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Dissociative mothers' subjective experience of parenting
Child Abuse & Neglect, Vol. 20, No, 10, pp. 933-942, 1996 Copyright © 1996 Elsevier Science Ltd Printed in the USA. All rights reserved 0145-2134/96 $15 00 + .00
Pergamon
PII S0145-2134(96)00082-8
DISSOCIATIVE MOTHERS' SUBJECTIVE EXPERIENCE OF PARENTING LYNN R. BENJAMIN Marriage and Family Therapist, Private Practice, Dresher, PA, USA
ROBERT BENJAMIN Progressions Health System, and Department of Psychiatry, Temple Universtty, Philadelphia, PA, USA
BRUCE RIND Department of Psychology, Temple University. Philadelphia, PA, USA
Abstract--This study examined to what extent the symptoms of dissociative mothers interfered with their parenting and their subjective experiences of mothering. A group of 54 dissociative inpatient or day-patient mothers, 20 nondissociative inpatient mothers, and 20 hospital staff mothers were screened for Dissociative Disorders using the Structured Clinical Interview for Dissociative Disorders (SCID-D). They were then asked to fill out a self-report questionnaire on various aspects of mothering. This questionnaire, the Subjective Experiences of Parentmg Scale (SEPS), examined 14 parenting characteristics: parenting partner support; relative support; abusiveness towards the child; extent to which symptoms interfered with parenting; constructive parenting traits; supportive versus hurtful discipline; extent of showing affection; ability to express affection; attachment behaviors; cognitive distortions; regulation of anger; self versus mother in parenting; subjective experience of mothering; and actions to promote the developmental growth of the child. Dissociatives presented significantly more negative parenting behavior and related attributes than staff controls on 13 of the 14 parenting characteristics. Compared to nondissociative patients, the dissociative cohort presented poorer parenting behavior and related attributes on 9 of the 14 characteristics. Overall, the dissociatives experienced more problems with parenting attitudes and behaviors than either comparison group. Dissociative mothers manifested affective, behavioral, and cogmtive difficulties m parenting.
Key Words--Dissociation, Parenting, Mothering. INTRODUCTION D I S S O C I A T I V E D I S O R D E R S E N C O M P A S S an array o f s u b t y p e s a l o n g a c o n t i n u u m in w h i c h the n o r m a l l y i n t e g r a t e d f u n c t i o n s o f c o n s c i o u s n e s s , m e m o r y , identity, or p e r c e p t i o n o f the e n v i r o n m e n t are d i s r u p t e d ( A m e r i c a n P s y c h i a t r i c A s s o c i a t i o n , Diagnostic and Statistical Manual of Mental Disorders, 1994, 4th ed.). K l u f t ' s ( 1 9 8 7 ) study o f the parental fitness o f mothers with Dissociative Identity Disorder (DID, formerly called Multiple Personality Disorder, M P D ) y i e l d e d startling results. O f the 75 m o t h e r s studied, 3 8 . 7 % w e r e d e e m e d c o m p e t e n t This research was supported by Progressions Health System and Northwestern Institute of Psychiatry, Fort Washington, PA. Received for publication August 14, 1995; final revision received March 29, 1996; accepted April 2, 1996. Reprint requests should be addressed to Robert Benjamin, M.D., 12 Mayo Place, Dresher, PA 19025-1228. 933
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or exceptional, 45.3% were deemed compromised or impaired, and 16% were deemed grossly abusive toward their children. This study suggested that the children of dissociative parents were a population at risk, and that individual treatment of the dissociative mother was not enough to stem developmental disruption to her children. Furthermore. a number of authors have demonstrated the intergenerational transmission of dissociative or other psychiatric disorders in children of dissociative parents (Braun, 1985; Coons, 1985; Kluft, 1984a). In our own clinical experience, the first two authors have noticed the struggles that dissociative mothers have with interpersonal relationships, and particularly with childrearing. In an effort to assist these mothers, we established a therapy group for mothers with dissociative disorders (Benjamin & Benjamin, 1995). We also hypothesized, again based on our clinical observations, that specific symptoms of dissociation served to impede the mothering of our client-mothers: switching and accompanying behaviors, hearing voices, having alter personalities, thinking in distorted ways, having amnestic episodes, depersonalizing, derealizing, and self-mutilating or having suicidal ideations. We examined parenting from various perspectives in the therapeutic literature (Benjamin & Benjamin, 1994a), and we began to utilize parenting as a clinical focus in our treatment of dissociative mothers (Benjamin & Benjamin, 1994b). Both in clinical anecdotes during individual therapy with dissociative clients and in our work with the partners of those clients (Benjamin & Benjamin, 1994c; 1994d; 1994e), we repeatedly heard examples of what appeared to be very poor parenting skills. Kluft's study of the fitness of dissociative mothers described his categorization of patients' behaviors as mothers based solely on retrospective analysis of interview data obtained during treatment. We wished to extend Kluft's research by surveying through a structured self-report how individuals diagnosed as dissociatives felt about their performance as mothers. Specifically, we were interested in their subjective experiences of how they related to their children and of how their dissociative symptoms interfered with their parenting. To that end, we designed a self-report scale that measured a wide variety of parenting characteristics (see below). To evaluate the mothering experiences of dissociatives, we obtained a sample of dissociative inpatients or day-patients, as well as two additional nondissociative control samples (nondissociative inpatient mothers and hospital staff mothers) that served as comparison groups. We hypothesized that the dissociative mothers would experience more struggles in mothering on the self-report measure than mothers in either control group.
METHOD
Subjects Subjects were 94 mothers associated with a suburban Philadelphia private psychiatric hospital who fell into one of three groups: patients diagnosed with a dissociative disorder (n = 54); patients with diagnoses other than dissociative disorder (n = 20); and staff (n = 20). The latter two groups acted as control groups against which to compare the dissociative patients. The mean age of the subjects was 37.50 (SD = 8.43), and their ages ranged from 23 to 58. Subjects had a mean of 2.34 children (SD = 1.16), with a range from 1 to 7. The mean number of natural children was 2.23 (SD = 1.18), while the mean numbers of stepchildren and adopted children were, respectively, .22 (SD = .66) and .11 (SD = .34). The mean of their youngest child was 8.74 (SD = 7.92), and the mean of their oldest child was 14.41 (SD = 8.61 ). The children ranged in age from newborn to 36 years old. Subjects had on average 1.57 children living with them at the time of the study (SD = 1.14), and had a mean of 1.22 sons (SD = .88) and 1.17 daughters (SD = .94). Of the 94 mothers, 90.4% were Caucasian, 8.5% were Black, and 1.1% were Native American. Seventeen percent of
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subjects lived in a large city, while 19.1% lived in smaller cities, 8.5% in rural areas, 28.7% in towns, and 26.6% in suburban areas. Seventy-four percent of subjects had been diagnosed with mental or emotional disorders, while 90.3% of all subjects had been or were currently in therapy. Seventy-two percent of subjects had a co-parenting partner at the time of the study. In comparing the three groups on the demographic variables just described, few differences emerged. One difference that did emerge was that staff subjects (M = 44.75 ) were older than nondissociative (M = 35.80) or dissociative (M = 35.44) patients, F(2, 91) = 11.54, p < .001. The latter two groups were equal in age. A related difference was that the mean age of the youngest child of staff subjects (M = 12.8) was greater than that for dissociative patients (M = 7.28), F (2, 91 ) = 8.65, p < .05. The mean age of the youngest child for nondissociatives (M --- 8.65) was not statistically different from the other two means. No other differences appeared for the quantitative demographic variables. For the categorical variables, no differences occurred in the distributions of race or residence, and the proportions of subjects with co-parenting partners were equal across the three groups. As expected, the three groups did differ significantly in having been diagnosed with a mental or emotional disorder, x 2 ( d f = 2, N = 94) = 60.87, p < .001, and having been in therapy, x 2 ( d f = 2, N = 94) = 23.71~ p < .001. While all dissociatives and nondissociatives had been diagnosed, only 30% of staff subjects had been. Finally, while all dissociatives and nondissociatives were or had been in therapy, 70% of staff subjects reported this. The 54 dissociative patients were broken down into subgroups based on their performance on the SCID-D in which scores can range from 0 to 20. Twenty-six (48.1%) of these patients were diagnosed with Dissociative Identity Disorder ( D I D ) , with a mean of 19.23 (SD = 1.14) and a range from 16 to 20. Twenty-five (46.3%) were diagnosed with Dissociative Disorder Not Otherwise Specified, with a mean of 14.76 (SD = 2.09) and a range from 11 to 19. Two (3.7%) were diagnosed with Depersonalization Disorder, each with a score of 14, and one ( 1.9%) was diagnosed with Dissociative Amnesia with a score of 9. The 20 nondissociative patients had a mean score of 7.70 (SD = 1.53) on the SCID-D, with a range from 5 to 11. These subjects all had primary diagnoses of depression, major depression, or affective disorder. The 20 staff subjects included psychiatric nurses, social workers, administrators, kitchen workers, and clerks. Their mean score on the SCID-D was 5.35 (SD = .75), with a range from 5 to 7.
