Excerpts from Must Read Books & Articles on Mental Health Topics
Articles- Part XI

The Politics of Hysteria
Joan Acocella, The New Yorker- 4/6/1998

In late 1989, Elizabeth Carlson, a thirty-five-year-old woman who lived with her husband and two children in a Minneapolis suburb, was in the hospital being treated for severe depression. She was referred to a psychiatrist, Diane Humenansky, who came to see her and went on seeing her after she left the hospital. As Carlson recalls, Humenansky soon suggested to her that perhaps her problem was not depression but multiple personality disorder. M.P.D., Humenansky explained, was an elusive illness: many diagnosticians failed to recognize the alternating personalities, or alters, for what they were, with the result that the woman--nine out of ten people with M.P.D. were women--often ended up getting misdiagnosed. But experts now knew that there were certain telltale signs of M.P.D. Did Carlson ever "zone out" while driving, and arrive at her destination without remembering quite how she got there? Why, yes, Carlson said. Well, that was an alter taking over the driving and then vanishing again. Another sign, Humenansky said, was "voices in the head." Did Carlson ever have internal arguments, telling herself, for example, "Turn right--no, turn left"? Yes, Carlson replied, that happened sometimes. Well, that was the alters quarrelling inside her head. Carlson was amazed and embarrassed. All these years, she had done these things, never realizing that they were symptoms of a serious mental disorder.
    Multiple personality, Humenansky explained, was associated with childhood sexual abuse, though the abuse might be forgotten. Carlson should think hard: had anyone ever taken liberties with her? Carlson didn't have to think hard. She distinctly remembered being molested by two men in her family. That didn't mean there weren't other episodes, Humenansky said. Worse ones, maybe.
    To help Carlson remember, Humenansky gave her books to read. One was Ellen Bass and Laura Davis's 1988 "The Courage to Heal," now known as the Bible of the recovered-memory movement. A third of American women were sexually abused as girls, "The Courage to Heal" stated, and if a woman was repeatedly molested she might have not only forgotten it but developed new personalities in which to seal off the terrible knowledge. "The Courage to Heal" gave first-person accounts. In a later edition, one woman wrote:

I remember splitting for the first time when I was about four and my father was trying to force me to sodomize my pet rabbit with a roofing nail. He got very angry when I refused, and finally, in a rage, he threw me down on the basement floor and raped me. When I came back to myself after the experience, here were three parts of me.... Benjamin-ageless, spiritual and protective; Bunny-little and worried; and Scarlet, the only female and the one who dealt with the sexual abuse.

    Humenansky also gave Carlson books about M.P.D. cases. One was the 1957 classic "The Three Faces of Eve," by Corbett Thigpen and Hervey Cleckley, the story of the shy housewife "Eve White" who on the odd weekend would metamorphose into "Eve Black," a vivacious party girl, leaving Eve White with unexplained hangovers and a reputation in local bars. As a result of this book and the 1957 movie based on it, featuring an Academy Award-winning performance by Joanne Woodward, Eve became, for awhile, the prototype of the multiple personality. In later cases, as in Eve's, there was often the naughty/nice split-- "librarian by day and streetwalker by night," to quote the M.P.D. expert Frank Putnam.
    Eve, however, was merely the John the Baptist of multiple personality; the Christ was "Sybil Dorsett," a Columbia University graduate student who in 1954, at the age of thirty-one, turned up in the office of the psychiatrist Cornelia Wilbur and stayed for eleven years. In 1973, this case became the subject of a best-selling book, "Sybil," by a journalist named Flora Rheta Schreiber. Three years later, the book was turned into a TV movie, with Sally Field as Sybil and Joanne Woodward, passing the torch, as Dr. Wilbur. Sybil became the most famous psychiatric patient in history, and the new model of multiple-personality disorder, in a form different from Eve's. For one thing, M.P.D. now had a clear cause: childhood sexual abuse. Eve had suffered traumas as a child, but she was never sexually assaulted. Sybil was repeatedly, by her mother. Furthermore, the mother's actions were sadistic, perverse, extravagant. According to the book, she probed the child's vagina with a knife and a buttonhook. She hung her upside down and, using an enema bag, filled her bladder with ice-cold water, then tied her to the family piano and forbade her to urinate while she, the mother, played Chopin. A second difference between Eve and Sybil was in the number of alters. As described by her therapists, Eve had had only three faces. ("Eve White" and "Eve Black" were later joined by "Jane.") Sybil had sixteen personalities. One could play the piano; another could install Sheetrock; two had English accents; two were boys. Sybil wasn't so much a person as a club.
    Prior to Sybil, M.P.D. had been one of the rarest of mental disorders. In a 1944 article, two researchers, W. S. Taylor and Mabel Martin, reported that a search of the medical literature had yielded only seventy-six cases that met their definition. But after Sybil M.P.D. exploded. One expert estimated that between 1985 and 1995 there were almost forty thousand new cases. Like Sybil, the modal M.P.D. patient was a white North American female around age thirty. Like Sybil, she said she had suffered child abuse, usually sexual. But Sybil's descendants outstripped her. Patients were soon producing a hundred, four hundred, a thousand alters. And, whereas Sybil had confined herself to human alters, later M.P.D.s branched out. The Georgia-based psychiatrist George Ganaway, one of the first authorities to caution against the fascination with M.PD., reported that he had been presented with "sages, lobsters, chickens, tigers, a gorilla, a unicorn, and 'God.'" In recollections of abuse, too, Sybil was rapidly outdone. Multiples were now reporting rape and sodomy--indeed, "satanic ritual abuse."
    Both Eve and Sybil had been suicidal, but the multiple personalities of the eighties and nineties were more ingeniously self-destructive. In one popular M.P.D. biography, "Suffer the Child," the subject pours drain cleaner on her genitals. Other multiples have shown journalists self-inflicted cuts and third-degree burns. Self-mutilation was accepted by many M.P.D. writers as a regular feature of the disorder, a "coping mechanism." Starting in 1990, self-mutilating patients had a newsletter, The Cutting Edge. In a recent issue, "Carla" writes that she doesn't really want to stop cutting herself, and that her new therapist has left the decision up to her, so she's cutting again, "yet it's been a time of tremendous growth and potential."
    Until about 1975, there had been no M.P.D. specialty. Multiple personality disorder had no separate listing in the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders," or D.S.M., the guidebook to diagnosis. But in 1980, after vigorous lobbying by interested therapists, the new edition of D.S.M. gave M.P.D. a primary-level listing among the dissociative disorders--conditions in which some part of mental functioning splits off from consciousness. In 1984, the new M.P.D. enthusiasts founded an organization of their own, the International Society for the Study of Multiple Personality and Dissociation (I.S.S.M.R. & D.), and began holding annual conferences, co-sponsored by Rush Presbyterian St. Luke's Medical Center, in Chicago. That hospital subsequently set up the country's first dissociative-disorders unit, under the M.P.D. expert Bennett Braun. Other units followed. Between 1970 and 1990, the average annual output of publications on M.P.D. increased six thousand per cent.
    Among those publications were two 1989 textbooks: "Diagnosis and Treatment of Multiple Personality Disorder," by Frank Putnam, and "Multiple Personality Disorder," by Colin Ross. Both offered treatment plans focussing on presumed childhood abuse. Using hypnosis, the therapist was instructed to flush out the alters and get them to divulge their secrets, a process that often involved protracted reenactments called "abreactions." In a typical abreaction, as Colin Ross described it, the patient might "cry out, plead with the father to stop, clutch her pubic area, try to push the father off, attempt to spit out semen, or curl up in the corner." These were violent scenes. David Calof, an M.P.D. therapist who has worked in nursing homes, reports that one of his patients had a stroke during an abreaction.
