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Page 4 of 7
Gathering History
The therapist begins to collect and organize data. History must be examined to learn five things about each personality or fragment: 1) who - the name or identifier of each personality state so that he or she can be easily addressed in the future; 2) when - the genesis of each personality state and the duration of time that it has executive control of the body; 3) why - why each personality state appeared, in terms of precipitating and perpetuating events associated with its development (this information might have to be obtained from another personality state) and why it is present at this time in life and/or treatment; 4) where - where the patient was at the time of this personality state's creation, where each personality state fits in the power structure, and where each personality fits into the system of personalities (see mapping below); and 5) what - the function of each personality state and how he or she aids the system as a whole. It is also interesting to learn from individual personality states exactly how each believes he or she was created. Care must be taken when obtaining this information; if the therapist becomes overinvested in its discovery, the progress of therapy may be retarded.
Working With Each Personality State's Problems
When history gathering has given the therapist an idea of the structure of the system, then work can begin on the individual problems of each personality state. This involves focusing on each personality state and sticking to the subject at hand. The therapist should generally not be too distracted by other personalities and new material competing for attention. Limits must be set regarding the amount of time to be spent with each personality state. Often because of time lost in switching, the different personalities feel slighted or believe that the therapist unilaterally reduced their treatment time.
It is not possible to deal with every problem or traumatic event experienced by every personality or fragment. Techniques must be developed to group the issues or to help one personality state be the therapist for others and do some of the therapy internally between sessions.
Another problem is dealing with somatic memories. This is the reexperiencing of specific traumatic memories along with their physiological concomitants. For example, the patient may remember being burned in the past and an actual blister may accompany this verbal report (Braun 1983b). Recall and reexperiencing of trauma is other perceived as if it were actually happening now.
When interacting with MPD patients, the therapist must work at several levels simultaneously. Having a quiet-room session using full leather restraints is not appropriate, nor is any abreactive technique, if a cognitive tree is not available on which to hang and integrate the emotions, behavior, and thought processes in order to make them congruent. Gathering emotions or facts is useless if they cannot be integrated. Abreaction, without cognitive structure, can be dangerous in an MPD patient because it can activate traumatic memories for which the patient has no defense or coping skill. This in turn can lead to an escalation of acting-out behavior and psychological or physical collapse.
Undertaking Special Procedures
Five special procedures can be used at specific times in therapy to uncover data and to help the patient's progress by developing mastery. These are 1) mapping, 2) sand worlds, 3) use of the quiet room and full leather restraints, 4) occupational therapy techniques, and 5) hypnosis. I developed the first three in conjunction with Dr. Roberta Sachs.
Mapping permits a more complex organization of the data that have been collected during the course of psychotherapy. The therapist, but preferably the patient, can draw or chart out the system(s) of personalities and their functions. As therapy progresses, the maps change and thus help to document the patient's progress over time. Maps provide ideas for the direction of therapy as well as how, among whom, and when to do integrations (Braun and Sachs 1986).
Sand worlds are constructed by the patient at appropriate times in therapy and are worked with individually as well as analyzed sequentially over time. These are created using a standard-sized shallow box filled with sand in which all types of small figures and toys are placed to express what the patient is thinking and feeling. Certain objects will take on special significance. This is a form of "play therapy" for these adult patients that allows them, child personalities, and fragments that are nonverbal or preverbal to communicate. It also assists verbal communication. Corrective experiences can be suggested or obtained. Secrets can also be expressed and understood in this manner without having to "tell" (Sachs and Braun 1986).
In the hospital, one might want to judiciously use the quiet room and/or full leather restraints as an adjunct to a special therapeutic procedure. This will produce safety for the patient and the staff, thereby facilitating the expression of emotion in a planned, controlled, and safe manner (Braun and Sachs 1985b; Young 1985).
Developing Interpersonality Communication
The Therapist should encourage interpersonality communication as an early step to co-consciousness and integration. This promotes the sharing of knowledge and information about various experiences in the patient's developmental history, which in turn promotes fusion as different personality states learn about the specific adaptive functions each has in protecting the system. It also allows for a sharing of needs and desires so that mutual influence and co-consciousness can be obtained. Interpersonality-state communication can be done at first via the therapist, then more directly via internal group therapy (Caul 1984). Traditional group therapy for MPD has been described by others (see Coons and Bradley [1985] and Chapter 7 in this book).
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