The Treatment Of Multiple Personality Disorder (MPD)

Dr. Kluft is Assistant Clinical Professor Psychiatry, Temple University School of Medicine, and Attending Psychiatrist, The Institute of the Pennsylvania Hospital, Philadelphia.

Overview of Treatment

This is an exciting but confusing epoch in the history of the treatment of Multiple Personality Disorder (MPD). On the one hand, as noted in the first part of this lesson, an increasing number of MPD patients are being identified, and seeking psychiatric help. On the other hand, despite the upsurge in the literature on their treatment remains in a pioneering phase. The first outcome studies are quite recent; controlled studies are not available. A considerable number of articles offer advice generalized from single cases or from small or unspecified data bases. Since MPD patients are quite diverse, it is not surprising to find that citations can be found which appear to argue both for and against many therapeutic approaches. "Multiple personality disorder delights in puncturing our generalizations, revels in shattering our security about our favorite techniques and theories, and exhilarates in the role of gadfly and disturber of the peace." In contrast, among those workers who have seen many patients with MPD, most of whom taught their techniques in workshops but were unpublished prior to the 1980's, fascinating convergence's as well as differences have been noted. Braun, observing commonalties of videotaped therapeutic behavior among experienced MPD therapists who professed different theoretical orientations, inferred that the clinical realities of MPD influenced clinicians from diverse backgrounds toward similar approaches and conclusions. He offered the hypothesis that in actual treatment settings experienced workers behaved much more alike than their own statements would suggest. Many authorities concur. There is also increasing agreement that the prognosis for most patients with MPD is quite optimistic if intense and prolonged treatment from experienced clinicians can be made available. Often logistics rather than untreatability impede success.

Despite these encouraging observations, many continue to question whether the condition should be treated intensively or discouraged with benign neglect. Concern has been expressed that naive and credulous therapists may suggest or create the condition in basically histrionic or schizophrenic individuals, or even enter a folie á deux with their patients. Arguments to the contrary have been offered. Over a dozen years, this author has seen over 200 MPD cases diagnosed by over 100 separate clinicians in consultation and referral. In his experience, referral sources have been circumspect rather than zealous in their approach to MPD, and he cannot support the notion that iatrogenic factors are major factors. Although no controlled trials compare the fates of MPD patients in active treatment, placebolike treatment, and no treatment cohorts, some recent data bears on this controversy. The author has seen over a dozen MPD patients who declined treatment (approximately half of whom know the tentative diagnoses and half who did not) and over two dozen who entered therapies in which their MPD was not addressed. On reassessment, two to eight years later, all continued to have MPD. Conversely, patients reassessed after treatment for MPD have been found to hold onto their rather well.

Treatment Goals

MPD does not exist in the abstract or as a freestanding target symptom. It is found in a diverse group of individuals with a wide range of Axis II or character pathologies, concomitant Axis I diagnoses, and many different constellations of ego strengths and dynamics. It may take many forms and express a variety of underlying structures. Generalizations drawn from the careful study of single cases may prove grossly inaccurate when applied to other cases. Perhaps MPD is understood most parsimoniously as the maladaptive persistence, as a post-traumatic stress disorder, of a pattern which proved adaptive during times when the patient was overwhelmed as a child.

In general, the tasks of therapy are the same as those in any intense change-oriented approach, but are pursued, in this case, in an individual who lacks a unified personality. This precludes the possibility of an ongoing unified and available observing ego, and implies the disruption of certain usually autonomous ego strengths and functions, such as memory. The personalities may have different perceptions, recollections, problems, priorities, goals, and degrees of involvement with and commitment to the therapy and one another. Therefore, it usually becomes essential to replace this dividedness with agreement to work toward certain common goals, and to achieve treatment to succeed.Work toward such cooperation and the possible integration of the several personalities distinguishes the treatment of MPD from other types of treatment. Although some therapists argue that multiplicity should be transformed from a symptom into a skill rather than be ablated, most consider integration preferable. (I the typer of this page and the creator of this website, Debbie would like to add a note right here: As an MPD patient and one who talks with many other MPDs, I personally feel that it should be transformed from a symptom into a skill rather than be ablated......most MPD patients that I speak with do not consider integration preferable. thank you for allowing me to interrupt.) In a given case, it is hard to argue with Caul's pragmatism: "It seems to me that after treatment you want a functional unit, be it a corporation, a partnership, or a one-owner business."

