This article was based on an interview carried out by Rob Spring and edited by Carolyn Spring. It was first published in the Trauma and Abuse Group journal ‘Interact’ in September 2011 and is reprinted with the kind permission of TAG.
My original training was as a Relate counsellor, or Marriage Guidance as it was known at the time, and then I went on to train as an analytical psychotherapist. This involved going to London for four years, and being in analysis myself three times a week. Apart from the seminars and the course itself, I also had to do baby observation: every week for a year I would go and just sit down and observe a newborn baby – the interactions with the parents, some of the non-verbal dynamics that were going on and which became early indicators of the attachment. That probably was more helpful than any other theoretical or practical training that I did. We weren’t allowed to intervene in any way, and I was lucky but there were some people in our group who were observing some very difficult attachment issues in the family they were assigned to. You weren’t supposed to intervene and try and change the dynamic, because that wasn’t why you were there. You were there to try and learn. But the interesting thing was actually that simply having someone there, in a benign way, in a non-judgmental way, just observing every week, seemed to have a positive effect. The parents presumably felt somehow supported and that they weren’t as alone in it, and even in the difficult situations something began to change without any actual intervention.
So that made me realise that it is not just the therapy that can have an impact, but what goes on around as well. I began to see intervention as something more than just one unitary way of helping – the therapy becomes a core part of it, but so do the support structures, and that has informed my work ever since. People need to be encouraged to have a life outside of therapy, because unless there is a chance to be able to put into practice what you are working through then your whole life can be the therapy, rather than the therapy being there to help you step fully into life.
After I finished my training, I returned to Norwich and very shortly afterwards someone came for help who didn’t fit into any of the criteria that I was expecting. I had that moment, shared by many people when they first come across someone with a dissociative condition, of realising that I had two choices. I could either say, “Oh, this is outside my remit, so you had better see someone else”, or I could change my approach and the way I worked. It became quickly apparent to me that there was very little knowledge of this condition and that it was mostly disbelieved anyway – there were some people working in the field, mostly in the voluntary sector and a few isolated professionals in the NHS, but they kept for the most part quiet because they were at risk of being ostracised by their colleagues. And of course that still happens today.
So in the absence of any real support or information in the UK, I went to the States. People there became mentors – sort of parental figures – and they helped me to build up a sense of confidence and a place of security from which I could operate. There was so much that I had to change. I had been trained to use the term ‘patients’, and of course originally I was trained as well to have them lie down on a couch. Both of these were fundamental issues which I had to change, because inherent in them both was a power inequality. The relationship between a therapist and client is always going to be an unequal one in terms of power, but it’s not power that is the problem, but rather the abuse or inappropriate use of it. Every relationship, from parent to child, or doctor to patient, or solicitor to client, has a power structure in it, and it is partly that which allows you to put confidence in that person – and hopefully that confidence will be warranted. One of the problems in our culture, although it is improving, is that in the past there was the Victorian sort of sternness in families, and all the abuses that went with that. And nowadays it has swung to the other extreme where the child can end up in control: it has gone beyond the adult’s responsibility to listen to the child, to the child being allowed to make all the decisions.
And this is something that is very pertinent in working with dissociation. Problems often arise in therapy because there is no clear understanding of where the boundaries or distinctions are. We don’t necessarily want the Victorian psychoanalyst approach, all powerful and obscure and cold and distant, but neither do we want a parody of the person-centered approach where there is no distinction at all between the therapist and client, as though we are all equal. If there aren’t clear boundaries, then as in parenting you can have a situation where a toddler is pleading for another biscuit, and because they will be furious if you don’t let them, you give in. And that leads to its own problems – actually what is more frightening for the child than not getting what they want is their perception that they have the power to control the adult. In my work with dissociation and complex trauma, I am always aware of trying to fit that middle ground.
