EDITORIAL
TODAY
THERAPEUTIC
PLURALISM
Richard P. Kluft, M.D.
A few short years ago, the clinician beginning the treat-
m. nt of a patient suffering multiple personality disorder
( PD) had very few resources or authorities to which to turn
fr guidance and direction. Scientific publications were few,
a d the number of identified experts in the field was very
li ~ited. In the span of a few short years, a vigorous literature
h s developed, and the number of clinicians who have ac-
 red a reasonable degree of expertise in the diagnosis and
treatment of MPD has expanded exponentially. Now the
n ophyte can study a helpful literature, and, in an increasing
n a
ay choose to join a local study group in order to further his
o her professional growth with regard to the dissociative dis-
o ders.
One of the interesting milestones of the increasing rec-
onition, treatment, and study of the dissociative disorders
i general and MPD in particular has been the growing re-
a ization that although certain approaches have been de-
s ribed in the literature and have demonstrated their effec-
t eness in the hands of experienced clinicians, a good many
p ychotherapists have not elected to utilize these methods of
t eatment. Instead, they have undertaken the psychother-
a y of MPD from a variety of perspectives and with an
i creasing diversity of treatment philosophies, and are
-ginning to share their differing approaches and experi-
e ces at the International Conferences on Multiple Person-
ity/Dissociative States and in their local communities.
I odays neophytes may be confronted not with a dearth of
i formation, as in the past, but with the dilemma of recon-
cling the different points of view (both explicit and implicit)
t which they have been exposed, and finding some way to
t tilize what they have learned from these different sources.
It is premature to offer a definitive description of the
:merging therapeutic pluralism in our field in terms of the
technical and theoretical diversity that is currently repre-
nted in contemporary practice. It is impossible within the
onfines of an editorial to pull together the common factors
thin thousands of colleagueswell-intentioned attempts to
rapple with the challenge of treating MPD. However, I will
ttempt to offer an overview of what I have encountered in
e literature, in conferences in North America and else-
here, and in conversations with colleagues working with
PD patients in North America, South America, theCarib-
can rim, Asia, Europe, and Australia. It is my hope that both
xpert and neophyte alike will find it useful to contemplate
hich of the several orientations listed below inform the
aterials they read and the advice that they receive, and
hereby be better able to appreciate why different authori-
ties and colleagues may give advices that are not consistent
with one another. I have chosen to describe orientations
rather than theoretical and technical approaches because I
have found that cliniciansstatements about their preferred
methods and their belief systems often prove unrelated to
what they actually do in their work with MPD.
It is my impression that seven approaches to the treat-
ment of MPD are being practiced today, and five have been
articulated and advanced as such. The first two of the seven
have been observed naturalistically, but never advocated
formally.
The first is what I call "Nantucket Sleigh Ride" therapy.
This expression comes from the days of whaling. Once the
whale was harpooned, the whaleboat that had carried the
harpooner and his crew was dragged along until the whale
tired and died. Many therapists encountering their first
cases of MPD appear to treat in this manner, which is best
described as a diffuse conglomeration of theories and prac-
tices conceived in desperation and employed in the fervid
hope that one will find something that works. Advice given
from therapists who have treated in this manner often are
overgeneralized from a limited data base and may reflect the
unique or serendipitous circumstances of their experiences
or the idiosyncrasies of their personal styles. Often they
attribute therapeutic importance to whatever temporally
preceded an improvement or the resolution of a crisis,
indulging in post hoc, propter hoc reasoning. The preva-
lence of this approach should not be understood as indica-
tion of its validity or appropriateness. It is acknowledged, but
not recommended.
A second perspective that also is quite common but
cannot be advocated is the stance I will term (facetiously)
"Modality Mayan" therapy. Its practitioners are all descen-
dants of the mythical innkeeper Procrustes who, having but
one size of bed, either shortened or lengthened his guests ac-
cordingly. Such therapists arc determined to treat MPD
patients with their modality of choice and explain MPD and
its therapy with their theory of choice. They are prepared to
defend their stance with the zeal of a fanatic, and rationalize
away any advice and/or data to the contrary. It is my impres-
sion that such individuals are so threatened by the challenge
posed to their preferred paradigms by MPD that they re-
double their efforts to insist upon their correctness. Such
colleagues give advice that flows readily from the basic tenets
of their preferred models, and frequently minimizes the im-
portanceof findings that are anomalous with regard to those
principles.
