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Ralph B. Allison: A RATIONAL PSYCHOTHERAPY PLAN FOR MULTIPLICITY Delta „r den tredje och sista artikeln om multipla personligheter. Tidigare artiklar har varit inf”rda i nr 6/77 (When the Psychic Glue Dissolves) och nr 2/78 (On Discovering Multiplicity). V„sentliga delar av den behandlingsplan som beskrivs nedan har anv„nts av andra terapeuter med gott resultat. F”r de som f”rs”ker hj„lpa patienter med multipla personligheter, f”rest†s denna behandlingsplan som en allm„n, men bell logisk, skissering av de faser som m†ste upptr„da f”r att den naturliga helande processen ska fortg† hos en patient med multipla personligheter. The severe mental disorder in which individuals cope with life's problems by splitting off a portion of their consciousness, thus creating several different alter-personalities, has been approached in different ways by those therapists who have written of their work. However, since most case reports in the literature are concerning the first such patient the author ever treated, the treatment methods were naturally based on their prior training and experiences with non-dissociated patients. Only one article given broad guidelines for therapists, and yet those authors focus mainly on what to avoid doing (Bowers, et al. 1971), Between the years 1972 and 1978, the author personally treated 36 patients with multiplicity, the condition which allows one to make alter-personalities. He was the primary therapist for all patients. Twenty-four, or 2/3, were brought to the desired goal of total personality fusion or integration. The other 12, or 1/3, dropped out of treatment, left the area, or died. During the years I was working with these patients, it became evident that any patient's successful treatment plan had to include certain basic ingredients which I will outline below. For the purposes of literary clarity, I will refer to patients In the feminine gender, since 85% of my patients were women. The few men treated had all been involved in serious legal problems, several having spent decades in various prisons. From their stories, one can speculate that many more male multiples find their way to prison than to private psychiatrists' offices. They are there in greater numbers than 15% suggests, but one would have to do case finding in courts, jails and prisons to find them. TYPES OF ALTER-PERSONALITIES. Before outlining the therapy plan, it is necessary to understand the nature of the several types of alter-personalities, or ego states, which may be manifested when active treatment with hypnotic techniques is undertaken. The most common reason for such a patient coming to treatment is because of the behavior of a very negative hostile personality, the "Persecutor." This one was created at an early age when the patient, as a young child, became angry at a beloved parental figure who did something to hurt her mentally or physically. The child could not accept the responsibility of having such anger and repressed it, creating a nucleus for a hostile alter-personality. Subsequent episodes generated more anger, which was again repressed, until the complex of angry feelings and paranoid attitudes became sufficiently empowered and dissociated from the rest of the unconscious mind that it could come out, control the body and express the child's anger. This often occurred with amnesia for the event on the part of the original personality, or ego. Then the child was chastised and punished for being so naughty. Since the child remembered nothing about the incident, she became angry at the "unfair" accusations and fed the energy supply of the Persecutor even more. Thus a vicious cycle was established which was continued into adulthood. Most commonly the next emotion to be repressed and dissociated is the erotic sexual drive, mixed with anger from a child molestation or rape. This is likely to create a hostile seducer who, in the case of a woman. uses sexual seductiveness as a tool for controlling and degrading men, just as the girl-child was controlled and degraded by the mate seducer, an example of identification with the aggressor. This Persecutor mixes sex with anger and sexualizes all relationships she has, but never in a loving way. When two such Persecutors have been created, the control mechanism is now out of balance, since the original personality, the one the patient was born with, is now outnumbered. Therefore, a "Rescuer" alter-personality must be created, often from an imaginary playmate. This one may also express righteous indignation toward exploiters of the patient, but not the murderous rage of the Persecutor. The Rescuer may be a smooth talker to get the patient out of legal difficulties and may take control of the body to prevent suicide or homicide which a Persecutor is about to commit. There may or may not be amnesia for the Rescuer's actions, as there is nothing emotionally objectionable requiring repression. The patient will state that she just found herself doing an act which got her out of the difficulty, but didn't know why she thought to do it. It was as if she was watching someone else operate her body for a while as she extricated herself from the difficult situation. If the first splitting off of a Persecutor is before the age when the personality is fully formed, about the age 8, the emotional trauma which caused the creation of the Persecutor may also drive the original personality into retreat in some deep recess of the mind. Then a substitute for the original personality must be formed, a False Front personality. This one is known to the family as the patient, but she is very neurotic, with many phobias, spells of depression and poor coping abilities. This one has the tendency to splinter, thus creating many "ego-states" or personality fragments, each with very limited characteristics. This False Front personality will, most likely, be the one