IATROGENIC FACTORS
IN THE
PERPETUATION OF
SPLITTING AND
MULTIPLICITY
Moshe Torero, M.D..
Moshe S. Torem, M.D. is Chairman, Department of Psychia-
try and Behavioral Sciences, Akron General Medical Center,
and Professor and Chairman of the Department of Psychia-
try at Northeastern Ohio Universities College of Medicine.
For reprints write Moshe S. Torem, M.D., Department of
Psychiatry and Behavioral Sciences, Akron General Medical
Center, 400 Wabash Avenue, Akron, Ohio 44307.
An eat-het version of this paper was presented as part of the
David Caul Memorial Symposirrrn: iatrogenesis and MPD, at
the Fifth International Conference on Multiple Personality/
Dissociative States, Chicago, Illinois, October 8. 1988.
ABSTRACT
The purpose of this paper is to increase the awareness of clinicians
who treat multiple pinsonality disorder patients to the possibility that
misuse of treatment techniques may perpetuate splitting and multi-
plicity, and thus contribute to chronicity in MPD patients. Many
MPD patients tend to have rapidly dissociative switching from one
ego-state to another. These trance-lihe states make the patients highly
suggestible to outside influences which include the therapists ' verbal
and non-verbal communication. Some therapists may have an. over-
investment in orormore alter- personalities, and thus ignore the needs
of the whole person. Treating an adult patient who is in an age
regressed ego-state, or alter personality, presents a particular chal-
lenge as to the patient's boundaries since violating those boundaries
may too perpetuate. splitting and multiplicity. The paper reviews and
discusses such issues as therapeutic limit setting, the issue of trust,
and counter-transference elements as they may contribute to the
perpetuation of splitting and multiplicity in lllPD patients. Case
vignettes are used to illustrate the above points, and suggest ways to
avoid potential pitfalls so that therapy will promote progress towards
integration and improved functioning of the whole person.
"The ability to be self-critical is the life blood of practice and
investigation . . . the term latrogenic becomes a mark of good
conscience rather than one of disapprobation."-A. Soifer (1970)
INTRODUCTION
Primum Non Nocere, -First of all be sure you do no harm.
This old Hipocratic dictum has guided physicians through
centuries, and has been fundamental to the sound practice
of the healing arts. The failure to regard this principle has
inspired many reforms in the field of physical and mental
health. In our times of modernized medical care, when new
diagnostic and therapeutic procedures are being intro-
duced at an increasing rate, this admonition applies more
than ever before. The term"Iatrogenic" originates from the
Greek word " latros" meaning physician, and " Genesis"
meaning origin. In other words, latrogenic stands for a
condition that originates with the physician andhis interven-
tions.
In this paper, I use the term Iatrogenic more broadly,
meaning a condition that develops in the patient, and
originates from the therapist through his/her actions,
behaviors, and statements, in the relationship with the
patient. Most of the literature on iatrogenic conditions deals
with the possible harmful effects of diagnostic and therapeu-
tic procedures (Andy, 1970; Illich, 197G). Relatively little has
been written on the negative side effects of a poor therapist-
patient relationship (Twemlow Gabbard, 1981; Torem 
Toren 1983; Torem Alen, 1987), or about the unhelpful,
biased attitudes on the part of physicians and therapists
towards patients and their conditions (Cavenan Cavenan,
1980; Margetts, 1987; Robertiello Schoenewolf, 1987).
Naturally, such biased and unhelpful attitudes may lead to
mis-diagnosis and from there to the wrong treatment. Once
the diagnosis of MPD is made, it is likely that certain atti-
tudes, behaviors, and interventions made by the therapist
may perpetuate the illness, postpone integration, and, at
times, promote further splitting, further dissociation, greater
anxiety, panic, depression, and thus increase patient
morbidity and reduce their ability to master the tasks of
adaptive functioning in the activities of daily living (Greases,
1988; Chu, 1986).
As therapists, we must be ready to examine the outcome
of our own interventions. Whatever interventions we use in
our psychotherapeutic efforts, it is not enough that they
make sense; that they fit a certain theoretical model. Such
interventions can only stand the test of time if they truly
affect the outcome in a positive way leading to healing,
integration and an improvement in the patient mental
state translated into more adaptive daily functioning. If a
certain therapeutic technique has the power to heal, it
certainly may also have the power to harm if misused by an
untrained and inexperienced therapist.
