Reading Room
Aspects of the Treatment of
Multiple Personality Disorder
by Richard P. Kluft, M.D.
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 series1-3 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.
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