THE PHENOMENOLOGY
AND TREATMENT OF
EXTREMELY COMPLEX
MULTIPLE PERSONALITY
DISORDER
RichardP. Kluft, M.D.
Richard P. Kluft, M.D., is Attending Psychiatrist at the Insti-
tute of the Pennsylvania Hospital, and Assistant Clinical
Professor, Temple University School of Medicine
For reprints write: Richard P. Kluft, M.D., Institute of the
Pennsylvania Hospital, 111 North 49th Street, Philadelphia,
PA 19139
ABSTRACT
Cor temporary reports indicated that the average number of person-
alit.es in recently reported patients with multiple personality disorder
(MPD) is larger than that reported in the older literature. A minority
of tnese recent patients demonstrate extreme complexity. A group of
26 patients with 26 or more personalities and under observation for
a n inimum of three years was studied. Their presentations, the
rev ons that appeared to underlie their complexity, and their courses
of /zeatment are reviewed. Findings indicate that this group of
pat: ents is diverse, with some proving readily treatable, and others
proving quite refractory. Observations that appear constructive for
the eatment of such patients are offered. The concept of personality
is dcussed and an alternative description is explored. The useful-
ness of the paradigms and metaphors of splitting and division as
heuristics for the understanding of MPD is challenged, and a
paradigm/metaphor of redoubling and reconfiguration is offered for
fun her study.
In recent years multiple personality disorder (MPD) has
been recognized, reported, and studied with increasing
frequency. The recent DSM-III-R, (American Psychiatric
Association, 1987) no longer describes MPD as rare. Cohorts
of MPD patients have become available for study, and pub-
lisl-.ed collections of data from groups of MPD patients are
slowly superseding the single case studies that had domi-
nated the literature of the field for the majority of the
twentieth century. One of the most consistent findings
across the newer explorations of MPD is that the cases being
encountered by con temporary clinicians and being reported
in the modern scientific literature tend to have more person-
alities than those described prior to the 1970s.
Most cases in the older literature had relatively few
personalities. Forty-eight of the 76 cases reviewed by Taylor
and Martin in 1944 were dual personalities; another 12 had
three personalities. Only one individual, a patient with 12
pe-sonalities, had more than 8. "Sybil," with 16 personali-
ties, reported in 1973 (Schreiber), was the first of the
modern more complex cases to be described. Within the
sar-te decade it was revealed that the celebrated "Eve" had 22
rather than 3 faces (Sizemore Pittillo, 1977), and Billy
Milligan, with 24 personalities, became cause celebre in the
media (Keyes, 1981).
As scientific investigators encountered increasing
numbers of MPD patients, their estimates of the average
number of personalities in such patients has increased. In
1979 I indicated that the number of alters in a series of 70
MPD patients clustered around a "modal range" of eight to
thirteen alters; 55.7% had between two and ten, and 44.3
percent had eleven and more (Kluft, 1984b). In 1984 (a) I
reported that a group of 33 successfully treated MPD pa-
tients had had an average of 13.9 alters. This group included
nine patients with 20 or more alters; one had had 86. In 1985
a survey by Schultz, Braun, and Kluft (1989) of 355 MPD
patients each reported by a different therapist, the patients
had an average of 15.8 alters. Putnam, Guroff, Silberman,
Barban, and Post (1986) found an average of 13.3 personali-
ties per patient in their series of 100. In the same year I
published an expanded series of 52 successfully treated MPD
patients. This group averaged 15.4 alters. There were thir-
teen cases with over 20 alters, and patients with as many as
110 alters were included. Newer and unpublished additions
to this research cohort include several successful treatments
of patients with over 100 alters. Among the more recent
series, Coons, Bowman, and Milstein (1988) are unique in
reporting a mean of 6.3 personalities. They explain their
findings by noting that their series was smaller than the
others reported and that they sampled the number of alters
"very early in therapy." In contrast, I (1979, 1984a, 1986) had
included only enumerations of alters from the records of
patients who had been treated to the point of stable integra-
tion.
My experience with very complex cases began in 1975.
I was asked to see in consultation a woman who was believed
to have three personalities. After a series of therapeutic
misadventures she suddenly appeared to manifest 21 addi-
tional entities. My explorations convinced me that they were
not conventional personalities, but were instead dramatic
efforts to encapsulate the impact of imprudent therapeutic
interventions. In essence, they were iatrogenic phenomena.
A single hypnotic intervention reduced the complement of
alters back to three. I had not anticipated any further contact
with this patient, but, following several months of further
therapeutic mishaps, she was transferred to my care. After a
year during which she tested me extensively, a protector
personality that had not emerged previously did so, told me
that she decided I could be trusted and revealed a total roster
of 33 alters. No outward sign had suggested such complexity.
47
DISSOCI.VF 10 \, Vol. 1. No. I. Decrioh r 19 S
She r ached integration in two and one-half years of treat-
ment and retained her gains for five years, after which she
reloc ted and was lost to follow-up.
I ~1976, while her treatment was proceeding, I discov-
ered PD in a patient with a complex somatoform presen-
tation (1984c). After meeting the second personality, which
had :merged in a spontaneous switch, I invited any others
that ight be present to come forward and introduce them-
selve . Four exhausting hours later, I had met 84 of the
addit onal 86 separate and distinct alters who would ulti-
mate be identified and integrated. Their rapid fluctuations
and rattles for control had totally obscured the classic
mani estations of MPD. This patient integrated after four
years ork and remains stable on nine yearsfollow-up.
erted by these two patients and a third encountered a
mont after the second, I began to appreciate that MPI)
pale ts existed who were far more complex than those
previ rusty reported. When I began to study my MPD patients
as a g oup, I found that such cases were far from uncommon.
In 19 9, I decided to collect information on this group.
Som hat arbitrarily, I defined extreme complexity as the
prese cc of at least twice as many alters as the upper limit of
the dal range of 8-13, i.e., 26 or more. In 1983 I described
findi gs in a series of 26 patients with 26 or more personali-
ties t: the 26th Annual Scientific Meeting of the American
Socie of Clinical Hypnosis; in 1984 I presented a series of
32 su h patients to the First International Conferences on
Multi ile Personality/Dissociative States. These papers were
not s i bmitted for publication at that time for two reasons.