Instruments Two instruments were used during the course of this study. To assess for or to rule out dissociation, we used the Structured Clinical Interview for Dissociative Disorders (SCID-D), an instrument with good to excellent reliability and validity (Steinberg, 1985; 1993; 1985/1993). The second was the Subjective Experience of Parenting Scale (SEPS), a self-report measure that was designed by the authors to elicit certain characteristics of parenting. Although other self-report inventories exist (Moos & Moos, 1981; Shea & Tronick, 1988), we wanted to target some specific issues (e.g., symptoms, attachment issues, cognitive distortions) that were not necessarily on other measures. Additionally, we knew that we would not be able to limit the age range of the subjects' children in the sample. Consequently, we had questions that dealt with mother-child relations from pregnancy through adolescence. For mothers with adult children, we asked them to report based on earlier experiences with their children. The questionnaire began with a series of 24 demographic items, followed by 128 questions that assessed a variety of parenting behaviors. These latter questions were followed by 7-point scales, which were anchored by bipolar adjectives such as " n e v e r " or " o f t e n " or "not at all" and " a great deal." Questions measured a wide variety of parenting behaviors including attachment behaviors, discipline, regulation of anger, and behaviors that promoted the child's development (see Table 1 for a complete list of characteristics).
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Procedures To proceed with our study, we sought and received approval to solicit subjects from the Research Committee and governing bodies of a suburban Philadelphia private psychiatric hospital. W e sent out flyers and met with unit clinical directors, attending psychiatrists, psychiatric nurses, social workers, and psychiatric technicians (aides) to alert them to our procedures and to the kinds of subjects we needed for our study. All subjects signed a consent form to participate with the knowledge that results would be entered into a pool of statistics and their confidentiality would be guarded. Subjects were asked to make up a four-digit n u m b e r to key the two survey instruments together. They were told that they could arrange an optional post-study appointment to discuss their feelings about participating in the survey and about parenting issues that may have been stirred up by their participation. In order to establish the validity of patients' chart diagnoses by their attending physicians, the first author administered the SCID-D to each subject. This instrument, keyed to D S M - I V criteria, is an interview protocol which assesses for the five types of dissociative disorders: Dissociative Amnesia, Dissociative Fugue, Dissociative Identity Disorder ( D I D ) , Depersonalization Disorder, and Dissociative Disorder Not Otherwise Specified ( D D N O S ) . Following this qualifying step, the interviewer then gave each subject oral instructions for the SEPS. A preliminary demographics section was then administered aloud to the interviewee. Next, the subject started the questionnaire in the presence of the interviewer. While the subject answered the questions, the interviewer scored the SCID-D. The interviewer asked the subject if she would like to have the results of the SCID-D. All participants in the study asked for results. No results were reported to treating therapists. Subjects returned the SEPS to the interviewer in a sealed envelope identified only by their previously selected personal identity code number. RESULTS The goal of the current study was to investigate the level of functioning in parenting behavior of w o m e n diagnosed as dissociative, using nondissociative patients and staff controls as comTable 1. Mean Parenting Characteristics of Dissociative Patients, Nondissociative Patients, and Staff Controls
Characteristic
Dissociatives
1. Parenting Partner Support 2. Relative Support 3. Abusiveness Towards Child 4. Symptoms Interfere with Parenting 5. Constructive Parenting Traits 6. Discipline: Supportive vs. Hurtful 7. Extent of Showing Affection 8. Ability in Expressing Affect 9. Attachment Behaviors 10. Cognitive Distortions 11. Regulation of Anger 12. Self vs. Mother in Parenting 13. Subjective Experience of Mothering 14. Acting to Promote Child's Development
4.68 3.00 2.18 .40 5.60 4.83 5.94 4.41 4.69 2.59 4.13 6.09 4.61 5.25
Nondissociatives Staff 5.57 3 98 1.95 •11 5.87 5.33 6.55 5.08 5.49 1.71 4.30 6.18 5.66 5.90
5.71 4.74 1.27 .02 6.25 5.87 6.58 5.76 6.09 1.35 5.23 6.14 5.57 5.84
t(D vs. N)
t(D vs. S)
1.80 2.10" .89 6.40*** 1.18 2.00* 2.22* 2.43** 2.79** 2.97** .47 .35 4.38*** 2.71"*
2.08* 3.58*** 3.60*** 8.38*** 2.85** 4.24*** 2.33* 4.90*** 4.88*** 4.19"** 3.01"* .20 4.00*** 2.50**
Note• A priori contrast t-values for dissoclatives (D) vs. nondissociatives (N) and for dissociatives vs staff controls (S) for each characteristic appear in the last two columns• Contrasts were signficant, indacated by *, when p < .025 one-tailed, which represents a Bonferroni correction for two nonorthogonal contrasts. **indicates p < .01. and ***indicatesp < .001. For all characteristics, means could range from 1 to 7 except for "symptoms interfere," which could range from 0 to 1. Analyses are based on n = 54 dissociatives, n = 20 nondissociatives, and n = 20 staff controls, except for: parenting partner support (ns = 46, 17, 17); relative support (ns = 54, 20, 18); abusiveness towards child (ns = 53, 19, 20); discipline supportive vs. hurtful, self vs. mother in parenting, and acting to promote chdd's development (ns = 54, 19, 20).
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parison groups. To this end, subjects' parenting behavior was assessed with a questionnaire consisting of 128 items that examined various aspects of parenting behavior. In order to reduce the large number of variables to be analyzed, variables intended to measure the same general aspects of parenting behavior were grouped together to form a smaller set of parenting characteristics. This smaller set consisted of 15 characteristics (see below).
Parenting Characteristics The 128 questions were grouped into 15 categories describing 15 distinct characteristics of parenting behavior. For each characteristic, Cronbach's alpha was used to assess its reliability-that is, the extent to which all the variables selected to comprise the characteristic were measuring a single construct. The first characteristic was labeled "parenting partner support" and consisted of three questions measuring the parenting partner's nonabusiveness, supportiveness, and knowledge ( a = .87). The second characteristic was called "relative support" and consisted of three questions assessing how supportive parents, in-laws, and other relatives were ( a = .73). The third characteristic, "nonrelative support," also consisted of three items assessing support from friends, support groups, and religious organizations ( a = .64). Because of a large number of missing values, however, this characteristic was dropped from the statistical analyses to be aescribed below. The next characteristic, "abusiveness towards child," consisted of three items assessing physical, sexual, and emotional abuse regarding subjects' children ( a = .56). Sixteen questions assessing a variety of dissociative symptoms that may have interfered with subjects' parenting were combined to assess the next characteristic, "symptoms interfering with parenting" ( a = .87). "Constructive parenting traits" were assessed by combining 16 items such as the importance to subjects of their children's physical and mental health and the extent to which subjects encouraged their children to have new experiences and make decisions ( a = .90). "Discipline: supportive versus hurtful" consisted of nine questions assessing styles of behavior such as the extent of being consistent, clear, and not emotionally abusive when disciplining their children ( a = .79). "Extent of showing affection" consisted of three items assessing how often subjects displayed affection verbally, nonverbally, and physically ( a = .76). "Ability in expressing affect" consisted of I 1 items assessing to what extent subjects felt they were able to express various emotions such as fear, excitement, and happiness ( a = .81). "Attachment behaviors" consisted of five questions asking subjects, for example, to what extent they comforted, listened to, or withdrew from their children ( a = .78). "Cognitive distortions" consisted of five questions assessing the degree to which subjects held distorted views regarding their children f e.g., your child is trying to hurt you or is abusing you) ( a = .76). "Regulation of anger" consisted of three items concerning how well subjects regulated their anger, such as extent of being calm, not yelling, and not using physical gestures when angry ( a = .75). " S e l f versus mother in parenting" consisted of four items in which subjects indicated how their mothering compared to that of their mothers' ( a = .77). "Subjective experience of mothering" consisted of 16 items that assessed how subjects experienced various aspects of being a mother, such as to what extent they liked becoming a mother and liked to play with their children, as well as how easy they found it to toilet train their children or wean them ( a = .86). Finally, "acting to promote child's development" consisted of nine items and measured the extent to which subjects acted to promote their children's developmental growth (e.g., encouraged self-care habits in their children and took their children on outings and trips) (c~ = .77 ). Alphas were acceptably high for the 14 characteristics that were used in the analyses that followed. All parenting characteristics could range from 1 to 7, except for "symptoms interfering with parenting," which could range from 0 to 1. This latter range represented the proportion of symptoms that subjects indicated interfered with their parenting.
