A paper presented to the Royal College of Psychiatrists by Dr Alan Sanderson on 25th November 2016 in London.
I’ve chosen an unusual topic but an important one. The significance of hallucinations in Dissociative Identity Disorder (DID) is important because DID includes a feature which I suggest will one day play a big role in our clinical work. I’ll expand on this later, but first some definitions, followed by clinical examples.
Hallucinations are usually defined as the apparent perception of a non-existent external object. That’s a slanted definition, for the wording is essentially negative, implying that hallucinations are unreal. This is, of course, strongly against the views of the experiencers, for whom hallucinations are meaningful events. Here are some famous historical figures who experienced hallucinations: Socrates, Jesus, Mohammed, Joan of Arc, Saint Teresa of Avila, Robert Schumann, Mahatma Gandhi and Carl Jung. This is just a tiny sample of the total. These individuals all heard voices or saw visions from which they received life-changing inspiration. They found nothing unreal about their experiences. Just the reverse.
We need a better definition of hallucination, one that can fit those inspiring experiences. Here’s one candidate: ‘A clear sensory experience of things inaccessible to others.’ Some of us might feel inclined to make exceptions of spiritual leaders and give them a special category, but with positively-felt hallucinations present in many of our patients, (more on this later) it’s hard to justify.
Multiple personality, DID as it became in DSM-4 (1994), has seen periods of great activity and great neglect. We are now in a period of neglect, in line with the current symptom suppression phase of contemporary psychiatry.
William James saw things very differently. He regarded double personality, as it was called in his day, as the way to a deeper understanding of consciousness. James used to say that in the study of human behaviour, extreme cases have special value because they best demonstrate the underlying mechanism. DID is an extreme behaviour, in which patients switch from one identity or personality to another without realising it, sometimes with chaotic results. We now know a great deal more about DID, especially its connection to extreme childhood abuse, but it still holds many secrets. The most curious of these and perhaps the least well understood is the Inner Self- Helper, a spiritual entity as distinct from an alternative personality (or alter, as they are usually called). I’ll expand on this later.
Diagnosis in DID has two essential features: firstly, two or more distinct personality states which alternately take control of executive function and secondly, amnesia (usually reported as ‘missing time’) occurring for significant events in the subject’s life. Voices are heard in around 50 per cent of cases. Characteristically, they are the alters speaking to each other. Conversations may be friendly or argumentative. Sometimes an unknown alter is discovered because of a reported voice. In a patient of mine, a distressed 7-year-old was identified because of constant inner crying. In DID, voices may be part of a flashback, which will often include a visual component. But they are real, and whether positive or negative, these hallucinations are often meaningful.
My patient, Rose would have threatening visions of her abusive father and brother. Sometimes she saw devils coming up through the floor. She didn’t say so, but if I saw her gaze fixed on what to me was an invisible object, I would ask.
Hearing voices can be an intensely distressing experience. Here’s a quote from a sufferer: ‘No sleep. The voices own you. They take you with them.’
Rose suffered greatly. I remember one session in which the satanic chanting seemed interminable. ‘Praise to the Mighty One! Praise to the Mighty One! Praise to the Mighty One! Praise to the Mighty One!’ This had continued at high volume night and day. No wonder Rose couldn’t sleep. In desperation, I summoned angels. The bombardment stopped. What a relief! How should one explain it? Who was the Mighty One? Were angels operative in the healing? With today’s knowledge (should I say ignorance?) the answer is closed to us and will remain closed until we start to study these phenomena.
Not all voices in psychiatric patients are distressing. Some may be helpful. In the 1970s, Wilson Van Dusen made a fascinating study of voices in chronic psychiatric patients. He would ask the voices questions and have the patient repeat the inner answer. Van Dusen described two distinct groups, lower order voices which seemed to want only to annoy the patient with obscene threats and trivialities and higher order voices which respected the patient and often produced knowledge far beyond the patient’s understanding. Interestingly, he found no voices on the patient’s own level. The ratio of lower to higher was 4 to 1. Do the higher order voices come from a ‘higher region’? Is their function to counteract the lower order voices? More unspoken questions. We need to ask.
It’s time now to return to the Inner Self-Helper that I mentioned earlier. Ralph Allison, an early pioneer of Multiple Personality, described this entity in the 1970s. Although its nature and origin are still debated by therapists in this area, the Inner Self-Helper is now widely accepted as a benevolent, spiritual presence. The Inner Self-Helper can be contacted in most DID cases. It is typically unemotional, compassionate and disinterested. It has access to the history of all the alters, with whom it may or may not speak as a voice. Many therapists regard it as the knowing one, from whom dependable assistance can be expected.
In my work with Rose, I had essential help from such an entity who, when asked, would advise on therapeutic activity. How did I find it? Simply by asking for the help of a Higher Being, with my patient in an altered state of consciousness. Rose had two Inner Self-Helpers with quite distinct functions. Real, who answered my call, was very much a co-therapist. She seemed to know everything that was going on within my patient’s inner world. Real never took executive control and she never spontaneously offered detailed information, but she would sometimes draw my attention to something (perhaps a distressed alter or demonic activity) which needed my intervention. The other Inner Self-Helper had the job of keeping my patient alive. I called her Rescuer. Since Rose had to travel a long way to reach me, there was always a danger that one of the other alters might hijack her on the way home. After a session but before Rose left, I would ask for Rescuer, so that the journey might go smoothly. Rescuer could only take charge if there was danger. She saw the journey home as a dangerous enterprise. This succeeded if all went as planned. I remember one occasion where Rose unexpectedly met a colleague at a London train station. Since there was no obvious danger, Rescuer withdrew. When the colleague departed, Rose was hijacked, got off at the wrong station and spent exhausting hours in a blank.
My thumbnail sketch has ended. I hope that it will encourage others to enter this utterly fascinating and important area of clinical activity, which I suggest may have implications far beyond the treatment of DID.
I’ll close with this quote from William James:
Our normal waking consciousness, rational consciousness as we call it, is but one special type of consciousness, whilst all about it, parted from it by the flimsiest of screens, there lie potential forms of consciousness entirely different.
Theoretical physics has entered this frontier of consciousness. They’re saying now that consciousness, not matter, is the ground of all reality. For psychiatrists and psychologists, phenomena like hallucinations, dissociated personalities and visions bring us to this same frontier.
We’re at the end. Or could it be just the beginning?
Schwartz, T. & Allison, R.B. (1998) Minds in Many Pieces: Revealing the Spirit Side of Multiple Personality Disorder. Cie Publishing.
Krakauer, S.Y. (2001) Treating Dissociative Identity Disorder: The Power of the Collective Heart. Brunner – Routledge.
Van Dusen, W. (1972) The Natural Depth in Man. Chrysalis Books (Swedenborg Foundation). Zinser, T. (2011) Soul-Centered Healing: A Psychologist’s Extraordinary Journey Into the Realms of Sub-Personalities, Spirits, and Past Lives. Union Street Press.
© Alan Sanderson 2016