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Date:         Thu, 1 Oct 1992 16:30:19 MDT
              <PSYCGRAD@UOTTAWA.BITNET>
From:         jdbecker@ACS.UCALGARY.CA
Subject:      multiple personalities

                   Abreaction in the Treatment
                of Multiple Personality Disorder
                         Jason D. Becker
                      University of Calgary












                                                                1
                          Introduction
   Multiple personality disorder (MPD) is the ultimate
dissociative disorder.The DSM-III-R definitional criteria for MPD
(APA,1987,p.106,as cited in,Putnam,1989) are:
             A. The existence within the individual
                of two or more distinct personality
                states (each with its own relatively
                enduring pattern of perceiving,
                relating to and thinking about the
                environment and one's self).

             B. Each of these personality states at
                some time,and recurrently,takes full
                control of the individual's behavior.

   Although it may seem paradoxical,dissociation,and the creation
of multiple personalities is functional in childhood,and has
great survival value.Ludwig (1983,p.93,as cited in,Putnam,1989)
has outlined seven major functions of dissociation:
             (1) The automatization of certain
             behaviors,(2) the efficiency and economy
             of effort,(3) the resolution of
             irreconcilable conflicts,(4) escape from
             the constraints of reality,(5) the
             isolation of catastrophic experiences,
             (6) the cathartic discharge of certain
             feelings,and (7) the enhancement of herd
             sense (e.g. the submersion of the
             individual ego for the group identity).

   Although MPD has been considered an extremely rare condition

historically,the 1980's and 90's have seen an exponential

increase in the number of cases reported.Ross and Gahan (1988)

estimate that the occurrence of MPD is more common than 1 in

                                                                2

10,000 in the general population.It is becoming increasingly

clear that the contemporary clinician can no longer remain

ignorant of the basic symptomatology,etiology,and treatment of

MPD.

