THE TREATMENT OF
DISSOCIATIVE
DISORDER PATIENTS:
AN OVERVIEW OF
DISCOVERIES,
SUCCESSES, AND
FAILURES
Richard P. Kluft, M.D.
Richard P. Kluft, M.D., is Director of the Dissociative
Disorders Program at The Institute of Pennsylvania Hospital,
and Clinical Professor of Psychiatry at Temple University
School of Medicine, both in Philadelphia, PA.
For reprints write Richard P. Kluft, M.D., The Institute of
Pennsylvania Hospital, 111 North 49th Street, Philadelphia,
PA 19139.
Presented at the Amsterdam Meetings of the ISSMP&D, May
20, 1992.
ABSTRACT
The treatment of dissociative disorder (DD) patients with mul-
tiple personality disorder (MPD) and allied forms of dissociative dis-
order not otherwise specified (DDNOS) has advanced rapidly over
the last two decades. It is clear that many patients with these con-
ditions can be treated successfully, and several schematizations of
the treatment process have been published. However, all studies to
date have been open; controlled studies remain to be done. This pre-
sentation will review what is known about the treatment of these
conditions, however flawed the state of our knowledge, as judged by
the criterion of being associated with good clinical results. A num-
ber of relevant issues will be discussed.
INTRODUCTION
It is my task to share the perspective of an experienced
clinician who has had considerable success in the treatment
of dissociative disorder (DD) patients. I will try to commu-
nicate my understanding of the current state of knowledge
about what works and what fails to work in the treatment of
these patients. That is, I will discuss, "What to do until the
controlled studies come." Everything that I share will rep-
resent the best I know as of the date of my last revision of
this manuscript. However, everything I say will fall short of
the criteria for demonstrating efficacy that Putnam held out
for the field in his 1986 paper, and in his Amsterdam pre-
sentation (1992) as well. I am reminded of an old medical
school jest, in which myfather remembered a professor telling
on the first day of classes: " Gentlemen, half of what we teach
you in your four years here will be true, and half will ulti-
mately prove false. Unfortunatelywe do not know which half
is which." I will aspire to an accuracy level above that of ran-
dom chance, but only time will tell if I have achieved it.
Most dissociative disorder patients under long-term treat-
ment today, apart from those with depersonalization disor-
der, have at least the rudimentary structure of multiple per-
sonality disorder (MPD). This is the case even if their overt
phenomenology is more consistent with a diagnosis of dis-
sociative disorder not otherwise specified (DDNOS) and might
be described by many as "ego state disorders, " consistent
with the terminology introduced by the Watkins (1979).
Longitudinal studies of MPD patients indicate that most of
them spend a considerable percentage of their lives with
manifest phenomenology consistent with a DDNOS diagno-
sis (Kluft, 1985, 1991a), and longitudinal studies of DDNOS
patients demonstrate that they often prove to merit an MPD
diagnosis on follow-up reassessment (Boon & Draijer, 1993;
Kluft, 1985, 1991a). Therefore, in the interests of simplici-
ty I will refer to all such patients as MPD for the remainder
of this communication.
HISTORICAL BACKGROUND
It often is useful to look backward before dwelling on
the present in order to contextualize what is contemporary
and pay appropriate homage to those giants of the past. As
an editor, I am all too aware that many of the fine manuscripts
I review owe their quality to the contributions of others who
are not being credited for their work by younger authors
who only know of the original sources from the reference
lists of the articles they have read, and have forgotten that
all knowledge begins somewhere, with someone. I regret
that the limitations of space preclude all but a cursory trib-
ute to a handful of selected individuals.
Over 90% of studied cultures and societies have condi-
tions in which another entity is understood to have taken
control of the body of the afflicted individual (Foulkes, per-
sonal communication, October, 1984). Despite the infinite
variety of the possession states, their common features are
that, "An individual suddenly seems to lose his identity to
become another person. His physiognomy changes and shows
a striking resemblance to the individual of whom he is, sup-
posedly, the incarnation. With an altered voice, he pronounces
works corresponding to the personality of the new individ-
ual" (Ellenberger, 1970, p. 13).
Until the end of the eighteenth century, many individ-
uals in Western Society demonstrated these phenomena.
They were understood, within the explanatory paradigms
of their eras, to be afflicted with the various Judeo-Christian
forms of possession, and were approached therapeutically
with the culturally-sanctioned Judeo-Christian rituals of
exorcism.
The emergence of what Ellenberger has termed "the
87
DISSOCIATION. `'oL VI, No. 2/3. une Sept,1993
I IATNE DISORDERS
first dynamic psychiatry" and the non-theological explana-
tion of mental illness can be traced to many cultural and
political changes in Europe. However, they were crystallized
in the November, 1775 confrontation of the celebrated exor-
cist, Father Johann Joseph Gassner, with the more "scien-
tific" physician, Franz Anton Mesmer, M.D. Mesmer's the-
ories of "animal magnetism," however erroneous, informed
a novel theory and practice of therapy that prefigured con-
temporary hypnosis. Mesmer demonstrated that he could
both induce and dispel the types of symptoms that Gassner
had been treating with exorcism, and concluded that Gassner
had achieved his successes not by the casting out of demons,
but by the unwitting use of his animal magnetism.
Notwithstanding, Mesmer was later discredited by a French
Royal Commission. Ironically, it was argued that Mesmer,
unwittingly, had cured his patients not by animal magnetism,
but by suggestion. The events of 1775 played an important
role in undermining the theological explanation of mental
disease. This abbreviated account is indebted to Ellenberger's
classic, The Discovery of the Unconscious (1970) .
With a change in the dominant paradigms for under-
standing (and expressing) mental illness, the possession states
did not abruptly cease to exist. Instead, what we now call
MPDand DDNOS began to be described in the literature
without a supernatural explanation. Viewed from this per-
spective, these conditions are no more than the secular expres-
sion of the same psychological structures that were found
in theJudeo-Christian possession syndromes. MPD is the con-
temporary and demystified form of an anthropological com-
monplace. In societies in which indigenous possession states
remain common, the psychopathological niche that MPD
occupies in American and Western European populations
is already filled, and MPD will remain uncommon (for a study
consistent with this hypothesis, see Adityanhjee, Raju, and
Khandelwal (1989).
Within years of this paradigm shift, Petetain described
patients which we would diagnose with MPD, and just after
1800, Benjamin Rush, a noted patriot and the founder of
American Psychiatry, noted such patients at the Pennsylvania
Hospital . However, the first attempt to delineate a specific
syndrome or disorder consisting of these phenomena was
made by Eberhardt Gmelin in 1791when he reported a case
of umgetauschte Personlichkeit, or exchanged personality
(Crabtree, 1993; Ellenberger, 1970; Greaves, 1993).
Over the course of the nineteenth century, numerous
authorities made many noteworthy contributions to the
description of MPD phenomenology, but all too many cases
were observed and studied rather than treated. Onno van
der Hart has spearheaded an effort to restore recognition
of Pierre Janet and his innumerable therapeutic contribu-
tions; his work is a valuable tribute to Janet as well as a resource
for the study of Janet 's techniques (e.g., van der Hart, Brown,
& van der Kolk, 1989; van der Hart, Brown, & Turco, 1990:
van der Hart & Brown, 1992; van der Hart & Friedman, 1989,
etc.).
Among the unrecognized pioneers, I hold in high
esteem a man whom I consider my teacher and mentor.
Antoine Despine, M.D., a French general practitioner of high
88
repute and a student of magnetism (hypnosis), appears to
be the first to have effected a non-exorcistic cure of MPD, in
his treatment of "Estelle." Although the original source
(Despine, 1840) is difficult to locate, Ellenberger (1970) has
described his therapeutics, I have summarized aspects of his
work (1984a, 1986) and Fine (1989) has done an exegesis
of his text that demonstrates his awareness of ideas and con-
cerns that we might have thought to be more modern insights.
