PTSD, Dissociative Disorders, Multiple Personality Disorders: Diagnosis and Treatment

PTSD, Dissociative Disorders, Multiple Personality Disorders: Diagnosis and Treatment

Presented at the 1993 AIH Conference, Falls Church, VA.

Abstract: A detailed discussion of the history, diagnosis, and psychiatric management of PTSD, dissociative disorders, and MPD. The cornerstone of therapy is the bringing into conscious awareness repressed memories of abuse and then to utilize those memories to help the patient integrate a new understanding of him or herself into his/her life. A thorough discussion of the roles and pitfalls of transference and countertransference in the treatment of these patients is included.

Keywords: post-traumatic stress disorder, multiple personality disorder, dissociative disorders, psychiatry, sexual abuse, transference, countertransference

I would like to thank Dr. Ted Chapman and the American Institute of Homeopathy for inviting me to talk today about Post-Traumatic Stress Disorder (PTSD) and Multiple Personality Disorder (MPD). Giving this talk gives me the opportunity to integrate two presently dissociated aspects of my own personality, namely psychiatry and homeopathy, and also gives me a chance to find out what people have learned about treating these difficult patients with homeopathy.

Dr. Chapman asked me to describe my path from being a naturopath-homeopath to a medical doctor to a psychiatrist to an MPD therapist. I am not sure I can really do that, but in looking back I think I can remember some aspects of myself as a homeopath which had to change for me to be able to treat these patients.

The first thing was that earlier I did not really regard myself as being a member of a team, and did not acknowledge that others with different expertise than mine would be helpful treating patients. My orientation was more that of, "Just give the right remedy and let it work." Also, I did not acknowledge the importance of a diagnosis, and I say this in the appreciation that one of homeopathy's strengths is in observing the defense mechanism in action without reducing that action to a diagnostic category. Still, I have found utility in having criteria for different illnesses, including being able to describe what one is seeing in a patient to other people. And finally, I was ignorant of psychotherapy as a homeopath, and although I dealt with issues of boundaries, transference, countertransference, and all the rest in every interaction, I was mostly unaware of it. And as I said, all this had to change for me to be able to treat patients with PTSD and MPD.

I imagine there are many people here who have had experience treating these patients, and also who are more knowledgeable about psychotherapy than I was when I was a homeopath, and I hope my talk won't be too elementary for those people. They know how controversial the dissociative disorders, and especially multiple personality is in psychiatry, and that in order to recognize these conditions in patients you have to think about them as possibilities and be open to them. People have spoken of this openness as requiring a paradigm shift in our usual ways of thinking, which should not be too difficult for homeopaths.

So, what does a homeopath need to know to treat post-traumatic stress disorder and multiple personality disorder? As I try to answer this question, let me acknowledge the people who have taught me, especially Richard Loewenstein and Frank Putnam. Putnam's book, Diagnosis and Treatment of Multiple Personality Disorder, has served as the template for this talk.

PTSD and MPD share many things in common, and the treatment of both involves the bringing into consciousness of repressed unconscious material and "working through" it to ultimately help the patient integrate a new understanding of himself or herself into every aspect of the patient's life. This hurts! Memories and the feelings that go with them are normally liked. Trauma modifies this linking. As David Spiegel wrote, "To remember painful events, one must reexperience painful affects (that is, feelings)," and this in a patient for whom survival was based on affect avoidance.

I would like to say a few words about the historical background of these disorders. Post-traumatic stress disorder originates historically in the "hysteria" diagnosed mostly in females by Freud's contemporaries at the end of the nineteenth century, and by shell shock in World War I. In World War II the label was most commonly battle fatigue, and then in Vietnam our modern diagnosis of post-traumatic stress disorder became popular. This diagnosis has also found great relevance for victims of abuse and accidents, witnesses of violence, and both soldiers and civilians in wars.

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Dissociation has a very interesting history. It was of great importance towards the end of the nineteenth century in the works of Janet, Charcot, William James, and Sigmund Freud, early in his career. In the early twentieth century Freud repudiated his early belief that the histories of seduction and incest that his female patients had related to him were historically true, and developed a model that consigned these reports to the realm of fantasy and wish fulfillment. In the 1930's the dissociative explanation declined in popularity, being replaced by the psychoanalytic idea of repression as an active unconscious defensive function responsible for the banishment of unacceptable ideas, affects, memories, and impulses. The renewed interest in dissociation has occurred because of many factors, including an increase in the diagnosis of multiple personality disorder, an increase in the diagnosis of post-traumatic stress disorder secondary to Vietnam, an increase in popular awareness of the persuasiveness of child abuse stem ming from Kempe's description of the "battered child syndrome" in 1962, a return of interest in hypnosis, and probably most fundamentally the women's movement.

Dissociation, it must be remembered, is a normal process, and is something we all do. As Judy Armstrong one remarked, "We can't be all that integrated or we wouldn't talk to ourselves." Some of you may notice that you are listening to my voice and not being aware of the sensation of the chair under your legs, and some of you may also be spacing out, or thinking about lunch: these are all aspects of normal dissociation.

