Dr. Kluft is Assistant Clinical Professor Psychiatry, Temple University School of Medicine, and Attending Psychiatrist, The Institute of the Pennsylvania Hospital, Philadelphia.
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among those workers who have seen many patients with MPD, most of whom taught their techniques in workshops but were unpublished prior to the 1980's, fascinating convergence's as well as differences have been noted.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 Ã¡ 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.
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."