Reading Room
Aspects of the Treatment of
Multiple Personality Disorder
by Richard P. Kluft, M.D.
page 2
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.
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