The key to joining with the
internal persecutors is to understand that they began life as
protectors, whose youth and desperate circumstances account for the
crudity of their functioning.  Child abuse of sufficient intensity and
duration
to produce MPD can
only occur in an atmosphere of enforced secrecy. Such families are
usually intensely patriarchal, and the other family members are
treated as property by the dominant male. One patient described
witnessing her father molesting a young boy he had abducted, and
then cutting up the body in his wood shop for more convenient
disposal. Under the circumstances, she was inclined to believe it
when he later threatened that he would cut out her tongue if she
talked about what she saw. Such dire threats commonly generate
alters dedicated to enforcing silence at all costs. These alters
may enter a period of quiescence during the patient's late
adolescent years, as she succeeds in distancing herself from the
family and forgetting becomes the primary defense against telling.
In therapy, these alters reawaken with a vengeance (in the most
literal sense). They will threaten and punish the patient for
talking to the therapist, and may even attempt to intimidate the
therapist; some of them can make phone calls using a masculine tone
of voice that will set your hair on end!

These alters do not initially recognize that the patient's
circumstances have changed sufficiently that talking about what
happened is now safe and necessary. Since they are usually products
of the patient's childhood, they are not very hard to befriend.
Once they begin to perceive you as a rewarding person to be with
who cares about all parts of the person in therapy, their
defensiveness rapidly evaporates, and they can be valuable allies
in preventing re-victimization of the patient.


GENERAL TECHNIQUES OF THERAPY:

The psychopathology seen in one MPD patient can be so complicated
and difficult that the treatment often feels like a comprehensive
examination on everything you learned in school and everything
you've seen since school, plus a few things you never even thought
of before. For this reason, it is hopeless to attempt to provide a
"treatment manual" for this problem. Your success will depend
entirely on your ability to maintain empathic and ethical contact
with a person who has an almost unlimited repertoire of self-
destructive and annoying behaviors. If you are the sort of
therapist that calls annoying patients "borderlines" and hates
doing therapy with them, you will not be comfortable or effective
with MPD.

Like "borderlines", patients with MPD will test your limits for
empathy and ethical connectedness. You will need to struggle to
maintain appropriate professional boundaries against a bewildering
onslaught of appeals to your vanity, your lust, your need to take
charge, and any other area in which you may be vulnerable. You must
realistically be prepared for some phone calls at inconvenient
times, some extended sessions, and some extra sessions. You and the
patient should be prepared to devote a minimum of two to three
hours weekly to the therapy even when things are going well, and
the commitment must usually be maintained for several years. Your
trustworthiness and empathy will be so severely tested that it
seems safe to assume that no therapist can expect to pass all the
tests proposed by just one multiple. If you have a great need to be
in control of therapy, you will fail with these patients. Remember
that at the core of their pathology is an experience of being
totally dominated and mercilessly abused by somebody they should
have been able to trust; typically, their relationship with you
will be powerfully influenced by their expectation that you will
ultimately betray them in some major way, and they will give you
every opportunity to do this as soon as possible, because the
suspense often feels worse to them than the betrayal. They know how
to deal with abuse in a relationship, but the absence of abuse puts
them into totally unfamiliar territory where they don't know the
rules. I have had such patients literally beg me to abuse them.

Paradoxically, your opportunity to win the patient's trust begins
right after the patient catches you in an obvious mistake. If you
insist that you have not made a mistake, you have fallen into a
recapitulation of the patient's original situation, where other
people's bad behavior was explained away and the patient was left
to feel helpless if not actually responsible. If you have the nerve
to say, "I'm sorry: I really blew it that time!", and to really
mean what you say, you've given the patient permission to be
imperfect, a liberty she probably never felt before. You've also
demonstrated how different you really are from her abusers, who
have usually been rigid, moralistic persons that demanded
perfection from everybody else while they broke every rule and
denied any wrongdoing. So, cherish your inevitable mistakes,
because they give you a priceless opportunity to demonstrate a
better standard of humanity.

