Oct 26

Schizophrenia and Dissociative Identity Disorder: Not the Same

FACT: Schizophrenia and Dissociative Identity Disorder are not the same.

QUESTION:

What’s wrong with the following popular jokes? (Besides their general offensiveness, I mean.)

1. What’s the worst thing about schizophrenia?      

Paying more than once for everything.

2. Roses are red/Violets are blue/I’m schizophrenic/And I am too.

3. A psychiatrist asked her multiple personality patient, “So do you feel like you’re cured?”      

He replied, “Absolutely. We’ve never felt better.”

 ANSWER:

The first two jokes confuse the definitions of the distinctly different conditions of schizophrenia and dissociative identity disorder (formerly known as multiple personality disorder). A diagnosis of schizophrenia does not include having more than one personality but may include having delusions or hallucinations, neither of which are likely to cause a sense of internal division.

The third one implies that integration of personalities has to be the only or ultimate goal of therapy for those with dissociative identity disorder (DID), a common myth that might have something to do with the popularization of “Sybil” and her supposed treatment, a topic that was addressed in yesterday’s post.

In fact, some individuals with DID do wish to achieve the merging of their different alters, but many do not. My own approach with clients with DID has been to find out what they want. (Note: This should not be a novel thought among therapists.) The upshot is that my experience has been to work with clients’ alters or “parts” to help them learn to co-exist, not to integrate.

Identifying as a dissociative with a system of different parts—and not identifying as a one-name/one-personality-only type of person—does often lead, when feeling safe enough, to using “we” versus “I” in self-reference. Thus, if a client with DID were to say to me, as in the above joke, “We’ve never felt better,” I’d be very happy for them.

Oct 25

Sybil “Exposed”: Not An Argument Against Multiplicity Itself

A newly released book by journalist Debbie Nathan, Sybil Exposed: The ExtraordinaryStory Behind the Famous Multiple Personality Case, is currently getting a lot of attention in the press, as well it should if it is accurate. It depicts highly fraudulent practices on the part of three individuals—the therapist, the author of the original book about Sybil (1973), and the patient herself—who allegedly conspired to make this woman’s condition and treatment into something that it wasn’t, turning her into “Sybil Inc.,” an immensely popular and lucrative enterprise.

On the positive side of this mess, the products generated by Sybil Inc. have served to popularize multiple personality disorder, now known as dissociative identity disorder (DID), and have given many people hope that their complex conditions could become better understood and treated.

On the negative side, the doubters—including some mental health professionals who don’t believe the condition actually exists in anyone—may now seize the chance to use Sybil Exposed to add fuel to that particular fire. See? Dissociative identity disorder is a crock, some are likely (illogically) to maintain.

I have neither read Nathan’s book nor can I weigh in on whether our Sybil of yore does represent one big fat lie, but I have witnessed and do strongly believe that there are those who do live with DID and that they represent one major truth: it is possible, it is indeed highly creative, when faced with severe childhood trauma, for one’s personality to become divided in order to withstand the torturous pain.

Do an online search for DID and you’ll find many up-to-date books that can serve to offset any indications, however shocking and upsetting, that this one particular patient/therapist/writer team may have fabricated multiplicity. (Clarification/ update, 6/10/12: In other words, there are still many experts who cite other case examples and histories; there are still many who believe that DID exists.) Two highly recommended books are The Dissociative Identity Disorder Sourcebook by Deborah Haddock and Multiple Personality Disorder From the Inside Out, edited by Cohen, Giller, and Lynn W.

With so many written and oral testimonies by those who’ve experienced DID firsthand, I confess that it’s beyond my ability to comprehend how anyone in my field could be a disbeliever. I contend that the therapists who disbelieve are either uninformed or unexposed or that they are so closed off to the possibility that they are unable or unwilling to see or accept it in their clients.

Moreover, clients may be unable or unwilling to reveal themselves fully in therapy if they sense any of the above characteristics in their shrinks.

For anyone who counters with, If they can hide it, it must not be so, consider your own personality. Do you routinely, for various reasons, keep parts of yourself in check? Please don’t say no. Because if you don’t, the rest of society may ask you to get some help learning how.

Oct 21

Therapist Boundaries (Violence): Two Movies

Do a Google search about therapist boundaries, specifically therapists and violence, and you’ll find plenty about clients attending therapy for being violent.

