MULTIPLE
PERSONALITY
DISORDER AND
THE SOCIAL
SYSTEMS:
185 CASES
Margo Rivera, Ph.D.
Margo Rivera, Ph.D., is Director of Education/Dissociation,
The Muskoka Meeting Place for Counseling and Education,
Gravenhurst, Ontario, Canada.
For reprin ts write Margo Rivera, Ph.D., The Muskoka Meeting
Place for Counselling and Education, Box 2242, Graven hurst,
Ontario, POC IGO, Canada.
This article is based on a paper presented at the Seventh
Annual International Conference on Multiple Per-
sonality/Dissociative States, Chicago, November 10, 1990.
ABSTRACT
A survey of 185 individuals in treatment for multiple personality
disorder regarding their involvement with the mental health and
social service systems documents the high level of social resources
these individuals use as a result of their post-traumatic symptoma-
lology. The data point to the cost effectiveness of accurate diagnosis
and effective treatment of multiple personality disorder.
INTRODUCTION
In the last fifteen years sincethe second edition of the
Comprehensive Textbook of Psychiatry (Freedman, Kaplan, 
Sadock, 1975) declared incest to occur in one person in a
million in the general population, there has been growing
knowledge about the high incidence of child sexual abuse
in North America (Rush, 1980; Badglev, 1984; Finklehor,
1984; Russell, 1986). During the same time period, clini-
cians have become increasingly aware of the use of dissoci-
ation as a defence by a great many victims of severe child
abuse (Putnam, 1985; Putnam, Guroff, Silberman, Barhan,
Post, 1986), and there has been an exponential increase
in suspected incidence of multiple personality disorder. In
the 1950s, Chris Sizemore ("Eve" of The Three Pares of Eve
[Thigpen Cleckley, 1953]) was said to be the only case of
multiple personality in the world. In the mid-1980s, Coons
(1985, 1986) estimated that " a minimum of six thousand
cases of multiple personality may be occurring nationwide."
Recently, researchers conducting the first systematic inci-
dence studies of dissociation and multiple personality dis-
order found that one in one hundred people in the gener-
al population endorse the symptoms of multiple personality
disorder as defined by the D.SAI III-H, and in certain clinical
populations such as incest sunivors, substance abusers, and
psychiatric inpatients, the incidence is much higher (Ross,
1 991).
As increasing numbers ofclinicians treat individualswith
MPD, a large body of oral testimony has developed about
the positive prognosis that a great many of these individu-
als have for complete cure, or at least substantial alleviation
of their debilitating symptomatology, when they receive appro-
priate treatment. The literature documents many case stud-
ies and some preliminary outcome data (Kluft, 1986b) that
confirm the widespread clinical impression that MPD is the
most severe psychiatric condition with a highly posifive prog-
nosis if appropriate treatment is available, undertaken, and
completed.
Individuals who suffer from multiple personality disor-
der usually exhibit a wide array of symptomatology that per-
meates their past and their present life. Suicidal depression,
severe somatic complaints, amnesia, self mutilation, passive-
influence phenomena, fugue episodes, unstable personal
relationships, sleep disturbances, nigh tm~u es, flashbacks, sex-
ual difficulties, intense dysphoria, and dramatic swings in
affect and behavior are among the many symptomsof this
post-traumatic condition (Putnam, 1989; Ross, 1989b).
Though some individuals with multiple personality disor-
der are consistently high-functioning (Kluft, I986a), a more
common pattern is inconsistent orconsistentlycompromised
personal, social, and professional competence. Their symp-
tomatology leads many individuals with multiple personali-
ty disorder to seek help from the mental health system, and
they usually share a long psychiatric history (average of 6.8
years) (Putnam, et al., 1986; Ross, 1989a; Rivera, 1991) of
multiple diagnoses and non-responsiveness to the usual treat-
ment for these diagnoses before they are eventually accu-
rately diagnosed as suffering from multiple personality dis-
order.
There is also general agreement in the literature that
the appropriate treatment for MPh is a regimen of intensive
psychotherapy (Braun, 1986; Putnam, 1989; Ross, 1989a).
The main work of the therapy is the strategic uncovering
and reworkingof the history of experiences of trauma. When
the traumas (which are sequestered in disaggregate self states
called alter personalities [Kluft, 1988]) are remembered,
abreacted, and cognitively reprocessed, the defensive dis-
sociative barriers between the states are gradually eroded.