Among the major stances in the literature and in work-
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I)ISSOCI V tl()N. Vol. I. Nip. 1:1)vcranher 198
settings is the third approach, and the first of the
lly articulated ones, that of strategic integrationism. It
s upon rendering the dissociative defenses and struc-
hat sustain MPD less viable, so that the condition in
e collapses from within. Its ideal goal is the integration
personality in the course of the overall resolution of
tient symptoms and difficulties in living. It is consis-
h the psychoanalytic tradition of the analysis and
non of pathological defensive structures. Within this
on, particular techniques and interventions are val-
ss for themselves than for the long-term goals to which
n contribute. Some strategic integrationists may use
tic, cognitive-behavioral, and other techniques quite
ly, but others use them rather sparingly. Many clini-
ager to receive concrete advice or preoccupied with
atientsimmediate crises may find strategic integra-
srecommendations frustrating and unsatisfying, be-
these therapists characteristically are focused upon
tire course of the treatment and the flow of transfer-
nd countertransference. With experience and in-
g equanimity in the face of the vicissitudes of work
PD, many therapists move toward this orientation.
ctical integrationism, a fourth stance, espouses the
deal goal as strategic integrationism, the integration
personality in the course of the overall resolution of
tients symptoms and difficulties in Iiving. However,
mination of treatments conducted by therapists with
ientation reveals a predominant focus on tactics,
interventions that serve as adroit devices for the ac-
shment of objectives. Such therapies are often quite
c, and employ specific techniques and modalities
ngeniously and creatively. Often the deliberateness
nfulness of the treatment is quite conspicuous. Tac-
d strategic integrationistsbehaviors often are indis-
hable when one observes a brief spell of therapy; their
nt emphases emerge more clearly over a longer pe-
study.
fifth stance may be described as personality-focused.
ans who work in this manner fall into two large
those who do so on the basis of a thoughtful theoreti-
ntation that does not regard dividedness per se as
matic, and those who appear to accord the personali-
ce validity as people and attempt to nurture them into
via some variety of corrective emotional experience.
st group often pursues a therapy that takes the form
oblem-solving inner diplomacy or group or family
among a number of selves, all of which are encour-
collaborate more smoothly and harmoniously with-
essarily ceding their separateness or autonomy. Inte-
is not devalued and may well be pursued if the
so desires, but a more facile and functional arrange-
mong the elements of the mind is the major objective
eatment. The second group of personality-focused
sts emphasize nurture as a curative agent. They are
intent upon providing the patient with a rather
e corrective emotional experience in an attempt to
he hurts of the past. Although occasional dramatic
es are reported with such approaches, a large num-
ber of nfortunate excesses have been committed under its
2
aegis, and the risks for misadventure are high. Because of the
frequency with which such therapies run into difficulty, the
second group approaches cannot be recommended.
A sixth stance that has emerged recently and gained a
certain degree of popularity might be described as adapta-
tionalist. In essence, this is the stance of a number of distin-
guished therapists who designate themselves primarily as
pragmatists, and who prioritize the attempt to help their
MPD patients manage their daily lives more smoothly and ef-
fectively above other goals, such as integration. It is often
associated with less intense treatment in terms of the fre-
quency of the sessions and the duration of the therapy.
There is no doubt that this is a legitimate and useful clinical
stance, especiallywith patients primarily motivated to achieve
symptomatic relief, with scant resources, or whose life cir-
cumstances preclude an intensive therapy. Unfortunately,
this stance has also been advocated bya number of therapists
who are overwhelmed, burned out, inadequately prepared
for work with MPD, and nihilistic.
A seventh and final stance that has been articulated is
based on the assumption that many current methods pro-
mote a dysfunctional and unnecessary regression, and that
clever interventions can stabilize the patient in a functional
state and discourage the symptomatic expression of MPD. It
remains for this approach, which has much in common with
the "leave it alone and it will go away" attitude of an older
skeptical point of view, to demonstrate its worth.
1am confident that the readership of DISSOCIATION
appreciates that the skills and orientations of many of the
stances outlined above should be within the repertoire of
any therapist who works with MPD, and that these stances
have been described, for the sake of illustration, as if they
existed in pure form and were more dramatically different
than they might appear in clinical practice. It is important to
identify these pluralistic trends and study both their inde-
pendent progress and their interplay over the next few years.
If our field can avoid divisive fractionalism on the one hand
and the premature exaltation of one particular stance as
invariably correct and inevitably superior on the other, in
time studies may emerge to allow the determination of
which stances inform effective psychotherapy and which do
not. Furthermore, it may be possible to learn whether there
are subgroups of MPD patients for which one stance is more
useful than another, providing an opportunity to match
particular patients to therapeutic approaches that will ad-
dress their problems more efficaciously. 
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