Understanding Dissociative Disorders
Dissociative disorders are complex and multifaceted mental health conditions that have been the subject of much clinical and legal discussion. The Dissociative Disorders Work Group of the DSM-IV proposed three core features of dissociative disorders: (1) a disruption in identity characterized by two or more distinct personality states, (2) a permanent or recurrent alteration of sense of self or of sense of agency over them, and (3) recurrent episodes of amnesia. There are four main types of dissociative disorders, which are identified separately based on the DSM System: (1) Dissociative Amnesia, (2) Dissociative Identity Disorder (formerly known as Multiple Personality Disorder), (3) Depersonalization/Derealization Disorder, and (4) Other Specified Dissociative Disorder and Unspecified Dissociative Disorder. A fifth type, Dissociative Fugue , while not listed in the DSM as a separate disorder, is described in the DSM as a subtype of Dissociative Amnesia.
While there has been some debate between DSM definitions distinguishing between primary and secondary Dissociative Disorders, both DSM systems include Dissociative Disorders in the wider category of "Trauma and Stress-Related Disorders" as described below. In whatever form it takes, dissociative disorders are characterized by disruptions in an individual’s memory or perception of themselves and/or their surroundings. These disruptions can lead to psychological symptoms such as memory lapses, forgetfulness, emotional detachment or numbness, and altered perception. Changes can also affect an individual’s motor skills, including the ability to walk or talk. Dissociative disorders are often linked to trauma, especially early childhood trauma.
Ethical Considerations of Diagnosing Dissociative Disorders
A host of ethical challenges are particularly pertinent when it comes to diagnosing dissociative disorders. Among them are: misdiagnosis, stigma, and confidentiality. Misdiagnosis is perhaps the most serious challenge. Those with dissociative disorders are at a higher risk of misdiagnosis because they are often treated by caregivers who are not experienced in recognizing the signs and symptoms of dissociative disorders. Misdiagnosis can lead to those with dissociative disorders being mislabelled as having post-traumatic stress disorder (PTSD), borderline personality disorder (BPD), or some other disorder more commonly known than dissociative disorder. Not only is this stigmatizing, but it can also lead to inappropriate treatment that fails to address the underlying problem and can even make it worse.
Stigmatization is a relevant ethical issue for two reasons: first, the stigmatization of dissociative disorders leads to misdiagnosis, as seen above, and second, it leads to a lack of awareness and understanding in the general population. Those with dissociative disorders must grapple with the symptoms of the disorder along with managing the stigma associated with it. Dissociative disorders are stigmatized in a way similar to mental illnesses such as depression, anxiety, and schizophrenia in that those with dissociative disorders may be perceived as being "crazy," "not normal," "unstable," or "unable to be in healthy relationships." This can lead, consciously or unknowingly, to discrimination in the workplace, by friends, and family alike.
The diagnosing of dissociative disorders also raises issues relating to confidentiality. Those with dissociative disorders hold within them the manifestations of their disorders. More specifically, their symptoms are often tied to the assumptions and realities of their alternate personalities. This can be particularly sensitive when it comes to adolescent or adolescent patients. For instance, if an adolescent patient develops a male alternate personality, should the therapist inform the parents? On the one hand, confidentiality is legally protected and practically beneficial. However, on the other hand, withholding such information from a parent to whom the adolescent alternately identifies could manifest itself in the form of severe emotional reaction or trauma.
Maintaining professional integrity as a mental health practitioner is essential. Inherent to integrity is advising against and leaving aside misdiagnosis, stigmatization, and breaches of confidentiality. That is not to say that this is easy to do as there can be both personal and practical reasons that may lead to a mental health practitioner deviating from integrity. That said, doing so can severely impact the life of a patient or former patient. The ethical duty of all mental health practitioners is to measure and weigh the diagnostic criteria fairly, apply that fairly weighed criteria accurately, and maintain fair confidentiality.
Legal Rights of Patients with Dissociative Disorders
Patients diagnosed with dissociative disorders have certain legal rights that practitioners must be aware of. One of the key legal principles underlying the treatment of patients with dissociative disorders is the right to privacy and informed consent. The right to privacy extends to the patient’s treatment records as well as their right to refuse treatment. There are both State and Federal laws governing the right to informed consent and the general rule of thumb is that a patient who presents for treatment or examination by a medical or mental health professional is presumed to have given their consent, absent contrary evidence.