Just as important as "I won't abuse you" is the therapist's
insistence on "and I won't let you abuse me!" Despite the horror
that these patients have lived through, indulgence of abusive and
destructive behavior is a disservice to the patient and ultimately
destructive to the therapeutic relationship. You'll find it
unusually difficult to know where to draw the line with these
patients, but you must make clear that serious acting out by the
patient will make it impossible for you to continue her therapy.

SPECIFIC THERAPEUTIC TECHNIQUES:

If you have extensive experience with psychotherapeutic treatment
of Post-Traumatic Stress Disorder, you'll not find it especially
difficult to work with multiples. Winning the patient's trust and
establishing a safe environment for the work of therapy are the
primary priorities at the outset. If the patient is still being
abused, it will generally be impossible to progress in therapy;
such abuse will not often be disclosed in the beginning, so the
clinician must have a high index of suspicion.

After demonstrating a consistent interest in the welfare of the
whole patient, avoiding all attempts by the alters to get you to
take sides in their endless internal battles, you will usually find
the patient to have gained enough trust that the serious work of
abreaction and integration can begin. A common error of the novice
is to rush into this part of therapy before there is a relationship
sufficient to sustain the patient while she undergoes the
dissolution of her defenses and comes face to face with the horror
inside. The patient's reaction to such premature interventions will
be to flee therapy or to act out self-destructively. No matter how
benign your intent, the posture of "This pain is for your own good"
is very difficult to distinguish from the rationalizations of the
original abuser.

Abreaction means re-experiencing the disowned memories with all of
their original force and genuine affect. This is an extremely
uncomfortable process and cannot ordinarily be accomplished within
the scope of a fifty-minute therapy session. After abreaction, the
patient will need increased support and assistance for several
days, just as would a person who was recently raped. Most people
with MPD are very isolated and will therefore make extreme demands
on the therapist following abreaction. Hospitalization for a few
days to complete a difficult abreaction and manage the aftermath
may be a necessary part of assuring the patient's safety. Some
insurers are becoming reasonably accommodating about this, but it's
essential to take time to work through the insurer's concerns about
abuse of benefits. Some hospital units now do a good job supporting
this kind of work, and others remain subject to extreme splitting
among the staff whenever the subject of MPD is mentioned. It is
essential that those who have primary responsibility for the care
of hospitalized multiples be oriented to the basic techniques
needed and accepting of this unusual pathology as a valid cause of
temporary disability.

The therapist will learn to manage most abreactions without the use
of hospital services, using a combination of extra time and special
supports, which may include Day Hospital services, pastoral
counseling, or such techniques as clinical hypnosis.

Many of the pioneers in the field of dissociation have been
experienced hypno-therapists. Dissociation and trance are closely
related, if not synonymous, which gives a natural advantage to
therapists who understand trance logic. I have tended to avoid use
of hypnotic strategies during the diagnostic investigation of these
cases in order to minimize my likelihood of suggesting symptoms to
the patient. It appears, however, that formal hypnotic
interventions may considerably facilitate the process of abreaction
and integration.

If hypnosis is used, it must be used non-coercively, with the clear
understanding that patient and therapist are collaborating to
develop the patient's skills in self-soothing and affect
management. The first several sessions should focus on maintaining
pleasant physical sensations in conjunction with soothing visual
images, and deepening the patient's sense of self-control. Only
when the patient is beginning to enjoy some mastery of the hypnotic
metaphor should serious inward investigations begin, and these
should be continued only as long as the patient can maintain a
sense of control over the process.

One experienced therapist gives the patient an imaginary VCR, so
she can run her abreaction while remotely controlling it. She can
be taught to speed up or slow down the action, freeze a single
image, turn the sound down, skip over some parts, and even view the
action from different angles or in reverse. This technique allows
the patient to "titrate" the abreaction so the traumatic images can
be present without the loss of control. There's an obvious analogy
to the practice of systematic desensitization.