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Preliminary Analyses Preliminary analyses were conducted on these characteristics using four groups of subjects: dissociative identity disorder patients, dissociative disorder not otherwise specified patients, nondissociative patients, and staff controls. These analyses revealed only one difference out of 14 parenting characteristics between the two types of dissociatives--symptoms of patients diagnosed with dissociative identity disorder (M = .52) interfered more with patients' parenting than they did for the patients diagnosed with dissociative disorder not otherwise specified (M = .29), based on an analysis of variance, F(3, 90) = 42.47, p < .001, and Tukey post-hoc test. Hence, these two dissociative subgroups, plus the several patients with other dissociative diagnoses, were combined into one dissociative group for all remaining analyses.
Multivariate Analysis Initially, a multivariate analysis of variance (MANOVA) was performed on the parenting characteristics across the three groups. The parenting partner support variable was excluded from this analysis because of too many cases of missing values. Missing data in the remaining 14 variables were filled in using group mean substitutions. Altogether, there were 7 missing values out of a total of 1,222 possible values. These substitutions were not, however, used in the univariate analyses to be described below. The MANOVA produced a highly significant result, Wilks' Lambda = .35, F(26, 151 ) = 4.20, p < .001, showing that the three groups presented different parenting behavior. To examine the nature of these differences, a series of univariate analyses was performed.
Univariate Analyses It was expected that dissociatives would present poorer parenting characteristics than either the staff controls or the nondissociative patients. Hence, the analysis of each characteristic consisted of performing two contrast analyses, the first comparing dissociatives with nondissociatives and the second comparing dissociatives with staff controls. Based on expectations, all contrasts were one-tailed. Moreover, because the two contrasts for each characteristic were nonorthogonal, a Bonferroni correction procedure was performed on the alpha level of .05 by dividing it by 2. Thus, the significance level for all contrasts was .025, one-tailed. Table 1 presents the means for the parenting characteristics across the three groups, as well as the results of the contrast analyses. As can be seen from the table, dissociatives displayed poorer parenting behavior than the other two groups. In particular, dissociatives presented significantly more negative parenting behavior and related attributes than staff controls on 13 of the 14 parenting characteristics. The only characteristic that did not differ between these two groups was self versus mother in parenting. Dissociative patients, compared to nondissociative patients, presented poorer parenting behavior and related attributes on 9 of the 14 characteristics. Thus, compared with both staff controls and nondissociative patients, dissociatives experienced more problems with their parenting behavior, which manifested themselves in affective, behavioral, and cognitive ways.
DISCUSSION In our study of the subjective experience of parenting of a dissociative cohort of mothers, we compared three groups: dissociative inpatient or day-patient mothers, nondissociative inpatient mothers, and staff mothers. The dissociative mothers reported poorer functioning in their parenting than either control group. Compared with staff controls, dissociative patients were
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poorer in parenting behavior in 13 of the 14 parenting characteristics assessed. These differences were expected. Of more concern to us was the fact that the dissociative cohort demonstrated poorer parenting behavior than the nondissociative cohort on 9 of the 14 characteristics. They had less support from relatives; they were hampered by their symptoms; they had a less supportive discipline style; they showed their children less affection; they were less able to express affect; they displayed less attachment behavior toward their children; they had more cognitive distortions about their children; they felt less comfortable about being a mother: and they took fewer actions to promote their children's development. The psychiatric literature has looked at the mothering behaviors of various patient populations: women in general with psychiatric disorders (Guttman, 1989; Rice, Ekdohl, & Miller, i 971; Rutter & Quinton, 1984); women with mood disorders (Beardslee et al., 1983; Cytryn et al., 1984; Davenport et al., 1984; DiNicola, 1989; Downey & Coyne, 1990; Fabian & Donohue, 1956; Frankel & Harmon, 1996; Gaensbauer et al., 1984; Keitner & Miller, 1990; Orvaschel, Weissman, & Kidd, 1980; Solnit & Leckman, 1984; Tronick & Field, 1986; Weissman, Paykel, & Klerman, 1972; Zahn-Waxler et al., 1984); women with personality disorders (Baron et al., 1985; Feldman & Guttman, 1984); women with schizophrenia (Cohler et al., 1977 ); women with alcohol-related disorders (Copans, 1989; Murray, 1989); and women with trauma histories (Cole & Woolger, 1989; Cole et al., 1992; Main & Hesse, 1990). Most studies point out how the psychiatric illness impedes the mother's ability to facilitate the growth of her children. To our knowledge, no studies other than Kluft's on parental fitness have examined the mothering of dissociative women and its implications for the intergenerational transmission of dissociation or other psychiatric disturbances. Over a decade ago, Kluft (1984b) hypothesized that parental inability to protect children and to provide restorative experiences was a key factor in the etiology of dissociative disorders. It is now time to mount studies to explore that connection. Our study had limitations. We utilized an inpatient and partial hospital sample which probably included the most seriously ill dissociative patients. Many more dissociative individuals are treated in an outpatient setting. Additionally, the self-report format is less reliable than direct observation, and perhaps even than direct interviewing. As Steinberg, Rounsaville, and Cicchetti (1990) noted of the potential inaccuracy of the Dissociative Experiences Scale (DES), a self-report measure of dissociative traits, the effects of the symptoms may impede the self-report of those very symptoms. We found that we had to caution our interviewees to mark only one answer per question after an early dissociative subject returned a survey booklet with many answers for each question. From what and how she wrote, it was apparent that her alternate parts mothered in distinct ways and disagreed as to how to answer the questions. Although that booklet was an excellent example of the incompatible perspectives that a dissociative mother has to resolve, we had to reject it from our data as impossible to score. Additionally, some subjects described their parenting in a positive way, yet contradicted themselves in later answers. For example, when the experimenter asked if a particular symptom got in the way of parenting, the person commonly answered " n o " and then described how it did. One mother described herself to be an excellent parent when she was with her son. She continued by explaining how she behaved like a child when she was with her child. She had no idea that her childlike behavior might be harmful to her son's development. Mothers' own unawarenesses of how their behaviors might impact their children may add to the imprecision of a self-report questionnaire like the SEPS. One problem of self-report might be circumvented by systematically examining the children of dissociative mothers. We hope with this study to open inquiry into the relationship between a clinical diagnostic group and their parenting. Given the information already published about the intergenerational transmission of dissociative disorders and the differences that we have been able to demonstrate
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between dissociative disorder patients and other patient groups, we would agree with Kluft that poor parenting may be a key etiological factor in its transmission. We believe that our study has many implications both for the individual and the family treatment of the dissociative patient. Similar to family intervention programs for other patient populations (Beardslee et al,, 1992), we think it is imperative that a focus on parenting be a part of treatment. A group with the goal of parenting education and support may be very useful. Additionally, working with a patient's partner around parenting issues, wherever possible, has many purposes: it engages the partner in treatment and ensures support for the patient, it reminds both partners that they must plan for the future health of their children, and it allows the partner to get emotional support that he otherwise might not get. Because understanding how dissociative disorders affect parenting may be important in explaining the transgenerational transmission of dissociation, our work needs to be replicated on larger samples and in other (e.g., outpatient) populations. This study of subjective parent data may be viewed as a pilot project and a prelude to a more objective attempt to delineate parenting characteristics in a dissociative population. Acknowledgement--The authors wish to thank Progressions, the hospital, and all of the women who so wilhngly gave their time to participate in this study
