The treatment of Dissociative Identity Disorder, (formerly known as Multiple Personality Disorder, and throughout thispaper will be referred to by the acronyms DID and MPD,interchangeably) is subject to personal preference, what is best for the patient, and plain dumb luck. The validity of this disorder is controversial, and unsurprisingly, the best way to treat it is subject to intense scrutiny.

     Where does DID come from? The etiology on this disorder appears to be apsychobiological response to a trauma occurring within a specific developmental window(Putnam, 1989).

     The first explanations of MPD comes from the 1800's to the turn of the centuryand is that of spirit possession. In the 1900's to the 1920's the explanations of MPD movesfrom a supernatural occurrence to a more biological one. The belief then agreed on is thatthere is a hemispheric disconnection syndrome, as knowledge of the lateralization of thebrain is discovered (Putnam, 1989).

     It isn't until the 1970's that the etiology of MPD comes to focus on trauma as thecause of DID. Case histories such as that of Sybil, the first case of MPD to bepsychoanalyzed, begins to open up a new level of realization to the psychiatric community.Child abuse is the most common trauma to be reported, namely, incest (68% of patientsreport this as their trauma), reported over an extended period of time (Putnam, 1989).

     There have been no large scale studies on the epidemiology of MPD. However,there are "guestimates." One "guestimate" is that 1 in 20,000 people has MPD (Sizemore,1989).

     Data on demographics are more substantial and give several figures. The female tomale ratio is 5:1 (Putnam, 1989) The reasons behind the prevalence of MPD and women isdebatable. There have been some theories that suggest that there is a genetic disposition tothe ability to dissociate that is gender linked. Cultural determinants may suggest thatwomen "choose" this as a psychological defense rather than any other form. The higherincidence of women with this disorder may also reflect that females are more often abusedthan males (Putnam, 1989). Also, there is speculation that males, often hostile, will end upin the criminal justice system whereas women are in the mental health system.(Putnam,1989)

     Recognizing and diagnosing MPD is a difficult task. Due to the professionalskepticism of MPD, many mental health workers do not have the necessary tools to makea diagnosis of MPD. In a survey of 1,000 psychologists in the APA, 8% of therespondents do not believe in the existence of the disorder. 62% of the respondents thatdo believe in this disorder believe it is extremely rare. 28% believe that DID is feigned forsecondary gain (Cormier, Thelan, 1998). With these numbers, many professionals could beoverlooking the symptoms of this disorder.

     There is a profile that a patient has that does however suggest that DID may in factbe the disorder. Core features of this profile include many prior diagnoses, and the patienthas no relief when treated for these disorders. Psychiatric symptoms include depressivesymptoms, dissociative symptoms, various anxiety and phobia symptoms. The patienttends to have substance abuse issues, hallucinations, thought disorders, delusions, presentcatatonic behavior, and often has recurrent suicidal ideations and self-mutilative behaviors(Putnam, 1989).

     The client is host to a wide variety of neurological and medical symptoms. Thesingle most common complaint is that of headaches, often diagnosed as migraines. Theymay present seizure like symptoms, sensory disturbances (often with a hysterical quality)such as numbness, tingling, and paralysis, namely in the limbs (Putnam, 1989) There ismention of blindness, mutisim, and psychogenic deafness (Sizemore, 1989).

     When a professional begins to wonder if MPD is the issue at hand, he finds himselfwondering how to go about diagnosing MPD, meeting an alternate identity, and thenconfirming the diagnosis.

     The DSM IV has specific diagnostic criteria which include:

1. The presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self).
2. At least two of these identities or personality states recurrently take control of the person's behavior.
3. Inability to recall personal information that is too extensive to explained by ordinary forgetfulness.
4. The disturbance is not due to the direct physiological effects of a substance or a general medical condition.

     When the clinician suspects MPD, there are a few things that they can do toevaluate further. Taking the patients history is the most difficult part of a multiple. Thehistories will have no chronological order and there are often wide gaps in their history fortimes that they cant account for in the present state and wider gaps of history that mayaccount for instances of abuse.