Over time I started to have a few more people coming to me with dissociative conditions. And my work in the NHS started with just one person – they didn’t know what to do with her and asked if I would be interested. So I was funded for that and it grew to the point where we set up a service-level agreement, so that for a certain block of hours a year I could take patients who were identified as having this condition. That continued and so the Pottergate Centre grew up out of that.
We now have about 450-500 people contact us every year. Free of charge we send people the two screening instruments, the DES (Dissociative Experiences Scale) and the SDQ-20 (Somatoform Dissociation Questionnaire), and we score them and return them with a standard letter which can be shown to a GP or other professional. I’m aware that we have to speak the language that those professionals will understand, so we say, “This is the screening instrument, and this is the history and pedigree of it. This is showing a likelihood that this person may well have a dissociative disorder, but this can only be confirmed by having a full assessment.” I will then try and encourage them to have that full assessment, but with many people that is as far as it goes.
From that point on, there are several things that I can suggest, depending on people’s individual circumstances. Firstly, if they are not involved in psychiatric services and they can afford it, we usually advise that they keep right out of psychiatric services, and pay for their own therapy. I will try to suggest a therapist if I know one, for example if one is a member of the ESTD; alternatively I may email TAG to see if they know of anyone in that locality. For people who cannot afford private therapy, there are occasionally voluntary organisations or Rape Crisis Centres that will be able to help. Many of us clinicians have started working with dissociation through these kinds of organisations, and if someone is already working with a therapist – someone they feel they fit with – then it’s often better for them to continue with them. I offer for their therapist to contact me, and I will try to encourage them and help them to have the confidence to continue with the work. The therapeutic relationship is what is important – it doesn’t matter how much an expert someone may be: if it doesn’t fit and it doesn’t feel right to the client, it is not going to work.
The other route is often trying to help someone with DID follow up with their GP and psychiatrist in order to try to get some appropriate treatment funded by the Primary Care Trust (PCT). Usually this is a huge, long process. We’re seeing more success now as time has gone on, because we are getting to the point where people are willing to entertain the possibility that the patient may be neither attention-seeking nor have Borderline Personality Disorder, but that their difficulties are caused by trauma and related to dissociation. Sometimes then a Trust will fund the person to be assessed with us at the Pottergate Centre. Other times people will pay for an assessment themselves, because it gives them more weight and an increased chance that their condition will be recognised.
The assessments are done jointly by myself and a psychiatrist colleague. The involvement of a psychiatrist firstly gives the report more credence. He can really establish whether this is the primary diagnosis, as often people will have multiple diagnoses, especially those who have been in the system for 15 years or so. And years ago someone may have made a decision about what the problem was, which takes them on a left turn. Once they are on that left turn, it is virtually impossible to get someone to go back and look to check that it was the correct turn. Partly, within the NHS, there is no time for someone to do that – so they never get a sense of that person as a whole being. That is what we provide with our full assessments – we look at everything and in effect start from scratch.
For the last 8 years or so, we have carried out the assessments jointly. People often think that a survivor having to sit with two men in a room must be terrifying, but we try to approach it right and it has never to my knowledge been a problem. I use the SCID-D (Structured Clinical Interview for Dissociative Disorders) as a basis, and as I ask the questions it allows my colleague to observe. Observing is just as important as the questions – being able to see the subtle changes and responses that otherwise we might miss. And I also observe while my colleague asks his questions. Then we both write a report and do a joint recommendation letter. A draft of that will be sent to the client to check that we have got the facts right, and then they can just receive it themselves or it can go on to whoever they have requested to have it.
The assessments are not cheap. The full one is £1200, and that includes any number of follow-ups afterwards, communications with professionals such as phone calls, letters, or anything that is required. Sometimes people have not had a psychiatric history so they just undergo the SCID-D, in which case the cost is £500. Some people say that a diagnosis isn’t necessary, and for privately-funded therapy that is true. But if you have to access funding from the PCT for psychiatric services or support, then really a proper diagnosis is the only option. The alternative is often being treated very badly – either receiving the wrong kind of treatment, or being told that you’re fine and don’t need any support at all. A diagnosis, or even encountering some of the language in the DES through the process of diagnosis, can also help the client sometimes to realise that perhaps they are not the only one – perhaps they are not crazy and how they are behaving is also how other people behave in those circumstances too. So that often helps.
