GUIDED IMAGERY AND MUSIC: A MUSIC THERAPY APPROACH TO MULTIPLE PERSONALITY DISORDER

GUIDED IMAGERY AND MUSIC: A MUSIC THERAPY APPROACH TO MULTIPLE PERSONALITY DISORDER(*)

Abstract: Case material is used to demonstrate how Guided Imagery and Music [GIM] can be used therapeutically to treat Multiple Personality Disordered clients. With carefully selected music and a trained therapist, a client can be led safely to deeper levels of the psyche and work through issues and experiences previously out of conscious awareness. Techniques for establishing co-consciousness and for developing new thought patterns, affects, attitudes and behaviors are explained.

INTRODUCTION

Music is an integral part of humanity's expressive repertoire. It gives voice to the innermost feelings of the individual and provides a collective bonding with mother, family, friends, lovers, ethnic group, nation and the world. Music gives structure to the strongest of emotions. Its subtle vibrations resonate with all matter including the human body discharging and recharging the energies of the body, mind and spirit [Wilson, 1985].

Music has been recognized in all cultures for its wholistic nature. In the Chinese tradition "music is a manifestation of the harmony of life and the energy flowing throughout the universe...Like the sounds of an orchestra the notes sweep together with spirit and skill to form a unified whole" [Connelly, 1979 p.107].

(*) Reprinted from Kluft, E.S. [Ed], [1993]. Experiential and Functional Therapies in the Treatment of Multiple Personality Disorder, Springfield ILL: Charles C. Thomas.

MUSIC AND MUSIC THERAPY

composing, performing, listening

Composer Roger Sessions [1971] described the three basic kinds of musical experiences:

Formal composing is left to a relative few, but the art of creating music through improvisation is common. When we simply whistle, hum or tap a rhythm on a table or desk, we engage in composing. Children naturally make up songs and play rhythms as part of their self expression. Improvisation with others allows spontaneous connection while maintaining individuality. In improvisational music therapy, the therapist and-or the client play spontaneously, revealing a sonic structure of inner experience and psychological patterning similar to the patterns of color and form revealed in a spontaneous drawing. This externalization of inner structure becomes the basis for creating change.

The music experience of performing carries with it a defined set of standards. Like a composer, a performer has often devoted years to disciplined study. The performers challenge is to allow the music to flow through him [or her], while expressing the inner music intent of the composer, who is usually another person. In the therapeutic setting, performing can be as simple as singing a song and reflecting the feelings elicited by the experience. The music touches these inner feelings and permits their expression.

Listening to music can alert one to a particular feeling and can enhance or change that feeling. In everyday life, music selection may be left to a family member or a disc jockey, whereas in therapy, careful selection can provide more purposeful listening experiences.

MUSIC THERAPY DEFINED

Music therapy can be distinguished from other treatment modalities by its heavy reliance on music as the agent and catalyst for therapeutic experience [Bruscia, 1989]. Bonny [1986] defined music therapy as"the systematic application of music as directed by the therapist to bring about changes in the emotional and-or physical health of the person"[p.4]. She described the therapeutic characteristics of music: [a] it is non-verbal, [b] it evokes emotional and physiological responses, [c] it stimulates symbolic representation, and [d] hearing it can create synesthesias of other senses. Effective music therapy depends upon the clinicians understanding of music's effect on the unification of the psyche, and the clinician"s own attentiveness to the musical elements of voice, structure, and vibration.

MUSIC THERAPY EXPERIENCES FOR THE CLIENT WITH MULTIPLE PERSONALITY DISORDER

Group Improvisation, Performance, and Listening

Music is most often composed for performance in a group, and is often listened to in a group as well. Group improvisation and performance can be highly effective with multiple personality disorder [MPD] clients, especially among those who share similar traumatic experiences. When music is sung, played, or listened to in a group therapy setting, each voice or instrument expresses its unique part, which is necessary for the whole. This process seems to reclaim the often lost birthright to belong, to express oneself and, to declare and claim one's experience, to be listened to, in effect, to have a voice. It brings connection and a sense of unity within an individual and between hospitalized clients. One commented, "singing together is like all our inside voices singing together". Another said, that when she sang in the group, she claimed her voice for herself. Clients share pains and hopes in the music group.

Effective and beneficial music is chosen or created cooperatively among group members and therapist. If the group session is to feature the playing or singing of classical or popular music, the therapist must choose carefully, so that the structure provides a secure container for the group experience. Improvised music, too, must be guided and shaped by the therapist, with careful attention to theme, development and closure.

Individual Composing

MPD clients are very creative. Some compose music that communicates their particular stage in the psychotherapeutic process. The musical compositions can [a] express their internal disharmony and fragmentation; [b] give voice to ego states that are usually hidden and mute to both client and therapist; [c] bring together several ego states, unknown to one another, together in a musical form; [d] help the client to work through a trauma in a musical score prior to its verbal revelation; [e] introduce an ego state prior to its more formal emergence in the therapy; and [f] forecast internal harmony or integration before it actually occurs.

Individual Listening

Music animates the emotions below consciousness [Sessions, 1971] and beyond defense mechanisms. Music and emotions both unfold through time. Zuckerkandl [1969] wrote of the interconnectedness between musical phrases as each tone points beyond itself to the next, moving the listener forward and carrying him/her through an emotional experience. Groff [1985], referred to music's ability to create continuity in the course of various states of consciousness and its use in therapy as "a continuous carrying wave that helps the subject move through difficult sequences and impasses"[p. 368]. The desire for completion inherent in tones, parallels human striving for resolution and wholeness [Bonny 1978c]. The structure and motion of carefully selected music creates a bridge or chaining process which can carry the MPD client forward into exploration, discovery, abreaction and resolution.

Music can serve as a prototype or model for communication, cooperation and co-consciousness which are essential parts of effective MPD treatment. Music is made up of many voices, vocal or instrumental, each working in fine precision, to communicate and express a feeling or musical idea. Each is unique and needs to be heard. In large ensembles a conductor or director serves as organizer or executive, allowing each voice its expression at the proper time in the context of the whole. Often instrumental cooperation or solos are featured, while the other voices support or listen. At times they question and answer one another. What occurs in music, is what occurs in psychotherapy for MPD. Music subtlety and supportively teaches the process.

