Relevance of Spirituality and Psychology in Understanding Diagnostic Psychological Issues
“Nico, I love you to the moon and back.”
These were words spoken to me by what I originally believed to be an “alter” of an individual who presented with symptoms of Dissociative Identity Disorder (DID), formerly known as Multiple Personality Disorder (MPD), and who was not related to me. What made these words so unique and startling was that these same exact words were always spoken to me by my Grandmother, Nina, who passed away 12 years ago in February of 2000. Other than me, only my grandmother and certain members of my family knew that phrase was ever spoken to me and what it meant to me. The details of this experience and subsequent similar interactions in clinical and personal settings will be discussed in more depth at the end of this Introduction, but this incident marked the first time that the conceptual frameworks of psychology and spirituality collided in my young career as a student of psychology.
This event left me with many unanswered questions and an opportunity to expand my professional and personal views. Is it possible to explore questions in mental health through the lens of spirituality as well as experimental science? Is the understanding of psychology through an anthropological lens scientifically valid in our current understanding of our bio-scientific lens Medical Model? Do non-western views of mental illness hold credibility, along with current, bio-scientific views? Is this desire to keep spirituality and psychological functioning separately a characteristic of western first-world countries only? Do other professionals in other countries have another understanding of spiritual domains in the mental health field? Are “alters” in individuals diagnosed with Dissociative Identity Disorder (DID) split parts of the self or are there additional explanation? If DID is more complex than presently identified, how would this change the fields of psychology? Should the diagnostic criteria in the forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and novel treatment methods be expanded to include the breadth of culturally-determined expressions of mental disorders? This unique experience was a start of a new understanding in my young career that brought science and spirituality not as opposing sides, but as compliments of each other.
Current Theoretical Problem: Why Study Cultural and Spiritual Experiences In Modern Day Psychology?
The basic thesis for this dissertation is a theoretical exploration to integrate cultural and spiritual experience with modern diagnostic criteria of Dissociative Identity Disorder seeking to establish a more complete model of this disorder. This calls for an anthropological approach to better understand different possible etiologies and cultural perspectives for DID, thereby expanding the diagnostic scope of the current Diagnostic and Statistical Manual of Mental Disorders. This anthropological approach is one that helped explain human experience prior to the advent of experimental science and does not compete with it, but complements it as an additional scientific approach researched in cross-cultural literature across the world. Prior to the development of psychology as a scientifically studied framework in the 19th and 20th centuries, physical and mental ailments were perceived as caused by such things as evil spirits, the devil, demons, spells, or even as a punishment from God. As the western world and psychology developed in the twentieth century, the influence of spiritual explanations of mental illness and physical ailments declined sharply. Dissociation and possession researchers Cardeña, van Duijl, Weiner, and Terhune (2009) commented that basic Western premises about the self are challenged by the experience of being taken over by some entity from within (e.g., DID) or from without (e.g., spirit possession). Like all models or theories, boundary lines are set as what is acceptable subject matter and what is not. These parameters state that science should be restricted to natural physical phenomena. This restriction is methodological in nature and means that science should not consider supernatural, non-material explanations themselves, but should not claim them to be wrong either. Instead, supernatural explanations should be left as a matter of personal belief outside the scope of science. This shift to a more bio-scientific model in medicine and psychology was based solely based in the physical world. This frame of reference is also known as the experimental or empirical model. Cultural and spiritual experiences within the domain of psychology have been outside the established parameters of modern science and psychiatry.
The influence of spirituality and its role in various dissociative experiences, however, can still be seen today in certain areas such as Central and South America, Africa, Asia and the Pacific Rim, while being largely ignored in Northern America and most European countries. Most non-Western cultures, which make up at least 80% of the world’s total population, exhibit culturally patterned dissociative symptoms, and play a significant part in billions of people outside North America (Lewis-Fernandez, 1992). Despite its influence in the majority of the world’s population, many have viewed and still view psychology and spirituality as incompatible. Only in the last decade, through multi-cultural awareness and neuro-psychiatry, has a reemergence of the mind, spirituality, and consciousness (i.e. non-material reality) begun to help reshape how we view science, medicine, and psychology.