In this lesson, the terms "unification," "integration" and "fusion" are used synonymously, and are understood to connote the spontaneous or facilitated coming together of personalities after adequate therapy has helped the patient to see, abreact, and work through the reasons for being of each separate alter. Consequently, the therapy serves to erode the barriers between the alters, and allow mutual acceptance, empathy, and identification. It does not indicate the dominance of one alter, the creation of a new "healthy" alter, or a premature compression or suppression of alters into the appearance of a resolution. Operationally.

"Fusion was defined on the basis of three stable months of 1) continuity of contemporary memory, 2) absence of overt behavioral signs of multiplicity, 3) subjective sense of unity, 4) absence of alter personalities on hypnotic re-exploration (hypnotherapy cases only), 5) modification of transference phenomena consistent with the bringing together of personalities, and 6) clinical evidence that the unified patient's self-representation included acknowledgment of attitudes and awareness which were previously segregated in separate personalities."

Such stability usually follows the collapse of one or more short-lived "apparent fusions." and subsequent further work in treatment. Post-fusion therapy is essential.

Modalities of Treatment

Many pioneers in the field of MPD developed their techniques in relative isolation and had difficulty publishing their findings. For example, Cornelia B. Wilbur had extensive experience with MPD and her work was popularized in Sybil, published in 1973, however, her first scientific article on treatment did not appear until 1984. There developed two "literature's," which overlapped only on occasion. The published scientific literature slowly amassed a body of (usually) single case applications of particular approaches, while an oral tradition developed in workshops, courses, and individual supervisions. In the latter, clinicians who had worked with many cases shared their insights. This "oral literature" remained largely unpublished until several special journal issues in 1983-1984.

Psychoanalytic approaches to MPD have been discussed by Ries, Lasky, Marmer, and Lample-de-Groot. It seems clear that some patients with MPD who have the ego strengths to undertake analysis, who are not alloplastic, whose personalities are cooperative, and who are completely accessible without hypnosis can be treated with analysis. However, these constitute a small minority of MPD patients. Some diagnosis being suspected; others also undiagnosed, have had their analyses interrupted by regressive phenomena not recognized as manifestations of the MPD condition. While psychoanalytic understanding is often considered desirable in work with MPD, formal psychoanalysis ought to be reserved for a small number cases. Psychoanalytic psychotherapy, with or without facilitation by hypnosis, is widely recommended. Bowers et al. Offered several useful precepts, Wilbur described her approaches, and Marmer discussed working with the dreams of dissociating patients. Kluft's articles on treatment described aspects of work in psychoanalytic psychotherapy facilitated by hypnosis, but their emphasis was on the hypnosis and crisis management aspects rather than the application of psychodynamic precepts. Kluft described the problems and impairment of ego functions suffered by MPD patients by virtue of their dividedness, and showed how they render the application of a purely interpretive psychoanalytic paradigm problematic.

Behavioral treatments have been described by Kohlenberg, Price and Hess, and most elegantly by Klonoff and Janata. There is no doubt that behavioral regimens can make dramatic transient impacts on MPD's manifest pathology, but there is no extant case report of a behavioral regimen's effecting a successful long-term cure. Klonoff and Janata found that unless the underlying issues were resolved, relapse occurred. Many workers think that behavioral approaches inadvertently replicate childhood traumas in which patients' pain was not responded to, or in confined or bound rather than allowed freedom. In fact, many patients experience them as punitive. Klonoff and Janata are currently working to improve their behavioral regimens to adjust for these problems. At this point in time, the behavioral therapy of MPD per se must be regarded as experimental.

