The first thing that often comes to mind for a patient as well as for the therapist is whether memories of early childhood abuse are truth or fantasy. Often such memories are dismissed automatically as being untrue – even by the adult who had been abused as a child. I believe that the reason for this is that people don’t want to believe that horrific abuse of a child can or has happened – to themselves or to others. This societal issue played out in the earliest history of Psychiatry. It may be helpful to examine the background for the use of the term “fantasy”in psychiatry.

Human communication presupposes that people, in general, present themselves and are taken pretty much at face value. In ordinary conversation, one generally does not assume that what one hears is fantasy. The only time one considers something spoken to be fantasy is when it is explicitly stated to be so or when the content is simply beyond the belief of the listener. The crux of childhood trauma is connected most definitely to the latter.

The use of the word fantasy in psychiatry is tied to Freud’s “seduction theory”of hysteria. But it is important and instructive to note that at the beginning of his work, prior to propounding the seduction theory, he used various words interchangeably in an 1896 paper entitled “The Aetiology of Hysteria” to describe “infantile sexual scenes”: Vergewaltigung (rape), Missbrauch (abuse), Verführung (seduction), Angriff (attack), Attentat (a French term, meaning an assault), Aggression, and Traumen (traumas).” All these words explicitly characterize sexual violence directed against the child by an adult. The infantile sex scenes were not characterized as fantasy according to that original work.

Many of Freud’s patients were suffering from what was then termed “hysteria.” Those working with DID, as patient or therapist, will recognize that the common denominator in all kinds of hysteria discussed at that time in psychiatry is dissociation. Freud’s patients were often daughters of prominent men in society, or even of his colleagues. It may or may not have been beyond his imagination to believe that the sexual misconduct of his own upper class community was factual, although clearly in “The Aetiology of Hysteria” he did not doubt that the molestation memories his patients presented were truth. Nowhere in that paper does he raise the question of the memories being fantasy.

However, having formulated his theory of neurosis at the end of the 19th century in Vienna, he had to find an explanation for the sexual memories that was acceptable to his colleagues, the Viennese circle of eminent neurologists and neuropsychiatrists who dismissed his early work.

The result was the “seduction theory.” My understanding is that Freud used the word seduction to soften the tone describing sexual abuse. Using the word seduction implied a consent by the infant, that the infant consented to have sex in the context of seduction. Even that partial blaming of the infant was too close to accusing adults of abuse, so it was rejected by his peers. Freud ended up repudiating the seduction theory, characterizing the expressed memories of his patients as wishful thinking. In other words, there had been no actual sexual conduct. The fault was in the patient, having fantasized a sexual relationship with their father.

In this way, he made the expressing of memories of early sexual experiences with their fathers acceptable in the context of therapy because there was no actual accusation of molestation. In my opinion, the case histories described genuine examples of incest, rape and gross sexual abuse – not fantasy. The explanation given by the seduction theory was that such molestation never actually happened but rather came from patients’ wishful thinking. In this explanation, Freud chose to use the word seduction and fantasy instead of the explicitly violent terms “sexual assault” and “rape” that he used in 1896.

With Freud having characterized the memories as “fantasy,” the word became embedded in the roots of psychoanalytic thinking about early childhood sexual trauma that has dominated American psychiatry up to the 1950s and beyond. Here then, in the very earliest roots of psychiatry, is the repetition of society’s historical shifting of blame onto the victim and away from the perpetrator. It is a consequence of refusing to consider even the possibility that such evil conduct can be perpetrated on a child – particularly by well-to-do educated adults that are often at the head of the family or at the pinnacle of society. The critical impact of this repetition in psychiatry is that it gave a pseudo-scientific/pseudo-medical gloss to the denial and dismissal of molestation memories.