The vast majority of dissociative disorders are traumatically induced. As Spiegel observed, "The way to avoid experiencing pain, fear, and helplessness is to dissociate the memories of events in which those emotions were experienced." In this way dissociation has survival value. As Putnam wrote, "It is a normal process initially used defensively to handle traumatic experiences, which evolves over time into a maladaptive or pathological process when it persists beyond the trauma context." The pathological aspects include constricted involvement with surroundings, superficial or nonexistent relationships, unpredictable reliving of trauma, being susceptible to triggers, such as the noise of a helicopter for a Vietnam veteran, or being susceptible to different stressors, such as marriage, pregnancy, childbirth, deaths of parents, etc.. This susceptibility can lead to nightmares, flashbacks, and affect states in which trauma reoccurs in overwhelming reenactments. Thus this defense to overwhelming trauma can become a mechanism by which the individual feels psychologically helpless once the trauma has passed.

I would next like to go over the definitions of some of these illnesses from the Diagnostic and Statistical Manual of Mental Disorders, known as the DSM, now in its third, revised edition. You should all be aware that the DSM is a document that was initially developed as a research tool to give researchers common definitions for psychiatric illnesses, and that it is a highly political document, which is to say that the definitions in the DSM are never universally agreed upon, and are always, up to this point, in a state of evolution. So it is not the last word, but it is a reasonably well-accepted area of agreement for diagnoses.

Post-traumatic stress disorder is defined by four criteria. The first is an event outside the range of usual human experience, which can include such experiences as witnessing domestic and community violence and experiencing natural and man-made disasters. The second criterion is that the event is persistently reexperienced in ways such as recurrent and intrusive recollections, recurrent dreams, sudden acting or feeling that the traumatic event were recurring, and intense psychological distress at exposure to events that symbolize or resemble an aspect of the traumatic event. The third criterion is persistent avoidance of the stimuli associated with the trauma, as indicated by such actions as efforts to avoid thoughts or feelings associated with the trauma, inability to recall important aspects of the trauma, diminished interest in significant activities, feelings of detachment and estrangement from others. The fourth criterion is persistent symptoms of incased arousal, reflecting increased activity of the autonomic nervous system as reflected in such symptoms as insomnia, irritability, poor concentration, hypervigilance, and exaggerated startle response. Note that PTSD may include both symptoms of numbing, amnesia and avoidance, as well as symptoms of increased activity, such as flashbacks, nightmares, and hypervigilance.

The incidence of PTSD has been estimated as follows: In 1991 Breslau interviewed 1,007 young urban adults. He found that 40% had a positive history for a traumatic event. Davidson found that 1 in 4 Americans younger than 30 have been exposed to a life-threatening experience of self or others, making PTSD one of the most common psychiatric diagnoses, perhaps surpassed only by simple phobia, depression, and alcoholism.

These figures emphasize the high prevalence of PTSD in our society and make it incumbent upon all of us who work with patients to take a trauma history with every patient, as well as an abuse history. Very often these life experiences will not be reported unless they are specifically asked about.

Dissociative disorders as a group are defined as follows in the DSM: "The essential feature of these disorders is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness," and this spans a continuum from daydreaming to MPD. In a nutshell, this means that events that would ordinarily be connected are divided from one another. This is a protective mechanism, as well as being a way of preserving memories without having to be conscious of them.

I will briefly outline the definitions of the dissociative disorders in the DSM-III-R.

Psychogenic fugue is a sudden unexpected travel from home or work with an inability to recall one's past, and the partial or complete assumption of a new identity. There is usually an acute traumatic precipitant to fugue states.

The next is psychogenic amnesia, which is the sudden inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness. This also usually occurs after a traumatic event.

There is depersonalization disorder, which is an experience of being detached from one's mental processes or body, or an experience of feeling like an automaton, or as if in a dream. This includes anesthesias, paresthesia, perceived changes in body size, and out-of-body experiences.

And finally, there is multiple personality disorder. There are two diagnostic criteria for MPD. The first is the existence within the person of two or more distinct personalities or personality states, each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self. And the second is, at least two of these personalities or personality states recurrently take over the full control of the person's behavior.

MPD is, after Putnam, "a psychobiological response to a relatively specific set of experiences occurring within a circumscribed developmental window." In this sense it is a developmental disorder, and interestingly, the period of development is roughly correlated to the period in life of highest hypnotizability in young children.

Historically, MPD was explained as a possession state or as a past life experience, perhaps. Today, current theories revolve around trauma as the cause of dissociative states, especially severe, sustained, and repetitive childhood sexual abuse, but, also including emotional abuse such as systemically-inflicted ridicule, demeanment, denigration, and intimidation, and also perhaps witnessing the abuse of others or the violent death of a relative or close friend, etc..

So, we must first ask ourselves, how prevalent is childhood trauma and sexual abuse?

