Dissociative Identity Disorder: Ethically Unsplitting the Split Personality

Emotional Behaviors and Controlling Contingencies: During abuse, emotional outbursts such as crying and responses to pain, which were originally respondent behaviors (Fordyce, 1976; Turk & Rudy, 1990), caused still more abuse and therefore came under control of avoidance and escape contingencies (Kohlenberg & Tsai, 1991). Pain-inflicted crying led to more pain being inflicted. Crying, smiling, and other emotional displays could come to be more under the control of operant stimuli and contingencies, or in the vernacular, became more voluntary, in an attempt to avoid further punishment. In addition, the care giver's abuse may have been erratic and difficult to predict but was still the focus of attempts by the abused person to predict and avoid further abuse; as a result, the abuse victim may have come to exhibit behaviors and emotions capriciously and histrionically; at other times, virtually no effect or behaviors would be exhibited. These attempts at self-control from the erratic stimulus events and draconian contingencies were probably not often successful in avoiding abuse. The person being abused could never learn to predict what produced or avoided abuse or reinforcement (love) and came to increasingly attend to himself or herself since other individuals provided unreliable discriminative stimuli as to how to behave.

In the present, however, the former victim has potentially "heightened" operant control of emotions and personalities when confronted with uncertainty or stimulus conditions reminiscent of the past. These individuals are often very skilled at altering their presentations of their self to manipulate others (Spanos, 1994). Kohlenberg and Tsai (1991) explained that these individuals are vigilant and attentive to the therapist's discriminative stimuli as to how to behave. At the same time, different personalities may be displayed with no obvious change in any public, environmental stimuli.

Some writers report that this disorder may only become apparent to a professional or others when "different people" attend meetings, interviews, or therapy; that is, the same individual attends but with a different self-report of identity, memories, and personality (Sackeim & Devanand, 1991). In so doing, individuals displaying these behaviors can receive a great deal of reinforcing attention from professionals for engaging in these behaviors. Individuals displaying behaviors correlated with a diagnosis of DID may be reassured of no further abuse and may be encouraged to try to "be themselves" in as many ways as they can. The different self-reports and personalities become a source of gratification (self-reinforcement) for the formerly abused victims and the professional alike (Spanos, 1994). The danger here is that a person with degrees of behavioral variability could be shaped iatrogenically to reporting to be a divergent person by professionals zealously looking for this disorder (Fahy, 1988; Merskey, 1992). To quote one skeptic, "the procedures used to diagnose MPD often create rather than discover multiplicity" (Spanos, 1994, p. 153).

Differential "Intelligence" and Physical Symptoms: This behavior pattern has been conceptualized as being largely a difference in verbal behavior, but other differences are reported to exist and are marshaled as evidence for this disorder. That is, the individuals who exhibit these behaviors are reported to be different in intelligence, medical prescription needs, different corrective prescriptions for vision, allergies, and so on (American Psychiatric Association, 1994). Some of these reported differences are explainable in the analysis presented here. For instance, a person's intelligence quotient score consists of his or her ability to answer specific types of questions and his or her attempts to perform some nonverbal tasks. Some of these are a person's learned verbal behaviors (Staats, 1963), in that the person, when displaying some personalities, does not "know as much" as other personalities. The person answers fewer questions correctly. In terms of nonverbal tasks, "I can't figure this one out" or "I don't know what to do here" can end the trial, just as performing slower or faster can alter the score. The score is taken as a measure of intelligence when all that are being measured are test-taking skills (Staats, 1993), which are largely self-reports. The reported differences in corrective lenses are explainable by self-report but the differences in medical conditions may be more difficult to explain.

Pain complaints, paralysis, blindness, and so forth, also consist of a self-report of a private event. Each of these may be accompanied by publicly observable events such as wincing, reluctantly moving, reporting or appearing to be unable to move or see (Fordyce, 1976; Skinner, 1974). Both the self-reports and the public evidence for these differences are under stimulus control of the different personality repertoires in cases of these behaviors. When such an individual displays a specific personality, the self-report of pain or other symptom comes or goes with the other behaviors. Originally, the public signs of pain were authentic afflictions in the past as the result of abuse; months or years later, such indications could be self-produced, rule-governed behavior as part of the personality repertoire. These pains and related behaviors could be reinforced and shaped into a "real" affliction by well-meaning others as the verbal behavior acquired differential stimulus control of operant pain behavior. The reports of pain and related behaviors can persist as operant behavior maintained by its consequences in the absence of the original painful stimuli (Bonica & Chapman, 1986; Fordyce, 1976).