Despine was referred a young woman of eleven whose
manifold symptoms had defied the efforts of many physi-
cians. After Despine exhausted his armamentarium of min-
erals, various baths, and massages, he learned from her moth-
er that Estelle was being serenaded and comforted by choirs
of angels and heard inner voices. He began to suspect a mag-
netic (i.e., hypnotic) psychopathology. He gradually gained
access to a number of alter states (but conservatively only
mentioned a few in his text, leaving the remainder of his
observations in a fascinating appendix). He learned how to
reach them both with hypnosis and by simple request. He
learned how to relate to avariety of personalities. He learned
how to bring about their reconciliation by addressing their
issues and their relationships with one another. Further, using
imagery suggested by the patient, he facilitated their join-
ing with hypnosis. Interestingly, Estelle stayed integrated until
her death.
Despine was indeed my teacher. When I first encoun-
tered MPD phenomena in 1970 and tried to get some advice
on treating them, most of those to whom I turned said that
I must have been duped or that I had caused them by some
error. I was assured that if I did not reinforce them, they
would go away. When this advice failed to benefit the
patients, I looked for help elsewhere. I felt confused by Thig-
pen and Cleckley's work with "Eve" (1954, 1957) because
much of what they said was inconsistent with my own expe-
rience, a misgiving validated when it proved that Eve had
not been treated successfully (Sizemore & Pittillo, 1977). 1
studied the landmark article by Bowers and her colleagues
(1971) , but I was too inexperienced to appreciate its wis-
dom, which encompassed basic principles but did not tell
me what to do, and too shy to call one of the co-authors.
This was prior to the publication of Sybil (Schreiber, 1973) ,
which described the work of Cornelia B. Wilbur, M.D. In
any case, after its publication I was told by a prestigious pro-
fessor that Sybil wasa fraud, and did not read the book until
I had been working with MPD for six years. It was before
Ralph Allison (1974) published his methods, and I did not
run across his article until a year or so after its publication.
Therefore, I read about Despine, over and over, in
Ellenberger (1970), and was able to read a part of his orig-
inal work. I read some Janet. Melding this with my psycho-
analytic orientation, I conceived of approaching MPD by treat-
ing at once the whole person and the alters, by working both
across personalities and with personalities individually, and
by using circumspect hypnotic interventions in order to address
dissociative phenomena that did not appear to yield easily
to alternative methods. I became both a psychoanalytic can-
didate and a student of hypnosis. What I learned from Despine
led me to achieve very good clinical results with MPD patients
DISSOCIATION, Vol. CI, No. 2 lime Sept. 1993
before I had the opportunity to meet the twentieth century
pioneers in the treatment of MPD, such as Wilbur, Caul, Bowers,
Newton, and Allison.
CURRENT S CHEMATA FOR THE TREATMENT OF MPD
At present awealth ofinformation is available concerning
the treatment of MPD. It is generally accepted that a sup-
portive-expressive psychodynamic psychotherapy, facilitat-
ed when necessary with hypnosis, employing the adjuctive
use of medication, availing itself on occasion of certain tech-
niques borrowed from cognitive and behavioral therapy, and
supported when possible with ancillary creative arts thera-
pies, is an appropriate approach for most MPD patients (Wilbur
& Kluft, 1989). Putnam's 1989 text, The Diagnosis and
Treatment of Multiple Personality Disorder, has a well-deserved
reputation as the most widely respected single book on the
treatment of MPD. It has the capacity to speak to the needs
of the rank beginner and the advanced clinician as well.
Many important articles on treatment are found in two spe-
cial MPD issues of Psychiatric Clinics of North America (March,
1984 and September, 1991) edited by Bennett G. Braun,
M.D., and Richard J. Loewenstein, M.D., respectively. Braun's
1986 Treatment of Multiple Personality Disorder, has much solid
information to offer. ClinicalPerspectives on Multiple Personality
Disorder, by Kluft and Fine (1993), has many pragmatic arti-
cles for the clinician, and offers a chance to observe the pro-
cess of several psychotherapies done by experts. Ross (1989)
and Bliss (1986) have written useful books, but are too unique
in their perspectives to be useful as introductory texts for
the field. Most of the hypnotic interventions now used for
work with MPD were published in the American journal of
Clinical Hypnosis between 1982 and the present.
There is general consensus that the treatment of MPD
has the form of a posttraumatic therapy as understood by
Herman (1992), and that its many steps or stages conform
to the three stage model Herman has described and acknowl-
edged was first proposed by Janet. Herman ' s stage 1 involves
the establishment of safety. Stage 2 involves remembrance
(of traumata) and mourning. Then, stage 3 is focused on
reconnection. In another contribution in this issue (Kluft,
I993a), I have compared the models of MPD therapy
described by Braun (1986) , Kluft (1991b) , and Putnam (1989) .
In essence, they all follow the sequence Herman outlined.
For example, I (1991b) have noted nine stages: 1) Establishing
the Therapy; 2) Preliminary Interventions; 3) History
Gathering and Mapping; 4) Metabolism of Trauma; Moving
Toward Integration/Resolution; 6) Integration/Resolution;
Learning New Coping Skills; 8) Solidification of Gains and
Working Through; 9) Follow-up. Of these, stages 1-3 are
designed to maximize safety and communication, stage 4
involves intense work with traumatic material, and stages 5-
9 involve reconnection, both within the alter system and
interpersonally.
It has become clear that the effective treatment of MPD
cannot begin with extensive work on traumatic materials.
This almost always leads to decompensation. Although the
patient may come for treatment because of the emergence
of such material, and some initial work with it may be nec-
essary, it is important to move the patient into what Fine
(1991) has called a phase of suppression in order to resta-
bilize the patient. Although many MPD patients appear to
be intellectually gifted and to have high egostrength, it does
not follow that one can proceed to address their traumatic
experiences in short order. Their vulnerabilities almost invari-
ably overwhelm and invalidate their strengths, an event that
can prove demoralizing to patient and therapist alike. Fine
(1991, 1993) and Kluft (1993a, 1993h) have addressed these
considerations and suggested therapeutic approaches that
take them into account. van der hart and Brown (1992) and
van der Hart, Boon, Steele, and Brown (1993) discuss these
concerns specifically in terms of abreaction and work with
traumatic memories.
I will offer a description of central concerns in the treat-
ment of MPD viewed through the lens of Herman's (1992)
three phase model. In the first, or safety phase, there must
be a prioritization on creating an atmosphere of safety in
the therapy, and an anticipation of what will be necessary to
make the next phase safe as well. Consequently the treat-
ment is governed by what I call Belafonte's law: "House built
on a weak foundation, it will fall! Oh, yes! Oh, yes! Oh, yes."
A primary concern is accorded to ego-strengthening. The
patient is reached by an empathic focus on self-experience,
and self-object transferences (Kohut, 1977). The patient is
taught many techniques to achieve self-efficacy (Bandura,
1977) in the treatment and in his or her life. The patient's
management of shame (Nathanson, 1992) and guilt is
addressed. Symptomatic relief is offered. The increasingly
strengthened patient, the gradually enhanced therapeutic
alliance within the therapeutic dyad, and the better-informed
therapist test out the techniques they may use in the man-
agement of traumatic material before moving deliberately
to encounter and master it. These concerns are addressed
in detail elsewhere (Kluft, 1993a).
Stage 2, which Herman (1992) calls remembrance and
mourning, involves the mastery and detoxification of the
patient's traumatic experiences. Here there are tensions
between the need to optimize the patient's independence
and autonomy, and the therapist's appreciation that this
type of work must be carefully controlled, dosed, and titrat-
ed lest it prove disruptive. The transferences are traumatic
(Loewenstein, 1993), and one is more impressed with the
posttraumatic aspects of MPD than the features of the many
alters. It is essential, notwithstanding the vicissitudes of mem-
ory, to provide the patient the opportunity to achieve a sense
of the continuity of his or her life, even across traumatic
events.
In Stage 3, which Herman calls reconnection, there is
a press to integrate the self by the joining and blending of
the personalities, to integrate with others by resolving inter-
personal problems and to treat whatever characterologic prob-
lems impede the patient's adjustment with others. Now the
patient has what I have called "single personality disorder,"
and must face the consequences of integration, the task of
grappling with "normal problems, " and the task of prepar-
ing for the future (Kluft, 1988a). Often both the dynamics
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DISSOCIATION, Vol. VI. No. 2 '3, June 'Sept 1993
and the transference assume the configurations of more clas-
sic psychoanalytic patterns.