    Confronted with this information, many therapists began viewing their patients in a new light. That is apparently what happened with Diane Humenansky. She attended lectures and read books on M.P.D. She spoke to Cornelia Wilbur. Soon she had a number of newly diagnosed multiples under her care. Humenansky has declined to be interviewed for this article; therefore my account of her treatment of Carlson is largely Carlson's account. It is hard to know what Humenansky was thinking. Carlson says Humenansky told her she had been through three divorces, had lost custody of her children to her third husband, and was herself taking antidepressants. In 1989, when she began treating Carlson, Humenansky was still a fully accredited physician--a graduate of Wayne State Medical School, though, according to Carlson, she claimed it was Harvard--with admitting privileges at several Twin Cities hospitals.
    Carlson says Humenansky gave her not just books but videotapes: the movie versions of "Sybil" and "The Three Faces of Eve," pornographic films, war footage of people being decapitated. She said that if Carlson felt any physical discomfort while watching the videos, that was a "body memory": it meant that such things had happened to her, too. Carlson also says that Humenansky had her do visualization exercises, "trying on" scenes of molestation by various people. Using this technique, Carlson soon recovered memories of being molested by as many as fifty relatives, including both parents, both sets of grandparents, aunts, uncles, and great-grandparents.
According to Carlson, Humenansky also used a technique called guided imagery, in which the patient is talked through an imaginary scene in order to awaken buried memories. In one scenario, Humenansky told Carlson to picture herself going downstairs. Look for an altar, Humenansky said. Carlson saw a stone slab. Look around for candles and daggers, Humenansky said. Carlson saw them. Now look for the baby, Humenansky said. Carlson does not remember at what point her own imagination, primed by the books and videos, took over, but soon she saw a pregnant woman. Then the baby was born, and the afterbirth was lying on the altar, and people in hooded robes were eating it, and so was she. (That was the first cannibalism scene Carlson recovered with Humenansky. Today, nine years later, she still has nightmares.) The therapy sessions often ended with Carlson's weeping uncontrollably. Carlson says Humenansky would give her tranquilizers and tell her to chew them so that they would take effect faster.
    It wasn't long before Carlson, under Humenansky's guidance, began identifying her different personalities. One of them was Little Miss Fluff, a nickname that she had been given as a child because she liked frilly dresses and crinolines. In the Eve Black slot, Carlson produced a hussy named Nikita. Sybil had had two male alters; so, quite soon, did Carlson. She also located two nuns, Sister Mary Margaret and Sister Mary Theresa (the latter wanted to join the Peace Corps) and a scared, depressed Old Lady.
    When Carlson's mood changed, Humenansky told her she had "switched," or changed alters. If she showed up for her session in a short skirt, that meant that Nikita was "out." If she was depressed, that was the Old Lady taking over. Interestingly, though--and this seems to be the case with many multiples who have not written memoirs--Carlson never quite got the hang of multiplicity. To this day, she doesn't know how many personalities she had. "After twenty-five, I lost count," she says. Humenansky had Carlson write down their names, ages, and key memories on index cards for reference, but, Carlson says, "I still couldn't keep the darn things straight." Once, she lost the card file, and they had to do the whole business all over again. Sometimes, she would walk into Humenansky's office and say that she didn't want to explore alters that day--she just needed to talk. Carlson recalls, "Dr. Humenansky said, `Well, who am I talking to?' And I would say, `This is just me, Elizabeth.' She said, `No, I want to know which alter I'm talking to.' `It's not an alter,' I said. `It's just me.' Finally she got out an index card and wrote down 'Just Me.'"
    Meanwhile, Carlson's mental condition was worsening. The main events of her week were her two appointments with Humenansky--an individual session and a group session with other M.P.D. patients. For a year, Carlson was so depressed that she rarely left her bedroom. Heavily drugged, she sometimes slept eighteen or twenty hours a day. She had terrible nightmares and woke up screaming and vomiting. "I stank, the room stank," she remembers. "Every few days or so, my husband or my daughter would take me and shove me into the shower and hose me down." Then she would go back to bed. Carlson's daughter, Lisha, who was in her teens, took over the household and the care of her younger brother. Eventually, she had to drop out of school. Carlson's marriage, which had already been troubled when she first began seeing Humenansky, deteriorated day by day. Carlson says Humenansky suggested that perhaps her husband was trying to kill her. Carlson threw him out of the house repeatedly. Meanwhile, she had cut off all contact with the rest of her family, because, as she now understood, they were still members of the cult that had abused her as a child, and if they found out what she was revealing in therapy they would murder her.
    "I just got crazier and crazier," Carlson recalls. She banged her head on walls and tore out her hair in chunks. "I was ready to kill myself. I thought it was better for me, and better for my children." When, in rare moments of protest, she asked Humenansky why the therapy wasn't helping, the doctor repeated to her a basic principle of M.P.D. treatment: "The patient has to get worse in order to get better."
    How could Carlson have believed what Humenansky was telling her? M.P.D. patients are often given strong medications--particularly benzodiazepines, such as Valium, Halcion, and Xanax. (In a 1995 court case, Colin Ross acknowledged that he had had one patient on fifty-one milligrams of Halcion a day, which is a hundred times the prescribed maximum for that drug.) During her time with Humenansky, Carlson took Xanax, Valium, and Ativan for anxiety; Pamelor, Desyrel, and Prozac for depression; and Restoril for insomnia. In the words of one former patient, "If you take enough drugs, you can remember about anything."
    Another factor in the M.P.D. epidemic was hypnosis. For well over a century, it has been recognized that the memories people produce under hypnosis are not necessarily accurate. Above all, subjects are exquisitely sensitive to cueing by the therapist. Experiments have shown that hypnotized subjects, given the appropriate suggestion, can recall former lives as chimpanzees. For these reasons, supreme courts in half the states no longer admit hypnotically refreshed testimony. Nevertheless, in a 1992 survey of more than a thousand psychotherapists with advanced degrees, the hypnosis expert Michael Yapko found that almost half of them believed that memories produced under hypnosis were more accurate than non-hypnotic recall.
    A third factor was the patients' hypnotizability. The ability to go into a trance varies from person to person, but it doesn't vary much in multiples. In the words of the M.P.D. theorist Eugene Bliss, they are "hypnotic virtuosos." If a highly hypnotizable woman goes to a therapist who believes in M.P.D. and in the accuracy of hypnotic recall, and if the therapist asks her, while she is under hypnosis, whether she has other "parts" to her personality (something that most of us feel we have, if only metaphorically) and whether she was abused as a child (something that many of us feel we were, if only psychologically), she is likely to produce.
    Believers in M.P.D. argue that many patients receive their diagnosis without having been hypnotized. But people who are highly hypnotizable often do not require formal hypnotic induction in order to go into a trance. Many diagnosed multiples, whether or not they have M.P.D., do have dissociative symptoms--"spells," trances--that make them vulnerable to suggestion. Elizabeth Carlson remembered vividly the meetings of the satanic cult: the color of the men's robes, the sight of the afterbirth on the altar. Humenansky didn't hypnotize her, and didn't have to, for Carlson was highly trance-prone.
