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The Journal of Psychiatry & Law 27/Fall-Winter 1999
latrogenic dissociative identity

disorder-an evaluation of the
scientific evidence
BY DANIEL BROWN, PH.D., EDWARD J. FRISCHHOLZ,

PH.D., AND ALAN W. SCHEFLIN, J.D., M.A., LL.M.
In recent years there has been a remarkable increase in malpractice

suits in which a retractor-plaintiffalleges that a defendant
therapisthas suggestively implanted afalse dissociative identity
disorder(DID) diagnosis.A criticalexamination of the arguments
used by plaintiff expert witnesses demonstrates that the scientific
evidence is insufficient, consisting largely of anecdotal case
reports, non-data-basedpro-false-memory opinionpapers, and
several methodologically questionable laboratorystudies. These
sparse datafail to meet a minimal standardof scientific evidence
justifying the claim that a majorpsychiatric diagnosis like
dissociative identity disorderper se can be produced through
suggestive influences in therapy. However, some scientific evidence
exists to show that behavioralreinforcement can affect the
frequency and type of alter behaviormanifesting in patients
who already have DID. Plaintiffexpert witnesses have confused
alter creation with altershaping. Based on the availablescientific
evidence, it is doubtful whether such plaintiff complaints could
meet a Frye-Daubert standardin a test of admissibility of such
testimony. Furthermore,currentmalpracticeclaims based in
iatrogenicDIDfail to considerotherplausible alternative
explanationsfor plaintiff's retractionbeliefs, such as the
manufacture of retractionbeliefs through systematic exposure to
post-treatmentpro-false-memory suggestive influences and/or
deceptive, factitious behavior on the part of plaintiff.
© 2000 by FederalLegal Publications,Inc.

550 IATROGENIC DID: EVALUATION OF EVIDENCE
I. Rise of lawsuits-misuse of iatrogenesis hypothesis
Currently there are estimated to be 800 malpractice suits

against or involving therapists for allegedly implanting false
memories of abuse.' The main complaint by plaintiffs in such
cases is that the therapist allegedly used suggestive therapeu-
tic practices during treatment to implant false memories of
abuse. These abuse memories were a central focus of the
defendant therapist's treatment and, at the time of treatment,
were taken to be true by the patient. Sometime after the treat-
ment had terminated, the abuse memories were retracted. The
patient had come to believe the abuse never happened and
subsequently sued the therapist for negligently "implanting"
or "reinforcing" belief in the false memory and for causing
psychological damage.
A good portion of these retractor malpractice cases contain

an additional plaintiff complaint regarding the diagnosis of
dissociative identity disorder (DID) or dissociative disorder
not otherwise specified (DDNOS) that was rendered during
the treatment by the defendant clinician.2 If the diagnosis of a
major dissociative disorder had been made by a clinician
prior to treatment by the defendant, plaintiffs complained that
the defendant had "uncritically accepted" the MPD/DID diag-
nosis.' If no such diagnosis of DID had been made previ-
ously, plaintiffs complained either that the defendant had
misdiagnosed DID because plaintiff "did not suffer from
mental illness" or that the defendant had "improperly imple-
mented . . a treatment regimen, encouraging and assisting
• . .[the patient] in developing 'personalities' which the
defendant allegedly represented were 'alter' personalities to
[the patient] when no such personalities existed." The "ther-
apy techniques" were claimed to be "suggestive and coer-
cive" in that they allegedly served to create fictional alter
personalities in an individual who purportedly did not have
them.
Typically, plaintiffs further alleged that this false dissociative
disorder arose due to "extensive hypnosis" and by treatment
procedures focusing on directly communicating with alter
personality states-naming them, identifying their functions
and memories, and attempting to integrate them. Additional
complaints are that the defendant negligently attempted to
recover "repressed memories" of abuse, under the assumption
that MPD was associated with extreme abuse. By looking for
these alleged memories, the therapist in fact negligently
implanted false memories of abuse, including extreme and
bizarre accounts such as satanic ritual abuse. Overall these
plaintiffs allege that the defendant therapist had been
"grossly negligent" in using an "unorthodox" or "experimen-
4
tal" treatment regarding the treatment of alleged MPD.
A critical issue in these false memory malpractice cases is

whether the defendant's treatment was indeed below the stan-
dard of care for the time that the treatment was rendered.
Most of these current malpractice cases date back to the late
1980s or early 1990s. According to a national survey con-
ducted regarding treatment of MPD in that time frame, the
great majority of clinicians treating MPD patients endorsed
individual psychotherapy with a psychodynamic orientation,
and they typically conducted this treatment with hypnosis. 5 In
other words, the type of treatment typically deemed as
unorthodox or experimental by plaintiffs was actually the
standard of care during the period in question, if by the "stan-
dard of care" it is meant that the great majority of clinicians
treating MPD used a comparable treatment approach.' Fur-
thermore, treatment procedures involving communication
with alters and integrating alters was very much the standard
of care during that same time frame. 7
In essence, a significant portion of the defendant therapists in

these malpractice suits are being sued for using treatment
procedures that have very much been within the standard of
care as generally accepted practices. In law, the burden of
proof would be on the plaintiff to demonstrate that the defen-
IATROGENIC DID: EVALUATION OF EVIDENCE
dant's treatment was outside of the standard of care. Surpris-

ingly, even in cases where the treatment procedures used by
the defendant were clearly comparable to those used by the
majority of clinicians who treat MPD, some plaintiffs have
been remarkably successful. For example, in the Burgess v.
Rush Presbyterian et al. case in Chicago, plaintiff received
nearly $11 million in a settlement against a national expert on
MPD, a number of other clinicians, and the inpatient psychi-
atric unit that specialized in MPD treatment. In Carl v. Ker-
aga et al. a Houston jury awarded plaintiff $5 million against
a psychiatrist, Gloria Keraga, a psychologist expert in MPD,
Judy Peterson, and an inpatient unit specializing in MPD at
Spring Shadows Glen Hospital. In Hess et al. v. Hernandez a
Wausau, Wisconsin, jury awarded plaintiff approximately
$850,000 in a suit against a psychiatrist. But in Greene v.
Timmons et al. a Charlotte, North Carolina, jury found the
defendant psychiatrist and psychologist not liable for negli-
gence in a similar type of lawsuit. Each of these malpractice
lawsuits involved plaintiff allegations of negligently implant-
ing false memories of abuse and a false diagnosis of MPD
through suggestion.8 A disturbing trend in these cases is that
plaintiff expert witnesses have been reasonably successful in
the courts in redefining the standard of care in trauma and
MPD treatment and then imposing this litigation-created
hindsight standard as a measure of what should have been
done by the defendants in treatment rendered five to 15 years
earlier.
A critical issue in these cases is whether the defendant indeed

used "suggestive and coercive" practices to "implant" or
"reinforce" a false diagnosis of MPD in a patient who
allegedly never had MPD. Typically, plaintiff's complaint
presumes that a major diagnosis like MPD can be implanted
through suggestion. 9 This presumption necessarily is based
upon expert testimony regarding scientific evidence that
MPD can be created through suggestion. This paper evaluates
the scientific evidence in support of this testimony. In our
opinion there is very little scientific evidence supporting the
553
iatrogenic MPD hypothesis. We also conclude that expert tes-

timony advancing the viewpoint that MPD can be created
through therapeutic suggestion grossly overgeneralizes from
sparse and inadequate scientific data, and thereby misleads
the court.
!1. History of the development of the

iatrogenesis hypothesis
A. Early The controversy about whether MPD is a legitimate psychi-

history atric condition and whether MPD can be created by sugges-
tion has a long history. Before and during the 19th century,
most social structures, whether ancient or modem, reported
the existence of possession states.'0 Throughout the 19th cen-
tury, European healers wrote extensively about what they
called "duality of the mind" or "the double brain" or "divided
consciousness."" The late 1880s through the early 1900s
were characterized by intense interest in dual and multiple
personality. 2 In America, Morton Prince published a detailed
case study of a patient with dual personality in The Dissocia-
tion of a Personality (1905/1978)." William James 4
addressed multiple selves within normal individuals. Boris
Sidis wrote about multiple layers of conscious and uncon-
scious awareness. 5 In the United Kingdom, F.W.H. Meyers
wrote about parallel selves within the same individual. 6
In France, Janet, Charcot, and Liebault wrote extensively
about dissociation and trauma. 7 Alfred Binet wrote On
Double Consciousness and investigated the transfer of infor-
mation across amnesic barriers.
While interest in major dissociative conditions flourished

regarding these views of dual and multiple personality, the
idea that MPD might be influenced by, and even created
through, suggestion was also prominent. Janet realized that
an MPD patient's recollection of trauma could be altered
through hypnotic suggestion, and that alter personality states
manifested themselves following hypnotic suggestion to
come forth in the treatment session. 9 Binet observed that

double consciousness could be created experimentally in nor-
mal hypnotizable individuals or self-created through autohyp-
2
nosis. 0
The work of Charcot 2l was also interesting in this regard.

Charcot studied patients suffering from "hysteria" and the
production of "hysteric" symptoms (i.e., unexplained medical
symptoms or conversion disorders). He described how hyp-
notic suggestions could temporarily produce "hysterical"
symptoms that seemed to bear a phenotypic similarity to
spontaneously occurring "hysterical" symptoms. For exam-
ple, following a separate hypnotic induction, a suggested
motor paralysis of specific body limbs could be produced
among patients suffering from different "hysteric" symptoms.
In addition, Charcot also reported two other important and
associated observations: (1) although verbal suggestions for
removal of prior (i.e., prehypnotic) "hysterical" symptoms
were at best temporarily successful, over time the original
"hysterical" symptom often appeared spontaneously; and
(2) hypnotically produced "hysterical" symptoms would only
be temporarily manifested and over time were unlikely to
reappear spontaneously. Hence hypnotic suggestions did not
seem to have lasting effects in producing new "hysterical"
symptoms or in preventing prior "hysterical" symptoms from
spontaneously reoccurring.
By 1910 the credulous view of MPD began to wane,22 in part

due to the ascendance of psychoanalysis and then behavior-
ism, and in part because of increasingly skeptical profes-
sional attitudes toward hypnosis and the relationship between
hypnosis and hysteria. After 1910 published cases of MPD all
but disappeared, and those patients likely to have had MPD
were diagnosed as schizophrenic. 23 While the reported preva-
lence rate of MPD drastically declined over the next half cen-
tury, the conflict between the credulous and the skeptical
views of MPD persisted and remained unresolved.
B. Critical In a critical review, Taylor and Martin24 raised the question of
reviews of whether multiple personality was "genuine or apparent."
MPD during They stated that "it is easy to confuse the question of gen-
the period uineness with that of cause. . . .An actual crack in a vase
of decline is genuine whether caused by earthquake, by intent, or by
mistake." z To answer this question, they reviewed 76 cases
reported in the literature from the 1800s to the mid-1940s.
While Taylor and Martin agreed that "various authors in the
last century and in this have thought that multiple personali-
ties are caused by suggestion" and "those authors are right in
part" for at least some patients,26 they mainly concluded that
"multiple personality is a genuine phenomenon ' 27 because
of the "wide distribution" of these cases, the fact that most of
them knew nothing about other cases, and the fact that many
of the cases had been judged as genuine multiples inde-
pendently by different observers. 28 They further stated that
skeptics who viewed multiple personality as a product of sug-
gestion "overlook more essential causes, ' 29 namely, that MPD
is a "failure of integration"30 and also an excessively learned
"protective role"'" in response to numerous etiological fac-
tors.
Thigpen & Cleckley 2 reported the now famous case of Mrs.

White, a meek housewife, who under hypnotic treatment
revealed two other personalities, Eve Black and Jane. Eve
herself later reported additional personalities.
Sutcliffe and Jones" critically examined the relationship

between multiple personality and hypnosis. They described
three periods in the history of multiple personality: hazy
beginnings; firm establishment of the diagnosis; and a
falling-off period. They considered a number of explanations
that might account for its popularity at the end of the 19th
century and its virtual disappearance half a century later.
First, in part, multiple personality had become a "diagnostic

fashion" in the late 19th century, and Sutcliffe and Jones
believed that the number of reported cases was inflated by
misdiagnosis. However, they added that "many of the cases

of multiple personality could not be dismissed as merely
wrongly diagnosed.""
Second, they believed that "certain general features of the

cases and their therapeutic setting point towards therapist
influence,"35 that "the subtle communication of expectations"
served to selectively shape the multiple personality behaviors
of these patients. Most importantly, however, they concluded:
"Shaping has played some part in the development of multi-
ple personality cases, but it does not explain the whole phe-
nomenon away. Some of the cases first manifested their dual
behavior outside the therapy session."36
Third, they considered the viewpoint that multiple personality

is a manifestation of hypnotic phenomena: "Multiple person-
ality cases have almost always been reported to be extremely
good hypnotic subjects. 3 7 Having voiced this viewpoint, they
nevertheless concluded that it was based "on inadequate
grounds," because some cases of MPD occur without hyp-
notic involvement and also because the case studies wherein
hypnosis is used to produce multiple personality-like behav-
iors are "incomplete" in that they fail to produce the full
range of behaviors characteristic of MPD. 8 After a thorough
review, Sutcliffe and Jones ultimately concluded that "it is
important to reject 'shaping in hypnosis' as an explanation of
multiple personality," but they noted that "multiple personal-
ity behaviors can be readily brought out in or shaped up in
hypnosis [for those patients who have the condition]."39
Fourth, Sutcliffe and Jones considered the viewpoint that

MPD behavior is "simulated." According to this belief,
patients who do not have MPD "act as if" they do, either
because they are deluded or because they are deliberately
deceiving the therapist. Sutcliffe and Jones concluded that
MPD does not conform to the typical interaction seen in sim-
ulation situations like acting, in that there is little evidence of
an agreed-upon set of rules about how to act in therapy and
no evidence of social pressure to conform to a new identity.
If simulations occur in MPD, according to Sutcliffe and
Jones, they are based on "wrong self perceptions."40 Overall,
Sutcliffe and Jones concluded, even after all these other
explanations have been considered, that MPD is a genuine
phenomenon:
• . .multiple personality cannot be entirely dismissed as an epiphe-
nomenon of fashion, or of shaping under the prejudices of the ther-
apist, or of hypnosis. Something remains to be characterized ...
In general, then, something remains of multiple personality when
the influence of circumstances which exaggerated and over-drama-
tized it have been removed. It appears that alterations of personality
are manifested in conditions
41
of faulty self-perception (delusions) on
the part of the subject.
It is noteworthy that the two major premodern critical

reviews of the MPD diagnosis in the last century-by Taylor
& Martin and by Sutcliffe & Jones-draw similar conclu-
sions. Both favor the credulous view of MPD, and both state
that suggestive influences might be operative in some cases
of MPD but that iatrogenesis via suggestion is not an ade-
quate general explanatory model for MPD. These conclusions
in each review were independently drawn from a careful
review of the evidence and were made during a climate of
general skepticism about, or disinterest in, MPD.
C. Resurgence In contrast to the infrequently reported cases of MPD in the

of interest in first half of the 20th century, reports of MPD cases progres-
MPD-the sively increased in the 1970s and 1980s. Only eight cases
modern period were reported between 1955 and 1970, and 79 cases were
reported between 1979 and 1981.42 From 1971 to the present
the accumulated number of cases has been estimated at about
6,000,41 so that some considered this dramatic increase an
"epidemic." The number of professionals interested in MPD
also dramatically increased in the 1980s. Subdisciplines
within science typically begin as "invisible colleges '45 or
informal networks of professionals all sharing an interest in
the same phenomenon. These informal networks eventually
evolve into more formal professional societies. Following
this predictable course, a new professional society, The Inter-

national Society for the Study of Multiple Personality Disor-
der/Dissociative States (ISSMPDDS; now known as the
International Society for the Study of Dissociation: ISSD),
and a new journal, Dissociation, appeared by the mid to late
1980s.
Yet despite a remarkable revitalization of interest in MPD

among a growing number of professionals comparable to
interest at the turn of the century, a skeptical voice persisted,
as it had at the end of the 19th century. Dell 46 was the first to
document, in 1988, the persistence of skepticism about MPD
in modern times despite the resurgent interest in it as a men-
tal disorder. In 1986 he randomly surveyed 120 members of
the International Society for the Study of Multiple Personal-
ity. Of the 52% who responded, 98% reported that they
had "encountered skepticism from fellow professionals,"
78% said that such skepticism was "intense," 47 and 32%
reported harassment by colleagues. Dell concluded that "the
present findings imply that skeptics strongly disagree with
the survey respondents about the clinical phenomena of
MPD.4 1 . . . Many of these incidents entail levels of skepti-
cism about MPD that would seem to far exceed the bound-
'49
aries of both professional conduct and good clinical care.
D. The Skeptics have argued either that (1) MPD does not exist as a
skeptics' naturally occurring psychiatric condition and is the product
position on of misdiagnosis; because MPD typically co-exists as a diag-
iatrogenesis nosis with a number of other psychiatric conditions, these
other conditions more parsimoniously explain the condition
than MPD; or that (2) MPD exists, but only as a product of
suggestive influences in therapy. According to this latter
viewpoint, a diagnosis of MPD can legitimately be made:
Alter personality states do exist, but only because they were
created in treatment. With respect to malpractice claims, the
former viewpoint pertains to allegedly negligent diagnostic
practice, and the latter to allegedly negligent or substandard
treatment. Because of the rapid increase in malpractice suits
alleging implanting a false MPD diagnosis through sugges-
tive and coercive treatment, we will critically examine the
scientific evidence used by plaintiff expert witnesses in sup-
port of this claim.
III. Single case demonstrations and quasi-experimental

studies on secondary personality states
A. Estabrooks The experimental creation of personality states with hypnosis