First, t was uncertain whether the field was moving toward
a ne nomenclature, and I did not want my materials
descr bed in a manner that would be confusing and incon-
siste with an emerging set of definitions. Second, the
contr.versy that surrounded MPD remained so intense that
it see ed prudent to defer the publication of materials that
migh well further inflame an already difficult situation. In
the i ~ terim, however, no uniform terminology has been
accepted by consensus within the field, and MPD has suc-
ceed d in achieving more general recognition as a genuine
clinical entity. Therefore it seems timely to communicate
some initial findings with respect to highly complex cases of
MPD
he records of all MPD patients in my files were re-
vieweu . Those patients who both had over 25 alters and had
been nder my clinical observation for a minimum of three
years ere selected for inclusion in this study. The applica-
tion f these inclusion criteria yielded a cohort of 26 MPD
pane ts who were both extremely complex and very thor-
ough y studied. They excluded over 100 such patients seen
prim. rily in consultation or less extensively whose full
com plexity was attested to only by self-report or by clinical
obse tions made by others. It is of note that from my first
obse ation of an extremely complex MPD patient until
1984, when several of my articles were published, extremely
com plex MPD patients constituted approximately 15 to 20
percent of the MPD patients that I assessed. Subsequently,
most of the MPD patients that I have seen were diagnosed by
colleagues and referred for consultation. With each year
more colleagues are more comfortable with the less com-
plex cases, and the substantial majority of those that are
referred to me are extremely complex.
Although the decision to report exclusively upon the
best-studied group of such patients has the benefit of exclud-
ing information that was not tested and reconfirmed within
a clinical context, it is acknowledged that if there exist any
unwitting biases within the manner of my conduct of the
therapy of these patients that might impact on the findings
of this study, those biases remain uncorrected. Further-
more, the data of this study may not prove accurate if
extended to that group of extremely complex patients that
did not remain in treatment.
FINDINGS
The Patients
The sample consisted of 24 women (92%) and 2 men
(8%); 94 percent were Caucasian. Both men were employed.
Three of the women were homemakers by choice, eleven
were disabled by their mental condition (and many de-
scribed themselves as homemakers on this basis), and ten
were employed. At the time of their entering treatment both
men were married, ten women were divorced, six never had
married, and eight were married. Six had been diagnosed
and entered treatment with the author between ages 20 and
29, thirteen between 30 and 39, four between 40 and 49, two
between 50 and 59, and one over 60. Twenty-four had had
extensive previous therapy. They had been given a wide
range of prior diagnoses. Fifteen had been in treatment over
a decade before their MPD had been recognized, and all but
two had been misdiagnosed for over five years. Nine received
their MPD diagnosis from myself; the remainder had been
referred with the diagnosis already established by a col-
league. Of those referred already diagnosed, in only four or
23.5 percent had the patient degree of complexity been
suspected or established; in no case had the entire comple-
ment of alters been discovered.
The number of alters varied widely, from 26 to over
4,500. The complexities involved in defining a personality
will be discussed below. For the purposes of this study,
undertaken before DSM-III (1980) was published, all enti-
ties with consistent senses of themselves, consistent ways of
behaving and interacting, personal memories, feelings, and
patterns of function, and the capacity to assume executive
control of the body, whether it was exercised routinely or
not, were accepted as personalities. Phenomenologic and
behavioral criteria were secondary. Ten patients, 40% (in-
cluding both the males), had between 26 and 50 alters. One
patient (4%) had between 51 and 75 alters, three (12%)
between 76 and 100 alters, five (19%) between 101 and 200
alters, two (8%) between 201 and 300 alters, and five (20%)
had more than 300 alters.
Despite these patientsdegree of complexity, unless
they were in the midst of an intense therapeutic process it
was unusual for more than one to six of their alters, in
DISSOCIATION. Vol. 1, No. 4: Da mks 1YtI
tion to the host, to play major ongoing roles in their
rpersonal lives at any particular point in time. When this
rred, usually the patient became dysfunctional. Con-
ly, the number of alters playing ongoing active roles in
tient private, inner world seemed unrelated to the
nt degree of dysfunction. With regard to this type of
nomenon, the altersdegree of conflict rather than their
r numbers seemed more correlated with problems in
tioning effectively. Thus, even in patients with the
al range of complexity (8-13), there are likely to be
ral personalities that, at a given moment in time, are less
e, less manifest, and perhaps less powerful or apparently
important than others. The more alters that a patient
the higher the percentage of them that will appear less
uently or openly. To anticipate a point, the more alters
are both present and active, the less clearly is the patient
y to display the features expected to be found in the
is descriptions of MPD, which are based on the alterna-
of a small number of well-defined alters.
The Presentation of Extremely Complex MPD
As a group, these patients had proven difficult to diag-
nos-. Of the eight (32%) whose MPD was first diagnosed by
the author, three had presented essentially self=diagnosed,
ans five were in his practice for months or years before the
MP 1 diagnosis was either first suspected or confirmed.
Non e of these five had presented with signs that immediately
sug. ested MPD, although in several cases this was due to the
del berate withholding of information or the provision of
disi tformation_ Of the 18 (69%) referred with the diagnosis
eit er already made or strongly suspected, the patients
wh a se treatment careers could be documented had aver-
ages over ten years within the mental health care delivery
system.
Although it is tempting to infer that the more multiple
a patient would be, the more evident would be his or her
MP 1, this did not prove to be the case. Many of the more
co plex cases had a small number of alters handling most
oft eir activities, and were no more obvious than other MPD
pat ents. Those with many alters active presented such rapid
fluutuations of appearance and behavior that the overall
ges It was one of confusion and chaos, and such disruption
of heir lives that poor ego strength was implied. Many
funs elled all activities through a beleaguered host, who,
bes -twith passive influence experiences and/or command
hal ucinations, was reduced to helplessness and despair.
Int restingly, the patients who presented to me self-diag
no- d had tried to tell previous therapists of their plight, but
has been disbelieved. These therapists had used fallacious
"casricious criteria" (Kluft, 1988) to discredit the diagnosis;
e.g , that the patient could not possibly have MPD because
she was aware of the other alters [sic!].
Another phenomenon that appears to have impacted
on he manifest appearance of these patients, and thus upon
the r ability to be diagnosed, is order effect. First brought to
the awareness of the MPD field by Frank W. Putnam, M.D.,
in . series of workshops and other presentations, this phe-
no enon relates to the fact that all alters are not the same
all he time. Alter A may be somewhat different when it has
been preceded by alter B than when it follows alter C. In
situations in which many alters are switching with rapidity
and facility, their appearance may not be as crisp and clear
as when they are elicited in the clinical situation from a rela-
tively placid baseline. In naturalistic circumstances, the
alters of a highly complex and rapidly switching MPD patient
may show few of the clear phenomena commonly associated
with the condition.
