A General Outline of Treatment

Virtually every aspect of treatment depends on the strength of the therapeutic alliance which must be cultivated globally and with each individual alter. In the face of severe psychopathology, painful material, crises, difficult transferences, and the likelihood that, at least early in treatment, the alters may have grossly divergent perceptions of the psychiatrist and test him rigorously, the patient's commitment to the task of therapy and collaborative cooperation are critical. This emphasis is implicit in a general treatment plan outlined by Braun, which has sufficient universality to be applied in most therapy formats. Braun enumerates 12 steps, many of which are overlapping or ongoing rather than sequential.

Step 1 involves the development of trust, and is rarely complete until the end of therapy. Operationally, it means "enough trust to continue the work of a difficult therapy."

Step 2 includes the making of the diagnosis and the sharing of it with the presenting and other personalities. It must be done in a gentle manner, soon after the patient is comfortable in the therapy and the therapist has sufficient data and/or has made sufficient observations to place the issue before the patient in a matter-of-fact and circumspect way. Only after the patient appreciates the nature of his situation can the true therapy of MPD begin.

Step 3 involves establishing communication with the accessible alters. In many patients whose alters rarely emerge spontaneously in therapy and who cannot switch voluntarily, hypnosis or hypnotic technique without hypnosis may be useful.

Upon gaining access to the alters, Step 4 concerns contracting with them to attend treatment and to agree against harming themselves, others, or the body they share. Some helper personalities rapidly become allies in these matters, but it is the therapist's obligation to keep such agreements in force.

History gathering with each alter is Step 5 and encompasses learning of their origins, functions, problems, and relations to the other alters.

In Step 6 work is done to solve the alters' problems. During such efforts prime concerns are remaining in contact, sticking with painful subjects, and setting limits, as difficult times are likely.

Step 7 involves mapping and understanding the structure of the personality system.

With the previous seven steps as background, therapy moves to Step 8 which entails enhancing interpersonality communications. The therapist or a helper personality may facilitate this. Hypnotic interventions to achieve this have been described, as has an internal group therapy approach.

Step 9 involves resolution toward a unity, and facilitating blending rather than encouraging power struggles. Both hypnotic and non-hypnotic approaches have been described. Some patients appear to need the latter approach.

In Step 10 integrated patients must develop new intrapsychic defenses and coping mechanisms, and learn adaptive ways of dealing interpersonally.

Step 11 concerns itself with a substantial amount of working-through and support necessary for solidification of gains.

Step 12 follow-up, is essential.

The Course and Characteristics of Treatment

It is difficult to conceive of a more demanding and painful treatment, and those who must undertake it have many inherent vulnerabilities. Dissociation and dividedness make insight difficult to attain. Deprived of a continuous memory, and switching in response to both inner and outer pressures and stressors, self-observation and learning from experience are compromised. The patients' alters may alienate support systems as their disruptive and inconsistent behaviors and their memory problems may cause them to appear to be unreliable at best. Traumatized families may openly reject the patient and/or disavow everything the patient has alleged.

The alters' switching and battles for dominance can create an apparently never-ending series of crises. Alters identifying with aggressors or traumatizers may try to suppress those who want to cooperate with therapy and share memories, or punish those they dislike by inflicting injury upon the body. Battles between alters may result in hallucinations and quasipsychotic symptoms. Some alters may suddenly withdraw the patient from therapy.

Painful memories may emerge as hallucinations, nightmares, or passive influence experiences. In order to complete the therapy, long-standing repressions must be undone, and dissociative defenses and switching must be abandoned and replaced. The alters also must give up their narcissistic investments in separateness, abandon aspirations for total control, and "empathize, compromise, identify, and ultimately coalesce with personalities they had long avoided. opposed and rejected."

In view of the magnitude of the changes required and the difficulty of the materials which must be worked through, therapy may prove arduousfor patient and therapist alike. Ideally, a minimum of two sessions a week is desirable, with the opportunity for prolonged sessions to work on upsetting materials and the understanding that crisis intervention sessions may be needed. Telephone accessibility is desirable, but firm nonpunitive limit-setting is very much in order. The pace of therapy must be modulated to allow the patient respite from an incessant exposure to traumatic materials. the therapist should bear in mind that some patients, once their amnestic barriers are eroded, will be in states of "chronic crisis" for long periods of time.