Family interventions have been reported by Davis and Osherson, Beale, Levenson and Berry, and Kluft, Braun, and Sachs. In sum, although MPD is all too often an aftermath of family pathology, family therapy is rately successful as a primary treatment modality. It often can be a valuable adjunct. Empirically, treatment of an adult MPD patient with a traumatizing family of origin frequently does no more than result in retraumatization. However, family interventions may be essential to treat or stabilize a child or early adolescent with MPD. Family work with the MPD patient, spouse, and/or children may allow relationships to be saved and strengthened, and protect the children from incorporating or being drawn in to some aspects of the MPD parent's psychopathology. In general, the concerned others in an MPD patient's family may require considerable education and support. They must bear difficult and crisis-filled cases, their support of the or with a colleague's cooperation, can be critical to the treatment's outcome.

Group treatment of the MPD patient can prove difficult. Caul has summarized the difficulties such patients experience in and impose upon hererogeneous groups. In brief, unintegrated MPD patients may be scapegoated, resented, disbelieved, feared, imitated, and, in many ways, require so much attention at times of switching or crisis that they may incapacitate the group's productivity. The materials and experiences they share may overwhelm the group members. MPD patients often are exquisitely sensitive and become engulfed in other's issues. They are prone to dissociate in and/or run from sessions. So many therapists have reported so many misadventures of MPD patients in heterogeneous groups that their inclusion in such a modality cannot be routinely recommended. They work more successfully in task-oriented or project-oriented groups such as that which occupational therapy, music therapy, movement therapy, and art therapy may provide. Some anecdotally describe their successful inclusion in groups with a shared experience, such as those that have been involved in incestuous relationships, rape victims, or adult children of alcoholics. Caul has proposed a model for undertaking an internal group therapy among the alters.

A number of workers have described the facilitation of treatment with amobarbital and/or videotaped interviews. Hall, Le Cann, and Schoolar describe treating a patient by retrieving material in amytal in treatment. Caul has described taping hypnotically- facilitated sessions, and offered cautions about the timing of playing back such sessions to the patient. While there are some patients whose personalities tolerate videotaped confrontation with evidence and alters from which they were profoundly dissociated, many are overwhelmed by such data or re-repress it. Such approaches are best considered on a case-by-case basis, and cannot be regarded as uniformly advisable or effective. Caul recognizes this and seems to advocate a version of what hypnotherapists refer to as "permissive amnesia," i.e., the patient can see the tape when he is ready to see it (an analogy to the suggestion the patient will remember a traumatic even when he or she is ready to do so).

Hypnotherapeutic interventions have an established role in the contemporary treatment of MPD despite the controversy which surrounds their use. On the one hand, a large number of clinicians have helped a good many MPD patients using such interventions. On the other hand, many prominent and eloquent individuals have raised concerns that hypnosis can concretize, exacerbate, or even create MPD (as noted in the first part of this lesson). Often the debate becomes arcane to those unfamiliar with the literature of hypnosis, and the specialized concerns of forensic hypnosis, in which workers struggle to guard against the induction of confabulated or false memories which are perceived as concrete reality, and, if so reported, can impede the judicial process. The thrust of the clinical literature is that judicious hypnotherapeutic interventions thoughtfully integrated into a well-planned psychotherapy, individualized to a particular patient and oriented toward integration, can be extremely productive and helpful, and that ill-advised hypnotic work, like any other inappropriate steps, may well miscarry. The use of hypnosis in exploration, in accessing personalities for therapeutic barriers, in encouraging alters communication, and in encouraging alters communication, and documented by Allison, Bowers et al., Braun, Caul, Erickson and Kubie, Gruenewald, Horevitz, Howland, Kluft, Ludwig and Brandsma, and Spiegel, among others.