-intentionally began with the work of Estabrooks in the 1920s.1° Estabrooks
splitting the was interested in the possibility of creating hypnotically pro-
personality grammed couriers for intelligence agencies." He believed
that hypnosis could be used to create second personalities in
the same individual, one of which was apparently normal and
the other of which would be hypnotically programmed to
carry secret intelligence information without knowing about
it at a conscious level. He hoped that such couriers would
reveal these secrets only under hypnosis by an interviewer
who gave specific suggestions to access the material, but that
the courier would otherwise resist disclosing this material
under interrogation or even torture. The extent to which
Estabrooks succeeded in his experiments to systematically
create artificial MPD for military purposes and "psychologi-
cal warfare" is unclear, since he worked "in the field where
publication was frowned on. 5 2 It is known, however, that
the Central Intelligence Agency formally conducted such
experiments in the 1950s and that Estabrooks served as a
consultant for at least some of them. Later Estabrooks
explained that creating unconscious couriers "rests in split-
ting a man's personality, or creating multiple personality,
with the aid of hypnotism."53 Often this required months of
hypnotic programming in selected, highly hypnotizable sub-
jects. Estabrooks claims to have been successful in creating
unconscious couriers who were amnesic for the secret infor-
mation they held. None of his writings, however, describes
even a single case in any detail, and there is no indication in
any of his writings that he ever succeeded in creating multi-
ple personality disorder.
B. Harriman Philip Harriman extended Estabrooks's original work with

-indirect the idea that MPD could be created in experimental subjects
suggestions with indirect hypnotic suggestions. In 1942 he reported "a
for secondary procedure for the experimental production of some of the
personality characteristic features of multiple personality. '5 4 In general,
states in the technique consisted of inducing a "profound hypnotic
normal trance" in a single subject, and then "suggest[ing] a role." He
individuals claimed that the highly hypnotizable subject "will act out the
part" according to the specific role suggested.5
More specifically, the procedure begins by inducing a deep

trance in a "good hypnotic subject." Next, Harriman intro-
duces suggestions to produce automatic writing in the sub-
ject, whose hand and arm have been dissociated from the
body through hypnotic suggestion. The subject is told that his
dissociated hand "will commence to write, as though
impelled by some force outside his field of awareness," fol-
lowing which he is told that he will be amnesic for every-
thing suggested to him. 5 6 After waking from the trance, the
amnesic subject is shown the automatic writing sample; typi-
cally the subject is unable to tell what the writing means. In
explaining the results, Harriman says
this procedure evokes three definite "personalities." The cryptic
automatic writing is done by a "personality" that the writer calls
X-2. In the post-hypnotic somnambulistic condition there appears a
"personality" that knows nothing about the meaning of the writing;
this phenomenon is referred to as X-3. . . .Finally . . .X-1
returns. X-l, of course, is the normal personality. . . .The only
"personality" induced by more or less direct hypnotic suggestions is
X-2. In this case, directions are given except
57
those which pertain to
the "loss of control" over arm and hand.
Harriman made the following observations about these "sec-

ond personality states":
The subjects seemed to have undergone rather profound alterations
in their personality integrations; hence, even to untrained observers,
they were "different persons" while they did the automatic writing.
. . .Similarly, when they were first asked to explain the meaning
of what they had written, they appeared to be bewildered, per-
plexed, and confused. 8
According to his observations, these secondary personality
states exhibited a number of characteristics such as handwrit-
ing changes, "speaking in a different tone," and discussing
topics "wholly remote from the interests of the 'normal
self.' "I'
Harriman interprets these results as the outcome of indirect

hypnotic suggestion and the manifestation of hypnotic behav-
ior. He believes these observations offer an explanation for
the iatrogenic creation of MPD:
The writer has no doubt at all that personalities X-2 and X-3 are
mere artifacts produced by the nature of the suggestions. ° There
remains a conviction that some of the phenomena of multiple per-
sonality have been unwittingly produced by the nature of the ques-
tioning and by the implied suggestions which have been given by
various investigators. When these fallacious procedures are coupled
with a precommitment to an elaborate theory of the nature of multi-
ple personality, it is61not hard to conjecture why some amazing cases
have been reported.
In other words, secondary personality states are naturally

occurring phenomena found in a select sample of good hyp-
notic subjects. Harriman believes that clinicians who might
have "unintentionally induced" these states might have misin-
terpreted what they saw as multiple personality.
Harriman claims to have replicated the production of these

62
secondary personality states "on more than fifty occasions,
although he fails to mention whether these were replicated in
the same subject, a few subjects, or a larger sample of sub-
jects.
Harriman subsequently made a number of modifications to

his procedure. The first involved hypnotically suggesting
profound depersonalization and also giving direct sugges-
tions to temporarily suppress manifestations of the normal
personality:
The subject is told repeatedly that everything is strange and unfa-
miliar . . . he is given as complete an experience of "depersonal-
ization" as the operator can produce. . . the operator now proceeds

to build up the attitude that the normal personality of the subject no
longer has any intimacy or close identity with him. It's as though
the normal personality were either non-existent or merely a distant
acquaintance . . .an amnesia is now established for all sugges-
tions. Now, when the subject is awakened from the trance, he
assumes a "different personality." The precise role which he is to
play is not defined for him. He has been told that his normal per-
sonality has "faded away." Invariably the subject adopts the role
which has been determined by phantasies. 63
The second modification entailed introducing a specific cue

to elicit learned secondary personality behavior:
When the pencil was turned bottom-up, his personality was to be
changed in a manner that he would not understand. His arm and
hand would seem as though they did not belong to him. . . .Con-
sequently, the rotation of the pencil became the conditioned stimu-
lus to induce "John-2."
The third modification was to "induce a personality state

through waking suggestion."' 65 Harriman discovered that hyp-
nosis was unnecessary, and that similar secondary personality
phenomena could be produced without ever inducing a hyp-
notic trance.
The fourth modification involved extensive training of the

subject. Harriman made a film, Cryptic Automatic Writing by
a Multiple Personality," wherein one subject was trained to
have profound alteration in his personality:
With a number of training periods, a good hypnotic subject builds
up a rather sharply defined set of multiple personalities. 67
It is important that the reader appreciate the serious limita-

tions inherent in the Harriman demonstrations. Most impor-
tantly, Harriman's demonstrations are by no means scientific
experiments. Harriman made no attempt to control extraneous
variables that might account for the effect. These "experi-
ments" were typically conducted as classroom demonstrations
in front of an audience of other students, and they typically
involved subjects whom Harriman had previously trained and
used in other demonstrations. It is clear that Harriman worked
repeatedly with a small number of subjects, some of whom
"participated in many hypnotic experiments," 6 so that obvi-
ous sample bias and demand characteristics clearly obscure
any interpretation of the results.
Second, it is clear from Harriman's own explanations as well

as from subsequent scientific research that the production of
secondary personality states is primarily a function of a per-
sonality trait, high hypnotizability, and consequently the pro-
cedure used to induce these states plays a minor role in their
production. Consistent with this view, Harriman noted that
"each of these dual personalities . . . arise[s] spontaneously
as a result of indirect suggestions. '69 He adds that such sec-
ondary personality states can be induced "without resorting to
hypnosis"; 7 i.e., they are subject specific, not procedure spe-
cific. According to Harriman "about 5 per cent of young
adults can be directly induced to do cryptic automatic writing
in the waking state."'7' This figure is roughly equivalent to the
distribution of the personality trait of very high hypnotizabil-
ity in the general population. Harriman stresses that these
states can be produced without hypnosis, and thus are not a
product of hypnotic procedures per se. In other words, differ-
ent phenotypic responses can be produced by exposure to dif-
ferent social contexts, but mostly among subjects who seem
to have some type of underlying dissociative/highly hypnotiz-
able genotype. This is similar to research in biological genet-
ics where the same underlying genetic materials (i.e.,
genotypes) have been observed to develop different surface
characteristics (i.e., phenotypes) as a result of being exposed
to different environments.
Third, the secondary personality states that Harriman demon-

strated were, for the most part, temporary states produced in
part by the subject as explanations for dissociated experi-
ences (like automatic writing). As such, Harriman's experi-
mentally produced secondary personality states fail to meet
the criteria for alter personality states characteristic of
patients with a diagnosis of MPD. According to DSM crite-

ria, an MPD patient's alter personality must take executive
control. This feature is fundamental to the definition of the
multiple personality disorder in the DSM conceptualization.
The secondary personality states that Harriman produced
temporarily in response to suggestions do not meet the crite-
rion of executive control. DSM also requires that a patient
with MPD exhibit two or more alter personality states, and
the modem classic MPD patient averages 13 alter personality
states. 73 It is noteworthy that with all of his attempts, Harri-
man says, "By none of these techniques has the author ever
succeeded in evoking more than two secondary personali-
ties. ' 74 Furthermore, genuine MPD patients spontaneously
produce discrete alter personalities, each with relatively sta-
ble characteristics, in a variety of contexts. By contrast,
Harriman's demonstration subjects produced "poorly acted,
ineffectual, compliant personalities"7 5 that were limited to the
time and context of the demonstration.
The secondary personality states that Harriman produced do

not meet the DSM criteria for alter personalities that take
executive control, so that generalizations about MPD from
these data cannot be made. Harriman overgeneralizes from
his data. He says, "Repeatedly the author has demonstrated in
the classroom and in the laboratory all the principal types of
7' 6
behavior described in the literature of multiple personality.
However, elsewhere he gives a more modest, qualified inter-
pretation when he says, "it is possible to create experimen-
tally some (emphasis added) of the phenomena [of multiple
personality] .
C. Leavitt- Leavitt78 expanded on Harriman's ideas in several important

direct hypnotic ways. He was the first to report the experimental production
suggestion of of secondary personality states in a patient. He claimed to
secondary have produced a more stable personality state with relatively
personality discrete characteristics in contrast to the temporary, ill-
states in defined states discussed by Harriman. Leavitt described the
patients case of a 20-year-old World War II soldier with right hysteri-
565
cal hemiparesis that developed subsequent to a war trauma in

which a buddy was killed. Previous treatment based on abre-
active reliving of battlefield experiences had failed.
Using Harriman's automatic-writing method, Leavitt pro-

duced secondary personality states "by suggesting that the
writing was under the control of a certain part of his [the sub-
ject's] personality unaware [sic] to him.'" 9 This resulted in
the spontaneous manifestation of a secondary personality,
Frank, who revealed additional unconscious material about
the war trauma. Later in the treatment, Leavitt attempted
something not reported by Harriman: the production of an
additional secondary personality by direct, not indirect, sug-
gestion, in which a very specific role was suggested. Leavitt
says, "It was decided to attempt to produce a personality in
direct contrast to the one already established":
"As you know, Dick, just as everyone has a good side to him, so
has he a bad side. It's as though an angel were standing on one side
of a man and the devil at the other side. . . . Well, let's give your
bad side a name. We shall call him Leo. I am going to talk with Leo
now. Leo, you know Dick pretty well, don't you-you're always
trying to get him to do bad things, aren't you." From this point
direct information was specifically requested. 8
According to Leavitt, "The contrast between Frank and Leo

was startling."" Leo was able to freely discuss aspects of the
war trauma that were too horrifying for Frank to discuss and
that were actively resisted by Dick.
Leavitt did not think these secondary personality states were

artifacts created through suggestion. Instead, he believed that
hypnotic suggestion allowed direct access to preexisting but
unmanifested parts of the mind. He says, "Certain elements
of the original personality may be isolated"8 2 [through hyster-
ical dissociation and later in hypnosis] "being manifested as a
distinct and separate personality entity."8 3 Thus Leavitt's
interpretation of these data was not that hypnotic suggestion
"created" new personality states so much as it allowed access
to pre-existing dissociated personality states.
D. Hilgard- Using a series of standardized measures of hypnotizability,

hypnotic Hilgard 4 conducted the first major studies of individual dif-
production ferences in hypnotic responsiveness. According to extensive
of secondary research with the Stanford Hypnotic Suggestibility Scales
personality (Forms A & B, and the graded difficulty scale, Form C),
states in the about 5%-10% of the general population are highly hypnotiz-
laboratory able, about 5%-10% are relatively non-hypnotizable, and the
remainder are moderately hypnotizable. Hilgard and his asso-
ciates also devised the Stanford Profile Scales to assess the
great range of hypnotic responding in very highly hypnotiz-
able subjects. Among the numerous types of subtalents
tapped by the Profile Scales, Hilgard included a suggestion
for the creation of secondary personality states. Specifically,
the highly hypnotizable subject was given a direct suggestion
to enact the role of a stupid person. Hilgard found that a
small percentage of subjects accepted the suggestion,
reported a different identity, and temporarily acted unintelli-
gent. When given selected items from the Wechsler Adult
Intelligence Scale, he found that IQ scores dropped off signif-
icantly, corresponding to the enacted role, especially for
highly hypnotizable subjects. While demonstrating that direct
hypnotic suggestions could produce secondary personality
states in a limited number of hypnotic subjects, Hilgard was
cautious to point out that producing these temporary states is
not an adequate demonstration that MPD can be created. Fur-
thermore, Hilgard acknowledged that these findings could be
interpreted equally as evidence in favor of (1) the suggestive
creation of personality states or (2) accessing pre-existing
dissociated personality states:
While a temporary personality state can be suggested to a small
number of hypnotizable subjects, a full-blown case of MPD has
never been observed in the laboratory. These, in full-blown form,
are quite rare, and our experience has not included any persistent
multiple personalities. The issue within hypnosis is whether hypno-
sis merely reveals underlying splits within the personality, or
whether it creates these personalities through suggestion. There is
no doubt that such effects appear within hypnosis, however they are
produced. . . . This is a puzzling matter, and the final answers are
not yet ready to be given. 5
It is noteworthy that in three decades of carefully designed
laboratory research on thousands of hypnotic subjects Hilgard
was unable to find a single case of "persistent multiple per-
sonality" created through hypnotic suggestion.
E. Kampman Kampman 6 conducted the first systematic study of the preva-

-prevalence lence of secondary personality states. She sampled 450 sec-
rates of ondary school children in an urban area in Finland. She found
hypnotically that approximately 17% "could enter a deep hypnotic state""7
induced and "about 7% of the volunteer subjects were able to respond
secondary to suggestions to create a secondary personality."" The spe-
personalities cific instructions were:
"You go back to an age preceding your birth; you are somebody
else, somewhere else." The suggestion was repeated many times,
and, at the same time, additional suggestions were given to the
effect that everything was completely normal and that nothing
miraculous was happening. 9
A psychiatric interview revealed that those who were able to

produce secondary personalities were "clinically healthier
and more adaptive" than those who could not, except that
these otherwise normal subjects had a greater capacity for
"identity diffusion" than those who could not produce sec-
ondary personality states. In contrast to Hilgard, who saw this
phenomenon as being quite rare, Kampman concluded:
The present study demonstrated that among highly hypnotizable
subjects the phenomenon of being able to respond to suggestions to
create multiple personalities is relatively common. 90
F. Conclu- Since the error rate in these largely anecdotal case studies
sions drawn and assessment studies is unknown, it is premature to draw
from firm conclusions about the prevalence rate for secondary per-
anecdotal sonality states. The extent to which sampling biases, expecta-
case studies tion effects, demand characteristics, experimenter biases, and
and quasi- other artifacts confound the results in these studies is also
experimental unknown, since none of these studies used adequate experi-
studies mental designs to control for these and other possible con-
founding variables. At best these reports are suggestive of a
phenomenon worthy of controlled scientific research. The

studies do, however, concur in their view that the manifesta-
tion of secondary personality states is a unique personality
trait found in a highly select group of subjects, who can man-
ifest these states in response to both hypnotic and waking
suggestions. While the occurrence of secondary personality
traits has been demonstrated at least in highly select experi-
mental subjects, the experimental creation of stable, enduring
multiple personality states has never been demonstrated in
any of these studies. Therefore claims that any of these stud-
ies offers scientific evidence that MPD can be created
through suggestion are grossly overgeneralized and unwar-
ranted.
IV. Controlled laboratory study of hypnotic

multiple role enactments
A. Hypnotic Laboratory investigation of the DID iatrogenesis hypothe-

multiple role sis is limited to a few published studies by Nicholas Spanos
enactments- and his associates. Spanos, Weekes, and Bertrand (1985) 9'
the Spanos designed a laboratory experiment to demonstrate that multi-
experiments ple personality could be constructed from a simulated psychi-
atric interview conducted in a certain way. The idea for the
research design came from Spanos's analysis of an expert
witness in a particular case: John Watkins's psychiatric inter-
view with Kenneth Bianchi, one of the defendants in the
notorious Hillside Strangler murder cases. 92 According to
Spanos, Watkins introduced a set of expectations to Bianchi
that he was to produce "another part of Ken" that was differ-
ent from Ken, and in so doing implicitly cued Bianchi to dis-
play and enact an alter personality role during a hypnotic
interview. Watkins, contrary to Spanos, interpreted Bianchi's
manifestation of an alter personality, Steve, in the hypnotic
interview as evidence that hypnosis established the conditions
for this pre-existing dissociated alter to emerge.
569
Spanos does not believe the alter emerged, but rather was
created by the hypnotic interview. He says:
A social psychological conceptualization suggests instead that
people learn to enact the role of the multiple personality patient
. . . using available information to create a social impression that
is congruent with their perception of situational demands and with
the interpersonal goals they are attempting to achieve.93
Spanos sees all human interactions as governed by a set of

rules. From a social learning perspective, prospective multi-
ple personality patients "learn to construe themselves as pos-
sessing multiple selves . . . and learn to reorganize and
elaborate on their personal biography so as to make it con-
gruent with their understanding of what it means to be a
multiple." 94 Patients learn the multiple personality role,
according to Spanos, in part from the implicit expectancies in
the therapy situation and in part based on their own motiva-
tions, fantasy productions, pre-existing beliefs, and whatever
information is available to them in the popular culture about
multiple personality. Thus for Spanos naturally occurring
MPD does not exist, but is necessarily the outcome of social
construction. Hence Spanos's theoretical explanation of MPD
attempts to account for phenotypical variations as a function
of differing social contexts. Spanos does not propose or
emphasize any genotypical component in his account of
MPD.
Spanos believes that therapists encourage patients to interpret

symptoms "in terms of one or more indwelling but uncon-
scious selves."95 "Highly leading hypnotic interviews during
which alter personalities are explicitly suggested and explic-
itly asked to 'come forth' and talk" are central to the process
by which multiple personality enactments are constructed.96
According to Spanos, the patient learns the "rules," such as
knowing which experiences and behaviors go with which
identity.9 7 The extent to which these "multiple role enact-
ments" are seen as real or as fantasy productions depends a
great deal on the "validating context" of therapy, so that the
therapist, as authority figure, helps legitimize these mul-

tiple role enactments as genuine dissociated personalities. 8
Specific therapeutic procedures, such as calling out alters,
conversing with alters, and enlisting alters in coping enhance-
ment and memory processing, further legitimize and reify
these role enactments. According to Spanos, "patients come
to adopt a view of themselves that is congruent with the view
conveyed to them by their therapist.""
The first experiment designed to test this socio-cognitive

model of MPD closely followed the original forensic inter-
view of Bianchi. A total of 48 subjects, 24 male and 24
female, were randomly assigned to one of three groups: the
Bianchi treatment group, the hidden-parts treatment group,
and the no-hypnosis control group. Subjects in all three
groups were explicitly asked to role play being an accused
murderer, Harry or Betty, who was undergoing a forensic psy-
chiatric interview.
The Bianchi treatment group received a hypnotic interview