As for the reports in the literature of allergic and other responses being present in some personalities and not others, these too can potentially be accounted for via verbal behavior mechanisms. There are reports that individuals can develop rashes, a wound or a burn or other physiological symptoms in response to another's verbal suggestions, that is, under hypnosis, although it has been argued that many of these symptoms are likely self-inflicted when observers are not present (Johnson, 1989). Actual reports of hypnotically induced dermatological changes are difficult to substantiate; such effects are difficult to produce and are not as common an occurrence as often reported (Johnson, 1989). These reports are not all due to the acts of the person showing the symptoms; instead, these symptoms may be due to an interaction of verbal behavior and conditioning mechanisms. Verbal behavior can also facilitate the development of stimulus control via respondent or operant conditioning (Skinner, 1957). If an experimenter were to flash a light in your eyes and then shock you, the experimenter would expect you to come to recoil to the light after some number of such pairings. If the experimenter were to tell you that he or she was going to shock you after every light flash, then it would be expected for you to recoil to the light sooner.

Relating this to the differential presence of symptoms is not a big leap. Here, the individuals who display the divergent personalities have self-instructed and subsequently conditioned themselves to display symptoms when performing different behavioral repertories. Over time, the symptoms may come under the stimulus control of the emotions displayed, in addition to the person's verbal behavior, and appear spontaneous to the person himself or herself. To support the argument for conditioning mechanisms producing somatic symptoms, Smith and McDaniel (1983) showed that a hypersensitive cellular response to tuberculin was modulated by respondent conditioning. Individuals can also exert control over a variety of autonomic functions as diverse as dysmenorrhea to seizure activity, via biofeedback (Adler & Adler, 1989).

How Should Therapy Address These Behaviors? From the foregoing assumptions, therapy for persons displaying the behaviors in question must consist of extinguishing a reasonable share of the behavioral variability in the repertoire and reinforcing behavioral stability and generalization; literally, to shape one personality. Kohlenberg (1973) reported being able to increase the frequency of specific behaviors composing one personality of an individual who exhibited DID-like behaviors by differential reinforcement of that personality. When placed on extinction, these behaviors returned to baseline frequencies. Other techniques might involve the client role-playing and rehearsing several social interactions and experiencing some situations expected to produce "normal" emotional behaviors. Price and Hess (1979) reported success at "reintegrating" the personalities in a dual personality individual by teaching assertiveness skills via role playing. Caddy (1985) also used assertiveness training and shaping in reintegration. The therapist might videotape clients as they behave, to use for feedback and in shaping and instructing more "cohesive" behavior. There might also have to be a way of teaching the client to engage in more "social-referencing;' or seeking public feedback in more instances of what is acceptable behavior. Whereas you or I might ask, "Did you see (or hear) something?" when we are unsure of seeing or hearing, individuals whose behaviors are consistent with the label of DID may have to learn to ask, "Am I still behaving as me?" The therapist could not answer this question alone but family members and significant others could. This process would have to continue until the person reports being the same individual with the same experiences, and has less observable variability in his or her personal repertoire.

Even if a therapist were to try to undertake such an intervention, and most would probably not, this process could be long and arduous, due to the multiple sources of control that would require adjustment, and the possibly well-meaning sabotage by those who attend to and reinforce the variability. Indeed, based on this account, control of the behaviors in this pattern would be difficult for anyone to establish. Even the therapist who encourages variance is not exerting control unless unpredictable behavior is the target behavior. As a result, these individuals may have been and will likely be in therapy for years (American Psychiatric Association, 1994).
- Phelps, Brady J; Dissociative Identity Disorder: The Relevance Of Behavior Analysis; Psychological Record; Spring 2000; Vol. 50 Issue 2

Personal Reflection Exercise #6
The preceding section contained information about understanding DID from a behavior analytic perspective.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 20
What is a behavioral therapy for DID clients recommended by Phelps? Record the letter of the correct answer the CEU Answer Booklet.