The work of abreaction and integration can certainly be
accomplished without the use of formal hypnotic techniques, but it
seems to me that hypnosis may considerably facilitate therapy with
traumatized patients.

The word "integration" refers to the totality of the process that
brings together dissociated ego states and improves the function of
the personality system. This process includes the development of
meaningful communication among alters, the sharing of memories and
feelings, and the development of a sense of community. Full
integration implies such harmonious cooperation of ego states as is
seen in a high-functioning professional, but this may not be a
realistic goal in every case. If the patient who entered treatment
with MPD can leave with an enhanced sense of security and
competence, and without any gross amnesias or power struggles among
alters, therapy has done well by this patient. Many hypnotically-
oriented practitioners encourage "fusion" rituals, which serve as
rites of passage when integration has proceeded to a suitable point
for two or more alters to give up their sense of separateness.
These rituals are no more than dramatizations of evolving
integration, and will not hold if integration has not occurred.

CONCLUSION:

Multiple Personality Disorder has long been recognized and
described, but only recently have large numbers of cases been
closely studied. It is a post-traumatic syndrome having obvious
connections to Post-Traumatic Stress Disorder and Borderline
Personality Disorder, as well as to the other Dissociative
Disorders. Diagnosis of MPD is difficult because of the secrecy and
poly-symptomatic presentations involved. Treatment is difficult and
prolonged, but substantial improvement can be expected when a
motivated patient is paired with a skilled and dedicated therapist.

The role of peer consultation cannot be overemphasized in the
development of an appropriate therapeutic armamentarium. Anybody
who tries to learn how to do this kind of therapy without adequate
ongoing consultation subjects both therapist and client to
unacceptable risks.

[REFERENCE - Putnam, Frank W.: Diagnosis and Treatment of Multiple
Personality Disorder; Guilford Press, 1989]                           RITUAL
ABUSE



HISTORICAL NOTES:

The concept of spiritual dualism goes back thousands of years in
human history--to the religions of ancient Egypt--and has
repeatedly led to the emergence of a deviant subculture or
counterculture.  Throughout the history of Christianity, various
heretical cults have been investigated and suppressed.  Fertile
ground for such cults exists when a substantial population is
oppressed by a morality so rigid that the average individual is
unable to hope for success by following the rules of church and
state.  In the Middle Ages, such conditions were rife in Europe,
giving rise to cults that attempted to solve existential problems
in non-traditional ways.  An overall goal was to align the self
with the power of evil in order to achieve material success in this
life and lenient treatment in the infernal domain to which most
felt condemned for eternity because of harsh religious doctrines.
Ritual murder and cannibalism, orgiastic sexual behavior, and the
extreme subjugation of women and children were the alleged
characteristics of these groups, although historical evidence is
always subject to the biases of the literati.  In twentieth century
America, there have been several notable apologists for such
"satanic" practices, and some elements of the youth counterculture
over the past thirty years have shown a persistent fascination with
occult symbols and practices.

BELIEFS AND PRACTICES OF CONTEMPORARY AMERICAN CULTS:


Over the past decade, therapists working with dissociated patients
have catalogued a large volume of reports from alleged survivors of
ritual abuse in cult settings.  Most of these reports concern
activities that may have occurred decades ago, involving young
children who were in a state of profound terror and dissociation,
at the hands of adult relatives with an apparent interest in
psychological manipulation of the children involved, and with every
possible precaution being taken to assure secrecy.  Orgiastic
sexual activity and gross sexual abuse of children, ritual murder
and cannibalism, and a wide variety of other disgusting practices
have been described.  There are sufficient similarities and
differences among these reports to suggest a widespread, poorly
organized network of small groups practicing a variety of rituals
directed to the defiance of traditional norms and to the
acquisition of power through magical incantations, ritual
sacrifices, and the consumption of blood and body parts.  Extensive
use of terror and other forms of coercion are allegedly employed to
assure secrecy among participants.  As might be expected, such
reports have engendered revulsion and extremes of both credulous
and rejecting attitudes among therapists.  Hard evidence has been
scarce. EVALUATION OF REPORTS OF ALLEGED CULT ACTIVITY:


As, in the 1980's, the trickle of reports concerning alleged cult
activity have grown to a flood, numerous investigators have taken
up strong and widely varied positions on their authenticity. Some
have crusaded to prove that ritual abuse in cults never happens,
while others seem convinced that there is a large and dangerous
organization out there abducting and killing children, now
operating out of day care centers and having clear links to
commercial child pornography, drug smuggling, and gun-running
operations.  Most of the arguments advanced by the "experts" who
hold these extreme positions fall short of any reasonable standard
of objectivity.  It seems clear that the therapist's readiness to
listen attentively to this material influences what will be heard
in therapy sessions, but this fact does not "explain" all the
reports.  After five years of listening to this material, reading
about it, and holding extensive discussions with colleagues, I
cannot reach a conclusion about the objective reality of what I am
hearing.  I have heard and read many first-person accounts of
patients with cult memories, and a few accounts from therapists of
their alleged contacts with current cult members or sites where
cult activity has recently occurred.  Little of what I have heard
seems objectively impossible, nor has anything been conclusively
proved.  My personal solution is to listen respectfully to patient
productions and to seek their ultimate meaning and function in that
patient's life.  In most cases, an accepting attitude by the
therapist seems more therapeutic than a skeptical one.

DIAGNOSIS OF CHILDREN WHO MAY HAVE BEEN RITUALLY ABUSED:

A number of therapists have described special techniques which may
be useful in the diagnosis and treatment of ritually abused
children.  These publications have generated an extensive list of
anxieties and behaviors which may be indicators of abuse.  It is
generally acknowledged that disclosure of the abuse is not obtained
without special techniques such as play therapy and the use of
anatomically correct dolls.

The major limitations of this literature are that many of the
symptoms listed are common among children, that there is scant
objective verification of the alleged special significance of the
symptoms, and that the techniques used to elicit disclosure of
alleged ritual abuse are often construed by courts to be unduly
leading.

The concern which legitimately arises in such cases is whether
specialists in detecting alleged ritual abuse of children
unwittingly traumatize the children, their families, and the
alleged perpetrators by well-intentioned but unsound assumptions
and methods.  The Little Rascals Day Care prosecution in Edenton,
North Carolina, exemplifies the potential of such investigations to
disrupt entire communities. FORENSIC CHILD EVALUATIONS IN ALLEGED RITUAL
ABUSE:

The experience of repeated, ritualized, terrifying abuse in
childhood could be expected to produce severe distortions of a
child's memory, sense of identity, and willingness to talk about
what happened.  The special vulnerabilities of child witnesses in
general make them unsuitable for the kind of courtroom examination
that an adult witness would routinely receive.  The bizarre nature
of some cult practices and the peculiar behaviors seen in victims
of alleged ritual abuse, together with the other special
characteristics of these cases, almost guarantee an appeal by law
enforcement to some mental health professional for scientific
"validation" of the child's credibility. It is extremely difficult
for any investigator to obtain reliable details of alleged ritual
abuse from child victims.  A child who has been repeatedly
threatened with death and possibly been a witness to the violent
deaths of others is not likely to talk about these experiences to
a stranger.  Some professionals may have their feelings strongly
engaged by this topic, and may be unable to resist the temptation
to draw the child out by asking leading questions and subtly
reinforcing the "interesting" responses.  Children may, in fact, be
so badgered by investigators, mental health professionals, and
parents, that the child's own recollections become totally
inaccessible.  Forensic evaluation of children is an extremely
challenging discipline requiring an extensive commitment of time
and specialized expertise.  Inexperienced professionals should
enter this area with extreme caution!