In terms of prior diagnoses, virtually all had received an
affective diagnosis with regard to their depression. Indeed,
virtually all merited the diagnosis of depressive disorder not
otherwise specified. Approximately two-thirds of the cases
referred already diagnosed had received a borderline diag-
nosis, but their therapist almost universally withdrew this
diagnosis after diagnosing the MPD. I considered seven
(27%) to have a bona fide borderline diagnosis in addition
to the MPD. This was made on the basis of borderline
stigmata that could be distinguished from the manifesta-
tions of their dissociative and posttraumatic symptoms and
signs and that had persisted for a long period of time and in
a wide variety of circumstances and settings. Nine (36%) had
been diagnosed as schizophrenic, mostly on the basis of
hallucinations due to the inwardly-perceived voices of alters.
None truly merited this diagnosis. Four had prior accurately
diagnosed eating disorders; two had psychoactive substance
abuse disorders.
Approximately half of the patients had had classic MPD
diagnoses that simply had gone unrecognized for long
periods. Most of the remainder had shown increasing signs
of dissociative phenomena in the course of their treatments,
and finally switched overtly in session. Four were accurately
self-diagnosed. Two were found to have MPD (switched
openly) in the course of investigating puzzling somatoforrn
symptoms. Five were diagnosed with the help of hypnosis,
four after much information had raised the suspicion of
MPD. In one case I proceeded with no suggestive evidence
other than the fact that the patient had come to me with a
history of 38 years of unsuccessful therapy and, after a year,
was not doing well with me either.
Pathways to Complexity
It may be difficult for many clinicians, even those quite
conversant with dissociation in other contexts, either to
believe that such complexity could exist or to conceive of
why it would develop and be sustained. Although patients
retrospective reports are without external verification, they
represent a useful source of information when this caveat is
kept in mind. It is of interest that external corroboration of
some aspects of alleged abuse was available in 12 cases
(46%), including confessions by perpetrators, legal records,
and the accounts of witnesses to the patientsmistreatment.
Based on the accounts available, the following factors,
listed in order of decreasing frequency, were found in
patients material. Table 1 lists prominent factors in the
given histories of these patients and the percentage of the 26
patients who gave such histories. It is self-evident that this was
a highly abused cohort. As children they had been so bom-
barded with outrages that they had not been able to develop
a cohesive and comprehensive system of alters within which
49
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ph
she
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mo
sev
ac ti
less
has
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tha
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clas
tin
[ASSOCIATION, Vol. 1, Ns). 4: Dcremh -r 1988
", ul~lll'[Kllul' 7'
their further traumata could be managed. Instead, new
alters were formed frequently on an ad hoc basis, and many
persi; ted, some becoming major, some highly specialized,
and same fairly inactive. Clearly their families were chaotic
and t! nsafe, as evidenced by the high percentage of incest
victims. Many formed a high percentage of their alters in
direcr response to traumatic events; the more traumata, the
more alters. These alters contained the memories of these
evens and/or their associated perceptions and affects. They
persi4ted as vehicles of memory, but rarely played major
roles in day-to-day life unless events analogous to their
uniq e experiences occurred. They were rarely invested in
separateness and often integrated immediately or with little
help ter being allowed to tell their stories. These patients
had many years to respond to traumatic events, since 81
percent had continued to be abused well into adolescence
and early adult life. Several had continued to be used even
after establishing their own families; five (19%) were still
being exploited well into their therapies.
Nearly three-fourths had rather vulnerable non-disso-
ciative coping styles and defenses. Consequently, under
stress they were readily overwhelmed forcing a resort to
switching, and, should this fail, the precipitation of new
alters One patient was so apprehensive about her consulta-
tion s ith me that no alter would agree to attend. A new alter
was formed for the occasion. The weakness of the other
available defenses also appeared to preclude the rapid
TABLE 1
Pathways to Complexity
Factor %
1. Longstanding severe abuse 100
2. Ongoing alter formation 96
3. Incest 92
4. Event-based division 85
5. Ongoing severe abuse 81
6. Weak non-dissociative defenses 73
7. Inner world phenomena 69
8. Complex splitting patterns 65
9. Vicious torment 58
10. Pain-phobic orientation 50
11. Alloplastic evasiveness 42
12. Ritualistic abuse 35
13. Others exploit condition 35
14. Epochal division 35
15. Ego-syntonic splitting 31
16. Mythic elaboration 19
17. Massive introjection 15
18. Obsessional mechanisms 12
19. Symbolic splitting 4
20. latrogenic dividedness 4
50
"metabolism" of these ad hoc alters, which then tended to
persist.
Over two-thirds had developed elaborate inner worlds,
in which the personalities interacted among themselves to
an extent that is far beyond the norm in MPD. These inner
alters were quite crucial to these patientspsychological
structure and could emerge and assume executive control.
Often personalities formed ad hoc as noted above were
incorporated into these systems, but in some cases alters
appear to have been created to do no more than to fill roles
in these inner worlds.
Almost two-thirds developed complex splitting patterns
so that more than one new alter emerged on each occasion
of the formation of new alters. Some developed separate
lines of alters, each of which divided further on each occa-
sion of new alter formation. Some had developed a pattern
of generating new alters in clusters, such as groups each of
whose members served different functions, or retained dif-
ferent aspects of a terrible experience.
All MPD patients were most unfortunate in their life
experiences, but for many the abuse was unusual even by the
norms of work with MPD patients. Wilbur has described
some such instances, ironically, as "creative abuse."
Half of this MPD cohort demonstrated what might be
called a pain-phobic orientation, by which is meant an
intense preoccupation with avoiding dysphoria, and/or
with protecting certain alters from dysphoria. Such patients
spent considerable time in therapy arguing against the ideas
of working with past traumata and exposing particular per-
sonalities to painful material. "But she can take it/handle
it" were common refrains. In many instances the alters being
protected would be absent from the therapy sessions for
prolonged periods, or be described as having died or gone
away.
A substantial minority had developed a pattern of form-
ing new alters in the face of trivial stressors and inconven-
iences, or whenever they felt cornered. They formed new
alters to evade confrontations or responsibilities in therapy,
and many, in the service of resistance, formed alters based
on the therapist. Severe narcissistic traits and the deliberate
abuse of autohypnosis was common in this group.
Ritualistic abuse was alleged by just over one third of
these patients, and many of the most complex cases en-
dorsed such experiences. A like number reported that oth-
ers encouraged and/or manipulated their condition. Inter-
estingly, since the personalities being manipulated perforce
lost much of their defense capacities, the creation of still
other alters to restore defensive balance or to propitiate the
manipulator was encouraged.