A number of clinicians advocate the provision of a very tangible corrective emotional experience, under rubric of reparenting. They undertake to create experiences within the treatment which offer to nurture the patient through a more positive recapitulation of various developmental issues and to provide more positive interjects. No published article addresses this approach. It is the author's experience that successful treatment does not necessitate such measures.

Also not available in the literature are papers on the successful approaches involving the coordinated efforts of a team of therapists employing several modalities in conjunction. This approach was pioneered by B. G. Braun and R. G. Sachs of Chicago.

Useful Principles and Caveats

According to an empirically-derived model, the patient who develops MPD had (1) the capacity to dissociate, which becomes enlisted as a defense in the face of (2) life experiences (usually of severe abuse) which traumatically overwhelm the nondissociative adaptive capacities of a child's ego. A number of (3) shaping influences, substrates, and developmental factors determine the form taken by the dissociative defenses (i.e., personality formation). Those who remain dissociated are given (4) inadequate stimulus barriers, soothing, and restorative experiences, and are exposed to pressures and further traumatization which reinforce the need for and shape of the dissociative defenses. The elements of the Four-Factor Theory of Etiology have certain implications for treatment. Whether or not a clinician elects to use hypnosis, he ought to be aware of its phenomena, and of how dissociative manifestations may express themselves in clinical settings, especially as psychosomatic and quasi-psychotic presentations. The patient brings his dissociative defenses into the therapy. One must "be gentle, gradual, and avoid imposing upon the patient any overwhelming experience that is not an inevitable concomitant of dealing with painful material. The material to be recovered brings with it the certainty of reliving anguish, and explains these patients' frequent evasiveness, protracted resistance's, and mistrust of the therapist's motives. The patient needs to be empathetically understood across and within all personalities; the therapist must deal with all with an "evenhanded gentle respectfulness, but help the patient protect himself from himself. A mutuality of working together and recognition of the difficult nature of the job to be done is essential. These treatments "sink or swim on the quality of the therapeutic alliance established with the personalities."

Certain principles advocated by Bowers et al. have stood the test of time. In summary, the therapist must remain within the limits of his competence and not rush to apply incompletely-understood and partially-mastered principles and techniques. The therapist must give integration priority over exploring fascinating phenomena and differences. He should help all alters understand themselves as more or less dissociated sides of a total person. The personalities names are accepted as labels, not as guarantees or individual rights to irresponsible autonomy. All alters must be heard with equal empathy and concern. Often one or more will be especially helpful in advising the therapist about readiness to proceed into painful areas. "Encourage each personality to accept, understand, and feel for each other personality, to realize each is incomplete so long as it is separated from the rest of the individual, and to unite with the others in common interests." Respect the patient's distress over facing painful material and the alters' misgivings over integration. Therapy must be gentle. ECT is contraindicated. Psychodynamic psychotherapy is the treatment of choice. Within its context, hypnosis may be valuable for dealing with serious conflicts among alters and, when used synthetically, to help the individual "recognize, consider, and utilize his various past and present experiences, impulses, and purposes for better self-understanding and increased self-direction." Intervene therapeutically with concerned others when necessary. Do not dramatize amnesia; assure the patient he will recover his past when he is able. Bowers et al. cautioned against irresponsible misuse of hypnosis, lest splitting be worsened, yet their classic article did not list "acceptable techniques" as there was a lack of space. Bowers and two co-authors, Newton and Watkins, in personal communications in a recent source within the rubric of the constructive use of hypnosis.

A General Outline of Treatment

Virtually every aspect of treatment depends on the strength of the therapeutic alliance which must be cultivated globally and with each individual alter. In the face of severe psychopathology, painful material, crises, difficult transferences, and the likelihood that, at least early in treatment, the alters may have grossly divergent perceptions of the psychiatrist and test him rigorously, the patient's commitment to the task of therapy and collaborative cooperation are critical. This emphasis is implicit in a general treatment plan outlined by Braun, which has sufficient universality to be applied in most therapy formats. Braun enumerates 12 steps, many of which are overlapping or ongoing rather than sequential.

