To what extent are those with DID treated fairly?

Due to the complex nature of Dissociative Identity Disorder (DID) the evolution of the disorder has been one that has historically at times been greatly misunderstood with both varying changes towards social attitudes and the development of social sciences. Active application of evolved psychology and research has meant that this disorder is now formally recognised by the American Psychiatric Association (APA). The Diagnostic and Statistical Manual of Mental Health disorders (DSM) is globally both renowned and recognised as a tool used in clinical psychology. Trained clinicians use this manual to establish a formal diagnosisby the symptoms described by those suffering with mental disorders. With ‘fair’ being the key word, this essay will discuss the societal, historical, judicial, ethical, and medical attitudes to those with the disorder and to what extent it has affected the adequate treatment by those affected with DID.

To be able to evaluate the question, it is important to determine what is meant by fairness.  Fairness is the “quality of treating people equally or in a way that is reasonable”[1]. It is vital to understand the ethical underpinning this essay takes with regards to this concept, as there exists two ethical frameworks in which this question can be answered. The first one is absolute egalitarianism which is the belief that everyone should be treated equally, regardless of differences. The second view is elitism, which is defined as a way of organizing a system, society, etc. so that only a few people have power or influence. This holds relevance as historical figures have viewed those with mental health disorders as a hindrance to society and often sought out alternate means to eradicate this ‘problem’ such as mass extermination. For example, Hitler viewed those with mental disorders as a hindrance to society and wanted to euthanise all of them to prevent their genes being passed on to the next generation[2]. This holds relevance as with those with mental disorders like DID were also part of the eugenics program and consequently this establishes the necessity of determining how to view fairness. Hitler viewed his actions as both ethical and just as the achievement he sought to gain was that of an Aryan race, therefore justifying his actions to his nation.  This essay however will argue from an egalitarian perspective due to current societal, historical, judicial, ethical, and medical attitudes. This holds significance as many of these views are developed from centuries of scientific discovery. Ancient Greece for example have still many of their own fundamental values ingrained into our society. Laws and criminal proceedings involving jurors, gave the power of prosecution to the people and (mostly) removed bias and malice. The production of many philosophers and the creation of Plato’s Republic provided insight into many ethical views. In addition, the development of the Hippocratic Oath created many ethical guidelines for Doctors when treating their patients. So the concept of fairness should be viewed holistically as it encapsulates the many principles that are now fundamental in the further development of our society.

To appropriately distinguish the historical timeline of those with DID, we must first underpin the societal beliefs that encompassed the diagnosis of those with mental disorders. Coupled with this, the impact of religious beliefs that juxtaposed that of science that we so heavily rely on today. The practice of exorcism dates to Christianity and this is repeatedly described in the Bible. Its important to note that the development of religious affiliation for societal conduct, was historically, religious scriptures. Mental disorders are shown throughout the bible and the earliest reference to exorcisms dates to the Book of Mark where it describes a story of a possessed boy that had symptoms of possession since childhood with the boy throwing himself into ‘fire or water’ to kill himself. [3] While it would be inconclusive to assume this story of Jesus and this ‘possessed’ boy is a story of Dissociative Identity Disorder, its indisputable to argue that there are not overlapping symptoms that align with that of DID. Irrational/ erratic behaviours described in the scripture coupled with a notable shift in personality to epileptic seizures. This may have been the first recorded document of DID. The lack of concrete research and scientific resources meant that the only form of understanding often came from Religious teachings that rationalised the explanation that these ‘different’ individuals were of a demonic nature. The term possession is defined as that of “being under the direct control of an external supernatural power.” [4] Historically those with symptoms of “unusual behaviour” and “personality changes,”[5] were said to be ‘possessed’ and ‘fallen’. This in turn outlines the beginnings of a direct correlation between mistreatment of those with mental disorders and the beliefs of what it is to be an ideal religious follower and conformist . The behaviour at this given time was deemed as a threat to social order and the only acceptable explanation was that of possession. The core practices and research we have access to today was non-existent during these time periods. The extent to which fair treatment can be determined is often aligned with the methodologies of the core practices at the given historical moment. Therefore, this gives questionable reason as to what can be labelled as fair.