This new push for an integration of spirituality and psychology has resulted in growing literature that links both domains that had been largely ignored (Bob, 2004; Brown, 2003; Bull, 2001; Koenig, 2005; Krippner, 1997; Moreira-Almeida, 2006; Moreira-Almeida & Koss-Chioino, 2009; Moreira-Almeida, De Almeida, Neto, & Dening, 2005; Ronquillo, 1991; Peres, Moreira-Almeida, Nasello, & Koenig, 2007; and Ross, 2011). Despite this growing literature and research, the area of spirituality continues to be highly misunderstood and underappreciated by the bio-scientific model of psychology in the present day.
Among the mental health diagnoses in today’s society, there is arguably none more controversial than Dissociative Identity Disorder, formerly known as Multiple Personality Disorder before 1994. There is much debate on whether DID is a true diagnosis, and even greater debate on how its mechanisms are expressed. The purpose of conducting this theoretical study is to understand how spiritual explanations can clarify an additional mechanism for what we consider “alters” to be in DID. By citing current cross-cultural research, it will be demonstrated that it is possible that in a significant number of cases, alters can be explained by contact with spirits, angels, demons, or other non-physical bound entities. Taking an anthropological approach to studying these phenomena, one can make a valid case that research and understanding in this area can be scientific, i.e. empirical in nature. By exploring past and current literature, it is argued that there is more to DID than by what it is defined in the DSM-IV and what we know of it in an experimental sense. I am not contending that the current bio-scientific model and DSM-IV criteria for DID is not scientifically valid, but simply that it misses this possible etiology. This theory is not set out to replace the current empirical model but simply adds a new perspective to complement it for a more complete integration of models, one in which the current DSM-IV opens the possibility to by addressing and being sensitive to cultural experiences in dissociative disorders. This adds important new implications for proper diagnosis and course of treatment. The main question addressed in this theoretical dissertation is how to bridge the current gap between contemporary views of DID in the United States with cross-cultural experiences of DID? American views on DID focus on pathological and somatic symptoms and characteristics of DID, while cross-cultural views also look at experiences such as “possession” and “incorporation” for further explanations. It is important to note that these views do not always fall under pathological lenses, but can be “normative” under many circumstances. The underlying question remains, how do all these views fit with the current understanding of the DSM and how can they be reconciled?
It is my hypothesis that through a better integration between the current understanding of DID and of spirituality, one can formulate a more accurate diagnosis and treatment for individuals in today’s plural societies, by using current literature as a framework and bridge for further research.
Definition of Terms
One must first address the concept of dissociation before the true nature of DID can be fully understood. The Webster’s Dictionary (2002) defines dissociation as “the splitting off of certain mental processes from the main body of consciousness, with varying degrees of autonomy resulting from the split.” It is important to note that everyone dissociates to some degree. It explains how you could be driving into work and an hour later you end up at work, yet not remember driving for that period of time. Rieber (2006, p.3) states that the most important aspect of dissociation is that it is a “specific mental capacity or ability that all human beings utilize during the course of their lives and that it is a mental process and cannot only be observed but also even to some extent measured, somewhat like a spectrum, with various quantities and qualities.” Dissociation can best be described along a continuum. The extent that one dissociates is the key question and one in which can lead to pathology or misunderstanding. DID would be on the extreme end of the continuum of dissociation and is a serious, legitimate mental health issue that warrants further study when it causes harm to the individual.
DID is defined in the DSM-IV-TR as:
The presence of two or more personality states or distinct identities (alters) that repeatedly take control of a patient’s behavior, so that the patient has an inability to recall selected memories or personal information. In dissociative identity disorders, the lack of recall is too great to be explained by normal forgetfulness, and is more complete and total than any type of role-specific memories. To fit the diagnosis, the disorder also cannot be explained due to the direct physical effects of a general medical condition or substance.
American Psychiatric Association (2000, p. 529)
In the DSM-IV-TR for most mental disorders such as mood, psychotic, anxiety, substance-related, and other dissociative disorders there is a specific criteria for each that states that the symptoms must cause a clinically significant distress or impairment in social, occupational, behavioral, or other important areas of functioning. The DSM-IV-TR allows for increased cultural awareness and exploration in the section for DID:
A cross cultural perspective is particularly important in the evaluation of Dissociative Disorders because dissociative states are a common and accepted expression of cultural activities or religious experience in many societies. In most instances, the dissociative states are not pathological and do not lead to significant distress, impairment, or help-seeking behavior. However, a number of culturally defined syndromes characterized by dissociation do cause distress and impairment and are recognized indigenously as manifestations of pathology (see p.783 and p.897), although symptomatology may take different forms in different cultures, such as recurrent brief episodes of dissociative stupor or spirit possession in India.