In 1968, sociologist Dianna Russell, at Mills College, studied 910 women in San Francisco. When she defined sexual abuse as being "any kind of expletive sexual contact or attempted sexual contact, not including exhibitionism or advances and propositions without contact, she found that 16% of the women had at least one experience of incestuous sexual abuse before the age of 18. If extrafamilial abuse was included, the percentage was 38% of the women before the age of 18. When she added exhibitionism and advances to the question, 54% of the women had expletive sexual experiences before that age of 18. Of the 930 women, 17% had at least one experience of nonforcible genital intercourse, rape, or attempted rape.

In 1985, the AMA, a conservative organization, estimated that more than one million children were abused per year, and that there were two thousand to five thousand deaths from child abuse each year.

In a 1986 survey by Putnam at the National Institutes of Mental Health, of 100 MPD patients, 97% reported significant childhood trauma, including 84% with histories of sexual abuse, 68% with specific incest histories, and 75% with histories of physical abuse.

What these numbers mean is that trauma is extremely common in our society, and that physical and sexual abuse towards women and children is pervasive.

What makes an event traumatic is, in part, an experience that is shameful and life-threatening, especially in which another person directly intended harm, and for which the victim was unprepared. The reaction is both cognitive and psychological. Trauma creates a situation where it is adaptive for a child or an adult to heighten the separation between behavioral states in order to compartmentalize overwhelming affects and memories generated by the trauma. An example of this which many of us may have experienced is being in an automobile accident and walking away from the accident without feeling the fear of the accident for hours or days.

Trauma encourages children and adults to use their abilities to enter dissociative states, an enhanced ability in children, which provide escape from the constraints of a painful reality, containment of traumatic memories and affects outside of normal conscious awareness, alteration or detachment of the sense of self, so that the trauma seems to happen to "someone else" or to a depersonalized self, and analgesia. This is true in PTSD as well as in MPD.

As Putnam has written, "In childhood, these dissociative states can become endowed with psychological and physical attributes associated with feelings and body images evoked by the trauma. This is a life-saying solution for an otherwise powerless, traumatized child. However, it becomes maladaptive when the trauma ceases, in an adult world that stresses continuity of memory, behavior, and a sense of self."

Regarding epidemiology, we estimate that 1% of the US population has MPD, about the same prevalence as schizophrenia. The diagnosis is made in women compared to men at a ratio of between 5 to 1 and 9 to 1. This may reflect girls' increased risk of physical and sexual abuse over boys for longer periods of time, and may reflect a tendency for men to react to abuse with criminal behavior more frequently than women, and perhaps to wind up in the criminal justice system more often than in the mental health system.

The average age at diagnosis of MPD is 28.5 years, and patients often have a long psychiatric history with many diagnoses. There is an average of 6 to 8 years between a patient's first contact with the mental health system and the diagnosis of MPD.

The symptom profile for PTSD as well as for MPD includes a profusion of psychiatric, neurological and medical symptoms with many diagnoses, extensive work-ups for atypical and unexplained symptoms, and poor responses to the standard treatments for the diagnoses, as well as a history of victimization. Patients will have often received previous psychiatric diagnoses of schizophrenia, bipolar disorder, schizoaffective disorder, personality disorders, especially borderline personality disorder, and epilepsy.

So to give you an overview of how patients with PTSD and MPD may present to your offices, I want to go through the common symptoms with which these patients may present.

The first are psychiatric symptoms, and the most common is depression. Depression is the most common presenting symptom in undiagnosed patients with MPD. In the NIMH survey of 100 MPD patients I mentioned, 88% of the patients complained of depression and 75% complained of mood swings. There is a frequent history of suicidal thought and attempts. The typical MPD patient who you first see, that is, the part of the system of alter personalities who presents to your office and who is sometimes referred to as the "host," is overwhelmed, anhedonic, negative, with low self-esteem. There may be complaints of decreased concentration, fatigue, sexual difficulties, and crying spells. Often there are sleep disturbances of the PTSD variety, including nightmares and terrifying hypnagogic phenomena, meaning phenomena when one is falling into sleep or waking up.

The next category is dissociative symptoms. It may take months before the patient will discuss these. These may include amnesia or a sensation of losing time, fugue episodes, and symptoms of depersonalization.

The patient may have symptoms of anxiety with such symptoms as dyspnea or palpitations, or may have phobic-like behavior to triggers, which can be any emotionally-charged stimulus.

The patient may have a history of substance abuse, and once again this may have to be specifically asked for. In the NIMH survey, one third of the patients had histories of polydrug abuse.

The patient may complain of hallucinations: of auditory hallucinations experienced as "loud though rs," or of such visual hallucinations as changes in the perceived body image; for example, when looking in a mirror. In the NIMH survey, 5 to 12% of the patients also complained of olfactory and tactile hallucinations.

There may be symptoms of thought disorder. Rapid switching among alters, which some patients refer to as "rolodexing", may resemble psychosis, with symptoms of thought blocking, thought withdrawal, and "word salad" speech.

