Traditional admonishment not to judge a book by its cover aside, the rear jacket of this book tells it all: “There are many ways in which to place severe posttraumatic dissociation in context, but the most basic way is to look hard at the historical, political, economic, social, and cultural contexts in which the inequities of capitalist patriarchy are constructed and secured. We live in a society which is structured so that everyone has at least one—and usually more than one—individual to blame for the abuses of power that are so keenly felt and seldomly clearly seen within a system developed to benefit the privileged few.”

Margo Rivera, a feminist psychologist, is assistant professor of psychiatry at Queen's University in Kingston, Ontario, and codirector of the personality disorders service at Kingston Psychiatric Hospital. Proffering many strong views, Dr. Rivera takes offense even with the term “disorder.” She shuns the use of the more modern term “dissociative identity disorder” (multiple personality disorder) because she feels that “disorder” is insulting to the people who have been all too insulted as it is.”

The author endorses the traditional position that most multiple personality patients have a history of child abuse, usually severe and prolonged, and that studies of prevalence show that well over a third of female children and a fifth of male children have sustained sexual abuse. She also reiterates Russell's study, which reported probably the most alarming (but contested) statistic that 54 percent of females sustain an abusive situation before the age of 18.

Rather than to attempt to dissect 11 chapters, all highly complex and all reflecting the creative intellect of Dr. Rivera, I will comment on the chapter on ritual abuse, probably the most interesting. Rivera is an expert on ritual abuse, and apparently she has a great deal of therapeutic experience with individuals who have sustained sadistic abuse. Strangely enough, although she seems to acknowledge the prevalence of satanic rituals, she does mention that “evidence of an international conspiracy of satanic cult groups that operate around a core of intergenerational families and practice murder, cannibalism, and ritual torture on a massive scale—or even of a plethora of individual groups that regularly rape, mutilate, and kill in the name of Satan—has not been found…My opinion is that some cases of alleged ritual abuse are imagined, concocted, confabulated, or exaggerated, and that some are not. But, frankly, I am not sure my opinion about this matter is worth very much.”

In this chapter the author relies, as elsewhere, on anecdotal experiences. Although disclaiming knowledge about “the prevalence or even the reality of satanic cults that operate in a widespread, intergenerational way,” she says that she has seen “individuals who bring to the therapy context vivid images and powerful accompanying affect being victimized within such contexts.”

As for treating people who have sustained ritual abuse, interestingly enough she states that “The first rule of therapy is that the therapist must survive the process.” She also discusses a self-care regimen that all experienced therapists who deal with substantially disturbed individuals probably employ, knowingly or not. But wisely she notes, “Different levels of support are needed at different stages of the therapist's experience.”

More Alike Than Different has an element of being a “survivors” manifesto rather than an objective scientific dissertation. The use of medications, a growing strength within the practice styles of most traditional psychotherapists, is not discussed. The book’s significance, however, is related to its clarity and thoroughness as Dr. Rivera relates simply to the issues, especially decrying the prevalence of child abuse.

It seems unfair for a reviewer to not more wholeheartedly recommend a book so painstakingly crafted as this one. However, I think the book would be most helpful, as the author says, for those who treat severely ill dissociated individuals, those who are in the process of formulating their own conceptual therapeutic framework, or those more experienced therapists who are struggling to “maintain the faith” and will find solace in Dr. Rivera’s words. To maintain balance, therapists should read other publications, many of which will strongly disagree with Rivera’s convictions.

Dr. Einspruch is clinical professor of psychiatry at Southwestern Medical Center in Dallas and at New York University Medical Center in New York City.