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!