Epochal divisions were common in most of this cohort
as isolated phenomena, but played a major role in a substan-
tial minority. With each major life change some or all of the
alters were created anew, and their predecessors might
either remain active or subside, and become covert or latent.
The dynamics of such configurations usually reflect the wish
to make a new start, rebirth fantasies, or anniversary phe-
nomena. The often followed moving, changes in schools,
changes in family constellations (such as the death of abus-
ers or the birth of a child) , marriage, or great pressure to take
DISSOCLITION. Vol. I, No. I: leecmher l9BH
flight. Obviously such a response pattern could either lead to
sequential dual personality, with one line of splits and the
nor-persistence of prior alters, or extreme complexity if
several lines divide and alters persist.
A minority find the process of creating alters pleasur-
able or took narcissistic gratification in being complex.
These patients constituted two-thirds of the 6 percent of
MPa patients who flaunt their psychopathology openly and
cultivate secondary gain from MPD (Kluft, 1985). Should
this persist beyond the first few months of therapy, it is an
ominous prognostic indicator.
Those few MPD patients who analogize their plights to
kncwn myths or creative works (or who generate their own)
ma) create a number of alters with little substance to fill in
roles in their myth or reconfigure the present alters to
par illel the personae of the myth/creative work. With such
patients, it becomes crucial to understand the communica-
tive function of the myth rather than to become enmeshed
within its details. One patient reconfigured her alters after
reading J.R.R. Tolkien Lord of the Rings, and presented a
complex cadre of alters based on hobbits, ores, and wizards;
another used Shakespear s I'empest, a situation that became
cle2r when I encountered an alter called Caliban.
Most MPD patients have alters based on identification,
internalization, and introjection, but a small percentage
havs formed a massive number of alters in this manner as a
defense against object loss. These patients were rejected by
large extended families, and introjected their members,
forming alters based upon them. The role of obsessional
phenomena in MPD is quite understudied, and more com-
mon than is generally understood. They lend themselves
readily to serving as the nidus for alter formation. A small
number of MPD patients have attributed special power to
particular symbols or numbers, and these come to influence
their manner of alter formation. One patient felt the num-
ber seven had special meaning to her. She wore a ring with
seven stones, and her alters emerged in groups of seven. She
spli off a first group of seven alters in a rather unremarkable
manner, and then split off alters on 33 additional occasions,
leading to 238 alters.
Finally, it is important to note that although there are
many reasons for alters to emerge gradually over the course
of therapy, implying to those who adopt post hoc propter
hoc reasoning that they are of iatrogenic origin, a misman-
aged therapy does have the potential to induce further alters
(Kluft, 1982, 1989).
THOUGHTS ON THE CONCEPT OF PERSONALITY
Work with extremely complex MPD raises intriguing
concerns as to the very nature of the personalities. Although
this is a subject too broad to be addressed in depth in this
article, an article that maintains that as many as thousands of
the;e entities may exist within a given patient must attempt
to ,hare the attitude such phenomena that informs its
ob 1
In the general psychiatric literature personality is taken
to . can: "The characteristic way in which a person thinks,
feels, and behaves; the ingrained pattern of behavior that
each person evolves, bothconsciously and unconsciously, as the
style or way of being in adapting to the environment"
(Talbott, Hales, Yodofsky, 1988, p. 1261). Generally, there
are two trends in contemporary thinking about MPD as to
the nature of personality. The stance taken by Coons (1984),
hewing to the more general usage of the term, is that "It is a
mistake to consider each personality totally separate, whole,
or autonomous. . . . Only taken together can all of the
personality states be considered a whole personality" (p.53).
Braun (1986) attempts to define personality in a manner
specific for use with MPD:"an entity that has the following:
a) a consistent and ongoing set of response patterns to give
stimuli; b) a significant confluent history; c) a range of
emotions available . . .; and d) a range of intensity of affect
for each emotion " (p. xii). He would describe less well-
elaborated entities as fragments. Braun notes that using this
definition may make MPD more acceptable if the number of
personalities is "riot alleged to be so great" (p. xii).
I have never been pleased with the term multiple per-
sonality disorder because I endorse the conventional defini-
tion of personality and, therefore, regard the term as some-
what paradoxical. In my own thinking, I conceptualize the
condition as disaggregate self state disorder (I have also used
disaggregate structured self state disorder). I concur with
Coons(1984) stance, have encouraged the use of the term
"alter" as a substitute for personality, and find the Braun
(1986) definitions inconsistent with certain observations in
my clinical experience (Kluft, 1985) and unduly defensive.
Furthermore, they create a situation in which patients who
quality for the DSM-Ill-R diagnosis of MPD may not have
personalities as so defined.
I have tended to define a personality, alter, or disaggre-
gate self state in a manner that stresses what such an entity
does and how it behaves and functions rather than by
emphasizing quantitative dimensions: A disaggregate self
state (i.e., personality) is the mental address of a relatively
stable and enduring particular pattern of selective mobiliza-
tion of mental contents and functions, which may be behav-
iorally enacted with noteworthy role-taking and role-playing
dimensions and sensitive to intrapsychic, interpersonal, and
environmental stimuli. It is organized in and associated with
a relatively stable (but order effect dependent) pattern of
neuropsychophysiologic activation, and has crucial psychody-
namic contents. It functions both as a recipient, processor,
and storage center for perceptions, experiences, and the
processing of such in connection with past events and
thoughts, and/or present and anticipated ones as well. It has
a sense of its own identity and ideation, and a capacity for
initiating thought processes and actions.
Therefore, a personality as defined above and eligible
for inclusion in this study might be a fragment in Braun
terminology; in fact, many extremely complex MPD patients
have too many personalities for most of them to quality as
such in this terminology. Braun uses the term polyfrag-
mented MPD to describe such situations. Further remarks
on the definition of personalities will be found in the
Treatment and Discussion sections of the article.
51
DISSOCIATION, L ol. I. No. 1 December 11)88
52
DISSOCIATION. Yol. I. No. 4: December 19811
ILLI STRATIVE EXAMPLES
n order to demonstrate the wide variety of phenomena
mitered within this group of patients a series of illustra-
(etches will be offered.
ase 4. A woman of 34 had 27 known alters, of which 3
s fulfilled Braun (1986) definition of personality, a
of which did so for periods of at least a year in the
e of therapy, and a dozen of which always fell short of
legree of definition. She was quite classical in her
enco
five s
alwav
dozes
cour
this
manifestations.
Case I9. A woman of 42 had over 1,600 separate entities.
Virtually all were very minor entities, flickering briefly into
action to influence the beleaguered host from behind the
scenes. There was one additional very well articulated alter
that never emerged unless requested to in the course of
therapy.This patient exemplifies what Braun described as
polyfragmented MPD. She did not appear to demonstrate
classicMPD until she had unified down to three alters.
