He describes Dissociative Identity Disorder:
Warwick Middleton: It represents a disruption in the usually integrated processes of consciousness, memory, identity and perception. Someone who dissociates separates off affect or memories or functions, but with not a complete awareness across all those processes. A person who is highly dissociative may switch into identity states where they feel that they are of a different age, a different sex, living in another time and place or responding to a different environment. It's a spectrum. The average person with DID is not the phantasmagoric representation that someone sometimes sees in Hollywood movies, it's much more a covert than it is an overt condition.
And characteristically people who have dissociative identity disorder don't usually come to a health professional saying 'I think I've got DID', they probably come because they hear voices, they have a history of self-harm, they may self-medicate using alcohol, drugs et cetera. And it's only when the condition is seen from outside that the full nature of the parallel processes become very apparent, that there are gaps in memory, that the person may be aware that they do things in ways that seemed very uncharacteristic of them, or people refer to them by different names which they find perplexing, that they find evidence that they have been places and they can't remember being there, they find evidence that they've done things, bought things, et cetera, find things in different handwritings, find drawings that they've done that they don't remember doing.
Lynne Malcolm: So it used to be known as multiple personality disorder. So this explains it, in a way, doesn't it, that different characters are developed within the one person, is that right?
Warwick Middleton: Yes, characteristically people with DID switch between different identity states, none of which has the full range of memory and the full range of affect that an integrated personality that's non-dissociative has. So one way to look at it is, yes, you might have multiple identities and name them and some of these may almost have delusions of separateness in that they in that state do not believe that they are connected to the other states. I've literally had people say things like, 'We are not multiple.' Or, 'Look, I'm not multiple but I think some of the others are.'
Lynne Malcolm: And are they sometimes not aware of the behaviour of the others?
Warwick Middleton: One way of conceptualising it is, yes, people with this condition switch between different identity states, but it can be usefully conceptualised as not so much as having multiple personalities but having access to less than one personality in any context or in any time. So if they are confronted with a certain event, a person with DID in that particular state summons up what resources that they can lay their hands on in that state, but that may mean that that precludes them from the full access to other resources or memories that may help their decision-making, which sometimes represents a situation where they do things that appear very unusual or reactive in a way that is totally out of keeping with the circumstances.
Lynne Malcolm: Warwick Middleton.
Kallena is now 52 years old and was first diagnosed with DID when she was in her mid-30s. She explains what was happening in her life leading up to that diagnosis.
Kallena: Before that I had been quite successful in study, career. I had a family. I thought my life was going really well, to be honest, or at least the parts of myself who were living my life at that stage thought things were going quite well.
Lynne Malcolm: And what were the parts that you were living with?
Kallena: Parts of myself that had been formed to manage living in everyday life in a way that wasn't possible for those who knew about a lot of the things that had happened to me. And because feelings are separated out, that is the feelings of the really bad things that happened, then also actually memory and physical sensations as well get separated out.
Lynne Malcolm: So did you have particular identities, and if so can you describe those?
Kallena: There were quite a lot. It would be very hard to describe them all. I think of mine in terms of being at several levels. There were the ones that turned out to be really fundamental to who I am myself. Then there were also another kind of a layer that were very prominent in everyday life and did a lot of things for me and had always done a lot of things that I had done in my life. There were also very dominant ones that knew a lot about the particular traumatic things I'd experienced as a child and also then as a young adult. Then there were also multitudes and multitudes of parts that simply were…I prefer just to call them just bits, just fragments of memory, short events, feelings, a lot of body memories and so on.
Lynne Malcolm: And were you aware of each of the parts, what they were doing and what they were saying?
Kallena: For me it was mixed. Some parts did know about others, and some parts did have some awareness of what others were doing and what others felt, whereas other parts didn't. With one part prominent in consciousness, for instance I would have no awareness of a lot of things that happened and had happened previously in my life or the other parts did, whereas with a different one it would be different again. And that also changed over time with therapy, as the aim of therapy is to increase the cooperation between parts and awareness between parts. So over the years that changed.