CURRENT STANCES TOWARD THE TREATMENT
OF MPD
It is impressive that although the vast majority of the
recent literature on the treatment of MPD advocates inte-
gration, and series of patients treated to integration have
been described and followed up, with the demonstration of
excellent stability (Kluft, 1984b, 1986), it is by no means cer-
tain whether working toward integration characterizes the
majority of MPD treatments in progress throughout the world.
In fact, if one interviews a wide variety of therapists who treat
MPD, a wide variety of therapeutic stances will be encoun-
tered. In 1988(b) I tried to classify what I encountered, in
an article entitled "Today's Therapeutic Pluralism," and
described seven basic orientations.
Although I have used other descriptors elsewhere, here
I will call the first stance Desperate Eclecticism. It is common
among therapists first encountering MPD and therapists who
do not make an effort to learn about MPD. It is best described
as a " diffuse conglomeration of theories and practices con-
ceived in desperation and employed in the fervid hope that
one will find something that works" (Kluft, 1988b, p.1) . When
therapists with this orientation give others advice, they usu-
ally overgeneralize from a limited data base and emphasize
serendipitous or idiosyncratic factors. They often become
convinced that whatever they did immediately before an
improvement or the resolution of a crisis was the key to the
treatment, recurrently making post hoc, propter hoc assump-
tions. They are very eager to learn new techniques, because
their style relies on the trial and error application of many
approaches until something appears to work. This stance is
acknowledged to exist, but cannot be recommended.
A second stance might be called TheProcrustian Imperative.
In short, to the man whose only tool is a hammer, everything
looks like a nail. Some therapists are deeply wedded to and
identified with a particular theory and modality of choice.
They become determined to treat MPD with their modality
of choice, and to understand MPD with their theory of choice.
They rationalize their dismissal of all advices and observa-
tion that would go contrary to their preferred paradigm.
Apparently they are sufficiently threatened that they find
learning new ideas intolerable. They offer advices that flow
from the basic principles of their preferred models, and min-
imize or discount the findings and events that are anoma-
lous with respect to their ideas. Such fanaticism is not to be
encouraged. I regret that 1 cannot find a source for a saying
I have heard attributed to Charcot, "A theory is a wonder-
ful thing, but it does not prevent other things from exist-
ing. "
A third stance could be termed Wishful Minimization. It
proceeds from the premise that MPD is not a genuine clin-
ical phenomenon that must be approached in order to be
resolved. Instead it is understood as an iatrogenic artifact, a
social psychological response to certain demand character-
istics inherent in certain situations, or some form of cha-
90
rade (with the possibility of sincere self-deception bya histri-
onic, manipulative, gullible, or mythomaniacal patient) . The
treatment philosophy can be reduced to " leave it alone and
itwill go away," presumably by non-reinforcement. This point
of view is very strong among skeptics, senior academicians
with minimal clinical experience with MPD phenomena, and
those who have never knowingly encountered MPDand there-
fore cannot believe that the modern literature on MPD is
credible. There is a body of evidence to suggest that it is
completely ineffective (Kluft, 1985); therefore, it is con-
traindicated.
A fourth stance might be called Personality-Focused.
"Clinicians who work in this manner fall into two large groups:
those who do so on the basis of a thoughtful theoretical ori-
entation that does not regard dividedness per se as prob-
lematic, and those who appear to accord the personalities
a face validity as people and attempt to nurture them into
health via some variety of corrective emotional experi-
ence"(Kluft, 1988b, p.2). The first group often do therapies
that involve a form of a problem-solving inner group ther-
apy or inner family therapy among the many selves. All parts
are encouraged to collaborate more smoothly without nec-
essarily moving toward integration. Integration may be pur-
sued if the patient so wishes, but a more harmonious and
functional arrangement among the alters is the major objec-
tive. Many patients have been helped by this approach. The
second group emphasize nurture as a curative element as
they try to undo the hurts of the past in a highly tangible
manner. Although occasional dramatic successes are report-
ed by such therapists, many unfortunate outcomes are also
noted. Consequently, it cannot be recommended. A detailed
discussion of some of the issues related to orientations that
do not advocate integration is available (Kluft, 1993c).
A fifth stance which has received much interest of late
might be called Adaptationalist. It describes a group of dis-
tinguished experts who see themselves primarily as prag-
matists. They may prioritize the management of life activi-
ties, the maintenance and improvement of function, and
accord integration a secondarygoal, which can be approached
only if life issues are resolved or stabilized. Some of these
therapists often point to the unavailability and/or expense
of treatments that move toward integration. There is not
doubt that this stance is an inevitable part of almost all MPD
therapies at times when the patient is overwhelmed, and is
called into play by therapists who prefer other stances but
appreciate that in a particular situation or with a particular
patient a more ambitious focus would ask too much of the
patient 's resources. Unfortunately, it is also a favored stance
of those who minimize the value of psychotherapy or are
motivated to select an approach that makes less demands
on an agency or generates lower bills for a third party. More
unfortunately still, it is often the stance of therapists who
are " burned out " and have little left to give to their work
with their patients. This stance offers them a rationale for
their inability to commit themselves to an optimal course of
treatment. The long-term stabilization or the capacity of
patients treated in this manner to terminate treatment in
an improved state and maintain that improvement has yet
D1SSOCIATION. Vol. VI. No. 2 3,, uneSept 1993
KLUFT
to be demonstrated.
The sixth and seventh stances, Strategic Integrationalism
and Tactical Integrationalism, are those most frequently taught
in workshop settings, and are associated with the vast major-
ity of successful treatments. Although there are some basic
theoretical and technical differences in these approaches,
they rarely can be distinguished completely from one anoth-
er. The vicissitudes of clinical practice often force a strate-
gic integrationalist to use approaches more central to tacti-
cal integrationalism, and vice versa. Therefore, the theoretical
differences are more pronounced than the technical ones,
and one might have to witness a number of hours of a num-
ber of MPD therapies in order to determine which orienta-
tion a given therapist implicitly followed.
Strategic integrationalism "focuses on rendering the dis-
sociative defenses and structures that sustain MPD less viable,
so that the condition in essence collapses from within. Its
ideal goal is the integration of the personality in the course
of the overall resolution of the patient's symptoms and dif-
ficulties in living" (Kluft, 1988b, p.2). Consistent with the
psychoanalytic tradition of the analysis and resolution of patho-
logical defensive structures, particular techniques and inter-
ventions are valued less for themselves than for the long-
term goals to which they contribute. Hypnotic,
cognitive-behavioral, and other techniques maybe used sparse-
ly or liberally. It is interesting that with experience, success,
and increasing equanimity with MPD treatment, more ther-
apists move toward this stance, which was exemplified by the
late Cornelia B. Wilbur, M.D., and melded with hypnotic
and cognitive approaches in the service of strategic goals by
Kluft.
Tactical integrationalism espouses the same ideal goal
as Strategic Integrationalism, but the actual conduct of the
therapy reveals a predominant concentration on tactics, and
on discrete interventions that serve as adroit devices to accom-
plish a series of objectives. Such therapies are often quite
eclectic and ingenious. Their planfulness and deliberate-
ness may be conspicuous. At times these therapies take the
form of a series of short-term therapies within the context
of a long-term therapy. The ancestry of this approach to MPD
is the eclectic hypnotic approaches used by many pioneers,
exemplified by Allison, Braun, and the late David Caul, M.D.,
more recently modified by the cognitive-behavioral contri-
butions of Fine (e.g., 1991, 1993), who has raised its expo-
sition to a new level of sophistication. Because more train-
ing programs at this point in time are cognitive-behavioral,
eclectic, and/or minimally supportive of the long-term psy-
chodynamic treatments, it seems likely that increasing num-
bers of young practitioners will find this model most con-
genial.