Case 6.A woman with 38 alters had about half a dozen
TABLE 2
Treatment Histories: 26 Cases
Total Hosps. Current
# M/F Age Alters Yrs Rx Visits/Wk #/Mos.) Alters
1. F 37 >100 5 1-2 0/0 1
2. F 39 238 3 2 1/2 238
3. F 55 33 3.5 1-2 0/0 1
4. F 34 27 4 1-3 3/7 ?
5. M 37 26 4 1 0/0 1
6. F 27 38 5 1 0/0 5
7. F 45 88 5 1 4/4 1
8. F 32 >150 4 1 0/0 1
9. F 39 >280 7 1-2 7/18 >280
10. F 51 409 7 1 (double) 0/0 <10%
11. F 33 36 4 1 1/1 36
12. F 39 56 3 1 3/5 3
13. F 37 42 5 1 2/1.5 1
14. F 42 86 5 1 0/0 1
15. F 27 >100 3 1 0/0 <10%
16. F 34 37 4 1-2 2/7 2
17. F 26 36 4 1-2 1/1 1
18. F 35 38 4 1-2 0/0 1
19. F 42 >1600 3.5 1-2 0/0 3
20. F 48 >150 5.5 2 3/14 1?
21. F 39 685 8 1-2 7/24 7
22. M 62 36 7 1 0/0 1
23. F 39 82 8 2 12/30 1
24. F 46 >4000 3 4 2/37 <5%
25. F 40 143 7 1-2 4/12 1
26. F 37 >_4500 7 4
(1 - 2 double)
3/52 1
Interrupted treatment against advice
*' Just returned after 3 year break of therapy
reasonsk Transferred to another therapist for logistic
that were quite consistent, while the remainder were subject
to frequent change and reconfiguration. The more she inte-
grated, the more this tendency for reconfiguration became
un.versal. The defensive power of the dissociative defenses
and switching rather than the alters per se dominated her
mental function.
Case 26. This patient, with over 4,500 alters, had only 300
that were as poorly defined as the alters in They were
remarkably full when they appeared, although many were
quite similar to one another. It was as if the same "basic issue"
typesof alters could he reduplicated readily, and generated
again and again over the course of the patient life (epochal
complexity). The sense of dealing with most was of dealing
wit i a full personality that integrated more readily than a full
personality because, despite their complexity, these alters
had rather circumscribed bits of traumatic memories that
were unique to them alone.
TREATMENT RESULTS
As of this writing, 13 of the patients (50%) are inte-
grated, one appears integrated but 1 suspect there is more to
be found, one is reduced to seven alters, one to six alters, two
to three alters and one to two alters. Three very complex
cases have integrated considerably, each alleging "over 90
percent," but none of these three patients can/will be
specific. Two patients left treatment rather than deal with
pailful material, and their state of integration is not assess-
able. One patient is essentially unimproved, and another,
who left treatment for three years and is newly returned, in
the interim redoubled all alters in a massive resistance.
In terms of general functioning, fifteen are fully em-
ployed and doing well, three are homemakers by choice, one
is a student, and seven remain disabled. Two are currently
hospitalized. Of the integrated patients, all are functioning
well but those two whose integration is most recent, and one
with medical problems. Some details of their treatment are
summarized in Table 2.
The data of Table 2 are not accurate in detail, but in
gestalt.Many patients refused to allow the precise details of
their cases to be published lest they be identified or simply
fee: uncomfortable. For similar reasons no effort has been
made to link the particular historical antecedents (such as
incest or ritual abuse) with specific patients. I anticipate that
this concession of precise accuracy in deference to the sen-
sitivities of the patients involved will be understandable and
acceptable to those clinicians and scientific investigators
fan-iliar with the treatment of MPD patients. The findings
indicate that the extremely complex MPD patient can achieve
anc sustain integration, although the therapy may be long,
intense, and punctuated by hospitalizations, some of which
ma,, be quite prolonged. They also suggest that extremely
complex MPD is a heterogeneous group, with some patients
making rapid gains, and others struggling for many times as
long to achieve comparable results. Members of the cohort
tha=merited a borderline diagnosis did achieve integration,
but the majority of those who broke treatment carried a
concomitant borderline diagnosis. Five ritual abuse survi-
vors are among the integrated and questionably integrated
groups, indicating that this type of patient can be teated
successfully.
The most salient prognostic features have proven to be
neither complexity per se nor severity of traumatization.
What appears most critical is the quality of the therapeutic
alliance across the alters. When the alters are willing to work
consistently, treatment proceeds regardless of all other dif-
ficulties.When the patientsprimary gratifications are de-
rived from their being MPD, treatment is problematic. One
patient in this group who left treatment. with me presented
herself to another experienced clinician in the field main-
taining that she had ten times the number of alters that I had
found, and requested free treatment due to the unusual
nature of her case.
OBSERVATIONS ON THE TREATMENT OF
EXTREMELY COMPLEX MPD
The general principles of the treatment of MPD as
outlined elsewhere (Braun, 1986; Kluft, 1987) remain rele-
vant with this more complex subgroup. Some observations
based on clinical experience with these patients that bear
upon their complexity per se may prove useful.
One must be vigilant to focus on the overall human
being and avoid becoming entranced by the panoply of psy-
chopathology. It is difficult to retain equanimity when con-
fronted by materials which by their very nature raise the issue
of their credibility. It is important to avoid making major
decisions about therapeutic strategy before one understands
why the complexity exists and what functions it serves.
Certain interventions are contraindicated on the basis of the
adverse responses of extremely complex MPD patients to
such interventions in their prior psychotherapies: the ex-
pression of fascination, surprise, excitement, dismay, belief,
disbelief, or the voicing of any opinion that could cause the
alters to feel a need to demonstrate their authenticity.
Likewise, the therapist stating that he or she is over-
whelmed or unable to cope with so many alters is counter-
productive.
It is useful to make it clear that the number of alters is not
important; that the critical issues are to understand how
such a number came to be and to make sure that no aspects
of the mind are neglected or lost in the shuffle in the course
of the therapy. I tell the patients that if they are cooperative
across the many alters, the complexity is not a problem. It is
my experience that these patients are exquisitely sensitive to
non-therapeutic interventions; the therapist who tells the
patient that he or she only wants to deal with a few at a time,
or does not want to hear about a newly discovered cohort,
has severely complicated the treatment. The documenta-
tion of alters differences in an intrusive way not related to
evident therapeutic goals is deferred. If these patients come
to feel that they are not being dealt with constructively, crises
in the form or chaos, flight, pseudo-compliance, and self-
destructive acts/suicidal behaviors are likely.
