ANNE SEXTON:
IATROGENESIS OF AN
ALTER PERSONALITY IN
AN UNDIAGNOSED CASE
OF MPD
ColinA.Ross, M.D.
Colin A. Ross, M.D., is Director of the Dissociative Disorders
Unit at Charter Hospital of Dallas.
For reprints write Colin A. Ross, M.D., Charter Hospital of
Dallas, 6800 Preston Road, Piano, Texas 75024.
Permission to reprint this chapter from Dr. Ross book,The
Osiris Complex: Case Studies in Multiple Personality Disorder, was
provided by the University of Toronto Press.
ABSTRACT
Controversy about whether multiple personality disorder (MPD) is
an iatrogenic artifact continues, but those proposing that the dis-
order is not valid have not described a single specific case of iatro-
genic MPD. Anne Sexton, a Pulitzer Prize-winning poet who com-
mitted suicide, had MPD which was not diagnosed byher psychiatrist.
Anne Sexton the poet appears to have been an alter personality cre-
ated within the therapy and reinforced by the psychiatrist. The only
clear example of the iatrogenic creation of an alter personality appears
to have occurred in an undiagnosed case of MPD treated by a psy-
chiatrist who suppressed the previously existing alter personalities
in favor of his own iatrogenic artifact.
INTRODUCTION
Anne Sexton, a Pulitzer Prize-winning poet, was horn in
1928 and committed suicide in 1974 (Middlebrook, 1991).
I was only vaguely aware of her in late 1991 when her for-
mer psychiatrist, Dr. Martin Orne, became the subject of an
ethical controversy in the American Psychiatric Association
because he had released audiotapes of therapy sessions to
Sexton biographer. He had done this with the family per-
mission, but the Ethics Commitee of the American Psychiatric
Association was concerned that this might nevertheless be
a violation of patient confidentiality. Apparently there was
little or no content in the tapeswhich Sexton had not already
made public through her poetry (Goodwin, 1991).
I decided to read Sexton s biographywhen I read a review
of it in the December 1991 issue of the American Journal of
Psychiatrywritten by Dr. Donald K. Goodwin. Goodwin writes,
"Over the next eighteen years she had many diagnoses. She
had suicidal depressions and mania, heard voices (at least
once) , went into trances, had amnesia and phobias, was hyper-
sexual, neglected her children and sexually abused one of
them, and had battered wife syndrome-all at the same time.
She overdosed repeatedly and was in and out of nearly every
psychiatric hospital in the Boston area during the eight years
that Orne saw her and the ten years that followed. Her Axis
I diagnosis was probably bipolar disorder. Axis 11? Anybody
guess. There probably should be a separate category for poets."
I realized, reading this paragraph, thatAnne Sexton prob-
ably had undiagnosedMPD. Martin Orne is a leading figure
in the hypnosis literature, editor of theInternational journal
of Clinical and Experimental Hypnosis, wrote papers prior to
Sextons death demonstrating that memories recovered dur-
ing hypnosis can be true or false, and has always been inter-
ested in the potential of hypnosis to contaminate forensic
cases (Orne, Dinges, and Orne, 1984). He was the first per-
son to publish a paper of mine on MPD which appeared in
a special issue of his journal devoted to MPD in 1984 (Ross,
1984) .
I remember being very impressed by the intelligence and
dedication of Orne editing of my paper. I also recall being
struck by his preoccupation with iatrogenesis in MPD: he was
very concerned to emphasize this issue and ensure that I
addressed it in my paper.
Much of the special issue was devoted to the Kenneth
Bianchi Hillside Strangler case in which Orne had been an
expert witness. Orne testified that Bianchi was faking MPD,
and his persuasive testimony is reviewed in detail in the 1984
paper (Orne et al., 1984) : Kenneth Bianchi insanity defense
based on MPD failed, and he was found guilty. In 1988, Orne
participated in a debate at the American Psychiatric Association
Annual Meeting in which he took the position that MPD is
rare, and that most cases diagnosed in the 1980s are iatro-
genic artifacts created when a suggestible hysterical patient
is asked leading questions by a naive diagnostician.
Orne position is that true MPD is rare, that false posi-
tive iatrogenic diagnoses are harmful, cause regression, and
should be discouraged by not feeding into the patient role-
playing. He is preoccupied with the idea that a diagnosis of
MPD results in the patient not being held accountable for
his or her behavior.
If Anne Sexton had undiagnosed MPD, I realized, and
committed suicide because of failure to diagnose and treat
her condition properly, and if Martin Orne were at some
level aware of this, then his public position on MPD could
be primarily defensive in nature and not truly an intellec-
tual or scientific stance. 1 decided to read the biography
specifically to see if I could find enough information to sup-
port a diagnosis of MPD. I expected to find, at best, scattered
circumstantial evidence to support a diagnosis of MPD and
was therefore unsure whether anything publishable would
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DISSOCIATION, Vol. V, No. 3, September 1992
ANNE SEXTON: IATROGENESIS OF AN ALTER PERSONALITY
come of my reading.
