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MPD and DID are Two Different Post-Traumatic Disorders Ralph B. Allison, M.D., Calif. Men's Colony State Prison, San Luis Obispo, CA c 1995 Ralph Allison ABSTRACT With the advent of DSM-IV, Multiple Personality Disorder (MPD) was renamed Dissociative Identity Disorder (DID). This assumes that there is only one condition to be named. Clinical experience reveals that there are at least two dissociative disorders commonly seen in practice, and it is proposed that both of these labels can be used, but for different subgroups of the dissociative patient population. The key item of differentiation is the age when the patient first suffered sufficient trauma to dissociate. If the first dissociation was before the age of seven, a condition that should be called MPD will be created. If the first dissociation occurred after the seventh birthday, a condition that should be called DID will be created. Each of these post-traumatic disorders is differentiated from the other by at least 15 factors, including the presence or absence of the Inner Self Helper, and the effective treatment plan. INTRODUCTION During the debate of the Committee on the Dissociative Disorders for the creation of DSM-IV, the condition then known as Multiple Personality Disorder (MPD) was renamed Dissociative Identity Disorder (DID). I was not a part of that debate, but I understand from those who were that there were two polarized groups composing the committee. One group were the therapists of multiples, and the other group characterized themselves as experts on hypnosis. The experts on hypnosis favored DID and won this battle. The experts on therapy felt beaten in this battle, as their "favorite disease" was abolished, as the name had great symbolism for both them and their patients. In this paper, I would like to attempt to restore a sense of balance between these two forces. In my opinion, no one can be a true expert on the treatment of multiplicity without being an expert in the use of hypnotic techniques in treatment of dissociators. Since dissociators are usually highly hypnotizable individuals, an education in the proper, ethical use of hypnotic methods is essential knowledge for these therapists. Therefore, as a result of seeing many multiples in many settings, and from using hypnotic techniques in therapy ever since I was first trained by Jay Haley during my residency at Stanford, I have come to the conclusion that both diagnostic labels can be used, because they can properly apply to two subgroups of patients I will call multiples. When first outlining the differences that can be identified between these two groups, I found 15 points on which they differed. Nowhere in medicine is it logical to consider two patient groups to be suffering from such disparate conditions to have the same diagnosis. Therefore, in the interest of "fine tuning" our diagnostic, and therefore our treatment, criteria, I suggest that MPD be applied one subgroup of multiples and DID to another equally important, but quite different, group of patients. ETIOLOGY MPD should be reserved for those dissociators who suffer their first major psycho-sexual- physical assault before their seventh birthday. DID should be reserved for those who suffer the first assault to which they respond by a defensive dissociative process after their seventh birthday. Child development specialists have long considered that it takes an average of seven years for any child to develop the personality that will be theirs for life. The personality of a child less than seven is too fragile to absorb life threatening trauma without reacting in some fashion. Obviously not all children react to early trauma by dissociating, but those who do develop psychological entities which are different than those created at an older age. Obviously, I am not pointing to the seventh birthday as a magic moment when all is solid, and the moment before all was liquid. The trauma to the younger child usually has occurred first at a much younger age, since it most likely will have occurred in the parental home setting. Therefore it is not uncommon to find severe abuse by parental figures from infancy on. However, if the patient came from a reasonably healthy family and then went out into the cruel world around him/her, that usually happened after the age of seven. Then the abuse most likely was caused by some member of the extended family or someone in the community. When the first abuse that caused dissociation happened at the age of eight because of a rape by a cousin, then the results are far different than if the rape was committed by the father or stepfather at the age of three. In the case of the younger set of victims of assault, they need to defend themselves from further abuse by these primary caretakers. Since they cannot have Basic Trust in their parental caretakers, they must ensure their physical survival by mental means. Those who are older when assaulted already have developed Basic Trust in their core family members, and they then have a need to protect themselves from others outside the core family. They feel too immature or untrained to defend themselves with physical means, so they resort to making defenders of their bodies within their minds. Therefore, MPD should be used for those who suffer the first major assault which causes a dissociative response before the seventh birthday. DID should be used for those who experience dissociation following the first major assault after the seventh birthday. MPD multiples will have been abused in the parental home. DID multiples will have been abused either in the home, school, or community. MPD multiples need to dissociate to ensure their physical survival after assault by a primary caretaker. DID multiples dissociate to defend themselves from further assault by those who are endangering their present welfare. They do not know how to do it with coping methods which must be learned from more experienced persons. CLINICAL PRESENTATION OF SYMPTOMS In the younger group, which I call MPD multiples, the first entity to dissociate from the Birth Personality (BP) is the Inner Self