The patient may complain of delusions, such as seeing himself or herself as a child, or of an alter personality insisting that he or she can hurt the body without it affecting that alter. The patient may have symptoms of catatonia.

There are likely to be suicidal and self-mutilative symptoms. In the NIMH survey, three-fourths of the patients had made at least one serious suicide attempt, and one-third of the patients had engaged in self-mutilation, usually cutting and burning. The self-mutilation may be bizarre, including mutilation of the genitals, or self-injection of HIV-positive blood.

There may be symptoms of transsexualism and transvestitism. Many MPD patients have alters who consider themselves to be of the opposite gender from the "host", and MPD patients will often wear gender-neutral clothing.

There may also be symptoms of sexual dysfunction, eating disorders, and the stigmata of borderline personality disorder. Regarding borderline personality disorder, recent research in Holland and in this country has found a significantly greater rate of histories of abuse in patients with borderline personality disorder than in controls.

Patients may present to your offices with neurological and medical symptoms, the most common of which is headaches, but also including syncope, seizure-like episodes, paresthesias, visual disturbances, functional limb paralysis, paresis, aphonia, etc.. Medical symptoms may include cardiorespiratory symptoms such as dyspnea or chest pain, or choking and smothering sensations, which may reflect specific abuse histories; GI symptoms such as functional bowel disorders, nausea, and abdominal pain; and, in a third of the cases, genitourinary symptoms and pain.

To diagnose MPD, one must first remember that the history-taking itself will often be de, stabilizing for the patient. On the other hand, one must be suspicious about MPD, and ask questions specifically about child abuse and incest.

Beware of MPD in patients whose histories lack a clear chronology with many inconsistencies, or who frequently say, "I can't remember," or who complain of terrible memories. As Putnam said,"If you begin to wonder who has the memory problem, you or your patient, consider MPD."

Ask about amnesia and lost time. For example, "Do you find yourself dressed in clothing that you don't remember putting on? Do you lose time? Do you find clothes in your closet you would never wear? Do you find objects in your home you do not remember buying? Do people act like they know you without you remembering them? Do you ever find yourself in a place without remembering how you got there?

Ask about symptoms of depersonalization and derealization. For example, "Do you ever feel you are watching yourself as if you are watching a movie or another person? Do you ever feel that you are unreal, mechanical, or dead?"

Ask about common life experiences. For example, "Have you often been called a liar when you believed you were telling the truth? Is there a history of erratic school performance? Is there a history of flashbacks, nightmares, intrusive images? Do you ever remember a past event in a way that was so vivid and so real that it seemed as if it were happening again? Do you awake in the morning with evidence that you were up during the night? Do you possess knowledge or skills you don't remember having acquired, such as foreign languages, musical or job skills? You may also consider asking family members for evidence of dissociation.

With all of these conditions, you must rule out organic disorders, including closed head injury, tumor, CVA, dementia, intoxication, seizure disorder, and other psychiatric disorders, including schizophrenia, psychotic depression, and as one wit put it, normal adolescence.

I would like to outline the stages of treatment of patients with MPD. Much of this is very relevant for patients with PTSD.

The most important step in the treatment of these patients is the establishment of a therapeutic alliance. The development of trust is a key issue, remembering that a common transference expectation is that the therapist is a cruel, harsh, and abusing parental figure. You must try to provide consistency and continuity for a patient whose life-long experience is that dependable relationships are impossible, and these patients are exquisitely sensitive to rejection, real or perceived.

You must try to provide proper caring, including modeling respect for all alters without developing favorites, setting limits on dangerous and destructive behaviors, as well as on inappropriate behavior towards the therapist. By doing so you will model self-respect for a patient for whom that is a nebulous concept.

One must also try to tolerate the patient's history, and to be sensitive to the difficulty of the abreactive work. As Putnam wrote, "Successful replacement of dissociative pathology is, in large part, dependent on a recovery and reworking of early traumatic events....This is the major task in the therapy of MPD and represents the bulk of the therapy." This is different from psychotherapy with patients whose histories do not include extensive trauma.

The next step in the therapy is actually meeting the alter personalities. This confirms the diagnosis of MPD. This may be terrifying for the patient: that he or she is not alone in the body; that he or she may not be able to suppress other personalities any longer, and that, "all hell will break lose." "The revelation of the multiplicity may seem like a devastating failure to the patient."(Putnam).

You may find yourself needing reminders that the alters are not separate people, and that all of the alters together constitute the personality of the patient. You should also assume that all alter personalities are listening all the time.

Types of alter personalities include the "host," which is the one with executive control most of the time, as well as children, persecutor, internal self-helpers and protectors, suicidal parts, promiscuous parts, cross-gender parts, substance abusers, demons, spirits, etc..

Alters are involved in a structure that, by dissociation, "binds pain and horror by dividing it into little parts and storing it in such a way that it is difficult to reassemble and remember." (Putnam), and so the core work in the treatment of the victims of MPD is the uncovering and working through of secrets.