TWO COMPETING HYPOTHESES
REGARDING ANNE SEXTON
I established two competing hypotheses before starting
the biography: the first was Orne, namely that it is impor-
tant and therapeutic to discourage any tendency towards
MPD in hysterics like Anne Sexton, who do not really have
the condition. The second hypothesis was that Anne Sexton
had true MPD and might have had a dramatically superior
outcome if her alter personalities were brought into the ther-
apy and her trauma uncovered and worked through.
Evidence in Favor of latrogenesis in Middlebrook's
Biography of Anne Sexton
I soon found circumstantial evidence supporting my clini-
cal intuition. In the first page of the Foreword, Dr. Orne
writes:
It is difficult to communicate fully how pervasive
Anne profound lack of self-worth was and how
totally unable she was to think ofany positive abil-
ities or qualities within herself. When I pressed her
to think hard about what she might be able to do,
she finally revealed that there was only one thing
that she might possibly be capable of-to be a good
prostitute and to help men feel sexually powerful.
[p. xiii]
This paragraph raises the possibility of childhood sexu-
al abuse. Both the feeling of being a prostitute and the lack
of self-worth are typical of victims of severe chronic child-
hood trauma. On the next page, we see that Anne Sexton
presented a clinical picture inconsistent with the working
diagnosis, another feature common in patients with undi-
agnosed MPD. Orne writes:
Originally, when Anne sought help following the
birth of her second child, she had been diagnosed
as having post-partum depression. When I first saw
her in therapy in the hospital in August 1956, a year
after the birth, her thoughts and behaviors were
not really consistent with the presumptive diagno-
sis.As I began to get to know Anne, I realized that
she was showing ideation that one might expect in
a patient with a thought disorder. [pp. xiv]
On page 65, the different diagnoses Sexton received,
again typical of undiagnosed MPD, are listed as " hysteric,"
" psychoneurotic," "borderline," and " alcoholic." It is evident
from other passages that the inability of psychiatrists to make
a clinically meaningful diagnosis lead to many complications.
In her Preface, Diane Wood Middlebrook, the biographer,
writes (pp. xix), " She conducted this career in the context
of a mental disorder that eluded diagnosis or cure. Suicidal
self hatred led to repeated hospitalizations in mental insti-
tutions. She became addicted to alcohol and sleeping pills.
By the time she committed suicide in 1974, misery had hol-
lowed her out and drinking had obliterated her creativity."
Martin Orne treated Anne Sexton for eight years, from
1956 to 1964, while he was in Boston and transferred her to
another therapist when he moved to Philadelphia, where
he currently is, at the Institute of the Pennsylvania Hospital.
The reason Orne began audiotapingAnne Sexton sessions
was that she was unable to remember them. He had Anne
listen to the tapes to try to recover memory of what hap-
pened during treatment. Orne diagnosis is made in the
Foreword:
Aswe continued to work together, it became increas-
ingly evident that in addition to her tendency to
absorb symptoms and mannerisms from those who
impressed her, Annes core problem was that she
suffered from a severe difficulty of memory. While
to some extent, each of us is selective in what we
remember, Anne selectivity was extreme in the
sense that she literally remembered almost noth-
ing of relevance from one session to the next. In
short, for this and other reasons, it was clear that
she had a condition that traditionally was known as
hysteria. [pp. xv]
This description by Martin Orne establishes that Anne
had a complex, chronic dissociative disorder, since she expe-
rienced recurrent episodes of psychologically-caused amne-
sia. This clinical information alone would warrant an aggres-
sive diagnostic work-up for MPD at any contemporary
Dissociative Disorders Clinic. Orne describes other disso-
ciative symptoms later in the Foreword:
There is one aspect of Annes life that has not been
clarified, that is, her tendency to become uncom-
municative in a self-induced trance, which could
last minutes, hours, or, in a few rare circumstances,
even days. Typically, the trance episode could eas-
ily be ended by a therapist familiar with the symp-
tom. But in therapy and out, the problem persist-
ed: when Anne was extremely angry, she was given
to entering a trance and becoming unresponsive.
Treatment helped to decrease these events, but they
were never eliminated. Anne also had a remark-
able fascination with death, and it seemed likely
that she used some of these trance episodes to play
out the role of dying, which perhaps helped her
not to suicide. [pp. xvii]
Recurrent episodes of both trance and amnesia estab-
lish that Anne had either dissociative disorder not otherwise
specified (DDNOS) or MPD. Research I have done with the
Dissociative Disorders Interview Schedule (Ross 1989) and
the Dissociative Experiences Scale (Bernstein Putnam,
1986) involves comparing 166 cases of clinically-diagnosed
MPD to 57 cases of clinically-diagnosed the finding
is that DDNOS is a milder variant ofMPD related to less severe
but still significant childhood trauma (Ross et al., 1992) . By
the end of the Foreword, it is clear that Anne Sexton was at
least three-quarters of the way out the dissociative spectrum
142
DISSOCIATION,
ROSS
to MPD.
Orne s hypothesis is that Anne Sexton role-played dying
in order to avoid actually killing herself. An alternative hypoth-
esis is that the trance was an autohypnotic protective with-
drawal designed to shut down murderous rage, rage that was
directed towards her children and finally towards herself in
completed suicide. We will see extensive evidence in favor
of the second hypothesis below.