Evenhandedness to the alters must be demonstrated
and demands for sustained attention soothed and con-
fronted rather than gratified. In dealing with patients of this
degree of complexity, it is extremely tempting to accord
53
DISSOCIATION, Vol. I,So. 4: Decemhcr 1988
atten
their
thele
and s
in tr:
emer
thera
(Klu
as th
alters
alters
forw
thera
of hi
exile
famil
other
with
after,
appe.
Rarel
alters
met,
may
team
decid
that t+
and c
terba
left-h .
they
invol
the o
influe
to be
rese
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alters
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a sub
deal
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T
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aware
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this is
alters
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"out"
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0
54
ion and priority to the personalities in proportion to
initial apparent distinctness and importance. None-
s, such a course is fraught with peril, The true function
gnificance of an alter cannot always be assessed early
atment. Often many of the most crucial alters will
e only after the therapy is well established and the
1st is trusted. In extremely complex cases layering
1984a), the emergence of additional groups of alters
rapy addresses the issues raised by the first groups of
that were encountered, may be anticipated. Some
cannot emerge until those that block their coming
d are mollified or integrated. Not unexpectedly, the
fists response to minor alters may be read as indicative
or her overall concern for the patient, who usually
fenced himself or herself as a minor figure in the
of origin. For the reasons noted above and many
, clinical experience dictates that all alters be treated
qual respect and periodically accessed and inquired
even if they have not emerged in session or have not
red to have any interest in the therapy process.
e following rather homely analogy may be useful.
-encountered alters, alters described as insignificant,
described or enumerated but which have not been
nd alters that one can only suspect may be present,
e seen as the members of a football team or baseball
not currently on the field, but who may ultimately
the outcome of the contest. I find it useful to assume
ey are analogous to the team substitutes, specialists,
aching staff. Like field-goal kickers, third-string quar-
ks, bullpen catchers, relief pitchers called in only for
nded power hitters, managers, and batting coaches,
re rarely on the field, infrequently noted, usually
d in playing some role that is in no way apparent to
tside observer, but may abruptly enter the play or
ce it decisively from behind the scenes. Some appear
hose who were so depleted that they enjoy an "injured
" status, or are deliberately held in reserve (red-
). Therefore the wise therapist always is aware of the
ood that when treating an extremely complex case of
interventions are being responded to and assessed by
whose roles and/or whose very existence remain
.These alters may prove to be the dominant forces in
equent portion of the therapy, and will he easier to
ith and less antagonistic if their presence has been
ated and addressed.
e amnestic barriers in extremely complex cases are
to and labyrinthine. It is useful to work toward maxi-
co-consciousness and the sharing of contemporary
ess and memory. I try to persuade as many alters as
le to listen as often as is possible and tolerable. Once
achieved, treatment has an impact far beyond the
stensibly in charge at the time of the session. It is not
mon to find considerable work occurs vicariously on
rt of alters with concerns analogous to those who are
uring the sessions. Virtually all of these patients had
which, when encountered, had rather abbreviated
s of treatment before they integrated because of this
atory vicarious therapy.
ce a good number of alters are known to be listening,
educative asides can be made to all, and comments that
address the concerns of many alters at once can be success-
ful. The personalities become accustomed to the virtues of
co-consciousness and consistent contemporary memory
within the benign environment of the therapist office. In
the course of this process, they usually begin to encourage
one another and support the therapy process.
As a group, these patients are prone to propose numer-
ous wishful plans and compromises which they advance as
ways of furthering their recovery, but which prove to be
evasions, conscious or unwitting, or variants of the flight into
health. It is best to explore such proposals sympathetically,
but to avoid colluding with them.
Unlike the more magical plans that such patients pro-
pose, the alters requests to he treated somewhat differently
with regard to the therapy often are productive. I had several
patients who had alters that reclined on the couch, alters
that sat in a chair, alters that insisted on different hypnotic
procedures, etc. Unless unduly inconvenient, such flexibil-
ity often was rewarded by enhanced cooperation; such
concessions often preempted more drastic demonstrations
of the alters needs to have their differences acknowledged.
It frequently appeared that such token concessions sufficed
to facilitate integration, and, in retrospect, proved to be
rituals of farewell.
These patients are extremely hungry for reassurance,
and request reassurance frequently. It is most useful to avoid
offering false reassurance, and to give encouragement in-
stead.What reassurance is offered should be based upon
specific and tangible evidence. Global statements ofreassur-
ance are most invariably experienced as pleasing lies or
manipulations to "set up" the patient.
These patients are easily startled and upset, and do best
with anticipatory socialization to upcoming work on painful
issues. This "advance warning" may have to be undertaken at
different levels of sophistication for the different groups of
alters. Fearful of surprise, and, as therapy progresses, de-
creasingly able to block out pain, their responses to unantici-
pated dysphoria may include regression, alloplastic behav-
iors, obstructionism, or further splitting. Because of this, if
the nature of the treatment at a given point in time is more
focused on doing particular pieces of work rather than a
more free-flowing process, I tend to anticipate for the pa-
tient the work to be clone in the next session, and to start the
next session with a review of our potential agenda. I deal with
potential objections and reservations, and am candid with
regard to whether the session is likely to be painful. We
either work out how to proceed and do so, or, if we cannot,
move on to explore the resistances and reluctances, or some
other subject that is either more pressing, more accessible,
or more tolerable. This manner of proceeding reduces the
number and frequency of sessions, and of crises.
It is the rule rather than the exception for additional
previously unknown personalities to enter the treatment.
Sometimes this is in the course of getting to know the patient
more completely, and sometimes it reflects the presence of
layering (Kluft, 1984a), in which as alters and conflicts that
kept certain other groups of personalities covered over or
hidden are addressed within the therapy, these other groups
I)1SSOCt1TlfN, Ln1. I. NIL 4: llrccmher 191+8
eit er emerge or become more accessible. Since the discov-
e of additional alters may be anticipated, and almost
in ariably unsettles the patient, it is useful to socialize the
pa ient in advance to the possibility that more alters may be
fo nd and that such events are quite normal and without an
im ct upon prognosis. In addition, since therapy is often
ex.erienced as traumatic, and the patient is someone who
reonded to trauma with the formation of alters, it is not
un sual for new alters to be formed in the course of the
trey tment.