The result is the development of a continuity of conscious-
ness and new, non-dissociative coping skills. This positive
outcome is referred to as personality unification, fusion or
integration. The process involves commitment by the indi-
vidual with multiple personality disorder to a rigorous and
79
DISSOCIATION. Vol. IV, No. 2, June 1991
MPD AND THE SOCIAL SYSTEMS: 185 CASES
often painful treatment which is almost always long-term,
encompassing three to five years (Putnam, 1989) or more
of therapy.
This increase of awareness about both the prevalence
of child abuse and severe dissociative disorders, including
multiple personality disorder, and the responsiveness of dis-
sociative conditions to appropriate treatment, raise critical
social policy issues. One of the most basic of these is the cost
of treating this condition.
In a time of recession, as both the public and private
sectors attempt to exercise fiscal restraint, how are the health
care systems to respond to reports of a disorder that demands
intensive and necessarily costly treatment? Though stories
of individuals suffering from severe, debilitating, and often
life-long symptomatology being completely healed, with the
consequent increased level of psychological and social func-
tioning, are heartening and sometimes inspiring, do we, as
a society, have the resources to offer treatment to a wide
cross-section of the population suffering from multiple per-
sonality disorder? Is treating MPD cost-effective?
A study, conducted by Education/Dissociation (a com-
munity education program funded by Health and Welfare
Canada) , offers data to address this important question. This
study involved 185 individuals in treatment for multiple per-
sonality disorder with a variety of mental health and social
service systems before they were accurately diagnosed and
appropriately treated. The results of the study indicate that
it is much more expensive not to treat individuals with mul-
tiple personality disorder effectively than it is to treat them.
METHODS
Seven hundred (700) questionnaires were distributed
at a conference held in Toronto, Ontario, for professional
training in treatment of multiple personality disorder and
dissociation. They elicited information about the childhood
abuse history of individuals in treatment for MPD and their
past and present involvement with mental health and social
services systems. In addition to a variety of workshops for
the professional development of service providers, an edu-
cational forum for individuals suffering from multiple per-
sonality disorder was facilitated during the conference.
Questionnaires were included in all conference packets, with
instructions that they could be completed by practitioners
treating individuals with multiple personality disorder or by
individuals with NiPD themselves.
One hundred and eighty-five (185) questionnaires were
returned with complete data. Seventy-five (75) individuals
in treatment for multiple personality disorder attended the
educational forum; 72% (n=54) returned completed ques-
tionnaires. Of the 625 professionals registered for the con-
ference, 282 indicated on their registration forms that they
had seen, assessed or treated an individual with MPI) in a
professional setting. Forty-seven (47%) percent (n=131) of
the registrants who were aware of having had professional
contact with an individual suffering from MPD returned com-
pleted questionnaires. Some of these professionals had client
contact that was minimal and therefore were clearly not privy
80
to the detailed information that would enable them to fill
out the questionnaire. Therefore the exact return rate for
qualified professional recipients cannot be determined.
Professionals in the following disciplines returned completed
questionnaires: social workers (35%); psychologists (22%);
and medical doctors-mainly psychiatrists (21%). The
remaining 22% represented a variety of disciplines, includ-
ing nurses and pastoral counselors.
There were no significant differences in any area between
the data from therapists about their clients and the data
from individuals with multiple personallity disorder about
their own histories, an interesting finding in itself.
FINDINGS
Ninety-two percent were female (average age 33.5 years);
8% were male (average age 28 years). Eighty-nine percent
experienced physical abuse in childhood; 98% sexual abuse;
most experienced both physical and sexual abuse.
Thirty-six percent disclosed their abuse in childhood.
Disclosures were made to parents (48% of the 36%), child
welfare agencies (38%), police (18%), a teacher (15%), a
friend/neighbor (12%), pastor (9%), doctor (6%). In 77%
of the cases in which abuse was disclosed, no protective action
was taken, and the most common reactions were (1) being
called a liar, (2) being beaten, and (3) being disbelieved.
Eighteen percent of the children who disclosed abuse were
removed from their homes. In one case, the abuser was jailed,
and in another case, the abuse stopped although both the
victim and the abuser remained at home together.