    Another important factor was the media. During the period of Carlson's therapy, magazines and newspapers were retailing utterly credulous stories about M.P.D. And then there was television. Phil Donahue was apparently the first talk-show host to present a program on M.P.D.; he was followed by Sally Jessy Raphael, Larry King, Leeza Gibbons, and Oprah Winfrey. Meanwhile, celebrities were coming forward with tales of childhood abuse: Roseanne, La Toya Jackson, Oprah herself. Some claimed to be multiples. Roseanne, for example, had unearthed twenty-one personalities in herself, including Piggy, Bambi, and Fucker, M.P.D. experts also went on TV. Bennett Braun appeared on the Chicago evening news with his star patient, who switched personalities on camera. Again and again, on the talk shows it was stressed that M.P.D. was not rare; it was common. "This could be someone you know," Sally Jessy Raphael said.
    On the average, people who receive a diagnosis of M.P.D. have already spent seven years in the mental-health system. According to various patient surveys, almost ninety per cent of them are depressed, sixty-one per cent have made serious suicide attempts, and fifty-three per cent have a history of substance abuse. Elizabeth Carlson came from a family of eight children, with a distraught mother. "I believed that that was how all families were," she says. "That if your mother was having a bad day, she beat the crap out of you, broke a broom over your head." As for being molested, Carlson thought that that was normal, too, and when she found out it wasn't, she figured it was her fault: "Because I was such a girly girl, always flouncing around, with the little anklets and the little ringlets. I had called attention to myself, and that's how those incidents happened to me." At fourteen, she started running away from home. Then she lapsed into a depression and was hospitalized. Her parents, feeling unable to cope with her, made her a ward of the state, and she was placed in a "youth center." There were further depressions and hospitalizations, and also suicide attempts.
    By 1989, when Carlson began seeing Dr. Humenansky, she was on her second marriage. She had two children and no money. She had tried to go back to college, but in the middle of class she would be seized by a panic attack and would have to leave the room. She had sometimes worked as a fitness instructor, but at this point she had been unemployed for four years, and was in the hospital again--her fifth psychiatric hospitalization, as she recalls. And when Humenansky told her that the cause of all her unhappiness was multiple personality disorder, her life made sense to her for the first time in years. It wasn't she who had done things wrong; it was her alters.
    Furthermore, Humenansky seemed to be offering her a kind of sympathy and care that she had been lacking for a very long time. Most diagnosed multiples have reported long histories of abandonment. Once they find the M.P.D. doctor, this relationship, in the words of the M.PD. expert Richard Kluft, is likely to become "the most powerful and/or gratifying event of their lives." M.P.D. therapy offered Carlson a further inducement: political solidarity. Child-molesting is primarily a crime against females, and, according to M.P.D. insiders, that was why M.P.D. had been so ignored in the past: because women had no political power.
    To own up to having been abuse reveal the damage done--in short, to have M.P.D.--was to stand up for women. The relationship between the M.P.D. movement and feminism is a thorny matter. On the one hand, M.P.D. and its underpinning, recovered memory, have been caustically criticized by a number of feminist writers, among them Janice Haaken, Ruth Leys, Debbie Nathan, Wendy Kaminer, Carol Tavris, Louise Armstrong, and Elaine Showalter. On the other hand, both M.P.D. and recovered memory are in large part feminist movements, whose supporters have accused those critics of being turncoats, abandoners of women.
    Actually, the M.P.D. craze was probably a side effect of the women's movement. While feminism rescued many women from positions of dependency, it left others behind--notably, a large number of working-class women. Many of these women had the same difficult lives that their mothers had had: early pregnancy, unkind husbands, boring jobs, little money, no education. But in the post-sixties period they also lost the protections that their mothers had had: a strong family structure and the belief that their fate was woman's fate. As the Marxists would say, they were deprived of false consciousness. All around them, they saw women who did not share this "woman's fate." How had they missed the boat? This state of affairs may help to explain not just M.P.D. but the general outbreak of female disorders in the last few decades: eating disorders, codependency, and so on. Wendy Kaminer, in her book "I'm Dysfunctional, You're Dysfunctional," tells of women in recovery groups accusing themselves of being passive, submissive. "These are women whom feminism bypassed," Kaminer writes.
    So were the multiples, with the difference that their disorder supplied what they lacked. Suddenly, with the establishment of the abuse history, they were no longer downtrodden. They were courageous-survivors. Furthermore, they were unusually intelligent--an article of faith in the M.P.D. literature. (Sybil was said by Schreiber to have had an I.Q. of 170.) Above all, they were creative, or they became so once they got into M.P.D. therapy.
    They were asked to inventory their alters, showing all the things they were--a project that, according to Colin Ross, might take a year. They were required to tell their story, and as the therapist made clear to them, it was a fascinating tale. For this project, furthermore, they had a support network. By the late eighties, there were clubs for multiples to join, newsletters to publish their poems, exhibitions of their art.
    In other words, M.P.D. therapy gave its clients something that they could not get from the society: an interesting job. Chris Sizemore ("Eve") has said that having M.P.D. was "fun" that when she recovered, the "magic" went out of her life. In Carlson's M.P.D. group, the women would get down on the floor, switch into their child personalities, and play board games, while Humenansky sat in a chair, smiling down on them--like Mother Goose, Carlson says. "There we'd be, playing Candyland, and our insurance companies would be getting charged for it." For most patients, life as a multiple cannot actually be fun, but, as Kluft has acknowledged, it may be preferable to their "baseline realities." And, no matter how bad things are, the patient at least has the pleasure of knowing that she has a famous illness. Humenansky told Carlson that she was going to write a book on M.P.D., and that Carlson's story would be part of it.
    Eventually, Carlson came to her senses. Another woman in her M.P.D. group recommended a new medication to her. She got a prescription from Dr. Humenansky, started taking the drug, and felt better, so she flushed all her other pills down the toilet. Around the same time, Humenansky brought a new patient into the group, and nobody liked her. "She monopolized the hour," Carlson says. "No one else could talk. Also, she kept lifting up her blouse and showing us where she had sprayed oven cleaner on her breasts." When the others protested, Humenansky said that if they didn't like the group they could start their own. They did so. Once a week they got together, and as they talked they began to notice certain odd things: all of them had similar abuse memories, memories that closely resembled events in the books Humenansky had given them. Carlson recalls, "One woman said, `I have a confession to make. I made up an alter named Nikki, because everybody else in the group had a Nikki, and I felt left out.' Slowly it began to dawn on us what had happened. Still, I didn't feel I could quit therapy." One day, she called Dr. Humenansky's office to confirm an appointment. As Carlson recalls, the doctor "said that the M.P.D. group was conspiring against her and that, on the advice of her attorneys, she was dropping all of us as patients. This was in November. I begged her to keep me until the holidays. Christmas was always hard for me. She said no and hung up. I cried. That was the end. Two years."
    Carlson's is by no means the most grotesque of the M.P.D. cases that have come to light in the past few years. Unlike Bennett Braun's star patient, Patricia Burgus, who switched alters on camera for the Chicago TV news, Carlson did not come to believe that she was a satanic priestess in charge of a nine-state region; that she had eaten parts of two thousand dead bodies per year; or that her children were cult members and practiced killers. Unlike Burgus, and also unlike Mary Shanley, another patient in Braun's unit at Rush, she did not hospitalize her children and confess that she had molested them. Unlike Shanley, she was not a primary-school teacher, and so she was not reported to the authorities by one of her therapists and effectively barred from practicing her profession for five years while she fought to have her name removed from the state's registry of child sex abusers.