who comes for help to the psychotherapist, with complaints of depression, headaches and blackouts. She is very fragile, being an alter-personality herself, and having very little depth and substance to her. In such a case, the original personality is fixated at the age level when the first split occurred, usually between the ages of two and five. She is described by the other personalities as a very frightened and shy little one, but one who is pure at heart. She will not come out until therapy is underway when she feels she will not be endangered by the adults in the real world. Often, she feels one or both of her parents are so unworthy of trust and love, she must reject them, as they rejected her, and she will adopt a person in today's world, such as a nurse, as a substitute parent. This is much more than psychoanalytic transference. The adult in today's world is her parent in her mind and must behave in such a way that the patient can grow through the dependency phase into one of adult independence and freedom from this parental figure. It is not wise for the primary therapist to accept this role, as the role of a therapist in quite different from that of a parent. and one person cannot do both well. The other psychic entity which may show itself during therapy is one I have come to call the Inner Self Helper or ISH. This Is an entity which is the same as the Transpersonal Self of Assagioli (1965) or Jung's Philemon (1965). We all have one but the multiple disconnects hers from the rest of the psychic apparatus so that it can operate as the Master Rescuer and Guide. It is much more than the superego of Freud. One ISH's self-definition is as follows- "I have many functions. I am the conscience. I am the punisher, if need be. I am the teacher, the answerer of questions. I am what she will be, although never completely, for she has her emotional outlets whichI do not need. But she will have my reasoning ability and my ability to look at things objectively. I will always be here and I will always be separate, but the kind of separateness which is yours, a oneness with a very fine line of distinction. An emergency backup, perhaps. I must be the ability to know. If I am gone, she is just a body. She can send part of me off and leave a small portion. But if all is taken, she in a shell. Now my function is overseer to the dump. I am kept busy sorting out the different messes and problems created between the alter-personalities. The ISH has no date of creation; it has always been there since birth, as the spiritual side of the personality. It can only love. It knows all of the past history of thepatient, In this lifetime and in others. It is aware of the helpers above it, one of whom has the answer to any question. It has no sense of personal sexual identity, but uses whatever sexual designation the main personality chooses for it. It is willing to talk to the therapist, but usually it will only answer questions and give instructions. Seldom can the therapist engage an ISH in a social discussion. The length of time an ISH can be out, in control of the body, is about 20 minutes, as its physical functioning is very draining on the patient. Therefore. it will only come out at times of extreme emergency or on the request of the therapist. It never willcome out to prove its existence to a doubting Thomas, since it knows it exists and sees no need to prove it to anyone else. To conserve energy and guarantee accuracy, it may pass on messages in written form via automatic writing in the patient's diary. THE PSYCHOTHERAPY PLAN The therapy plan can best be understood as being composed of eight intertwining stages, which usually occur in the order listed below: 1. Recognition of the existence of the alter-personalities 2. Intellectual acceptance of having multiple personalities 3. Coordination of alter-personalities 4. Emotional acceptance of being multiple 5. Elimination of Persecutors 6. Psychological fusion 7. Spiritual fusion 8. Post- fusion experiences. For those trained in the profession of medicine, it is much like dealing with any patient with a physical disease. There must be a correct diagnosis made, which is then explained to the patient. The patient must accept the accuracy of the diagnosis to agree to cooperate in the treatment plan. Since the main psychological defense mechanisms used by multiples are denial, repression and dissociation, an approach of openness, education and expectation of active participation is needed to counteract these tendencies. 1. ) Recognition of the Existence of Alter-Personalities. The patient must be informed, gently but truthfully, of whatever the therapist finds out, such the the reason for the blackout spells and who comes out in the trance. The patient may ask the therapist to find on why she insulted her best friend during a blackout. When the therapist induces a hypnotic trance and calls for whatever part of the mind knows the reason, some alter-personality will come out to explain or confess. Video-taping, audiotaping, and quick developing photographs can be used to record the appearance of this entity. When the patient returns to consciousness, these records can then be shown to the patient when she is ready and willing to learn the facts. An internal dialogue (Allison, 1974) can be requested, out loud, between the main personality and the one who knows about the event. In this way the therapist learns almost as much as the patient does about the attitudes and moods of the alter-personalities and the relationships between them. Automatic writing may be the easiest way to establish such cross-comnmunication and also provides a permanent record of the various alter-personalities' handwriting. Regardless of what mechanical methods are used to show the patient the data available to the therapist, no amount of convincing evidence is ever enough to really persuade the patient that this is not all a fantasy (which it is, from another point of view. ) But confrontation must be done so that the patient is allowed to be aware ofhe same data which is available to the therapist. Eventually, this will lead into the second stage of treatment. 