Troubling Trends in the Mental Health Profession

November 23, 1995

As a man of Christian faith, I have always felt a bit out of step with the trends of psychology. Even during my graduate and post-doctoral training I often held different, and sometimes opposing, views from those of my colleagues, professors, and clinical supervisors. During recent months I have become increasingly concerned over three trends within the mental health professions.

In this edition of the Counseling Newsletter I will address these disturbing mental health movements. I hope that you will consider my thoughts and opinions and contrast them with your own experience. As always, I would welcome hearing your response to what you read.

Multiple Personality Disorder: Assumptions and Assessment

From the outset let me unambiguously state that I recognize some children are and have been victims of sexual and physical abuse. In my work at Atascadero State Hospital and in private practice I provide treatment to both perpetrators and victims. Also, let me clearly state that I am convinced that behavioral problems may originate from such abuse. With this caveat as a preface, I’d like to share some thoughts on Multiple Personality Disorder (MPD) and the assessment thereof.

MPD has come to serve as a convenient diagnostic label to explain a litany of complex and bizarre clinical behavior. In my workI have seen the diagnosis of MPD used in an indiscreet and sweeping manner.

Since the 1970’s the diagnostic category of MPD (known as Dissociative Identity Disorder in DSM-IV) has become increasingly popular and “trendy.” MPD has come to serve as a convenient diagnostic label to explain a litany of complex and bizarre clinical behavior. In my work I have seen the diagnosis of MPD used in an indiscreet and sweeping manner.

Based upon a limited review of the literature and discussions with a variety of mental health professionals, I’ve come to understand that a basic model of childhood development and childhood memory provides the substructure upon which the notion of MPD is built. The most common theory espoused by many clinicians asserts that most adult MPD sufferers were abused as children. It is often reported that this abuse (sexual or otherwise) was perpetrated by a trusted friend or family member. The assault is believed to have been of such traumatic proportion that it is repressed from memory and dissociated from the patient’s conscious awareness. This “amnestic response” is said to serve to protect the patient’s fragile psychological state. Further, the psychological defense of repression is reported to be so complete as to compromise the integration of the mind resulting in the development of multiple and separate personalities. These personalities are said to be distinct and sequestered with relatively autonomous faculties of memory, thought, and emotion.

It is interesting to note that these distinct “personalities” produce a variety of psychological symptoms that are commonly displayed in a number of mental illnesses. These symptoms include relationship difficulties, depression, weight and body image problems, panic attacks, demoralization, and feelings of isolation and loneliness. Although this clustering of symptoms could lead to several diagnostic considerations, it appears to be currently fashionable to conclude that they are manifestations of MPD and are the direct outcome of childhood sexual abuse.

As stated above, MPD and its treatment, is predicated upon the notion that children commonly have an amnestic response to traumatic events. In response to severe abuse children are theorized to dissociate these memories through a type of protective amnesia. Sometime after these events (sometimes as long as 20-30 years later) the memories are allowed to surface with the aid of long-term “uncovering” psychotherapy. I find two problems with this theory and its clinical application.

First, discussions with colleagues that treat such patients reveal that other than the patient’s report, they rarely seek corroborating information to confirm the report of childhood abuse. It appears that other actual proof of the sexual or physical assault is thought be to unnecessary. Why is there rarely an attempt to confirm the patient’s account of physical abuse? Clinicians seldom make the effort to call family physicians or school nurses to gather corroborating reports. If the patient had suffered the severe forms of physical or sexual abuse as reported (broken bones, seared skin, whip and belt marks, tears due to penetration with foreign objects) there is a good possibility that some health care provider or teacher may have noticed and documented such harm. What concerns me most is that many of my colleagues do not go to the effort to check it out. Consequently, thorough clinical assessment is short-changed or abandoned in favor of a popular diagnostic label.

A second problem with MPD concerns the idea of repressed childhood trauma which is at odds with much of the clinical literature concerning childhood memory. Based upon a review of the literature and clinical experience, it seems that children do not repress severe trauma from memory, but rather, these traumatic events are remembered all too well. The challenge for the child is not that of working to remember the traumatic event—but to stop ruminating over it. This tendency to remember and dwell upon traumatic events is exemplified during anniversaries of the trauma or when the child is in an environment that simulates the setting in which the trauma originally occurred.

The challenge for the child is not that of working to remember the traumatic event—but to stop ruminating over it.

Good evidence for this tendency to remember and relive, not repress, childhood trauma, is found in the experiences of children held in the concentration camps of WW II Germany. When queried, adults who were children in the concentration camps are able to give very detailed and precise accounts of their dreadful confinement. They clearly describe the living conditions, faces and uniforms of the German officers, and the smells and textures of everyday life in that horrifying environment.

