Aspects of the Treatment of Multiple Personality Disorder

It is generally agreed that the treatment of multiple personality disorder (MPD) can be a demanding and arduous experience for patient and psychiatrist alike. Difficulties and crisis are intrinsic to the condition, and occur despite therapists' experience and skill. Seasoned clinicians may react with greater composure, and exploit the therapeutic potential of these events more effectively, but are unable to prevent them (C. Wilbur, personal communication, August 1983). In order to appreciate why these patients often prove so difficult, it is helpful to explore certain aspects of the condition's etiology and the patients' was of functioning.

Etiology

The etiology of MPD is unknown, but a wealth of case reports, shared experience, and data from large series^1-3 suggests that MPD is a dissociative response to the traumatic overwhelming of a child's non-dissociative defenses.⁴ The stressor cited most commonly is child abuse. The Four Factor Theory, derived from the retrospective review of 73 cases, and confirmed prospectively in over 100 cases, indicates that MPD develops in an individual who has the capacity to dissociate (Factor 1).⁴ This appears to tap the biological substrate of hypnotizability, without implying its compliance dimensions. Such a person's adaptive capacities are overwhelmed by some traumatic events or circumstances (Factor 2), leading to the enlistment of Factor 1 into the mechanisms of defense. Personality formation develops from natural psychological substrates which are available as building blocks (Factor 3). Some of these are imaginary companionships, ego-states,⁵ hidden observer structures, ⁶ state-dependent phenomena, the vicissitudes of libidinal phases, difficulties in the intrapsychic management of introjection/identification/internalization processes, miscarried of introjection/identification/internalization processes, miscarried mechanisms of defense, aspects of the separation-individuation continuum (especially rapprochement issues), and problems in the achievement of cohesive self and object representation. What leads to the fixation of dividedness is (Factor 4) a failure on the part of significant others to protect the child against further overwhelming, and/or to provide positive and nurturing interactions to allow traumata to be "metabolized" and early or incipient dividedness to be abandoned.

The implications for treatment can only receive brief comment. The clinician is facing a dissociative or hynotic⁷ pathology, and may encounter amnesia, distortions of perception and memory, positive and negative hallucinations, regressions, and revivifications. His patient has been traumatized, and needs to work through extremely painful events. Treatment is exquisitely uncomfortable: it is, in itself, a trauma. Hence resistance is high, the evocation of dissociative defenses within sessions is common, and recovery of memories may be heralded by actions which recapitulate often are dominated by the images of those who have been abusive.

Because of the diversity of Factor 3 substrates, no two MPD patients are structurally the same. MPD is the final common pathway of many different combinations of components and dynamics. Generalizations from accurate observations of some cases may prove inapplicable to others. It is difficult to feel "conceptually comfortable" with these patients. Also, since these patients have not been adequately protected or soothed (Factor 4), their treatment requires a consistent availability, a willingness to hear out all personalities with respect and without taking sides, and a high degree of tolerance so that the patient can be treated without being excessively retraumatized, despite the considerable (and sometimes inordinate and exasperating) demands their treatment makes on the therapist, who will be tested incessantly.

Switching and battles for dominance can create an apparently unending series of crises.

The Instability Of The MPD Patient

An individual suffering MPD has certain inherent vulnerabilities. The very presence of alters precludes the possibility of an ongoing unified and available observing ego and disrupts autonomous ego activities such as memory and skills. Therapeutic activity with one personality may not impact on others. The patient may be unable to address pressing concerns when some personalities maintain they are not involved, others have knowledge which would be helpful but are inaccessible, and still others regard the misfortunes of the other alters to be to their advantage.

A therapeutic split between the observing and experiencing ego, so crucial to insight therapy, may not be possible. Cut off from full memory and pensive self-observation, alters remain prone to react in their specialized patterns. Since action is often followed by switching, they find it difficult to learn from experience. Change via insight may be a late development, following a substantial erosion of dissociative defenses.

The activities of the personalities may compromise the patients' access to support systems. Their inconsistent and disruptive behaviors, their memory problems and switching, can make them appear to be unreliable, or even liars. Concerned others may withdraw. Also, traumatizing families who learn that the patient is revealing long-hidden secrets may openly reject the patient during therapy.

Switching and battles for dominance can create an apparently unending series of crises. Patients resume awareness in strange places and circumstances for which they cannot account. Alters may try to punish or coerce one another, especially during treatment. For example, one commonly finds personalities which identified with the aggressor-traumatizer and try to punish or suppress personalities which reveal information or cooperate with therapy. Conflicts among alters can lead to a wide variety of quasi-psychotic symptomatology. Ellenberger⁸ observed that cases of MPD dominated by battles between alters were analogous to what was called "lucid possession." Unfortunately, emphasis on the phenomena of amnesia in MPD has led to underrecognition of this type of manifestation. The author has described the prevalence of special hallucinations, passive influence phenomena, and "made" feelings, thoughts, and actions in MPD. ⁹ As amnestic barriers are broached, such episodes may increase, so that positive progress in therapy may be accompanied by symptomatic worsening and severe dysphoria.