    But if Carlson's case was not the most scandalous it was nonetheless a landmark. In 1993 and 1994, Carlson and another woman in her M.P.D. group, Vynnette Hamanne, sued Diane Humenansky. Humenansky denied most of their allegations. At the Carlson trial, she testified that she had complied with "the requisite standard of care in all respects." Nevertheless, Carlson was awarded $2.5 million in damages and Hamanne $2.7 million. According to the women's attorneys, Edward Glennon, R. Christopher Barden, and Christopher Yetka, these were the largest jury verdicts ever delivered in the United States in a case involving recovered memory. They set an example. Several former patients have filed lawsuits against Bennett Braun, and all but a few have been settled. Patricia Burgus's suit against him and her other therapists was settled last fall for $10.6 million by the insurance companies involved. (Braun objected to the settlement and denied all wrongdoing alleged in this and other suits.) In addition to Carlson and Hamanne, nine other former patients sued Humenansky; all these cases were settled out of court. In two suits she was also accused of having sexual relations with her patients, an allegation she denied. In 1996, her license to practice medicine in the state of Minnesota was suspended indefinitely by the Board of Medical Practice. The report ordering her suspension cites a letter Humenansky sent in her defense: "With respect to the numerous complaints and civil lawsuits filed against her, Respondent blamed those on the `perpetrators of childhood sexual assault.'"
    If Carlson didn't have multiple personality disorder, has anyone ever had it? Every culture has what medical anthropologists call its "idiom of distress." In China and Southeast Asia, there is a serious disorder, koro, in which a man imagines, with terrible dread, that his penis is being retracted into his body. Koro is almost unheard of in the United States, just as anorexia nervosa, said to afflict up to one per cent of young American women, is virtually unheard of in societies where people have koro. Mental disorders also go in and out of vogue. Two hundred years ago, there was a fashion for somnambulism. The somnambulists were said to have otherworldly powers: while sleepwalking, it was reported, they would write poems, swim rivers, walk over rooftops. Today, somnambulism is considered a minor complaint, usually confined to children, who will generally do something quite unremarkable, such as eat a sandwich or go to the bathroom, before returning to bed.
    Most psychiatric professionals do seem to believe that multiple-personality disorder is real but that it rarely occurs spontaneously and therefore does not deserve to be a primary-level diagnosis. Like the majority of psychiatric patients, people diagnosed with M.P.D. tend to be "co-morbid"; that is, they meet the diagnostic criteria for more than one disorder. According to one authority, the average M.P.D. patient qualifies for three or four other psychiatric diagnoses (another expert makes it eleven)--typical accompaniment being depression, antisocial personality disorder, and borderline personality disorder. If M.P.D. overlaps so heavily with those disorders, should it be counted as a disorder in its own right? When faced with a patient who is chronically depressed, or who seems to have no sense of responsibility to others (antisocial personality disorder), or who fluctuates between rage and neediness (borderline personality disorder)--all common and serious problems--and who also tends to zone out now and then, why would a diagnostician hone in on the last symptom and start asking questions that nudge the patient toward the historically rare diagnosis of M.P.D.?
    M.P.D. is part of the history of hysteria, a disorder in which the patient shows symptoms--usually physical (paralyses, numbness, pain) and sometimes psychological (outbursts, spells) in the absence of any evident organic cause. That is only half the definition, however. Hysteria has always been regarded as a women's syndrome. (Hence the disorder's name, from the Greek hystera, or "uterus.") Hysteria can be traced back four thousand years, but in the late nineteenth century it acquired a new importance, particularly in France. The celebrated Parisian neurologist Jean-Martin Charcot published more than a hundred case histories on the subject, and gave famous lecturedemonstrations in which his patients, under hypnosis, would undergo hysterical attacks. Bookstores sold collections of photographs of hysterics in mid-attack. The number of patients multiplied year by year.
    Why did this happen? A number of trends--the rise of neurology, the fad for spiritualism, the whole nineteenthcentury cult of the irrational--clearly contributed. Another factor, no doubt, was the new campaign for women's rights. Hysteria was not merely a female complaint, it was widely regarded as a manifestation of women's moral weakness--their deceitfulness, their immaturity, their fusses and tears and attention-seeking. "As a general rule, all women are hysterical," the French physician Auguste Fabre wrote in 1883. "What constitutes the temperament of a woman is rudimentary hysteria." Such theories came in handy as European society in the late nineteenth century was hit by the first great wave of modern feminism. Women couldn't be granted the vote, opponents said. They were irresponsible, hysterical.
    It was during the hysteria fad that M.P.D.--it was called "double consciousness" then--began to receive attention, as a subtype of hysteria. By the turn of the century, however, hysteria began dying out in Europe, and double consciousness with it. Neurosis was being handed over to a new generation, indeed, to one man, Sigmund Freud, and, according to modern M.P.D. enthusiasts, it was Freud who killed M.P.D. He abandoned hypnosis, which was essential to the study of dissociation. He also abandoned dissociation--the idea that memories could be walled off, pristine, in the mind. But that's not all. In his seduction theory his--belief, during the eighteen-nineties, that his patients' hysterias were due to their having been molested as children--he discovered what modern M.P.D. theorists see as the mother lode. And then he walked away from it. He switched theories, from actual seduction to fantasized seduction--in other words, childhood sexuality. As a result, psychoanalysis was born, and, according to M.P.D. adherents, multiple-personality disorder was thrust back into darkness for almost a century.
    The return of M.P.D. began with the child-protection movement in the nineteen-seventies. In 1962, in the Journal of the American Medical Association, a group of Denver pediatricians, headed by C. Henry Kempe, published an article called "The Battered Child Syndrome," demonstrating via X-rays that very small children had been beaten, presumably by their parents, hard enough to break their bones. This fact, it is now said, had been known to pediatricians for years; only Kempe's group had the stomach to publish it. In any case, it created a furor.
    The child-protection movement was quickly joined by feminists, and they gave it a new twist. To Kempe's group, the problem was that children were being physically assaulted. To the feminists, the problem was that female children were being sexually assaulted. Furthermore, as the feminists saw it, this was not something that the society discouraged. In the words of Florence Rush, a social worker, speaking at a New York Radical Feminist Rape Conference in 1971, sexual abuse was a way of teaching a girl "to accept a subordinate role; to feel guilty, ashamed, and to tolerate, through fear, the power exercised over her by men."
    Out of this meeting between feminism and the child-protection forces came the recovered-memory, or R.M., movement, spread by so-called "recovery manuals"--notably, "The Courage to Heal," which sold three-quarters of a million copies in its first and second editions. Were you "bathed in a way that felt intrusive to you?" Were you "fondled, kissed, or held in a way that made you uncomfortable?" Then you were an abuse victim. As "The Courage to Heal" defined sexual abuse, these experiences qualified, just like rape. And, once dwelt upon, such memories tended to generate others--for example, rape. By such means, the R.M. movement persuaded hundreds of thousands of women that they were part of a worldwide sisterhood of sex-abuse victims, condemned for the rest of their lives to live out the consequences of the trauma-like survivors of the Holocaust. (It was from the Holocaust victims that the R.M. claimants took their name: they, too, were "survivors.") Many of these women began suing their alleged abusers, and state after state rolled back its statutes of limitations to permit them to do so. Recovered memory was accepted as evidence in criminal trials as well--most famously in California in the 1990 conviction of George Franklin, whose grown daughter Eileen Lipsker suddenly remembered that her father was responsible for the unsolved murder, twenty years earlier, of an eight-year-old friend of hers. (The conviction was later reversed.)
