The Therapist's Reactions

Working to cure MPD can be arduous and demanding. Most therapists feel rather changed by the experience and believe their overall skills have been improved by meeting the challenge of working with this complex psychopathology. A smaller number feel traumatized. Certain initial reactions are normative: excitement, fascination, over investment, and interest in documenting the panoply of pathology. These reactions are often followed by bewilderment, exasperation, and a sense of being drained. Many feel overwhelmed by the painful material, the high incidence of crises, the need to bring to bear a variety of clinical skills in rapid succession and/or novel combinations, and the skepticism of usually supportive colleagues. Many psychiatrists, sensitive to their patients isolation and the rigors of therapy, find it difficult both to be accessible and to remain able to set reasonable and non-punitive limits. They discover that patients consume substantial amounts of their professional and personal time. Often the therapist is distressed to find his preferred techniques ineffective and his cherished theories disconfirmed. As a result, the therapist may become exasperated with some alters' failure to cooperate with or value the goals of the therapy, and/or their incessant testing of his or her trustworthiness and goodwill.

The psychiatrist's empathic tendencies are sorely taxed. It is difficult to feel along with the separate personalities, and to remain in touch with the "red thread" of a session across dissociative defenses and personality switches. Furthermore, the material of therapy is often painful, and difficult to accept on an empathic level. Four reaction patterns are common. In the first, the psychiatrist retreats from painful affect and material into a cognitive stance and undertakes an intellectualized therapy in which he plays detective, becoming a defensive skeptic or an obsessional worrier over "what is real." In the second, he or she abandons a conventional stance and undertakes to provide an actively nurturing corrective emotional experience, in effect proposing to "love the patient into health." In the third, the therapist moves beyond empathy to counter-identification, often with excessive advocacy. In the fourth, the psychiatrist moves toward masochistic self-endangerment and/or self-sacrifice on the patient's behalf. These stances, however they are rationalized, may serve the therapist's counter-transference needs more than the goals of the treatment.

Therapists who work smoothly with MPD patients set firm but non-rejecting boundaries and sensible but non-punitive limits. They safeguard their practice and private lives. They know therapy may be prolonged, thus they avoid placing unreasonable pressures upon themselves, the patients, or the treatment. They are wary of accepting an MPD patient whom they do not find likable, because they are aware that their relationship with the patient may become quite intense and complex and go on for many years. As a group, successful MPD therapists are flexible and ready to learn from their patients and colleagues. They are comfortable in seeking rather than allowing difficult situations to escalate. They neither relish nor fear crises and understand them to be characteristic of work with MPD patients. They are willing to be advocates on occasion.

Hospital Treatment

An MPD patient may require hospitalization for self-destructive episodes, severe dysphoria, fugues, or alters' inappropriate behaviors. Sometimes a structured environment is advisable for difficult phases of treatment; an occasional patient must seek treatment far from home. Such patients can be quite challenging, but if the hospital staff accepts the diagnosis and is supportive of the treatment, most can be managed adequately. Failing these conditions, an MPD patient's admission can be traumatizing to the patient and hospital alike. An MPD patient rarely splits a staff splits itself by allowing individual divergent views about this controversial condition to influence professional behavior. Unfortunately, polarization may ensue. MPD patients, experienced as so overwhelming as to threaten the sense of competence of that particular milieu. The staff's sense of helplessness vis-à -vis the patient can engender resentment of both the patient and the admitting psychiatrist. It is optimal for the psychiatrist to help the staff in matter-of-fact problem-solving, explain his therapeutic approach, and be available by telephone.

The following guidelines emerge from clinical experience:

1. A private room offers the patient a place of refuge and diminishes crises.
2. Treat all alters with equal respect and address the patient as he or she wishes to be addressed. Insisting on a uniformity of name or personality presence on a uniformity of name or personality presence provokes crises or suppresses necessary data.
3. Make it clear that the staff is not expected to recognize each alter. Alters must identify themselves to staff members if they find such acknowledgment important.
4. Anticipate likely crises with staff; emphasize one's availability.
5. Explain ward rules personally, having requested all alters to listen, and insist on reasonable compliance. If problems emerge, offer warm and firm responses, eschew punitive measures.
6. As such patients often have trouble with verbal group therapy, encourage art, movement, or occupational therapy groups, as they tend to do well in these areas.
7. Encourage a cooperative therapeutic thrust despite staff member's disagreement about MPD; emphasize the need to maintain a competent therapeutic environment for the patient.
8. Help the patient focus on the goals of the admission rather than succumb to a preoccupation with minor mishaps and problems on the unit.
9. Clarify each staff member's role to the patient, and emphasize that all members will not work in the same way. For example, it is not unusual for patients whose therapists elicit and work intensively with various alters to misperceive staff as unconcerned if they do not follow suit, even though it usually would be inappropriate if they did so.