An analogous situation prevails when memories come forward as distressing hallucinations, nightmares, or actions. It is difficult to conserve of a more demanding and painful treatment. Long-standing repressions must be undone, the highly efficient defenses of dissociation and switching must be abandoned, and less pathological mechanisms developed. Also, the alters, in order to allow fusion/integration to occur, must give up their narcissistic investments in their identities, concede their convictions of separateness, and abandon aspirations for dominance and total control. They must also empathize, compromise, identify, and ultimately coalesce with personalities they had long avoided, opposed, and reflected.

Adding to the above is the pressure of severe moral masochistic and self-destructive trends. Some crises are provoked; others, once underway, are allowed to persist for self-punitive reasons.

The Therapist's Reactions

Certain therapist reactions are nearly universal. ¹⁰ Initial excitement, fascination, overinvestment, and interest in documenting differences among alters yield to feelings of bewilderment, exasperation, and a sense of being drained by the patient. Also normative is concern over colleagues' skepticism and criticism. Some individuals find themselves unable to move beyond these reactions. Most psychiatrists who consulted the author felt overwhelmed by their first MPD cases. ¹⁰ They had not appreciated the variety of clinical skills which would be required, and had not anticipated the vicissitudes of the treatment. Most had little prior familiarity with MPD, dissociation, or hypnosis, and had to acquire new knowledge and skills.

Many psychiatrists found these patients extraordinarily demanding. They consumed substantial amounts of their professional time, intruded into their personal and family lives, and led to difficulties with colleagues. Indeed it was difficult for the psychiatrists to set reasonable and nonpunitive limits, especially when the patients may not have had access to anyone else able to relate to their problems, and the doctors knew the treatment process often exacerbated their patients' distress. It was also difficult for dedicated therapists to contend with patients whose alters frequently abdicated or undercut the therapy, leaving the therapist to "carry" the treatment. Some alters attempted to manipulate, control, and abuse the therapists, creating considerable tension in sessions.

A Psychiatrist's empathic capacities may be sorely tested. It is difficult to "suspend disbelief," discount one's tendency to think in monistic concepts, and feel along with the separate personalities' experiences of themselves. having achieved that, it is further challenging to remain in empathic touch across abrupt dissociative defenses and sudden personality switches. It is easy to become frustrated and confused, retreat to a cognitive and less effectively-demanding stance, and undertake an intellectualized therapy in which the psychiatrist plays detective. Also, empathizing with an MPD patient's experience of traumatization is grueling. One is tempted to withdraw, intellectualize, or defensively ruminate about whether or not the events are "real." The therapist must monitor himself carefully. If the patient senses his withdrawal, he may feel abandoned and betrayed. Yet if he moves from the transient trial identification of empathy to the engulfing experience of counteridentification, an optimal therapeutic stance is lost, and the emotional drain can be ennervating.

The Practical Psychopharmcology Of MPD

Kline and Angst tersely state pharmacological treatment of MPD is not indicated. ¹¹ There is general consensus 1) that drugs do not affect the core psychopathology of MPD; and 2) that, nonetheless, it is sometimes necessary to attempt to palliate intense dysphoria and/or to try to relieve target symptoms experienced by one, some, or all personalities. At this point in time treatment is empirical and informed by anecdotal experience rather than controlled studies.

Different personalities may present with symptom profiles which seem to invite the use of medication, yet the symptom profile of one may be so much at variance with another's as to suggest different regimens. A given drug may affect personalities differently. Alters who experience no effect, exaggerated effects, paradoxical reactions, appropriate responses, and various side effects may be noted in a single individual. Allergic responses in some but not all alters has been reported and reviewed. ¹² The possible permutations in a complex case are staggering.

It is tempting to avoid such a quagmire by declining to prescribe. However, distressing drug-responsive target symptoms and disorders may coexist with MPD. A failure to address them may leave the MPD inaccessible. The author has reported cross-over experiences on six MPD patients with major depression. ^4,1,3 He found if dissociation alone was treated, results were unstable due to mood problems. Relapse was predictable if medication was omitted. Medication alone sometimes reduced chaotic fluctuations which were chemically triggered, but did not treat the dissociation. An example is a depressed MPD woman who repeatedly relapsed on therapy alone. Placed on imipramine, she became euthymic but continued to dissociate. Therapy abated dissociation. With medication withdrawn, she relapsed in both depression and dissociation. Imipramine was reinstituted and fusion was achieved with hypnosis. On maintenance imipramine she has been asymptomatic in both dimensions for four years.