"that was taken almost verbatim from the Bianchi inter-
view."1 0 This group received a "hypnotic induction cere-
mony" (HIC)and was also given instructions that called forth
a "part" (CFI-"calling-forth instructions"). Specifically, the
Bianchi subjects were told after being hypnotized:
I've talked a bit with Harry (Betty) but I think perhaps there might
be another part of Harry (Betty) that I haven't talked to, another
part that maybe feels somewhat differently from the part that I've
talked to. And I would like to communicate with that other part. 01
In the Bianchi group, the experimenter talked with the "part"

directly and asked it, "Are you the same thing as Harry
(Betty) or are you different in any way?"' 2 Responses were
scored in terms of whether or not the subject reported a dif-
ferent identity and also reported a name other than Harry or
Betty. Those who adopted a different identity or name were
told that the interviewer would contact them again in the
future by addressing the part by its name, but that otherwise,
upon the subject's awakening, the interviewer would again
talk with Harry or Betty.
The non-hypnosis control group (PII-"personality informa-

tion instructions") was told that all people have thoughts and
feelings that are "walled off" from the conscious mind and
that "it's almost like there are different people inside of us
with different feelings and ideas."' 13 They were not told
explicitly that they had different parts and were not given an
interview to call forth parts. Hypnosis was not used in the
interview.
The hidden-parts group was given the same personality infor-

mation instructions as the control group. Hypnosis was used
for the interview. They were given the additional instructions
that hypnosis was a technique (HTI-"hypnosis as a tech-
nique" instruction) that could be used "to get behind the men-
tal wall to the blocked-off parts" and that the hypnotist "will
get behind the wall and will be talking to the part."'"
A summary of the instructions given to all three groups:

Bianchi group (HIC, HTI, CFI, PII); hidden-parts group
(HIC, PII); and no-hypnosis control group (PII).
In a second session, subjects in all three groups were given

several personality inventories to ascertain whether those
subjects who enacted parts produced these "parts" with test
profiles that were essentially different from their original
role-played identity.
As expected, significantly more subjects in the two "parts"

groups than in the control group enacted a new identity who
confessed to the murder. The Bianchi group, characterized by
the clearest explicit experimental demand to produce "parts,"
had significantly more subjects that produced different identi-
ties (81%) and different names (83%) than the other two
groups. Both the Bianchi group and the hidden-parts group
had subjects who produced a part that was different from
Harry or Betty and reported amnesia significantly more than

did the subjects in the control group. None of the control sub-
jects adopted a different name or became amnesic. A total of
41% of the subjects in both "parts" groups reported both a
different name and amnesia, and these were considered "mul-
tiples" by Spanos. Compared with the "non-multiples" these
"multiples" showed evidence of significant differences on
psychological tests as compared with their original testing.
The multiples also "maintained this role successfully in their
second [interview] session."105
Spanos et al. interpret these data as a laboratory demonstra-

tion of the "major symptoms of multiple personality"'1' 6 07 and
thus conclude that they have demonstrated the iatrogenic cre-
ation of multiple personality. They say:
[O]ur findings indicate rather clearly that when given the appropri-
ate inducements, enacting the multiple personality role is a rela-
tively easy task.10
The hypnotic context plays a critical role in shaping these

expectancies, according to Spanos. The reason why "multi-
ples" (second name/different identity plus amnesia) were
"created" more often in the Bianchi group than in the hidden-
parts group was because "it was in this treatment that the
enactment was given particularly clear and consistent legiti-
mation. Here, subjects' "parts" were addressed directly.' °9
Spanos adds, however, that although the hypnotic context
"provide[s] a legitimizing context for redefining the situation
as one in which displays of 'cross-personality' remembering
are now considered role appropriate,""' this view "does not
deny that long-standing attributes and cognitive styles may
predispose some people to adopt this role more easily and
more convincingly than others.""'
Frischholz and Sachs"12 conducted an experiment with 120

subjects designed to replicate the Spanos et al. 1985 study."3
They used the same three conditions: Bianchi (HIC, HTI, PII,
CFI), hidden parts (HIC, PII) and no hypnosis (PII) where
(1) HIC=administered a hypnotic induction ceremony (yes/no);
(2) HTI=administered instructions that hypnosis is a tech-
nique that makes it possible to find out more about people
(yes/no); (3) PII=personality information instructions that we
all have walled-off parts/feelings (yes/no); and (4) CFI=call-
ing-forth instructions that specifically asked another part of
the subject to come out and be heard (yes/no). However, the
modified Frischholz and Sachs design also included an exper-
imental condition that had only PII and CFI instructions (but
not HIC or HTI).
The results essentially replicated the Spanos et al. study, with

some important differences. The Frischholz and Sachs find-
ings demonstrated that neither a hypnotic induction (HIC) nor
instructions about hypnosis as a technique to get at blocked-
off parts (HTI) were necessary to produce the same effects
manifested in the Bianchi treatment, which included the
combination of HIC, HTI, CFI, and PII instructions. Further-
more, Frischholz and Sachs found that none of the effects in
the Bianchi experiment were correlated with hypnotic respon-
sivity.
Collectively, the Frischholz and Sachs results and the Spanos

et al. 1985 results suggest that explicit instructions to access
(PII) and enact (CFI) "parts" result in multiple role enact-
ments in certain subjects. However, hypnosis is neither a nec-
essary nor a sufficient condition to produce signs of role
enactment in role-playing subjects. In other words, contrary
to Spanos et al.'s claim, the Frischholz and Sachs data
demonstrate that hypnosis does not legitimize or facilitate the
production of MPD-like symptoms.
Another interesting finding from the Frischholz and Sachs

study is that subjects given PII, CFI and HTI but not a hyp-
notic induction ceremony (HIC), though they were led to
believe it would be forthcoming, failed to manifest any of the
behavioral criteria (e.g., different name, different identity,
amnesia) characterized as having a different identity/person-
ality in this first session of what they believed was a two-part

experiment. Perhaps this was because they were waiting for
the administration of a hypnotic induction ceremony before
they would produce these phenomena. This has also been
observed in other hypnosis experiments where subjects hold
back their optimal performance in a waking condition and
then let themselves go during the hypnotic condition."1 4 Dur-
ing the second session of the Frischholz and Sachs study,
where the subjects were hypnotized, they did produce such
phenomena. In contrast, the behavior of real MPD patients
does not typically show such cross-contextual specificity.
Spanos, Weekes, Menary and Bertrand (1986)"1 attempted

to replicate the multiple role enactment experiments with
two important modifications: the psychological testing was
conducted before, not after, the hypnotic session, and age
regression was used in the hypnotic session. Spanos et al.
hypothesized that MPD patients learn to "construct a past his-
tory that is consistent with their self-presentation as possess-
ing multiple identities, ' ' 6 to construct a trauma history. The
role-playing paradigm of an accused murderer, Harry or
Betty, was used over three interview sessions. In the first ses-
sion, all role-playing murder suspects received a standard
psychiatric interview and psychological tests. In the second
session, the treatment group was hypnotized and given
explicit instructions to produce other "parts." Then an age
regression was conducted:
• . .just allow that finger to rise if I mention an age at which some-
thing important happened that is quite closely connected to the
reason why you're in jail now . . .I want you to feel as you were
at that age." 7
The instructions for the no-hypnosis control group were the

same as those used in the Spanos et al. 1985 study. In the
third session, subjects who previously had reported a second
personality produced it again on cue. Those subjects, along
with subjects in the experimental group who did not produce
second personalities, filled out questionnaires while under
575
hypnosis, while the control subjects filled out the same ques-
tionnaires without hypnosis.
The results of this study essentially replicated those of the

Spanos et al. 1985 research. A total of 60% of the subjects in
the treatment group reported a different part with a different
name, and 80% reported amnesia for the hypnotic interview.
The additional finding of the Spanos et al. 1986 investigation
was that 81% of those subjects who reported second person-
alities said that these personalities were created in their per-
sonal history prior to age 10, and that these alter personalities
reported significantly more negative emotions and retrospec-
tive problematic personal histories than control subjects.
Spanos et al. interpret these data as follows:
These findings replicate and extend those of Spanos et al. and sup-
port the contention that explicit clinical interviews similar to the
one employed here can both encourage the adoption of multiple
personality enactments and legitimate their occurrence' .
Adoption of the multiple personality role requires that patients pro-
vide a personal biography that accounts convincingly for "how they
got that way." Along these lines our role-playing multiples pro-
vided retrospective descriptions that were similar in many respects
to the retrospective accounts in clinical case studies of multiple per-
sonality patients. . . . The retrospective descriptions . . . may be
strongly influenced by implicitly held conceptions of the traumatic
childhood origins of psychopathology, and may be organized and
elaborated into biographical accounts that serve to legitimate an
ongoing self-presentation as a multiple personality patient. 9
The third study by Spanos et al. (1991) extended the age-

regression instructions "to regress beyond birth to a previous
life."'2 As with multiple personality, Spanos views past-life
reports as "rule-governed, contextually supported social con-
structions.' 2' In the first experiment, low, medium, and high
hypnotizable subjects were explicitly told that
reincarnation was a belief common to many cultures and that scien-
tists had begun to collect evidence in support of reincarnation. . ..
It is possible to regress individuals even further back, beyond the
point of birth to a previous life. People can actually relive and re-
experience a past life through hypnosis. 22
Subjects who reported a past-life identity were then inter-

viewed about the details of this life and about the extent to
which they "experienced their primary self as fading into the
23
background during their past-life identity enactment."
A total of 32% of the experimental subjects reported past-life

identities, and the majority supplied names, times and loca-
tions in history for these past lives, although most of the
descriptions followed historical times with which the subjects
were quite familiar. Psychological testing showed that fan-
tasy-proneness as well as hypnotizability, but not psy-
chopathology, significantly predicted production of past-life
identities as well as their subjective intensity. Spanos et al.
interpret these data as "consistent with the hypothesis that
past-life reports are fantasies that subjects construct on the
basis of their often limited and often inaccurate historical
information."'24
In order to ascertain the extent to which these past-life

reports were a function of information given to them, a sec-
ond experiment was conducted in which half the subjects
were or were not told explicitly that past lives were often of
the opposite sex and from far-away locations. As predicted,
those subjects supplied with the information "incorporated
the target information into their past-life reports significantly
more often than did subjects in the neutral condition." In
the third experiment in this series, experimental and control
subjects were or were not given explicit information that past
lives were usually traumatic. As predicted, those supplied the
misinformation reported significantly higher levels of abuse
than those in the neutral condition.
Across the Spanos regression experiments, high hypnotizabil-

ity and fantasy-proneness significantly predicted reporting
past lives in a hypnotic context, and pre-existing favorable
attitudes about reincarnation significantly predicted those
subjects who were most likely to interpret these past-life pro-
ductions as real instead of as fantasies. A fourth experiment
provided some additional evidence that validation arising
from the interview context also predicted the credibility sub-
jects gave to their past-life reports. Subjects who were told
that scientific evidence validated reincarnation were signifi-
cantly more likely to take their reports as a sign of real past
lives than were subjects told that the experiment was about
creative fantasy.
Overall the data from all three Spanos et al. experiments, and
from the Frischholz and Sachs experiment, demonstrate that
certain subjects who are encouraged to role play second iden-
tities according to an explicit set of instructions may report
secondary personality states with or without hypnosis. These
reports represent a complex interaction of subject variables
(hypnotizability, fantasy-proneness, pre-existing attitudes and
beliefs) and the nature of the interview context (expectancies,
explicit instructions provided, and the way the interview is
conducted). Apart from demonstrating the complexity of the
variables involved in the generation of secondary-personality
reports, considerable caution is warranted with respect to
Spanos's interpretation of these data as evidence supporting
iatrogenic MPD. There is a vast difference between the pro-
duction of a temporary report in a laboratory and a genuine
enduring psychiatric condition.
B. Critique of The Spanos socio-cognitive model reduces MPD to socially

the scientific constructed role enactments. In this model, the often severe
evidence re: psychopathology associated with clinical MPD is minimized,
the Spanos and no consideration is given to the neurobiology of MPD.
role-enactment Very recent studies suggest a possible neurobiological basis
experiments to MPD in at least certain MPD patients. Sar et al., at Istan-
1. Neuro- bul University, conducted an important neurobiological
biological assessment of three male and three female patients diagnosed
evidence with dissociative identity disorder (DID). The diagnosis was
confirmed at a high level of confidence using a widely
accepted structured clinical interview. Five of the six DID
patients had previously reported a history of childhood sexual
abuse. Neurobiological functioning was assessed using a
SPECT, which measures radioactively tagged patterns of

blood flow to different brain regions during a particular task.
Accepting the premise that localized blood flow is a reason-
able indicator of which areas of the brain are more or less
active during a given task, the SPECT technology is a direct
way to measure localization of brain activity during particu-
lar tasks. Three trials of cerebral perfusion (blood flow) were
conducted for each patient: one while the host personality
was manifest, and two others when an alter personality was
present. A total of 18 cerebral perfusion measures were taken
across all six DID patients. The study was designed to assess
whether similar or different cerebral perfusion patterns per-
sisted across switches from the host personality to alter per-
sonality states. Persistent patterns of cerebral hypofusion
were discovered across conditions in the majority of patients,
irrespective of whether the host personality or an alter per-
sonality was present. Bilateral frontal perfusion deficits were
found in five of the six DID patients in all three states-the
host and the two alter personality states. Bilateral parietal
deficits were found in five of the six DID patients, but these
were not always observed across conditions except in three of
the six DID patients. The researchers conclude:
. . . this is the first study to suggest that frontal and parietal lobes
are involved as neuromediators in DID126 . . . This finding is inde-
pendent of changing personality states.
No regional perfusion changes were noted across personality

states.
Nijenhuis et al. 27 conducted a PET scan study of a female

MPD patient, whose diagnosis was also confirmed with the
SCID-D. The objective of this cerebral perfusion study was
to identify changes, if any, across manifestations of the host
personality and an alter personality that presented with trau-
matic recollections. Audiotaped scripts were prepared for
either neutral or traumatic autobiographical accounts previ-
ously reported in treatment. There were eight PET scan ses-
sions in which either the host personality or the alter
personality listened to the neutral or traumatic memory
scripts on two occasions each. Significant changes in regional
blood flow occurred only in the condition when the alter per-
sonality state was presented with the traumatic memory
script. These changes were accompanied by associated psy-
cho-physiological changes in blood pressure and heart rate
and by subjective reports of increases in the emotional and
sensorimotor dimensions of memory. Nijenhuis et al. interpret
these findings as supportive of state-dependent and script-
dependent memory characteristics of patients with DID. In
other words, significant neurological and psycho-physiologi-
cal changes occur when the MPD patient manifesting as an
alter personality with traumatic recollections has that memory
stimulated by a trauma script.
Because the methodology of cerebral perfusion studies is in

its infancy and the number of subjects in these studies is lim-
ited, it is unwise to draw definitive conclusions from these
data. Nevertheless these data do raise an important possibility
that MPD/DID may have a neurobiological basis. The frontal
lobes are involved in decision-making and executive control.
The parietal lobes are involved in integration of experience
and getting the whole picture. The clinical description of
MPD/DID is one of impaired executive control and of a frag-
mentation or dissociation of unitary identity into alter person-
ality states. In this sense, the discovery of a possible
dysfunction of the frontal and parietal lobes in at least certain
MPD patients is highly consistent with the main clinical fea-
tures of the illness. The additional discovery that significant
changes occur in regional blood flow (and possibly in
regional brain activity) when an alter personality experiences
traumatic memory is supportive of a possible neurobiological
basis to dissociative processing of traumatic memory in
MPD/DID patients. If additional neurobiological studies were
to firmly establish neurobiological deficits in patients with
genuine DID, these data would essentially refute the socio-
cognitive model, unless proponents of the socio-cognitive
model took the unlikely position that social interactions
caused brain dysfunction. Proponents of the socio-cognitive

position would have the burden of proof to demonstrate that
role-playing subjects under a Bianchi-type treatment condi-
tion displayed the cerebral perfusion changes associated with
MPD. Currently no such data about this possibility are avail-
able.
In our opinion, even though the neurobiological investigation

of DID is in its infancy, these neurobiological findings cast
serious doubt on the credibility of the socio-cognitive model
as sole explanatory model for MPD.
2. The problem How do we critically evaluate the evidence from the Spanos
of ecological research? These studies might be criticized on the grounds of
validity ecological validity. It is doubtful whether inducing relatively
healthy college students to temporarily enact secondary per-
sonality roles is an adequate demonstration that a major psy-
chiatric disorder, MPD per se, can be created in the
laboratory. Furthermore the motivational context of the labo-
ratory experiments was quite different from the clinical con-
text in that laboratory subjects were told they must role play
being an accused murderer. This research context biases the
subjects' responses in favor of pretending and then lying to
avoid criminal responsibility as part of their enacted role-
not exactly a context of "openness" conducive to the therapy
setting.
3. Simulated Do multiple-role enactments constitute an adequate labora-