The Diagnostic and Statistical Manual of Mental health disorders is a book used by psychologists to diagnose psychiatric disorders as described by symptoms of the sufferers. Dissociative Identity Disorder was first coined in the 1880s and labelled as “Hystero-Epilepsy” by Dr. Jean-Martin Charcot [6]. Many in the psychology community at the time seemed to dismiss this illness as it seemed to have many overlapping symptoms with other developing psychiatric illnesses like schizophrenia. Dissociative Identity disorder is now characterised by “the presence of 2 or more distinct split identities or personality states that continually have power over the person’s behaviour.[7]” This misunderstood disease of the mind, is said to be developed from childhood trauma. The development for this disorder could be argued to be an evolutionary advantage, as many suffers of this disorder often develop a personality to ‘cope’ with the pain. Whether this is psychological or physical. Sufferers often have varying symptoms, but common ones are that of time loss and forgetfulness. 

The prevalence of this disorder is unknown, as many studies conducted are often confounding in statistics and variables. However, a study[8] conducted in Turkey used sample population of 994 participants and among them, 0.4% had dissociative identity disorder. This study demonstrated a minimum prevalence, as when those who were symptomatic with the disorder were contacted again, only 53% were willing to attempt to get a clinical diagnosis. This issue that researchers faced when conducting this study to move to phase 3, speaks to the current societal attitudes we have when we speak about mental health/disorders. Though this study used a heavily well-known scale, the Dissociative Experience Scale (DES), the accuracy of mental health tests are not always accurate.  The DES is a questionnaire and is completely reliant on subjective accounts of an individual’s behaviour. When referring to assessments of an individual with DID and mental health it would be a grave injustice if a person were to receive a misdiagnosis. To determine whether an individual has DID and is not showing symptoms of other psychological affiliations, there needs to be scientific justification to determine whether the DES is beneficial in outlining the difference between dissociative disorders and other psychiatric disorders.

In 1993 a multicentre analysis[9] was performed on the validity of the DES and determined that “the [DES] performs quite well as a screening instrument to identify subjects with multiple personality disorder”.  The importance of this study demonstrates the necessity of assessing those with dissociative disorders fairly, due to the nature of the illness. Studies can only demonstrate a cause-and-effect relationship between the difference in neuro-autonomy in non-sufferers compared to suffers. It has been found that sufferers have “smaller cortical and subcortical volumes in the hippocampus, amygla parietal structures”.[10]  Due to the biological nature of the illness, it cannot be cured although the symptoms it presents may be treated. However there have been cases like that of Sybil and Billy Milligan where the psychiatrist had used a method known as fusion to construct the original personality back to a whole.

DID is a trauma-based mental illness, that often is a result of physical/ sexual abuse as a young child. It is likely that those who grow up in impoverish areas are often neglected by their parental figures and society, and consequently have a greater likelihood to have a deteriating mental health.

On October 27^th 1977, William (Billy) Stanley Milligan was arrested, on the grounds of sexual assault. Fingerprint evidence, linked Billy to the scene of the crime of one of his victims[11]. However, during court proceedings, Mr. Schweickart, Billy’s public defender, had discovered the existence of Billy’s other personalities, and believed him to not be responsible for the crimes he committed.   The publicity of this case coupled with its notoriety, gives insight into the dichotomy between justice, and the judicial system, more specifically the treatment of those with mental illness. This is due to the justice system in Western society, having inadequate treatments for those struggling with mental illnesses. As of 2018, 59% of prison records in the UK fail to add the screening results for an inmate’s likelihood to be at risk of self-harm[12]. To keep in mind, this is prior to any forms of imprisonment. The importance of this statistic is to demonstrate the purposeful lack of data in modern day prisons, in order to manipulate statistics. This in part may be due to keeping the cost of each prisoner as low as possible and inflating profits.[13] In the case of Mr. Milligan, he had been told by an officer, “You, goddamned sonofabitchin’ rapist.[14]” At this point, fingerprints and victims’ testimony was strong evidence for actus rhea, where there is enough evidence to demonstrate that the crime physically took place. However, there was a lack of mens rea or guilty mind. These are two elements that are accepted in most courts as a necessity for a crime to be committed. But there are exceptions to Mens rea, such as diminished capacity, in which Billy would later demonstrate and be exonerated of his crime. The officer’s comment could have been viewed as an indicator of the proceedings that awaits Billy and the unconscious bias there may be throughout the court case. In all court cases in the United States, there exists a presumption of innocence[15]. Commonly known as “innocent until proven guilty”.  The officer’s comment could be a demonstration of the injustice that is prevalent in our treatment of those suffering with mental issues. The issues faced by court prosecutors when addressing DID is determining how to address the sufferers. In the case of Billy Milligan, the defence had to contact somebody who had major experience in this field of psychology.  They contacted Dr. Cornelia Wilbur, who had by that point had history in this branch of psychology with her publication of the book Sybil.  A book detailing the life of a woman with the alias Sybil who had 16 personalities. Dr. Wilbur brought a concept known as fusion, which is effectively a full recovery from this condition. “The goal of treatment is to achieve fusion of each personality so the person can begin to function as an integrated whole.”[16] This method, involves finding commonalties between personalities and slowly combining them. Billy Milligan himself had shown diminished capacity, but the personality responsible for the rapes was a lesbian named Adaline. She was aware that her actions were morally/ legally wrong but still decided to commit them anyway. She had a guilty mind but still committed the actions, therefore she should be punished. However, this view raises debates into whether sufferers with DID are clinically insane or suffering from an affliction known as non-insane autonomism. 