Having received a diagnosis with an assessment from ourselves, it is then a geographic lottery in terms of what happens next. It really does depend on where you live. When people do manage to access services, it is never because a psychiatric service or the PCT have said, “We must do something about this.” It has always been because in most cases the patient has found the energy to fight – they have in effect said, “I’m not going to let them get away with this any more” and have gone to their MP, or contacted a mental health solicitor, or submitted a complaint. It is a bit like the vote for women – none of these things happen because we ever so nicely ask for it and they ever so nicely say, “I think it’s about time we offered it.”
I usually get to go into a local service to offer my services because they have been badgered by a patient to get in touch with me, and eventually they have given in. My work usually involves me going out to a psychiatric service, doing an assessment, meeting up with a multi-disciplinary team, putting forward a treatment protocol, and helping train an in-house psychologist if there is one. If not, then they may use someone from the private sector instead. And I will help to supervise, or act as a consultant for them to come back to. Because it can be a bit like on that programme Supernanny – in she goes and sorts everything out, but then she goes away and it all reverts back to square one. It’s only after the second visit that things start improving and working. So I have to do more than two visits. And then the problem is actually rarely with the therapy and the patient or client. The problem is invariably with the multi-disciplinary team, and unless there is a strong team, working as a team, invariably the whole thing comes apart.
I call it ‘institutional dissociation’ and it reminds me of my very first case when I started working with dissociation in the NHS 25 years ago. There were two different professionals, one a psychologist and one a psychiatric nurse on night duty in the inpatient ward. Both were working with the same patient, but had opposing views of that patient. The psychologist’s view was, “She’s a waste of time; she stirs up all the other patients; there’s nothing wrong with her; she’s attention-seeking; she needs to be out of here.” And the nurse would say, “You don’t understand – I see her at night cowering in the corner. She’s there in the dark, whimpering, and she’s absolutely terrified.” So there was this battle between two professionals who would normally get on alright, as though only one of them could win. And they were locked into the position of having to prove that they were right, rather than beginning to acknowledge that perhaps they were seeing a different facet of the same person.
The most difficult people to work with in this field are the psychiatrists. Psychologists very often understand DID, but may become overwhelmed in their work and don’t get the support they need. There are also some really good psychiatric nurses. But the denial and cynicism in psychiatry I would put down to a cultural thing. Going back a few years, GPs would be seen as God-like – they would have to have the answer, and the patient would come along saying, “I hope you can help me.” That has changed now, and it has become a partnership, with a good GP now turning to the patient and saying, “What do you think it is?”
I believe that any treatment helping someone with a trauma background has to be a partnership in which the person is there both to be helped but also to be a partner in their own recovery. Psychiatrists are not always so good at that – they are more inclined towards crisis intervention, where they are used to someone coming along in a state, grateful for the help they are getting, and doing what they are told. That model simply doesn’t work with DID.
The psychiatrists who won’t accept DID, who say it’s all made up or implanted by a therapist or it’s attention-seeking, tend to be the old-school type, who feel they have to know everything. Often they are not very good at adapting, and working as a team – they tend to be the ones who control the multi-disciplinary team, rather than be a member of it. And the other side is that most of them are used to offering drugs. A lot of people with DID, when they first present to a psychiatrist, are terrified of their voices and they will push-push-push the psychiatrist to medicate away those voices. Unless the psychiatrists are properly informed, they will assume that the voices are psychotic, rather than being the dissociated parts of the personality, and they prescribe an anti-psychotic, which of course doesn’t work. The terror for the patient is huge, because their whole control of life, perhaps following a breakdown, is suddenly gone. They’ve had a job, they’ve been fine apart from some little relapses and losing time and things, and now suddenly they find themselves saying things that people say they’ve said but of which they have no memory, or they are suddenly collapsing and can’t go to work. It’s absolutely terrifying. So the pressure can come from the patient as well for the psychiatrist just to prescribe and they can end up taking a vast cocktail of drugs.