                 Clinical Symptomatology of MPD
   Recognizing and diagnosing MPD is often a very difficult task.
One reason is that MPD symptomatology is complex,and includes a
number of psychiatric,neurological,and medical symptoms.Another
reason is that due to its relative rarity,budding clinical
psychologists and psychiatrists rarely receive exposure to,or
information about,this disorder in their years of clinical
training.A third reason is that the very existence of MPD is
questioned; a widespread professional scepticism of MPD exists.
   Symptoms that should raise the suspicions of clinicians to the
possibility that a patient may have MPD are discussed by Putnam
(1989,p.57-70),and thus most of what follows is taken from this
source.Putnam prefaces his discussion of MPD symptomatology with
the caveat that "In order to detect MPD in a patient,it is
important to look beneath the superficial expression of a given
symptom for possible dissociative dynamics underlying the
process" (p.58).
   The most common psychiatric presenting symptom in MPD is
depression.Many MPD patients also describe "mood swings",and the
                                                                3
"host" personality initially presented for treatment usually has
low self-esteem,is overwhelmed,anhedonic,and generally expresses
a negative outlook on life.Sleep disturbances (e.g. nightmares)
are also common.The main difference between depressive symptoms
in MPD and those found in major depression is that depression in
MPD is not chronic; periods of depression may be interspersed
with periods of happiness or feeling good.
   The most common dissociative symptom in MPD is amnesia or
"time loss".About 80% of MPD patients are unaware of the
existence of alternate personalities,and thus it is not uncommon
for them to find themselves in strange places,suddenly driving
the car,in a conversation with someone they don't know,etc.Other
dissociative symptoms include fugues,depersonalization,and
somnambulism (sleepwalking).Dissociative experiences are often
not reported by MPD patients due to the fact that the experiences
themselves produce a disturbance of memory and recall that
prevents the patient from easily recalling them.
   Anxiety,phobic,panic symptoms may be present in MPD patients
and are often the result of "switching".The host personality may
experience an anxiety attack during switching to other alter
personalities,or,the "cued" aspect of personality switches may
give rise to phobic behavior,in which the patient avoids certain
places,objects,social situations,words,or other emotionally
                                                                4
charged stimuli that may trigger switches to other alternate
personalities or elicit flashbacks of traumatic memories.
   Most MPD patients experience auditory and/or visual
hallucinations.Olfactory and tactile hallucinations have also
been reported but are much less common.
   Patients may also suffer from delusions to the extent that
they feel they are being controlled (which does have some basis
in fact),or that many alters have an intense and incontrovertible
belief that they are separate and can physically harm another
personality without doing harm to themselves.
   Perhaps because of the symptoms described above it is
extremely common to find suicidal behavior in patients with
MPD.Some patients may also engage in self-mutilation.
   At certain times,MPD patients may exhibit thought disorder.
This is caused by a phenomenon known as "rapid switching" or the
"revolving-door crisis",and occurs when no single alter
personality is able to gain and maintain control over the
patient's behavior.The patient may show signs of blocking and
thought withdrawal,and their speech may be a jumble of words that
do not make sense ("word salad").Thought disorder in MPD can be
distinguished from "true" thought disorder by the fact that it is
usually temporary,and is associated with a particular crisis.
   Other psychiatric symptoms in MPD include substance abuse,
                                                                5
transsexualism and transvestism,and catatonia.
   The most common neurological symptom reported in MPD is
headache.Headaches may result from conflicts and struggles for
control among alters,or from "forced switching" (e.g. when a
clinician asks to speak with a different alter).
   MPD patients may exhibit a number of other neurological
symptoms,which may include: loss of consciousness and/or
seizures; convulsions; numbness and tingling in limbs; visual
disturbances; "hysterical" blindness,or deafness,or motor
disturbances; disturbances of gait; paresis; aphonia; oral/facial
twitching (resembling tardive dyskinesia); symptoms associated
with anxiety or panic attacks (labored breathing,palpitations,
chest pain,choking and smothering sensations); gastrointestinal
symptoms; unexplained nausea and/or abdominal pain; and pain
involving the reproductive system.
   In addition to the psychiatric,neurological,and medical
symptoms listed above,MPD patients have been described as
suffering from classical cognitive errors such as all-or-nothing
thinking,personalization,or overgeneralization (Ross & Gahan,
1988).Although spatial limitations restrict an elaborate
discussion of the main points of this fine paper,the core
assumptions of MPD,according to Ross and Gahan (1988),are:
     1. Different parts of the self are separate selves.