As one meets the alters one begins to gather history about the origin, functions, attributes, relationships, and agendas of each of the alters, and one develops a working relationship with the alter system.

It is also time for initial stabilizations which include contracts for safety and ending present abusive situations, including drug and alcohol abuse.

The patient's acceptance of the diagnosis must begin at this point, although practically speaking this is an issue that many patients have terrific difficulty with throughout much of the treatment.

A simultaneous step is the development of communication and cooperation among the alter system. Often there are alters who will deny the existence of other parts of the mind, so one must start to develop means of internal communication, establishment of common goals, and the development of an internal decision-making process.

After this has begun, the patient is ready to begin metabolizing the trauma, which is exceedingly painful, and means making a conscious decision to re-live, re-feel, and remember those things that were initially dissociated precisely because they were so painful. The metabolizing of the trauma constitutes the bulk of the therapy.

As the trauma is worked through, the patient approaches resolution and, in many patients, integration of alters, and then the development of post-resolution coping ski!Is, including consolidating gains and substituting non-dissociative defenses to deal with life stress, and developing a new and more integrated sense of personal identity.

And finally, this is followed by grief work, often for the loss of the alters, but more for the loss of many years of life because of the abuse and trauma.

I would like to touch on a few common themes and issues in the therapy of these patients. The first is the need for boundary management, including frequency of sessions, length of sessions, money, availability of the therapist outside of sessions, and so forth; this will be spoken about later by Miranda Castro. As Richard Kluft tells his patients, "I am on call, but not on tap."

Another-common theme is control. As Putmam wrote, "The host's desperate struggle to maintain control and the apparent frailty of this control is often mirrored in the therapist's feelings of loss of control over the treatment process...Struggles for control in therapy should be understood as mirroring internal struggles among the alters for control of the patient's behavior; struggles for control of the dissociated material the patient is permitted to experience consciously; and the need of a victim to be in control so that "it" never happens again." As Kernberg said, "It is as if the patient's life depends on keeping the therapist under control."

Another common issue is rejection. These patients are exquisitely sensitive to rejection, and many multiples will repeatedly force the therapist into acceptance-rejection situations as part of the testing that goes on in therapy.

There is the issue of secrets: of the past as well as of the present, including on-going abuse. "Much of the treatment involves the slow unwrapping of secrets and the processing of their contents." (Putnam). Patients often have internal and external injunctions against telling their secrets.

There are set-ups and tests of the therapist by the patient. Putnam wrote,"Fear of abuse by the therapist, as by the parents, etc. before, can paradoxically lead to frequent maneuvering by the patient of the therapist into situations where he or she may symbolically recapitulate an original abusive situation, especially around contracts and boundary management issues."

Another testing area is the therapist's ability to hear, recognize, deal with, and tolerate traumatic material. It is as if the patient is thinking, "Will the therapist find me to be the degraded and worthless human being -- or monster -- that I believe I am?"

Another important issue in therapy is, "What really happened?" Such questions are often sources of painful confusion for the MPD patient as well as for the therapist. "Confusion of past and present, of real and unreal, and of dream, fantasy and memory may overwhelm the patient at times. Not uncommonly, patients will retreat into a phase during which they announce that they "made it all up." Understandably, both patients and therapists will wish for some tangible truth as to what really did happen. Unfortunately, in the majority of cases, no hard incontrovertible evidence remains beyond the physical and psychological scarring of the patients....The real test of the authenticity of MPD is the test of time." (Putnam).

There may be themes of recapitulation of the abuse in the therapy. This occurs on two levels: within the personality system in which persecutor alters may harm the body, as well as within the therapy. This is usually symbolic, "but in some cases of therapist psychopathology, it may lead to sexual acting out" and other forms of abusive behavior. As Putnam wrote, "a therapist who feels forced to do something aversive to the patient for the `sake' of the patient should think again."

There are many issues in the therapy of guilt and shame, and these may well include reality-based guilt feelings, such as those of a patient of mine who remembered during treatment that she had physically abused her teenage daughter when the daughter was an infant.

There are many body image issues for these patients, and these may lead to mutilation of the breasts or genitals, or requests for sex-change operations. These issues can also be expressed in a cavalier attitude towards the body, where some alters abrogate any responsibility for the body's safety to other parts of the alter system.

There is often am bivalence about treatment, which is a property of the alter system as a whole. This can lead to resistances to treatment, which, besides pointing out therapist error, may include attempts to prevent expression of the disturbing material. These resistances can take the form of fugues, trances, depersonalizations, acting out, internal uproar and acute decompensations.

MPD patients often get conversion symptoms which can be highly symbolic of the material which they conceal. But one always has to remember that these patients can get "real" medical illnesses too.

Next, I would like to say a few words about transference. Transference is defined as "responses to a therapist that are primarily based on, and displaced from, significant childhood figures, especially parents and siblings."