With many people, therapy can take anything from six to 15 years. In my own work, I’ve had several people who came to me for 10 to 15 years and who have finished their work. Four out of six have done extremely well and have ‘integrated’. However, I do believe that even when you have integrated, under certain stressors you will revert, because the condition is still hard-wired. But hopefully it will be temporary. One of my previous clients chose not to integrate and continued living with three parts who went on to enjoy a positive lifestyle, with good communication and co-operation and really liking each other. She was against integration from the start, and in the early days integration was seen as the only way forward. Some people still think so, but I don’t. I think it has to be a choice, and the most important thing is communication between the parts so that there is always time to think and discuss and negotiate, rather than being in a cycle of action-reaction all the time.
In working with Primary Care Trusts, I realised several things. Firstly, if I went in to do a treatment proposal and said that the work would take six to 15 years, it wouldn’t ever get the green light. And we have to be pragmatic about that. Secondly, there are three stages to therapy. The first stage is symptom reduction, getting to know the therapist, establishing boundaries, the here and now, grounding and so on. The second stage revolves around better communication between the parts, and starting to deal with and process the trauma of the different parts. And finally the third stage is integration – although of course they all overlap. What I have realised is that it is only realistic to expect the NHS to work with those first two stages. I tend to anticipate no more than three to five years of treatment from the NHS, so I look in terms of getting the client or patient to a certain point within three years, and establishing a support structure that needs to be in place to achieve that. So I am trying to make it realistic, and I actually believe that having a time limit is not necessarily a bad thing, because it keeps a focus. If the treatment is open-ended, then there is always the next thing that will come up. So I work towards someone being empowered so that they can decide what to do next, and to get them back to functioning in life again. The important thing is to put in place the support structure to help the patient to get out into the community.
But there are mistakes that I have learned from. In the early days of working with psychiatric services it was clear that some patients were not coping at all and sometimes needed 24-hour care, usually because they did not have a partner or someone who could take on that kind of role in their lives. So an expensive package of support would be put together, because it was clear that unless they had it, they would not even be able to begin the work of therapy. I would suggest starting with that package, but say that it would then need to tail off. But somehow it never did, and over time I began to see the reasons why. These were patients who had never had what they deserved and had not been cared for, protected and nurtured as a child as they ought to have been, so understandably they had a huge and deep longing for care which had never gone away. When a situation is put in place where someone is given 24-hour care, at an unconscious level the patient works to hold onto it, so that it cannot tail off. It is too much to let go of.
I think it’s a problem for partners too when they end up in a supportive role or even as a paid carer. On the one hand the person may not even be alive without them fulfilling this role, but there also has to be a focus on getting to a place where they can be a partner again. If it is not built into the programme, then the chances of it changing become very remote, and a lot of people have learned from bitter experience where nothing has shifted. It infantilises the survivor but it also puts the supporter in a permanent parental role, which for a time can both save the situation and is necessary, but which generates its own problems in the long-run. The problem is not with the adult host or ANP part of the survivor, but with the younger parts – they now have a non-abusive father or mother, and they will not let go if given half a chance!
There is a very narrow dividing line, in my opinion, between on the one hand the need to be allowed to be in a dependent relationship with your therapist, where you can be whatever you are and whichever ‘part’ you are, to say whatever you need to say and express how frightened and needy you feel, and on the other hand the need for the therapist and other professionals to do everything they can to keep handing responsibility back to the client, to enable them to get on with their life and take adult control of it.