In a similar manner, the children of Chowchilla, California, who were kidnapped in a school bus and buried in sand for many hours, remembered every detail of their chilling experience. Psychological assistance was not precipitated by a need to recall memories from this traumatizing event and to exhume forgotten memories, but rather, to help them move away from the constant ruminative preoccupation with the experience.

Concerning the diagnosis of MPD/DID and repressed childhood memories the clinical and professional implications are numerous, but I will mention only a few.

1. Competent treatment is always based upon thorough assessment and accurate diagnosis. The proliferation of the use of MPD/DID as a diagnostic category seems to be symptomatic of less than rigorous assessment. These trendy diagnoses are often used when the presenting signs and symptoms might be more directly and elegantly accounted for by traditional and common diagnostic nomenclature.

2. The efficacy of mental health treatment has been debated (particularly in Christian circles) for nearly 100 years—and the debate is more vigorous now than ever before. In the midst of this zeitgeist, it is imperative that our treatment be theoretically sound. The current conceptualization of MPD as related to childhood memory is very tenuous. The notion that children repress memories of traumatic events is largely inconsistent with both the empirical literature and the observable behavior of most children.
3. Public confidence in the mental health professions is built upon our ability to exercise prudent and measured judgment. The attraction toward “popular” diagnoses erodes public trust and our professional integrity.

Self-Esteem as a Virtue

When I question the notion of self-esteem I do so with some hesitation—it is like questioning family values. As a culture we have come to wholeheartedly endorse the notion that everyone should feel good about himself or herself. At both Atascadero State Hospital and at the private practice office a common presenting problem I hear from patients is, “I have low self-esteem.” It seems that mental health professionals, as well as the general public, are quite persuaded that improving one’s self-esteem is the key to solving a number of life’s problems. It is difficult for most clients to articulate the problems they are experiencing due to their sense of low self-esteem—but upon exploration it often becomes clear that their report of low self-esteem often means, “I am depressed and lethargic,” or, “I am confused and feel trapped.”

Many people come to counseling with the hope that their self-concept or self-esteem can be altered or raised by talking with someone. I agree with the assertion that discussing matters with a mental health professional can be very helpful in clarifying and sorting out matters concerning ones thoughts and feelings. But I am not sure that I can truly make people feel better about themselves. Even if I believed I could generate such a fantastic result, I am not sure that doing so would be good.

I contend that there is no inherent virtue in elevated self-esteem. In fact, an inflated sense of self can be quite damaging to oneself and to others. Conversely, I strongly believe that mental health professionals of all persuasions should challenge their patients (and themselves) to soberly assess their behavior and thinking patterns and then realistically align their sense of self in accordance with that standard.

Therefore, when patients come with complaints of “low self-esteem” I work to recast their notion of self-concept. I reason with them that their goal ought not be to have a “good” self-concept—but a realistic one.

It is not a sign of health to feel better about oneself than is indicated by one’s actions. If patients are behaving in an irresponsible or self-centered manner, my role is not to coddle their fragile sense of self. Rather, the challenge is to confront them with who they really are and elucidate how their behavior impacts others.

Unfortunately, current cultural trends allow low-self esteem to be used as a double-barreled excuse. It gives license to a lack of effort and persistence. Yet, I also hear mental health workers explain destructive and evil behavior as a direct result of poor self-esteem. Such confounded logic is puzzling. I treat a number of people who do not feel particularly good about themselves and yet they live in a very respectful and caring manner toward others. Their disparaging self-concept does not lead them to offend or violate the rights of others. Rather, their sense of insecurity prompts them to be especially sensitive and socially cautious.

…feeling good about oneself may simply be a sign of overconfidence, narcissism, or unwillingness to work hard.

I have also found it informative to explore the relationship of self-esteem and achievement. In 1989 (see reference section for citation) researchers compared the mathematical skills of students from eight different countries. American students ranked lowest in mathematical competence and Korean students ranked highest. Researchers also asked students to rate how good they thought they were at mathematics. Ironically, American students ranked as highest in self-judged mathematical ability, while the Korean students ranked lowest. Mathematical self-esteem had an inverse relationship to actual mathematical ability. Although American students felt good about their mathematical skills—their perception of their ability was quite distorted. Many self-esteem theorists posit that only those who feel good about themselves do well. Yet, these findings suggest that feeling good about oneself may simply be a sign of overconfidence, narcissism, or unwillingness to work hard.