American Psychiatric Association (2000, p. 519)
The current edition allows for an addition of a culture-specific section, “the inclusion of a glossary of culture-bound syndromes, and the provision of an outline for cultural formulation designed to enhance the cross-cultural applicability of DSM-IV” (American Psychiatric Association, 2000, p. xxxiv). These additions open the door for further cross-cultural sensitivity and understanding which is proposed in this thesis. Scientific advancement in psychology over the last century has helped to better understand DID, but there is a key component missing in today’s conceptualization of DID. This missing component includes the spiritual dimensions of the human experience.
A brief definition and understanding of spirituality needs to be discussed. The Webster’s Dictionary (2002) defines it as “the quality or fact of being spiritual.” With ‘spiritual’ meaning “the quality or fact of being spiritual, incorporeal or immaterial in nature, and predominately spiritual character as shown in thought, life, etc.” In faith, one finds a belief that is not based on proof such as the spiritual, incorporeal, or immaterial. Spirituality has been around since the dawn of humanity and is one of the driving forces behind our existence and understanding of what it means to be human. It means many things to many different people and also includes concepts related to mediumship, possession, and trance. Spirituality and faith in one’s beliefs is a universal aspect that holds everyday importance for billions of individuals. Even today the role of spirituality varies greatly between countries, cultures, and individuals. A fuller explanation and definition on spirituality and culture will be discussed in Chapter Three.
Clinical & Personal Experience: A New Reality
The main limitation of spirituality is the fact that by definition it is “incorporeal or immaterial in nature.” This makes it impossible to define and to “prove” by current experimental scientific means. We are left with personal experiences, stories, myths, and anecdotes to substantiate the spiritual. The studying of these experiences fall into the scientific field of anthropology, which will be discussed further in Chapter Four. If to be spiritual means to have belief in something that one cannot see, touch, feel, smell, and hear then it would be impossible to prove that it exists on an experimental, physicalist, scientific basis. What science and psychology do is to give a framework for establishing finding evidence to support theories and hypotheses. This establishment of truth comes from the five known senses and replication of this evidence in quantifiable terms. There is an argument that there is substantiation of these phenomena, but what is lacking is consistent reproduction and replication of evidence of spiritual phenomenon. Everyone has their own unique experience of the world; we each live in our own reality that is shaped by historical and social context and norms. Other cultural perspectives should not be dismissed on the grounds that they do not share the same experiences or viewpoints as us. Different cultural perspectives are a valid form of human experience and should be considered in the larger context of anthropological study.
Personal Experiential Journey
As a basis for this dissertation, current literature studying various cultural perspectives and anthropological experiences are utilized. These experiences have helped to open my eyes, not by blindly accepting, but by asking questions and seeking guidance. As I researched these events for a better understanding and for this dissertation, it became obvious that more and more people across the world share in these unique experiences. These included fellow professors at the Massachusetts School of Professional Psychology, professional colleagues of mine, personal acquaintances, individuals across the world, and other professionals in the field of science in a literature review. My interest in this area started with an experience that shifted my views significantly and brought me to a new path in my clinical understanding of psychology and how it relates to individuals.
Due to this initial event and subsequent experiences, I now talk to and consult with different psychologists and spiritual healers from all walks of life. They share similar stories with me and help me to further my study in this area. The experience I mentioned earlier in this chapter began in May of 2010. Due to confidentiality issues I will call the individual “Mary”. She was in her early thirty’s, and was recently divorced with several children. She presented with increased anxiety and depression due to her recent divorce and struggles with being a single mother. She mentioned periods where she would not remember and would lose consciousness, which were usually triggered by a severe headache and a ringing sound in her ears. When she regained consciousness, her children would speak of behaviors and mannerisms that were not typical for her. She would feel drained, but yet she successfully engaged in a part-time job while her kids were at school and took care of all of her motherly duties. She mentioned that these episodes happened since she was younger, but increased since the divorce. She was fearful that her behaviors were becoming increasingly harmful to herself. She stated that during several of these periods, that when she regained consciousness she had cut marks on her arms. She admitted to cutting herself during parts of her adolescent years, but had not done so in over 10 years. Her children denied any harm done to them, but were scared that she could hurt herself. I immediately recognized possible characteristics of some form of a dissociative disorder. Unlike many individuals with DID, she denied being sexually abused as a child, but stated that she did experience emotional abuse growing up. As a teenager she did experience a relationship where physical, sexual, and emotional abuse occurred. Her marriage also consisted of emotional abuse, along with other incidents that she did not disclose.