Step 1 involves the development of trust, and is rarely complete until the end of therapy. Operationally, it means "enough trust to continue the work of a difficult therapy."

Step 2 includes the making of the diagnosis and the sharing of it with the presenting and other personalities. It must be done in a gentle manner, soon after the patient is comfortable in the therapy and the therapist has sufficient data and/or has made sufficient observations to place the issue before the patient in a matter-of-fact and circumspect way. Only after the patient appreciates the nature of his situation can the true therapy of MPD begin.

Step 3 involves establishing communication with the accessible alters. In many patients whose alters rarely emerge spontaneously in therapy and who cannot switch voluntarily, hypnosis or hypnotic technique without hypnosis may be useful.

Upon gaining access to the alters, Step 4 concerns contracting with them to attend treatment and to agree against harming themselves, others, or the body they share. Some helper personalities rapidly become allies in these matters, but it is the therapist's obligation to keep such agreements in force.

History gathering with each alter is Step 5 and encompasses learning of their origins, functions, problems, and relations to the other alters.

In Step 6 work is done to solve the alters' problems. During such efforts prime concerns are remaining in contact, sticking with painful subjects, and setting limits, as difficult times are likely.

Step 7 involves mapping and understanding the structure of the personality system.

With the previous seven steps as background, therapy moves to Step 8 which entails enhancing interpersonality communications. The therapist or a helper personality may facilitate this. Hypnotic interventions to achieve this have been described, as has an internal group therapy approach.

Step 9 involves resolution toward a unity, and facilitating blending rather than encouraging power struggles. Both hypnotic and non-hypnotic approaches have been described. Some patients appear to need the latter approach.

In Step 10 integrated patients must develop new intrapsychic defenses and coping mechanisms, and learn adaptive ways of dealing interpersonally.

Step 11 concerns itself with a substantial amount of working-through and support necessary for solidification of gains.

Step 12 follow-up, is essential.

The Course and Characteristics of Treatment

It is difficult to conceive of a more demanding and painful treatment, and those who must undertake it have many inherent vulnerabilities. Dissociation and dividedness make insight difficult to attain. Deprived of a continuous memory, and switching in response to both inner and outer pressures and stressors, self-observation and learning from experience are compromised. The patients' alters may alienate support systems as their disruptive and inconsistent behaviors and their memory problems may cause them to appear to be unreliable at best. Traumatized families may openly reject the patient and/or disavow everything the patient has alleged.

The alters' switching and battles for dominance can create an apparently never-ending series of crises. Alters identifying with aggressors or traumatizers may try to suppress those who want to cooperate with therapy and share memories, or punish those they dislike by inflicting injury upon the body. Battles between alters may result in hallucinations and quasipsychotic symptoms. Some alters may suddenly withdraw the patient from therapy.

Painful memories may emerge as hallucinations, nightmares, or passive influence experiences. In order to complete the therapy, long-standing repressions must be undone, and dissociative defenses and switching must be abandoned and replaced. The alters also must give up their narcissistic investments in separateness, abandon aspirations for total control, and "empathize, compromise, identify, and ultimately coalesce with personalities they had long avoided. opposed and rejected."

In view of the magnitude of the changes required and the difficulty of the materials which must be worked through, therapy may prove arduousfor patient and therapist alike. Ideally, a minimum of two sessions a week is desirable, with the opportunity for prolonged sessions to work on upsetting materials and the understanding that crisis intervention sessions may be needed. Telephone accessibility is desirable, but firm nonpunitive limit-setting is very much in order. The pace of therapy must be modulated to allow the patient respite from an incessant exposure to traumatic materials. the therapist should bear in mind that some patients, once their amnestic barriers are eroded, will be in states of "chronic crisis" for long periods of time.