It will be interesting to track the fates of these stances
over time. It is possible that trends in the education of psy-
chiatrists and psychologists rather than prior demonstrations
of efficacy may determine which become most popular. At
this moment in time, it is important for the clinician to appre-
ciate that these stances are more useful as heuristics and
general principles than as a guide to the vicissitudes of daily
practice. Because the circumstances and stability of an MPD
patient may vary considerably, and because some aspects of
the treatment may require interventions otherwise absent
from the therapy, a therapy that is purely based on one stance
from beginning to end is a rarity. A therapist needs the flex-
ibility to work with the model that best suits the immediate
situation, even if it differs from the one that governs the
overall strategy. For example a skillful strategic integrationalist
therapy may begin with an adaptational stance or a person-
ality-focused approach in order to stabilize the patient's life
and/or build rapport. The patient might be approached
with techniques most characteristic of tactical integra-
tionalism in order to build ego strength and prepare the
patient for work on traumata. With momentum and an
increased therapeutic alliance a more classic strategic inte-
grationalist stance may then come to dominate the therapy,
except for occasions when the application of specific tech-
niques proves necessary to reach otherwise inaccessible mate-
rial.
It is the opinion of many experienced therapists that
when treatment must be given with less than optimal inten-
sity, adopting a tactical integrationalist stance, from which
one is prepared to move toward adaptational and person-
ality-focused stances when the patient may be unable to move
forward for the moment, is a prudent decision.
CURRENTLY ACCEPTABLE APPROXIMATIONS TO
CLINICAL WISDOM
I have chose this rather oblique and apologetic title because
in the interests of expressing a large number of ideas and
observations rather rapidly I will inevitably appear to be more
sure of myself on the printed page than I am in the privacy
of my own mind. I want to emphasize once again that much
of the best we know is quite flawed, tentative, and subject to
reconsideration in the face of further experience and infor-
mation. Since much of the work I will refer to is my own,
perhaps the following information about me will help the
reader to contextualize these remarks.
I have been working with dissociative disorder patients
(knowingly) since December 1970. I have seen well over a
thousand patients with DDs in consultation, and have taken
over 200 into treatment for at least three months. Of these,
150 have achieved stable integration by research criteria (Kluft,
1986). Approximately 10% of my patients have interrupted
their treatment, for a wide variety of reasons. Of the remain-
der, about 10% have ended treatment without a mutually
satisfactory result (integration, symptomatic relief, and rel-
atively unobstructed pursuit of life goals). The remainder
integrated and left intense treatment or are still in therapy.
Of those who reached stable integration, at last systematic
follow-up virtually all were doing reasonably well in life, and
still integrated. When I started doing follow-up research I
saw the full spectrum of MPD psychopatholgy; currently I
tend to be working with populations at the extremes of high
ego strength and cooperation on the one hand and the most
refractory and difficult patients with one or more prior treat-
ment failures on the other. I do not enter patients whom I
treat for other therapists in my dissociative disorders pro-
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DISSOCIATION, Vol. VI, No. 213. Done Sept. 1993
TREATMENT OF DISSOCIATIVE DISORDERS
gram into my statistics unless they later become my patients,
because they often come from different states or countries,
and I have no way of following them in a standardized man-
ner.
The Natural History of MPD Project
From 1972 through 1990 I followed a series that ulti-
mately included approximately 250 MPD patients over time,
and published a study on this work involving 210 patients in
1985, entitled "The Natural History of Multiple Personality
Disorder." When I started finding cases of MPD I was work-
ing in a community hospital as well as a specialized psychi-
atric facility. In that community hospital, it was customary
that if a physician ' s name was on a patient ' s chart, even as
a prior consultant, upon the hospital admission or the emer-
gencyward visit of the patient, the physician would be informed.
The medical ethos dictated that continuity of care was to be
preserved, and also that no one would take over care of anoth-
er doctor's patient unless this had been agreed upon or insist-
ed upon. Perhaps this was wasteful financially, but we all got
to know our patients well, and often knew their families.
Over eighteen years I was able to follow MPD patients I
had diagnosed in the community. I was not restricted to fol-
lowing those I knew and treated. I also could follow those I
had seen in consultation or for inpatient treatment and
returned to another therapist or to their family doctor or
minister. I saw those that had no mental health treatment;
those who were treated by therapists who thought my diag-
nosis was crazy (and usually said so!) ; and those treated by
professionals who accepted the diagnosis, but did not or
would not address the MPD, and tried to either treat around
the MPD or to treat it as if it were another more familiar dis-
order. I could see what happened to all cohorts over time.
In assessing the patients I originally used my clinical inge-
nuity, and then a semi-structured interview called the CSDS
(Center for the Study of Dissociative States) Protocol. It remains
unpublished, but was distributed widely, and many of its items
made their way into the SCID-D (Steinberg, 1993).
In a typical scenario, a patient who had been assigned
to me for psychiatric hospitalization in 1975 and returned
at discharge to a community mental health center for treat-
ment with a therapist who did not address the MPD might
be hospitalized for the consequences of an automobile acci-
dent in 1983. I would be informed, and if I were not con-
sulted, I nonetheless would get permission to visit and inter-
view the patient. In this manner I got second, third, fourth,
and more opportunities to reassess persons who at one time
had unequivocally qualified for the diagnosis of MPD. The
range of follow-up for the 1985 study was 3-13 years.
What I found is that of all the patients who had had MPD
on assessment and had received no psychiatric treatment
whatsoever in the meanwhile continued to demonstrate MPD
or DDNOS with the features of MPD on follow-up. Although
it is possible to argue that I induced an iatrogenic artifact
or compelling demand characteristics initially and they per-
sisted, or that !did so twice or more as I reassessed the patients,
their interval histories indicated that they were living with a
DD adaptation before the first assessment and in the inter-
92
val between the assessment. Therefore, while these criticisms
maybe leveled at the phenomenology I elicited, they do not
address the given history, often buttressed by family mem-
bers. I tended to visit these patients during evening visiting
hours to maximize the likelihood of getting corroboration.
The presence or absence of the phenomena of MPD was my
main concern. I did not focus on particular details, which I
appreciated might change over time, and were subject to
many possible contaminants. Although I observed the types
and levels of dissociative symptomatology varied and fluc-
tuated, I discovered that the natural remission rate of MPD
which is not reinforced by specific MPD psychotherapies is
nil. Hence minimalizing approaches may diminish an MPD
patient's demonstration of overt MPD phenomena, but they
are unlikely to make the condition improve in any lasting
sense.
What of the patients in treatment with therapists who
totally discounted the MPD diagnosis? On repeated reex-
amination, all retained their MPD. Many, when I asked how
they conducted themselves with their therapists, described
concealing the MPD because the therapist appeared so unac-
cepting of it. Therefore, therapy that denies the MPD does
not lead to its remission.
When a patient with MPD is in treatment with a thera-
pist who does his or her best, acknowledges the MPD, but
does not address the MPD specifically (in this series it was
usually because the therapist did not know how to treat MPD) ,
most patients retain their MPD. One patient nonetheless found
a way to get well by bringing in all the alters with their issues
while each alter passed for the host in its sessions. A second
may have spontaneously integrated in a compassionate but
non-specific therapy. The patient believed that this had hap-
pened, and even with aggressive hypnotic efforts I could not
elicit alters in a follow-up several years later. In this series,
then, perhaps 3% of MPD patients integrated thoroughly in
non-specific treatments. 97% of those in non-specific treat-
ments did not integrate and retained their MPD.
If we now compare these percentages to the figures in
my 1984b paper, we find that in that series, of 123 MPD patients
whose treatments were monitored, 20 patients were still in
active intense treatment at the time the study ended, and
their outcome remained to be established. Ten treatments
were considered failures, 10 were interrupted, and 103 reached
completion or ended. In 83 or (81 %o)of the completed treat-
ments the patients reached integration by research criteria.
The follow-up component demonstrated that only 6% had
relapsed into behavioral MPD, and that only 26% in all con-
tinued to use dissociative defenses; i.e., about one patient
in twenty relapsed into a diagnosable dissociative disorder,
and about one patient in four continued to use occasional
dissociative coping, or had been found to have ego state phe-
nomena without behavioral expression. Unpublished results
indicate that those who relapsed fully had a poor long-term
prognosis, while all of the others were able to work through
their residual MPD-like coping styles in an additional spell
of therapy.
Although it would be appropriate to argue that many
factors make this an atypical series (e.g., the unusual degree
DIS50CIATION, Vol. 1'I. No. 2 :3. June.'Sept.
KLUFT
of experience of the prime therapist, who had successfully
integrated many MPD patients before beginning the series,
and most of the study having been done when there were
so few people treating MPD that the patients were very eager
to cooperate and very protective of the therapists involved,
etc.), it nonetheless demonstrates the superiority of specif-
ic treatment to non-specific treatment and to non-treatment.
