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Treatment of Multiple Personality Disorder

Issues in the Psychotherapy of Multiple Personality Disorder

Edited by: Bennett G. Braun, M.D.
Director, Dissociative Disorders Program,
Rush-Presbyterian-St. Luke's Medical Center

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The 3-P Model Of MPD

The 3-P model of MPD is diagrammed in Figure1. Two predisposing factors are hypothesized to be necessary: 1) an inborn biological/psychological capacity to dissociate that is usually identified by excellent responsivity to hypnosis and 2) repeated exposure to an inconsistently stressful environment. The inconsistency is in the patient's receiving love and abuse for the same behavior, at unpredictable times. An abusive family environment has been the source of this inconsistent stress in the vast majority of MPD cases studied so far. However, other events such as the death of a family member, frequent geographic relocation, and cultural dislocation can also be identified as sources of stress. Both of these predisposing factors are necessary for MPD to develop. Neither alone is sufficient.

The precipitating event in the 3-P model refers to a specific overwhelming traumatic episode to which the potential MPD patient responded by dissociating. If such events are not common in the environment of a patient with a dissociative capacity, then this typically results in a specific dissociative episode. Dissociative episodes are necessary but not sufficient conditions for the development of MPD. Many persons have a number of dissociative episodes throughout the course of their lives. As long as these episodes are not linked by a common affective theme and/or neurophysiological state (Braun 1984d), the person is unlikely to develop MPD.

The perpetuating phenomen associated with the development of MPD are interactive behaviors usually with the abuser and enabler and include separate memories that the patient ultimately links together by a common affective theme. For example, the child who has been abused starts to have pleasant and unpleasant memories of his or her parents. After continuous exposure to inconsistently abusive situations, the patient with dissociative capacity begins to file the memories of these traumatic events separately, and they begin to take on a life history of their own. For each fragment of affectively linked memories, a specific adaptive response to similar traumatic experiences develops. This chaining together of memories and development of associated response patterns is perpetuated by continuous unpredictable environmental trauma (Braun 1984d). Gradually the patient's personality is split because the different adaptive responses to the trauma have become functionally separated by an amnestic barrier. Thus, the patient is not aware that he or she is viewed by others as behaving inconsistently. This leads to the development of different personality states, each of which has its own adaptive function in the face of a particular kind of trauma.

Dissociation And MPD

To dissociate means "to sever the association of one thing from another" (Braun 1984d, P. 171). To this I would now add that what we see as MPD, especially in children, may well be a disorder of lack of association, since a significant association may never have been achieved from which to be dissociated. This makes developmental sense. When we speak of dissociation in the clinical context, we are usually referring to a defensive process. This is unfortunate because normal healthy individuals with a dissociative capacity do so even in the absence of psychological trauma (Frischholz 1985). For example, many people become so absorbed while watching a movie or a play that they temporarily identifying with the actors in the drama (Hilgard 1970; Spiegel 1974; Tellegen and Atkinson 1974). However, these dissociative episodes are unlikely to become united by a common affective theme if they do not occur with sufficient frequency or if their occurrence can be predicted.

Highly traumatic events promote the use of dissociation as a psychological/behavioral defense in persons with an inborn biopsychological capacity to dissociate. If the dissociative individual's psychosocial environment is chronically and inconsistently permeated with traumatic events, then the individual instinctively resorts to dissociation as a defense because the trauma is simultaneously perceived as unpredictable and overwhelming. Such persons are likely to develop MPD especially if inconsistency of love and abuse is present and repeated. If the individual's psychosocial environment has a low potential for psychological trauma, then this person is less likely to use dissociation as a defense and typically is a normal, highly hypnotizable individual. However, in individuals with little or no dissociative capacity, the occurrence of chronic but unpredictable traumatic events is likely to stimulate denial as the primary psychological defense. Such individuals are likely to develop a psychiatric disorder other than MPD.

The trauma is usually associated with some form of inconsistent and unpredictable abuse. For example, a child may be severely beaten or affectionately hugged for the same behavior on different occasions. This usually begins at an early age in the family environment. When an individual with dissociative capacity uses it to defend against such abuse for the first time, he or she learns that the horrible memory can be kept out of conscious awareness. If the abuse is chronic and inconsistent, then dissociation becomes the preferred form of defense because it minimizes the perception of trauma.

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