The Therapist's Reactions

Working to cure MPD can be arduous and demanding. Most therapists feel rather changed by the experience and believe their overall skills have been improved by meeting the challenge of working with this complex psychopathology. A smaller number feel traumatized. Certain initial reactions are normative: excitement, fascination, over investment, and interest in documenting the panoply of pathology. These reactions are often followed by bewilderment, exasperation, and a sense of being drained. Many feel overwhelmed by the painful material, the high incidence of crises, the need to bring to bear a variety of clinical skills in rapid succession and/or novel combinations, and the skepticism of usually supportive colleagues. Many psychiatrists, sensitive to their patients isolation and the rigors of therapy, find it difficult both to be accessible and to remain able to set reasonable and non-punitive limits. They discover that patients consume substantial amounts of their professional and personal time. Often the therapist is distressed to find his preferred techniques ineffective and his cherished theories disconfirmed. As a result, the therapist may become exasperated with some alters' failure to cooperate with or value the goals of the therapy, and/or their incessant testing of his or her trustworthiness and goodwill.

The psychiatrist's empathic tendencies are sorely taxed. It is difficult to feel along with the separate personalities, and to remain in touch with the "red thread" of a session across dissociative defenses and personality switches. Furthermore, the material of therapy is often painful, and difficult to accept on an empathic level. Four reaction patterns are common. In the first, the psychiatrist retreats from painful affect and material into a cognitive stance and undertakes an intellectualized therapy in which he plays detective, becoming a defensive skeptic or an obsessional worrier over "what is real." In the second, he or she abandons a conventional stance and undertakes to provide an actively nurturing corrective emotional experience, in effect proposing to "love the patient into health." In the third, the therapist moves beyond empathy to counter-identification, often with excessive advocacy. In the fourth, the psychiatrist moves toward masochistic self-endangerment and/or self-sacrifice on the patient's behalf. These stances, however they are rationalized, may serve the therapist's counter-transference needs more than the goals of the treatment.

Therapists who work smoothly with MPD patients set firm but non-rejecting boundaries and sensible but non-punitive limits. They safeguard their practice and private lives. They know therapy may be prolonged, thus they avoid placing unreasonable pressures upon themselves, the patients, or the treatment. They are wary of accepting an MPD patient whom they do not find likable, because they are aware that their relationship with the patient may become quite intense and complex and go on for many years. As a group, successful MPD therapists are flexible and ready to learn from their patients and colleagues. They are comfortable in seeking rather than allowing difficult situations to escalate. They neither relish nor fear crises and understand them to be characteristic of work with MPD patients. They are willing to be advocates on occasion.

Hospital Treatment

An MPD patient may require hospitalization for self-destructive episodes, severe dysphoria, fugues, or alters' inappropriate behaviors. Sometimes a structured environment is advisable for difficult phases of treatment; an occasional patient must seek treatment far from home. Such patients can be quite challenging, but if the hospital staff accepts the diagnosis and is supportive of the treatment, most can be managed adequately. Failing these conditions, an MPD patient's admission can be traumatizing to the patient and hospital alike. An MPD patient rarely splits a staff splits itself by allowing individual divergent views about this controversial condition to influence professional behavior. Unfortunately, polarization may ensue. MPD patients, experienced as so overwhelming as to threaten the sense of competence of that particular milieu. The staff's sense of helplessness vis-à -vis the patient can engender resentment of both the patient and the admitting psychiatrist. It is optimal for the psychiatrist to help the staff in matter-of-fact problem-solving, explain his therapeutic approach, and be available by telephone.