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(1984). A developmental view of affective disturbances in the children of affectively ill parents. Amerwan Journal of Psychiatry, 141,219-222. Davenport, Y. B., Zahn-Waxler, C., Adland, M. L., & Mayfield, A. (1984). Early child-rearing practices in famihes with a manic-depressive parent. American Journal of Psychiatry, 141,230-235. DiNicola, V. F. (1989). The child's predicament in families with a mood disorder. Psychiatric Clinics of North America, 12,933-949. Downey, G., & Coyne, J. C. (1990). Children of depressed parents: An integrative review. Psychological Bulletin, 108( 1 ), 50-76. Fabian, A. A., & Donohue, J. F, (1956). Maternal depression: A challenging child guidance problem. American Journal of Orthopsychiatry, 26,400-405. Feldman, R. B., & Guttman, H. A. (1984). Famihes of borderline patients: Literal-minded parents, borderhne parenls, and parental protectiveness. American Journal of Psychiatry, 141, 1392-1396. Frankel, K. A., & Harmon, R. J. (1996). Depressed mothers: They don't always look as bad as they feel. Journal of the American Academy of Child and Adolescent Psychiatry., 35 ( 3 ), 289- 298. Gaensbauer, T. J., Harmon, R. J., Cytryn, L., & McKnew, D. H. (1984). Social and affective development m infants with a manic-depressive parent. American Journal of Psychiatry, 141,223-229. Guttman, H. A. (1989). Children m families with emotionally disturbed parents. In L. Combrinck-Glaham (Ed), Children in family contexts (pp. 252-276). New York: The Guilford Press. Keitner, G. I., & Miller, I. W. (1990). Family functioning and major depression: An overview. American Journal of Psychiatry, 147, 1128-1137. Kluft, R. P. (1984a) Multiple personality m childhood. Psychiatrw CIimcs of North America, 7, 121-134 Kluft, R. P. (1984b). Treatment of multiple personality disorder. Psychiatric Clinics of North America, 7, 9-29. Kluft, R. P. (1987). The parental fitness of mothers with multiple personality disorder: A preliminary study. Child Abuse & Neglect, 2,273-280. Main, M., & Hesse, E. (1990). Parents' unresolved traumatic experiences are related to infant dtsorganized attachment status: Is frightened and/or frightening parental behavior the linking mechanism? In M. T. Greenberg, D. Clcchetti, & E. M, Cummings (Eds.), Attachment in the preschool years ( pp. 161 - 182 ). Chicago, 1L: The Umversity of Chicago Press. Moos, R., & Moos, B. (1981). Famtly environment scale manual. Palo Alto. CA: Consulting Psychologists Press, Murray, J. B. (1989). Psychologists and children of alcoholic parents. Psychological Reports, 64,859-879. Orvaschel, H., Weissman, M. A., Kidd, K. K. (1980). Children and depression: The children of depressed parents: the childhood of depressed patients; depression in children. Journal of Affective Disorders'. 2, 1-16. Rice, E. P., Ekdohl, M. C., & Miller, L. ( 1971 ). Children of mentally ill parents. New York: Behaworal Publications. Rutter, M., & Quinton, D. (1984). Parental psychiatric disorder: Effects on children. Psychological Medictne, 14, 853-880. Shea, E., & Tronick, E. Z. ( 1988 ). The maternal self-report inventory: A research and chnical instrument for assessing maternal self-esteem. In H. E. Fitzgerald, B. M. Lester, & M. W. Yogman ( Eds. ), Theory and research in behavtoral pediatrics (pp. 101-139). New York: Plenum Press. Solnit, A. J., & Leckman, J. F. (1984). On the study of chddren of parents with affective disorders. Amerwan .hmrnal of Psychiatry, 141,241-242. Steinberg, M. (1985). The structured clinical mterview fi~r DSM-III-R dissociative dtsorders New Haven, CT: Yale University School of Medicine. Steinberg, M. (1993). The structured clinical interview for DSM-IV dis~octative dtsorders(SCID-D). Washington, DC: American Psychiatric Press. Steinberg, M. ( 1985/1993). Interviewer's guide to the structured climcal mterv~ew fi~r DSM-IV dt~,~actative di,~orders. Washington, DC: American Psychiatric Press. Steinberg, M., Rounsaville, B., & Clcchetti, D. V. (1990). The structured chmcal interview for DSM-III-R dissociative disorders: Preliminary report on a new diagnostic instrument. American Journal of Psychiatry, 147, 76-82 Tronick, E. Z., & Field, T. (1986). Maternal depression and infant disturbance. San Francisco, CA: Jossey-Bass. Weissmam M., Paykel, E., & Klerman, G. (1972). The depressed woman as a mother. Social Psychtatr3_', 7, 98-108. Zahn-Waxler, C., McKnew, D. H., Cummings, M., Davenport, Y. B., & Radke-Yarrow, M. (1984). Problem behawors and peer interactions of young children with a manic-depressive parent. Amerwan Journal ofP,~ychiatr3, 141,236240
R6sum~---Cette recherche a examin6 dans quelle mesure les sympt6mes de mbres souffrant d'un d6sordre de dissociation entravaient leur comp6tence en tant que parents et leurs exp6riences maternelles subjectives. On a admmistr6 le Structured Clinical Interview for Dissociative Disorders (SCID-D) ~ un groupe de 54 m~res ayant ces sympt6mes et trait6es dans un service interne ou une clinique de jour et h deux autres groupes, c.-a-d. 20 patientes non symptornatiques et 20 m~res faisant partie du personnel hospitaller. On leur demanda de remplir un questionnaire, le Subjective Experiences of Parenting Scale (SEPTS), concernant divers aspects de leur r61e maternel, y compris les 14 caract6ristiques suivantes : l'appui que leur procure leur conjoint, l'appui de leurs proches parents, les mauvals traitements inflig6s ~t leur enfant, la mesure dans laquelle les sympt6mes entravent leurs r61e de parent, leurs quaht6s de parent, les mesures disciplinaires vs celles qm font du tort, la capacit6 de d6montrer de l'affection, d'extfrioriser leurs sentiments, les comportements qui d6montrent une capacit6 d'attachement maternel, les distorsions cognitive,~, le
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L.R. Benjamin, R. Benjamin, and B. Rind
contr61e de la col6re, leur capacit6 de donner de sores en tant que parent, leur experience personnelle en tant que m~re et les mesures qu'elles prennent pour promouvoir le d6veloppement de leur enfant. Les m~res souffrant de dissociation r6v~lent plus de traits ndgatifs en tant que parents et dans divers autres respects que le groupe du personnel hsopitalier, soit pour 13 des 14 caract&istlques. Compar6es h l'autre groupe de m~res-patientes, elles &aient moins dou6es en tant que parent ainsi que dans d'autres respects, dans 9 sur 14 caractdristiques. Dans l'ensemble, les m~res dissooatives connaissent un plus haut degr~ de probl6mes au niveau de leurs attitudes et de leur comportement que Fun ou l'autre des deux groupes et manifestent des difficult& affectives, cognitives et de comportement en tant que parent. Resumen--Este estudio examin6 hasta que punto los sintomas de madres disociativas interfieren con el cmdado parental y sus expenencias maternales subjetivas. Un grupo de 54 madres disociativas atendidas con mtemamiento o ambulatorias, 20 madres internas nodisociativas, y 20 madres del personal hospitalario fueron evaluadas utilizando la Entrevista Cl~nica Estructurada de los Des6rdenes Disociativos (ECED-D). Despu6s se les solicit6 responder a un cuestionario de autoreporte, la Escala de Experiencias Parentales Subjetivas (EEPS) que examinaba 14 caracteristicas parentales: apoyo parental de pareja; apoyo relatlvo: conducta abusiva hacia el nifio; nivel de interferencia de los sintomas con el cuidado parental; rasgos parentales constructivos: disciplina de apoyo versus dolorosa; magnitud del afecto demostrado; habilidad de expresar afecto; conductas de apego; distorsiones cognitivas; regulaci6n de la ira; el yo versus la madre en el cuidado parental; experienoa parental subjetiva; y acciones para promover el crecimiento evolutivo del nifio. Las madres disociativas presentaron significativamente mils conductas parentales negativas y atributos relacionados que el grupo control en 13 de las 14 caracteristicas parentales. Comparadas con las pacientes &sociativas, la pareja disociativa presentaba conductas parentales y atributos relacionados mils pobres, en 9 de las 14 caracteristlcas. En general, las madres disoclativas expenmentaron mils problemas con las actitudes y conductas parentales que cualquiera de los grupos comparados. Las madres disooativas manifestaron dificultades afectivas, conductuales~ y cognitivas en la crianza.
Pergamon
PII S0145-2134(96)00082-8
DISSOCIATIVE MOTHERS' SUBJECTIVE EXPERIENCE OF PARENTING LYNN R. BENJAMIN Marriage and Family Therapist, Private Practice, Dresher, PA, USA
ROBERT BENJAMIN Progressions Health System, and Department of Psychiatry, Temple Universtty, Philadelphia, PA, USA
BRUCE RIND Department of Psychology, Temple University. Philadelphia, PA, USA
Abstract--This study examined to what extent the symptoms of dissociative mothers interfered with their parenting and their subjective experiences of mothering. A group of 54 dissociative inpatient or day-patient mothers, 20 nondissociative inpatient mothers, and 20 hospital staff mothers were screened for Dissociative Disorders using the Structured Clinical Interview for Dissociative Disorders (SCID-D). They were then asked to fill out a self-report questionnaire on various aspects of mothering. This questionnaire, the Subjective Experiences of Parentmg Scale (SEPS), examined 14 parenting characteristics: parenting partner support; relative support; abusiveness towards the child; extent to which symptoms interfered with parenting; constructive parenting traits; supportive versus hurtful discipline; extent of showing affection; ability to express affection; attachment behaviors; cognitive distortions; regulation of anger; self versus mother in parenting; subjective experience of mothering; and actions to promote the developmental growth of the child. Dissociatives presented significantly more negative parenting behavior and related attributes than staff controls on 13 of the 14 parenting characteristics. Compared to nondissociative patients, the dissociative cohort presented poorer parenting behavior and related attributes on 9 of the 14 characteristics. Overall, the dissociatives experienced more problems with parenting attitudes and behaviors than either comparison group. Dissociative mothers manifested affective, behavioral, and cogmtive difficulties m parenting.