Integration Versus Resolution
Like many therapists, I encounter patients who are not
interested in pursuing integration, and prefer to work
toward a more harmonious relationship among the alters.
I have discussed the resistance and reluctance to approach
integration at length elsewhere (Kluft, 1993c). Follow-up
data indicates that only a small percentage of patients with
stable integration elect to abandon it. Of the patients who
have done so to date, only one or fwo chose to do so because
they preferred dissociated life. Of patients who worked for
a resolution, however, over 70% returned to work for inte-
gration. That is why there is no separate resolution catego-
ry in my research -- most of the patients found that "func-
tional MPD" was a myth for them and wound up in the
integration group. Under pressure, most had experienced
a return of dysfunctional dividedness, and/or had found
that by maintaining dissociative boundaries they were prone
to revictimization (a problem discussed at length elsewhere
[Kluft, 1990] ). They found that living with dissociation con-
tinued to confront them with the perils of what I have called
" multiple reality disorder. " Using different patterns of per-
ception and thought, drawing information from different
databases, and oblivious to the contradictory nature of many
of the precepts they were accepting simultaneously, they kept
making errors that predisposed them to further harm, self .
defeat, and unnecessary mishaps.
On the basis of this experience, I think that although it
may be possible to live as a "well MPD," this is an outcome
that cannot be endorsed for a patient without explaining
the associated risks and obtaining informed consent. Naturally,
when confronted with an MPD patient so overwhelmed that
the difficult therapy necessary to affect fusion would be con-
traindicated, ego strengthening and working for a more har-
monious alignment of the alters is the most humane and
reasonable course, with the hope of pursuing integration at
some later date.
The Prognosisof MPD
With the exception of an early article by the late David
Caul (1988), the study of the prognosis of MPD patients has
been largely a matter of experts sharing anecdotal impres-
sions with one another. Putnam (1986) studied Kluft ' s 1984
data and found that complexity affected length oftreaunent
for patients with 18 alters or less-one could predict about
3 months of therapy per alter. At higher degrees of com-
plexity this ratio did not hold.
The figures cited above from my own research would
indicate an optimistic prognosis for MPD. However, the aver-
age clinician rapidly becomes aware that they do not describe
the modal encounter of the modal MPD patient with the
average MPD-sensitized psychotherapist. In another outcome
study, Coons (1986) followed 20 MPD patients for an aver-
age of 39 months. 67% were considered greatly improved,
and 25% had integrated completely and maintained their
integration. This would suggest that MPD has a favorable,
but only a moderately favorable prognosis. It might appear
impossible to reconcile these findings at first glance.
However, in fact, these studies are not readily compa-
rable. and neither can be considered either typical or defini-
tive. Dr. Coons' patients were from a state hospital setting.
Their average education was less than the completion of
high school. They were treated by 20 therapists, many of
whom were trainees, and all but one of whom was treating
his/her first case of MPD. Most saw their patients once a
week, below the recommended minimal frequency, which
is twice a week (Wilbur & Kluft, 1989).
In contrast, almost all of my series' patients were from
the private sector. Almost all were high school graduates and
many had college or graduate degrees. My series was begun
after I had successfully integrated 20 MPD patients; the other
clinicians were experienced (e.g., Cornelia B. Wilbur, M.D.,
was contributing cases). The average intensity of treatment
was twice a week. These factors explain much of the differ-
ence.
However, there is another problem as well. My series
included a number of patients who did not improve rapid-
ly, and therefore were not part of the integration cohort that
was the primary focus of the research. If we look at the whole
spectrum of my series, it becomes clear that it includes a
good many patients that do very well rapidly, and a smaller
percent that do not. In fact, one could make a speculative
case that there are at least two types of MPD patients, one of
which integrates rapidly, and one of which does not, and
that while about 75% of my series consists of the rapidly inte-
grating patients, only about 25% of Dr. Coons' patients is
this type. Conversely, about 75% of Dr. Coons' series con-
sists of patients whose response to treatment is less positive,
while this type of patient constitutes only 25% of my series.
I now will offer a preliminary report on some research
in progress that strongly suggests that this is the case. I have
developed a 12 item instrument designed to indicate the
MPD patient's baseline level of function in a number of cru-
cial dimensions, and then to follow the patient's function
across time at regular intervals. Progress as measured by this
instrument, which will be published soon (Kluft, in press),
was charted for 33 MPD patients already in treatment, and
for a group of 10 MPD patients newly taken into treatment.
Interestingly, the established patients showed great hetero-
geneity in their ratings, with some improving, some remain-
ing fixed, some declining, and some fluctuating up and down.
However, of the new patients, seven made rapid gains in
their ratings, and in their clinical improvement. Two made
moderate gains, and showed some fluctuations. One showed
minimal gains, and fluctuated widely.
A retrospective review of the other patients in the year
cohorts in which the established patients had entered ther-
apy demonstrated that excepting those with three years of
treatment or less, most of the other patients in the relevant
93
DISSOCIATION, Vol. - uue~ Sept, 19'13
TREATMENT OF DISSOCIATIVE DISORDERS
year cohorts had already terminated intensive treatment suc-
cessfully. They were integrated and seen infrequently in fol-
low-up.
Further study of the instrument and the scores demon-
strated that what was being measured was not a "honeymoon
effect;" nor was a higher score easier to obtain if one start-
ed at a lower level, as one would expect for new patients.
Instead, it appears that some patients rapidly embrace the
therapy situation and progress very rapidly, while others,
usually protesting how hard they are working, do not. I hypoth-
esize that the patients in my study who integrated rapidly
were more like the fast-responders, or High Trajectory Patients,
which I infer were less highly represented in a less educat-
ed state hospital clinic population than in a small number
of private practices. Since the slower-responding or Low
Trajectory Patients do not improve as rapidly, one might
speculate that a person with a private sector practice spe-
cializing in DDs would gradually accumulate such patients
until they came to dominate his or her practice. This indeed
was the case in the practice studied in the treatment trajec-
tory study. Of the 33 established cases, about 25 were
responding much more slowly than the other MPD patients
who had entered treatment in the same year as themselves,
while the other eight were in their second to fourth years of
therapy.
Interestingly, in the year after the study concluded, at
a two-year level seven of the 10 new patients (all of whom
had been High Trajectory from the first) maintained or
improved on their trajectories modestly. The patient who
was at the lowest level skyrocketed ahead into a High
Trajectory pattern and made many dramatic improvement
in her life and in her intrapsychic function. One of the mod-
erate group remained on a slow and fluctuating pattern of
improvement. The second in the moderate group struggled
through the second year without improving her rating, and
began to deteriorate severely in the third year. At this time
I think that we are on the verge of demonstrating MPD to
be avery heterogeneous condition, and will soon be able to
distinguish a few subtypes of MPD and further study their
prognostic implications. Although these results are too
crude and preliminary to be definitive, they offer the hope
that in the future it may be possible to determine the prog-
nosis and treatment course of the majority of MPD patients
during a trial of therapy.
The Cost-Effectiveness of MPD Treatment
In an era in which financial concerns often threaten to
crowd therapeutic advances from the mental health pro-
fessions' field of vision, it is instructive to observe that a num-
ber of studies of seriously ill MPD patients has demonstrat-
ed that although their treatment is expensive, specific MPD
treatment ultimately leads to a reduction in overall expen-
ditures. Ross and Dua (1993) projected a savings of $84,
899.44 (Canadian) per patient for the application of spe-
cific treatment over the first 10 years after the making of the
diagnosis. Quimby, Andrei, and Putnam (1983) studied the
financial aspects of the treatment of one MPD patient who
had been institutionalized chronically under a mistaken diag-
nosis, and was rehabilitated and discharged. They showed
that while therapy costs increased after the diagnosis, spe-
cial nursing charges were massively reduced. After dis-
charge, but while still receiving specific therapy, the weekly
costs for her treatment were only 6-21% of her baseline cost
to the taxpayer. Rivera (1991) followed 185 MPD patients'
involvement in the overall healthcare delivery system of
Canada, and concluded that although specific treatmentwas
expensive, it was cost-effective and brought about savings by
reducing the overall demand for services necessitated by the
complications of the MPD. All in all, it seems that the initial
high level of expenditure necessary to bring specific treat-
ment to MPD patients is more than compensated for by long-
term savings. The data available to date indicate that the spe-
cific treatment of MPD is both clinically effective and
cost-effective for most MPD patients.