The other thing is that professionals can be very frightened at what appears to be aggression, being difficult or attention-seeking. That can make them very defensive. But with me it’s the opposite, because I believe that that is where the change in a patient will come from. It is where the energy is. With the people who come to therapy ever so grateful for the help you’re giving them, who are always on time and never complain, often there is no change! But when people turn up with attitude, when they say, “Who the f**k do you think you are, knowing more about it than I do?!”, then my response is, “Great! Now I can do business with you.” Once that energy is channelled appropriately and given a chance, there will be huge change.
Often someone with DID will have a very aggressive protector or internalised abuser and my first task before I do any work at all is always to negotiate with this part, to get their permission. Otherwise, regardless of what the host or the ANP (Apparently Normal Personality) will say, when the younger child parts come along and tell you their story, they will go away and be harmed because they didn’t have permission to tell you. So I have to negotiate and meet, and once I’ve met that part, even if they tell me to f**k off, then I will respond with, “I’m really pleased I’ve met you, I need to learn your rules …”
There is nearly always some aspect of an ‘internalised abuser’. As a child you internalise both your good and your bad experiences from a parent – that is inevitable. So for some people it feels like the actual abuser is inside, and someone may say, “He’s there again” – there’s a confusion between the internal He and the actual He. So I have to say, “Well, it’s not the same as the He that used to do that, but you’ve got an inside He who may behave like him, trying to protect you or follow his orders.” That often explains why a woman may have a male part, who can try to believe that the abuse wasn’t happening to them. Instead it’s as if they swap sides, as a way of trying to feel protected, like Stockholm Syndrome – if you can’t fight them, join them. That can happen not just externally in the case of the famous case with Patty Hearst, but also internally as well. It’s a defensive strategy and quite understandable.
Certain sectors of the NHS, such as at the Maudsley, only work with the ‘adult’ and won’t engage with child alters. The problem is that because of the power dynamic, patients who want to please you will often comply and they might say that such an approach works, but in my experience, it doesn’t. There are some clinicians in private practice who think that that is the only way to work with DID. I don’t. I don’t go looking for parts, or say that every part has to come out, but I work to put a structure and a balanced power dynamic in place where if there is permission and things are stabilised enough, then anyone who wants to come out is welcomed by me. But what I do say right from the start is that whatever is said will be communicated on to everybody else in the team or system.
For example, if a part tells me something that happened to them, then I have to find a way of communicating that to the adult, the host or the ANP. But I’ve got to be sensitive with that, because dissociation is about protecting the person from being overwhelmed by trauma. So I can’t just wade in there and tell the adult what that traumatised part has told me. Just mentioning it in very general terms might to start with be enough to make her dissociate – it may be that she can’t cope with hearing any more about it, or might even say, “I don’t want to hear this.” But I do insist on at least saying the basics, so that slowly we can work on what The Haunted Self talks about in terms of diminishing the phobia of attachment. The adult somehow has to begin to take on board ownership of the trauma, the emotional trauma history from which she has separated and dissociated. So my focus is always on helping that communication. It’s about creating a ‘thinking space’ within the therapy, because dissociation is often like being in war-time, moving from one crisis to the next, without time to think about anything.
The other thing I focus on is trying to get all the dissociated parts to start to work more as a committee, rather than independently of each other. But within that there has to be a distinction between the adult parts and the child parts. The adult parts need to listen to the children, but it shouldn’t be the children making the decisions, as I was talking about earlier. This is very important.
Honesty from you as the therapist is all-important. In my experience, most people with complex trauma and dissociation have such finely-tuned antennae that they spot if you’re a fraud or you’re trying to put one over them in some way. So you remain professional at all times, but you have to be absolutely straight and honest. So if someone says to me, “You look tired”, I would have been trained to say, “Well, what does that feel like?” But if I am tired, I might say, “You’re right – I had a terrible night.” If I don’t feel tired, I’d say, “I don’t actually feel tired – I may be tired but I don’t feel it. So I don’t know what has made you ask me that?” Because at that point I don’t know whether they have picked up before me that I am actually tired and I’m just not aware of it yet, or whether something about me has triggered a transference response, or some projection. Perhaps they are worried about what they talked about in our previous session, and they feel as if they are asking too much of me. Or perhaps they feel that they may have damaged me in some way.