It is common for adult women in treatment for MPD to
describe evidence of MPD in one or both parents, which can
include clear descriptions of switching and names of parental
alter personalities. I kept an eye out for such descriptions
of Anne parents and found the following about her father:
Forgiveness came very hard to Anne. She retained
distressing memories of her father drinking
binges, partly because in childhood she didn rec-
ognize them. "He would just suddenly become very
mean, as if he hated the world," she later told her
psychiatrist." He would sit and look atyou as though
you had committed some terrible crime. He hated
everyone? Mostly I remember the expression on
his face." It seemed that he singled her out for ver-
bal abuse when he was drinking, complaining that
her acne disgusted him and that he could not eat
at the same table with her. She felt invaded by his
expressions of revulsion, and it seemed that no one
tried to shield her from these attacks. [pp. xiv]
This is a typical description of switching in an alcoholic
father with undiagnosed MPD, but it is not conclusive for
the diagnosis. Amnesia and abrupt changes of behavior are
usually written off as due to the alcohol in men with serious
alcohol abuse problems, when often the alcohol is actually
triggering the emergence of abusive alter personalities. In
such men, a careful psychiatric history will reveal periods of
recurrent amnesia going back into childhood, "alcohol black-
outs" when the person has not been drinking, and abrupt
emergence of violent behavior during periods of sobriety,
accompanied by a history of serious abuse in childhood, audi-
tory hallucinations starting before the alcohol consumption,
and other classical features of MPD.
One can suspect but not conclude that Anne father
had MPD. Could it be that she felt"invaded" by incestuous
rape, not just by verbal abuse, and that this was the "terrible
crime" her father expressed in his face, and projected onto
her when he looked at her? If true, this would be the typi-
cal blame-the-victim psychology of an incestuous pedophile.
These were my thoughts as I read the paragraph ahoutAnne
father, not expecting to find more conclusive evidence of
paternal incest. The passage establishes serious emotional
abuse of Anne by her father.
What about Anne Sexton mother? She was also an abus-
er, as documented on page 14, in discussion of psychoso-
matic symptoms in Anne arising directly from the abuse:
Arthur Gray Staples [Anne maternal grandfather]
died in April 1940, and during the following sum-
mer Anne was hospitalized at the Lahey Clinic for
severe constipation. Anne later recalled this as a
very traumatic period in her life, remembering her
mother routinely inspecting her bowel movements
and threatening her with a colostomy if she didn
cooperate with efforts to regulate her elimination
[p. 14].
Anne mother also abused her sexually:
Sexton was to raise the question of whether she was
"normal," by which she meant heterosexual, early
in her psychiatric treatment, and later to explore it
in the context of sexual intimacy with women. Behind
that question were other memories that troubled
her self-esteem, focused on genital inspections by
her mother. From the earliest period of toilet train-
ing, she had to report to her mother daily and show
her the stool before flushing it away. This was a com-
mon child-rearing practice at the time. But Sexton
also recalled another humiliating experience, from
about her fourth year: her mother laying her down
on the bathroom floor, pulling her legs apart, and
inspecting her vulva,"looking at me and saying how
we had to keep it clean and musn touch-there
was something she looked at and it was growing,
and 1 know-I don  t remember, I know-I had a
little cyst-they had to operate and take it off." As
Dr. Orne commented, "In many ways, her mother
was a dangerous relationship." [p. 591
The point is, the veracity of the incest narra-
tive cannot be established historically, but that does
not mean that it did not, in a profound and lasting
sense," happen." It is clear from many sources that
Sexton physical boundaries were repeatedly tres-
passed by the adults in her family.in ways that dis-
turbed her emotional life from girlhood onward.
As she put it: I have frozen that scene in time, made
everyone stop moving. I thought I could stop all
this from happening. That what I want to believe-
when I in that hard place-that notwhat I believe
now, just when In that child in trance. I can grow
up because then all these things will happen. I want
to turn around and start everything going back-
ward. [p. 59]
This is riot conclusive, but is suggestive of the existence
of a child alter personality stuck in the past at the time of
the trauma, and constantly reliving the trauma internally. If
such a child existed, it might have been contacted and healed
in an active MPD psychotherapy. Is there any direct evidence
of the existence of alter personalities in the biography?
The subsequent quotations, in my mind, conclusively
establish the diagnosis of MPD. The first of them, though, is
merely suggestive. The way in which I built up the diagno-
sis of MPD in reading Anne Sexton biography is much the
same as the way I build it up during a diagnostic assessment
in the clinic: I lookfor suggestive evidence and indirect clues,
then keep them in mind as I pursue the history, waiting to
see how they link up with other details and whether they
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DISSOCIATION, Vol. V, No. 3, Septembcr 1992
ANNE SEXTON: IATROGENESIS OF AN ALTER PERSONALITY
lead to a definite diagnosis.