     To be able to diagnose DID the professional must meet an identity. One way toelicit an identity is to go by direct inquiry. Putnam suggests opening with a broad question,such as, has the patient ever felt like more than one person (1989). Often this will open thedoor to more specific questions, for instance, if a patient replies, yes, "I have a part of methat is hostile, or wounded" the clinician can then ask if he may speak to the hostile part.This question often causes distress in multiples as they are often trying to repress theseparts. If these questions do not work, the clinician may have to ask for an identity tosurface. There is conflict in directly asking a patient to present an alter, as there is fear iniatrogenically creating MPD. However, this can prove or disprove the existence of DID inthe individual. When asking for an alternate identity, one should ask in a way that isinviting, not demanding, and calling them by function can prove rewarding. One shouldavoid the word personality, as well, and refer to the alternate identities as parts, facets, orsides, as this is a theme of treatment, as the personalities are part of the whole. When apatient presents the alternate identities on 3 or more occasions, each time acting similarly(Ross, 1989), one can be reasonably certain that this is most likely the case. When theclinician meets the identities, confirmation of the diagnosis can be made. (Putnam, 1989).

     One note, the clinician should make use of a neurological as well as a physicalexam to rule out the possibility that amnesia that often accompanies DID is not organicallybased, caused for instance by a tumor, cerebral vascular accident, or dementing illness. Aphysical exam is useful to detect instances of self mutilation (injuries caused by razorblades and glass can be missed by a casual observation, long sleeves hide arm injury, andstandard clothing can hide injury to breasts, inner thighs, legs, back and buttocks), anddetect scarring from instances of abuse. Also, physical exam can detect surgical scarringthat the patient may or may not remember, suggesting amnesia for important life events(Putnam, 1989).

    There are atypical presentations of DID such as alternate identities, without the amnesia.Another atypical presentation is when post traumatic stress disorder and a pathologicalgrief reaction exists concurrently. Multiples can also be highly functioning, maintainingprofessional jobs, which may include, lawyers, professors, and psychologists.

     When the diagnosis is confirmed, Treatment issues then arise. The first issue intreatment, is presenting the diagnosis to the host identity. Reactions to the diagnosis canvary widely, from the patient feeling like a total failure (hiding the disorder is often a goalin the patient), to feelings of relief that the secret is finally out. The reaction of the patientis usually a good indicator of the way treatment will work, as this is one secret of hislife,and will indicate how he may react to other secrets in his life (Putnam, 1989).

     In therapy, treating the multiple will be a series of tests. These tests will be fromthe patient to the clinician, in order to determine whether or not the clinician is worthy ofthe clients trust.

     When beginning treatment, most clinicians wonder if they have inadvertentlycaused an iatrogenic case of MPD or if they are exasperating the condition. Theseconcerns are caused as the patient suddenly is presenting alternate identities at breakneckspeed. It is not uncommon to meet several, perhaps 7-8 in the next two sessions (Putnam,1989). This is attributed to the fact that they are no longer in the closet, hiding theirmultiplicity, and alters, no longer needing to pretend to be the host show their distinctness.The clinician begins to doubt his ability to treat this disorder. He wonders if he shouldrefer the patient to another clinician, or if he continues treatment, he may cause more of aproblem. Once the clinician continues with therapy, he becomes an instant expert in thefield (Putnam, 1989).

     To begin working with a multiple, there are tasks in treatment. Establishing thetherapeutic alliance is the most important issue in working with a client who is deeplydisturbed. This is the same as any other change oriented treatment, but it extends further.The therapeutic alliance must extend to all the identities with in the system in order touncover the issues that caused the DID. The alliance is not easy, nor will it happeninstantly. The multiple must be heard, and each identity needs to be listened to.Transference issues are strong, particularly concerning issues with the abusive parent. Theclinician must be prepared for this and with time, these transference issues will resolve,provided that the clinician is able to be empathetic and available, especially during times ofcrisis. The patient will be able to break off these issues as trust is won (Putnam, 1989).