MPD is not a tory demonstration of genuine MPD? Biscuits made from
demonstration scratch rarely look, smell, feel or taste the same as biscuits
of genuine MPD made from a mix. Neither the cause nor the end result is the
same, although the end results may seem to have some phe-
notypic similarities.
Spanos sees his laboratory subjects as actively engaged in

socially constructing a false reality. The experimental proto-
col explicitly calls for the subjects to simulate:
These patients are conceptualized as actively involved in using
available information to create a social impression
28 that is congruent
with their perception of situational demands.
This is analogous to a therapist telling patients who come to

therapy, "I expect you to simulate this MPD disease for the
duration of the therapy I am biased to believe in, so be skilled
enough to read the social cues and give me what I expect.
You are to manifest different identities with different charac-
teristics." Indeed, Spanos demonstrated that many subjects in
the experimental groups temporarily enacted the role of hav-
ing different identities. Is this evidence demonstrating that
MPD has been created in the laboratory? We definitely think
not. It is evidence that certain individuals in a high-demand
social context designed to produce secondary-personality
roles report such role enactments temporarily. But these role
enactments are not identical with alter behavior in MPD
patients, nor are they proof that a major psychiatric condi-
tion, MPD, has been created. They are simply simulations. In
a position similar to our own, Gleaves, in an important criti-
cal review of the MPD/DID iatrogenesis model, states, "The
socio-cognitive model appears to begin with the assumption
that multiple identity enactments and DID are equivalent phe-
29
nomena."1
Consider a hypothetical experiment using a design similar to

that of Spanos et al. (1985), in which normal college students
are given explicit instructions to play the role of a schizo-
phrenic and are told that hearing voices and talking incoher-
ently at times are common to schizophrenics. In a context of
a high demand to role play a schizophrenic, it is likely that a
significantly higher portion of subjects in the experimental
group relative to a neutral-instruction control group would
report hearing voices and would talk incoherently. We would
conclude that certain subjects played the role temporarily as a
function of the interaction between personality variables and
the high-demand social context. We would not make the logi-
cal error of concluding that those subjects who had enacted
the role had become schizophrenic. Anyone who uses the

Spanos data to conclude that MPD can be created in the labo-
ratory has made the logical mistake of confusing instructed
simulation with creation of the disorder.
In all three papers published by the Spanos group, all sub-

jects, including the control subjects, were instructed to play
the role of an accused murderer. The only difference between
the experimental groups and the control groups was that the
hypnotic subjects given instructions to call forth parts embel-
lished their roles. According to Spanos, subjects simulating
hypnosis are more likely than those not simulating hypnosis
to shape their fantasy productions in line with the expecta-
tions transmitted to them by the hypnotist.'30 However, the
Frischholz and Sachs study showed that calling forth (CFI)
and personality information (PH) instructions alone, without
hypnotic instructions, also led to role enactments. A conser-
vative interpretation of these data is that subjects given
"parts" instructions, with or without hypnosis, are more prone
than control subjects to multiple-role enactments. Irrespective
of hypnosis, if subjects are explicitly instructed to role play
having "parts" (CFI, PII) and some report "parts," does that
constitute a demonstration that a major psychiatric disorder,
MPD, has been created? Or is it rather simply a demonstra-
tion that some subjects could be induced to role play accord-
ing to the provided script? Is asking an individual to simulate
being drunk the equivalent of actually being intoxicated?
It is clear that Spanos et al.'s 1985 conclusion that MPD is a

role enactment based on their observation of role-playing
subjects is based on circular logic: You ask a subject to pre-
tend that he has alters and he complies; then you conclude
that having alters is the product of role playing. In his critical
review of the MPD/DID iatrogenesis argument, Gleaves
made a similar point:
Numerous critiques of the iatrogenic position have been published.
• . . The conclusions reached by these researchers have generally
been that, although some of the phenomena of DID can be created
iatrogenically, there is no evidence to suggest that the disorder per
se can be created. Thus, the iatrogenesis mechanism is insufficient
to explain all or even many reported cases of the disorder.'
Spanos's conclusion of the iatrogenic nature of MPD also

suffers from an additional logical error. Even if it were true
that MPD could be created iatrogenically, that does not prove
that every case of MPD is iatrogenic. This leaves open the
case for noniatrogenic MPD cases. There is no indication that
iatrogenic production of MPD, if possible, accounts for a
small, a medium, or a large number of MPD cases.
Another logical error is to assume that normal college volun-

teer research subjects and clinic MPD patients process social
cues in a similar manner. Presumably Spanos's laboratory
subjects are healthy enough to understand correctly the
implicit expectancies and explicit role-playing instructions
given to them-what Spanos calls the social "rules." In con-
trast, genuine MPD patients are often severely disturbed, pas-
sive, and confused about both their internal state and their
perception of the interpersonal context. Spanos's view of the
interpersonal context of his experiments presumes a level of
social skill yet to be demonstrated in clinic MPD patients as a
group. If MPD patients were well enough to read implicit
social rules with such skill, they probably would not need
psychiatric treatment as much as they do.
Spanos's view of the MPD patient also presumes that the sub-
ject is an active agent who correctly understands social inter-
action rules and remembers them accurately so as to enact the
desired role. By way of contrast, DSM defines MPD as a loss
of executive control. The MPD patient often engages in expe-
riences that are subsequently disremembered. By limiting his
research to healthy college volunteer subjects, Spanos fails to
establish whether genuine MPD patients are capable of skill-
fully interpreting the social contextual rules in the way he
portrays. Demonstrating temporary "multiple identities" in
healthy simulating laboratory subjects certainly is not the
same as demonstrating that the MPD disorder can be created.
Furthermore, Spanos found that multiple role enactments

were significantly predicted by healthy fantasy-proneness,
but not by psychopathology. Genuine MPD patients often
have high levels of psychopathology and multiple co-morbid
psychiatric diagnoses, and in such patients psychopathology
correlates significantly with alter personality manifestations.
It did not in the Spanos research. Spanos does not account for
this inconsistency.
Spanos's definition of MPD is problematic. He defines "mul-

tiple personality" in terms of any subject who reports a dif-
ferent identity and/or name plus amnesia in response to very
explicit role-playing instructions to produce these phenom-
ena. Again, it is clear that Spanos's reasoning that MPD is a
social role construction because it was observed among col-
lege students asked to play a social role while participating in
a psychological experiment is circular. One cannot conclude
that something is X simply by observing X.
Thus the Spanos studies alone do not adequately define MPD

for several reasons:
1. Situationally bound enactment of predefined secondary-

personality roles presumes sufficient executive control to do
it. Genuine MPD is defined in DSM as the loss of executive
control.
2. Genuine DID was defined in DSM-IV as the loss of a uni-

fied identity ("dissociative identity disorder"). Presumably
none of Spanos's laboratory subjects suffered from a funda-
mental loss of a unified identity as a result of the experimen-
tal instructions. At most, some of Spanos's subjects reported
the ordinary sense of self as "fading into the background"
during the secondary-personality enactment, but it never dis-
appeared completely as is found in MPD.' 2
3. Genuine MPD is characterized by enduring alter-personal-

ity states that are defined by a relatively stable set of person-
ality characteristics over time. The alter-personality states
manifest themselves spontaneously and in response to
requests to communicate with them. Their appearance is not
limited to a particular context, such as the therapy session,
and alters manifest themselves in a variety of extratherapeu-
tic contexts. The secondary-personality states reported by
Spanos's subjects in the laboratory were very temporary role
enactments. Spanos failed to conduct follow-up interviews to
see if these states endured beyond the one or two experimen-
tal sessions. Spanos offered no evidence that these states
manifested spontaneously outside of the context of the exper-
iment. Thus the research as designed fails to offer any evi-
dence whatsoever for suggestively producing enduring
secondary-personality states with relatively stable character-
istics that occur both within and outside of the context of
suggestion. In this sense, Spanos's data on suggestively pro-
ducing temporary personality states is not a demonstration of
suggestively producing stable alter personalities as found in
genuine MPD patients.
4. According to DSM-IV the essential features of DID are the

existence of alter-personality states that take executive con-
trol and for which there is some degree of amnesia.'33 Most of
the clinical literature on MPD/DID concurs that genuine
MPD is accompanied by a number of clearly defined clinical
features in addition to alter behavior. These clinical features
typically include phenomena such as identity loss, voices,
disremembered experiences, time loss, passive influence
experiences, depersonalization and derealization, and marked
shifts in ability and states of consciousness. '1 According to
Gleaves, "These dissociative symptoms, measured by objec-
tive means, have been found to discriminate patients with
DID from those with a variety of other disorders including
schizophrenia." 3 5 The problem, however, is that while using
this cluster of largely dissociative symptoms enables more
reliable and valid diagnostic discrimination between major
dissociative disorders and other psychiatric conditions, there
is considerable overlap in the range of dissociative symptoms
within the group of dissociative disorders. DSM-IV handles

the problem of differential diagnosis within the dissociative
disorders group by emphasizing what is unique to each. With
respect to DID, alter behavior is given prominence, and with
respect to dissociative amnesia, significant gaps in autobio-
graphical memory are emphasized. However, emphasizing
alter behavior as the uniquely defining feature of DID as
compared with other dissociative disorders in DSM-IV was
never meant to imply that this larger cluster of clinical fea-
tures typically associated with DID was unimportant in the
diagnosis of DID. A full appreciation of the psychopathology
of DID necessarily includes an assessment of the full range of
associated clinical features even where alter behavior is given
diagnostic prominence.
Spanos's focus on role-enacted secondary personalities and

amnesia is an attempt to create by suggestion in the labora-
tory those features of DID given prominence in DSM.
Gleaves, however, has argued that creating laboratory analogs
specifically to alter behavior does not constitute an adequate
test of DID. For Gleaves, an adequate scientific test of sug-
gestively creating a major psychiatric condition like DID nec-
essarily must include a demonstration that each of these
clinical features alone, and together in combination, could be
produced in a stable way through suggestive influences.3 6 In
other words, laboratory experiments would need to be
designed to show that, for example, time loss, identity loss,
voices, disremembered experiences, and depersonalization
could be suggestively created individually and in combina-
tion. Because the Spanos experiments are limited to reports
of secondary personalities and associated amnesia, they do
not serve as an adequate test to show that the entire range of
clinical features of MPD can be created through suggestion.
Gleaves has argued that "conclusions based solely on data
relevant to the concept of multiple identity enactment cannot
be generalized to the complex dissociative psychopathology
37
of DID."'
5. Genuine MPD is usually accompanied by trauma-related
symptoms (intrusive reexperiencing symptoms, generalized
numbing, physiological reactivity, panic states, shifting states
of consciousness), extreme emotional distress, and reports of
past trauma and abuse. An adequate demonstration that MPD
could be created in the laboratory through suggestion must
show that each of these types of trauma-related symptoms,
alone and in combination, along with false memories for
complex events, could be created through suggestion.
4. Stacking the Spanos's laboratory subjects are explicitly encouraged to play

deck to prove a role, to pretend being an accused murderer who is undergo-
the hypothesis ing a psychiatric interview.
They were instructed to role play Harry/Betty throughout the inter-
view and to use any knowledge they had about criminals and any
information that they could pick up from the setting, to give a con-
vincing performance. 3 '
Genuine MPD patients seen in the clinic are not given

instructions to pretend, and it is doubtful that therapists
explicitly tell these patients to simulate having alter personal-
ities. Furthermore, Spanos's laboratory subjects were explic-
itly asked to fake it, even to lie (even if they were not told the
specific content of what to lie about):
All of the subjects in these studies had been explicitly asked to fake
their responses, and, consequently, it can be argued that people who
were not faking would be unlikely to develop multiple identities
after exposure to leading hypnotic interviews. a9
In many respects the design of Spanos's experiments stacks

the deck by utilizing high-demand instructions for the sub-
jects to act specifically in the manner that supports the
hypotheses Spanos wanted to prove. Ironically, Spanos fails
to mention that laboratory subjects typically respond to the
expectancies and demands of the research and try to comply
by reporting what they sense the researcher is trying to
prove.Y° None of the research designs in Spanos's three pub-
lished studies on iatrogenic MPD adequately controls for
such demand characteristics and response biases that might

alternately explain the results. For example, in the Spanos et
al. 1985 experiment, the control group is exposed only to PII
and no hypnosis (HIC, HTI). This stacks the deck to prove
that hypnosis legitimizes the production of MPD-like symp-
toms. However, the Frischholz and Sachs 1991 experiment
includes another type of control group that has both implicit
(PII) and explicit (CFI) demands about what the subjects are
supposed to do. In that case, subjects produced the same level
of MPD-like symptoms without any hypnosis (HIC, HTI) as
subjects in the Bianchi condition (PII, CFI, HIC, HTI).
Because Spanos et al. (1985) did not include such a control
group, their experimental design "stacks the deck" to impli-
cate hypnosis as a legitimizing variable without consideration
of alternative hypotheses that could have been tested if other
types of control/comparison groups had been included in
their study.
The expectancies of participants in psychotherapy are quite

different from the expectancies of Spanos's laboratory experi-
ments. In therapy, patients are expected to say whatever
comes to mind, and therapists generally do not tell patients to
act in certain ways. Spanos has made the logical error of
assuming that psychotherapy is far less open-ended than
indeed is the case, and that his model of social influence in
the laboratory is also valid for the psychotherapy context. Yet
Spanos offers no real evidence that the laboratory experiment
and the psychotherapy context have the same set of expectan-
cies and social interaction rules.
Furthermore, important specific misinformation is intention-

ally supplied to the subjects in all of the Spanos experiments,
such as the presumption that the given subject has different
"parts," that such parts occurred at different ages, and that
parts are associated with traumatic personal memories. In
Spanos's social learning model, laboratory subjects are taught
to act like multiples through the misinformation supplied to
them. Here again, Spanos has made the logical error of
589
assuming that psychotherapists "train" patients to be multi-

ples by supplying them systematically with specific misinfor-
mation about alter-personality roles, the characteristics of
these alters, and the content of their reported personal memo-
ries. In reality, it is doubtful that therapists skilled in working
with MPD patients actually engage in this kind of behavior to
the extreme that Spanos believes. Communication with parts
typically occurs after the patient has reported or manifested
alter-personality behaviors, or at least after the patient has
reported disremembered experiences. Spanos offers no evi-
dence that therapists conduct "explicit clinical interviews" in
any way similar to those used by Spanos in his studies to
induce secondary-role enactments.' 41 In order to demonstrate
that secondary-role enactments can be created in an interview
context, Spanos has had to invent a fictional version of psy-
chotherapy that is more a parody of therapy than an actual
factual account of the social interaction of psychotherapy
with MPD patients.
Of course, the Spanos hypothesis fails to account for cases

where alter behavior and other manifestations of MPD are
observed by laypersons before any therapy occurs.
5. Overgeneral- Spanos has seriously overgeneralized from the data of his

izationfrom 1985, 1986 and 1991 laboratory experiments that multiple
the data personalities can be created in the laboratory. The more con-
servative interpretation merited by these data is that certain
individuals with certain personality characteristics in a partic-
ular social context report temporary role enactments of differ-
ent identities that are limited to the context of the experiment.
1. The three published studies by Spanos and his associates

currently constitute the entire database of laboratory research
designed to demonstrate that MPD can be created through
suggestion. The studies are methodologically flawed, and the
conclusions drawn from them go far beyond what the data
warrant. These few studies do not represent a sufficient data-
base, nor do they serve as adequate scientific proof that MPD
can be created through suggestion even in the laboratory.

These data-based studies in and of themselves do not meet an
acceptable standard of scientific evidence that MPD can be
iatrogenically created.
2. These personality states only were reported in a high-

demand context where secondary-personality role enactments
were explicitly demanded. Spanos's research designs fail to
address whether different identities significantly occur in a
low-demand or neutral context. Nor do the research designs
provide any evidence beyond speculation about what occurs
in psychotherapy with MPD patients. Spanos did not factu-
ally establish that the expectancies, social interaction rules,
and information supplied in interviews are comparable in the
laboratory and in the psychotherapy situation, and until such
scientific evidence is available, it is inappropriate to general-
ize from these laboratory data to the alleged iatrogenic cre-
ation of MPD in psychotherapy. These data do not offer
direct support for the iatrogenic MPD hypothesis, and at best
show that certain experimental subjects will play the role if
you tell them exactly what role to play.
3. The actual data from the three Spanos studies implicate

the personality characteristics of the subject at least as much
as, if not more than, the behavior of the interviewer in the
production of secondary-personality states. The Spanos data
suggest that subject characteristics such as fantasy-proneness,
high hypnotizability, prior favorable beliefs, and prior infor-
mation about multiple personality contribute significantly to
these secondary-personality role enactments. Interviewers
who introduce a strong demand to enact alter personalities,
and who also systematically supply misinformation about
MPD and past histories, also significantly contribute to such
role enactments. However, the independent contribution of
implicit interview expectancies per se in the production of
secondary-personality states is less clear. In the past-lives
experiment, for example, the interviewer context "required
that subject's fantasies be framed as autobiographical histori-
cal minidramas that are narrated by an . . .identity other
than the subject." 142 It is doubtful that therapists generally act
like this.
4. The Spanos data do provide some valuable insights as to

how a therapist might unwittingly "validate" MPD in a
patient who already has the condition. The Spanos et al. 1991
study addresses therapy as a "validating context."' 43 At best,
the Spanos et al. 1991 experiment shows only that a given
therapist's unwitting or intentional validation of alter behav-
ior would affect the patient's view of the alters' personality
states and their reported histories as real rather than as fan-
tasies, but these data do not show that such validation, even if
it occurred, actually created the secondary personality. At
best, such a therapist, through behavioral reinforcement,
might increase the frequency of occurrence of alter behavior
in patients who have MPD.
5. The research designs used by Spanos are not specific

enough to address the question of whether the reported
secondary-personality states in hypnosis are the product of
suggestive influences or the manifestation of preexisting
personality states. While Spanos offers his experimental data
as evidence in favor of secondary-personality states created
through suggestion in a simulated hypnotic context, an
equally plausible alternate explanation is that the social con-
text allowed subjects to gain access to and/or permit expres-
sion of preexisting personality states. For example, Watkins,
the expert who conducted the Bianchi forensic interviews,
believes that many normal individuals who have a unitary
personality also have a variety of "ego states" that sometimes
manifest themselves under certain conditions. Many normal
people, for example, resort to discourse about "parts" when
in conflict ("a part of me feels this and another part of me
feels that"), and normal people sometimes manifest quite dif-
ferent sides of themselves with certain people and when in an
altered state of consciousness-e.g., when drunk. Watkins has
hypothesized that the hypnotic state allows direct access to

the pre-existing "ego states."' 4
Does hypnosis iatrogenically create or allow access to preex-

isting secondary-personality states in certain individuals? In
1965 Hilgard stated that the answer to this question is "not
yet ready to be given." 54 Spanos's research designs several
decades later were not set up to answer this question any
more definitively. Therefore Spanos's interpretation of these
data in favor of the iatrogenesis position remains highly spec-
ulative, reflecting his preexisting theoretical bias. He never
attempted to determine whether his normal research subjects
had preexisting secondary-personality states prior to their
participation in the simulated hypnotic interview.
Overall the Spanos data offer no evidence that either stable