In that vein, on page 16, I read a brief description of
Anne nanny, Nana, who was a maternal great-aunt, during
a period when Nana was in an apparent delirium. I thought
the passage might be evidence of Nana s being aware of the
existence of alter personalities in Anne:
Anne, visiting her in her room, would often find
her distracted and uncomprehending: "Youe not
Anne!" Nana would cry out. Anne remembered Nana
calling her "horrible and disgusting" and once attack-
ing her with a nail file. One night, before Anne s
horrified eyes, Nana was carried off to a mental hos-
pital. Electroshock therapy seemed to improve her
condition and she returned home. "She wasn like
someone mad, she was suffering," Anne remem-
bered. [p. 16]
As I made note of this passage as a clue to MPD in Anne,
I thought to myself that I was stretching things. Nevertheless,
I considered the possibility that Nanas" delirium" was real-
ly a dissociative state and that she and Anne had seen some-
thing about each other that the doctors had missed. Could
Nana have had MPD, too? It is stated several times in the
biography that Nana indulged in extended backrubs, hug-
ging, carressing, and other sexualized behavior with Anne:
Could there have been more? Could Anne Sexton have been
sexually abused by her father, her mother, and her great-
aunt? If this were truly a multi-generational incest family,
this would be possible, and it would be possible that many
members of the family had dissociative disorders.
On page 16, there is a further description of Nana s pos-
sible perception of Anne MPD and an unequivocal descrip-
tion of an internal auditory hallucination. I suspect that this
was the voice of a persecutory alter personality who eventu-
ally forced Anne to complete suicide. The passage also describes
the extreme self-blame characteristic of incest survivors.
Additionally, Anne idealization of Nana suggests the pos-
sibility of terrible historical facts being covered up by the
idealization:
After Anne Sexton s own breakdown, she worried
about ending up in a mental institution like Nana.
More important, she believed that she had personally
caused her great-aunt breakdown, and that Nana,
who condemned her as "not Anne," but a "horri-
ble and disgusting" imposter, had sentenced her to
a breakdown as well. Nana rage took root in Sexton
as a frightening symptom, which she described as
a "tiny voice" in her head "shouting from far away,"
telling her she was awful, often taunting her to kill
herself." [I] should never have left Nana. She d never
have gotten sick--them I always be just me_" [p.
16]
One of the indirect clues to MPD is Schneiderian pas-
sivity experiences described by the German psychiatrist Kurt
Schneider, but mistakenly thought by him to be symptoms
specific for schizophrenia (Kluft, 1987). These experiences
are also called made actions, thoughts, and feelings, and
involve the experience that one actions, feelings, or
thoughts are not one s own, that one is not the agent of
one own behavior, but is instead controlled by some out-
side power or force. In MPD, these experiences are due to
the intrusion of unrecognized alter personalities intoone 's
actions, thoughts, or feelings. Such experiences are suggestive
of, but not conclusive for, the diagnosis of MPD. A classical
description of Schneiderian passivity is given in Anne own
words at the bottom of page 26, as Anne talks about her hus-
band, Kayo:
"When he s gone, I want to be with someone, I want
lights and music and talk. When I say running I
don mean running from something, but some-
thing I express by action-people, people, talk, talk,
wanting to stay up all night, no way to stop it. I don
really want to have an affair with anyone, but I have
to; it the quality of action. I first had this feeling,
I suppose, when I was dating, after Kayo went into
the service. Pound, pound, pound heart; makes me
feel crazy, out of control." [p. 26]
My hypothesis about Anne Sexton having MPD was
strengthened when I read a description of her by her close
friend. This is a diagnostic clue overlooked by Dr. Orne, the
American journal of Psychiatry reviewer, who made a diagno-
sis of manic depressive illness, and the biographer:
Her closest neighbor, Sandy Robart, recalled that
"Anne always dropped ten years or more in her
mother presence. She was overwhelmed-she was
awed. I think it was probably an attempt to please.
I can see her standing at the phone in the kitchen,
talking to her mother, and feeling that Anne had
turned into a little girl." [p. 30]
This is a naturalistic observation of a switch to a child
personality outside therapy by someone who never consid-
ered the possibility of MPD and is evidence of switching of
executive control outside therapy. It will seem to the skep-
tical reader that I am concluding too much from too little
at this point, and seeing MPD everywhere, but the conclu-
sive evidence to follow will confirm my contention.
Anne had many psychosomatic symptoms besides con-
stipation, including "intense pains in her stomach, for which
her internist found no physiological basis. She became prone
to attacks of anxiety that left her panting and sweating" (p.
32). She also experienced Schneiderian rage attacks which
are described on the same page: "Increasingly, Sexton
became prone to episodes of blinding rage in which she
would seize Linda and begin choking or slapping her. In
later life, she recalled with great shame a day she found Linda
stuffing her excrement into a toy truck and as punishment
picked her up and threw her across the room. She felt she
could not control these outbursts, and she began to be afraid
she would kill her children."
Dr. Orne thoughts on the case appear again at this
point in the biography:
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DISSOCIATION, Vol. V, No. 3, September 1992
ROSS
This hypothesis about mental illness is omnipresent in
contemporary psychiatry. According to this biological hypoth-
esis, no one is to blame for Anne Sexton suicide except
her bad genes. The other people in her life, including her
mother, father, great-aunt, and doctors, are not at fault because
biological psychiatry had not yet advanced to the point at
which serotonergic anti-depressants were available, there-
fore, her biologically-based illness was beyond cure. In this
reductionist model, Anne Sexton suicide was as biologi-
cally based as cancer.