Helper (ISH). The "Mind" that is left I shall call the Original Personality (OP). The ISH is then the creator of all subsequent alter-personalities, no matter what type. The ISH creates them to assure the physical survival of the child, who is known to the ISH as his/her "charge." Prior to this first dissociation, that which becomes the ISH has been the "charge's" source of inspiration, the "still small voice within" which I prefer to call the Essence of the patient. The ISH role is only a temporary "job assignment" for the Essence, which desires to return to an original state of unity within the multiple's mind. Within the DID multiple's mind, (with the BP intact), the first assault will create a defensive alter-personality. The mind is mature and strong enough not to need the Essence to dissociate and take on the role of ISH. Therefore, no ISH exists, and the only dissociative entities are alter-personalities which have been developed in response to the particular type of abuse that the person suffered. If it is sexual abuse, i.e. a rape, then the alter-personality will be sexualized and may become a prostitute, using aggressive sexual behavior to control and degrade men. If no more assaults occur, there may be no more alter-personalities created. This would then result in someone with only a Dual Personality, one "normal" and one socially deviant. In the case of the MPD multiple, the second dissociated entity to form would be a False-Front alter-personality. This must be created by the ISH to replace the (OP) which has been deemed by the ISH to be too inadequate to stay in social control of the body. This first False-Front is designed and manufactured by the ISH to present an image to the abusive parent which will assure its survival. It may be made completely compliant, cooperative without crying, and able to absorb abuse without responding angrily. This will be the child the abusive parent can continue to abuse without any adverse reactions being created. In the case of the DID multiple, the next alter-personality developed will be unique to the next traumatic situation. If there are no more traumas suffered, there will be no more alter-personalities created. If the first trauma was a rape, with a prostitute being created. If the second is a physical assault by boys, then the second one might be a tough masculine protective alter-personality. The OP of the MPD multiple will disappear from any social control of the body with the creation, by the ISH, of the first False-Front alter-personality. The OP will be hidden in a deep recess of the mind, where it will be kept safe from further assault. It will also be kept protected from any social training by live human beings, until it reappears in the safety of an ethical therapist's office. Then the OP must start growing again, taking up where s/he left off. Thus, the patient who comes in for therapy as an adult is not the OP. It is the latest of a long series of False-Front alter-personalities. It is the one designed by the ISH to deliver the body for therapy, and take the body out the door at the end of the session. Unfortunately for the naive therapist, no False-Front alter-personality can grow and mature with verbal therapy. They are programmed to be what they are, which is usually a whimpy, depressed, suicide-prone whiner. The BP of the DID multiple will be in charge of the body at all times, except when certain emotions trigger off the appearance an alter-personality. Therefore, s/he who comes in for therapy can grow and learn with verbal therapy. The BP can make constructive changes if provided with the proper tools and incentives. Whereas the DID multiple will have few alter-personalities, the MPD multiple must create a large number over the years of "growing up." After the first False-Front alter-personality has been created by the ISH, if the abuse continues, anger-energy builds up inside the child. Since the False-Front has been specifically created not to process anger, it has to go somewhere. The ISH then has to create a Persecutor alter-personality to hold and express the anger. This one will inevitably come out and attack a sibling, for example, which will create the need for a counter-balancing alter-personality. The ISH then has to create a Rescuer alter-personality. As the child grows in chronological age, each False-Front alter-personality becomes obsolete and must be replaced by another one which is designed to cope with the new responsibilities of the next year(s) of life. In addition to these inevitable alter-personalities, the specific bad home life may make necessary some disabled alter-personalities, such as deaf ones who cannot hear the parental arguing. There may also be those who identify with important persons in the neighborhood or school, and these will be modeled on significant characteristics of these other children. The MPD multiple can make up to 60 legitimate alter-personalities of all types. Beyond that, one should doubt the reality of the other "creatures" seen as being true alter-personalities since the ISH will likely have run out of personality characteristics to use in new alter-personalities. THERAPY ISSUES Since only a live patient can benefit from psychotherapy, suicide prevention is a must for these patients. The DID multiple will rarely attempt suicide, since the BP is usually functioning well in a number of social arenas, such as home and work. These patients will make their suicide attempts when the alter-personality has put them in jail, or another such embarrassing situation. It is when they feel helpless and hopeless, not knowing why they are in such predicaments, that they make their suicide attempts. It is at that point, of course, that they are also most amenable to entering into meaningful therapy. The MPD multiple, on the other hand, will have a history of numerous suicidal attempts, often under bizarre conditions, and frequent rescues from death. This is because the False-Front alter-personalities have run out of programs to use solve normal problems, and they view suicide as the only way out. The ISH has to rescue them, so s/he calls for help, and the body ends up in the