The issue of negative effects of psychotherapy has been
well known. Hans H. Strupp and his colleagues (1977)
focused on this issue in their book Psychotherapy for Better
or Worse. In their introduction they wrote:
Today we witness a coalescence of seemingly desperate
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DISSOCIATION, Vol. II, No. 2: June 1989
farces toithin the field of psychotherapy. There isa height-
ened awareness of the possibility negative effects, while
in the fn.chlic domain theproliferation
aimed thus farprimariy at medical practitioners, but is
showingsigns of extending to psychotherapists, is
matic of ca serious problem. From both perspectives, there is
considerable urgency for a systematicanalysis of the prob-
lem. Negative effects cannotbe ignored, nor can they
remain shrouded in secrecy. For the good of the profession,
as well as that of the public, pstrhotherapist.s, as well as
researchers, must face the issues Thestudy of
negative effects isboth significant and timely.
H. Strupp and his colleagues then ask:"What constitutes a
negative effect in psychotherapy?" Their answer is divided
into the following categories:
I. An exacerbation of the presenting symptoms:
If the patient presented with depression, severe
anxiety, sudden mood swings, panic attacks, headaches,
insomnia, amnesia, etc., and during therapy there is a
worsening of these presenting symptoms in terms of
their intensity or frequency, that fits under this category.
2. Appearance of new symptoms:
These may include a number of new symptoms such
as an erosion of solid interpersonal relationships, and a
decreased ability to experience pleasure, or severe psy-
chosomatic symptoms, withdrawal, regression and rage,
acting out, drug and alcohol abuse, etc.
3. Misused or abused therapy:
This is different from the exacerbation of present
ing symptoms, or the development of new ones. It may
take a number of forms. H. Strupp described it as" the
substitution of intellectualized insights for other obses-
sional thoughts in patients, as in a patient who appears
to benefit from therapy in the sense of achieving and
internalizing therapeutic insights, but who maybe merely
substituting these insights for early obsessional thoughts."
Others have described it as utilization of a psvchothera-
peutic experience to rationalize feelings of smugness,
superiority over others or utilizing "insights" to aggres-
sively comment on other people behavior. For the
patient with MPD, learning the jargon of dissociation
may he misused as forms of secondary gains and
rationalizations for not taking responsibility for one
own behavior. Many authors writing about psychother-
apy in general, have pointed out that for some patients,
therapy may become an end in itself. MPD patients may
(as a result of poor therapy) spend more time in
dissociated altered states of consciousness, writing in
their journals, or dissociated internal dialogues, paint-
ing their pictures, and neglecting to assume responsibil-
ity for the important tasks in adaptive daily living.
4. Undertaking unrealistic tasks or goals:
As a result of some aspect of psychotherapeutic
interventions, the patients feel constrained to under-
take or pursue goals for which they are really ill-equipped
and which place great strain on their psychological
resources. Such situations, according to Ann Appel-
baum, (1977) may arise from the patient intense need
to please the therapist, which may be related to ob-
sessive dependency on the therapist. Some therapists
feel that patients with MPD are blessed with greatcrea-
tive powers and should write books about their experi-
ences, or will turn into artists in the form of painters,
poets, and the like. Not only are such goals unrealistic
for the majority of MPD patients, but even the patient
who achieves such goals may still be dysfunctional in
other major arenas of life.
5. Loss of trust in therapy and the therapist:
As a result of the previously mentioned situations,
the patient may lose trust in the therapy, or in the
therapist. This may create a hardening towards lirturc
help in general. Moreover, a loss of confidence in the
therapist may be generalized to a disillusionment to any
form of human relationship. The therapist must he very
careful not to raise the patients initial hope to the point
of creating an illusion of that which cannot be accom-
plished.
SOURCES OF MISDIAGNOSIS
Certainly, it is well known today that the under-diagnosis
of MPD is much more common than the over-diagnosis of
this condition (Braun, 198:3; Coons, 1989: Kluft, 987; Wilbur,
1984).