In the treatment of multiple personality disorder, there may be a transference relationship towards the therapist for each personality. For example, if the I therapist touches the patient, one alter may feel nurtured, another alter may feel it is abusive or will lead to abuse, while a third alter regards the touch as a welcomed invitation to sexual intimacy. As the saying goes,"With a multiple there are usually more than two sides to a story." Cleft suggests that we understand this seeming deception by the MPD patient "as a re, enactment in the transference of a desperate coping style, rather than proof of"poor character." If you work with patients with multiple personality disorder, you will be tolerated by some alters, liked by other alters, loved by other alters, despised by other alters, and, at times, murderously hated by yet others.

Several of us today are going to talk about countertransference issues. We believe that this is such an important topic that it would not hurt to approach it from a number of different points of view.

Countertransference is defined as "those responses on the part of the therapist towards the patient which are displaced from earlier figures in the therapist's experience; I am also using the term to refer to the unconscious reactions of the therapist to the patient that affect the therapy. Transference and countertransference occur in all relationships and are neither good nor bad. Like a lot Of therapy issues, especially in MPD treatment, you do not see these phenomena unless you look for them. The issues of transference and countertransference are not stressed outside of psychiatry and other psychotherapeutic disciplines, and consciousness of them can be used to aid the therapy, while unconsciousness of them can lead to all kinds of trouble.

"Many of the alters of a multiple patient are likely to engender distinct and separate countertransference responses within the therapist. Thus, a therapist.., may simultaneously be aware of hostility towards one alter, sexual feelings towards another alter, and a wish to hold and nurture a third alter." (Putnam). The disorder itself also evokes a variety of responses within the therapist ranging from fascination to fear. This can reach a degree where the therapist, as Steven Manner says, "sometimes experiences dissociation and confusional states as the patient evokes in the therapist what the patient has experienced." And it is not only dissociation which can be transferred to the therapist. As Judith Herman has written,"The patient's palpable anxiety is highly contagious."

The therapist may find him- or herself confused as to who is the patient: is it the host? is it some of the alters? It can also be difficult to keep all the information straight when you find yourself taking life histories from dozens of different alters of one patient.

There is a countertransferential issue of being "real" with the patient. As Putnam wrote, "Multiples push against every traditional therapeutic boundary...Every therapist must come to some equilibrium between the reality-based need of the multiple to be responded to in an active, direct or real manner, and the therapist's need to maintain a therapeutic stance toward the patient in which he or she is both comfortable and effective. One must be flexible in order to be effective with multiples, and yet one must be rigid with regard to certain treatment boundaries or the therapy degenerates into chaos. Such paradoxes permeate the treatment of MPD."

These patients can seem to be undergoing ceaseless change which can be frustrating to the therapist and lead to an overreaction to pathological behavior in the patient. "Multiples seem to teeter continuously on the brink of total disaster." (Putnam), and it can be a great stress to treat patients who are chronically suicidal and often acutely suicidal.

The therapist may have difficulties in hearing the details of the patient's past trauma. Trauma is contagious, especially in the hypnotic field of the dissociative patient. The therapist may feel that he or she is in mourning. Herman reports that "therapists working with survivors of the Nazi Holocaust report being `engulfed by anguish,' or `sinking into despair.' The hopeless feelings are extremely contagious. Repeated exposure to stories of human rapacity and cruelty inevitably challenges the therapist's basic faith, and heightens the sense of personal vulnerability."

The patient also may have been both a victim and a victimizer, and this can lead to countertransferential feelings in the therapist of anxiety, rage, revulsion, fear of death, concern, sympathy, and a sense of helplessness.

The therapist may unconsciously identify with the perpetrator of the trauma. As Judith Herman has written, "This experience may be horrifying for the therapist, and represents a profound challenge to her identity as a caring person. Sarah Haley, a social worker who has worked with veterans, writes, `The first task of treatment is for the therapist to confront his or her own sadistic feelings, not only in response to the patient, but in terms of his or her own potential as well.'" As Krystal wrote, "What we cannot own up to, we may have to reject in others." Furthermore, as Putnam wrote, "Empathic reactions elicited in the therapist by the details of childhood physical and sexual abuse can be powerful, and may lead to sadistic, punitive, voyeuristic and sexual impulses in the therapist."

In the therapy and in abreactions, the patient may blame the therapist for making him worse, not better. (This should be no problem for homeopaths!) This may lead to a therapist's reluctance to follow up clues of undisclosed trauma. The treatment of these patients is, of itself, traumatic, and it can feel traumatic for both the therapist and the patient.

The therapist may also suffer from "bystander guilt," and assume too much responsibility for the patient's life, with the attendant risk of burnout. Herman has written, "The therapist may wish, consciously or unconsciously, to compensate for the atrocious experiences the patient has endured. Impossible expectations are inevitably aroused and inevitably disappointed. The rageful struggles that follow upon disappointment may replicate the initial abusive situation, compounding the original harm."