The selection of music must enhance communication and cooperation. Selections that are fragmented in construction or that feature exaggerated or distorted voices are not appropriate. Repetitive or rigid music would tend to reinforce these patterns in the listener so it is contraindicated. Also inappropriate are abrupt musical changes which may trigger unprepared or unsupported abreactions. Selections should be listened to by the therapist prior to it's use to eliminate music conducive to imagery that stimulates self perpetuating, unhealthy inner worlds or imaginary structures. Careful choice of music creates and reinforces safety and control, matches the the client's emotional state and allows for emotional exploration, and provide resolution or regenerative alternatives.

GUIDED IMAGERY AND MUSIC

Carefully selected music for listening seems to effect patterns of emotion and structures of thinking. However, an honest clinician will acknowledge the difficulty in describing the underlying principles involved in its therapeutic influence. Stewart [1990] stated that the shapes and patterns in music, under the correct circumstances, resonate through rigid inner states of consciousness and realign them, pulling the listener out of rigidity into a new form. One aspect of music therapy includes the experience of listening to such elements of the music as voice, structure, and vibration.

Imagery, the thought process of imagination, is the communicative mechanism between perception and emotion. Imagery and music, two of humanity's oldest healing resources combine to form an effective therapeutic modality. Guided Imagery and Music [GIM], as originated by Dr. Helen Bonny [1978b, 1978c, 1980] is a specific method of self-exploration that uses classical music to access the imagination. Sometimes referred to as music assisted psychotherapy [McDonald, 1990] music interacts with and therapeutically influences the imaginative process. GIM has been defined as a "music-centered, transformational therapy which uses specifically programmed classical music to stimulate and support a dynamic unfolding of inner experiences in service of physical, psychological and spiritual wholeness" [Morgan, 1990, p.3]. Appropriately chosen music, being multidimensional, will evoke emotional response, activate the senses, impact the body physiologically, and stimulate symbolic representation of imagery [Bonny, 1986]. Music-facilitated imagery can bring issues into focus, and enhance the potential for adaptive solutions [Bonny 1978a]. Clark and Keiser [1989] describing GIM, emphasized the wholeness provided by self actualization in the imaginal realm, and the benefits which often went beyond stated goals.

Typical GIM sessions are 90 minutes long, beginning with a preliminary conversation, guided physical relaxation, concentration on a relevant image, and the selection of a taped music program each carefully constructed for both musical contour and the various elements which contribute to it [Bonny, 1978b]. The contour carries the listener into a deep emotional experience and then delivers him-her safely back to the present; it begins as a baseline, builds to a peak, stabilizes and then returns to the baseline. Musical variables are pitch, tonality, rhythm, tempo, mood and vocal and instrumental considerations. Tapes are selected on a session by session basis to match the mood and needs of the client. Once the music begins, the therapist gives encouragement and comfort, and actively inquires into the client's imaginative process as it is occurs.

GIM AS THERAPY FOR MPD: THEORETICAL RATIONAL

Ego State Theory and Therapy

Ego states as conceptualized by Watkins and Watkins [1990] refer to the two basic processes of differentiation and integration. An ego state consists of segments or introjects within the self system that are bound by common factors like age or experience. Normally an individual experiences many ego states and can move from one to another within a psychic organization which could be described as integrated multiplicity. A person can feel and act young and playful in one state, and yet remain aware of his potential to change to another state in which he feels and acts parental or authoritative. In a psychotic process, the boundaries between the ego states of an an individual and between this individual and others becomes too permeable and undifferentiated and they blend into everyone else around them. Conversely, MPD can result when the ego states of an individual are too rigidly bound and impermeable, so that amnesic barriers are formed and the ego states acquire their own separate identities and existences.

Ego state therapy is "the use of group and family techniques for the resolution of conflicts between the various ego states which constitute a family of self" [Watkins and Watkins, 1990, tape 2]. The challenge of working with the dissociative process in psychotherapy is in relating properly to the fragmented ego states created by trauma. The client learns that traumatic memories can be brought to light and explored, that new points of view have a unifying effect on their psyche, and the work of therapy brings with it a sense of control over the memories and a method for managing them [Spiegel, 1989, p. 300]. GIM is a process that retrieves lost ego states and allows this work to proceed.

Hypnosis, GIM and the Dissociative Process

The state of consciousness experienced in GIM is similar to that of hypnosis. In ordinary waking consciousness, focussed mindfulness and peripheral awareness work together or in balance. Under hypnosis, persons are also awake and alert, but peripheral awareness is diminished by the intense, receptive focus and concentration of the trance state [Spiegel and Spiegel, 1987]. In a hypnotizable individual intense concentration can spontaneously result in a self-altering and totally absorbing trance state [Tellegen & Atkinson, 1974]. Peripheral awareness is lost, and the focus is all that exists. Such dissociation does not usually cause problems. Likewise, therapeutic hypnosis or GIM usually have no more negative consequences to the subject than do becoming absorbed at the computer, in a movie theater, or at a concert.

However, dissociative states induced by intense fear, coercion, or abuse can become pathological and lead to such disorders as MPD. There is a causal relationship between childhood trauma and the development of MPD [Coons, 1980], a disorder which manifests in an individual as two or more distinct personality states, each with its own patterns of perceiving, relating, and thinking [American Psychiatric Association, 1987], and which seriously impairs the ego functions of memory and identity.

In MPD, transitions from one personality to another can be rapid and uninvited, triggered by psychological and/or environmental stress, or elicited on request [American Psychiatric Association, 1987].The authors have found that transitions can also be initiated by music, so that a treatment format using music can successfully [a] elicit the ego states responsible for holding trauma, [b] assist the client in working through the trauma, and [3] enhance the development of a more unified ego functioning.

Imprinting, Resonance and Resolution

Music

Experience not only imprints the individual's psychology, but also the physical body. Godwin [1987] discussed the physical effect of sound on the human body stating, "The human body is a living resonator for sound...Muscles, blood circulation and nerves are all moved by the power of vibration [p. 262]". The authors believe that physical and psychological imprinting is based on vibration.