Of the entire sample (185), 19% were involved with the
child welfare system as children, and 15% as adults regard-
ing their own children. Fifty-seven percent of the entire sam-
ple had problems with drug abuse. Of those who abused
drugs, 33% reported abusing both prescription and illegal
drugs. Twenty-eight percent used prescription drugs only,
and 39% illegal drugs only. Fifty percent of the sample abused
alcohol. Twelve percent had a criminal record. Fifty-five per-
cent had been on social assistance due to their inability to
work consistently because of their dissociative symptoma-
tolo v.
Eleven percent had never been in treatment before receiv-
ing the diagnosis of multiple personality disorder. The involve-
ment of the remaining 89% with the mental health system
was extensive, with an average of6.8years ofpsychiatric inter-
vention before the diagnosis of multiple personality disor-
der and the commencement of effective treatment. Seventy-
three percent had received diagnoses that they were able to
list for the study. They received an average of three diag-
noses each, and a total of forty-six different diagnoses were
reported altogether, most frequently, Depression (46%),
Borderline Personality Disorder (37%), and Schizophrenia
(33%). They were hospitalized for psychiatric symptoms an
average of four times each (see Table 1).
DISCUSSION
Two studies, one completed at the Royal Ottawa Hospital
DISSOCIATION, Vol.
(Fraser & Raines, 1990), and the other at St. Boniface Hospital
in Winnipeg (Ross & Dua, in press) documented the life-
time psychiatric health care costs for two small cohorts of
patients eventually treated for multiple personality disorder.
Their findings are most relevant in connection with the high
use of social resources documented in this survey. Both stud-
ies found that millions of dollars had been spent by the men-
tal health systems on ineffective and counterproductive treat-
ment and hospital care before diagnosis. Both studies also
found that while, in some cases, the treatment costs increased
for a time after the commencement of intensive psy-
chotherapy for MPD, a significant cost saving was effected in
a very short time, and those who completed treatment left
the mental health system for the first time in their lives (Fraser
& Raines, 1990; Ross & Dua, in press).
These two studies documented the psychiatric health
care costs of undiagnosed, untreated multiple personality
disorder. Add to these the cost of drug and alcohol abuse
treatment, social assistance payments to individuals unable
to work consistently prior to the completion of appropriate
treatment, child welfare and legal justice costs documented
by the Education/Dissociation study "Multiple Personality
and the Social Systems," and it becomes clear just how expen-
sive it is to allow thousands of individuals with histories of
prolonged childhood abuse and severe dissociative symp-
tomatology to go undiagnosed and untreated.
These are only the financial costs, the tax dollars squan-
dered. The personal suffering and the waste of human poten-
tial that is represented by each individual who remains untreat-
ed for many years because mental health and social service
personnel are not trained to recognize their problem is incal-
ports and services that they must utilize as a direct outcome
of their condition. 
REFERENCES
Badgley, R. (1984). Ottawa, Ontario:
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culable. There is no doubt
that both psychothera-
peutic treatment forindi-
vidualswith multiple per-
sonality disorder and
training for profession-
als in the health, mental
health, social service and
education systems so that
they can recognize and
treat severe dissociative
disorders are exception-
ally cost-effective.
In summary, individ-
uals who suffer from MPD
as a result of a childhood
history of trauma use high
levels of social resources
as a result of their post-
traumatic syrnptomatol-
ogy. Though providing
them with effective treat-
ment is expensive, it is a
great deal less costly than
continuing to allow them
to remain undiagnosed
and untreated and paying
for all of the social sup -
TABLE 1
Involvement in Social Systems
Social Assistance/Welfare 55%
Child Welfare
19%
  As adult 15%
Criminal Record 12%
Mental Health System
57%  Drug Abuse
* Alcohol Abuse 50%o
  Previous Psychiatric Treatment 89%
Additional findings:
Average of Four Psychiatric Hospitalizations Each
Average of 6.8 Years in Treatment Before Accurate Diagnosis
Average of Three Previous Diagnoses Each
Most Common Diagnoses: Depression
Borderline Personality Disorder
Schizophrenia
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DISSOCIATION, Vol. IV. No.
MPD AND THE SOCIAL SYSTEMS: 185 CASES
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