The biomedical model of mental illness may have facil-
itated wealthy families in institutionalizing their relatives in
genteel, expensive, psychoanalytically-oriented mental hos-
pitals, where the"schizophrenic" family members could wan-
der the grounds and receive "humane" but ineffective psy-
choanalysis. How many of these "schizophrenics" had
undiagnosed MPD and were hidden away from public view
by multi-generational incest families?
Who is Dr. Brunner-Orne, you might have asked? Dr.
Brunner-Orne is Martin Orne mother. He first saw Anne
Sexton while he was covering for his mother while she was
away on holidays. Anne was originally referred to Dr.
Brunner-Orne because she had treated his father for alco-
holism. Dr. Brunner-Orne notes are quoted on page 26 as
stating that Anne had "difficulty controlling her desire for
romance and adventure," suggesting that Dr. Brunner-Orne
also missed the post-traumatic nature of Anne Sexton act-
ing out.
Feeling that the case for a diagnosis of MPDwas still incon-
clusive at this point, I read the following:
There are several things to comment on in this passage.
First, the statement that Anne never exhibited symptoms of
schizophrenia contradicts Dr. Orne statement in the
Foreword that at times she had a thought disorder, and also
contradicts the evidence of auditory hallucinations and
Schneiderian passivity experiences in the biography. If these
symptoms were dismissed as chameleon-like hysteria (assum-
ing they were ever observed by Dr. Orne), why is it that the
"depression" is thought to be genuine? And why did other
therapists think Anne Sexton was schizophrenic if she never
exhibited Schneiderian symptoms?
Anne Sexton symptom profile from the biography, includ-
ing the diagnostic confusion with schizophrenia, is classical
for MPD and fits the description in MPD textbooks perfect-
ly (Putnam, 1989; Ross, 1989). If the newer anti-depressants
might have treated the "more serious aspects of her depres-
sion," this would presumably include her suicide: an impli-
cation of this position is that Dr. Orne could not be faulted
for his patient suicide because it was biologically driven
and the necessary biological treatments did not come on
the market for over two more decades.
The biographer echoes this viewpoint:
Dr. Orne recalled that when he an treating Sexton,
"She was very, very sick, but like many interesting
patients, didn fit textbook criteria. I did the diag-
nostic work on her when she was at the hospital,
which indicated that she was a hysteric in the clas-
sic sense: like a chameleon, she could adopt any
symptom. She experienced profound dissociation,
and she had lesions of memory. Some therapists
were convinced thatAnne was schizophrenic. I don t
doubt that hospitalized in a ward of schizophren-
ics she would exhibit their symptoms; that is why I
discharged her as soon as possible from Westwood
Lodge, where there were schizophrenic patients in
treatment. But I never saw evidence in her of loose
associations or formal thought disorders, or other
major symptoms of schizophrenia. She certainly had
a depressive illness for many years, which was never
really resolved. One wonders whether the new anti-
depressant drugs might not have successfully treat-
ed the more serious aspects of her depression." [p.
39]
At the outset of Sexton treatment, Dr. Brunner-
Orne had noted the possibility that her difficulties
derived from a post-partum depression; later notes,
however, convey doubts that she had a "true" organ-
ically-based depression. Yet anecdotal evidence of
breakdowns on both sides of the family suggests a
genetic predisposition to abiologically-based illness,
a supposition reinforced by Sexton extreme phys-
iological symptoms: wildly alternating moods, anorex-
ia, insomnia, waves of suicidal and other impulses,
rages, rapid heartbeat. It is possible that biochem-
ical imbalances throughout her life intensified the
underlying psychological vulnerabilities that were
the primary focus of her psychotherapy. [p.37]
Throughout the period of treatment annotated by
Dr. Orne, Sexton referred casually and knowl-
edgeably to concepts such as transference, resis-
tance, defense, regression, acting out-all in the
course of providing the doctor with " memories"
that sound suspiciously like updated versions of Freud
and Breuer Studies on Hysteria. It seems likely that
by 1958, Sexton had read the case history of the
first hysteric in psychoanalytic literature and had
found another namesake in the famous patient Freud
and Breuer called Anna O. Moreover, Orne and
Sexton were both taking notes on her case, he in
longhand, she in poetry. As she was to tell him rather
grandly later on, "therapy is a art, Dr. Ornel"
[p. 55]
For whatever reason, a particularly dramatic
development in her own case was the emergence
during the summer and fall of 1957 of a flamboy-
antly naughty role she liked to play, called Elizabeth,
and of a memory or fantasy, narrated in trance,
about an incestuous experience with her father.
Early in Sexton therapy, the Elizabeth per-
sona began making appearances while Sexton was
in trance by scrawling messages in child-like hand-
writing across pages torn from a lined notebook.
Sexton toldDr. Orne how she had chosen the name.