For example, a child of four, over-hearing his parents in a violent fight, is affected psychologically by the vibrations of their voices and the physical violence. There is no defense against the violence and no possibility for resolution of the fear and pain created in him. The sounds resonate in him, and become part of his physical and emotional being. He is, in effect, imprinted musically. The fight is a composition and has a form. The parents' language has rhythm, mood, and intensity. Their voices, like instruments, play melodies in counterpoint. Each separate voice and sound has a distinct tonal quality and pitch. The physical violence, with its dynamic changes, is the percussion.

When trauma results in dissociation and multiplicity, music can help restore unity within the traumatized individual. In GIM, properly selected music resonates with the rhythm, mood, and intensity of an imprinted experience, causing it to awaken. A few notes of a particular timbre or rhythm can activate an internal representation of an experience, even a traumatic one. An entire experience can unfold as the music continues, and the previously unresolvable can be resolved as the music selection reaches its completion.

Guided Imagery

Guided imagery helps the client gain access to internal representation or imprints of experience. Structured linguistic and perceptual techniques used in response to a client's imaginative process simplify and clarify complex human experience and behavior [Andreas and Andreas, 1987; Bandler and Grinder, 1975]. With carefully chosen language, a therapist can help a client change limited models of living to more flexible ones with more options [Cameron-Bandler, 1985]. The clients images, resonating with the music and the therapist's responsive language, can forge and structure choices, changes and integrations.

The structure and resonance of music, together with the elicited, verbalized imagery of the client-listener and the structured, verbal responses of the therapist, create a process of controlled dissociation. Because there is a strong connection between MPD and hypnosis in etiology, phenomenology, and treatment [Ross, 1989] the clients imaginative process and the therapist's careful responses can transform traumatic experiences. The neurological processes that link abuse, dissociation, and visual imagery [Ross, 1989] enable the metaphors and imagery used in GIM to stimulate controlled dissociation and healing. Amnesic barriers are dissolved, internal communication is facilitated, affect and knowledge are joined and adaptive behaviors for safety and wholeness are generated.

GIM IN THE DIAGNOSIS AND TREATMENT OF MPD

Making the Diagnosis

In the beginning, or diagnostic, stage of GIM with an MPD client, the imagery can be overwhelming, because it actually describes the ego organization and defenses with which he or she lives from day to day. The imagery replicates the rigidity or spliting of multiple unrelated ego states. The fragmentation makes formulation of a correct assessment and treatment plan challenging, and problems around the issue of trust hinder the development of a therapeutic alliance. Imagery sessions, while usually rich in content and detail, are also often fragmented and sometimes alarmingly unrelated sequentially. A clinician unfamiliar with dissociative disorders might label the client borderline or even psychotic, but the observed phenomena are the successful, previously adaptive dissociative reactions to dangerous, harmful, and hurtful events. This imaginative process, seemingly unreal to the clinician, reflects defenses and strengths.

Diagnostic and Prognostic Imagery

As GIM sessions continue, common themes and images may become prevalent in a client's verbalized imagery, which, when occurring in numbers, are strongly indicative of a dissociative disorder.

Visual and Kinesthetic Clues

Often a first clue to childhood trauma is a confusing visual image with a kinesthetic memory of some kind. A client sees something which is confusing and simultaneously feels pain somewhere in her body. This happened to Susan.

She turned...and the door slammed in her face. Susan knew there was something beyond that door, something hidden....[her] arm began to hurt. She described it as feeling hot and painful, as if someone were squeezing her upper arm. I...asked who was hurting her. She didn't know. I suggested that she ask her arm, and she saw a young man holding her by the arm and saying she was not to tell anybody...[Pickett, 1987-88, pp.169-170]

Robin's visual clues, as heard in her verbalized imagery, included fragments of her trauma mixed with potential healing, symbolized by a white crystal door. Before healing, Robin had to deal with the trauma. Her dissociation by ascending did not work. She was quickly brought back to the imagery of her trauma.

The nuns surround me. They take off my gown and use linen cloths to put oil all over my body. The nuns leave. I am alone. I pick up matches and set the oil on fire. The trees around me drop their leaves from the heat. I am aware that I am ascending, the earth drops quickly behind. I am entering a white crystal door there. It is a lie. There is no warmth. I am in a room in chains.

Feelings of Unreality and Dissociation

A sense of unreality puts distance between the imager and the imagined material. This is often coupled with clear examples of the dissociative process. Jenny herself, her partner, and the situation were all unreal.

I'm in a ballroom dancing with someone...He's not real...I feel I'm dancing alone...The ballroom is filled with people dancing...I watch from the stairs...they look like robots...expressionless faces...they don't know I'm watching...I'm a blob...no, I'm not a blob...I don't see my face.

Ellen described imagery about the physical abuse she suffered. She escaped her pain anger, and helplessness by "dying". Her use of the past tense kept the experience from being too immediate. She disassociated from it and seemed to recall dissociating by dying:

All of a sudden she grabbed me and started to beat me and all I could do was to start fighting back. I could not win. I just wanted her to quit what she was doing to me. She hit me again and again...and again. I began to hate her more and more with every hit. I finally got away by dying.

Susan also used the past tense to dissociate from the incident recalled in her imagery. Here, the dissociative process, which she had used from a very young age to protect herself from repeated physical, sexual, and emotional abuse, was very clear.

Susan...met the child self as she left her kindergarten class, and walked home with her. Susan saw the boy grab the little Susan, and pull her into the bushes. Susan stepped in and lifted up part of the little Susan, so that the child's...body was lying limp on the ground, and being hurt by the boy...another little Susan was safely above the scene...[Pickett, 1987-88, p.170]

Fragmentation and Shifts in Identity

During the assessment stage, the imagery is barren and fragmented, with hints of death, decay, and the past:

Dawn...sun's coming up...water, birds, no people, soft warm breeze...hear the birds...smell the ocean air...a pit...dead animals...decayed...off by itself...close to the island...people in colonial times.

Early in the GIM sessions, clues about secrets and indications of multiplicity frequently emerge that are often provocative:

The large snake is never found out. This special snake's name is Zoe. It's got lots of other names though and unless you know them all you can't unlock the secret to its hiding place and woo it out.

Shifts in ego states are often exemplified by changes in personal pronouns. In one session Jane was talking about the music, and then made an abrupt shift into another, potentially destructive ego state:

It is a person of power in my life. It controls me. It can have plenty of power or very little. It has red or blue eyes. It does not walk. It jumps on your back and rides no matter what. [shift in voice tone and personal pronoun]am in control at all times no matter what happens. I control all of her. She does only as I tell her. I can destroy her if I wish. One day I will destroy her and it won't hurt me at all.

