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.