alter personalities or the range of clinical features typically
associated with MPD can be created in the laboratory, and the
data certainly offer no support whatsoever that MPD per se
can be created through suggestive influences. At best, these
data support the view that certain individuals in a high-
demand context, and/or under extreme interview conditions
wherein misinformation is systematically supplied, report
temporary secondary-personality states. The interpretation of
these secondary-personality states remains unresolved
because the Spanos experiments do not offer evidence to
determine whether the social context of the interview sugges-
tively creates secondary-personality states or allows for the
manifestation of preexisting states. Overall these data offer
little evidence that the disorder MPD per se can be created
through suggestive influence.
V. Laboratory studies on shaping alter behavior

in MPD patients
Although the Spanos experimental studies offer little support

that MPD as a psychiatric disorder per se can be created
through suggestive influences, these data do offer some sup-
port that MPD patients, like laboratory subjects, might shape
their alter-personality behavior according to the demands of
the social context. Spanos reported that his laboratory sub-
jects were "shaping their enactments in terms of perceived
contextual demands. 1116 While his data fail to demonstrate
that alter-personality states can be created through sugges-
tion, it remains an open question as to whether the behavior
of alter personalities in MPD patients who already have alters
might be influenced by the social context.
Kohlenberg' 47 conducted a laboratory study using a single

patient diagnosed with MPD. The purpose of the study was to
determine whether alter-personality behavior could be shaped
by social cues in an interview. The 51-year-old MPD patient
had three personalities that typically manifested in rapid suc-
cession in a single interview session. Each alter personality
was amnesic for the others. The baseline was established for
each of the alter personalities over 10 sessions by asking the
alter personality a series of 25 questions in a neutral manner.
During the next, contingency phase of the experiment, over
the next 10 sessions each answer to a question given by one
of the three alters was selectively reinforced "by giving the
patient a token and touching his hand."'48 During the final,
extinction phase, over the last 10 sessions "reinforcement was
given noncontingently at the end of each session," as it had
49
been in the baseline phase.
The results showed that all three alter personalities mani-

fested for similar amounts of time during the baseline period.
During the contingency phase, selective reinforcement of a
particular alter "resulted in an increase in the frequency of
this personality" and a decrease in the manifestation of the
other two alter personalities. 5 0 During the extinction phase,
the rate of manifestation of the previously reinforced person-
ality decreased to below the baseline rate. Although restricted
to only a single case, these data imply that the rate of mani-
festation of alter personality states in at least certain patients
diagnosed with genuine MPD may be at least in part a func-

tion of social reinforcement. Kohlenberg believed that the
professional attention given to alter-personality behavior can
reinforce it.
However, demonstrating that one can shape a particular

behavioral response is not the same as demonstrating that one
has created such a response in the first place. Conditioning
studies have generally shown that almost all behavior among
almost all species can be significantly altered from its base-
line frequency of occurrence through the use of selective
reinforcement. 15' Hence symptom shaping is not necessarily
the same as symptom creation or iatrogenesis. It has yet to be
shown whether MPD patients are significantly more condi-
tionable (i.e., more susceptible to the effects of selective rein-
forcement) than college students or patients suffering from
other types of mental illness.
Frischholz and Sachs attempted to replicate the Kohlenberg

study 52' using two MPD patients, a schizophrenic patient, and
a normal, highly hypnotizable subject. The baseline, contin-
gency, and extinction phases consisted of five sessions each.
As predicted, different types of contingency reinforcements
(direct: giving tokens; indirect: taking notes, paying atten-
tion) of either selected personality for each MPD patient
resulted in a progressive increase in the rate of manifestation
of the selected personality over the five reinforcement ses-
sions; and selective extinction (direct: no tokens; indirect:
yawning and looking away) of either selected personality
resulted in a progressive decrease in the rate of manifestation
of the extinguished personality. Additional conditioning case
studies were carried out using the evaluative dimension of the
semantic differential.
Collectively the data showed that selective reinforcement sig-

nificantly altered the subjects' responses, whether that sub-
ject was a patient suffering from MPD, a patient suffering
from schizophrenia, or a normal, highly hypnotizable subject.
In other words, selective reinforcement or extinction of
responses can be accomplished with patients suffering from
either schizophrenia or MPD. However, few would conclude
that selective behavioral reinforcement of a schizophrenic's
responses is evidence that schizophrenia is an iatrogenic ill-
ness. We fail to understand the logic of proponents of the
socio-cognitive model of MPD in their singling out MPD, as
if the demonstration that MPD-like symptoms can be shaped
is tantamount to the conclusion that the disease can be cre-
ated. If so, based on the Frischholz and Sachs data, socio-
cognitive proponents would similarly have to conclude that
schizophrenia had been iatrogenically created.
In addition, this phenomenon (selective reinforcement/extinc-

tion) also works with normal, highly hypnotizable subjects
and is not observed only among patients suffering from some
type of mental illness.
These data are valuable in supporting the hypothesis that alter

behavior in patients who genuinely have MPD may be shaped
by social interaction and learning. However, some caution is
warranted in drawing conclusions, since the entire scientific
data base currently consists of three subjects. Furthermore a
very clear conceptual distinction must be drawn between alter
creation and alter shaping. The Spanos experiments were pur-
portedly designed to address alter creation, although, as we
have seen, the research design does not allow conclusions
about alter creation per se. Alter creation through suggestion
has not been established in the laboratory. The Kohlenberg
and the Frischholz & Sachs experiments are designed to
address alter shaping, and they do provide some insights that
alter shaping might occur, at least in certain patients with
MPD. Alter shaping has also not been established with ade-
quate scientific evidence, but what little research is available
seems promising.
Alter shaping-not alter creation-is a concept that is gener-

ally accepted by clinicians experienced in the diagnosis and
treatment of MPD patients. Fine, for example, addressed the

problem of "iatrogenic creation of additional alter personali-
ties""53 in patients following therapist errors such as boundary
transgressions and other mistakes that "range on a continuum
from minor mistakes to inexcusable violations.'15 4 Fine pre-
sented a number of cogent case illustrations of inadvertently
created alters in patients who genuinely had MPD. Like Fine,
other experts on MPD concur that alter shaping and some-
times additional alter creation (the appearance and disappear-
ance of alters during treatment of those who genuinely have
MPD), but not iatrogenic alter creation (creation of the condi-
tion MPD per se), commonly occurs in MPD treatment. 5
VI. The debate about mechanisms-alter creation

vs. alter access
The debate as to whether the hypnotic context creates or

accesses pre-existing secondary-personality states has a long
history and is yet unresolved. A heated professional debate
took place in the 1970s about the nature of hypnosis that is
worth considering in light of the current controversy about
MPD. The debate about hypnosis then was whether hypnosis
was an altered state of consciousness (trance) or a response to
social influence. The state theorists, represented by Hilgard,
Ome, Fromm and others, argued that hypnosis was a unique
altered state of consciousness characterized by attentional
skill, fading of the generalized reality orientation, altered
information processing, and significant changes in cognition
and perception. The social influence theorists, represented by
T.X. Barber and Spanos, argued that the construct of a special
state or trance was irrelevant to hypnotic responding, and that
all aspects of hypnotic responding could be explained in
terms of manipulation of the implicit expectancies and moti-
vations and by explicit suggestion. Barber, for example, felt
that even unusual and dramatic examples of hypnotic
responding, like the production of bum blisters following
suggestions for hypnotically hallucinated heat, could be
demonstrated in the laboratory without ever formally induc-
ing a trance state, provided that the subject's motivation,
attitude, and efficacy expectations were experimentally
manipulated so that the subject was led to believe he could
produce the suggested phenomenon. This view became
known as the task motivational position, because Barber and
Spanos believed the entire range of hypnotic phenomena
could be produced without a trance state if the subject were
properly motivated for the specific task in question through
indirect and direct suggestive influences.
Eventually the debate was settled through a series of sophisti-

cated experiments using a simulator design. 5 6 '57 In these
experiments, simulators were used as control subjects. Simu-
lators were defined as very low hypnotizable subjects through
pre-experimental hypnotic screening. Because very low hyp-
notizable subjects were not able to enter a trance state, by
definition, they could serve as controls. Such research pre-
sumes that genuine hypnotic responding is a function of both
state effects and social influence effects, while simulator
responding is a function mainly of social influence effects.
By comparing the performance of low hypnotizable subjects
explicitly asked to simulate hypnotic performance with the
performance of highly hypnotizable subjects where the exper-
imenter is blind to which subject is in which group, it is pos-
sible statistically to apportion the variance of the overall
hypnotic responding that is attributable primarily to expecta-
tion and other social influence effects (simulator response)
and that is attributable to hypnotic talent. The emerging view
from this kind of research clearly established that genuine
hypnotic responding was the outcome of both trance state
effects and social influence effects, but that in highly hypno-
tizable subjects compared with moderately hypnotizable sub-
jects, trance-state effects typically contributed as much, if not
more, to the variance of the overall hypnotic effect as did
social influence effects.'58
If we learned anything from the state/task-motivational con-

troversy regarding hypnosis in the 1970s, it was that both
positions represented a partial truth, and that something as
complex as hypnotic responding could not be explained
solely in terms of either theory. Proponents of either side of
the current controversy about MPD as either a naturally
occurring psychiatric disorder or as an iatrogenic product of
social influence could learn from the hypnosis debate. In our
opinion, it is reasonable to assume that MPD is a naturally
occurring psychiatric disorder and that alter behavior in those
who have the disease can be shaped by social influence. The
little available data-based scientific evidence we have
reviewed is consistent with this position: (1) There is no ade-
quate scientific evidence that the disorder MPD per se can be
created by suggestive influences, but (2) there is some sparse
but interesting evidence that alter behavior can be shaped
through social influence in those who genuinely have the
disorder.
VII. Confounding alter creation with alter shaping
In our opinion, false-memory proponents who have strongly

argued that MPD is solely an iatrogenic illness have exhibited
the same kind of all-or-nothing thinking that Barber and
Spanos exhibited about hypnosis in the 1970s. They were
wrong about hypnosis then, and we believe Spanos is wrong
once again in applying the same type of approach to MPD a
decade later. A more reasonable position is the hypothesis
that in most instances MPD is a naturally occurring psychi-
atric disorder that cannot be created by social influence. In
those who genuinely have MPD as a disorder, it is also possi-
ble to shape its clinical manifestations, including alter behav-
ior. Indeed, treatment would otherwise be impossible. Interest
in alter behavior in general, and in the manifestation of par-
ticular alter personalities, is likely to positively reinforce
these alters so that they manifest more frequently. The partic-
ular social context influences not only the rate of manifesta-
tion of alters, but also which alters will manifest. Certain
alters may "disappear" and new alters may "appear," depend-
ing on the expectations of the interview context.
We suspect that it might be possible to iatrogenically produce

MPD in rare situations,5 9 wherein (1) the individual has cer-
tain personality characteristics (e.g., high hypnotizability,
fantasy-proneness, shifting states of consciousness related to
some form of psychopathology, and prior favorable beliefs
about MPD) and (2) there is evidence of a social context that
highly demands the production of MPD and systematically
supplies misinformation consistent with this diagnosis. How-
ever, this is a highly specific set of conditions, and in our
review of the evidence in malpractice cases alleging iatro-
genic MPD, most of the evidence falls far short of fulfilling
these criteria.
In our opinion, the fundamental error in logic made by propo-

nents of the MPD iatrogenesis position is that they have con-
founded alter shaping with alter creation. Anyone who has
observed MPD patients in the clinic is undoubtedly struck by
the extent to which alters respond to social cues. The counter-
transference response to this observation is typically to be
skeptical that MPD exists, and to see it as manipulative
behavior and/or suggestive responding as part of the patient-
therapist interaction. We believe it plausible to interpret these
observations as examples of alter shaping. Some critics mis-
interpret these observations and erroneously conclude that the
presence of such social influence effects must mean that the
disorder itself is a product of social influence.
Furthermore, some critics have argued that encouraging com-

munication with alters iatrogenically creates them. 160 A more
plausible position is that communication with alters posi-
tively reinforces their manifestation but rarely creates them.
McHugh and other critics offer an alternative treatment
approach: to discourage communication with alters and never
focus on the past. They advocate that the treatment of the
MPD patient should focus entirely on current life functioning

in order to prevent treatment regression. The data from the
Kohlenberg and the Frischholz & Sachs alter-shaping experi-
ments imply that McHugh's approach does nothing more than
completely discourage any manifestation of alter behavior in
the treatment hour, but does not necessarily eradicate alters
nor MPD as a disorder. McHugh makes the logical error of
confounding alter shaping and alter creation by assuming that
his treatment approach eradicates MPD as a disorder instead
of simply discouraging alters from manifesting themselves in
the particular social context advocated by his treatment
approach. But a demand characteristic is not a cure. Telling
MPD patients not to report alters means that the therapist will
not hear about alters-not that the alters will cease to exist.
It is very important that such confounding of alter creation

and alter shaping not be played out in the courtroom as it has
been in the clinical scientific literature. Plaintiffs who have
retracted having DID, and who now allege that the defendant
therapist negligently suggested false DID, typically use the
argument that the alter behavior disappeared after the
allegedly negligent treatment stopped. The Kohlenberg and
the Frischholz & Sachs data on behavioral reinforcement and
extinction of alter behavior clearly demonstrate that in those
patients who genuinely have MPD, the frequency of alter
manifestation significantly increases when it is positively
reinforced and decreases when it is negatively reinforced.
From the perspective of behavioral reinforcement, there is
absolutely nothing surprising about the observation that alter
behavior manifested itself with greater frequency in treatment
with the defendant therapist and decreased or disappeared
once the plaintiff initiated a lawsuit. What is surprising to us
is the failure to grasp the point that the disappearance of
alters subsequent to the defendant's treatment in the context
of a lawsuit does not constitute evidence that the MPD condi-
tion never genuinely existed. Such "disappearance" of alters
in the retractor is likely to mean, in part, that sociocultural
influences operative in the context of the lawsuit strongly
negatively reinforce the manifestation of any alters, such as
the possibility of receiving several million dollars if no alters
appear until the lawsuit is won or settled.
VIII. Resurgence of skeptical opinions-the manufacture

of controversy
A. The first modem published skeptical opinions appeared in the

Manufactur- professional literature in the late 1980s concurrently with
ing a minority the dramatic increase in professional interest in MPD in the
opinion 1980s. In the United Kingdom, Fahy responded to the "dra-
matic rise in the number of [MPD] cases"' 6' by challenging
the validity of MPD as a diagnosis. In his opinion, the preva-
lence rate for MPD was inflated by the use of "excessively
vague"'162 diagnostic criteria and by a failure to consider MPD
as "part of a specific personality disorder" such as borderline
personality.'63 Fahy correctly noted that many MPD patients
in research samples had been given a number of diagnoses
prior to the MPD diagnosis. He further comments, "When
MPD was finally diagnosed, it arbitrarily became the primary
diagnosis," and reasons that "it is inappropriate that the diag-
nosis of MPD should receive priority."' 4
Fahy's main criticism is that such diagnostic practices "create

a separate syndrome of MPD," while Fahy sees MPD as "a
non-specific symptom of a variety of psychiatric disor-
ders."'65 Fahy's argument, however, is inaccurate; it overlooks
the obvious fact that the main diagnostic criteria for MPD
are very specific (the manifestation of alter personalities that
take executive control) and are not shared with any other
psychiatric diagnosis. Fahy's logic illustrates another flaw:
either-or thinking. He assumes that a given patient has either
MPD or some other condition, such as borderline personality
or an affective illness, and in so doing he fails to consider the
rather common problem of multiple co-morbid psychiatric
diagnoses within the same patient.
Fahy's article also makes clinicians aware of the laboratory

paradigms on iatrogenic MPD. Fahy believes that "an indi-
vidual may learn to enact the MPD role, collecting impres-
sions from popular books and films." Furthermore, "the
psychotherapist could be an unwitting accomplice in mould-
ing the presentation, both by providing the patient with infor-
mation and by selective reinforcement of symptoms."'" 1 To
his credit, however, Fahy correctly points out that such labo-
ratory experiments "do not provide an entirely satisfactory
comparison with MPD" in that suggestive creation of tempo-
rary simple personality states are not comparable to the per-
sistent complex alter personalities found in genuine MPD
patients. He says, "There is scanty evidence that short-term
exposure to hypnosis can induce well-developed alternates
through the use of hypnosis alone. . . there is little evidence
that the therapeutic use of hypnosis is directly responsible for
the disorder."' 167
From South Africa, Simson wrote a letter to the British Jour-

nal of Psychiatry the following year emphasizing the iatro-
genic perspective: "There is no convincing evidence that
MPD is a naturally occurring condition, let alone a distinct
diagnosis. '168
Simson adds:
My hypothesis is that MPD is an iatrogenic, largely culture-bound
disorder. . . .Selective reinforcement of symptoms, unconscious
and conscious, progressively shapes the symptoms and behavior of
the patient, and the depiction of MPD is elaborated and reinforced.
Patients usually show clear primary and secondary gain,
69
but this is
often not noted or acknowledged by their therapists.
In contradistinction to consistent data from a number of lon-

gitudinal studies of MPD that generally show an unremitting
course over time without treatment, 171 Simson makes the arbi-
trary assumption that the normal course of MPD is "sponta-
neous remission" unless it is reinforced by the clinician.
Merskey's "The Manufacture of Personalities,"'' also in the
British Journal of Psychiatry, became the first widely cited
opinion about iatrogenic MPD. Merskey doubts that MPD is
a naturally occurring phenomenon. He sees it as necessarily
the product of suggestion. The background to his skepticism
is his own clinical experience. He says, "In 89 cases of clas-
sic dissociative or conversion disorder. . . I encountered no
MPD. In 36 years I found none among many more patients
with conversion disorders."'72 In arguing this position,
Merskey reviews early historical "classic" cases of MPD
reported in the literature from 1791 to 1943, half of which
were reported before 1900. This historical review is meant
"to determine if there is any evidence that MPD was ever a
spontaneous phenomenon.' ' 7 He concludes that "no report
fully excluded the possibility of artificial production.' 7 4
Some of these cases represent "misdiagnosis" of organic and
bipolar conditions, according to Merskey, although it is rea-
sonable to question the validity of Merskey's attempt to
establish what he believes to be the "correct" diagnosis based
solely on his analysis of historical materials, many of which
are over 100 years old. The remainder of these cases Merskey
explains in terms of suggestive influences, either through the
"development of fantasies as a solution to emotional prob-
lems," "retraining," or "implicit demand under hypnosis.75
He says:
Suggestion, social encouragement, preparation by expectation, and
the 1reward
76
of attention can produce and sustain a second personal-
ity.
However, Merskey never gives any details as to how such

alleged suggestive influences "train" patients other than to
overgeneralize from the results of the only laboratory study
investigating iatrogenesis and MPD. Merskey says, "Spanos
et al. (1986) obtained telling experimental evidence that pro-
cedures employed routinely to diagnose MPD encourage and
legitimate enactments of the syndrome."'
Merskey's paper has been cited frequently in courts as "sci-

entific evidence" for the creation of MPD by therapeutic sug-
gestion. In our opinion, the use of such evidence is highly
questionable. Other than a historical analysis, without full
records, by a non-historian reviewing very old cases, the
paper does not contain any scientific investigation of contem-
porary MPD cases. Merskey's paper is filled with very gen-
eral comments about therapeutic expectancies, hypnosis used
in treatment, patients who were repeatedly interviewed, and
patients who were sometimes asked to name personalities.
Merskey's paper lacks any detailed presentation of data about
specific allegedly suggestive practices or any detailed analy-
sis of how such suggestive practices serve to manufacture
MPD. Thus while "The Manufacture of Personalities" is a
reflection of Merskey's belief, it is not scientific evidence.
Another critical article frequently used in malpractice litiga-

tion on allegedly implanting a false MPD/DID diagnosis is
McHugh's "Psychiatric Misadventures.'17 McHugh describes
what he sees as a destructive pattern that occurs every
ten years in the modem history of psychiatry: a new "mis-
direction" resulting from "the intermingling of psychi-
atry with contemporary culture." These trends have included,
for example, the anti-psychiatry and deinstitutionalization
movement. The current trend, according to McHugh, is the
"misidentifi[cation] of hysterical behavior" as MPD. McHugh
believes such patients enter therapy with "standard psychi-
atric complaints," following which the therapist, influenced
by the "sexual politics in the 1980s and 1990s," suggests that
such symptoms "represent the subtle actions of several alter-
native personalities" and also that "they were sexually abused
as children. 17 McHugh believes these practices have reached
"epidemic" proportions and will eventually be discredited.
The problem with McHugh's few publications on MPD/DID,

like those of Merskey, is that they are mere speculation. From
deposition testimony in several cases, McHugh has made it
clear that other than an occasional consultation, he has very
605
little actual clinical experience with ongoing treatment of