In Susan's 6th session the metaphor of fragmentation also revealed the ego strength to establish a strong executive part and to begin the work of healing:

I am inside the castle, invisibly floating through the halls and rooms...The Queen is striding down the steps- her robe, a brilliant red with ermine cuffs, blowing behind her. She is tall, thin, regal, and I study her face and see it is my own.

There is another Susan in the kitchen, fat and dumpy, dressed in a coarse gown and sweating over a steaming cast iron pot. I see myself slide chopped vegetables into the pot, then stand back and wipe sweat from my forehead...I catch a glimpse of a figure in a dark blue robe....like Merlin...and am not surprised to see that the figure is also me, old and bent and wise.

And I find myself, a younger self, in the stables, currying a magnificent red horse. This Groom Susan is loving and confident...speaking in a soothing undertone.

I am this castle. The castle is my own body, and the different parts of myself, working together to take care of the castle, to defend it. In return the castle takes care of them, providing a place to live. I can feel my legs formed of rough blocks of stone. I can feel large rooms inside me, and curving stairs and halls [Pickett, 1987-88, pp.170-171].

Many Ego States

In a session early in treatment, Susan's imagery indicted that there were many traumas and ego states, that she needed to put aside her fear and face them directly by naming them, and that a positive outcome might result from her growing empowerment:

The bushes move and out struggle the dwarfs. They have followed me. I am afraid they will try [to hurt me]....[I know] they are necessary for the castle. I tell them I would like to be their friend and one dwarf steps forward and says, `We don't trust you'. I put away my sword. I tell the dwarfs, `I need to see you as you are'...The dwarf says, `We are human too, just in a different shape.' The dwarfs all toss back their hoods, letting their cloaks fall to the ground. They are short and misshapen, their faces compressed and bulging. Ugly, but not repulsive.

And I begin to sob, because in the sunlight their faces change, melting into the faces of children, beautiful children, with soft glowing faces full of light. They are so beautiful. They crowd close to me, and I gather them in my arms, still sobbing. It is the staying in the darkness...that has made them so misformed...Unless I can name them, they will go back into the darkness...I promise them they can stay with me. I reach into my saddlebags. I pull out handfulls of carved wooden horses, each one about three inches high. I stand them on the ground...I wave my hands over the inert wood and the carvings grow,..into red ponies, [one] for each child..." I help the smallest of the children onto their ponies. They are all young- four, five, six years old. I watch myself and all my beautiful children as we ride together back down the hills. I will love them and care for them, and help them to grow up to be the people in my stories...I begin to...feel...resolved...Each aspect or person of the castle has his or her own role, but the roles can overlap. The different aspects of myself will work together, to assure the children will be made welcome, and stay in the daylight [Pickett, 1987-88 pps. 171-172].

In Ann's imagery the many people traveling together, with similar intent, are positive indicators...

I see an exodus of people walking across the desert. They are going to make it because they work as a team.

A favorable prognosis could be inferred from imagery below which indicated a positive therapeutic alliance and what this client was learning from it:

"colors...sunlight...people are whole, accessible...dancing and holding...they breathe the air and feel everything...I am watching, I see love, health, balance...they touch with gentle hands...let each other know they care,..they are acceptable, loved, and wanted...they believe what I am showing them, they work together like they are one team"

The Therapy: Principles and Techniques

From the development of trust, through integration, to post-integrative work, the treatment principles followed by a majority of clinicians and summarized by Kluft [1987] apply to GIM work with MPD clients. Once the MPD diagnosis has been made, GIM sessions are used to meet the client's different ego states, facilitate interpersonal communication among them, uncover serious physical, emotional, and sexual trauma, and assist with integration. Rapport and trust between client and therapist must be developed as much as possible in order to allow the revelation of trauma, of the pain it caused originally, and of its subsequent results. This brings congruity and meaning to fragmentation and sets the stage for the generation of cognitive and behavioral patterns.

GIM with MPD clients involves the use of specific techniques in which the client's imagery, the interplay of the musical selections, and the therapist's responses are all factors. The descriptions below are illustrated by extracts from the case history of Susan. Although the discussion focuses mainly on the client's verbalized imagery and the therapist's responses, the music stimulated and shaped the process. A detailed description of the way in which the music guides and interweaves with the imagery is given in the Reframing section.

The Executive and the Courtyard

An executive ego state can promote purpose, identity, and healing in the overall system, and can also function as co-therapist. Smith, Titus and Carr [1989] define the executive as "one that is generally aware of the various other personalities and has the assertive strength to...monitor...their needs and behavior" [pp 4-5]. They encourage fostering executive traits in a fairly responsible personality, if one has not developed spontaneously.

Healing is also promoted by a container, assembly hall, inner circle, or some other imagined place of safety, where ego states gather and bear witness to the work of therapy.

Susan's courtyard, was first perceived by her as the prospective space to be left in her body from the necessary removal of her uterus because of fibroid tumors [Pickett, 1987-88]. The creativity stimulated by GIM led to its establishment and functioning before the depth of Susan's complexity was known to the therapist. This castle courtyard was an apparent metaphor for ego cohesiveness. It became the arena for the work of therapy, while the executive Susan became a weekly guide and aide to the therapist in learning the identities of her internal victims, perpetrators, and helpers. Each emerging ego state came to the circle in the courtyard to share traumatic memories.

The following imagery was related by the ego state who arose spontaneously as the executive of the assembly, who presented for the sessions, and who came to be known as the "Big Susan".

This Susan is the missing piece! She needs to leave the hall and garden, and join the others. And she can't find the door.

I create a door...she has to bend to reach the knob. She will have to stoop to go through...She has to open it herself.