     Boundary Management is critical in treating a multiple. Once the frequency of thesessions is set, it must be adhered to. Indeed there are times that a multiple may need to beseen for extra sessions, when there is a crisis or self harm is an issue. Work sessions of anhour and a half tend to be useful (Putnam, 1989). The therapist needs to be availableoutside of the therapeutic sessions, whether it be by calling the answering service, or whatever the clinician and client decide upon. Multiples are prone to having outside of therapycrises. There does need to be made note that the therapist needs to be aware that the clientwill try to manipulate this as a form of a test. (Putnam, 1989)

     Common themes in treating a multiple include trauma abuse from the past, andtrauma abuse in the present. The first involves past abuse situations, or what caused themultiplicity. Trauma in the present includes the stresses of living in a single minded world,and trauma inflicted by the self (Putnam, 1989).

     Control is a major issue in the treatment process. One self or another will try todominate certain areas in the therapeutic process. This tends to cause depression in thehost personality who feels like prior to therapy there were little to no problems (Putnam,1989).

     Multiples are sensitive to rejection, and often see it when it does not exist. Mostmultiples fear that there will be an increase in the rejection now that the diagnosis isconfirmed.

     The issue of secrets is one that permeates the world of MPD. These clients haveworked their entire lives to keep the unbearable pain locked away from themselves. Thisbegins in early childhood while the abuser threatened them with death and pain.

     Transference issues are a vital part of therapy with a multiple. This can help withuncovering abuse issues. For instance, if a therapist touches an alternate personality andthat alter reacts strongly with recalling an instance of abuse, this is a transference issuethat services the client as well as a clinician.

     There are precipitants to a transference reaction. also known as trigger responses.Reality based experiences both in and out of therapy is a high source of transferenceissues. Multiples are easily "triggered" into a total recall of a past event. The host identitymay or may not be aware of what the stimulus was. Many transference reactions aretherapist evoked. Some instances of this include:

     An abreacative episode when the clinician wears some clothing that reminds thepatient of the abuser, the therapist’s stance on an issue, therapeutic interventions, if carriedout in a way that reminds the patient of a disciplinary or other experience in childhood,cancelled sessions, vacations or other separations, or interruptions during sessions, andtherapeutic error (Putnam, 1989)

     There are many forms of transference reactions. How the client will react variesbased upon what triggered the transference episode, and what makes up the personalitysystem. If the system is composed of scared child parts the abreaction may take place thatthe client will act as a scared child part, hiding under the furniture. If the system is mostlycomposed of teen parts that took the abuse, the transference issues will possibly react witha seductive teen. Systems are often composed as having a wide range of alternateidentities and reactions can vary widely, perhaps to confuse the clinician (Putnam, 1989).

     Multiples tend to evoke unique and complex issues with the therapist, resulting incounter-transference issues. Some identities are promiscuous and may cause feelingswithin the clinician, some are easier to get along with and the therapist may align his favorwith this identity. There are also issues about who the patient is and who his allianceshould be with (Putnam, 1989)

     There are a variety of therapeutic techniques that can be implemented in treatingthe multiple. These include talking through, assembling memories, dream work, journals,mapping the personality system, and hypnosis.

     Talking through situations and with the personality system has been proven to beeffective in treatment of MPD. It can lead to "no self harm contracts," boundaries issues,and working with alters in times of crisis. When using talking through techniques, assumethat all identities are listening. Although this is not always true, it helps to make sure thatthe clinician will not make mistakes by saying things that other identities are not supposedto hear. Talking through is best achieved by calling for all identities to listen to what isgoing on. This helps all identities to feel like they are a part of the process, and saves timeand energy on behalf of the therapist. (Putnam, 1989)

     Assembling whole memories from a multiple is a time consuming task. Memoriesof a traumatic event can be held in one alter, or across many identities. One part may havethe memory of a traumatic event, but no emotions, and another part may have the trauma'semotions, but no recollection of the trauma. Assembling the memories in the multiple willlead to acceptance of the trauma, and then lead to healing. (Putnam, 1989)