Leaving his office after an episode of automatic writ-
ing, she had become very despairing. She hadwalked
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ANNE SEXTON: IATROGENESIS OF AN ALTER PERSONALITY
In this passage, the child alter personality, Elizabeth,
who holds paternal incest memories, is asking to come into
therapy and disclose the trauma, and the adult host per-
sonality is co-conscious and agreeing to the request. If this
is correct, then the proper response would be to work active-
ly with Elizabeth in therapy. How do the biographer and
Dr. Orne justify suppressing Elizabeth as a regressive role-
play?
On page 57, the biographer devotes several paragraphs
to doubting the reality of the sexual abuse, pointing out that
Anne was reading about incest at the time she was making
the disclosures, and adducing the family s denial as evidence
146
for a long time, thinking about suicide and trying
to forget herself, and she had begun to be afraid
that someone would notice her and ask her name.
"Looked (for some reason) at the back of my watch
[inherited from Elizabeth Harvey, her father  s
mother] and the initials E.H. were on it. So I thought,
 must be E.H. [...I To [my] truthful knowledge,
I had never been Elizabeth before.
By September, she was typing letters which she
left unsigned, though "Elizabeth" appeared in the
return address on the envelopes. Somewhat com-
ically, the writer claimed that she had to type her
introductory letter in the dark so Anne wouldn
read it. "Help me somehow," Elizabeth urges Dr.
Orne. "There must be something you can do about
this except sit there like a blinking toad. " Anne
would be more cooperative "if she were less afraid
of what you thought [...] I the one whol talk."
Elizabeth explains that formerly, Anne "thought
of me as a brother that died-she used to think
about him all the time-there wasn really any broth-
er-but she liked to pretend about him-I not
so different from her, but I would tell you what she
doesn dare think-She acts her life away. [...] I
am part of her sometimes, but she is not part of
me. [...} Nana knew I was not Anne."
Elizabeth wanted Dr. Orne to put Anne under
hypnosis during therapy, so that she, Elizabeth, could
speak openly: "If you give her time to get dissoci-
ated she will be willing... I know a lot," she promised.
When Dr. Orne would not agree to hypnotize his
patient, both Anne and Elizabeth began appeal-
ing for a session under sodium pentothal. Together
"they" laboriously typed a letter, one line super-
imposed on another: "Only sometimes do I lie,"
says one; "it me that wants pentothal," says anoth-
er.
At several points in her therapy, Sexton made
an association, while in trance, between the name
Elizabeth and "a little bitch," the angry words her
father once used when he was drunk and spanked
her for some naughtiness. She also associated this
phrase with a night, recalled several times in trance
at widely-spaced intervals, when her father came
into her room and fondled her sexually. [pp. 59-
60]
Her "Elizabeth characteristics attracted approval,
even though it was approval she didn wholly respect;
and she had now been able to associate these with
the poetry class. [p. 60]
But Sexton desire to give these characteris-
tics a name and a personality signaled what Dr. Orne
regarded as a dangerous tendency. Discussing
Elizabeth later, he commented that after a brief ini-
tial interest in this manifestation, he observed that
Sexton was perilously close to developing multiple
personality disorder, so he disengaged himself
from acknowledging Elizabeth as a person distinct
from Anne. "It was helpful to let her play out the
fantasy of Elizabeth, to develop aspects of herself
that had been held in check. Let me emphasize
that this was a fantasy: Anne did not have multiple
personality disorder, though she could have been
encouraged in that direction," he said. "Once my
interest dropped, so did hers, and no doctor ever
saw Elizabeth again." As therapy went on, Dr. Orne
stressed the positive sides that Sexton expressed
through this persona: her charismatic leadership,
her sense of fun, her capacity for pleasure, her self-
confidence. "Elizabeth" expresses a side of your child-
hood which showed you assets you never really
owned," Dr. Orne told her. "The `magicyou,
`Elizabeth,is the one who involves people. But you
don view it asyou." The focus of therapy as it per-
tained to Elizabeth was an effort to help Sexton
realize and tolerate the feelings she wanted to split
off and act out. [pp. 60-611
in favor of the memories not being real. What about Dr.
Orne?:
Dr. Orne hypothesis is that "Elizabeth" was a fantasy
role-play that had to be suppressed before it got out of con-
trol. "Elizabeth" was a playful way of expressing aspects of
Anne character she wanted to disown and act out. It was
good therapy, according to Dr. Orne, not to feed into this
escape from reality. My understanding of the case is that
Elizabeth was not a role for expressing pleasant abilities and
feelings, but an alter personality who held abuse memories.
The focus of Martin Orne  therapywas to suppress the infor-
mation about the trauma and the feelings that went along
with it, and his diagnosis was an example of reverse iatro-
genesis: he suppressed Anne Sexton s MPD and her alter
personalities by demand characteristics, therapist attitude,
and direct instruction. The therapy reinforced pathologi-
cal dissociation and, at the same time, invalidated the seri-
ousness and efficacy of the patient dissociative defenses.
Elizabeth was told she was unreal and that the doctor did
not want to talk to her anymore. It is remarkable how con-
fident biographer and psychiatrist are about the correctness
of their hypothesis, given the fact that Anne Sexton killed
herself.
