There's a new television show on Showtime called "United States of Tara" which is about a woman with multiple personalities. My wife and I have watched the first two episodes, and while I didn't expect to like it, I kinda do.
The question of why I'm liking it is relevant. I'm liking it primarily because it is a show that addresses a complicated and misunderstood mental illness - Dissociative Identity Disorder or DID - and it is managing to do this so far without too distorting the depiction of this condition so that it becomes an utter caricature of itself. That is a major accomplishment in my book, as so many shows concerned with mental illness feel exploitive. "United States of Tara" is no "In Treatment", and as it is just getting started, there is still plenty of time for it to degenerate, but so far, so good, I think.
The main character, played by the talented Toni Collette, is a forty-something muralist, wife and mother (of two teenage children) named Tara. Very early on, we see Tara transform into a new character named "T", an impulsive and promiscuous teenage female who goes out on a shopping spree with Tara's credit cards and with Tara's actual teenage daughter in tow. Later still, we meet "Buck" who is a middle aged male redneck sort of stereotype; a hyper-masculine man prone to fist fighting. Finally, we meet "Alice" who is a controlling, Martha Stewart type character.
While watching, I'm ending up pausing the show so as to talk with my wife about how the show's depiction of multiple personality fits with how the actual condition appears in real life, at least with regard to my limited experience treating patients with this condition. For instance, there is a scene where the Alice alter is talking to husband Max (played by John Corbett), informing him about another alter's motives. This is a small detail but a telling one and, in my estimation, an accurate one. Within the architecture of a DID system, alters are not all created equally. Instead, different alters have different levels of knowledge and insight concerning the personality system in which they are embedded and their personal history. Some alters are fully aware of the presence of other alters, may have extensive access to memory, and may even be able to "read the minds" of the other alters. Other alters do not have this privileged access and may be entirely in the dark, knowing only that they frequently experience blackouts. In the United States of Tara, it appears that Alice may be one of these privileged alters, while Tara is not. It would be so easy for the writers to get this sort of thing wrong but they didn't.
Another comment I had was that the few alters who have been introduced feel more or less authentically superficial. I read some criticism somewhere (I can't find it now!) about the show which accused the writers of simply stringing a set of stereotypes together in place of doing actual character development work, but in my experience, many public facing alters (not all but many) really do come across as stereotypes. They are not fully developed people but instead fantasies of people as imagined by a person who needed their stereotyped attributes in order to cope at some time. They can be incredibly one-dimensional, in my experience. Sometimes they have been created to fulfill one purpose and one purpose alone, and that is all they do. There are often more well developed alters in the system as well, but plenty of stereotypes. So that part feels accurate so far.
Alters are frequently specialized, occupying different niches within the life of of the total person in which they exist in much the same way that professions within society have specialized over the course of civilization. So, you tend to see people with DID exhibiting alters who have specialized in specific roles; defensive, executive, economic, social, emotional/vulnerable, sexual, etc. I find the existence of an alter like Buck entirely plausible as an instance of a defensive function. Buck's maleness is not odd or weird though Tara is female; it is a function of the ferocity that Buck needs to bring to his role. Overt aggression is a masculine function in society and so Buck was "born" male. He is adult because he needs to be responsible. He is a redneck because that gives him license to be a loose cannon (e.g., to act out aggressively on impulse). You expect a "redneck" caricature to punch people in the face. It is psychotically weird when viewed from the outside, but the internal logic works just fine.
The alters "T" and "Alice", and also the alter "Tara" (who has not been presented as an alter but who very definitely is an alter) are also reasonably drawn to my eye as well. Tara fulfills social and economic functions. She is the facade that is presented to the world. She has little knowledge of the larger system (she knows it exists but does not have access to the thoughts of the other alters). She exists as a pleasant front behind which the other alters can rest until needed, or hide their vulnerability. She works and therefore brings in money. She is the first alter you meet and the one you think is the primary person (e.g., the original identity which happens to be plagued by these other more partial, more fantastic identities). It's important to keep in mind, however, that in cases of DID, there is no "original" or "primary" person. There is just the alter system, which can only reasonably be thought of in systems or ecological terms. Most people have a unitary experience of self, but people with DID have a true multiplicity.
The alter "T" exists to to rebel and break rules. Why this function should be needed in the ecological system of a person living with DID isn't made clear in the show, so I will try to help make it more clear. In my experience, there is always a rebellious aspect to the DID alter system, which forms as a normal reaction to the difficult conditions that caused the system to come into existence in the first place. Namely, there generally isn't any DID without substantive child abuse having taken place first. So, you have a situation where dissociation becomes a coping strategy that a young child uses in order to cope with sometimes horrific abuse. I don't know if abuse is always required to be present in order for DID to form; I only know that in the examples of DID that I've known intimately, it has been present or at least claimed to have occurred. So - one or more alters come into existence that hold abuse memories and pain, often cast as children or actual infants, and then in response to the pain that these pain-holding alters contain and encapsulate, come into being the duty-bound defenders, like Buck, and also the rebellious rejecters, like "T" who cannot stand to be controlled or duty-bound and who instead act out in hedonistic and self-destructive ways. Buck is a angry reaction to abuse designed to keep it from reoccurring, where T is a more primitive rejection of abusive control (and hence her younger age). These same dynamics get acted out with some frequency by non-multiple abuse victims as well, but in an integrated and owned fashion, without the need to have new "selves" take on new roles.