MPD/DID patients and is generally unfamiliar both with the
clinical features of MPD/DID and with what usually occurs
in their treatment. Thus McHugh's opinion is informed
neither by actual in-depth clinical experience with contempo-
rary MPD/DID patients nor by any scientific research on
MPD. Furthermore, with regard to McHugh's main hypothe-
sis that hysterical behavior is implicated in DID iatrogenesis,
Gleaves has shown that such phenomena are no more preva-
lent in DID than in any other psychiatric condition. 8 '
Seltzer 8' has argued that "iatrogenic factors and cultural

influences on suggestible patients" have played a major role
in the diagnosis of MPD. He attributes the rise in MPD cases
to many factors, but singles out "nebulous diagnostic criteria
embraced by eager therapists concerned with child protection
and influenced by radical feminist thought for whom this is
an intriguing and exciting diagnosis."'' No support is offered
for this conclusion, identical to McHugh's position, that ther-
apists working with DID are inclined to support radical femi-
nism. In Seltzer's opinion, no MPD cases have been
described without "shaping and iatrogenic or cultural influ-
ences."' 83 Indeed, he believes that "the whole history of MPD
may be an error, sprung from the influence of hypnosis and
suggestion by enthusiastic practitioners," which thereby
makes the therapist "an accomplice in molding the presenta-
tion."'41 Seltzer concludes that "it is entirely likely that MPD
never occurs as a spontaneous natural event in adults."'8
To demonstrate his viewpoint, Seltzer describes five cases of

MPD diagnosed by a friend of his, D, who is "an empathic,
competent counselor trained in MPD technique," which
appears to involve hypnosis and guided imagery. In each case
Seltzer alleges that D falsely implanted DID and/or false
abuse memories. Seltzer suggests that in all of these cases,
and perhaps in every MPD case, the MPD is "the result of
overactive imaginations in vulnerable, creative individuals
with low self-esteem." 8 6 Because these patients wish to
please their therapists, and because therapists have a pre-

existing bias in favor of child abuse and dissociation, a sym-
biotic relationship develops in which patients continue to
come up with horrendous memories and with alters, and ther-
apists continue to reinforce this behavior, thereby encourag-
ing more of it. Seltzer cites Spanos et al. (1985) for the
proposition that "people can learn to enact the MPD role
while therapists maintain this role enactment."' 8 7 When you
add to this powerful relationship tools like hypnosis and
guided imagery, which "can create imagined memories that
patients gradually assume to be fact," patient perceptions of
reality can easily be manipulated. Seltzer notes that he has
seen a total of eight "false MPD" patients from this therapist.
He concludes that "these cases support the position that there
is little evidence that MPD is a distinct diagnosis but rather
an intriguing, iatrogenic phenomenon." '
To conclude that a series of cases from one therapist discred-

its all cases from every other therapist is a monumental viola-
tion of the rules of logic. The existence of possible false
positives does not prove the nonexistence of true positives. It
should also be clear that Seltzer even fails to prove the exis-
tence of false positives. At best, he has demonstrated that the
therapist discussed in the case studies had an agenda and mis-
diagnosed patients by ascribing MPD to them. There is no
indication that (1) the actual MPD condition was created in
the patients iatrogenically, (2) other therapists agreed with
the diagnosis, or (3) the patients demonstrated MPD on
objective tests. Seltzer's own preexisting bias against MPD
leads him to make the same type of mistakes allegedly made
by the therapist in his pro-MPD bias. Suppose Dr. X believes
that the only real mental illness is schizophrenia, and he diag-
noses all of his patients with it. Dr. Y then takes eight of
these cases and shows that none of them have schizophrenia.
Has Dr. Y proved that schizophrenia does not exist? Of
course not-no more than Dr. Seltzer has proved that MPD
does not exist.
Piper's work' 9 attacking MPD is paradigmatic of the Ameri-
can pro-false-memory position. He raises several objections
to MPD. He states that the diagnostic criteria are "vague
and poorly elaborated"'9 " and that patients diagnosed with
MPD have symptoms that overlap with many other condi-
tions. Piper uses the diagnostic ambiguity hypothesis to
explain the dramatic increase in cases diagnosed (incorrectly)
as MPD in the past several decades. Piper also challenges
the often assumed association between childhood abuse
and MPD. He believes many of these abuse reports are
false memories. He further attacks the generally accepted
treatment procedures for working with MPD patients that
entail communication with alter personalities. He fears that
this approach "must certainly sanction and reinforce the
patient's belief in his or her dividedness, and encourage
the production of more symptoms."' 9' Last, Piper believes
MPD can arise from "mutual shaping of MPD symptoms,"''
and that the use of hypnosis is at times a contributing fac-
tor in creating MPD symptoms. Although Piper does believe
some patients genuinely have MPD, he takes issue with
the "much larger number" of patients who have been mis-
diagnosed with MPD, due either to inaccurate diagnos-
tic practices or to suggestive therapy techniques that have
created it.
Once again, Piper's comments are only speculation. He offers

no research data to support his contention that a "much larger
number" of patients have been misdiagnosed with MPD due
to misdiagnosis or to suggestive practices. As with other pro-
ponents of the DID iatrogenesis model, the actual scientific
data supporting suggestive creation of DID in therapy are
lacking in their published papers.
Ofshe and Watters9 3 conclude that MPD is created by thera-

pists who believe childhood abuse "causes" MPD and who
therefore "hunt for alter personalities or for repressed memo-
ries."' 194 According to Ofshe and Watters, patients present to
therapy "the standard fare" of problems, but not with dissoci-
ation or with recovered memories. 195 The clinician misinter-

prets these symptoms as signs of MPD, tries "to convince
clients they have the suspected disorder," 96 and subsequently
tries "bringing out the other personalities" through a "series
of directed questions"' 97 and "leading questions."'" These
questions "elicit" alter-personality states, which in turn con-
firms the therapist's bias and justifies a "hunt" for more
alters. The patient is then encouraged "to act out the
'part.' "99 Through this process of persuasion or undue influ-
ence, the patient is "indoctrinat[ed] . . .into the MPD belief
system."" °
Among the proponents of the DID iatrogenesis model, Ofshe

and Watters present the most detailed account of how DID is
allegedly created in therapy. There is no evidence, however,
that Ofshe and Watters ever conducted laboratory research to
test whether such suggestive influences actually occur in psy-
chotherapy, and no data exist specifically on suggestive influ-
ences in therapy per se.201 Nor is there any mention by Ofshe
and Watters of the evidentiary sources from which they have
drawn their opinions about what allegedly occurs in psy-
chotherapy. Furthermore, they do not elaborate at all on the
procedures by which they have analyzed this evidence. While
it is generally known that Ofshe has certainly reviewed medi-
cal records as an expert witness in a large number of malprac-
tice cases wherein therapists were being sued for allegedly
suggestively implanting false memories and a false DID con-
dition, Ofshe by judicial rulings is not qualified to testify
regarding the standard of care in DID diagnosis or treatment.
Furthermore, the objectivity of Ofshe's analysis of factual
issues has come under attack in scholarly articles in peer-
reviewed journals. Beyond hypothesis generation, it is
unclear how Ofshe and Watters's opinions about allegedly
suggestive therapeutic practices constitute scientific evi-
dence.
B. The David Gleaves wrote a major critique in the 1996 Psychologi-
current cal Bulletin of the logical and evidentiary limitations of the
debate: iatrogenic DID position.0 2 After reviewing the available sci-
Gleaves v. entific data, he concludes that there is no evidence that a psy-
Lilienfeld et al. chiatric disorder like MPD per se can be created through
suggestive influences:
Numerous critiques of the iatrogenic position have been published
in the literature. . . .The conclusions reached by these researchers
have generally been that, although some of the phenomena of DID
can be created iatrogenically, there is no evidence to suggest that
the disorder per se can be created. Thus, the iatrogenesis mecha-
nism is insufficient
2 3
to explain all or even many reported cases of
the disorder. 1
Gleaves further argues that the diagnosis of DID is not lim-

ited to the manifestation of alters, but typically includes "a
relatively clear set of clinical DID features" such as identity
loss, time loss, disremembered experiences, depersonaliza-
tion, voices, and passive influence phenomena. Thus a suffi-
cient laboratory test for the iatrogenic creation of MPD
necessarily must include evidence that the entire set of clini-
cal DID symptoms could be created in a stable way through
suggestive influences:
Conclusions based solely on data relevant to the concept of multi-
ple identity enactment cannot be204generalized to the complex disso-
ciative psychopathology of DID.
According to Gleaves, laboratory data on secondary role enact-

ments do not constitute a sufficient test.
Gleaves further addresses the allegation made by proponents

of the iatrogenic MPD model that the assessment and treat-
ment procedures used by certain trauma therapists create
the MPD. He discusses the evidence demonstrating that
questionnaires and structured clinical interviews reliably
and validly discriminate MPD from other psychiatric condi-
tions. He asserts that the speculation that hypnosis creates
MPD is "contradicted by available data."2 "5 Treatment meth-
ods such as communication with alters, Gleaves explains, are

not designed to reify alters as different people:
The general recommendation is that one speaks with alters to
understand all aspects of the person in therapy but not as if they
were different people.2
He adds that such inter-alter communication gradually leads

to integration of dissociated parts in treatment:
Alters who once argued that they were separate people gradually
become more similar through therapy. 0 7
He summarizes his arguments about treatment by saying,

"The data do not support the hypothesis that assessment or
treatment procedures are responsible for the creation of
DID ."208
Overall, Gleaves draws a strong conclusion:

I conclude that the sociocognitive model of the etiology of DID is
fundamentally flawed and lacking in support. . . Thus, I recom-
mend that the sociocognitive model be abandoned as an etiological
explanation of DID.21
In response to Gleaves's critical review of the DID iatrogene-

sis model, Lilienfeld and a number of contemporary propo-
nents of a sociocognitive model have responded in defense of
the iatrogenic model of DID.2 10 This recent paper reflects sev-
eral important modifications in, or clarifications of, the
sociocognitive model (SCM) of DID previously advocated
by Spanos. 2" Lilienfeld et al. shift the debate away from
the existence of DID as a diagnostic entity to its etiology.
Although Lilienfeld et al. concede that some extreme propo-
nents of the iatrogenesis position have argued that DID does
not exist, they take the position that DID, as defined by "rela-
tively distinctive features that are rarely found in other condi-
tions,' ' 2 2 such as alter behavior and amnesia, does exist:
The fact that certain individuals exhibit the features of DID is not
in dispute-but rather its origins and maintenance . . . . Is DID
best conceptualized as a naturally occurring response to early
trauma, or as a socially influenced product that unfolds in response
to the shaping influences of therapeutic practices, culturally based
scripts, and social expectations?213
According to SCM proponents, the clinical features of DID

occur as a result of sociocognitive influences, which include
iatrogenesis. "These two models diverge most sharply in their
explanations for the emergence of alters."' 4
Lilienfeld et al. do not assert that all cases of DID are the
result of suggestive therapeutic practices. They believe the
etiology of DID is the product of the complex interaction of a
variety of factors, such as personality factors (absorption,
fantasy-proneness, and type of psychopathology), sociocul-
tural scripts available through the media and popular litera-
ture, and certain therapy techniques and/or interviewing
practices that serve to "reify" alter personalities:
Patients with DID synthesize these role enactments by drawing
upon a wide variety of sources of information, including the print
and broadcast media, cues provided by therapists, personal experi-
ences, and21observations of individuals who have enacted multiple
identities. 1
Thus Lilienfeld et al. explain the etiology of DID as a result

of both iatrogenic and sociocultural factors. They further
state:
Thus, the principal unresolved question appears to be not whether
iatrogenesis sometimes plays a role in either the etiology or mainte-
nance of DID, but rather its relative importance compared with
other potential causal factors, such as media influences, widely
available cultural scripts regarding the expected features of DID,
individual differences
21 6
in personality and psychopathology, and per-
haps early trauma.
Lilienfeld et al. further dilute the iatrogenic position by stat-

ing that "iatrogenic factors do not typically create DID in
vacuo, but instead operate in many cases on a preexisting
21 17
substrate of psychopathology (e.g., BPD).
Specifically with respect to iatrogenic DID, Lilienfeld et al.

argue that patients with DID "begin therapy with few or no
detectable signs or symptoms," 218 and during treatment show
an increase in the number of alters, especially when treated
by certain therapists in certain geographic areas and times in
history, and especially when therapists utilize certain tech-
niques and interviewing methods that "reify" the alters.
219
In contrast to the original Spanos SCM model for DID,
which implicated hypnosis in the etiology of DID, Lilienfeld
et al. say:
The SCM does not maintain that hypnosis is necessary for the cre-
ation of DID, because hypnotic procedures do not possess any
inherent or unique features that are necessary for facilitating
responsivity to suggestion.2 2 0
They add that suggestive interviewing without hypnosis is

sufficient to produce the effects, and that certain techniques
such as "mapping the alter system" and "establishing direct
contact with alters" serve to "reify" the alters. They conclude
that Gleaves's own conclusion about the sociocognitve model
is wrong:
Careful scrutiny of his [Gleaves's] central arguments, however,
suggests that this conclusion is premature and unwarranted.2 1
They assert that the SCM is a viable etiological explanation

for DID.
It is not the purpose of this paper to discuss the merits or lim-

itations of either the Gleaves or the Lilienfeld et al. positions
in detail. However, the Lilienfeld et al. modified SCM model
has several important implications as to how the courts might
interpret malpractice claims alleging that a therapist sugges-
tively implanted MPD/DID.
1. Since Lilienfeld et al. concede the existence of DID as

defined by DSM-IV, complaints alleging negligence based on
the theory that the diagnosis does not exist or is fraudulent
have no evidentiary foundation.
2. The modified SCM model dilutes the issue of proximate

cause. Lilienfeld et al. say that "a wide variety of sources of
information" may contribute to the creation of DID, and that
sociocultural forces alone, without therapy, can cause DID.
Even where iatrogenic factors operate, Lilienfeld et al. say
that this occurs "on a preexisting substrate of psychopathol-
ogy."'' 22 They add that multiple identity enactments may also
be the result of "individual differences in personality and
psychopathology, and perhaps early trauma. ' 223 According to
this modified position, iatrogenic creation of DID in therapy
only "sometimes" occurs in therapy, and even when it is said
to occur, it becomes exceedingly difficult to apportion the
relative contribution of the defendant therapist's treatment,
the patient's own psychopathology, and the "wide variety of
informational sources" that allegedly have contributed to the
creation of the MPD/DID. Appreciation for the complexity of
factors alleged to be operative in the etiology of MPD/DID
other than therapy dilutes the role of therapy as the proximate
cause of the alleged falsely suggested DID. Proponents of the
modified SCM model would have to concede by their own
arguments that the greater the exposure of the plaintiff to
media and informational influences, cultural scripts, and
other MPD patients, as well as the greater the psychopathol-
ogy of the plaintiff, the less likely it is that the therapist was
the main contributing cause of the allegedly iatrogenic DID.
At any rate, exaggerated plaintiff complaints that the thera-
pist was the cause of the MPD, or that "nothing was wrong
with me until I was hypnotized," become difficult to justify.
3. Lilienfeld et al. are careful to qualify their position. They

concede that the often observed lack of obvious alter behav-
ior prior to treatment might have an alternative explanation,
"that these features were present but had not yet been
elicited, '2 4 and that the trauma model of DID might equally
well explain this phenomenon. The occurrence of time-
released symptom effects is well documented for other psy-