Why did Dr. Orne decide to suppress the "Elizabeth"
role while encouraging the poet role? How did he decide
that the poet persona was more real or healthy than the
DISSOCIATION, Vol. V, No. 3, September 1992
ROSS
child one? The answer to this might seem self-evident, name-
ly that "poet" was afunctional adult role which brought mean-
ing to Anne Sexton life and a respected position in the
adult world.
Unfortunately, this is not the psychological reality of Anne
Sexton life. The poet persona was, in fact, an artifact of
therapy: the poet alter personality was deliberately fostered
and encouraged by Martin Orne at the expense of the other
alter personalities in the system, including Mrs. A.M. Sexton
the mother and wife, Elizabeth, the angry voice that instruct-
ed suicide, the promiscuous personality, and any other per-
sonalities not described in the biography. Anne Sexton the
poet was stimulated by the therapy to a level of malignant
hypertrophy, resulting in exacerbation of the neglect and
abuse of Anne children, extensive frustration and suffer-
ing for her husband described in the biography, failure of
her marriage, alcoholism, and eventual suicide.
The evidence in support of this contention begins with
this passage:
Writing put her into a state similar to a trance, mak-
ing her dangerously inattentive to her children, she
was aware. Being in an institution full-time, she
thought, might ease the burden of guilt she felt
about ignoring her family. " Only time I am there
iswhen I am thinking about poetry or writing-
shuffling between methods of escape-liquor, pills,
writing-I don have anything else."
just as the act ofwriting took Sexton out of her-
self, into what she felt was another identity, so the
finished poem conveyed meanings she had no con-
sciousness of intending. [p. 61]
The last sentence could apply to any writer, but in Anne
Sexton case the phenomenon was due to switching between
alter personalities who were partially or fully amnesic for
each other. The biographers understanding ofAnne Sexton
is that she transmuted her ability to concoct pseudomemo-
ries into art, developing a true and meaningful identity as a
poet. Actually, Anne was socialized in her therapy to believe
that her trauma memories were not real and not worthy of
serious sustained psychotherapeutic exploration.
Two passages, the first from page 62, the second from
page 63, convey the basic principles of both the therapy, the
poetry career, and the biography:
For the next month, spurred by distress over Dr.
Orne s plans and the increasing extravagance of
what she now called "truth crimes"-"lies" that she
had been dealing with as "memories" in trance-
Sexton typed about fifteen single-spaced pages of
this personal record. "I do not understand why I
must do these things-it makes me lose sight of any
true me": this was her main theme. "I suspect that
I have no self, so I produce a different one for dif-
ferentpeople. I don believe me, and I seem forced
to constantly establish long fake and various per-
sonalities." (She doubted even the sincerity of her
two suicide attempts; these were, she suggested, atten-
tion-getting acts. But her worst "truth crime" was
the invention of Elizabeth. "I made her up-I think
I did. [...] Any element of truth about her is just a
certain freedom of expression, a lack of sexual [I
guess] repression. I could say `she feelsbut not, o
never me." Sexton also admitted having faked the
" total amnesia" about Elizabeth she had been pro-
fessing to Dr. Orne. "I would feel better, less guilty,
if I thought Elizabeth were true-I would rather
have a double personality than be a total lie.") [p.
62]
Yet all that was" sick" or " hysterical" about her
behavior in day-to-day life could be turned into some-
thing valuable through the act of writing poetry.
Poetry, too, required a trance-like state for its dis-
closures. "Only in that funny trance can I believe
myself, or feel my feeling," Sexton observed. If in
therapy trance led to lying, at her typewriter it led
to art. She could draw a simple equation: in trances
she was a channel of lies; at her typewriter she was
a channel of poetry. "Think I am a poet? False---
someone else writes-I am a person selling poet-
ry." [p. 63]
Anne Sexton literary world failed her as well. The poets,
editors, critics, and others in that milieu lacked the serious
literary-critical standards, the serious ability toread which
should have made it evident, obvious in fact, that the poet-
ry is morbid, unhealthy, and extremely limited in range,
rhythm, emotional depth, and energy. Anne Sexton work
is the poetry of a single alter personality and of an organ-
ism heading to suicide: it taps only a tiny subregion of the
whole human being memory, experience, thought, and
feeling. The world might be more enriched if it had a vol-
ume of Elizabethswriting to read.
The fact that Anne Sexton was only an alter personali-
ty, and that she represented an escape from the serious work
of life and therapy, is supported by the following paragraph:
This was a decisive change of identity, and she had
firmly achieved it by the end of 1957, when she dis-
continued the practice of submitting her poems
for publication under the name Mrs. A.M. Sexton
and began signing them "Anne Sexton." Later she
would comment, regarding her first book," By God,
1don think I the one who writes the poems!
They dont center in my house-I cant write about
Kayo, nothing-I was very careful about the picture
on my book: didn t want it to look suburban, want-
ed just to be a face, a person whose life you couldn
define. " Renaming herself was a stage in her sym-
bolic reconstitution: she annulled the "Mrs." that
indicated her dependent relationship to a husband
and stepped forth in a euphonious triad of sylla-
bles all her own. [p. 65]
Complications of the Iatrogenic Creation of a Poet Personality
Anne Sexton renaming herself was not a stage in a sym-
bolic reconstitution, it was a stage in a progression towards
147
DISSOCIATION,
ANNE SEXTON: IATROGENESIS OF AN ALTER PERSONALITY
suicide. The malignant overtaking of Anne Sexton fifes-
pace by one alter personality, reinforced by her psychiatrist
and her literary friends, was protested by her husband, who
is made to look possessive and petulant in the biography.