A psychiatrist's empathic capacities may be sorely tested

Depression, anxiety, panic attacks, agoraphobia, and hysteroid dysphoria may coexist with MPD and appear medication-responsive. However, response may be so rapid, transient, inconsistent across alters, and/or persist despite withdrawal of drugs, as to cause question. There may be no impact at all. The same holds for the insomnia, headaches, and pain syndromes which can accompany MPD. The author's experience is that, in retrospect, placeboid responses to the actual medications are more common than clear-cut "active drug" interventions.

Neither automatically denying nor readily acceding to the patient's requests for relief is reasonable. Several questions must be raises: 1)Is the distress part of a medication-responsive syndrome? 2)If the answer to 1) is yes, is it of sufficient clinical importance to outweigh possible adverse impacts of prescription? If the answer to 1) is no, whom would the drug treat (the physician's need to "do something." an anxious third party, etc.)? 3) Is there a non-pharmacological intervention which might prove effective instead? 4) Does the overall management require an intervention which the psychiatrist patient's "track record" in response to interventions similar to the one which is planned? 6) Weighing all considerations, do the potential benefits outweigh the potential risks? Medication abuse and ingestions with prescribed drugs are common risks.

Hypnotic and sedative drugs are frequently prescribed for sleep deprivation and disturbances. Initial failure or failure after transient success is the rule, and escape from emotional pain into mild overdose is common. Sleep disruption is likely to be a long-standing problem. Socializing the patient to accept this, shifting any other medication to bed-time (if appropriate), and helping the patient accept a regimen which provides a modicum of relief and a minimum of risk is a reasonable compromise.

Minor tranquilizers are useful as transient palliatives. When used more steadily, some tolerance should be expected. Increasing doses may be a necessary compromise if anxiety without the drug is disorganizing to the point of incapacitating the patient or forcing hospitalization. The author's major use of these drugs is for outpatients in crisis, inpatients, and for post-fusion cases which as yet have not developed good non-dissociative defenses.

...alters may emerge who are afraid, angry, or perplexed at being in the hospital.

Major tranquilizers must be used cautiously. There are ample anecdotal accounts of adverse effects, including rapid tardive dyskinesia, weakening of protectors, and patients' experiencing the drug's impact as an assault, leading to more splitting. Those rare MPD patients with bipolar trends may find these drugs helpful in blunting mania or agitation; those with hysterical dysphoria or severe headaches may be helped. Their major use has been for sedation when minor tranquilizers failed and/or tolerance has become an issue. Sometimes supervised sedation is preferable to hospitalization.

When major depression accompanies MPD, response to tricyclic antidepressants can be gratifying. When symptoms are less straightforward, results are inconsistent. A trial of antidepressants is often indicated, but its outcome cannot be predicted. Ingestion and overdosage are common problems.

MAOI drugs are prone to abuse as one alter ingests forbidden substances to harm another, but can help patients with intercurrent atypical depression or hysteroid dysphoria. Lithium has proven useful in concomitant bipolar affective disorders, but has had no consistent impact on dissociation per se.

The author has seen a number of patients placed on anticonvulsants by clinicians familiar with articles suggesting a connection between MPD and seizure disorders. ^14,15 None were helped definitively: most responded to hypnotherapy instead. Two clinicians reported transient control of rapid fluctuation on Tegretol, yet over a dozen said it had no impact on their patients.

The Hospital Treatment Of Multiple Personality

Most admissions of known MPD patients occur in connection with 1) suicidal behaviors or impulses; 2) severe anxiety or depression related to de-repression, emergence of upsetting alters, or failure of a fusion; 3) fugue behaviors; 4) inappropriate behaviors of alters (including involuntary commitments for violence); 5) in connection with procedures or events in therapy during which a structured and protected environment is desirable; and 6) when logistic factors preclude outpatient care.

Very brief hospitalizations for crisis interventions rarely raise major problems. However, once the patient is on a unit for a while, certain problems begin to emerge unless one strong and socially-adapted alter is firmly in control.

On the part of the patients, alters may emerge who are afraid, angry, or perplexed at being in the hospital. Protectors begin to question procedures, protest regulations, and make complaints. Sensitive alters begin to pick up on staff's attitudes toward MPD; they try to seek out those who are accepting, and avoid those who are skeptical or rejecting. These lead to the patient's wishing to evade certain people and activities. Consequently, their participation in the milieu and cooperation with the staff as a whole may diminish. Rapidly, their protective style makes them group deviants and exerts polarize them, and the second toward protecting staff group cohesion from the patient. The patient experiences the latter phenomenon as rejection. Some alters are too specialized, young, inchoate, or inflexible to comprehend the unit accurately or conform their behavior within reasonable limits. They may view medication, rules, schedules, and restrictions as assaults, and/or repetitions of past traumata, and perceive to encapsulate the admission as a traumatic event, or to provide an alter which is compliant or pseudocompliant with treatment.