According to my clinical experience, incest and sexual abuse within a family is not uncommon but is often ignored and disbelieved. A 1988 Finnish study, carried out on 9000 15-year-old schoolgirls, had found the prevalence of incest to be .2% with biological fathers and 3.7% with step-fathers.1 Father-daughter incest is and was not as rare as many would like to believe, even today. In my experience, the rate of incest in certain communities is staggeringly high, such as in aboriginal communities suffering the aftermath of cultural genocide.

DID as the result of early childhood trauma is not uncommon and is almost completely ignored and disbelieved. I am confident that this kind of molestation is widespread. Being part of the upper strata of society, being of any particular religion or ethnic group does not impart any immunity to this. In short, I believe Freud’s insight at the very beginning was correct. It seems far more plausible that Freud’s patients were in fact victims of incest, sexual assault, and abuse.

Returning to the use of the word seduction, it is often misunderstood as not being part and parcel of violence. It infers that there is some form of participation by the child, or that there is a quality of love, as it is conventional understood, embedded in the seduction2. This is because seduction has a soft romantic connotation for most people. However, one must not forget that it has nefarious connotations in cases of fraud or of trapping people into sexual exploitation such as trafficking for example. There can be no “consent” by an infant or child to incest or other early childhood abuse – sexual or otherwise.

Let’s not continue any such misunderstanding. Considering the use of the term “seduction” when analyzing the relationship between an adult and an infant, toddler or other young child is wrong, dangerous and a critical warning that bad things are happening. Calling something seduction, when in the the context of sexual contact with a child, whether it be an infant, toddler, or beyond is violent. While it does not necessarily physically injure the child, that is often the case. In all cases of which I am aware, it most definitely injures the child’s psychosocial development – at least through the first 5 stages as categorized by Erickson. Through seeing that injury in a child, one cannot avoid the conclusion that it was the result of violence.

Molestation in the guise of seduction is violence. Do not be deceived by it being dressed up in fancy clothes, fancy language, or accompanied by gifts. Seduction of a child is molestation. It is violence, full-stop.

I have gone into some detail because Freud’s seduction theory and characterization of expressed memories of sexual abuse as wishful thinking had been embraced for a century as a fundamental truth. It is only with the more recent findings of the severity, prevalence and universality of incest and sexual abuse that it is being questioned.

To me, the rate of occurrence of incest and abuse has been – and continues to be – grossly underestimated. Taking sexual abuse as a myth to be dismissed re-traumatizes all those who have been abused. Even as society now begins to acknowledge the violence against young children, in particular young girls, one continues to see the societal prejudice against acknowledging abuse and its effects on boys.

With respect to the statistics on DID, there is reported to be a 6:1 ratio of DID diagnoses for women as compared to men. It is my clinical experience that women tend more often toward direct self-harm and thus are shepherded into the mental health system while men are more likely to engage in physical altercations with the result that they are shepherded into the criminal justice system.

The tension over the question of declaring the memories to be fantasy or reality continues. It prevents many trauma patients from receiving proper diagnoses as well as proper treatment. In my psychiatric practice, after gaining a few decades of experience, it was clear that the body doesn’t lie3. Traumatic events may not be recalled with precision. Whether this is due to the age of the individual when abused or the intensity of the circumstances is irrelevant. The real tension should be understood as the difference between explicit and implicit memory. The body stores only implicit memory when conceptual faculties are not yet developed, or when they are overwhelmed at the time the trauma is inflicted.

Events that might have seemed phantasmagorical to Freud or to a currently practicing therapist may be explicit memory or it may simply be implicit memory being stored and subsequently expressed in archetypal forms. Simply because you cannot imagine the trauma does not mean that the trauma did not happen.

You know a large boat has passed in the ocean by its wake, you don’t need to know what country the boat came from, or how many people were on it, in order to know that it passed by. For treatment, the fact that trauma has occurred is the point to work with. As a therapist, you see the wake of the trauma, you don’t need to dig out the details. The details as expressed by the patient indicate the triggers and the impact of those triggers. They are not points for cross-examination by the therapist. I encourage therapists to avoid this as well as to redirect patients from cross-examining themselves in their internal dialogues.