Elizabeth probably concluded that Dr. Orne didn want to
talk to her because she was a bad girl,confirmation of her
guilt and self-hatred which would have been compounded
by her doctor leaving her to move to Philadelphia. Besides
the costs borne by Anne Sexton herself, there was a heavy
price paid by the family:
On a typical day, as she described it, she would "take
half an hour to clean the house," then rush to the
typewriter, not moving until Linda came home from
nursery school at lunchtime. "Linda eats, then I put
on a record or put her in front of television and go
back to my desk. At moments I feel so guilty I read
her a story... I always willing to cuddle, but I won
bother to prepare food: there I sit." Sexton realized
that she was being neglectful, but the pressure
angered her, too. "If I didn have [Linda] there to
reflect my depression, it wouldn be so bad, " she
told her psychiatrist. "Any demand is too much when
I m like this. I want her to go away, and she knows
it." Nothing she was learning about herself in ther-
apy seemed to help her function as a mother, and
she struggled with shocking feelings of rage toward
Linda. "Ie loved joy, never loved Linda... Something
comes between me and Linda. I hate her, and slap
her in the face-never for anything naughty; I just
seem to be constantly harming her... Wish I didn t
have a mother-in-law at my every move. They act as
if I werecrazy or something when I getangry." Sexton
felt as though she were leading two lives, one in
treatment, and one in the midst of her family. [p.
73]
The therapy was reinforcing undiagnosed MPD rather
than assisting Anne towards integration. Given the fact that
incest tends to keep being transmitted from generation to
generation in multi-generational incest families, in the
absence of effective treatment, one realizes that Anne
Sextons children were at risk for sexual, emotional, and
physical abuse, and neglect. The following passage about
Anne s daughter Linda is particularly poignant, given that
Linda is now, in identification with her mother, a published
novelist :
As Linda neared puberty, she had begun to dislike
her mothers intrusiveness more than ever. For sev-
eral years, she had been pretending to be asleep
when her mother got into bed with her and clung
to her. But one night, when Linda was around fif-
teen, Anne had insisted that she come to the big
bed and spend the night. Kayo was away on a trip,
and Anne didn  t want to be alone. They watched
television for awhile, then Linda fell asleep. In the
middle of the night, she woke, feeling that she
couldn tbreathe. It was dark, but she realized that
148
her mother was lying astride her, rubbing against
her and kissing her on the mouth. "I felt suffocat-
ed. I remember pulling out of bed and throwing
up. Mother followed me into the bathroom and
soothed my head." [ p. 324]
CONCLUSION
With that final quotation, the argument in favor of Anne
Sexton having MPD is difficult to refute. The purpose of this
chapter has not been to single out Martin Orne for attack,
nor is it to speculate about his reasons for making the audio-
tapes of his sessions with Anne Sexton public. Martin Orne
has had the courage to state his opinions in public and to
make his therapy available for public scrutiny. It was not an
expected standard of psychiatric practice to be able to diag-
nose MPD in the Fifties and Sixties, therefore, Martin Orne
cannot be charged with diagnostic incompetence or failure
to practice to reasonable standards. In fact, he is much more
receptive to the diagnosis of MPD than are many psychia-
trists.
We should try to learn from Martin Orne mistakes so
that they can be avoided in the future.
I suspect that many potentially treatable people with undi-
agnosed MPD have committed suicide. For instance, although
1 have no evidence to support such a diagnosis, Sylvia Plath,
a poet Anne Sexton knew, also wrote morbidly about sex
and death, and might have had a dissociative disorder. Sylvia
Plath committed suicide, as did Virginia Woolf, a victim of
childhood sexual abuse whose writings could be reviewed
for evidence of a dissociative disorder.
The main point of this paper is to present a compelling
argument for the iatrogenic complications of failing to diag-
nose MPD. Anna 0 also had MPD. Her diagnosis can be sup-
ported convincingly by quotation from Breuer and Freud s
case history inStudies on Hysteria (1986), as I did in my book
Multiple Personality Disorder: Diagnosis, Clinical Features, and
Treatment (Ross, 1989) . Anna 0, whose real name was Bertha
Pappenheim, decompensated when forced to nurse her dying
father, who may have sexually abused her; however, there is
no mention of childhood sexual abuse in the case history.
Anna 0 achieved a healthier adjustment than did Anne
Sexton. She became a social worker and ran a home for
teenage prostitutes and unwed mothers, most of whom were
probably sexual abuse victims. Anna 0 was able to undo in
her professional life some of the long-term consequences
of the paternal incest she probably experienced in her own
childhood. Bertha Pappenheim diagnosis of MPD is cer-
tain, but her incest history is speculative, unlike Anne
Sexton, for whom both are certain. 
DISSOCIATION, W. V, No.3, September 1992
ROSS
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