She dwindles, growing smaller and smaller until she is the size of a six-year-old, the size to go through the door...Gathered outside are the Queen, the Wise Woman, the Cook, and Groom, and all the little children who had been dwarfs but now are real. They are applauding her courage at opening the door at last...The others come forward. They promise they will help her learn, and she won't have to do things she is not ready to do. Everyone will help her. And the door stands open...All of the doors entering into this courtyard are open. I feel that openness, in my body and in my mind. I sense that whatever I need for complete healing is available to me now....The groom takes the small door off its hinges- so it can never be shut again. For this Child-Susan is the one who was molested,and has been shut away from the rest of me for all those years. And now she is out [Pickett, 1987-88, p.173]

Wisdom from Within: The Archetypal Wise Figure

Steeped in ancient practices, women healers and tribal shamans regarded the unity and sanctity of all things. They used the non-rational intuitive aspects of the imaginative mind for healing purposes [Achterberg, 1985]. As more is learned abut the role of negative experience and emotions on body and mind, the sacred traditions of a tantric yoga techniques can deepen the insight of the modern investigator into the role the mind plays in healing. These practices involve visualization. The imagery provides an"outer structure on which to project an inner strength", Clifford, [1984,p. 84]. The strength is identified in the projection, and mind and body become identified with the visualization and together foster healing.

Archetypal wise figures appear spontaneously during GIM sessions, or can be evoked. Such guides avail themselves of unconscious knowledge or intuition in the healing process. Susan's "Wisewoman" became active very early in therapy, first appearing fleetingly as a female Merlin, then laying out banquet plates in the castle, and later waiting in the courtyard with other figures. As the revelation of multiple traumata continued, two other figures of wisdom appeared in the imagery, "Angel" and "Big Pretty Woman". In the following excerpt, Wisewoman helped Susan face forgotten trauma:

With Wisewoman at my side, I travel back through the years to when I was a baby...She leads me up the stairs. It's difficult for me to see the stairs...I don't want to see...I don't want to see my mother in an apron, running up the stairs. I want to make her disappear. And Wisewoman puts her arm around me. Shetells me that I can watch.

The recollection and abreaction of physical trauma followed.

The Phantom Anchor and Reaching Through Time

It is important to protect the client as much as possible during the revelation of trauma and, subsequently, to bring some kind of healing to the situation in that same session. The technique of phantom anchor [Klein, 1989] can alter the self-hatred and guilt which often result from trauma. Using this technique, the therapist, immediately following the client's abreaction, obtains permission to hold the client's right arm gently at the elbow and suggest that they can reach through time to that child in pain and `hold' him/her just as the client is being held in the present. The tactile sensation, real and imagined, serves to anchor the experience and the image. If touching the client is contraindicated, the therapist can make the connection verbally: "Just as I am present with you here, right now, you can be present with the child". The therapist can then suggest that the client reach out to the child, and talk with the child, and ask, "What is being learned or decided right now as a result of the experience you just had? What will be the affect you in the years to come?" The therapist then suggests that the client comfort the child-self by giving him knowledge that the adult client now has, but didn't have at the time. If the client is unable to do this, the therapist can make comforting, beneficial statements and generative suggestions for the future care of the child.

A variation of this technique was used when Susan arrived for a session upset and disturbed by the weeklong auditory hallucinations she had been having in which she repeatedly heard the word spider. She was fearful of discovering what the surfacing memory was. The therapist suggested that nothing could be worse than what had already occurred, and that she would be with her, holding her arm. Susan quickly took on the affect of a very young child and said,

my arms are very fat...spiders on the piano keys...hands, spider man hand...I can't get away from his pinching...spider bites...his hands, spider...my funny older brother making me laugh; the spider is hurting me...it's the spider, not my brother...I can't see.

Susan was panicked and thrashing around, and her words were unusually unclear. The therapist, concerned that this material had made Susan lose her observing ability, suggested that she,

Freeze the image, and reach through time to yourself as this little girl-from right here in this room where we are together. Take her arm, in the same way I am holding your arm, here right now, and tell that younger you what she needs to know in order to both go through this experience and to observe it.

Susan responded in an adult voice, those are your brother's hands, not spiders. Your brother is hurting you. He is bad. He is hurting you and pretending it is spiders.

The therapist asked, "What does the child need"? Susan replied,

I am picking her up and holding her and rubbing her shoulders where her brother had been pinching her. I am telling her that people have lied to her, lied to her for years. My self...and 12 other Susans, at many ages are all listening in.

The therapist asked, "What does the child need?" Susan replied, to herself and the Susans,

You are all being lied to [right now by your brother], but one day you will be big enough and strong enough to know your own truth. Then you can all be together. We can all help each other. We can get past all the fears and learn to hear each other and to tell the truth. To my adult self I am saying, I can learn to hold all of those Susan's and to stay in my own body. There is room for everybody.

The therapist suggested, "Gather each . . . one- by -one, into yourself". Susan responded,

They are all dressed in white- angels holding candles...going upstairs, the littlest first. As they go they all reach a point where their heads are all the same height. I put them inside, and I can feel their presence in my chest and legs and in my shoulders.

The Chorus

The selecting of choral music can sometimes decrease anxiety and facilitate a different quality of listening to the many fragmented ego states. The music lends a structure which fosters integration in the therapeutic work.

Prior to one GIM session, Susan's chiropractor had told her that her back problem, which might require surgery, was the result of a physical trauma. At that time, she was overwhelmed by her MPD symptoms, and her work and social life were fraught with stress and anxiety. Susan began the session by describing her sensations:

Phantom hands hitting me around the face and someone telling me I won't listen...and others hurting me, by squeezing my spine to make me remember some thing...I am not listening...they are angry and all want to talk fast...I can't listen to all of them at the same time...they want to all be together.

The therapist asked, "Can you get them to talk one at a time or slower?....No', Susan shrieked, `they all have to talk at once and they have to go fast...And if I don't go fast with them I won't be ready in time!" The therapist asked, "to whom do you need to listen to right now", and Susan replied with panic in her voice, "all of them,..they are dying...I can only listen to one at a time, and they are tired of taking turns...If I could listen to all of them at once, we could be together. When I listen, I can only listen to one at a time, and they are tired of taking turns...If I could listen to all of them at once, we could be together".