(A) UNDER-DIAGNOSIS
The following are some common reasons for the under-
diagnosis of MPD:
1. Ignorance:
The lack of awareness, and the lack of knowledge of
what MPD is all about; what the presenting symptoms
are, what the differential diagnosis is, and how to make
it, are probably the most common reasons for the fact
that clinicians misdiagnose patients with MPD (Rosen-
baum. 1981; Kluft, 1987).
2. The lingering myth that MPD is a rare condition:
This is still written in most textbooks of psychiatry
and psychology, and is probably a major reason why cli-
nicians, even when confronted with this condition,
think they must have made a mistake. Since MPD is such
a rare diagnosis, the patient must have some other, more
common illness (Thigpen (leckley, 1984).
3. MPD symptoms overlap the symptoms of most
other psychiatric disorders:
Today, we know that MPD may present itself clini-
cally with such great variability that it may masquerade
as almost any other psychiatric condition. In order to
diagnose MPD the clinician must be very experienced,
astute, and familiar with the specific psychodynamics,
psychopathology and life history of MPD (Kluft, 1987;
Coons, 1984; Spiegel, 1984).
4. Denial-countertransference:
The material any clinician hears from patients with
MPD is filled with so many horror stories of abuse that
the clinician finds it hard to believe that this could have
possibly happened. It is sometimes easier for clinicians
to believe that the patients have made up these stories,
or that they are merely the fantasies of a sick mind. It is
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ll1SSOCIATION, Vol. II, No. 2: June 1989
IATROGENI V 'ORS PERPETUATION OF SPLITTINGAND MULTIPLICITY
easier to declare the patient psychotic than to believe
that such horror stories of abuse and incest could have
possibly happened (WatkinsWatkins, 1984;Altschuler,
1989).
5. Clinicians tend to diagnose conditions they know
how to treat:
Patients with MPD will make the inexperienced and
untrained clinician feel helpless and incompetent. It is
not enough to make the diagnosis of MPD. It is also very
important that any clinician who makes a certain diag-
nosis also be aware of his/her own feelingsfor the need
to feel competent and helpful. If a therapist uses mostly
biological modes of treatment, he must be aware ofhis
own tendency to make more diagnoses of conditions
that are treated by the use of biological modalities, such
as medications. If one does not know how to treat a
patient with MPD, but knows well how to treat a patient
with schizophrenia or manic depressive illness, it is clear
how biased one may become toward making one diag-
nosis or another (Buckley, 1970; Illich, 1987).
(B) OVER-DIAGNOSIS
Although this is rather rare compared to the under-
diagnosis of MPD, there have been some cases described
where this may happen (Torem Toth, 1985; Braun, Kluft
Torem, 1988). Here the sources of misdiagnosis may be
the following:
1. Clinician s bias in favor of MPD:
Certain patients with borderline personality disor-
der maypresent with extreme ego fragmentation and
dissociative features. These patients are very different
than those with a true multiple personality disorder
(Kemp, Gilbertson Torem, 1988). A similar phe-
nomenon may happen to a patient with schizophrenia
that may present with ego-fragmentation. When this
patient. is seen by a therapist who believes that patients
with MPD have a better chance to heal, recover, and get
well than do patients with schizophrenia, and if such a
clinician is newly familiar with multiple personality
disorder, he/she may become overly optimistic, and
want to assign this diagnostic label to many patients,
even when the data may point otherwise. Another cit-
ation that we must be aware of is that clinicians who do
not use biological treatments have greater faith in
the power of psychotherapy and therefore will be un
comfortable in making diagnoses of conditions that
must be treated with medication. These reasons of
wanting to feel helpful and competent may contribute
to the over-diagnosis, as well as to the under-diagnosis of
MPD (Torem Toth, 1985).
2. Over-diagnosis due to a fad:
We must be aware that many patients are quite
educated, and may find out that there are certain diag-
nostic entities that interest certain clinicians, and that it
ismore fashionable to have MPD than to have schizo-
phrenia or borderline personality disorder. Some
patients may come in and declare themselves as having
MPD so that they can get more attention, more time
and energy from an expert MPD therapist than if
they just merely had schizophrenia or a border line per-
sonality disorder. This condition tends to occur more on
in-patient units where patients with MPD are treated in
a milieu including psychiatric patients with other diag-
nostic entities (Spanos, 1985; Fahey, 1988; Margetts,
1987; Torero Toth, 1985).