But there seems to be a lack of practicality, as it is important to keep in mind that Billy’s case it is a case study. Furthermore, personalities cannot come out by demand. The relevance of this is that why it is important to keep proceedings fair, the proceedings are consequently expensive and time consuming. This cost will be reflected to the taxpayers as all these treatments from psychological evaluations, to transport, to the price of therapy. This raises questions to whether it is reasonable to expect taxpayers to cover these costs especially considering the nature of the crime.

The importance of Billy Milligan’s case demonstrates the challenges faced, by those with mental disorders, and raised many ethical questions. The creation of these personalities demonstrates that each of them have their own free will and most can determine from what we say is right or wrong. Consequently, these personalities can be viewed as individuals and during the method of fusion are treated as such. With this deductive reasoning, the purpose of fusion and eradication of personalities could be viewed as murder, as the end goal is to rid the original host body of these other personalities. Depending on a person’s philosophical stance on consciousness depends on whether this treatment of fusion can be determined as fair, from a moral standpoint. Physicalism is the belief that everything we perceive is physical, and thus other personalities existing in those with Dissociative identity disorder are nothing more/ greater than a mental disorder that has a biological basis and matter as we know it is independent from the mind. Consequently, the process of fusion is necessary in order for the host’s personality to be fused together and quality of life for the host takes precedent over the others. Consciousness simply can be explained by brain activity. However, we do not all experience reality the same. The hard-conscious problem [17]argues that science cannot seem to transfer conscious qualitative experience into empirical data. Example given: How bitter is an apple? This question can be broken down into its chemical components and theoretically it is possible to determine its pH.  However, if two people were to consume the apple, their subjective experience would be different, and they would most likely give different qualitative responses when asked this question. To circumvent this, there’s an opposing view to that of physicalism known as Idealism.

Idealism is a “metaphysical view that associate’s reality to idea in the mind rather than to material objects”[18] . Greek philosopher Plato believed that the world around us is constructed by ideas in the mind, thus what we see and experience is not real. Hence, when referring to DID we view each personality as their own being and consequently they are to be protected from harm. The experiences made are not of the host-personality, rather that of the personality that oversees the body during the time of the experience. Although, Dissociative Identity disorder is defined as that of “2 distinct identities….” We need to consider what we mean by dissociation. As this is “a mental process where a person disconnects from their thoughts, feelings, memories or sense of identity.”[19] When looking into this, this seems to cause issues, when we think of this idea of personality vs identity. The importance of this comes when we think of the prior term used for DID. Historically it has been referred to as multiple personality disorder.  A person with Dissociative Identity Disorder, is said to have less than one personality[20] whereas Multiple would show more than one personality. The difference in terms changes the perspective in regard to the way the disorder should be treated. This is important as it encompasses this idea whether fusion is fair, as if you look at it from an MPD approach then that means fusion and eradication of the personality would be unreasonable as it bases that the host personality takes president over the others. So, fusion would be viewed as unfair or unjust. To further this idea, those advocating for fusion seemingly assume that the disease hinders a person and that their quality-of-life decreases, nevertheless they can function normally, and be members of society. Seemingly those in the Turkish study seemingly were doing ok, and hadn’t realized their quality of life was different to what we consider normality.. Although, this is not necessarily true. As while the creation of personalities stems from child-sexual trauma, it does not necessarily mean that personalities cannot coincide.  With the case of Billy Milligan, many of the personalities apart from Adeline wanted to protect Billy and although they each differed, they presented a united front during Billy’s arrest. To further this point, the host personalities only took full control of Billy when he tried to commit suicide. This demonstrates a level of morality amongst the other personalities, and henceforth the concept of fusion is viewed as unfair.