The Choral music of Brahams' Requium-, Parts I and V [Bonny, 1978a], 17 minutes long, was selected for listening. The therapist suggested that Susan listen to the voices, letting them sing to her, in harmony, like the music. Susan reported her imagery:

They are all crying together...they are all angry. We are a whole battalion of Susan's, an army...me and other Susan's have baby Susan's on our backs. We all have long spears...I tell them I am angry we are so broken apart...angry that we had to become so many Susans. I point to the house I grew up in and tell them, we need to work together, not fight. It is the people in that house that we are angry at...The house bursts into flames...while we are singing...Out of the top of the house comes another Susan, all in white...she has wings...so she can escape the fire...she is very tiny...and we are holding her and comforting her and loving her, and she is growing bigger...than all of us together...we watch the house burn into cinders, and crumble...We are my self, and my 12 selves at many ages...all together. There are many little ones. I tell them that one day we all will be big enough and strong enough to know our own truth...and to be together. I tell my adult self, I can learn to hold all of these Susans and to stay in my own body...there is room for all of us". Angel Susan has gotten very, very big and she can contain what I will become...I put them inside all together, melting inside, melting into me.

The angel, "born" from a purification of the past by fire, and both executive and a container of all Susan's parts, represented the potential for reconstructing an integrated ego.

Using Visual and Kinesthetic Dissociation

GIM and MPD are both dissociative phenomena. MPD is created by repeated dissociations that occur under extreme stress. In GIM sessions, therapeutically controlled visual and kinesthetic dissociation [Cameron-Bandler, 1985; Densky and Reese, 1986; Rossi, 1986; Spiegel and Spiegel, 1978] can help the client recover lost memories, while providing needed control or safety from emotion that would otherwise be overwhelming or re-traumatizing.

First, the "bail out" procedure [Klein, 1989] needs to be established in case it is necessary to interrupt the dissociating process to prevent re-traumatizing the client. In this procedure therapist and client establish physical contact by clasping hands as if in a handshake; the therapist then gently lifts the client to a standing position. The postural change completely interrupts the dissociative process and can be employed in the session as needed.

Once the bail-out procedure has been established, the client visualizes and project onto the far wall a "photograph" of his or her younger self at a minute before a traumatic event occurred. The client is instructed to be the "projectionist" sitting in a booth, turning the still picture into a movie, controlling the on/off switch, and running it forward or backward. This imaginative process involves both visual and kinesthetic dissociation. The client can watch a younger self go through a traumatic event while watching the current self looking at the movie. Subsequently, the client is guided back into the body and is asked to let the present-day self reassure the younger self that he or she will never have to experience the trauma again. The client is then asked to reintegrate the younger self into the body.

Visual and kinesthetic dissociation was employed to help Susan remember and observe a preverbal experience about which she had no recollection prior the session and about which she could not talk or accept comfort. At the beginning of the session, Susan verbalized imagery about approaching, but being unable to pass through, a dungeon doorway. She winced and doubled over, as if in considerable pain, then grabbed her shoulder and pushed her thumb into the soft spot between shoulder and collarbone. She did not have the language to talk about this pain.

At this point, the therapist suggested she step back and watch herself on the "movie screen" and gave her control of the picture, emphasizing that she could just watch without feeling the event, or switch back and forth between watching and feeling. Susan said:

I both see the film and feel inside my own body. I know I have to feel, but I'm so afraid, and I jump back and forth between feeling and watching the film. I can feel the pain in my shoulder, something pushing between the tiny baby bones. I can feel a great hollow blankness where my vagina should be. It's a hollow tube piercing into myself, an area of grey, a nothing. And at the same time I can see Jim has the baby pinned on a high table, a bassinet, pinching a nerve in her shoulder. It is so dark, so hard to see, and I cast a white light on the scene. Jim is forcing the fingers of his right hand inside of her. She is not crying, not moving. It is as if she were dead...This not feeling makes it worse.

The therapist reassured Susan that she was in control of feeling or stepping back when needed. Susan continued,

Both the baby and Jim are struggling for control. I tentatively feel inside my body. It is blank. I step back to see the still photo, but now it doesn't hold still. It is a series of photos. Jim seems to jump from place to place around the baby, in different clothes, at different times, always in darkness. In the flash of a camera, Wisewoman's white light, caught anger and fear on Jim's face.

The therapist suggested Susan take the photo back to the first time, and Susan continued,

Jim is at my side. [She raised her right hand] I have no word for right...no words to describe what I, as the baby, am feeling. I shift back to the photo. I can see Jim's penis lying across the baby's body, a huge penis lying across such a tiny baby. She is truly tiny, perhaps a month old. I am behind and to the side of Jim, I can't see the baby or see what he is doing.

At the therapist's suggestion to shift to a position from which she could see, Susan responded with the following account and comments:

Jim emerges from the shadows. His hand is over the baby's mouth. He's trying to force his fingers into her vagina, and stroking the top of his penis at the same time. The baby tries to wiggle away, she tries to move her legs and can't. She tries to cry. Jim hits the baby. I know it is horrible for the baby, but I don't feel the pain. I know it is there and I have gone to great lengths to avoid it all my life. I gesture, unable to find the words for `chest', for `shoulder'. Jim hits the baby again...The baby can't stop crying. Then I show [the therapist]...how Jim puts his hand over her mouth and nose, hits her again. She goes limp.

And I, as an adult, entered the room, entered the film bringing Wisewoman's white light. Jim disappears. I pick up and hold the babies lifeless body. I feel a real caring and protecting, and a real respect for this tiny baby. She is not totally dead; she has strength that has kept her alive- that kept me alive. I hold her close to my chest, rocking and dancing her to revive her. The other Susan's are inside me, and tell me to hold Baby, to never let her go. Dance the baby. Dance the baby. I watch my self dance, and now I can feel this baby, I can feel that I am holding her, and she is laughing. Her curly head is peeking over my shoulder as she laughs.

Reframing

An integratire approach includes all ego parts; no ego state is discarded. By gentle and caring confrontation of the internal persecutor it is possible to find alternatives to self destructive actions. Reframing[Bandler and Grinder, 1982]can help to understand the meaning of internal self abuse and to generate alternatives.

Before the reframing procedure begins, communication must be established with the part that is generating the disturbing behavior. Then the therapist asks the executive to express appreciation to the ego part for coming forward. The therapist thanks both for their participation and asks all other parts to listen. It must be conveyed that no rejection or elimination is intended and that the therapist understands that this ego part has absorbed painful experiences. A dialogue is conducted between therapist and problematic part until some positive intentions can be clarified and separated from the unwanted behavior. Then this part and the executive are employed to find alternative behaviors to fulfill the positive intentions and to take responsibility for generating these new alternatives whenever they are appropriate in the future. The procedure is concluded by the therapist's assurances that the client has learned and can repeat this process of choosing alternatives at other times.