Lynne Malcolm: So before therapy did any of these parts interact with each other?
Kallena: Yes, some did. For me it was largely younger ones, they had much more of an awareness of other parts. But then there were also ones who had no awareness that any others existed at all, considered they were the only part or person here and that the life they knew was really what my whole life had been.
Lynne Malcolm: So the characteristics of some of the parts, did they resemble people that you'd known from your past?
Kallena: No, I don't think they particularly resembled anyone I'd known. Sure, there were parts that were really angry and upset and so on, but they were all really individual in themselves. The ones that really lived the life most, they were focused on either being able to do particular kinds of things or express particular kinds of feelings. Like for instance, there was one who just liked to have fun and who was good at sport because we thought sport was fun, things like going skiing and so on. So she was good at those kind of things and loved them and had a lot of fun, and was good at teasing people and being very social and so on, whereas others were very introverted. There was another one who was very good academically, who really had no connection with the body at all, who wouldn't have been able to ski for the life of her, but was academically very good and successful.
There can be physiological changes between parts. For instance, for me I had parts that needed glasses and parts that didn't. And certainly the physical changes between parts can be felt very much, simply in terms of body language, posture, ways the body can move. So as I said, I had parts that could ski, parts that absolutely couldn't. So I had parts that could speak English and parts that couldn't speak English, so language differences, lots of things like that, yes.
Lynne Malcolm: And were you able to flip between parts depending on what the need was? Say you were in a part that couldn't speak English and you were at work or you were having to order something at the shop, what would you do?
Kallena: Well, I guess those sorts of parts just wouldn't come out in those settings because it's not safe to be seen to be in that sort of setting if you suddenly appear and you don't know where you are and you don't understand where you are. For me that didn't happen very much.
Lynne Malcolm: So what's your memory of how people responded to you over the years that you are living with these parts?
Kallena: Overall, at the times I was functioning reasonably well there was no difference to anyone else. Because my parts never blatantly showed themselves as different to people, because the whole core of being like this was to hide what had happened. So of course you want to pretend and act as if you are normal. So in my case, none of my parts literally ever showed themselves blatantly as different or unique or separate to another part to anyone else probably, other than my therapist. Ever. Even all those years.
Lynne Malcolm: So it's your private way of coping but on the outside people didn't necessarily detect it.
Kallena: On the outside almost no one would know. Certainly there were times in my life where it became more obvious, when things became very unsettled or we were under a lot of stress. And particularly I'd say in my late teenage years because I was still in an abusive environment, things were still very, very difficult. I did have contact with the mental health system at that stage. I was actually diagnosed as bipolar, so it was interpreted as, oh, her mood is changing really much, suddenly she is depressed, suddenly she is manic. They weren't interpreting the difference, that I was actually switching from an extremely shut-down and traumatised part to suddenly being a part of that is extroverted and having fun. So it was that misinterpretation of what was actually going on. And nobody bothered to ask me at any time anything about what was happening to me.
Lynne Malcolm: You're with All in the Mind on RN, I'm Lynne Malcolm and I'm speaking with Kallena about the psychiatric condition she's lived with for much of her life. It's called Dissociative Identity Disorder, which was once known as multiple personality disorder.
Professor Warwick Middleton is the director of the Trauma and Dissociation Unit at Belmont Hospital in Brisbane. He explains the role that he believes childhood trauma plays in the development of DID.
Warwick Middleton: It has become very apparent in every study of series of patients with DID that the vast majority of them give a history of being sexually, physically, emotionally abused, or emotionally deprived from an early age, usually well before the age of eight, and with abuses continuing for a long period of time. So a child who doesn't have a developed sense of identity, at a young age is being physically or sexually or emotionally abused, usually all three, and they have no way of escape from the people who are their primary caregivers but also their primary abusers. So in this double-blind, the only way you can not go crazy or suicide is to find a way of compartmentalising trauma at the same time as eking out some sort of relationship with a poor attachment figure.