                                                                6

     2. The victim is responsible for the abuse.

     3. It is wrong to show anger (or frustration,defiance,a
        critical attitude...).

     4. The past is present.

     5. The primary personality can't handle the memories.

     6. I love my parents but she hates them.

     7. The primary personality must be punished.

     8. I can't trust myself or others.

   It is important to note that Ross and Gahan do not reject
other therapies,favoring strict cognitive therapy.Instead they
believe that the faulty cognitions of MPD may be "points of
therapeutic entry into the clinical problem" (Ross & Gahan,1988,
p.237),and amenable to cognitive therapy.
   The biopsychosocial history of MPD patients may also alert the
clinician to the possibility of MPD.MPD patients commonly receive
extensive medical and neurological examinations for atypical or
unexplained symptoms,as well as for the neurological and medical
symptoms listed above.MPD patients usually remain unhelped by the
standard treatments used for their (mis)diagnosed disorders.
   A very disturbing statistic for MPD patients,and clinicians,is
that the average length of time from first presentation to a
mental health professional for symptoms of MPD to correct
diagnosis was 6.8 years in 100 patients studied by Putnam et al
(1986,as cited in,Putnam,1989).Thus MPD patients may have a
                                                                7
history of multiple previous (mis)diagnoses,and similarly to
their neurological and medical disorders,MPD patients will have a
history of nonresponsiveness to the standard treatments for these
diagnoses and disorders (Putnam,1989).Diagnoses often applied to
MPD patients incorrectly include depression,schizophrenia,
schizoaffective disorder,manic-depressive illness,and a host of
personality disorders (most commonly borderline personality
disorder) (Putnam,1989).
   In terms of work history the MPD patient typically has had
many jobs,and job changes are frequent (Putnam,1989).
                         Etiology of MPD
   Current theories of MPD involve traumatically induced
dissociation.In particular,MPD may be characterized as a
dissociative disorder resulting from childhood trauma.Of the 100
MPD patients studied by Putnam et al. (1986,as cited in,Putnam,
1989),97% reported significant trauma in childhood.Of these
patients the most commonly reported traumas,in rank order were
sexual abuse,physical abuse,physical and sexual abuse,extreme
neglect,witness to violent death,other abuses,and extreme
poverty.Some combination of sexual and physical abuse was
reported by two-thirds of the patients.
   The most commonly reported form of sexual abuse is incest; in
addition to the numerous combinations of oral,genital,and anal
                                                                8
sexual contact,enemas,douches,and other "hygiene" preparations
and utensils are frequently used in sexually and physically
abusive ways with these patients (Putnam,1989).
   Sexual abuse in MPD appears to differ from the sexual abuse
reported by other victims.Sexual abuse in MPD is characterized by
extreme sadism: bondage situations; insertion of a variety of
instruments into the vagina,mouth,and anus; and various forms of
physical and sexual abuse are commonly reported (Putnam,1989).
Putnam asserts that "after one has worked with a number of MPD
patients,it becomes obvious that severe,sustained,and repetitive
child sexual abuse is a major element in the creation of MPD"
(1989,p.49).
   The physical abuse reported by MPD patients appears to be as
equally sadistic and bizarre,and again differs from the types of
abuse found in other victims.Assaults with implements,burning by
matches or steam irons,and cutting with razor blades or glass are
commonly reported by MPD patients (Putnam,1989).Many patients
report that the abuse was ritualized,and some report that it was
done to "cleanse" or "purify" them (Putnam,1989).
   Other abuses reported by multiples include confinement abuses,
and emotional abuse.Confinement abuses involve: tying the child
up; locking the child in closets,cellars,or trunks; stuffing the
child in boxes or bags; or even burying the child alive (Putnam,
                                                                9
1989).Putnam comments that "confinement abuses,which repeatedly
subject a terrified child to prolonged periods of isolation and
sensory deprivation,may specifically contribute to the
development of a chronic dissociative process such as MPD" (1989,
p.49).
   Emotional abuse usually involves ridicule,demeanment,and
denigration,which was often systematically inflicted upon them as
children (Putnam,1989).Threats of violent punishment or other
abuses is common,as is destroying pets in front of the children
as an example of what was going to happen to them (Putnam,1989).
   We still have not answered the question "How do traumatized
children develop MPD?".One answer to this question has been
proposed by Putnam (1989).
   Very briefly,Putnam believes that we are all born with the
potential for multiple personalities,but that through the course
of normal development most of us succeed in consolidating an
integrated sense of self.Patients with MPD do not consolidate an
integrated sense of self because the recurring trauma instead
creates a situation in which it is adaptive for the child to
heighten the separation between behavioral states,in order to
compartmentalize overwhelming affects and memories generated by
the trauma.
   A second substrate proposed by Putnam asserts that the
                                                               10
development of MPD may be facilitated by the propensity of
children to enter into a specific kind of state of
consciousness,the dissociative state.Dissociative states are
characterized by significant alterations in the integrative
functions of memory for thoughts,feelings,or actions,and
significant alterations in sense of self.With their higher level
of hypnotizability,children may be more likely to or more easily
able to invoke dissociative states as defenses against
overwhelming trauma.
   A third substrate proposed by Putnam is the capacity of
children for fantasy in general,and the ability to project
"personality" into objects and situations in particular.
   The number of alter personalities that will develop seems to
be positively correlated with the age at which the abuse began
(and how long it continued),and the severity of the abuse.
   To summarize,victims of MPD rather than integrating a self
across behavioral states,create multiple "selves" by elaborating
a series of dissociative states into alter personalities.In the
context of trauma,this is functional and has survival value for
the child,as it protects them against the overwhelming affects
and memories generated by the trauma.In an adult world that
stresses continuity of memory,behavior,and sense of self,MPD is
maladaptive.
                                                               11
                        Treatment of MPD
   There is no professionally agreed upon treatment or therapy
for MPD.Nor is their any efficacy data on specific techniques or
proposed therapies.Therapists dealing with multiples must rely on
clinical experience,common sense,and the clinical (anecdotal) and