With these patients there is also a real possibility of seduction, both as a form of testing and as an attempt to gain control over the therapist in perhaps the only way that the patient had the illusion of control over her abusers in the past. At some point in the therapy, the therapist can virtually count on a seduction attempt by the patient, and it probably does not matter much what the sexes are of the patient or of the therapist.

Furthermore, multiples evoke desires and fantasies of rescue in many therapists under the intense pressures of traumatic transference and countertransference. As Joan Turkus has written, "The helplessness of the victimized patient almost seems contagious." Patients have to be helped to see that they themselves are responsible for their behavior and recovery.

Next, many therapists suffer from the fantasy of being the greatest MPD therapist in the world. Putnam writes, "Therapists' tendencies toward feelings of omnipotence and grandiosity are actively fostered by MPD patients as part of testing and set-ups," and are supported by therapists' defenses against feelings of helplessness. "Multiples have an uncanny ability to activate grandiose and self-righteous feelings of rescue, and unless this tendency is analyzed and controlled, the potential for corrupting the therapy relationship is great. Such extreme boundary violations [as sexual contact between the patient and the therapist], are frequently rationalized on the basis of the patient's desperate need for rescue and the therapist's extraordinary gifts as a rescuer." (Herman).

Next, the therapist may have to deal with being "bad-mouthed" by the MPD patient. The defamed therapist may well feel deceived, betrayed, abused, and angered by the patient he has worked so hard to help. In the patient, any positive feelings towards the therapist will be counterweighted by negative feelings. For example, one of my patients, after twenty months of three-times-a-week therapy, said that she had allowed herself to rely on me and feel some trust in me. Within ten minutes, two alters, with which I had worked very closely, came out to say that they no longer trusted me and did not want to work with me any more.

The therapist may also be concerned about colleagues' reactions to working with MPD patients. This may be particularly true of psychologists, psychiatric nurses, and social workers who rely on psychiatric back-up.

In this minefield, as Herman has written, "the two most important guarantees of safety are the goals, rules, and boundaries of the therapy contract and the support system of the therapist." And I can add, it also helps to have a sense of humor.

I want to close this section of my talk by reading a paragraph from the book, Trauma and Recovery, by Judith Herman: "Integrity is the capacity to affirm the value of life in the face of death, to be reconciled with the finite limits of one's own life and the tragic limitations of the human condition, and to accept these realities without despair. Integrity is the foundation upon which trust in relationships is originally formed, and upon which shattered trust may be restored. This interlocking of integrity and trust in caretaking relationships completes the cycle of generations and regenerates the sense of human community which trauma destroys." That is the goal we all need to strive for in sharing the lives of these patients.

I would next like to describe some of the common psychotherapeutic techniques which are used in the treatment of patients with multiple personality disorder, as well as with post-traumatic stress disorder.

One is to assume, again, that when one is talking to a patient with MPD, all parts of the system are listening, and that one can talk over the particular alter that is `out' and address the whole system.

Next is the work of assembling whole memories from fragments: alter by alter, joining behavior to affect, to sensation, and to knowledge. We use the BASK model, B-A-S-K, amnemonic where the letters stand for the behavior, affect, sensations, and knowledge of a particular traumatic event. Often these four components of a memory are distributed among different alters in the system, and the work of abreaction is to reconnect these dissociated aspects of a memory.

Next, we often use journals and diaries which allow alters access to the therapist in writing before they are actually ready to come out and talk.

I want to say a word about working with internal persecutor personalities. In multiples, suicide is an ever-present issue. The therapist must come to terms with a high background level of suicidal ideation. Suicidal gestures are frequent, and serious attempts axe not uncommon. In the NIMH survey, more than 61% of the therapists reported serious suicide attempts by their patients.

"Persecutors" develop from a masochistic turning inward of hostile affect and from early helper personalities who were initially created to cope with abuses, but who over time identified with the abusers and now resent having suffered for "others." These persecutors hold much of the vital force of the patient and need to be brought into the therapy. I have developed a way of thinking which I call the Father Flannagan school of MPD therapy, which holds that, "there's no such thing as a bad alter," although faith in this precept has been severely tested on numerous occasions when an alter has made his or her initial appearance be causing some serious abuse of the body. However, most often, these angry, powerful alters become most trustworthy internal helpers.

We also use maps, and ask the personality systems to diagram themselves, showing degrees of relationships among the various alters.

A common tool used in the treatment of these patients is hypnosis. MPD patients, and, to some extent, PTSD patients, live in more of a hypnotic state than the rest of us, and hypnosis can be a real boon in facilitating the recovery of memories, accessing alter personalities, and in progressing therapy in an efficient way.

As I have mentioned several times, abreactions are an integral part of this work. The APA definition of an abreaction is, "emotional release or discharge after recalling a painful experience that had been repressed because it was consciously intolerable." Abreactions have been used in the treatment of posttraumatic stress disorder since World War I, and they are facilitated by the use of hypnosis or by Amytal or other barbiturates. Abreactions are necessary so that the dissociated and repressed memories and affects can be recovered on a conscious level so that the patient may work through them.