And at the most extreme…I mean, I've literally seen and I've written and researched this area, where that sort of very disturbed, traumatic attachment literally can go on for decades, and the same person is still being sexually abused by the same perpetrator for 50 years. So these cases that have become more apparent in the international press, the Josef Fritzl cases, where somebody is literally imprisoned, are by no means rare, but usually the abuse doesn't need the physical restraints of an actual dungeon. The psychological process of imprisoning a person work just as well.
Lynne Malcolm: Warwick Middleton.
Kallena certainly has trauma in her background. And you may find her story disturbing.
Kallena: Well, for the first…well, over 20 years of my life it was very much centred around what happened in my nuclear family. It was, looking back on it now, an extremely dysfunctional family, with a lot of things that happened in it that really shouldn't happen to any child at all. Starting from when I was absolutely an infant, I was treated in ways that were extremely hurtful and painful and terrifying. A lot of times I probably believed I was going to die, which is I think at the core of why a lot of these separations happen, is that you really believe you're going to die.
Lynne Malcolm: It's so extreme.
Lynne Malcolm: So it was all within your nuclear family, abuse…was it sexual abuse as well?
Kallena: Yes it was, yes, for over 20 years.
Lynne Malcolm: And are your memories of that clear?
Kallena: Very clear, a lot of it, yes, now. Although, as I said, for much of my life there were parts living it who had no idea that much of this happened and who if anyone had asked, and as people occasionally did, would have answered that; oh no, I had a fine childhood, I grew up in a good family and everything was fine with no problems, and I did well at school, which I did, and I was quite successful with no issues really.
Lynne Malcolm: So were the perpetrators eventually exposed or charged?
Kallena: No, they've died now. I would not have been capable of speaking out about it earlier while they were still around. There has been recognition for me though since that, yes, criminal things did happen, but not officially at a criminal court level, but there has been recognition officially though.
Lynne Malcolm: And that recognition has been extremely important to Kallena in her healing.
The Australian Royal Commission into Institutional Responses to Child Sexual Abuse has recently resumed hearings, and the emerging reports are deeply disturbing. In Kallena's case though, the abuse all took place within the nuclear family. Professor Warwick Middleton:
Warwick Middleton: The biggest institution in our society is the one that we don't have a Royal Commission about and that's the one called the family and it is in many cases closed and fairly hierarchical, and it's very, very hard for the average abuse survivor to speak out about what happened in the family, which is why various state laws that are in the process of being repealed represent a long overdue reform which in recent months, and in concert with a recommendation from the Royal Commission is being altered so that victims of child sexual abuse are not limited by a statute of limitation as to when they can take legal action.
Lynne Malcolm: People who develop dissociative identity disorder often create many separate identities or parts, which serve to protect them from the horrifying memories and realities of their earlier trauma. But even with these protective mechanisms in place, daily life can be a struggle. So, is there effective treatment for DID?
Warwick Middleton: The overall finding is that the vast majority of cases, when a patient with DID enters into some regular structured therapy with somebody who has sound boundaries and a functional understanding of trauma, things improve. Not everyone has a marvellous outcome, and for some, as I mentioned, you are still wrestling with somebody who presents as an adult but in fact is still being abused by the same people who have abused them all their lives.
And when you're talking about treatment, the first thing you are trying to do is achieve a basic level of safety, which means first and foremost is that they are in a situation where they are no longer susceptible to being abused, and that's easier said than done in some cases. And in order to become more integrated you need to process the trauma, you need to deal with…there's strong affects to do with shame, humiliation, fear, emotions that were imposed by abusers.