Sixteen years after the case of Mr. Milligan the prejudices surrounding the case did not cease.  In 1993, William Diehl published a book (later released as a film) known as Primal Fear. The story revolves around a Chicago lawyer who attempts to defend an altar boy called Aaron Stampler from accusations of murder.  His defense was reason by insanity, which by law encompasses many mental disorders, such as schizophrenia, but in the plot, it was Multiple Personality Disorder. By the end of the film, it was discovered that Aaron had been faking the existence of his alter Roy. Demonstrations of violence was common throughout the movie by Aaron, and erratic outbursts were common and shown during criminal proceedings. This led to the court finding him not guilty of murder by reason of insanity. He was consequently transported into a mental health facility where he would be given substantial preferential treatment. The ableist undertones in this ‘twist’ I believe negates the experiences of those with DID. This is not the first time where Hollywood has used DID as a ‘trope’, where the extreme behavior demonstrated is that of violence and murder. In 2014 M. Night Shyamalan released his critically acclaimed movie Split. In which the story revolves around a man named Kevin who had been diagnosed with the disorder and abducts 3 girls.  In the movie there is continuous reference to The Beast which is an extremely violent personality that would seek to inflict pain on anyone. He has inhuman strength and speed and is viewed as extremely erratic. The issue with this is Hollywood repeatedly disregarding actual mental health issues for the sake of profit. {murder, movies have higher grossing….] The media throughout history has had significant impact on current societal views. Only in 1974, the first lesbian kiss was shown on national television, with Alison Steadmean in a BBC drama called girl and 40 years later, in 2014 there was the first gay marriage in the UK. Although, with the disabled community, there are setbacks in Hollywood with hiring those with mental disorders.  Hollywood is seemingly pumping out movies with increased LGBT representation and racial diversity but is yet uninviting of those with disabilities as in television they only made up 3.1% of all regular characters. In addition, only 12% of all disabled characters are played by disabled actors.[21]   The importance of this statistic is to show the seemingly mal intentions behind the creation/ representation of disabled characters. A study conducted on media and representation found that               a single supportive newspaper column would expect to increase public support for LGBTQ by 0.24%[22].The comparatives between LGBTQ and the disabled is that both minority groups evolved from national scrutiny. And the statistic of 0.24% is to demonstrate the effect of media outlets on public opinion. In addition, experts in this field of psychology believe that the sufferers with DID are more likely to self-harm then harm others.[23] The ISSTD (International Society for the Study of Trauoviesma and Dissociation), publicly scrutinised Split. “It acts to further marginalize those who already struggle on a daily basis with the weight of stigma.[24]” The movies that exploit the struggles of those suffering with mental issues are sending indirect messages to the viewers that the problems that the suffers face are not only less valid, but that it is ok for the illness to be demonised.  To further add to this point, there is a difference in the portrayal in physical disabilities opposed to mental. Over half of mental disorders depicted in newspaper outlets are negative in tone, with 18.5% associated violence with the disorders.[25]  This statistic shows the ableist undertones that not only are prevalent in Hollywood, but society as a whole.  To sum up, the media’s vilification of this disorder, and its ability to influence public perception is why DID is treated unfair by the outlets.

