Article: Recommendations for Home of the Innocents - Pat McClendon's Clinical Social Work

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"Recommendations for Home of the Innocents (HOTI) Regarding Therapeutic Intervention"

By: Patricia D. McClendon, MSSW candidate

Date: August 16, 1992

Note: I wrote up this brief paper to present to my field placement supervisor and her supervisors in regards to unrecognized and untreated dissociative disorders in their agency's client population. I relied on mostly quoted material because quite honestly, I didn't expect them to believe me. HOTI is an emergency shelter for abused and neglected children, so what I have written here, I believe, would apply to all such facilities.

Introduction

Since many children at HOTI (Home of the Innocents) have histories of physical, sexual, emotional abuse, as well as, neglect and abandonment issues - careful psychiatric evaluations are imperative. All child victims of abuse or significant trauma should be evaluated for dissociative disorders, as well as, other psychiatric disorders. In light of the recent increase and/or increase in reporting of child abuse, the importance of prudent evaluation is essential. Diagnoses given to the victims undoubtedly influence how others (family, friends, communities, and professionals) view them and treat them. An erroneous diagnosis can doom these child victims to a lifetime of inappropriate psychiatric treatment, as well as, stigmas of being beyond help for the rest of their lives. A diagnosis now can certainly influence further evaluations from being objective. Early intervention and treatment of children who are dissociative can turn the tide in reducing child abuse in future generations.

Definition of Dissociation

"Dissociation can be defined as a complex psychological process, with psychodynamic triggers, that produces an alteration in the person's consciousness. During this process, thoughts, feelings, and experiences are not integrated into the individual's awareness or memory in the normal way." ¹

In 1984, (Braun) proposed a speculative concept of multiple personality and other dissociative phenomena. It brought together a number of approaches to understanding dissociation under the rubric of neuropsychophysiologic (NPP) state-dependent learning (SDL). In that paper, (Braun) proposed that multiple personality disorder represents an extreme point on a continuum of response patterns that includes hypnosis, repression, ego states, and dissociative disorders. Although multiple personality disorder has its place on the continuum, neither hypnosis nor dissociation alone can create multiple personality. Multiple personality disorder is created by means of repeated dissociations that occur under extreme stress, usually the extreme stress of child abuse. These dissociations often have similar NPP affective states that allow them to be linked together, permitting the association of facts, the development of congruent, stable memories, ranges of emotion, and response patterns. Central to the proposal is that the linked affective states are NPP-based. The inclusion of NPP is what differentiates this concept of dissociation from those that are solely psychological.

The NPP state is central to the concept of memory linked to state-dependent learning. The basic tenet of state-dependent learning is that something that is learned in one NPP state is most expeditiously retrieved under the same NPP state. Personalities are formed, shaped, and expressed through the individual's continuous interaction with the environment. Behaviors are expressed, and shaped by environmental responses. If the reinforcement of behavior occurs in a sufficiently disparate, dissociated NPP state, the effects of that interaction will not be available under the usual NPP state. If the NPP states are too disparate, retrieval in not possible.

If enough environmental interactions occur under similar NPP states, as in circumstances in which a child endures abuse frequently but also experiences more positive interactions (Braun & Sachs, 1985), the informations learned under the NPP state of abuse will be linked together. This chaining of knowledge, memory and interactive patterns forms an alter personality with its own response patterns, life history, and range of affect. ²

To dissociate means "to sever the association of one thing form another." To this (Braun) would now add that what we see as MPD, especially in children, may well be a disorder of lack of association, since a significant association may never have been achieved from which to be dissociated. This makes developmental sense... ³

(T)here is a problem about the difference between splitting and dissociation. (Ross) consider(s) splitting and dissociation to be synonymous, and (Ross) consider(s) borderline personality disorders, which is based on splitting, to be an Axis I dissociative disorder. ⁴

Braun's BASK Model of Dissociation

The complex phenomena of dissociation can be conceptualized in a BASK (B-A-S-K) model. The four letters of the acronym represent Behavior, Affect, Sensation and Knowledge, processes that function in parallel on a time continuum represented by the arrows in Figure 1. If we continue to define dissociation as the separation of an idea or thought process from the main stream of consciousness, then we may use the BASK model (Figure 1) to illustrate that dissociation can occur on any one or more of the levels - e.g., on Behavior as it might in automatism, on Affect and Sensation as when hypnosis is used to create an anesthesia. Dissociation may occur in all the processes at once for a greater or lesser period of time. In this model, mental health is the congruence over time of the BASK components.

...Dissociation can be shown as one extreme on a continuum of awareness (Figure 2). The continuum runs from full awareness - through suppression, which is a conscious putting-out-of-mind of something we don't want to think about - through denial, which is a mechanism we use until we have the capacity to cope in other ways - through repression, which Freud identified as being due to pathological psychological conflict - to dissociation itself, which (Braun) believe(s) includes repression, but unlike the classical definition of repression, has a major NPP component. Although there is a vertical bar in the Figure at each point where we name a successively severe diminution of awareness, the progression from left to right should be seen as the gradual shadings of a true continuum.