But can you find any reliable info about therapists being violent? Against their clients? No? Do we have to (misguidedly) look to the movies for such things?

I. Good Will Hunting

Will (Matt Damon) in the movie Good Will Hunting (1997) is one character who has to attend therapy after an episode of violence. Finding the right shrink for Will, who trusts no one who tries to help him, turns out to be no easy feat. Well, maybe the less traditional, more directive kind of therapist we eventually find in Sean Maguire (Robin Williams) will fill the bill.

But before Will gets anywhere close to the meaningful catharsis the film wants him to have, he has to put Maguire through the usual hoops, in one instance meanly and provocatively maligning Maguire’s dead wife. What follows is this disturbing scene involving terrible therapist boundaries:

Lesson #1 (You Wouldn’t Pick Up From The Movies): It’s never okay to choke a client. (Or harm a client in any way.) (Unless, of course, in self-defense.) Even if the client then backs off and actually moves on to have one particular wowie-zowie life-changing therapy session.

JC Schildbach, LMHC, RespecttheBlankie.com: “Despite what the filmmakers would have us believe, this is not a valid technique for establishing rapport or ensuring appropriate transference with clients who have suffered abuse–even when therapist and client are both from south Boston and the client just shit-talked the therapist’s dead wife.”

II. What About Bob?

Next up, there’s actually worse things a shrink can do. In the film What About Bob? (1991), the psychiatrist played by Richard Dreyfuss goes nuts himself dealing with Bob (Bill Murray), his dependent client who follows him, uninvited of course, on vacation.

Lesson #2 (You Might Not Pick Up From the Movies): Even unsuccessful attempts at killing one’s (annoying) clients are not allowed.

Well, at least Leo Marvin’s “death therapy” doesn’t work, and while there’s an unhappy ending in store for him—catatonia and psychiatric hospitalization—there’s a happy ending for Bob, who marries Lily,  becoming Leo’s brother-in-law. And there’s more: We find out in the Epilogue that Bob goes on to get his psychology degree and to write the bestselling Death Therapy.

Oct 19

“Prime” (The Movie) Therapy: More Boundary Issues

Prime, a 2005 film billed as a romantic comedy, features a therapist named Lisa (Meryl Streep) who has a client named Rafi (Uma Thurman) whose new boyfriend happens to be Lisa’s son, David. Although Rafi is talking about David in therapy, she hasn’t yet put a name to him; thus, neither therapist nor client knows that the man in question is who he is to Lisa. A weird boundary issue not likely to happen in the real world. Could it happen? Yes. Likely? No.

Although it does happen on a regular basis that a client talks about someone the therapist knows, it’s usually not someone as close to the therapist as a family member or close friend. Sometimes it’s clear to both parties that certain connections exist, sometimes not. Sometimes the therapist hears about someone she knows but can’t disclose this to her client because that someone is also a client—thus, such info is confidential.

Back to Prime. When Lisa does inadvertently learn—outside the therapy office—that Rafi’s involved with David, she doesn’t know what to do. Rafi doesn’t yet know what Lisa knows. So she consults someone—her own shrink? her supervisor?—I don’t think it’s clear which type of advisor this is. A decision is made for Lisa not to share with Rafi what she now knows. The reasoning is that it’s in the best interests of Rafi not to know her boyfriend is her shrink’s son because telling her could do more harm than good to the therapeutic bond—especially if the relationship with David winds up ending sooner than later anyway.

Just writing the above paragraph felt aggravating and tedious to me—which parallels how I felt about the movie at this particular juncture. Although the film already felt iffy, now it was ruined because Lisa knew Rafi was dating David and didn’t decide to disclose this to Rafi. Why, I wondered, couldn’t Rafi be allowed into the loop and given the chance to decide how she feels about both her therapy and dating relationships in the light of this new info?

Here’s what Roger Ebert’s review indicated about Lisa’s decision:

…when the characters have depth and their decisions have consequences, I grow restless when their misunderstandings could be ended by words that the screenplay refuses to allow them to utter.

…In my opinion, [the] responsibility is to declare a conflict of interest, but then I’m not a shrink and besides, then we wouldn’t have a movie.