research literature.Therapy for MPD can only be described as
eclectic.
   However,one technique that does appear to be fundamental to
the treatment of MPD is abreaction.Abreaction is defined as the
"emotional release or discharge after recalling a painful
experience that has been repressed because it was consciously
intolerable.A therapeutic effect sometimes occurs through the
partial discharge of desensitization of the painful emotions and
increased insight" (APA,1980b,p.1,as cited in Putnam,1989).
   In order to produce therapeutic benefit,the emotional content
that has been split off and repressed must be recovered and re-
experienced.Abreactions are a painful but necessary precursor to
a stable resolution or integration (Ross & Gahan,1988; Putnam,
1989).Going after past traumas too soon however,before a patient
is stabilized and prepared for the hard and painful work
involved,may lead to pronounced dissociative symptoms and other
crises that may effectively disrupt the therapy (Putnam,1989).
Thus,if the trauma is to severe,or the patient is not ready,the
                                                               12
best policy may be to reinforce the dissociation and prevent
abreaction (Ross & Gahan,1988).
   Inducing abreactions is done primarily through hypnotic or
drug facilitated means,and may be accompanied by external cues
and/or suggestion.Choosing a method of induction is largely
determined by the therapist's experience,the patient,and how
repressed the traumatic material is (how close is it to conscious
awareness).Most therapists favor hypnosis over drug induction
(Putnam,1986,as cited in Putnam,1989),as hypnosis can be rapidly
induced in cooperative subjects,does not have any medical
contraindications,and is easily structured (Putnam,1989).Drug
facilitated abreactions on the other hand,usually require
medical/anaesthesia backup,may be contraindicated in certain
medical conditions,and the patient's level of awareness may be
difficult to control (Putnam,1989).If however,the patient is
resistant,or the therapist has little or no experience with
hypnosis,drug facilitated abreactions may be used.Furthermore,
drug facilitated abreactions can be rapidly induced,and do not
require the level of trust or rapport necessary for hypnosis
(Putnam,1989).Drug facilitated abreactions or "narcoanalysis" is
used primarily in the treatment of post traumatic stress
reactions.Although MPD certainly qualifies,Maoz and Pincus (1979)
have listed those types of patients who are likely/unlikely to
                                                               13
respond to narcoanalysis.The most germane points regarding MPD
are that patients who are likely to respond poorly to
narcoanalysis are: those suffering from psychopathic and other
personality disorders; patients who show persistent regressive
and childish behavior; patients who have already developed a
chronic post-traumatic reaction.The greatest limiting factor in
narcoanalytic treatments for MPD patients is that Maoz and Pincus
recommend that the patient be treated during the first six months
after the trauma,before a neurotic reaction pattern has
stabilized and become chronically embedded in the personality.
Thus although war veterans and rape victims may benefit from
narcoanalysis,the vast majority of MPD patients do not qualify
(exceptions might be those children who have witnessed the
violent death of a family member/their family).
   The role of the therapist,and the physical environment,are two
critically important factors in the abreaction session.
   First and foremost,a sense of safety is absolutely necessary.
The therapist should create an atmosphere of basic trust and
confidence,and reassure,support,and provide structure for the
patient (Maoz & Pincus,1979; Putnam,1989).The therapist helps the
patient re-experience and work through the feelings of pain,
anger,guilt,horror,shame,fear,isolation,hopelessness,and
helplessness evoked by the past experience,and provides support
                                                               14
and reassurance in the here-and-now (Maoz & Pincus,1979).
   The physical setting of therapy is important to the patient's
sense of safety.Privacy must be guaranteed,external intrusions
and interruptions must be minimized,and the environment should
not offer any objects that make convenient weapons (e.g. letter
openers,scissors) or present dangerous possibilities (e.g. open
windows in multi-story offices) (Putnam,1989).For patients who
may become dangerous to themselves or others,unmanageable,or
disruptive,voluntary restraints may be used to ensure the safety
of both the patient and staff (Young,1986).This may be especially
helpful when working with extremely violent or angry alters,child
alters who regress,or so called "running alters".
   Although the abreaction session itself may produce a cathartic
effect,the material obtained from the session must be processed
in "regular" psychotherapy sessions.This "integrative phase"
usually involves organizing the abreacted material into a
coherent,cohesive form for discussion and working through in
which the patient gains insight.
                           Conclusion
   The ultimate goal of therapy is usually integration,or the
"fusing" of the alternate personalities into one core (original)
personality.Sometimes though the core personality has "died" with
the abuse,and integration therefore results in an amalgamation of
                                                               15
the alters.Multiples may also reject integration on the grounds
that it is essentially murder.In cases such as these treatment
may focus on communication among the alters,and being able to
function more effectively and efficiently during the course of
their life.
   At any rate,the probability that a clinician may find
him/herself opposite a multiple is increasing.In order to
differentially diagnosis and effectively treat MPD,today's
clinician must be informed about basic symptomatology,etiology,
and treatment.This involves acknowledging that MPD exists; that
it is a result of severe childhood trauma; that the
symptomatology of MPD is complex,and involves many psychiatric,
neurological,and medical symptoms (of which the clinician should
be informed); and that much of the work in treating MPD revolves
around the recovery/abreaction of dissociated traumas.
   The diagnosis and treatment of MPD is a very complicated
process.This paper does not attempt to provide the reader with
"the answers" regarding diagnostic,etiologic,and treatment issues
in MPD.Rather its purpose was to introduce the perhaps first-time
reader to the important issues regarding this fascinating,but
equally disconcerting disorder.The interested reader may find
Putnam (1989) and Ross and Gahan (1988) particularly helpful.In
addition a number of paperbacks exist that are excellent sources
                                                               16
of information.Particularly good are The Minds of Billy Milligan
(Keyes,1981),and When Rabbit Howls (Chase,1990).
   As a final note,MPD has great potential for increasing our
understanding of the internal dynamics of the human mind.And
until our theories of personality and psychopathology can account
for the processes involved in MPD they remain inadequate and
incomplete.
