IATROGENESIS IN TREATMENT
The basic goal of treating patients with MPD is an
improvement in their level of function regarding adaptive
daily living, and full integration of the personalities. How-
ever, in their zealousness to help patients work through their
abreactions, flashbacks, and traumatic memories, some cli-
nicians get so involved in the details that they may forget the
whole picture. In this global goal it is the improvement in the
patient daily functioning, and movement towards integra-
tion that must be a priority. The following are some specific
issues that must be addressed:
1. Therapistsover-investment in one or more alters:
Therapists, because of their own needs, may be
come overly-invested in child alters, and spend a great
deal of time in play therapy, forgetting that they are
dealing with an adult individual who needs to leave the
therapy session and be responsible to Lake care of his/
her own needs as an adult. Such over-investment may
also take place with alters that are pleasant and nice to
the therapist, while the therapist avoids the hostile al-
ters that carry with them a great deal of anger, sadness,
and painful memories.
Case Illustration: This patient, Lynn is a 33-year-old woman
who has been in therapy due to MPD for over three years.
She is seen two to three times a week. The patient had a
number of personalities referred to by the therapist as "the
little ones." In a typical session, the patient regresses into a
younger state, calling herself "Katie," stating she is 5 years of
age. She refers to the therapist as "good mommy," and sits
down on the floor to play with her teddy bears and crayons.
The therapist responds by sitting on the floor and spending
the session talking to this patient at her age-regressed level.
This goes on for weeks while, at the same time, the patient
acts out by alcohol abuse and sexually promiscuous behavior
in an altered ego-state in which she calls herself "William,"
declaring she is gay, and hates women. The therapist has
avoided addressing these behaviors with the reasoning that
"the little ones" have been neglected for many years, and
they are weak -- therefore their needs must be addressed
first.The therapist went on stating that she would be ma-
nipulated by "William," who is a bully.
2. Suggestibility:
Patients with MPD suffer from a condition which is
underlined by dissociation, and a high degree of hypno-
tizability and suggestibility. Therefore, any clinician
must be very careful in the use of hypnosis and hypnotic
suggestions with these patients. Some alters, due to their
need to please the therapist, may create by dissociation
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DISSOCIATION, Vol. Il, No. 2: f unr 1989
new ego-states as a response to the thcrapist squestion-
ing and to imbedded suggestion in his questions about
the existence of more personalities (Braun, 1984).
CaseIllustration: The patient, Sharon, is a 38-year-old, mar-
ried, mother of two children. She has been in therapy for
over 18 months in twice per week sessions. The therapist has
identified 12 personalities. In one session, the patient
facial expression conveys sadness and tearfulness. The thera-
pist, observing this behavior, responds by saving, "Who are
you?" "You look so sad.... What is your name? ... I don  t
think Ie talked to you before." These questions have
imbedded suggestions to the patient. The therapist may, in
fact, be suggesting to the patient that she is supposed to be
someone else with a different name. The patient responds by
saying that her name is "Sadie," and she is only six years old,
and carries all of the sadness. The therapist must be aware of
the suggestibility inherent in spontaneous trance states, and
devise questions to be neutral, non-leading, and avoid im-
bedded suggestionsof multiplicity. Such investigating ques-
tions may be phrased as, " How old are you feeling right
now?" or "How would you like me to call you right now? "
These questions suggest to the patient the recognition of
being one person, although, at times, when in an altered
ego-state, he may feel as if he were a different person.
3. Boundaries:
In some ways MPD can be viewed as an illness
created in a chaotic childhood where boundaries were
blurred and violated. These patients frequently have
unrealistic expectations of relationships with other
people. Often, what they experienced in childhood
tends to be replicated in the relationship the patient
develops with the therapist. This issue was pointed out
by Dr. James Chu (1986) who said,
Although each therapist mustchoose where the
boundaries are to be according to his or her style and
comfort, boundaries are essential to helping the mu.l-
tiplemaintain control and prrspective.. The self
perceived neediness on the part of the multiple is
endless, and the wisetherapist recognizes that it is
stabilizing in the long run to be clear as to what is
realistically possible or not. Furthermore, therapists
need to feel comfortable with boundaries that protect
their own privacy.