And the average abuser does things like manipulating a child sexually, then saying that they must be enjoying it, they wanted it, they are doing it because the child wanted it, it's their fault, the child is a slut, moving through to 'and if you tell anyone no one will believe you', 'you'll go to hell' or 'I will kill you' or…and the manipulation of the special relationship that the abuser forms, that 'you are special and I'm doing this because I really love you and I care for you'. These are the sort of things that are painful, difficult things to process, and you are trying to do that in a manageable way without going in to quickly.
So some people achieve a lot of integration, some maintain, some switching between different states and find they don't want to ever change that. Others, things go reasonably well, the amnestic barriers just slowly merge. It's not like you've lost anything, you've just taken away an artificial partition; it's like one of those office plans where you can have movable walls and move progressively towards an open plan office where everyone can see everyone else.
Lynne Malcolm: Professor Warwick Middleton from Belmont Hospital in Brisbane.
Kallena has had long-term psychotherapy to treat the DID she's lived with for most of her life.
Kallena: And the way that works really is it's about relationships because the trauma originally happens in relationships. So in that therapeutic relationship then someone begins to be safe enough for all the different parts to actually begin to show themselves and to begin to develop some kind of relationship with one consistent other person, and then gradually begin to feel this person as safe enough to express more and more of what they know, what they feel. So there are stages of different parts going through, yes, everything that they experienced, then that knowledge being shared slowly and gradually between all the parts.
And then more and more as all the parts in that relationship to one consistent other person, who is good enough in how they relate to all parts and treats all equally and respects all equally, the parts begin to learn to cooperate. There are also techniques and skills that we learn to help ourselves begin to start to communicate with each other more internally inside our head. Then also externally we wrote in journals a lot that then other parts would be able to read what one part had written or what one was doing, so then we'd keep track and learn to communicate inside our head more.
So gradually over years and years work through to be able to contain what they call co-consciousness, when all parts are actually present and actually aware of what's happening in the world and so are actually functioning together. Until finally, for me it actually happened that they absolutely naturally, with no effort or intention or anything, the parts just fused together and I have one whole self now and have had for some time.
Lynne Malcolm: Amazing. And it was almost like a real team effort, with all your parts together working towards healing.
Kallena: Oh yes. I guess that's the whole point really.
Lynne Malcolm: So how did that finally feel, when you realised that all the parts were now together? How did that feel emotionally?
Kallena: Well, at first it was actually terrible because it was so extraordinarily different. Things like suddenly thinking, 'But isn't this day over yet? How can this day be so long?' Because we had no concept of actually the length of time that a whole day took because we had always constantly been switching. So we had no capacity developed to actually live through a whole day without going back and having a break. We hadn't realised it but even all these years we've been co-conscious, there was still constant changing of which part was actually dominant, doing whatever was being done at the time, even making decisions, because it always seemed there was someone else to make particular decisions. Those things were very difficult to get used to.
Lynne Malcolm: I've noticed through our conversation that very often you are talking about 'we', you express yourself as 'we', and now do you have trouble adjusting to using the word 'I' as a single person?
Kallena: No, not really. I am using it because I'm relaxing and talking freely as I do to people who I speak to openly about having DID. But overall, no, I don't have difficulty because even all these years we were hiding in the community and we used 'I', we only used 'we' in those instances where it felt safe to do so. So no, it's not actually hard, it's the way we've always been.
Lynne Malcolm: So do you feel that you are a happier person now than you were when you lived with parts?
Kallena: Yes, I think I do feel better in myself overall now, yes, but it's a controversial question because this issue of whether it's something to aim for or whether it's right or even desirable to get to a point of no longer having parts…it's something that's not right for everyone. And yes, I do find myself being a lot more content than I ever would have before.
On the other hand, I do feel I actually miss my parts, certainly at times, as a sense of comfort to having others inside you who you know and can communicate with in this sense of never being alone. I do miss that, there's times I really miss them. There's times I miss this sense of, oh, I've had enough of this, someone come and take over for me. But overall, no, I'm glad I'm like this now.
Lynne Malcolm: Thanks to Kallena for sharing her powerful story with us today.