The right to privacy is very broad, and is based on the patient’s interest in keeping the information private and whether there is any legitimate public interest which is promoted by disclosure. Certain laws, such as HIPAA regulations, govern the confidentiality of a patient’s medical or mental health diagnosis. Under HIPAA, a patient has the right to receive a copy of the notice of privacy practices, which is a written statement explaining the doctor’s privacy practices. The doctor or therapist must make a good faith effort to obtain a written acknowledgment that the notice has been received. A patient may designate a personal representative to act on his/her behalf in asserting any rights and exercising any of the individual’s rights. As a general rule, the consent must be voluntary and in writing. If the patient is a minor or unable to give informed consent, the consent must come from a legally authorized representative or surrogate. Another important legal principle is the right to refuse treatment. A patient with a dissociative disorder who refuses treatment should be informed of any consequences of that refusal. Competent adults have the right to refuse treatment, and this includes the right to refuse psychotropic drugs or any other treatment or intervention.
In cases where a patient has been admitted to a hospital or facility because they are a danger to themselves or others, the right to treatment can be limited or even suspended. However, generally speaking the right to treatment requires that a competent patient be provided with adequate and appropriate treatment to restore him/her to a condition in which they can make reasonable treatment decisions. The treatment must be provided in the least restrictive environment possible, so if the patient can be effectively treated through outpatient therapy, that should be the goal. Involuntary treatment of a patient with a dissociative disorder can only be undertaken in the absence of informed consent if there is clear and convincing evidence that the patient suffers from a mental disorder requiring immediate treatment; that the patient is not competent to refuse treatment; and that the treatment is necessary to prevent harm to the patient or others.
If the patient is incompetent or otherwise legally unable to consent to treatment, then the rights of the patient are vested in a legal guardian. There is a presumption that a person has capacity to make their own health care decision, unless that presumption is rebutted. If a treating physician concludes that a patient does not have capacity to make their own informed consent, the patient has a right to contest such a finding in court. The presumption of capacity cannot be overcome without objective evidence that the person lacks the ability to understand or appreciate the consequences of their decisions.
Informed Consent and Ethical Therapy Practices
Informed consent is a surprisingly recent phenomenon: before the 1970s, patients were rarely included in the decision-making process about treatment. Even after the field shifted, ethics were not always well followed, and were almost never tested in court. The standards of common practice are ever-evolving: public disclosure requirements for psychotropic drugs are still being decided by organizations such as the FDA.
Dissociative disorders – particularly those with an onset in childhood – as well as their causative factors, are rife with ethical considerations and concerns. Both the disorder itself and the traumatic events that caused the dissociative state may have violated the patient’s informed consent, putting their very ability to provide informed consent at risk. For example, some therapists may require their patients to shop around for a better therapist, or only refer them to other refugees of their own practice, violating anti-kickback statutes (Osswald 2018). Other therapists may discourage their patients from seeking help from other professionals, disregarding the patient’s ability to make decisions and making the patient overly reliant on them (Newberg et al. 2000). This is not to say that these violations are strictly conscious. For example, in a study by Stockmarr et al (2018), fewer than half of dentists felt confident in their knowledge of the prevalence of MDMDs among their patient populations, or even their own ability to recognize them. If dentists lack the training or awareness for conditions commonly misunderstood and undiagnosed by even mental health professionals, such as conversion disorder or somatic symptom disorder, it stands to reason that therapists could be similarly unprepared to treat MDs.
Thus, therapists need to prioritize informed consent and ethical practice when treating this notoriously vulnerable population . This can take the form of actions such as fully informing patients of the potential side effects of all treatments, including medication and psychotherapy. This can be difficult due to the lack of studies demonstrating long-term effects within this population, meaning that clients may not be able to make informed decisions about their treatment. More established conditions may demand their own specialized treatments, involving transference-focussed psychotherapy (TFP) or Eye Movement Desensitization and Reprocessing (EMDR). The potential benefits of alternative treatment modalities such as somatic experiencing therapy and sensorimotor psychotherapy are still largely unexplored. Of course, as with any condition, treatment should be tailored to the individual, as well as the client’s preferred treatment modality.
The treating therapist has to balance their own ethical and legal obligations with the understanding that one’s own informed consent is likely complicated by having an MD, so that it can be difficult for the patient to identify what is ethical or legal, or even which they prefer. This creates risks for the treating therapist: as mentioned above, MD can cause pervasive mistrust of authority figures under the most benign of circumstances, and when that authority figure is their therapist, this could be especially heightened. Additionally, MDs are already prone to suicidal, depressive, dissociative, or self-harm thoughts, meaning that the potential for suicide is especially threatening to their and their therapist’s wellbeing. Thus, therapists must consider these risks and make sure that they have thorough explanations of the risks and benefits that go above and beyond mere informed consent, as well as a plan to protect themselves and their clients in case of the worst-case scenario.
Legal Implications in the Criminal Justice System
The intersection of mental health, especially dissociative disorders and their legal implications, is one of the less frequently written areas of law. However, it does come up in a couple of ways.
How do we know that someone who committed murder, for instance, has Dissociative Identity Disorder, and what does that mean in terms of culpability?
