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The debate about DID is not merely an insider squabble within academia. The fantasy model not only cast doubts on victims of trauma who speak up, Brand said, but lends credence to viewpoints opposing proven methods of treating and supporting DID patients through therapy — therapy that involves engaging alters and working through past traumas.
According to Brand's recently completed international study on the treatment of dissociative disorders (a broad category that includes DID), psychological therapy produces numerous positive results. It was the first study of its kind: Brand recruited 292 therapists and 280 patients from nineteen countries and tracked their progress over 30 months. She discovered that patients who were in therapy for the longest periods of time experienced the fewest instances of depression, PTSD, and general distress.
Long-term therapy also led to a decrease in the number of suicide attempts, self-inflicted injuries, and hospitalizations. Brand found that 38 percent of patients in the earliest stages of therapy had attempted suicide in the previous year. But those in the most advanced stage of therapy had made no such attempts. And while 40 percent of patients in the first stage of therapy required hospitalization in the year prior to the study, only 5 percent of patients in the advanced stage of therapy needed to be hospitalized.
This research, Brand said, not only demonstrates that people with DID can and should be helped through treatment, but that treatment also has financial implications. Research shows that the cost to treat DID patients nearly doubles if patients aren't properly diagnosed. It costs an average of $75,000 annually to treat a single person with DID if he or she has not been properly diagnosed, according to Brand. That amount plummets to $39,000, for those who have received accurate DID diagnoses and have begun DID-specific mental health treatment. "These are savings to the individual patient and also to the mental health system," she said. Those savings primarily come from a reduction in hospitalizations and emergency room visits.
In addition, incorrect diagnoses can have irreversibly harmful impacts for people with DID. For example, if a patient is misdiagnosed as having schizophrenia — a disorder characterized by hallucinations or delusions, an entirely different phenomenon than DID — he or she may be prescribed antipsychotics, which can be very sedating and can have serious side effects, such as permanent facial tics. DID patients misdiagnosed with bipolar disorder may be given lithium, which also carries major side effects.
There are no existing anti-dissociation medications, and experts agree that the disorder cannot be directly treated with prescription drugs, because it's not associated with a specific chemical imbalance in the brain (which is a factor in schizophrenia and bipolar disorder). Brand said that this is likely one of the reasons that pharmaceutical companies don't fund studies on DID, which contributes to the illness being under-researched.
Given these factors, Brand and other supporters of the trauma model have become increasingly frustrated with the fantasy model and those who contend that treatment that helps patients cope with past traumas, including talking with alters, is unhelpful or even harmful.
In a recent Psychological Bulletin article that critiqued the trauma model, Steven Jay Lynn, a psychology professor at the State University of New York-Binghamton, along with researchers from six other institutions, including Harvard University, maintained that a variety of stressors "can foster the propensity to fantasize." Although the researches stated that they were "open to the possibility that trauma may play a nonspecific causal role in dissociation," their central argument was that the evidence that trauma leads to DID is weak and that the trauma model ignores critical variables like "fantasy proneness" and "suggestibility."
In an email, Lynn told me there is evidence to suggest that "DID is co-created by patient-therapist interactions." He also suggested that media representations — most famously in the movies The Three Faces of Eve (1957) and Sybil (1976, starring Sally Field), and more recently in the Showtime television series United States of Tara (2009–11) — have popularized the concept of DID and the role of trauma in leading to split personalities, and may have encouraged more diagnoses. He further stated that he has treated patients who previously experienced "suggestive therapeutic procedures" and "came to believe they had multiple identities," only to later "disavow their DID diagnosis as they came to appreciate that their self-perceptions were shaped by their treating therapist."
Lynn told me that critics often incorrectly characterize his position as one that says that people with DID are deliberately faking. He and his colleagues, he said, do not doubt that "some people come to genuinely believe that they house multiple indwelling selves."
But Lynn and his colleagues remain highly skeptical of the role of trauma in causing dissociation. And they are skeptical of DID patients' stories of abuse. "Highly dissociative individuals tend to score highly on measures of symptom exaggeration," he wrote in his email, "raising suspicions about the authenticity of some of these individuals' memories and symptoms."
The people closest to Elyse have never doubted that the abuse that she recalls today occurred — nor do they question the legitimacy of her DID. The fact that some psychologists do not take DID seriously and believe that sufferers have exaggerated their stories of abuse makes Elyse visibly angry.