Extremely complex MPD patients frequently rush Io-
wa d fusion prematurely, either to please the therapist or to
ev. de dealing with painful issues in the treatment (often
eit er strong feelings in the transference or the anticipated
pa n of the memories of other alters). Such apparent fusions
fai nearly universally, and must be interpreted as indica-
tio s for more work to be done rather than as proofs of a
pos r prognosis.
Such patients integrate rather slowly and may remain
un table for long periods. It is not rare for further alters to
su face after many years of apparently stable integration.
Ev n the most thorough therapy may leave areas untouched,
an some alters are suppressed with such dedicated and
int icate defenses that their appearance is postponed until
ye. rs of a unified reconfiguration have loosened the forces
th.t bound them so strongly.
Extremely complex cases have several pathways to inte-
gr. Lion, and the several pathways may be encountered in a
sin le patient. It is not uncommon for large numbers of
alt rs with similar concerns to coalesce rapidly, but, unfortu-
na ely, this may happen before their unique memories have
ben recovered and worked through. This may require
expensive uncovering work within the alter that results from
the integration.
Some patients work primarily in the context of a psy-
ch dynamic uncovering therapy. The process of therapy
ge ~s channelled through one or a small number of alters.
Ern sion of the dissociative barriers gradually allows the alters
to now more and more about one another, to empathize
an . identify with one another, and to work on themes in
co mon. Many may fuse at once or in rapid sequence. They
m. fuse into a whole, into other alters, or coalesce. One
pa ient had over 100 alters who worked in this manner for
fo r years and then requested help in integrating com-
pl:tely. They were joined in a single hypnotic procedure.
Other patients work in an obvious sequence, often from
th most recent alters backward, or from the most venerable
fo and in time. Patients who behave in this manner usually
fu - one alter at a time. This is an uncommon pattern in the
m. st complex cases.
Many pursue treatment by working on one incident
aft-r another. If a number of alters were related to a particu-
lar event, they often coalesced together, simply ceased to
ex st, or joined an emerging central alter after the incident
wa. worked through.
The integration of alters who shared a related theme was
qu to common. Those with similar concerns come together,
an . as they do so, it is a curious phenomenon that the patient
of - n begins to appear more classically multiple as the
number of alters is reduced. For example, a patient with over
ten alters who were concerned with themes of sexuality
rarely showed overt signs of concern with sexual themes
until they coalesced into a single powerful alter with sexual
concerns that made her presence felt quite forcefully.
Closely related to the above is a variant found most
commonly in psychodynamic psychotherapy, in which themes
are not pursued in a structured manner, but rather emerge
in the course of therapy, often as the feelings emerge in the
transference. A common outcome is for the alters to remain
separate in a depleted form, and require some more focused
work to achieve fusion. If inquiry is not made, the therapy
remains incomplete and the alters remain, ready to become
active once again should stressors recur.
As more therapists and patients become involved in
mapping the patientssystems of personalities (Braun, 1986),
it becomes more common to encounter patients whose
process of integration has been guided by strategies derived
from the discovery of that mapping effort. No such proce-
dure was employed with the patients in this series, but this
pathway is mentioned for the sake of completeness.
As noted in a previous communication (Kluft, 1986),
complex MPD patients arc more prone to the relapse into
dividedness of apparently integrated alters than are rela-
tively simple cases. This should be anticipated, and efforts
made to educate the patient that such events are no more
than indications of more work to be done.
On occasion, work with the extremely complex MPD
patient requires some departure from the gentle and un-
pressured pace that is customary in work with this condition.
The very complexity itself may serve the function of a
character resistance that effectively precludes psychother-
apy, and require confrontation and firm structuring. Gener-
ally the extremely complex MPD patient spends several
months merely settling into the treatment, and is further
disrupted by being pressured to address painful issues early
in therapy. However, should it become clear that if a preoc-
cupation with the MPD per se or a justification of the
patient particular sensitivities is dominating the sessions, it
may be necessary to explore the defensive functions being
served by such preoccupations, and attempt to move the
treatment forward. This is not to diminish the importance of
careful pacing, but to insist instead on the importance of
dealing with resistance. A substantial majority of this group
of MPD patients perceive that any attempt to deal with
resistances constitutes an attack and a criticism from the
therapist; their expressions of hurt and rejection may come
to dominate the therapy. Of course, this too must be ad-
dressed.
ILLUSTRATIVE VIGNETTES
Case 8. Although she had suffered profound and pro-
longed abuse and had approximately 150 alters, this woman
was ferociously motivated and prepared to be counterpho-
bic to resolve her MPD. She was very pleased that I had not
attempted to deny her MPD and talk her into behaving as if
unified, as had a prior therapist. After she understood what
therapy would require of her, she threw herself into treat-
55
DiSSOCI:1TIO y ,Vol.]. \a. t: lleecmber 1988
ment
ters sp
was se
hypno
such i
years,
was t
integr
with 3
both
tan tly,
and p
occasi
throu
some
necess
tate in
Cr
trade
fined r
with t
was so
that s
douhl
that e
needs.
and, i
denial
integr.
crises
forced
patien
the pa
to coa
attituS
patien
and a
C
of the
ness.
or two
they w
had ni
relativ
force
C
alters
prote
media
quiver
ment
new a
childr
long
ineffe
the in
integr
hypn
hole-heartedly across all alters. Alters fused in clus-
7ntaneously after abreacting traumata. Although she
n only one session per week on the average, and
iswas only used on a few occasions, she worked with
tensity that she achieved integration in under two
nd has sustained integration for over four years. She
ered to follow-up status after two years of post-
[ion therapy.
se 6. Although she was highly motivated, a woman
 alters was mortified by what had befallen her, and
ecovered and shared information slowly and liesi-
with exquisite humiliation and overwhelming shame
in. It required four years of two sessions per week and
nal three-hour sessions to allow her to share and work
h her experiences, and finally to integrate. Although
naterial emerged in dreams, hypnosis was usually
ry both to recover historical materials and to facili-
egration. The treatment was gentle in the extreme.
se 26. Ultrasensitive, pain-phobic, and readily dis-
hy contemporary events, paralyzed by real or imag-
jections, and prone to shed new alters in connection
e pain of therapy, a woman with thousands of alters
incapacitated by somatic and dissociative symptoms
e required extensive hospital care. Seen for two
and two single sessions per week, she complained
en therapy of this intensity was inadequate to her
Her pressure to evade painful material was intense,
her most characteristic alter, she maintained strong
that she had ever been abused down to the last few
tions. Her therapy was characterized by innumerable
nd complications. The inpatient staff and I were
to impose stringent structure in the face of the
smost anguished and persistent protests. Gradually
ient salters began to work on painful materials and
esce along lines of commonalities of experience and
e. All integrations were facilitated by hypnosis. As the
achieved increasing integration she was astonished
palled at her behavior over the course of treatment.