2. ) Intellectual Acceptance of Having Multiple Personalities. As the patient comes to trust the therapist and realizes that the therapist is honestly reporting that alter-personalities are working while the patient is unconscious, she will develop an intellectual acceptance of being multiple. This is a very difficult diagnosis for most patients to accept, and any doubt expressed by relatives or friends will be seized upon to undermine the therapist's opinion. She does not really believe it, but is willing to act as if it is true. This is the point when definitive psychotherapy can begin. As the therapist identifies the Persecutors. the patient superficially accepts their existence and agrees to do whatever the therapist advises in order to eliminate the danger of bodily harm they represent. The most efficient way to proceed with psychotherapy is under age regression or revivification. First, one must make a list of the ages important in the creation and strengthening of the most dangerous persecutor. To do this, the patient is asked to close her eyes, relax and let one index finger be raised by the part of the unconscious mind that knows these ages. As the therapist counts from zero to the patient's current age, the ages indicated by the finger raising are noted on paper. Then, the patient is asked to grow younger, while the therapist counts backwards from the current age, and to stop at the age at which the therapist stops counting. This age is the first one indicated by the finger signal and, when the therapist asks firmly to talk with "the five year old Margaret, " it is often as if one is really talking to a five year old child who wonders why she is in the strange doctor's office but can be encouraged to tell how she thinks Mommie and Daddy are being so mean to her. The purpose of the therapeutic interchange is to identify the conflicting feelings or mistaken ideas engendered by the early stress situation. Then the therapist must act as the child's counsellor, helping her to come to a better resolution of her conflicting feelings and attitudes. To do this requires some ingenuity on the part of the therapist. One example of what can be done is shown by the case of a woman whose aunt had the patient sexually stimulate her, the aunt's, body while playing "Doctor and Nurse." The patient, age regressed to six, said she knew this was wrong and hated the aunt for making her do it. But the aunt had paid her 25› (1 Swedish crown) each time she did it. The ambivalence between the hatred of the aunt and the greed for the money had to be resolved. The patient was asked to visualize the aunt in a chair in front of her, and the money paid to her in a bowl in her hands. She was then told that it was necessary for her to give the money back to the aunt. When she finally realized the need to give up her greed for the money, she threw the bowl into the chair and could then go on to the next episode, at age seven. Every episode like this must be worked through to a proper conclusion, to eliminate the hold the alter-personality has in the patient's mind, as a means of providing away of expressing negative feelings. The feelings must be modified from negative to at least neutral ones such as pity or tolerance. No episode can be ignored or further therapy will be stalled until it is resolved. During this phase of therapy, the patient must be introduced to the ISH, be advised of the wisdom of the ISH and urged to submit to its guidance at all times. She may see the ISH as a harsh parent at first, but since it always gives advice with love, eventually she will learn to submit to its will and thus solve many problems as they arise. The therapist and ISH must talk often enough to be able to work cooperatively in all projects. The ISH is the co-therapist 24 hours a day, 7 days a week and therefore can take a tremendous burden off the shoulders of the therapist. 3. ) Coordination of the Alter -Personalities. The therapist must introduce the personalities to one another and develop coordination between the Rescuers. Often several have been working parallel but are unaware of each other. Suicide prevention is a first priority item, and one Rescuer will have that major duty. She must know who to call and where to go in case of suicidal acting out. The positive side of Persecutors must be sought. If one is found, then age regression therapy can be used to deal with the conflicts creating the negative side. T'hen it might be willing to convert to a Rescuer and eventually blend in with the original personality. In case of violent behavior, the touch on the forehead procedure first described by Odencrantz (1968) can be used. Whenever an alter-personality is acting or threatening to act violently, an attendent should touch a sensitive spot in the midforehead with a finger, just above the eyebrows and call for a Rescuer to come forth to control the body. Nurses and relatives should be taught this simple but effective method of aborting dangerous acts. On a hospital ward, where one personality wants to elope, the therapist can get the ISH to agree to cause the patient to faint as soon as she passes through the outer door. After twice finding herself on the floor in the hospital corrider, the Persecutor decides to stay on the ward. 4.) Emotional Acceptance ofBeing Multiple. Since denial is the first psychological defense mechanism, the evidence leading to a logical conclusion that the patient has created alter-personalities is, at first, denied by her. no matter how overwhelming the evidence mnay seem to others. However, as therapy progresses, inevitably the balance of forces between personalities changes so that a more complete