RITUAL ABUSE AS AN ISSUE IN CUSTODY DISPUTES:

It is not uncommon for child abuse to be alleged by one parent
against another during custody disputes.  When this occurs, the
courts, social service agencies, therapists, and children involved
may be subject to bewildering pressures and tensions.  When the
sorts of abuse alleged go well beyond the common range of reported
events, skepticism among the involved officials may conduce to an
assumption that the accusing spouse is mentally unbalanced and
manipulating the children.  When the parties are socially prominent
and influential persons or have family connections to such persons,
the pressures and tensions are multiplied.  Many of these cases end
in general dissatisfaction and bitterness, as the material
questions of what really happened are never fully resolved.  The
courts are obliged to consider the children's health and welfare
together with the parental interests on both sides, and the
decision on custody often comes down to the judge's subjective
decision on who is most credible.  The parent alleging bizarre and
disgusting acts that strain the credulity of seasoned professionals
is at a serious disadvantage in the these proceedings, given the
usual lack of physical evidence.  Therapists having the misfortune
to be caught up in such cases must limit their participation to
narrowly-defined areas of expertise.  All participants in such
cases are somehow victimized, and the full reality of what happened
is rarely apparent to anyone.
 PSYCHOLOGICAL TESTING OF ALLEGED RITUAL ABUSE VICTIMS:

The sparse and impressionistic literature on the psychological
testing profiles of alleged ritual abuse victims offers little
substantive data on which to base any firm conclusions.  It appears
that the Dissociative Experiences Scale is a valid and reliable
indicator of major dissociative pathology.  MMPI results are often
invalidated by inconsistencies in cognition or by poly-symptomatic
presentations.  Rorschach and TAT responses are often dominated by
affect-laden responses with a high valence of color, movement, and
animal percepts on the Rorschach and intensely conflict-laden or
idealized relationship constructs on the TAT.  Patients who have
progressed to the uncovering stage in therapy may present traumatic
derivatives directly in their responses to projective testing.

These sorts of intensely pathological profiles can suggest a range
of diagnoses from borderline or histrionic personality disorders
through Post Traumatic Stress Disorder to frank psychosis.  The
examiner must use considerable discretion to avoid premature
closure on diagnostic formulations, and must be aware that not all
stories of bizarre persecution represent delusions.

LAW ENFORCEMENT ISSUES IN RITUAL ABUSE CASES:

Experienced and concerned law-enforcement officials have
extensively investigated cases of alleged ritual abuse over the
past decade.  Some of these investigations have led to prosecutions
and a few to convictions. These investigations present some unusual
difficulties for even the most sophisticated officers.  The very
high level of emotional arousal generated by reports of multi-
perpetrator, multi-victim child sexual abuse rings, especially when
linked with accounts of occult rituals and deviant belief systems,
can generate so much confusion in victims, parents, therapists,
investigators, attorneys, judges, and juries that the sum total of
all this confusion frequently obliterates any factual basis for
prosecution.  The yield of such investigations, in terms of
successful prosecutions, is low in comparison to many other kinds
of criminal activity.

There are many sources of information available for investigators
who seek training in these issues.  Unfortunately, some of these
sources provide information which is not credible, and may further
confuse those in attendance.  The FBI maintains a Behavioral
Science Unit which offers free consultation to law-enforcement
agencies and prosecutors regarding investigations of violent
crimes.

Local agencies are advised to have a protocol developed for the
management of such investigations in advance of their occurrence.
Clinicians are urged to avoid polarization when dealing with law-
enforcement on child abuse cases:  cops hate molesters as much as
therapists do, but they have different rules and priorities they
must follow.  Polarization during investigations serves only to
derail prosecutions. POST-TRAUMATIC PERSONALITY ISSUES:

Many, but not all, persons with Ritual Abuse memories present with
severe dissociation.  Whether or not dissociated, survivors of
extreme childhood abuse share with other survivors of severe trauma
a disruption of or failure to develop healthy, positive feelings
about themselves and others.  It should surprise no one that
children who are tortured, raped, and verbally abused by their own
parents from their earliest years through adolescence will come
into adulthood with negative feelings about themselves and others.
Such survivors commonly allow themselves to be re-victimized,
engage heedlessly in self-damaging and risky behaviors, are unable
to maintain healthy connections to others, and alternate between
hopeless, helpless feelings and a maniacal lust for power over
others.  The resultant "Post-Traumatic Personality Disorder" is
what makes the therapy of chronically traumatized individuals so
challenging, whether or not they manifest gross use of dissociation
as a defense.  Similar issues are central in psychotherapy of
substance abusers, eating-disordered clients, rebellious teenagers,
perpetrators of abuse, "borderlines" and other "difficult"
psychotherapy clients.

THERAPY WITH RITUAL ABUSE SURVIVORS:

For those cases in which reports of ritual abuse occur
spontaneously, and in which exploration of these memories results
in a coherent history that explains previously mystifying symptoms
and leads to their resolution, it seems useful to assume that such
abuse has, in fact, occurred, and to proceed with treatment on the
basis of that assumption.

Therapy for Ritual Abuse survivors follows the basic outline
discussed above for other trauma survivors, with or without severe
dissociation.  Treatment may be complicated by extreme reactions to
certain symbols or dates, implanted suggestions of self-
destruction, actual cult interference with patient or therapist,
and, not least, the therapist's sense of horror and outrage on
hearing of activities whose cynical brutality surpasses our wildest
imaginings.

Unfortunately, what we hear from cult survivors is consistent with
well-authenticated accounts of cruelty perpetrated by individuals
and groups throughout history and in contemporary media accounts.
Scapegoating of unusual religious groups in general because of the
activities of a few such groups is extremely inappropriate.  More
cruelty has been perpetrated by mainstream religious groups and
practitioners than by small, secretive cults.
 BOUNDARY ISSUES IN THE PSYCHOTHERAPY OF SURVIVORS OF SEVERE TRAUMA:

Responsible psychotherapists are universally aware of the dilemmas
that attend treatment of adults who were severely abused in
childhood.  Classical rules about therapist neutrality and
restrictions on therapist activity, if applied mechanically in all
cases, lead to therapeutic failure in patients for whom self-
regulation and self-soothing are at a rudimentary stage of
development.  The resourceful therapist will carefully and
continuously evaluate each patient regarding their need for
external limit-setting and therapist activity.  Early in therapy,
there may be a legitimate need for considerable therapist activity
to make the therapy safe and comforting; later, it will be
necessary to give progressive responsibility to the patient for
self-regulation and self-soothing.  These judgements must be
continuously refined in an atmosphere of thoughtful caring, and it
is impossible to avoid all error in any given case.

The vital role of peer consultation in assisting therapists to
navigate the tangled web of transference and countertransference
that arises in such cases cannot possibly be overemphasized.

[REFERENCE - Sakheim, David K. and Devine, Susan E.: Out of
Darkness; Lexington Books, 1992]

[BIBLIOGRAPHY - the interested reader is referred for more
information to CompuServe Medsig Forum Library 1 MPDREF.exe]

[ACKNOWLEDGEMENTS - my heartfelt gratitude to Frank Putnam, David
Sakheim, and Susan Devine, whose publications helped me to
understand what I was observing; to Maureen O'Brien for her
excellent resource list; to the brave and hard-working therapists
at Park Center who did the work of therapy while I stood back and
gave advice; to all on Medsig 16 who helped me to clarify my ideas;
and to Barbara, without whose support the rest would be
meaningless!]

                        COPYRIGHT NOTICE:

      THIS DOCUMENT IS COPYRIGHT 1993 JOHN M. RATHBUN, M.D.

IT IS UNLAWFUL TO REPRODUCE OR DISTRIBUTE THIS MATERIAL EXCEPT IN

      ACCORDANCE WITH THE LICENSE NOTICE ON THE TITLE PAGE!