Early in the therapy, Susan expressed fear of an internal abuser. The therapist assured her that the abuser probably did exist, but could be managed. Susan's introduction to this introjected perpetrator began by the therapist saying,

I'd like all the parts to listen in to what I am going to say right now. I wouldn't be surprised if there were an abuser inside; you've been abused. When that aspect is ready to emerge, we will work with it, and find out more about it. Know that whatever it does, it's been doing all along, and there is some kind of protection here. When he or she surfaces, we will make friends. We will not try to get rid of anyone.

Since that session, several child ego states, both aggressive and victimized, have made themselves known. In the session, Susan informed the therapist that "Matthew," also known as "The Devil", was about to emerge. Matthew, 12 years old, was violent, and had hit the dog in a rage. Susan only know of him through other ego states, and was frightened. The therapist began the refraining procedure.

The music selected [Skaggs, 1990] was designed for inner dialogue and would not be appropriate for all reframing sessions. For example, music with fuller orchestration and chording would be better for bringing cohesion to an unusually fragmented, chaotic client. It was chosen here to give gentle, sustained guidance to Matthew, who was likely to emerge with intense feelings. It features a series of solo instrumentations with orchestra:

Cello Concerto in E minor by Elgar, third movement, Adagio, Nobilmente. The therapist asked to speak to Matthew. The sustained melody which is gently supported by low strings both solemnly intense and introspective helped him to emerge. With the increase in harmonic and dynamic tension matching Matthew's own circumstances, he scornfully stated his resentment at being "here in this fat woman". As the music returns to the original theme, again supported by orchestral strings, the tension resolved somewhat, and Matthew continued, "I have been listening and I think this is stupid". The therapist greeted Matthew, who responded angrily. She thanked him for coming, reminded him that everyone was listening, expressed sympathy for his discontent, and added that she suspected he was there in that body for a particular reason. When he responded with an affirmative GRUNT, she asked, "How did you get here? What happened to you?"

Piano Concerto in G by Ravel, Adagio Movement. The piano replicates the tonal range established by the cello in the Elgar concerto. This provided continuity although the Ravel piece fostered more freedom of expression. The beautifully sustained opening piano melody was supported by a deliberate, consistent accompanying pattern played by the left hand. These juxtaposed rhythms of melody and accompaniment resulted in a subtle stirring of tension. The initial theme was restated by the woodwinds and shortly, the full orchestra expanded in contrasting themes. At this point Matthew explained, "I hurt others to keep them from hurting me...but I never got to hurt the big mean ones who hurt me first...they beat me up...I took the beatings for the scared ones...little ones" While Matthew is relating this, the music builds in both the harmonic and dynamic tension of the music increased, and then subsided, as the original theme was played plaintively by the English horn. The strings continued their supportive accompaniment, the piano played softly in the higher tonal range, and the flute and English horn closed the movement with a final ascending and descending melodic line.The therapist expressed sympathy at Matthew's pain and asked him to continue. He said, "When you hurt people they leave you alone and stop hurting you...It makes me feel powerful to hurt others...Expressing anger feels good.

Violin Concerto by Mendelssohn, Adagio Movement. Written in the Romantic style, this piece represented an interplay of emotions and ideas, and facilitated a long conversation between Matthew and therapist about the reasons for his aggressive behavior. The opening violin solo helped him focus on this material and express himself. The slow tempo and accompanying strings provided calmness and support. As the brass and timpani joined the strings and woodwinds, the music moved into a minor mode and increased in intensity. Matthew voiced his concerns about vulnerability and threatened to strangle the therapist if she tried to tell him what to do. Then the music returned to the initial theme, providing the opportunity to clarify the therapeutic alliance. The therapist gave permission for Matthew to (a) feel powerful, (b) be angry (c) make his own decisions, and (d) be alone when he wants to be. Matthew began to cry.

E-flat Concerto for Two Pianos, K.365, by Mozart, Adagio movement. The therapist suggested that Matthew might be able to generate alternative behaviors to violence, while still protecting himself and getting his needs met, and suggested that he consult the internal others who were listening. The change to the Classical style of this piece was ideal for affording structure to which alternatives to violence could be generated. The introduction, less sustained than the Mendelssohn piece, allowed Matthew to cry and talk simultaneously. The interwoven themes of both piano solos were played in sequence in response to each other, the second theme building in intensity to full diminished chords played simultaneously by four hands. At this point, Matthew suggested that he could pound on pillows or strangle clay, instead of hurting the dog or a person. As the initial theme was repeated in the recapitulation, with rapidly ascending scales setting a striving quality, Matthew stated that he wanted to have fun as the others were learning to do, and to learn to ride Susan's bicycle. The full chords in the brief coda brought Matthew's assent in finding alternative behaviors in the future.

Intermezzo from Notre Dame by Florent Schmitt. This piece opened with a declamatory statement in unison by the strings, which were then joined by full orchestra. Matthew stated that he had been watching others come forward and did not want to be left behind.

Fairy's Kiss by Stravinsky, Adagio movement. Brief solo melodies were played by cello, flute, clarinet, and horn, accompanied by harp and strings. These were reminiscent of the different voices heard in Susan's circular meeting place. Matthew said, "Now when they all stand in the circle and hold hands, I will be with them". As the tempo quickened and full orchestra completed the music, Matthew "joined the circle with the others in the courtyard".

Ecology checks

GIM sessions with MPD clients should end with ecology checks by which the therapist can stay in touch with all parts of the system and make sure that any changes or revealed traumata don't inadvertently challenge, corner or threaten some aspect of the system's functioning. The prevention of an ego state's sabotage of a contract made with another and the avoidance of one ego state causing fear or sadness in another are major concerns. Such checks can be done through the client's image of the circle or courtyard. At a meeting of all ego states, the therapist can inquire whether everyone feels all right about the session or is upset, and whether anyone has comments to make or needs to talk. Interpersonal communication among the parts is encouraged and new contracts can be made to replace old ones when necessary. If ecology checks are established firmly enough, someone in the system would remember even if the therapist were to forget.