    Like M.P.D., the R.M. movement was enthusiastically supported by the media. But even apart from their coverage of the "epidemic," the press, together with television and movies, must be seen as a crucial source of both R.M. and M.P.D. They supplied the imagery for the memories. With the "Freddy" movies around, with rap singers singing about butchering women, what's a little afterbirth-eating? The media supplied alters too-- M.P.D. patients were reporting Mr. Spock alters, Ninja Turtle alters. The very form of the disorder, with its "switching," seemed to come from our fast-cutting visual entertainments. George Ganaway has pointed out the video-game-like quality of M.P.D. therapy: as soon as one layer of alters has been identified and its dark deeds reenacted, another layer would descend, and another, until, as Ganaway put it, "the therapist finally tires of the game or the host personality runs out of quarters." Finally, the entertainment industry gave the R.M./M.P.D. movement its tone, its combination of luridness and piety.
    Michael Jackson fondling his genitals and singing "Heal the World"--this is the same strange land from which we got R.M./M.PD. enthusiasts retailing sex stories under the banner of child protection. But the single most important cause of the epidemic was the culture wars of the eighties and nineties. Oddly, both sides embraced M.P.D. and R.M. To leftists, these traumatic conditions were simply further demonstrations of the victimization of the populace by white males. To the right, the sexual crimes behind R.M. and M.P.D. were surely the results of the new permissiveness that was tearing society apart. The Christian fundamentalists were in the front ranks of the movement. So were the feminists. Feminist therapists began leading groups to help women unearth their abuse memories; they set up workshops to teach other therapists how to spot M.P.D.
    At the same time, many people started asking questions about this weird development. If M.P.D. was such a widespread disorder--Colin Ross estimated its prevalence at one per cent, roughly the same as for schizophrenia--why did it show such a narrow distribution, with the vast majority of M.P.D. patients being white, female, and North American? And why were so many of them coming out of the offices of so few therapists, the very ones who were publicizing this new syndrome? Among the early doubters were Corbett Thigpen and Hervey Cleckley, the therapist/authors of "The Three Faces of Eve," back in 1957. Nearly three decades later, Thigpen and Cleckley wrote an article saying that since the publication of "Eve" hundreds of "multiples had come in or been sent to them by therapists for confirmation of the diagnosis. In all these cases, they said, they had found exactly one true M.P.D.
    Then one of Sybil's therapists spoke up: Herbert Spiegel, who had handled Sybil's case when Cornelia Wilbur was out of town. One day; Spiegel says, while he was having a session with Sybil, he asked her a question. "And Sybil said, `Well, do you want me to be Helen?' I said, `Why would you think I would want that? 'She said, `Well, when I talk to Dr. Wilbur, when I get to this thing, she wants me to be Helen.' And I said, `No, you don't have to if you don't want to. I can hear you just as Sybil.' And she said, `Fine, I'd prefer it that way.' That's when I found out what Connie was doing with this case." Spiegel, who is a hypnosis expert, noted that Sybil was naturally dissociative: she spontaneously entered self-hypnotic trances. And those trances were what Wilbur called Sybil's alters. As Spiegel explains it, "When Sybil got into those states, Connie, who was a psychiatrist knowing nothing about hypnosis made it easier for herself to communicate with them by giving them a name." Spiegel adds that when Flora Rheta Schreiber was negotiating with a publisher for the book that was to become "Sybil" she suggested to him that he coauthor it with her. He was interested. Then she told him that it was going to be a case history of multiple-personality disorder. "I said to her, `But Sybil wasn't a multiple personality. Those things were artificial fragments, artificially created by Connie. When Sybil was with me, she didn't have to be those people.' And Schreiber said, `We have to call it a multiple. That's what the publisher wants. That's what will make it sell.' I said, `No, thanks.' And, after that, when I saw Connie at conferences she wouldn't speak to me. She looked the other way."
    To answer such charges, the M.P.D. treaters needed evidence, in the form of studies showing, for example, that the kind of abuse their patients were alleging--violent abuse, repeated over many years--could in fact be forgotten and then accurately recalled, as was said to be happening in M.P.D. therapy. There was no such evidence. Meanwhile, memory research, a hot field at this time (partly because of R.M.), was demonstrating exactly the opposite: that even for traumatic events memory degrades quickly and is highly inaccurate. Nor, in the vast majority of cases, could the M.P.D. experts show that their patients had ever been sexually abused. Sexual abuse, it must be said, is very hard to prove. Child-molesters do not normally volunteer this information. But very few therapists even looked for corroboration. Most were content to cite the percentage of multiples alleging abuse--often after years of abuse-focused therapy, not to speak of exposure to the recovery manuals. Or they cited figures on the prevalence of "abuse"--that is, physical or sexual. Children are physically abused every day, and by current definitions I and most of my childhood friends would be considered to have a physical-abuse history. (That is, we were spanked often. That was discipline in the fifties.) But, according to the M.P.D. expert Richard Kluft, "M.P.D. is primarily a disorder of sexually abused women." This has never been demonstrated.
    Another thing that the M.P.D. people could not prove was that childhood sexual abuse causes any kind of adult psychopathology, let alone M.P.D. Many studies have found that people reporting childhood sexual abuse show higher levels of psychological disturbance, but when the subjects are matched with controls on "family pathology"-that is, when people who come from terrible families that abused them sexually are compared with people who come from families equally terrible--except that they didn't abuse them sexually--the two groups' psychopathology rates turn out to be about equal. One 1994 study tried to separate the effects of five kinds of maltreatment: sexual abuse, physical abuse, verbal abuse, emotional neglect, and physical neglect. The findings indicated that the most damaging is emotional neglect. As for sexual abuse, a recent report summarizing many studies says, "A substantial number of these investigations find that a majority of victims suffer no extensive harm."
    Many people view this finding with repugnance. So do I. (If only a minority suffer extensive harm, that's still a problem.) According to Ian Hacking, in his 1995 book on M.P.D., "Rewriting the Soul," our discomfort is rooted in "consequentialist ethics," the idea that for something to be bad it must have bad results. Adults who engage children in sex, Hacking says, should be condemned on absolute grounds, regardless of the consequences for the child. Most people would agree with him--I would--but such a position has no bearing on the claim that sexual abuse causes multiple personality disorder.
    If the science behind M.P.D. was poor, that is because M.P.D. was never really part of science. Rather, it was a belief system. In part, R.M./M.P.D. was a liberationist movement, akin to the human-potential movement of the sixties. Bass and Davis, in "The Courage to Heal," advised the reader to dance her feelings. They told her that when she came to terms with her abuse she would release untapped potential that would transform not only her own life but the world: "Imagine all women healed--and all that energy no longer used for mere survival but made available for ... freeing political prisoners, ending the arms race." Gloria Steinem, in her best-selling book "Revolution from Within," actually sang the praises of M.P.D. as a source of untapped creativity: "People in different alters can perfect a musical or linguistic talent that is concealed to the host personality, have two or even three menstrual cycles in the same body, and handle social and physical tasks of which they, literally do not think themselves capable." But liberation had its nastier side too. According to the feminist therapist-writer Judith Herman, any skepticism regarding abuse reports amounted to "identification with the perpetrator." People asking questions about R.M. and M.P.D. were accused by others of protecting sex criminals. Or, it was suggested, they might be sex criminals. And it was this stepped-up passion, this paranoid edge, that made the movement vulnerable to the thing that would finally undo it: the satanic-ritual-abuse, or S.R.A., craze.