Just as self-esteem is a poor measure of one’s current abilities, it is also a poor predictor of future behavior. In reviewing the available literature there is little to show that accepted measures of self-esteem have any predictive validity, regarding either positive or negative behavior.

From a Christian perspective the matter of self-esteem is a challenging issue and has been the topic of much debate. Paul C. Vitz, professor of psychology at New York University, concisely captures the tension, “Self worth, a feeling of respect and confidence in one’s being, has merit. But an ego-centered, ‘let me feel good’ self-esteem can ignore our failures and need for God.”

The concept of self-esteem is somewhat bankrupt because it is self-referential. “I feel good about myself because I choose to.” This position is both childlike and philosophically untenable. This is to say, self-esteem is not a gift that one can bestow on oneself. Self-esteem and self-worth are not self-generating, but rather, self-worth is a response to something or someone outside of us. For example, feelings of self-worth may legitimately derive from a job well done, consistent and faithful effort on a project, loyal friendship, or self-sacrifice. In such instances, self-worth is not something to be sought after and pursued. Rather, it is a by-product of our relationship to something or someone.

Ultimately all sense of genuine self-worth is derived from a relationship with the loving God who created and sustains us. We have worth because God regards us a worthy and worthwhile. We are loved and valued because God loves us and values us. As Christian mental health professionals we have both the joy and responsibility to bring this liberating truth to those we serve.

The Trap of Victimhood

It seems to be quite in vogue these days to be a victim of one thing or another. From Oprah to Dan Rather we hear of people suffering as victims under nearly ever imaginable type of oppression. Here is a brief listing of the categories of “victimhood” recently covered by the media: mail order scams, addictions of every type, the New Age Movement, parents who were under-protective and/or overly-protective, the political right and/or the political left (which ever suits your fancy). I do not challenge the assertion that people are victimized and sometimes abused by others. But I am bothered by the trend within our culture, and particularly within the mental health profession, which allows (and sometimes encourages) clients to organize their lives around the principle of victimhood. It seems that even if one has been victimized, there is little advantage in continuing as if the victimization is the defining event in one’s life.

Once a person has chosen to assume the fixed role of victim is very difficult to convince them that it is better to work through these issues and relinquish the role. Often times, victimhood becomes quite comfortable and familiar. Understanding oneself primarily as a victim does have a few untoward advantages. For example, the victim’s lifestyle provides an easily accessible explanation for ongoing poor choices and decisions. “Career victims” also project responsibility for their own lives onto others. In many cases little is required of the victim other than continuing to behave and think as a victim. Those who might challenge their role are quickly cast aside as insensitive and unempathic.

I strongly contend that clinicians have the responsibility to emphasize the notion of choice as a reality of everyday life. Even if one has been hurt and damaged in the past, one can still make informed, mature, and responsible choices. These choices need not be determined by past experiences as victim (see Romans 6).

The position of victim can serve as a toxic source of resentment, anger, and retribution. For those who have been aggrieved, the challenge is to acknowledge and recognize the wrong done—but not to aggrandize or exaggerate it. There is a need to engage in the process of personal care and repair. As a part of the healing process, victims must acknowledge the past and move forward. To remain stuck in the midst of a painful past leads to intensified resentment and hatred. In some cases I have even seen the role of victim lead to a false sense of moral superiority and self-righteousness.

For those who have been victimized I offer a short list of suggestions:

• Acknowledge and recognize how you were hurt and aggrieved. This was a historical event. Tell your story to God, your pastor (or spiritual mentor), and those close to you.
• Avoid rationalizations and excuses for current weaknesses. Find the help and support you need to progress and grow.
• Come to believe that traumatic events need not define who you are and who you might become. “He who began a good work in you will see it to completion.” Phillipians 1:6
• Choose to not become resentful and hateful. Rather, do what you can to forgive and move on.

REFERENCES

Multiple Personality Disorder: Assumptions and Assessment

McHugh, P. R. (1992) Psychiatric Misadventures. The American Scholar, Autumn 1992, 497-511.

McHugh, P. R. (1994). Psychotherapy Awry. The American Scholar, Winter 1994, 17-30.

Loftus, E. (1994). The Myth of Repressed Memory: False Memories and Allegations of Sexual Abuse.

St. Martins Press.

Self-Esteem as a Virtue

LaPointe, A., Mead, N.A., & Phillips, G. (1989) A World of Difference: An International Assessment of Mathematics and Science. Princeton, N.J.: Educational Testing Service, p 10.

Guinness. O. & Seel, J. (1992). No God but God: Breaking with the Idols of Our Age. Chicago: Moody

Press.