hospital ER again, followed by a 72 hour hold on the psychiatric ward. There the Rescuer alter-personality convinces the psychiatric resident that the suicide attempt was just a misunderstanding with her boyfriend, and it will not happen again. Unless the MPD multiple is in serious therapy with an ethical therapist who uses this incident to do effective therapy, the patient will be discharged, only to return a month later with a similar story. The therapy plan for the DID multiple must be individualized, depending on the nature of the few alter-personalities. The basis principle is that the BP must learn adult coping methods to deal with the problem that each alter-personality was designed to solve. Unfortunately, the methods used by the alter-personalities are usually ineffective over the long haul, and training in assertiveness, and other such complex socially responsible behavior is required. What is needed is for the BP to become able to cope with similar problems in the proper fashion for the society in which the person is living. That will cause the alter-personality to become obsolete. When that happens, it might disintegrate of its own accord, since, without a purpose, it cannot exist. However, for the MPD multiple, a more complex and structured therapy plan is needed. The basic steps were outlined in 1980 in Minds In Many Pieces as follows: 1. Recognition of the existence of the alter-personalities. 2. Intellectual acceptance of this condition. 3. Coordination of alter-personalities. 4. Emotional acceptance of multiplicity. 5. Neutralization of persecutors. 6. Psychological integration. 7. Post-fusion experiences. 8. Spiritual integration. Whereas in the DID multiple, there is no ISH to work with the therapist, in the MPD multiple, the ISH is an essential co-therapist who is always waiting inside to be invited to participate in reconstructive therapy. Therapy must be guided by the therapist and ISH, not by the patient. S/he will be running away from the pain of effective therapy and will be creating numerous crises to divert the therapist from dealing with her intrapsychic issues. A clear plan of action must be followed by the therapist, who can be guided by the ISH, who knows which issues and alter-personalities need to be addressed in what order. The ISH can also give the therapist feedback so that mistakes can be quickly corrected. The methods of treating the DID multiple can be multiple, including hypnotic visualizations as needed, assertiveness training, job training and supportive psychotherapy. However, in the case of the MPD multiple, those methods are inadequate. A major goal is for the therapist to bring forth the OP, who is the patient who needs to be rehabilitated. That requires extensive use of many hypnotic techniques, and the regular use of age-regression sessions. Each Persecutor alter-personality needs to be evaluated and understood, which can only be done effectively in the context of hypnotic age-regression sessions. In those sessions, the assault/conflict situation which preceded the creation of that particular alter-personality must be identified. Then the misunderstandings the child developed and the emotional reactions s/he had are explored and resolved. To do that effectively takes four basic steps as follows: 1. Abreaction 2. Reframing 3. Acceptance 4. Discharge How to do this is described in the manual for the course on Working With the Inner Self Helper (ISH) During and After Therapy, given at this meeting. These steps must be followed, without fail, in dealing with each Persecutor alter-personality. This will bring about the Neutralization of each Persecutor, and thereby the obsolescence of the associated Rescuer alter-personalities. This must be done for all Persecutor alter-personalities before the ISH will deem it safe for her to bring out the OP, who then must assimilate all of these parts into herself. That is what constitutes Psychological Integration. The final Spiritual Integration of the OP and the ISH will occur sometime after formal psychotherapy has been completed. That requires that the integrated OP be exposed to many real life situations, so that s/he can learn how to cope with them in a socially constructive fashion. When the ISH considers his/her "charge" to have passed these "tests of the School of Hard Knocks," s/he will then blend in with the OP, accomplishing the final goal of Spiritual Integration into the Birth Personality. THERAPY WHILE INCARCERATED Since I have worked part of my career in jails and prisons, and have seen a number of alleged multiples faced with serious criminal charges, I have been able to arrive at some tentative conclusions about the wisdom and reasonableness of treating either kind of case while the person is incarcerated. This includes the forensic psychiatric hospital as well as a prison where rehabilitation services are added to the custodial operations. Before I discuss that issue, I must make one caveat regarding the finding of either of these diagnoses, MPD or DID, in the severely criminal subgroup of our society. I am excluding from consideration here the issue of malingering, and will assume that the clinical picture shown by the defendant in jail or the inmate in prison is not fabricated for the purpose of a defense. In the case of the MPD multiple, once the Essence has taken on the role of ISH, it is committed to the welfare of its charge, and it is operating under the highest ethical standards. It cannot condone the killing of its charge by anyone. It also will not allow its charge to fatally harm anyone else. It cannot prohibit an angry alter-personality from striking out in self-defense against an attacker. But, once its charge's physical safety is assure, the ISH can block all physical action that would lead to the death of the attacker. These patients, therefore, would not be likely to murder someone, especially a stranger who was not attacking them at the time. So, in those cases where the subject of forensic evaluation is an alleged MPD multiple, with early child abuse history before the age of seven, it is not likely that this person would commit "cold-blooded" murder. I have