One has to wonder as to the wisdom of therapists
touching patients without asking asking for permission,
and even if such permission is given, what effect will it
have on hidden alter personalities. Tarachow (1962)
wrote, "The task of setting aside the other as a real object
I regard as the central problem in the theory of the
treatment process," (p. 377). He spoke of the therapeu-
tic barrier, and the importance of observing it in order
to make real progress in the patient treatment.
Case Illustration: The patient, Nancy, is a 26-year-old single,
college student. She has been in therapy for MPD for over
two years. One day, the patient came upon the therapist in
a shopping mall, and they entered into a conversation. The
therapist introduced the patient to her husband, and went
on to show her the new clothes she bought on sale for her
children. During the following session, the patient regressed
into a child-like ego-state and cried, asking to be held while
she was alone in the dark closet, afraid of the monsters. The
therapist responded empathically, holding the patient, who
suddenly switched into an altered ego-state, accusing the
therapist of being cheap and uncaring about little kids. She
continued to lash out in anger at the therapist. The therapist
reported later on how devastated she felt, and responded by
withdrawing from the patient, who was described as "un-
grateful," since the therapist had always been so good to her.
4. Limit Setting:
Experienced clinicians know that part the effec-
tive treatment of patients with MPI) is the containment
of dysfunctional behaviors. Endless gratification of
patients with MPD becomes not only a problem for the
therapist, who eventually develops a sense of anger
and hostility, but also because it clearly does not pro-
duce a positive outcome for patients with MPD. This is
not only damaging to the therapist own private life, but
also promises to patients with MPI) that any of their
excessive needs can be met, and they should notbe
concerned with facing the limitations of reality. Thera-
pists who start neglecting their personal lives in promis-
ing patients to meet needs that cannot be fulfilled must
seriously examine such behavior, and determine to what
extent they provide a masochistic role model for
patients to identify with.
CaseIllustration: The patient, Lillian, is a 28-year-old college
student who has had a long history of many psychiatric
hospitalizations in which she was misdiagnosed as having
schizophrenia, and was treated with antipsychotic medica-
tions, The therapist, who correctly made the diagnosis of
MPD, is highly invested in the treatment of this patient, and
has vowed to protect her from further hospitalization. In one
session, the therapist learns of an incident in which the
patients friend took the patient to a nearby hospital emer-
gency room following the patient attempt to cut her wrists.
The therapist responds,"You should have called me.... I will
always be there for you.... you can call me anytime, day or
night." This was followed by numerous incidents of acting
out by the patient. The therapist was called at home, at times,
after working long hours. The therapist became resentful,
and accused the patient of testing her sincerity. She became
more depressed, and made a serious suicidal attempt, fol-
lowed by an admission to the intensive care unit of a general
hospital.
5. Trust
Patients with MPD have a ver difficult time estab-
lishing trust in anyone, including the most competent
clinician. Since patients with MPD have backgrounds of
severe abuse, neglect, and abandonment, including
betrayal from their own parents, these patients have
never experienced in their childhood the meaning ofa
stable, trustful relationship. A workable level of trust
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DISSOCIATION, Vol. II, No. June 198(f
between the therapist and patients with MN) usually
takes many months to develop, and is constantly tested
as to the limit of such a trusting relationship. It. must be
remembered that patients with MPD fully expect people
who are nice to them to follow it up by betrayal of the
trust. In fact, they may even provoke the therapist to act
out withanger and then look for evidence of a failing of
the trust.
Case Illustration: The patient, Linda, is a 31-year-old, mar-
ried, mother of three. She has been in psychotherapy for
over a year, during which she had two hospitalizations. In
one session, the therapist announced to the patient that she
was going on vacation for three weeks. The patient re-
sponded by dissociating into a child-like state, and started
crying, talking in the voice of a young child, saving she was
afraid the therapist would not return, and that she would be
abandoned. The therapist responded by moving closer to
the patient, holding her arms in a motherly hug, and saying,
"I am a good mommy. I will be back. You can trust me." The
patient suddenly changed, and switched into an angry ego-
state. In that ego-state the patient accused the therapist of
breaking promises in the past. and not being there for the
patient when she was supposed to. The therapist responded
by disclosing to the patient the itinerary of her vacation, and
where she could be located. She also promised t.o write the
patient a postcard once a week. he patient reacted to that
by switching into another hostile, and angry ego-state, saying
to the therapist, "I am undeserving of such kindness. You
shouldn bother to spoil your vacation worrying about mc."