Key Words--Dissociation, Parenting, Mothering. INTRODUCTION D I S S O C I A T I V E D I S O R D E R S E N C O M P A S S an array o f s u b t y p e s a l o n g a c o n t i n u u m in w h i c h the n o r m a l l y i n t e g r a t e d f u n c t i o n s o f c o n s c i o u s n e s s , m e m o r y , identity, or p e r c e p t i o n o f the e n v i r o n m e n t are d i s r u p t e d ( A m e r i c a n P s y c h i a t r i c A s s o c i a t i o n , Diagnostic and Statistical Manual of Mental Disorders, 1994, 4th ed.). K l u f t ' s ( 1 9 8 7 ) study o f the parental fitness o f mothers with Dissociative Identity Disorder (DID, formerly called Multiple Personality Disorder, M P D ) y i e l d e d startling results. O f the 75 m o t h e r s studied, 3 8 . 7 % w e r e d e e m e d c o m p e t e n t This research was supported by Progressions Health System and Northwestern Institute of Psychiatry, Fort Washington, PA. Received for publication August 14, 1995; final revision received March 29, 1996; accepted April 2, 1996. Reprint requests should be addressed to Robert Benjamin, M.D., 12 Mayo Place, Dresher, PA 19025-1228. 933
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L.R. Benjamin, R. Benjamin. and B. Rind
or exceptional, 45.3% were deemed compromised or impaired, and 16% were deemed grossly abusive toward their children. This study suggested that the children of dissociative parents were a population at risk, and that individual treatment of the dissociative mother was not enough to stem developmental disruption to her children. Furthermore. a number of authors have demonstrated the intergenerational transmission of dissociative or other psychiatric disorders in children of dissociative parents (Braun, 1985; Coons, 1985; Kluft, 1984a). In our own clinical experience, the first two authors have noticed the struggles that dissociative mothers have with interpersonal relationships, and particularly with childrearing. In an effort to assist these mothers, we established a therapy group for mothers with dissociative disorders (Benjamin & Benjamin, 1995). We also hypothesized, again based on our clinical observations, that specific symptoms of dissociation served to impede the mothering of our client-mothers: switching and accompanying behaviors, hearing voices, having alter personalities, thinking in distorted ways, having amnestic episodes, depersonalizing, derealizing, and self-mutilating or having suicidal ideations. We examined parenting from various perspectives in the therapeutic literature (Benjamin & Benjamin, 1994a), and we began to utilize parenting as a clinical focus in our treatment of dissociative mothers (Benjamin & Benjamin, 1994b). Both in clinical anecdotes during individual therapy with dissociative clients and in our work with the partners of those clients (Benjamin & Benjamin, 1994c; 1994d; 1994e), we repeatedly heard examples of what appeared to be very poor parenting skills. Kluft's study of the fitness of dissociative mothers described his categorization of patients' behaviors as mothers based solely on retrospective analysis of interview data obtained during treatment. We wished to extend Kluft's research by surveying through a structured self-report how individuals diagnosed as dissociatives felt about their performance as mothers. Specifically, we were interested in their subjective experiences of how they related to their children and of how their dissociative symptoms interfered with their parenting. To that end, we designed a self-report scale that measured a wide variety of parenting characteristics (see below). To evaluate the mothering experiences of dissociatives, we obtained a sample of dissociative inpatients or day-patients, as well as two additional nondissociative control samples (nondissociative inpatient mothers and hospital staff mothers) that served as comparison groups. We hypothesized that the dissociative mothers would experience more struggles in mothering on the self-report measure than mothers in either control group.
METHOD
Subjects Subjects were 94 mothers associated with a suburban Philadelphia private psychiatric hospital who fell into one of three groups: patients diagnosed with a dissociative disorder (n = 54); patients with diagnoses other than dissociative disorder (n = 20); and staff (n = 20). The latter two groups acted as control groups against which to compare the dissociative patients. The mean age of the subjects was 37.50 (SD = 8.43), and their ages ranged from 23 to 58. Subjects had a mean of 2.34 children (SD = 1.16), with a range from 1 to 7. The mean number of natural children was 2.23 (SD = 1.18), while the mean numbers of stepchildren and adopted children were, respectively, .22 (SD = .66) and .11 (SD = .34). The mean of their youngest child was 8.74 (SD = 7.92), and the mean of their oldest child was 14.41 (SD = 8.61 ). The children ranged in age from newborn to 36 years old. Subjects had on average 1.57 children living with them at the time of the study (SD = 1.14), and had a mean of 1.22 sons (SD = .88) and 1.17 daughters (SD = .94). Of the 94 mothers, 90.4% were Caucasian, 8.5% were Black, and 1.1% were Native American. Seventeen percent of
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subjects lived in a large city, while 19.1% lived in smaller cities, 8.5% in rural areas, 28.7% in towns, and 26.6% in suburban areas. Seventy-four percent of subjects had been diagnosed with mental or emotional disorders, while 90.3% of all subjects had been or were currently in therapy. Seventy-two percent of subjects had a co-parenting partner at the time of the study. In comparing the three groups on the demographic variables just described, few differences emerged. One difference that did emerge was that staff subjects (M = 44.75 ) were older than nondissociative (M = 35.80) or dissociative (M = 35.44) patients, F(2, 91) = 11.54, p < .001. The latter two groups were equal in age. A related difference was that the mean age of the youngest child of staff subjects (M = 12.8) was greater than that for dissociative patients (M = 7.28), F (2, 91 ) = 8.65, p < .05. The mean age of the youngest child for nondissociatives (M --- 8.65) was not statistically different from the other two means. No other differences appeared for the quantitative demographic variables. For the categorical variables, no differences occurred in the distributions of race or residence, and the proportions of subjects with co-parenting partners were equal across the three groups. As expected, the three groups did differ significantly in having been diagnosed with a mental or emotional disorder, x 2 ( d f = 2, N = 94) = 60.87, p < .001, and having been in therapy, x 2 ( d f = 2, N = 94) = 23.71~ p < .001. While all dissociatives and nondissociatives had been diagnosed, only 30% of staff subjects had been. Finally, while all dissociatives and nondissociatives were or had been in therapy, 70% of staff subjects reported this. The 54 dissociative patients were broken down into subgroups based on their performance on the SCID-D in which scores can range from 0 to 20. Twenty-six (48.1%) of these patients were diagnosed with Dissociative Identity Disorder ( D I D ) , with a mean of 19.23 (SD = 1.14) and a range from 16 to 20. Twenty-five (46.3%) were diagnosed with Dissociative Disorder Not Otherwise Specified, with a mean of 14.76 (SD = 2.09) and a range from 11 to 19. Two (3.7%) were diagnosed with Depersonalization Disorder, each with a score of 14, and one ( 1.9%) was diagnosed with Dissociative Amnesia with a score of 9. The 20 nondissociative patients had a mean score of 7.70 (SD = 1.53) on the SCID-D, with a range from 5 to 11. These subjects all had primary diagnoses of depression, major depression, or affective disorder. The 20 staff subjects included psychiatric nurses, social workers, administrators, kitchen workers, and clerks. Their mean score on the SCID-D was 5.35 (SD = .75), with a range from 5 to 7.
Instruments Two instruments were used during the course of this study. To assess for or to rule out dissociation, we used the Structured Clinical Interview for Dissociative Disorders (SCID-D), an instrument with good to excellent reliability and validity (Steinberg, 1985; 1993; 1985/1993). The second was the Subjective Experience of Parenting Scale (SEPS), a self-report measure that was designed by the authors to elicit certain characteristics of parenting. Although other self-report inventories exist (Moos & Moos, 1981; Shea & Tronick, 1988), we wanted to target some specific issues (e.g., symptoms, attachment issues, cognitive distortions) that were not necessarily on other measures. Additionally, we knew that we would not be able to limit the age range of the subjects' children in the sample. Consequently, we had questions that dealt with mother-child relations from pregnancy through adolescence. For mothers with adult children, we asked them to report based on earlier experiences with their children. The questionnaire began with a series of 24 demographic items, followed by 128 questions that assessed a variety of parenting behaviors. These latter questions were followed by 7-point scales, which were anchored by bipolar adjectives such as " n e v e r " or " o f t e n " or "not at all" and " a great deal." Questions measured a wide variety of parenting behaviors including attachment behaviors, discipline, regulation of anger, and behaviors that promoted the child's development (see Table 1 for a complete list of characteristics).