Pragmatic Empirical Ground Rules for the Treatment of MPD
Because the treatment of MPD is a relatively new field,
itmay appear presumptuous for anyone to offer a list of rules
about how to conduct the psychotherapy. Many therapists
are instantly offended when they are told that there is a right
way to do things; they may feel that their creativity, their
unique perspectives, and/or their special talents are not being
taken into consideration. Therefore I will explain how these
rules were derived, and the reader can come to his or her
own conclusions about their merit.
I have now consulted to approximately 1,200 therapists
about the psychotherapies of roughly 1,600 MPD patients.
Each time I did a consult, I wrote down what, if anything,
was going wrong in the therapy. When I had the notes from
1,000 consultations, I tabulated them and reformulated every
type of error and mistake into rules that were meant to help
therapists avoid that type of mishap. In my next 100 con-
sultations I tried to see how many of these rules could be
broken without impeding the recovery of the patient. Much
to my surprise, I found that if a therapist bent even one of
these rules strongly, the patient was unlikely to do well. If
the patient was improving, it was at a much slower rate than
was possible, because a certain degree of impasse and block-
age was being built into their therapy.
It is on the basis of this experience, and furthermore,
because I learned that most of the treatments had improved
when the rules were applied firmly, that I feel comfortable
in sharing them. These rules were first published in 1991(b) ,
and the version in which they were presented at the
Amsterdam conference was discussed at length in Clinical
Perspectives on Multiple Personality Disorder (1993b).
1) Maintain a Secure Frame and Firm Boundaries. MPD is
a condition that was created by broken boundaries.
In western society, most MPD occurs in connection
with intrafamilial violence and abuse, as a conse-
quence of actions that break our laws and violate
our mores. Therefore, a successful treatment will have a
secure treatment frame and firm, consistent boundaries.
Because the patient was hurt by others' breaking
the rules of how families and societies should con-
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DISSOCLLT10N, Vol. VI. No. 2 3. June Sept 1993
KLUFT
duct themselves, the scrupulous observation of the
appropriate boundaries of therapy is essential. The
treatment frame must he firm and consistent.
Confidentiality must be preserved. Double rela-
tionships with patients must be avoided. Every time
you, the therapist, do anything hut therapy with the
patient you take the risk that something other than
what is therapeutic will occur in the treatment.
2) Focus on Achieving Mastery'. MPD is a condition of sub-
jective and at time objective dyscontrol. Unwanted
and unwelcome experiences were imposed upon a
youngster who had no choice but to endure them.
The MPD patient may have little sense of mastery,
or of an internal locus of control. Therefore there has
to be a focus on mastery and the patient's active partici-
pation in the treatment process. It is important to get
the patient to do things, to take steps to be an active
partner in the therapy. "Therapy must be done with
the patient rather than to the patient" (Kluft, 1993b,
p.28). Tasks, assignments activities-these all can
be useful. If the patient is not held accountable for
what is asked, there is considerable risk of encour-
aging a regressive dependency in which the patient
looks to the therapist to supply whatever is perceived
as needed, and the therapist may feel constrained
to supply it.
3) Establish and Maintain a Strong Therapeutic Alliance.
MPD is a condition of perceived and genuine invol-
untariness. Its sufferers did not choose to be trau-
matized, and they find their symptoms are often
beyond their control. Therefore, the therapy must be
based on a strong therapeutic alliance, and efforts to estab-
lish this must be undertaken throughout the entire treat-
ment process. Even if the last ten sessions have been
productive, the first concern I have with a patient
is whether the patient and I are understanding one
another. Are we engaged in doing what we need to
do and addressing what we need to address? If we
are not, that is the first problem with which I must
deal.
It is a common error among those without a
strong psychoanalytic background to mistake an
apparent positive transference for a good therapeutic
alliance. Patients' acting positively toward you may
mean that they have positive feelings toward you.
However, this may be a reaction formation against
their hostile feelings, or a submissive compliance
because they see you colored by their experience
with an abuser toward whom they had to demon-
strate affection. The presence of a strong therapeutic
alliance means that the patient and you are doing
the work of the therapy in a regular manner and
there is some hope that the treatment will progress
on that basis. It is crucial to cultivate a joint com-
mitment to the work of the therapy.
4) Deal with Buried Traumata and Affect. MPD is a con-
dition of buried traumata and sequestered affect.
Therefore, what has been hidden away must be uncovered,
and what feeling has been buried must be abreacted. it is
occasionally possible to achieve a salubrious reconfigura-
tion of the alters without dealing with the past and to direct
the therapy to the smoother functioning of the alters, but
integration cannot be achieved without dealing with the
impact of the past. The sense that the past has been
dealt with and mastered is an essential aspect of the
patient's recovery.
5) Reduce Separateness and Conflict Among Alters. MPD is
a condition of perceived separateness and conflict among
the alters. Therefore, therapy must emphasize their collab-
oration, cooperation, empathy, and identification with one
another so that their separateness becomes redundant and
their conflicts muted. It is essential to make it clear
that all of the alters are "in it together," that no one
alter can win, and that the most effective strategy is
to find a way for all to win together.
6) Work to Achieve Congruence of Perception.MPD is a con-
dition of autohypnotic alternative realities; i.e., mul-
tiple reality disorder. When a patient recounts a mem-
ory of an event, you may not be able to be confident
that it is historically accurate. You only know that it
is a signal, a semiotic device that says "something
bad happened to me. I am in a posttraumatic state. "
We know all too well that memory is a very complex
and tricky area of study. The therapist must be pre-
pared to validate the patient's distress, but cannot
allow himself to be put in the position of being obliged
to validate everything that the patient says. All too
often, what the patient says in one personality is dif-
ferent from the account given by another alter .
My favorite example of this was described by
Loewenstein (1991b), who had been persuaded to
prescribe the antidepressant imipramine for an MPD
patient:
At this point, the host personality report-
ed triumphantly that her depressive symp-
toms had abated without a single side
effect. Just after this, the patient switched
and a second alter emerged. This alter com-
mented acidly that she discerned absolutely
no positive or negative effect from the new
medication and questioned why she was tak-
ing it. Suddenly, a third switch revealed a
mournful looking alter with tremulous
hands who reported tremor, dry mouth,
constipation, dizziness on standing, palpi-
tations, and several other side effects since
beginning the medication. She denied any
benefit from the medication. Finally, anoth-
er quick switch produced an adolescent alter
who whispered conspiratorially, "Please
don't tell them. Whenever she puts a pill
up to her mouth to take it, I take it away
95
DISSOCIATION,
TREATMENT OF DISSOCIATIVE DISORDERS
96
and save it in my stash for my overdose. "
This patient had not taken a single dose of
the prescribed medication. (Loewenstein,
1991b, p. 727)
Now, let us suppose that the first alter had said, "My
uncle raped me." Furthermore, suppose a second
said, "My father raped me." Perhaps a third per-
sonality might say, "My father and uncle are the most
wonderful people in the world. " Yet another might
say, "I was born into a different family, and I don ' t
even know those people and who they are talking
about." As the therapist you are often dealing with
problematic alternate realities. Never hesitate to con-
front the patient, not in the manner of an inter-
rogator or detective, but in a gentle way. You may
ask about alternative explanations or statements that
you have heard, and invite participation in a mutu-
al exploratory process rather than accord prema-
ture veracity to one version or another.
Closely linked with this is the need to commu-
nicate quickly, tersely, and nicely. Therefore, the ther-
apist's communications must be clear and straight. There
is no room for confusing communications. If you make
long and complex interventions, MPD patients may
switch in the middle of your interpretation if they
are upset by what you are saying. For all practical
purposes, they will never hear it. Yet as you talk they
will nod their heads "yes" because they know they
are supposed to, and, like many abused children,
they will comply with the implicit demands of the
(potentially dangerous) authority figure.
You will want to be terse, quick, and on target.