    Like the M.P.D. movement, the S.RA epidemic of the eighties was kicked off by a mass-market book, "Michelle Remembers," by Michelle Smith and Lawrence Pazder. Smith was a Canadian housewife, Pazder the psychiatrist who, in a year's worth of trance sessions, helped her recover her memory of being tortured at age five by a satanic cult. Briefly, the Satanists starved her, vomited on her, sodomized her, electro-shocked her, drove her into a rock embankment in an exploding automobile, gave her rubdowns with bloody gobbets of cut-up dead people, dumped her in an open grave and threw dead kittens on her. After a year of this, they let her go, and she forgot the whole thing until her sessions with Dr. Pazder, twenty-two years later. In 1980, Smith and Pazder published their account of this. Later, they divorced their respective spouses and married each other.
    In recent years, "Michelle Remembers" has been widely smirked at, but soon after its publication the day-care scandals of the mid-eighties erupted, with children, often under aggressive interrogation, claiming that they had suffered atrocities of the same sort. Before long, adult women were also reporting such memories. In 1983, the F.B.I. initiated a study examining the evidence in more than three hundred alleged crimes by organized cults. Investigators could not find corroboration for a single one. To believers, though, this made little difference. Again, Christian fundamentalists were in the forefront. And, again, many feminists lined up on their side. In 1993, Ms. published a story in which a woman described her torture by a cult and asserted that S.R.A. was another arm of the patriarchy. How was it possible for feminists to support a movement so conservative, so alarmed about sex, so concerned with the endangerment of females, who obviously, for their own protection, should not go out in the world and, above all, should never place their children in day care? Well, the eighties was a period of vigorous backlash against feminism. In that tormented context, many feminists clearly felt that any woman alleging abuse, even by a devil with a tail, had to be believed.
    In a number of quarters, S.R.A. became part of M.P.D. treatment. Witness Elizabeth Carlson's therapy. Yet there was a big difference between M.P.D. and S.R.A. Though crediting M.P.D. might be hard, the S.R.A. stories of robed cultists dining on babies, of priests collecting blood, semen, and urine in chalices for group libations were frankly ludicrous. And this lack of credibility created a crisis in the M.PD. world. If the believers in M.PD. defended S.R.A., this would put them in the position of kooks. But if they repudiated the S.R.A. stories they would be casting doubt on everything they had stood for up to then, because the therapeutic procedures that had produced the S.R.A. stories--indeed, in many cases, the patients who had produced the S.R.A. stories--were the same as those that had produced the M.P.D. stories.
    Predictably, the moderates walked out, and the hard-liners stayed and took a harder line. Extremism swamped the field. Bennett Braun descried a cult involving the Ku Klux Klan, the neo-Nazis, organized crime, big business, and the military, together with FTD florists. (The flowers sent to his hospitalized patients, Braun said, were color-coded with instructions from the cult: "Pink flowers mean suicide, red means cutting," and so on.) Colin Ross, in a proposal for a book to be called "C.I.A. Mind Control," claimed that the enemy was not Satanists but the C.I.A. He declared that federal agents were programming M.P.D. into children "with specific letter, number and other access codes for contacting alter personalities." Local police forces were supposedly in on the cults. So was Kenneth Lanning, who had headed the F.B.I study. Reading about these new M.PD. theories--grand-scale, multinational, with laptop-toting Satanists--one is almost nostalgic for the old-style abuse stories, with Uncle Joe out by the woodshed. At least, they were about human things: sex, weakness, sorrow.
    As Nicholas Spanos pointed out in his book on M.P.D., "Multiple Identities and False Memories," the witchcraft panics of the sixteenth and seventeenth centuries tended to fizzle out in any given community once the accusations spiralled up the social scale and hit people of power. That is what happened with recovered memory. Among the accused was a mathematics professor at the University of Pennsylvania, Peter Freyd. In 1990, Freyd's daughter, Jennifer, a psychology professor at the University of Oregon, claimed that with the help of her therapist she now remembered that her father had molested her throughout her childhood, from fondling at age three to rape at sixteen. (She has never retracted the substance of these accusations.) Peter Freyd denied the charges, and Pamela Freyd--Peter's wife, Jennifer's mother, and also a Ph.D.--got together with a group of psychiatrists and founded the False Memory Syndrome Foundation, to help families faced with such claims. With the aid of publicity in the local press, and with an advisory board including some of the biggest names in American psychology, the foundation converted what for most accused families had been a private disaster into a public scandal, something that they could admit had struck their house. And so they began to fight back.
    Meanwhile, criticism of M.P.D. within the profession was mounting at a furious pace. In a 1993 issue of the Harvard Mental Health Letter, Paul McHugh, director of psychiatry at Johns Hopkins, called for an immediate end to M.P.D. treatment: "Close the dissociation services and disperse the patients to general psychiatric units. Ignore the alters. Stop talking to them, taking notes on them, and discussing them in staff conferences." The popular press suddenly reversed itself. In 1991, Time had published a trusting and righteous article on the new incest-remembereds. Two years later, the magazine printed a cover story entitled "Lies of the Mind," warning that the R.M. movement might do "irreparable damage" to the psychotherapy profession. The TV talk shows began featuring "retractors," as patients repudiating their recovered memories were called, in place of or together with survivors. Public television produced caustic reports on M.P.D., R.M., and S.R.A. Even Hollywood backpedalled. In the most recent M.P.D. movie, the 1996 "Primal Fear," a murderer, having escaped conviction on the ground that he had M.P.D., turns out to have faked the disorder.
    But the most dramatic change took place in the courts, as the wave of R.M. suits (patients suing abusers) gave way to an opposing wave of malpractice suits (patients suing therapists). In Springfield, Missouri, there was the case of Beth Rutherford, who in 1993 "remembered" in therapy that her father had repeatedly raped her and forced her into coat-hanger abortions. (The father, a minister, lost his job.) Two years later, a medical examination found Rutherford to be a virgin. In Appleton, Wisconsin, there was Nadean Cool, who in M.P.D. therapy developed a hundred and twenty-six alters, including the devil and a duck. To flush out the devil, Cool's therapist had subjected her to an exorcism, bringing along a fire extinguisher, because, he was quoted as saying, "sometimes Satan leaves rings of fire." (The press had a wonderful time with these stories.) Then, there were the cases against Humenansky, Braun, and others, resulting in multimillion-dollar settlements. As the suits against therapists multiplied, suits against alleged abusers receded, and those that were filed did not fare well: between 1989 and 1996, almost half were dismissed.
    Desperate to shake off the scandal, M.P.D. therapists changed the disorder's name. In 1994, in the fourth edition of D.S.M., multiple-personality disorder was unglamorously rechristened "dissociative identity disorder." Other new words followed. "Recovered memory" became "delayed recall." "Satanic ritual abuse" became "sadistic abuse." But these maneuverings were minor compared with the changes in technique. All the procedures that M.P.D. authorities had so enthusiastically recommended--hypnosis, abreactions, alter-probing--they now backed away from. It was like a Presidential campaign: everyone moved to the center. Everyone was afraid of being sued.
    Many therapists objected to this backpedalling, regarding it as cowardice. In a recent essay, the psychoanalyst Sue Grand describes her reaction when a patient voiced a suspicion that she had been a victim of incest. Instead of just worrying about the patient, Grand began worrying about herself as well:

I will be implicated. Financially ruined, professionally humiliated. I am a little girl, terrorized, with a shameful secret. Even as she weeps, she does not yet know, but she has lost me. I hear the howls of judicial accusation: Have I suggested this? How can I demonstrate that I haven't? Should I start taping to protect myself, and how to explain this to the patient? ... Suddenly I feel I must demonstrate to the patient that these [incest] images may be more symbolic than literal.