se 7.A woman with 88 alters was so configured that all
hers were very complex and very invested in separate-
he course of the treatment involved working with one
hers and the host until those alters integrated or said
uld integrate when they could join with an alter that
it yet been treated. In essence, each alter was treated
ly independently until it felt it had dealt with all that
ned it and was prepared to yield separateness.
se 21. This highly complex woman with 685 known
had an extremely intricate inner world dedicated to
ting the host from pain. The host either withdrew im-
ely in the face of real or imagined stress or sat
ng, tearful, and ineffectual. After seven years of treat-
he was completely unintegrated, continued to form
ters, was self-mutilative and suicidal, and abused her
n, despite energetic therapeutic efforts and many
ospital stays. Finally the impact of years of apparently
tive treatment began to take hold, and the leaders of
er world and the strongest protectors decided to
= te. In the course of a year, with the use of many
is interventions, all known alters integrated down to
four-the host, a protector, an alter that bore the worst hurt,
and an alter that bore the anger. However, at this point, the
patient felt she could absorb no more, and three new alters
were created to further insulate the host from the pain of
recovered traumata. She currently is attempting to stabilize
at her present level of dividedness, and fighting off further
memories, but the dissociative barriers are reduced in effec-
tiveness, and all remaining alters are chronically flooded
with memories of traumata that they feel unprepared to
address directly in treatment. Her situation is unstable.
DISCUSSION
The above materials offer a description of some aspects
of the presentation, phenomenology, and treatment of
extremely complex MPD. Because the patients about whom
this report is written were those who were studied most
comprehensively, the findings are based on extensive expe-
rience with them. Therefore, the decided advantage of the
wealth of the material in terms of depth must be qualified by
acknowledging that the selection criteria may have gener-
ated findings that may not be applicable to all extremely
complex MPD patients. Patients seen in consultation, unsuc-
cessful treatments of under three yearsduration, or rela-
tively new in treatment may not prove to share the same
characteristics found in this cohort. The requirement of
being able to stay in treatment for three years or more may
screen out certain subgroups of extremely complex MPD
patients. Likewise, three yearsexposure to me and my style
of treatment may introduce some confounding systematic
artifact that contaminates the objectivity of the observations.
It is clear that extremely complex cases are being found by
clinicians of all disciplines and theoretical leanings, and
have been rioted throughout North America and elsewhere.
Many of the findings of this study are self-evident and require
no further elaboration and discussion. However, the issue of
complexity itself raises profound questions about the basic
nature of MPD, and the study of extremely complex cases
offers a useful perspective from which to reconsider this
condition.
Despite Young s (1988) useful corrective observations,
there remains a tendency to conceptualize and describe
MPD with the language of splitting and division. This proves
very problematic in attempts to comprehend extremely
complex MPD. If indeed one sees the mind as a unity that is
torn asunder in MPD, it becomes very challenging to imag-
ine that unity distributed among more than a small number
of alters without straining credulity. How can one grapple
with a "pie" represented as divided in a hundred or a
thousand portions without the metaphor becoming absurd?
This literal-minded approach to the problem of complexity
naturally leaves both sympathizer and skeptic alike in a state
of puzzlement, if not open disbelief.
However, if the language and metaphors of division and
splitting are abandoned, this implicit reification and the
difficulties that spring from it cease to be as vexing. It is clear
that the alters in MPD are not so much polarized opposites,
as was once believed to be the case, as different adaptational
solutions to difficult circumstances, only some of which take
56
DISSOCIATION, 1~ol. I. No. 4: Deceinher 1988
the form of being opposites (Kluft, 1987). The study of
extremely complex cases with large numbers of alters, many
of which have considerable similarities to one another,
emphasizes that the alters are the vehicles of the patient
defensive and adaptational requirements, and the elabora-
tion of their differences is a secondary phenomenon (Kluft,
1935). Alters may have their own relatively enduring pat-
terns of perceiving, relating to, and thinking about the
environment and themselves (American Psychiatric Associa-
tion, 1987), but many alters may have virtually the same
pa_tern, and be quite autonomous despite their similarity.
One of the most efficient, effective, and difficult to detect
ways of encapsulating the impact of trauma is to form
isomorphic MPD (Kluft, in press); i.e., to form a virtual
double of one self as an alter. Such instances, found aplenty
in extremely complex MPD, challenge the splitting and
division paradigms and metaphors for the creation of alters,
which are fragile vessels at best (Young, 1988). They suggest
instead that the mind, rather than dividing itself, rather
multiplies itself, recopies itself selectively, or rearranges a
finite number of elements in patterns of great potential
variety. It is the relatively consistent discontinuity, the rela-
tively persistent dissociation of these copies and reconfigu-
rations along the dimensions of memory and identity, that
leads to the ongoing disaggregation of self states, which
characterizes disaggregate self state disorder, i.e., multiple
personality disorder.
If one understands the process of alter formation as one
of defense reduplication and/or reconfiguration rather
than division, the problem of wondering how the mind
becomes divided into such complexity ceases to be relevant.
The alters become different patterns of whole and/or par-
tial copying and/or reconfiguring, which, when activated,
may be more or less similar to one another, and inevitably
will have a lot in common. This is more consistent with
Putnam unpublished findings on order effect than is the
notion that the alters are discrete portions of some primal
unity, and that any overlaps among them challenge the
reality of the diagnosis of MPD (one of the " capricious
criteria" [Kluft, 1988] ). This line of reasoning may appear
novel, but was in fact implicit in the work of Az.anr (1887). It.
is also consistent with I.ifton (1986) study of the process of
doubling in adult adaptation to situations of extreme stress
and conflict.
Another potential benefit of the reduplication/recon-
figuration model is to avoid the use of a language that
implicitly links the phenomena ofMPD with those of border-
line personality disorder. Much unnecessary conceptual
and clinical confusion has been generated by the utilization
for MPD of terms that are so strongly associated with border-
line personality disorder that they suggest an unnecessary
and inaccurate connection between these two conditions,
although they have been demonstrated to be discrete, al-
though often coexisting, psychopathologies (Horevitz Rc
Braun, 1984).
Perhaps the phenomenologic findings across extremely
complex MPD patients and the fact that many of them are
anomalous with regard to the paradigms of dividedness and
splitting are indicators that these paradigms, however useful
they have been, have exhausted their potential as heuristics
for the study of MPD. If this proves to he the case, an
important aspect of the study of MPD may be ready to
undergo a revolution or paradigm shift (Kuhn, 1970). 
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