chiatric conditions, such as schizophrenia, in that the psy-
chotic symptoms generally appear in early adulthood
irrespective of contextual influences. More recently, several
long-term prospective studies on childhood abuse have
shown that certain distinct patterns of symptoms, including
dissociative symptoms, are likely to emerge at specific points
in the overall life cycle. 2 Thus the emergence of DID symp-
toms at a given point in the life cycle, irrespective of whether
the individual is in therapy, can be explained as a function
of naturally occurring time-released effects. If such DID
symptoms emerge concurrently with therapy, it does not nec-
essarily follow that the therapy caused their occurrence.
While proponents of the SCM have speculated that therapy
"causes" the occurrence of DID symptoms, they fail to con-
sider plausible alternative explanations like time-released
effects, and also offer no scientific research designed to
establish causality.
4. Proponents of the modified SCM concede that their model

has not been substantiated by scientific research: "Although
the relative paucity of data on the role of iatrogenic factors in
DID renders a definitive verdict premature, a variety of lines
of evidence converge upon the conclusion that iatrogenesis
plays an important, although not exclusive, role in the etiol-
ogy of DID."226
'
We agree that there is a "paucity" of data, in that actual labo-

ratory research on the iatrogenic model is limited to the three
Spanos studies and the Frischholz & Sachs study. In the next
section of this paper we address whether such "paucity of
data" meets a criterion of admissibility as testimony. Is suing
a therapist for allegedly implanting MPD simply a "junk sci-
ence" fad, given that even proponents of the iatrogenesis
model admit the "paucity" of scientific evidence to support
their position?
615
C. A critical In recent malpractice cases wherein a plaintiff alleges that a

examination defendant therapist negligently implanted or reinforced a fic-
of the tional MPD diagnosis through "hypnosis" and/or "suggestive
scientific and coercive practices," plaintiff expert witnesses-e.g.,
evidence William Grove, James Hudson, Paul McHugh, Richard
Ofshe, and August Piper-have consistently testified either
that (1) MPD does not exist or is, at best, very controversial
as a legitimate psychiatric diagnosis, or (2) MPD exists only
because it was iatrogenically created by the defendant thera-
pist(s). In support of their court testimony, these experts cite
what they claim is peer-reviewed, published scientific litera-
ture demonstrating that MPD is iatrogenic. The following
table summarizes all of the evidence used by these experts in
the courtroom as "evidence" that MPD can be iatrogenically
created in psychotherapy.
The obvious observation from reviewing the table is that the

great majority of the evidence is not at all scientific, if we
define scientific evidence as data-based findings from
controlled experimental studies. Most of the "evidence" is
simply opinion papers published by a vocal minority of simi-
larly inclined advocates, some written by the same individu-
als who consistently serve as plaintiff expert witnesses. While
there is nothing wrong with these opinions as opinions, it is
disingenuous to offer these papers as examples of a generally
accepted body of "scientific evidence" in court testimony. As
these works have been reviewed here in some detail, it should
be obvious to the reader that none of them meets the defini-
tion of scientific evidence.
Moreover, some of the papers cited as evidence in favor of

227
iatrogenic MPD actually reach the opposite conclusion.
Plaintiff experts attempt to give the court the impression that
there is a substantial body of scientific literature supporting
iatrogenic MPD. What they fail to tell the court is that most
of these so-called scientific treatises contain no experimental
data whatsoever; they are merely statements of beliefs. Snow-
ing the court with an increasing number of published opinion
papers as "scientific evidence" only serves to distract from

the fact that hard scientific data to support the iatrogenic
hypothesis are very sparse indeed.
Evaluation of the "scientific" evidence
re: iatrogenic DID
Citation Opinion Anecdotal case Survey Data-based
only report lab study
Taylor & x
Martin, 1944
Sutcliffe & x
Jones, 1962
Thigpen & x
Cleckley, 1984
Fahy, 1988 x
Simson, 1989 x
Merskey, 1992 x
McHugh, 1993 x
Piper, 1994 x
Ofshe & x
Watters, 1994
Spanos & x
Burgess, 1994
Harriman, x
1942a,b;1943
Leavitt, 1947 x
Kampman, 1976 x
Dell, 1988 1
Pope et aL, 1999 x

Spanos et al., x
1985
Spanos et al., I
1986
Spanos et al.,
1991
Frischholz & I
Sachs, 1991
A similar argument could be made about the survey studies.

The fact that there is disagreement about MPD as a diagnosis,
or that a sample of clinicians (of undetermined size) is skepti-
cal of MPD, does not refute its general acceptance by the
wider community of clinicians, as evidenced by its inclusion
in DSM.
While the case demonstrations by Harriman, Leavitt and Hil-

gard and the survey by Kampman are interesting, 228 they do
not meet the definition of controlled scientific experiments
and therefore do not constitute scientific evidence pertaining
to iatrogenic MPD.
The three published Spanos et al. studies (1985, 1986, 1991)

meet the definition of controlled scientific experiments. In
our opinion, it is quite remarkable that the iatrogenic MPD
position has been taken seriously by the courts, given that the
entire data base of "scientific evidence" consists of a grand
total of three experimental studies-all coming out of the
same laboratory. Furthermore the Spanos studies, whether
taken individually or as a unit, fail to meet any of the five
main criteria (A-E) or any of the five subcriteria (A1-5)
listed above as necessary to establish scientific proof of the
iatrogenesis hypothesis. Smoke and mirrors do not serve as a
substitute for scientific fact in the courtroom; experts who try
to impress the court with the number of published opinion
papers, survey papers or anecdotal case reports to disguise
the fact that very little data-based scientific research actually
exists do a disservice to justice.
We are not taking the position that iatrogenic MPD does not
occur. That is a matter to be determined by appropriate scien-
tific inquiry. Our position is that an adequate body of scien-
tific evidence supporting the iatrogenic DID hypothesis
certainly does not currently exist. A handful of anecdotal
case studies and three methodologically flawed experimental
studies from the same laboratory are a remarkably poor data
base of evidence. The burden of proof is on the plaintiff
alleging suggestively created MPD in psychotherapy to pro-
duce sufficient and credible scientific evidence. We therefore
agree with the recent holding by the Washington Supreme
Court that DID is a real psychiatric disorder recognized as

such by a majority of mental health professionals. 9
IX. Criteria of scientific proof of iatrogenic MPD
Three experimental studies all coming from the same

research group, and all biased by a high demand to produce
the very phenomena the studies try to prove, hardly constitute
adequate scientific evidence that MPD can be created in the
laboratory. What type of scientific evidence would constitute
reasonable scientific proof that MPD could be created? What
follows is a minimal list of the criteria that need to be met:
A. The laboratory experiment succeeded in suggestively

creating:
(1) Alter personality states that: (a) had unique experiences and
behaviors associated with them that showed consistency
across time and context; (b) were not temporary but endured
over months and years; and (c) were relatively context-free, in
that they occurred both spontaneously and upon demand
across a variety of settings.
(2) A loss of executive control concurrent with the manifestation
of alter personality states.
(3) A relatively enduring loss of a unitary sense of self or frag-
mentation (dissociated identity).
(4) The entire range of clinical features-e.g., time loss, amnesia,
disremembered experiences, handwriting and other skilled-
based changes.
(5) Implanted false memories of complex abuse scenarios.
B. The research design reasonably controlled for method-

ological artifacts such as sample bias, experimenter bias,
response bias, or demand characteristics that might otherwise
substantially increase the error rate and confound interpreta-
tion of the results as either supportive or unsupportive of the
iatrogenesis hypothesis.
C. The research design contained procedures to determine
definitively that the resultant secondary personality behavior
was a consequence of suggestive creation and not a result of
accessing preexisting personality states.
D. The research design included comparisons of the labora-

tory and therapy context in terms of social interactional rules,
expectancies, and suggestive practices to determine relative
equivalence before any generalizations can be made from
suggestively creating MPD in the laboratory to allegedly sug-
gestively creating MPD in psychotherapy.
E. Appropriate scientific procedures are used to determine

the base rate by which iatrogenic MPD actually occurs in
psychotherapy, if at all, prior to any statements being made
about the relative ease or difficulty of creating MPD in psy-
chotherapy.
X. The Frye-Daubertstandard and Rule 702
Under the Frye rule23° expert witnesses are disallowed from

giving testimony on matters of scientific opinion in the courts
unless "the thing from which the deduction is made must be
sufficiently established to have gained general acceptance in
the particular [scientific] field in which it belongs." Under
the Frye rule, only reasonably valid scientific evidence (what
the court called "reliable" evidence) would be admitted as
expert testimony. In Daubert v. Merrell Dow Pharmaceuti-
cals, Inc. 2 1 the United States Supreme Court concluded that
the Frye rule would no longer govern federal trials and the
new Daubert standard would favor the "relevance" of the sci-
entific evidence over its reliability or validity. Under
Daubert, the judge, not the scientific community, serves as a
"gatekeeper" as to the relevance of the scientific testimony,
typically in the form of a pretrial Daubert hearing in which
experts on both sides of the issue present opinions on the sci-
entific evidence in question and the judge then makes a deter-
mination as to its admissibility or inadmissibility at trial. The

Court gave judges several guidelines to follow to determine
whether an expert opinion is or is not "scientific": (1) Has the
theory been tested? (2) Are the findings or opinions published
or peer reviewed? (3) Is there a known error rate? (4) Are
these scientific opinions "generally accepted"?
Recently the Frye and Daubert rules have been used to either
admit or disallow expert testimony in civil and criminal cases
based on recovered memories of childhood abuse. The pre-
trial determination is based on whether or not the concept of
recovered memories is generally accepted within the scien-
tific community (the Frye standard) and whether or not there
is a generally accepted body of reasonably methodologically
sound experimental findings published in peer-reviewed
professional literature that supports the expert's scientific
opinion. Expert witnesses favoring memory testimony have
convinced judges that recovered memory testimony is not
"scientific" in New Hampshire (State v. Hungerford), Rhode
Island (State v. Quattrocchi) and Maryland (Doe v. Maskell),
but were unsuccessful in Michigan (Isely v. Capuchin
Province) and Massachusetts (Shahzade v. Gregory).232 Their
strategy was based on a highly selective, outdated review of
the scientific literature of recovered memories. More recently
Brown, Scheflin and Whitfield23 have addressed the logical
and evidentiary errors inherent in the strategies used by pro-
false-memory expert witnesses to argue against the admissi-
bility of recovered memories in the courtroom, and they have
summarized the current scientific literature on dissociative
amnesia for recovered memories of childhood sexual abuse.
Currently a total of 68 data-based experimental studies exist,
all of which present evidence documenting substantial forget-
ting and later recovery of childhood abuse memories. These
68 studies include 35 studies published in peer-reviewed
journals and another 19 from other peer-reviewed sources.
The studies represent progressive methodological improve-
ments and thus lower error rates. Brown et al. argue that
this substantial data base clearly meets a Frye-Daubertstan-
dard favoring admissibility of recovered memory testimony,
and that courts that have decided against admissibility have
not appraised themselves of this rapidly growing scientific
evidence.
It is notable that defense attorneys have never used a

Frye-Daubertstrategy as a defense in malpractice cases
alleging implanting a false MPD diagnosis and false memo-
ries. This is quite remarkable in light of the evidence
reviewed in this paper, since the entire data base of "scien-
tific" evidence consists of three methodologically flawed
experimental studies from the same laboratory, anecdotal
case reports for which there is no known error rate, and a
handful of peer-reviewed publications from a small group
who acknowledge adherence to a political action group.
Absent are substantial experimental data. If the courts were
to decide on the admissibility of malpractice cases alleging
suggestively implanted MPD in a manner consistent with the
way they have decided the admissibility or inadmissibility of
recovered memory testimony, then at least some courts would
find plaintiffs' complaints inadmissible due to a lack of sci-
entific foundation. In our opinion, if the courts really dis-
cerned that there is virtually no hard scientific evidence for
the iatrogenic MPD position, few of these cases would pass
the gatekeeping function.
XI. Alternate explanations
Given that there is virtually no adequate scientific evidence

that supports the malpractice allegation that a major psychi-
atric diagnosis, MPD, can be created through suggestive
influences in therapy, it is important to consider alternate
explanations for plaintiffs' complaints other than the allega-
tion that the defendant therapist "implanted" MPD that never
occurred.
One possibility is that the patient never had MPD/DID and

was misdiagnosed. It is conceivable that the patient had
another psychiatric diagnosis characterized by shifting states,
such as an affective illness or borderline personality. It is also
conceivable that the patient had DDNOS: manifested alter
behavior that did not meet the full criteria for MPD/DID. The
defendant therapist might have misconstrued these shifting
states as MPD. However, given that many MPD patients have
multiple co-morbid psychiatric diagnoses, diagnostic overlap
is also quite possible. Furthermore it is not always easy to
distinguish between DDNOS and MPD/DID. Therefore thera-
pists who misconstrue another related diagnosis and/or
DDNOS as MPD/DID are not necessarily committing mal-
practice.
Another possibility is that the patient had genuine MPD/DID

that improved over time. In our research on retractors
(Scheflin and Brown, this issue) we found that a number of
plaintiffs in malpractice litigation had been effectively treated
for their dissociative disorder, so that by the time the treat-
ment ended they had achieved partial or full integration of
alter-personality states. At the point of partial or full integra-
tion and thereafter, these patients showed a decrease in the
overall number of alters, reported greater co-consciousness
across alters, and had more voluntary control over switching
personality states. Sometime after treatment ended, these
patients came in contact with systematic pro-false-memory
influences in the form of media exposure, literature, involve-
ment in pro-false-memory advocacy groups, or attorneys
instigating malpractice lawsuits. Based on these influences,
these patients then sued their therapists for malpractice, now
claiming that the defendant therapists had implanted the
MPD/DID and that they never had it. At that point in time,
because of the at least partially successful treatment of the
MPD/DID, the patient had more voluntary control over disso-
ciative processes and in the context of the lawsuit was able to
actively suppress most if not all further manifestations of
alter behavior. Since Kohlenberg established that an environ-
623
ment that discourages alter behavior extinguishes the mani-

festation of alters but does not eradicate the disorder (MPD),
it is not surprising that in the context of litigation based on
the premise that the MPD/DID never was real, the plaintiff
rarely if ever shows alter behavior. The plaintiff, however, in
such cases has made the logical error of confusing alter inte-
gration and/or alter suppression with the nonexistence of
alters in the first place.
A third possibility is that the patient had factitious MPD or

DDNOS or DID co-existing with factitious behavior. In our
study of retractors we found that one out of three plaintiffs
in malpractice cases alleging iatrogenic MPD had either
factitious MPD or a dissociative condition co-existing with
significant factitious behavior. In these cases the patient
intentionally fabricated or embellished the MPD behaviors
for the purpose of getting attention from the defendant thera-
pist and subsequently, in the context of the malpractice law-
suit, blamed the therapist for iatrogenically creating it. In
Hess v. Fernandez, for example,2 2 the medical records indi-
cated a major dissociative condition. However, the patient
clearly had exaggerated and embellished the multiplicity to
get attention from the therapist. An independent consultant
used during the treatment and prior to the lawsuit had alerted
the therapist to the significant factitious behavior, even
though he did not contest the fact that she also had a dissocia-
tive condition. The consultant's recommendation was not to
engage in treatment that might reinforce the factitious behav-
ior. The therapist altered the treatment based on this recom-
mendation and eventually terminated the patient. Later, after
being influenced by pro-false-memory literature given to her
by an attorney, she sued the therapist for iatrogenically creat-
ing the MPD. The jury found against the defendant therapist.
High (this issue), much as the evidence in the Hess case illus-
trates, has shown that the factitious hypothesis is an impor-
tant alternative explanation for at least some malpractice
cases alleging therapist-created MPD. In other words, the
patient engages in a pattern of intentional deception, fabricat-
ing or embellishing MPD behavior in a way that may not be

detectable to the therapist. Some years later in the current
climate, where pro-false-memory ideas have saturated the
popular culture, the patient engages in factitious and/or
malingering retraction behavior, now suing the therapist with
the claim that the therapist created the very MPD behavior
that had been intentionally embellished previously by the
patient to get attention. The factitious motivation continues
in that the patient seeks attention from the courts, and in
extreme cases it is reinforced in the plaintiff as a "high priest"
of the false-memory movement. The factitiousness is now
compounded by malingering in that in addition to getting
attention, the patient is encouraged to seek a large financial
reward.
XII. Conclusions
1. At present the scientific evidence is insufficient and inade-
quate to support plaintiffs' complaints that suggestive influ-
ences allegedly operative in psychotherapy can create a major
psychiatric disorder like MPD per se. While secondary role
enactments sometimes occur in the laboratory with and with-
out hypnosis, there is virtually no scientific support for the
unique contribution of hypnosis to the alleged iatrogenic cre-
ation of MPD in appropriately controlled research.
2. There is some promising but insufficient laboratory and

clinical evidence that alter personality behavior (the fre-
quency of occurrence and the appearance or disappearance of
specific types of alters) can be shaped in social interactions
and influenced by learning in at least some patients who gen-
uinely have MPD and manifest alter personalities.
3. Alter shaping is not to be confused with alter creation.
4. The currently available scientific evidence does not

resolve the debate between alter creation and alter access.
Alter access remains as a plausible alternative explanation for
observed instances of secondary-personality states reported
with and without hypnosis in response to social cues. No sci-
entific evidence exists that favors the alter-creation interpre-
tation over the alter-access interpretation of these data.
5. The relative contribution of personality factors and sever-

ity and type(s) of psychopathology within plaintiffs, com-
bined with the relative contribution of a "wide variety of
informational sources" within the general culture, make it
difficult for plaintiffs to establish factually that the defendant
therapist was the proximate cause of allegedly suggested
false MPD.
6. Plaintiffs' complaint alleging that MPD had been iatro-

genically created in treatment by the defendant fails to con-
sider plausible alternative explanations, which include:
related psychiatric conditions misdiagnosed as MPD; genuine
DID that has effectively responded to treatment and is subse-
quently denied due to pro-false-memory suggestive influ-
ences; and factitious behavior on the part of the patient that is
later misattributed to allegedly negligent therapy subsequent
to pro-false-memory suggestive influences.
Notes I. S. Taub, "The legal treatment of recovered memories of child sexual

abuse," J. Legal Med., 17:183-214, 1996, p. 186.
2. For a more detailed discussion of the historical development of false-
memory malpractice cases, see D. Brown, A.W. Scheflin, and D.H.
Hammond, Memory, Trauma Treatment, and the Law. New York:
Norton, 1999. A more detailed discussion of the architecture of
false-memory malpractice cases can be found in D. Brown, A.W.
Scheflin, and D.C. Hammond, "False Memory Lawsuits: The Weight
of the Scientific and Legal Evidence," AAPL/APA Manfred
S. Guttmacher Award Lecture, American Psychiatric Association
annual convention, Washington, DC, May 16, 1999.
3. The diagnosis of multiple personality disorder (MPD) appeared in

DSM-III (1980) and DSM-II1R (1987). The name was changed to
dissociative identity disorder (DID) in DSM-1V (1994). American
Psychiatric Association, Diagnostic and Statistical Manual of
Mental Disorders.Washington, DC: American Psychiatric Press. We

use the terms interchangeably throughout this paper. MPD refers to
the literature prior to 1994, and DID to the more recent literature.
4. For a discussion of a typical plaintiff complaint, see Burgess et al. v.
Rush-Presbyterian-St. Luke's Medical Center, State of Illinois, Cook
County Circuit Court Case No. 91 L 8493. Subsequent false-memory
malpractice lawsuits have used this as a prototype. For a discussion
of plaintiff complaints from the perspective of a plaintiff expert
witness, see R. Ofshe and E. Watters, Making Monsters: False
Memories, Psychotherapy, and Sexual Hysteria. New York: Charles
Scribner's Sons, 1994.
5. F.W. Putnam and R.J. Lowenstein, "Treatment of Multiple

Personality Disorder: A Survey of Current Practices, Am. J.
Psychiat., 150:1048-1052, 1993.
6. A.W. Scheflin, "The Evolving Standard of Care in the Practice of
Trauma and Dissociative Disorder Therapy," Bull. Menninger Clin.
(in press).
7. For a detailed discussion of the development of trauma and
dissociative disorders treatment, see Brown, Scheflin & Hammond,
supra note 2, chapter 13.
8. See Burgess et al. v. Rush-Presbyterian-St. Luke's Medical Center,
supra note 4; Carl v. Peterson et al., U.S. District Court, Southern
District, Houston Case No. H-95-661; Hess et al. v. Fernandez,
Marathon County, WI, Circuit Court Case No. 95-CV-138; Greene v.
Timons et al., Mecklenberg, NC, Superior Court Case No. 96-CVS-
5235.
9. Brown, Scheflin & Hammond, supra note 2.