    But the cause that was most damaged was feminism. Like hysteria in the nineteenth century, M.P.D. erupted in the twentieth century at the same time as a bitter struggle for women's rights. And, like hysteria, it was an excellent argument against women's rights. Point for point, M.P.D. repeats the old weak-woman stereotype. In the alternating personalities, we have woman's notorious volatility ("La donna e mobile"). In the contest between the child alters and the hussy alters, we have the Madonna/whore split. With the amnesia and the involuntary switching, we have woman's long-recognized moral incapacity--the notion that she cannot be held responsible for her behavior. In the hidden cause, the childhood sexual trauma, we get further essential components of femininity. Women are childlike, passive, wounded. Above all, women are sex; they are what's between their legs. Meanwhile, in the therapy, with its relentless focus on the patient's feelings, we have woman's famous subjectivity, her preference for emotion over action, her status as a creature of phone calls and girl talk. More than a disorder, M.P.D. is a memory--a memory of women, invoked by men. (Apart from Cornelia Wilbur, who died six years ago, all the major M.P.D. theorists have been male.) On the cover of "Michelle Remembers" is a little blue-eyed girl, hugging her doll, and smack in the middle is a shot of the child's little crotch. The artist is looking up the dress of a five-year-old. For a very long time, the most advantageous thing a woman could be in our society was childlike and sexual at the same time, and that is the state to which multiple-personality disorder restores her. The M.P.D. diagnosis is a tradeoff. The patient forfeits the privileges of being an adult-- self-knowledge, moral agency. In return she is given back the sex-child dream, the cotton panties of yesteryear. If one were so minded, one might suggest that M.P.D. was an anti-feminist conspiracy. But it was less a conspiracy than a reflex of our current politics. Year after year, disadvantaged groups knock on the door of the society, protesting their position. The society offers reparation. Some mechanisms of reparation--affirmative action, for example--are practical and useful, aimed at giving the group a genuine place in the world, but they take effect slowly. In the interim, other consolations are offered, such as the idea that the society works not by one set of truths but by many, and that every group is entitled to its own "narrative." Fed this fantasy, the disadvantaged group goes off and makes up its narrative, until, very soon, the story becomes too extravagant. At that point, it is attacked, and then the situation becomes clear: that in this promise of an alternative truth what the disadvantaged were given was not a place in the world but a sort of refugee camp, where they could go on dreaming the same dreams as before, based on their history of powerlessness.
    As I was finishing this account, I again asked for an interview with Diane Humenansky, and she again declined. According to her lawyer's office, she does not want further publicity. Shortly after her lawsuit was concluded, Elizabeth Carlson was diagnosed with lupus. Taking her two children (her marriage had now ended), she moved to Florida. There she was also diagnosed with a degenerative joint disorder and a debilitating rheumatic condition. A few months ago, she had a small stroke. When she goes out, she has to use a wheelchair. She is forty-four. I asked her whether she blames herself for her M.P.D-therapy disaster. "No," she replied. "Or not anymore. It could have happened to anyone. But I'm not as naive as I used to be about trusting professionals." In 1993, she founded the National Association Against Fraud in Psychotherapy, and despite her health problems she still works, counseling retractors and accused families.

How I Perceive and Manage My Illness
Esso Leete (1989), Schizophrenia Bulletin, 15, pp.197-200

Abstract
The article describes some of the ongoing problems psychiatric patients encounter on a daily basis as perceived by an individual who has lived with schizophrenia for more than 25 years. Specific carefully planned coping strategies which are seen as critical to the recovery process are presented.
    More than by any other one thing, my life has been changed by schizophrenia. For the past 20 years I have lived with it and in spite of it--struggling to come to terms with it without giving in to it. Although I have fought a daily battle, it is only now that I have some sense of confidence that I will survive my ordeal. Taking responsibility for my life and developing coping mechanisms has been crucial to my recovery. I would like to share some of these with the reader now.

    To maintain my mental health, I found I had to change my priorities and take better care of myself. I modified my attitudes, becoming more accepting and nonjudgmental of others. In addition, I altered my behavior and response to symptoms. I have also had to plan for the use of my time. When one has a chaotic inner existence, the structure of a predictable daily schedule makes life easier. Now, obviously structured activity can be anything, but for me it is work--a paying job, the ultimate goal. It gives me something to look forward to every day and a skill to learn and to improve. It is my motivation for getting up each morning. In addition, my hours are passed therapeutically as well as productively. As I work, I become increasingly self-confident, and my self-image is bolstered. I feel important and grownup, which replaces my usual sense of vulnerability, weakness, and incompetence. Being a member of the work force decreases stigma and contributes to acceptance by my community, which in turn makes my life easier.
    Research continues to show that one of the differences between the brain of a "normal" person and one who has schizophrenia is a major difficulty filtering or screening out background noises. I am hyper-alert, acutely aware of every sound or movement in my environment. I am often confused by repetitive noises or multiple stimuli and become nervous, impatient, and irritable. To deal with this, I make a deliberate effort to reduce distractions as much as possible.
    I often have difficulty interacting with others socially and tend to withdraw. I have found I feel more comfortable, however, if I socialize with others who have similar interests or experiences to my own. To counteract my problem with poor eye contact, I force myself to look up from time to time, even if I have to look a little past the person with whom I am speaking. If I do become overwhelmed in a social situation, I may temporarily withdraw by going into another room (even the restroom) to be alone for a while.
    I attempt to keep in touch with my feelings and to attend immediately to difficulties, including symptoms like paranoia. For example, instead of constantly worrying about the police surprising me, I always choose a seat where I can face the door, preferably with my back to a wall instead of to other people. In general, instead of working myself up emotionally over some threatening possibility, I will check out reality by asking the people I am with questions like who they are calling, where they are going, or whatever. It clears the air immediately, and usually I am satisfied with their answer and can go on about my business. In other words, I cope by recognizing and confronting my paranoid fears immediately and then moving on with my life, freeing my mind for other things. Also, I have learned to suppress paranoid responses, and I make an effort not to talk to myself or to my voices when others are nearby. It can be done through self-discipline and practice.
    In addition, I suffer from feelings of isolation, alienation, and loneliness. This is difficult to deal with because on the one hand I need to be with people, but on the other hand I am frightened of it. I have come to realize my own diminished capacity for really close friendships, but also my need for many acquaintances. An ongoing and reliable support system has been extremely important. I have gained much practical information, insight, and support from my peer-run support group, a very comfortable means of coming to accept and deal with mental illness. Also, it has been invaluable to have someone I trust (often my husband) with whom I can "test reality." I let him know my perceptions and he gives me feedback. I am then able to consider the possibility that my perceptions may not be accurate, and I modify my response accordingly if I wish. In this way I can usually acknowledge more conventional ways of thinking, instead of automatically incorporating outside information into my delusional system.
    A common complaint from persons with a mental illness is that of impaired concentration and memory. This can make holding a job or even completing a thought very difficult. To overcome the effects of a poor memory, I make lists and write down all information of importance. Through years of effort I have managed to develop an incredible amount of concentration, although I am only able to sustain this for relatively brief periods of time.
    Sometimes, I still find it difficult to keep my thoughts together. 1 therefore request that communication be simple, clear, and unambiguous. It helps me if the information is specific, as vague or diffuse responses only confuse me. When speaking to someone, I may need more time to think and understand before responding, and I take this time. Likewise, I have learned when working on a task to be careful, perhaps taking more time than others, and to concentrate fiercely on what I am doing. And I must be persistent.