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L.R. Benjamin, R. BenJamin,and B. Rind
Procedures To proceed with our study, we sought and received approval to solicit subjects from the Research Committee and governing bodies of a suburban Philadelphia private psychiatric hospital. W e sent out flyers and met with unit clinical directors, attending psychiatrists, psychiatric nurses, social workers, and psychiatric technicians (aides) to alert them to our procedures and to the kinds of subjects we needed for our study. All subjects signed a consent form to participate with the knowledge that results would be entered into a pool of statistics and their confidentiality would be guarded. Subjects were asked to make up a four-digit n u m b e r to key the two survey instruments together. They were told that they could arrange an optional post-study appointment to discuss their feelings about participating in the survey and about parenting issues that may have been stirred up by their participation. In order to establish the validity of patients' chart diagnoses by their attending physicians, the first author administered the SCID-D to each subject. This instrument, keyed to D S M - I V criteria, is an interview protocol which assesses for the five types of dissociative disorders: Dissociative Amnesia, Dissociative Fugue, Dissociative Identity Disorder ( D I D ) , Depersonalization Disorder, and Dissociative Disorder Not Otherwise Specified ( D D N O S ) . Following this qualifying step, the interviewer then gave each subject oral instructions for the SEPS. A preliminary demographics section was then administered aloud to the interviewee. Next, the subject started the questionnaire in the presence of the interviewer. While the subject answered the questions, the interviewer scored the SCID-D. The interviewer asked the subject if she would like to have the results of the SCID-D. All participants in the study asked for results. No results were reported to treating therapists. Subjects returned the SEPS to the interviewer in a sealed envelope identified only by their previously selected personal identity code number. RESULTS The goal of the current study was to investigate the level of functioning in parenting behavior of w o m e n diagnosed as dissociative, using nondissociative patients and staff controls as comTable 1. Mean Parenting Characteristics of Dissociative Patients, Nondissociative Patients, and Staff Controls
Characteristic
Dissociatives
1. Parenting Partner Support 2. Relative Support 3. Abusiveness Towards Child 4. Symptoms Interfere with Parenting 5. Constructive Parenting Traits 6. Discipline: Supportive vs. Hurtful 7. Extent of Showing Affection 8. Ability in Expressing Affect 9. Attachment Behaviors 10. Cognitive Distortions 11. Regulation of Anger 12. Self vs. Mother in Parenting 13. Subjective Experience of Mothering 14. Acting to Promote Child's Development
4.68 3.00 2.18 .40 5.60 4.83 5.94 4.41 4.69 2.59 4.13 6.09 4.61 5.25
Nondissociatives Staff 5.57 3 98 1.95 •11 5.87 5.33 6.55 5.08 5.49 1.71 4.30 6.18 5.66 5.90
5.71 4.74 1.27 .02 6.25 5.87 6.58 5.76 6.09 1.35 5.23 6.14 5.57 5.84
t(D vs. N)
t(D vs. S)
1.80 2.10" .89 6.40*** 1.18 2.00* 2.22* 2.43** 2.79** 2.97** .47 .35 4.38*** 2.71"*
2.08* 3.58*** 3.60*** 8.38*** 2.85** 4.24*** 2.33* 4.90*** 4.88*** 4.19"** 3.01"* .20 4.00*** 2.50**
Note• A priori contrast t-values for dissoclatives (D) vs. nondissociatives (N) and for dissociatives vs staff controls (S) for each characteristic appear in the last two columns• Contrasts were signficant, indacated by *, when p < .025 one-tailed, which represents a Bonferroni correction for two nonorthogonal contrasts. **indicates p < .01. and ***indicatesp < .001. For all characteristics, means could range from 1 to 7 except for "symptoms interfere," which could range from 0 to 1. Analyses are based on n = 54 dissociatives, n = 20 nondissociatives, and n = 20 staff controls, except for: parenting partner support (ns = 46, 17, 17); relative support (ns = 54, 20, 18); abusiveness towards child (ns = 53, 19, 20); discipline supportive vs. hurtful, self vs. mother in parenting, and acting to promote chdd's development (ns = 54, 19, 20).
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parison groups. To this end, subjects' parenting behavior was assessed with a questionnaire consisting of 128 items that examined various aspects of parenting behavior. In order to reduce the large number of variables to be analyzed, variables intended to measure the same general aspects of parenting behavior were grouped together to form a smaller set of parenting characteristics. This smaller set consisted of 15 characteristics (see below).
Parenting Characteristics The 128 questions were grouped into 15 categories describing 15 distinct characteristics of parenting behavior. For each characteristic, Cronbach's alpha was used to assess its reliability-that is, the extent to which all the variables selected to comprise the characteristic were measuring a single construct. The first characteristic was labeled "parenting partner support" and consisted of three questions measuring the parenting partner's nonabusiveness, supportiveness, and knowledge ( a = .87). The second characteristic was called "relative support" and consisted of three questions assessing how supportive parents, in-laws, and other relatives were ( a = .73). The third characteristic, "nonrelative support," also consisted of three items assessing support from friends, support groups, and religious organizations ( a = .64). Because of a large number of missing values, however, this characteristic was dropped from the statistical analyses to be aescribed below. The next characteristic, "abusiveness towards child," consisted of three items assessing physical, sexual, and emotional abuse regarding subjects' children ( a = .56). Sixteen questions assessing a variety of dissociative symptoms that may have interfered with subjects' parenting were combined to assess the next characteristic, "symptoms interfering with parenting" ( a = .87). "Constructive parenting traits" were assessed by combining 16 items such as the importance to subjects of their children's physical and mental health and the extent to which subjects encouraged their children to have new experiences and make decisions ( a = .90). "Discipline: supportive versus hurtful" consisted of nine questions assessing styles of behavior such as the extent of being consistent, clear, and not emotionally abusive when disciplining their children ( a = .79). "Extent of showing affection" consisted of three items assessing how often subjects displayed affection verbally, nonverbally, and physically ( a = .76). "Ability in expressing affect" consisted of I 1 items assessing to what extent subjects felt they were able to express various emotions such as fear, excitement, and happiness ( a = .81). "Attachment behaviors" consisted of five questions asking subjects, for example, to what extent they comforted, listened to, or withdrew from their children ( a = .78). "Cognitive distortions" consisted of five questions assessing the degree to which subjects held distorted views regarding their children f e.g., your child is trying to hurt you or is abusing you) ( a = .76). "Regulation of anger" consisted of three items concerning how well subjects regulated their anger, such as extent of being calm, not yelling, and not using physical gestures when angry ( a = .75). " S e l f versus mother in parenting" consisted of four items in which subjects indicated how their mothering compared to that of their mothers' ( a = .77). "Subjective experience of mothering" consisted of 16 items that assessed how subjects experienced various aspects of being a mother, such as to what extent they liked becoming a mother and liked to play with their children, as well as how easy they found it to toilet train their children or wean them ( a = .86). Finally, "acting to promote child's development" consisted of nine items and measured the extent to which subjects acted to promote their children's developmental growth (e.g., encouraged self-care habits in their children and took their children on outings and trips) (c~ = .77 ). Alphas were acceptably high for the 14 characteristics that were used in the analyses that followed. All parenting characteristics could range from 1 to 7, except for "symptoms interfering with parenting," which could range from 0 to 1. This latter range represented the proportion of symptoms that subjects indicated interfered with their parenting.
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Preliminary Analyses Preliminary analyses were conducted on these characteristics using four groups of subjects: dissociative identity disorder patients, dissociative disorder not otherwise specified patients, nondissociative patients, and staff controls. These analyses revealed only one difference out of 14 parenting characteristics between the two types of dissociatives--symptoms of patients diagnosed with dissociative identity disorder (M = .52) interfered more with patients' parenting than they did for the patients diagnosed with dissociative disorder not otherwise specified (M = .29), based on an analysis of variance, F(3, 90) = 42.47, p < .001, and Tukey post-hoc test. Hence, these two dissociative subgroups, plus the several patients with other dissociative diagnoses, were combined into one dissociative group for all remaining analyses.
Multivariate Analysis Initially, a multivariate analysis of variance (MANOVA) was performed on the parenting characteristics across the three groups. The parenting partner support variable was excluded from this analysis because of too many cases of missing values. Missing data in the remaining 14 variables were filled in using group mean substitutions. Altogether, there were 7 missing values out of a total of 1,222 possible values. These substitutions were not, however, used in the univariate analyses to be described below. The MANOVA produced a highly significant result, Wilks' Lambda = .35, F(26, 151 ) = 4.20, p < .001, showing that the three groups presented different parenting behavior. To examine the nature of these differences, a series of univariate analyses was performed.