CONCLUDING REMARKS

Music resonates in the human experience with deep emotion. The combination of music and imagery can be used therapeutically to treat MPD clients. GIM creates an interactive concentrated listening and imagining experience. With carefully selected music and a trained therapist, a client can be led safely to deeper levels of the psyche and work through issues and experiences previously out of conscious awareness. New thought patterns, affects, attitudes and behaviors can be generated. By eliciting and confronting fragmented ego states and the traumata that caused them, GIM techniques help the client to unify his functioning and integrate his being. Research into the ways music, imagery and discrete response work together is needed, as is more study into the results of their application to the treatment of MPD.

GLOSSARY

Multiple Personality Disorder - is a psychiatric disorder which manifests in an individual as two or more distinct personality states [unaware of one another]; each has its own patterns of perceiving, relating and thinking, and each recurrently takes full control of the individual's behavior [DSM III-R,[1987]. This causes the usual ego functions of memory and identity to be seriously impaired. Transitions from one personality to another can be rapid and uninvited, triggered by psychological or environmental stress, or elicited on request.

REFERENCES

Achterberg, J.[1985]. Imagery and healing. Boston, New Science Library.

American psychiatric association.[1987]. Diagnostic and statistical manual of mental disorders [3rd ed., rev.]. Washington, DC: Author.

Andreas, S. Andreas, C.[1987]. Change your mind and keep the change. Moab UT: Real People Press.

Bandler, R. and Grinder, J.[1975]. The structure of magic. Palo Alto CA: Science and Behavior Books.

Bandler, R. and Grinder, J.[1982]. Reframing. Moab, UT: Real People Press,.

Bonny, H.L. [selector]. [1978a]. Emotional expression 1: selection 2, Brahams Requiem, parts 1 and 5 [Cassette Recording].Salina KS: Bonny foundation.

Bonny, H.L.[1978b]. Facilitating guided imagery and music sessions. Monograph #1. Salina, KS: Bonny foundation.

Bonny, H.L.[1978c]. The Role of Taped Music Programs in the GIM Process. Monograph #2. Salina, KS: Bonny foundation.

Bonny, H.L.[1980]. GIM therapy: past. present and future implications. Monograph #3. Salina, KS: Bonny foundation.

Bonny, H.L.[1986]. Music and healing. Music Therapy. 6A, 1:3-12.

Braun, B.[1984].Towards a theory of multiple personality and other dissociative phenomena. In B.G.Braun [Ed.] psychiatric Clinics of North America 7:171-193.

Braun, B.[1989]. Psychotherapy of the survivor of incest with dissociative disorder. In R.P. Kluft [Ed.]. Psychiatric Clinics of North America 12:307-324.

Bruscia, K.E.[1989]. Defining music therapy. Spring City, PA.:Spring House Books.

Cameron-Bandler, L.[1985]. Solutions. San Rafael, CA: FuturePace.

Clark, M.F. & Keiser, L.H.[1989]. Teaching guided imagery and music. Garrett Park, MD: Archedigm.

Clifford, T.[1984]. Tibetan buddhist medicine and psychiatry. York Beach, ME: Weiser.

Connelly, D. M.[1979]. Traditional acupuncture: the law of the five elements. Columbia, MD: Center For Traditional Acupuncture.

Coons, P.M.[1980]. Multiple personality: diagnostic considerations. Journal of Clinical Psychiatry. 41:330-336.

Densky A. B.& Reese M.[1986] Programmers Pocket Summary. Indian Rocks Beach, FL: Authors. [available from authors, 2060 collier Ave., Fort Meyers, FL 33901]

Godwin, J.[1987]. Music. mysticism and magic. New York, NY:Arkana press.

Grof, S.[1985]. Beyond the Brain. Buffalo, NY: New York State Univ. Press.

Klein, R.[1989,June]. Seminar in Neurolinguistic Programming [training requirement]. American Hypnosis Training Academy, Silver Spring, Maryland.

Kluft, R. P.[1987]. An update on multiple personality disorder. Hospital and Community Psychiatry, 38:370.

McDonald, R.[1990]. The efficacy of guided imagery and music as a strategy of self-concept and blood pressure change among adults with essential hypertension. [unpublished doctoral dissertation, Walden University, Minneapolis, MN.]

Morgan, C.[1990]. AMI, 4th annual conference report. Newsletter of the Association for Music and Imagery, 3[2]. [Available from Ed., S. Hale, P.O. box 777, Sandia Park, NM., 87047].

Pickett, E.[1987-1988]. Fibroid tumors and response to guided imagery and music: Journal of Imagination. Cognition and Personality, 7 (2):165-176.

Ross, C. [1989] Multiple personality disorder: Diagnosis, clinical features and treatment. Wiley series in general and clinical psychiatry. New York: John Wiley and Sons.

Rossi, E. L [1986]. The psychobiology of mind-body healing. Markam, Ontario, CN.

Skaggs, R.: [selector]. [1990] Conversations [Casette Recording.]. Atlanta: Southeastern Institiute For Music-Centered Psychotherapy.

Sessions, R.[1971]. The musical experience of composer, performer, listener. Princeton, N.J.: Princeton University Press.

Smith, R.D.,Titus, E., & Carr, M.[1989]. Integrative treatment in multiple personality disorder. Medical Psychotherapy. 2[1],1-10.

Spiegel, D.[1989]. Hypnosis in the treatment of victims of sexual abuse, In R.P. Kluft [Ed.] R.P. Psychiatric Clinics of North America 12,295-305.

Spiegel, H. & Spiegel, D.[1978]. Trance and Treatment: clinical uses of hypnosis. Wash. D.C.: American Psychiatric Press, 1978.

Stewart, R.J.[1990]. Music, power, harmony, London, ENG: Blanford Press

Tellegen, A. & Atkinson, G.[1974]. Openness to absorbing and self-altering experiences: a trait related to hypnotic susceptibility. Journal of Abnormal psychology 83, 268-277.

Watkins, J. & Watkins, H.[1990,June]. Ego state therapy, Workshop presented at the Second Annual Eastern Regional Conference on Abuse and Multiple Personality, Alexandria VA.

Wilson, T Narrator.[1985]. Chant: the healing power of the voice and ear. [Cassette Recording]. Richardson, TX: sound of Light.

Zuckerkandl, V.[1969]. Sound and Symbol. Princeton, N.J.: Princeton University Press.

AMI Publications.

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By Eugenia Pickett and Carolyn Sonnen

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