disorganization of the personality develops. The Persecutor become more active and more independent, with less attempt to keep the patient out of serious trouble. This process will lead to acts of which the main personality is unaware, which are in stark contrast to the main personality's code of conduct. The evidence for this destructive behavior becomes so overwheelming that the patient can find no other explanation than that the Persecutor has done the foul deed. The deed itself comes about in the normal course of living and cannot be contrived by a therapist trying to convince the patient of the existence of alter-personalities. Once the breakthrough to acceptance comes about, a chain reaction occurs. The patient becomes a very active partner with the therapist in organizing the treatment activities. Although frightened of what she will find, she wants to know more about those entities she has created, so silent internal dialogue with them, writing notes to them in her diary, and other ways are used voluntarily to break down the barriers previously created by the dissociative process. The patient 's curiosity about the nature of her psychic siblings must be supported and directed by the therapist. The ISH is finally seen as the Wise One who can safety be obeyed in all matters. That entity replaces the therapist as the one to ask questions of when the therapeutic hour is over. But the ISH may place seemingly impossible demands on the therapist in each hour, such as "Teach her tolerance" or "Show her it is safe to have friends." These tasks seem very difficult at the time, but the patient needs only to be exposed to a short demonstration of human goodwill to get the message she needs that day. The drive to get well i at its peak now. Anyone who tries to keep the patient in the sick role is rejected, be he lover, spouse or parent. Some patients feel they must move out of the home where their partner has been a willing caretaker, if they see as as only meeting the need of the caretakers to keep them sick. Many previously valued relationships may be sacrified if they seem, to the patient, to stand in the way of recovery. This may focus much more attention on the relationship with the therapist, to the exclusion of all other relationships. The demands for the therapist to meet all needs the patient has expected from parents, spouse and friends may be very intense, and the therapist must clearly define his/her role at this time without rejecting the patient altogether. The other problem is the hostility the family members may have developed towards the therapist when the patient starts standing up to them, wanting to change rules of conduct they have lived with for years. Their own unconscious guilt about their part in creating the problems leading to their child's severe emotional problems may very well be displaced onto the therapist who will then be blamed for "putting all those thoughts in my daughter's head about her having other personalities. She was perfectly alright until she went to that crazy doctor." This, of course, counteracts the fact that these very same relatives were the ones who brought her to the doctor because of her abnormal behavior. This displacement of parental guilt feelings must be recognized and understood for what it is. 5. ) Elimination of the Persecutors. At some point in the therapy focused on each Persecutor, the therapist will feel that all the psychological work has been done that can be done, both in age regression and in developing new and positive relationships with people in today's world. But the Persecutor is still there, trying to seriously harm or even kill the patient and possibly others. The threat of legal prosecution may he hanging over the patient's head because of a Persecutor 's misbehavior. The patient may beg the therapist to get rid of the Persecutor, who is no longer needed or wanted. But how do you get rid of a Persecutor? First. the therapist must conceptualize that it is possible to amputate a part of the mind, just as it is possible to amputate a gangrenous foot, and for the same reason, to save the patient's live. The next step is to design a ritual which symbolizes what the patient wants to happen, the expulsion of negative emotional energy from her entire being. Some patients will have their own ritual, which they learned from their families, and all the therapist need do is tell them to get started expelling the Persecutor in any way they feel will work. For the majority of patients who do not know what to do, I ask them to do what I call "The Bottle Routine." The essential steps in this ritual, which is done with the patient in a light trance, are as follows: a) Have an object, such as a bottle. ready but placed out of the patient's view. b) Tell the patient to go inside her head but still maintain control over her body. c) Instruct her to go to the high level where her ISH is and combine with the ISH, thus being able to utilize its power to get rid of the Persecutor. d) Have the patient envision a beam of pure healing energy coming in through the top of her head, energy which can help push out the Persecutor. e) Ask her to completely enclose the Persecutor in this energy and start shoving her down out of her head. f) The therapist stands at the side of the patient and tells the patient to shove the Persecutor out her shoulder and arm. g) While giving this instruction, the therapist cups his/her hand on the side of the patient's head, as if shoving something down, and tells the patient that he/she will help her push out the Persecutor. h) While moving the hand down the patient's side, the therapist intones that the Persecutor is being pushed out of the head, brain. eyes. ears, mouth, neck, shoulder, arm, elbow, wrist and hand. Before getting to the hand, place the bottle or other object in the patient's hand. i) When the therapist's hand touches the patient's hand, the