I have been asked to say a few words about the allopathic psychopharmacology of these patients, and there is one point in here which I think is extremely relevant to homeopathy. As far as allopathy is concerned, it is very important to identify the target symptom so that in the therapist's desperation to do something, medicines are not used in a shotgun manner. The symptom that is being targeted should affect a large proportion of the alter system. In the NIMH study, 46% of surveyed therapists observed differential medication sensitivities across alter personalities. For example, some alters would respond positively to a drug, others might have a range of side-effects, while other alters would be unaffected. I want to emphasize this point because I suggest that homeopaths who are treating these patients will have to evaluate the effects of the remedies across the alter system, and not only in the alter who happens to be in your office requesting treatment. This is especially important when trying to address the question of whether the patient is better as a whole.

Loewenstein points out that most problems in the treatment of MPD are not solvable with medications, and that one must try to identify the symptoms in the patient which are valid psychopharmacological targets. Having said that, it must also be remembered that MPD patients may have intercurrent medication-responsive psychiatric disorders, and they do get real medical illnesses.

Allopathic medications are usually targeted at symptom relief, and they include benzodiazepines, especially clonazepam, for improved sleep and decreased nightmares and flashbacks, anti-depressants, clomipramine for obsessive-compulsive symptoms, and propranalol for the hyperarousal symptoms of PTSD.

In this regard, Loewenstein points out that "virtually all MPD patients will develop overt PTSD as the underlying trauma history is uncovered during treatment."

There is some recent work in the allopathic treatment of PTSD described by Davidson, which includes the use of monoamine oxidize inhibitors and antidepressants, which are seratoninergic.

A brief word about other supports in the treatment of MPD and PTSD, it is good to include support for families and significant others, who are often severely stressed by having a loved one with one of these illnesses. In the case of MPD, it is often prudent to have the children of patients evaluated for signs of child abuse, dissociation, or PTSD. There are also helpful groups and expressive therapies, such as art and movement therapies. Finally, hospitalization, while it is extremely problematic other than in specialized units such as at Sheppard Pratt, is sometimes necessary when a patient is incapable of maintaining safety as an out-patient.

A word about crisis management: in these patients crises can be expected to occur with dismaying regularity. Treatment is traumatizing in its own way, and "getting well represents an immense loss to the patient," as Herman has said. Turks has written, "Crisis is to be expected in MPD psychotherapy as it ensues from the psychopathology of the patient, not necessarily from the lack of expertise of the therapist. It is usual for patients with MPD to create chaos and confusion in their environments because they struggle with internal chaos, depression, and suicidality. They often unconsciously recreate and reenact traumatic situations from the past again and again."

The best management of crises is definitely prevention. This can include prearranged hypnotic cues which can be used to lower anxiety states in patients, and such trance logic creations as safe places. We also frequently use safety contracts with patients. It is also important to remember that a crisis may be a form of limit-testing by the patient of the therapist. We should also remember some advise from Joan Turkus, "It is important to remember that when you do not know, finally, what to do, it may be helpful simply to ask the patient."

What does therapeutic resolution mean for these patients? Ultimately at the end of treatment, the patient may remain a multiple or move on to integration and fusion of the alter personalities into one personality. David Caul wrote, "It seems to me that after treatment you want to be a functional unit, be it a corporation, a partnership, or a one-owner business." It is a mistake to make integration the goal or focus of therapy. This can be extremely threatening to alters, who may wonder if integration means that they will die, disappear, or be annihilated, and thus may actively work against treatment if integration is framed as the goal.

In closing, there are a few points that I would like to stress. The first is that every patient should be asked about trauma and abuse as part of initial history-taking, and secondly that it is always important to rule-out organic illnesses.

I would like to point out that there is a big difference in a medical approach to a patient, be it a homeopathic or an allopathic approach, and psychotherapy, especially with traumatized patients, in which the therapist is seeking an empathic connection with the patient to use as a tool of therapy, and has less of the concrete symbols which separate the patient from the doctor, be they a white coat or three volumes of Clarke's Materia Medica. I think this is why the issues of transference and countertransference are particularly present in psychotherapy.

I would like to suggest to you that empathy with these patients is not enough, because of what was said about countertransference. Treatment of these patients is as much a learned and a learnable skill as is homeopathy, but I do not believe that because one is a doctor or is a good homeopath, that one is automatically prepared to treat these patients. Consider being part of a team of treaters.

I want to emphasize to everyone who is audacious enough to treat patients with PTSD and MPD, to make sure that your own support system is intact before treating these patients. This may include individual supervision and therapy for yourself.

Finally, I want to say a word about why one should consider getting involved with these patients after all the difficulties that have been outlined. These patients are survivors, and their courage is compelling, and their treatment can be very gratifying.

American Institute of Homeopathy.

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By Clifford Passen

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