Univariate Analyses It was expected that dissociatives would present poorer parenting characteristics than either the staff controls or the nondissociative patients. Hence, the analysis of each characteristic consisted of performing two contrast analyses, the first comparing dissociatives with nondissociatives and the second comparing dissociatives with staff controls. Based on expectations, all contrasts were one-tailed. Moreover, because the two contrasts for each characteristic were nonorthogonal, a Bonferroni correction procedure was performed on the alpha level of .05 by dividing it by 2. Thus, the significance level for all contrasts was .025, one-tailed. Table 1 presents the means for the parenting characteristics across the three groups, as well as the results of the contrast analyses. As can be seen from the table, dissociatives displayed poorer parenting behavior than the other two groups. In particular, dissociatives presented significantly more negative parenting behavior and related attributes than staff controls on 13 of the 14 parenting characteristics. The only characteristic that did not differ between these two groups was self versus mother in parenting. Dissociative patients, compared to nondissociative patients, presented poorer parenting behavior and related attributes on 9 of the 14 characteristics. Thus, compared with both staff controls and nondissociative patients, dissociatives experienced more problems with their parenting behavior, which manifested themselves in affective, behavioral, and cognitive ways.
DISCUSSION In our study of the subjective experience of parenting of a dissociative cohort of mothers, we compared three groups: dissociative inpatient or day-patient mothers, nondissociative inpatient mothers, and staff mothers. The dissociative mothers reported poorer functioning in their parenting than either control group. Compared with staff controls, dissociative patients were
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poorer in parenting behavior in 13 of the 14 parenting characteristics assessed. These differences were expected. Of more concern to us was the fact that the dissociative cohort demonstrated poorer parenting behavior than the nondissociative cohort on 9 of the 14 characteristics. They had less support from relatives; they were hampered by their symptoms; they had a less supportive discipline style; they showed their children less affection; they were less able to express affect; they displayed less attachment behavior toward their children; they had more cognitive distortions about their children; they felt less comfortable about being a mother: and they took fewer actions to promote their children's development. The psychiatric literature has looked at the mothering behaviors of various patient populations: women in general with psychiatric disorders (Guttman, 1989; Rice, Ekdohl, & Miller, i 971; Rutter & Quinton, 1984); women with mood disorders (Beardslee et al., 1983; Cytryn et al., 1984; Davenport et al., 1984; DiNicola, 1989; Downey & Coyne, 1990; Fabian & Donohue, 1956; Frankel & Harmon, 1996; Gaensbauer et al., 1984; Keitner & Miller, 1990; Orvaschel, Weissman, & Kidd, 1980; Solnit & Leckman, 1984; Tronick & Field, 1986; Weissman, Paykel, & Klerman, 1972; Zahn-Waxler et al., 1984); women with personality disorders (Baron et al., 1985; Feldman & Guttman, 1984); women with schizophrenia (Cohler et al., 1977 ); women with alcohol-related disorders (Copans, 1989; Murray, 1989); and women with trauma histories (Cole & Woolger, 1989; Cole et al., 1992; Main & Hesse, 1990). Most studies point out how the psychiatric illness impedes the mother's ability to facilitate the growth of her children. To our knowledge, no studies other than Kluft's on parental fitness have examined the mothering of dissociative women and its implications for the intergenerational transmission of dissociation or other psychiatric disturbances. Over a decade ago, Kluft (1984b) hypothesized that parental inability to protect children and to provide restorative experiences was a key factor in the etiology of dissociative disorders. It is now time to mount studies to explore that connection. Our study had limitations. We utilized an inpatient and partial hospital sample which probably included the most seriously ill dissociative patients. Many more dissociative individuals are treated in an outpatient setting. Additionally, the self-report format is less reliable than direct observation, and perhaps even than direct interviewing. As Steinberg, Rounsaville, and Cicchetti (1990) noted of the potential inaccuracy of the Dissociative Experiences Scale (DES), a self-report measure of dissociative traits, the effects of the symptoms may impede the self-report of those very symptoms. We found that we had to caution our interviewees to mark only one answer per question after an early dissociative subject returned a survey booklet with many answers for each question. From what and how she wrote, it was apparent that her alternate parts mothered in distinct ways and disagreed as to how to answer the questions. Although that booklet was an excellent example of the incompatible perspectives that a dissociative mother has to resolve, we had to reject it from our data as impossible to score. Additionally, some subjects described their parenting in a positive way, yet contradicted themselves in later answers. For example, when the experimenter asked if a particular symptom got in the way of parenting, the person commonly answered " n o " and then described how it did. One mother described herself to be an excellent parent when she was with her son. She continued by explaining how she behaved like a child when she was with her child. She had no idea that her childlike behavior might be harmful to her son's development. Mothers' own unawarenesses of how their behaviors might impact their children may add to the imprecision of a self-report questionnaire like the SEPS. One problem of self-report might be circumvented by systematically examining the children of dissociative mothers. We hope with this study to open inquiry into the relationship between a clinical diagnostic group and their parenting. Given the information already published about the intergenerational transmission of dissociative disorders and the differences that we have been able to demonstrate
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between dissociative disorder patients and other patient groups, we would agree with Kluft that poor parenting may be a key etiological factor in its transmission. We believe that our study has many implications both for the individual and the family treatment of the dissociative patient. Similar to family intervention programs for other patient populations (Beardslee et al,, 1992), we think it is imperative that a focus on parenting be a part of treatment. A group with the goal of parenting education and support may be very useful. Additionally, working with a patient's partner around parenting issues, wherever possible, has many purposes: it engages the partner in treatment and ensures support for the patient, it reminds both partners that they must plan for the future health of their children, and it allows the partner to get emotional support that he otherwise might not get. Because understanding how dissociative disorders affect parenting may be important in explaining the transgenerational transmission of dissociation, our work needs to be replicated on larger samples and in other (e.g., outpatient) populations. This study of subjective parent data may be viewed as a pilot project and a prelude to a more objective attempt to delineate parenting characteristics in a dissociative population. Acknowledgement--The authors wish to thank Progressions, the hospital, and all of the women who so wilhngly gave their time to participate in this study
REFERENCES American Psychiatric Association. (1994) Diagnostic and statistical manual of mental disorders (DSM-1V) (4th ed.}. Washington, DC: Author. Baron, M., Gruen, R., Asnls. L., & Lord, S ( 1985 ). Familial transmission of schizotypal and borderline personality disorder. American Journal oJ Psychiatry, 142, 927-934. Beardslee. W. R., Bemporad, J., Keller, M. B., & Klerman, G. L. (1983). Children of parents with major affective disorder: A review. American Journal of Psychiatry. 140, 825-832. Beardslee, W. R., Hoke, L., Wheelock I., Rothberg, P. C., van de Velde, P., & Swatling, S. (1992). Initial finding on preventive intervention for families with parental affective disorders. American Journal of Psychiatry, 149, 1335-1340. Benjamin. L. R., & Benjamin, R. (1994a). Various perspectives on parenting and their implications for the treatment of dissociative disorders. Dissociation, 7(4), 246-260. Benjamin, L. R , & Benjamin. R ( 1994b ). Utilizing parenting as a clinical focus in the treatment of dissociative disorders. Dissociation, 7(4). 239-245 Benjamin, L. R., & Benjamin, R. (1994c). A group tot partners and parents of MPD clients, part I: Process and format. Dtsaoctation, 7( l ), 35-43. Benjamin, L. R., & Benjamin, R. (1994d). A group for partners and parents of MPD clients, part II: Themes and responses Dissociation. 7(2 ), 104-111. Benjamin, L R., & Benjamin, R. ~ 1994e). A group for partners and parents of MPD clients, part IlI: Marital types and dynamics. Dissociation, 7 ( 3 ), 191 - 196. Benjamin, L. R , & Benjamin, R. (1995). A therapy group for mothers with dissociative disorders. International Journalfi,r Group P~sychotherapy. 45( 3 t, 381-403. Braun, B. G. (1985) The transgeneratlonal incidence of dissociation and multiple personality disorder. In R. P. Kluft (Ed.), Childhood antecendents of multiple personality ( pp. 127-150). Washington, DC: American Psychiatric Press. Cohler, B. J., Grunebaum, H U., Weiss, J. L., Gamer, E., & Gallant, D. H. (1977). Disturbance of attention among schizophrenic, depressed and well mothers and their children. Journal of Child Psychology and Psychiato,, 18, 115-135. Cole. P. M., & Woolger, C. ( 1989 }. Incest survivors: The relation of their perceptions of their parents and their own parenting behavior. Child Abuse & Neglect. 13, 1-8. Cole, P. M., Woolger C., Power, T. G , & Smith, K. D. (1992). Parenting difficulties among adult survivors of fatherdaughter incest. Chdd Ahu~e & Neglect. 1 6 , 2 3 9 - 2 4 9 Coons, P. M. (1985) Children of parents with multiple personality disorder. In R. P. Kluft (Ed.), Childhood antecedent.~ ~" multiple personuh O" (pp 151-165). Washington, DC: American Psychiatric Press. Copans, S. ( 1989 ). The invisible family member: Children in families with alcohol abuse. In L. Combrinck-Graham (Ed.), Children in ]amily context~ (pp. 277-298). New York: The Guilford Press. Cytryn, L., McKnew, D. H , Zahn-Waxler, C., Radke-Yarrow, M., Gaensbauer, T. J., Harmon, R. J., & Lamour, M.