D. Spiegel (1984, 1988) described what he termed the
"traumatic transference." In this situation, the patient sub-
consciously expects to be traumatized in a close relationship
with the therapist as a reenactment of the childhood abuse.
If the therapist is perceived as nice and kind, the patient sees
that as a seduction to be followed by betrayal. If the therapist
keeps a distance, it will be perceived as being cold and
uncaring, allowing the patient to be exposed to excessive
risks and dangers, without proper interventions. The thera-
peutic solution is the interpretation of such behaviors as a re-
enactment of the past.
6. Misalliances:
It is basic knowledge that a working and therapeutic
alliance are a necessary cornerstone for any effective
psychotherapy to take place. At times, however, a mis-
alliance may develop in the relationship between the
therapist andthe patient (Langs, 1975) . The misalliance
may be based on any type of dynamic constellation
in which the patient and the therapist unconsciously live
out a compromise derived from the pathological intra-
psychic and interactional needs that each of them has.
What may happen is a form of a collusion between
the two that may perpetuate the patient splitting,
delusions of separateness, and the existence of alter
personalities and ego states for the sake of pleasing the
therapist, and so maintaining the relationship. Effective
therapy with MPD patients is a most challenging task.
Being aware of their own countertransferences and im-
perfections allow therapists to develop a mature and
realistic approach that will help to diminish the iso-
genic factors in treatment.
CaseIllustration: The patient (Francine) is a 24-year-old,
single, college student who has been in therapy due to MPD
for over one year. The therapist reports the patient to be
extremely talented in drawing and painting, and brings into
supervision and discussion groups the patient drawings,
emphasizing with pride her talents and skills. However,
these drawings are done (according to the therapist) by an
alter personality named Carla. The therapist reports having
a very good relationship with Carla, and has attended art.
shows and visited art museums with Carla, rationalizing this
by encouraging the patient creativity, and ability to possibly
make a future career of drawing. At the same time, little
attention is paid to the patient host personality, Francine,
and the difficulties she has in concentration, sleep, relation-
ships with men, and in studying for exams. The patient
alter personality Carla, has made more than one statement
to the therapist on how well they get along, and how, in fact,
she could be the one to handle everything, providing the
therapist helps her to get rid of Francine, who is described
by Carla as being chronically depressed, and incompetent.
The therapist does not explore the meaning of such state-
ments, and, in fact, ignores them to continue interacting
with the Carla personality in helping her plan for a future art
exhibit of her drawings. The therapist offers the patient
names and phone numbers of various art galleries that might
be interested in selling her artwork. Two weeks later Francine
reports to the therapist suicidal ideas. The therapist re-
sponds by asking for Carla so they can discuss her recent
drawings.
The foregoing case illustrates how, at times, therapists
treating MPD may enter into a misalliance. This might
include writing a book together. In some cases, the patient
artistic talents are used by the therapist as a narcissistic
expression of the therapists own subconscious needs. Th-
erapists must be aware of their own needs, and ensure that
these needs are to be met outside of therapeutic work. In
therapy, priority should be given to the patientsneeds, and
moving them forward towards integration and improve-
ment in their adaptive functions with the activities of daily
living.
7. Ownership of Unacceptable Behaviors:
Case Illustration: The patient, Theresa, is a 34-year-old,
married, mother of three children who had been accused by
Children Services Board of abusing her children physically
and emotionally. Children s Serv
take the children out of the patient home, and place them
in foster homes. The patient is allowed to see them once per
month under supervision. The patient has amnesia to the
abuse, and claims to love her children. She is feeling per-
plexed, and has no understanding of why she is being
accused of abusing her kids.
During therapy, it is found that the patient abused her
children when she was in an altered personality state, calling
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DISSOCIATION, Vol.II,No. `l:
herself Sylv via sees herself as being single, never mar-
ried, and does nut. recognise these children as being hers.