therapist firmly tells the patient to push into the bottle all of the negativity which has been called by the name of the Persecutor and to keep pushing until it is all gone. When the patient has gone through what appear to be appropriate contortions, possibly with yelling between the Persecutor and the primary personality, she will give one last squeeze of the hand on the bottle before giving it up to the therapist. If she keeps prolonging the final push, the therapist can tell her that he/she will count to three, when she can get the last of the negativity out of her. When the bottle Is finally rejected, it is thrown away in the trash, with the comment that it will never again be used by humans. Only with such comments can the patient know the therapist is sincere about the meaning of the ritual. j) After this, the patient may be tested, if the therapist has any doubts, by trying to call out the Persecutor. Usually, the patient will report that the head is now quieter, the Persecutor to gone, and any testing would just sow seeds of doubt without any purpose being served. If the preparatory psychotherapy has been done, and the patient truly wants to be well, there will be no psychic entity by the Persecutor's name to be called forth. All the other personalities will, most likely, be left intact and can later report what they saw happen to their departed sibling. The meaning of this ritual in very important to the patient. Usually, she will realize she is responsible for the creation of the Persecutor, which had gotten too powerful for her to control. She also asserted herself for the first time in years and fought a battle of Good versus Evil. The therapist was not the combatant, but a catalyst who helped along the process and was a guide who taught her how to do something she never dared try before. The patient learned she need not be afraid of this self-made monster and will be able to deal equally well with the other Persecutors, when their turns come. The patient may feel reborn and able to deal with problems in a new way, even if she isn't sure what those ways might be. 6.) Psychological Fusion. When the primary personality, the one the patient is born with, has been uncovered and is assuming responsibility for all acts of the body, when the ISH is considered the true guide in all matters moral and interpersonal. and when all the Persecutors have been neutralized in some fashion, then psychological fusion of the Rescuer personalities with the original personalities will take place. This process is spontaneous, since, without Persecutors, there in no need for Rescuers, and, without a need, an alter-personality loses strength and direction. Prior to this final fusion, there may be times when several of the Rescuers will fuse because their jobs are done. This fusion process may be very disrupting to the mentat equilibrium of the patient, with disturbances of memory, mood, and ability to know how to perform familiar tasks. It may be necessary to have someone stay with the patient full time while the internal dynamics are changing so rapidly. The patient usually wonders if she can still form new alter-personalities. The answer is, "Yes, you can, if you want to. But please don't." If, shortly after psychological fusion, the patient has a severe emotional upset, such as getting jealous of a rival for her lover's attention, she may split off an angry personality. Because of the uproar this will cause, she may have to be hospitalized, and, during the next few hours, she will most likely become fully aware that she did split off this angry fragment and will bring it back into the fold. At this point the patient has one, the original personality, with all of the positive characteristics of her alter-personalities. She has rejected the negative qualities, at least for now. She listens to her ISH and follows its instructions. Then catastrophy strikes. One problem after another comes to plague her,. just when she feel she deserves a rest from life's problems. But if one carefully listens to be nature of these current difficulties, one finds that they are almost exact duplicates, in the emotions created, of the types of crises during which she created alter-personalities in the past. Only now she knows better than to try escaping from them. She can cope with them in a more adult, effective way. Only with this re-experiencing can the patient learn how to handle these problems effectively. The therapist is there for support and guidance, but the ISH instructs the patient as to the best ways to respond to each crisis. 7.) Spiritual Fusion. When several months have gone by during which the patient listens to her ISH, eventually there is no discernible difference between be attitudes of be ISH and the main personality. When these two thought patterns are identical, fusion of the ISH and of the main personality has come about, a state I call spiritual fusion. This is the last healing of the cleavage which occured in childhood and signals the end of the period called illness. After that, the patient will have problems in living and may need helpful counselling, but she is no longer self-defined as mentally ill. At this point she has the capacity for as much insight as does anyone, even though she may still make mistakes. 8.) Post - Fusion Experiences. For an indefinite time after fusion, the process of being exposed to old problems in new dress continues from before. Legal charges may have to be faced and resolved. Marriages may be broken or the vows renewed. New occupational directions may be necessary. Many patients leave the town where they were identified as sick and move to new surroundings where they take on normal social roles without the stigma of once having been multiple. Life continues to present its problems, but now they can cope in a more effective way and conscious way instead o



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