When looking through the lens of digital aged media, we need to consider, that this is not necessarily a universal media outlet to access. Many non-western countries have bans/ limitations on foreign media outlets, due to the potential disruption they can potentially cause[26]. When it comes to DID, it is seemingly only demonized in the Western outlets. In Spiritualistic continents like Asia and Africa, disorders that show different personalities, are mostly seen as a blessing. A study conducted with schizophrenia patients found that Indians and Africans had a more positive outlook / experience when it came to hallucinations / hearing voices - and embraced it as such.[27] This statistic is to demonstrate is the negative stigma around mental illness in the western world, however while we view DID as an illness and something that decreases the quality of life, in non-western cultures/society it is viewed as a gift, often demonstrated a higher being/ level of spirituality. Culture variations in the way this disorder is perceived has led to favoritism with the sufferers. . Many of the sufferers tend to have preferential treatment as opposed to non-sufferers, as they are said to be blessed by the spirit. For example, in Haitian culture, they say “It is an honor to be entered and ridden by a Loa”.[28] In Haiti, acquisition of a spirit and demonstrating some degree of dual personality is glorified and revered. However, due to this illness being trauma-based it is important to look at the statistics on abuse against children. In Haiti, 2/3 children are subject to abuse, with the most common abusers being parental figures. (Mothers and fathers).

[1] https://dictionary.cambridge.org/dictionary/english/fairness

[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5719686/

[3] The Book of Mark. [Book] [70 A.D.]

(CITED:02/12/20)

Mark 9:14-29

[4] Encyclopaedia Britannica. Adam Augustyn, Adam Zeidan, et al. [Online] [May 01 2014]

(CITED: 13/11/20)

https://www.britannica.com/topic/possession-religion

[5] ibid

[6] Psycom. Arnold Lieber MD. [Online] [November 18 2018]

(CITED:13/11/20) https://www.psycom.net/mchugh.html#:~:text=Dr.,this%20new%20disease%20Hystero%2DEpilepsy.

[7] WebMD. Smitha Bhandari, MD [Online] [January 22 2020]

(CITED:13/11/20)

https://www.webmd.com/mental-health/dissociative-identity-disorder-multiple-personality-disorder#1

[8] G. Akyuz 1999 Frequency of dissociative identity disorder in the general population in Turkey https://www.researchgate.net/publication/13211228_Frequency_of_dissociative_identity_disorder_in_the_general_population_in_Turkey

[9] Carlson (EB) 1993 Validity of the Dissociative Experiences Scale in screening for Multiple Personality Disorder: A multicenter study

https://pubmed.ncbi.nlm.nih.gov/8317572/

[10] Bilhar (D)A systematic review of the neuroanatomy of dissociative identity disorder

[11] Keyes, D 1981, The Minds of Billy Milligan, Weidenfeld and Nicolson, London

[12] Parliament. House of Lords (2017). Mental Health in Prisons: the eighth report. (HL 2017-2019). London: The Stationary office **https://publications.parliament.uk/pa/cm201719/cmselect/cmpubacc/400/400.pdf

[13] Robbins, (IP) ‘Managed Health Care in Prisons as Cruel and Unusual Punishment’. The Journal of Criminal Law and Criminology (1973-), vol. 90, no. 1, 1999, pp. 195–238.

[14] Keyes, D 1981, The Minds of Billy Milligan, Weidenfeld and Nicolson, London. PP:14.

[15] Coffin v. United States, 156 U.S. 432 (1895)

[16] https://psychcentral.com/lib/can-you-recover-from-dissociative-identity-disorder#1

[17] https://iep.utm.edu/hard-con/

[18] https://www.qcc.cuny.edu/socialsciences/ppecorino/intro_text/Chapter%204%20Metaphysics/Idealism.htm

[19] https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/dissociation-and-dissociative-disorders#:~:text=Dissociation%20is%20a%20mental%20process,disorder%20and%20dissociative%20identity%20disorder.

[20] https://www.psychiatry.org/patients-families/dissociative-disorders/expert-q-and-a#:~:text=Dissociative%20identity%20disorder%20involves%20a,rather%20less%20than%20one%20personality.

[21] https://rootedinrights.org/an-open-letter-to-hollywood-inauthentic-representation-of-disability-isnt-representation-at-all/

[22] https://doi.org/10.1146/annurev-lawsocsci-102209-152825

[23] https://www.healthline.com/health-news/movie-split-harms-people-with-dissociative-identity-disorder#What-is-DID?

[24] ibid

[25] https://dx.doi.org/10.1192%2Fpb.bp.116.054775

[26] https://doi.org/10.1007/s10708-010-9393-3

[27] https://news.stanford.edu/2014/07/16/voices-culture-luhrmann-071614/

[28] https://www.nationalgeographic.com/culture/article/haiti-ancient-traditions-voodoo