If you figure out an interpretation or intervention
that combines the past, present, future, transference,
reality, and everything you could want to include-
if as this interpretation or intervention formulates
itself in your mind, you know that this should go
directly from your lips to the pages of a book enti-
tled "What Really Great Therapists Say to their Really
Lucky Patients"-go home and tell it to your moth-
er. She is probably the only person on the face of
the earth who is not yet disillusioned with your nar-
cissism.
Certainly, the MPD patient does not need this
sort of thing from you. MPD patients need short bits
of insight that they can metabolize without blowing
them out of proportion or experiencing some form
of mental indigestion.
7) TreatAllPersonalitiesEvenhandedly and with Consistency.
MPD is a condition related to the inconsistency of
important others. Therefore, the therapist must be even-
handedto all of the alters and must avoid playingfavorites "
or dramatically altering his or her own behavior toward
the different personalities. The therapist's consistency across
all of the different alters is one of the most powerful assaults
on the patient's dissociative defenses. If an MPD patient
has a therapist who will change in response to which
alter is out, he or she now has multiple therapist dis-
order. It is more helpful if the patient who switch-
es in order to get away from what the therapist is
saying finds the therapist very much the same. This
allows the therapist to "bore the patient into health"
instead of becoming involved in a process that is
parallel to the patient's psychopathology. I frequently
am consulted by therapists who have spent years
playing with child alters, without the treatment's
having been advanced.
8) Restore Shattered Basic Assumptions. The shattering of
the basic assumptions described byjanofBulman
(1985), that one is relatively invulnerable, that life
is meaningful, and that one can see oneself in a pos-
itive light, is profoundly demoralizing. It is not uncom-
mon for these patients to be sure that some situa-
tion or some finding in therapy will be too much
for them to manage, so they might as well hurt or
destroy themselves, or yield to persons who want
them to do something that is not in the patient's
best interests. They often feel impotent. MPD patients
generally feel very badly about themselves, and can-
not be reassured by being told that they are good
or not at fault. Their usual response to such efforts
is to perceive the therapist as uncomprehending
(of their true badness) or as having ulterior motives
(because in their experience, kind words have often
been the prelude to exploitation or harm). Therefore,
the therapy must make positive efforts to restore morale and
to inculcate realistic hopes. Perhaps you will recall that
I advocated activating the patient, giving the patient
things to do, and following up all assignments, even
if the assignment was to think about something. The
way I have found MPD patients can accept reassur-
ance and gradually rebuilt shattered assumptions is
when they can be reminded of what they thought
they could not accomplish, but in fact were able to
do. I point out that despite the patient's genuine
conviction that he or she is powerless, together we
have seen many situations in which that belief
proved erroneous. On the basis of past experience,
1maintain that the patient will be able to work with
me to handle the current challenges, in the face of
his or her belief that this is impossible and beyond
his or her capacities.
9) Minimize Avoidable Overwhelming Experiences. MPD is
a condition stemming from overwhelming experi-
ences. Therefore, it is essential to pace the therapy. It is
important to prevent the patient's being given more
pain by the therapy than can be tolerated, with con-
sequent decompensation. When in doubt as to
whether the patient can handle a particular obser-
vation or information at a given point of treatment,
it is better to withhold than to risk imposing poten-
tially devastating pain. It is useful to apply an axiom
DISSOCIATION. Vol. VI. No. 2 3.uric Sept 1993
KLUFT
that has been linked with my name, "Kluft's rule of
thirds." If you know you and the patient are plan-
ning to deal with difficult material in a session, but
you cannot get into this material in the first third
of the session so that you can work on it in the remain-
der of the first third and the second third, reserv-
ing the last third to process the material and resta-
bilize the patient, do not proceed with the exploration
of the material. It is more productive to explore the
resistance that has caused the patient to delay get-
ting into the material, or, if pressed to begin explo-
ration too late in the session, to probe the masochis-
tic dynamics that cause the patient to think that he
or she should be exposed to potentially painful and
disruptive material without sufficient time to man-
age it in a safe and thoughtful manner.
10) Model, Teach, and Reinforce Responsibility. MPD is a
condition that often results from the irresponsibil-
ity of important others. Therefore, the therapist must
be very responsible and must hold the patient to a
high standard of responsibility once the therapist
is confident that the patient, across alters, actually
understands what reasonable responsibility entails.
Bear in mind that MPD patients may not appreciate
what responsibility means. Their consciences or
superegos are not normal in some respects. They
usually have been exposed to two standards: that
they were always wrong and that someone else was
always right, no matter what the circumstances. They
also often have lacunae (holes) in their moral rea-
soning, because they are very phobic of certain mem-
ories, affects, etc. They usually have a set of inter-
nal rules that allow them to escape from particular
feared situations and obligations. It may take months
to deal with this. The therapist begins by being firm,
but knowing the patient may not be able to com-
ply. The therapist must be very responsible and must hold
the patient to a high standard of responsibility once the
therapist is confident that the patient, across alters, actu-
ally understands what reasonable responsibility entails.
This usually results from discussion of the patient's
response to the assignments and tasks given in the
therapy.
11) Take an Active, Warm, and Flexible Therapeutic Stance.
MPD often results in part because people who could
have taken action to protect a child did nothing.
The therapist can anticipate that passivity, affective bland-
ness, and technical neutrality will he experienced as uncar-
ing and rejecting behavior, and that the therapy is better
served by taking a warm and active stance that allows a
latitude of affective expression. There are several com-
pelling reasons for this advice. The first is that such
a stance is much more effective with trauma victims,
who often perceive relative remoteness in the ther-
apist as a distancing of the therapist from them and
their shameful circumstances. The second is that in
an interpersonal field that may become dominated
by traumatic transferences, the therapist may be seen
as a dangerous and hurtful person. If the therapist
has not been relatively real, the patient may have
more than the usual amount of difficulty seeing the
therapist through his or her projections, and the
patient may, in the grips of powerful emotions, be
unable to distinguish past and present and behave
toward the therapist as if he or she were an enemy
the patient has -to attack in order to be safe.
There is a third reason why I think it is impor-
tant to be warm and to have shown a wide spectrum
of affect expression in the therapy. I am not advo-
cating extreme reactivity or "acting out," only the
demonstration of a series of natural responses with-
in a mild range. You will make countertransference
errors with these patients very frequently. If you treat
many, it will be a daily experience. The pressure
and the complexity of the transferential field and
the projective identifications can be extreme. Coons
(1986) has tabulated the types of countertransfer-
ential responses therapists have to MPD patients,
and Loewenstein (1993) has studied them in depth.
Suffice it to say that since you will make errors, minor
and major, with some degree of frequency, the only
way to recover them is your having a reasonablywide
range of responses to the patient already in your
shared history as a therapeutic dyad.
If the therapist is effectively bland, and suddenly
starts screaming at the patient, the enormity of the
change may rupture the therapeutic alliance and
the good feeling that may exist between the two of
you. Conversely (and here we must recall that per-
ception relates to change from a baseline, not to an
absolute scale of things), a therapist with a wider
range of baseline expression will be perceived to be
"even worse than usual." I recall a patient's remark-
ing after I had made an error, "Boy, you are even
crankier than usual today! " In that context, it is rare
that an error will have the potential to destroy the
therapy.
I believe that the wider affective stance is good
insurance for the patient ' s investment in the ther-
apy. I am prepared to hear the objection that this
rule simply covers over the ineptitude and poor con-
trol of the therapist, and may be designed to ratio-
nalize my flaws of character. However, the treatment
of MPD can be incredibly intense work. I have never
met a therapist who treats MPD patients on a regu-
lar basis who does not find himself or herself in sit-
uations like this fairly frequently.
12) Address and Correct CognitiveErrors. MPD patients usu-
ally have developed many cognitive errors (Fine,
1988a, 1990) . It becomes crucial to explore how the
MPD patient thinks, and address the thinking prob-
lems in therapy. The therapy must address them and cor-
rect these cognitive errors on an ongoing basis.You do
97
DI550Ct1TI0\.1 Mr.2 3. Jam! *pi. [993
TREATMENT OF DISSOCIATIVE DISORDERS
not need to do formal cognitive therapy, but you
must be aware that if you say, "ABC, Julia, " to an
MPD patient, and she smiles and says, "ABC, Dr. Kluft,"
you may not have shared a mutual understanding.