She described herself as spiritual, but did not state any particular religious affiliation. She was raised Catholic, but indicated that ever since she remembered she and the rest of her family were witnesses to “paranormal activity”. This was standard in their house and she was engaged with this activity with her mother and siblings. In the course of her upbringing she recalls spiritist activity that was experienced by everyone in the house. These instances included having lights, televisions, and other electrical appliances turning ‘on and off’, sometimes on demand by her mother. Her family witnessed material objects move and defy gravity when no one was moving it. “Mary” admitted to seeing and hearing what she believed were spirits and other entities. She stated she would have dreams that would come true the next day. She also experienced dreams where she felt that entities were doing things to her, and when she woke up she said she would have strange marks on her. She had several unexplained marks on her body. She was concerned that her growing anxiety and depression due to the divorce and subsequent changes increased paranormal activity around her.
At one point in May, she stated that my “grandmother” wanted to speak to me. Thinking this was an “alter” wishing to communicate, I accepted this invitation. As this alter came forth, I felt that it was more likely that this could have been a caring, motherly “alter”. In order to investigate this idea, I asked a list of 15 questions that pertained to me, my grandmother, or family, thinking that it would be impossible for a “alter” to answer these questions. The goal was to demonstrate to the “alter” that it was a part of “Mary” and not some separate entity. Only a few selected people in my family would know the answer to these questions. To my amazement and shock, the “alter” answered every question correctly. And to close the interaction, she stated the quote at the beginning of this chapter, which was my grandmother’s farewell to me. Convinced that I was in fact speaking to a spirit and not an “alter”, I started to consult with supervisors and other professionals. This incident ignited numerous other examples in my professional and personal life that continues on a daily basis to this day. Consultation and additional research showed that the possibility of spirituality integrating with psychology was possible and needed to be explored further, which brings me to my interest in this area.
Doctoral Project Outline
The purpose of this study is to explore the history of dissociation and DID from theories associated with the spiritual, to a more observable and measurable explanation of dissociation and DID in our current society. A review of anthropological literature associated with dissociative phenomena in various cultures will be examined to allow for a broader understanding of dissociation and DID throughout different regions of the world. Finally a current understanding that integrates frameworks that entail a scientific and a spiritual exploration utilizing various cultures around the world will be presented. The focal question is not aimed to discredit the observations made in empiricism-based approaches but to simply add to these observations for a more encompassing understanding. There are other cultural experiences than what are known in western society, and in these cultures, individuals fully believe that they can be (and are) taken over by spirits and that these experiences have psychological consequences.
A detailed definition and history of dissociation and DID will be explored in Chapter Two, in addition to a review of prominent psychologists who laid the foundation for further understanding and study. The shift to a more empirical model of psychology at the beginning of the twentieth century and the effect it had on the study of dissociation will be explained in this chapter. Past and current research in the area of spiritual involvement in understanding DID will be discussed at the beginning of Chapter Three along with an exploration of the continued impact of culture within each edition of the DSM. Cross-Cultural experiences and research of spirituality and possession trance will also be examined in Chapter Three to further understand all possible etiologies of DID from an anthropological standpoint. Implications of integration of psychology and spirituality will be explored for modern clinical applications in Chapter Four. The distinctions of these world-views limit their insights, in turn, such that each sees a different world, with different values, and that each has validity in our understanding of the world. One should hear both viewpoints, give each their due with respect for each, and explore new ways to incorporate them both. The goal of this work is to broaden the horizon of our understanding of DID and dissociation by investigating etiologies in both an experimental science and anthropologic inquiry.