The following guidelines emerge from clinical experience:

1. A private room offers the patient a place of refuge and diminishes crises.
2. Treat all alters with equal respect and address the patient as he or she wishes to be addressed. Insisting on a uniformity of name or personality presence on a uniformity of name or personality presence provokes crises or suppresses necessary data.
3. Make it clear that the staff is not expected to recognize each alter. Alters must identify themselves to staff members if they find such acknowledgment important.
4. Anticipate likely crises with staff; emphasize one's availability.
5. Explain ward rules personally, having requested all alters to listen, and insist on reasonable compliance. If problems emerge, offer warm and firm responses, eschew punitive measures.
6. As such patients often have trouble with verbal group therapy, encourage art, movement, or occupational therapy groups, as they tend to do well in these areas.
7. Encourage a cooperative therapeutic thrust despite staff member's disagreement about MPD; emphasize the need to maintain a competent therapeutic environment for the patient.
8. Help the patient focus on the goals of the admission rather than succumb to a preoccupation with minor mishaps and problems on the unit.
9. Clarify each staff member's role to the patient, and emphasize that all members will not work in the same way. For example, it is not unusual for patients whose therapists elicit and work intensively with various alters to misperceive staff as unconcerned if they do not follow suit, even though it usually would be inappropriate if they did so.

Medications

It is generally agreed that medication does not influence the core psychopathology of MPD, but may palliate symptomatic distress or impact upon a co-existing drug-responsive condition or target symptom. Many MPD patients are treated successfully without medication. Kluft noted six patients with MPD and major depression, and found treating either disorder as primary failed to impact on the other. However, Coryell reported a single case in which de conceptualized MPD as an epiphenomenon of a depression. While most MPD patients manifest depression, anxiety, panic attacks, and phobias, and some show transient (hysterical) psychoses, the drug treatment of such symptoms may yield responses which are so rapid, transient, inconsistent across alters, and/or persistent despite the discontinuation of the medication, that the clinician cannot be sure an active drug intervention rather than a placebo-like response has occurred. It is known that alters within a single patient may show different responses to a single medication.

Hypnotic and sedative drugs are often prescribed for sleep disturbance. Many patients fail to respond initially or after transient success, and try to escape from dysphoria with surreptitious overdosage. Most MPD patients suffer sleep disruption when alters are in conflict and/or painful material is emerging, i.e., the problem may persist throughout treatment. Often one must adopt a compromise regimen which provides "a modicum of relief and a minimum of risk." Minor tranquilizers are useful, but tolerance can be expected, and occasional abuse is encountered. Often high doses become a necessary transient compromise if anxiety becomes disorganizing or incapacitating. In the absence of coexisting mania or agitation in affective disorder, or for transient use with severe headaches, major tranquilizers should be used with caution and generally avoided. A wealth of anecdotal reports describe serious adverse effects; no documented proof of their beneficial impact has been published. Their major use in MPD is for sedation when minor tranquilizers fail or abuse/tolerance has become problematic. Many MPD patients have depressive symptoms, and a trial of tricyclics may be warranted. In cases without classic depression, results are often equivocal. Prescription must be circumspect, since many patients may ingest prescribed medication in suicide attempts. Monoamine oxidose inhibitor (MAOI) drugs give the patient the opportunity for self-destructive abuse, but may help atypical depressions in reliable patients. Patients with coexistent bipolar disorders and MPD may have the former disorder relieved by lithium. Two recent articles suggested a connection between MPD and seizure disorders. Not with standing that the patients cited had, overall, equivocal responses to anticonvulsants, many clinicians have instituted such regimes. The author has now seen two dozen classic MPD patients others had placed on anticonvulsants, without observing a single unequivocal response.

Postfusion Therapy

Patients who leave treatment after achieving apparent unity usually relapse within two to twenty-four months. Further therapy is indicated to work through issues, prevent repression of traumatic memories, and facilitate the development of non-dissociative coping strategies and defenses. Patients often wish and are encouraged by concerned others to "put it all behind (them)," forgive and forget, and to make up for their time of compromise or incapacitation. In fact, a newly-integrated MPD patient is a vulnerable neophyte who has just achieved the unity with which most patients enter treatment. Moratoria about major life decisions are useful, as is anticipatory socialization in potentially problematic situations. The emergence of realistic goal-setting, accurate perception of others, increased anxiety tolerance, and gratifying sublimations augur well, as does a willingness to work through painful issues in the transference. Avoidance coping styles and defenses require confrontation. Since partial relapse or the discovery of other alters are both possible, the integration per se should not be regarded as sacrosanct. An integration's failure is no more than an indication that it's occurrence was premature, i.e., perhaps it was a flight into health or it was motivated by pressures to avoid further painful work in treatment.

