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!

next: The Treatment Of Multiple Personality Disorder (MPD): Current Concepts