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 This "oral literature" remained largely unpublished until several special journal issues in 1983-1984.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.