Many patients remain in treatment nearly as long after integration as they required to achieve fusion.

Postfusion Therapy

Patients who leave treatment after achieving apparent unity usually relapse within two to twenty-four months. Further therapy is indicated to work through issues, prevent repression of traumatic memories, and facilitate the development of non-dissociative coping strategies and defenses. Patients often wish and are encouraged by concerned others to "put it all behind (them)," forgive and forget, and to make up for their time of compromise or incapacitation. In fact, a newly-integrated MPD patient is a vulnerable neophyte who has just achieved the unity with which most patients enter treatment. Moratoria about major life decisions are useful, as is anticipatory socialization in potentially problematic situations. The emergence of realistic goal-setting, accurate perception of others, increased anxiety tolerance, and gratifying sublimations augur well, as does a willingness to work through painful issues in the transference. Avoidance coping styles and defenses require confrontation. Since partial relapse or the discovery of other alters are both possible, the integration per se should not be regarded as sacrosanct. An integration's failure is no more than an indication that it's occurrence was premature, i.e., perhaps it was a flight into health or it was motivated by pressures to avoid further painful work in treatment.

Many patients remain in treatment nearly as long after integration as they required to achieve fusion.

Follow-up Studies

Case reports and a recent study of the natural history of MPD suggest that untreated MPD patients history of MPD suggest that untreated MPD patients do not enjoy spontaneous remission, but instead many (70-80%) appear to shift to a one-alter predominant mode with relatively infrequent or covert intrusions of others as they progress into middle age and senescence. Most case reports do not describe complete or successful therapies. Many of those which appear "successful" have no firm fusion criteria, unclear follow-up, and offer confusing conceptualizations, such as describing "integrations" in which other alters are still occasionally noted. Using operational fusion criteria defined above, Kluft has followed a cohort of intensively-treated MPD patients and periodically studied the stability of their unification. The 33 patients averaged 13.9 personalities (there was from 2 personalities to as many as 86) and 21.6 months from diagnosis to apparent integration. Reassessed after a minimum of 27 months after apparent fusion (two years after fulfilling fusion criteria), 31 (94%) had not relapsed into behavioral MPD and 25 (75.8%) showed neither residual nor recurrent dissociative phenomena. No genuine full relapse was noted. Of the two with MPD, one had feigned integration and the other had a brief reactivation of one of 32 previously integrated alters when her spouse was found to be terminally ill. Six had alters which had not assumed executive control, and were classified as intrapsychic. Of these, two had new entities: one formed upon a lover's death, the other upon the patient's return to college. Three patients showed layering phenomena, groups of preexisting alters which had been long-suppressed, but were beginning to emerge as other alters were solidly integrated. The other relapse events were partial relapses of previous alters under stress, but those alters remained intrapsychic. Object loss, rejection, or the threat of those experiences triggered 75% of the relapse events. Four of these eight patients were reintegrated and have been stable after another 27 months of follow-up. Three remain in treatment for the newly-discovered layers of alters, and all are approaching integration. One individual worked years to initiate a relapse autohypnotically, and only recently returned for treatment. In sum, the prognosis is excellent for those MPD patients who are offered intensive treatment and are motivated to accept it.

Summary

MPD appears to be quite responsive to intense psychotherapeutic interventions. Although its treatment may prove arduous and prolonged, results are often gratifying and stable. The most crucial aspects of treatment are an open-minded pragmatism and a solid therapeutic alliance.

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