A static model of the dynamic continuum of dissociation also is useful to comprehension of the BASK model (Figure 3). As with maps of the world, not everyone will agree with where the lines are drawn; some will agree, some disagree with the placement of "repression" as a "dissociative episode." (Braun) also propose(s) that, on the horizontal axis between "dissociative disorder" and "Atypical dissociative disorder," we should place "post traumatic stress disorder." A strong case can be made for identifying post traumatic stress disorder (PTSD) as a dissociative disorder... ⁵

Prevalence of MPD/Dissociative Disorders

MPD (and other dissociative disorders) were believed to be rare prior to the 1980's. The increase in the recognition of severe child abuse parallels the increase of the recognition and diagnosis of dissociative disorders. In 1986, Coons estimated that there were between 6,000 to 30,000 cases of MPD nationwide. ⁶

In 1991, Colin Ross has estimated that 1% of the adults in North American have MPD and 10% have dissociative disorders (DDs). ⁷

Summary: Prevalence of DDs in Clinical/Non-Clinical Populations ⁸

Populations                                    n    %MPD     %DDs

adults w/chemical dependency problems         100     14      39
general adult psychiatric inpatients           ?       5.4    21   
(two year study)

adolescents assessed at                        34     17      35 
psychiatric facility

prostitutes                                    20      5      35

exotic dancers                                 20      5      50

Prevalence in Recovering Addicts

Merriman's research, "comprising of two studies covering a large outpatient sample of recovering addicts, suggests that clinically significant dissociation is present in over 50% of recovering addicts, and multiple personality (as a subset of dissociation) occurs in upwards of five percent of recovering addiction-prone people." ⁹

Some Key Findings ¹⁰

* 97% of MPD victims report a history of childhood trauma, most commonly a combination of emotional, physical and sexual abuse.

* Multiple personality disorder (and other dissociative disorders) can be reduced or prevented by early diagnosis and treatment of traumatized children and by working to eliminate abusive environments.

* While usually not diagnosed until adulthood, 89% of MPD victims have been mis- diagnosed at least once.

* MPD (and other dissociative disorders) victims require treatment techniques which specifically address the unique aspects of the disorder. Standard psychiatric interventions used in the treatment of schizophrenia, depression and other disorders are ineffectual or harmful in the treatment of MPD (and other DDs).

* Appropriate treatment results in a significant improvement in the quality of life for the MPD (and other DDs) victim.

* Multiple personality disorder (and other DDs) are treatable.

Recommendations

1. Re-evaluate current residents of program for dissociative disorders. Those children who are identified as having a dissociative disorder should be referred to a clinician who has experience and has had specialized training in treating dissociative disorders.

2. Evaluate all abused children entering the HOTI for DDs/MPD. Evaluation should include a comprehensive history as to type, frequency, severity of abuse and identification of perpetrator.

3. All staff need to be trained to work with MPD and DD clients. It is essential that staff understand disruptive and/or unacceptable behavior in terms of dysfunctional coping strategies.

4. Frequent relocation traumatizes children and increases the likelihood that children will use dissociation as a means to cope. Therefore, frequent relocations (i.e., foster care placements) need to be eliminated or at least minimized.

5. Residential Programs. Initially there needs to be a female residential treatment facility aimed at preventing unwanted pregnancy and breaking the cycle of multi-generational abuse. Residential units would be grouped by age: very young to age 10, age 10 to age 14, and, age 14 to age 18. An adult unit may be added in the future. For teenage girls who already have children, the Transitional Home Program would be a model provided that appropriate treatment modalities were incorporated. A parallel program for males is also recommended. Implementation of this program would require participation and involvement of mental health resources in the community. A joint venture involving Jefferson Hospital should be considered, since they currently have a dissociative disorders unit. Such a partnership could be desirable for Jefferson Hospital due to ready access for placements, referral sources, etc.

References

1. Putnam, Frank W., M.D. (1985) "Dissociation as a Response to Extreme Trauma", Childhood Antecedents of Multiple Personality (edited by Richard P. Kluft), American Psychiatric Press, Inc., Washington, D.C., p. 66-67.

2. Braun, B. G., M.D. (March 1988) "The BASK Model of Dissociation", Dissociation, 1(1), p. 5.

3. Braun, B. G., M.D. (1986) "Issues in the Psychotherapy of Multiple Personality Disorder", Treatment of Multiple Personality Disorder, American Psychiatric Press, Inc., Washington, D.C., p. 7-8.

4. Ross, Colin A., M.D. (1989) Multiple Personality Disorder - Diagnosis, Clinical Features, and Treatment, John Wiley & Sons, New York, N.Y., p. 87.

5. Braun, B. G., M.D. (March 1988) "The BASK Model of Dissociation", Dissociation, 1(1), p. 5-6.

6. Coons, P.M., M.D. (1986) "The Prevalence of Multiple Personality Disorder", Newsletter of the International Society for the Study of Multiple Personality and Dissociation. 4(4), p. 6-8.

7. Ross, Colin A., M.D. (1991) "Epidemiology of Multiple Personality Disorder and Dissociation", The Psychiatric Clinics of North America, W. B. Saunders Co., Philadelphia, Pa., 14 (3), p. 505-506.

8. Ross, (1991), p. 507.

9. Merriman, Stephen R. (Jan./Feb. 1991) "Dissociation and Multiple Personality Disorder", The Counselor, 9(1), p. 26.

10. ---,(1985) "Multiple Personality Disorder: Key Findings", Investigations, 1(3/4), p. 3

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