Another nice aspect of "T" is the suggestion that she is promiscuous. In my experience with a sexually abused female DID patient, some alters were promiscuous. This seems to me in part a function of how sexual abuse can shape women's (and men's) self-concepts. The abuser makes you into a sexual object, and then you start to see yourself as a sexual object. So you start offering yourself as a sexual object to the others around you. This dynamic also happens to abuse victims who are not DID, but when it happens within a DID alter system, it often gets encapsulated as an alter.
What is blatantly and oddly missing from United States of Tara, then, is the abuse history, and the alters which carry and contain the abuse memories and emotional pain that alters like Buck and T would seem to imply. To my mind, Buck and T and Alice don't make sense without some other pain-containing, probably very young alter(s) in relation to which they are essentially reactions. I have a few thoughts about why the writers have not presented us with this pain-containing aspect of the alter system. Possibly, they are just getting started, and it is possible that they will do so in later episodes. Alternatively, they are sensitive to the fact that the introduction of the abuse theme and the need to depict the abuse-containing alters (who might cry uncontrollably and mutely rock in the corner of the room or act in an infantile manner) would introduce a profoundly sad tone to the show's comedic energy which might turn off viewers. I hope it is the former rather than the latter.
There are a few conceits or mistakes that the show is promoting. There is this idea that the alters are now coming out because "Tara has gone off of her medications"; that they were under control before but now she is off her medications as a part of some kind of integration push, possibly therapeutic (although we have not yet been introduced to any therapist or psychiatrist). To suggest that medication could successfully control or suppress an alter system in a patient with DID is not terribly plausible. The main dynamic in DID is dissociation. Dissociation is a psychological phenomena (occurring at the level of attention and memory) more than it is neurological (occuring due to brain damage of some sort). DID is a coping style, learned very early on before the consolidation of normal unitary adult identity has taken place in people who are (usually) abused, and also who have a talent (possibly biologically based) for dissociation. Dissociation is not schizophrenia (where voices are are auditory hallucinations that do typically respond to anti-psychotic medication) in any way shape or form. DID does produce a truly psychotic-acting individual, but this is a different form of psychotic than the paranoid psychotic we think of due to schizophrenia, and produced by a different mechanism.
Another potential conceit is that the family household depicted in United States of Tara is fairly functional and organized. In reality, DID is a serious condition that is generally associated with a lot of behavioral chaos and a more disorganized family life. It is certainly possible that a DID family could hold itself together as well as the family depicted in the show, but it does seem more unlikely to be that way (to me) than not. Those individuals I've worked with have far more chaotic and troubled home lives than anything I've seen depicted here.
United States of Tara is produced and broadcast by Showtime, a premium network, and thus it will not be easily viewable by many readers in the short term. Until DVDs or iTunes/Amazon downloads are available, You can, if you like, visit the Showtime website and watch the first episode online.
I know from long online experience that there are many people out there who might read this who themselves live with DID, or with a family member who has DID. It's apparently not anywhere near as rare as we had previously thought (or maybe the Internet has just helped many different people find each other who would have been isolated otherwise). In the spirit of finding each other, I'd really appreciate it if those of you who have first hand knowledge of DID could leave a comment below, helping to flesh out what it is like to have DID; how the alter systems tend to be set up and how they function. There are a lot of mistaken beliefs out there about DID, and still many people who think they are alone in dealing with this complicated issue. Your observations can thus be of substantial help and comfort to future readers.
Editor's Note: February 27, 2009
We've just posted a Wise Counsel Interview with Dr. John Kihlstrom, who is a professor of psychology at UC Berkeley, and a well known research clinical psychologist in the field of hypnosis and dissociation. I encourage anyone who is interested in the topic of dissociation to listen to that interview as it is eye opening.
In the interview Kihlstrom talks about whether there is always abuse or trauma involved in cases of dissociative disorder, and in his very educated opinion, based on a lot of careful research he and others have done, the answer is no. Trauma is not associated with dissociation, or at least not with the key feature of dissociation which is amnesia (memory loss). And if you think about it, that makes some sense. After all PTSD, which is the prototypical post trauma response is usually characterized by the inability to forget trauma; not so much by a disposition to repress knowledge that it happened. Kihlstrom isn't saying that abuse doesn't occur in such cases, but that abuse doesn't cause the dissociation to occur.
This is a complicated area and one that is hard to study, but when quality research is available to illuminate an issue, you are somewhat foolish to not take it seriously. So - I wish to change my above essay in light of what I've learned today (although I won't actually do that). The show will apparently work fine without any linking of a past abuse with Tara's present day DID, even though it is now clear that that is in fact the direction they are going in.