     Dreams play an important role in treating the multiple. Often, an alter tells thehost or other personalities through the use of dreams, traumas that have occurred. Thiswill open doors for identities that hold traumas to surface and share their own memories.(Putnam, 1989)

     Journals are an excellent way of recovering memories, and mapping the personalitysystem. The use of writing will give the client the feeling of continuity across time. Manyalters will announce themselves through the medium of writing. This also can unite theidentities in a common bond. Each part can add his/her own piece of the puzzle to the lifehistory. (Putnam, 1989)

     Mapping the personality system is a way for the therapist to understand his client.This also is a way for the client to understand himself. Maps can take shape in numerousways, including pie charts, architectural schemes, clock faces. The therapist can use thismap to help generate images, arrange meetings, and so on. Once a map is created theclient and the clinician can use it to see if things are making sense with the way things aregoing in therapy, and to signal if there are any other alters that are unaccounted for.

     Hypnosis can be a useful tool in treating MPD as multiples tend to be easilyhypnotized. There must be precautions in using hypnosis because of the skepticism inMPD. There are concerns about creating MPD iatrogenically (Spanos, 1996). Theinduction of the trances can be done simply by using visual fixation and using repetitivestatements. (Bliss, 1986) Hypnosis can be used to strengthen the ego, break throughamnesiac barriers, contact alters, cause abreaction or age regressions, and recovertraumatic material. This often speeds up the therapeutic process.

     There are no medications proven to treat MPD. Medications can be used to treatnon dissociative symptoms such as depression or anxiety. The most often requestedmedication is that of a sedative, but caution needs to be applied, as these can be thevehicle for suicide attempts. (Putnam, 1989)

     Group therapy is a little studied area in treating the multiple. Putting a multiple in ageneral group therapy tends to be more detrimental to therapy as the other group membersoften see the multiple as a self centered, attention seeking, faking, lying, or guilty ofone-upping the rest of the group. This tends to leave the client feeling isolated. There alsohave been no studies on the effectiveness of group therapy with a group of only MPDpatients. However, there is the risk of multiples trying to out multiple each other.Abrecative triggers are more often reported with this kind of group therapy as one patientshares triggering material.

     Videotaping the therapy session can help teach the client what he acts like whenthey are in a dissociative state. There must be permission across all identities. Theidentities need to be aware of why the taping is taking place.

     Integration is usually the end product of treating MPD. Unsurprisingly there isusually a great deal of resistance to integration. There is a fear in the parts of dying, Thereis fear in the Host of not being able to cope with life as a single person. There are highexpectations that the host will remain a single being, and not rely on dissociation to copewith everyday crisis. The process of integration is a time consuming one, relying on theexpectation that all the parts will be willing to comply. Integration can be achieved viahypnosis, although therapy that teaches the host not to rely on dissociation usually worksbetter. (Sizemore, 1989)

     When a part has resolved its issues that created that particular identity then it canbe ready to proceed with joining the host identity. It can be as simple as one day theidentity is there and the next it is gone or it can be carefully orchestrated by the clinician.(Schriber, 1973, Bliss, 1985) The clinician can use age progression, (Schriber 1973) tobring all the identities to the same age for easier integration, or they can integrate thealters at what ever age they were. The client may opt to remain a multiple, and forcingintegration will just frustrate all the parties involved. However, integration refusal is oftenjust a treatment resistance issue.

     After the dramatic climax of integration, the additional sessions after seem bland.However, it is crucial that the client continues therapy, faced with "single personalitydisorder" (Sizemore, 1989). The client is often faced with fugue episodes. This is causedby the client trying to dissociate into another identity but no identity comes, resulting inthe amnesia. This is a time of confusion, and support is needed, although the client will tryto end therapy.

     Multiple Personality disorder is one of confusion and of pain. It can be trying on allparties involved, but tends to have the ultimate reward, a legacy of pain resolved.

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