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                           REFERENCES
American Psychiatric Association.(1980b).A Psychiatric Glossary
   (5th ed.).Washington,D.C.: APA.
American Psychiatric Association.(1987).Diagnostic and
   Statistical Manual of Mental Disorders,(3rd ed. revised).
   Washington,D.C.: APA.
Chase,T.(1990).When Rabbit Howls.Toronto: Jove.
Keyes,D.(1981).The Minds of Billy Milligan.New York,NY: Random
   House.
Ludwig,A.M.(1983).The psychobiological functions of dissociation.
   American Journal of Clinical Hypnosis,26,93-99.
Maoz,B.,& Pincus,C.(1979).The therapeutic dialogue in narco-
   analytic treatments.Psychotherapy: Theory,Research,and
   Practice,16,91-97.
Putnam,F.W.,Guroff,J.J.,Silberman,E.K.,Barban,L.,Post,R.M.(1986).
   The clinical phenomenology of multiple personality disorder: a
   review of 100 recent cases.Journal of Clinical Psychiatry,47,
   285-293.
Putnam,F.W.(1989).Diagnosis and Treatment of Multiple Personality
   Disorder.New York,NY: Guilford Press.
Ross,C.A.,& Gahan,P.(1988).Techniques in the treatment of
   multiple personality disorder.American Journal of
   Psychotherapy,42,40-52.
                                                               18
Ross,C.A.,& Gahan,P.(1988).Cognitive analysis of multiple
   personality disorder.American Journal of Psychotherapy,42,229-
   239.
Young,W.C.(1986).Restraints in the treatment of a patient with
   multiple personality disorder.American Journal of
   Psychotherapy,40,601-606.


Jason Becker: jdbecker@acs.ucalgary.ca
Comments: Gated by NETNEWS@AUVM.AMERICAN.EDU