A case in point is the case of Chris Costner Sizemore, the woman who was diagnosed with Dr. Robert John Lifton as having Dissociative Identity Disorder (previously called Multiple Personality Disorder) in 1954. She later became the subject of Lifton’s book "Mary Alice I" and the movie "Three Faces of Eve," in which Joanne Woodward won an Academy Award for her performance.
While Chris Costner Sizemore has lived a relatively normal life, there are other case studies, such as in "Twelve Lives", in which the lawyer defending Tanya Breidy used her MPD to win an acquittal in the brutal slaying of twelve of her relatives in 1994; and in "All The Faces of Me" in which Rene Orlean Fourie murders her infant son in a Toni Mack murder case, that are quite different.
It is clear that there are people, like Chris Costner Sizemore, who have not harmed themselves or anyone else, despite many years of having Dissociative Identity Disorder. On the other hand, there are others, like Tanya Breidy and Rene Orlean Fourie, who have killed not only themselves and others, but also committed other acts of violence. Both Tanya Breidy and Rene Orlean Fourie were diagnosed as having MPD, and Tanya Breidy is serving multiple life sentences.
The legal issues come up in a couple of different ways. One of the most obvious has to do with civil issues. For instance, in California, the only way a child can be involuntarily removed from a parent is if the parent abuses the child. The social workers are given training in abuse, but this includes things like bruises and burns on the child, not in disorders such as Dissociative Identity Disorder. Are social workers, or the courts, not going to take away the child because the child was crying, or had some other behavioral issue?
Another legal issue comes up in criminal defense. If someone is on trial, the criminal defense attorney must present a complete defense. This means that if there is a rational basis for bringing up a mental disorder diagnosis, like Dissociative Identity Disorder, he must do so for the client.
The problem is that the general public does not blame a person with mental illness for his or her actions, as long as those actions are within the realm of civility. In other words, someone with Bipolar Disorder, for instance, will not be found guilty for committing a violent act if it is determined to be a psychotic episode and that person has not been taking medication at the time of the episode. Likewise, if someone has depression, and does something abnormal as a result of the depression being so severe, he or she will not be charged with a crime for that act.
However, we fear that the opposite will occur in a high profile case if Dissociative Identity Disorder is brought into the picture. The public does not understand Dissociative Identity Disorder, and the majority of people believe the images that have been portrayed on daytime television programming or soap operas – that the person is just pretending, or that the person is evil incarnate and is "possessed" by the "evil alter". But those of us who have been touched on any level by such a disorder know it to be different.
The result could be that defendants with Dissociative Identity Disorder and Dissocative Amnesia will end up with a diagnosis of Bipolar Disorder, Schizophrenia or Schizoaffective Disorder in order to remove them from the stigma of Dissociative Identity Disorder being assigned to them in favor of a "more treatable" diagnosis such as Bipolar Disorder, Schizophrenia or Schizoaffective Disorder.
What does this mean for the legal system? It means that even when mental health is allowed to in, there may be biases, mistakenly placed diagnoses, and a misunderstanding of Dissociative Identity Disorder in particular.
Balancing Ethical Care with Legal Obligations
Mental health professionals are bound to provide ethical care to all of their patients but the ethics can become quite complicated when working with patients who have dissociative disorders or who have been traumatized. Such patients may demonstrate behavior…or histories of behaviors…that conflict with the legal and ethical duties of the mental health professional. Sometimes this contradiction can be resolved if the professional gets creative in finding a solution to the problem. For example, a patient who stole their mother’s car to come to a therapy appointment has clearly violated the law. Illinois allows a therapist to admit a client to a psychiatric unit in order to prevent them from acting on their thoughts of violence with biodata evidence. In that scenario, the professional can balance the duty to provide ethical care and the law by admitting the patient to the psychiatric unit and notifying the police of their actions. Providing treatment in the secure environment of the hospital fulfills the ethical obligation to protect the patient from harm and the legal duty to report the patient’s crime to the police. While there are certainly creative solutions to some situations, that is not always the case and there are other tools and solutions available to the professional. Often it is a misunderstanding of the law that leads to a poor outcome . Mental health professionals treat in accordance with their training, licensure and the law. Many professionals are not lawyers nor have they had legal training and when they misinterpret the law it can be quite damaging to their patients. Illinois architects and engineers make a similar misinterpretation of the law when they submit their calculations for client approval before acting on them. If a structural engineer performs calculations to confirm that an existing building is safe or can be remodeled without concern and then submits those calculations with their signature, in California, they are then prohibited from reviewing those calculations again. In cases where there is a known dissociative disorder, the professional should verify the current laws in their state to ensure they are in compliance with their legal duty to their patient and to the public. The law’s application to a case is often a complicated, gray situation that requires the guidance of an experienced legal professional intended to "partner" with the mental health professional. Ethics committees can play a big role for mental health professionals to further help them maintain the line between care and the law. In difficult situations, collaboration with ethics committees, the courts and experienced counsel is expected and encouraged to protect the professional and their patient.