not even seen any who are guilty of killing in self-defense, since the ISH has ways of getting away from the scene of harm once personal safety is secured. The ISH will not allow revenge to take place, if that will cause death of someone else. They just will not be allowed to do that by those entities supervising them. In the case of the DID multiple, the alter-personality is made for self-defense by the non-dissociated Essence, not for planned offense against others. It may play a role in street gangs, but to plan an execution of anyone else would be quite against its reason for existence. Survival is the reason for its existence, and killing "in cold blood" is not a tool for survival. Therefore, in those cases where what appear to be hostile alter-personalities who have allegedly killed a stranger "in cold blood," I recommend that neither MPD nor DID be used as an diagnosis. These individuals have more likely created revengeful "imaginary playmates" from their imaginations, and this process can occur before or after age seven with equal ease. In the cases I have evaluated, these Imaginary Malignant Playmates (IMPs) have been made by the defendant when he knew of violent harm being done to members of his family, members he should have but could not protect. In his distress at being unable to protect them, he sought a means of revenge against this abuser of a helpless family member. He made up this IMP out of his personal imagination, to use as a tool of revenge, not self-protection. The reason we see him in court is that he has used this IMP as a tool of destruction against some stranger in the community, usually doing unto them what the original villain did unto the beloved relatives he could not protect at the time. This type of individual I cannot and will not include in the MPD or DID categories. He is, more properly, Whoever Has an Imaginary Malignant Playmate (WHIMP). I called these the Maybe Multiples in Courts and Corrections in 1987, but WHIMP seems accurately descriptive. They are too cowardly to face the attacker of childhood themselves, so they make a hitman in the form of an IMP, and let it do the dirty deeds they dare not do. They are very confusing since they are only seen in the forensic setting, where the expert witness are wondering first whether they are real or the products of malingering. We need to be very careful not to confuse these WHIMPs with their IMPs with the other two types of multiples already described. But, on the issue of whether or not to recommend treatment in an incarceration setting for the DID or MPD multiples, my opinion is mixed. The MPD multiples would be too fragile to survive the demands of any prison, no matter how progressive, without further disintegration. Also, with the bureaucratic organization of the treatment staff, is would be highly unlikely that a single competent, ethical therapist in an institution would be able to allot the time and continuity of care to such a person. It would seem impossible to treat an MPD multiple in a prison or jail setting. I would also find it difficult to envision how any forensic psychiatric hospital could do any better, since it must operate under very strict rules at all times. Any therapist and ISH of an MPD multiple will be constantly denied the means to meet the special needs of the therapy which will inevitably occur. They are best treated on an out-patient basis in a community setting, where the full array of opportunities exist. Only there can the community resources be used effectively when needed in the total therapy plan. On the other hand, it is reasonable to expect to be able to treat the DID multiple in either a prison or forensic hospital setting. These places operate on a social learning, behavioral modification model, and that is just what most of these patients need. They need to learn how to behave in a socially constructive and appropriate way, instead of splitting off another "self" to do what they don't know how to do. They need the social, education, and communication skills that such institutions provide to all their clients. The therapist provides the role of coordinator, referrer, and stimulator of the use of these institutional services. These functions can be well managed by most of the treatment staff members of any well run such institution. CONCLUSIONS The dissociative defense mechanisms which some abused individuals utilize for their own personal protection create a different clinical picture depending on the age of the individual being abused. Therefore, it seems reasonable to separate these patients into at least two groups. The term MPD should be used for those severely abused before the age of seven, as they develop a different and much more complex set of clinical symptoms than do the patients abused at a later age. The Original Personality is not operating socially and therefore cannot have an Identity Disorder. In truth, the ISH has created Multiple Personalities. The term DID can be reasonably applied to those who first use the dissociative defense mechanism after their seventh birthday. They then develop alter-personalities of a different type because they have different needs to fulfill. The Birth Personality then does indeed have an Identity Disorder. Neither one of these labels should be applied to criminal defendants who have clearly killed "in cold blood" in a fashion similar to the way someone else attacked their relatives, but not themselves. These persons are not likely to have created alter-personalities of the same type as those created by the two groups described here. Recognizing the existence of these subgroups is essential if we are to provide adequate, ethical and responsible management and therapy to any of them. Much of the confusion in the past decade has resulted from mixing these two groups, MPD and DID, into one pool and then applying the same diagnostic and therapeutic principles to all of them. This is not reasonable in any field of medical practice, and it is no more reasonable in the practice of treatment of those patients of ours who suffer from dissociative disorders. 



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