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(1984). A developmental view of affective disturbances in the children of affectively ill parents. Amerwan Journal of Psychiatry, 141,219-222. Davenport, Y. B., Zahn-Waxler, C., Adland, M. L., & Mayfield, A. (1984). Early child-rearing practices in famihes with a manic-depressive parent. American Journal of Psychiatry, 141,230-235. DiNicola, V. F. (1989). The child's predicament in families with a mood disorder. Psychiatric Clinics of North America, 12,933-949. Downey, G., & Coyne, J. C. (1990). Children of depressed parents: An integrative review. Psychological Bulletin, 108( 1 ), 50-76. Fabian, A. A., & Donohue, J. F, (1956). Maternal depression: A challenging child guidance problem. American Journal of Orthopsychiatry, 26,400-405. Feldman, R. B., & Guttman, H. A. (1984). Famihes of borderline patients: Literal-minded parents, borderhne parenls, and parental protectiveness. American Journal of Psychiatry, 141, 1392-1396. Frankel, K. A., & Harmon, R. J. (1996). Depressed mothers: They don't always look as bad as they feel. Journal of the American Academy of Child and Adolescent Psychiatry., 35 ( 3 ), 289- 298. Gaensbauer, T. J., Harmon, R. J., Cytryn, L., & McKnew, D. H. (1984). Social and affective development m infants with a manic-depressive parent. American Journal of Psychiatry, 141,223-229. Guttman, H. A. (1989). Children m families with emotionally disturbed parents. In L. Combrinck-Glaham (Ed), Children in family contexts (pp. 252-276). New York: The Guilford Press. Keitner, G. I., & Miller, I. W. (1990). Family functioning and major depression: An overview. American Journal of Psychiatry, 147, 1128-1137. Kluft, R. P. (1984a) Multiple personality m childhood. Psychiatrw CIimcs of North America, 7, 121-134 Kluft, R. P. (1984b). Treatment of multiple personality disorder. Psychiatric Clinics of North America, 7, 9-29. Kluft, R. P. (1987). The parental fitness of mothers with multiple personality disorder: A preliminary study. Child Abuse & Neglect, 2,273-280. Main, M., & Hesse, E. (1990). Parents' unresolved traumatic experiences are related to infant dtsorganized attachment status: Is frightened and/or frightening parental behavior the linking mechanism? In M. T. Greenberg, D. Clcchetti, & E. M, Cummings (Eds.), Attachment in the preschool years ( pp. 161 - 182 ). Chicago, 1L: The Umversity of Chicago Press. Moos, R., & Moos, B. (1981). Famtly environment scale manual. Palo Alto. CA: Consulting Psychologists Press, Murray, J. B. (1989). Psychologists and children of alcoholic parents. Psychological Reports, 64,859-879. Orvaschel, H., Weissman, M. A., Kidd, K. K. (1980). Children and depression: The children of depressed parents: the childhood of depressed patients; depression in children. Journal of Affective Disorders'. 2, 1-16. Rice, E. P., Ekdohl, M. C., & Miller, L. ( 1971 ). Children of mentally ill parents. New York: Behaworal Publications. Rutter, M., & Quinton, D. (1984). Parental psychiatric disorder: Effects on children. Psychological Medictne, 14, 853-880. Shea, E., & Tronick, E. Z. ( 1988 ). The maternal self-report inventory: A research and chnical instrument for assessing maternal self-esteem. In H. E. Fitzgerald, B. M. Lester, & M. W. Yogman ( Eds. ), Theory and research in behavtoral pediatrics (pp. 101-139). New York: Plenum Press. Solnit, A. J., & Leckman, J. F. (1984). On the study of chddren of parents with affective disorders. Amerwan .hmrnal of Psychiatry, 141,241-242. Steinberg, M. (1985). The structured clinical mterview fi~r DSM-III-R dissociative dtsorders New Haven, CT: Yale University School of Medicine. Steinberg, M. (1993). The structured clinical interview for DSM-IV dis~octative dtsorders(SCID-D). Washington, DC: American Psychiatric Press. Steinberg, M. ( 1985/1993). Interviewer's guide to the structured climcal mterv~ew fi~r DSM-IV dt~,~actative di,~orders. Washington, DC: American Psychiatric Press. Steinberg, M., Rounsaville, B., & Clcchetti, D. V. (1990). The structured chmcal interview for DSM-III-R dissociative disorders: Preliminary report on a new diagnostic instrument. American Journal of Psychiatry, 147, 76-82 Tronick, E. Z., & Field, T. (1986). Maternal depression and infant disturbance. San Francisco, CA: Jossey-Bass. Weissmam M., Paykel, E., & Klerman, G. (1972). The depressed woman as a mother. Social Psychtatr3_', 7, 98-108. Zahn-Waxler, C., McKnew, D. H., Cummings, M., Davenport, Y. B., & Radke-Yarrow, M. (1984). Problem behawors and peer interactions of young children with a manic-depressive parent. Amerwan Journal ofP,~ychiatr3, 141,236240
R6sum~---Cette recherche a examin6 dans quelle mesure les sympt6mes de mbres souffrant d'un d6sordre de dissociation entravaient leur comp6tence en tant que parents et leurs exp6riences maternelles subjectives. On a admmistr6 le Structured Clinical Interview for Dissociative Disorders (SCID-D) ~ un groupe de 54 m~res ayant ces sympt6mes et trait6es dans un service interne ou une clinique de jour et h deux autres groupes, c.-a-d. 20 patientes non symptornatiques et 20 m~res faisant partie du personnel hospitaller. On leur demanda de remplir un questionnaire, le Subjective Experiences of Parenting Scale (SEPTS), concernant divers aspects de leur r61e maternel, y compris les 14 caract6ristiques suivantes : l'appui que leur procure leur conjoint, l'appui de leurs proches parents, les mauvals traitements inflig6s ~t leur enfant, la mesure dans laquelle les sympt6mes entravent leurs r61e de parent, leurs quaht6s de parent, les mesures disciplinaires vs celles qm font du tort, la capacit6 de d6montrer de l'affection, d'extfrioriser leurs sentiments, les comportements qui d6montrent une capacit6 d'attachement maternel, les distorsions cognitive,~, le
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contr61e de la col6re, leur capacit6 de donner de sores en tant que parent, leur experience personnelle en tant que m~re et les mesures qu'elles prennent pour promouvoir le d6veloppement de leur enfant. Les m~res souffrant de dissociation r6v~lent plus de traits ndgatifs en tant que parents et dans divers autres respects que le groupe du personnel hsopitalier, soit pour 13 des 14 caract&istlques. Compar6es h l'autre groupe de m~res-patientes, elles &aient moins dou6es en tant que parent ainsi que dans d'autres respects, dans 9 sur 14 caractdristiques. Dans l'ensemble, les m~res dissooatives connaissent un plus haut degr~ de probl6mes au niveau de leurs attitudes et de leur comportement que Fun ou l'autre des deux groupes et manifestent des difficult& affectives, cognitives et de comportement en tant que parent. Resumen--Este estudio examin6 hasta que punto los sintomas de madres disociativas interfieren con el cmdado parental y sus expenencias maternales subjetivas. Un grupo de 54 madres disociativas atendidas con mtemamiento o ambulatorias, 20 madres internas nodisociativas, y 20 madres del personal hospitalario fueron evaluadas utilizando la Entrevista Cl~nica Estructurada de los Des6rdenes Disociativos (ECED-D). Despu6s se les solicit6 responder a un cuestionario de autoreporte, la Escala de Experiencias Parentales Subjetivas (EEPS) que examinaba 14 caracteristicas parentales: apoyo parental de pareja; apoyo relatlvo: conducta abusiva hacia el nifio; nivel de interferencia de los sintomas con el cuidado parental; rasgos parentales constructivos: disciplina de apoyo versus dolorosa; magnitud del afecto demostrado; habilidad de expresar afecto; conductas de apego; distorsiones cognitivas; regulaci6n de la ira; el yo versus la madre en el cuidado parental; experienoa parental subjetiva; y acciones para promover el crecimiento evolutivo del nifio. Las madres disociativas presentaron significativamente mils conductas parentales negativas y atributos relacionados que el grupo control en 13 de las 14 caracteristicas parentales. Comparadas con las pacientes &sociativas, la pareja disociativa presentaba conductas parentales y atributos relacionados mils pobres, en 9 de las 14 caracteristlcas. En general, las madres disoclativas expenmentaron mils problemas con las actitudes y conductas parentales que cualquiera de los grupos comparados. Las madres disooativas manifestaron dificultades afectivas, conductuales~ y cognitivas en la crianza.