I do declare, Mr. Ebert, even though you are not a shrink, you do make a good deal of sense.

If you’ve seen Prime, what did you think? If you haven’t, you might want to form your own opinion and get back to me. I mean, it does have Meryl Streep after all. Here’s the trailer:

Oct 14

“50 50”: Problems With the Therapist/Patient Boundaries

There’s a new movie in theaters called 50 50 about a young man, Adam, who is diagnosed with cancer. Joseph Gordon-Levitt is the lead actor.

I saw the trailer while at another movie, found it interesting–a mix of humor and seriousness—and proceeded to my next usual step, reading a synopsis.

What I learn is that Adam sees a therapist post-diagnosis. Cool. And that she happens to be young and inexperienced in her career. Okaaay—tell me more. He falls for her. Yeah, that can happen, of course. It might be that she falls back for him. Aaarghh!!! Not another therapist-crossing-boundaries film!!!

I look up Roger Ebert‘s review. He’s had cancer himself. He hated The Bucket List, about two men dying of cancer, because it wasn’t realistic. I listened to him and therefore haven’t seen this popular movie.

Well…ta da! Ebert likes it! But what’s he say about the therapist thing?

Anna Kendrick plays Katherine, Adam’s therapist, who gets just as involved as his oncologist is aloof. I know therapists are supposed to observe a certain distance, but in a case like this, I don’t see how one can. I would make a terrible therapist.

Okay, I won’t become a movie critic if you won’t become a shrink. But what about this over-involvement thing? I need to know more.

I turn next to Rex Reed. Wow. Even snarkier than usual. He really does not like this movie:

When Adam undergoes his first chemo treatment, his duplicitous girlfriend (badly overacted by Bryce Dallas Howard) waits four hours in the car because she can’t stand the interiors of hospitals. His stressed-out mother (and what, you may well ask, is Anjelica Huston doing in this blunder?) acts like a cross between Lady Macbeth and Zasu Pitts. Eventually Adam gives up and falls for his psychiatrist (Anna Kendrick) in a sex game that is pure cardboard.

A what!? A ‘sex game’??? Oh crap—I had really wanted to like this movie. Ebert liked this movie. But more importantly, another bad depiction of a therapist?! Clearly something we don’t need in this world.

I search for a female critic. I need one who’ll actually take the trouble to explain this 50/50 therapist/patient relationship to me.

So many many reviews I sift through. Over and over again, it’s the therapist is “inexperienced”—really?! That’s all you’ve got?

I keep skimming. Finally, whoa…bingo! Carrie Rickey calls out the young shrink as “unprofessional”…But, just how unprofessional?

Update: Well, now I can tell you from actually seeing it myself.

Adam’s unexpected breakup with his girlfriend, who has cheated on him, and Katherine’s own admission that she’s pining for her recent ex are factors involved in each of them starting to notice the other as fuller individuals, that is, as not just therapist and client. We can see that Katherine knows she shouldn’t reciprocate Adam’s interest, but we don’t see her consulting a supervisor, for example, or showing her internal conflict in a significant enough way. This stuff can happen when someone’s as inexperienced as she—but that doesn’t make it okay.

By the time Adam is told his cancer isn’t shrinking and that he needs a major and highly risky surgery, Katherine’s presence in the waiting area with his family and best friend seems much more personal than professional. At his bedside, this is even clearer.

Before 50/50 ends, Katherine meets Adam at his home to start their first date. His best friend, who has hated all of Adam’s previous girlfriends, approves of her. The implication is that Adam, a nice guy, has finally found his match. Isn’t that sweet.

I should note that the onus of maintaining appropriate boundaries, which are there to keep therapy safe for the client, is solely on the therapist no matter how a client feels or what he expresses to her.

If Katherine and Adam were in the non-movie world, I would like to see Katherine managing her own attraction somehow and continuing to support him in her professional capacity. Then, when Adam no longer needs to be in a medical setting on a frequent basis, he could be referred to another therapist who’s competent enough to help him.

Although it’s made to look in 50/50 as though nothing bad could come of such nice young people finding each other, that’s not what many clients-who’ve-become-lovers-with-their-shrinks in the real world will tell you. Issues of betrayal of trust and/or exploitation of trust, for instance, commonly arise in the dynamics of romantic relationships that started out as therapeutic ones.