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13. M. Prince, The Dissociation of a Personality. New York: Oxford

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16. F.W.H. Myers, Human Personality and Its Survival of Bodily Death.
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20. Binet, supranote 18.
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23. Id., p. 35.
24. W.S. Taylor and M.F. Martin, "Multiple Personality,"
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25. Id., p. 281.
26. Id., p. 293.
27. Id., p. 291.
28. Id., p. 292.
29. Id., p. 294.
30. Id., p. 297.

31. Id.
32. C.H. Thigpen and H.M. Cleckley, The Three Faces of Eve. New
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33. J.P. Sutcliffe and J. Jones, "Personality Identity, Multiple
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34. Id., p. 258.
35. Id., p. 248.

36. Id., pp. 248-250.

37. Id., p. 231.
38. Id.,p. 251.
39. Id.
40. Id., p. 256.
41. Id., pp. 251, 259.
42. E.L. Bliss, Multiple Personality, Allied Disorders, and Hypnosis.
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43. Elzinga et al., cited in Lilienfeld et al., infra note 210.
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48. Id., p. 529.
49. Id., p. 530.

50. G.H. Estabrooks, Hypnotism. New York: E.P. Dutton, 1943.
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55. P.L. Harriman, "The Experimental Induction of a Multiple
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56. Harriman, supra note 54, p. 245.
57. Id., p. 246.
58. Id., p. 253.
61. Id., p. 255.

62. Id., pp. 244-245.
63. P.L. Harriman, "A New Approach to Multiple Personalities," Amer.
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66. Cited in Harriman, supra note 63.
67. Id., p. 641.


71. Id., p. 247.

72. American Psychiatric Association, supra note 3.
73. F.W. Putnam, Diagnosis and Treatment of Multiple Personality

Disorder.New York: Guilford, 1989.
75. Id., p. 640.
76. Id., p. 639.
78. H.C. Leavitt, "A Case of Hypnotically Produced Secondary and

Tertiary Personalities," Psychiat.Rev., 34:274-295, 1947.
79. Id., p. 279.
80. Id., p. 280.
81. Id.
82. Id., p. 293.
83. Id., p. 295.

84. E.R. Hilgard, Hypnotic Susceptibility. New York: Harcourt, Brace &
World, 1965.
85. Id., pp. 206-207.

86. R. Kampman, "Hypnotically Induced Multiple Personality: An
Experimental Study," Int. J. Clin. & Expt. Hypnosis, 26:215-227,
1976.
87. Id., p. 215.
88. Id., p. 217.
89. Id., p. 220.
90. Id., p. 223.

91. N.P. Spanos, J.R. Weekes, and L.D. Bertrand, "Multiple Personality:
A Social Psychological Perspective," J. Abnorm. PsychoL., 94:362-
376, 1985.
92. J.G. Watkins, "The Bianchi (L.A. Hillside Strangler) Case:
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32:67-101, 1984.
93. Spanos et al., supra note 91, p. 363.
94. N.P. Spanos, "Multiple Identity Enactments and Multiple Personality
Disorder: A Sociocognitive Perspective," Psychol. Bull., 116:143-
165, 1994.
96. Spanos, supra note 94, p. 153.

98. N.P. Spanos, E. Menary, N.J. Gabora, S.C. DuBreuill and
B. Dewhirst, "Secondary Identity Enactments During Hypnotic Past-
Life Regression: A Sociocognitive Perspective," J. Abnorm. & Soc.
PsychoL., 61:308-320, 1991.
101. Id., p. 367.
102. Id.
103. Id., p. 368.
104. Id.
105. Id., p. 372.
106. For a more detailed discussion of Spanos's interpretation of
role enactments as multiple personality, see N.P. Spanos, Multiple
Identities & False Memories: A Sociocognitive Perspective.
Washington, DC: American Psychological Association, 1996.
107. N.P. Spanos, J.R. Weekes, E. Menary, and L.D. Bertrand, "Hypnotic
Interview and Age Regression Procedures in the Elicitation of
Multiple Personality Symptoms: A Simulation Study," Psychiat.,
49:298-311, 1986, p. 299.

109. Id., p. 373.
110. Id., p. 374.
111. Id.
112. E.J. Frischholz & R.G. Sachs. A critique of social psychological
conceptualizations of multiple personality disorder. Manuscript
submitted for publication, 1987; E.J. Frischholz and R.G. Sachs,
Shaping Versus Creating: Factors Determining the Symptoms of
Multiple Personality Disorder.Paper presented at the 99th annual
meeting of the American Psychological Association, San Francisco,
1991.
113. Spanos et a1., supra note 91.
114. Hilgard, sujpra note 84.
115. Spanos eta 1., supra note 107.
116. Id., p. 300.
117. Id., p. 303.
118. Id., p. 308.

119. Id., p. 310.
120. Spanos et a I., supra note 98, p. 308.
121. Id.
122. Id., p. 310.

123. Id.
124. Id., p. 311.

125. Id., p. 313.

126. V. Sar, S.N. Unal, E. Kiziltan, and T. Kundakci, "Frontal and
Parietal Hypofusion in Dissociative Identity Disorder," poster
session at the annual convention of the International Society of
Traumatic Stress Studies, November 21-23, 1998.
127. E.R.S. Nijenhuis, personal communication.

128. Spanos, supra note 94.
129. D.H. Gleaves, "The Sociocognitive Model of Dissociative Identity
Disorder: A Reexamination of the Evidence," Psych. Bull, 120:42-
59, 1996.
130. Spanos et al., supra note 91.
131. Gleaves, supra note 129.

133. American Psychiatric Association, supra note 3.
134. Gleaves, supra note 129; R.J. Loewenstein, "An office mental status
examination for complex chronic dissociative symptoms and multiple
personality disorder," Psychiat. Clin. N. Amer., 14:567-604, 1991.
135. Gleaves, supra note 129, p. 43.
136. Id.
137. Id.,p. 44.

140. M.T. Orne, "The Nature of Hypnosis: Artifact and Essence,"
J. Abnorm. & Soc. PsychoL, 58:277-299, 1959.

143. Id.
144. J.G. Watkins and H.H. Watkins, Ego States: Theory and Therapy.
New York: Norton, 1997.
145. Hilgard, supra note 84, p. 207.
146. Spanos et al., supranote 91, p. 365.

633
147. R.J. Kohlenberg, "Behavioristic Approach to Multiple Personality:

A Case Study," Behavior Therapy, 4:137-140, 1973.
148. Id., p. 138.
149. Id.
150. Id., p. 139.

151. B.F. Skinner, "Behaviorism at Fifty," Science, 140:951-958, 1963.
152. Frischholz & Sachs, supra note 112.

153. C.G. Fine, "Treatment Errors and latrogenesis Across Therapeutic
Modalities in MPD and Allied Dissociative Disorders," Dissociation,
2:77-82, 1989, p. 77.
154. Id., p. 81.

155. Ross, supra note 22, pp. 69-70; Gleaves, supra note 129,
p. 54. See Gleaves, supra note 129, p. 54, "Additional alters can be
iatrogenically created." While most DID experts concur that alter
shaping and sometimes the creation of additional alters occurs in
patients who have DID, Ross recently has argued that "pure
iatrogenic cases" of DID sometimes occur as the result of an
interaction between "poor therapy techniques" and certain
"premorbid backgrounds" of patients. While acknowledging the
possibility that alter creation in patients who do not have DID may
occur in "extreme cases," Ross adds that "the threshold for creation
of iatrogenic DID may be higher than many skeptics assume" (Ross,
supra note 22, pp. 69-70).
156. See D. Brown and E.F. Fromm, Hypnotherapy and Hypnoanalysis.

Hillsdale, NJ: Erlbaum, 1986, p. 23, for a discussion of the
experiments designed to apportion the relative contribution of state
and expectancy effects to overall hypnotic responding.
157. Orne, supranote 140.

158. However, recent proponents of the expectancy or task motivational
view of hypnosis have stated the opposite, even going to the extreme
of saying that a "virtual consensus" concurs that the state theory
is no longer fashion. S.J. Lynn, B. Myers, and P. Malinoski,
"Hypnosis, Pseudomemories, and Clinical Guidelines: A
Sociocognitive Perspective." In J.D. Read and D.S. Lindsay (eds.),
Recollections of Trauma (Plenum, 1997), pp. 305-336.
159. Ross, supra note 22.
160. P.R. McHugh, "Psychiatric Misadventures," Amer. Scholar, 61:497-
510, 1992.
161. T.A. Fahy, "The Diagnosis of Multiple Personality Disorder: A

Critical Review," Brit. J. Psychiat., 153:597-606, 1988, p. 597.
162. Id., p. 598.

163. Id., p. 603.
164. Id., p. 604.

165. Id.
166. Id., p. 601.
167. Id.
168. M.A. Simson, "Multiple Personality Disorder," Brit. J. Psychiat.,
155:565, 1989, p. 565.
169. Id.
170. The three naturalistic outcome studies on dissociative identity
disorder include: P.M. Coons, "Treatment Progress in 20 Patients
with Multiple Personality Disorder," J. Nerv. & Ment. Dis., 174:715-
721, 1986; R.P. Kluft, "reatment of Multiple Personality Disorder:
A Study of 33 Cases," Psychiat. Clin. N. Amer., 7:9-29, 1984; J.W.
Ellason & C.A. Ross, "Two-Year Follow-Up of Inpatients with
Dissociative Identity Disorder," Am. J. Psychiat., 154:832-839,
1997.
171. H. Merskey, "The Manufacture of Personalities: The Production of

Multiple Personality Disorder," Brit. J. Psychiat., 160:327-340,
1992.
172. Id., p. 328.
173. Id., p. 327.

174. Id.
175. Id., p. 337.

176. Id.
177. Id.
178. McHugh, supra note 160.
179. Id., pp. 505-506, 509.

180. Gleaves, supra note 129, p. 44.
181. A. Seltzer, "Multiple Personality: A Psychiatric Misadventure," Can.
J.Psychiat., 39:442-445, September 1994.
182. Id., p. 442.
183. Id.
184. Id.
185. Id.
186. Id., p. 444.

187. Id.
188. Id., p. 445.
189. A. Piper, "Multiple Personality Disorder," Brit. J. Psychiat.,
164:600-612, 1994.
190. Id., p. 600.
191. Id., p. 607.
192. Id., p. 609.
193. R. Ofshe and E. Watters, supra note 4.
194. Id., p. 205.
195. Id., p. 209.
196. Id., p. 214.

197. Id., p. 211.
198. Id., p. 214.

199. Id., p. 213.
200. Id., p. 217.
201. D. Brown, "Pseudomemories, the Standard of Science, and the
Standard of Care in Trauma Treatment," Amer. J. Clin. Hypnosis,
37:1-24, 1995.
202. Gleaves, supra note 129.

203. Id., p. 42.
204. Id., p. 44.

205. Id., p. 46.
206. Id., p. 48.
207. Id.
208. Id., p. 49.
209. Id., p. 54.

210. S.O. Lilienfeld, S.J. Lynn, I. Kirsch, J.F. Chaves, T.R. Sarbin and
G.K. Ganaway, "Dissociative identity disorder and the
sociocognitive model: Recalling the lessons of the past."
Unpublished manuscript submitted by plaintiff expert witness S.J.
Lynn in Daly et al. v. Bell et al., a malpractice case alleging false
implantation of dissociative identity disorder by the defendant
therapists. Green County, WI, Circuit Court Case No. 98-CV-17.

212. Lilienfeld et al., supranote 210, p. 13.
213. Id.,p. 9.
214. Id., p. 5.
215. Id.,p. 3.
216. Id., p. 37.

217. Id.
218. Id.,p. 6.
220. Lilienfeld et al., supra note 210, p. 17.
221. Id., p. 19.

222. Id., p. 35.
223. Id., p. 37.

224. Id., p. 16.
225. F. Putnam, "Developmental pathways in sexually abused girls,"
presented at Psychological Trauma: Maturational Processes and
Psychotherapeutic Interventions, Harvard Medical School, Boston,
MA, March 20, 1998; A.B. Silverman, H.Z. Rienherz and R.M.
Giaconia, "The long-term sequelae of child and adolescent abuse:
A longitudinal community study," Child Abuse & Neglect, 20:709-
723, 1996; C.S. Widom and S. Morris, "Accuracy of adult
recollections of childhood victimization: Part 2. Childhood sexual
abuse," Psychol. Assessment, 9:34-46, 1997.
226. Lilienfeld et al., supra note 210, p. 36.

227. Taylor and Martin, supra note 24; Sutcliffe and Jones, supra note 33.
228. Harriman, supra notes 54, 55, 63; Hilgard, supra note 84; Kampman,
supra note 86; Leavitt, supra note 78.
229. State v. Greene, 139 Wash.2d 64, 984 P.2d 1024 (1999).
230. Frye v. United States, 54 App. D.C. 46, 293 F. 1013 (1923).
231. Daubert v. Merrell Dow Pharmaceuticals, Inc., 509 U.S. 579, 113
S.Ct. 2786, 125 L.Ed.2d 469 (1993).
232. For a discussion of Frye-Daubert rulings on repressed memories, see
chapter 13 in Brown et al., supranote 2.
233. D. Brown, A.W. Scheflin, and C.L. Whitfield, "Recovered
Memories: The Current Weight of the Evidence in Science and in the
Courts," J. Psychiat. & Law, 27:5-156, 1999.
234. Hess et al. v. Fernandez, supra note 8.

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latrogenic dissociative identity

BY DANIEL BROWN, PH.D., EDWARD J. FRISCHHOLZ,

In recent years there has been a remarkable increase in malpractice

© 2000 by FederalLegal Publications,Inc.

I. Rise of lawsuits-misuse of iatrogenesis hypothesis

Currently there are estimated to be 800 malpractice suits

A good portion of these retractor malpractice cases contain

A critical issue in these false memory malpractice cases is

In essence, a significant portion of the defendant therapists in

dant's treatment was outside of the standard of care. Surpris-

A critical issue in these cases is whether the defendant indeed

iatrogenic MPD hypothesis. We also conclude that expert tes-

!1. History of the development of the

A. Early The controversy about whether MPD is a legitimate psychi-

While interest in major dissociative conditions flourished

come forth in the treatment session. 9 Binet observed that

The work of Charcot 2l was also interesting in this regard.

By 1910 the credulous view of MPD began to wane,22 in part

Thigpen & Cleckley 2 reported the now famous case of Mrs.

Sutcliffe and Jones" critically examined the relationship

First, in part, multiple personality had become a "diagnostic

misdiagnosis. However, they added that "many of the cases

Second, they believed that "certain general features of the

Third, they considered the viewpoint that multiple personality

Fourth, Sutcliffe and Jones considered the viewpoint that

It is noteworthy that the two major premodern critical

C. Resurgence In contrast to the infrequently reported cases of MPD in the

this predictable course, a new professional society, The Inter-

Yet despite a remarkable revitalization of interest in MPD

III. Single case demonstrations and quasi-experimental

A. Estabrooks The experimental creation of personality states with hypnosis

B. Harriman Philip Harriman extended Estabrooks's original work with

More specifically, the procedure begins by inducing a deep

Harriman made the following observations about these "sec-

Harriman interprets these results as the outcome of indirect

In other words, secondary personality states are naturally

Harriman claims to have replicated the production of these

Harriman subsequently made a number of modifications to

ization" as the operator can produce. . . the operator now proceeds

The second modification entailed introducing a specific cue

The third modification was to "induce a personality state

The fourth modification involved extensive training of the

It is important that the reader appreciate the serious limita-

Second, it is clear from Harriman's own explanations as well

Third, the secondary personality states that Harriman demon-

patients with a diagnosis of MPD. According to DSM crite-

The secondary personality states that Harriman produced do

C. Leavitt- Leavitt78 expanded on Harriman's ideas in several important

cal hemiparesis that developed subsequent to a war trauma in

Using Harriman's automatic-writing method, Leavitt pro-

According to Leavitt, "The contrast between Frank and Leo

Leavitt did not think these secondary personality states were

D. Hilgard- Using a series of standardized measures of hypnotizability,