    Many times when becoming acutely ill, I am frightened of everything, feeling small and vulnerable. When I am in distress, I do whatever makes me feel better. This may be pacing, curling up into a ball, or rocking back and forth. I have found that most of these behaviors can be accomplished without appearing too strange, believe it or not. For example, I can pace by taking a walk, I can curl up when I sleep, and I can rock in a rocking chair or hammock or even by going to an amusement park. I am often able to relax by physically exercising, reading, or watching a movie. In general, then, I think I am discovering how to appear less bizarre.
    I find it crucial to schedule time between events rigidly. For example, I will not agree to give two talks on the same day. I find I must also give myself as much time as I can in which to make decisions; I have an enormous amount of ambivalence, and pressure to come to a decision quickly can immobilize me (It is not a pretty picture.) Too much free time is also detrimental. Therefore, I find it useful to structure my leisure time and to limit it. Perhaps some day I will be able to handle it in greater increments, but for now I find it best to keep very busy, with minimal amounts of leisure time.
    Perhaps the coping strategy I use the most is compulsive organizing. I think a controlled environment is probably so important to me because my brain is not always manageable. Making lists organizes my thoughts. It also increases self-esteem, because when I have accomplished something and crossed it off my list, it is a very concrete indication to me that I am capable of setting a goal, working toward it, and actually accomplishing it. These "small" successes build my confidence to go out and try other things. As a part of this process, I break down tasks into small steps, taking them one at a time. Perhaps organizing and giving speeches about my illness is another coping skill--and the audience response is a type of reality-testing.
    In general, then, I believe I do have an irritable brain. I am supersensitive to any stimulus. My behavior is sometimes erratic, and I am easily frustrated and extremely impulsive. I regret that I still have times of uncontrollable angry outbursts. I cope with these and other symptoms by taking low doses of medication. Before I came to realize the role medications could play in my illness, I was caught in a vicious circle. When I was off the medication, I couldn't remember how much better I had felt on it, and when I was taking the medication, I felt so good that I was convinced I did not need it. Fortunately, through many years of trial and error, I have learned what medication works best for me and when to take it to minimize side effects based on my daily schedule. Increasing my medication periodically is one means I often use for stabilization during a particularly stressful period.
    I want to emphasize that stress does play a major role in my illness. There are enormous pressures that come with any new experience or new environment, and any change, positive or negative, is extremely difficult. Whatever I can do to decrease or avoid high-stress situations or environments is helpful in controlling my symptoms. In general terms, all of my coping strategies largely consist of four steps. (1) recognizing when I am feeling stressed, which is harder than it may sound; (2) identifying the stressor, (3) remembering from past experience what action helped in the same situation or a similar one, and (4) taking that action as quickly as possible. After I have identified a potential source of stress, I prepare mentally for the situation by anticipating problems. Knowing what to expect in a new situation considerably lowers my anxiety about it. In addition, I try to recognize my own particular limitations and plan in advance, setting reasonable goals.
    Please understand that these are the kinds of obstacles that confront individuals with a psychiatric disorder every day. Yet we are perceived as weak. On the contrary, I believe we are among the most courageous. We struggle constantly with our raging fears and the brutality of our thoughts, and then we are subjected as well to the misunderstanding, distrust, and ongoing stigma we experience from the community. Believe me, there is nothing more devastating, discrediting, and disabling to an individual recovering from mental illness than stigma.
    Life is hard with a diagnosis of schizophrenia. I can talk, but I may not be heard. I can make suggestions, but they may not be taken seriously. I can report my thoughts, but they may be seen as delusions. I can recite experiences, but they may be interpreted as fantasies. To be a patient or even ex-client is to be discounted. Your label is a reality that never leaves you; it gradually shapes an identity that is hard to shed. We must transform public attitudes and current stereotypes. Until we eliminate stigma, we will have prejudice, which will inevitably be expressed as discrimination against persons with mental illness.
    We rarely read about people who have successfully dealt with their emotional problems and are making it, and they will not usually identify themselves to us because they are all too aware of the general attitude. The current image the public has of the mentally ill must be changed, not to mention that of the individual himself. We have grown up in the same society and have the same feelings about mental illness, but we must also live with the label.
    Ultimately, we must conquer stigma from within. As a first step--and a crucial one--it is imperative for us as clients to look within ourselves for our strengths. These strengths are the tools for rebuilding our self-image and thus our self-esteem. I found that I first had to convince myself of my worthiness, then worry about others. Each time I am successful at a task it serves to reinforce my own capabilities and boost my confidence. Just this way, persons with mental illness can and must change the views and expectations of others.
    Obviously, education about mental illness is critical for all parties involved, especially for the patient. I have made an extensive study of my disorder and have found education invaluable in understanding my illness, coming to terms with it, and dealing with it. We must conscientiously and continually study our illnesses and learn for ourselves what we can do to cope with the individual disabilities we experience.
    Many of us have learned to monitor symptoms to determine the status of our illness, using our coping mechanisms to prevent psychotic relapse or to seek treatment earlier, thereby reducing the number of acute episodes and hospitalizations. My own personal warning signs of decompensation include fatigue or decreased sleep; difficulty with concentration and memory; increased paranoia, delusions, and hallucinations; tenseness and irritability; agitation; and being more easily overwhelmed by my surroundings. Coping mechanisms may include withdrawing and being alone for awhile; obtaining support from a friend; socializing or otherwise distracting myself from stressors; organizing my thoughts through lists; problem-solving around specific issues; or temporarily increasing my medication. Yet too many times our efforts to cope go unnoticed or are seen as symptoms themselves. If others understood us better, perhaps they would be more tolerant. We did not choose to be ill, but we all choose to deal with it and learn to live with it. By learning to modulate stress, we will more effectively manage our illness, thus endowing ourselves with an ongoing sense of mastery and control. I find my vulnerability to stress, anxiety, and accompanying symptoms decreases the more I am in control of my own life. Unfortunately, our progress continues to be measured by professionals with concepts like "consent" and "cooperate" and "comply" instead of "choose," insinuating that we are incapable of taking an active role as partners in our own recovery.
    I see my schizophrenia as a mental disorder with a genetic predisposition, predictably expressing itself in times of extreme stress, but often exacerbated by rather ordinary fluctuations in my environment. Mental illness is a handicap with biological, psychological, and social ramifications, making it a formidable obstacle to be overcome, I understand that life may be more difficult for me than for others and that I must preside over it more attentively for this reason. As with other chronic illnesses, it has demanded that I work harder than most. I know to expect good and bad times and to make the most of the good. I take my life very seriously and do as much with it as I can when I am feeling well, because I know that I will have difficult times again and will likely lose some of my gains.
    Although there is no magic answer to the tragedy of mental illness, I contend that we need not be at its mercy. Appropriate treatment can help us understand our disease and we can learn to function in spite of it. We can overcome our illness and the myths surrounding it. We can successfully compensate for our disabilities. We can overcome the stigma, prejudice, discrimination, and rejection we have experienced and reclaim our personal validity, our dignity as individuals, and our autonomy. To do this, we must change the image of who we are and who we can become, first for ourselves and then for the public. If we do acknowledge and seriously study our illnesses, if we build on our assets; if we work to minimize our vulnerabilities by developing coping skills; if we confront our illnesses with courage and struggle with our symptoms persistently--we will successfully manage our lives and bestow our talents on society, the society that has traditionally abandoned us.

The Author
At the time of the writing of this article, Esso Leete was the director and founder of the Denver Social Support Group and Program Director of Consumer Centered Services of Colorado. As a primary mental health consumer, she has been on many local committees and boards, as well as being the Vice President of the Client Council of the National Alliance for the Mentally Ill. She has been designated as a national Switzer Scholar and has received an award for the most outstanding consumer advocate in Colorado for the last 25 years.