But the point is that I don’t know. Nothing I say is proposing, “This is definitely what is happening”, which is what my training would have been to say, as if I know without any doubt what is going on for someone, and they just have to do what I say. That just doesn’t work, so everything I offer and say is always tentative and handing it back: “You may be right that I’m tired and I’m just not aware of it, but if I’m not I don’t know if there’s anything else going on?”
One of the biggest issues for therapists in working with DID is self-preservation and boundaries. What happens is that your heart goes out to the client, and you want to help. The trouble is, as Bruno Bettelheim said: “Love is not enough.” In working with complex trauma and dissociation, with all the difficulties of disorganised attachment, it can become very topsy-turvy and you can be viewed either as an abuser or as the abused: that’s the framework that people have grown up in. You’re either the victim, or the one who’s creating the problem. So there’s often no sense of shared responsibility for the therapy, and for an inexperienced therapist that can be confusing and they can be hurt by that. It’s not that someone is trying to hurt you – it’s just the nature of it.
So I do the opposite of what people sometimes do. I start by being very rigid, and not changing anything. And then when I’ve established a base, I may begin to open up. Because what someone has got to be able to tolerate and learn is the solidity of things rather than the softness of a relationship, because abuse and attachment is about solidity never existing. And so even though it may appear hard, I’ve got to get that hardness there. So the session starts and finishes at set times, and when you go you’ve got to be responsible for going. I have to encourage the adult to carry on looking after the system. Sometimes people who come for therapy have had enough of having to care for themselves, and they can treat you a bit like a childminder, but that doesn’t aid their recovery.
My traditional session length is 50 minutes. A lot of people with DID will need more than that but that’s what I do to start with, just once a week for 50 minutes. We won’t get into any kind of detail in sessions, but we will just begin to build a structure that has some continuity about it. If the client can’t manage that, then the whole thing won’t work and when crises come up there will be nothing solid to stand on. You have to establish that hardness, that solidity to start with.
Years ago I took someone on whom the PCT had tried to manage for years, and at the end of each therapy session with them she would switch into a child part and then not come back out of it again. So the psychologist would have to order a taxi, someone else would have to take her home, and the whole thing just became unmanageable. So right from the start, having assessed her, I said to the adult, “This can only work if you the adult take responsibility for leaving the sessions, because I’m not going to be able to take you home or anything like that.” And that was fine, because it was the first session and I was just talking to the adult. But during the second session the child part came out and I was talking to her for a bit and then I said, “Can I speak to the adult now?” because we were nearing the end of the session. “I don’t know where she is,” she replied. So I said, “Well, can the adult come back?” and I called her back but there was no contact at all. I said, “There’s only five minutes. I’m really sorry, but you do need to try.” And it wasn’t happening. So I began to wonder what on earth I was going to do, but I knew that if I didn’t solve it then, it would happen every time and the therapy wouldn’t work.
So the time was up and I said, “Well, I’m sorry, but the session is over”, and she didn’t move. She had her bags with her, and I had never done anything like it before, but I was very direct and said to her, “Pick up your bags, please!” And she sort of obediently did, and I said, “I’m going to take you to the door, and I’m going to show you out and then I’ll see you next week.” So I did and she just stood there outside the door. I could see her from the window, standing there just like that. I was thinking, “What do I do? Do I leave her?” and then I thought, “I’ve got to.” And after about 15 minutes she left.