Other patients may be upset or fascinated by them. Some may feign MPD to evade their own problems, or scapegoat these individuals. MPD patients' switching can hurt those who try to befriend them. Some cannot help but resent that the MPD patient requires a great deal of staff time and attention. They may believe such patients can evade the accountability and responsibilities they cannot escape. A more common problem is more subtle. MPD patients openly manifest conflicts most patients are trying to repress. They threaten others' equilibria and are resented.

It is difficult to treat such patients without staff support. As noted, the patients are keenly perceptive of any hint of rejection. They openly fret over incidents with the therapist, staff, and other patients. Hence, they are seen as manipulative and divisive. This engenders antagonisms which can undermine therapeutic goals.

Also, such patients can threaten a milieu's sense of competence. The [patient becomes resented for the helplessness with the psychiatrist who, they feel, has inflicted an overwhelming burden upon them by admitting the patient.

The psychiatrist must try to protect patient, other patients, and staff from a chaotic situation. MPD patients do best in private rooms, where they retreat if overwhelmed. This is preferable to their felling cornered and exposing a roommate and milieu to mobilized protector phenomena. The staff must be helped to move from a position of impotence, futility, and exasperation to one of increasing mastery. Usually this requires considerable discussion, education, and reasonable expectations. The patients can be genuinely overwhelming. The staff should be helped in matter-of-fact problem solving vis-a-vis that particular patient. Concrete advice should precede general discussions of MPD, hypnosis, or whatever. Staff is with the patient 24 hours a day, and may be unsympathetic with the goals of a psychiatrist who appears to leave them to work out their own procedures, and then finds fault with what has occurred.

The psychiatrist must be realistic. Almost inevitably, some staff will "disbelieve" in MPD and take essentially judgmental stances toward the patient (and the psychiatrist). In the author's experience it has seemed more effective to proceed in a modest and concrete educational manner, rather than "crusade." Deeply entrenched beliefs change gradually, if at all, and may not be altered during a given hospital course. It is better to work toward a reasonable degree of cooperation than to pursue a course of confrontation.

The following advice is offered, based on over 100 admissions of MPD patients:

1. A private room is preferable. Another patient is spared a burden, and allowing the patient a place of refuge diminishes crises.
2. Call the patient whatever he or she wants to be called. Treat all alters with equal respect. Insisting on a uniformity of names or the presence of one personality reinforces alters' need to prove they are strong and separate, and provokes narcissistic battles. Meeting them "as they are" reduces these pressures.
3. If an alter is upset it is not recognized, explain this will happen. Neither assume the obligation of recognizing each alter, nor "play dumb."
4. Talk through likely crises and their management. Encourage staff to call you in crises rather than feel pressed to extreme measures. They will feel less abandoned and more supported: there will be less chance of psychiatrist-staff splits and animosity.
5. Explain ward rules to the patient personally, having requested all alters to listen, and insist on reasonable compliance. When amnestic barriers or inner wars place an uncomprehending alter in a rule-breaking position, a firm but kindly and non-punitive stance is desirable.
6. Verbal group therapy is usually problematic, as are unit meetings. MPD patients are encouraged to tolerate unit meetings, but excused from verbal groups at first (at least) because the risk/benefit ratio is prohibitively high. However, art, movement, music, and occupational therapy groups are often exceptionally helpful.
7. Tell staff that it is not unusual for people to disagree strongly about MPD. Encourage all to achieve optimal therapeutic results by mounting a cooperative endeavor. Expect problematic issues to be recurrent. A milieu and staff, no less than a patient, must work things through gradually and, all too often, painfully. When egregious oppositionalism must be confronted, use extreme tact.
8. The patients should be told that the unit will do its best to treat them, and that they must do their best attend the tasks of the admission. Minor mishaps tend to preoccupy the MPD patient. One must focus attention on the issues which have the greatest priority.
9. Make it clear to the patient that no other individual should be expected to relate to the personalities in the same manner as the psychiatrist, who may elicit and work with all intensively. Otherwise, the patient may feel staff is not capable, or is failing, when staff is, in fact, supporting the therapy plan.

This article was printed in PSYCHIATRIC ANNALS 14:1/JANUARY 1984

A lot has changed since that time. I'd like to encourage you to find the differences and similarities between then and now. Though many things have been learned over the years there is still a long ways to go!

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