She reports pouring boiling water on the kids, stating she
hates those children, and hates Theresa.
One day, the patient reports to the therapist a dream in
which she sees herself to be the abuser of her kids. The
patient starts crying, and accuses herself of being an unfit
mother, and that she will never get custody of her kids again.
She expresses guilt and remorse, saving how awful she feels
remembering the episodes of the abuse. The therapist
admits feeling empathic to the patient, and responds by
saving, "Come on, Theresa, you know you have always been
a good and loving mother to your kids. I told you we will work
together to get your kids hack. You know you didn t abuse
your kids. You love your kids. It was Sylvia who did it. We will
simply have to make sure that Sylvia doesn do that again."
The above case illustrates how the therapist interven-
tions perpetuate splitting, and disowning of unacceptable
behaviors, which is part and parcel of MPD.
S. Therapists Communication and Perception of
Patient:
The following case illustrates how the therapists
language, as well as the therapist s perception of MPD
might contribute to the perpetuation of splitting and
multiplicity daring therapy.
Case Illustration: The patient, Rose, is a 27-year-old female
studying for her masters degree in social work, and has been
in therapy due to MPD for over six months. In consultation,
the therapist reports that the patient has 20 different person-
alities. She refers to the patient repeatedly as " they," and
discusses with great pride the fact that she has witnessed 18
different personalities "come out" to talk to her. In a discus-
sion with the therapist it is revealed that her perception of
the patient is that of a group of "people" of various ages
trapped in the same body. The therapist conceptualizes her
role as getting to know them all, and encouraging them to
express their talents and creativity in their separate and
unique ways. During one session, the patient reported (in an
alter personality " Paul") feeling a fear of dying if " he"
continues to get close to Rose. The therapist responds by
reassuring Paul that he would not die and that the therapist
will guarantee his continuing existence since he had so
much to contribute to the patient s survival, and deserves
special credit for it. This perpetuated the patient confusion
regarding her identity in general and her sexual identity in
particular.
9. Overemphasis on Internalization:
Following is a case which illustrates how the
therapist interventions may, in fact, encourage the
patient to continue to dissociate, and perhaps stay frag-
mented as a way of coping with daily living, while at the
same time showing how overemphasis on the patients
internal world may foster a regression that could be
accompanied by a loss of employment, and being placed
on disability. The challenge of effective therapy with
MPD patients is to continue therapeutic progress by
pacing them gradually towards greater insight, aware-
ness of behaviors, acceptance of the past, as well as
behaviors iii the present while maintaining adaptive
functioning with the activities of daily living. This deli-
cate balance is indeed of crucial importance to both the
patient and therapist. Therapists in this field must have
knowledge and awareness of the risks involved in a pre-
mature overemphasis upon the past. Too much focus-
ing on the patient internal world may contribute to a
dysfunctional regression in the patient, and may unnec-
essarily perpetuate splitting and multiplicity.
Case Illustration: The patient, James, is a 35-year-old married
man, and father of two. He has been in treatment for MPD
for over two years. During this time the patient had lost his
job and was placed on Social Security Disability. However,
the therapist sees the patient three times per week, and
proudly reports on the great accomplishments in therapy,
and speaks of the productive therapeutic work the patient is
engaged in. This includes always being on time for sessions,
following all instructions of the therapist regarding writing
in a journal, doing therapeutic drawings, practicing inner
dialogues, and developing insights about the patients child-
hood, including acceptance of abuse by his parents. The
patient reported to the therapist that he has been spending
an average of five to six hours every day writing in his diary,
and doing therapeutic drawings, as well as inner dialogues.
The wife complains of the patient neglecting his family and,
at times, even avoiding family dinners. When this is discussed
during the consultation time, the therapist reports with
pride that she asked the patient to dissociate and assigned
the task of playing with his children to a child personality,
"Tommy" who has been very playful with die therapist in
sessions and would know best how to relate to little children.
CONCLUSION
This paper has focused on the potential for the iatro-
genic worsening of MPD. Therefore, it has emphasized
possible negative outcomes. These remarks must be placed
in the context of the overall literature of the MPD field. The
illustrations cited are not meant to be seen as typical of the
behaviors of therapists working with MPD patients; instead
they depict the types of situations one must make efforts to
avoid. 
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