Julia's "ABC" response may have been the product
of an inner process something like this: "Hey, the
jerk is asking you a question, give him the answer
so he'll leave us alone." "I don't understand what
the answer is. somebody tell me. " " Say A." (Aloud,
the patient says "A.") "I don't believe B" "I don't
believe it either." "Kluft is really going to be angry
if we don't say 'B.'" "I don't want to say 'B.'" "Sally
will get scared if Dr. Kluft gets angry." "I'm not afraid
of him." "Sally and the other kids will cry all week
if they think he is angry, and then they won't let us
go to session and then he'll really be angry." "OK
already, say whatever you want." (Aloud, the patient
says "B.") A similar process goes on for "C. " The
emitted " ABC" would seem to indicate a complete
mutual communication, when in fact the patient
has verbalized what was expected in response to a
dysfunctional chorus of inner voices, and has felt
confused and on the verge of psychosis throughout
the process. It is imperative to sensitize yourself to
the presence of compliant agreement used as a
defense against being touched by the process of the
therapy, or of masking total incomprehension.
The Crucial Role of the First Two Phases of Treatment
MPD patients areoften very vulnerable people, and the
treatment of MPD is very demanding. The therapy asks a lot
from an already beleaguered and traumatized person. It is
useful to engage in some unscientific calculations, which I
call "the mathematics of misery." These figures should be
regarded as a speculation, and not cited as anything more.
We all would agree that a single serious sexual assault is odi-
ous and constitutes an egregious traumatization. No one
would trivialize a rape, and recovery for a rape may require
considerable treatment over a protracted period of time. If
we make the estimate that the average MPD patient is mis-
used twice a week, perhaps 50 weeks of the year, and use the
statistic from Schultz, Braun, and Kluft 's 1989 study of 355
MPDpatients, that the average MPD patient reports having
been abused an average of ten years, then an average or
modal MPD patient may have endured 2 X 50 x 10 = 1,000
exploitations.
We appreciate how difficult it is for the victim of a sin-
gle rape to undergo an affectively-charged review of his or
her experiences, even if he or she had functioned well
before. How much more difficult it must be for a victim of
a hundred or a thousand-fold more abuses, whose prior level
of function may have been compromised, or, if apparently
normal, achieved at the cost of all her concentration and
effort.
Therefore, it is important to begin therapy not by
addressing the painful and traumatic material, but instead
to building up the patient's ego strength adaptive capaci-
ties, and supports. I do not know any competent mental
health professional who works with MPD on a regular basis
who approaches trauma early in therapy except to contain
irruptions of the material as best they can. Unfortunately, I
frequently encounter neophytes who pursue this practice,
and who have come to believe that a period of decompen-
sation is an inevitable concomitant of beginning the thera-
py. The subject of strengthening the patient for treatment
was the focus of another communication at the Amsterdam
conference, to which the reader is referred (Kluft, 1993b).
Hypnosis
Because the subject of the use of hypnosis in MPD is the
subject of many articles, including two recent reviews (Kluft,
1992a, 1992h), I will not dwell upon it at length here. It is
clear that hypnosis has many important roles to pay in the
treatment of MPD, especially in the service of facilitating sta-
bilization, strengthening, and integration. It is also clear that
any use of hypnosis to retrieve memories is fraught with the
same concerns and constraints that attend such procedures
with any group of patients and under any circumstances.
Furthermore, it is clear that due to the high hypnotiz-
ability of this group of patients, and the ubiquity of sponta-
neous trance and autohypnotic episodes among them, the
omission of efforts to induce formal heterohypnosis is no
assurance that an hypnotic ambiance will not pervade the
entire treatment. Therefore, the therapist who works with
this patient group is well-advised to study hypnosis through
an appropriate series of courses under the aegis of or cospon-
sored by a recognized hypnosis society, medical school, or
department of psychology.
Integration
At this point in time it has been established that MPD
patients can achieve and sustain a full integration (Kluft,
1984b, 1986). However, our understanding of the process
remains metaphoric at best. Integration is a puzzling event
when it occurs. I remain confused and disconcerted by the
fact that I can work with a "personality " over a period of
years, only to find that it has ceased to be separate, either
spontaneously, through some mediated process, or via an
integration ritual. I have addressed this subject at length
elsewhere (Kluft, 1993c).
Desiderata
As we look to the future, I am acutely aware of the need
for more research about the psychotherapy of MPD. To date
most research in the field has focused on phenomenolgy,
psychophysiology, and epidemiology. We can describe and
discover MPD with increasing efficiency, but our treatment
remains informed by the experiences and advices of a small
group of pioneers.
At this moment, we cannot be sure whether our current
approaches to the treatment of MPD are approaching a defini-
tive stage, or are quite primitive with regard to the forms
they will take in the future. I would like to see the develop-
ment of valid and reliable instruments and protocols that
will facilitate the carrying out of multitherapist and multi-
center studies on the treatment of MPD. I also would like to
98
DISSOCIATION, Vol. VI, No. 2 1 unc 5ept.1993
KLUFT
see research analyzing the work of those therapists who are
recognized as most expert and effective. Clearly, some effec-
tive therapists are doing things that others are not, and what
those therapists say they are doing may not correspond to
their actual behaviors (Bennett G. Braun, M.D., personal
communication, May, 1979, cited in Kluft, 1984b). If these
differences bear on efficacy, they should be studied and
explained in a manner that will allow other therapists to use
them to enhance their work.
I am deeply saddened that the therapeutic techniques
of the late Cornelia B. Wilbur, M.D., were never studied sys-
tematically. We cannot reconstruct them from the observa-
tions of those who consulted her, because her style was to
encourage and enhance the skills and approaches of her
consultees, rather than to teach them to do things her way.
As useful as Schreiber's (1973) Sybil may be, it is a lay source,
with contents selected for reasons other than their clinical
importance, which depicts Dr. Wilbur as she was learning
to treat MPD, and does not illustrate her interventions when
she was at the peak of her power. Many times Dr. Wilbur
told me that if she had to treat Sybil with the expertise she
had acquired by the 1980s, she would have needed four rather
than 11 years to complete her therapy. There is no known
record of Dr. Wilbur at work during the years that she felt
she was most effective.
We need to study the effect of contemporary culture
and psychoeducational measures upon the manifestations
and clinical course of MPD. Although I am aware that some
will be offended by this observation, it is clear to me that my
MPDpatients in the 1970's, as a group, simply worked in
therapy, got well, and went on about their lives. As we have
learned more about the condition, and as MPD patients edu-
cate themselves about their disorder (at times with greater
dedication and assiduity than their therapists) , report them-
selves triggered by discussions of MPD and child abuse on
television talk shows, and beg to be referred to support groups,
I see a sizable percentage of the MPD patients of the 1990s
as behaving differently in many ways from the patients I began
to work with in the 1970s. Most of those newer ways seem to
be associated with a longer and more stormy clinical course.
Something is happening, and it requires objective and unde-
fensive study.
Much as we need to learn as much as we can about treat-
ing MPD, we also need to know what constitutes adequate
care as opposed to ideal care on the one hand and inade-
quate care on the other. We also need to learn what level of
care a given MPD patient needs (rather than wants). I am
shocked and chagrined by efforts to prescribe insufficient
and inadequate care to MPD patients in the name of cost-
containment. Likewise, I am disconcerted and upset with
the pleas and imperious demands by some MPD patients for
an extremely intense and expensive level of treatment, and
an insistence that anything less constitutes abuse. Absent
objective data, we and our patients may become the victims
of economic politics.
A final area of research I consider urgent is the study of
the protection and well-being of the therapist who works
with MPD and other traumatized subgroups. There is an inher-
ent risk of burn-out and secondary posttraumatic stress among
therapists who work with considerable numbers of trauma
patients. While some of us have managed to deal with this
quite nicely, others have not. I have no idea of why this is
so, nor have I been able to find any factors that distinguish
those who experience from those who avoid such conse-
quences. However, as more and more MPD patients are rec-
ognized and more and more therapists are becoming
involved in their care, the need to look to the welfare of our
colleagues and ourselves becomes all the more compelling.

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