About an hour later I got a phone call from the adult saying, “What happened? The last time I remember, I was in your room and then I found myself back home.” So I explained it, and then the next time she came back when I asked her to at the end of the session, and it never happened again. I always remind people that dissociation is about survival, about doing whatever is necessary. People can end up being rescuers, but actually the best person to rescue them is the client themselves. Even though this particular lady was dissociated, she got herself home because she knew she needed to – enough of her knew she needed to. So although there is amnesia, there is also some overall sense of what needs to be done in order to keep receiving the help they need.
As time goes on with a client, if it feels that they need longer sessions, then I will do that, but it’s all by negotiation. What I try to steer away from is the action-reaction cycle, so that they are phoning up in a crisis and you are responding to that all the time. Sometimes it’s hard even with two or three sessions a week to hold on, so I will always say that they can send as many emails as they like. I don’t answer them, but I print them out and bring them to the session. I know a lot of therapists do respond to emails but for me I felt that it was creating a sense of being available all the time. Also, if it will be helpful, I might schedule a weekly telephone call for ten minutes. If you, the client, ring up, you ring up – if you don’t, you don’t. But it’s scheduled and it’s available if it’s wanted or needed.
Having said that, I will get to know people well enough so that if someone phones up and says that they are going to kill themselves, and this is out of character, then I know to act. Whereas if it’s someone who regularly makes such phone calls, I know that I don’t need to act because they can actually cope. So I start very firm and then it is tailored both to what feels right for that individual client and also what I can offer.
In terms of session frequency, I always start out with once a week and that might continue for three to six months. I need to establish something that is held and manageable, something that is not too much and that isn’t touching on things that stir everything up without there being the containment to manage it. I’m looking to establish that continuity, and it might be that every time they come either very little is said or we just talk about everyday things. It’s about beginning to get a sense of how it might map out. It might be a lot of intellectual stuff, which is fine, because it sets up a framework. Then over time you can open it up if they can tolerate it and if it feels right. I’ve never seen someone more than three times a week, and usually it’s twice a week, and often at least one if not both sessions are longer. That is the sort of pattern that it usually evolves into.
It takes time to build up the trust because of attachment. It is so hard for the client to trust that you are there to try and help them. You have to build up the trust, and sometimes that comes even by making mistakes. You don’t mean to make them, but at least then you can say, “I’m sorry, I made a mistake” and that itself can be revolutionary for the client. Often someone with DID will have such perfectionist expectations of themselves, and somehow that is transmitted onto you and you can start feeling that you have to be perfect – which isn’t normal in terms of being a human being, and of course it’s impossible.
Disorganised attachment is in my view the primary cause of DID. Dissociative disorders used to be seen as being caused by emotional, physical or sexual abuse alone, but in my experience there has invariably been something that has gone seriously wrong with the attachment in the first place, and in the vast majority of cases abuse has then been superimposed upon that. I would also say that the majority of people with DID that I have known have been involved in some sort of organised abuse. I call it ‘organised abuse’ rather than ‘ritual abuse’ – but I’m in no way inferring that Satanic Ritual Abuse doesn’t exist, because it clearly does. But the basis from which I start is that there is a bunch of paedophiles who are finding some way of justifying and allowing themselves to feel alright about what they are doing. And I think you have to start with something as concrete and raw and clear as that, because otherwise the fighting of Satanic Ritual Abuse can become a cult of its own. This is where I’ve had numerous discussions and some disagreements with colleagues about it, but I think that it is hard enough to raise the profile and awareness of DID as it is, without putting off both professionals and the public by talking about SRA. It is unfortunately a public image issue. And I also think that it can breed a sort of increased hyperarousal, so that both the client and the therapist can end up hyperaroused by the presence or issue of SRA, with a whole language to it that can become cult-like in and of itself. So that is where I can end up disagreeing with some colleagues in terms of emphasis, but I have no doubt at all that DID is almost always caused by very serious abuse and that many survivors have suffered at the hands of organised groups of paedophiles.